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BMJ Open: first published as 10.1136/bmjopen-2014-005055 on 5 September 2014. Downloaded from http://bmjopen.bmj.com/ on April 16, 2023 by guest. Protected by copyright.
The role of hospital managers in quality
and patient safety: a systematic review
Anam Parand,1 Sue Dopson,2 Anna Renz,1 Charles Vincent3
To cite: Parand A, Dopson S, ABSTRACT

Renz A, et al. The role of Strengths and limitations of this study
Objectives: To review the empirical literature to
hospital managers in quality
identify the activities, time spent and engagement of ▪ This is the first systematic review of the literature
and patient safety: a
hospital managers in quality of care. that has considered the evidence on Boards’ and
systematic review. BMJ Open
2014;4:e005055. Design: A systematic review of the literature. managers’ time spent, engagement and work
doi:10.1136/bmjopen-2014- Methods: A search was carried out on the databases within the context of quality and safety. This
005055 MEDLINE, PSYCHINFO, EMBASE, HMIC. The search review adds to the widely anecdotal and commen-
strategy covered three facets: management, quality of tary pieces that speculate on what managers
▸ Prepublication history and care and the hospital setting comprising medical should be doing by presenting what they are actu-
additional material for is subject headings and key terms. Reviewers screened ally doing.
available. To view please visit 15 447 titles/abstracts and 423 full texts were checked ▪ The review reveals conditions and actions condu-
the journal (http://dx.doi.org/ against inclusion criteria. Data extraction and quality cive to good quality management and offers a
10.1136/bmjopen-2014- assessment were performed on 19 included articles. model to transparently present these to managers
005055). Results: The majority of studies were set in the USA considering their own part in quality and safety.
and investigated Board/senior level management. The ▪ The search for this review has screened a vast
Received 13 February 2014
most common research designs were interviews and amount of the literature (over 15 000 articles)
Revised 19 August 2014
Accepted 20 August 2014 surveys on the perceptions of managerial quality and across a number of databases.
safety practices. Managerial activities comprised ▪ The small number of included studies and their
strategy, culture and data-centred activities, such as varied study aims, design and population samples
driving improvement culture and promotion of quality, make generalisations difficult. With more literature
strategy/goal setting and providing feedback. on this topic, distinctions could be made between
Significant positive associations with quality included job positions.
compensation attached to quality, using quality ▪ The quality assessment scores are subjective
improvement measures and having a Board quality and may not take into consideration factors
committee. However, there is an inconsistency and beyond the quality assessment scale used.
inadequate employment of these conditions and
actions across the sample hospitals.
healthcare managers.1–3 In line with this,
Conclusions: There is some evidence that managers’
time spent and work can influence quality and safety there have been calls for Boards to take
clinical outcomes, processes and performance. responsibility for quality and safety out-
However, there is a dearth of empirical studies, further comes.4 5 One article warned hospital leaders
weakened by a lack of objective outcome measures and of the dangers of following in the path of
little examination of actual actions undertaken. We bankers falling into recession, constrained by
present a model to summarise the conditions and their lack of risk awareness and reluctance to
activities that affect quality performance. take responsibility.6 To add to the momentum
are some high profile publicity of hospital
management failures affecting quality and
safety, eliciting strong instruction for man-
agerial leadership for quality at the national
1
Department of Surgery & INTRODUCTION level in some countries.7 8
Cancer, Imperial College Managers in healthcare have a legal and Beyond healthcare, there is clear evidence
London, London, UK moral obligation to ensure a high quality of of managerial impact on workplace safety.9–12
2
Said Business School,
University of Oxford, Oxford,
patient care and to strive to improve care. Within the literature on healthcare, there are
UK These managers are in a prime position to non-empirical articles providing propositions
3
Department of Experimental mandate policy, systems, procedures and and descriptions on managerial attitudes and
Psychology, University of organisational climates. Accordingly, many efforts to improve safety and quality. This lit-
Oxford, Oxford, UK have argued that it is evident that healthcare erature, made up of opinion articles, editor-
Correspondence to managers possess an important and obvious ials and single participant experiences,
Dr Anam Parand; role in quality of care and patient safety and present an array of insightful suggestions and
a.parand@imperial.ac.uk that it is one of the highest priorities of recommendations for actions that hospital
Parand A, et al. BMJ Open 2014;4:e005055. doi:10.1136/bmjopen-2014-005055 1

Open Access
managers should take to improve the quality of patient subordinates, oversees staff, is responsible for staff recruit-
care delivery in their organisation.13–17 However, ment and training, and holds budgetary accountabilities.
researchers have indicated that there is a limited evi- Therefore, all levels of managers including Boards of
dence base on this topic.18–21 Others highlight the litera- managers were included in this review with the exception
ture focus on the difficulties of the managers’ role and of clinical frontline employees, e.g. doctors or nurses,
the negative results of poor leadership on quality who may have taken on further managerial responsibil-
improvement (QI) rather than considering actions that ities alongside their work but do not have a primary offi-
managers presently undertake on quality and safety.22 23 cial role as a manager. Those who have specifically taken
Consequently, little is known about what healthcare on a role for quality of care, e.g. the modern matron,
managers are doing in practice to ensure and improve were also excluded. Distinction between senior, middle
quality of care and patient safety, how much time they and frontline management was as follows: senior manage-
spend on this, and what research-based guidance is avail- ment holds trust-wide responsibilities26; middle managers
able for managers in order for them to decide on appro- are in the middle of the organisational hierarchy chart
priate areas to become involved. Due perhaps to the and have one or more managers reporting to them27;
broad nature of the topic, scientific studies exploring frontline managers are defined as managers at the first
these acts and their impact are likely to be a methodo- level of the organisational hierarchy chart who have front-
logical challenge, although a systematic review of the evi- line employees reporting to them. Board managers
dence on this subject is notably absent. This present include all members of the Board. Although there are
systematic literature review aims to identify empirical overlaps between senior managers and Boards (e.g. chief
studies pertaining to the role of hospital managers in executive officers (CEOs) may sit on hospital Boards), we
quality of care and patient safety. We define ‘role’ to aim to present senior and Board level managers separ-
comprise of managerial activities, time spent and active ately due to the differences in their responsibilities and
engagement in quality and safety and its improvement. position. Only managers who would manage within or
While the primary research question is on the managers’ govern hospitals were included, with the exclusion of set-
role, we take into consideration the contextual factors tings that solely served mental health or that comprised
surrounding this role and its impact or importance as solely of non-acute care community services (in order to
highlighted by the included studies. Our overarching keep the sample more homogenous). The definition of
question is “What is the role of hospital managers in ‘role’ focused on actual engagement, time spent and
quality and safety and its improvement?” The specific activities that do or did occur rather than those recom-
review research questions are as follows: mended that should or could occur.
▸ How much time is spent by hospital managers on
quality and safety and its improvement? Search strategy
▸ What are the managerial activities that relate to Literature was reviewed between 1 January 1983 and 1
quality and safety and its improvement? November 2010. Eligible articles were those that
▸ How are managers engaged in quality and safety and described or tested managerial roles pertaining to
its improvement? quality and safety in the hospital setting. Part of the
▸ What impact do managers have on quality and safety search strategy was based on guidance by Tanon et al.28
and its improvement? EMBASE, MEDLINE, Health Management Information
▸ How do contextual factors influence the managers’ Consortium (HMIC) and PSYCHINFO databases were
role and impact on quality and safety and its searched. The search strategy involved three facets
improvement? (management, quality and hospital setting) and five
steps. A facet (i.e. a conceptual grouping of related
search terms) for role was not included in the search
METHODS strategy, as it would have significantly reduced the sensi-
Concepts and definitions tivity of the search.
Quality of care and patient safety were defined on the Multiple iterations and combinations of all search
basis of widely accepted definitions from the Institute of terms were tested to achieve the best level of specificity
Medicine (IOM) and the Agency for Healthcare and sensitivity. In addition to the key terms, Medical
Research and Quality Patient Safety Network (AHRQ Subject Headings (MeSH) terms were used, which were
PSN). IOM define quality in healthcare as possessing the ‘exploded’ to include all MeSH subheadings. All data-
following dimensions: safe, effective, patient-centred, bases required slightly different MeSH terms (named
timely, efficient and equitable.4 They define patient Emtree in EMBASE), therefore four variations of the
safety simply as “the prevention of harm to patients”,24 search strategies were used (see online supplementary
and AHRQ define it as “freedom from accidental or pre- appendix 1 for the search strategies). Additional limits
ventable injuries produced by medical care.”25 Literature placed on the search strategy restricted study partici-
was searched for all key terms associated with quality and pants to human and the language to English. The
patient safety to produce an all-encompassing approach. search strategy identified 15 447 articles after duplicates
A manager was defined as an employee who has had been removed.
2 Parand A, et al. BMJ Open 2014;4:e005055. doi:10.1136/bmjopen-2014-005055

