Leadership behaviours of executives in healthcare are considered to be of prime importance (Burke, 2006), with strategy, structure and process being key elements of team and organisational effectiveness (Yammarino et al, 2008). This research identified that executives were clear on what type of leadership behaviour is expected of them; seeing themselves as transformational, setting clear goals and expecting the best from their teams. They also identified elements of autocratic and transactional leadership were required frequently in the achievement of targets. There was acute recognition of the tensions between quality and safety and the target-driven approach required by commissioners and the current financial climate. External drivers for quality and safety included losing foundation trust status and the resultant financial penalties. It was acknowledged the commissioners have huge power and influence over the direction of where the organisation concentrates effort to influence policy which could also provide tension with the quality and safety strategy. Finance and ‘doing more for less’ are constant themes, with competition to keep quality and safety on the agenda. Quality and safety has a reputation for being problematic, many executives believed changing the organisational culture requires evaluation.