EFQM Excellence Model SANIT Management in the Health Sector 2004 (Case Hospital Comarcal de Igualada) Prof. Magdalene Rosenmöller Universidad de Navarra EFQM Excellence Model European Quality Award Model (www.efqm.org) Structure Processes Results 14 EFQM Model in Health Care 1
The EFQM Model (efqm) Is based on a self assessment Conclusions are as good as the analysis done The focus is on processes Is client oriented Uses the means of continuous improvement (benchmarking or reengineering of processes) Is based on group work (with people from different departments 15 The EFQM Model (efqm) Allows to integrate (not substitute) other quality improvement initiatives. Is focused on results and on facilitators. It s not only about to do things, but look at the effects of it. Depends on the level of leadership in the organisation (and gives details on how to evaluate this level) Promote the continuous improvement, instead of compliance with some standards. Expects the institutions to demonstrate positive tendencies. 16 EFQM Model in Health Care 2
The health sector is somehow difficult Bases of TQM Dominance of management aspects over technical ones Rational process of decision making Challenges in Health Conceptual aspects Structural aspects Implementation aspects 17 Problems and Challenges of the implementation of the EFQM model in Hospitals Conceptual Aspects Structural Aspects Implementation Aspects 18 EFQM Model in Health Care 3
Conceptual Aspects Professionals are not identifying with the way the efqm model is seeing the company (or institution) Quality Vision Physicians think they are always doing quality work Relation with other quality initiatives The models and the system of auto evaluation is only a means to make a diagnosis and establish the base line situation. TQM is seen as a way to reduce costs. 19 Conceptual Aspects Professionals are not identifying with the way the efqm model is seeing the company (or institution) Quality A Vision health centre is not a business and cannot be managed as if it Physicians would think be one. they are always doing quality work. The physician patient relationship is very special. Relation with other quality initiatives The professional engagement of the physicians is to always act The models in the best and interest the of system the patient. of auto evaluation is only a means Health to is make a completely a diagnosis different and product establish to those manufactured the base line situation. by other companies. TQM is It is seen unacceptable as a way that to the reduce management costs vision is above the clinical (technical) vision. 20 EFQM Model in Health Care 4
Conceptual Aspects Quality Vision Physicians Different perception think they on what are quality always means: doing quality work. Quality in the client perspective Quality in provider perspective Relation with other quality initiatives Quality in the funding institutions perspective The models and the system of auto evaluation Usually it is the only client, a who means in the end to defines make quality, a but inhere he has limited information and does not understand it diagnosis and establish the base line situation. Internal quality vision. TQM is seen as a way to reduce costs. 21 Conceptual Aspects Physicians think they are always doing quality work. There is not a unique way to do things right. The physician redefines it in each moment. The acceptable practices not a point but an area. Relation with other quality initiatives The models and Do the the system Area of of auto minimum acceptable necessary practices evaluation is only a means to make a diagnosis and establish the base line situation. that we are doing now is not the best quality... Not do anything inappropriate Start quality improvement actions in the clinical area means Don t even start to think this!!! TQM is seen as a way to reduce costs. 22 EFQM Model in Health Care 5
Conceptual Aspects Relation with other quality initiatives The models and the system of auto evaluation Certification is only of a continuous means education to make a Protocols diagnosis and establish the base line Commissions situation. Professional qualifications, (licenses, etc.. ) Audits TQM is Peer seen review as a way to reduce costs Accreditations... 23 Conceptual Aspects The models and the system of auto evaluation is only a means to make a diagnosis and establish the base line TQM is not quick way to solve problems. situation. TQM is seen as a way to reduce costs The objective is to establish a better (common) knowledge of the functioning of the institutions and the subsequent identification of improvement areas. 24 EFQM Model in Health Care 6
Conceptual Aspects TQM is seen as a way to reduce costs Concept of value for the client. Diminish costs may result in a better perception of the value. Back to the different vision what is means to do it well (quality) in a hospitals. 25 Structural Aspects The responsibility for the health of the patient is with the physicians not with the manager. In a hospitals there are 2 organisations not always compatible: the hospital and the physicians. Complex structures and highly hierarchical with subcultures. Special patient physician relation Professional autonomy (exist as well in universities) Lack of (formal) authority of the manager over the physician Conflict of the TQM philosophy and the management of health institutions. 26 EFQM Model in Health Care 7
Implementation Aspects Need to know TQM in order to be able to implement it with success. The experience in training is important. Need to focus on the clients of the institutions and their needs. Perception that the professionals will loose with TQM turn to be very critical The manager can loose as well: power goes to the improvement groups 27 Implementation Aspects Assure a ambience of empowerment. The concept of measurement is not well established in health management Mostly the focus is on non clinical aspects, which are the most accessible, but ignoring the most critical activity : health care provision. All problems inherent of bad project management. 28 EFQM Model in Health Care 8
