Continuous quality improvement in orthopedic surgery: changes and implications with health system funding reform.

T otal health expenditure was expected to reach $219.1 billion or $6105 per Canadian in 2015,1 with orthopedic care accounting for approximately 12% of total hospital acute care costs.2 In 2012–13, providing health care in Ontario consumed 42 cents of every tax dollar. Without modification, health spending would account for up to 70 per cent of the provincial budget by 2025.3 In an effort to stem the tide, health system funding reform (HSFR) was implemented in April 2012 as part of Ontario’s Action Plan for Health Care. A major constituent was the introduction of standardized bundled payments for quality-based procedures (QBP), which serve to reward care that improves patient outcomes. The United States and other countries are also moving toward bundled pricing.4,5 Of the QBPs currently in place in Ontario, 20% (4 of 20) involve orthopedic surgical procedures.6 The principle behind HSFR, and the ethos for establishing mandated QBPs, is to improve the quality of health care. The adage goes, “improve the quality of care, enhance patient satisfaction, and thereby improve patient outcomes and lower costs.” However, what is quality improvement, and how is it best enacted and then measured?