The EFQM excellence model: European and Dutch experiences with the EFQM approach in health care. European Foundation for Quality Management.

One way to meet the challenges in creating a high performance organization in health care is the approach of the European Foundation for Quality Management (EFQM). The Foundation is in the tradition of the American Malcolm Baldrige Award and was initiated by the European Commission and 14 European multi-national organizations in 1988. The essence of the approach is the EFQM Model, which can be used as a self-assessment instrument on all levels of a health care organization and as an auditing instrument for the Quality Award. In 1999 the EFQM Model was revised but its principles remained the same. In The Netherlands many health care organizations apply the EFQM Model. In addition to improvement projects, peer review of professional practices, accreditation and certification, the EFQM Approach is used mainly as a framework for quality management and as a conceptualization for organizational excellence. The Dutch National Institute for Quality, the Instituut Nederlandse Kwaliteit, delivers training and supports self-assessment and runs the Dutch quality award programme. Two specific guidelines for health care organizations, 'Positioning and Improving' and 'Self-Assessment', have been developed and are used frequently. To illustrate the EFQM approach in The Netherlands, the improvement project of the Jellinek Centre is described. The Jellinek Centre conducted internal and external assessments and received in 1996, as the first health care organization, the Dutch Quality Prize.     

The EFQM Excellence Model. German experiences with the EFQM approach in health care.

OBJECTIVE: To expand on previous reports by illustrating experiences German health services organizitions made in their assessment against the European Foundation for Quality Management (EFQM) Excellence Model. To provide an evaluation of the EFQM method compared to peer auditing and accreditation concepts within health care. DESIGN: To indicate the EFQM method and scoring system and draft the process of self-assessment in health services organizitions. To refer to the experiences of German health care pioneers during their early assessments. RESULTS: Using the EFQM approach, an organizition can earn up to 1.000 points. More than 50% of German hospitals scored 200-300 points and not a single organizition achieved over 450 points. To make a comparison, the best score obtained in an industrial setting was between 650-750 points. In addition to the numbers, this report describes success factors and best practices of self-assessments, as well as limitations, barriers and lessons learned during the implementation phase. CONCLUSION: The Excellence Model is a systematic quality management approach to gain competitive advantage. It is non-governmental, non-financier driven, and generic enough to address health care issues. Having its foundation in industry, however, it is not specific enough to cover all areas relevant to health care. Integrating the management-smart method of self-assessment with clinical standards as delivered by peer auditing and accreditation systems generates the potential to deliver excellence in health care.     

The EFQM excellence model is useful for primary health care teams

BACKGROUND: Primary care teams are facing an increased need to develop quality programmes at local level. GPs must lead this process and promote a positive organizational culture if they want to achieve and maintain a continuous improvement of the service. OBJECTIVE: The aim of the present study was to test the applicability and reliability of the European Foundation for Quality Management (EFQM) excellence model self-assessment questionnaire in a primary health care organization. METHOD: A cross-sectional study was carried out of the EFQM questionnaire to compare the scores achieved by a primary health care team in Spain caring for 42 000 inhabitants using internal self-assessment with the scores achieved by professional management auditors through an external audit. RESULTS: The scores of each criterion achieved by self-evaluation are similar to or lower than those assessed by the external evaluation. There is agreement in the areas suitable for improvement. CONCLUSIONS: The experience proves the applicability of the EFQM excellence model for primary health care teams and its reliability, at least when the team undergoing self-assessment know they are going to be re-evaluated. There is high concordance in the identification of areas for improvement.     

EFQM approach and the Dutch Quality Award.

Different approaches to improve quality are used in organizations delivering health care. Donabedian introduced structure, process and outcome, from which other approaches like self-assessment, accreditation, visitation, International Standards Organisation (ISO) and European Foundation for Quality Management (EFQM) can be aligned. The EFQM model is one such approach that has been adopted and adapted by the Dutch Institute for Quality Management. This article describes the background and progress relating to the use of the EFQM business excellence model within Dutch health care organizations. In addition the process for applying for the European Quality Award and the Dutch Quality Award are described in detail. Finally, the reader is enlightened regarding the work of the European ExPeRT research group who are promoting the use of quality models within health care.     

