Do quality management systems influence clinical safety culture and leadership? A study in 32 Australian hospitals

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Objective: This study aimed to explore the associations between the organization-level quality arrangements, improvement and implementation and department-level safety culture and leadership measures across 32 large Australian hospitals. Design: Quantitative observational study, using linear and multi-level modelling to identify relationships between quality management systems and clinician safety culture and leadership. Setting: Thirty-two large Australian public hospitals. Participants: Quality audit at organization level, senior quality manager at each participating hospital, 1382 clinicians (doctors, nurses and allied health professionals). Main outcome measures: Associations between organization-level quality measures and department-level clinician measures of teamwork climate, safety climate and leadership for acute myocardial infarction (AMI), hip fracture and stroke treatment conditions. Results: We received 1332 valid responses from participants. The quality management systems index (QMSI, a questionnaire-based measure of the hospitals' quality management structures) was 'positively' associated with all three department-level scales in the stroke department, with safety culture and leadership in the emergency department, but with none of the three scales in the AMI and hip fracture departments. The quality management compliance index (QMCI, an external audit-based measure of the quality improvement activities) was 'negatively' associated with teamwork climate and safety climate in AMI departments, after controlling for QMSI, but not in other departments. There was no association between QMCI and leadership in any department, after controlling for QMSI, and there was no association between the clinical quality implementation index (CQII, an external audit-based measure of the level of implementation of quality activities) and any of the three department-level scales in any of the four departments, after controlling for both QMSI and QMCI. Conclusions: The influence of organization-level quality management systems on clinician safety culture and leadership varied depending on the hospital department, suggesting that whilst there was some consistency on patient safety attitudes and behaviours throughout the organizations, there were also other factors at play.

Original languageEnglish
Pages (from-to)60-66
Number of pages7
JournalInternational Journal for Quality in Health Care
Issue numberSupplement 1
Publication statusPublished - 6 Feb 2020


  • hospital quality management systems
  • leadership
  • multi-level research
  • quality improvement
  • safety culture
  • teamwork


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