Table 1

Table of characteristics and summary findings of included studies

First author; year (country)MethodsSample size (number of organisations)Population sample (level of management reported on (position of managers))Outcome measureManagement roles (managerial quality and safety activities, time spent and engagement and key perceived importance and context factors)Quality assessment score for qualitative studiesQuality assessment score for quantitative studiesFindings pertaining to research questions (time spent; activities, engagement; impact (including perceived effectiveness); contextual factors)
Baker et al; 2010 (Canada)32)Mixed methods (interviews, case studies, surveys)n=15 interviews;
n=4 Board case studies; n=79 surveys (79 organisations)
Managers (Board management)Perceptions of managers on management Board practices in quality and safety▸ Less than half (43%) of Boards reported that they addressed quality and patient safety issues in all meetings
▸ One-third of Boards spend 25% of their time or more on quality and patient safety issues
▸ More than 80% of Boards have formally established strategic goals for 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
16/20 (80%)12/22


Balding; 2005 (Australia)46Mixed methods (action research, surveys and focus groups)n=35 (1 hospital)Managers (middle management
(nursing managers and allied health managers))
Self-reported perceptions of managers on their engagement in a QI programmeFive elements deemed essential to middle manager engagement:
▸ Senior management commitment and leadership (e.g. senior management provides strategic direction for QI plan)
▸ Provision of resources and opportunities for QI education and information 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)
14/20 (70%)15/22 (68%)Activities
Bradely et al; 2003 (USA)47Qualitative (interviews)n=45 (8 hospitals)Clinical staff and senior management (senior management (unspecified))Perceptions of roles and activities that comprise senior management’s involvement in quality improvement effortsFive common roles and activities that captured the variation in management involvement in quality improvement efforts:
▸ Personal engagement of senior managers
▸ Management’s relationship with clinical staff
▸ Promotion of an organisational culture of quality improvement
▸ Support of quality improvement with organisational structures
▸ Procurement of organisational resources for quality improvement efforts
19/20 (95%)NAActivities
Bradely et al; 2006 (USA)40Mixed methods (surveys and interviews)n=63 survey respondents (63 hospitals); n=102 interviewees (13 hospitals)Managers (senior management (chief operating officer, vice president, medical director, CNO, director of volunteers,programme director))Perceptions of management-related factors around the HELP programme▸ Providing resources for needed staffing or staff training
▸ Promoting the programme among the governing Board, physicians who were initially less involved, and other administrators
▸ Senior management support reported as the primary enabling factor in the implementation of such programmes (96.6%), along with a lack of support as the primary reason for not implementing the programme (65.0%)
▸ The interviews supported that having an administrative champion was considered essential to their programme’s success
19/20 (95%)17/22
Braithwaite et al; 2004 (Australia)52Mixed methods (ethnographic work, observations and focus groups)n=64 managers in focus groups (1 hospital); ethnographic case studies and n=4 observed (2 hospitals)Managers (frontline management (medical managers, nurse managers and allied health managers))Observations and self-reported perceptions of clinician-managers’ activities▸ Quality was the least discussed topic (e.g. continuous quality improvement)
▸ The most discussed topic was people (e.g. staffing, delegating) and organisational issues, e.g. beds and equipment
16/20 (80%)NATime
Caine and Kenwrick; 1997(UK)41Qualitative (interviews)n=10 (2 hospitals)Managers (middle management (clinical directorate managers))Self-reported perceptions of managers on the managers’ role in facilitating evidence-based practice in their nursing teams▸ Managers saw their role in research implementation as a facilitator, ensuring quality and financial objectives and standards were met
▸ Managers perceived their facilitatory behaviours produced a low level of clinical change
▸ Managers are not actively advocating research-based practice and failing to integrate it into everyday practice. Their behaviour inhibited the development of evidence-based nursing practice
▸ Devolved responsibility of use of research to individual professionals
14/20 (70%)NAActivities
Fox, Fox and Wells; 1999 (USA)42Quantitative (surveys and self kept activity logs)n=16 (1 hospital)Managers (frontline management (nurse administrative managers (NAMs)))Self-reported perceptions of managers on their activities impacting unit personnel productivity and monitored time/effort allocated to each function and managers’ hours worked, patient admissions and length of stay▸ The small amount of total management allocated to QI (2.6%) was the least time spent of all management functions
▸ A negative relationship between time spent in QI activities and unit personnel productivity. An increase (from 2.5% to 5%) in QI time/effort by NAMs would reduce staff productivity significantly by approximately 8%
▸ The greater the experiences of NAMs as managers, the more time spent on QI. These seasoned NAMs spent more time on monitoring, reporting QI results and quality improvement teams (statistics nor provided)
NA13/22 (59%)Time
Impact (objective outcome measure)
Harris; 2000 (UK)43Quantitative (surveys)n=42 (42 hospitals)Managers (middle management (nurse managers))Self-reported perceptions of managers on managers’ quality and safety practices▸ The majority of managers (91%) who received collated incident information used it to feed back to their own staff. 60% always fed back to staff, 28% sometimes did, 2% never did
▸ Of the trusts that had written guidance on types of clinical incident to report, 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
NA13/22 (59%)Activities
Jha and Epstein; 2010 (USA)50Quantitative (surveys)n=722 (767 hospitals)Managers (Board)Perceptions of managers on the role of managers in quality and safety and quality outcome measurement (from HQA) i.e. 19 practices for care in 3 clinical conditions▸ Two-thirds (63%) of Boards had quality as an agenda item at every meeting
▸ Fewer than half (42%) of the hospitals spent at least 20% of the Board's time on clinical quality
▸ 72% of Boards regularly reviewed a quality dashboard 
▸ Most respondents reported that their Boards had established, endorsed or approved goals in four areas of quality: hospital-acquired infections (82%), medication errors (83%), the HQA/Joint commission core measures (72%), and patient satisfaction (91%)High-performing hospitals were more likely than low-performing hospitals to have:
▸ Board reviews of a quality dashboard regularly (<0.001) and of clinical measures (all <0.05)