Different Quality Strategies Accreditation Certification Peer Review Clinical Guidelines Performance Indicators Patient Surveys Others External Mechanism ISO certification EFQM European Foundation for Quality Management 29 Quality in the HITs Spain Catalonia first introducing quality indictors 1998 Plan of Quality Improvement incl monitoring and incentives (prospective payment) Accreditation UK Internal market to improve quality of services provided Emphasis on measuring and improving quality standards 1998 A First Class service: Quality in the new NHS June 1999 6 main clinical indicators death J30 post op; emergency readmission (hip fracture > 65); inpatient waiting lists/1000 pop., 5y survival breast/cervical cancer New method of clinical governance: NICE National Institute for Clinical Excellence CHImP Commission for Health improvement Accreditation - hospital standards, Germany Contracts including quality assurance measures Licensing of medical services Länder & self administration representation of hospitals and professionals 30 EFQM Model in Health Care 9
QUALITY OF CARE, PATIENT ORIENTATION, INFORMATION TO PATIENTS AND PROFESSIONALS. Overview on Quality of Care a) Approval and regulation of pharmaceuticals. b) Trained professionals. c) Quality assurance systems: - Approval of safety - Health Technology Assessment - Use of guidelines on effectiveness - Basic training - System of licensing/revalidation e) Internal and external performance. 31 Definitions 32 EFQM Model in Health Care 10
Dimensions Sources: Saturno et al. 1994, NHS 1997, European Commission 1998, David et al. 2001 and Oxford Handbook of Public Health 2001. 33 Levels of analysis Source: European Commission 1998 34 EFQM Model in Health Care 11
Levels of analysis Source: "The Quality of Care: How can it be assessed?" in Donabedian (1988;1744) 35 The assessment of quality of care (Donabedian) Structure: This denotes the attributes of the settings in which care occurs. Structure includes: Material resources (facilities, equipment and money) Human resources (number and qualifications of personnel) Organizational structure (medical staff organization, methods of peer review, methods of reimbursement). Process: It denotes what is done in giving and receiving care. Process includes the patient s activities in seeking care and carrying it out as well as the practitioner s activities in making a diagnosis and recommending or implementing treatment. Outcome: refers to what results are achieved (performance). 36 EFQM Model in Health Care 12
Measurement Tools System performance done at national level, European level and global level. Issues addressed include: the general environment of the country, system planning and financing and resource allocation, legislation, other regulatory mechanisms, health priorities, professional recognition and overall quality management. Organisational and Clinical level of performance there is a wide variety of mechanisms which carry out assessment. There are two different approaches: External Assessment and Internal Assessment. External Assessment consists of external inspection to ensure public accountability, transparency, self regulation, quality improvement and value for money. Internal approaches are used inside healthcare organizations and focus on bringing change from within. 37 Measurement Tools: External Assessment The International Organization for Standardization (ISO) model provides standards against which organizations or functions may be certificated by accredited auditors. The European Foundation for Quality Management (EFQM) model is a framework for self-assessment and it is also used by facilities applying for external review in order to achieve the European Quality Award or national awards. The Accreditation model is a voluntary procedure external to an establishment, for the purpose of obtaining public and peer recognition of the quality of that establishment. The Peer review or Visitatie model of clinical departments consists of standards based on-site survey conducted by medical professionals in order to assess the quality of professional performance of peers. The Registration and licensing statutory model consists of programmes to ensure that professional staff or provider organizations achieve minimum standards of competence. 38 EFQM Model in Health Care 13
Internal approaches to performance at an institutional level include notions of corporate performance such as: Patients rights Risk management Benchmarking Measurement Tools: Internal Assessment Clinical governance Clinical measures at the micro level: clinical audit of evidence-based processes, quality teams and quality circles, continuous quality improvement, and numerical outcomes indicators of performance. 39 Overview Actors involved in quality of care International level: Council of Europe, European Union, World Health Organization, International Organizations National level: Patients, Care providers, payers, politicians, health administrators Definition Quality of care Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (IOM 1990) Process of assessing Structure-Process-Outcome (Donabedian, 1988) Structure: The attributes of the settings in which care occurs Process: What is done in giving and receiving care. Outcome: Refers to what results are achieved. Dimensions Effectiveness Efficiency Technical Competence Appropriateness Acceptability Patient/Care Safety Assessment methods System performance Health priorities, system planning, financing and resource allocation Institutional and Clinical perform. External Assessment ISO, Accreditation, Licensing, EFQM, Peer review Internal self-assessment patients rights, risk man., clinical governance, clinical audit, indicators 40 EFQM Model in Health Care 14