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Master Thesis 3de Versie
Master Thesis 3de Versie
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.
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.
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.
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.
1.14 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 front-
lines (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).
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 multi-
disciplinary 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.
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.
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).
* 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.
Leadership measurement Foster & Pitts, 2009 Malcolm Baldrige National Quality Award criteria
for organizational performance (MBNQA)
Leadership measurement -
tool
MeSH Leadership and Godfrey et al., 2003 Microsystem Assessment Tool (MAT)
Nelson et al., 2002
Outcome assessment or
Process assessment Weeks et al., 2000 Malcolm Baldrige Criteria for Organizational
Performance
* 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 Donaher et al., 2007* The Human Capital Competencies Inventory
Inventory
Barbuto et al., 2000* MLQ
Gunther et al., 2007*
Table 5. Continuation
MLQ LPI MBCOP MAT
Research & Individualized
consideration
Education
Decisively
Steering at result
Interconnecting
leadership
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 INK-
management 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
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3. Develop 9. Time and energy 15. Reward 21. Take risks 27. Genuine
relationships contributions conviction
4. Set example 10. Let people know 16. Ask about learning 22. Enthusiastic and 28. Ensure growth
positive
5. Praise people 11. Search outside 17. Show others 23. Freedom and 29. Make progress
choice
6. Challenge people 12. Share dream 18. Support decisions 24. Goals and plans 30. Appreciate and
support
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.
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 self-
assessment 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