Values are goals that transcend situations and meet needs. They play an important guiding role in a person's life and social relationships [1]. A cultural value system is a unique set of perceptions and opinions that each society, organization, and individual acquires in the context of the larger environment in which they live. It acts as a universal implicit constraint on thoughts and behaviors. In 2013, Yang proposed that cultural values are common to the mainstream group in the current cultural context and are generally shared by other members. They are a set of values that individuals are taught through education and propaganda in the process of continuous social evolution, that form individual values [2].

In 1964, in the book "Management Squared,” published by Mouton and Black, scholars of management at the University of Texas, it was mentioned that "in reality, the style of enterprise leaders has a decisive effect on the business style of the company" [3]. Here, style refers to the cultural values of leaders. Numerous business management practices have shown that the cultural values upheld and promoted by a business leader not only influence and determine individual behavior but also affect the overall organizational behavior and the management and effectiveness of the organization. Fritzsche tested five hypotheses by modeling structural equations with 174 working professionals. Hypothesis 2 stated that an altruistic value structure is positively related to ethical behavior (R2 = 0.33, P < 0.05) and has the largest path coefficient; thus, altruistic values have a positive influence on ethical decision-making. Regarding hypothesis 3, the value of structured self-improvement was negatively related to ethical behavior (R2 = 0.22, P < 0.05). Therefore, it can also be assumed that self-improvement values negatively impact ethical decision-making. The t values of the other hypotheses were not significant (P > 0.05) [4]. Guay and Choi used a sample of 215 leaders and 1284 followers from 10 organizations. By building hierarchical linear models for leaders, they found that high levels of neuroticism were significantly correlated with organizational citizenship behavior (γ = 7.43, P < 0.05); this interaction also significantly improved the fit of the model to the data (= 8.59, P < 0.01). Thus, they concluded that the development and motivation of transformational leaders could counteract neuroticism and introversion of followers and encourage them to exhibit organizational citizenship behaviors [5].

The main people in charge of a hospital are the legal representative; proposer; implementer; and advocate of the hospital’s system, norms, and culture. They play an important role in the construction and development of hospitals. Their personal beliefs, pursuits, and standards for judging right and wrong inevitably affect the spirit, personality, and development of the hospital, and their cultural values influence and even determine the behavior, management, and effectiveness of the entire organization.

Patient safety culture is part of hospital safety culture; as such, the cultural values upheld by the director are very important influencing factors. Therefore, evaluating the cultural values of hospital leaders is important for patient safety. Many scales exist for measuring the cultural values of leaders in nonmedical fields. For example: from a managerial perspective, in 1980, the Dutch literary scholar, Hofstede, divided cultural values into four dimensions: power distance, uncertainty avoidance, masculinity/femininity, and collectivism/individualism [6]. More than 10 years later, the international universal applicability of the scale was fully considered and was made applicable in the Chinese national context. Chinese scholar, Mike Peng, used the questionnaire method to study several countries around the world and finally identified a fifth dimension (long-term orientation/short-term orientation). Schwartz classified individual cultural values into four dimensions by studying cultural practices around the world: conservatism, change acceptance, transcendence, and self-reinforcement, and developed the final Schwartz Value Survey scale [7]. The List of Values (LOV) scale was further developed by Kahle, based on previous studies by Maslow (1954), Rokeach (1973), and Feather (1975)[8]. The LOV scale contains nine individual value entries that can be divided into five motivational domains: self-directedness (self-respect and achievement of aspirations), achievement (being respected), hedonism (enjoyment and pursuit, excitement), maturity (sense of belonging and harmonious interpersonal climate), and security (the need to feel safe) [8]. However, scales measuring the cultural values of senior healthcare executives in the medical field are rarely reported.

The cultural value orientations of senior healthcare executives towards humanistic care, medical ethics, risk awareness, and patient safety may affect patient safety culture. Therefore, in this study, we adopted the Delphi method to develop a cultural value scale for senior healthcare executives. We also explored new mechanisms and paths to improve patient safety by encouraging the executives to reshape their cultural values, with patient safety as a core concept. Emphasizing the importance of patient safety culture and behavioral reengineering, through internalization to all employees, organizations, and systems, can help improve doctor-patient relationship and establish methods to achieve higher level of patient safety.

