Table 3.

Illustrative quotations regarding hospital organisational culture

Domain of culture	Hospitals with substantial positive culture change	Hospitals without substantial culture change
Learning environment	Data to drive change. “We participate in all these registries…[LSL] has really opened my eyes to make some hypotheses [about] what we need to look at as a group to improve patient care…to utilize that data to drive change.” (ID F_18; RN Chest Pain Center) Search for root causes. “Now everyone is focusing on the whys. It is not just because I said so… You trust more to depend on the next person than you may have in the past… It is just alot more comfortable.” (ID G_10; CathLab CV Technician) Greater creativity. “We have some very creative people, but there hadn’t been a lot of permission to…think out of the box…and to realize that some of the best ideas came from a respiratory technician. As that openness developed, some of those great ideas were really valued.” (ID I_02; CMO) Shared responsibility for problem solving. “[Previously], quality efforts such as Plan-Do-Study-Act were…not really institutionalized. It was like, ‘Okay, whatever.’ [Now] we have created a really good safe, open environment to work on creative problem solving, where everybody has an equal voice.” (ID A_12; Chief Executive)	Data not valued. “We had to convince our physician leaders, and it was a struggle. We had to put the data in front of them, and we had to show them, ‘Look, this patient had a bad outcome because nobody could reach the right person.’ Even still, it still was like, ‘Well, that was a one-off.’” (ID H_07; Chief Nurse for Quality) Lack of creativity. “We struggle with creative problem solving. We’re so squarely in the box that we can’t even see the edge…it’s part of the culture. People are afraid to take risks, for whatever reason.” (ID B_05; Supervisor of Pharmacy) Lack of shared responsibility for problem solving. “There’s a lot of people that want to bring the problems forward; however, they don’t want to problem solve. They [say], ‘Here you go. Here’s the problem that I see. Now fix it.’” (ID E_04; Quality Analyst)
Senior management	Engagement and visibility. “Every meeting that I’ve been to, there has always been senior management at the meeting. They have been very, very supportive and whatever [the coalition] wanted, if the hospital can do it, they have done it…I was just shocked to see especially upper management. You just don’t see that.” (ID C_19; Paramedic) Responsiveness and support. “I could stop and ask X something and she gets right back with me. It’s not, ‘I’ll have my assistant call you.’ I like the respect shown towards me. I mean, that was unheard of [before].” (ID A_01; Paramedic) Empowerment of middle managers. “LSL has helped me to be…more vocal about patient care and processes within cardiology…that maybe aren’t working. The biggest change for me is being that go-between between management and the rest of the mid-levels…and finding the solution between the two…management is usually very supportive.” (ID F_03; Physician Assistant) Higher levels of accountability. “Now it seems they’re better prepared to present information and discuss during the meeting. Then it seems like there’s ownership taken, and responsibility is given to people to pursue and follow up on what the committee decides.” (ID I_01; Interventional Cardiologist)	Lack of engagement and visibility. “Even though the people at the highest level are involved in LSL…it is not heard straight from the top…that this is a priority. There is always one more barrier.” (ID H_06) Lack of responsiveness and support. “We pointed out to some of the VPs…we need these [positions]. The response [was]: ‘there aren’t resources for that now…we will continue to evaluate and decide…’ it speaks for itself when over a year later we still don’t have anybody in these roles.” (ID B_15; Cardiologist) Lack of empowerment. “We get a lot of promises, but things don’t happen…it is very difficult to get approval for a lot of the things we [need].” (ID B_01; Medical Director, Cardiology Administration)
Psychological safety	Freedom to voice concerns. “I’ve seen a fair amount of growth as a group…people challenge each other. Somebody will make a statement. Somebody else will say, I don’t totally agree…it has been important for people to…challenge some of the things that even the docs say.” (ID J_18; Cardiovascular Administrative Director) Greater respect across disciplines. “In the beginning there were…individuals who were more forceful in their opinions…The group has evolved…LSL was the first opportunity to show we all have stuff to offer and we know what we are talking about…it was slow but that change is there.” (ID J_12; Pharmacist) Shared ownership. “It has changed a lot. At first we were kind of timid…we were a little bit silo-ed…as we went through [LSL] we transitioned into, ‘what can I do to fix my part?’…It transitioned from everyone telling everyone else what to do to looking at themselves and saying, ‘this is what we are going do to make this work.’ I think that that was really a turning point.” (ID C_8; Director, Emergency, Trauma and Critical Care) Supportive relationships. “Getting to know the group and what we were all about initially, it was a little bit harder to say anything. Now…I won’t be afraid to speak up. I know the core members…feel the same way. We could all speak up, and we would have each other’s back, and not be afraid to defend what we’ve done.” (ID F_17; Pharmacist CVU) Transparency. “Over the last year we have been moving the bar to a more transparent, open conversation-type culture…to have more input from all of the team players.” (ID G_05; Administrator) Managing hierarchy. “We have all been together in the same room [working] not as doctor-to-pharmacist, but on the same team…that’s a different perspective. You get used to dealing with people not in a power role, but more of an equal role, no matter what position you are.” (ID F_1; Chair of Cardiology) Complementarity. “Our physician champion, has been much more willing to say, ‘I don’t know,’ and rely on other people, which is something that I don’t think he necessarily did a while back. I don’t think he was afraid to speak up, but I think it’s hard for docs to say they don’t know something, because everybody expects them to know everything.” (ID J_07; Quality Improvement Associate)	Lack of freedom to voice concerns. “There are some [staff] that maybe feel ‘I can’t speak up just yet, or maybe if I tell A, it’s okay, but I can’t really tell B because I might get in trouble for it.’ I still see a little bit of that.” (ID B_06; Heart Center Manager) Deference to authority. “There is still this deference to authority…we tend to put our physicians up there…‘our physician said it should be, so it should be.’” (ID H_07; Director of Quality) Lack of shared ownership. “Meetings were a little intimidating at times. I’d be sitting there and they’d be like, ‘Well, it’d be great if Pharmacy could do this.’ I’m like, ‘Is there no one else around here who can do an intervention? Why is it all falling on me?’ It got a little dicey at times.” (ID D_07; Pharmacist) Lack of supportive relationships. “I wish that our group would have created that personal relationship, because once you have that, people can be a little bit more vulnerable…we’re pretty stiff and regimented…sometimes comments are filtered as opposed to unfiltered.” (ID H_13; Senior Executive)