RESEARCH ARTICLE Open AccessImproving patient safety cultu.docx

RESEARCH ARTICLE Open Access
Improving patient safety culture in Saudi
Arabia (2012–2015): trending, improvement
and benchmarking
Khalid Alswat1, Rawia Ahmad Mustafa Abdalla2, Maher
Abdelraheim Titi1, Maram Bakash1, Faiza Mehmood1,
Beena Zubairi1, Diana Jamal2 and Fadi El-Jardali2,3*
Abstract
Background: Measuring patient safety culture can provide
insight into areas for improvement and help monitor
changes over time. This study details the findings of a re-
assessment of patient safety culture in a multi-site Medical
City in Riyadh, Kingdom of Saudi Arabia (KSA). Results were
compared to an earlier assessment conducted in 2012
and benchmarked with regional and international studies. Such
assessments can provide hospital leadership with
insight on how their hospital is performing on patient safety
culture composites as a result of quality improvement
plans. This paper also explored the association between patient
safety culture predictors and patient safety grade,
perception of patient safety, frequency of events reported and
number of events reported.
Methods: We utilized a customized version of the patient safety
culture survey developed by the Agency for
Healthcare Research and Quality. The Medical City is a tertiary
care teaching facility composed of two sites (total
capacity of 904 beds). Data was analyzed using SPSS 24 at a
significance level of 0.05. A t-Test was used to compare

results from the 2012 survey to that conducted in 2015. Two
adopted Generalized Estimating Equations in addition
to two linear models were used to assess the association
between composites and patient safety culture outcomes.
Results were also benchmarked against similar initiatives in
Lebanon, Palestine and USA.
Results: Areas of strength in 2015 included Teamwork within
units, and Organizational Learning—Continuous
Improvement; areas requiring improvement included Non-
Punitive Response to Error, and Staffing. Comparing
results to the 2012 survey revealed improvement on some areas
but non-punitive response to error and Staffing
remained the lowest scoring composites in 2015. Regression
highlighted significant association between managerial
support, organizational learning and feedback and improved
survey outcomes. Comparison to international benchmarks
revealed that the hospital is performing at or better than
benchmark on several composites.
Conclusion: The Medical City has made significant progress on
several of the patient safety culture composites despite
still having areas requiring additional improvement. Patient
safety culture outcomes are evidently linked to better
performance on specific composites. While results are
comparable with regional and international benchmarks,
findings
confirm that regular assessment can allow hospitals to better
understand and visualize changes in their performance
and identify additional areas for improvement.
Keywords: Patient safety culture, Riyadh, Trending,
Benchmarking
* Correspondence: [email protected]
2Department of Health Management and Policy, American

University of
Beirut, Beirut, Lebanon
3Department of Health Research Methods, Evidence, and
Impact, McMaster
University, CRL-209, 1280 Main St. West, Hamilton, ON L8S
4K1, Canada
Full list of author information is available at the end of the
article
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made. The Creative Commons Public Domain Dedication waiver
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the data made available in this article, unless otherwise stated.
Alswat et al. BMC Health Services Research (2017) 17:516
DOI 10.1186/s12913-017-2461-3
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Background
Patient safety (PS) and the prevention of harm has been
linked to developing a strong patient safety culture
(PSC) [1]. Creating and maintaining a strong PSC in

healthcare organizations is linked to better performing
health organizations [2].
Evidence on patient safety culture in hospitals can
provide healthcare leaders and policymakers with the
information they need to improve quality and prevent
errors. Administrators, managers and policymakers
alike will reap the benefits of improving patient safety
culture in improved quality, improved patient out-
comes, reduced errors and a more cost effect health-
care system [1, 3–6].
Patient safety culture is determined by multiple factors
within a health organization and can support the pre-
vention and reduction of harms to patients. It is the out-
come of different factors within a healthcare institution
including attitudes, values, skills and even behaviors to
commit to patient safety management [7].
International accreditation organizations are now re-
quiring PSC assessments as an integral component of
their surveys and provide important information that
would help better understand overall organizational per-
ception on areas related to PS [8, 9]. So in response to
these requirements, many hospitals around the world
are using different tools for redesigning and restructur-
ing their work environments to support safe job per-
formance and promote PSC [9]. The Hospital Survey on
Patient Safety Culture (HSOPSC) has become the most
frequently used tool to assess patient safety culture [10].
This tool measures different aspects of patient safety
culture and can help hospitals better understand the fac-
tors that determine how they relate to their actions,
managerial support, organizational activities, feedback
about errors, communication, teamwork within and
across units, staffing, handoffs and response to error

[10]. In spite of the abundance of literature and evidence
that attests to the importance of patient safety culture
assessments, this topic has not been sufficiently ad-
dressed in in the Arab world and particularly in the
Kingdom of Saudi Arabia (KSA). The existing evidence
about KSA found that organizational learning [11, 12],
teamwork within units, in addition to feedback and
communication about errors are among the strongest
aspects of patient safety culture [12]. On the other hand,
and in accordance with international trends, punitive re-
sponse to error [11, 12] staffing, and teamwork across
units are some of the areas requiring improvement [12].
Evidence from a multi-site facility in Riyadh also con-
firmed that the composites on organizational learning,
and teamwork within units were areas of strength while
punitive response to error, staffing and communication
were areas of weakness [13].
In Lebanon, a national study that targeted hospital em-
ployees used an adapted Arabic version of the HSOPSC.
The study found that teamwork within units, hospital
management support for patient safety, and organizational
learning and continuous improvement were areas of
strength. Areas requiring improvement at the national
level were teamwork across hospital units, hospital hand-
offs and transitions, staffing, and non-punitive response to
error [14]. The study also found significant associations
between patient safety culture outcomes and composite
scores [15].
A study in Oman focusing on patient safety culture
from the nursing perspective found perception of patient
safety was associated with better scores on supervisor or
manager expectations, feedback and communications
about errors, teamwork across hospital units, and hos-
pital handoffs and transitions [4]. Another study focus-

ing on public hospitals in Palestine found that the
composites with the lowest scores were non-punitive re-
sponse to error, frequency of events reported, communi-
cation openness, hospital management support for
patient safety and staffing [16].
Assessments of patient safety culture using the Agency
for Healthcare Research and Quality (AHRQ) tool
should ideally be repeated every two or 3 years [17, 18].
This recommendation was also highlighted in the Saudi
Central Board for Accreditation of Healthcare Institu-
tions (CBAHI) accreditation standards which recom-
mends conducting a patient safety culture assessment on
an annual basis [19]. We have yet to document a study
that has conducted and reported such repeated assess-
ments in the Eastern Mediterranean Region, and specif-
ically in the Kingdom of Saudi Arabia. Such assessments
can provide hospital management and higher leadership
with some insight on how their performance has chan-
ged as a result of quality improvement plans that were
developed in response to the findings of the patient
safety culture survey.
This particular study is a second round assessment of
a previous patient safety culture survey conducted in
2012. This study focused on the same multi-site facility
in an effort to determine whether performance on pa-
tient safety culture composites has changed. The current
study also compares results to the previous assessment
in 2012 in addition to benchmarking to other initiatives
conducted regionally and internationally. To our know-
ledge, this is the first study to perform this type of as-
sessment in the context of Kingdom of Saudi Arabia
(KSA) and Arab countries.
Objectives

We aim to re-assess PSC in a large multi-site healthcare
facility in Riyadh, Kingdom of Saudi Arabia and to com-
pare it with an earlier assessment conducted in 2012 and
Page 2 of 14
benchmarked against regional and international studies.
Furthermore, we explored the association between PSC
predictors and outcomes while considering demographic
characteristics and hospital size.
Methods
Design, setting and sampling
The tool used was adapted from the Hospital Survey
on Patient Safety Culture (HSOPSC) developed by the
Agency for Healthcare Research and Quality. The sur-
vey is available in English and was translated to
Arabic in a previous study conducted in Lebanon
[14]. The research team piloted the translated version
in 2012 survey and made minor changes to the word-
ing of some statements to better fit the context of
the hospital. The changes were cross checked with
the English version to make sure not to alter the ori-
ginal meaning [13]. Minimal changes were made to
the current version and they only related to categories
of employment.
The Medical City is a tertiary care teaching hospital
with a capacity of 800 beds. It has a wide range of spe-
cialties and services and serves patients from all over
KSA. The facility is divided into two settings: the larger
setting (Site A) has 700 beds and the smaller setting
(Site B) has 100 beds. Site A is located towards the

North of Riyadh and offers free medical services with a
wide range of specialties. Site B is located towards the
center of Riyadh and was the first educational hospital
in Saudi Arabia but offers fewer services compared to
Site A given its smaller size. The Dental Site is within
Site A and offers inpatient and outpatient dental
services.
The survey randomly sampled staff including physi-
cians, registered nurses, other clinical or non-clinical
staff, pharmacists, laboratory technicians, dietary de-
partment staff, radiologists, and administrative staff
including managers and supervisors. The two sites
had a total of 9000 hospital employees of which 4500
were targeted and 2592 responded to the survey (re-
sponse rate of 57.6%). Data collection spanned July
2015 to December 2015. The survey was available in
electronic format for all respondents. Some respon-
dents preferred paper based surveys and as such were
provided with the surveys in sealed envelopes. A total
of 397 respondents returned the completed surveys in
designated boxes in sealed envelopes to maintain the
confidentiality of their responses. The consent form
was included on the first page of the survey and de-
tailed the information for participants and some defi-
nitions. Respondents were asked not to write their
names or sign any section of survey.
Surveys were provided in both English and Arabic
with respondents favoring the English version. Data was
not collected on language for either the online version
of the survey. It should be noted, however, that the ratio
of English to Arabic surveys in the paper based version
was 3 to 1 which confirms preference of the English
version.

