Master Thesis 3de Versie

Successful clinical team leadership: competences and assessment A research concerning the competences and existing assessment instruments on successful clinical team leadership by using literature and professional opinions in the Radboud University Nijmegen Medical Centre

Student: Loes Custers Student number: I502170 Master Public Health: Health Services Innovation Supervisor 1: Dr. Wil Buntinx Supervisor 2: Drs. Louk Hollands Placement coordinator: Ger Brouns Placement: Scientific Institute for Quality of Healthcare (IQ healthcare) Nijmegen - UMC St Radboud Nijmegen Placement supervisors: Dr. Mariëlle Ouwens and Dr. Mirjam Harmsen Period internship: April 2009 – December 2009 Date: 10 December 2009

Faculty of Health, Medicine & Life Sciences University Maastricht

Acknowledgements After my graduation in nursing in June 2007 at the HAN University of Applied Sciences, I wanted to expand my knowledge about health care more in depth by applying for another academic study. I soon found an appropriate study, namely Health Sciences at the Maastricht University. Because of my nursing background, it was possible to skip the bachelor of Health Sciences, after achieving a methodology and statistics test, an application essay, and a letter of expectations. Eventually, I started the master Public Health, specialization Health Services Innovation, in September 2008. An interesting master for me, because of its practical interfaces with my nursing background. Indeed, the course was developed to equip health professionals for the challenges of innovation in the health care field. This thesis is the final result of the master study Public Health, and the final product with regard to my graduation project. The graduation period at the Scientific Institute for Quality of Healthcare (IQ healthcare) UMC St Radboud Nijmegen, had its ups and downs, but overall it was very instructive to me. The internship has given me a good impression of the practice of health care research. I would like to thank some people in realizing this master thesis: -

Dr. W. Buntinx and Drs. L. Hollands for supervising my graduation project;

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Dr. M. Ouwens for providing a placement for my internship and her help during my graduation project;

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Dr. M. Harmsen for her practical guidance during my graduation project;

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IQ healthcare for the use of its workplace and facilities;

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All professionals in the UMC St Radboud who have contributed to the study;

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All colleagues and students at IQ healthcare who were interested in my work and provide sociability during the breaks.

Finally, I want to thank my family and friends for their support, which was of great importance during the study. Loes Custers

Summary Health care today routinely fails to deliver its potential benefits. The Institute of Medicine talks about a chasm between the care patients receive and they actually should receive. To overcome this chasm, several quality improvement programmes are introduced in health care practice. Leadership is frequently mentioned as an essential principle in achieving quality improvement at all levels of the chain of effect. Clinical team leadership is focused on the microsystems, the basic building blocks of the entire organisation. The competences of clinical team leadership should be defined to assess the performance of clinical team leaders, and eventually to improve shortcomings in leadership that could affect also other levels in the health care system. IQ healthcare and the integral intern audit team of the UMC St Radboud searched for opportunities to assess clinical team leadership. The following problem statement was formulated in this study: What are important competences of successful clinical team leadership in health care and how can these competences be assessed in clinical practice? The problem statement was answered using literature gathered by PubMed and, in addition, an expert panel of 10 clinical team leaders of the UMC St Radboud replied a questionnaire about the most important competences of clinical team leadership. A total of 13 competences were identified using literature on quality improvement models and clinical team leadership. Sixteen competences were identified on the basis of professional opinions. Of these competences, 69% were identified by both the literature and professional opinions, which resulted in a total of 18 competences. The Multifactor Leadership Questionnaire (MLQ), the Leadership Practice Inventory (LPI), The Malcolm Baldrige National Quality Award criteria for organizational performance (MBNQA) and the Microsystem Assessment Tool (MAT), were the most common existing assessment instruments in the literature that are useful in measuring clinical team leadership. However, none of these instruments is able to measure all competences of clinical team leadership, so a different tool might be needed. Further analysis of the existing assessment instruments on leadership is also recommended. In case of the UMC St Radboud, the MBNQA, in particular the INK-management model, is useful since it is able to measure the largest amount of competences, and provides future opportunities by offering a framework to evaluate the performance at all organizational levels. However, the UMC St Radboud should investigate how this framework can integrate within the implemented Team Climate Inventory (TCI).

Table of Contents Acknowledgements .................................................................................................................II Summary.................................................................................................................................III Table of Contents ...................................................................................................................IV Introduction............................................................................................................................VI 1.1 Introduction of the research topic ..................................................................................VI 1.2 Research setting ............................................................................................................VII 1.3 Problem statement en research questions.....................................................................VIII 1.4 Structure of the thesis...................................................................................................VIII 1Theoretical framework........................................................................................................IX 1.5 Quality improvement in the health care system ............................................................IX 1.6 Leadership and quality improvement in health care .......................................................X 1.7 Leadership at the microsystem level ...............................................................................X 1.8 Improvement models on leadership ...............................................................................XI 1.9 Definition of clinical team leadership .........................................................................XIV Methods................................................................................................................................XVI 1.10 Research design........................................................................................................XVII 1.11 Data collection........................................................................................................XVIII 1.12 Research population...................................................................................................XIX 1.13 Data analysis..............................................................................................................XIX 1.14 Trustworthiness...........................................................................................................XX 2Results..................................................................................................................................XX 1.15 Competences of successful clinical team leadership ................................................XXI 1.16 Competences of successful clinical team leadership according to professionals . XXVII * Non underlined competences of clinical team leadership: comptences that were also identified in literature on clincal team leaderhsip an models of quality improvement (paragrapth 4.1) * Underlined competences of clinical team leadership: competences that were not recognized previously .................................................................................................XXVIII 1.17 Existing assessment instruments useful for measuring clinical team leadership? XXVIII 1.18 Assessment of successful clinical team leadership competences by existing instruments ....................................................................................................................XXXII Discussion.........................................................................................................................XXXV 1.19 Discussion.............................................................................................................XXXV

1.20 Conclusion.........................................................................................................XXXVIII 1.21 Recommendations ...............................................................................................XXXIX 1.22 Limitations ..................................................................................................................XL References..............................................................................................................................XL Appendix: Description of assessment instruments on clinical team leadership ............LII

Introduction This introductory chapter clarifies firstly the importance of the research topic, clinical team leadership and its related components in health care. The second paragraph gives information about the Radboud University Nijmegen Meidcal Centre (UMC St Radboud) and Scientific Institute for Quality of Healthcare (IQ healthcare), the institute that has raised the research questions of this thesis. In addition, the relevance of the study from the institute’s perspective is motivated. The third paragraph describes the problem statement, the assumptions, the aim and the research questions. In the final paragraph, the structure of the master thesis is presented.

1.1

Introduction of the research topic

Health care today harms too frequently, and fails to deliver its potential benefits. Quality problems are everywhere, affecting many patients (Institute of Medicine, 1999). The Institute of Medicine (2001) even talks about a chasm between the care patients receive and the care they actually should receive. In bridging this chasm, the interest in quality improvement raised to strive for optimal patient safety in health care. There are several principles that contribute to overcoming the quality chasm. Patient centeredness, multidisciplinary care, care coordination, evidence-based medicine, continuous quality improvement, and efficient care are examples that are recognized in various health care improvement programmes, such as the integrated care model or disease management (Ouwens, 2007), the chronic care model (Wagner, Austin, Davis, Hindmarsh, Schaefer, & Bonomi, 2001), and the paradigm for health care quality (Massoud et al., 2001). Using their principles, all those programmes underline the essence of teamwork or teamwork components like leadership. Leadership plays a vital role when it comes to the progress of health care. It is mentioned as the enterprise of quality improvement needed at all levels of the health care system (Leape & Berwick, 2000). Special attention should be paid to clinical team leadership, that focuses on the microsystem level, where the front-line health care professionals do their work. The performance of a microsystem can be optimized when the clinical team leader performs his tasks adequately. Since the microsystems are the composed building blocks of the entire organisation, the overall performance will be improved by improving the microsystems

(Nelson et al., 2002). However, to improve the performance of a clinical team leader, more insight is needed. The competences of clinical team leadership should be known to assess the performance of clinical team leaders. The competences of clinical team leadership and their assessment are discussed in this study with regard to the Radboud University Nijmegen Medical Centre (UMC St Radboud).

1.2

Research setting

UMC St Radboud is a leading academic centre with expertise in medical science and health care. Expertise plays an essential part in the organization and connects research, education, and patient care. The more than 8500 staff and 3000 students are committed and ambitious, helping to shape the future of health care and medical science (UMC St Radboud, 2009). IQ healthcare, the centre where this study about leadership in health care was executed, is directly connected to the UMC St Radboud. IQ healthcare is one of the leading centres for health services research related to quality improvement in healthcare in Europe. It aims to help different parties in health care with their decisions and activities related to quality and safety by performing scientific studies and evaluations. Research is mainly organized in four domains: implementation science, quality in hospital and integrated care, quality of nursing, and allied health care and health care ethics (Scientific Institute for Quality of Healthcare, 2009). One of the studies Ouwens (2007) conducted for IQ healthcare was about integrated care for patients with head and neck cancer. In a doctoral thesis she described that a team climate in which team members are encouraged to develop and implement new ideas, can lead to better health care and health outcomes. To assess team climate and the team areas that could be improved, Ouwens (2007) used a multidimensional measure called the Team Climate Inventory (TCI) by Anderson and West (1996). This 44-question measure consists of four scales that are essential for developing and implementing innovations: team vision, participative safety, task orientation, and support for innovation. The TCI-tool proved to be a valid, reliable, and discriminating measure of team climate among hospital teams (Ouwens, 2007). However, it is not an efficient scale to assess leadership within health care teams, because the leadership function is simply not indicated as an assessment item. The fact that leadership and leadership assessment are missing items, has led to new questions within IQ healthcare and especially within the integral intern audit team of the UMC St Radboud, that

structurally uses the TCI to assess team climate at all clinical wards of the UMC St Radboud. This study on leadership in health care teams strives for answering some of these questions IQ healthcare and the auditors of the intern audit team are dealing with.

