1. LEADERSHIP - EUSKALIT Kudeaketa Aurreratua - … · 2005-11-22 · the EFQM Excellence model and...

1. LEADERSHIP

“ Zumarraga Hospital is an example to all of us”. CEO of Osakidetza.

Zumarraga Hospital – Hospital de Zumarraga 3

1 LEADERSHIPINTRODUCTION

Prior to 1998, the concept of leadership in Zumarraga Hospital (ZH)was that of the traditional chain of command over employees. In thecourse of 1998, as a direct consequence of self-assessment againstthe EFQM Excellence model and strategic review, this concept wasassessed and reviewed on the basis of what type of leadership ZHwould need to develop our strategy and deliver our Mission. As a resultof this reflection, the Management Team (MT) developed a newapproach based on shared leadership among our people. A ZH leaderwas defined as a person who has other employees reporting tohim/her, and who involves and coordinates them to deliver thehospital’s goals and objectives to thus meet the needs andexpectations of the customer and of the Health System.

In 1999, also as a direct consequence of self-assessment in 1998,we adopted management by processes as a key element of change.This system was chosen for its capacity to bring together and integratestrategy, processes and results, and for the possibilities it offers interms of involving people in continuous improvement. At the sametime, the concept of leadership in ZH was subject to another reviewcycle, culminating in the new concept of process leader (1a), referred toas PL, as the person responsible for continuous improvement of his/herprocess. The immediate consequence of this was that 71 peoplebecame leaders, though 34 of these had no MT or Unit responsibility.

Leadership is systematically assessed and reviewed throughassessment against the EFQM Excellence model and through thePeople’s Voice Process. This process is the vehicle through whichpeople’s perception of leadership is measured and surveyed.

The development of a culture of Excellence in ZH is rooted in thecommitment, belief, clear leadership and participation of our ChiefExecutive (CE) and all other MT members in improvement activities.The acceptance of responsibility by all other ZH leaders, and theleadership style adopted by the hospital enable our people to feelinvolved in improvement, to develop a sense of belonging and toactively contribute to the delivery of the hospital’s goals and objectives.

As the purpose of this criterion is to explain the role and system ofleadership in ZH management, it is essential to be familiar with thecontent of the other 4 enabler criteria if this is to be fully understood.1a. LEADERS DEVELOP THE MISSION, VISION, VALUESAND ETHICS AND ARE ROLE MODELS OF A CULTURE OFEXCELLENCEDefinition of leadership

In ZH, leadership is understood as a series of attributes whichenable people to accept responsibility for improving the way the

people, resources and processes of the hospital are managed. Theprofile of a middle manager, or Unit Head, is a person committed to thegoals and policies of the hospital, who provides the necessaryresources and information to deliver them, who provides and assessestraining, who devolves responsibility to others and duly recognisesthem, and who acts as a role model for those who report to him/her. Theprofile of a PL, with or without direct leadership responsibility, has beendefined as a person with: the will to improve, as this is voluntary;knowledge of his/her process and the quality management toolsavailable to improve it; and empowerment, or the degree of self-management and responsibility given to him/her to improve (5a).

Any ZH employee can be a leader. At the current moment in time, wehave 74 leaders, 18% of the total number of staff and a pioneer figure inthe Health Sector. This figure is broken down as follows:- Steering Committee (5)- Unit Heads (40)- Process Leaders (74, of which 5 are Directors and 37 Unit Heads).4 process teams, made up of 24 people, are currently being trained anddeveloped. This will broaden the scope of leadership in the hospital.Development of the ZH Mission, Vision and Values

As can be seen throughout this submission document, theunequivocal commitment and personal involvement of the CE and MTmembers have been the drivers of the Total Quality culture in ZH and of

Figure 1a-1: MISSION, VISION & VALUES (MV&V)the development of the ZH Mission and Values. The Mission and Vision aredeveloped within the global management system, beginning with theirdefinition and moving through to the stage where they are translated intogoal-based strategies, which are themselves further detailed in terms ofCritical Success Factors (CSF), process objectives and indicators (2c).Processes are thus managed to deliver the Mission and Vision.

MissionMission

VisionVision

Strategic Plan

Strategic Plan

Business Plan

Business Plan

ProcessesProcessesStrategic

Key

Support

ResultsResultsKey Results

EFQM Assessment

CustomersCustomers

PeoplePeople

Health SystemHealth System

SocietySociety

SuppliersSuppliers

ValuesValues

Stakeholders

Figure 1a-2: ZH MANAGEMENT SYSTEM

The ZH management system, and the integration of Total Quality intoit, promotes the establishing of improvement priorities, teamwork,results measurement and the use of innovation and learning for thecontinuous improvement of our strategy and activities. Numerousexamples of this can be seen throughout this submission document.

The MT and all other leaders stimulate and encourage a culture ofcontinuous improvement by promoting training in the EFQM model, bytaking active part in the assessment of other organisations, by sharing theirknowledge with other Health Centres and by participating in working groupsand congresses or contributing articles for publication. All ZH leaders areinvolved in establishing and developing the Mission and Strategic Plan (SP).Different mechanisms are used to systematically stimulate and developpeople participation and empowerment to ensure the highest possible levelof leadership in the hospital (crit. 2, 3 and 5). Fig. 1a-3 shows step-by-stepthe role of ZH leaders in this process, and the criteria in this document inwhich these actions are detailed.

Leaders’ involvement cascades down the establishedorganisation chart and command chain (Figs. 0-4, 2d-5). All

leaders are involved at one step or another of the process, either interms of participation, communication or management and assessment,whilst the delivery of the MV&V involves all ZH people.

Leadership effectiveness is assessed every year by the MT.Various mechanisms are used:

A

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MISSIONZumarraga Hospital is a public hospital of Osakidetza / the Basque Health Service,

providing specialised healthcare to improve the health of the population and meet theneeds and expectations of its customers.

To do so, we will follow and develop a philosophy of Continuous Improvement, interms of:

• The involvement and professional development of those who work in thehospital;

• Efficiency and financial equilibrium;• Promoting global improvement of the Health System through innovation,

teaching and cooperation with other organisations.VISION

We aspire to being a hospital of Excellence, continuously improving in professionaland technical terms and fully satisfying the needs of Society, our people andespecially of our customers.

VALUESWe work for the patient

Mutual respectTeamwork

Open communication

Results focusedCommitment to innovation

Sense of belongingConsensus


a) People satisfaction survey: A series of different items have beenprogressively included since 1999 to assess the effectiveness ofleadership in ZH from both a global and specific perspective. The layoutof the survey allows for middle managers to assess Management, andfor ZH people to assess middle management.

Survey results are analysed in meetings with Management, Unit Heads andhealthcare professionals from different ZH Services. All relevant suggestionsfrom the survey are included in the BP (2a). The satisfaction ratings of a seriesof items from the survey are shown in Fig. 1a-4. As can be appreciated fromthis data, results in leadership effectiveness show a highly positive trend.