Data management and analysis
Data was analyzed using IBM SPSS Statistics 24.0 at
a significance level of 0.05. The tool included a total
of 44 items, 42 of them measure 12 patient safety
culture composites (two of which are patient safety
culture outcomes). The tool includes four outcomes,
two of which are included within the composites,
they are: frequency of events reported and overall
perception of patient safety. The two other outcome
variables are patient safety grade and number of
events both of which are multiple choice questions.
The HSOPSC includes both positively and negatively
worded items scored using a five-point scale reflect-
ing agreement or frequency of occurrence on a five-
point Likert scale. The total percent positives, nega-
tives and neutrals were calculated for each compos-
ite making sure to reverse negatively worded items
[18]. Composites that had at least 70% positive
response was considered an area of strength
whereas those scoring less were considered areas for
improvement.
Composite level scores were also calculated. This was
done through adding up the score for each item within a
composite then dividing by the number of non-missing
items within the scale. Computed scores ranged from 1
to 5. Internal consistency was measured using Cron-
bach’s alpha.
Confirmatory Factor Analysis was conducted results
confirmed that 9 of the 12 composites loaded on one
factor with acceptable eigen values and percent variance
explained. The three composites supervisor/manager ex-
pectations, overall perception of patient safety, and staff-
ing each loaded on two factors. Detailed results are not

reported in this paper.
Demographic characteristics of respondents were sum-
marized using univariate analysis.
In fulfillment of the comparative component within
this study, the two datasets were merged to combine
survey items from the 2012 survey with those of the
2015 survey. Only scale related items were merged,
demographics were not included. A Student T-Test was
used to examine whether a statistically significant differ-
ent exists between the survey items for each of 2012 and
2015 datasets.
Results from this hospital were also benchmarked
against similar initiatives in the United States (US) [17]
and Lebanon [15]. Comparison to the benchmark value
was done using the below formula [20]:
Page 3 of 14
%Distance from benchmark ¼ ððbenchmark value
–hospital resultÞ=benchmark valueÞ� 100:
Categories of achievement were determined by the
value of % distance from benchmark as follows:
➢ Values <10% were categorized as Meets or better
than benchmark (☑). Values below zero (0) indicate
that the benchmark value is lower than the hospital re-
sult thus giving a result of “meet or better than
benchmark”.
➢ Values between [10–50%] were categorized as

Deviates slightly from benchmark (▣).
➢ Values exceeding 50% were categorized as Major
deviation from benchmark (☒).
The four outcome variables were regressed against
the 10 composite scores, respondent’s gender, age, ex-
perience, degree, respondent position, patient inter-
action and size of the hospital. Four regression models
were used to analyze the association between the com-
posites and the outcome variables. The first two
models were Generalized Estimating Equations which
included recoded versions of the variables on number
of events reported and patient safety grade. These two
outcomes were reduced to include three items each.
Patient safety grade was reduced to include the cat-
egories: “Poor or Failing,” “Acceptable,” and “Excel-
lent/Good.” Number of events was reduced to include:
“>5 events reported,” “1 to 5 events reported,” and “No
events reported.” Linear regression was used for the
two composites on frequency of events and overall per-
ception of patient safety. For the purpose of linear re-
gression, the independent variables were entered as
dummy variables.
Results
General results
A total of 4500 surveys were sent to respondents of
which 2592 completed (2128 from Site A and 441 from
Site B, in addition to a total of 23 respondents from den-
tal and combined sites) yielding an overall response rate
of 56.7%.
Analysis revealed that the majority of respondents
were females (84.1%) and around half were aged be-

tween 30 and 45 (46.4%) and married (64.4%). Around
half the respondents indicated working in Medical de-
partments (51.9%) while 30.6% worked in Surgical de-
partments. The majority of respondents indicated
working as Registered Nurses (78.3%) (Table 1). Most
respondents reported holding a Bachelor’s degree
(56.2%) and having 3 to 5 years of experience (25.2%)
at the hospital, 6 to 10 years of experience in their
work area (31.5%) and 6 to 10 years of experience in
their profession (32.3%). Most respondents indicated
working 40 to 60 h a week (92.9%) and having direct
contact with patients (90.9%).
Less than half the respondents gave their hospital a
Very Good patient safety grade (49.4%) while 55.8% re-
ported no events (55.8%), 27.8% reported 1 to 2 events,
and 10.6% reported 3 to 5 events. It is worth noting that
only 1.3% of respondents reported 21 or more events
(Table 1).
Areas of strengths and areas requiring improvement
Areas of strength (those where percent positive rating
exceeds 70%) and those requiring improvement (scoring
below 70%) were then examined [10]. The dimensions
considered areas of strength were Teamwork within
units (84.8%), Organizational Learning – Continuous
Improvement (86.3%), Management support for patient
safety (75.3%) and Feedback and Communication about
error (71.8%) (Table 2).
Areas of strength and those requiring improvement
were derived. A major area of strength highlighted in the
survey findings included the degree to which the hos-
pital is engaging in actions to improve patient safety
(94.8% positive). Additional areas of strength were re-

vealed within the composite on Teamwork within units.
Respondents indicated that staff support each other
within the unit (90.1% positive responses), and work to-
gether as a team (89.3% percent positive). Moreover, as
highlighted within the composite on Hospital Manage-
ment Support for Patient Safety, 86.9% of respondents
indicated that the actions of hospital management reflect
that patient safety is a priority for the administration
(Table 2).
Areas requiring improvement related to staffing. In
fact, respondents indicated that hospital employees work
longer than what should be considered best for patient
safety (11.2% positive response). As for the dimension
on Non-Punitive Response to Error, 13.7% of staff were
worried that their mistakes were being kept in their
personnel file and 29.3% felt that they were being written
up when reporting an event (Table 2). Other items that
reflect areas of strength and items requiring improve-
ment are listed in Table 2.
Comparing results from 2015 to 2012
The difference in mean scores on the survey compos-
ites was statistically significant between 2012 and
2015. Results improved on all survey composites indi-
cating better performance in 2015 compared to the
initial survey. Non-punitive response to error and
Staffing remained the lowest scoring composites in
2015. The highest ranking composite for both surveys
were Organizational Learning-Continuous Improve-
ment. While Teamwork within Units had the second
highest score in 2012, it ranked third in 2015 while
Page 4 of 14

Feedback and Communication about Errors ranked
second (Table 3).
Comparative against regional and international findings
Composite scores were compared to similar studies done
in Lebanon, Palestine and United States. As compared
to the US, the Medical City in Riyadh was found to meet
or exceed benchmarks for dimension pertaining to
Teamwork within Units, Organizational Learning—Con-
tinuous Improvement, Management Support for Patient
Safety, Feedback and Communication About Error, Fre-
quency of Events Reported Staffing, and Non-Punitive
Response to Error (Table 4).
Table 1 Socio-demographic and professional characteristics of
respondents in addition to frequency of events and patient
safety grade
N (%)
Gender
Male 398 (15.9%)
Female 2103 (84.1%)
Age group
Below 30 year old 925 (37.3%)
Between 30 to 45 years old 1152 (46.4%)
Between 46 to 55 years old 253 (10.2%)

Above 55 years old 151 (6.1%)
Marital Status
Single 851 (34.2%)
Married 1602 (64.4%)
Divorced/ Separated 16 (0.6%)
Widowed 13 (0.5%)
Others 6 (0.2%)
Highest Education
Under High School Level 2 (0.1%)
High School Level 7 (0.3%)
Diploma Level 836 (33.5%)
Bachelor’s Degree 1403 (56.2%)
Master’s Degree 127 (5.1%)
Doctorate Degree 102 (4.1%)
Others 19 (0.8%)
Work Area
Many different hospital unit/No Specific
Unit
21 (0.8%)

Administrative 138 (5.4%)
Medical 1332 (51.9%)
Surgical 786 (30.6%)
Diagnostics 99 (3.9%)
Other 191 (7.4%)
Staff Position
Administrator/Manager/Director 47 (1.9%)
Physician 141 (5.6%)
Specialist 61 (2.4%)
Coordinator 10 (0.4%)
Assistant/Aide 39 (1.6%)
Pharmacist 36 (1.4%)
Therapist 1 (0%)
Registered Nurse 1969 (78.3%)
Resident/PG/Intern 64 (2.5%)
Assistant/Clerk/Secretary/Facilitator 28 (1.1%)
Technician 52 (2.1%)
Other, please specify: 67 (2.7%)

Table 1 Socio-demographic and professional characteristics of
respondents in addition to frequency of events and patient
safety grade (Continued)
Tenure in Profession
Less than 1 year 133 (5.3%)
1 to 5 years 741 (29.6%)
6 to 10 years 809 (32.3%)
11 to 15 years 348 (13.9%)
16 to 20 years 222 (8.9%)
21 years or more 252 (10.1%)
Hours worked per week
Less than 20 h per week 25 (1%)
20 to 39 h per week 148 (6%)
40 to 60 h per week 2280 (92.9%)
Contact with Patients
YES, I typically have direct interaction
or contact with patients.
2229 (90.9%)
NO, I typically do NOT have direct
interaction or contact with patients.

224 (9.1%)
Patient Safety Grade
A – Excellent 495 (19.3%)
B - Very Good 1235 (48.1%)
C – Acceptable 650 (25.3%)
D – Poor 51 (2.0%)
E – Failing 5 (0.2%)
Missing 133 (5.2%)
Frequency of Events
No event reports 1352 (55.8%)
1 to 2 event reports 678 (28.0%)
21 event reports or more 32 (1.3%)
Missing 144 (5.9%)
Page 5 of 14

Table 2 Cronbach’s alpha and distribution of positive responses
and scores for survey composites and items
Composites and survey items Average% positive responsea
Mean (Standard deviation)
Overall Perception of Safety (Cronbach’s α = 0.234) 59.5 3.41
(0.54)
It is just by chance that more serious mistakes do not happen
around here (R)b 29.4 2.72 (1.06)
Patient safety is never sacrificed to get more work done 76.6
3.80 (0.97)
We have patient safety problems in this unit (R) 49.7 3.19
(1.09)
Our policies and procedures and systems are effective in
preventing errors 82.1 3.91 (0.75)
Supervisor/Manager Expectations & Actions Promoting Patient
Safety (Cronbach’s
α = 0.395)
60.8 3.44 (0.60)
My supervisor/manager says a good word when he/she sees a
job done according
to established patient safety procedures
74.2 3.74 (0.94)
My supervisor/manager seriously considers staff suggestions for

improving
patient safety
76.4 3.80 (0.87)
Whenever pressure builds up, my supervisor/manager wants us
to work faster,
even if it means taking shortcuts (R)
52.1 3.27 (1.06)
My supervisor/manager overlooks patient safety problems that
happen over
and over (R)
40.4 2.94 (1.16)
Organizational learning and Continuous Improvement
(Cronbach’s α = 0.614) 86.3 4.03 (0.53)
We are actively doing things to improve patient safety 94.8 4.31
(0.64)
Mistake have led to positive changes here 76.8 3.78 (0.78)
After we make changes to improve patient safety, we evaluate
their effectiveness 87.4 4.01 (0.69)
Teamwork within units (Cronbach’s α = 0.757) 84.8 3.40 (0.60)
Staff support one another in this unit 90.1 4.11 (0.71)
When a lot of work needs to be done quickly, we work together
as a team to
get the work done

89.3 4.11 (0.71)
In this unit, people treat each other with respect 85.4 4.03
(0.75)
When members of this unit get really busy, other members of
the same unit
help out
74.2 3.75 (0.95)
Non-punitive Response to Error (Cronbach’s α = 0.694) 24.8
2.62 (0.79)
Staff feel like their mistakes are held against them (R) 31.4 2.82
(1.04)
When an event is reported, it feels like the person is being
written up, not the
problem (R)
29.3 2.76 (1.02)
Staff worry that mistakes they make are kept in their personnel
file (R) 13.7 2.29 (0.93)
Staffing (Cronbach’s α = 0.210) 33.8 2.79 (0.57)
We have enough staff to handle the workload 56.1 3.29 (1.18)
Staff in this unit work longer hours than is best for patient care
(R) 11.2 2.17 (0.89)
We use agency/temporary staff than is best for patient care (R)
45.2 3.14 (1.08)