We conducted a literature review and used the Delphi method and hierarchical analysis to design a system of cultural value indicators for senior healthcare executives. First, initial scale entries were constructed using a literature review method. Three rounds of the Delphi method were conducted to anonymously collect expert opinions. After each round, the collected questionnaires were analyzed, organized, and presented for a new round of expert consultation until there was no disagreement in the expert opinion [9]. Finally, the reliability and validity of the scale were measured by calculating the weight of each indicator using hierarchical analysis and conducting a pre-experiment on the scale and shown in Fig. 1

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Figure 1 Flow chart of scale development

We used the Delphi technique to determine the scale structure of the cultural values of contemporary senior healthcare executives by considering the opinions of experts from different fields focusing on humanistic care, medical ethics, risk awareness, and patient safety. The Delphi technique is a data collection tool that researchers use to get the perspective of people with a voice in the problem-solving process. It has three basic features: confidentiality of participation, controlled analysis of group responses, and controlled feedback [11]. The principles of anonymity, feedback, and statistics were strictly followed. The opinions of the participating experts were kept confidential to improve their responding confidence and to avoid unconditional agreement with the opinions of other well-known experts.

The consultation questionnaire was rated on a 5-point Likert scale, with experts scoring each indicator according to its importance and operability (1 = strongly disagree, 2 = agree, 3 = average, 4 = agree, 5 = strongly agree). Each entry was followed by a blank space for the experts to provide open-ended comments and corresponding reasons. Statistical analyses of the data collected at the end of each round of the study were performed. According to the principle of index screening for the collected consultation questionnaires, the indexes with mean importance and feasibility ≥ 4.0 and coefficient of variation < 0.25 were retained; the indexes with mean importance and feasibility < 4.0 and coefficient of variation ≥ 0.25 were deleted. If only one of the inclusion criteria for importance mean and coefficient of variation was satisfied, or if all of them were not satisfied, the indicators were added, modified, combined, and deleted after a group discussion with reference to the experts' revision. The results of the analysis conducted at the end of each round were communicated to the participants in the following successive rounds of questionnaire analysis to inform them about the general trends. This enabled the participants to reexamine their ideas by comparing them with the results, methods, and perspectives presented to them.

The coefficient of the expert positivity degree was expressed using the questionnaire recovery rate. A coefficient of expert degree ≥ 70% indicates that the enthusiasm of experts is high, and that the study is of certain research significance [9].

The expert authority coefficient (Cr) is based on the average value of the judgment coefficient (Ca) and familiarity coefficient (Cs); that is, Cr = (Ca + Cs)/2. When Cr ≥ 0.70, it is considered that the authority of experts and the reliability of prediction is high [14].

Ca is judged based on four aspects: work experience, theoretical analysis, peer knowledge, and expert intuition, and is classified according to three levels: large, small, and medium. The specific judgement criteria were work experience (degree of influence on expert judgement: large = 0.5, medium = 0.4, small = 0.3), theoretical analysis (degree of influence on expert judgement: large = 0.3, medium = 0.2, small = 0.1), reference to domestic and international literature (degree of influence on expert judgement: large = 0.1, medium = 0.1, small = 0.1), and intuition (degree of influence on expert judgement: large = 0.1, medium = 0.1, small = 0.1) (Table 1).

Cs indicates the expert's familiarity with the content1 of the consultation and is rated on a 5-point Likert scale with the following criteria: very familiar = 1, familiar = 0.8, more familiar = 0.6, average = 0.4, and unfamiliar = 0.2.

The coefficient of the degree of coordination of expert opinion is primarily a way of judging the consistency of experts' evaluations of each indicator and whether there are large differences or identifying highly coordinated experts and those with heterogeneous opinions. It generally includes Kendall’s W coordination coefficient (W) and the coefficient of variation (CV) [15]. W generally fluctuates in the range of 0.5. In this study, W was considered statistically significant at P < 0.05. The closer W was to 0.5, the higher the level of expert coordination and the stronger the agreement with expert opinion.

The AHP is based on the idea of decomposing complex problems into several simpler elements [12]. This involves simplifying the complex problem, comparing the advantages and disadvantages of different solutions, making a sublinear prediction of the solution, and finally selecting the best solution based on the data [13]. We used AHP to define the weight of each cultural value index. First, we established the target tree, stratified the entire index system, and established a target tree of cultural values. Then, we built the matrix; the judgment matrix of pairwise comparison was constructed using the hierarchical structure of the target tree (Table 2). Finally, the index weight and the weights of the indicators at each level were calculated, and a consistency test was performed. If the consistency ratio (CR = CI/RI) was less than 0.1, the judgment matrix was considered to have a satisfactory consistency. Otherwise, the judgment matrix was readjusted. The decision process of the expert group was implemented using the YAAHP software.