SEQUENCE OFMANAGEMENT

LEADERS’ ROLE REF.

Mission

The MT and a team of ZH leaders and people reviewthe Mission, incorporating any previously undetectedstakeholder needs. Unit Heads and PLs disseminateand check the validity of the Mission with teammembers.

2a,2d

Vision

Management and a group of ZH people formulate theVision. The contribution of non-leaders enriches theprocess in the respect that their perspective is differentfrom that of Management.

2a,2d

Values Leaders work together to identify, review,communicate and role-model ZH values.

2a,2d

Hospital GoalsThe MT communicates hospital goals and reachesconsensus agreement with Unit Heads and PLs fortheir deployment in Units.

2c,2d

CSFThe MT identifies the CSF for delivery of the goals,and Unit Heads and PLs develop the processesrequired to meet these goals.

2c,2d

BSCLeaders establish indicators and design the balancedscorecards required for process monitoring andassessment, and inform their teams accordingly.

2d,5a

SWOT analysisand selection ofstrategies

The MT formulates the SP, and conducts a SWOTanalysis of internal and external factors to select themost appropriate strategies to deliver ZH goals.

2d,5a

ProgrammeContract

The MT negotiates the Programme Contract with theDept. of Health, communicates the Programme tohospital Units and monitors its progress. Unit Headsand PLs are involved in the dissemination and deliveryof the Programme.

2d

Business Plan

The MT formulates and disseminates the BusinessPlan (BP). Unit Heads and PLs participate inestablishing process objectives and indicators, andinform their Units accordingly.

2d

CommunicationManagement communicate the BP to all other ZHleaders, who in turn inform their people and driveimprovement.

2d

MonitoringUnit Heads and PLs ensure day-to-day managementand monitoring of plans, and establish any necessarycorrective actions.

2d

ProcessManagement

The MT and process teams and leaders coordinateand participate in process design, monitor and assessprocess results against established targets andprioritise, lead, coordinate, participate in and provideresources for improvements. Leaders participatedirectly in specific improvement initiatives, such asClinical and Non-Clinical Committees, improvementteams and working groups.

5

Assessment

Final assessment of the plans is conducted by the MT,Unit Heads and PLs, and documented in a report usedto communicate the findings to stakeholders and asthe basis for drawing up a new Plan.

2e

Figure 1a-3: ROLE OF LEADERS IN THE MANAGEMENT SYSTEM

% AGREEMENT*PEOPLE SATISFACTION SURVEY ITEMS99 01 03

I trust in the decisions taken by the Management Team. 14 41 66I trust in the decisions taken by the Head of my Unit. 44 64 71The hospital’s strategy is being adjusted for improvement. 16 51 69The Head of my Unit discusses with the team any projectsaffecting our Unit. --- 52 71

In my Unit, we cooperate with other Services to deliver thehospital’s goals 52 56 63

The Head of my Unit practices what he/she preaches 48 64 78Figure 1a-4: RESULTS OF PEOPLE SATISFACTION SURVEY ITEMS (* % agreement: % of

people who responded “I totally agree” and “I agree”, discarding all neutral answers).

% AgreementVALUES1999 2001 2003

We work for the patient 71 83 78Mutual respect 67 86 90Teamwork 47 61 63Open communication 48 58 67Results focused 25 77 91Commitment to innovation - 63 74Sense of belonging 35 81 91Consensus - 59 69

Figure 1a-5: % AGREEMENT WITH ZH VALUES

ASSESSMENT TYPE /SOURCE OF LEARNING

YR IMPROVEMENTS

97 Participation of 3 leaders from the TechnicalCommittee in the formulation of the SP (1,3,4)

98Study of best practices in leadership, identifyingthe need to systematically assess and review(1,3,6,7,8)

99

Inclusion of items on leadership effectiveness inpeople satisfaction survey (1,3,7)Review of Mission (inclusion of suppliers) andidentification of values (1,5)Formulation of the Mission of each process (1,5,7,8)Dissemination of MV&V by leaders, with visualsupport (1,3,7)

00Training of leaders in TQM (2,3,6)Mission included in in-house magazine toincrease dissemination (2,5)

01

Formulation of the Vision by more than 80 ZHpeople (1,7)Modification of the people satisfaction survey toassess leadership (1,2,5)

02 Formulation of the SP, involving the collaborationof over 80 ZH people (1,3,5,9)

03 Design of the leadership process (1,2,3,6,7,9)Review of the ZH Mission (1,3,9)

1. Assessment byMT2. Assessment byPL3. EFQMassessment4. Assessment byTechnicalCommittee5. People’s Voice6. Training7. Benchmarking8. External expert(Costa)9. External expert(Gesco)10. InnovationCapital Model

04 Study on incorporating the assessment ofpersonalised leadership (1,2,5,7,9,10)

Figure 1a-6: EXAMPLES OF IMPROVEMENT CYCLES RELATED TO 1a.One area for improvement identified through the 1998 assessment

against the EFQM Excellence model was the need to reflect theorganisation’s commitment to a quality culture in the form of a series ofwritten Values. The following year, various items were included in thepeople satisfaction survey to measure our people’s perception of thecoherence of these values (Fig. 1a-5). 2001 and 2003 satisfaction ratingsare a reflection of the effectiveness of our management system.b) Qualitative assessment: contact with focus groups, with representativesof ZH Services and the various communication channels used throughoutthe hospital provide the MT with an instant snapshot of people’s perceptionat any given moment, thus enabling us to improve the approach anddeployment of leadership.c) Sources of learning: Assessment against the EFQM model and experthelp provided by external assessors have enabled us over the years tocheck the implementation and effectiveness of our approach, and toestablish improvement actions accordingly. Similarly, the contribution ofexternal experts to improving our management system, benchmarkingleadership practices in other organisations such as ASLE, Irizar, Gasnalsa(all 3 EQA Prize Winners) and Euskalit (The Basque Quality Foundation),and learning at technical seminars and from specialist publications have allbeen instrumental in identifying and introducing improvements into ourmanagement system (Fig. 1a-6).1b. LEADERS ARE PERSONALLY INVOLVED IN ENSURINGTHE ORGANISATION’S MANAGEMENT SYSTEM ISDEVELOPED, IMPLEMENTED AND CONTINUOUSLY IMPROVED

Since 1992, on publication of the Osakidetza Integral QualityPlan (Overview), Continuous Improvement has been

systematically established as the basis of management in ZH,following the principles of Business Excellence. After analysing theexperiences of other Health Centres and receiving encouragementfrom Osakidetza itself, we decided in 1995 to adopt the EFQMBusiness Excellence Model as a reference framework for assessing,learning, identifying and implementing areas for improvement intoour management system.