When the work is in “crisis mode” we try to do too much, too
quickly (R) 22.8 2.56 (1.01)
Hospital Management Support for Patient Safety (Cronbach’s α
= 0.519) 75.3 3.76 (0.62)
Hospital management provides a work climate that promotes
patient safety 85.3 3.95 (0.68)
The actions of hospital management show that patient safety is
a top priority 86.9 4.07 (0.77)
Hospital management seems interested in patient safety only
after an adverse
event happens (R)
53.6 3.26 (1.10)
Teamwork Across Hospital Units (Cronbach’s α = 0.627) 67.0
3.59 (0.62)
There is good cooperation among hospital units that need to
work together 73.0 3.69 (0.82)
Hospital units work well together to provide the best care for
patients 85.5 4.03 (0.77)
Hospital units do not coordinate well with each other and this
might affect
patient care (R)
55.8 3.30 (1.04)
It is often not easy to work with staff from other hospital units
(R) 53.7 3.35 (0.97)

Page 6 of 14
Compared to Lebanon, the Medical City in Riyadh fared
better on dimensions relating to Teamwork Within Units,
Teamwork across units, Supervisor/Manager Expectations
& Actions Promoting Patient Safety, Organizational Lear-
ning—Continuous Improvement, Management Support
for Patient Safety, Feedback and Communication about
Error, Frequency of Events Reported, Staffing, Handoffs &
Transitions and Non-punitive Response to Error (Table 4).
Results from the Medical City were found to be better
than the Palestine benchmark with the exception of the
composite relating to Staffing (Table 4).
Generalized estimating equations findings patient safety
grade
Table 5 shows how increases in patient safety com-
posite scores affect outcomes. A one unit increase on
Table 2 Cronbach’s alpha and distribution of positive responses
and scores for survey composites and items (Continued)
Hospital Handoffs & Transitions (Cronbach’s α = 0.783) 55.8
3.39 (0.75)
Things “fall between the cracks”, i.e., things might go
uncontrolled and get lost
(ex: medical records, medical treatment, patient information and
education,
discharge criteria) when transferring patients from one unit to
another (R)

45.5 3.18 (1.01)
Important patient care information is often lost during shift
changes (R) 66.8 3.59 (0.96)
Problems often occur in the exchange of information across
hospital units (R) 46.2 3.22 (0.95)
Shift changes are problematic for patients in this hospital (R)
64.5 3.56 (0.93)
Communication Openness (Cronbach’s α = 0.533) 45.0 3.36
(0.83)
Staff will freely speak up if they see something that may
negatively affect patient care 64.5 3.84 (1.07)
Staff feel free to question the decisions or actions of those with
more authority 34.3 3.08 (1.21)
Staff are afraid to ask questions when something does not feel
right (R) 36.2 3.15 (1.15)
Feedback and Communications About Error (Cronbach’s α =
0.732) 71.8 4.04 (0.79)
We are given feedback about changes put into place based on
event reports 56.5 3.69 (1.06)
We are informed about errors that happen in this unit 79.0 4.21
(0.95)
In this unit, we discuss ways to prevent errors from happening
again 79.9 4.22 (0.93)
Frequency of events reported (Cronbach’s α = 0.902) 68.8 3.92

(1.10)
When a mistake is made, but is caught and corrected affecting
the patient, how often is
this reported?
65.6 3.83 (1.21)
When a mistake is made, but has no potential to harm the
patient, how often is this reported? 65.9 3.86 (1.22)
When a mistake is made that could harm the patient, but does
not, how often is this reported? 74.9 4.07 (1.17)
athe composite-level percentage of positive responses was
calculated using the following formula: (number of positive
responses to the items in the composite/
total number of responses to the items (positive, neutral, and
negative) in the composite (excluding missing responses))*100
bNegatively worded items that were reverse coded
Table 3 T-test to compare composite scores in 2012 to scores in
2015
2012 2015 P-value
Mean SD Mean SD
Frequency of Event Reporting 3.64 1.16 4.04 1.54 <0.001
Overall Perceptions of Safety 3.43 0.59 3.60 1.56 <0.001
Supervisor/manager expectations and actions promoting safety
3.46 0.65 3.57 1.34 <0.001
Organizational Learning-Continuous Improvement 3.89 0.69
4.16 1.14 <0.001

Teamwork Within Hospital Units 3.85 0.75 4.04 0.71 <0.001
Communication Openness 3.25 0.85 3.45 1.08 <0.001
Feedback and Communication About Errors 3.73 0.95 4.11 1.10
<0.001
Non-punitive Response to Error 2.68 0.81 2.76 1.26 0.013
Staffing 2.84 0.62 3.02 1.19 <0.001
Hospital Management Support for Patient Safety 3.69 0.76 3.85
1.05 <0.001
Hospital Handoffs and Transitions 3.36 0.79 3.82 2.29 <0.001
Teamwork Across Hospital Units 3.52 0.71 3.76 1.36 <0.001
Page 7 of 14
all patient safety composites with the exception of
non-punitive response to error significantly increased
odds of reporting better patient safety grades. A one-
unit increase in staffing had 1.04 higher odds of
reporting better patient safety grade (95% CI = 1.01–
1.08). A one unit increase on remaining composites
increased odds of reporting better patient safety grade
ranging from an OR of 1.12 to 1.66. Noteworthy is
the finding that a one unit increase on Hospital Man-
agement Support for Patient Safety had 2.43 higher
odds of reporting better patient safety grade (95%
CI = 2.09–2.83) (See Table 5).

Female respondents had 0.62 lower odds (95%
CI = 0.62–0.63) of reporting better patient safety grades
while those aged above 55 had 1.28 higher odds of
reporting better patient safety grades (95% CI = 1.14–
1.42). Work experience was associated with higher pa-
tient safety grades whereby 3 to 5 years of experience
was associated with 0.96 lower odds of reporting better
patient safety grades whereas respondents with 11 to
15 years or 16 to 20 years of experience had significantly
greater odds of reporting better patient safety grades
(See Table 5). Respondent positions such Physicians, Co-
ordinators, Pharmacist, Nurses, and Resident/PG/Intern
were all associated with lower odds of reporting better
patient safety grades. However, Assistant/Aide and
Technicians had higher odds of reporting better patient
safety grades. Respondents who did not have patient
interaction and those working in the smaller setting also
had lower odds of reporting better patient safety grades
(See Table 5).
Number of events reported
A one unit increase in Hospital Management Support
for Patient Safety had 1.15 higher odds of reporting
higher number of events (95% CI = 1.08–1.23). More-
over, a one unit increase in Hospital Handoffs and Tran-
sitions had 1.10 higher odds of reporting higher number
of events (95% CI = 1.06–1.14). Teamwork within units,
Communication Openness, Non-punitive Response to
Error, Staffing, and Teamwork across Hospital Units
were all associated with lower odds of reporting higher
number of events (See Table 5).
Female respondents had 1.56 higher odds (95%CI = 1.45–
1.67) of reporting higher number of events. Respondents
aged 46 and above were found to have significantly lower

odds of reporting higher number of events. This observa-
tion is reversed when it comes to years of experience
where more experienced respondents had consistently
higher odds of reporting higher number of events. More-
over, respondents holding Masters or Doctoral degrees
had significantly lower odds of reporting higher number
of events. As for respondent positions, Physicians, Spe-
cialists, Assistant/Aide, Registered Nurse, Resident/PG/
Intern, Technicians and Other all had significantly
lower odds of reporting higher number of events. How-
ever, Pharmacists had 2.97 higher odds of reporting
higher number of events (95% CI = 2.30–3.84). As ex-
pected, respondents who had no patient interaction had
0.64 lower odds of reporting higher number of events.
The smaller hospital also had significantly lower odds
of reporting higher number of events (OR = 0.87, 95%
CI = 0.87–0.87) (See Table 5).
Table 4 Benchmarking 2015 results to similar initiatives in the
US and Lebanon
Page 8 of 14
Table 5 Generalized estimating equations
Patient safety grade Number of events reported
OR (95% CI) P-value OR (95% CI) P-value
Patient Safety Culture Composites
Supervisor/Manager Expectations & Actions Promoting Patient
Safety 1.20 (1.19–1.22) <0.001 1.27 (0.91–1.78) 0.162

Organizational learning and Continuous Improvement 1.66
(1.55–1.77) <0.001 1.10 (0.99–1.22) 0.073
Teamwork within units 1.61 (1.59–1.62) <0.001 0.82 (0.76–
0.89) <0.001
Communication Openness 1.22 (1.10–1.35) <0.001 0.93 (0.90–
0.97) 0.002
Feedback and Communications About Error 1.50 (1.29–1.74)
<0.001 0.99 (0.97–1.01) 0.282
Non-punitive Response to Error 1.09 (0.93–1.27) 0.308 0.83
(0.71–0.98) 0.029
Staffing 1.04 (1.01–1.08) 0.007 0.74 (0.67–0.83) <0.001
Hospital Management Support for Patient Safety 2.43 (2.09–
2.83) <0.001 1.15 (1.08–1.23) <0.001
Hospital Handoffs & Transitions 1.12 (1.11–1.13) <0.001 1.10
(1.06–1.14) <0.001
Teamwork Across Hospital Units 1.48 (1.45–1.50) <0.001 0.94
(0.90–0.98) 0.004
Gender
Male 1 1
Female 0.62 (0.62–0.63) <0.001 1.56 (1.45–1.67) <0.001
Age
Less than 30 years of age 1 1

Between 30 and 45 1.06 (0.92–1.23) 0.423 0.96 (0.81–1.14)
0.641
Between 46 and 55 1.00 (0.72–1.40) 0.995 0.56 (0.46–0.69)
<0.001
Aged above 55 1.28 (1.14–1.42) <0.001 0.40 (0.38–0.43) <0.001
Experience at the hospital
1 to 2 years 1 1
3 to 5 years 0.96 (0.85–1.08) <0.001 1.54 (1.21–1.94) <0.001
6 to 10 years 0.67 (0.57–0.78) 0.291 1.44 (1.35–1.53) <0.001
11 to 15 years 1.07 (1.01–1.14) 0.025 1.55 (1.51–1.59) <0.001
16 to 20 years 0.78 (0.49–1.24) <0.001 2.38 (1.54–3.68) <0.001
More or equal to 21 years 1.58 (1.55–1.60) 0.463 3.34 (2.53–
4.41) <0.001
Highest Degree
Under High School Level - - 1
High school level - - 0.50 (0.19–1.28) 0.148
Diploma level - - 0.36 (0.12–1.09) 0.070
Bachelors Degree - - 0.65 (0.26–1.62) 0.354
Masters Degree - - 0.49 (0.30–0.81) 0.005