A proposed adaptation of the EFQM fundamental concepts of excellence to health care based on the PATH framework.

OBJECTIVE: The use of the European Foundation for Quality Management (EFQM) Model in health care has found that this model is useful in promoting quality improvement, but its use in health care organizations is challenging because being a generic model, it does not cover the clinical aspects or the specifics of this field. For that reason, this article aims to bring the EFQM fundamental concepts of excellence closer to health care, using a specific model as a reference to this field: the Performance Assessment Tool for quality improvement in Hospitals (PATH) conceptual framework, developed by the WHO Regional Office for Europe. METHOD: A content analysis was performed to independently identify the contents that defined the elements of both frameworks. Then, using defined criteria, two independent researchers compared the contents of the elements of both frameworks. The elements from both frameworks that were equivalent were aggregated. Several experts discussed the aspects with discrepancies between the two comparisons. Finally, the EFQM framework is adapted to health care by adding to those aggregated elements the aspects that were exclusive from one of the models. RESULTS: The EFQM framework has many correspondences to a health care-specific framework. The EFQM-health care-adapted framework has eight quality dimensions, two of them (customer focus and safety) being overlapped with the other six (staff, results orientation, responsive governance, leadership and constancy of purpose, clinical effectiveness, and partnership development). This model also has two methodological dimensions (management by processes and facts and continuous learning; improvement and innovation). CONCLUSION: This adapted model seems useful for health care organizations, but it needs to be further used to corroborate this preliminary finding.     

Transforming a run down general practice into a leading edge primary care organisation with the help of the EFQM excellence model

This article explains how a primary care team transformed a run down general practice into a leading edge healthcare organisation by adopting the principles of the EFQM excellence model. The decisions surrounding the choice of approach, challenges faced, benefits achieved and lessons learned are all described in such a way that the reader may appreciate the issues which faced the members of the 15-man team. In particular, the practice team found that describing indicators of quality and gathering evidence to test out assumptions regarding performance were vital elements in the pursuit of a continuous improvement culture that was to benefit patients, staff and key stakeholders alike. Whilst an increase in workload was experienced in the early days, the knowledge that this was associated with improved performance made the efforts worthwhile and the team eager to adopt a regular, never-ending cycle of self-assessment and improvement.     

Towards an economic model of the Dutch health care sector

This paper describes the construction of a model of the Dutch health care sector. It discusses the behaviour of patients, general practitioners, medical specialists and hospital managers. It also analyses the various ways the actors interact, such as general practitioners supplying the services demanded by patients, specialists dispatching referrals made by general practitioners or hospital managers boosting output to match an increasing amount of specialist services. Numerical simulations illustrate the various mechanisms in the model. © 1997 John Wiley & Sons, Ltd.     

Clinical governance is "ACE"--using the EFQM excellence model to support baseline assessment

The introduction of clinical governance in the "new NHS" means that National Health Service (NHS) organisations are now accountable for the quality of the services they provide to their local communities. As part of the implementation of clinical governance in the NHS, Trusts and health authorities had to complete a baseline assessment of their capability and capacity by September 1999. Describes one Trust's approach to developing and implementing its baseline assessment tool, based upon its existing use of the European Foundation for Quality Management (EFQM) Excellence Model. An initial review of the process suggests that the model provides an adaptable framework for the development of a comprehensive and practical assessment tool and that self-assessment ensures ownership of action plans at service level.     

Values in European health care markets: Values in European health care markets

The discipline of public health has played an important rolein showing that the health of populations depends on more thanthe amount and quality of the health services available. Therelationship between health services and health status has beena traditional theme within the discipline. This paper proposesthat public health has a part to play in current health reformdebates and research, which have been dominated by attentionto economic incentives and the technical operation of the systems.The focus has been on the inputs to and processes within healthsystems, with relatively little attention to the likely impactof these changes on outcomes and population health. The paperconsiders one aspect of health reforms which affects populationhealth status: the part played by the social values of choiceand equity. It gives an analysis of these concepts to help evaluatereforms, and as a basis for empirical research into the impactof reforms. It considers how the NHS reforms have affected choiceand equity and how to increase patient choice and uphold certaintypes of equity which many health service staff and the publicbelieve to be important. It shows how some types of choice conflictwith some types of equity and that different groups in societybenefit according to whether choice or equity is more prominentin health reform. The purpose of this paper is to help researchers,public health practitioners and policy makers consider, fora particular health reform, the following questions: i) willreforms increase the choices which are important to most people?,ii) what will the effect be on different types of equity?, iii)how will the changes affect population health?, iv) how shouldpublic health aims be pursued in systems with market competition?     