1.3

Problem statement en research questions

The following problem statement can be formulated: What are important competences of successful clinical team leadership in health care teams and how can these competences be assessed in clinical practice? The leading assumption of this study is that clinical leadership in health care teams can affect and may improve the quality of care. It aims to define and assess clinical team leadership as a tool to improve the quality of care. In relation to this, four main questions are defined: 1) What are competences of successful clinical team leadership in literature on clinical team leadership and models of quality improvement? 2) What are competences of successful clinical team leadership according to professional opinions in the UMC St Radboud Nijmegen? 3) Which existing assessment instruments are useful in measuring clinical team leadership? 4) Can the competences for successful clinical team leadership found in the literature and by professional opinions be assessed by existing instruments?

1.4

Structure of the thesis

The next chapters of this thesis will work towards answering the previous research questions. Chapter 2 provides the theoretical considerations concerning clinical team leadership in health care. Chapter 3 addresses the research methods and strategies that were used. Chapter 4 pays attention to the results of the study by answering the formulated research questions. Finally, chapter 5 includes the discussion and conclusions in relation to the theoretical considerations, and the related recommendations for practice.

1

Theoretical framework

This chapter provides background information about clinical team leadership. Firstly, the need for quality improvement in the health care system is described, and a framework to improve health care quality is presented. Paragraph two highlights the importance of leadership in health care improvement. Paragraph three explains more about leadership at the microsystem level. Based on the microsystem level, paragraph four mentioned addition improvement models. Finally, paragraph five is focused on the understanding of clinical team leadership according to the literature.

1.5

Quality improvement in the health care system

Patients should be able to count on receiving care that meets their needs and is based on the best scientific knowledge. However, this is frequently not the case. Many patients are harmed by medical errors, while the care was supposed to help them (Institute of Medicine, 2001; Berwick, 2002). The Institute of Medicine (2001) stated that there is not just a gap, but a chasm between the care patients receive and the care they actually should receive. In 1999, the institute called for an effort to make health care safe (Institute of Medicine, 1999; Leape & Berwick, 2005). Therefore, quality improvement is critical, it should bridge the quality chasm (Institute of Medicine, 2001). The nature of the health care system is the key concept for effective quality improvement (Berwick & Nolan, 1998; Nolan, 1998). In realizing real improvement, the entire system should change and individuals at all organizational levels should work together as a team (Berwick 1996; Berwick, 2003). An underlying framework for understanding redesign in health care systems is ‘The Chain Of Effect’ (D.M. Berwick, personal communication, December 11, 2001). It analyzes the needed changes at four different levels (Figure 1): (1) the experience of patients and communities, (2) the functioning of small units of care delivery (microsystems), (3) the functioning of the organizations that house or otherwise support microsystems (macrosystems), and (4) the environment of policy, payment, regulation, accreditation, and other such factors, which shape the behavior, interests, and opportunities of the organizations at level 3 (Berwick, 2002).

Figure 1.Chain Of Effect in Improving Healthcare Quality Source: Berwick (2001)

1.6

Leadership and quality improvement in health care

Leadership is increasingly aimed at leading changes within health care teams. It is needed at all levels of the health care system and an essential ingredient of success in the search for safety, as it is throughout the enterprise of quality improvement (Berwick, 1996; Leape & Berwick, 2000). Leaders have the potential to influence team processes that contribute to team innovation. Their role is critical for success in realizing effective team performance. The extent to which the leader defines team objectives and organizes the team to ensure progress toward achieving these objectives contributes substantially to team innovation (West et al., 2003). Leaders also ought to be playing a central role in making the changes in the health care system. Especially, clinicians have an opportunity to exercise leadership for the improvement of health care (Berwick, 1994).

1.7

Leadership at the microsystem level

According to The Chain Of Effect Model, clinical team leadership is focused on leadership at the microsystem level. Microsystems are the small units of work that actually give the care that the patient experiences (Berwick, 2002). The clinical microsystem concept is originally based on an understanding of the systems theory connected with the theory of James Quinn (1992), who describes in his theory the significance of small replicable units to build a relevant effective system design. Later on, these units were called microsystems.

Microsystems are the basic building blocks of the larger meso- and macrosystems. The performance of each individual microsystem should be optimized, to ultimately achieve better results in the whole macrosystem. Batalden et al. (2003) address the importance of leadership as one of the success characteristics of high performing clinical microsystems. Firstly, they define the differences between the concepts of ‘leader’, ‘leadership’ and ‘leading’. Someone who is guiding or leading is labelled as a leader, the phenomenon itself is better known as leadership and leading refers to the active process. Leading and leadership by leaders exist at all levels and between the different microsystems. The role of leadership as success characteristic consists of maintaining consistency of purpose, establishing clear goals and expectations, fostering positive culture, and advocating for the microsystem in the larger organisation. In this context, leaders have to balance setting and reaching collective goals with empowering individual autonomy and accountability (Nelson, Batalden, & Godfrey, 2007). In addition a distinction is made between three fundamental processes of leading: (1) building knowledge, (2) taking action, and (3) reviewing and reflecting. The first process addresses that microsystem leaders should build knowledge about the structure, processes and patterns of work within their microsystems. The second process requires microsystem leaders to take action with regard to the knowledge they have built. Finally, reviewing and reflecting means that leaders should take time for the evaluation of the structure, process and patterns of the microsystem (Berwick, 1996). As Heifetz (1994) stated: “a good leader needs to be both on the dance floor in the middle of the action and up in the balcony seeing the larger pattern of what is happening and knowing when and how to intervene in a way that promotes progress on difficult problems” (p. 252) .

1.8

Improvement models on leadership

Several quality improvement programmes and models on the microsystem level have their vision on leadership in health care teams, and assert to overcome the quality chasm. Some prominent models are discussed below.

The Integrated Care Model

The integrated care model, also known as disease management, is described as an organizational process of coordination that seeks to achieve seamless and continuous care, tailored to the patient’s needs and based on a holistic view of the patient (Mur-Veeman, Hardy, Steenbergen, & Wistow, 2003). The essence of integrated care is divided into five principles: patient centeredness, multidisciplinary care, coordination of care, evidence-based medicine, and continuous quality improvement. Clinical teams should carry out these principles to achieve a higher quality of care (Ouwens, 2007). Leadership is not a direct principle of the integrated care model. However, leaders with a clear vision of the importance of integrated care are mentioned as essential requirement for successful implementation of the model (Ouwens, 2007). The Chronic Care Model The chronic care model, as its name already suggests, emphasizes the optimization of chronic care. It consists of the following elements: community resources and policies, health care organisation, self-management support, delivery system design, decision support, and clinical information systems. The ultimate goal of the model is to activate patients’ interaction with a prepared, proactive practice team (Bodenheimer, Wagner, & Grumbach, 2002). When it comes to leadership, much attention is paid to the previously discussed relation between leadership and improvement in health care. Considering the chronic care element ‘health care organisation’, Wagner et al. (2001) describe that senior leaders should support improvement at all levels of the organization. Senior leadership must identify care improvement as important work, and translate it into clear improvement goals and policies that are addressed through application of effective improvement strategies that encourage comprehensive system change. Crew Resource Management Crew Resource Management (CRM) is a way of team training with an accent on communication. It can been seen as a group of strategies in proactive risk management, aimed at identifying potential sources of error and initiation of corrective action to prevent unwanted outcomes (Taylor, Hepworth, Burhaus, Dittus, & Speroff , 2007). Some of these strategies can particularly be relevant to health care, for instance, the standardisation of briefings and debriefings, the establishment of team training, and the incorporation of behaviours to

monitor other team members on actions that are critical to safety (Musson & Helmreich, 2004). Figure 2 shows improvements that are accomplished by the introduction of CRM in diabetes care. For leadership it is important to sustain improvements and integrate CRM into an enduring culture through endorsement, role modelling, and booster training.

Figure 2. Example of changes following the implementation of CRM in diabetes care Source: Taylor et al. (2007)

The Paradigm for Health Care Quality The paradigm for health care quality is a monograph that was presented in 2001 as an update on quality improvement methodology. It includes the following main principles: client focus, understanding of work as processes and systems, testing changes and emphasizing the use of data, and teamwork. The paradigm underlines the importance of improvement throughout a team approach of problem solving (Massoud et al., 2001). In addition, the principle teamwork accentuates the involvement of key people in the improvement of a process. This often leads to more clarity and incorporation of insights and needs of clients into health care delivery. Moreover it helps reveal the errors that occur during hand-offs. Finally, given the opportunity and authority, staff can often identify problems and generate more ideas to resolve them (Massoud et al., 2001).

Model of Behavior Change The model of behaviour change is useful in succeeding the implementation of new innovations in health care teams. Self-management training and the related self-efficacy are of great importance (Figure 3). A team should manage its own condition to create a kind of confidence among the team members. Bourbeau, Nault, and Dang-Tan (2004) summarized the following self-efficacy strategies for the patient as useful: (1) practice, (2) feedback, (3) reattribution of the perceived causes of failure when there are negative experiences, and (4) sharing experience. However, to improve self-management and self-efficacy this strategy can also be applied in a broader perspective, at all levels of the chain of effect. In this case, especially at the microsystem level.

