As healthcare continues to consume more and more of provincial government spending, there is a continuing pressure to improve efficiency and cut overall costs. In this increasingly constrained healthcare system, value for money is a growing focus of discussions around accountability and system sustainability; healthcare leaders are required to find ways of measuring, enforcing, and reporting on that value. In 2014, our organization began implementing an innovative system of structured incentives, linking distribution of Ministry of Health and Long-Term Care academic physician funding to quality and performance goals. Through a carefully planned process of benchmarking, stakeholder consultation, model improvement, and change management, we were able to move to a new value for money allocation model. The new model drives accountability by linking distribution of government payments to quality and performance outcomes. Initial results include increased stakeholder satisfaction as well as broader physician engagement in corporate and academic quality improvement initiatives.

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In early 2023, after three years of pandemic and delayed care, Ontario faced an overwhelming backlog of elective surgical procedures and unacceptable wait times. With hospitals experiencing historic health human resources shortages and critical capacity limitations, disruptive change was required. The Ontario government proposed to address these mounting access-to-care issues by paying for-profit healthcare clinics and surgi-centres to provide insured services, resulting in considerable controversy, much opposition, some praise, and many public protests. Previous experiences with for-profit independent health facilities had generated both complaints and documented problems with their operations. This article examines these concerns against the ethical principles of autonomy, beneficence, non-malfeasance, and justice. While much of this unease can be effectively addressed through collaboration and oversight, the complexity and costs involved in ensuring equity and quality may make it difficult for such facilities to maintain profitability.

Clinical ethics and clinical ethics supports, particularly regarding resource allocation and end of life decisions, are well developed in our healthcare system and in most hospitals; this is not the case for the broader category of leadership ethics. Most health managers and executives regularly need to make leadership decisions/choices that require ethical reflection. Without formal training, regular practice, and broad discussion on this issue of leadership ethics, Canadian hospital leaders are increasingly finding their decisions questioned and often end up in the headlines after being judged as failing to make the ethical grade. This article discusses the importance leadership ethics in today's healthcare environment, examines some of the complex ethical challenges created by the current healthcare context and external environment, and then presents an argument for more formal and mandatory leadership ethics education for executives and other health leaders.