Medicine meets millennium

Citation

(2001), "Medicine meets millennium", International Journal of Health Care Quality Assurance, Vol. 14 No. 1. https://doi.org/10.1108/ijhcqa.2001.06214aac.001

Medicine meets millennium

Medicine meets millennium

World Congress on Medicine and HealthAbstracts from the "Managing Excellence in Health Care" conference

Hanover, Germany

Tuesday 15th August 2000

Exclusively for readers of this journal, below are the abstracts from the "Managing Excellence in Health Care" conference organised by the European Foundation for Quality Management Health Care Working Group (Chairman: Mike Perides, London, UK).

Background to the "Medicine Meets Millennium" event

The "Medicine Meets Millennium" event was held as the medical scientific part of the World Exposition (EXPO 2000) in Hanover. This unique event was aimed at sharing best practice and supporting further networking of professionals enthusiastic about securing continuous improvement within healthcare. The conference was structured to accommodate four themes: Concepts, Implementation, Beyond Europe and The Next Steps. The scientific committee and organisers, Dr Johannes Moeller and Professor Dr Jochen Breinlinger-O'Reilly, ensured that some of the most well recognised speakers in the area of applying the EFQM Excellence Model within healthcare (Europe and World-wide) were able to contribute to this unique event.

The delegates therefore received a mixture of world-wide, Europe-wide, organisation-wide (healthcare and private sector) and even individual experiences of applying the EFQM Excellence Model in practice. The rich mix of presentations left no one unaware of the hurdles, learning and benefits and striving for continuous quality improvement within healthcare.

Abstracts

EFQM – The Vision and Mission – Today and in the FutureDr Moustafa Naguib – Chairman of the EFQM Executive Committee, Brussels, Belgium

The mission of the European Foundation for Quality Management (EFQM) is "to be the driving force for sustainable excellence in Europe" and the vision to see "a world in which European organisations excel". Currently EFQM has 850 members all over Europe for whom it provides a number of support/information services and opportunities, which includes benchmarking, award process, training, publishing, networking and the recognition/commitment/achievement scheme. As part of the Recognition/Commitment/Achievement Scheme, EFQM have co-ordinated the development of a generic macro customer satisfaction tool. This European customer satisfaction index (ECSI) is comprehensive enough to elicit different stakeholder perspectives. When used widely amongst Europe in public, private, voluntary, large and small organisations it has the potential to enable benchmarking in such a way that has never been possible before.

Supporting the formal structure of the EFQM are a number of steering groups, working groups and communities of practice. The EFQM Healthcare Working Group is a formally recognised, self-managed community of practice whereby like-minded professionals share best practice, undertake joint working and promote the benefits of using the EFQM Excellence Model within health care. The EFQM Healthcare Working Group also influences the EFQM strategy through its representation on the EFQM Steering group. With regards to future strategy EFQM are concentrating on:

• •

  Internet development (Web site development in conjunction with national partner organisations);

• •

  expansion of the model with related techniques (developing supporting materials and techniques within the model framework); and

• •

  the growth of delivery partner networking (using the knowledge and resources of national partner organisations and others to reach a wide audience).

More importantly EFQM always strive for providing increased value for its customers. "The EFQM recognise the importance of supporting all its customers, regardless of size or sector, on their journey to Excellence and will continue to do so in the twenty-first Century".

For more information, contact Dr Moustafa Naguib on email: Guntli@hilti.com

Concepts of quality managementProfessor Dr Hans-Dieter Seghezzi – University of St Gallen, Switzerland

The number of health care organisations which install a quality management system is constantly increasing. Some systems are based on concepts which were developed by the organisation itself but most use one of the well-known models for quality management. These models are discussed in the following parts of this paper.

In the 1980s Donabedian published a successful model for health care organisations which contains three levels: "structure", "processes" and "results". Outside this sector it is almost unknown. We used this model as an input for the "Hierarchy of Quality" which subdivides the systems into four levels: society, enterprise, processes' and product (service) quality. This hierarchy served as a foundation for newer models like the EFQM Excellence Model. Donabedian's Model and the Hierarchy of Quality offer basic concepts but no guidelines for developing, implementing and evaluating a system. The same is true for the Generic Organisation Model IGOM which we developed at the University of St Gallen some years ago. The IGOM consists of the three enabling elements "Leadership and Culture", "Resources" and "Operations" and the two result elements "Products and Services" and "Outcome".

