Marjorie M. Godfrey

172 Pages·2013·1.42 MB·English

School of Health Sciences, Jönköping University

Improvement Capability at the Front Lines of Healthcare
Helping through Leading and Coaching

Marjorie M. Godfrey

DISSERTATION SERIES NO. 46, 2013

JÖNKÖPING 2013
© Marjorie M. Godfrey, 2013

Publisher: School of Health Sciences
Print: Intellecta Infolog

ISSN 1654-3602
ISBN 978-91-85835-45-4
Abstract
This thesis addresses improvement capability at the front lines of healthcare
with a focus on interprofessional health care improvement teams who
provide care and improve care. The overall aim is to explore high
performing clinical microsystems and evaluate interventions to cultivate
health care improvement capabilities of frontline interprofessional teams.
Methods
Descriptive and evaluative study designs were employed in the five studies
that comprise this thesis. A total of 495 interprofessional health care
providers from a variety of health care contexts in the United States (Study I,
II, III & IV) and Sweden (Study V) participated in the studies. The mixed
methods research included qualitative observation, interviews, focus groups
and surveys analyzed with qualitative manifest content analysis. The
quantitative data were analyzed with statistics appropriate for non-parametric
data.
Findings
Study I and II describe how leaders who understand health care
improvement can create conditions for interprofessional teams to provide
care and simultaneously improve care. Study III evaluates clinical
microsystem processes and tools successfully adapted in two different
hospitals. Frontline staff reported that they needed help to balance providing
care and improving care. Study IV and V explored and tested team coaching
to help interprofessional teams to increase their improvement capabilities
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within improvement collaboratives. The participants perceived team
coaching mostly positively and identified supportive coaching actions. In
Study V, an intervention with ―The Team Coaching Model‖ was tested in
Sweden and showed increased acquisition of improvement knowledge in the
intervention teams compared to teams who did not receive the coaching
model.
Conclusions
The thesis findings show leaders can help cultivate health care improvement
capability by designing structures, processes and outcomes of their
organizational systems to support health care improvement activities, setting
clear improvement expectations of all staff, developing the knowledge of
every staff member in the microsystem to know their operational processes
and systems to promote action learning in their daily work, and providing
help with team coaching using a Team Coaching Model.

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Original Studies
This thesis is based on the following papers, which are referred to by their
Roman numerals in the text:
Study I
Godfrey M.M., Nelson E.C., Wasson J.H., Mohr J.J., Batalden P.B.
(2003) Microsystems in health care: Part 3. Planning patient-centered services.
Joint Commission Journal of Quality and Safety, 29(4), 159-70.

Study II
Huber T.P., Godfrey M.M., Nelson E.C., Mohr J.J., Campbell C., Batalden P.B.
(2003) Microsystems in health care: Part 8. Developing people and improving
work life: what front-line staff told us. Joint Commission Journal of Quality and
Safety, 29(10), 512-22.

Study III
Godfrey M.M., Melin C.N., Muething S.E., Batalden P.B., Nelson E.C. (2008)
Clinical microsystems, Part 3. Transformation of two hospitals using
microsystem, mesosystem and macrosystem strategies.
Joint Commission Journal of Quality and Patient Safety, 34(10), 591-603.

Study IV
Godfrey M.M., Andersson Gäre B., Nelson E.C., Nilsson M., Ahlström G.
(2013) Coaching interprofessional health care improvement teams: The
coachee, the coach and the leader perspectives. Journal of Nursing
Management, DOI: 10.1111/jonm.12068.
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Study V
Godfrey M.M., Thor J., Nilsson M., Andersson Gäre B. (2013) Testing a
Team Coaching Model to develop improvement capability of frontline
teams: A comparative intervention and process evaluation pilot study;
Manuscript submitted.

The articles have been reprinted with the kind permission of the respective
journals.