Figure 3. Causal model of behaviour change Source: Bourbeau et al.(2004)

1.9

Definition of clinical team leadership

When looking at the literature, clinical team leadership is not a clearly defined concept. Authors that describe clinical leadership talk differently about the phenomenon, which means no general agreement can be established. According to Vance and Larson (2002), a single definition is not necessary because an appropriate choice of definition depended upon the theoretical, methodological and substantive aspects of leadership being considered. Three different contexts of clinical leadership can be distinguished in the literature: (1) clinical leadership programmes or evaluations, (2) work of managers who work in clinical settings, and (3) work of clinicians who practice at an expert level and who have or hold a leadership position (Stanley, 2006). In addition, many authors use clinical leadership interchangeably with the words ‘nursing leadership’ or ‘clinical nurse leadership’. Therefore it is remarkable that clinical leadership is particularly popular in nursing literature. However, Olsen & Neale (2005) underline the need for clinical leadership at all levels of the organization.

In his paper ‘Clinical leadership: the elephant in the room’, Edmonstone (2008) considers a vision that is not only focused on nursing leadership, but on clinicians in general: front-line health care professionals. His reasoning is in line with Malby (1998), who suggests that clinical leadership simply referred to anyone in a clinical role who exercised leadership. Health care professionals who perform clinical leadership should competing responsibilities as both leaders and clinical providers. Clinical leaders are those who retained some clinical role, but at the same time took on a significant part in matters of strategic direction, operational resource management, and collaborative working with colleagues in their own and other clinical professions, with health care managers, and with other managers and professionals in other agencies. More briefly, Cook & Leathard (2004) describe a clinical leader as an expert clinician, involved in providing direct clinical care, and influencing others to improve the care they provide continuously. Clinicians who became full-time general managers in health care organizations are not mentioned as clinical leaders because they are not directly involved anymore in care providing. In order to clarify the concept of clinical leadership in depth, a distinction can be made with managerial leadership in health care. Managerial leadership centralized mainly the overall needs of the organization (macro-view), while clinical leadership, by contrast, has a prime focus on the patient, client group or service (micro-view) (Edmonstone, 2008). Clinical leadership is a topical issue in nursing. Cook (2001) adopted a quotation of the Royal College of Nursing (RCN), that describes that clinical nurse leaders are crucial to the success of patient care initiatives. Carryer, Gardner, Dunn, & Gardner (2007) highlight the role of the nurse practitioner in clinical leadership, that is derived from a strong base of clinical experience and education, which develops both extensive and extended clinical skills and critical awareness of the place of nursing in health service delivery. Clinical nursing leadership reflects all of the complexity of the culture, the organization, the practice setting and situational variables of each clinical nurse leader, the environment in which they operate or how and where the impact is felt. Although, clinical leadership is often associated with the nursing profession, this study emphasizes on front-line health care professionals who exercise leadership, nurses but also doctors or allied health professionals. This corresponds to the third context of clinical leadership Stanley (2006) talks about, and the definition Malby (1998) suggests.

Methods Firstly, this chapter addresses information about the research design of the study. The second paragraph focuses on the sources that are used to collect the data for the study and the related phases of qualitative research. Thirdly, the research population is described more profound.

The fourth paragraph reports how the collected data were analysed. Finally, the fifth paragraph discusses the psychometric properties of the study.

1.10 Research design Polit and Beck (2005) define research as a systematic inquiry that uses disciplined methods to answer questions or solve problems. The ultimate goal of research is to develop, refine, and expand a base of knowledge. In accordance with this statement, the study is designed to answer the following question: What are important competences of successful clinical team leadership in health care teams and how can these competences be assessed in clinical practice? The question predicts the research design of the study, qualitative research. The questions are focussed on the phenomenon clinical team leadership, as opposed to quantitative research, that for instance pays attention to the number of leaders that perform successful clinical team leadership (Baarda & de Goede, 2001; Frederiks & te Wierik, 2004). In addition, to understand the opinions, experiences, and interpretations of clinical team leaders about leadership, it is important to gain more insight from them (A. Krumeich, personal communication, March 3, 2009). Qualitative research is a field of inquiry in its own right. It crosscuts disciplines, fields, and subject matters. A complex, interconnected family of terms, concepts, and assumptions surround the term qualitative research (Denzin & Lincoln, 2005). This qualitative study is performed with the help of two research methods. Research questions one and three are answered on the basis of literature. They discuss what is already known about clinical team leadership competences and its assessment. The second question is answered using opinions of experts obtained through a questionnaire. Finally, the fourth research question uses the information gained from the previous three research questions. Table 1 gives an overview of the research methods for each research question, the strategies, identified keywords and their inclusion criteria. Table 1. Properties of the research methods for each research question Research questions 1) What are competences of successful clinical team leadership in literature on clinical team leadership and models of quality improvement?

2) What are competences of successful clinical team leadership according to professional opinions in the

3) Which existing assessment instruments are useful in measuring clinical team leadership?

4) Can the competences for successful clinical team leadership found in the literature and by professional opinions be assessed by

Research methods

Literature study

Research strategies

• Database: PubMed;

Keywords

“clinical leadership”

Conditions for collection and inclusion criteria

UMC St Radboud Nijmegen? Expert panel • Questionnaire.

• Snowball strategy.

• Prominent data on

quality improvement are provided by experts of the University of Maastricht; • All abstracts are viewed;

• Relevant papers are viewed completely;

• Papers published in English;

• Papers that describe

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•UMC St

Radboud experts that exercise clinical leadership: department heads and senior nurses; • Minimal 10 respondents.

existing instruments? Literature study

• Database: PubMed. “leadership assessment”; “leadership questionnaire”; “leadership performance”; “leadership quality”; leadership measurement; leadership measurement tool; leadership assessment inventory. MeSH terms: leadership AND outcome; assessment OR process assessment; leadership AND inventory; leadership AND psychometrics.

• Papers that describe the

application of a leadership assessment instrument, are collected;

• Papers that describe

Literature study and professional opinions

• Usage of data

obtained in previous research questions.

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• Definitions of the subscales of instruments are used in comparing the with the competences.

leadership assessment as part of a larger instrument;

• Papers published in English;

• Papers published after 1999.

one or more competences of clinical leaders or clinical team leadership.

1.11 Data collection The literature studies on the competences and assessment of clinical team leadership are performed with the help of a bibliographic strategy. References are searched by PubMed, a free search engine for accessing the Medline database of citations, abstracts and some full text articles on life sciences and biomedical topics. In searching for relevant papers different search keywords were applied. In addition, Medical Subject Headings (MeSH terms) are utilized in finding subject relevant literature. MeSH terminology provides a consistent way to retrieve information that may use different terminology for the same concepts (Polit & Beck, 2005). Both keywords and MeSH terms are defined in Table 1. Apart from computerized strategies, the snowball strategy is employed to gather data concerning research question one. According to this strategy, the citations from relevant primary papers are used to track down

earlier research upon which the papers are based (Cooper, 1998). The primary papers are provided by two experts in health care science at the University of Maastricht, and comprise a selection of the most prominent data on quality improvement. In collecting appropriate data for the second research question, the experts are consulted by email. This strategy is cost-effective, however, Polit & Beck (2005) express that emails tend to yield low response rates. To overcome low response rates, follow-up reminders were also send. This procedure involves additional mailings urging nonrespondents to complete and return their forms. The follow-up reminders were sent about 14 days after the initial mailing (Polit & Beck, 2005). The initial mail that was sent to the experts, included a brief description of the content of the study and the problem statement, the request for contributing the study, and a questionnaire. The questionnaire consists of the following question: what are, in your opinion, the competences of successful clinical team leaders in healthcare? In addition, the experts were asked to mention a minimal of five competences. The follow-up reminders consist of a request to answer the initial email.

1.12 Research population To obtain data about the competences of successful clinical team leadership in practice, some experts in the UMC St Radboud that exercise clinical team leadership participate in the study. This is in accordance with the definition of clinical team leadership that was described earlier: clinical leadership refers to anyone in a clinical role who exercised leadership (Malby, 1998). According to the UMC St Radboud this concerns department heads and senior nurses. The department head is a medical professional, who is responsible for the final performance of a clinical ward. Senior nurses have an additional responsibility in the coordination, organization and planning of daily care. Questionnaires were sent to 17 professionals, 10 department heads and 7 senior nurses. A total of 10 follow-up reminders are mailed to 5 department heads and 5 senior nurses. 1.13 Data analysis The aim of the data analysis was to identify regularities, patterns, and recurrent themes to label the categories and subcategories with the help of the theoretical concepts (Polit & Beck, 2005). In the study the data analysis was based on the competences of successful clinical team leadership, determined by the respondents. The following steps were applied in this study to

analyse the data: (1) all the mentioned competences are listed in one document; (2) the competences are read carefully; (3) the competences are divided into segments; (4) segments with similar themes are grouped; (5) all groups receive a code (keyword) that represents a certain competence best. Herewith, the grouped segments are linked to the competences of clinical team leadership found in the literature; (6) the groups and codes are reviewed once again and a second researcher will reflect on the analysis; (7) the segments are translated in English.

1.14 Trustworthiness The data that were gathered in this study should be protected against falsification. In research terms the phenomenon of falsification is also known as bias, an influence that produces a distortion or error in the study results. Unfortunately, bias can seldom be avoided totally because the potential for its occurrence is so pervasive (Polit & Beck, 2005). In this study, a variety of strategies and criteria were adopted to eliminate or minimize bias. Firstly, method triangulation was applied to increase the credibility of the study. This means that at least two methods are used to address the same research problem (Morse, 1991). In the present study, these two methods are qualitative literature search and data collection using questionnaires. The results of the study will be presented to the respondents to serve as a check on the viability of the interpretation, also known as member check. In addition, the face validity is considered by the supervisors of this thesis. Likewise, the transparency and the plausibility are achieved through careful description of the research process. Finally, theory development involves that the collected research data are compared to the theoretical starting points of the study, so that similarities and differences can be found. This increases the objectivity and stimulates the development of a new theory.

2

Results

This chapter presents, for every research question individually, the study outcomes that were collected with the help of the previous explored research methods. It consists of four paragraphs. Successively, paragraph one describes the results of the first research question, paragraph two the second research question and so on.

