Document Type


Date of Degree

Fall 2010

Degree Name

PhD (Doctor of Philosophy)

Degree In

Health Services and Policy

First Advisor

Ward, Marcia M

First Committee Member

Vaughn, Thomas E

Second Committee Member

Uden-Holman, Tanya

Third Committee Member

Helms, Charles

Fourth Committee Member

Scott-Cawiezell, Jill


Within the last decade there has been considerable national attention focused upon hospital quality and patient safety performance. Improvements in performance have been realized, but the rate of improvement has been slow. There is an increasing consensus that new ideas and national strategies are needed to accelerate improvement efforts in addressing quality/safety issues. Currently, within the hospital setting more attention is being paid to the role of leadership starting with the board of trustees in addressing gaps in performance. Organization-wide awareness of critical gaps in performance, accountability structures, and organizational ability are considered critical facilitators of improvement efforts. The characteristics of awareness, accountability, ability, and action are components of a "4A" conceptual framework that is used most prominently by the National Quality Forum (NQF) in their Safe Practices for Better Healthcare toolkit to frame governance and leaderships' responsibilities in establishing leadership structures and systems to ensure the safety of patients and staff.

This study utilizes the National Quality Forum's version of the 4A model to frame an empirical examination of the relationship between leadership structure and system characteristics and hospitals' implementation of the medication reconciliation innovation. A Patient Safety, Culture, and Leadership survey was used to capture Iowa hospital CEO/Quality Leaders' perceptions of board and leadership awareness and accountability characteristics. And, on a quarterly basis since mid-2006 a separate web-based survey has captured Iowa hospital Quality Leaders' perceptions of medication reconciliation implementation.

Both cross-sectional and longitudinal analyses were conducted to examine the relationship between leadership structures and systems and hospital-wide deployment of the medication reconciliation initiative.

This study finds evidence that board-level awareness characteristics - the time the board spent in meetings on quality and safety issues, and the frequency of board receipt of a formal quality/safety report - were positively related to hospitals' early efforts to deploy the medication reconciliation initiative. Over time hospitals' financial ability was positively related to deployment of this initiative.

Further research should focus on how healthcare governance and leadership teams can use the elements of leadership structures and systems safe practices to effectively create and sustain a culture of safety.


Governance, Leadership, Medication Reconciliation, Safe Practice


vii, 151 pages


Includes bibliographical references (pages 131-151).


Copyright 2010 Lance L. Roberts