title: Exploration of contextual factors in a successful quality improvement collaborative in English ambulance services: cross-sectional survey.
abstract: OBJECTIVE
  Clinical 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).
  
  
  METHODS
  We 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.
  
  
  RESULTS
  There 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.
  
  
  CONCLUSIONS
  Despite 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.
authors: Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Lincoln, UK.
authors: Viet-Hai
authors: VH
authors: Phung
authors: Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Lincoln, UK.
authors: Nadya
authors: N
authors: Essam
authors: Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Lincoln, UK.
authors: Zahid
authors: Z
authors: Asghar
authors: Clinical Governance Audit, and Research, East Midlands Ambulance Service NHS Trust, Lincoln, UK.
authors: Anne
authors: A
authors: Spaight
authors: Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Lincoln, UK.|Clinical Governance Audit, and Research, East Midlands Ambulance Service NHS Trust, Lincoln, UK.
authors: Aloysius N
authors: AN
authors: Siriwardena
mesh_terms: D000552:Ambulances; D003430:Cross-Sectional Studies; D004632:Emergency Medical Services / Q000592:standards*; D004739:England; D005260:Female; D006801:Humans; D007857:Leadership; D008297:Male; D015279:Organizational Culture; D058996:Quality Improvement / Q000458:organization & administration*; D011795:Surveys and Questionnaires
keywords: health care; leadership; management; organizational theory; pre-hospital care; quality improvement