Brenda Bulman (left) and Dr Adrian Davies describe how 'Developing Excellence', an integrated approach to quality improvement, resulted in better services for patients

In 1995 the South Tees Acute Hospitals NHS Trust (STAHT) introduced the European Foundation for Quality Management (EFQM) Excellence Model in three pilot areas: the Directorate of General Surgery; the Division of Women & Children; and the Directorate of Information.

The success of these pilots in improving the effectiveness and efficiency of services led to the adoption of the model across the whole organisation.

Use of the model as a practical quality management tool has resulted in an overhaul of many of the Trust's clinical and non-clinical processes, a programme of leadership development which includes 360° appraisal, and a portfolio of patient, staff and key performance results.

The STAHT provides acute health-care services to 300 000 people on Teesside and specialist care for around 1.5 million people throughout the Northern and Yorkshire region. With a workforce of 5000 and a budget of £180 million, the Trust is one of the Region's largest employers.

The quality journey started in the late 1980s, with the then hospital units' involvement in district-wide and national initiatives such as a national demonstration site for total quality management. The Trust had embraced many quality initiatives such as¥ISO 9000, Investor in People, and Quality Circles, but they were seen as a fragmented group of separate entities and not part of a coordinated approach to continuous quality improvement (see Figure 1, below).

Figure 1: Fragmented approach to quality improvement – like pieces of an incomplete jigsaw
incomplete jigsaw

The EFQM Model has provided the mechanism for building upon all of the previous quality improvement initiatives and integrating them into routine operations. The Trust calls its approach 'Developing Excellence' (see Figure 2, below).

Figure 2: Developing Excellence – an integrated approach
complete jigsaw

The EFQM Excellence Model

The EFQM Excellence Model is a generic framework of criteria, which allows self-examination. It is based around the practices of 'excellent' companies. The principles are:

  • 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
  • Public responsibility.

These principles of business excellence are reflected in the nine criterion parts of the model which are displayed as nine boxes, five of which are referred to as enablers and four as results, but all are inextricably linked (see Figure 3,below).

Figure 3: The EFQM Organisational Excellence model
algorithm

The model is based on the premise that:

'Excellent results with respect to performance, customers, people and society are achieved through leadership driving policy and strategy, people, partnerships and resources and processes.' (EFQM 1999)

Each of the nine criteria has a definition. For instance, leadership is defined as follows:

'How leaders develop and facilitate the achievement of the mission and vision, develop values required for long-term success, and implement these via appropriate actions and behaviours, and are personally involved in ensuring that the organisation's management system is developed and implemented.' (EFQM 1999)

The nine criteria are then broken down into sub-criterion parts. Each of these sub-criteria has a statement. For example, leadership has four sub-criteria, and 1a in leadership is:

'Leaders develop the mission, vision and values and are role models of a culture of excellence.' (EFQM 1999)

It is these statements and the accompanying guidance against which an organisation or individual team can assess itself.

Underpinning the use of the Excellence Model is the RADAR Logic. RADAR stands for Results, Approach, Deployment, Assessment and Review (see Figure 4,below): determine the Results you want to achieve; develop an integrated set of Approaches; Deploy those approaches; then Assess and Review the approaches to identify, prioritise, plan and implement improvements.

Figure 4: RADAR Logic
flow chart

The Excellence Model criteria and the RADAR Logic enable self-assessment in terms of strengths and areas for improvement. It is also possible to derive a numeric baseline if the scoring mechanism is applied. (See Further reading for more information.)

Developing Excellence at South Tees

The first corporate assessment identified many areas for improvement. We thought we were good. In NHS terms we delivered what was expected of us. We had met all of our financial targets and we had achieved local, national and international awards.

It was therefore very sobering to discover we had scored a grand total of 217 points out of a possible 1000! (Top European companies score 700). The priority areas for improvement were leadership, people management, processes, customer, people and business results (now known as key performance results).

