7 Leadership in Quality Management and Safety

The symptoms or the sufferings generally considered to be inevitable and incident to the disease are very often not symptoms of the disease at all, but of something quite different.

Florence Nightingale (1860, p. 12)


This chapter will focus on quality management (QM) and the maintenance of safety within health care management. You will read about recent significant events related to quality management that have occurred in the United Kingdom and the United States, bringing international attention to patient safety issues. Finally, Lean, a QM strategy, and the plan-do-study-act cycle (PDSA) will be introduced to familiarize you with QM terms and techniques often used in the province of Saskatchewan.

Quality management refers to “the philosophy of a health care culture that emphasizes patient satisfaction, innovation and employee involvement” (Folse, adapted by Wong, 2015, p. 392). Quality assurance (QA) refers to the regular monitoring and evaluation of services to ensure that they meet the established standards of practice. Quality improvement (QI) refers to the ongoing work required to support optimum health for patients, through continued review and revision of processes and procedures according to best practices, emphasizing patient satisfaction, innovation, and employee involvement (Folse, adapted by Wong, 2015).


Figure 7.1 Rigorous Training Ensures Highest Quality
Health Care and Outcomes for Patients 

[n.d.], “Infusion Protocol Display,” photo courtesy of the Saskatchewan Health Authority (formerly Regina Qu’Appelle Health Region) collection number 2003.8-1304, is licensed under a Creative Commons Attribution 4.0 International License.

QI is a fundamental responsibility of all health care providers. Florence Nightingale, one of the first QI experts, changed the provision of health care throughout the world. Her vision of nursing in hospitals “foreshadowed what, more than a century later would be designated a Magnet hospital” (Shiller, 2013, p. 1).


Learning Objectives

  1. Describe the key issues leading to the development of Magnet hospitals.
  2. Identify how Magnet hospitals changed health care in the United States.
  3. Describe the key issues leading to the publication of the Francis report in the UK.
  4. Describe the features of “a culture of safety.”
  5. Appraise the use of Lean in health care.
  6. Appraise the plan-do-study-act (PDSA) cycle as a basis for QI work.
  7. Identify your leadership imperative to create safe work environments and support QI work.

7.1 Magnet Hospitals

Emergence of Magnet Hospitals

Hospitals are a vital health care resource for our communities. Community members usually spend the first and last days of their lives in these buildings, and they regard the hospital as an important health resource that will support them should they be injured or become critically ill. Thus, when hospitals are forced to shut down beds and deny admission to sick people, it becomes a community crisis. Such a crisis occurred in the United States during the 1980s and 1990s when many hospital beds were closed due to a shortage of nurses. However, not all hospitals faced calamity. Some hospitals were fully staffed and remained untouched by the nursing shortages. In 1982, a research team from the American Academy of Nursing identified 41 such hospitals that were not experiencing nurse employment or retention issues. These hospitals became known as Magnet hospitals.

A review of the Magnet hospitals (McClure, Poulin, Sovie, & Wandelt, 1983) revealed 14 attributes or “forces of magnetism” (Goode, Blegen, Park, Vaughn, & Spetz, 2011) that were unique to Magnet hospitals. These “forces” or environmental influences were associated with higher levels of nurse job satisfaction and reduced nurse burnout (McHugh et al., 2013). Magnet hospitals also displayed improved patient outcomes, such as lower patient fall rates, overall reduced mortality rates, and lower mortality rates for very low birth weight infants (McHugh et al., 2013).

The Magnet Recognition Program, formalized in the 1990s, required hospitals desiring Magnet status to demonstrate evidence of organizational reform of nurses’ work environment that would facilitate the achievement of desired patient outcomes. The 14 forces of magnetism described by McClure et al. (1983) had evolved into five goals: (1) transformational leadership; (2) structural empowerment; (3) exemplary professional practice; (4) new knowledge and improvements; and (5) empirical outcomes that are embedded in each of the four previous domains (McHugh et al., 2013). There are presently 389 hospitals in the United States that have demonstrated reform of nurses’ work environment and achieved Magnet hospital status.