A


Continuous Improvement is embodied in the Mission and envelops thewhole management system (1a-1). It is, additionally, a strategic process, adriver of improvement for the whole hospital (crit. 5).

The management system described throughout this submissiondocument is subject to improvement using the mechanisms shown inFigs. 1b-1 and 1b-4. The improvement cycle begins with EFQMassessment, training and benchmarking, all of which contribute toidentifying areas for improvement. The first self-assessment exercisewas conducted towards the end of 1996, once the MT had been trainedappropriately in this activity, and proved to be a major source oflearning: 24 action plans were identified, incorporated into the BP anddeveloped. The second self-assessment exercise was conducted in1998, as a result of which 5 areas for improvement were prioritised, oneof which was management by processes.

Figure1b-1: MANAGEMENT SYSTEM & CONTINUOUS IMPROVEMENT

After conducting another mini self-assessment exercise in 1999,the MT decided to subject the ZH management system to externalassessment. The submission document was prepared and compiledin the course of 2000 with the help and guidance of Osakidetza andEuskalit, and this process in itself proved to be an important sourceof learning as this was a pioneer activity in the Health Sector. ZHwas subsequently awarded the Basque Govt. “Silver Q” for Quality(400-500 points after assessment against the EFQM model), and, 3years later, the “Gold Q” Award (500+ points against the EFQMmodel). These awards have proved to be a great stimulus for ourpeople, and the submission documents are used as training materialboth inside the hospital and externally for other healthcareorganisations (Fig. 1c-6).

Since 2000, the feedback reports from external assessment havebeen used for prioritising and incorporating areas for improvementinto ZH plans. The findings of these reports were distributed to andanalysed by ZH employees, and were at the heart of the 2003 SP.The ever increasing number of ZH people who have trained asassessors against the EFQM model and subsequently becomemembers of the Euskalit Assessors Club (6 people at the time ofwriting this document, all of whom conduct external assessments ofother organisations), together with specific training anddissemination activities of the model within the hospital andparticipation of our people in benchmarking activities, have beenmajor factors in ZH people understanding and using the model. Forexample, prior to 2003, areas for improvement were prioritised bythe MT on the basis of 4 criteria; impact on the customer, impact onthe organisation, viability and the need for improvement. Since2003, areas for improvement are prioritised according to theirimpact on CSF and goals, and integrated into the SP and annualBP.

Benchmarking and training in clinical, professional and managementrelated activities are considered essential for improving themanagement system. Leaders are actively involved in developing theseactivities, encouraging people to identify and implement best practicesand training initiatives, many examples of which can be found in this

submission document. For example, the CE and other leaders give in-house training every year to Unit Heads, PLs and other employees inthe EFQM model, management by processes, ISO certification andTQM. The integration of a quality management culture in the hospital,together with the training given to our leaders in management tools, hasprovided us with a solid base for improving our management system.For example, in 2004, the hospital was chosen by Osakidetza to pilottheir quick self-assessment model (Evalexprés).

The involvement of leaders in improving our management system alsotakes the form of actively stimulating and encouraging ZH people toparticipate in hospital improvement and work teams. All MT memberstake an active part themselves in these initiatives (Fig. 3c-2).

The defined profile of ZH leaders (1a), coupled with theirinvolvement in the day-to-day business of the hospital, are the

essential ingredients for stimulating and encouraging our people toparticipate in continuous improvement and the ZH management system.All PLs and practically all Unit Heads drive improvement of theprocesses which affect them. Deployment covers all the hospital’sprocesses. The methodology of management by processesdetermines that a Mission statement be drawn up for each process,defining the “why, what and who” of each one (5a), and this hasbeen done to cover all hospital activities. Over 90% of hospitalleaders participate in working groups and/or improvement activities.This, together with the use of the model, training and benchmarkinghave brought about the advances in our management system

described in Fig. 2-2.In ZH, we use two systems to assess, review andimprove our performance in this area of management:

a)The system for assessing the approach itself helps to identifyareas for improvement and incorporate them into the managementsystem. This has led to improvements in self-assessmentmethodology, increased participation in the Assessors Club andbroadened the scope of training for ZH leaders and people.

b)The system for leading and developing management-relatedimprovement. This has led to a wider definition of leaders in thisarea (PLs, quality coordinators) and to an increase in the amount oftraining in management for ZH people.

In this respect, in addition to qualitative assessment, a series ofindicators are used to measure progress:

1. The people satisfaction survey includes items which enable usto measure the involvement of leaders in improvement (1b-2 & 7a-18).

% AGREEMENTPEOPLE SATISFACTION SURVEY ITEM 01 03

Considerable effort is being made to improve how thehospital is run.

63 74

ZH people show an interest in working efficiently. 86 91Hospital users receive a high quality service. 83 83

Figure 1b-2: RESULTS OF PEOPLE SATISFACTION SURVEY ITEMS

2. Assessment against the model has enabled us to assess ourmanagement in this area and identify areas for improvement (Fig.1b-3):

EFQM SELF-ASSESSMENT EXTERNAL ASSESSMENT

1997 3711998 433 2000 401-4501999 512 2002 450-5002004 643 2003 501-550

Figure 1b-3: SCORES OBTAINED AFTER ASSESSMENT

3. The sources of learning used in this criterion have beencovered in 1a (Fig. 1a-6). Some examples of improvements afterassessment and review are shown in Fig. 1b-5.

D

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EFQM SELF-ASSESSMENT

TRAINING INMANAGEMENT

MANAGEMENTBENCHAMRKING

BENCHMARKING

LEARNING

RELEVANTINFORMATION

Customer VoicePrimary HealthCare VoicePeople’s VoiceSociety’s Voice

Osakidetza PlanDept of Health Plan

STRATEGIC PLANBUSINESS PLAN

AREAS FORIMPROVEMENT

MANAGEMENT BY PROCESSES

IMPROVEMENT TEAMS

IMPROVEMENTMECHANISMS


MECHANISMS FOR IMPROVING THE MANAGEMENT SYSTEMHOW ROLE OF LEADERS LEADERS EXAMPLES / EVIDENCE OF IMPROVEMENT

Conduct self-assessment againstEFQM model Four self-assessment exercises since 1997 (Fig. 1b-3)

Prepare external assessment

MTCertificationCoordinator Three external assessment exercises since 2000 (Fig. 1b-3)EF

QM

ASSE

SSM

ENT

Strategic Plan MT / Others Use of the 2000 external assessment feedback report for formulation of SPTraining of Management andleaders in health management PLs and Unit Heads All Management and around 20 PLs have attended year-long training courses in management, and

specific training in management tools.

Training in management tools

MT, PLs and UnitHeadsCertificationCoordinator

Leaders receive and give training in management improvement tools (EFQM Model, management byprocesses, communication, prioritisation of problems, ISO Certification, strategy planning, 5Smethodology, Total Quality, etc.)Guide to Process Management, drawn up by the CE and Certification Coordinator

Dissemination of EFQMsubmission document MT 2000 and 2003 submission documents given to all ZH people and used by leaders in 2002, with the

aid of a guidebook on the Model, as training material.

