Table 4.

Theme 3 (staff support, upskilling, and shared learning) and Theme 4 (Patient engagement, experiences, and expectations) summary, illustrated with participant quotations.

Theme 3: staff support, upskilling, and shared learning
Sub-theme: staff support and capacity
‘So, like my early examples where you know, that culture just didn’t support a reporting or a learning organisation. I think if they [staff] feel supported and comfortable that you know, nothing adverse will come, it’s just about learning, I think they’re more than happy to support that process.’ (Participant 20) ‘Usually the nurses are mostly involved in quality management. But in big hospitals they’re really stressed because they have the doctors, the residents, that put pressure on them, we put pressure on them. And in hospitals there are really few, they don’t have enough staff, so there’s another type of pressure.. I think the solution is to, to get, get more in the field.’ (Participant 11) ‘I think the most challenging is about, I suppose, getting everyone onto the same value proposition that it’s a good use of their time. Obviously, everyone’s always busy and everyone’s got priorities and actually, you know, getting, having, sort of, different conversations with different people to actually find a thing that connected to say this is a good use of your time. Because you need that buy-in, that sort of buy-in. There are a lot of willing people but they’re willing to do it in their own time. But if you actually want to do this together, you’ve got to, there’s a compromise that, you know, has to happen from there. So I think that’s probably, and that takes time. And, you know, it’s all about agile and, you know, quick movements and parts from there. But if you don’t spend that, you know, you do have to invest time to make time.’ (Participant 8) ‘The characteristics of effective initiatives include empowerment of staff and having safety/quality Champions.’ (Participant 9)
Sub-theme: staff upskilling
‘I think we have a big problem on education because patient safety, quality management nobody teaches it in the faculty of medicine or the residency.’ (Participant 11) ‘Clinician education in safety/quality plays an important role. Education needs to be ongoing through the career.’ (Participant 9) ‘We also are teaching hospital, and you see most of the health care workers wherever they are, we do also teach some of these models of patient safety, so that right, when they go back to their facilities, then well, they their workforce can actually start implementing these.’ (Participant 18) ‘Or that like, for example, university hospital staffers and the big private hospitals they have well-established, say, residency programs for the physicians and they are an educational hospital. And they are working a lot on building capacity of their health care providers, including physicians, nurses and other health care providers.’ (Participant 23) ‘Really think that if we could push, that we have these discussions right from medical school, nursing school it will really make a big impact. It will change the attitudes of the professionals, even as they come to practice. So, that is one of the biggest gaps that exist. When we come to talk to these people and they have already been in the system, they have already developed bad cultures, so again, changing those attitudes will take a bit of time.’ (Participant 18) ‘I think there’s an awful lot that needs to go into teamwork and the non-technical skills, the communication skills for everybody.’ (Participant 20) ‘So, we address processes to say: “Let’s put in place huddles” and “let’s put in place improved ways for people to hand over” and “let’s talk about open disclosure”. But we don’t address the fact that we have a huge population of people working in health that actually don’t know how to communicate well, that don’t know how to have a good conversation, that don’t listen. So, we’re not dealing with the human factors.You can mandate a huddle and you can mandate handover, mandate all of these sorts of things but when you talk to people about communication in health, often it’s the attitude, behaviour of individuals and their communication skills.’ (Participant 1)
Sub-theme: hared learning
‘We have a, like ISQua webinars, like an hour. We call them the “quality hour”. We present best practices from our country. Hospitals that really stood up and how did they do that. And it’s interesting because we have seen something like 400–500 people watching every time. Mostly doctors, managers from, from the systems. Things are getting to others so the information is flowing.’ (Participant 11). ‘International collaborations have been valuable – learning what has been successful in other countries.’ (Participant 16)
Theme 4: patient engagement, experiences, and expectations
Sub-theme: patient engagement and experiences
‘When we come to talk to these people and they have already been in the system, they have already developed bad cultures, so again, changing those attitudes will take a bit of time, like I said I’ve been here for 25 years, and they have never heard about patient centred issues.’ (Participant 18) ‘Emerging Leaders in Patient Safety, we had on the, we had 30 scholars, 10 faculty, 2 or 3 of the faculty were always patient advocates. And the feedback from the scholars saying: this is the best part; I’d never dreamt of the patient’s experience before. And several of those people totally changed their careers and gone into patient safety as a result of the, you know.so, you know, I think the patient experience is something people need to hear.’ (Participant 2)
Sub-theme: patient expectations
‘Patient attitudes and health literacy beginning to show signs of change but will take a long time to alter entrenched culture of healthcare.’ (Participant 5) ‘We have the problem of the patients, like, the education level is really low. There is not a complaint culture in Romania. They say if you have a problem, the hospital or anywhere else, you’re just, OK, if you manage this and nothing really bad happened, you won’t do a formal complaint or something. So, this is a problem ‘cause there are a lot of risks and a lot of adverse events happen in the hospital but the patients do not follow them through. So, if they, let’s say, if a patient falls on the stairs because of the medication, and he stays a few days more in the hospital, let’s say he doesn’t get a bad injury. He says: “Thank God it wasn’t worse.” And that’s all.’ (Participant 11) ‘That is part of what I’m doing presently continuously to engage and advocate and … all the patients they … practitioners in the health care system, that’s the communication and collaborative is not … they are … doctors believe they are the top … so they notice … tend to be afraid or there is conflicts in working together and what they want … is to ensure that is collaborative and adequate … communication, similar the health care staff and this will also work for the patients themselves for them to know that they are not passenger, they are partner in their own care. So, if patients know their rights to be able to inform the doctors or nurse or whatever in this system that this is what is … for, like if you have health care accreditation … be able to speak … the doctor … procedure … to me, so this how was me trying to improve on, so presently there are communication challenges within the health care.’ (Participant 21)
‘Well…the health systems are different; not because of what they do but how they manage their culture at a broader level. So, in China, of course, huge populations, they don’t have the same requirements around volumes of staff versus numbers of patients. So, the clinicians there deal with significantly more patient load than what clinicians here would deal with. But of course, here, outside of safety and quality you’ve also got unions that have a voice. And you’ve got public discussion around number of hospital beds, number of nurses, the number of doctors, so…you’ve got much more open conversation about, and more open opportunities to criticize and have your politicians respond that you do in other countries that are…Yeah, yeah. ‘Cause it’s public pressure. Whereas that’s emerging in places like China, that’s emerging, that public pressure and that public voice. But it’s still, there is still, I think, an umbrella of silence. People don’t want to be critical and they are, like I said, they’re dealing with extremely large numbers of….I mean, that’s, the clinicians here would just not cope, not cope at all with the volume. So, their approaches to safety and quality have to be different because of culture, volume, the fact that they’re not, they don’t have that union voice, you know, all those other sorts of things that impact on health system as part of a broader system of public services.’ (Participant 1)