Essential Learning Activity 7.1.1

Watch this video titled “Magnet Recognition Program Overview” (5:55) by Mouayad Mohtar, to find out more about the five requirements of Magnet hospitals, then answer the following questions:

  1. What are the five components of the Magnet model?
  2. What are the main characteristics of each of the five components?

Patient Outcomes and Magnet Hospitals

The Magnet hospital model was originally developed to improve RN recruitment and retention. As researchers studied Magnet hospitals, they soon came to the realization that improved patient outcomes were a direct positive outcome of the organizational reform of the nurses’ work environment. A meta-analysis of the literature from 2006 to 2012 by Krueger, Funk, Green, and Kuznar (2013) indicated that there are eight categories of nurse-related variables (nurse hospital work environment, Magnet status, nurse–physician communication, job demands, staffing, education, years of experience, and certification) that have an impact on patient outcomes. Sixteen studies retained in the review revealed that there are significant relationships between these nurse-related variables and three patient outcomes: patient adverse advents (infections, pressure ulcers, prolonged length of stay, mortality rates, failure to rescue, medication errors, patient falls, post-operative hemorrhage, acute myocardial infarction, congestive heart failure, stroke, and craniotomy); cost of patient care; and expected patient outcomes (self-care and readiness for discharge) (Krueger et al., 2013). Review of the Magnet hospital research indicated that staffing was the most stable nurse variable predictor of patient outcomes (Krueger et al., 2013). Magnet hospital research from 2006 to 2015 successfully demonstrated the association between improved nurse variables and successful nurse and patient outcomes. Additionally, a comparison of Magnet hospitals and non-Magnet hospitals demonstrated significantly greater improvements in work environment and nurse and patient outcomes for Magnet hospitals (Kutney-Lee et al., 2015).

Research Note

Ma, C., & Park, S. H. (2015). Hospital Magnet status, unit work environment and pressure ulcers. Journal of Nursing Scholarship, 47(6), 565–573.


To identify how organizational nursing factors at different structural levels (i.e., unit-level work environment and hospital Magnet status) are associated with hospital-acquired pressure ulcers (HAPUs) in US acute care hospitals (Ma & Park, 2015, p. 565).


Cross-sectional observational study used responses from 33,485 RNs to measure work environments.

The unit of analysis was the nursing unit, and the study included 1,381 units in 373 hospitals in the US…. Both hospital and unit environments were significantly associated with HAPUs, and the unit-level work environment can be more influential in reducing HAPUs (Ma & Park, 2015, p. 565).

Application to practice

Investment in the nurse work environments at both the hospital level and unit level has the potential to reduce HAPUs, and in addition to hospital-level initiatives (e.g., Magnet recognition program), efforts targeting on-unit work environments deserve more attention (Ma & Park, 2015, p. 565).

7.2 The Francis Report

A public inquiry into poor care at the Mid Staffordshire NHS Foundation Trust in the UK documented the unnecessary deaths of up to 1,200 people between 2005 and 2009 (Francis, 2013). The first report (Francis, 2010) coming out of the inquiry described an organization that was focused on saving money and creating efficiencies in the system rather than on providing safe quality care to patients. The second report (Francis, 2013) advocated for the organizational culture to be changed to a culture where patient safety and well-being would be the primary focus of management and staff (Muls et al., 2015). Shock waves swelled throughout the UK as news regarding the abusive care spread to the public. Major regulatory organizations and all trusts in the UK reviewed their policies, procedures, and actual processes for provision of care. Action plans were developed to create change and ensure that organizations had a culture responsive to patients’ needs and preferences, with an emphasis on patient safety.


