Canadian healthcare is under increased scrutiny to improve quality and performance, and for good reason. The proliferation of provincial-level quality councils underscores the urgency to establish an aligned national quality agenda. Patient safety has long been held as a critical element of a high-quality healthcare system; with the inexorable growth in spending, efficiency has more recently been introduced. Efficiency and quality are both factors in Ontario's Excellent Care for All legislation introduced in June of 2010, and Quebec's l'Institut national d'excellence en santé et en services sociaux (INESSS) arising from the Castonguay report. These associations of quality and efficiency are also echoed in the US, Australian and UK public debates. The development of a quality agenda has concurrently precipitated discussion regarding responsibility for quality, particularly but not exclusively with the emergence of quality issues in the technical and interpretive pathology arena. The discussion and debate on responsibility have become preoccupations at the national, provincial, institutional and individual profession levels.