Managers in healthcare have a legal and moral obligation to ensure a high quality of patient care and to strive to improve care. These managers are in a prime position to mandate policy, systems, procedures and organisational climates. Accordingly, many have argued that it is evident that healthcare managers possess an important and obvious role in quality of care and patient safety and that it is one of the highest priorities of healthcare managers. In line with this, there have been calls for Boards to take responsibility for quality and safety outcomes. One article warned hospital leaders of the dangers of following in the path of bankers falling into recession, constrained by their lack of risk awareness and reluctance to take responsibility. To add to the momentum are some high profile publicity of hospital management failures affecting quality and safety, eliciting strong instruction for managerial leadership for quality at the national level in some countries.
Beyond healthcare, there is clear evidence of managerial impact on workplace safety. Within the literature on healthcare, there are non-empirical articles providing propositions and descriptions on managerial attitudes and efforts to improve safety and quality. This literature, made up of opinion articles, editorials and single participant experiences, present an array of insightful suggestions and recommendations for actions that hospital managers should take to improve the quality of patient care delivery in their organisation.
However, researchers have indicated that there is a limited evidence base on this topic. Others highlight the literature focus on the difficulties of the managers’ role and the negative results of poor leadership on quality improvement (QI) rather than considering actions that managers presently undertake on quality and safety.
Consequently, little is known about what healthcare managers are doing in practice to ensure and improve quality of care and patient safety, how much time they spend on this, and what research-based guidance is available for managers in order for them to decide on appropriate areas to become involved. Due perhaps to the broad nature of the topic, scientific studies exploring these acts and their impact are likely to be a methodological challenge, although a systematic review of the evidence on this subject is notably absent. This present systematic literature review aims to identify empirical studies pertaining to the role of hospital managers in quality of care and patient safety.
We define ‘role’ to comprise of managerial activities, time spent and active engagement in quality and safety and its improvement. While the primary research question is on the managers’ role, we take into consideration the contextual factors surrounding this role and its impact or importance as highlighted by the included studies.
Our overarching question is “What is the role of hospital managers in quality and safety and its improvement?”
The specific review research questions are as follows:
How much time is spent by hospital managers on quality and safety and its improvement?
What are the managerial activities that relate to quality and safety and its improvement?
How are managers engaged in quality and safety and its improvement?
What impact do managers have on quality and safety and its improvement?
How do contextual factors influence the managers’ role and impact on quality and safety and its improvement?
Quality of care and patient safety were defined on the basis of widely accepted definitions from the Institute of Medicine (IOM) and the Agency for Healthcare Research and Quality Patient Safety Network (AHRQ PSN). IOM define quality in healthcare as possessing the following dimensions: safe, effective, patient-centred, timely, efficient and equitable. They define patient safety simply as “the prevention of harm to patients”, and AHRQ define it as “freedom from accidental or preventable injuries produced by medical care.” Literature was searched for all key terms associated with quality and patient safety to produce an all-encompassing approach. A manager was defined as an employee who has subordinates, oversees staff, is responsible for staff recruitment and training, and holds budgetary accountabilities. Therefore, all levels of managers including Boards of managers were included in this review with the exception of clinical frontline employees, e.g. doctors or nurses, who may have taken on further managerial responsibilities alongside their work but do not have a primary official role as a manager. Those who have specifically taken on a role for quality of care, e.g. the modern matron, were also excluded. Distinction between senior, middle and frontline management was as follows: senior management holds trust-wide responsibilities; middle managers are in the middle of the organisational hierarchy chart and have one or more managers reporting to them; frontline managers are defined as managers at the first level of the organisational hierarchy chart who have frontline employees reporting to them.
Board managers include all members of the Board. Although there are overlaps between senior managers and Boards (e.g. chief executive officers (CEOs) may sit on hospital Boards), we aim to present senior and Board level managers separately due to the differences in their responsibilities and position.
Only managers who would manage within or govern hospitals were included, with the exclusion of settings that solely served mental health or that comprised solely of non-acute care community services (in order to keep the sample more homogenous). The definition of ‘role’ focused on actual engagement, time spent and activities that do or did occur rather than those recommended that should or could occur.