Paying for Quality or Buying Compliance? Rethinking Performance-Based Executive Compensation in Ontario Hospitals

Ontario's Excellent Care for All Act requires hospitals to link executive compensation to quality improvement plan targets. More than 15 years later, this article asks whether the evidence supports that design. A narrative review of Ontario policy documents, Canadian and international research on executive pay and pay-for-performance was conducted, and behavioural science on incentives was analyzed. Pay-at-risk in Ontario is small, largely penalty-only under compensation restraint, and was associated with conservative target-setting. International evidence shows short-lived process gains, little effect on patient outcomes, and predictable gaming. No published evaluation was identified linking the Act's pay-at-risk requirement to patient outcomes. Boards can remain compliant while redesigning the link as a small, shared, multi-year, independently verified component weighted towards patient safety and workforce outcomes. The Healthcare Executive Incentive Framework 2030 sets out domains, weights, governance safeguards, and an evaluation agenda.