A formal survey was conducted at 13 public hospitals in Guilin, Guangxi. Using a whole-group sampling method, the survey included the secretaries, directors, and vice presidents of each hospital (leaders with administrative decision-making power). Formal questionnaires were distributed to the office managers of each hospital, who then distributed them to hospital-level leaders and collected the questionnaires. Overall, 100 questionnaires were distributed, of which 94 were collected and validated.

Reliability and validity analyses were conducted using the 39 entries of the scale.

The Cronbach’s α coefficient is the best coefficient for reliability: the larger the coefficient value, the better the consistency and reliability. Its value ranges from 0 to 1, and a coefficient value above 0.7, indicates good reliability [16]. Regarding the split-half reliability coefficients, items were divided into two equal halves based on the parity of item numbers. The half reliability coefficient should be greater than 0.70 to achieve an acceptable level [17]. Higher split-half reliability coefficients indicate better scale reliability and internal consistency. The correlation coefficient between the two groups was then calculated, and the Spearman–Brown formula was applied to estimate the reliability of the entire scale.

Validity analysis generally includes content and structural validity. Content validity is mainly used to measure the appropriateness and consistency of the content using the expert consultation method, where the experts determine whether the content of the consultation scale is applicable. The construct validity was analyzed using correlation and confirmatory factor analysis (CFA). If the Spearman correlation coefficient of the dimension-total is between 0.3 and 0.8, the correlation coefficient between dimensions is less than 0.8, and the item-total score is between 0.3 and 0.8, it can be inferred that the scale has good correlation and discrimination [18]. If the Kaiser–Meir–Olkin (KMO) value is above 0.8, and the Bartlett's sphericity test score is less than 0.5, there is a significant difference between the entries, indicating that the data can be used for factor analysis [19].

Following a literature review and discussions within the research team, an initial index system for hospital directors' cultural values was preliminarily constructed. This system comprised 4 first-level indicators (Humanistic Care, Medical Ethics, Sense of Urgency, and Value of Life), 13 second-level indicators (Humanistic Spirit, Humanistic Institution, Humanistic Literacy, Humanistic Realm, Medical Ethics Construction, Medical Style Construction, Humanitarianism, Consciousness of Active Cognition, Critical Awareness of Potential Risks, Scientific Judgment Awareness, Quality of Life, Life Expectancy, and Medical Safety), and 35 items, forming the initial item pool for the Hospital Directors' Cultural Values Scale.

Overall, 20 experts with different work experiences in teaching and research, administration (n = 18), and business technology (n = 2) were invited to participate in the expert consultation. One expert failed to respond to the questionnaire within the required time frame; 19 experts met the inclusion criteria. The 19 experts were from 11 provinces and cities, including Beijing (n = 1), Nanjing (n = 3), Wuhan (n = 2), Hangzhou (n = 2), Jinan (n = 1), Sichuan (n = 2), Weifang (n = 2), Hefei (n = 2), Harbin (n = 3), and Hohhot (n = 1). The mean age (mean ± standard deviation) was 54.7 ± 5.9 years, and all of them had postgraduate degrees or higher. Among them, two had master degrees (10.5%) and 17 had PhDs (89.5%). All experts involved in this consultation participated in hospital management practices and research work. There were 18 experts with senior titles (94.7%) and one with an associate title (5.3%) (Table 3).

In the process of expert consultation, the response rate was 95% (20/19) in the first round, and 100% (19/19) in the second and third rounds. One expert did not respond within the specified time. All questionnaires recovered were valid, with an efficiency rate of 100%. The authority coefficients of the experts in the three rounds were 0.86, 0.87, and 0.88, indicating that the experts involved in this consultation had high authority. The expert coordination coefficients (W) of the importance level indicators in the first round were 0.024, 0.095, and 0.112, and the W values of feasibility were 0.026, 0.155, and 0.309, respectively. The W values of the importance indicators in the second round were 0.090, 0.108, and 0.141, and the W values of feasibility were 0.044, 0.254, and 0.330, respectively. The W values for the importance level indicators in the third round were 0.115, 0.225, and 0.206, and the W values for feasibility were 0.052, 0.271, and 0.363, respectively. After three rounds of expert consultation, the W-values of importance and operability for each level of indicator gradually increased, fluctuating around 0.5, and the differences between these changes were statistically significant (P < 0.05). The coefficients of the three coordination levels are listed in Table 4.