In summarising one can state that there exist some basic concepts or models like Donabedian's model, the Hierarchy of Quality or IGOM which are very helpful to develop general models and tailor-made systems but are not detailed enough for the practical implementation of a management system in an organisation.

One of the practical models which is particularly tailored to services is the Gap Model of Berry, Parasumaran and Zeithaml. The service company Servqual offers measures and benchmarking with this model. Many service organisations and as far as I know also health care organisations have chosen this model for the evaluation of their quality results. Originally it contains five interfaces where the difference (gap) between planned and actual quality is measured. In St Gallen, we have enlarged the model by four more gaps and made it acceptable for all types of businesses. The Gap Model limits itself to the operational level. Questions of policy and strategy are not included.

The model of the ISO standard series 9000 is used in the health care sector but its orientation towards manufacturing industry is an obstacle for broader acceptance. This will change in the very near future when the two new ISO models of 9001:2000 and 9004:2000 will be issued. Both are process oriented models with the enabling elements "management responsibility", "resource management", "product (and/or service) 'realisation"' and "measurement, analysis and improvement". Both models focus on customers and use the same structure and terminology. Whereas the ISO 9000 series does not treat the results the Balanced Score Card is completely result-oriented which explains why controllers like it very much. Compared with the traditional instruments of controlling the Balanced Score Card goes far beyond pure financial results. It adds the results of Internal Business Processes, Learning and Growth (mainly people) and Customers.

The most advanced among the management models which are formalised are the excellence models of the awards. The EFQM Excellence allows organisations to define their own philosophy of excellence so is much more flexible as far as the normative and strategic issues are concerned. The new structure of ISO 9000 series and the structure of the EFQM Model are compatible. This helps those many thousands of companies which use both models.

In summarising, there are good concepts and models available for organisations which wish to implement a quality management system. But it is advisable to study the scopes and features of the different models in advance.

Implementing excellence in the Dutch Health Care SystemUdo Nabitz – The Jellinek Center for Addition Research, Amsterdam, The Netherlands

The Jellinek Centre is a treatment centre for people with addictions. In 1999 the staff treated 4,146 clients. The Jellinek Center with an annual budget of 25 million Euro and 500 staff is located in Amsterdam in The Netherlands and serves the population of Amsterdam and surrounding areas.

The first quality policy of the Jellinek Centre was formulated in 1988. In 1992 the Jellinek Centre switched to the total quality management (TQM) approach using the EFQM Model as a conceptual framework and self-assessment tool. The first self-assessment (still ongoing) was done in 1992 by the management team. Additional to the management team are more than 20 teams which have assessed their quality and performance against the EFQM Model in departments such as: detox, inpatient and outpatient services and more recently the Support department.

In the Jellinek Centre a modified workshop procedure is used to carry out self-assessments. That means an internal auditor and the head of the team prepare the self-assessment by adjusting the workbook to the specific needs of the department, e.g. specifying indicators and measurements. They also collect the relevant documentation and data for the result criteria. Each member of the team receives the workbook and the material and makes an individual assessment as a homework assignment. Some days later the whole team comes together for a consensus workshop where they agree a consensus score and formulate improvement projects. The workshop takes on average eight hours from which a report emerges which contains a profile of the ratings of the sub-criteria, a radargraph of the scores and a description of the improvement projects. The report is then used to inform the annual planning and the budgeting for the team. In that way the self-assessment is fully integrated in the planning and evaluation cycle. In 1996 the Jellinek Centre won the Dutch Quality Award.

The next challenge for the Jellinek is a Business Process Redesign Project in order to improve the care process drastically. Also the new EFQM Excellence Model including the RADAR logic is used as self-assessment tool, which puts more emphasis on learning and innovation. The last self-assessment undertaken by the management team was June 2000 and the findings have further stimulated the organisation to strive for excellence.