Essential Learning Activity 7.2.1

Watch this video of Catherine Foot interviewing Robert Francis QC (chair of the Francis inquiry) titled “Catherine Foot in conversation with Robert Francis” (9:47), then answer the following questions:

  1. Describe one of the patient stories that Francis shared. Why did the board or coroner not hear about this patient?
  2. Why did staff not come forward with examples of poor patient care?

Watch a short video titled Diane Eltringham: Nurses responses to the Francis Report” (3:04), then answer the following questions:

  1. What happened to care delivery after the Francis report?
  2. How has the organizational culture changed?
  3. What was the change that made the biggest difference to patient care?

7.3 Patient Safety Culture

Health care systems around the world have come to the realization that the presence of a positive patient safety culture within each organization is essential for high-quality and compassionate patient care (Institute of Medicine, 2000; WHO, 2008). Improvement of patient safety is also considered to be a cost-effective intervention since it reduces costs associated with iatrogenic illnesses. Medication error is one documented example of a cost that may be lowered by placing an emphasis on patient safety. In the United States, medication errors cost approximately $19.5 billion and led to 2,500 excess deaths in 2008 (Shreve et al., 2010, as cited in Saleh, Darawad, & Al-Hussami, 2015). Ulrich and Kear (2015) summarize patient outcomes found in safety literature by stating that there is mounting empirical evidence demonstrating a direct link between patient safety culture and patient outcomes, financial outcomes, patient satisfaction, health care clinician behaviours, and the safety of health care professionals. In other words, for a health care organization to be successful, it must exhibit a positive patient safety culture.

Definition of a Patient Safety Culture

An initial review of the literature indicates that the term patient safety culture has emerged recently from the work on health care quality improvement. Saleh, Darawad, and Al-Hussami (2015) suggest that the concept of a safety culture first appeared in response to the Chernobyl nuclear reactor accident (1986), which was a direct outcome of human action rather than mechanical breakdown. A culture of safety is defined by the European Society for Quality in Healthcare as

The integrated pattern of individual and organizational behavior, based upon shared beliefs and values that continuously seek to minimize patient harm, which may result from the processes of care delivery. (European Union Network for Patient Safety, 2010, p. 4)

Insights into Patient Safety Cultures

The 2013 Francis report emphasizes the need for organizations to keep alive a culture that is responsive to patients, or patient-centred. The UK Department of Health developed and publicized “6 C’s” that were to guide their vision and strategy for leadership in nursing, midwifery, and care staff. These 6 C’s, consisting of care, compassion, competence, communication, courage, and commitment, were not new; however prioritizing them as principles to guide the organizations was new (Muls et al., 2015).


Essential Learning Activity 7.3.1

Watch the video “6 C’s in Nursing” (3:32) to find out more, then answer the following questions:

  1. List and describe the 6 C’s in nursing that lead innovation and change in the patient care environment in the UK.
  2. Do you think these 6 C’s are present in the Canadian health care environment? Please discuss.


Health care organizations around the world are striving to strengthen their safety cultures. Cultures do not change easily; instead they adapt to existing conditions and tend to mirror their environment. Many different aspects of an organization play a role in the development and maintenance of a safety culture. Sammer et al. described a safety culture as consisting of “seven subcultures, including leadership, teamwork, evidence-based practice, communication, learning, just (a culture that identifies errors as systems failures rather than individual failures) and patient-centred” (as cited in Saleh et al., 2015, p. 340).

One example of how these subcultures interact, or fail to interact, may be found in a recent study centred on the patient safety culture in nephrology practice settings across the US. This study revealed gaps between how nurses perceive patient safety and how managers and administrators perceive it. Research results illustrated a need for further discussion between care providers and managers regarding patient safety and a need for overall transparency and open communication throughout the organization (Ulrich & Kear, 2015).

Nursing attributes, such as burnout and sense of coherence, are also known to have a direct association with the patient safety culture. A Norwegian study supported this connection by indicating that there was “an association between a positive safety culture and absence of [RN] burnout and high ability to cope with stressful situations” (Vifladt, Simonsen, Lydersen, & Farup, 2016, p. 33).