1.15 Competences of successful clinical team leadership Several prominent competences of clinical team leadership can be distinguished using literature on clinical team leadership and models of quality improvement. Some competences are mentioned frequently, while other competences are not explicit described. The literature sources used different words in defining competences of successful clinical team leadership. To avoid ambiguity, the competences are formulated as keywords and presented in Table 2. The table shows the competences and the corresponding literature sources. A distinction is made between literature on clinical team leadership and the literature concerning models of quality improvement. The competences are described with respect to their contents. Improvement In the literature about both quality improvement models and clinical team leadership, the role of leadership in health care improvement is quoted frequently. Concepts like continuous quality

improvement, change, reform, innovation, evidence based practice, and high

performance are well known. Effective leadership is mentioned as a requirement that is crucial in achieving change in health care practice (Cook, 2001; Institute of Medicine, 2001). The involvement of leaders, especially clinical team leaders, in striving for excellent performance in health care delivery includes various tasks. Batalden et al. (2003) describe that leaders should build knowledge on, for instance, the methods that are associated with better practice. Clinical leaders are supposed to create a culture and provide an environment for continuous improvement (Institute of Medicine, 2001). They are responsible for the introduction of new and more effective ways of delivering services based on evidence-based practice (Cook, 2001; Edmonstone, 2008). In realizing improvements, leaders work through and with their team members, whereas engagement, help, support, and influence are of substantial importance (Cook & Leathard, 2004; Davidson, Elliott & Daly, 2006; Ham, 2003; Holleman, Poot, Mintjes, & Achterberg, 2009; Nelson et al., 2008). Leaders negotiate in the process of change and pave a way for their teams in continuous development (Davidson et al., 2006). Finally, leaders have a significant task to enhance the durability of improvements. They should foster development, sustain improvement and promote continuous improvement by coaching and supporting the frontlines (Holleman et al., 2009; Nelson et al., 2007; Nelson et al., 2008; Taylor et al., 2007).

Goal & vision Nelson et al. (2007) determine leadership in the microsystem concept as one of the success characteristics of high-performing microsystems. As success characteristic, the leadership role is to maintain constancy of purpose and establish clear goals and expectations. The leader, the person who is leading, should reach collective goals together with the whole professional team (Barach & Johnson, 2006; Foster, Johnson, Nelson & Batalden, 2007; Nelson et al., 2007). The task of leaders in goal setting is also highlighted in the integrated care model. Ouwens (2007) state that leaders with a clear vision are of great importance. In the scope of health care improvement, Wagner et al. (2001) explain that leadership should translate improvement into clear goals and policies. Leaders should be capable of defining and communicating the purpose of the organization clearly. They are responsible for the creation and articulation of the vision and goals and, in addition, provide clear and visible values, and high expectations. Learning organizations need leadership at many levels that can provide clear strategic and sustained direction and a coherent set of values and incentives to guide group and individual actions (Institute of Medicine, 2001). Apart from quality improvement programs, papers about clinical team leadership also promote goal setting and goal establishing as essential tasks in leadership. Davidson et al. (2006) for instance, define leadership as follows: ‘A multifaceted process of identifying a goal or target, motivating other people to act, and providing support and motivation to achieve mutually negotiated goals. Leaders are often described as being visionary, equipped with strategies, a plan, and a desire to direct their teams and services to a future goal.’ Moreover, Johns (2003) clarifies that vision gives meaning and direction to practice. Finally, clinical team leaders should develop a clear view of themselves as leaders, of themselves as part of the team, in their relation to other team members, and of themselves as clinical leaders within the organization (Dierckx de Casterlé, Willemse, Verschueren & Milisen, 2008). Table 2. Competences of successful clinical team leadership and corresponding literature Literature on quality Literature on clinical team improvement models leadership Batalden et al., 2003 Carryer et al., 2007 Improvement Bodenheimer et al., 2002 Institute of Medicine, 2001 Nelson et al., 2007 Taylor et al., 2007 Wagner et al., 2000 Wagner et al., 2001

Cook, 2001 Cook & Leathard, 2004 Davidson et al., 2006 Edmonstone, 2008 Ham, 2003 Holleman et al., 2009 Johns, 2003 Stanley, 2008

Goal & vision

Collaboration

Reviewing & reflecting Patient-centerness Communication

Barach & Johnson, 2006 Batalden et al., 2003 Foster et al., 2007 Institute of Medicine, 2001 Nelson et al., 2007 Nelson et al., 2008 Ouwens, 2007 Wagner et al., 2001 Batalden et al., 2003 Institute of Medicine, 2001 Nelson et al., 2007 Nelson et al., 2008 Batalden et al., 2003 Barach & Johnson, 2006 Bourbeau et al., 2004 Foster et al., 2007 Nelson et al., 2007 Batalden et al., 2003 Institute of Medicine, 2001 Nelson et al., 2007 Institute of Medicine, 2001

Support & coaching

Batalden et al., 2003 Barach & Johnson, 2006 Foster et al., 2007 Institute of Medicine, 2001 Massoud et al., 2001 Nelson et al., 2007 Nelson et al., 2008 Wagner et al., 2001

Role models

Bourbeau et al., 2004 Taylor et al., 2007 Batalden et al., 2003 Foster et al., 2007 Barach & Johnson, 2006 Batalden et al., 2003 Bourbeau et al., 2004 Foster et al., 2007 Nelson et al., 2008

Respect Knowledge

Influencing

Batalden et al., 2003 Institute of Medicine, 2001 Bourbeau et al., 2004

Responsibility

Institute of Medicine, 2001

Creativity

Davidson et al., 2006 Dierckx de Casterlé et al., 2008 Edmonstone, 2008 Johns, 2003 Stanley, 2008

Cook & Leathard, 2004 Davidson et al., 2006 Dierckx de Casterlé et al., 2008 Edmonstone, 2008 Johns, 2003 Dierckx de Casterlé et al., 2008 Edmonstone, 2008

Dierckx de Casterlé et al., 2008 Edmonstone, 2008 Dierckx de Casterlé et al., 2008 Johns, 2003 Stanley, 2008 Cook, 2001 Cook & Leathard, 2004 Davidson et al., 2006 Dierckx de Casterlé et al., 2008 Holleman et al., 2009 Johns, 2003 Olsen & Neale, 2005 Davidson et al., 2006 Stanley, 2008 Cook & Leathard, 2004 Carryer et al., 2007 Cook & Leathard, 2004 Dierckx de Casterlé et al., 2008 Hyrkäs & Dende, 2008 Johns, 2003 Stanley, 2008 Cook & Leathard, 2004 Holleman et al., 2009 Cook, 2001 Cook & Leathard, 2004 Carryer et al., 2007 Davidson et al., 2006 Dierckx de Casterlé et al., 2008 Edmonstone, 2008 Johns, 2003

Collaboration Collaboration, or cooperation, within health care teams contributes significantly to achieving transformation (Cook & Leathard, 2004). Therefore, collaboration is also an important theme for leaders in the health care sector. In daily work, clinical leaders make time and space to operate through and with people to improve care (Edmonstone, 2008). This includes the cooperation through and with patients and fellow colleagues, and it involves multidisciplinary and interdisciplinary working relationships as well (Davidson et al., 2006;

Dierckx de Casterlé et al., 2008; Johns, 2003; Institute of Medicine, 2001). The clinical team leader has an additional task in establishing and maintaining working relationships, in order to realize optimal collaboration which the patient will benefit from. Nelson et al. (2008) go one step further by addressing collaboration across systems. Clinical team leaders should understand system thinking, that is the way of how units relate to each other. Then leaders can invest in the collaboration between the micro-, meso-, and macro-organization. Reviewing & reflecting One of the fundamental processes of leading that can be recognized by leaders at work is reviewing and reflecting, which contains the creation of a structure for reflection (Barach & Johnson, 2006; Batalden et al., 2003; Foster et al., 2007; Nelson et al., 2007). Clinical leaders should take the time and space to review established clinical practice with their colleagues, because this can lead to the implementation of new and more effective ways of delivering services (Edmonstone, 2008). Part of the structure of review and reflection is also an awareness of the temporal limits of the members’ participation in the work of the microsystem and the ability to anticipate the future time when the current leaders turns are over. Eventually, review and reflection about the actions of the leader himself, the individual team members, and the reflection of the care team as a whole can increase professional growth and development in the entire organization (Batalden et al., 2003). Patient-centerness Patient-centredness comprises care organized around the physical, social and emotional needs and preferences of patients, and explicitly involves patients in their own care (Ouwens, 2007). Clinical team leadership has always had a prime focus on the patient, client group or service (Edmonstone, 2008). Special attention should be paid to the responsibility of leaders in providing a patient focus and optimizing patient-centredness (Institute of Medicine, 2001). Communication Effective communication skills are required in the realization of successful clinical leadership and seeking reciprocal respect within the clinical team. Leaders should demonstrate openness, and a great willingness to discuss positive as well as negative issues. Clinical leaders are supposed to promote direct communication by stimulating conversations between team

members and by keeping all team members informed about each other (Dierckx de Casterlé et al., 2008; Johns, 2003; Stanley, 2008). Listening is a component of communication that is mentioned by the Institute of Medicine (2001). In particular, the leader is supposed to listen to the needs and aspirations of those working on the front-line. Support & coaching In the context of clinical team leadership, support and coaching cover the ability of a leader to motivate team members to change (Cook & Leathard, 2004; Davidson et al., 2006). Leaders should create a supportive environment for their team members, that encourages and enables success (Institute of medicine, 2001). Team members receive also support and coaching by their clinical leaders when it comes to the stimulation of professional autonomy and accountability. Leaders are obliged to give coworkers the chance to develop both personally and professionally, and enable them to develop into leaders themselves. Leaders can support their team members by giving them added responsibilities and motivate them in reaching the organizational goals (Dierckx de Casterlé et al., 2008; Nelson et al., 2007). Role models Role modeling is often associated with quality improvement. It means that team members can observe in their leader the successful behavior (Grol, Wensing & Eccles, 2005). Clinical leaders operate as exemplary role models, for instance in case of implementing an innovation. They are an inspiration to others in functioning as positive clinical role models for their team members in demonstrating a particular behavior (Bourbeau et al., 2004; Davidson et al., 2006; Stanley, 2008; Taylor et al., 2007). Respect Cook & Leathard (2004) determine ‘respecting’ as one of the five attributes of the work of effective clinical nurse leaders. It involves having a regard for the signals that emanate from individuals, both patients and team members, and the wider organizational arena. Respecting these signals enables people to position themselves appropriately to respond to both individual and organizational needs. Effective clinical leaders have well-developed perceptual ability and, therefore, respect signals from individuals with whom they work.

