Table 7 Overall findings; presented in themes from the published papers

Macro level

I Governmental Rationale for Revising the Quality Improvement Regulation

• Implementation issues with the previous Internal Control Regulations

• Lack of management competencies and responsibilities throughout the Norwegian healthcare services

• A need to promote quality improvement as a managerial responsibility

II Expectations of Resilient Capacities

• Hospitals were expected to adapt their risk management to specific context, activities, and conditions

• The new regulation might serve as a catalyst for hospital managers to gain a bird’s eye perspective on activities and conditions in their unit; department; clinic

• The Government suspected a gap between top-level hospital managers’ priorities and what is done at the clinical level [49]

Meso level

I Changes in Supervisory Work due to the new Quality Improvement Regulation

• No substantial change in the inspectors’ approach

II Inspectors’ Work to Apply Regulation and Facilitate Adaptive Capacities

• Inspectors balanced trade-offs daily, adapting their supervision to specific contexts and cases

III Learning from Supervision

• Supervision provides a glimpse into hospital risk management; thus, positive feedback could misleadingly make hospital mangers think that every aspect of their system is fine

IV Supervisory Impact on Hospital Performance

• Inspectors demonstrated a general concern about the impact of supervision on hospital performance

V Improvement Potentials in Supervisory Practice

• Inspectors could improve their follow up strategies, use expert inspectors, and add more hospital self-assessment activities, to facilitate learning [41]

Micro level

I Adaptive capacity in hospital management and practice

• The flexible regulatory design was perceived essential because it is impossible to anticipate every possible event due to different risks and elements of variation and uncertainty

II Implementation efforts and challenges with quality improvement

• Hospital managers had too many obligations and lack time to prioritize systematic PDSA methodology

• Most physicians worked unconsciously in correspondence with the PDSA methodology

III Systemic changes

• Different types of meetings, councils, and committees had been established in recent years

• A cultural shift displayed the importance of continuous and structured quality improvement

IV The potential to learn

• Difficult to learn from adverse events, as well as from successful outcomes, due to time pressure

• Supervision could sometimes be useful; however, inspectors’ recommendations were occasionally difficult or impossible to practically implement [50]