Doctorate Degree - - 0.33 (0.17–0.65) 0.001
Position at the hospital
Administrator/Manager/Director 1 1
Physician 0.50 (0.40–0.64) <0.001 0.43 (0.35–0.51) <0.001
Specialist 1.65 (0.74–3.67) 0.223 0.32 (0.24–0.43) <0.001
Coordinator 0.65 (0.65–0.65) <0.001 1.01 (0.58–1.76) 0.964
Assistant/Aide 1.89 (1.34–2.67) <0.001 0.27 (0.23–0.31) <0.001
Pharmacist 0.53 (0.52–0.55) <0.001 2.97 (2.30–3.84) <0.001
Registered Nurse 0.60 (0.57–0.64) <0.001 0.29 (0.17–0.50)
<0.001
Resident/PG/Intern 0.18 (0.14–0.22) <0.001 0.14 (0.11–0.18)
<0.001
Assistant/Clerk/Secretary/Facilitator 0.65 (0.65–0.65) 0.611
1.02 (0.91–1.14) 0.734
Page 9 of 14
Linear regression findings
Overall perception of safety
Perception of patient safety improved by 0.131 (P-Value
<0.001) for a one unit increase in the score on Super-
visor/Manager Expectations and Actions Promoting
Safety, by 0.10 (P-Value =0.003) for every unit increase

in the score on organizational learning and continuous
improvement, and by 0.052 (P-Value =0.007) for a one
unit increase in the score on Non-Punitive Response to
Error. A one unit increase in the composites on Staffing,
Hospital Management Support for Patient Safety, Hos-
pital Handoffs & Transitions were also found to increase
overall perception of patient safety by 0.079 (p-value
=0.002, 0.114 (p-value <0.001) and 0.12 (p-value <0.001)
(See Table 6).
As age of respondents increased, overall overall per-
ception of patient safety progressively decreased. How-
ever, respondents with higher educational degrees had
significantly better perception of patient safety. Special-
ists and respondents working in the larger site also had
significantly lower overall perception of patient safety
(Table 6).
Frequency of events reported
Linear regression analysis showed that a one unit in-
crease in the score on Feedback and Communications
about Error increased the frequency of events reported
by 0.431 (P-Value <0.001) (See Table 6).
Respondents aged between 30 and 45 years reported
−0.172 fewer events (p-value =0.021) compared to re-
spondents aged below 30. Moreover, respondents with 6
to 10 years reported 0.202 more events (p-value = 0.031)
compared to respondents with 1 to 2 years of experi-
ence. As for respondent positions, Administrator/Man-
ager/Director, Physician, Specialist, Registered Nurses
and Assistant/Clerk/Secretary/Facilitator were all signifi-
cantly less likely to report higher number of events (See
Table 6).
Discussion

This is the first study to conduct a repeated assessment
of patient safety culture in a country where a dearth of
such studies exist. Findings confirm that tangible im-
provement has been achieved on some composites while
other areas still require further work. These findings are
of utmost importance in the context of KSA where such
assessments are limited but can provide valuable infor-
mation to hospital leaders on how performance has
changed as a result of quality improvement plans. Study
findings also provide recent data on patient safety cul-
ture in the context of a leading health provider in a
major city in KSA.
When comparing study findings to previous studies,
evidence indicated that Organizational Learning [11, 12],
Teamwork within Units, and Feedback and Communica-
tion about Errors are among the strongest aspects of pa-
tient safety culture [12] whereas the highly Punitive
Response to Error [11, 12] Staffing, and Teamwork
across Hospital Units as areas requiring improvement
[12]. Another study conducted at a multi-site facility in
Riyadh confirmed Organizational Learning, and Team-
work within Units as areas of strength and Punitive Re-
sponse to Error, Staffing and Communication as areas of
weakness [13]. In Lebanon, Teamwork within Units,
Hospital Management Support for Patient Safety, and
Organizational Learning and Continuous Improvement
were areas of strength. Areas requiring improvement at
the national level were Teamwork across Hospital Units,
Hospital Handoffs and Transitions, Staffing, and Non-
punitive Response to Error [14]. The study also found
significant associations between patient safety culture
outcomes and composite scores [15]. A similar study in
Oman found that higher Overall Perception of Patient
safety was associated with better composite scores on

Supervisor or Manager Expectations, Feedback and
Communications about Errors, Teamwork across Hos-
pital units, and Hospital Handoffs and Transitions [4].
In Jordan, the main area of strength was Teamwork
within Units [21]. Another study focusing on public
hospitals in Palestine found that the composites with
the lowest scores were Non-punitive Response to
Error, Frequency of Events Reported, Communication
Openness, Hospital Management Support for Patient
Safety and Staffing [16].
Table 5 Generalized estimating equations (Continued)
Technician 2.84 (2.49–3.24) <0.001 0.55 (0.53–0.58) <0.001
Other 1.04 (0.98–1.12) 0.189 0.19 (0.06–0.63) 0.006
Interaction with patients
No 0.81 (0.74–0.88) <0.001 0.64 (0.54–0.76) <0.001
Yes 1 1
Hospital Size
Small 0.56 (0.56–0.57) <0.001 0.87 (0.87–0.87) <0.001
Large 1 1
Page 10 of 14
Table 6 Linear regression model

Perception of patient safety Frequency of events reported
Beta (Standard error) P-value Beta (Standard error) P-value
Patient Safety Culture Composites
Supervisor/ Manager Expectations & Actions Promoting
Patient Safety
0.131 (0.027) <0.001 −0.009 (0.057) 0.880
Organizational learning and Continuous Improvement 0.100
(0.034) 0.003 0.133 (0.071) 0.060
Teamwork within units 0.055 (0.029) 0.059 −0.107 (0.061)
0.080
Communication Openness −0.026 (0.020) 0.181 −0.004 (0.041)
0.922
Feedback and Communications About Error 0.008 (0.022) 0.728
0.431 (0.046) <0.001
Non-punitive Response to Error 0.052 (0.019) 0.007 −0.061
(0.04) 0.125
Staffing 0.079 (0.026) 0.002 −0.017 (0.054) 0.748
Hospital Management Support for Patient Safety 0.114 (0.030)
<0.001 0.119 (0.063) 0.056
Hospital Handoffs & Transitions 0.120 (0.023) <0.001 −0.031
(0.047) 0.515
Teamwork Across Hospital Units 0.003 (0.032) 0.926 −0.014
(0.066) 0.834

Gender
Male 0.142 (0.054) 0.008 0.048 (0.11) 0.667
Female 0 0
Age
Less than 30 years of age 0 0
Between 30 and 45 −0.055 (0.035) 0.122 −0.172 (0.074) 0.021
Between 46 and 55 −0.137 (0.068) 0.042 0.022 (0.143) 0.880
Aged above 55 −0.203 (0.094) 0.031 0.16 (0.195) 0.412
Experience at the hospital
1 to 2 years 0 0
3 to 5 years 0.038 (0.036) 0.287 0.136 (0.075) 0.071
6 to 10 years 0.010 (0.045) 0.825 0.202 (0.094) 0.031
11 to 15 years 0.061 (0.056) 0.278 0.173 (0.117) 0.140
16 to 20 years 0.046 (0.089) 0.607 0.03 (0.185) 0.871
More or equal to 21 years 0.086 (0.091) 0.345 0.048 (0.19)
0.801
Highest Degree
Under High School Level 0 0

High school level 0.483 (0.237) 0.042 −0.288 (0.493) 0.559
Diploma level 0.528 (0.237) 0.026 −0.326 (0.492) 0.508
Bachelors Degree 0.583 (0.247) 0.019 0.076 (0.513) 0.882
Masters Degree 0.569 (0.258) 0.027 −0.231 (0.533) 0.665
Doctorate Degree 0.271 (0.283) 0.339 −0.105 (0.597) 0.861
Position at the hospital
Administrator/Manager/Director 0.229 (0.123) 0.064 −0.656
(0.269) 0.015
Physician −0.167 (0.099) 0.093 −0.597 (0.203) 0.003
Specialist −0.292 (0.128) 0.023 −0.858 (0.265) 0.001
Coordinator 0.152 (0.216) 0.482 0.356 (0.449) 0.429
Assistant/Aide 0.001 (0.101) 0.995 0.037 (0.21) 0.860
Pharmacist 0.083 (0.152) 0.585 −0.37 (0.332) 0.266
Registered Nurse −0.161 (0.109) 0.143 −0.499 (0.218) 0.023
Resident/PG/Intern 0.084 (0.181) 0.641 −0.279 (0.404) 0.490
Page 11 of 14
Results of this survey showcased areas of strength and
those requiring improvement and also showed whether

any changes can be observed compared to the previous
assessment. Areas of strength in this assessment were
Teamwork within units, Organizational Learning – Con-
tinuous Improvement, Management support for patient
safety and Feedback and Communication about error;
the last composite being a new addition compared to
the previous assessment [13]. The findings on these
composites in particular reflect commitment from hos-
pital management to focus on feedback as a means of
improving reporting. Moreover, the effect of size con-
tinues to impact survey outcomes with smaller hospitals
showing better overall scores reflecting that the impact
of fewer hierarchical and bureaucratic requirements
serve to the benefit of the smaller setting [13].
It is worth noting that Non-punitive Response to Error
remains the composite with the lowest score in 2015.
This reflects a culture which places more emphasis on
punishment in addressing errors; this reflects ineffective
policies that cannot prevent errors, improve reporting
and ultimately impact patient safety [22]. Studies show
that fear of punishment would reduce frequency of error
reporting among nurses [2] and this is confirmed in the
regression results from this study.
Evidence links hospital cultures that foster sharing and
reporting of errors to better patient safety and quality of
care [23]. This should go hand in hand with addressing
issues such as poor communication, lack of visible lead-
ership, poor teamwork, lack of reporting systems, inad-
equate analysis of adverse events and inadequate staff
knowledge about safety [4].
The study also benchmarked hospital performance to
similar assessments in the US and Lebanon. While there
are no major deviations from benchmarks, some areas of

slight deviation indicate that additional attention is re-
quired to consistently improve future performance.
Comparing to other countries in the region showed that
the Medical City fares much better on integral compos-
ites. For instance, Management Support for Patient
Safety had a percent positive score of 75.3% while it
scored 37% in Palestine [16] and 25.2% in Oman [4].
Moreover, Feedback and Communication about Error
received 71.8% percent positive response in Riyadh but
scored 46% in Palestine [16]. Some other composites
were found to be common areas requiring improvement
across the three countries such as Staffing, Communica-
tion Openness and Non-Punitive Response to Error.
Of note is the significant association between most
safety culture composites and lower number of events
report. In fact, only Hospital Management Support for
Patient Safety and Hospital Handoffs and Transitions
were found to be associated with higher number of
events. The significant association between Feedback
and Communication about Error and Frequency of
events reported is also of note in this context. This indi-
cates that the underlying system that governs these pro-
cesses may actually improve reporting compared to
other patient safety culture composites. Incident and
event reporting are critical to maintain patient safety.
Hospital staff are often too busy to report, unsure about
the mechanisms of reporting or simply insufficiently en-
gaged in the importance of reporting [24].
Another interesting observation is the impact of
higher scores hospital management on improved patient
safety grade and higher number of events reported. This
highlights the importance of managerial commitment
particularly as evidence shows a link between adminis-

trative support and performance in process of care,
lower mortality rates (Jiang et al. 2009), and better over-
all hospital performance [25–27].
Furthermore, results indicated that pharmacists were
almost three times as likely to report events. This is in
line with findings in the literature that indicate that
pharmacists’ role in in error reporting [28]. Still, this in-
dicates the need to work on improving the reporting
process through addressing communication and feed-
back channels to ensure that pharmacists continue to re-
port [28] and that other staff members are equally
inclined to report errors.
To our knowledge, this is the first study to conduct a
re-assessment of patient safety culture in Riyadh. Results
Table 6 Linear regression model (Continued)
Assistant/Clerk/Secretary/Facilitator 0.006 (0.121) 0.961
−0.478 (0.24) 0.046
Technician −0.052 (0.100) 0.607 −0.096 (0.213) 0.652
Other 0 0
Interaction with patients
No 0 0
Yes 0.068 (0.062) 0.273 0.108 (0.13) 0.406
Hospital Size
Small 0 0

