Patient involvement in quality improvement: a survey comparing naturalistic and reflective approaches.

BACKGROUND: This study investigates reflective and naturalistic approaches to patient involvement in quality improvement. The reflective approach, using, for example, interviews, provides insights into patient needs and demands to support an established improvement agenda. The naturalistic approach, for example, observations, is used to discover practical problems and opportunities that professionals are currently unaware of. METHODS: We assessed the use of naturalistic and reflective approaches in quality improvement to see whether they differed in their impact on patient needs, financial improvements and improved patient flows. Four possible combinations were used as a starting point: restrictive (low reflective-low naturalistic), in situ (low reflective-high naturalistic), retrospective (high reflective-low naturalistic) and blended (high reflective-high naturalistic). Data were collected through an online cross-sectional survey using a web-based survey tool. The original sample was based on a list of 472 participants enrolled in courses on improvement science in three Swedish regions. The response rate was 34%. Descriptives and ANOVA (Analysis of Variance) in SPSS V.23 were used for the statistical analysis. RESULTS: The sample consisted of 16 projects characterised as restrictive, 61 as retrospective and 63 as blended. No projects were characterised as in situ. There was a significant effect of patient involvement approaches on patient flows and patient needs at the p<0.05 level (patient flows, (F(2, 128)=5.198, p=0.007) and patient needs (F(2, 127)=13.228, p=0.000)). No significant effect was found for financial results. CONCLUSIONS: Moving beyond restrictive patient involvement is important to meet new patient needs and improve patient flows. This can be done either by increasing the use of a reflective approach or by increasing the use of both reflective and naturalistic approaches. A blended approach with high levels of both is likely to produce better results in addressing new patient needs and improving patient flows.

Predicting Outcome for Early Attention Training After Acquired Brain Injury.

Background: The training of impaired attention after acquired brain injury is central for successful reintegration in daily living, social, and working life. Using statistical process control, we found different improvement trajectories following attention training in a group of relatively homogeneous patients early after acquired brain injury (ABI). Objective: To examine the contribution of pre-injury factors and clinical characteristics to differences in outcome after early attention training. Materials and Methods: Data collected in a clinical trial comparing systematic attention training (APT) with activity-based attention training (ABAT) early after brain injury were reanalyzed. Results: Stroke patients (p = 0.004) with unifocal (p = 0.002) and right hemisphere lesions (p = 0.045), and those with higher mental flexibility (TMT 4) (p = 0.048) benefitted most from APT training. Cognitive reserve (p = 0.030) was associated with CHANGE and APT as the sole pre-injury factor. For TBI patients, there was no statistical difference between the two treatments. Conclusion: Our study identifies indiscernible factors predicting improvement after early attention training. APT is beneficial for patients with right-hemispheric stroke in an early recovery phase. Knowledge of prognostic factors, including the level of attention deficit, diagnosis, and injury characteristics, is vital to maximizing the efficiency of resource allocation and the effectiveness of rehabilitative interventions to enhance outcomes following stroke and TBI.

Exploring power shifts as an enabler for a strengthened patient role in quality improvements: a Swedish survey study.

OBJECTIVES: This study examined the relationship between professionals' perceptions of a strengthened role for the patient and of patient involvement in quality improvement (QI) and whether professionals' experiences in improvement science were a moderator on such a relationship. DESIGN: From a predominantly close-ended, 44-item questionnaire, 4 questions specifically concerning professionals' perception on patient involvement in QI were analysed. SETTING: Three Swedish regions. PARTICIPANTS: 155 healthcare professionals who had previously participated in courses in improvement science. RESULTS: The covariate patient involvement was significantly related to a perceived strengthened patient role. There was also a significant interaction effect between degree of patient involvement and professionals' experience in the area of improvement science on a strengthened patient role. The result shows that there is a relationship between the perceived level of patient involvement in improvements and professionals' perceptions of a strengthened patient role. In this study, the covariate, perceived patient involvement, was significantly related to experiences of more equal relationships between patients and healthcare professionals. There was also a significant interaction effect between the degree of patient involvement and professionals' experience in the area of improvement science, for a more equal relationship between patients and healthcare professionals. CONCLUSION: Increased patient involvement in QI is a means of strengthening the patient role and supporting a more equal relation between patients and healthcare professionals. Furthermore, empirical evidence shows that the healthcare professionals' experiences in the area of improvement science support a strengthened patient role and a more equal power relationship, but for this to happen, the mindset of professionals is key. Future research is needed to capture and investigate the experiences from patients and relatives about being involved in QI in healthcare, and to study the effects on quality in care processes.