Essential Learning Activity 7.3.2

Explore the tools and resources on the Leader page of the Canadian Patient Safety Institute website.

Explore the proposed framework titled “The measurement and monitoring of safety” published in 2014 by the UK’s National Health Service.

Now answer the following questions:

  1. What are the five dimensions required to measure and monitor safety?
  2. How would you measure each dimension of the proposed framework in Canadian hospitals?

7.4 Lean

Lean arose from the Toyota success story of the 1960s. It is a management strategy used to evaluate organizational processes, identifying those that add value to the business, eliminating waste, and improving the flow with a focus on creating better value for time and money (Crema & Verbano, 2015; Johnson, Smith, & Mastro, 2012). Crema and Verbano (2015) maintain that this strategy emphasizes standardization of process in order to facilitate the identification of unexpected events that can be fixed quickly.

The Lean approach has been used in the following areas of health care: recruitment and hiring, nursing informatics, laboratory functions, patient care environment, radiology, patient safety, trauma care, and cost reductions. In addition, Lean has contributed to process improvements with regards to clinical procedures, appointment compliance, patient flow, referrals, wait and discharge times, and re-hospitalizations. Johnson, Smith, and Mastro (2012) highlight the fact that Lean is being used more and more frequently as a system-wide operating framework.

The Lean approach was introduced to all Saskatchewan health care organizations in 2010 by the provincial government as a quality improvement approach. Lean has faced many challenges over the past years. However, despite these challenges, it has continued to provide health care leaders with excellent tools and processes that support continuous QI.


Essential Learning Activity 7.4.1

To see an example of Lean in action, watch this YouTube videoAdvanced Lean in Healthcare” (3:08) from Lucile Packard Children’s Hospital at Stanford, then answer the following questions:

  1. What does Lean aim for?
  2. How is patient flow improved?
  3. Who or what is at the centre of Lean?


Lean focuses on resource optimization rather than on excellence or quality of patient care. Concerns have been voiced about the Lean emphasis on “doing more with less” and the need for significant changes. There also has been evidence of anxiety within the health care community regarding misplaced priorities and the safety of patients in a Lean health care environment.

Provision of patient-centred care comes from the specialized knowledge base in concrete ways that nurses practise in their varied roles, from management to direct care. While Lean methods of improving efficiency and cost-cutting strategies are important for hospitals and governments, some health care leaders and researchers believe that Lean methods ignore the actual work of nurses (Wagner, Brooks, & Urban, 2018, p. 22).

However, many researchers, such as Simons et al. (2015), believe that Lean management has the potential to contribute to a patient safety culture. Lean, with its inherent philosophy of quality management, places the patient at the centre and Lean tools are used to motivate employees and increase the efficiency of the organization while also improving patient care quality and patient safety. Other researchers, such as Crema and Verbano (2015), suggest that Lean, a business management strategy with an ability to analyze, design, and manage processes, is an excellent tool to strengthen medical error avoidance. Finally, Kaplan, Patterson, Ching, and Blackmore (2014) emphasize that Lean tools are not the sole answer to an organization’s concerns and are best employed as part of a comprehensive management system with commitment to organizational change and innovative leadership.

Johnson, Smith, and Mastro (2012) advocate that nurses are the ideal leaders of groundbreaking Lean and QI work. Nurses combine experience leading interdisciplinary teams, systems knowledge, and strong assessment skills with a focus on patient advocacy and a commitment to quality patient care. These combined attributes are required to steer an organization toward QI changes that are focused on both cost efficiency and maintenance of a strong patient safety culture. Health care requires nurses, with their versatile skills, knowledge, and experience, to take leadership of QI innovations.

