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Some time ago I gave a presentation to approximately 20 senior members of a health-care organisation. The delegates had a variety of backgrounds including medicine, nursing, management, audit and training and development. The organisation was one that had a reputation for being at the leading edge of service delivery. The subject matter was the European Foundation for Quality Management (EFQM) Excellence Model and its suitability within all health-care environments.
I began by explaining the origin of the EFQM Excellence Model and moved on to explain its fundamental concepts, namely: results orientation, customer focus, leadership and constancy of purpose, management by processes and facts, people development and involvement, continuous learning, innovation and improvement, partnership development and public responsibility.
I then took each fundamental concept in turn and provided as much clarity as I could, given the time constraints. Results orientation was described as supporting the notion that you cannot manage what you cannot measure and that stakeholders (patients, customers, government) want to see what they are "purchasing". Furthermore, without performance measurement an organisation cannot demonstrate continuous improvement; it can only provide rhetoric. I explained that customer focus meant that an organisation had to put the customer at its centre and design services and products to meet the needs and wishes of those customers. Furthermore, strong leadership was needed to secure robust performance measurement systems, a culture of continuous improvement and a true customer focus. Constancy of purpose was explained as retaining, and always striving for, one overall vision, irrespective of the regular diversions from new government directives and changing health-care needs. The constant vision would probably concentrate on meeting the needs of the organisation's customers and stakeholders.
Process management meant understanding patient care pathways from the moment patients enter the health-care system to the moment they leave. Moreover, designing and improving processes should ensure that the needs of customers, rather than the organisation, are met – for instance the timing of outpatients' clinics, one-stop diagnostic initiatives, the provision of relevant information and implementation of evidence-based practice. An example given of management by facts was that organisations should determine the views of customers before purporting that they are meeting their customer needs in a satisfactory way. An organisation cannot presume, therefore, that because customers do not complain they are happy with the service.
Next was people development and involvement, which was described as being vital for securing excellence – particularly as shared values and a culture of trust and empowerment is a necessary ingredient for motivating employees towards delivering a quality service based on the needs of customers. Continuous learning, innovation and improvement was aligned to the many research and audit projects that are undertaken by health-care professionals, in addition to the implementation of good ideas from anyone who has a stake in the service. Partnership development was felt to be an easier concept to describe, because health-care professionals readily recognise that the successes of health-care interventions are often affected by social issues such as poverty, education and family support. Nevertheless, these partnerships are not necessarily subjected to formal performance measurement – a process which would be inherent when applying the principles of the EFQM Excellence Model.
Public responsibility was described as the image of the organisation and whether the customers felt the health-care institution provided a good standard of care. Clearly there have been a number of incidents within the UK's National Health Service that have compromised public perception. An excellent organisation would, therefore, take demonstrable steps to minimise and indeed eradicate such failures in its system.
When I came to this natural break in my presentation, I was interrupted by one of the most senior members of the group. The delegate expressed that despite hearing what I had been saying, the language could be likened to that of "an alien from the planet Zaag". The delegate also expressed concerns that health care was so far from this ideal that it was unrealistic to expect that excellence could be achieved in the current health-care climate.
There were two main areas of concern that arose from this interjection. First, that the language of quality was so alien to this particular health-care organisation that it implied customers' and employee needs were not being considered, let alone met. And, second, that the leadership was so overwhelmed by the concept of excellence that it was not driving the values of total quality management. Clearly, as an advocate for quality, I began to question the evidence on which that delegate was basing her/his beliefs. While this stimulated debate, it did concern me later how much time some health-care employees spend discussing the reasons why they cannot achieve excellence, rather than using this effort to at least start the journey.
Since that workshop, I have attended the 5th European Forum for Quality Improvement in Healthcare where Wim Schellekens (MD, MPH Dutch Institute for Healthcare Improvement CBO) gave a plenary presentation entitled "Pioneers with a passion for patients". He explained that "bad quality is unnecessary suffering for patients" and that providing a quality service meant that health-care professionals needed to be equipped with their specialist knowledge and expertise in addition to that of total quality management and excellence. To do this would mean all practitioners of health care would need to be conversant with at least some, or all, of the tools of quality, which include process mapping, costs of quality, statistical process control and cause-and-effect diagrams. Once achieved, the language of quality would not then be likened to that of an alien planet.
However, these practitioners would need to be motivated and supported by their leaders to apply the quality techniques within their area of work. Wim Schellekens maintained that it is simply not enough to know and understand the tools of quality – you need to apply them as well.
Sue JacksonUniversity of SalfordCentre for Excellence Development