Open Access
Screening maintain the original meanings, interpretations and raw
Three reviewers (AP, AR and Dina Grishin) independ- data offered by the articles.39
ently screened the titles and abstracts of the articles for
studies that fit the inclusion criteria. One reviewer (AP)
screened all 15 447 articles, while two additional RESULTS
reviewers screened 30% of the total sample retrieved This section provides an overview description of the
from the search strategy: AR screened 20% and DG reviewed studies and their key findings. The findings are
screened 10%. On testing inter-rater reliability, Cohen’s considered under four main headings: managerial time
κ correlations showed low agreement between AR and spent on quality and safety; managerial quality and
AP (κ=0.157, p<0.01) and between DG and AP (κ=0.137, safety activities; managerial impact on quality and safety;
p<0.00).29 However, there was a high percentage of and contextual factors related to managers’ quality and
agreement between raters (95% and 89%, respectively), safety role. The section ends with a proposed model to
which reveals a good inter-rater reliability.30 31 summarise the review findings.
Discrepancies were resolved by discussion and consen-
sus. The main inclusion criteria were that: the setting Description of the studies
was hospitals; the population sample reported on was From the 19 included studies, the majority were carried
managers; the context was quality and safety; the aim out and set in the USA (14 studies) and investigated senior
was to identify the managerial activities/time/engage- management and/or Boards (13 studies). Of these, 3
ment in quality and safety. The full inclusion/exclusion focused on senior managers alone (e.g. chief nursing offi-
criteria and screening tool can be accessed in the online cers), 9 concentrated on Board managers and 1 included
supplementary appendices 2–3. Figure 1 presents the a mixture of managerial levels. Only 3 investigated middle
numbers of articles included and excluded at each stage managers and 3 examined frontline staff (e.g. clinical dir-
of the review process. ectorate managers and unit nurse managers). The settings
Four hundred and twenty-three articles remained for of the study were mostly trust or hospital-wide; a few arti-
full text screening. One reviewer (AP) screened all articles were set in specific settings or contexts: elderly care,40
cles and a second reviewer (AR) reviewed 7% of these. evidence-based medicine,41 staff productivity,42 clinical risk
A moderate agreement inter-rater reliability score was management43 and hospital-acquired infection preven-
calculated (κ=0.615, p<0.001) with 73% agreement. The tion.44 Two studies involved specific interventions,45 46 and
primary reoccurring difference in agreement was regard- 7 studies concentrated specifically on QI rather than
ing whether the article pertained to quality of care, quality and safety oversight or routine.35 40 45–49 There
owing to the broad nature of the definition. Each article were a mixture of 6 qualitative designs (interviews or focus
was discussed individually until a consensus was reached groups); 8 quantitative survey designs and 5 mix-methods
on whether to include or exclude. Hand searching and designs. All but one study employed a cross-sectional
cross-referencing were carried out in case articles were design.46 The primary outcome measure used in most
missed by the search strategy or from restriction of data- studies was perceptions of managerial quality and safety
bases. One additional article was identified from hand practices. All reported participant perceptions and a
searching,32 totalling 19 articles included in the system- majority presented self-reports, i.e. either a mixture of self-
atic review (figure 1). reports and peer reports, or self-reports alone.41 43 45 46
Several studies asked participants about their own and/or
other managers’ involvement with regard to their specific
Data extraction and methodological quality QI intervention or quality/safety issue.40 41 44–47 With
The characteristics and summary findings of the 19 some variations, the most common research design was to
included studies are presented in table 1. This table is a interview or survey senior manager/Board members (par-
simplified version of a standardised template that was ticularly Board chairs, presidents and CEOs) perceptions
used to ensure consistency in data extracted from each on the Board/senior managers’ functions, practices, prior-
article. Each study was assessed using a quality appraisal ities, agenda, time spent, engagement, challenges/issues,
tool developed by Kmet et al,34 which comprised of two drivers and literacy (e.g. familiarity of key reports) on
checklists (qualitative and quantitative). Random quality and safety.35–38 48–51 Five of these studies included
included articles (32%) were scored by Ana Wheelock objective process/outcome measures, such as adjusted
for scoring consistency. All articles were scored on up to mortality rates.35 37 38 49 50 No other studies included clin-
24 questions with a score between 0 and 2; table 2 shows ical outcome measures.
an example definition of what constitutes ‘Yes’ (2), The quality assessment scores ranged between 50% and
‘Partial’ (1) and ‘No’ (0) rating criteria. The total per- 100%; one study scored (what we consider to be) very low
centage scores for each study are presented in table 1. (i.e. <55%), eight studies scored highly (i.e. >75%), two
All studies were included regardless of their quality other articles scored highly on one out of two of their
scores. Some cumulative evidence bias may results from studies (quantitative/qualitative) and the remaining eight
two larger data sets split into more than one study scored a moderate rating in-between. Almost half of the
each.35–38 Through a narrative synthesis, we aimed to articles did not adequately describe their qualitative

Open Access
Figure 1 Review stages based on PRISMA flow diagram.33
studies. Specifically, 8 failed to fully describe their qualita- data but only presented percentages, and only one study
tive data collection methods, often not mentioning a stan- reported to appropriately controlled for confounding
dardised topic guide, what questions were asked of variables. Across all articles, all but 3 studies reported
participants, or no mention of consent and confidentiality clear objectives and asserted conclusions clearly sup-
assurances. In 7 studies there was no or vague qualitative ported by the data.
data analysis description, including omitting the type of
qualitative analysis used. Six of the studies showed no or Managerial time spent on quality and safety
poor use of verification procedures to establish credibility The studies on Board level managers highlight an inad-
and 9 reported no or poor reflexivity. Positively, all study equate prioritisation of quality and patient safety on the
designs were evident, the context of studies were clear and Board agenda and subsequent time spent at Board meet-
the authors showed a connection to a wider body of ings. Not all hospitals consistently have quality on their
knowledge. Board agenda, e.g. CEOs and chairpersons across 30 orga-
Similarly to the qualitative studies, 7 quantitative nisations reported that approximately a third of all Board
studies did not fully describe, justify or use appropriate meetings had quality on their agenda,35 and necessary
analysis methods. However, compared with the qualita- quality items were not consistently and sometimes never
tive studies, the quantitative studies suffered more from addressed.36 In all studies examining time spent on quality
sampling issues. Three studies had particularly small and safety by the Board, less than half of the total time was
samples (e.g. n=35) and one had an especially low spent on quality and safety,32 37 38 48–51 with a majority of
response rate of 15%. Participant characteristics were Boards spending 25% or less on quality.32 38 45 49–51
insufficiently described in 5 studies; in one case the Findings imply that this may be too low to have a positive
authors did not state the number of hospitals included influence on quality and safety, as higher quality
in data analysis. Several studies had obtained ordinal performance was demonstrated by Boards that spent

