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;
- Dr. M. Ouwens for providing a placement for my internship and her help during my
graduation project;
- Dr. M. Harmsen for her practical guidance during my graduation project;
- IQ healthcare for the use of its workplace and facilities;
- All professionals in the UMC St Radboud who have contributed to the study;
- 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

1) What are competences
of successful clinical team
leadership in literature on
clinical team leadership
and models of quality
improvement?
Research questions
2) What are 3) Which existing 4) Can the
competences of assessment instruments are competences for
successful clinical useful in measuring clinical successful clinical
team leadership team leadership? team leadership found
according to in the literature and by
professional professional opinions
opinions in the be assessed by
 UMC St Radboud existing instruments?
Nijmegen?
Research Literature study Expert panel Literature study Literature study and
professional opinions
methods
• Questionnaire.
Research • Database: PubMed; • Database: PubMed. • Usage of data
strategies • Snowball strategy. obtained in previous
research questions.
Keywords “clinical leadership” - “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.
• Definitions of the
Conditions • Prominent data on •UMC St • Papers that describe the subscales of
for quality improvement Radboud experts application of a leadership
instruments are
collection are provided by experts that exercise assessment instrument,
used in comparing
and of the University of clinical are collected;
the with the
Maastricht; leadership:
inclusion • All abstracts are department
• Papers that describe competences.
criteria heads and senior leadership assessment as
viewed;
nurses; part of a larger
• Relevant papers are • Minimal 10
instrument;
viewed completely; respondents. • Papers published in
• Papers published in English;
English;
• Papers published after
• Papers that describe 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 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).

Table 2. Competences of successful clinical team leadership and corresponding literature

Literature on quality Literature on clinical team
improvement models leadership
Improvement Batalden et al., 2003 Carryer et al., 2007
Bodenheimer et al., 2002 Cook, 2001
Institute of Medicine, 2001 Cook & Leathard, 2004
Nelson et al., 2007 Davidson et al., 2006
Taylor et al., 2007 Edmonstone, 2008
Wagner et al., 2000 Ham, 2003
Wagner et al., 2001 Holleman et al., 2009
Johns, 2003
Stanley, 2008
 Goal & vision 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
Collaboration Batalden et al., 2003
Institute of Medicine, 2001
Nelson et al., 2007
Nelson et al., 2008
Reviewing & Batalden et al., 2003
Barach & Johnson, 2006
reflecting Bourbeau et al., 2004
Foster et al., 2007
Nelson et al., 2007
Patient-centerness Batalden et al., 2003
Institute of Medicine, 2001
Nelson et al., 2007
Communication 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
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

Role models Bourbeau et al., 2004 Davidson et al., 2006

Taylor et al., 2007
Respect Batalden et al., 2003
Foster et al., 2007
Knowledge Barach & Johnson, 2006
Batalden et al., 2003
Bourbeau et al., 2004
Foster et al., 2007
Nelson et al., 2008
Creativity Batalden et al., 2003
Institute of Medicine, 2001
Influencing Bourbeau et al., 2004
Responsibility Institute of Medicine, 2001
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 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.

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 Excellent specialist Reviewing & Reflect on and with your fellows
All-round clinician with specific Skills for (self) reflection
Reflecting
expertise Be able to handle reverse
Specialised expertise Stress resistant
Skills Progress control
Knowledge
Support & Be able to motivate Planning & Enterprise
Stimulate Planning
 Coaching Stimulate Organization Organizing
Coaching Ability to organize
Coaching Management
Role of coach Project plan
Enthusiasm to reach the goal Delegate
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
Respect Integrity Patient- Customer focus
Integrity Individual oriented
centerness
Honesty Individual oriented leadership
Integrity Affinity for patiënt care
Sensitivity
Transparency
Involvement
Involvement
Hart of the matter
Communication Optimal communication Goal & vision Vision on the profession
Communicate clearly and Vision
consistently Vision development
Adequate communicative skills Vision
Adequate communicative skills Strategy development
listening; interrogating; Strategy
summarizing Strategy
Communication Reaching goals
Listening Conceptual thinking
Listening
Listening
Interconnecting Interconnecting leadership Steering at Result Steering at result
Interconnecting leadership Steering at result
Leadership
Research & Leading researcher Creativity Be proactive
Research Initiative
Education Education Flexibility
Education Flexibility
Training Flexibility
Improvement Innovative Collaboration Share whenever possible
Innovative Partnership

Decisively Decisively Role models Being an example

Decisively
Resolute

* 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 self-
report 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
“Leadership assessment” Drenkard, 2001 Transformational Leadership Assessment Tool

Fichtner et al., 2001* Scale Leadership Assessment and Team

“Leadership questionnaire”
Evaluation (SLATE)
Barbuto et al., 2000* Multifactor Leadership Questionnaire (MLQ)
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
 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 Baruto-Wheeler Servant Leadership
Questionnaire
“Leadership performance” Phillips, 2005 Clinical Nursing Leadership Learning and Action
Process Model (CLINLAP)
“Leadership quality” -
Leadership assessment Fichtner et al., 2001* SLATE
instrument
Psychometric assessment -
leadership
Leadership inventory Munir et al., 2009 Global Transformational Leadership Scale

Adams, 2007 Leadership Practices Inventory (LPI)

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

Donaher et al., 2007* The Human Capital Competencies Inventory

Barbuto et al., 2000* MLQ

Gunther et al., 2007*
Kornør & Nordvik, 2004 CPE Questionnaire

Leadership measurement 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

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

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 Donaher et al., 2007* The Human Capital Competencies Inventory
Inventory
Barbuto et al., 2000* MLQ
Gunther et al., 2007*

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
MLQ LPI MBCOP MAT
Improvement Intellectual Challenging the 1A: vision, values, and mission. X
stimulation process 1B: communication and
 organizational performance.
2A: organizational governance.
2C: societal responsibilties,
support of key communities, and
community health.
Goal & Vision Idealized influence Inspiring a shared 1A: vision, values, and mission. X
attributed; vision; 1B: communication and
Contigent reward. Modelling the way. organizational performance.
2B: legal and ethical behaviour.
Collaboration Enabling others to act
Reviewing & Idealized influence Challenging the 1A: vision, values, and mission. X
attributed process; 2A: organizational governance
Reflecting
Encouraging the heart.
Patient-centerness 1A: vision, values, and mission.
1B: communication and
organizational performance.
2B: legal and ethical behaviour
Communication Enabling others to act 1B: communication and
organizational performance.
Support & Coaching Inspirational Inspiring a shared 2C: societal responsibilties, X
motivation; vision; support of key communities, and
Individualized Enabling others to act; community health.
consideration. Modelling the way.
Role models Modelling the way 1A: vision, values, and mission.
Respect Idealized influence Enabling others to act X
behavior
Knowledge X
Creativity Intellectual
stimulation
Influencing
Responsibility 2B: legal and ethical behaviour.
2C: societal responsibilties,
support of key communities, and
community health.
Planning & 1A: vision, values, and mission.
1B: communication and
Organisation
organizational performance.
The table is continued on the next page

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

• 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
accomplishments
2 . Talk about future 8. Actively listens 14. Follow through 20. Public recognition 26. Take initiative

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

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 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

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