Facilitating internal audit quality and improving the performance of medical clinics

Figures & data

Figure 1. A graphical representation of the qualitative data structure.

Table 1(a). Descriptive statistics of the variables (level 1).

Variable	Sample	Mean	S.D.
Audit-enabling leadership	586	3.‏90	0.‏89
Trust	586	3.96	0.91
Psychological safety	586	3.83	0.91
Medical clinic performance	80	3.96	0.91
Gender (1 = female)	586	1.32	0.47
Family status (1 = single)	586	1.25	0.44
Tenure in the medical clinic	586	12.65	8.56

Table 1(b). Descriptive statistics of the variables (based on randomly sampled respondents) (level 2).

Variable	Sample	Mean	S.D.
Audit-enabling leadership	80	3.97	0.72
Trust	80	3.95	0.72
Psychological safety	80	3.89	0.73
Internal audit quality	80	3.92	0.71
Medical clinic performance	80	3.96	0.77
Gender	80	1.47	0.50
Family status	80	1.10	0.30
Tenure in the medical clinic	80	14.61	6.30

Table 2(a). Correlations between the research variables (level 1).

Gender	–
Family status	-0.018	–
Tenure in the medical clinic	0.072	-0.071	–
Trust	-0.068	0.049	-0.038	–
Audit-enabling leadership	-0.023	0.069	-0.040	0.768***	–
Medical clinic performance	0.006	0.066	0.006	0.552***	0.662***	–
Psychological safety	-0.070	0.038	-0.009	0.733***	0.738***	0.585***	–

N = 586; *p < .05; **p < .01; ***p < .001.

Table 2(b). Correlations between the research variables (level 2).

Gender	–
Family status	0.017	–
Tenure in the medical clinic	0.027	-0.039	–
Trust	0.241*	0.097	0.041	–
Audit-enabling leadership	0.172	0.146	-0.024	0.851***	–
Internal audit quality	0.140	0.192	0.035	0.836***	0.892***	–
Medical clinic performance	0.145	0.071	-0.050	0.688***	0.762***	0.762***	–
Psychological safety	0.123	0.074	0.050	0.876***	0.871***	0.879***	0.678***

N = 80; *p < .05; **p < .01; ***p < .001.

Note. Based on randomly sampled respondents.

Table 3. Fit-of-indices for the measurement models.

	χ^2	df	χ^2/df	AIC	CFI	TLI	RMSEA CI90%	SRMR
Baseline model (four factors)	369.09	181	2.04	23574.17	0.‏986	0.‏984	0.036 - 0.048	0.‏024
Alternative model 1 (three factors)	1138.79	184	6.18	24525.23	0.‏931	0.‏992	0.089 - 0.099	0.‏046
Alternative model 1 (one factor)	1138.79	188	7.42	24882.41	0.‏913	0.‏903	0.100 - 0.110	0.‏059

Table 4. SEM results for the baseline model.

Variable	Medical clinic trust	Medical clinic psychological safety	Internal audit quality	Medical clinic performance
	Estimate (S.E.)	Estimate (S.E.)	Estimate (S.E.)	Estimate (S.E.)
Audit-enabling leadership	0.84*** (0.05)	0.47*** (0.08)	0.49*** (0.09)	0.39*** (0.17)
Trust		0.51*** (0.09)
Psychological safety			0.43*** (0.08)
Internal audit quality				0.53*** (0.17)
Gender	0.14 (0.08)	-0.11 (0.06)	-0.00 (0.06)	0.05 (0.10)
Tenure in the medical clinic	0.01 (0.00)	-0.09 (0.11)	-0.09 (0.10)	-0.01 (0.00)
Family status	-0.06 (0.13)	0.01 (0.00)	0.01 (0.00)	-0.18 (0.17)

*p < .05; **p < .01; ***p < .001.

Figure 2. Illustrative results of the model.

Notes: Dashed lines denote direct relationships; Dashed lines denote link that were not originally hypothesized; Trust-quality internal audit link is not shown (because only significant relationships are shown here), but was originally hypothesized.

**p < .01; ***p < .001; Control variables are not shown here.

Table 5(a). SEM results for baseline and alternative models.