TRAI

NING

INM

ANAG

EMEN

T

Articles in media MT Publication of articles on management, continuous improvement and results assessment.Visits to other organisations All Deeper knowledge of best practices of other organisations.Visits by other organisationsTutoring organisations

PLs and Unit HeadsMT

The experience of explaining our management system to other organisations and tutoring over 15hospitals and numerous healthcare professionals is a rich source of learning and knowledge.

Attendance at Courses andScientific Seminars All Constant updating with respect to clinical and management tools.

Participation in working groups All ZH leader participation in various working groups with Osakidetza

MAN

AGEM

ENT

BENC

HMAR

KING

Collaboration with Associations,etc.

PLs and Unit HeadsMT

Membership of organisations such as Euskalit (6 EFQM assessors, members of the 400 Club,promoters of 5S), Board Member of SECA (Spanish Society for Quality in Healthcare), of theInternational Society for Quality in Healthcare and of the Observatorio Ciudadanía (Citizens’Watchdog) enables ZH leaders to keep up-to-date with the latest advances in technology andmanagement and to incorporate them into our management system.

Continuous Improvement All Encouragement for leaders to identify and implement best practices and training. Participation inworking groups and Committees (all Management and a significant number of leaders)

SP and BP MT and PLs Communication, monitoring and assessment of plans in their respective Units and processes.

Technical and other Committees All Leaders analyse and prioritise improvement suggestions from these Committees and include them,where appropriate, in the BP.

Analysis of surveys MT Leaders analyse survey results with ZH people to incorporate areas for improvement into themanagement system (5e, 6, 7, 8)

IMPR

OVE

MEN

TS T

OM

ANAG

EMEN

TSY

STEM

Use of the Innovation CapitalModel MT Methodology for the assessment and management of continuous improvement and innovation in

organisations. ZH is pioneering the validity and application of this model in the Health Sector.Figure 1b-4: MANAGEMENT SYSTEM IMPROVEMENT MECHANISMS LED BY LEADERS


YR IMPROVEMENTS

98

Technical Committee members included in the process for adapting the SP (1,3,4)Setting up of the Library and Teaching Committee and absorption of the Central Quality Committee into the Technical Committee (1,3,6)Greater impetus given to training in quality for all leaders (1,3,5)Improvement actions identified through self-assessment are included in BP (1,3)

99 Creation of a team of people to support the deployment of Management by Processes (1,3,6,7)

00External assessment against the EFQM model(1,2,3,6)Increase in the number of improvement teams (teams for analysing survey results, environmental management, implementation ofthe Baby Friendly Hospital Initiative (UNICEF)) (1,2,3,4,6)

01EFQM submission document distributed to all ZH employees (2,3)Inclusion of items in people satisfaction survey to assess performance of leaders in this area (1,3,6,7)Creation of 5S implementation team, and of groups for strategy planning (1,2,3,6)

02 Creation of working groups for formulating ZH Vision statement, for ISO Certification and for compiling the next submissiondocument (1,2,3,5,6,7). 10 leaders participate in compiling the submission document (1,3,6)

03 Increase in the amount of training for ZH people in processes and certification (2,3,4,5).ZH becomes a member of the Group for Promoting 5S (5,6)

1. Assessment by MT

2. Assessment by PL

3. EFQM assessment

4. People’s Voice

5. Training

6. Benchmarking

7. External experts

8. Innovation CapitalModel

9. Mas Innovación(specialised company) 04

Piloting of the Innovation Capital Model for use in health organisations (1,8)Creation of process teams and practical training (1,2,3,5,6,8)Steering Committee training in high performance teams, as a pilot experience for implementation of process teams (1,9)

Figure 1b-5: EXAMPLES OF IMPROVEMENT CYCLES RELATED TO 1b.1c. LEADERS INTERACT WITH CUSTOMERS, PARTNERSAND REPRESENTATIVES OF SOCIETY

To deliver the Mission, ZH leaders interact primarily withcustomers, suppliers and representatives of PrimaryHealthcare, the Health System and Society. ZH leadership

style promotes the proactive participation of our leaders in identifyingstakeholder needs and responding to them to improve our servicesaccordingly. This has meant that ZH has pioneered several services in thehealth sector. Management by processes, together with complementaryfactors such as empowerment, knowledge management andcommunication create a synergy for our leadership in this area.Though there are many channels through which ZH leaderssystematically interact with stakeholders, one of them stands out asbeing particularly important and specific: contact with customers. Thespecial nature of the relationship between the hospital and its customers

helps us to understand and appreciate the intensity of the personalinvolvement of our healthcare professionals and their relationship withcustomers, and is, at the same time, an excellent source of information oncustomer needs and service commitment. The need to coordinate ouractions with the Primary Healthcare Service to ensure continuity of patientcare, together with assessment and learning activities undertaken in thisrespect, have led to the setting up of multiple communication channels andcollaboration initiatives with Primary Healthcare professionals, making ZH areference in this area of healthcare management.

Strong ties have also been established and developed with other healthcentres and their people, with professional associations and social trustsand with Excellence promoting bodies such as Euskalit. These relations arefostered as sources of learning and knowledge sharing in the clinical andmanagement field.

Figs. 1c-1 to 1c-4 show multiple examples of interaction between ZHleaders and the four key stakeholder groups involved. These channels of

AD


contact also contribute key information for establishing our strategy andplans. Fig. 2a-1 shows how these channels are linked to processes, andhow they are used to improve our management system. Examples ofdissemination activities are shown in Fig. 1c-6.

Assessment and review of the effectiveness of leadership inthis area, both in terms of our approach to it (the system)

and how it is practiced, is conducted through surveys (customers,suppliers and Society), assessment against the EFQM model andqualitative analysis by the MT. The sources of learning related to thissub-criterion are shown in Fig. 1a-6. The people satisfaction surveyincludes several items which enable us to assess various aspects relatedto the interaction of our leaders with stakeholders. Results trendsconfirm the effectiveness of our approach (Fig. 1c-5).

% A GREEMENTPEOPLE SATISFACTION SURVEY ITEMS 99 01 03The Head of my Unit considers customer satisfaction ournumber one priority. 47 73 87

In my Unit, we work to meet the needs of our customers. 71 95 95In my Unit, we know who the end beneficiary of our work is. 80 85 85My Unit understands the needs of its customers. 52 78 78

Figure 1c-5: RESULTS OF PEOPLE SATISFACTION SURVEY ITEMS

Quantitative and qualitative analysis by the MT, through surveyfindings (6a and 8) and learning activities, have enabled us to improveour approach in this area of management. Examples of improvementsafter successive assessment and review cycles are shown in Fig. 1c-7.