Implementing Excellence in the UK Health Care SystemDr Kate Barnard/Henry Stahr – NHS Executive/Director for the Centre for Excellence Development, Salford, UK

The National Health Service is one of the largest organisations in the world employing about one million people and having a budget of £45 billion. Demands and expectations of the service continue to increase for which the Government has committed the biggest increase in funding to health care that the NHS has ever seen. In line with the new NHS plan, the money has to be accompanied by modernisation and reform. Delivery of the Plan will depend in large part on building capacity and capability across the service. A new Modernisation Agency will be established to help clinicians and managers redesign local services around the needs and convenience of patients. This Agency will draw on the experience of a number of national improvement initiatives including the NHS Learning Network. One key element of that network is the promotion and development of the use of the EFQM Excellence model in health care.

Salford Royal Hospitals NHS Trust was one of the first UK hospitals to use the EFQM Excellence model in health care. The NHS Executive as part of its Learning Network agreed to designate this Centre as a specialist learning centre for the promotion and development of the EFQM excellence model into the NHS. The Centre provides learning opportunities to share experience and a practical approach for using the internationally respected EFQM Excellence Model to put quality at the heart of the clinical and managerial process. The approach provides a powerful method for integrating all other initiatives into an overarching framework that ensures continual improvement in clinical and non-clinical practice focused on patient needs.

In addition the Centre is carrying out research into the use of the EFQM Excellence model in health care in order to strengthen its ability to impact on the provision of NHS health care services. The public and the Government want to see real improvements. They want rapid change for the better. All parts of the Learning Network have their work cut out to deliver high quality support that delivers results. The EFQM has an important part to play in this learning movement, to sustain improved performance in NHS organisations and health systems. Its power comes in its systematic and comprehensive approach to improvement. There are immense opportunities for Learning Centres like Salford to make a big difference to health care. For more information, contact Henry Stahr at email: hstahr@mcmail.com

Implementation of excellence in a private hospital groupDr Oliver Wagner – Chief Medical Officer, SANA Kliniken Gessellschaft, Munich, Germany

The Sana Kliniken-Gesellschaft mbH is the biggest private group of currently 51 acute care hospitals with more than 13,000 beds and over 18,000 employees in Germany. By September 1998 Sana became a general member of the European Foundation for Quality Management (EFQM) and launched its internal EFQM program in 1998. The holding based department for "Medical and Quality Management" developed hospital specific strategies and instruments relating to this program. An EFQM-assessor-training-academy was initialised and a proprietary, hospital specific training concept set up. Since March 1999 more than 400 people (predominantly the leadership team) have been trained. Following this qualification process the hospitals initialised their own EFQM project teams, currently about 90 percent of the hospitals within the Sana-group to perform simulated European Quality Award (EQA) application self-assessments.

Another part of the strategy has been to establish an EFQM-Competence-Centre within the department for "Medical and Quality Management" to support local teams and assure a standardised approach for continuous improvement. The continuous improvement project allows problem-based assessment and the introduction of countermeasures. To share the experiences, a regular EFQM-Forum was established early 2000, where project teams interact and benchmark within Sana. In addition to the hospitals within the Sana-Group the management holding completed a full self-assessment in 2000. The lessons learned during this process and the benefits gained were shared at the conference. For more information regarding this project, please contact: Dr Oliver Wagner at email: wagnero@sana.de

Excellence in health care educationProfessor Dr Hans Sonntag – The Dean, Medical School, University of Heidelberg, Germany

Current pre-clinical and especially clinical education for medical students in Germany does not meet requirements for sufficient medical education since it lacks active participation of medical students in learning as well as integration of new teaching methods like problem-based learning (PBL), computer-based training (CBT), etc. Although medical education in Germany is governed by Federal Law, medical schools may introduce new concepts of teaching methods in a certain manner. The Medical School of the University of Heidelberg, therefore, entirely redesigned the structure of medical education.