Knowledge Clinical leaders are required to have a double package of knowledge, skills and expertise, because they have to fulfill the roles of both clinician and leader (Malby, 1998). Firstly, the clinical team leader should be clinically competent and maintains expert clinical credibility (Johns, 2003; Stanley, 2008). A strong base of clinical experience, understanding and education of clinical practice is required (Carryer et al., 2007; Hyrkäs & Dende, 2008). Secondly, as Batalden et al. (2003) describe, the role of leadership involves building knowledge about the structure, processes, and patterns of work in the clinical microsystems. Finally, apart from the two roles, clinical leaders should have a dose of self-knowledge and self-awareness to continuously improve their personal development in leadership (Dierckx de Casterlé et al., 2008). Creativity Creativity in practicing clinical team leadership is directly connected to improvement in health care. It has to do with the ability of clinical leaders to generate new ways of working and the way in which team members are stimulated by their leaders to demonstrate creativity (Holleman et al., 2009). Creativity results from engaging actively with the surroundings to seek new possiblities. The successful clinical leader takes time to understand a situation within its wider context (Cook & Leathard, 2004). Influencing Cook (2001) reports about the key abilities of clinical leadership in nursing, providing direction, influencing change, and empowering others. Clinical leaders are defined as “nurses who are directly involved in providing clinical care that continuously improve care through influencing others.” For instance, leaders can influence their team members through the provision of meaningful information or by helping them to see and understand a situation from different perspectives (Cook & Leathard, 2004). Responsibility The Institute of Medicine (2001) describes various responsibilities for leaders in managing change in health care. The content of these responsibilities are, for the greater part, equal to the competences earlier described. The institute claims, for instance, the responsibility for

creating and articulating the organization’s vision and goals, listening to the needs and aspirations of people working on the front line, providing direction, creating incentives for change, aligning and integrating improvement efforts, and creating a supportive environment, and a culture of continuous improvement that encourage and enable success. Clinical team leaders should prove their responsibilities, on several facets in care delivery, to other team members and the public. Thereby, they are trained to think in quite a specific way, with a strong emphasis on individual responsibility (Edmonstone, 2008).

1.16 Competences of successful clinical team leadership according to professionals Seventeen experts in the UMC St Radboud were invited to give their opinion on the competences of successful clinical team leadership, 10 department heads and 7 senior nurses. Ten experts, 4 department heads and 6 senior nurses send a response email. This corresponds to a total response rate of 59%. Table 3 shows, in random order, the most prominent competences of clinical team leadership according to the professional opinions of the respondents in the UMC St Radboud. The competences were divided into 83 segments, the segments were classified in 16 groups that were coded with a keyword. A total of 11 competences (69%) was already identified in literature on clinical team leadership and models of quality improvement (Paragraph 4.1). Interconnecting Leadership, Steering at Result, Research & Education, Decisively, and Planning & Organization are underlined in the table because these competences were not recognized previously. Interconnecting Leadership and Steering at Result refer to the prominent behavior competences on leadership, formulated by the UMC St Radboud. Interconnecting Leadership gives direction, steering, and support to a group of people, working- or project team, by setting goals, accomplishing, and maintaining of effective liaisons. The competence steering at result formulates qualitative and quantitative results in Result Drive Agreements (RDA’s), aims at actions and decisions to realize and evaluate results (UMC St Radboud, 2004). Table 3. Competences of clinical team leadership by the respondents Knowledge

Support &

Excellent specialist All-round clinician with specific expertise Specialised expertise Skills Knowledge Be able to motivate Stimulate

Reviewing & Reflecting

Reflect on and with your fellows Skills for (self) reflection Be able to handle reverse Stress resistant Progress control

Planning &

Enterprise Planning

Coaching

Respect

Communication

Interconnecting Leadership Research & Education Improvement Decisively

Stimulate Coaching Coaching Role of coach Enthusiasm to reach the goal Involve employees/colleagues and pay attention to their process Affinity with human resource management Be able to put employees in the right position Create basis for support Integrity Integrity Honesty Integrity Sensitivity Transparency Involvement Involvement Hart of the matter Optimal communication Communicate clearly and consistently Adequate communicative skills Adequate communicative skills listening; interrogating; summarizing Communication Listening Listening Listening Interconnecting leadership Interconnecting leadership

Organization

Organizing Ability to organize Management Project plan Delegate

Patientcenterness

Customer focus Individual oriented Individual oriented leadership Affinity for patiënt care

Goal & vision

Vision on the profession Vision Vision development Vision Strategy development Strategy Strategy Reaching goals Conceptual thinking

Steering at Result

Steering at result Steering at result

Leading researcher Research Education Education Training Innovative Innovative

Creativity

Be proactive Initiative Flexibility Flexibility Flexibility Share whenever possible Partnership

Decisively Decisively Resolute

Role models

Collaboration

Being an example

* Non underlined competences of clinical team leadership: comptences that were also identified in literature on clincal team leaderhsip an models of quality improvement (paragrapth 4.1) * Underlined competences of clinical team leadership: competences that were not recognized previously

1.17 Existing assessment instruments useful for measuring clinical team leadership? A total of 1596 references were found, applying the keywords described in Table 1. Some of these references were recognized twice or more. Eventually, 35 studies were adopted because they described the application of a leadership assessment instrument. Table 4 gives an overview of the included studies. It shows for each keyword the corresponding literature and the coherent assessment instruments.

The following 13 assessment instruments were identified: Transformational Leadership Assessment Tool (3%), Scale Leadership Assessment and Team Evaluation (SLATE) (3%), Multifactor Leadership Questionnaire (MLQ) (49%), Baruto-Wheeler Servant Leadership Questionnaire (3%), Clinical Nursing Leadership Learning and Action Process Model (CLINLAP) (3%), Global Transformational Leadership Scale (3%), Leadership Practices Inventory (LPI) (14%), CPE Questionnaire (3%), Malcolm Baldrige National Quality Award criteria for organizational performance (MBNQA) (5%), Quality Work Competence Questionnaire (3%), Microsystem Assessment Tool (MAT) (5%), The Integrated Leadership Practice Model (5%) and the Human Capital Competencies Inventory (3%). The percentages indicate the quantity of an assessment instrument over the 35 studies that were adopted. Only the four most common assessment instruments on leadership in the literature, are discussed in this study: the MLQ, the LPI, the MBNQA, and the MAT. Multifactor Leadership Questionnaire (MLQ) The Multifactor Leadership Questionnaire proposed by Bass and Avolio (1994), is a selfreport measure based on the multifactor leadership theory. It includes 78 items designed to measure nine subscales of leadership. The subscales are divided over three behavioral domains that range from non-leadership, termed laissez-faire, to transactional leadership, based upon rewards and punishments, to transformational leadership, based upon attributed and behavioral charisma (Kanste, Mietunen & Kyngäs, 2007) .

Table 4. Search in assessment instruments for measuring clinical team leadership Literature Assessment instruments Drenkard, 2001 Transformational Leadership Assessment Tool “Leadership assessment” Fichtner et al., 2001*

“Leadership questionnaire”

Barbuto et al., 2000* Dunham-Taylor, 2000 Gunther et al., 2007* Hendel et al., 2005 Horwitz et al., 2008 Jeff et al., 2008 Johnson et al., 2004 Kleinman, 2004

Scale Leadership Assessment and Team Evaluation (SLATE) Multifactor Leadership Questionnaire (MLQ)

Menaker & Bahn, 2008 Raup, 2008 Snodgrass & Shachar, 2008 Stordeur et al., 2001 Turner, et al., 2002 Wylie & Gallagher, 2009 Xirasagar, 2008 Xirasagar et al., 2006 Xirasagar et al., 2005 Garber et al., 2009

“Leadership performance”

Phillips, 2005

“Leadership quality” Leadership assessment instrument Psychometric assessment leadership Leadership inventory

-

Leadership measurement

Leadership measurement tool MeSH Leadership and Outcome assessment or Process assessment

Fichtner et al., 2001*

Baruto-Wheeler Servant Leadership Questionnaire Clinical Nursing Leadership Learning and Action Process Model (CLINLAP) SLATE

Munir et al., 2009

Global Transformational Leadership Scale

Adams, 2007 Bowles & Bowles, 2000 Krugman & Smith, 2003 Laurent et al., 2007 Strack et al., 2008

Leadership Practices Inventory (LPI)

Donaher et al., 2007*

The Human Capital Competencies Inventory

Barbuto et al., 2000* Gunther et al., 2007*

MLQ

Kornør & Nordvik, 2004

CPE Questionnaire

Foster & Pitts, 2009

Malcolm Baldrige National Quality Award criteria for organizational performance (MBNQA)

Wallin et al., 2006

The Quality Work Competence Questionnaire

Fichtner et al., 2001*

SLATE

Godfrey et al., 2003 Nelson et al., 2002

Microsystem Assessment Tool (MAT)