7.5 Plan, Do, Study, and Act

The plan-do-study-act (PDSA) cycle is one of several quality improvement tools or techniques used to improve care. It is easily used at all levels of the organization and focuses on the development, testing, evaluation, and implementation of quality improvement solutions. The PDSA cycle consists of plan (decide on the change to be tested), do (perform the change), study (look at the data before and after the change and determine what has been learned), and act (plan another change cycle with required modifications or move to full implementation). Large-scale changes are implemented only after a PDSA cycle consisting of rapid small-scale sequential or parallel tests has been conducted to investigate the proposed changes and determine if they work (Gillam & Siriwardena, 2013). PDSA has been described as a tool that can be used to evaluate current service delivery and to test and develop innovative ideas (Byrne, Xu, & Carr, 2015).


Essential Learning Activity 7.5.1

Watch these two videos for more detailed information on how to use PDSA: “PDSA Part 1” (4:45) and PDSA Part 2” (3:45).


This chapter introduced the philosophy of QM in health care and highlighted events across the international health care environment that have put a focus on patient safety culture, such as the development of Magnet hospitals in the US and the Francis inquiry in the UK. In addition, common QI approaches such as Magnet hospitals and Lean were described and discussed, with a focus on their contribution to patient safety. Finally, PDSA, a prevalent QI tool, was introduced.

After completing this chapter, you should now be able to:

  1. Describe the key issues leading to the development of Magnet hospitals.
  2. Identify how Magnet hospitals changed health care in the United States.
  3. Describe the key issues leading to the publication of the Francis report in the UK.
  4. Describe the features of “a culture of safety.”
  5. Appraise the use of Lean in health care.
  6. Appraise the plan-do-study-act (PDSA) cycle as a basis for QI work.
  7. Identify your leadership imperative to create safe work environments and support QI work.



  1. Apply the proposed 2014 NHS framework for measuring and monitoring safety to a hospital where you have had a clinical placement. Can you see areas for improvement in measurement and monitoring of safety?
  2. You are the director of nursing for a long-term care facility. When an elderly woman falls out of her bed during the night and breaks her hip, you look at recent incident reports and notice that there has been an increase in residents’ nighttime falls. Use the PDSA QI tool to find a solution that will reduce the nighttime falls of residents.


Byrne, J., Xu, G., & Carr, L. (2015). Developing an intervention to prevent acute kidney injury: Using the plan, do, study, act (PDSA) service improvement approach. Journal of Renal Care, 41(1), 3–8. doi: 10.1111/jorc.12090

Crema, M., & Verbano, C. (2015). Investigating the connections between health lean management and clinical risk management: Insights from a systematic literature review. International Journal of Health Care Quality Assurance, 28(8), 791–811. doi:10.1108/IJHCQA-03-2015-0029

European Union Network for Patient Safety [EUNetPaS]. (2010). Use of patient safety culture instruments and recommendations. Aarhus, DK: European Society for Quality in Health Care—Office for Quality Indicators. Retrieved from http://www.pasq.eu/DesktopModules/BlinkQuestionnaires/QFiles/448_WP4_REPORT%20%20Use%20of%20%20PSCI%20and%20recommandations%20-%20March%20%202010.pdf

Folse, V. N. as adapted by Wong, C. (2015). Managing Quality and Risk. In P. S. Yoder-Wise, L. G. Grant, & S. Regan (Eds.), Leading and managing in Canadian nursing (pp. 391-410). Toronto: Elsevier.

Francis, R. (2010). The Mid Staffordshire NHS Foundation Trust Inquiry. Retrieved from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/279109/0375_i.pdf

Francis, R. (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry Executive Summary. Retrieved from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/279124/0947.pdf

Gillam, S. & Siriwardena, A. N. (2013). Frameworks for improvement: Clinical audit, the plan-do-study-act cycle and significant event audit. Quality in Primary Care, 21, 123–130.

Goode, C. J., Blegen, M. A., Park, S. H., Vaughn, T., & Spetz, J. (2011). Comparison of patient outcomes in Magnet and non-Magnet hospitals. Journal of Nursing Administration, 41(12), 517–523.

Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press.

