In the last 20 years, clinicians, academics, policymakers, and countless other groups have worked to improve the state of US healthcare. Initiatives aimed at fixing the system to deliver on value and improve patient safety have been tried but with new solutions come new challenges. Across the country, healthcare quality professionals are stepping up to the plate and changing the game. This year, the National Association for Healthcare Quality (NAHQ) commissioned the topic of Quality as a Business Strategy for the Special Issue of JHQ, 2020.

Healthcare has roots in a cottage industry where the craft of medicine was practiced at a local level. Today, healthcare is big business, accounting for 17.8% of gross domestic product in 2018.1

This big business has high stakes for patients and the US economy, and it must do better. In 2020, medical error should not be the third leading cause of death in the United States.2 And, healthcare waste should not be cited between $760 and $935 billion annually in the United States.3 The cost of healthcare measured in human lives lost or harmed, and the waste that will exacerbate our country's challenges to balance macroeconomic priorities is too much to manage.

There is no question that the last 2 decades have offered the healthcare industry new insights and opportunities to improve and innovate, but as an industry, we have not come far enough or fast enough when it comes to improving patient safety, quality, or financial outcomes. Today, healthcare leaders, executives, and board members at hospitals alone experience an average of a 2% operating margin4 and for that reason must grapple with the real challenges of improving performance or risk going out of business. Certainly, there is no red pen that will solve the challenges healthcare faces. A full-scale paradigm shift to focus on and effectively implement quality and value must occur to affect an industry of this magnitude.

Over the decades, healthcare has sought to improve with the introduction of process measures, then outcomes measures, and now, there is a focus on value. In effect, we have experienced a shift from acknowledging that there were boxes to check, to checking those boxes, to seeing if the check marks were improving care. Transitions to new models take time, but time is running out, and savvy healthcare leaders are looking for new solutions, where quality is not a department, or an activity, but instead, it is a business strategy.

Over the years, NAHQ has highlighted leading organizations who have made quality their business strategy and deployed their strongest resource to improve healthcare, their workforce.

The healthcare workforce is leading the way with these changes, and we see examples of that in the manuscripts highlighted in this Special Issue of JHQ. The individuals who authored these articles and their colleagues who implemented these improvements are proof that there is power in people, and that the healthcare workforce is the key lever to pull when leveraging quality as a business strategy. We can be sure there is no silver bullet that will change healthcare. And, there are no software solutions, consultant engagements, or buzz worthy trends that can replace the need for an ongoing organizational commitment to workforce readiness to deliver on value.

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