Weeks et al., 2000

Malcolm Baldrige Criteria for Organizational Performance

Perra, 2000

The Integrated leadership Practice Model

* The paper is mentioned twice or more, using different keywords

The table is continued on the next page

Table 4. Continuation Literature

Assessment instruments

MeSH Leadership and Inventory

Donaher et al., 2007*

The Human Capital Competencies Inventory

Barbuto et al., 2000* Gunther et al., 2007*

MLQ

MeSH Leadership and Psychometrics

-

* The paper is mentioned twice or more, using different keywords

Leadership Practice Inventory (LPI)

The Leadership Practices Inventory is a 30-item leadership behavior measurement instrument that has been used extensively across organizational sectors. It was developed and revised by Kouzes and Posner (1988). The LPI is based on a leadership framework, which incorporates five fundamental practices of exemplary leadership that are consistent with transformational leadership style: (1) challenging the process, (2) inspiring a shared vision, (3) enabling others to act, (4) modeling the way, and (5) encouraging the heart (Bowles & Bowles, 2000; Krugman & Smith, 2003; Tourangeau & McGilton, 2004). Malcolm Baldrige National Quality Award criteria for organizational performance (MBNQA) The Malcolm Baldrige National Quality Award was established to improve organizations performance practices and capabilities, to facilitate communication and sharing of best practices information, and to serve as a working tool for understanding and managing performance and guiding planning and training (Shirks, Weeks, & Stein, 2002). It provides a set of criteria and subdivided dimensions for organizational quality assessment and improvement in several sectors including health care. Leadership is one of the seven criteria can be used as a tool for self-evaluation, and widely recognized as a robust framework for design and evaluation of health care systems (Foster., 2007; Nelson et al., 2007). Microsystem Assessment Tool (MAT) The microsystem concept, explained by Nelson et al. (2007) forms the basis of the Microsystem Assessment Tool (MAT). This concept is an organizational framework for providing and improving care, by focusing on clinical microsystems. In creating the MAT self-assessment tool, the 10 characteristics of high performing microsystems where used. With the MAT individuals can assess the functioning of their microsystem and identify potential areas to focus improvements (Mohr & Batalden, 2002; Mohr, Batalden, & Barach, 2004). Moreover, it addresses the nature of the interaction between the microsystem and the parent organization, and offers considerable insight into the functioning of a microsystem.

1.18 Assessment of successful clinical team leadership competences by existing instruments Table 5 gives an overview of the accessibility of the competences of clinical team leadership in relation to the MLQ, LPI, MBNQA, and the MAT. In addition, it describes the corresponding items of the existing instruments that can assess these competences Eighteen competences of clinical team leadership were identified using the literature and professional opinions in the UMC St Radboud. A percentage of 22% of the competences (improvement, goal & vision, reviewing & reflecting, and support & coaching) can be measured by each of the four selected assessment instruments. Three assessment instruments are able to measure the competence respect (6%). Communication and role models are competences that can be assessed by two instruments (11%). 7 competences, collaboration, patient-centredness, knowledge, creativity, responsibility, planning & organisation, and research & education, are just assessable by one assessment instrument (39%). 22% of the competences (influencing, decisively, steering at result and interconnecting leadership) cannot be assessed by any of the instruments.. Multifactor Leadership Questionnaire The MLQ evaluates different leadership styles: transformational leadership, transactional leadership and passive-avoidant behaviors. The leadership styles are divided into several subscales that are used to assess the extent to which a leader exhibits a certain leadership style (Tejeda, Scandura, & Pillai, 2001). The subscales include idealized influence attributed (IIA), idealized influence behavior (IIB), inspirational motivation (IM), intellectual stimulation (IS), individualized consideration (IC), contingent reward (CR), management-by-exception active (MBEA), management-by-exception passive (MBEP), and laissez-faire leadership (LP). Table 5 shows which subscales of the MLQ correspond to which competences of clinical team leadership, found in the literature and by professional opinions. Herewith, the definitions of the subscales were used to compare the content of the subscales with the competences. The definitions of the subscales are described in the Appendix. The MLQ comprises in total 7 competences of clinical team leadership (39%): improvement, goal & vision, reviewing & reflecting, support & coaching, respect, creativity, and research & education. Some subscales (33,3%), MBEA, MBEP and LP do not correspond to the competences. Both, IIA and IS contain two competences of clinical team leadership.

Leadership Practices Inventory The definitions of the five practices of the LPI (challenging the process, inspiring shared vision, enabling other to act, modelling the way, and encouraging the heart), are employed to consider if the LPI assesses the competences of clinical team leadership (Appendix). Table 5 gives an overview of which practices correspond to which competences. The five practices represent 8 competences, which is equal to 44% of all the competences of clinical team leadership. The practices involve the competences, improvement, goal & vision, collaboration, reviewing & reflecting, communication, support & coaching, role models, and respect. The practices challenging the process, inspiring a shared vision, modelling they way, and enabling others to act, are similar to more competences. Malcolm Baldrige National Quality Award criteria for organizational performance The leadership category of the Malcolm Baldrige criteria for organizational performance examines how senior executives guide personal actions and sustain the organization. In addition, it examined the organization’s governance system and how the organization fulfils its legal, ethical, and societal responsibilities and support its communities (Baldrige National Quality Program, 2009). Leadership is the first criterion of organizational performance and consists of two assessment items: 1) senior leadership, and 2) governance and societal responsibilities. Senior leadership is divided into a) vision, values, and mission, and b) communication and organizational performance. Governance and societal responsibilities is subdivided into a) organizational governance, b) legal and ethical behaviour, and c) societal responsibilities, support of key communities, and community health. The items and their subdivisions are used to perceive if the MBNQA assesses the competences of clinical team leadership. In Table 5, the items are demonstrated as a number, the sub-items as a letter. The items contain 9 competences of clinical team leadership (50%): improvement, goal & vision, reviewing & reflecting, patient-centredness, communication, support & coaching, role models, responsibility, and planning & organisation. Whereas, 6 competences are encouraged by more than one (sub-)item. Table 5. The competences of successful clinical team leadership found in the literature and by professional opinions in the UMC St Radboud, and the corresponding items of existing instruments that can assess these competences Improvement

MLQ Intellectual

LPI Challenging the

stimulation

process

MBCOP 1A: vision, values, and mission. 1B: communication and

MAT X

organizational performance. 2A: organizational governance. 2C: societal responsibilties, support of key communities, and

Goal & Vision

Idealized influence

Inspiring a shared

attributed;

vision;

Contigent reward.

Modelling the way.

community health. 1A: vision, values, and mission.

X

1B: communication and organizational performance. 2B: legal and ethical behaviour.

Collaboration Reviewing & Reflecting

Enabling others to act Idealized influence

Challenging the

1A: vision, values, and mission.

attributed

process;

2A: organizational governance

X

Encouraging the heart. 1A: vision, values, and mission.

Patient-centerness

1B: communication and organizational performance. Enabling others to act

Communication Support & Coaching

Role models Respect

Inspirational

Inspiring a shared

motivation;

vision;

Individualized

Enabling others to act;

consideration.

Modelling the way. Modelling the way

Idealized influence

Enabling others to act

2B: legal and ethical behaviour 1B: communication and organizational performance. 2C: societal responsibilties,

X

support of key communities, and community health. 1A: vision, values, and mission. X

behavior

Knowledge Creativity

X Intellectual stimulation

Influencing Responsibility

2B: legal and ethical behaviour. 2C: societal responsibilties, support of key communities, and community health. 1A: vision, values, and mission.

Planning &

1B: communication and

Organisation

organizational performance. The table is continued on the next page

Table 5. Continuation MLQ

Research &

Individualized

Education Decisively Steering at result Interconnecting

consideration

leadership

LPI

MBCOP

MAT

Microsystem Assessment Tool Leadership is one of the success characteristics of high performing microsystems, that is utilized to assess the functioning of microsystems and identify potential areas to focus improvements. The definition of leadership described in the microsystem concept, is used to find out if the MAT assesses the competences of clinical team leadership. Six competences (33%) can be measured using the MAT: improvement, goal & vision, reviewing & reflecting, support & coaching, respect, and knowledge. Because the MAT does not define (sub-) items, the included competences are ticked off in Table 5.

Discussion This final chapter discusses the study outcomes that were presented in the previous chapter. Based on the discussion, the conclusions and recommendations are set up. Finally, the chapter describes the limitations of the study that should be taken into account.