The role of professional logics in quality register use: a realist evaluation.

BACKGROUND: Clinical practice improvements based on quality-register data are influenced by multiple factors. Although there is agreement that information from quality registers is valuable for quality improvement, practical ways of organising register use have been notoriously difficult to realise. The present study sought to investigate the mechanisms that lead various clinicians to use quality registers for improvement. METHODS: This research involves studying individuals' decisions in response to a Swedish programme focusing on increasing the use of quality registers. Through a case study, we focused on heart failure care and its corresponding register: the Swedish Heart Failure Register. The empirical data consisted of a purposive sample collected longitudinally by qualitative methods between 2013 and 2015. In total, 18 semi-structured interviews were carried out. We used realist evaluation to identify contexts, mechanisms, and outcomes. RESULTS: We identified four contexts - registration, use of output data, governance, and improvement projects - that provide conditions for the initiation of specific mechanisms. Given a professional theoretical perspective, we further showed that mechanisms are based on the logics of either organisational improvement or clinical practice. The two logics offer insights into the ways in which clinicians choose to embrace or reject certain registers' initiatives. CONCLUSIONS: We identified a strong path dependence, as registers have historically been tightly linked to the medical profession's competence. Few new initiatives in the studied programme reach the clinical context. We explain this through the lack of an organisational improvement logic and its corresponding mechanisms in the context of the medical profession. Implementation programmes must understand the logic of clinical practice; that is, be integrated with the ways in which work is carried out in everyday practice. Programmes need to be better at helping core health professionals to reach the highest standards of patient care.

Beneficial effects of early attention process training after acquired brain injury: A randomized controlled trial.

BACKGROUND: Evaluation of outcome after intensive cognitive rehabilitation early after brain injury is complicated due to the ongoing biological recovery process. OBJECTIVE: To evaluate the efficacy of Attention Process Training early after acquired brain injury through time-series measurement with statistical process control. DESIGN: Randomized controlled trial. METHOD: Patients with acquired brain injury (n = 59) within 4 months' post-injury in interdisciplinary rehabilitation received an additional 20 h of attention training with Attention Process Training or with activity-based attention training. The primary outcome variable was Paced Auditory Serial Attention Test (PASAT) evaluated using statistical process control. RESULTS: Both groups improved (p < 0.001), although a higher number of patients improved with attention process training (χ2 (1, n = 59) = 5.93, p = 0.015) and the variability was significantly decreased. The Attention Process Training group maintained or improved performance at 6 months follow-up (χ2 (1, n = 51) = 6,847, p = 0.033). Attention Process Training required fewer intervention hours for improvement. Based on individual performance, 3 improvement trajectories were identified: stationary, steady, and rapid improvers. CONCLUSION: The results indicate that attention training is promising early after acquired brain injury and that Attention Process Training boosts functional improvement. Notably, in the present group of relatively homogeneous patients, 3 different trajectories were identified for recovery after acquired brain injury regardless of intervention.

Exploring the phase for highest impact on radicality: a cross-sectional study of patient involvement in quality improvement in Swedish healthcare.

OBJECTIVES: Involving patients in quality improvement is often suggested as a critical step for improving healthcare processes. However, this comes with challenges related to resources, tokenism, validity and competence. Therefore, to optimise the use of available resources, there is a need to understand at what stage in the improvement cycle patient involvement is most beneficial. Thus, the purpose of this study was to identify the phase of an improvement cycle in which patient involvement had the highest impact on radicality of improvement. DESIGN: An exploratory cross-sectional survey was used. SETTING AND METHODS: A questionnaire was completed by 155 Swedish healthcare professionals (response rate 34%) who had trained and had experience in patient involvement in quality improvement. Based on their replies, the impact of patient involvement on radicality in various phases of the improvement cycle was modelled using the partial least squares method. RESULTS: Patient involvement in quality improvement might help to identify and realise innovative solutions; however, there is variation in the impact of patient involvement on perceived radicality depending on the phase in which patients become involved. The highest impact on radicality was observed in the phases of capture experiences and taking action, while a moderate impact was observed in the evaluate phase. The lowest impact was observed in the identify and prioritise phase. CONCLUSIONS: Involving patients in improvement projects can enhance the quality of care and help to identify radically new ways of delivering care. This study shows that it is possible to suggest at what point in an improvement cycle patient involvement has the highest impact, which will enable more efficient use of the resources available for patient involvement.