CONTACT TYPE LEADERS’ ROLELEADERSINVOLVED

REF.

Direct contact withcustomers

Leaders maintain direct and daily contact with customers, providing services and identifying needs andexpectations. All 2a

5dCustomer satisfactionsurveys

Leaders assess results, communicate them to ZH people and propose improvements to be included in the BPand/or the inclusion of new items in global and specific surveys for customers and those who accompany them.

All 6

Complaints andsuggestions

Personalised complaints handling. Leaders propose improvement actions after assessing customer suggestionsand the follow-up report from the PALS. All 5e

Focus groups Leaders decide on the need for a focus group, participate in it, draw up action plans and report on conclusions. All 5ePrimary Healthcaresurveys

Leaders assess findings and put forward improvement proposals. All Primary Healthcare doctors are informed ofthe findings. All 6

Meetings with PrimaryHealthcare Mg’ment

The MT hold regular meetings with Primary Healthcare Management to monitor the delivery of common goals,and to identify, deploy and monitor joint improvement plans.

MT 2a

Contact with PrimaryHealthcareprofessionals

Leaders participate directly in problem solving and joint training activities with Primary Healthcare professionals,as well as in Advisory Bodies and joint working parties (Technical Committee and Outpatients Process Team). All 2a

CUSTOMERS

Meetings with PHCCM The MT and the Outpatients Process Team hold meetings with the PHCCM to identify areas for improvement andestablish joint plans to improve customer care and the continuity of patient care.

MT 2a

Figure 1c-1: INTERACTION CHANNELS OF ZH LEADERS WITH CUSTOMERS

Stakeholders

Collaboration of leaders in Quality Research Projects (Kaliker, Programme Contract), in Osteba (TechnologyAssessment Agency), O+IKER (Basque Institute for Health Research), the Process Group, the e-OsabideGroup, the Quality Assurance Group (Osakidetza), the Working Group on Values, the Working Group on PeopleManagement Strategy and various other Groups with the Dept. of Health for the assessment and improvement ofmanagement systems (Programme Contract, Clinical Management, Professional Career) and the Basque Govt.(R+D+I Programme).

All 3c

Programme Contract MT negotiates, communicates and monitors the Programme Contract. MT 4bContact withOsakidetza

Management hold follow-up meetings on plans, management control, collaboration on development lines andwith working groups for general improvements to the Health System.

MT 2a

Surveys Management identify the need for a survey and draw up questionnaires to measure stakeholder satisfaction. MT 4c,8aPublications,submission documents

Leaders collaborate in studies and publications of Osakidetza, the Dept. of Health and Professional Associationsto disseminate improvements in the clinical and management field.

All 2a

HEALTHSYSTEM Third Party Agreements Management identify their needs, inform them of our portfolio of services and mail them the ZH in-house

magazine. MT 2a,8a

Figure 1c-2: INTERACTION CHANNELS OF ZH LEADERS WITH THE HEALTH SYSTEM

Local InstitutionsRegular meetings with local Town Councils to identify their needs and expectations, to learn of any plans that mayhave an effect on the demand for our services and to collaborate in training plans and environmentalmanagement.

CE 2a,8

Dissemination ofmanagement expertise

Active participation in information exchange, teaching and media initiatives to share our expertise and experiencein TQM (Fig. 1c-5), and in Quality Associations such as SECA and ISQ.

MT & 4leaders

4e,8a

Dissemination ofclinical expertise

Medical and nursing healthcare leaders contribute to the dissemination of clinical advances and to informing on theresults achieved by the hospital through practical demonstration, teaching and articles in specialist publications.

Health CareLeaders

4e,8a

Health Education Leaders promote and support the participation of ZH healthcare professionals in health care conferences, inschools, Professional Associations, on local TV (36 people) and in other media. Various 4e,

8aEnvironmentalManagement

In addition to their involvement in specific work groups, leaders participate actively in communicating andmanaging the environmental policy of the hospital. All 4c,

8bRecognition Interviews and/or written recognition for individuals and institutions in the ZH in-house magazine. MT 3eSurvey Preparation and assessment of Society satisfaction surveys. All 8a

University

Collaboration in Projects on Customer Research and Management by Processes (Univ. Miguel Hernández deAlicante, Informática Gipuzkoa, Faculty of Sociology of the Univ. Of the Basque Country), training in the EFQMExcellence Model (Engineering Faculty and Economics Dept. of the Univ. of the Basque Country) and training inassessment in universities (National Association for the Assessment and Accreditation of Quality).

CE 4a

ProfessionalAssociations

Participation in professional bodies, organisation of and participation in technical seminars (National Congresseson Surgery, Urology and Radiology, and international conferences on Surgery, Paediatrics and Quality). All 2a,

4eMeetings with PatientsAssociations

Contact with representatives of Patients’ Associations to identify their needs and expectations and how best torespond to them. All 2a,

8a

Social Representatives Training for Union representatives on a national level, and participation in a think tank in connection with theProject for Sustainability in the Spanish National Health Service. CE 8b

SOCIETY

Euskalit Collaboration as members of Euskalit, through the dissemination of ZH best practices in talks or publications, andthe participation of six ZH employees in the Assessors Club. MT 1b,

8aFigure 1c-4: INTERACTION CHANNELS OF ZH LEADERS WITH SOCIETY

AR


Supplier survey Preparation and assessment of survey findings for detailed knowledge of their needs and the degree to which ZH meets them. MT 4b,4c

Supplierassessment MT Review (with Unit Heads) of the efficiency of the partnership established with the supplier. All 4a

Supplierrecognition

Annual recognition by the MT of those suppliers considered as outstanding for their contribution to the development of thehospital (posted on the website)

MT 1c

SUPPLIERS

Meetings withsuppliers

ZH leaders and people are in direct and constant contact with suppliers to introduce improvements into our services. All 4a

Figure 1c-3: INTERACTION CHANNELS OF ZH LEADERS WITH SUPPLIERS

Year Presentations in Technical Seminars Visits Training-Publications

1999

- Attendance in 6 Congresses, giving talksand papers (Congress of the Spanish Societyfor Quality In Healthcare).

- Visit to ZH of MTs of5 different hospitals tolearn of ourexperience in EFQMand management byprocesses

- Support for 4 research projects into management, and consensus in the externalassessment of 2 organisations.- Training seminars with 5 institutions (Universidad Complutense de Madrid,Cámara de Comercio, H. Monte Naranco and 2 others).- Publication of articles in various publications such as Osteba, Qualitas Hodie,Diario Médico, Spanish Healthcare Quality Magazine, etc.

2000

- Attendance at 3 Congresses, giving 5 talks,papers and workshops (Congress on Qualityin Healthcare, Seminars on Healthcare Costs,etc.)

- Visit to ZH of MTs of5 organisations toshare our experiencein management(Euskalit, Danobat ,Oncological Instituteof Catalonia, etc.)