Open Access
above 20%/25% on quality.49 50 Board members recog- study.38 48 From this review it is unclear to what degree
nised that the usual time spent is insufficient.48 However, Board involvement in the credentialing process has a sig-
few reported financial goals as more important than nificant impact on quality.38 41
quality and safety goals,32 and health system Boards only
spent slightly more time on financial issues than quality.51 Data-centred
Frontline managers also placed less importance and time Information on quality and safety is continually supplied
on QI,42 identified as the least discussed topic by clinical to the Board.51 At all levels of management, activities
managers.52 around quality and safety data or information were
recognised in 6 studies.35 38 43 45 47 53 Activities included
Managerial quality and safety activities collecting and collating information,43 reviewing quality
A broad range of quality-related activities were identified information,35 38 53 using measures such as incident
to be undertaken by managers. These are presented by reports and infection rates to forge changes,53 using
the following three groupings: strategy-centred; data- patient satisfaction surveys,35 taking corrective action
centred and culture-centred. based on adverse incidents or trends emphasised at
Board meetings38 and providing feedback.43 47 The
Strategy-centred studies do not specify the changes made based on the
Board priority setting and planning strategies aligned data-related activities by senior managers; one study
with quality and safety goals were identified as Board identified that frontline managers predominantly used
managerial actions carried out in several studies. High data from an incident reporting tool to change policy/
percentages (over 80% in two studies) of Boards had practice and training/education and communication
formally established strategic goals for quality with spe- between care providers.45 However, overseeing data gen-
cific targets and aimed to create a quality plan integral erally was found to be beneficial, as hospitals that
to their broader strategic agenda.32 37 Contrary findings carried out performance monitoring activities had sig-
however suggest that the Board rarely set the agenda for nificantly higher scores in process of care and lower
the discussion on quality,37 did not provide the ideas for mortality rates than hospitals that did not.38
their strategies32 and were largely uninvolved in strategic
planning for QI.48 In the latter case, the non-clinical Managerial impact on quality and safety outcomes
Board managers felt that they held ‘passive’ roles in We have considered the associations found between specific
quality decisions. This is important considering evidence managerial involvement and its affect on quality and safety.
that connects the activity of setting the hospital quality Here, we summarise the impact and importance of their
agenda with better performance in process of care and general role. Of the articles that looked at either outcomes
mortality.38 Additionally, Boards that established goals in of management involvement in quality or at its perceived
four areas of quality and publicly disseminated strategic importance, 6 articles suggested that their role was benefi-
goals and reported quality information were linked to cial to quality and safety performance.32 35 38 40 49 53 Senior
high hospital performance.35 38 50 management support and engagement was identified as
one of the primary factors associated with good
Culture-centred hospital-wide quality outcomes and QI programme
Activities aimed at enhancing patient safety/QI culture success.35 38 40 49 Conversely, 6 articles suggest that
emerged from several studies across organisational managers’ involvement (from the Board, middle and front-
tiers.44 47 48 53 Board and senior management’s activities line) has little, no or a negative influence on quality and
included encouraging an organisational culture of QI safety.35 38 41 42 44 49 Practices that showed no significant
on norms regarding interdepartmental/multidisciplin- association with quality measures included Board’s partici-
ary collaboration and advocating QI efforts to clinicians pation in physician credentialing.35 38 Another noted that if
and fellow senior managers, providing powerful mes- other champion leaders are present, management leader-
sages of safety commitment and influencing the organi- ship was not deemed necessary.44 Two articles identified a
sation’s patient safety mission.47 53 Managers at differing negative or inhibitory effect on evidence-based practices
levels focused on cultivating a culture of clinical excel- and staff productivity from frontline and middle man-
lence and articulating the organisational culture to agers.41 42
staff.44 Factors to motivate/engage middle and senior
management in QI included senior management com- Contextual factors related to managers’ quality
mitment, provision of resources and managerial role and safety role
accountability.40 46 Findings revealed connections Most of the articles focused on issues that influenced
between senior management and Board priorities and the managers’ role or their impact, as opposed to dis-
values with hospital performance and on middle man- cussing the role of the managers. These provide an
agement quality-related activities. Ensuring capacity for insight in to the types of conditions in which a manager
high-quality standards also appears within the remit of can best undertake their role to affect quality and safety.
management, as physician credentialing was identified Unfortunately it appears that many of these conditions
as a Board managers’ responsibility in more than one are not in place.