Public trust in Dutch health care

This article describes the development of a valid and reliable instrument to measure different dimensions of public trust in health care in the Netherlands. This instrument is needed because the concept was not well developed, or operationalized in earlier research. The new instrument will be used in a research project to monitor trust and to predict behaviour of people such as consulting "alternative practitioners". The idea for the research was suggested by economic research into public trust. In the study, a phased design was used to overcome the operationalization problem. In the first phase, a qualitative study was conducted; and, in the second, a quantitative study. In the first phase, more than 100 people were interviewed to gain insight into the issues they associated with trust. Eight categories of issues that were derived from the interviews were assumed to be possible dimensions of trust. On the basis of these eight categories and the interviews, a questionnaire was developed that was used in the second phase. In this phase, the questionnaire was sent to 1500 members of a consumer panel; the response was 70 percent. The analysis reveals that six of the eight possible dimensions appear in factor analysis. These dimensions are trust in: the patient-focus of health care providers; macro policies level will have no consequences for patients; expertise of health care providers; quality of care; information supply and communication by care providers and the quality of cooperation. The reliability of most scales is higher than 0.8. The validity of the dimensions is assessed by determining the correlation between the scales on the one hand, and people's experience and a general mark they would assign on the other. We conclude that public trust is a multi-dimensional concept, including not only issues that relate to the patient-doctor relationship, but also issues that relate to health care institutions. The instrument appears to be reliable and valid.     

The balanced scorecard: an incremental approach model to health care management

The balanced scorecard represents a technique used in strategic management to translate an organization's mission and strategy into a comprehensive set of performance measures that provide the framework for implementation of strategic management. This article develops an incremental approach for decision making by formulating a specific balanced scorecard model with an index of nonfinancial as well as financial measures. The incremental approach to costs, including profit contribution analysis and probabilities, allows decisionmakers to assess, for example, how their desire to meet different health care needs will cause changes in service design. This incremental approach to the balanced scorecard may prove to be useful in evaluating the existence of causality relationships between different objective and subjective measures to be included within the balanced scorecard.     

Choices in health care: the European experience

This paper examines some policies to increase or restrict consumer choice in western European health systems as regards four decisions: choice between public and private insurance; choice of public insurance fund; choice of first contact care provider and choice of hospital. Choice between public and private insurance is limited and arose for historical reasons in Germany. Owing to significant constraints, few people choose the private option. Choice of public insurance fund tends to be exercised by younger and healthier people, the decision to change fund is mainly associated with price and, despite complex risk adjustment mechanisms, it has led to risk selection by funds. Choice of first contact care provider is widespread in Europe. In countries where choice has traditionally been restricted, reforms aim to make services more accessible and convenient to patients. Reforms to restrict direct access to specialists aim to reduce unnecessary and inappropriate care but have been unpopular with the public and professionals. Patients' take up of choice of hospital has been surprisingly low, given their stated willingness to travel. Only where choice is actively supported in the context of long waiting times is take up higher. The objectives, implementation and impact of policies about choice have varied across western Europe. Culture and embedded norms may be significant in determining the extent to which patients exercise choice.     

Choices in Dutch health care: mixing strategies and responsibilities

In the light of experience that choices in health care appear to be not so much hindered by a lack of insight into how choices should be made in theory, as uncertainty as to how choices could be made in practice, this paper sets out to deepen our insight into the dynamics of health care policy making within the concrete socio-economic and political context. The paper examines how Dutch policy-makers have dealt with the priority issue in health care over the past 10 years by means of a gradual incremental approach. In this approach, use is made of a mix of strategies and shared responsibilities, with an important role for the actors at the meso and the micro levels; while at the same time, the government has not abandoned the tried and trusted policy of national rationing (i.e. keeping the production capacity limited and setting a ceiling on production in order to resist the pressure on the public system of Dutch health care). Looking at the declining percentage of Gross National Product assigned to health care annually, the broad accessibility and the good overall quality of Dutch health care, it may be concluded that the issue of choice has not come off badly under this mixed approach. The degree to which the system can respond adequately to likely developments, such as a recession, worsening waiting lists, further liberalisation (i.e. the application of market forces in health care) and, by way of extension, the ongoing integration of 'Europe' is questioned.     