Large −0.098 (0.034) 0.004 −0.087 (0.071) 0.223
Page 12 of 14
can provide valuable insight to hospital leaders on how
their quality improvement plans over a span of 3 years
have affected patient safety culture. Despite using a pre-
validated survey which was also provided in Arabic, the
values of Cronbach’s Alpha are still considered low and
did not improve much compared to the previous assess-
ment [13]. However, it should be noted that they are
comparable to a similar assessment in the region where
the values were attributed to the use of two languages
and the wide range of respondents [14]. Evidence also
shows that lower Cronbach’s Alpha values are typically
expected with psychological constructs where diverse
items are being measured [29].
Conclusion
Study findings indicate that while tangible improvements
were observed, there are still areas that the hospital can
enhance in effort to improve overall patient safety cul-
ture. Study findings will guide and inform overall strat-
egies to further improve patient safety practices. There
is a need to invest further in determinants of patient
safety culture, particularly areas that impact event
reporting. Results confirm that regular assessment can
allow hospitals to better understand how overall per-
formance improved and if any other areas need further
enhancement.
Abbreviations
CI: Confidence interval; HSOPSC: Hospital Survey on Patient

Safety Culture;
OR: Odds ratio; PS: Patient safety; PSC: Patient safety culture;
SD: Standard
deviation; US: United States
Acknowledgements
Authors would like to thank all study respondents for their
participation for
their support.
Funding
No funding was provided for conducting this study.
Availability of data and materials
Kindly contact the corresponding author for a copy of the
dataset. Requests
will be reviewed by the study team before they are sent.
Authors’ contributions
KA contributed to the study design, manuscript development
and review,
RA, MT, MB, FM and BZ contributed to data collection and
review. DJ
contributed to data analysis and review, and FE contributed to
study design,
data analysis, manuscript development and review. All authors
read and
approved the final version of the manuscript.
Ethics approval and consent to participate
No local ethical review was required as advised by hospital
administration of
King Saud University Medical City. The study adhered to all
ethical
considerations pertaining to confidentiality of the responses
provided by

employees, informed consent form was provided and anonymity
of
responses was ensured. The survey was available in an online
format and
adhered to all ethical standards.
Competing interests
The authors declare that they have no competing interests.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional
claims in
published maps and institutional affiliations.
Author details
1King Khalid University Hospital, King Saud University
Medical City, Riyadh,
Saudi Arabia. 2Department of Health Management and Policy,
American
University of Beirut, Beirut, Lebanon. 3Department of Health
Research
Methods, Evidence, and Impact, McMaster University, CRL-
209, 1280 Main St.
West, Hamilton, ON L8S 4K1, Canada.
Received: 3 November 2016 Accepted: 19 July 2017
References
1. Kohn LT, Corrigan J, Donaldson MS. To err is human:
building a safer health
system. Washington, D.C.: National Academy Press; 2000.
Available from:
https://www.ncbi.nlm.nih.gov/books/NBK225182/.
2. Child AP, Institute of M, Committee on the Work

Environment for N, Patient
S. Keeping patients safe: transforming the work environment of
nurses.
Washington, D.C.: National Academies Press; 2004. Available
from: https://
www.ncbi.nlm.nih.gov/books/NBK216190/.
3. Saleh AM, Darawad MW, Al-Hussami M. The perception of
hospital safety
culture and selected outcomes among nurses: An exploratory
study. Nurs
Health Sci. 2015;17(3):339–46.
4. Ammouri AA, Tailakh AK, Muliira JK, Geethakrishnan R, Al
Kindi SN. Patient
safety culture among nurses. Int Nurs Rev. 2015;62(1):102–10.
5. Clarke S, Ward K. The role of leader influence tactics and
safety climate in
engaging employees’ safety participation. Risk Anal.
2006;26(5):1175–85.
6. Mustard LW. Caring and Competency. JONA’s Healthc Law
Ethics Regul.
2002;4(2):36–43.
7. International JC. WHO Collaborating Center for Patient
Safety’s nine life-
saving Patient Safety
Solution

s. Joint Comm J Qual Patient Safety/Joint
Comm Resources. 2007;33(7):427–62.
8. Deilkas ET, Hofoss D. Psychometric properties of the
Norwegian version of
the Safety Attitudes Questionnaire (SAQ), Generic version
(Short Form 2006).
BMC Health Serv Res. 2008;8:191.
9. Hughes LC, Chang Y, Mark BA. Quality and strength of
patient safety
climate on medical-surgical units. Health Care Manag Rev.
2009;34(1):19–28.
10. Sorra J, Nieva VF, Westat I, United S, Agency for
Healthcare R, Quality.
Hospital survey on patient safety culture. Rockville: Agency for
Healthcare
Research and Quality; 2004. Available from:
https://www.ahrq.gov/sites/
default/files/wysiwyg/professionals/quality-patient-safety/
patientsafetyculture/hospital/userguide/hospcult.pdf.
11. Al-Ahmadi TA. Measuring Patient Safety Culture in
Riyadh's Hospitals: A

Comparison between Public and Private Hospitals. J Egypt
Public Health
Assoc. 2009;84(5–6):479–500.
12. Alahmadi HA. Assessment of patient safety culture in Saudi
Arabian
hospitals. Qual Safety Health Care. 2010;19(5):e17.
13. El-Jardali F, Sheikh F, Garcia NA, Jamal D, Abdo A.
Patient safety culture in a
large teaching hospital in Riyadh: baseline assessment,
comparative analysis
and opportunities for improvement. BMC Health Serv Res.
2014;14:122.
14. El-Jardali F, Jaafar M, Dimassi H, Jamal D, Hamdan R. The
current state of
patient safety culture in Lebanese hospitals: a study at baseline.
Int J Qual
Health Care. 2010;22(5):386–95.
15. El-Jardali F, Dimassi H, Jamal D, Jaafar M, Hemadeh N.
Predictors and
outcomes of patient safety culture in hospitals. BMC Health
Serv Res.

2011;11:45.
16. Hamdan M, Saleem AA. Assessment of patient safety
culture in Palestinian
public hospitals. Int J Qual Health Care. 2013;25(2):167–75.
17. Famolaro T, Yount ND, Burns W, Flashner E, Liu H, Sorra
J. Hospital Survey
on Patient Safety Culture 2016 User Comparative Database
Report. Rockville:
Agency for Healthcare Research and Quality; 2016.
18. Famolaro T, Yount ND, Burns W, Flashner E, Liu H, Sorra
J, et al. Hospital
survey on patient safety culture: 2016 user comparative
database report.
Rockville: Agency for Healthcare Research and Quality; 2016.
Available from:
http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/q
uality-
patient-
safety/patientsafetyculture/hospital/2016/2016_hospitalsops_rep
ort_
pt1.pdf

19. National Hospital Standards. Saudi Central Board for
Accreditation of
Healthcare Institutions (CBAHI) 2015.
Page 13 of 14
https://www.ncbi.nlm.nih.gov/books/NBK225182/
https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/
quality-patient-
safety/patientsafetyculture/hospital/userguide/hospcult.pdf
quality-patient-
quality-patient-
uality-patient-
ort_pt1.pdf
uality-patient-

ort_pt1.pdf
uality-patient-
ort_pt1.pdf
20. Quality AfHRa. National Healthcare Quality and Disparities
Report 2016.
[cited 2016 7/5/2016] Available from:
https://nhqrnet.ahrq.gov/inhqrdr/.
21. Khater WA, Akhu-Zaheya LM, Al-Mahasneh SI, Khater R.
Nurses’ perceptions
of patient safety culture in Jordanian hospitals. Int Nurs Rev.
2015;62(1):82–91.
22. Nieva VF, Sorra J. Safety culture assessment: a tool for
improving patient
safety in healthcare organizations. Qual Safety Health Care.
2003;12(Suppl 2):
ii17–23.
23. Blignaut AJ, Coetzee SK, Klopper HC. Nurse qualifications

and perceptions of
patient safety and quality of care in South Africa. Nurs Health
Sci.
2014;16(2):224–31.
24. Pearson P, Steven A, Howe A, Sheikh A, Ashcroft D, Smith
P. Learning about
patient safety: organizational context and culture in the
education of health
care professionals. J Health Serv Res Policy. 2010;15(Suppl
1):4–10.
25. Jha AK, World Health O, World Alliance for Patient S,
Research Priority
Setting Working G. Summary of the evidence on patient safety :
implications for research. Geneva: World Health Organization;
2008.
26. Jiang HJ, Lockee C, Bass K, Fraser I. Board oversight of
quality: any
differences in process of care and mortality? J Healthc
Manage/Am College
Healthc Exec. 2009;54(1):15–29. discussion -30
27. Joshi MS, Hines SC. Getting the board on board: Engaging

hospital boards
in quality and patient safety. Jt Comm J Qual Patient Saf.
2006;32(4):179–87.
28. Patterson ME, Pace HA, Fincham JE. Associations between
communication
climate and the frequency of medical error reporting among
pharmacists
within an inpatient setting. J Patient Safety. 2013;9(3):129–33.
29. Field AP. Discovering statistics using SPSS: (and sex and
drugs and rock ‘n’ roll).
Los Angeles [i.e. Thousand Oaks, Calif.]. London: SAGE
Publications; 2009.
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Page 14 of 14
https://nhqrnet.ahrq.gov/inhqrdr/AbstractBackgroundMethodsRe
sultsConclusionBackgroundObjectivesMethodsDesign, setting
and samplingData management and analysisResultsGeneral
resultsAreas of strengths and areas requiring
improvementComparing results from 2015 to 2012Comparative
against regional and international findingsGeneralized
estimating equations findings patient safety gradeNumber of
events reportedLinear regression findingsOverall perception of
safetyFrequency of events
reportedDiscussionConclusionAbbreviationsFundingAvailability
of data and materialsAuthors’ contributionsEthics approval and
consent to participateCompeting interestsPublisher’s
NoteAuthor detailsReferences
healthcare

Review
Importance of Leadership Style towards Quality of
Care Measures in Healthcare Settings:
A Systematic Review
Danae F. Sfantou 1, †, Aggelos Laliotis 2, † ID , Athina E.
Patelarou 3, Dimitra Sifaki- Pistolla 4,
Michail Matalliotakis 5 ID and Evridiki Patelarou 6,*
1 2nd Department of Cardiology, Attikon University Hospital,
National and Kapodistrian University of
Athens Medical School, Athens 12462, Greece;
[email protected]
2 Department of Upper Gastrointestinal and Bariatric Surgery,
St. Georges, NHS Foundation Hospitals,
London SE170QT, UK; [email protected]
3 Department of Anesthesiology, University Hospital of
Heraklion, Crete 71500, Greece;
[email protected]
4 Clinic of Social and Family Medicine, School of Medicine,
University of Crete, Crete 71500, Greece;
[email protected]
5 Department of Obstretics and Gynaecology, Venizeleio
General Hospital, Heraklion, 71409, Greece;

[email protected]
6 Florence Nightingale Faculty of Nursing and Midwifery,
King’s College, London SE18WA, UK
* Correspondence: [email protected]; Tel.: +44-7596-434-780
† These authors have equally contributed to the manuscript.
Academic Editor: Sampath Parthasarathy
Received: 1 August 2017; Accepted: 25 September 2017;
Published: 14 October 2017
Abstract: Effective leadership of healthcare professionals is
critical for strengthening quality and
integration of care. This study aimed to assess whether there
exist an association between different
leadership styles and healthcare quality measures. The search
was performed in the Medline
(National Library of Medicine, PubMed interface) and EMBASE
databases for the time period
2004–2015. The research question that guided this review was
posed as: “Is there any relationship
between leadership style in healthcare settings and quality of
care?” Eighteen articles were found
relevant to our research question. Leadership styles were found
to be strongly correlated with quality
care and associated measures. Leadership was considered a core

element for a well-coordinated and
integrated provision of care, both from the patients and
healthcare professionals.
Keywords: leadership; leadership style; quality of care; nursing
1. Introduction
Nowadays, both evidence-based medicine and nursing are
widely recognized as the tools for
establishing effective healthcare organizations of high
productivity and quality of care. Management
and leadership of healthcare professionals is critical for
strengthening quality and integration of care.
Leadership has been defined as the relationship between the
individual/s who lead and those who
take the choice to follow, while it refers to the behaviour of
directing and coordinating the activities of
a team or group of people towards a common goal [1,2]. There
are many identified styles of leadership,
while six types appear to be more common: transformational,
transactional, autocratic, laissez-faire,
task-oriented, and relationship-oriented leadership.
Transformational leadership style is characterized
by creating relationships and motivation among staff members.