6
Open Access
Table 1 Table of characteristics and summary findings of included studies
Findings pertaining
Population to research questions
sample (level of Quality Quality (time spent; activities,
management assessment assessment engagement; impact
Sample size reported on Management roles (managerial quality and safety activities, score for score for (including perceived
First author; (number of (position of time spent and engagement and key perceived qualitative quantitative effectiveness);
year (country) Methods organisations) managers)) Outcome measure importance and context factors) studies studies contextual factors)
Baker et al; Mixed methods n=15 interviews; Managers (Board Perceptions of ▸ Less than half (43%) of Boards reported that they addressed quality and 16/20 (80%) 12/22
2010 (interviews, n=4 Board case management) managers on patient safety issues in all meetings (55%) Time
(Canada)32 case studies, studies; n=79 ▸ One-third of Boards spend 25% of their time or more on quality and patient
management Board Activities
surveys) surveys (79 practices in quality
safety issues Impact
organisations) and safety ▸ More than 80% of Boards have formally established strategic goals for Context
quality with specific targets, but a majority of Board chairs indicate that their
Boards did not provide the ideas for strategic direction or initiatives
▸ Board chairs reported a low participation in education on quality and safety:
43% reported that all the Board members participated, 19% stated that more
than half participated and 23% said it was less than a quarter of the Board
▸ Most Board chairs (87%) reported Board member induction training on
responsibilities for quality and safety, although almost a third (30%) reported
few or no opportunities for education on this, 42% reported some
opportunities and 28% reported many
▸ Approximately half (57%) of the Board chairs acknowledged recruitment of
individuals that have knowledge, skills and experience in quality and patient
safety onto the Board. A Board skills matrix included quality and safety as
one of the competency areas
▸ Over half (55%) of board chairs rated their board’s effectiveness in quality
and safety oversight as very/extremely effective and 40% as somewhat
effective
Parand A, et al. BMJ Open 2014;4:e005055. doi:10.1136/bmjopen-2014-005055
Balding; 2005 Mixed methods n=35 Managers (middle Self-reported Five elements deemed essential to middle manager engagement: 14/20 (70%) 15/22 (68%) Activities
(Australia)46 (action (1 hospital) management perceptions of ▸ Senior management commitment and leadership (e.g. senior management Engagement
research, (nursing managers managers on their provides strategic direction for QI plan) Impact
surveys and and allied health engagement in a QI ▸ Provision of resources and opportunities for QI education and information
focus groups) managers)) programme dissemination (e.g. basic QI skills provided to all staff)
▸ Senior and middle manager role accountability (e.g. senior managers and
middle managers agree QI roles and expectations)
▸ Middle manager involvement in QI planning (e.g. senior and middle
managers plan together)
▸ Middle managers own and operate QI programme (e.g. ongoing review and
evaluation of the progress of the QI programme by the middle and senior
managers)
Bradely et al; Qualitative n=45 Clinical staff and Perceptions of roles Five common roles and activities that captured the variation in management 19/20 (95%) NA Activities
2003 (USA)47 (interviews) (8 hospitals) senior management and activities that involvement in quality improvement efforts: Engagement
(senior management comprise senior ▸ Personal engagement of senior managers Impact
(unspecified)) management’s ▸ Management’s relationship with clinical staff
involvement in ▸ Promotion of an organisational culture of quality improvement
quality improvement ▸ Support of quality improvement with organisational structures
efforts ▸ Procurement of organisational resources for quality improvement efforts
Bradely et al; Mixed methods n=63 survey Managers (senior Perceptions of ▸ Providing resources for needed staffing or staff training 19/20 (95%) 17/22 Activities
2006 (USA)40 (surveys and respondents (63 management (chief management-related ▸ Promoting the programme among the governing Board, physicians who were (77%) Engagement
interviews) hospitals); operating officer, vice factors around the initially less involved, and other administrators Impact
n=102 president, medical HELP programme ▸ Senior management support reported as the primary enabling factor in the Context
interviewees (13 director, CNO, director implementation of such programmes (96.6%), along with a lack of support as
hospitals) of volunteers, the primary reason for not implementing the programme (65.0%)
programme director)) ▸ The interviews supported that having an administrative champion was
considered essential to their programme’s success
Continued
Table 1 Continued
Findings pertaining
Braithwaite Mixed methods n=64 managers Managers (frontline Observations and ▸ Quality was the least discussed topic (e.g. continuous quality improvement) 16/20 (80%) NA Time
et al; 2004 (ethnographic in focus groups management (medical self-reported ▸ The most discussed topic was people (e.g. staffing, delegating) and
(Australia)52 work, (1 hospital); managers, nurse perceptions of organisational issues, e.g. beds and equipment
observations ethnographic managers and allied clinician-managers’
and focus case studies health managers)) activities
groups) and n=4
observed
(2 hospitals)
Caine and Qualitative n=10 (2 Managers (middle Self-reported ▸ Managers saw their role in research implementation as a facilitator, ensuring 14/20 (70%) NA Activities
Kenwrick; (interviews) hospitals) management (clinical perceptions of quality and financial objectives and standards were met Impact
1997(UK)41 directorate managers)) managers on the ▸ Managers perceived their facilitatory behaviours produced a low level of
managers’ role in clinical change
facilitating ▸ Managers are not actively advocating research-based practice and failing to
evidence-based integrate it into everyday practice. Their behaviour inhibited the development
practice in their of evidence-based nursing practice
nursing teams ▸ Devolved responsibility of use of research to individual professionals
Fox, Fox and Quantitative n=16 Managers (frontline Self-reported ▸ The small amount of total management allocated to QI (2.6%) was the least NA 13/22 (59%) Time
Wells; (surveys and (1 hospital) management (nurse perceptions of time spent of all management functions Activities
1999 (USA)42 self kept administrative managers on their ▸ A negative relationship between time spent in QI activities and unit personnel Impact (objective
activity logs) managers (NAMs))) activities impacting productivity. An increase (from 2.5% to 5%) in QI time/effort by NAMs would outcome measure)
unit personnel reduce staff productivity significantly by approximately 8%
productivity and ▸ The greater the experiences of NAMs as managers, the more time spent on
monitored time/effort QI. These seasoned NAMs spent more time on monitoring, reporting QI
allocated to each results and quality improvement teams (statistics nor provided)
function and
managers’ hours
worked, patient
admissions and
length of stay
Harris; Quantitative n=42 (42 Managers (middle Self-reported ▸ The majority of managers (91%) who received collated incident information NA 13/22 (59%) Activities
2000 (UK)43 (surveys) hospitals) management (nurse perceptions of used it to feed back to their own staff. 60% always fed back to staff, 28%
managers)) managers on sometimes did, 2% never did
managers’ quality ▸ Of the trusts that had written guidance on types of clinical incident to report,
and safety practices 80% of managers had general guidance and fewer (20%) had written
specialty specific guidance
▸ 76% of managers reported information collation of clinical incidents. Of
these, 59% were involved in data collection themselves
Jha and Quantitative n=722 (767 Managers (Board) Perceptions of ▸ Two-thirds (63%) of Boards had quality as an agenda item at every meeting NA 22/22 (100%) Time
Epstein; (surveys) hospitals) managers on the ▸ Fewer than half (42%) of the hospitals spent at least 20% of the Board’s time Activities
2010 (USA)50 role of managers in on clinical quality Impact (objective
quality and safety ▸ 72% of Boards regularly reviewed a quality dashboard outcome measure)
and quality outcome ▸ Most respondents reported that their Boards had established, endorsed or Context
measurement approved goals in four areas of quality: hospital-acquired infections (82%),
Open Access
(from HQA) i.e. 19 medication errors (83%), the HQA/Joint commission core measures (72%),
practices for care in and patient satisfaction (91%)High-performing hospitals were more likely
3 clinical conditions than low-performing hospitals to have:
▸ Board reviews of a quality dashboard regularly (<0.001)
and of clinical measures (all <0.05)
Continued
7
8
Table 1 Continued
Open Access
Findings pertaining
▸
Quality performance on the agenda at every Board meeting (0.003)
▸
At least 20% of Board time on clinical quality (0.001)
▸
Has a quality subcommittee (0.001)
Jiang et al; Quantitative n=562 (387 Managers (Board and Perceptions of ▸
75% of CEOs reported that most to all of the Board meetings have a specific NA 20/26 (77%) Time
2008 (USA)37 (surveys) hospitals) senior management managers on agenda item devoted to quality. Only 41% indicated that the Boards spend Activities
(presidents/CEOs)) managers’ practices more than 20% of its meeting time on the specific item of quality.The Impact (objective
in quality and safety; following activities were most reported to be performed: outcome measure)
and outcomes of ▸ Board establishing strategic goals for QI (81.3%) Context
care (composite ▸ Use quality dashboards to track performance (86%)
scores of ▸ Follow-up corrective actions related to adverse events (83%)The following
risk-adjusted M activities were least reported to be performed:
indicators) ▸ Board involvement in setting the agenda for the discussion on quality
(42.4%)
▸ Inclusion of the quality measures in the CEO’s performance evaluation
(54.6%)
▸ Improvement of quality literacy of Board members (48.9%)
▸ Board written policy on quality and formally communicated it (30.8%)
Jiang et al; Quantitative n=490 (490 Managers Perceptions of Board practices found to be associated with better performance (all p<0.05) in NA 22/24 (92%) Activities
2009 (USA)38 (surveys) hospitals) (Board and senior managers on POC and adjusted M included: Impact (objective
management (CEOS manager’s practices ▸ Having a Board quality committee (83.8%POC, 6.2M versus 80.2%POC, outcome measure)
and hospital in quality and safety; 7.9M without a committee) Context
and POC measures ▸ Establishing strategic goals for quality improvement (82.8% POC, 6.6M
presidents reports))
(20 measures in 4 versus 80.3% POC, 7.9M)
clinical areas); and ▸ Being involved in setting the quality agenda for the hospital (83.2% POC,
outcome measures 6.4M versus 80.9% POC, 7.7M)
(composite scores of ▸ Including a specific item on quality in Board meetings (83.2% POC, 6.5M
risk-adjusted M versus 78.5% POC, 8.6M)
indicators) ▸ Using a dashboard with national benchmarks and internal data that includes
indicators for clinical quality, patient safety and patient satisfaction (all above
80% POC and below 6.5M versus all below 80%POC and above 7M)
▸ Linking senior executives’ performance evaluation to quality and patient
safety indicators (83.1% POC, 6.6M versus 80.4% POC, 7.6M)Practices that
did NOT show significant association with the quality measures for process
and M include:
▸ Reporting to the Board of any corrective action related to adverse events
(82.5% POC, 7.0M versus 81.8% POC, 6.6M)
▸ Board’s participation in physician credentialing (82.8% POC, 6.9M versus
81.5% POC, 6.9M)
▸ Orientation for new Board members on quality(82.9% POC, 6.8M versus
81.7% POC, 7.0M)
▸ Education of Board members on quality issues (82.8% POC, 7.0M versus
81.9% POC, 6.9M)
Joshi and Mixed n=37 survey Managers (Board and Perceptions of ▸ Board engagement in quality was reported as satisfactory (7.58 by CEOs 12/20 (60%) 16/20 (80%) Time
Hines; 2006 methods respondents; senior management managers on and 8.10 by Chairs on a 1–10 scale where 10 indicates greatest satisfaction) Activities
(USA)35 (surveys and n=47 (CEOs, Board chairs)) managers’ practices ▸ Board engagement was positively associated with perceptions of the rate of Engagement
interviews) interviewees (30 in quality and safety progress in improvement (r=0.44, p =0.05), and marginally associated with Impact (objective
hospitals) and ACM and ACM scores (r=0.41, p=0.07) outcome measure)
risk-adjusted M. ▸ Approximately one-third of Board meetings are devoted to discussing quality Context
issues (reported at 35% by CEOs and 27% by Chairs)
Continued
Table 1 Continued
Findings pertaining
▸ Integrating Quality Planning and Strategic Planning was also rated as