Statistical process control: A feasibility study of the application of time-series measurement in early neurorehabilitation after acquired brain injury.

BACKGROUND: Progress in early cognitive recovery after acquired brain injury is uneven and unpredictable, and thus the evaluation of rehabilitation is complex. The use of time-series measurements is susceptible to statistical change due to process variation. OBJECTIVE: To evaluate the feasibility of using a time-series method, statistical process control, in early cognitive rehabilitation. METHOD: Participants were 27 patients with acquired brain injury undergoing interdisciplinary rehabilitation of attention within 4 months post-injury. The outcome measure, the Paced Auditory Serial Addition Test, was analysed using statistical process control. RESULTS: Statistical process control identifies if and when change occurs in the process according to 3 patterns: rapid, steady or stationary performers. The statistical process control method was adjusted, in terms of constructing the baseline and the total number of measurement points, in order to measure a process in change. CONCLUSION: Statistical process control methodology is feasible for use in early cognitive rehabilitation, since it provides information about change in a process, thus enabling adjustment of the individual treatment response. Together with the results indicating discernible subgroups that respond differently to rehabilitation, statistical process control could be a valid tool in clinical decision-making. This study is a starting-point in understanding the rehabilitation process using a real-time-measurements approach.

Interrupted Time Series Versus Statistical Process Control in Quality Improvement Projects.

To measure the effect of quality improvement interventions, it is appropriate to use analysis methods that measure data over time. Examples of such methods include statistical process control analysis and interrupted time series with segmented regression analysis. This article compares the use of statistical process control analysis and interrupted time series with segmented regression analysis for evaluating the longitudinal effects of quality improvement interventions, using an example study on an evaluation of a computerized decision support system.

Unpacking the key components of a programme to improve the timeliness of hip-fracture care: a mixed-methods case study.

BACKGROUND: Delay to surgery for patients with hip fracture is associated with higher incidence of post-operative complications, prolonged recovery and length of stay, and increased mortality. Therefore, many health care organisations launch improvement programmes to reduce the wait for surgery. The heterogeneous application of similar methods, and the multifaceted nature of the interventions, constrain the understanding of which method works, when, and how. In complex acute care settings, another concern is how changes for one patient group influence the care for other groups. We therefore set out to analyse how multiple components of hip-fracture improvement efforts aimed to reduce the time to surgery influenced that time both for hip-fracture patients and for other acute surgical orthopaedic inpatients. METHODS: This study is an observational mixed-methods single case study of improvement efforts at a Swedish acute care hospital, which triangulates control chart analysis of process performance data over a five year period with interview, document, and non-participant observation data. RESULTS: The improvement efforts led to an increase in the monthly percentage of hip-fracture patients operated within 24 h of admission from an average of 47% to 83%, with performance predictably ranging between 67% and 98% if the process continues unchanged. Meanwhile, no significant changes in lead time to surgery for other acute surgical orthopaedic inpatients were observed. Interview data indicated that multiple intervention components contributed to making the process more reliable. The triangulation of qualitative and quantitative data, however, indicated that key changes that improved performance were the creation of a process improvement team and having an experienced clinician coordinate demand and supply of surgical services daily and enhance pre-operative patient preparation. CONCLUSIONS: Timeliness of surgery for patients with hip fracture in a complex hospital setting can be substantially improved without displacing other patient groups, by involving staff in improvement efforts and actively managing acute surgical procedures.

Prospects and problems of transferring quality-improvement methods from health care to social services: two case studies.

INTRODUCTION: This study examines the use of quality-improvement (QI) methods in social services. Particularly the key aspects-generalizable knowledge, interprofessional teamwork, and measurements-are studied in projects from the QI program Forum for Values in Sweden. METHODS: This is a mixed-method case study. Two projects using standard QI methods and tools as used in health care were chosen as critical cases to highlight some problems and prospects with the use of QI in social services. The cases were analyzed through documented results and qualitative interviews with participants one year after the QI projects ended. RESULTS: The social service QI projects led to measurable improvements when they used standard methods and tools for QI in health care. One year after the projects, the improvements were either not continuously measured or not reported in any infrastructure for measurements. The study reveals that social services differ from health care regarding the availability and use of evidence, the role of professional expertise, and infrastructure for measurements. CONCLUSIONS: We argue that QI methods as used in health care are applicable in social services and can lead to measurable improvements. The study gives valuable insights for QI, not only in social services but also in health care, on how to assess and sustain improvements when infrastructures for measurements are lacking. In addition, when one forms QI teams, the focus should be on functions instead of professions, and QI methods can be used to support implementation of evidence-based practice.