Johnson, J. E., Smith, A. L., & Mastro, K. A. (2012). From Toyota to the bedside: Nurses can lead the lean way in health care reform. Nursing Administration Quarterly, 36(3), 234–241. doi: 10.1097/NAQ.0b013e318258c3d5

Kaplan, G. S., Patterson, S. H., Ching, J. M., & Blackmore, C. C. (2014). Why Lean doesn’t work for everyone. BMJ Quality & Safety, 23, 970–973. doi:10.1136/bmjqs-2014-003248.

Krueger, L., Funk, C., Green, J., & Kuznar, K. (2013). Nurse-related variables associated with patient outcomes: A review of the literature 2006–2012. Teaching and Learning in Nursing, 8, 120–127.

Kutney-Lee, A., Witkoski Stimpfel, A., Sloane, D. M., Cimiotti, J. P., Quinn, L. W., & Aiken, L. H. (2015). Changes in patient and nurse outcomes associated with magnet hospital recognition. Medical Care, 53(6), 550–557. doi:10.1097/MLR.0000000000000355

Ma, C., & Park, S. H. (2015). Hospital Magnet status, unit work environment and pressure ulcers. Journal of Nursing Scholarship, 47(6), 565–573.

McClure, M., Poulin, M., Sovie, M., & Wandelt, M. (1983). Magnet Hospitals: Attraction and retention of professional nurses. Kansas City, MO: American Nurses Association.

McHugh, M. D., Kelly, L. A., Smith, H. L., Wu, E. S., Vanak, J. M., & Aiken, L. H. (2013). Lower mortality in magnet hospitals. Medical Care, 53(5), 382–388.

Muls, A., Dougherty, L., Doyle, N., Shaw, C., Soanes, L., & Stevens, A. M. (2015). Influencing organizational culture: A leadership challenge. British Journal of Nursing, 24(12), 633–637.

Nightingale, F. (1860). Notes on Nursing: What It Is, and What It Is Not. New York: D. Appleton and Company. Retrieved from http://digital.library.upenn.edu/women/nightingale/nursing/nursing.html

Saleh, A. M., Darawad, M. W., & Al-Hussami, M. (2015). The perception of hospital safety culture and selected outcomes among nurses: An exploratory study. Nursing and Health Sciences, 17, 339–346.

Shiller, J. (2013). A Magnet hospital in Victorian London? RNL Reflections on Nursing Leadership, 39(2), 1–4.

Simons, A. A. M., Houben, R., Vlayen, A., Hellings, J., Pijls-Johannesma, M., Marneffe, W., & Vandijck, D. (2015). Does lean management improve patient safety culture? An extensive evaluation of safety culture in a radiotherapy institute. European Journal of Oncology Nursing, 19, 29–37. doi: 10.1016/j.ejon.2014.08.001

Ulrich, B. & Kear, T. (2015). Patient safety culture in nephrology nurse practice settings: Results by primary work unit, organizational work setting and primary role. Nephrology Nursing Journal, 42(3), 221–237.

Vifladt, A., Simonsen, B. O., Lydersen, S. & Farup, P. G. (2016). The association between patient safety culture and burnout and sense of coherence: A cross-sectional study in restructured and not restructured intensive care units. Intensive and Critical Care Nursing, 35, 26–34.

Wagner, J. I. J., Brooks, D. D., & Urban, A. M. (2018). Health care providers’ spirit at work within a restructured workplace. Western Journal of Nursing Research 40(1), 20–36. doi: 10.1177/0193945916678418

Wong, C. (2015). Understanding and designing organizational structures. In P. S. Yoder-Wise, L. G. Grant, & S. Regan (Eds.), Leading and managing in Canadian nursing (pp. 125–148). Toronto: Elsevier.

World Health Organization [WHO]. (2008). Summary of the evidence on patient safety: Implications for research. Spain: WHO.


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Leadership and Influencing Change in Nursing by Joan Wagner is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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