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Table 3 Importance of factors amongst subgroups

From: Important factors for effective patient safety governance auditing: a questionnaire survey

Factor Board of directors (n = 22) Chief of medical staff (n = 35) Nursing officer (n = 40) Medical department head (n = 55) Director of quality and patient safety (n = 59) Overall (n = 211)
Category: board positioning of audits
 Audit as an improvement tool as well as a control tool 100 100 100 100 100 100
 Spreading the purpose and value of audit by board of directors 94 91 95 87 94 93
 Departments receive support during improvement actions after audit 67*R 91* 92* 100 78 88
 Audit results are embedded in the planning and control cycle of the hospital 94 100 97 98 97 98
 Board of directors addresses departments when follow-up on auditing results is not going according to plan 94 87 97 87 90 91
 Dissemination of audit results to all personnel 94 100 97 98 95 97
 Follow-up on auditing results by head of department 100 100 97 100 98 99
Category: organisation and content of audits
 Department is aware of audit purpose 100 100 97 98 100 99
 Audit is adjusted fit to individual departments 78*R 97 92 100 97* 95
 Department knows that the audit team is coming 67 77 59*R 81* 80* 75
 Extensive and detailed audit report 44 53 72 57 NA 59
 Audit also focuses on health care pathways 100 97 97 94 100 98
 There is room soft signals, not only facts, in the audit report 83 97* 90 89 75*R 86
 Audit also focuses on care provided by healthcare professionals and adverse events 78 82 83 97 NA 81
 Patients as an information source during audits 94 89 95* 72R 86 85
 Auditors get a tunnel vision on department because of selective information during preparations 69*R 94* 92* 84 88 87
Category: competences and composition of audit team
 Patients as auditors 67 74 78* 57 55*R 64
 Patients are not suited to be an auditor because they are not objective 22*R 29 33 50* 45 39
 Patients are not suited to be an auditor because they do not have sufficient knowledge regarding healthcare guidelines 17*R 41 41 47* 43 41
 Patients are not suited to be an auditor because confidentiality cannot be secured. 17*R 41 33 44 51* 41
 Quality of the auditors 94 100 97 94 100 98
 Evaluation of individual auditors 83*R 94 90 98 98* 95
 Multidisciplinary audit team 94 94 100 94 86 93
 Medical specialist on the audit team 78 88* 79 92* 61*R 79
 Chairman of the audit team is a high-profile employee 50 68 53 59 51 56
 The department to be audited influences the composition of the audit team 17* 29 13* 48*R 15* 26
 Auditors coming from other hospitals taking part in the audit team 94 97 95 90 91 93
 Only employees with a (para)medical education should be auditors 39 30* 46 56* R 19* 37
Category: cultural factors and attitudes towards auditing
 Staff sees added value of audit 89 91*R 69* 82 67* 78
 Presence of head of department on audit day 94 94 80* 96*R 93 92
 Time investment 72 83 72* 90*R 83 82
 Staff feel that audit contributes to patient safety 94 97 90 96 97 95
 Quality is ‘part of the job’ 67* 74 71* 90*R 66* 75
 Importance of audit outcomes 78 62 70 56 69 66
 Learning culture at department 100 100 100 100 100 100
  1. *Subgroups differ significantly (p < 0.05) with the reference group (R)