satisfactory (7.67 by CEOs and 8.85 by Chairs)
▸ Approximately two-thirds of respondents reported using patient satisfaction
surveys (70% and 65% reported by CEOs and Chairs, respectively)
▸ Low level of CEO expertise in QI, as reported by themselves (2.70) and by
Board Chairs (3.35%) on a scale of 1–10 where 1 is low familiarity and 10 is
high familiarity
Levey et al; Qualitative n=96 (18 Managers (Board and Perceptions of ▸ Few CEOs were willing to take the lead for transformation to a ‘culture of 13/20 (65%) NA Time
2007 (USA)48 (interviews) hospitals) senior management managers on quality’ Activities
(hospital Board managers’ role in ▸ Board members were largely uninvolved in strategic planning for QI Engagement
members, CEOs, chief quality and safety ▸ In terms of the Board’s quality functions, respondents largely agreed that Context
medical officers, chief physician credentialing was their critical responsibility
quality officers, ▸ Non-physicians reported that they felt relegated to ‘passive’ roles in decisions
medical staff leaders)) on quality and seemed reluctant to assume leadership roles in the quality
domain
▸ Board meeting agendas maintained a focus on financial issues, although
patient safety/care and QI were gaining prominence
▸ About half of the respondents said that quality was not sufficiently
highlighted during meetings. Estimates of time devoted to quality and safety
issues at Board meetings were between 10% and 35%
Mastal, Joshi Qualitative n=73 Managers (Board and Perceptions of ▸ Two CNOs reported that nursing quality was never addressed at Board 12/20 (60%) NA Time
and Shulke; (interviews and interviewees; senior management managers on meetings Context
2007 (USA)36 a focus group) 1 focus group (Board chairs, CEOs, managers’ role in ▸ Few of the CNOs, CEOs and Board chairs responded that issues are
(63 hospitals) CNOs)) quality and safety discussed more frequently, such as at every meeting
▸ Quality and patient safety measures for nurses are not consistently
addressed during all hospital Board meetings
▸ Staffing concerns are the most frequent measure of nursing quality reported
at the Board level
Poniatowski, Quantitative n=515 (16 Managers (frontline Self-reported ▸ Managers reviewed on average 65% of the PSN events reportedAs a result NA 10/20 (50%) Activities
Stanley and (surveys) academic management—unclear perceptions of of what was learned from PSN data, 162 managers detailed their changes
Youngberg; medical whether frontline or managers on their made to:
middle managers (unit practices with PSN ▸ Policies and practices (59%)
2005 (USA)45 centers) nurse managers)) ▸ Training, education and communication between care providers (27%)
▸ Purchase of new equipment and supplies (8%)
▸ Staffing (6%)
Prybil et al; Quantitative n=123 (712 Managers (Board and Perceptions of ▸ Health system Boards spent 23% of their Board meeting time on quality and NA 14/22 (64%) Time
2010 (USA)51 (surveys) hospitals) senior management managers on their safety issues. They only spent slightly more on financial issues (25.2%) and Activities
(CEOs and Boards)) role in quality and strategic planning (27.2%) Context
safety ▸ Almost all (96%) CEOs said that the Boards regularly received formal written
reports on quality targets
▸ 88% of CEOs said that the Boards had assigned quality and safety oversight
to a standing Board committee
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▸ All but one (98.9%) of the CEOs stated that they have specific performance
expectations and criteria related to quality and safety
▸ CEOs reported 59% of the Boards formally adopted system-wide measures
and standards for quality
Continued
9
10
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Table 1 Continued
Findings pertaining
Saint et al; Qualitative n=86 Senior hospital staff Perceptions of ▸ Although committed leadership by CEOs can be helpful, it was not always 16/20 (80%) NA Activities
2010 (USA)44 (interviews) (interviewees) and managers (mixed managers on necessary, provided that other hospital leaders were committed to infection Engagement
(14 hospitals) levels (nurse managers’ practices prevention Behaviours of leaders who successfully implemented/facilitated Impact
managers, chief in HAI practices to prevent HAI:
physicians, Chairs of ▸ Cultivated a culture of clinical excellence and kept their eye on improving
medicine, chief of patient care
staffs, hospital ▸ Developed a vision
directors, CEOs and ▸ Articulated the organisational culture well and conveyed that to staff at all
clinical non-managerial levels
staff)) ▸ Focused on overcoming barriers and dealing directly with resistant staff or
process issues that impeded prevention of HAI
▸ Cultivated leadership skills and inspired the people they supervised
(motivating and energising them to work towards the goal of preventing HAI)
▸ Thought strategically while acting locally; planned ahead and left few things
to chance
▸ They did the politicking before issues arose for committee votes
▸ They leveraged personal prestige to move initiatives forward
▸ They worked well across disciplines
Vaughn et al; Quantitative n=413 (413 Managers (Board and Perceptions of ▸ 72% of hospital Boards spent one-quarter of their time or less on NA 21/22 (95%) Time
2006 (USA)49 (surveys) hospitals) senior management managers on quality-of-care issues. About 5% of Boards spent more than half of their time Activities
(chief executives and managers’ role in QI on these issues Engagement
senior quality and observed ▸ A majority of respondents reported great influence from government and Impact (objective
executives; Board, hospital regulatory agencies (87%), consumers (72%) and accrediting bodies (74%) outcome measure)
executives, clinical quality index on quality priorities. Although 44% of respondents also noted that multiple Context
leadership)) outcomes government and regulatory requirements were unhelpfulBetter QIS are
(risk-adjusted associated with hospitals where the Board:
measures of ▸ Spends more than 25% of their time on quality issues (QIS 83–QIS mean
morbidity, M and 100 across hospitals)
medical ▸ Receives a formal quality performance measurement report (QIS 302)
▸ Bases the senior executives’ compensation in part on QI performance (QIS
complications) 239)
▸ Engages in a great amount of interaction with the medical staff on quality
strategy
Weingart and Qualitative Managers (senior Perceptions of Executives developed and tested a set of governance best practices in patient 14/20 (70%) NA Activities
Page; 2004 (case study n=30 management managers on safety, such as: Impact
(USA)53 documentation (10 hospitals (executives)) manager’s practices ▸ Creation of a Board committee with explicit responsibility for patient safety
analysis and and other in quality and safety ▸ Development of Board level safety reports, introduction of educational
meeting stakeholder activities for Board members
discussions organisations) ▸ Participation of Board members in executive walk rounds
and focus ▸ Executives reviewed measures to assess safety (e.g. incident reports,
group) infection rates, pharmacist interventions, readmissions, etc)
▸ Executives endorsed a statement of public commitment to patient safety
▸ Executives believed their behaviours affected their organisations’ patient
safety mission
ACM, appropriate care measure; CEO, chief executive officer; CNO, chief nursing officer; HAI, healthcare-associated infection; HQA, Hospital Quality Alliance; M, mortality; NA, not applicable;
POC, process of care; PSN, Patient Safety Net; QI, quality improvement; QIS, quality index scores.
Open Access
Table 2 Example of rating criteria from Kmet’s quality assessment tool34
Rating Criteria to verify whether question or objective is sufficiently described
Yes Is easily identified in the introductory section (or first paragraph of methods section). Specifies (where applicable,
depending on study design) all of the following: purpose, participants/target population, and the specific intervention
(s)/association(s)/descriptive parameter(s) under investigation. A study purpose that only becomes apparent after
studying other parts of the paper is not considered sufficiently described
Partial Vaguely/incompletely reported (e.g. “describe the effect of” or “examine the role of” or “assess opinion on many
issues” or “explore the general attitudes”...); or some information has to be gathered from parts of the paper other
than the introduction/background/objective section
No Question or objective is not reported, or is incomprehensible
N/A Should not be checked for this question
Two studies found that a Board quality committee is a factors suggest certain organisational factors that should
positive variable in quality performance, but that fewer be put in place alongside individual factors to prepare
than 60% had them.38 50 Similarly, compensation and per- for such a role (e.g. standardised quality measures,
formance evaluation linked to executive quality perform- motivation, education and expertise, and a good rela-
ance was identified in 4 articles 35 37 38 49 and associated tionship with clinicians). The processes present the strat-
with better quality performance indicators,38 49 but quality egy, culture and data-centred areas where managers
measures were insufficiently included in CEOs’ perform- (according to the literature) are and/or should be
ance evaluation.35 37 The use of the right measures to involved (e.g. driving improvement culture, goal setting
drive QI was raised in relation to Board managerial and providing feedback on corrective actions for adverse
engagement in quality 35 and to impact on patient care events). The outputs identify managerial influences that
improvement,51 yet almost half of this sample did not for- are positive, negative or have little or no established asso-
mally adopt system-wide measures and standards for ciation with quality performance (e.g. positive outcomes
quality. To aid them in these tasks, evidence indicates the of care, achieving objectives and engaging others in
common use of QI measure tools, such as a dashboard or quality of care). This helps to identify areas where it is
scorecard,37 49 50 with promising associations between possible to make an impact through the processes men-
dashboard use and quality outcomes.38 50 tioned. With further empirical studies on this topic, this
Other factors linked to quality outcomes include man- model could be strengthened to become a more robust
agement–staff relationship/high interactions between the set of evidence-based criteria and outcomes.
Board and medical staff when setting quality strategy,49
and managerial expertise. Although a connection between
knowledge and quality outcomes was not found,38 high DISCUSSION
performing hospitals have shown higher self-perceived Our review examined the role of managers in maintain-
ability to influence care, expertise at the Board and partici- ing and promoting safe, quality care. The existing
pation in training programmes that have a quality compo- studies detail the time spent, activities and engagement
nent.50 Disappointingly, there is a low level of CEO of hospital managers and Boards, and suggest that these
knowledge on quality and safety reports,35 possibly little can positively influence quality and safety performance.
Boardroom awareness on salient nursing quality issues,36 They further reveal that such involvement is often
and little practice identified to improve quality literacy for absent, as are certain conditions that may help them in
the Board.32 37 There is however promise for new man- their work.
agers through relevant training at induction and by Evidence from the review promotes hospitals to have a
recruitment of those with relevant expertise.32 Board quality committee, with a specific item on quality
at the Board meeting, a quality performance measure-
ment report and a dashboard with national quality and
The quality management IPO model safety benchmarks along with standardised quality and
The input process output (IPO) model is a conceptual safety measures. Outside of the Boardroom, the implica-
framework that helps to structure the review findings in tions are for senior managers to build a good infrastruc-
a useful way (see figure 2).54 55 This literature may be ture for staff–manager interactions on quality strategies
conceptualised by considering what factors contribute and attach compensation and performance evaluation
(input) to managerial activities ( process) that impact on to quality and safety achievements. For QI programmes,
quality and safety (output). The three factors are inter- managers should keep in mind its consistency with the
related and interchangeable, presented by the cyclical hospital’s mission and provide commitment, resources,
interconnecting diagram. This diagram enables a clearer education and role accountability. Literature elsewhere
mental picture of what a manager should consider for supports much of these findings, such as the use of
their role in quality and safety. Specifically, the input quality measurement tools21 56 better quality-associated