Evaluating a breakthrough series collaborative in a Swedish health care context.

This study evaluated the use of the Breakthrough Series Collaborative methodology in a Swedish county council improvement program, comparing measurements at the beginning and after 6 months. A questionnaire was used, and improvement processes and outcomes were analyzed. The results showed an overall large engagement in improvements, although the methodology and facilitators were seen as only moderately supportive.

Two different strategies to facilitate involvement in healthcare improvements: a Swedish county council initiative.

BACKGROUND: From a management point of view, there are many different approaches from which to choose to engage staff members in initiatives to improve performance. OBJECTIVE: The present study evaluated how two different types of improvement strategies facilitate and encourage involvement of different professional groups in health-care organizations. METHODS/DESIGN: Empirical data of two different types of strategies were collected within an improvement project in a County Council in Sweden. The data analysis was carried out through classifying the participants' profession, position, gender, and the organizational administration of which they were a part, in relation to their participation. SETTING: An improvement project in a County Council in Sweden. PARTICIPANTS: Designed Improvement Processes consisted of n=105 teams and Intrapreneurship Projects of n=202 projects. INTERVENTION: Two different types of improvement strategies, Designed Improvement Processes and Intrapreneurship Projects. MAIN OUTCOME MEASURES: How two different types of improvement strategies facilitate and encourage involvement of different professional groups in healthcare organizations. RESULTS: Nurses were the largest group participating in both improvement initiatives. Physicians were also well represented, although they seemed to prefer the less structured Intrapreneurship Projects approach. Assistant nurses, being the second largest staff group, were poorly represented in both initiatives. This indicates that the benefits and support for one group may push another group aside. CONCLUSIONS: Managers need to give prerequisites and incentives for staff who do not participate in improvements to do so. Comparisons of different types of improvement initiatives are an underused research strategy that yields interesting and thoughtful results.

Design, application and impact of quality improvement 'theme months' in orthopaedic nursing: a mixed method case study on pressure ulcer prevention.

BACKGROUND: While there is growing awareness of quality problems in healthcare systems, it remains uncertain how best to accomplish and sustain improvement over time. OBJECTIVE: To report on the design and application of quality improvement theme months in orthopaedic nursing, and evaluate the impact on pressure ulcer as an example. DESIGN: Retrospective mixed method case study with time series diagrams. SETTING: An orthopaedic department at a Swedish university hospital. METHOD: The interventions were led by nursing teams and focused on one improvement theme at a time in two-month cycles, hence the term 'improvement theme months'. These included defined objectives, easy-to-use follow-up measurement, education, changes to daily routines, "reminder months" and data feedback. The study draws on retrospective record data regarding one of the theme topics, pressure ulcer risk assessment and prevalence, in 2281 orthopaedic admissions during January 2007-October 2010 through point prevalence measurement one-day per month. Data were analysed in time series diagrams and through comparison to annual point prevalence data from mandatory county council-wide measurements prior to, during and after interventions from 2003 to 2010. By using document analysis we reviewed concurrent initiatives at different levels in the healthcare organisation and related them to the improvement theme months and their impact. RESULTS: The 46 monthly point prevalence samples ranged from 28 to 66 admissions. Substantial improvements were found in risk assessment rates for pressure ulcers both in the longitudinal follow-up (p<0.001) and in the annual county council-wide measurements. A reduction in pressure ulcer rate was observed in the annual county council-wide measurements. In the longitudinal data, wider variation in the pressure ulcer rate was seen (p<0.067); however, there was a significant decrease in pressure ulcer rates during the final ten-month period in 2010, compared to the baseline period in 2007 (p=0.004). Improvements were moderate the first years and needed reinforcement to be maintained. CONCLUSIONS: The theme month design and the way it was applied in this case showed potential, contributing to reduced pressure ulcer prevalence, as a way to conduct quality improvement initiatives in nursing. For sustainable improvement, multi component interventions are needed with regular monitoring and reminder efforts.