1.19 Discussion Based on the literature and the opinions of clinical team leaders in the UMC St Radboud, 18 competences on clinical team leadership were identified as most important for successful clinical team leadership (Table 5). Slightly more than two third of the competencies (69%),

were mentioned both in the literature and by clinical team leaders in the UMC St Radboud. The competences improvement, goal & vision, reviewing & reflecting, and support & coaching are prominent, in particular. These competences are determined in the literature and by clinical team leaders, as well as in all four selected assessment instruments that measure leadership. To be successful, a clinical team leader should master skills that are conguent with the 18 major competencies of clinical team leadership. In measuring clinical team leadership, the existing assessment instruments, MLQ, LPI, MBNQA, and MAT are useful in greater or lesser extent. None of the existing assessment instruments is able to measure all the 18 competences of clinical team leadership found in this study. Only some competences can be measured by the selected instruments on leadership. The MBNQA is most obvious, since the Malcolm Baldrige criteria examine most of the competences of clinical team leadership (50%). An additional advantage is that the organizational performance criteria of the Malcolm Baldrige show many parallels with the European Foundation for Quality Management (EFQM) Excellence model, that has also a Dutch application: the management model by the Dutch Quality Institute, the Instituut Nederlandse Kwaliteit (INK). This Dutch translation might be suitable in assessing clinical team leadership in the UMC St Radboud. Self-assessment is emphasized in the teaching programs of the INK (Minkman et al., 2007; Nabitz et al., 2000). Inter alia, the institute developed a self-assessment questionnaire for measuring leadership styles, that is part of the publication ‘Leiderschap als kunst’ by Van Loon and Roozendaal (2006). Machteld Dronkers, expert in leadership and responsible for the management development program on leadership in the UMC St Radboud, also recommended a publication of Van Loon: ‘Het geheim van de leider’ (M. Dronkers, personal communication, June 15, 2009; Van Loon, 2006). However, it should be noted that the MBNQA as well as his derivatives, the EFQM Excellence model and the INK-management model, are designed to focus more at the entire organization while clinical team leaders, who are highlighted in this study, are part of the microsystems. Following the Baldrige Malcolm criteria, leadership is defined as how senior leaders guide the organization (Foster et al., 2007). Instead of clinical team leadership, senior leadership or managerial leadership is focused on the macrosystem, concerning the chain of effect on improving healthcare quality (Berwick, 2001). Discrepancies between these different organizational levels may cause problems in measuring clinical team leadership. However, Foster et al. (2007) refute this partly by stating:

“microsystems that operate within the context of a larger organization face many challenges. In the ideal world, organizational alignment would be clear and consistent at all levels, though the outstanding performers do not live in such a world. While the Malcolm Baldrige assessment can make those gaps clear, organizational leadership must be committed to closing them” (p.341). Despite its organizational basis, the Malcolm Baldrige is especially focused on the health care sector, by using criteria developed for health care organizations (Goldstein & Schweikhart, 2002). This is in contrast with the EFQM Excellence model and the INK-management model, that do not go into specific standards and norms for health care. Anyway, the EFQM Excellence model is general and aligns conceptually with the ideas of Donabedian (1982), who looked at health care services. The dimensions of Donabedian, structure, process, and outcome, fit well with the EFQM Excellence model (Nabitz et al., 2000). The Leadership Practice Inventory is able to measure 44% of the competences on clinical team leadership indicated in this study. The LPI is not explicitly based on team leadership in health care, but centralized transformational leadership that is commended as highly effective and suitable for nursing (Bowles & Bowles, 2000). In a study of Huber et al. (2000) about nursing administration instruments, the LPI was best on criteria related to psychometric properties and ease of use. In case of nursing, the LPI is used in practice at the microsystem level, to measure leadership practices of nurses working in the larger marcosystem (Tourangeau & McGilton, 2004). Nevertheless, clinical team leadership focuses on front-line health care professionals in general, and not only on nursing leadership (Edmonstone, 2008). The LPI is considered as an assessement instrument that measures leadership behaviors (Tourangeau & McGilton, 2004). Similarly, the UMC St Radboud places value on behavioral competences that a successful leader should show: interconnecting leadership and result orientation. Perhaps the Leadership Practices Inventory can play a role by assessing the behavioral competences in clinical team leaders in the UMC St Radboud. Still, a disadvantage is the lack of a Dutch LPI version. The Multifactor Leadership Questionnaire comprises 39% of the competences on clinical team leadership found in this study. It is remarkable that the questionnaire is employed in almost half of the studies adopted to analyze existing assessment instruments useful in measuring clinical team leadership (Table 4). Psychometric properties of the MLQ are discussed in various articles (Antonakis, Avolio, & Sivasubramaniam, 2003; Avolio, Bass, &

Jung, 1999; Kanste et al., 2006; Tejeda et al., 2001). In the study of Huber et al. (2000), the psychometrics of the MLQ are rated optimal. Initially, other researchers point out their doubts about the psychometric properties of the MLQ, but eventually, their final conclusions are mostly positive (Kanste et al., 2006; Tejeda et al., 2001). There are concerns on the ease of use of the MLQ, that may arise from the “full range” basis of the questionnaire which attempt to embrace diverse leadership styles (Antonakis et al., 2003; Huber et al., 2000). Just like the LPI, the MLQ is not specifically aimed at clinical team leadership, but some nursing studies applied the questionnaire (Kanste et al., 2006). Moreover, unlike the LPI, the MLQ reasoned from a macrosystem and environmental perspective, since it measures leadership behaviors in the organization and compare them to the norms outside the organization (Tejeda et al., 2001). This form of assessment allows the UMC St Radboud to evaluate their performance on leadership at the higher levels of the organization, and is not especially focused on clinical leadership within the microsystems. In the Netherlands, Den Hartog, Van Muijnen, & Koopman (1997) investigated the MLQ, which resulted in a Dutch edition. The Microsystem Assessment Tool scores the lowest, and is capable to examine 33% of the competences on clinical team leadership identified in this study. While the microsystem concept forms the basis of the MAT, it is the only assessment instrument that paid special attention to clinical microsystems. However, leadership in the clinical microsystems (clinical team leadership) is just one of the success characteristics that can be assessed by the MAT. Using the self-assessment tool individuals can assess the functioning of their whole microsystem and the nature of the interaction between the microsystem and the parent organization. This will help them to identify the areas for improvement. However, the MAT clearly does not have the depth of for instance the Malcolm Baldrige assessment (Foster et al., 2007; Mohr et al., 2004). Further empirical testing and research is required to overcome the limitations to use the MAT (Mohr & Batalden, 2002).

1.20 Conclusion This study discussed the important competences of successful clinical team leadership and the existing assessment instruments that are useful to measure them. Based on literature and opinions of clinical team leaders in the UMC St Radboud, 18 competences and 4 assessment instruments were identified.

Unfortunately, the study shows that none of the existing assessment instruments is specifically aimed to measure leadership within the clinical microsystems. In parallel, the instruments are either not able to measure all the 18 competences of clinical team leadership found in this study. Thus, as Foster et al. (2007) already conclude, a different tool might be needed, which recognizes leadership in the clinical microsystem context. However, to improve health care quality, clinical team leaders should keep their eye on the whole chain of effect by improving the relations with the parent organisation and not just focusing on their own microsystem. Building on this reasoning, existing assessment instruments that stress the organizational perspective provide as well suitable opportunities in measuring clinical team leadership. Therefore, a further analysis of the existing assessment instruments on leadership is recommended. In case of the UMC St Radboud, it is preferable to look at the opportunities that existing assessment instruments can offer, before long-term options will be applied. Chances can be found in using the Malcolm Baldrige criteria. In particular, the INKmanagement model is interesting, since it offers a similar Dutch framework to evaluate not only leadership, but all the criteria that are necessary to optimize the performance of a health care system at the different organizational levels. Hence, the INK-management model creates future possibilities for the UMC St Radboud because it measures additional criteria that are also essential when improving the microsystems, and eventually the entire organization. In this way, clinical team leadership remains to be part of the larger organization, in the context of the chain of effect. However, the integral intern audit team of the UMC St Radboud, should investigate how a new model in measuring criteria for organisational performance can be integrated in practice within the already implemented Team Climate Inventory. 1.21 Recommendations •

When choosing an (existing) assessment instrument in measuring clinical team leadership, all organizational levels of the UMC St Radboud should be recognized. Therefore, Berwick’s Chain of Effect could be a useful basis.

•

A further analysis of the posiblities of the INK-management model to measuring clinical team leadership in the UMC St Radboud, should be considered.

•

It should be investigated how an (existing) assessment instrument in measuring clinical team leadership can be integrated in practice and how this instrument relates to the already implemented Team Climate Inventory (TCI).

1.22 Limitations This study has several limitations. First, there are some shortcomings due to the research design of the study. Qualitative research is inherently subjective and not statistically representative, unlike quantitative research. For example, the selection criteria of both literature and the professional opinions are subjective. Secondly, the study involved the opinions of only 10 clinical team leaders from the UMC St Radboud. This sample size is relatively small for making real comparisons. Thirdly, the opinions of other professionals about the competences of clinical team leadership are not gathered and the results are based just on the situation in the UMC St Radboud. Thus, making generalizations beyond the sample of clinical team leaders must be done with caution. Moreover, the respondents were asked to list the five most important competences of clinical team leadership by email, more information regarding their choice or the understanding of their answers is not determined. In addition, there is also a lack of information according to the literature on clinical team leadership and the existing assessment instruments, because only available unpaid publications are used in the study. This might make the results of the study incomplete. Finally, with regard to the data analysis a second researcher was consulted in reflecting the coding procedure. However, this researcher did not reflect on the translations of the segments in English.

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Appendix: Description of assessment instruments on clinical team leadership Multifactor Leadership Questionnaire (MLQ) The Multifactor Leadership Questionnaire is originally based on the multifactor leadership theory, that was proposed by Bass and Avolio (1994). It is perhaps the most widely used comprehensive theory of leadership that encompasses a range of leader behaviors (Kanste et al., 2007). The behavioral domains within the multifactor leadership theory range from nonleadership, termed laissez-faire, to transactional leadership, based upon rewards and punishments, to transformational leadership, based upon attributed and behavioral charisma (Figure 4). The MLQ has been the primary measurement tool used in research on multifactor leadership theory (Tejeda et al., 2001). It is a self-report measure that has 78 items designed to measure nine subscales of leadership. Idealized influence (attributed, IIA) is an eight-item subscale

that assesses subordinates' perceptions of how much the leader makes personal sacrifices, deals with crises and obstacles, and exhibits self-confidence. Idealized influence (behaviour, IIB) is comprised of 10 items which assess the degree to which the supervisor is perceived as espousing important values, beliefs, and a sense of mission. Inspirational motivation (IM) is represented by 10 items that measure the leaders' setting of high standards and orientation toward the future. Intellectual stimulation (IS) is a 10-item subscale that assesses subordinates' perceptions of the degree to which the supervisor accepts their ideas and encourages them to challenge the status quo by re-examining critical assumptions. Individualized consideration (IC) is composed of nine items that measures the extent to which subordinates perceive the supervisor as treating them as individuals, rather than as part of a group, and promotes their professional know-how. These five subscales represent transformational leadership. Contingent reward (CR) is represented by nine items that measure the supervisor's exchange-related behavior, in which rewards are contingent upon subordinates' agreement to task performance. Active management-by-exception (MBEA) is a nine-item subscale that assesses the degree to which the leader actively searches for subordinate mistakes. Passive management-by-exception (MBEP) is composed of five items that represent subordinates' perception that the supervisor does not get involved in their work unless problems attract the leader's attention. These three subscales represent transactional leadership. The laissez-faire leadership (LF) is an eight-item subscale that measures the subordinates' perception of leadership inaction (Kanste et al., 2007). Although the Multifactor Leadership Questionnaire is one of the most widely used instrument to measure the multifactor leadership theory in organizational sciences, psychometric concerns about the MLQ hinder the widespread acceptance of the multifactor leadership theory. There are doubts about the factorial structures and construct validity among nurses and outside English-speaking cultures (Kanste et al., 2007; Tejeda et al., 2001).