Open Access
Figure 2 The quality management IPO model (IPO, input process output; QI, quality improvement).
compensation, a separate quality committee,16 57 and recent studies present more time spent on quality and
has also emphasised poor manager–clinician relation- safety than the earlier studies. Yet even the most recent
ships as damaging to patients and QI.58 59 empirical studies not included in our review conclude
Some of the variables that were shown to be associated that much improvement is required.60
with good quality performance, such as having a Board This review presents a wide range of managerial activ-
committee, compensation/performance and adoption of ities, such as public reporting of quality strategies and
system-wide measures, were lacking within the study hos- driving an improvement culture. It further highlights
pitals. There are also indications of the need to develop the activities that appear to affect quality performance.
Board and senior managerial knowledge and training on Priorities for Boards/managers are to engage in quality,
quality and safety. Furthermore, this review indicates that establish goals and strategy to improve care, and get
many managers do not spend sufficient time on quality involved in setting the quality agenda, support and
and safety. The included studies suggest time spent by the promote a safety and QI culture, cultivate leaders,
Board should exceed 20–25%, yet the findings expose manage resisters, plan ahead and procure organisational
that certain Boards devote less time than this. resources for quality. Again, much of the findings
Inadequacies of time allocated to quality at the Board support the assertions made in the non-empirical litera-
meeting hold concerning implications for quality. If little ture. Above all, involvement through action, engage-
time is taken to consider quality of care matters at the ment and commitment has been suggested to positively
highest level, an inference is that less attention will be affect quality and safety.61 While researchers have
paid to prevention and improvement of quality within stressed the limited empirical evidence showing conclu-
the hospital. While the position that the item appears on sive connection between management commitment and
the agenda is deemed of high importance, it is unimport- quality,21 some supporting evidence however can be
ant if the duration on this item is overly brief. In this vein, unearthed in research that concentrates on organisa-
the inadequate time on quality spent by some may reflect tional factors related to changes made to improve
their prioritisation on quality in relation to other matters quality and safety in healthcare.62–64 In addition to this
discussed at the meetings or the value perceived to be evidence, a few studies have specifically investigated the
gained from discussing it further. It might instead impact that hospital managers have on quality and safety
however be indicative of the difficulties in measuring (rather than examination of their role). These studies
time spent on quality by management. Some of these have shown senior managerial leadership to be asso-
studies provide us not necessarily with Board managers’ ciated with a higher degree of QI implementation,65
time on quality and safety but their time spent on this at promotion of clinical involvement,66 67 safety climate
Board meetings. The two may not equate and time spent attitudes68 and increased Board leadership for quality.57
on quality may not necessarily be well spent.36 The emer- A clear case for the positive influence of management
ging inference that managers greatly prioritise other involvement with quality is emerging both from the find-
work over quality and safety is not explicit, with further ings of our review and related literature.
research required to identify what time is actually There is a dearth of empirical research on the role of
devoted and required from managers inside and outside hospital managers in quality of care and patient safety
of the Boardroom. Perhaps encouragingly, the more and QI. This evidence is further weakened by the largely

Open Access
descriptive nature of many of the studies. They mostly Review limitations
lack theoretical underpinnings and appropriate objective There are several limitations of the present review per-
measures. Very few studies reported objective clinical taining to the search strategy and review process, the
quality outcome measures that better show the influence limited sample of studies, publication bias, and limita-
of managerial actions. Moreover, the content of many of tions of the studies themselves. Specifically, the small
the articles was dominated by the contextual issues sur- number of included studies and their varied study aims,
rounding managers’ roles, rather than actual manager design and population samples make generalisations dif-
practices. Some of the outlined managerial actions would ficult. Grouped demographics, such as middle manage-
further benefit from more detail, e.g. the literature fails ment, are justified by the overlap between positions.
to present changes made based on the data-related activ- With more literature on this topic, distinctions could be
ities at the Board or senior management level. Only one made between job positions. Furthermore, more
study clearly demonstrated that senior management and research on lower levels of management would have pro-
Board priorities can impact on middle management vided a better balanced review of hospital managers’
quality-related activities and engagement. Considering work and contributions to quality. Restricting the lan-
the likely influence that seniors have on their managers, guage of studies to English in the search strategy is likely
examination of the interactions between the different to have biased the findings and misrepresent which
roles held (e.g. Boards setting policies on quality and countries conduct studies on this topic. There is an over-
middle managers implementing them) would improve reliance on perceptions across the studies, which ultim-
our understanding of how these differences reflect in ately reduces the validity of the conclusions drawn from
their time spent and actions undertaken. Supplementary their findings. As most of the study findings relied on
work could also resolve contradictions that were found self-reports, social desirability may have resulted in exag-
within the review, clarifying for example, the positive gerated processes and inflated outputs. Although,
impact of managerial expertise versus knowledge on encouragingly, one of the included studies found that
quality and who sets the Board agenda for the discussion managers who perceived their Boards to be effective in
on quality. Research on this area is particularly required quality oversight were from hospitals that had higher
to examine middle and frontline managers, to take into processes-of-care scores and lower risk adjusted mortality.
consideration non-managers’ perceptions, and to assess The quality assessment scores should be viewed with
senior managers’ time and tasks outside of the caution; such scores are subjective and may not take into
Boardroom. Future studies would benefit from better consideration factors beyond the quality assessment scale
experimental controls, ideally with more than one time used. Owing to the enormity of this review, the publica-
point, verifications and reflections on qualitative work, tion of this article is some time after the search run
robust statistical analysis, appropriate study controls, con- date. As there is little evidence published on this topic,
sideration of confounding variables, and transparent we consider this not to greatly impact on the current
reporting of population samples, methodologies, and relevance of the review, particularly as the literature
analyses used. Box 1 presents the key messages from this reviewed spans almost three decades. However, we
review. acknowledge the need for an update of the data as a
limitation of this review.
Box 1 Key messages from the systematic literature review