A project leader was assigned to each of these areas and these people became the Developing Excellence Steering Group. The chief executive and chairman are active members of the group.

The group meets monthly to agree the priorities for corporate improvement activities and associated funding, then to monitor and review progress. Reports are made to the Management Group and the Trust Board quarterly.

The annual review day for Developing Excellence involves an update of progress from all the development activities, review of the overall approach taken, and the planning of next year's agenda. Recommendations are presented to the Management Group and then to the divisional managers, who ensure that they are actioned.

The role of the Developing Excellence Steering Group is now almost redundant. The Management Group will shortly take over the lead and will continue to steer Developing Excellence.

This group is now the main internal driver for improvement and is regarded throughout the Trust as a core aspect of our business, and a key mechanism through which we can deliver clinical governance and the requirements of the National Plan.

Trust-wide changes are quite large scale, and take time, particularly when major cultural changes are involved. By using the model as a systematic framework for achieving real change the Trust now has:

  • Well-developed effective integrated clinical leadership
  • A culture of innovation through systematic process review and redesign
  • An emphasis on results monitoring, especially focused on clinical performance, patient, GP , staff and customer satisfaction

Leadership development

Developing effective leaders has been the keystone in progressing this work throughout the Trust. The Leadership Development Programme involves 360° appraisal using the Leadership Effectiveness Analysis (LEA) diagnostic questionnaire, then clarification of future roles, and identifying future behavioural competencies. This gives participants an idea of their development needs.

360° appraisal was successfully piloted with a group of interested clinical directors. So far, all the chiefs of service, the corporate directors, the divisional managers, 37 of the 39 clinical directors and all process leaders have taken part in the Leadership Development Programme, which starts with the LEA. In total, approximately 320 leaders have embarked on the Programme.

Process redesign

We have developed a simple approach to process redesign based on three stages:

  • Understanding the current process
  • Redesign
  • Implementation.

Central to this work is the role of the process leader, who is charged with facilitation of discussions, helping to break down operational barriers and to redesign and establish new multidisciplinary teams working effectively together to deliver the service.

Improving the colposcopy and cardiac services

One of the initial process reviews was the colposcopy service. The review was led by the consultant and a local GP and involved all the staff. The process was redesigned around what patients said they wanted for the service; the positive clinical evidence available about the benefits of a 'see and treat' for some patients; and improving job satisfaction for staff.

The result is a clinically led service supported by a nurse colposcopist. Through discussion with all local GPs, a new process of referral and recall for consultation was agreed.

Evaluation of this new process has demonstrated great improvement:

  • Direct referral from cytology means that the time taken to &enerate appointments has been reduced from 13.5 days to 24 hours
  • Consultation time has increased from 10 minutes to 30 minutes
  • There is patient choice for a 'see and treat' service, with a less than 10% over-treatment rate
  • The waiting time for new referrals is 2-4 weeks
  • The non-attendance rate is down from 20% to 10%
  • Unnecessary smears have been reduced by 100%
  • Patient, GP and staff satisfaction is very high.

The significant improvements in patient care provided by the colposcopy service has been recognised by a Charter Mark award.

This total approach of Developing Excellence, using the EFQM model, has also had an impact in developing medical staff to take lead roles in changing clinical practices and managing change. Their involvement in process review and redesigning clinical services has been a key factor in ensuring that patients have access to services that are more efficient, effective and patient focused.

We have also used the model to help develop clinical governance within the Trust. Working through the existing directorates structure, a programme of training and development has been set in place for all clinical leaders. This has also been made available to all professional groups across the different healthcare agencies.

In addressing the key factors of clinical governance the model incorporated some of the main criteria for establishing a clinical governance culture, e.g. clinical leadership, lifelong learning, self-assessment and self-regulation.

There are many examples of improvement across the Trust. The Cardiothoracic Division is a prime example of how all staff have been involved in using the Developing Excellence model to develop better patient services. By using the model to develop a hoØistic approach to improving service delivery, significant improvements have been made, e.g. in postmyocardial infarction stress testing.

