International Journal for Quality in Health Care Advance Access originally published online on February 2, 2007
International Journal for Quality in Health Care 2007 19(2):74-79; doi:10.1093/intqhc/mzl074
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Improving quality at the hospital psychiatric ward level through the use of the EFQM model
1 Avedis Donabedian Foundation, Barcelona, Spain
2 Ward for Adolescents, Department of Psychiatry
3 Quality Improvement Unit
4 Paediatrics ICU, Hospital Gregorio Marañón, Madrid, Spain
Address reprint request to: Paula Vallejo, Avedis Donabedian Foundation, Barcelona, Spain. E-mail: vallejop{at}gmail.com
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Abstract |
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Objective. To describe the implementation of the European Foundation for Quality Management (EFQM) model as a quality framework for improving a psychiatric hospital ward.
Methodology. Two self-assessments were conducted using the EFQM model. The self-assessment methods combined two approaches proposed by the EFQM: the award simulation approach and the questionnaire approach. Work groups were set up to improve the areas for improvement identified on the self-assessment.
Results. The EFQM was a useful framework for self-assessment at the ward level and a good system for identifying areas for improvement. Only one of the 32 sub-criteria did not apply at the ward level. The self-assessment score was 209 points in 2003 and 311 points 2 years later (an increase of 48.8% from the initial score).
Discussion. The main difficulties were ensuring that clinical personnel understood the EFQM model, the extra effort demanded by the initial phase and the lack of decision-making capacity in certain relevant areas. Adapting the self-assessment methodology to the specific context facilitated the process, as did a high level of involvement of the part of manager and staff.
Conclusions. It is possible to implement the EFQM model at the hospital was level and it has a positive influence on staff communication and involvement. It is important, when working at this level, to adequately focus the scope of the project on improving quality in those areas where there is decision-making capacity.
Keywords: EFQM, psychiatry, quality of healthcare, quality improvement
Among the international models available to guide quality improvement processes, the European Foundation for Quality Management (EFQM) is a multidimensional model based on eight concepts of excellence [1] comprising nine criteria [2]. The EFQM model has been widely used as a self-assessment tool in healthcare organizations in most European countries, in out-patient care, hospitals, rehabilitation clinics, acute care, primary and specialized care [3]. Even though, in theory, the EFQM model can be applied both on an organizational level and on a departmental level; most of articles published in the international literature are based on application of the EFQM to healthcare organizations as a whole. The novelty of the experience reviewed in this article is that the EFQM model was used as a self-assessment method and a quality improvement guide at a hospital ward level, specifically in a psychiatric ward in a general hospital. The fact that this project was carried out in a relatively small ward, with a small group of professionals and within the context of a larger organization that sets the basic management directives, influenced both the methodology and the results. The aim of this article, therefore, is to describe implementation of the EFQM Excellence model as a quality framework for improving performance in a psychiatric hospital ward, so this experience can serve as a basis for other wards that might want to take a similar approach.
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Setting
A university general hospital in Madrid opened the city's first short-term hospitalization ward for adolescents with acute psychiatric disorders in the year 2000. The ward has 20 beds for young people 12–17 years of age. It is staffed by a multidisciplinary team of 34 professionals, with an approximate staff-to-patient ratio of 2.5:1. The ward covers a catchment area of 3.5 million people. It has been estimated that 15% of the population in this area are between 12 and 18 years of age.
Process for implementing the EFQM within the ward
In 2002, the professionals in the ward wanted to implement a system to improve quality of care in the ward and, after studying similar experiences, they decided to use the EFQM model as a reference. The launch of the project was a self-assessment of the ward to identify areas for improvement in 2003. A quality improvement plan was developed on the basis of the results of the self-assessment, and the plan was implemented during the following 2 years. Another self-assessment in 2005 had a dual goal: to evaluate the results achieved with the improvement plan and to identify new areas for improvement. The methods of this project, therefore, had two main phases: identification of areas for improvement via self-assessment and improvement of those areas, mainly carried out by improvement teams.