CONCLUSION
▸ There is a dearth of empirical evidence on hospital managerial The modest literature that exists suggests that managers’
work and its influence on quality of care. time spent, engagement and work can influence quality
▸ There is some evidence that Boards’/managers’ time spent, and safety clinical outcomes, processes and perform-
engagement and work can influence quality and safety clinical ance. Managerial activities that affect quality perform-
outcomes, processes and performance. ance are especially highlighted by this review, such as
▸ Some variables associated with good quality performance
establishing goals and strategy to improve care, setting
were lacking in study hospitals.
▸ Many Board managers do not spend sufficient time on quality
the quality agenda, engaging in quality, promoting a QI
and safety. culture, managing resisters and procurement of organ-
▸ There is a greater focus on the contextual issues surrounding isational resources for quality. Positive actions to con-
managers’ roles than on examining managerial activities. sider include the establishment of a Board quality
▸ Research is required to examine middle and frontline man- committee, with a specific item on quality at the Board
agers, to take into consideration non-managers’ perceptions, meeting, a quality performance measurement report
and to assess senior managers’ time and tasks outside of the and a dashboard with national quality and safety bench-
Boardroom. More robust methodologies with objective marks, performance evaluation attached to quality and
outcome measures would strengthen the evidence. safety, and an infrastructure for staff–manager interac-
▸ We present a model to summarise the evidence-based promo- tions on quality strategies. However, many of these
tion of conditions and activities for managers to best affect
arrangements were not in place within the study
quality performance.
samples. There are also indications of a need for

Open Access
managers to devote more time to quality and safety. 10. Zohar D, Luria G. The use of supervisory practices as leverage to
improve safety behavior: a cross-level intervention model. J Saf Res
More than one study suggest time spent by the Board 2003;34:567–77.
should exceed 20–25%, yet the findings expose that 11. Flin R. “Danger-men at work”: management influence on safety.
certain Boards devote less time than this. Much of the Hum Factor Ergon Man 2003;13:261–8.
12. Guidotti TL. How can managers visibly promote safety and health
content of the articles focused on such contextual protection? J Occup Environ Med 2010;52:1141–2.
factors rather than on the managerial role itself; more 13. Conway J. Getting boards on board: engaging governing boards in
quality and safety. Jt Comm J Qual Patient Saf 2008;34:214–20.
empirical research is required to elucidate managers’ 14. Gautam KS. A call for board leadership on quality in hospitals. Qual
actual activities. Research is additionally required to Manag Health Care 2005;14:18–30.
15. Caldwell C, Butler G, Grah J. Breakthrough quality: what the board
examine middle and frontline managers, non-manager must do. Trustee 2008;61:32–3, 1.
perceptions, and to assess senior managers’ time and 16. Goeschel CA, Wachter RM, Pronovost PJ. Responsibility for quality
tasks outside of the Boardroom. We present the quality improvement and patient safety: hospital board and medical staff
leadership challenges. Chest 2010;138:171–8.
management IPO model to summarise the evidence- 17. McGinn P, Dave R. What is the board’s role in quality? Trustee
based promotion of conditions and activities in order to 2007;60:40.
18. Øvretveit J. Leading improvement effectively: review of research.
guide managers on the approaches taken to influence 2009. http://www.health.org.uk/public/cms/75/76/313/560/Leading%
quality performance. More robust empirical research 20imrpovement%20effectively.pdf?realName=YUaqJk.pdf (accessed
with objective outcome measures could strengthen this 21 Dec 2012)
19. Flin R, Yule S. Leadership for safety: industrial experience. Qual Saf
guidance. Health Care 2004;13:45–51.
20. West E. Management matters: the link between hospital
Acknowledgements The authors would like to thank Miss Dina Grishin for organisation and quality of patient care. Qual Saf Health Care
helping to review the abstracts and Miss Ana Wheelock for helping to assess 2001;10:40–8.
the quality of the articles. 21. Glickman SW, Baggett KA, Krubert CG, et al. Promoting quality: the
health-care organization from a management perspective. Int J Qual
Contributors All coauthors contributed to the study design and reviewed Health Care 2007;19:341–8.
drafts of the article. The first author screened all the articles for inclusion in 22. Gaucher E, Kratochwill EW. The leader’s role in implementing total
this review and appraised the study quality. AR and Dina Grishin screened a quality management. Qual Manag Health Care 1993;1:10–8.
sample of these at title/abstract and full text, and Ana Wheelock scored the 23. Thorman KE, Capitulo KL, Dubow J, et al. Perinatal patient safety
from the perspective of nurse executives: a round table discussion.
quality of a sample of the included articles. J Obstet Gynecol Neonatal Nurs 2006;35:409–16.
Funding This work was supported by funding from the Health Foundation 24. Aspden P, Corrigan JM, Wolcott J, et al. Patient safety: achieving a
new standard of care. Institute of Medicine, ed. Washington:
and the National Institute for Health Research (grant number: P04636). National Academies Press, 2004.
Competing interests None. 25. AHRQ. AHRQ Patient Safety Network Glossary. 2011. http://www.
psnet.ahrq.gov/glossary.aspx?indexLetter=P (accessed 19 May
Provenance and peer review Not commissioned; externally peer reviewed. 2012)
26. Merali F. NHS managers’ commitment to a socially responsible role:
Data sharing statement The extraction table of the included studies and the NHS managers’ views of their core values and their public
individual study quality scores can be made available on request to the image. Soc Responsibility J 2005;1:38–46.
corresponding author at a.parand@imperial.ac.uk. 27. Mintzberg H. The nature of managerial work. New York: Harper &
Row, 1973.
Open Access This is an Open Access article distributed in accordance with 28. Tanon AA, Champagne F, Contandriopoulos AP, et al. Patient safety
the terms of the Creative Commons Attribution (CC BY 4.0) license, which and systematic reviews: finding papers indexed in MEDLINE,
permits others to distribute, remix, adapt and build upon this work, for EMBASE and CINAHL. Qual Saf Health Care 2010;19:452–61.
29. Cohen J. A coefficient for agreement for nominal scales. Educ
commercial use, provided the original work is properly cited. See: http://
Psych Meas 1960;20:37–46.
creativecommons.org/licenses/by/4.0/ 30. Cicchetti DV, Feinstein AR. High agreement but low kappa: II.
Resolving the paradoxes. J Clin Epidemiol 1990;43:551–8.
31. Viera AJ, Garrett JM. Understanding interobserver agreement: the
kappa statistic. Fam Med 2005;37:360–3.
32. Baker GR, Denis JL, Pomey MP, et al. Effective governance for
REFERENCES quality and patient safety in Canadian Healthcare organizations: a
1. Kizer KW. Patient safety: a call to action: safety is a critical report to the Canadian Health Services Research Foundation and
component of quality. MedGenMed 2001;3:10. the Canadian Patient Safety Institute. Ottawa: Canadian Health
2. Kizer KW. Establishing health care performance standards in an era Services Research Foundation and Canadian Patient Safety
of consumerism. JAMA 2001;286:1213–17. Institute, 2010.
3. Berwick D. Will is the way to win the patient safety war. Health Serv 33. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for
J 2007;117:18–19. systematic reviews and meta-analyses: the PRISMA statement. Ann
4. Institute of Medicine. Crossing the quality chasm: a new health Intern Med 2009;151:264–9.
system for the 21st century. Washington: National Academy Press, 34. Kmet LM, Lee RC, Cook LS. Standard quality assessment criteria
2001. for evaluating primary research papers from a variety of fields.
5. Gosfield AG, Reinertsen JL. The 100,000 lives campaign: Edmonton: Alberta Heritage Foundation for Medical Research, 2004.
crystallizing standards of care for hospitals. Health Aff 35. Joshi MS, Hines SC. Getting the board on board: engaging hospital
2005;24:1560–70. boards in quality and patient safety. Jt Comm J Qual Patient Saf
6. Denham CR. Is your hospital as safe as your bank?...Time to ask 2006;32:179–87.
your board. J Patient Saf 2009;5:122–6. 36. Mastal MF, Joshi M, Schulke K. Nursing leadership: championing
7. Francis R. Report of the Mid Staffordshire NHS Foundation Trust quality and patient safety in the boardroom. Nurs Econ
Public Inquiry London: The Stationery Office. 2013 http://www. 2007;25:323–30.
midstaffspublicinquiry.com/report (accessed 18 Mar 2013) 37. Jiang HJ, Lockee C, Bass K, et al. Board engagement in quality:
8. National Advisory Group on the Safety of Patients in England. A findings of a survey of hospital and system leaders. J Healthc
promise to learn—a commitment to act: improving the safety of Manag 2008;53:121–34.
patients in England 2013. https://www.gov.uk/government/uploads/ 38. Jiang HJ, Lockee C, Bass K, et al. Board oversight of quality: any
system/uploads/attachment_data/file/226703/Berwick_Report.pdf differences in process of care and mortality? J Healthc Manag
(accessed 15 Aug 2013) 2009;54:15–29.
9. O’Dea A, Flin R. Site managers and safety leadership in the offshore 39. Walsh D, Downe S. Meta-synthesis method for qualitative research:
oil and gas industry. Saf Sci 2001;37:39–57. a literature review. J Adv Nurs 2005;50:204–11.