Evaluating a questionnaire to measure improvement initiatives in Swedish healthcare.

BACKGROUND: Quality improvement initiatives have expanded recently within the healthcare sector. Studies have shown that less than 40% of these initiatives are successful, indicating the need for an instrument that can measure the progress and results of quality improvement initiatives and answer questions about how quality initiatives are conducted. The aim of the present study was to develop and test an instrument to measure improvement process and outcome in Swedish healthcare. METHODS: A questionnaire, founded on the Minnesota Innovation Survey (MIS), was developed in several steps. Items were merged and answer alternatives were revised. Employees participating in a county council improvement program received the web-based questionnaire. Data was analysed by descriptive statistics and correlation analysis. The questionnaire psychometric properties were investigated and an exploratory factor analysis was conducted. RESULTS: The Swedish Improvement Measurement Questionnaire consists of 27 items. The Improvement Effectiveness Outcome dimension consists of three items and has a Cronbach's alpha coefficient of 0.67. The Internal Improvement Processes dimension consists of eight sub-dimensions with a total of 24 items. Cronbach's alpha coefficient for the complete dimension was 0.72. Three significant item correlations were found. A large involvement in the improvement initiative was shown and the majority of the respondents were satisfied with their work. CONCLUSIONS: The psychometric property tests suggest initial support for the questionnaire to study and evaluate quality improvement initiatives in Swedish healthcare settings. The overall satisfaction with the quality improvement initiative correlates positively to the awareness of individual responsibilities.

Framework for assessing quality of care for inflammatory bowel disease in Sweden.

AIM: To create and apply a framework for quality assessment and improvement in care for inflammatory bowel disease (IBD) patients. METHODS: A framework for quality assessment and improvement was created for IBD based on two generally acknowledged quality models. The model of Donabedian (Df) offers a logistical and productive perspective and the Clinical Value Compass (CVC) model adds a management and service perspective. The framework creates a pedagogical tool to understand the balance between the dimensions of clinical care (CVC) and the components of clinical outcome (Df). The merged models create a framework of the care process dimensions as a whole, reflecting important parts of the IBD care delivery system in a local setting. Clinical and organizational quality measures were adopted from clinical experience and the literature and were integrated into the framework. Data were collected at the yearly check-up for 481 IBD patients during 2008. The application of the quality assessment framework was tested and evaluated in a local clinical IBD care setting in Jönköping County, Sweden. RESULTS: The main outcome was the presentation of how locally-selected clinical quality measures, integrated into two complementary models to develop a framework, could be instrumental in assessing the quality of care delivered to patients with IBD. The selected quality measures of the framework noted less anemia in the population than previously reported, provided information about hospitalization rates and the few surgical procedures reported, and noted good access to the clinic. CONCLUSION: The applied local quality framework was feasible and useful for assessing the quality of care delivered to IBD patients in a local setting.

How does lean work in emergency care? A case study of a lean-inspired intervention at the Astrid Lindgren Children's hospital, Stockholm, Sweden.

BACKGROUND: There is growing interest in applying lean thinking in healthcare, yet, there is still limited knowledge of how and why lean interventions succeed (or fail). To address this gap, this in-depth case study examines a lean-inspired intervention in a Swedish pediatric Accident and Emergency department. METHODS: We used a mixed methods explanatory single case study design. Hospital performance data were analyzed using analysis of variance (ANOVA) and statistical process control techniques to assess changes in performance one year before and two years after the intervention. We collected qualitative data through non-participant observations, semi-structured interviews, and internal documents to describe the process and content of the lean intervention. We then analyzed empirical findings using four theoretical lean principles (Spear and Bowen 1999) to understand how and why the intervention worked in its local context as well as to identify its strengths and weaknesses. RESULTS: Improvements in waiting and lead times (19-24%) were achieved and sustained in the two years following lean-inspired changes to employee roles, staffing and scheduling, communication and coordination, expertise, workspace layout, and problem solving. These changes resulted in improvement because they: (a) standardized work and reduced ambiguity, (b) connected people who were dependent on one another, (c) enhanced seamless, uninterrupted flow through the process, and (d) empowered staff to investigate problems and to develop countermeasures using a "scientific method". Contextual factors that may explain why not even greater improvement was achieved included: a mismatch between job tasks, licensing constraints, and competence; a perception of being monitored, and discomfort with inter-professional collaboration. CONCLUSIONS: Drawing on Spear and Bowen's theoretical propositions, this study explains how a package of lean-like changes translated into better care process management. It adds new knowledge regarding how lean principles can be beneficially applied in healthcare and identifies changes to professional roles as a potential challenge when introducing lean thinking there. This knowledge may enable health care organizations and managers in other settings to configure their own lean program and to better understand the reasons behind lean's success (or failure).

