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This study aims to give an account of how stakeholders in one NHS Hospital Trust responded to the clinical governance initiative, the effects on quality improvement and the practical accomplishment of legitimacy.

Sociological new institutionalism theory was utilised to explain the political and ceremonial conformity that marked the clinical governance process. A case study was employed using ethnographic methods. The qualitative data were obtained by documentary analysis, observation of meetings and ward activity and 28 semi‐structured interviews. A grounded theory approach was adopted in the analysis of the interviews.

Errors and inconsistencies were found in Trust documentation and reporting systems were poor. In practice clinical governance was inadequately understood and the corporate goals not shared. Nevertheless, during the same period the Trust obtained recognition for having appropriate structures and systems in place resulting in external legitimacy.

The results only relate to the Trust considered but the study has identified that, although the organization responded to isomorphic governmental pressures in the production of appropriate institutional documentation, the impact of clinical governance to improve the quality in practice was found to be inconsistent.

The Trust promoted and endorsed clinical governance success but the lack of organizational processes and knowledge management equally promoted its failure by denying the resources to implement the desired actions.

Whilst the study identified that clinical governance had been a “ceremonial success”, it is argued that the practical accomplishment in the improvement of quality of care for patients will remain a paper exercise until organizational and practice issues are addressed.

This paper aims to examine the association between political connections, political uncertainty and audit fees. The authors use various measures of political connections and uncertainty: political connections (civil and military), political events (elections) and a general measure of political stability (i.e. a world bank index).

The authors measure the association between political connections, political uncertainty and audit fees. Audit fees reflect auditors’ perceptions of risk. The authors examine auditors’ business risk, clients’ audit and business risk after controlling for the variables used in prior audit fee research.

Results indicate that civil-connected firms pay significantly higher audit fees than non-connected firms owing to the instability of civil-political connections. Military-connected firms pay significantly lower audit fees than non-connected firms owing to the stable form of government. Furthermore, considering high leverage as a measure of clients’ high audit risk and high return-on-assets (ROA) as a measure of clients’ lower business risk, the authors interact leverage and ROA with civil and military connections. The results reveal that these risks moderate the relationship between political connection and audit fees. Election risk is independent of risk associated with political connections. General political stability reinforces the theme that a stable government results in lower risks.

The authors combine cross-sectional measures of political uncertainty (civil or military connections) with time-dependent measures (general measures of political instability and elections).