Open Access
40. Bradley EH, Webster TR, Schlesinger M, et al. The roles of senior 56. Naranjo-Gil D. Strategic performance in hospitals: the use of the
management in improving hospital experiences for frail older adults. balanced scorecard by nurse managers. Health Care Manage Rev
J Healthc Manag 2006;51:323–36. 2009;34:161–70.
41. Caine C, Kenrick M. The role of clinical directorate managers in 57. Weiner BJ, Alexander JA, Shortell SM. Leadership for quality
facilitating evidence-based practice: a report of an exploratory study. improvement in health care; empirical evidence on hospital
J Nurs Manag 1997;5:157–65. boards, managers, and physicians. Med Care Res Rev
42. Fox RT, Fox DH, Wells PJ. Performance of first-line management 1996;53:397–416.
functions on productivity of hospital unit personnel. J Nurs Adm 58. Edwards N, Marshall M, McLellan A, et al. Doctors and managers:
1999;29:12–18. a problem without a solution? BMJ 2003;326:609–10.
43. Harris A. Risk management in practice: how are we managing? Clin 59. Wilkinson JE, Powell A, Davies H. Are clinicians engaged in
Perform Qual Health Care 2000;8:142–9. quality improvement? A review of the literature on healthcare
44. Saint S, Kowalski CP, Banaszak-Holl J, et al. The importance of professionals’ views on quality improvement initiative: Health
leadership in preventing healthcare-associated infection: results of a Foundation Report. 2011. http://www.health.org.uk/public/cms/75/76/
multisite qualitative study. Infect Control Hosp Epidemiol 313/2440/Are%20clinicians%20engaged%20in%20quality%
2010;31:901–7. 20improvement.pdf?realName=y8NfS4.pdf (accessed 21 Dec 2012)
45. Poniatowski L, Stanley S, Youngberg B. Using information to 60. Jha AK, Epstein AM. A survey of board chairs of English hospitals
empower nurse managers to become champions for patient safety. shows greater attention to quality of care than among their US
Nurs Adm Q 2005;29:72–7. counterparts. Health Aff 2013;32:677–85.
46. Balding C. Embedding organisational quality improvement through 61. Stanton P. The role of an NHS Board in assuring the quality of
middle manager ownership. Int J Health Care Qual Assur clinically governed care and the duty of trust to patients. Clin
2005;18:271–88. Governance 2006;11:39–49.
47. Bradley EH, Holmboe ES, Mattera JA, et al. The roles of senior 62. Lukas CV, Holmes SK, Cohen AB, et al. Transformational change in
management in quality improvement efforts: what are the key health care systems: an organizational model. Health Care Manage
components? J Healthc Manag 2003;48:15–28. Rev 2007;32:309–20.
48. Levey S, Vaughn T, Koepke M, et al. Hospital leadership and quality 63. Shortell SM, Bennett CL, Byck GR. Assessing the impact of
improvement: rhetoric versus reality. J Patient Saf 2007;3:9–15. continuous quality improvement on clinical practice: what it will take
49. Vaughn T, Koepke M, Kroch E, et al. Engagement of leadership in to accelerate progress. Milbank Q 1998;76:593–624, 510.
quality improvement initiatives: executive quality improvement survey 64. Keroack MA, Youngberg BJ, Cerese JL, et al. Organizational factors
results. J Patient Saf 2006;2:2–9. associated with high performance in quality and safety in academic
50. Jha A, Epstein A. Hospital governance and the quality of care. medical centers. Acad Med 2007;82:1178–86.
Health Aff 2010;29:182–7. 65. Parker VA, Wubbenhorst WH, Young GJ, et al. Implementing quality
51. Prybil LD, Peterson R, Brezinski P, et al. Board oversight of patient improvement in hospitals: the role of leadership and culture. Am J
care quality in community health systems. Am J Med Qual Med Qual 1999;14:64–9.
2010;25:34–41. 66. Weiner B, Shortell S, Alexander J. Promoting clinical involvement
52. Braithwaite J, Finnegan TP, Graham EM, et al. How important are in hospital quality improvement efforts: the effects on top
quality and safety for clinician managers? Evidence from management, board, and physician leadership. Health Serv Res
triangulated studies. Clin Governance 2004;9:34–41. 1997;32:491–510.
53. Weingart SN, Page D. Implications for practice: challenges for 67. Duckers MLA, Stegeman I, Spreeuwenberg P, et al. Consensus on
healthcare leaders in fostering patient safety. Qual Saf Health Care the leadership of hospital CEOs and its impact on the participation
2004;13:52–6. of physicians in improvement projects. Health Policy
54. Flin R, Maran N. Identifying and training non-technical skills for 2009;91:306–13.
teams in acute medicine. Qual Saf Health Care 2004;13:80–4. 68. Vogus TJ, Sutcliffe KM. The impact of safety organizing, trusted
55. Kunzle B, Kolbe M, Grote G. Ensuring patient safety through effective leadership, and care pathways on reported medication errors in
leadership behaviour: a literature review. Saf Sci 2010;48:1–17. hospital nursing units. Med Care 2007;45:997–1002.

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To cite: Parand A, Dopson S, ABSTRACT

Parand A, et al. BMJ Open 2014;4:e005055. doi:10.1136/bmjopen-2014-005055 1

2 Parand A, et al. BMJ Open 2014;4:e005055. doi:10.1136/bmjopen-2014-005055

Parand A, et al. BMJ Open 2014;4:e005055. doi:10.1136/bmjopen-2014-005055 3

4 Parand A, et al. BMJ Open 2014;4:e005055. doi:10.1136/bmjopen-2014-005055

Parand A, et al. BMJ Open 2014;4:e005055. doi:10.1136/bmjopen-2014-005055 5

▸ Integrating Quality Planning and Strategic Planning was also rated as

Parand A, et al. BMJ Open 2014;4:e005055. doi:10.1136/bmjopen-2014-005055 11

12 Parand A, et al. BMJ Open 2014;4:e005055. doi:10.1136/bmjopen-2014-005055

Box 1 Key messages from the systematic literature review

Parand A, et al. BMJ Open 2014;4:e005055. doi:10.1136/bmjopen-2014-005055 13

14 Parand A, et al. BMJ Open 2014;4:e005055. doi:10.1136/bmjopen-2014-005055

Parand A, et al. BMJ Open 2014;4:e005055. doi:10.1136/bmjopen-2014-005055 15

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