To coordinate and implement the main self-assessment tasks, an assessment team was set up. This multidisciplinary assessment team consisted of five people in 2003 and, 2 years later, it was increased to eight to represent a greater number of the ward's professions. Practically, all job descriptions were involved in the assessment team, along with the ward manager and a quality improvement specialist. Even when technical support was provided by the hospital's Quality Improvement Unit, the work was designed and carried out by the ward's professionals, without any extra financial or human resources. Members of the unit lacked knowledge of the EFQM, so the assessment team members were trained in quality improvement and EFQM.
Self-assessment methods
The EFQM proposes different approaches or methodologies for carrying out the self-assessment. In the ward, we decided to adopt two combined approaches for each of the two self-assessments performed. First, we drew up a submission document for the ‘award simulation’ approach as a data-gathering tool. Secondly, as a self-assessment method, we used a specific case questionnaire approach.
The submission document for the ‘award simulation’ approach is a document with an established format that describes the organization's achievements across a range of areas related to each sub-criterion of the EFQM model. The assessment team drew up the first draft of the submission document, which was handed out to all the professionals in the ward, who were asked to review it and provide their own suggestions and comments. On both occasions, more than half of the staff handed in their suggestions concerning the draft, so the final submission document is considered a document approved by the ward staff, and as such, a very good source of information on which to base the self-assessment.
To perform the self-assessment using the questionnaire approach, we used a questionnaire called ‘Perfil’ [4]. Perfil is an electronic questionnaire provided by the EFQM representative in Spain, which consists of 120 questions grouped under EFQM sub-criteria, with a rating scale of 1–100. We began by conducting the individual self-assessments. Each member of the assessment team individually rated the ward's development on the 120 questions, using the information provided on the submission document as a reference. This was followed by consensus sessions to discuss and reach a consensus on the results of the individual self-assessments, as well as to pinpoint strengths and areas for improvement. The final score for each question was the average of the scores of all assessors, except for questions with >25% discrepancy between the ratings given by the different assessors, which were discussed and rated again during the consensus meetings. The Perfil software automatically calculated the final score, taking into account the weights of the EFQM criteria.
Quality improvement methods
The self-assessments were not an end in themselves, but the starting point for a quality improvement system. After we had identified the ward's areas for improvement on the basis of the EFQM model during the self-assessment phase, on both occasions we prioritized these areas using a prioritization matrix and set down specific initiatives for improvement over the next 2 years, specifying the individual responsible for each, the working calendar, an outline of the measures to be taken and the methods to be used to assess results. The improvement initiatives were usually assigned to improvement teams, although, exceptionally, some were entrusted to individuals. Quarterly team meetings were held to coordinate and follow-up on quality improvement initiatives. Workers from all shifts attended meetings, which in fact already existed in the ward as a coordination mechanism. One of the permanent topics on the agenda for these meetings is follow-up on quality improvement initiatives.
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Results |
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The key result obtained by this project was the introduction of a structured system for quality management based on EFQM model principles in the ward. The EFQM was found to be a valid framework for periodic assessment of ward performance. Of the 32 sub-criteria of the model, only sub-criterion 4.B. ‘Finances are managed’ could not be included in the self-assessment, because finances are managed at a hospital level and neither the ward manager nor the rest of the staff have any control over it. The questions related to that sub-criterion, therefore, were considered not applicable. The issues covered by the rest of the criteria were relevant, but for some sub-criteria, an effort was needed to narrow the focus to areas that were directly controlled at the ward level. For example, for criteria 5 ‘Processes’, key processes could be fully assessed, whereas support processes could be only partially assessed, as some of those processes are managed by other departments.