	Baseline model	Model 1	Model 2	Model 3
Audit-enabling leadership → Trust	***0.84	***0.84	***0.84	***0.84
Audit-enabling leadership → Psychological safety	***0.47	***0.47	***0.47	***0.47
Intra-team trust → Psychological safety	***0.51	***0.51	***0.51	***0.51
Medical clinic psychological safety → Internal audit quality	0.42***	***0.36	0.42***	0.42***
Audit-enabling leadership → Internal audit quality	***0.49	***0.45	***0.49	***0.49
Internal audit quality → Medical clinic performance	**0.52	**0.52	**0.51	**0.57
Audit-enabling leadership → Medical clinic performance	*0.39	*0.39	*0.38	*0.44
Internal audit quality → Trust	—	0.10	—	—
Medical clinic trust → Medical clinic performance	—	—	0.03	—
Medical clinic psychological safety → Medical clinic performance	—	—	—	0.10-
χ^2	40.50	39.47	40.46	40.14
DF	26	25	25	25
Δχ^2	—	1.023 n.s.	0.034 n.s.	0.359 n.s.
RMSR (SRMSR)	0.035	0.035	0.035	0.035
RMSEA	0.08	0.13	0.11	0.11
CFI	0.98	0.97	0.97	0.97
TLI	0.96	0.95	0.95	0.95

*p < .05; **p < .01; ***p < .001; n.s. (not statistically significant).

*Controls and coefficients that were not statistically significant in the baseline model are not shown here.

Table 5(b). Indirect and total effects for audit-enabling leadership on internal audit quality (AL → IAQ).

Path	Estimate	CI 90%
Path 1. AL→ Tru → PS → IAQ	0.‏18*	(0.30, 0.09)
Path 2. AL→ PS → IAQ	0.20*	(0.34, 0.10)
Total indirect effects of AL → IAQ: path 1 + path 2	0.38*	(0.55, 0.22)
Total effect of AL → IAQ: path 1 + path 2 + direct AL → IA	0.‏87*	(0.96, 0.77)

Audit-enabling leadership (AL), trust (Tru), psychological safety (PS), internal audit quality (IAQ).

*p < .05.

Table 5(c). Indirect and total effects for audit-enabling leadership on medical clinic performance (AL → UP).

Path	Estimate	CI 90%
Path 3. AL→ Tru → PS → IAQ → UP	0.‏09*	(0.18, 0.04)
Path 4. AL→ PS → IAQ → UP	0.‏10*	(0.22, 0.04)
Path 5. AL→ IAQ → UP	0.‏26*	(0.47, 0.14)
Total indirect effects of AL → UP: path 3 + path 4 + path 5	0.‏46*	(0.70, 0.25)
Total effects of AL → UP: path 3 + path 4 + path 5 + direct AL → UP)	0.85*	(0.65, 1.03)

Audit-enabling leadership (AL), intra-team trust (Tru), team psychological safety (PS), internal audit quality (IAQ), medical clinic performance (UP).

*p < .05.

Table 6. Measurement items and sources and MSA-Kaiser values.

