• Viet-Hai Phung, Nadya Essam, Zahid Asghar, Anne Spaight, and Aloysius N Siriwardena.
• Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Lincoln, UK.
• J Eval Clin Pract. 2016 Feb 1; 22 (1): 778577-85.

Rationale, Aims And ObjectivesClinical leadership and organizational culture are important contextual factors for quality improvement (QI) but the relationship between these and with organizational change is complex and poorly understood. We aimed to explore the relationship between clinical leadership, culture of innovation and clinical engagement in QI within a national ambulance QI Collaborative (QIC).MethodsWe used a self-administered online questionnaire survey sent to front-line clinicians in all 12 English ambulance services. We conducted a cross-sectional analysis of quantitative data and qualitative analysis of free-text responses.ResultsThere were 2743 (12% of 22 117) responses from 11 of the 12 participating ambulance services. In the 3% of responders that were directly involved with the QIC, leadership behaviour was significantly higher than for those not directly involved. QIC involvement made no significant difference to responders' perceptions of the culture of innovation in their organization, which was generally considered poor. Although uptake of QI methods was low overall, QIC members were significantly more likely to use QI methods, which were also significantly associated with leadership behaviour.ConclusionsDespite a limited organizational culture of innovation, clinical leadership and use of QI methods in ambulance services generally, the QIC achieved its aims to significantly improve pre-hospital care for acute myocardial infarction and stroke. We postulate that this was mediated through an improvement subculture, linked to the QIC, which facilitated large-scale improvement by stimulating leadership and QI methods. Further research is needed to understand success factors for QI in complex health care environments.© 2016 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd.

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