▸ 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)
NA22/22 (100%)Time
Impact (objective outcome measure)
Jiang et al; 2008 (USA)37Quantitative (surveys)n=562 (387 hospitals)Managers (Board and senior management (presidents/CEOs))Perceptions of managers on managers’ practices in quality and safety; and outcomes of care (composite scores of risk-adjusted M indicators)▸ 75% of CEOs reported that most to all of the Board meetings have a specific agenda item devoted to quality. Only 41% indicated that the Boards spend more than 20% of its meeting time on the specific item of quality.The following activities were most reported to be performed:
▸ Board establishing strategic goals for QI (81.3%)
▸ Use quality dashboards to track performance (86%)
▸ Follow-up corrective actions related to adverse events (83%)The following activities were least reported to be performed:
▸ 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%)
NA20/26 (77%)Time
Impact (objective outcome measure)
Jiang et al; 2009 (USA)38Quantitative (surveys)n=490 (490 hospitals)Managers
(Board and senior management (CEOS and hospital presidents reports))
Perceptions of managers on manager's practices in quality and safety; and POC measures (20 measures in 4 clinical areas); and outcome measures (composite scores of risk-adjusted M indicators)Board practices found to be associated with better performance (all p<0.05) in POC and adjusted M included:
▸ Having a Board quality committee (83.8%POC, 6.2M versus 80.2%POC, 7.9M without a committee)
▸ Establishing strategic goals for quality improvement (82.8% POC, 6.6M versus 80.3% POC, 7.9M)
▸ Being involved in setting the quality agenda for the hospital (83.2% POC, 6.4M versus 80.9% POC, 7.7M)
▸ Including a specific item on quality in Board meetings (83.2% POC, 6.5M versus 78.5% POC, 8.6M)
▸ 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) 
NA22/24 (92%)Activities
Impact (objective outcome measure)
Joshi and Hines; 2006 (USA)35 Mixed methods (surveys and interviews)n=37 survey respondents; n=47 interviewees (30 hospitals)Managers (Board and senior management (CEOs, Board chairs))Perceptions of managers on managers’ practices in quality and safety and ACM and risk-adjusted M.▸ Board engagement in quality was reported as satisfactory (7.58 by CEOs and 8.10 by Chairs on a 1–10 scale where 10 indicates greatest satisfaction)
▸ Board engagement was positively associated with perceptions of the rate of progress in improvement (r=0.44, p =0.05), and marginally associated with ACM scores (r=0.41, p=0.07)
▸ Approximately one-third of Board meetings are devoted to discussing quality issues (reported at 35% by CEOs and 27% by Chairs)