To be able to do the self-assessment, a great deal of effort was needed to train the staff. At present, all the workers in the ward have basic notions of the EFQM model, whereas 58% of them attended EFQM courses and have a more comprehensive knowledge of the model. Other than the training, the main facilitating element was the high level of involvement in the project by the ward manager and staff. The ward manager sponsored the project and took an active part in all phases. Staff involvement is evidenced by the fact that over half gave suggestions on the submission document on both occasions, the improvement groups were made up of volunteers and the response ratio on the work climate survey was >90%. Regarding difficulties, it took a great deal of effort to ensure that the language and principles of the EFQM model were fully understood by the clinical professionals. Furthermore, as all the activities were carried out without any additional help and without any detriment to patient care, the initial phase of the project demanded extra effort on top of the regular workload. Once the areas for improvement were identified in the improvement plan development phase, another difficulty cropped up: it was not possible to influence some of the improvement areas that had been identified. For example, on the survey for psychiatrists from out-patient care centres, the referral process was identified as a weak area, but, when trying to improve it, it was found that some of the burdens of the procedure came from the Department of Mental Health and, therefore, it was not possible to modify them. It was also very difficult to improve aspects related to facilities, as the needed budget had to be assigned by hospital managers.
Regarding the results of the self-assessments, in 2003, the ward obtained 209 points, which increased 2 years later by 102 points, reaching 311 points. This constitutes a 48.80% increase from the initial score. Table 1 shows the evolution of the results between these two dates, comparing the scores in 2003 and 2005 out of the total score assigned to each criterion by the EFQM. Regarding the differences between criteria, in 2003, the criterion with the highest rating accounted for 28.7% of the total score, whereas the criterion with the lowest rating only accounted for 6.6% (maximum value for all the criteria/minimum value for all criteria = 4.34). In 2005, the criterion with the highest rating accounted for 39% of the total score, whereas the criterion with the lowest rating accounted for 24% (maximum value for all the criteria/minimum value for all criteria = 1.62). This trend towards more equivalent scores among different sub-criteria reflects more homogeneous development in all management aspects of the organization.
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Regarding the implementation of quality improvement initiatives, Table 2 summarizes the most important initiatives carried out between the two self-assessments. Following the 2003 self-assessment, four work groups were set up (processes, assessment of result indicators, improvement in staff satisfaction and ward safety) and another two professionals were appointed to be in charge of improvement initiatives individually (coordination with out-patient healthcare centres and improvement in customer satisfaction survey). With respect to results, some examples of the key indicators for each of the criteria are shown in Table 3. Efficiency in the use of resources improved, due to an increase in annual admissions as well as a decrease in length of hospital stays, although the ward is treating patients with more complex clinical diagnoses (the percentage of patients admitted with four, five or more than five diagnoses rose by 5.1, 7.8 and 9.3 points, respectively). Customer satisfaction improved, reaching an average of 9.3 out of 10, and the three aspects (included in Table 2) that received the lowest scores in the initial satisfaction surveys underwent a statistically significant increase, whereas the rest of the items remained stable. The quality of healthcare showed a drop in the number of physical restraints, improved coordination with Out-patient Mental Health Centres (improvement in delivery of discharge report) and improvement in quality of medical records. Social recognition was manifested when the ward was awarded second place in the 5th Public Excellence and Quality Prize awarded by the Community of Madrid in 2005. With regard to people results, although there was an increase in the training received and given by the professionals and a rise in the number of scientific publications, which are considered strong motivational factors for professionals, the score on the professional satisfaction survey did not improve and remained practically stable.
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Discussion |
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The main limitation of this study is that, being a descriptive study, it is not possible to determine whether there is a causal relationship between the methods and the results obtained. The limited number of result indicators used in the ward prior to implementation of the quality improvement system and, therefore, the lack of data limit the possibility of objective measurement of improvement. It is also worth emphasizing that the project has been in place for only 4 years, and a more accurate review could be made after a longer period. The specific characteristics of this project, it being a very new ward, being the first quality improvement project in the ward, lack of staff EFQM knowledge and high level of commitment and participation by the ward manager and staff, strongly influence the development of the project, raising the question whether these results could be obtained in wards with different characteristics. Even with these limitations, given that this is one of the first experiences of EFQM implementation at a ward level, specifically in psychiatric care, the different phases of the project are being published [5–7] with the aim of helping other wards to implement similar processes.