Transformational leaders typically
have the ability to inspire confidence, staff respect and they
communicate loyalty through a shared
vision, resulting in increased productivity, strengthen employee
morale, and job satisfaction [3,4].
Healthcare 2017, 5, 73; doi:10.3390/healthcare5040073
www.mdpi.com/journal/healthcare
http://www.mdpi.com/journal/healthcare
http://www.mdpi.com
https://orcid.org/0000-0003-0681-2053
https://orcid.org/0000-0002-2967-184X
http://dx.doi.org/10.3390/healthcare5040073
http://www.mdpi.com/journal/healthcare
Healthcare 2017, 5, 73 2 of 17
In transactional leadership the leader acts as a manager of
change, making exchanges with employees
that lead to an improvement in production [3]. An autocratic
leadership style is considered ideal
in emergencies situation as the leader makes all decisions
without taking into account the opinion

of staff. Moreover, mistakes are not tolerated within the blame
put on individuals. In contrary,
the laissez-faire leadership style involves a leader who does not
make decisions, staff acts without
direction or supervision but there is a hands-off approach
resulting in rare changes [4]. Task-oriented
leadership style involves planning of work activities,
clarification of roles within a team or a group
of people, objectives set as well as the continuing monitoring
and performance of processes. Lastly,
relationship-oriented leadership style incorporates support,
development and recognition [5].
Quality of care is a vital element for achieving high
productivity levels within healthcare
organizations, and is defined as the degree to which the
probability of achieving the expected health
outcomes is increased and in line with updated professional
knowledge and skills within health
services [6]. The Institute of Medicine OM has described six
characteristics of high-quality care
that must be: (1) safe, (2) effective, (3) reliable, (4) patient-
centred, (5) efficient, and (6) equitable.
Measuring health outcomes is a core component of assessing
quality of care. Quality measures

are: structure, process, outcome, and patient satisfaction [6].
According to the National Quality
Measures Clearing House (USA), a clinical outcome refers to
the health state of a patient resulting
from healthcare. Measures on patient outcomes and satisfaction
constitute: shorter patient length of
stay, hospital mortality level, health care-associated infections,
failure to rescue ratio, restraint use,
medication errors, inadequate pain management, pressure ulcers
rate, patient fall rate, falls with injury,
medical errors, and urinary tract infections [7].
There are numerous publications recognizing leadership style as
a key element for quality of
healthcare. Effective leadership is among the most critical
components that lead an organization
to effective and successful outcomes. Significant positive
associations between effective styles of
leadership and high levels of patient satisfaction and reduction
of adverse effects have been reported [8].
Furthermore, several studies have stressed the importance of
leadership style for quality of healthcare
provision in nursing homes [9]. Transformational leadership is
strongly related to the implementation
of effective management that establishes a culture of patient

safety [10]. In addition, the literature
stresses that empowering leadership is related to patient
outcomes by promoting greater nursing
expertise through increased staff stability, and reduced turnout
[11]. Effective leadership has an
indirect impact on reducing mortality rates, by inspiring,
retaining and supporting experienced staff.
Although there are many published studies that indicate the
importance of leadership, few of these
studies have attempted to correlate a certain leadership style
with patient outcomes and healthcare
quality indicators.
Therefore, the aim of this review was to identify the association
between leadership styles with
healthcare quality measures.
2. Materials and Methods
This systematic review was designed and conducted in line with
the published guidelines for
reporting systematic reviews and meta-analyses [12].
Systematic review of the existing literature on
leadership style and quality of healthcare provision was
performed. The main review question was:

“Which is the relationship between styles of leadership in
healthcare settings and quality of care?”
A systematic, comprehensive bibliographic search was carried
out in the National Library of Medicine
(Medline) and EMBASE databases for the time period between
2004–2015 in the PubMed interface.
Search terms used were chosen from the USNML Institutes of
Health list of Medical Subject Headings
(MeSH) for 2015. The included MeSH terms were: “Nurse
Administrators”; “Nurse Executives”;
“Physician Executives”; “Leaders”; “Leadership”; “Managers”;
“Management style”; “Leadership
style”; “Organizational style”; “Organizational culture/climate”;
“Leadership Effectiveness”; “Quality
of healthcare”; “Patient outcome Assessment”; “Quality
indicators, Healthcare”; “Healthcare quality,
Access and Evaluation”; and “Quality Assurance, Healthcare”.
References used by each identified
study were also checked and included in the study according to
the eligibility criteria.

Five major inclusion criteria were adopted:
• Papers published in peer-reviewed journal
• Papers written in the English language
• Papers published from 2004 to 2015 (focus on more recent
knowledge)
• Human epidemiological studies
• Studies used a quantitative methodology reporting the
leadership style and healthcare
quality measures
Studies that did not meet the above criteria were excluded,
while those that complied with the
inclusion criteria were listed and further reviewed.
Studies were evaluated and critically appraised (Aveyard
critical appraisal tool) by two
independent reviewers. Literature screening (a three-stage
approach-exclusion by reading the title, the
abstract, and the full text) and extraction of the data were
conducted by two reviewers, independently.
In cases of uncertainty, a discussion was held among the
members of the team to reach a common

consensus. Data were extracted systematically from each
retrieved study, using a predesigned standard
data collection form (extraction table). The following
information was extracted from each one of the
included studies (Table 1): authors, year of conduction, country,
study design, subjects, population,
research purpose, leadership style definition, outcome
definition, and main findings.
Table 1. An overview of studies’ characteristics, outcome
definitions and main findings.
Author et al. (year)
Main Study
Characteristics
Aim of the Study Leadership Style Definition Outcome
Definition Main Findings
Al-Mailam (2004) [13] Kuwait,
cross-sectional study

Four public and private
hospitals
266 administrators and
physicians
To explore the
impact of leadership
styles on employee
perception of
leadership efficacy.
Two categories of administrators’
and physicians’ leadership style:
- Transformational leaders
- Transactional leaders
Leadership style
(Multifactor Leadership
Questionnaire)
Leadership style
(midpoint = 33,
average score)
Hospital director: 26.89

Department Head: 25.74
Leadership efficacy
[midpoint = 6.0
average score, (F-value)]
Both Medical director and Department Head = 4.44, (32.41 and
48.43)
Type of hospital and transformational leadership style
(average score, (SE))
public vs. private hospital
Hospital director: 29.48 (0.71) vs. 24.62 (0.73)
Department head: 27.28 (0.71) vs. 24.41 (0.67)
Armstrong et al. (2006)
[14]
Central Canada,
Small community hospital
40 staff nurses
To test a theoretical
model.
Structural empowerment
(Conditions of Work
Effectiveness Questionnaire-II)

Magnet hospital
characteristics—Practice
Environment
(Lake’s Practice Environment
Scale of the Nursing Work
Index, PES of NWI)
Safety climate
(The Safety Climate Survey)
Total Empowerment scale
[mean score (SD)]
17.1 (4.26) Cronbach α = 0.94
Total PES
[mean score(SD)]
2.5 (0.64) Cronbach α = 0.85
Safety Climate
[mean score(SD)]
3.53 (0.80) Cronbach α = 0.81
Empowerment and professional practice characteristics
[r (p-value)]
Nursing model of care 0.61 (<0.01)
Management ability 0.52 (<0.01)
Collaborative relationships

0.316 (<0.005)
Empowerment and patient safety culture
[r (p-value)]
Patient safety culture 0.50 (<0.01)
Support 0.51 (<0.01)
Informal power 0.43 (<0.01)
Opportunity 0.45 (<0.01)
Combined effect of magnet hospital characteristics on
patient safety culture and empowerment
46% of variance,
F = 13.32, dF = 1.31 p = 0.0001
Table 1. Cont.
Main Study
Characteristics

Keroack et al. (2007) [15] US, 2003–2005
Exploratory investigation
79 Academic Medical
Centers
patient-level data
site visits
To identify
organizational
factors associated
with quality and
safety performance.
Hospitals’ leadership style:
- Authentic hands-on
leadership style
Patient safety
(Agency for health Care
Research and Quality,
AHRQ-preventable
complications, and Patient
Safety Indicators)

Mortality
(mortality rates bases on
AHRQ and inpatient quality
indicators, IQIs)
Effectiveness
(The Joint Commission
Hospital Core Measures)
Equity
(Measures)
Composite scores for quality and safety
CI 95% (median score %)
Group 1 vs. Group 2 vs. Group 3 vs. Group 4 vs. Group 5
67.18% vs. 62.36% vs. 60.22% vs. 58.68% vs. 56.05%
Factors associated with top performing organizations:
• Shared sense of purpose
• Authentic hands-on leadership style
• Accountability system of quality and safety
• Focus on results
• Culture collaboration
Kvist et al. (2007) [16] Finland
Kuopio University

Hospital
631 patients
690 nurses
76 managers
128 doctors
To investigate the
perception of the
quality of care and
the relationships
between
organizational
factors and quality
of care.
Quality of care
(measured by Humane Caring
Scale)
Organizational factors
(by using questionnaires)
Quality of care
(ratings)
Patients 1.51 to1.66
Nurses 1.81 to2.19

Managers 1.82 to 2.08
Organizational factors an Quality of care
- (coefficient of determination)
Nursing staff vs. managers vs. physicians0.462 vs. 0.548 vs.
0.337
- [standardized coefficient SC, (p-value)]
Nursing staff: work vs. values 0.248 (0.01) vs. 0.447 (0.001)
Managers: Work vs. leadership 0.472 (0.05) vs. 0.568 (0.05
Physicians: work vs. values
0.289 (0.05) vs. 0.539 (0.05)
Table 1. Cont.
Main Study
Characteristics
Vogus, Sutcliffe (2007) [17] US, 2003–2004

cross-sectiona
l1033 RNs
78 nursing managers
78 care units
To examine the
benefits of bundling
safety organizing
with leadership and
design factors on
reported medication
errors.
Safety organizing
(Safety organizing Scale)
Trust in manager
(2 survey items assessing
perceptions for nurse manager)
Use of care pathways
(Seven-point Likert Scale,
single survey item)
Reported Medications
errors
(number of errors reported to a

unit's incident reporting
system)
Medications errors
(mean, SD) 12.04, 11.31
Safety organizing and trusted leadership
(β, coefficient, p-value)
−0.60, 0.18, p < 0.001
Safety organizing and care pathways
−0.82, 0.25, p < 0.001
Casida, Pinto-Zipp (2008)
[18]
New Jersey, US, 2006
Four acute care hospitals
37 Nurse Managers
278 staff nurses
To explore the
relationship
between nursing
leadership styles
and organizational
culture.