After introduction of the Academic Year in the pre-clinical curriculum a tight temporal interlocking of content in the subjects of anatomy, physiology and biochemistry, an increased interdisciplinarity of teaching as well as the introduction of PBL and CBT was established.

In the Clinical Curriculum a block system of education, each block consisting of five modules, was established. Every module is concerned with a special topic like e.g. gastrointestinal diseases or infectious diseases. It lasts two to four weeks and teaching will be done by lecturers coming from topic-related disciplines. This new Heidelberg Curriculum in Medicine (HEICUMED) is based upon current subject matter with integration of as many interdisciplinary elements as possible. Essential to the programme is the continuous tutorial-based support where compulsory subjects are covered in small groups. New educational methods, such as PBL and CBT, will be implemented in the scope of a new programme. Next to the obligatory exams new forms of testing will be introduced which promote and evaluate clinical, practical and communicative schedules.

Comparing HEICUMED with a Model of Excellence in Education it can be stated that it fulfils quite a number of requirements which are proposed in this model. This concerns especially the enabler categories like leadership, people management, policy and strategy, resources and processes. The categories of results, like people's satisfaction, customers' satisfaction, impact on society and business results will have to be evaluated shortly after having started HEICUMED in 2001. There is already an external evaluation of teaching running with the "old" kind of education to validate evaluation criteria as a control for the comparison with a new HEICUMED.

HEICUMED will totally change medical education in Germany, by:

• •

  taking into consideration the requirements for a state of the art education in the whole medical field;

• •

  considering all new methods of education and, therefore, giving to all students the chance to find their own optimal pathway of learning; and

• •

  corresponding to most of the parameters (for the enablers) of the Model of Excellence of Education of the EFQM.

Excellence in Irish Health Care System/nursing aspectsKay Ennis – Quality Assurance Facilitator, Dublin, Ireland

Health care in the new millennium faces many challenges. In the Irish sector there are pressures from increased consumerism, calls for reform/efficiencies, management clinician divide, mix of private and public care with an old management style together with recruitment and retention of nursing problems.

In the past nursing has not succeeded in knocking down the door in formulating the tenets of health reform and has failed to convince others that nursing must be taken seriously as an important source of ideas and intellectual force. There is a pressing need to refocus on the essential elements that give nursing its structure, its character and its presence and strength. In the past there has been a strong focus on advanced nursing practice reform which essentially has created an elitist nursing agenda alienating the majority of nurses who give care and it is this that the profession has to tackle.

For progression to occur the profession must be clear about the message it sends regarding its implicit and explicit value base. There must be a commitment through innovative schemes that bind nursing's essential ingredients – empowering, enabling and educating people to take control of their own lives together with a way in which to marry science and caring.

Strong leadership is now required to discover the route ahead, adopt a strategy shared not just among nurses but with the wider partners, medical colleagues, managers, politicians and the public of the implicit and explicit values of nursing. They must envision, enable, energise and empower their colleagues about doing the things that make a difference and be prepared to gamble on the things they think are right.

Excellence in Health Care – the WHO perspectiveProfessor Dr Bernhard Guentert – The Dean, School of Public Health, University of Bielefeld, Germany

The World Health Organisation (WHO) acts as the directing and co-ordinating authority on international health activities. Upon request, it supports governments with technical or expert advice. The WHO mission statement is the "Health for All in the 21st Century" declaration. Target 16 of the declaration is termed "Managing for Quality of Care" and it covers the needs that:

• •

  The effectiveness of major public health strategies should be assessed in terms of health outcomes, and decisions … should be taken by comparing health outcomes and their cost-effectiveness;

• •

  all countries should have a nation-wide mechanism for … quality of care for at least ten major health conditions, including measurement of health impact, cost-effectiveness and patient-satisfaction;

• •

  health outcomes should show a significant improvement, and surveys should show an increase in patient satisfaction with the quality of services received.

The WHO orientation is very quality conscious with a clear focus on outcomes and soundly based connections towards a quality assessment approach. The WHO point of view shows clear tendency towards action and it bears significant resemblance to both the enabler and the result criteria of the EFQM approach. It does not, however, advocate one specific approach to quality management.