Medical clinic performance	MSA(i)-Kaiser values
1. This medical clinic adequately completes assigned duties	0.‏84
2. This medical clinic fulfills its responsibilities as expected	0.‏77
3. This medical clinic meets formal performance requirements of the work	0.‏80
4. This medical clinic fails to perform its essential duties (reverse-scored item)	0.‏89
Internal audit quality	MSA(i)-Kaiser values
Internal audit—Learning	0.87
Internal audit serves as a tool for learning work processes in my medical clinic	0.‏88
In my medical clinic, there is a thorough learning practice of the internal audit processes	0.‏93
In my medical clinic, the results of internal audit are brought before the employee in order to enable him/her to learn about mistakes and errors	0.‏91
In my medical clinic, proposals are submitted on ways to correct the mistakes found in the internal audit	0.‏83
In my medical clinic, regular reviews on procedures and memorandums are held as a result of internal audit	0.‏89
In my medical clinic, regular reviews of work procedures are held as a result of internal audit	0.‏86
In my medical clinic, specific guidance is provided to help learn the subjects in which mistakes or errors were found	0.‏78
When errors at work are found by the internal audit, they are studied and corrected along with the relevant employees in my medical clinic	0.‏84
Internal audit in my medical clinic makes me question why we perform tasks the way we do	0.‏97
We can see the difference between activities that are performed as a result of internal audit	0.‏89
The internal audit delves into points that are not emphasized during routine work	0.‏85
In my medical clinic, there is no process for thoroughly learning from internal auditing processes (reverse-scored item)	0.98
Internal audit—motivation	0.92
The internal auditing has an essential role in achieving the objectives of the top management	0.‏78
The internal auditing has an important role in increasing employees’ motivation to better perform their work	0.‏87
The employees in my medical clinic resist the internal auditing (reverse-scored item)	0.‏86
The internal auditing leads me to resist it (reverse-scored item)	0.‏96
Internal audit—process improvement	0.81
The internal auditing helps to improve the efficiency of work processes in my medical clinic	0.‏87
The internal auditing tracks the rectification of mistakes and errors	0.‏87
In my medical clinic, we keep track of the process improvement following the findings of the internal auditing	0.‏95
The internal auditing contributes to the improvement of work processes in my medical clinic	0.‏96
In my medical clinic, the internal auditing leads to an improvement of work processes	0.‏87
My medical clinic improves its work processes following internal auditing	0.‏88
Work processes in my medical clinic have been improved following the internal auditing	0.‏97
Mistakes and errors in my medical clinic have been corrected following the internal auditing	0.‏98
Mistakes and errors are repeated in my medical clinic in spite of the internal auditing	0.‏87
Internal audit—deterrence	0.85
In my medical clinic, we are cautioned against taking improper actions	0.‏93
Misbehaviour by employees in my medical clinic is deterred	0.‏88
Members of my medical clinic are motivated to perform their work faithfully in accordance with the top management guidelines	0.‏87
In my medical clinic, we adhere to secrecy-keeping policies	0.‏78
Members of my medical clinic are motivated to adhere to the rules and guidelines	0.‏88
My medical clinic adheres to security guidelines regarding patient’s personal information	0.‏97
Members of my medical clinic are motivated to behave in accordance with administrative norms	0.‏87
Trust
I believe that members of my medical clinic have high integrity	0.‏83
I can expect members of my medical clinic to treat me in a consistent and predictable fashion	0.‏91
In general, I believe that the motives and intentions of members of my medical clinic are good	0.‏92
I don’t think that members of my medical clinic treat me fairly (reverse-scored item)	0.‏90
Members of my medical clinic are open and up-front with me	0.‏89
In general, I believe that members of my medical clinic do not treat me fairly (reverse-scored item)	0.‏74
Psychological safety
If you make a mistake at work, it is not held against you in this medical clinic	0.‏82
Members can raise problems and tough issues for discussion in the medical clinic	0.‏90
People in this medical clinic do not reject others for being different	0.‏81
It is safe to take a risk in this medical clinic	0.‏92
It is always an option to ask other members of this medical clinic for help	0.‏91
No one in my medical clinic would deliberately act in a way that undermines my efforts	0.‏88
Audit-enabling leadership
Audit-enabling leadership: professional and knowledgeable	MSA(i)-Kaiser values
Proficiency:	0.91
Proficient in organizational issues brought to their attention	0.‏93
Professionally skillful in addressing issues	0.‏82
Fosters proficiency at work	0.‏94
Is not particularly proficient at work (reverse-scored item)	0.‏95
Instructing and teaching:	0.89
Professionally supports their employees in organizational processes at work	0.‏86
Professionally guides their employees at work	0.‏94
Fosters professional supporting processes at work	0.‏88
Professionally teaches their followers at work	0.‏83
Audit-enabling leadership: relational
Participative:	0.87
Co-operates with other members	0.‏84
Involves others in the decisions	0.‏92
Involves others in emerging problems	0.‏91
Does not involve the team in the decision-making process (reverse-scored item)	0.‏86
Attentiveness:	0.85
Is capable of attentiveness to others at work	0.‏86
Encourages attentiveness to others at work	0.‏94
Pays the utmost attention to their employees at work	0.‏78
Does not listen at all to others at work (reverse-scored item)	0.‏94
Creating commitment:	0.86
Is committed to realizing the potential of employees at work	0.‏87
Takes responsibility for their employees’ performance	0.‏95
Supports employees vis-à-vis the management team	0.‏84
Builds commitment among their followers at work	0.‏91
Is not committed to their employees at work (reverse-scored item)	0.‏86