How Clinical Governance Shapes Quality of Care: The Mediating Role of Patient Safety Culture

Abstract

Purpose Clinical governance is widely implemented internationally, yet the mechanism by which it influences quality of care, and whether that mechanism operates uniformly across health systems with differing resource levels, remains untested within a single sample. This study examined whether patient safety culture mediates the relationship between clinical governance and quality of care, and whether perceptions differ between higher-resource and variable-resource health systems.

Methods A cross-sectional survey collected responses from 377 healthcare professionals in seven countries (Saudi Arabia, the United Arab Emirates, Kuwait, Egypt, Jordan, Iraq, and Lebanon) using a validated 41-item instrument measuring three constructs across eleven dimensions. Data were analysed using reliability testing, correlation, ordinary least squares regression, mediation analysis with an indirect-effect test, group comparison with false discovery rate correction, and importance-performance mapping.

Findings Clinical governance predicted patient safety culture (β = 0.826, R² = 0.682) and predicted quality of care as a total effect (β = 0.580, R² = 0.337). When both were entered jointly, the direct governance-to-quality path was not significant (β = 0.093, p = 0.176) while safety culture remained a strong predictor (β = 0.590, p < 0.001). The indirect effect accounted for 84.2% of the total effect, indicating full mediation. Respondents in higher-resource systems scored higher than those in variable-resource systems on all three constructs, with large effect sizes (Cohen d = 0.78 to 1.27). Freedom from blame was the lowest-scoring dimension measured.

Conclusion Clinical governance appears to influence quality of care predominantly through patient safety culture rather than directly, and perceptions diverge sharply along the resource gradient of the systems studied. Governance reform may require concurrent investment in safety culture, and aggregating health systems of differing resource levels obscures a difference exceeding one standard deviation.