The results of the self-assessments, the 209 points obtained in the year 2000, are similar to the scores of other organizations that have used the EFQM for the first time as a self-assessment tool, as has been found in several healthcare organizations in Germany [8] and Spain [9–10]. The 103 point increase in just 2 years represents an almost 50% improvement in the initial score, which constitutes a very significant improvement in such a short period of time. In general, criteria that had received the lowest ratings in 2003 were the ones that showed the greatest increase. This trend towards more equivalent scores among the different sub-criteria reflects a more mature management system in the organization [8]. It should also be noted that the EFQM scoring system for result criteria shows a bias against new organizations, because in order to present a positive trend in results, it is necessary to have at least three consecutive periods of data and the ward had been operating for fewer than 3 years in 2003. This fact and the introduction of a new system to evaluate results in the different areas led to a greater increase in result criteria than enabler criteria, with only one exception, although other published studies using the EFQM mainly improved in enabler criteria [11] or some of each, e.g. processes and ‘people results’ [12].
One of the innovative aspects of this experience is the methodology used to conduct the self-assessment. The EFQM proposes different approaches for self-assessment: the award simulation approach, the pro-forma approach, work meetings, questionnaires and improvement matrices. Because none of these was totally suited to the characteristics and needs of the ward, a combination of two of the above approaches was used: a submission document was used to gather data and a questionnaire was used to conduct the assessment. By using this combination, we benefitted from both approaches: the drafting of the submission document proved to be a highly didactic process in itself. It fostered communication and, as it was reviewed by all ward staff, facilitated their involvement in the identified areas for improvement. For all these reasons, despite the fact that it is not recommended that this document be used for the first self-assessment [13], we consider that the effort was very much worthwhile. In addition, the Perfil questionnaire proved to be an easy and intuitive tool for conducting the individual self-assessments and proved very useful during the consensus meetings. Other than the methods used, the facilitating factors that we identified in this experience are similar to the ones pointed out in other publications, e.g. the great leadership staff commitment [8]. Some of the difficulties faced by this project had also already been identified in similar projects, e.g. the difficulty in understanding the EFQM approach by clinicians [12] and the difficulty in the EFQM terminology [8, 14, 15]. The use of versions of the EFQM model adapted to healthcare [16–18] would undoubtedly help simplify matters. The initial effort needed in the first stage of the project is commonly seen in other similar projects [8, 19]. Finally, this experience has shown that it is not always possible to implement initiatives in areas of interest related to the model when working at a ward level, given that many matters are beyond the control of the ward manager and staff. This could affect staff motivation concerning quality improvement, when they realize that it is not possible to put certain key guidelines into practice. This limitation has also been found in other experiences, which draw attention to the fact that when the model is applied to specific wards, there are sub-criteria that do not fall into the managers' area of decision-making [9] and it has also been found when working in whole healthcare organizations in the public sector [13]. In the ward, we are trying to get around this limitation by delimiting the scope of action of quality improvement projects, even though this also entails limiting our capacity for improvement.
This experience shows that the principles of the EFQM model can be implemented at any organizational level, even on a small scale, such as in a hospital ward, without the need for a top–down structure to coordinate vertical implementation of such projects. To implement the model at the ward level, it is important to clearly delimit the scope of the project and to exclude measures that are beyond the decision-making scope of the ward, so as not to frustrate participants by the lack of results. Working on a ward level allows a high percentage of staff members to participate in the project, which, in turn, improves communication within the ward and fosters awareness of problem areas, leading to a greater degree of staff involvement with the improvement project.
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References |
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- The fundamental concepts of excellence. (2003) (European Foundation for Quality Management, Brussels) http://www.efqm.org/Portals/0/FuCo-en.pdf (Accessed 19 July 2006).
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