- Support for 6 R&D projects on Quality Management Systems (Primary HealthcareResearch Fund for process mapping, Escuela Andaluza de Salud Pública,adaptation of the Latin American Model of Excellence, a Think Tank from theSpanish Ministry of Health, etc.).- Training in management and Quality given in 9 centres (Hospitals, University ofthe Basque Country, Tarragona Regional Council, Escuela Andaluza de SaludPública, etc.).- 2 publications on TQM

2001

- National Congress of Hospitals, on theoccasion of being awarded the Golden HelixPrize.- Healthcare Quality and ManagementCongresses, giving a total of 8 talks andpapers.- Workshop on Management By Processes inthe International Congress of Quality inHealthcare.

- Visit to ZH of 6organisations to learnof our managementsystem and share ourexperiences (La FeHospital, FundaciónMatía, UniversidadCatólica de Chile,etc.)

- Dissemination of our EFQM-based submission document to 140 centres.- Dissemination of ZH management tools (People and Primary Healthcaresatisfaction surveys, process documentation and map, etc.) to over 20organisations.- Continuous tutoring for 2 centres on how to write an EFQM-based submissiondocument.- Training workshops in 14 organisations in the healthcare, business and socialsectors.- Articles and collaboration in Quality and Excellence publications (adaptation of theEFQM model for the health sector, Spanish Healthcare Quality Magazine, bestpractices of the Euskalit 400 Club, etc.).- Link to the Basque Government Euskadikalitatea website.

2002

- Presentation given on the occasion ofwinning the Premio Ciudadanía 2002 Award.- Paper given in the II Meeting of ExcellenceAward Winners.- Workshop presentation, 4 papers and posterdisplay at the Congress of the SpanishSociety for Quality in Healthcare.

- Visit to ZH of MTs of6 healthcare centres(Hospital del Mar,Cruz Roja deBarcelona, Clínica LaZarzuela, etc.)

-Tutoring for 2 healthcare centres on how to write an EFQM-based submissiondocument.- Participation in the ”Guide to process-based management”, published by Euskalit.- Training workshops on the EFQM model and processes for 6 healthcareorganisations (H. Clínico de Salamanca, Escuela Andaluza de Salud Pública, H.General de Asturias , etc.).- Collaboration in publications on ISO certification and knowledge management.

2003

- 6 papers given in the Congress of theSpanish Society for Quality in Healthcare.- Presentations given at the EuropeanConference on Human Resources, a Seminaron Hospital Administration, the NationalCongress on Clinical Documentation and theNational Congress on Surgery.

Visits to ZH byManagement from 8differentorganisations.

- Use of the ZH submission document for training in 4 healthcare centres and otherhealthcare organisations.- Training in the EFQM model, TQM and management by processes in 13organisations and Regional Health Services (Autonomous Communities of Madrid,Navarre and Cantabria, the Engineering School, Hospital San Pablo, HospitalRamón y Cajal, etc.).- Dissemination of the ZH submission document, surveys and SP methodology to27 organisations.- Participation in a Think Tank with Osakidetza on Clinical Management andassessment against the EFQM Excellence model.- Preparation of training material for a Masters Course in Healthcare Management,and collaboration in 2 such publications.

2004

- 7 papers given in the Congress of theSpanish Society for Quality in Healthcare.- Presentations given at NationalSeminars, on the BSC, at the University ofZaragoza, in the Spanish Ministry of Health,for the Signo Project, at the NationalRadiology Congress, at Seminars onNursing, for the Regional Govt. of Castilla-León and at the Premio Ciudadanía Awardceremony.

Visits to ZH byManagement from 4differentorganisations.

- Training in the EFQM model, TQM, Strategy Planning, Communication,Management by Processes and Environmental Management for 14 organisationsand Regional Health Services (Autonomous Communities of Murcia, Madrid and theCanary Islands, the Spanish Ministry of Health, Escuela de Salud Publica, InstitutoCarlos III, etc. )- Participation in a Think Tank with Osakidetza on the viability of the Evalexpressystem, professional careers structures, People Management, etc.-Training in Quality and Assessment given to 200 university academics fromSpanish universities (ANECA Project)- Dissemination of the ZH submission document, surveys and SP methodology to25 organisations.- Article published in the Qualitas Hodie magazine.- Participation in the Science and Technology Plan of the Basque Government.

Figure 1c-6: EXAMPLES OF TQM DISSEMINATION ACTIVITIES



YR IMPROVEMENTS

98

Creation with Primary Healthcare representativesof the Joint Technical Committee. Focus group forformulating the survey. Distribution of surveyresults to leaders (1,3)

99

Deployment of improvement actions identifiedthrough Primary Healthcare survey (system forlocating ZH doctors more readily, assessment ofthe quality of outpatients reports) (1,5,7)Analysis of stakeholder needs with ZH leaders (1,3)ZH in-house magazine mailed to stakeholders(1,3,9)

00 Establish system for supplier recognition(preferential supplier) (1,2,3,9)

01 Replacement of Joint Technical Committee withmeetings with PHCCM (1,5)

0203

Extended range for gathering information onstakeholder needs, expectations andperception, through surveys on suppliers, TownCouncils, Health System and otherorganisations (1,2,3,6,9)

1. Assessment by MT2. Assessment by PL3. EFQM assessment4. People’s Voice5. Primary HealthcareVoice6. Customer, Supplier,Health System andSociety Surveys7. TechnicalCommittee8. Training9. Benchmarking10. Innovation CapitalModel

04 Greater range of participative contact withSociety, and ISO 14001 Certification (1,2,3,6,9)

Figure 1c-7: EXAMPLES OF IMPROVEMENT CYCLES RELATED TO 1c1d.LEADERS REINFORCE A CULTURE OF EXCELLENCEWITH THE ORGANISATION’S PEOPLE

The measures taken and developed in ZH with respect to this sub-criterion must be understood within the framework of constraints

described in crit. 3. Although all ZH systems must be coordinated andinterlinked to ensure our people are motivated and cared for, foursystematically managed factors have been identified as key in this area:

empowerment, communication, training and recognition. All four factorstogether provide a synergy through which to deliver the hospital’s goals.The leaders involved in the day-to-day activities related to these factorshave been selected for their operational efficiency in these areas. TheCE and MT provide guidance, and define and deploy the plans whichenable us to deliver and assess these factors. Deployment at Unit levelis the responsibility of Unit Heads. Process teams and leaders managecontinuous improvement and encourage their team members toparticipate in continuous improvement.

