Open Access Research article

Healthcare system intervention for prevention of birth injuries – process evaluation of self-assessment, peer review, feedback and agreement for change

Monica E Nyström12*, Anna Westerlund12, Elisabet Höög12, Charlotte Millde-Luthander3, Ulf Högberg24 and Charlotta Grunewald3

Author Affiliations

1 Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, SE, 171 77, Sweden

2 Department of Public Health and Clinical Medicine, Umeå University, Umeå, SE, 901 87, Sweden

3 Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, SE, 171 77, Sweden

4 Department of Women's and Children's Health, Uppsala University, Uppsala, SE, 751 85, Sweden

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BMC Health Services Research 2012, 12:274  doi:10.1186/1472-6963-12-274

Published: 24 August 2012



Patient safety is fundamental in high quality healthcare systems but despite an excellent record of perinatal care in Sweden some children still suffer from substandard care and unnecessary birth injuries. Sustainable patient safety improvements assume changes in key actors’ mental models, norms and culture as well as in the tools, design and organisation of work. Interventions positively affecting team mental models on safety issues are a first step to enhancing change. Our purpose was to study a national intervention programme for the prevention of birth injuries with the aim to elucidate how the main interventions of self-assessment, peer review, feedback and written agreement for change affected the teams and their mental model of patient safety, and thereby their readiness for change. Knowledge of relevant considerations before implementing this type of patient safety intervention series could thereby be increased.


Eighty participants in twenty-seven maternity units were interviewed after the first intervention sequence of the programme. A content analysis using a priori coding was performed in order to relate results to the anticipated outcomes of three basic interventions: self-assessment, peer review and written feedback, and agreement for change.


The self-assessment procedure was valuable and served as a useful tool for elucidating strengths and weaknesses and identifying areas for improvement for a safer delivery in maternity units. The peer-review intervention was appreciated, despite it being of less value when considering the contribution to explicit outcome effects (i.e. new input to team mental models and new suggestions for actions). The feedback report and the mutual agreement on measures for improvements reached when signing the contract seemed exert positive pressures for change.


Our findings are in line with several studies stressing the importance of self-evaluation by encouraging a thorough review of objectives, practices and outcomes for the continuous improvement of an organisation. Even though effects of the peer review were limited, feedback from peers, or other change agents involved, and the support that a clear and well-structured action plan can provide are considered to be two important complements to future self-assessment procedures related to patient safety improvement.