The results of the first round of expert consultation were analyzed; the mean scores of the important values of two secondary indicators, quality of life and life expectancy, were lower than 4 and the coefficient of variation was higher than 0.25. Three indicators i.e. preparedness, more than less strong, and less than not strong, were used to understand the latest medical situation at home and abroad and the quality of life and life expectancy of general diseases and special patients.

Based on the average score of the important values of each index in the first round and the qualitative revision opinions of the experts, we made three types of modifications to the expert consultation questionnaire in the first round. (1) Deletion: According to the screening principle, the average score of the important values was lower than 4 and the coefficient of variation was higher than 0.25, following the expert's qualitative revision opinions, five secondary and nine tertiary indicators were deleted. (2) Modification: For the second-level indicators, the construction of medical ethics was merged. The descriptions of the three second level and five third level indicators were modified to express the meaning of the indicators more clearly and accurately. (3) Increase: Since the experts of the secondary indicators were aware of the primary indicators’ distress, it was believed that they should not only stay conscious but also reflect on whether they have taken actions to control risks and reduce medical errors and accidents. Therefore, after discussions with the research group, four secondary indicators were added: awareness of risk monitoring and early warning, awareness of risk decision-making, handling mechanisms of sudden medical adverse events, and learning optimization mechanisms. The three-level indicators were also reconstructed by adding 11 indicators.

After sorting and statistically analyzing the results of the first round of expert consultation, the questionnaire was revised, and the second round of expert consultation was conducted. The mean of the importance values of the four first-level indicators was above 4.50 points; the mean of the importance values of the secondary indicators was above four points; only one of the three-level indicators had an importance value mean below four points, and the coefficient of variation was above 0.25. The indicator is a positive response to risk, does not evade it, and is not a prevaricate.

In this study, the following three types of modifications were made to the second round of expert consultation questionnaire: (1) Deletion: a one third-level indicator was deleted because the mean score of important values was lower than 4 and the coefficient of variation was higher than 0.25 and because of the qualitative modification opinions of the experts; (2) Modification: experts generally believe that the “sense of urgency” in the first-level indicators should be revised to “risk awareness” and “life attention” should be revised to “patient safety”; revise the statement description of 1 second-level indicator and 10 third-level indicators to clearly express the meaning of the indicators. (3) Increase: an increase in one secondary index, “medical ethics review system” corresponded to an increase in four tertiary indicators.

The mean values of the four indicators in the third round were above 4.77 points; the average results of the important values of the secondary indicators were above 4.70, and that for only one indicator, “learning optimization consciousness,” was relatively low at 4.59. The mean of the importance values of the three-level indicators was also above 4.40, and the coefficient of variation for all indicators was less than 0.25. This shows that the third round of expert coordination was good, the views of the experts were highly uniform, and the indicators were unanimously endorsed by the experts.

Through three rounds of Delphi expert consultations, an evaluation index system for senior healthcare executives' cultural values was formed. The scale contains 4 first-level, 13 second-level, and 39 third-level indicators (Table 5).

In this study, we adopted the three-round Delphi method to construct a cultural value index system for senior healthcare executives. First, based on the full retrieval of domestic and foreign literature and interpretation of policy documents, this study initially constructed an expert consultation questionnaire through group discussions. After three rounds of repeated validation of expert consultation, experts reached a consensus to form a cultural value evaluation index system for senior healthcare executives and gained the weight of each index. By combining quantitative and qualitative methods, the cultural values scale was found to have high reliability and validity. Therefore, it can be used as a reliable and effective tool. The final version of the cultural values scale contained four first-level indicators, 13 dimensions, and 39 items.

In considering which aspects of cultural values should be embodied, our team of experts developed four core indicators. According to the opinions of experts in the Delphi method, patient safety (0.3679) had the highest weight obtained using the AHP. The combination weight of the secondary indicator to which it belonged (“patient-centered,” [0.1910]) was also the highest; followed by medical security (0.1770). The World Health Organization uses the indicator “respecting patients’ participation in medical decision-making" to evaluate the quality of medical services in various countries [20]. Currently, many developed countries include "patient participation" as part of the law. France issued the Law of Bioethics in 1988 to protect patients' rights to information [21]. Germany established its first patient university in October 2006 to provide health education and patient empowerment [22]. The results of this study also lead to comparable conclusions. Therefore, in the process of reshaping the cultural values of senior healthcare executives in the future, the value of patient safety should be emphasized.

