In 1991 the Society’s nominating Committee chaired by Hannu Vuori wrote to me informing me that the Committee would be putting forward my name as President of the then International Society for Quality Assurance. I was to be the third president following the Swedish medical scientist, Peter Reizenstein and the American medical executive Bill Jessee.
I was somewhat nonplussed, being used to a process where nominations are normally advertised for such a position. Moreover, although I had been on the Board since 1986, having assisted in the organisation of Melbourne Conference in 1989, nobody asked me whether I wanted the job.
The perception, according to Dr Vuori, was that I had the financial and administrative capacity to maintain the Society at that time. The finances of the Society had always been on a roller coaster. Membership would increase at each annual scientific meeting and then fall off as the benefits of membership became non-apparent to those outside the “Club of Udine”. Different countries would provide a different but transient audience.
The Society provided very little for its members for the simple reason that there was not the organisation to provide an ongoing worldwide service. It was still a “club”. That required a budget, which the Society had not had until the creation of the secretariat and guaranteed government support.
When I came into office in September 1991, I found the standard of administration and the finances varied between the ad hoc and the chaotic. In fact, the Society was living off its next year’s subscriptions. This meant the Society was severely underfunded, depending on erratic membership dues, subscriptions to the journal and some profit-sharing from the annual scientific meetings.
Thus there were a number of matters that needed to be straightened out. Fortunately I inherited a British treasurer, Charles Shaw, and a Swedish secretary, Mats Beckman, who were prepared to work and put up with my communications with them out of hours.
The Vice-President, Enrique Ruelas, had carriage of the 1992 annual scientific meeting in Mexico City. Peter Reizenstein continued as Editor of the Journal.
Very early in its existence the journal, Quality Assurance in Health Care, was established and published by Pergamon Press, but with the collapse of the Maxwell empire, the publication shifted to the Dutch-based publishing house Elsevier.
After a promising start, the journal’s citation index hardly budged out from the asterisked class. Unlike the relationship with Pergamon, where there had been a link between Reizenstein and Maxwell, there was none such with Elsevier.
However, to give Peter Reizenstein credit, he had recognised that having a journal is crucially important as no society with international pretensions could be without an ongoing means of communication.
However Elsevier, as joint owners, were unhappy with its performance.
In essence, the Society had to be fixed up. There was a need for a permanent secretariat, but at that stage there were no volunteers to host it and put up the required money to fund it. Furthermore, it seem that some of the more influential members continued to hold the view that the difficulties would disappear if one wished hard enough.
Under the then constitution, the day-to-day responsibility resided with the president and there were several challenges:
- the Journal had to be put on a firm financial basis. That, in turn, meant it needed to have a sense of relevance;
- there was a need to ensure that annual scientific meeting arrangements were in order. A three-year schedule of meetings – Mexico, Maastricht and Venice – had been put in place before my Presidency began. However, when I visited Mexico City six months before the 1992 meeting to find no bookings made, I booked the venue to my credit card;
- there was a need to establish a strategic plan incorporating a permanent secretariat to provide continuity.
- the Society had been incorporated in Sweden and that required review.
Some time after the untimely death of Peter Reizenstein and a period of interim editorship, this role shifted to Heather Palmer at Harvard University. It was recognised that ultimately journal viability depended on the North American market. Palmer, as a contemporary worker in the field, had wide credibility. Moreover, she could attract both high quality and diverse contributions. An expansion to a group of regional editors helped provide a wider perspective than the Journal ever had previously.
Journals, if run properly, cost a great amount because editing is a time-consuming task. In return, they are expected to generate revenue to enable them to continue.
Even then the view was held that quarterly journals were increasingly disadvantaged in a world where
(a) communication was increasingly speeded up,
(b) immediacy of publication was increasingly important,
(c) the outlets for information transfer needed considerable expansion,
(d) the content must be interesting enough to attract subscriptions.
The journal was changed to bi-monthly from a quarterly publication. The journal experienced a name change to The International Journal for Quality in Health Care, adding International and deleting Assurance since quality assurance is seen as limiting the range of the journal and international gives the journal the right niche in the market. One of the people who was critical in the survival of the Journal was Janet Boullin, originally employed by Pergamon but then with the transfer of the Journal to Elsevier she followed, and when the journal ended up at Oxford University Press, so did Janet. She was a cultured understated professional who was integral to the survival challenges the Society faced.
As President I travelled a great amount, mostly at my own expense (but then, that was part of the implied social contract of taking the task seriously). Any idea that having the President in Australia was the equivalent of embedding him under the floorboards in mushroom potting mix was dispelled quickly.
The Annual General Meeting in Mexico City in 1992 was the commencement of my stewardship. The Conference turned out to be a great success despite the early uncertainty and even though I gave the opening address in Spanish. This achievement indicated one of many levels the help I received – and the Society was to receive – from the Australian Government. Our Mexican embassy translated my speech into Spanish. The embassy also provided a reception before the start of the Conference.
As somebody remarked to me, Spanish is the easiest language to speak badly; but I thought that the following year opening the conference in Dutch in Maastricht was a bridge too far.
Being “parachuted” into a role of President required gaining a degree of legitimacy and as I had less than two years to accomplish same, it was a challenge opening up the processes to a wider audience. I chaired meetings of the Board in Stockholm, Oxford, Melbourne and Chicago. The Chicago meeting was important as there had been a degree of alienation of the Joint Commission on the Accreditation of Healthcare Standards (JCAHO) – an important player in this field in North America; my immediate task was to effect some rapprochement.
At the same time the Board initiated a review of the constitution as a means of focusing the Society on its structure and functions.
A regional meeting in Melbourne in April 1993 at the Howard Florey Institute was attended by senior figures in the Australian and New Zealand health systems, and it was notable by the attendance of the Chief Operating Officer of JCAHO, Karen Timmons, and then President of the International Society for the Technology Assessment in Health Care, Jane Sisk, from Columbia University. I was interested to see if there was common ground for sharing resources between the two Societies.
At Maastricht in June 1993 at the AGM, the new constitution was adopted with little opposition – 97 per cent of those eligible voted in favour. This led to the separation of the membership into individual and institutional categories from which constituencies the President would be drawn on a rotating basis. The constitutional changes provided for the position of an executive officer and a permanent secretariat.
The task was to encourage the constituency to believe that having an organisation working to improve the quality of health care across the globe was important. This ultimately led to the establishment of the Society’s secretariat in Melbourne.
This could not have been done without crucial help from government, first from the Australian Government and then from the Victorian Government. This support was significant, but Chris Brook, a highly influential Australian public health physician, coming onto the Board at Maastricht ensured that degree of Australian continuity. He became President–elect and then President following Charles Shaw who in turn had succeeded Enrique Ruelas.
My formal association with ISQua finished following the St John’s Meeting in Newfoundland in June 1995 with the end of my Immediate Past President term.
By that time the Secretariat had been established in Melbourne and the Society – from being on shaky ground four years before – was now on a firm financial basis. The encouragement of Government and significant NGO support through the institutional membership proved one of the lasting changes which has enabled annual meetings to be held every year since, the secretariat to be shifted to Ireland, the journal to be maintained and the activities greatly expanded.
In 1995 I wrote “ ISQua is an international acorn.”
Some acorn; some tree!