Three categories of nurse
managers’ leadership style:
- Non-transactional
laissez-faire leaders
Leadership style
Questionnaire)
Nursing unit
Organizational culture
(the Denison’s Organizational
Culture Survey)
Leadership style
[MLQ scores, mean (SD)]
Transformational vs. transactional vs. laissez-faire
2.8 (0.83) vs. 2.1 (0.47) vs. 0.83 (0.90)
NMs’ leadership style and organizational culture
(r, p-value)

Transformational vs. transactional vs. laissez-faire
0.60 (p = 0.00) vs.0.16 p = 0.006) vs.−0.34 (p = 0.000)
Raup (2008) [19] US
15 academic health centers
15 managers
15 staff nurses
To explore the role
of leadership styles
used by nurse
managers in nursing
turnover and patient
satisfaction.
Two categories of ED nurse
managers’ leadership style:
- Transformational leadersNon
- Non-transformational leaders
Leadership style
Questionnaire, MLQ)
Nurse staff turnover and

patient satisfaction
(managers’ data for nurse
turnover and patient safety
scores)
Leadership style
(% ED nurse managers)
transformational vs. Non-transformational
80% vs. 20%
Nurse staff turnover and patient satisfaction
[impact of leadership style:
Fisher’s exact test = 0.569]
Mean staff nurse turnover (%)
transformational vs. Non-transformational 13% vs. 29%
Mean ED overall patient satisfaction (%)
transformational vs. Non-transformational76.68% vs. 76.50%
Table 1. Cont.
Main Study

Characteristics
McCutcheon et al. (2009)
[20]
Canada
Correlation survey
Seven hospitals
51 units
41 nurse managers
717 nurses
680 patients
To assess the
relationship
between leadership
style, nurses’ job
satisfaction, span of
control, and patient
satisfaction.
Four categories of managers’

leadership style:
- Management by exception
- Laissez-faire
Nurses’ Job Satisfaction
(measured by
McCloskey-Mueller
Satisfaction Scale
Patient Satisfaction
(measured by the Patient
Judgments of Hospital
Quality Questionnaire)
Nurses’ Job Satisfaction
(Mean) 3.2
(mean) 2.16 (moderate satisfaction)
JS and leadership style
Transformational vs. transactional vs. management by
exception vs. laissez-faire (Beta)
0.20 vs. 0.12 vs. −0.08 vs. 0.02
Span of control and leadership style on JS

exception vs. laissez-faire [coefficient, (p-value)]
−0.0024 (<0.01) vs.
−0.0015 (<0.05) vs. 0.0026 (<0.01) vs. 0.0014 (<0.05)
Span of control and leadership style on patient satisfaction
[coefficient, (p-value)]
exception vs. laissez-faire
−0079(<0.05) vs. −0070 vs.
−0103 vs. 0.0045
Singer et al. (2009) [21] US, 2004–2005
92 hospitals
senior managers,
physicians, hospital
workers
questionnaires
18361 safety climate
surveys
5637 organizational
culture surveys
To assess the aspects
of general
organizational

culture that are
related to hospital
patient safety
climate.
Safety climate
(Patient Safety Climate in
Healthcare Organization)
Organizational culture
(Competing Values
Framework)
Organisational culture
(average score)
hierarchical organizational culture vs. entrepreneurial culture
31.6 points vs. 15.7points
Safety climate
(% PPR-percent problematic response) (higher PPR relates to
lower level of safety climate)
17.1% PPR
Highest safety climate hospitals vs. lowest safety climate
hospitals (mean PPR, p = 0.000) 11.5 vs. 24.6
Relationship of organizational characteristics with patient
safety climate
[overall average PPR (SD) p < 0.05]

group culture vs. entrepreneurial culture vs. hierarchical
culture vs. production-oriented culture
−0.241 (0.011) vs.−0.279 (0.0022) vs. 0.300 (0.011) vs. 0.0666
(0.017)
Organizational culture and safety climate
[mean (SD] high vs. low safety climate
group culture: 40.1 (6.7) vs. 26.9 (7.8)
entrepreneurial: 15.3 (2.31) vs. 13.9 (0.9)
production-oriented: 20.20 (2.1) vs. 22.4 (2.1)
hierarchical: 24.6 (2.8) vs. 36.7 (6.2)
Table 1. Cont.
Main Study
Characteristics
Alahmadi (2010) [22] Saudi Arabia,

13 general hospitals
223 health professions
(nurses, technicians,
managers, medical staff)
To assess whether
organisation culture
supports patient
safety.
Patient safety culture
(Hospital Survey on Patient
Safety Culture questionnaire)
Patient safety
Excellent or very good vs. acceptable vs. failing or poor (%)
60% vs. 33% vs. 7%
Determinants of overall patient safety score(Standardised
coefficient B)
Organisational learning/continuous improvement: 0.128
Management role: 0.216
Communication and feedback about errors: 0.215
Teamwork: 0.160
Armellino et al. (2010)

[23]
US
descriptive correlation
study
Adult Critical Care Unit
(ACCU) tertiary hospital
102 Registered Nurses
To explore the
association between
structural
empowerment and
patient safety
culture among
nurses.
Structural empowerment,
SE
(Conditions of Workplace
Effectiveness Questionnaire)
Patient safety climate
(Hospital Survey on Patient
Safety Culture)

Total structural empowerment, SE
(CWEQ-II, mean score)
20.55 (moderate), Cronbach’s α = 0.89
Moderate SE vs. low level of SE vs. high level of SE (%)
79.2% vs. 1.98% vs. 18.91%
Structural empowerment and patient safety climate (PSC)
- Total CWEQ-II score and overall perception of
safety(Pearson’s correlation coefficient)0.32 p < 0.05
- Total CWEQ-II empowerment score and HSOPC safety
grade(total SE score)
Grade A vs. Grade B vs. Grade C vs. Grade D22.667 vs.
20.987 vs. 19.763 vs. 15.889
Cummings et al. (2010)
[24]
Canada, 1998–1999
Secondary analysis of
data
90 hospitals
21,570 patients

5228 nurses
To explore the
association of the
role of hospital
nursing leadership
styles with 30-day
mortality.
Five categories of hospitals’
leadership style:
- high resonant
- moderately resonant
- mixed
- moderately dissonant
- high dissonant
30-day mortality Hospital Nursing leadership styles and 30-day
mortality
High dissonant vs. moderately dissonant vs. mixed type vs.
moderately resonant vs. high resonant (%)
4.3 vs. 8.8 vs. 8.1 vs. 7.4 vs. 5.2

moderately resonant vs. high resonant Beta (SE)
Ref vs.−0.64 (0.24) * vs. 0.05 (0.11) vs.−0.08 (0.10) vs.−0.40
(0.19) *
moderately resonant vs. high resonant aOR 95% CI
Ref vs. 0.86 (0.56–1.31) vs. 1.10 (0.96–1.27) vs. 0.90 (0.77–
1.04)
vs. 0.77 (0.59–1.01)
Table 1. Cont.
Main Study
Characteristics

Ginsburg et al. (2010) [25] Canada, 2006
Two cross-sectional
surveys
49 general acute care
hospitals
54 patient safety officers
(PSOs)
282 patient care managers
(PCMs)
PSOs and PCMs
questionnaires
To explore
organizational
leadership towards
patient safety and its
relationship with
five types of
learning from
patient safety
events.
Two categories of organizational
leadership style:

- Informal organizational
- Formal organizational
Leadership style
(PCM questionnaire)
Learning from PSEs
(four types of
PSE-minor/moderate/major
events/major near-miss)
Learning from PSEs
[Mean (SD)]
major event analysis 3.63 (0.56)
major event dissemination/communication 2.86 (0.80)
moderate event learning 3.03 (0.76)
minor events learning 2.53 (0.67)
major near-miss events learning 3.03 (0.75)formal
organizational leadership 3.90 (0.44)
informal organizational leadership 2.34 (1.28)
Learning from Near-miss Events
(β, p-value)
hospital size −0.339 p < 0.10
formal leadership style 0.467 p < 0.05
Learning from Major events dissemination/communication

(β, p-value)
hospital size and formal leadership style −1.106, p < 0.001
Purdy et al. (2010) [26] Canada,
Cross-sectional study
21 hospitals (61 medical
and surgery units)
697 nurses
1005 patients
To assess the
relationship of
nurses' perceptions
on their work
environment and
quality outcomes.
Work environment
(Conditions of Workplace
Effectiveness Questionnaire,
and Work Group
Characteristics Measure)
Patient care
quality/patient satisfaction
(Nursing Care Quality

Questionnaire and The
Therapeutic Self-care
Questionnaire-Acute Care
Version)
Work environment and patient outcomes
[χ2 = 21.074 df = 10]
Work unit
(β, p-value)
structure empowerment and group processes 0.64 p < 0.001
group processes and nurse-assessed quality 0.61 p < 0.001
group processes and falls −0.19 p < 0.05
group processes and nurse-assessed risk −0.17 p < 0.05
Individual
(β, p-value)
psychological empowerment and empowerment behavior
0.47 p < 0.001
psychological empowerment and job satisfaction 0.39 p < 0.001
psychological empowerment and nurse assessed quality of care
0.22 p < 0.001
Squires et al.
(2010) [27]
Ontario, Canada, 2008

cross-sectiona
l267 nurses
To test a model of
examining
relationships among
leadership,
interactional justice,
work environment,
safety climate
quality of the
nursing and patient
and nurse safety.
Nurse managers leadership:
- Resonant Leadership
Leadership (measured by
Resonant leadership Scale)
Nursing work
environment
(by using Perceived nursing
work environment)
Safety climate

(measured by Safety Climate
Survey)
Final model
χ2 = 217.6(138) p < 0.001
-resonant leadership and leader-nurse relationship
(standardized coefficient) 0.52
nurse leader-nurse relationship and safety climate
(standardized coefficient) 0.53
work environment and emotional exhaustion
(standardized coefficient) −0.51
safety climate and medication errors (standardized coefficient)
−0.22
Healthcare 2017, 5, 73 10 of 17
Table 1. Cont.
Main Study
Characteristics

