This study examines the impact of organisational and structural change on the evolution of quality and safety in health organisations, specifically in mental health services. Design/methodology/approach Data was gathered through semi-structured interviews. Twenty-five executive management team members in both public and private mental health services were interviewed and data was analysed using Burnard's framework. Findings Three overarching themes emerged: 1) organisational characteristics, leadership and accountability; 2) sustaining collaboration and engagement with stakeholders; 3) challenges to and facilitators of quality and safety. Taken together, the findings speak to the disruptive and disorienting impact of ongoing organisational change and restructuring on leaders' ability to focus on, and advance, the quality and safety agenda. Research limitations/implications Typical with qualitative research of this nature, the potentially limited generalisability of the findings must be acknowledged. Practical implications There is a need for strategies to implement change that are informed by evidence and theory and informed by decades of research on this topic, rather than introduced ad hoc. Change agents must pair effective change management and implementation science strategies to specific contexts, depending on what is being implemented and ensure appropriate evaluation of organisational change to bolster the evidence base around quality and safety and inform future decision-making. Originality/value The study explores an identified gap in the literature on the impact of ongoing organisational restructuring and transformation on the evolution of quality and safety in mental health services.