Figs. 1d-1 to 1d-4 show the main channels used to develop each of thesefour factors, the role of ZH leaders in this respect, which leaders areinvolved, who is affected by this and the sub-criteria of this submissiondocument in which these points are detailed. The MT provides coordinationand support for the management system and for all other ZH leaders.Empowerment: Devolved responsibility and self-direction are strongmotivational tools systematically used in the hospital and coordinatedthrough our system of management by processes (crit. 3).Communication: The “open doors” policy, by means of which all ourpeople have direct access to any leader, and the communication plans andchannels systematically developed in the hospital since 1999 are the maintools used in this area (crit. 3).Training: Training, both for specific job skills and in relation toimprovements in management, is a basic pillar of our organisation. Thetechnical development of ZH people is a stated element of our Vision (Fig.1a-1). Training and personal tutoring are therefore key elements ofleadership widely deployed throughout the hospital (3b, 4e).Recognition: Recognition at an individual and Unit level takes many forms(3e). The role of leaders is to be aware of the efforts and achievements ofour people and to recognise them accordingly.

EMPOWERMENT

HOW LEADERS’ ROLE LEADERSINVOLVED

PEOPLEAFFECTED REF.

Hierarchicalempowerment

Leaders devolve responsibility and decision making powers through the command chain, e.g.establishing BP action plans, changes in shift scheduling, recruitment, HR budgets and thedesign or modification of services.

MT and UnitHeads All

Overview3a, 3c, 4b,

4cMT appoints PLs as a systematic element of empowerment for the continuous improvement ofprocesses. MT PLs

All processesManagement byprocesses In turn, PLs empower their process team members, and describe, design, assess and improve

their respective processes. PLs All5a, 5b

Clinical self-management

All leaders encourage and support empowerment in terms of decision making in the clinicalarea, for improved face-to-face patient care in healthcare processes.

MT and UnitHeads

Healthcareprofessionals (80%) 3c

Working groupsLeaders identify the need to create groups and participate actively in them, monitoring allsubsequent actions, providing the necessary resources and conditions, accepting theconclusions of the group and supporting the decisions taken (Fig. 3c-2)

MT, UnitHeads & PLs All 3c, 5a, 5b

Knowledgemanagement

Leaders stimulate and encourage people to identify their needs, and promote training and theacquisition of knowledge, taking active part in training initiatives.

MT and UnitHeads All 3b

People satisfactionsurvey

Leaders participate in the focus group for approving survey content, analyse and disseminatesurvey results and support people to achieve their professional plans, objectives and targets.

MT, UnitHeads & PLs All 7a

Figure 1d-1: MECHANISMS OF PEOPLE EMPOWERMENT DRIVEN BY LEADERS

COMMUNICATION

HOW LEADERS’ ROLE LEADERS INVOLVED PEOPLEAFFECTED REF.

General staffmeetings

The MT communicates the ZH strategic structure, goals, plans and matters of generalinterest to all ZH people in general staff meetings. MT All 2d

Meetings with Units Management and leaders meet with Unit representatives to inform them of Unitobjectives, establish action plans and comment on any relevant matters. MT and Unit Heads All 2d

Balanced Scorecards Leaders design content and layout of BSC, and assess process and/or Unit performance. MT, Unit Heads and PLs All 2d ,5b

Induction procedure Leaders inform new recruits of procedure, explain ZH goals and culture and introducethem to their immediate leaders and colleagues. MT and Unit Heads New

recruits 3a

Working groups Leaders lead, take active part in and inform working groups on all relevant matters(Fig. 3c.2). MT, Unit Heads and PLs Various 3c

Surveys Leaders take part in designing the survey system, assess and communicate theresults, identify areas for improvement and propose action plans accordingly. MT and Unit Heads All 3d, 7a

Focus groups Leaders identify the need to create a focus group, take active part in them and assessthe results. MT and Unit Heads All 3d, 7a

Social events Leaders are involved in designing, organising and setting up social events and attend them. MT, Unit Heads and PLs All 3dAccessibility All leaders are easily accessible on a day-to-day basis. MT, Unit Heads and PLs All 3d

Miscellaneous Leaders design and participate in all types of communication channels for informationof all kinds (Intranet, in-house magazine, etc., Fig. 3d-1). MT, Unit Heads and PLs All 4e

Figure 1d-2: MECHANISMS OF COMMUNICATION DRIVEN BY LEADERS

AD


TRAINING

HOW LEADERS’ ROLE LEADERS INVOLVED PEOPLEAFFECTED REF.

Continuing Training Leaders select training needs, are involved in drawing up training plans, monitor deliveryand encourage people to take part in continuing training programmes. MT, Unit Heads & PLs All 3b 4e

On-the-job training Leaders train people through knowledge sharing and training in technique as part of day-to-day working life. MT, Unit Heads & PLs All 3b 4e

Self-training Leaders encourage self-training activities for people under their charge. MT and Unit Heads All 3b 4e

Publications Leaders encourage and take active part in contributing to publications on technical andmanagement matters. MT and Unit Heads All 3b 4e

Research Projects Leaders organise, encourage and participate in research projects. MT and Unit Heads All 3b 4eClinical Sessions Leaders participate in, and encourage others to participate in clinical sessions. MT and Unit Heads Doctors 3b 4eCongresses andSeminars

Leaders participate in, advise on and encourage others to attend and present papers attechnical seminars and congresses. MT and Unit Heads All 3b 4e

Involvement inteaching

Management train other leaders and ZH people, especially healthcare professionals, inquality management tools. MT, Unit Heads & PLs All 3b 4e

ISO Certification Leaders organise, give and encourage people to take part in quality assurance training. MT, Unit Heads & PLs Various 5a 5bTutoring inmanagement byprocesses

Management train and provide personal tutoring for PLs. MT PLs 5a 5b

In-house magazine Leaders contribute to the magazine by publishing articles on quality management andhealth education. MT, Unit Heads & PLs All 3d

Figure 1d-3: MECHANISMS OF TRAINING DRIVEN BY LEADERS

RECOGNITION

HOW LEADERS’ ROLE LEADERS INVOLVED PEOPLEAFFECTED

REF.

Meetings Leaders recognise individuals and Units in various meetings. MT, Unit Heads & PLs All 3eNew appointments MT appoints PLs or assigns special responsibilities (e.g. Quality Coordinator) MT PLs 3e, 5aHierarchical Leaders recognise people for a job well done. MT and Unit Heads All 3ePromotion andAdjustment

Leaders define recognition criteria and select people for promotion and adjustmentproceedings (crit. 3). MT and Unit Heads All 3b, 3e

Timetable Leaders concede to a flexitime policy for those with a proven record ofresponsibility. MT and Unit Heads Doctors 3e

Working conditions Leaders are sensitive to the conditions in which our people work, selectingimprovement actions and encouraging their deployment.

MT, Unit Heads andPLs All 3e

Resources Leaders give preferred status for the provision of support resources and training tothose with a proven performance record, and to encourage improvement. MT and Unit Heads All 3e, 4b

Letters Leaders personally write and present ZH people with letters of recognition forpersonal or team achievement.


Congratulations The Head of Human Resources, on behalf of the MT, personally congratulates allZH people on their birthdays and on the birth of their children.