In actively managing customer relationships they have achieved year-on-year improvement in all areas of patient satisfaction, and now score very positively in customer satisfaction surveys and focus groups. Their innovative approach to patient involvement has led to this work being presented and well received at the 5th Annual International Quality in Healthcare Conference in Amsterdam, 2000.

In the Division of Medicine, the medical admissions unit has successfully used the approach to reconfigure services onto one hospital site and open an admissions assessment unit with 40% of emergency admissions being discharged within the first 24 hours compared with 10% 2 years ago.

Results

The Trust now regularly obtains perception data from patients, GPs and their staff through surveys and focus groups. At corporate level the key performance results are presented to the management group on a monthly basis. An example of the redesigned report is shown in Figure 5, replacing thick documents on activity, finance and manpower, which used to form part of the management group report. The new key performance report was introduced in March 2000.

Figure 5: Key performance results
statistics

In 1999, STAHT was recognised as one of three National Specialist Learning Centres within the NHS. This is primarily the result of STAHT using the Excellence Model as part of its approach to organisation development.

Early in 2000 the Trust was approached by the Northern and Yorkshire NHSE venture to provide leadership in developing a region-wide Learning Alliance. To achieve this additional goal the Learning Centre has changed its name to The Northern and Yorkshire Learning Alliance and will undertake three main streams of work:

  • The National Learning Contract (South Tees)
  • The Northern and Yorkshire Learning and Service Improvement Contract
  • Consultancy support.

Benefits and keys to success

The benefits of applying the Excellence Model may be summarised as follows:

  • Systematically identifying strengths and areas for improvement based on evidence and not assumptions.
  • Developing a common understanding of what we are trying to achieve
  • Increasing the rate of continuous improvement and opportunities for radical change
  • Engaging staff in driving forward change
  • Enthusing staff, developing teams and promoting continuous learning
  • Recognising the need for ownership of performance standards
  • Sharing good ideas and best practice
  • Demonstrating real evidence of improvement
  • Comparing ourselves with others
  • Measuring progress
  • Having a framework for integrating all our development activity and focusing our effort and resources

Success requires:

  • Commitment from the chief executive and management group from the outset
  • Stability and consistency in the top team
  • Clear guidelines and a strong project management focus for every project
  • A champion at Trust board level to maintain 'visibility'
  • Focus on quality and improvement rather than the Excellence Model itself
  • Involvement of the clinicians and managers from the early stages
  • Resources (the Trust allocated substantial financial resources to the programme)
  • Recognition that organisation development is very important if the infrastructure is to be right for step improvements
  • A gradual start, but demonstrate that dramatic improvements to patients and staff can be achieved by this approach. Gain some expertise and credibility before deploying the approach organisation wide. Success takes time – there is no 'quick fix'.

Finally:

  • Developing Excellence is not a magic wand – it is a tool, a means to an end, not an end in itself.
  • It can be time consuming, especially for clinical staff who have other major demands, particularly at the beginning when there is much to be learned.
  • It should not be referred to as BQF, EFQM, 'the boxes' or any other name that can be seen as another 'management' initiative.
  • It is important to choose interesting and willing departments initially, who will want to use the model and demonstrate results.
  • It is not a quick fix nor is it dot-to-dot management. It is a flexible framework of excellence that allows self-examination and can be used in many different ways.

We believe that application of the EFQM Model in the NHS has the potential to improve dramatically the way we deliver healthcare.

Further reading

Stahr H, Bulman B, Stead M. The Excellence Model in the Health Sector. Chichester: Kinsham Press, 2000.

Further information on the EFQM Excellence Model, 1999, Public and Voluntary Sector, is available from:

http://www.efqm.org email: info@efqm.org

http://www.quality-foundation.co.uk email: mail@quality-foundation.co.uk

Guidelines in Practice, February 2001, Volume 4(2)
© 2001 MGP Ltd
further information | subscribe