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Specific conceptualizations of performance underlying accreditation manuals may not be neutral. Perhaps, more normative accreditation manuals are associated with authoritative management styles, or more balanced accreditation manuals with comprehensive management styles. Our comparative analysis is a first step toward better understanding the relationship between the conceptualization of performance and the management style adopted in a particular healthcare organization. This relationship could help explain the variation observed in healthcare organization performance.

Recent work on health system strengthening suggests that a combination of leadership and policy capacity is essential to achieve transformation and improvement. Policy capacity and leadership are mutually constitutive but difficult to assemble in a coherent and consistent way. Our paper relies on the nested model of policy capacity to empirically explore how health reformers in seven Canadian provinces address the question of policy capacity. More specifically, we look at emerging representations of policy capacity within the context of health reforms between 1990 and 2020. Based on the exploration of the scientific and grey literature (legislation, annual reports of Ministries, agencies and organizations, meeting minutes, press, etc.) and interviews with key informants (n = 54), we identify how policy capacity is considered and framed within health reforms A series of core dilemmas emerge from attempts by each province to develop policy capacity for and through health reforms.

In publicly funded health systems, reform efforts have proliferated to adapt to increasingly complex demands. In Canada, prior research (Lazar et al., 2013, Paradigm Freeze: Why is it so Hard to Reform Health Care in Canada?, McGill-Queen's Press) found that reforms at the end of the 20th century failed to change the fundamentals of the Canadian system based on physician independence and assured universal coverage only for medical and hospital services. This paper focuses on reforms since the turn of the millennium to explore the transformative capacities developed in seven provinces within this system architecture. Longitudinal case studies, based on scientific and grey literature, and interviews with key informants, trace the patterns of reform in each province and reveal five objectives that, to varying degrees, preoccupied reformers: (1) address chronic disease, (2) align health system actors with provincial objectives, (3) shift from hospital to community-based care, (4) integrate physicians, and (5) develop improvement capacities. The range of strategies adopted to achieve these objectives in different provinces is compared to identify emerging pathways of reform and extract lessons for future reformers. We find significant cross-learning between provinces, but also note an emergent dimension to reforms, where multiple strategies aggregate through time to create unique patterns, presenting their own set of possibilities and limitations for the future.