The WHO characteristic lies in its approach to enable governments and to empower the people concerned to adapt their own system to the requirements of quality care. To support this, WHO is involved in various initiatives to compare structures and outcomes of health care systems. Further details are available at: bernhard.guentert@uni-bielefeld.de

Co-operative TQM in Health Care/developing countriesDagmar Orth – German Technical Cooperation International (GTZ), Eschborn, Germany

GTZ (German Technical Cooperation) is an official development co-operation implementing organisation that operates on behalf of BMZ (German Ministry of Economic Cooperation). The main role of GTZ's co-operation is to secure sustainable organisational development through policy advisory services, crisis prevention, conflict handling, poverty alleviation, gender equality, environmental protection and conservation of natural resources, building-up of the civil society, promotion of democracy and solidarity, and more recently quality management.

Since January 1999, GTZ has been working with the European Foundation for Quality Management (EFQM) Excellence model focusing on self-assessment, process management, people and clients. The approach is first to experience TQM (total quality management) in the parent organisation, and then to offer it as a product to partner countries for which there is an increasing demand. GTZ's quality management (QM) consultancy in the health sector focuses on equal and just access, need-oriented and cost-efficient services, motivating staff and expanding the acceptance of quality. GTZ supports its partners with training in the planning, introduction and methods of QM which includes assessment and follow-up of QM-activities, and national and international exchange of experiences and identification of best practices.

The presentation focused on the work undertaken in Benin and El Salvador. In Benin, an original and systematic approach, adapted to the local context was developed by the people. They used modern QM-strategies without transferring an external model and without naming it QM. They focused on staff, processes, results and successes, implementing a standardised self-assessment and an evaluation with a peer reviewer on the basis of a self-developed score. In El Salvador, people involved in the project adapted the given TQM-System to focus on clients, workers and processes. Both projects reached an improvement of quality of services, a better acceptance from the clients and an improved satisfaction and motivation of the staff members.

The conclusions reached were; one to one transfer of complex QM models is problematical, therefore it is better to "first adapt – then adopt". Second, QM has many universally applicable aspects including knowledge related to concepts and methods, experiences of QM, positive attitudes, methods of communication, motivation, and empowerment. If you would like more information about the project, contact Dagmar Orth, email address: dagmar.Orth@gtz.de

Excellence in medical engineeringDr Johann Walter – Director, Siemens Medical Engineering, Erlangen, Germany

The products of Siemens Medical Engineering encompass classical x-ray diagnostic systems and computer tomography, magnetic resonance imaging and ultrasonic devices, as well as modern digital imaging and archiving and electronic patient recording systems. Medical Engineering is present worldwide not only with sales and service but also with business groups, e.g. for oncology care systems in the USA.

Like several other Siemens groups Medical Engineering has been applying the European Foundation for Quality Management (EFQM) model for many years. The definition of "Excellence" is one of the major improvements in the "EFQM Excellence Model" released last year. Based on the areas for improvement defined in a first EFQM assessment five years ago Medical Engineering focused the whole group on "Processes". Measuring process maturity over the years revealed several levels on the way to Excellence. While ISO 9000 is standard in industry nowadays process definition represents the basic level, process management and improvement comprise the advanced level, and linking business processes to strategy characterises the mature level. Excellence is defined by full customer and partner orientation of all processes.

Introducing an effective "customer" oriented EFQM assessment approach in the last few years has led to a high level of acceptance of EFQM as an Excellence Model. The EFQM assessment has become more or less an integrated part of the annual planning cycle, which contains strategic and budget planning as well as people survey. The results of focusing on business and process improvements have become evident by increasing process maturity and EFQM scores over the past five years. That goes hand in hand with the financial results and the success of Medical Engineering Group within Siemens.

Some of the key learning points have been: "invest in the enablers so that you will attain results" (customer/people survey), "ask yourself – do you spend more time on self-assessments than you do on improvements" and ensure that you do not. Siemens are five years down the road of EFQM but still not on top of it although they have made great inroads because it is part of day to day planning. For further information, contact Johann Walter, email address: johann.walter@med.siemens.de