The changing structure of Dutch mental health care

Current mental health care policy in The Netherlands emphasizes a major shift from intramural to extramural care. A decline in psychiatric hospital admissions is to result from intensified psychiatric care offered by non-residential provider agencies, an increase in sheltered housing and day care capacity and an integral role in mental health care for the general practitioner. To allow for such a far reaching change, fortification of the greatly fragmented non-residential sector of Dutch mental health care was necessary (in 1982 more than 300 agencies in a country of 14.5 million inhabitants). Mergers have recently led to 60 Regional Institutes for Ambulatory Mental Health Care (RIAGG). This amalgamation within the non-residential sector is considered a major step towards the integration of the entire Dutch mental health care system. The article provides insight into the development of mental health care policy in The Netherlands and offers an analysis of the process of merger of non-residential services. As a necessary preface to this material a sketch of the historical and administrative context of Dutch health care is provided.     

'European primary care': a visionary report of the Dutch Health Council on primary health care in the European Union

Although the agenda of the European Union (EU) does not directly provide for it, it seems reasonable to assume that due to the process of European social and economic integration there will be mounting pressure on the presently widely differing systems for primary care to move towards a more uniform orientation. In 2004, during its rotating presidency of the EU, the Dutch government asked its Health Council for advice on the current level of knowledge with regard to the organisation and significance of primary care. The Council formulated a set of key recommendations for the future development of primary care in Europe. The Council defines primary care as: generalist care, consisting of general medical, paramedical and pharmaceutical care, nursing and supportive care and non-specialised mental and social health care together with preventive and health educational activities linked to these forms of care. This care is for all health problems, is aimed at ambulatory patients, and is delivered close to the patients' homes. It is easily accessible to all, and provides emergency care when necessary. The main differences in the provision of primary care between countries in Europe concern the presence or absence of registration with a general practitioner and the gate-keeper role of primary care. International comparative research has identified the presence of precisely these features as predictors of better health outcomes in terms of morbidity and mortality. They therefore form a prominent role in the key recommendations, which state, among other things, that a patient should choose a primary-care team in the context of an integrated care circuit, thereby giving up his or her freedom to select care givers outside that circuit, in the interest of quality continuity and the efficiency of care. Other key recommendations are: close cooperation between primary-care teams, preventive services and public health and occupational health, a transparent provision on information between all providers of care, and the creation of a European Center for primary-care development.     

Coping with asthma in the central city: parental experiences with children's health care

Asthma is the most common chronic illness among children in the United States. Poverty and asthma are tightly related, with poor children having higher rates of asthma than non-poor children. To document how poor parents with asthmatic children cope with health care-related barriers on a day-to-day basis, the author conducted 38 in-depth interviews with central city Phoenix (Arizona) parents. Barriers facing parents include a lack of health insurance and/or personal transportation, the expense of using private insurance, treatment delays, and language/communication. Instances of parents overcoming barriers are highlighted and offered as opportunities for designing capacity building interventions and policies that build on parents' strengths.     

Living kidney donors' experiences with the health care system

The purpose of this study was to explore living kidney donors' perceived experiences with the health care system from the period prior to being tested as a potential donor, through to post donation discharge and follow-up. Qualitative methodology, using a phenomenological approach, explored the experiences, feelings, and ideas of 12 purposefully selected living kidney donors' interface with the health care system. Eight men and four women were interviewed four to 29 years post donation. Interviews were audio taped and transcribed verbatim. An iterative and interpretive analysis was conducted. Themes emerging from the data included factors influencing living kidney donors' decision to be tested as potential donors, the importance of emotional support, and humanistic care. This in turn impacted on their experience of: (1) the role of information in the decision-making process; (2) their tolerance of issues related to hospitalization and; (3) their perception of the quality of care. The findings of this study provide suggestions for the role of social work and improvement in the health care system to better address the needs of living kidney donors.