Figure 4. Overview of the behavioral domains of the multifactor leadership theory Source: Bass & Avolio (2003)

Leadership Practice Inventory (LPI) The Leadership Practices Inventory is a leadership behavior measurement instrument that has been used extensively across organizational sectors. It was developed and revised by Kouzes and Posner (1988). The LPI is based on a leadership framework, which incorporates five fundamental practices of exemplary leadership that are consistent with transformational leadership style (Bowles & Bowles, 2000; Krugman & Smith, 2003; Tourangeau & McGilton, 2004). (1) challenging the process: leaders search for opportunities to change the status quo. They look for innovative ways to improve the organization. In doing so, they experiment and take risks. And because leaders know that risk taking involves mistakes and failures, they accept the inevitable disappointments as learning opportunities. (2) inspiring a shared vision: leaders passionately believe that they can make a difference. They envision the future, creating an ideal and unique image of what the organization can become. Through their magnetism and quiet persuasion, leaders enlist others in their dreams. They breathe life into their visions and get people to see exciting possibilities for the future.

(3) enabling others to act: leaders foster collaboration and build spirited teams. They actively involve others. Leaders understand that mutual respect is what sustains extraordinary efforts; they strive to create an atmosphere of trust and human dignity. They strengthen others, making each person feel capable and powerful. (4) modeling the way: leaders establish principles concerning the way people should be treated and the way goals should be pursued. They create standards of excellence and then set an example for others to follow. Because the prospect of complex change can overwhelm people and stifle action, they set interim goals so that people can achieve small wins as they work toward larger objectives. They unravel bureaucracy when it impedes action; they put up signposts when people are unsure of where to go or how to get there; and they create opportunities for victory. (5) encouraging the heart: accomplishing extraordinary things in organizations is hard work. To keep hope and determination alive, leaders recognize contributions that individuals make. In every winning team, the members need to share in the rewards of their efforts, so leaders celebrate accomplishments. They make people feel like heroes (Kouzes & Posner, 2001). The LPI is a 30-item inventory, with six statements reflecting each of the five leadership practices. It was recently revised from a 5- to a 10- point Likert scale with a range of summed scores from 30 to 300, to increase the sensitivity to changes in leadership behavior. Table 5 shows a brief description of each item in the LPI. Two parallel forms of the LPI were developed, one for self-evaluation and another for evaluation of another person, the observers tool (Krugman & Smith, 2003; Tourangeau & McGilton, 2004). By completing the LPI, the clinical leader and his observers can give feedback on the use of the five leadership practices. Both the leader himself and the observers will indicate how frequently the leader engage in each of thirty behaviors. The more frequently he demonstrate the behaviors included in the LPI, the more likely the leader will be seen as an effective leader. In healthcare the LPI is been used in a number of nursing studies, although there exists little information about its use in health care, specifically with and about nurses. Further research is needed to gather evidence of LPI psychometric properties. Because of the shortage in psychometric properties. Tourangeau & McGilton (2004) recommended a three-factor solution of the LPI. This alternative has a lighter respondent burden, requires less research costs, and consumes less power in further analytical procedures than the traditional five-factor LPI solution.

Table 6. Description of the 30-items of the LPI. Source: Tourangeau & McGilton (2004) 1. Seek opportunities

7. Describe image

13. Treat others

19. Clear philosophy

25. Celebrate

2 . Talk about future

8. Actively listens

14. Follow through

20. Public recognition

accomplishments 26. Take initiative

3. Develop

9. Time and energy

15. Reward

21. Take risks

27. Genuine

relationships 4. Set example

10. Let people know

contributions 16. Ask about learning

22. Enthusiastic and

conviction 28. Ensure growth

5. Praise people

11. Search outside

17. Show others

positive 23. Freedom and

29. Make progress

6. Challenge people

12. Share dream

18. Support decisions

choice 24. Goals and plans

30. Appreciate and support

Malcolm Baldrige National Quality Award In 1987, the National Institute of Standards and Technology (NIST) established the Malcolm Baldrige National Quality Award to improve organization performance practices and capabilities, to facilitate communication and sharing of best practices information, and to serve as a working tool for understanding and managing performance and guiding planning and training (Shirks et al., 2002). The MBNQA provides a set of criteria and subdivided dimensions for organizational quality assessment and improvement in several sectors including health care. The criteria can be used as a tool for self-evaluation, and are widely recognized as a robust framework for design and evaluation of health care systems (Foster et al., 2007; Nelson et al., 2007). Table 6 summarizes the Malcolm Baldrige Criteria for Performance Excellence, their subdivided dimensions, and definitions. In addition, figure 1 represents the related framework. Table 7. Malcolm Baldrige Performance excellence criteria, dimensions and their definitions

Source: Foster et al. (2007)

Figure 5. Inter-relatedness of the Malcolm Baldrige criteria for health care organisations.

Source:Foster et al., 2007.

The use of the criteria is intended to increase the competitiveness of U.S. organization through the formal Baldrige Award process itself, through the adoption and use of the criteria by other groups, and form the informal use by organizations for self assessment (Shirks et al., 2002). Organizations applying for the Award, have to earn points in each of the seven main criteria. (Goldstein & Schweikhart, 2002). A 0 percent score signifies no systematic evident approach. In contrast, a 100 percent score indicate an effective, integrated, fully deployed approach that is supported by a strong fact based, systematic evaluation and improvement process and organizational learning. Scores are given in bandwidths according to the degree to which the organization matches the descriptions given for the particular criteria (Shirks et al., 2002). The scoring of response to the criteria and Award applicant feedback are based on two elements: 1) Process and 2) Results. The scoring guidelines of both elements should be observed in assigning scores to item responses (Baldrige national Quality Program, 2009) In employing the Malcolm Baldrige criteria, not only the performance of the leader is assessed, but the whole health care organization. However, the award recipients show a constellation of strengths that suggest that certain basic leadership and management practice are correlated with a fundamental ability to achieve desired results (Goonan & Stoltz, 2004). Doubts about the Malcolm Baldrige Performance Excellence Criteria, grounded on limited evidence about performance improvement by implementing interventions (Minkman, Ahaus & Huijsman, 2007). For example, in the study of Shirks et al. (2002) there was no system wide improvement measurable. Moreover, Goldstein & Schweikhart (2002) reported only improvement of some performance dimensions in hospitals of the U.S. Despite these comments, the model has a possibilities for the further development of practical and evidence based tools for improving health care organisations (Minkman et al., 2007).

The MBNQA criteria can be linked to the European version of the European Foundation for Quality Management (EFQM), the EFQM Excellence model (Figure 6). This model was also developed to structure and review the quality management of an organisation. It describes that excellence is visionary and inspirational leadership, coupled with constancy of purpose. The EFQM excellence model is used in several European countries, including the Netherlands, and it defines leadership as one of the main assessment items crucial in the development of the organisation.

Figure 6. EFQM Excellence model Source: EFOM (1999)

The Dutch National Institute for Quality translated the EFQM Excellence model into the INK-management model (Figure 7). This Dutch model is used in health care as a selfassessment instrument, for instance by the NIAZ, the Dutch Institute for the Accreditation of Hospitals (Nabitz, Klazinga, & Walburg, 2000).

Figure 7. INK-model Source: www.ink.nl

Microsystem Assessment Tool (MAT) The microsystem concept, explained by Nelson et al., 2007) forms the basis of the Microsystem Assessment Tool (MAT). This concept is an organizational framework for providing and improving care, by focusing on clinical microsystems: small groups of people working together on a regular basis to provide care to discrete subpopulations of patients. In creating the MAT self-assessment tool, the 10 characteristics of high performing microsystems where used (Table 7). With the MAT individuals can assess the functioning of their microsystem and identify potential areas to focus improvements (Mohr & Batalden, 2002; Mohr et al., 2004). Moreover, it addresses the nature of the interaction between the microsystem and the parent organization, and offers considerable insight into the functioning of a microsystem. The MAT is designed to be used quickly and easily by microsystem members to evaluate their own front-line units. The MAT can be seen as a checklist that describes the definitions of the 10 success characteristics, followed by a series of three descriptions. The unit members should check the description that best describes the current microsystem and the care it delivers (Foster et al., 2007). The clinical microsystem concept is highlighted and promoted by several health care researchers. However, information on the assessment of high performance in microsystems is limited. Mohr & Batalden (2002) conclude that more research is needed in how to assess clinical microsystems functioning, performance, outcomes, and safety, and how to replicate

‘best practices’ in other settings. Perhaps, more research on the Microsystem Assessment Tool and his psychometric properties can contributed to accomplish this. Table 8. Definitions of the success characteristics of high-performing clinical microsystems Source: Foster et al. (2007)

Figure 8. Success characteristics of high-performing clinical microsystems. Source: Nelson et al., 2007