▸ 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 
12/20 (60%)16/20 (80%)Time
Impact (objective outcome measure)
Levey et al; 2007 (USA)48Qualitative (interviews)n=96 (18 hospitals)Managers (Board and senior management (hospital Board members, CEOs, chief medical officers, chief quality officers, medical staff leaders))Perceptions of managers on managers’ role in quality and safety▸ Few CEOs were willing to take the lead for transformation to a ‘culture of quality’
▸ Board members were largely uninvolved in strategic planning for QI
▸ In terms of the Board’s quality functions, respondents largely agreed that physician credentialing was their critical responsibility
▸ Non-physicians reported that they felt relegated to ‘passive’ roles in decisions 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% 
13/20 (65%)NATime
Mastal, Joshi and Shulke; 2007 (USA)36Qualitative (interviews and a focus group)n=73 interviewees; 1 focus group (63 hospitals)Managers (Board and senior management (Board chairs, CEOs, CNOs))Perceptions of managers on managers’ role in quality and safety▸ Two CNOs reported that nursing quality was never addressed at Board meetings
▸ Few of the CNOs, CEOs and Board chairs responded that issues are 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
12/20 (60%)NATime
Poniatowski, Stanley and Youngberg;

2005 (USA)45
Quantitative (surveys)n=515 (16 academic

Managers (frontline management—unclear whether frontline or middle managers (unit nurse managers))Self-reported perceptions of managers on their practices with PSN▸ Managers reviewed on average 65% of the PSN events reportedAs a result of what was learned from PSN data, 162 managers detailed their changes made to:
▸ Policies and practices (59%)
▸ Training, education and communication between care providers (27%)
▸ Purchase of new equipment and supplies (8%)
▸ Staffing (6%) 
NA10/20 (50%)Activities
Prybil et al; 2010 (USA)51Quantitative (surveys)n=123 (712 hospitals)Managers (Board and senior management (CEOs and Boards))Perceptions of managers on their
role in quality and safety
▸ Health system Boards spent 23% of their Board meeting time on quality and safety issues. They only spent slightly more on financial issues (25.2%) and strategic planning (27.2%)
▸ 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
▸ 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

NA14/22 (64%)Time
Saint et al; 2010 (USA)44Qualitative (interviews)n=86 (interviewees) (14 hospitals)Senior hospital staff and managers (mixed levels (nurse managers, chief physicians, Chairs of medicine, chief of staffs, hospital directors, CEOs and clinical non-managerial staff))Perceptions of managers on managers’ practices in HAI▸ Although committed leadership by CEOs can be helpful, it was not always necessary, provided that other hospital leaders were committed to infection prevention Behaviours of leaders who successfully implemented/facilitated practices to prevent HAI:
▸ Cultivated a culture of clinical excellence and kept their eye on improving patient care
▸ Developed a vision
▸ Articulated the organisational culture well and conveyed that to staff at all levels
▸ 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 
16/20 (80%)NAActivities
Vaughn et al; 2006 (USA)49Quantitative (surveys)n=413 (413 hospitals)Managers (Board and senior management (chief executives and senior quality executives; Board, executives, clinical leadership))Perceptions of managers on managers’ role in QI and observed hospital
quality index outcomes (risk-adjusted
measures of morbidity, M and medical

▸ 72% of hospital Boards spent one-quarter of their time or less on quality-of-care issues. About 5% of Boards spent more than half of their time on these issues
▸ A majority of respondents reported great influence from government and regulatory agencies (87%), consumers (72%) and accrediting bodies (74%) on quality priorities. Although 44% of respondents also noted that multiple government and regulatory requirements were unhelpfulBetter QIS are associated with hospitals where the Board:
▸ Spends more than 25% of their time on quality issues (QIS 83–QIS mean 100 across hospitals)
▸ Receives a formal quality performance measurement report (QIS 302)
▸ Bases the senior executives’ compensation in part on QI performance (QIS 239)
▸ Engages in a great amount of interaction with the medical staff on quality strategy 
NA21/22 (95%)Time
Impact (objective outcome measure)
Weingart and Page; 2004 (USA)53Qualitative (case study documentation analysis and meeting discussions and focus group)
n=30 (10 hospitals and other stakeholder organisations)
Managers (senior management (executives))Perceptions of managers on manager's practices in quality and safetyExecutives developed and tested a set of governance best practices in patient safety, such as:
▸ Creation of a Board committee with explicit responsibility for patient safety
▸ Development of Board level safety reports, introduction of educational activities for Board members
▸ Participation of Board members in executive walk rounds 
▸ Executives reviewed measures to assess safety (e.g. incident reports, 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 
14/20 (70%)NAActivities
  • 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.