Humanistic care is defined as attention to the needs of the human personality, spiritual development, and respect for human rights. In addition to providing necessary medical and technical services to patients, hospitals need to address their psychological, cultural, and health needs [23–26]. There are four dimensions under the indicator of humanistic care: humanistic spirit, humanistic literacy, humanistic system, and humanistic environment. This is a better and more comprehensive way to reflect on the values of senior healthcare executives.

The occurrence of this new crown epidemic was the best manifestation of increased risk awareness. During the coronavirus disease pandemic, there were many medical malpractices due to the surge in the workload of doctors, who sometimes failed to meet basic medical needs [27]. Such tragic events could have been prevented if the leaders of our hospital had worked out in advance the various detailed procedures for seeing a doctor during the pandemic for both patients with fever and ordinary patients [28–29]. Therefore, hospital leaders must have a good risk awareness. When such a situation does not occur, a variety of alternatives should be prepared in advance to deal with such emergencies and prevent them from occurring.

Finally, “medical ethics” scored the lowest. The discipline of "medical ethics" runs throughout the entire university career of medical students, and there are various ethical system norms in the professional careers of medical personnel. According to a cross-sectional study, many tertiary hospitals have established medical ethics review committees, but county-level hospitals lack awareness of medical ethics reviews, and there is no standardized ethics review committee [30]. Many hospital leaders are unsure about the ethical system norms in their own hospitals [31–32]. Therefore, senior healthcare executives should establish a standardized medical ethics review committee and standardize various ethical systems from their own perspective and not allow the medical ethics committee to become a decoration.

The cultural value index system for senior healthcare executives constructed in this study included 4 first-level, 13 second-level, and 39 third level indicators. The Cronbach' coefficient is currently recognized as the best coefficient for measuring reliability; a coefficient of 0–1 and above 0.7 is suggestive of good reliability [33]. In this study, the Cronbach's coefficients of the total scale, humanistic care, medical ethics, risk awareness, and patient safety were 0.969, 0.897, 0.871, 0.858, and 0.873, respectively, indicating that the cultural value scale had high reliability. Before conducting the exploratory factor analysis, KMO and Bartlett sphericity tests were conducted. When the KMO value was > 0.5, and Bartlett sphericity test P was < 0.05, the questionnaire had structural validity, and the next step of exploratory factor analysis could be carried out [34]. The KMO value of this study was 0.919, and the approximate Bartlett sphericity test was equal to 10348.998 and 741 (P < 0.001), meeting the basic conditions for exploratory factor analysis. A total of 13 common factors were extracted, and the cumulative variance contribution rate of the overall variance was 88.219%, which was greater than 60% [35–38], indicating that the cultural values scale had high validity. Based on the results of the exploratory factor analysis, a confirmatory factor analysis was conducted. In addition to the standard fit index (NFI), incremental fit index (IFI), and irregular fit index (TLI/NFI) [39–42], all other indicators met the adaptation standard except for the Akaike Information Criterion. The adjusted AGFI = 0.902, goodness-of-fit index = 0.905, and CFI = 0.911 were significantly correlated with the items (P < 0.001). Therefore, the fitting index of the model was good [43–47].

This study has several limitations that warrant consideration. First, the confirmatory factor analysis (CFA) yielded suboptimal indicator loadings for several items. Although the sample size met statistical requirements for CFA, these results suggest potential measurement issues with the scale in the current context. Further validation with larger and more diverse samples is essential to establish the scale’s robustness and generalizability.Second, the use of convenience sampling—driven by the specific characteristics of the target population—may introduce selection bias and limit representativeness. Critically, the absence of township-level participants undermines the sample’s coverage of key socioeconomic and geographic strata. Consequently, findings may not be generalizable to rural or township populations, potentially affecting the external validity of the results.

The index system of cultural values of senior healthcare executives constructed in this study contains four primary, 13 secondary, and 39 tertiary indicators. The scale had high authority and scientific validity, good reliability and validity, and can be used as a tool to measure the cultural values of senior healthcare executives. This study can provide a reference basis for easing the doctor-patient relationship and improving the culture of patient safety.