Acting between guidelines and reality- an interview study exploring the strategies of first line managers in patient safety work.

BACKGROUND: Safety culture can be described and understood through its manifestations in the organization as artefacts, espoused values and basic underlying assumptions and is strongly related to leadership-yet it remains elusive as a concept. Even if the literature points to leadership as an important factor for creating and sustaining a mature safety culture, little is known about how the safety work of first line managers' is done and how they balance the different and often conflicting organizational goals in everyday practice. The purpose of this study was to explore how health care first line managers perceive their role and how they promote patient safety and patient safety culture in their units. METHODS: Interview study with first line managers in intensive care units in eight different hospitals located in the middle of Sweden. An inductive qualitative content analysis approach was used, this was then followed by a deductive analysis of the strategies informed by constructs from High reliability organizations. RESULTS: We present how first line managers view their role in patient safety and exemplify concrete strategies by which managers promote patient safety in everyday work. CONCLUSIONS: Our study shows the central role of front-line managers in organizing for safe care and creating a culture for patient safety. Although promoted widely in Swedish healthcare at the time for the interviews, the HSOPSC was not mentioned by the managers as a central source of information on the unit's safety culture.

Co-Leadership - A Management Solution for Integrated Health and Social Care.

INTRODUCTION: Co-leadership has been identified as one approach to meet the managerial challenges of integrated services, but research on the topic is limited. In the present study, co-leadership, practised by pairs of managers - each manager representing one of the two principal organizations in integrated health and social care services - was explored. AIM: To investigate co-leadership in integrated health and social care, identify essential preconditions in fulfilling the management assignment, its operationalization and impact on provision of sustainable integration of health and social care. METHOD: Interviews with eight managers exercising co-leadership were analysed using directed content analysis. Respondent validation was conducted through additional interviews with the same managers. RESULTS: Key contextual preconditions were an organization-wide model supporting co-leadership and co-location of services. Perception of the management role as a collective activity, continuous communication and lack of prestige were essential personal and interpersonal preconditions. In daily practice, office sharing, being able to give and take and support each other contributed to provision of sustainable integration of health and social care. CONCLUSION AND DISCUSSION: Co-leadership promoted robust management by providing broader competence, continuous learning and joint responsibility for services. Integrated health and social care services should consider employing co-leadership as a managerial solution to achieve sustainability.

Psychometric properties of the Hospital Survey on Patient Safety Culture, HSOPSC, applied on a large Swedish health care sample.

BACKGROUND: A Swedish version of the USA Agency for Healthcare Research and Quality "Hospital Survey on Patient Safety Culture" (S-HSOPSC) was developed to be used in both hospitals and primary care. Two new dimensions with two and four questions each were added as well as one outcome measure. This paper describes this Swedish version and an assessment of its psychometric properties which were tested on a large sample of responses from personnel in both hospital and primary care. METHODS: The questionnaire was mainly administered in web form and 84215 forms were returned (response rate 60%) between 2009 and 2011. Eleven per cent of the responses came from primary care workers and 46% from hospital care workers. The psychometric properties were analyzed using both the total sample and the hospital and primary care subsamples by assessment of construct validity and internal consistency. Construct validity was assessed by confirmatory (CFA) and exploratory factor (EFA) analyses and internal consistency was established by Cronbachs's α. RESULTS: CFA of the total, hospital and primary care samples generally showed a good fit while the EFA pointed towards a 9-factor model in all samples instead of the 14-dimension S-HSOPSC instrument. Internal consistency was acceptable with Cronbach's α values above 0.7 in a major part of the dimensions. CONCLUSIONS: The S-HSOPSC, consisting of 14 dimensions, 48 items and 3 single-item outcome measures, is used both in hospitals and in primary care settings in Sweden for different purposes. This version of the original American instrument has acceptable construct validity and internal consistency when tested on large datasets of first-time responders from both hospitals and primary care centres. One common instrument for measurements of patient safety culture in both hospitals and primary care settings is an advantage since it enables comparisons between sectors and assessments of national patient safety improvement programs. Future research into this version of the instrument includes comparing results from patient safety culture measurements with other outcomes in relation to safety improvement strategies.

[Quality and shortages of patient safety--how reduce the costs?]. / Brister i patientsäkerhet och ovrig kvalitet--hur minska kostnaderna?

There is a sizable "poor quality and safety" problem in health care, not only in terms of suffering to patients but also in economic terms. Few studies have assigned costs to the problems. Decisions about whether to take action and which actions to take would be assisted by economic evidence. The article presents research which shows subjects and services where there is evidence both of poor quality and of effective interventions The article shows ways systematically to incorporate economic considerations into decisions about improvement and practical methods for estimating the costs of a quality problem and possible savings. A simple method is presented which would allow a purchaser or provider to make a comprehensive overview of a range of healthcare problems to help decide where to invest resources to save costs. Economic criteria and estimates, however, should not be the only criteria for selecting improvement subjects. Understanding of the costs of both the problem and the solution would encourage more effective quality and safety improvement and provide one way of measuring the progress of an action to solve the problem.

[Patient safety and quality problems--what is the cost?]. / Brister i patientsäkerhet och ovrig kvalitet--vilka ar kostnaderna?

Available evidence indicates a sizable "poor quality and safety" problem in health care. Costs can be assigned but few studies have done so. This article, the second in a series of three, summarises research which has calculated the economic cost of these problems. Adverse drug events account for a major part of the problem and have been estimated to be approximately 1.5% of the UK NHS annual budget. Other quality deficiency problems that have been costed in various studies are the use of inefficient medical procedures, hospital acquired infections and variation in clinical practice. There are only a few studies reporting the effectiveness of different actions to reduce adverse events and waste, and even less evidence about the cost of these different interventions. There is, however, sufficient evidence to suggest certain actions would not only relieve considerable patient suffering, but would make significant economic savings for health care and society. When planning for interventions to improve quality and reduce safety deficiencies, the costs of the problem should be calculated and weighed against the costs of the intervention, i.e the "quality cost" should be estimated. It should be decided how a potential saving could be retained by a unit which has invested in such an intervention. The third article describes methods for estimating quality costs in health care.

[Quality and shortages of patient safety--how big is the problem?]. / Brister i patientsäkerhet och ovrig kvalitet--hur stort ar problemet?

Patient safety is essential to quality health care, to ensure patients are not harmed, but also to ensure that resources are not wasted. More research evidence is becoming available about deficiencies in health care quality and safety. This evidence is reviewed in three consecutive articles in Läkartidningen. Research has discovered high rates of "adverse events" in health care services. The actual rate varies depending on definition, methods of measurement, and type of service. Rates as high as 46% of patients admitted to hospital have been reported. Sometimes high reported rates indicate that a service is serious about collecting data, rather than being an unsafe service. Generally, half of the events can be classified as "avoidable", and a significant proportion as "serious" causing death, disability or a longer hospital stay. Adverse drug events account for a high proportion and are probably the most well studied of patient safety problems. Although most of the current research has been done in the US, there is some evidence which suggests that problems within Swedish health care are of a similar magnitude and type. This article summarises the main studies and focuses on evidence of the economic consequences of deficiencies in patient safety and quality.