Castle, Decker
(2011) [28]
US, 2008
3867 NHAs (Nursing
Home Administrator)
3867 DONs (Director of
Nursing)
To assess the
relationship of
leadership style and
quality of care.
Four groups of leaders:
- Consensus manager
- Consultative autocrat
- Shareholder manager
- Autocrat
Leadership style
(Bonoma-Slevin leadership

model)
Quality of care
(Nursing Home Compare
Quality Measures and 5-Star
Rating Scores)
Leadership style
Consensus manager vs. consultative vs. shareholder manager
vs. autocrat:
NHA: 33% vs. 22% vs.19% vs. 26%
DON: 30% vs. 20% vs.25% vs. 25%
Leadership and quality of care
[Incident-rate ratio (SE), p-value]
NHA/DON both Consensus Managers:
Percent physical restraint use: 0.97 (0.43), p < 0.05
Percent with moderate to severe pain: 0.51 (0.21), p < 0.01
Percent high-risk residents with pressure ulcers: 0.62 (0.24),
p < 0.05
Percent had a catheter inserted and left in bladder: 0.79 (0.19),
p < 0.001
NHA/DON both Consensus Managers:
(Five-star quality measure score, squares regression)
4.02 p < 0.01

Havig et al.
(2011) [9]
Norway,
Cross-sectional study
40 wards of nursing
homes
414 employees
13 nursing home
directors40 wards
managers
444 staff questionnaires
378 relatives
900 h of field observation
To assess the
relationship
between ward
leaders’ task—and
leadership styles, on
measures of quality
of care.
2 categories of hospitals’

leadership style:
- Task-oriented leaders
- Relationship-oriented leaders
Quality of care
(The national regulation for
quality of care in nursing
homes and home care)
Staffing
Care level
Leadership style and quality of care
[coefficient (p-value)
Task-oriented leadership style
Relatives vs. staff vs. field observations
0.36 (0.02) vs. 0.63 (>0.01) vs. 0.28 (0.12)
Relationship-oriented leadership style
0.12 (0.19) vs. 0.01 (0.91) vs. 0.10 (0.37)
Staffing and quality of care
[coefficient (p-value)Total staffing level
−0.95 (0.31) vs. 0.10 (0.90) vs. 1.17 (0.30)
Ratio of RNs
0.32 (0.66) vs. 0.52 (0.42) vs. 0.20 (0.83)

Ratio of unlicensed staff
−2.05 (>0.01 vs. −0.80 (0.22) vs. −2.59 (>0.01)
Care level
[coefficient (p-value)
−0.20 (>0.01) vs. −0.11 (>0.01) vs. −0.11 (0.02)
Healthcare 2017, 5, 73 11 of 17
Table 1. Cont.
Main Study
Characteristics
Kvist et al.
(2013) [29]
Finland, 2008–2009
Cross-sectional,

descriptive quantitative
design
Four hospitals
2566 patients
Nursing staff
To examine nurses’
and patients’
perceptions of the
Magnet model
components of
transformational
leadership and
quality outcomes.
One category of hospitals’
leadership style:
- Transformational
leadership style
Transformational
Leadership style
(transformational leadership
scale)

Job satisfaction
(The Kuopio University
Hospital Job Satisfaction)
Patient Safety Culture
(The Hospital Survey on
Patient Safety Culture)
(Revised Humane Caring
Scale)
Transformational Leadership style
Support for professional development by nurse managers
(mean, SD) 3.66, 0.96
(mean, SD)Teamwork within units 3.64, 0.69
Supervision 3.60, 0.80
Communication openness 3.57, 0.68
(mean, SD, p-value)
Professional practice 4.49, 0.67
Human resources 3.80, 1.13
PS average score
(mean, SD) 4.18, 0.69
Total JS
(mean, SD) 3.59, 0.62

Transformational leadership
(mean, SD) 3.47, 0.81
(mean, SD) 3.3, 0.47
Healthcare 2017, 5, 73 12 of 17
3. Results
3.1. Bibliographic Search
A total of 2824 records were retrieved through our searches in
Medline and EMBASE databases.
Following reading the titles and abstracts of the retrieved
records 212 remained for further evaluation.
Another 194 articles were excluded after reading the full article.
Figure 1 shows the exact sequence and
process of study identification, selection and exclusion in each
step of the search. Finally, 18 studies
were considered to be appropriate for answering our primary
research question.
Healthcare 2017, 5, 73 10 of 14

3. Results
3.1. Bibliographic Search
A total of 2824 records were retrieved through our searches in
Medline and EMBASE databases.
Following reading the titles and abstracts of the retrieved
records 212 remained for further
evaluation. Another 194 articles were excluded after reading the
full article. Figure 1 shows the exact
sequence and process of study identification, selection and
exclusion in each step of the search.
Finally, 18 studies were considered to be appropriate for
answering our primary research question.
Figure 1. Prisma flowchart.
3.2. Overview of the Included Studies

Among 18 included studies, seven were conducted in the USA,
six in Canada, two in Finland,
one in Saudi Arabia, one in Kuwait, and one in Norway. Among
the relevant studies, 14 were
cross-sectional, two were descriptive correlation studies, one
was a secondary analysis of data, and
one was an exploratory investigation. Diverse care settings were
represented in the studies.
Identified settings included: hospitals/healthcare settings (n =
16), acute and critical care units (n = 1),
and oncology settings (n = 1). In addition, study samples
consisted exclusively of employees (n = 16),
or combination of employees and managers (n = 2). Patient
safety climate, patient satisfaction,
mortality, and quality of care were the main outcomes of
interest. Leadership was assessed in these

studies according to leadership styles, behaviors, perceptions,
and practices. The most commonly
Figure 1. Prisma flowchart.
3.2. Overview of the Included Studies
Among 18 included studies, seven were conducted in the USA,
six in Canada, two in Finland,
one in Saudi Arabia, one in Kuwait, and one in Norway. Among
the relevant studies, 14 were
cross-sectional, two were descriptive correlation studies, one
was a secondary analysis of data,
and one was an exploratory investigation. Diverse care settings
were represented in the studies.
Identified settings included: hospitals/healthcare settings (n =
16), acute and critical care units
(n = 1), and oncology settings (n = 1). In addition, study
samples consisted exclusively of employees
(n = 16), or combination of employees and managers (n = 2).
Patient safety climate, patient satisfaction,
mortality, and quality of care were the main outcomes of
interest. Leadership was assessed in these

Healthcare 2017, 5, 73 13 of 17
studies according to leadership styles, behaviors, perceptions,
and practices. The most commonly used
tool to measure leadership was the Multifactor Leadership
Questionnaire, MLQ, (n = 7). The variety
of the quality measures and different definitions/scales used
among a limited number of included
studies did not allow the performance of a meta-analysis of the
retrieved findings.
3.3. Leadership Style and Patients Outcomes
Improved quality of healthcare services (moderate-severe pain,
physical restraint use, high-risk
residents having pressure ulcers, catheter in bladder) was
reported for consensus manager leadership
style [28]. Resonant leadership influenced the quality of safety
climate which, in turn, impacted on
medication errors [27]. Resonant leadership style was related to
lower 30-day mortality and presented
a strong association of 28% lower probability of 30-day
mortality comparing with high-dissonant
(14% lower) followed by hospitals with mixed leadership styles

[24]. The task-oriented leadership
style was found to relate to higher levels of quality of care
based on the assessment made by relatives
and staff [9]. Furthermore, formal leadership style was
positively associated with learning from minor
and moderate patient safety events, while informal leadership
presented no effect [25]. Patients were
more satisfied when the manager followed a transactional
leadership style [24]. However, Raup found
that there was no association between leadership style and
patient satisfaction [19].
3.4. Organizational Culture and Quality of Care
Important relationships between workplace enforcement and
practice environmental conditions
for staff nurses and patient safety were observed [14]. Authentic
hands-on leadership style, behaviors
and organizational practices of distinctive leadership were
associated with significant differences
in patient level measure of quality and safety; such as mortality
patterns, patient safety, equity and
effectiveness in care [15]. Transformational leadership was
found to positively relate with effective
nursing unit organization culture, while transactional leadership

had a weak relationship. In addition,
laissez-faire leadership was negatively related to nursing unit
organization culture [18]. Findings
confirmed that the higher total structural empowerment score
was correlated to a higher safety
level and empowering workplaces contributed to positive effects
on nursing quality of care [23,26].
Higher entrepreneurial culture was also related to higher levels
of safety climate for the patient [30].
Alahmadi also found that the variables that contributed to
patient safety score included management
role, organization learning, continuous improvement,
communication, teamwork, and feedback about
errors [22]. Singer et al. found that higher group culture was
associated with higher safety climate
overall but more hierarchical culture was correlated with lower
safety climate suggesting that general
organizational culture is important to organizations’ climate of
safety [21]. Role ambiguity and role
conflict on the units were found to relate to higher turnover
rates for nurses. The increased likelihood
of medical error was related to the higher level of role
ambiguity and a higher turnover rate. Finally,
lack of employer care and team support were the most common
reasons for leaving [31].

4. Discussion
Effective leadership in health services has already been
extensively studied in the literature,
especially during the last decades [32]. Several societal
challenges have revealed the urgent need for
effective leadership styles in health and social services.
Nevertheless, studies that use quantitative data
or assess the impact of leadership in health care quality
measures are neglected, while most studies
have adopted a qualitative approach [33]. The present literature
review attempted to fill this gap,
while it managed to identify the most recent publications to
assess the correlation between leadership
styles with healthcare quality measures.
Among the main findings, correlation of leadership with quality
care and a wide range of patient
outcomes (e.g., 30-day mortality, safety, injuries, satisfaction,
physical restraint use, pain, etc.) were
stressed in most of the identified articles [9,24,27,28].
Therefore, leadership is considered a core
element for a well-coordinated and integrated provision of care,
both from the patients and healthcare

Healthcare 2017, 5, 73 14 of 17
professionals. It is essential regardless of where care is
delivered (e.g., clinics or inpatient units,
long-term care units, or home care facilities), especially for
those who are directly involved with
patients for long periods of time [34].
Additionally, effects of leadership style on patient outcomes
were evident in the aforementioned
findings. Other studies [35] agree with our main findings and
stress the theoretical interactions of
effective leadership and patient outcome as follow; effective
leadership fosters a high-quality work
environment leading to positive safety climate that assures
positive patient outcomes. Failure of
leadership to create a quality work place ultimately harms
patients [29,35]. Most of these studies are
focusing on nursing leadership. Particularly, as also reported by
the current study, transformational
and resonant leadership styles are associated with lower patient
mortality, while relational and

task-oriented leadership are significantly related to higher
patient satisfaction [35–37]. Furthermore,
increased patient satisfaction in acute care and homecare
settings has been found to be closely related
to transformational, transactional, and collaborative leadership
[36,37]. Overall, the vast majority
of studies assessing patient outcomes in the literature, have
reported adverse outcomes defined as
unintentional injuries or complications associated with clinical
management, rather than the patient’s
primary condition, resulting in death, disability, or extended
stay in hospital [17,37].
Furthermore, leadership has been recognized as a major
indicator for developing qualitative
organizational culture and effective performance in health care
provision [14]. Similarly to our study,
other studies that used primary quantitative data revealed a
strong correlation of leadership and
safety, effectiveness, and equity in care. For instance,
transformational leadership increases nursing
unit organization culture and structural empowerment [18]. This
has an impact on organizational
commitment for nurses and in return higher levels of job
satisfaction, higher productivity, nursing

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