Five types of practice-based improvement ideas in health care services: an empirically defined typology.

The aim of this study is to empirically identify and present different kinds of practice-based improvement ideas developed in health care services. The focus is on individual placement needs, problems/issues, and the ability to organize work on the development, implementation, and institutionalization of ideas for the health care sector. This study is based on a Swedish county council improvement program. Health care departments and primary health care centers in the Kalmar County Council were invited to apply for money to accomplish improvement projects. A qualitative content analysis was done of 183 proposed applications from various health care departments and primary health care centers. The following 5 types of improvement projects were identified: organizational process, evidence and quality, competence development, process technology, and proactive patient work. This illustrates the range of strategies that encourage letting individual units define their own improvement needs. These projects point to the various problems and experiences health care professionals encounter in their day-to-day work. To generalize beyond this improvement program and to validate the typology, we applied it to all articles found when searching for quality improvement projects in the journal Quality Management in Health Care during the last 2 years and found that all of them could be fitted into at least 1 of those 5 categories. This article provides valuable insights into the current state of improvement work in Swedish health care, and will serve as a foundation for further investigations in this quality improvement program.

Swedish healthcare management practices and quality improvement work: development trends.

PURPOSE: The purpose of this paper is to empirically examine developmental trends in healthcare organisation management practice and improvement work. DESIGN/METHODOLOGY/APPROACH: Primary healthcare centre (n = 1,031) and clinical hospital department (n = 1,542) managers were surveyed in spring 2007 (response rate 46 per cent). This article compares results from this survey with a study in 2003. A theoretical framework based on organisational inner context, organisational outer context, external environment and outcomes form the analytical base. Comparisons were made using independent two-sample t-tests. FINDINGS: A general aspect, identified empirically, is the tendency toward increased external pressure on leaders in their improvement work. Higher management decisions, patient pressure and decisions made by policymakers increasingly influence and shape the choices made by healthcare managers about where to focus improvement efforts. Three different trends are empirically identified and elaborated: take-control logic; practice-based improvement; and patient-centeredness. RESEARCH LIMITATIONS/IMPLICATIONS: Healthcare leaders should carefully design new management control systems that support healthcare micro systems. Findings support the general assumption that staff increasingly tend to focus organisational changes on management control. ORIGINALITY/VALUE: This study extends management research with a unique survey. Through two measurements made in 2003 and 2007, several important trends about how healthcare organisations are managed and developed are identified.

Patient safety as perceived by Swedish leaders.

PURPOSE: The purpose of this paper is to survey Swedish healthcare leaders' patient safety awareness, the priority they give to safety issues and their views on suitable safety management strategies. DESIGN/METHODOLOGY/APPROACH: A total 623 leaders of a sample of 1,129 responded to a mail questionnaire (55 percent response rate). Descriptive statistics of the responses are presented as frequency distributions across respondent subgroups. Means were tested for similarity by a repetitive one-way ANOVA procedure. Homogeneous response groups were sought by hierarchical cluster analysis. FINDINGS: Swedish healthcare leaders show relatively high safety awareness and how their organizations prioritize safety management. There is a marked polarization between leaders; half feel that the system works reasonably well, and that adequate funds are available to improve or maintain services. The other half thinks the system needs major change and calls for additional funding. A majority sees system errors as the main cause for adverse events; a substantial minority find human errors to be more important. Two-thirds were willing to make safety performance information on organizations and specialties public, one third was restrictive. RESEARCH LIMITATIONS/IMPLICATIONS: Survey instruments used to explore leaders' patient safety views have not yet been rigorously tested against psychometric criteria. One hospital type was slightly over-represented and three regions somewhat under-represented in the respondent groups. ORIGINALITY/VALUE: This is the first systematic attempt to explore the views of Swedish healthcare leaders on patient safety. It provides input to a national strategy to improve patient safety.