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Contents
Abstract ........................................................................................................ 3
Methods .................................................................................................... 3
Findings ..................................................................................................... 3
Conclusions .............................................................................................. 4
Original Studies ............................................................................................ 5
Contents ......................................................................................................... 7
Acknowledgements ..................................................................................... 10
Definitions ................................................................................................... 15
Abbreviations .............................................................................................. 17
1.0 Introduction .......................................................................................... 18
2.0 Background ........................................................................................... 23
Quality Improvement in Health Care ....................................................... 23
Profound Knowledge through Integration of Professional Knowledge and
Improvement Knowledge ......................................................................... 30
Experiential Learning Theory ................................................................... 33
Quality Improvement Collaboratives ....................................................... 37
Coaching Reflective Practice ................................................................... 39
3.0 Rationale for the Thesis ....................................................................... 47
4.0 Overall Aim and Specific Aims ........................................................... 49
The specific questions of the studies were: .............................................. 49
5.0 Methods ................................................................................................. 50
5.1 Participants ........................................................................................... 54
Study I ...................................................................................................... 54
Study II ..................................................................................................... 55
Study III .................................................................................................... 55
Study IV ................................................................................................... 55
Study V ..................................................................................................... 56
5.2 Intervention—Study III, IV, & V........................................................ 57
5.3 Data Collection...................................................................................... 62
Study I & II ............................................................................................... 62
Study III .................................................................................................... 64
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Study IV ................................................................................................... 65
Study V ..................................................................................................... 67
Quantitative Data Collection .................................................................... 68
5.4 Data Analyses........................................................................................ 70
Qualitative Content Analysis ................................................................... 70
Quantitative Analysis ............................................................................... 71
Study IV ............................................................................................... 71
Study V ................................................................................................. 72
5.5 Ethical Considerations ......................................................................... 73
Quality Improvement Ethical Framework ........................................ 74
6.0 Findings ................................................................................................. 76
6.1 The clinical microsystem 5Ps: purpose, patients, professionals,
processes, patterns with leadership guide the assessment, design, redesign
and creation of patient-centered services. (Study I) ................................. 76
6.2 Creation of a human resource value chain linked to the organization‘s
vision, goals, values and staff professional development contributes to a
culture of doing your job and improving your job. (Study II) .................. 80
6.3 Adaptation and implementation of clinical microsystem processes and
tools to local contexts and organizational support. (Study III) ................ 83
The overall findings of Study I, II & III ................................................... 86
6.4 Coachees, coaches and leaders perceive team coaching as mostly
positive for development of interprofessional teams‘ improvement
capability (Study IV) ................................................................................ 88
6.5 Team coaching increases health care improvement teams‘ and leaders‘
knowledge and skills and is perceived positively by staff and leaders.
(Study V) .................................................................................................. 92
7.0 Discussion .............................................................................................. 95
Clinical microsystems: the context .......................................................... 96
Leadership ................................................................................................ 98
Helping ................................................................................................... 103
Reflective Coaching ............................................................................... 105
8.0 Method Discussion.............................................................................. 110
Trustworthiness in the qualitative studies (Study I, II, III, IV, V) ..... 111
Trustworthiness in the qualitative studies (Study IV, V) ................... 116
9.0 Conclusion and Implications ............................................................. 120
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10.0 Summary in Swedish ........................................................................ 125
Svensk sammanfattning ........................................................................... 125
Metoder .................................................................................................. 126
Resultat ................................................................................................... 126
Konklusioner .......................................................................................... 127
References ................................................................................................. 128
Appendices A & B .................................................................................... 152
Appendix A. Team Coaching Model Manual ....................................... 152
Appendix B. Translated Quality Improvement Knowledge Application
Tool (QIKAT) and Coaching Evaluation Survey Tools administered
during and at the end of improvement collaborative. ............................. 165

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Acknowledgements
The African proverb ―it takes a village to raise a child‖ popularized by Hillary Clinton in her
1995 book, It Takes a Village and Other Lessons Children Teach Us, comes to mind when
thinking about what it takes to ―raise a doctoral student.‖ In my case, I would say, ―it takes
several countries, academic institutions, health care organizations, many colleagues, friends
and a family to raise a doctoral student.‖
I am indebted to more people that I can name. In light of this, I would like to offer
my appreciation to the following ―villages‖ and hope those who are not listed by name, know
I include them in the various villages. The villages in the United States start with The
Dartmouth Institute for Health Policy and Clinical Practice where I started my formal health
care improvement education. Having the opportunity to study with Paul Batalden, Eugene
Nelson, Gerry O‘Connor, Jack Wennberg, Elliott Fisher and Stephen Plume provided me with
a strong base to grow from. Being part of this innovative community has been exciting and
filled with many opportunities, one being the opportunity to pursue my doctoral studies, and I
am appreciative. Tina Foster has been supportive in so many ways as one of the leaders at
TDI. Thank you Tina.
Another village is the Institute for Healthcare Improvement (IHI). Don Berwick,
Maureen Bisognano and Tom Nolan have always welcomed and encouraged the development
of and teaching about clinical microsystems. I am grateful for their leadership and friendship
over the years. The IHI ―village‖ includes so many colleagues I have learned from and taught
with over the years that I thank them for their ongoing support. Appreciation goes to the
Vermont Oxford Network for believing in the idea of team coaching and supporting testing
the idea. Special thanks are offered to the hundreds of health care professionals, families and
coaches I worked with during the VON improvement collaborative. Paul Plsek who led the
improvement collaborative with me is an amazing contributor to health care improvement
innovation and thinking and I am grateful for his friendship and guidance. Special
appreciation goes to the Cystic Fibrosis Foundation. Bruce Marshall is an extraordinary
leader who is curious and supportive of every CF Center in the US and around the world.
Bruce has always believed in and had faith in clinical microsystems and coaching to improve
care for people with CF. I am grateful to Bruce for giving me lots of space to try out new
ideas and models-thank you Bruce! All of the CF interprofessional teams, the CF Center
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