Head of HumanResources All 3e

Celebratory events Leaders organise and participate in retirement parties, events to celebrate externalrecognition and leaving parties.


Participation

Leaders identify the need to create a working group, are involved in selecting thegroup members and take active part in these groups, stimulating and encouragingpeople involvement and giving recognition for outstanding individual or teamperformance.

MT, Unit Heads andPLs All 3b

In-house magazine Leaders put forward individuals or Units for mention in the magazine, and publiclycongratulate them on receiving awards and accolades.

MT, Unit Heads andPLs All 3d

Figure 1d-4: MECHANISMS OF PEOPLE RECOGNITION DRIVEN BY LEADERS

The MT assesses and reviews the effectiveness of leadership byanalysing the results of the People’s Voice Process, of the

Communication and Training Plans and of self-assessment against theEFQM Excellence model. People satisfaction surveys include several itemswhich enable us to measure the effectiveness of our approach (Fig. 1d-5).

PEOPLE SATISFACTION SURVEY ITEMS % AGREEMENT

Leadership 99 01 03The Head of my Unit practices what he/she preaches. 48 64 78Hospital Management is receptive to staff problems. --- 38 55I have a satisfactory personal relationship with the Head ofmy Unit.

--- 79 85

EmpowermentThe Head of my Unit encourages me to stretch my decisionmaking powers. 20 38 66

The Head of my Unit encourages me to contribute ideas onhow to improve my work.

36 51 71

The Head of my Unit empowers me to take decisions. 37 63In ZH, we work largely on a consensus basis. --- 48 69My suggestions and contributions are listened to and takeninto consideration.

--- 43 63

TrainingThe Head of my Unit encourages and supports me in thearea of continuing training.

25 48 78

CommunicationThe Head of my Unit discusses with the team any projectsaffecting our Unit.

--- 52 71

The Head of my Unit encourages us to speak openly. 44 51 70RecognitionThe results I achieve are duly recognised. 17 31 48In my Unit, recognition is given for a job well done. 34 52 65

Figure 1d-5: RESULTS OF PEOPLE SATISFACTION SURVEY ITEMS

Improvements in leadership related to this sub-criterion are directlyattributable to improvements in the personal skills of leaders and toimprovements to the system itself. The sources of learning used in thisrespect are described in 1a (Training and Benchmarking). Theselearning sources, together with the study of best practices andassessment exercises, have enabled us to implement numerousimprovement actions, the effectiveness of which is shown in the resultsof satisfaction survey items (Fig. 1d-5). Examples of improvements afterassessment and review cycles are shown in Fig. 1d-6.

AR



YR IMPROVEMENTS

98

Nursing staff budget management conducted byHead of Nursing and her team (1,3)Unit leaders and people meet to discuss surveyresults (1,3,6)

99

Development of empowerment through PLs(1,3,6,7)Launching of the ZH in-house magazine (1,3,7)Training for leaders in management by processesand improvement tools (1,3,5,6,7)

00Systematic development of ISO Certification(1,2,6,7)Development of the Intranet (2,4,7)

01

Induction procedure (1,2,4)Transmission of knowledge in managementthrough the in-house magazine and throughtraining in 5S (1,5,6,7)

02 Appointment of Certification Coordinators andtraining in quality (1,2,3,5,7)

03 Involvement of 5 ZH employees in internal auditsfor ISO 9001:2000 Certification (1,2,4,7)

1. Assessment by MT2. Assessment by PL3. EFQM assessment4. People’s Voice5. Training6. External experts7. Benchmarking

04 Creation of 4 process teams, and training in highperformance team management (1,3,6,7)

Figure 1d-6: EXAMPLES OF IMPROVEMENT CYCLES RELATED TO 1d.1e. LEADERS IDENTIFY AND CHAMPION ORGANISATIONAL CHANGE

Changes to the ZH management system and to processes, gearedtowards adapting our operations to current and future stakeholder

needs and to improved delivery of our Mission, is a pivotal aspect of ouractivity. Similarly, commitment to innovation is one of the stated values ofour corporate culture (1a-1). In this respect, change management and theinvolvement of leaders in it has been a distinguishing factor of ZH. Changeis managed as shown in Fig. 1e-1.Identification of change: The changes required in the hospital, in ourmanagement system and in our external relations were previously identifiedthrough various information sources, through changes in technology, resultsassessment, assessment against the EFQM model, the requirements ofOsakidetza, etc. Nowadays, the need for change is centred around thedemands of the SP and identified through strategic analysis and the drawingup of ZH strategies. For example, the implementation of management byprocesses was derived from an area for improvement included in an EFQMexternal assessment feedback report. Similarly, through SWOT analysisconducted as part of SP review, we concluded it was necessary to conductan in-depth review of our management by processes system in 2004.

Nowadays, the sources of information used to understand the internaland external drivers of change in the hospital, and to anticipate currentand future stakeholder needs, are those described in 2a & 2b.

Figure 1e-1: FLOW DIAGRAM OF CHANGE MANAGEMENT

Prioritisation: Many of the changes which take place nowadays inZH are decided against business criteria, i.e. on the basis of theircapacity to deliver business objectives, and are therefore prioritisedon the basis of the strategic structure of the hospital and SWOTanalysis (2c). The Continuous Improvement Process (1b) and keyprocess management (2c) are complementary guides to selectingchange. On the other hand, some changes which take place in ZH aremandatory, either by law or through instructions received from the

Dept. of Health or Osakidetza , and these changes affect all networkcentres. In some cases, ZH has driven pilot change in Osakidetza andin the Spanish Public Health System (ISO certification, assessmentagainst the EFQM Excellence model, etc.). Both types of change areprovided for in ZH planning.Planification: On the basis of the definition and deployment of the SP,change is managed in two ways:

a) Changes affecting one process only, or those changes with lowlevel repercussion in the hospital, are developed through processes andmanaged using PDCA cycles (crit. 5).

b) Changes affecting many processes, changes requiring a longimplementation time and a lot of resources and breakthrough changeare managed as a unitary project. In this case, a global analysis is madeof the variables affecting change (people, customers, technologies,etc.), the effect of this change on the organisation is calculated usingspecifically conducted SWOT analysis, the potential risks involved areevaluated and the ensuing project is designed.

Change project planning entails investment, the provision of financialresources, whether specific information and training are necessary forZH people and assessment tools to measure the effectiveness andimpact of the change. Through applying the EFQM Excellence model,we have discovered the benefits of using partnerships to implementcertain change projects (Gesco, Elirecon, UNICEF, etc.) and ofnetworking with other centres suffering similar problems to ours to learnfrom them prior to implementing change (Euskalit, 400 Club,benchmarking activities, etc.) (crit. 4).Development, management and monitoring of change: After theplanning stage, change is implemented through:a) Processes, following the system described in 5a & 5b. Theeffectiveness of change is monitored by PLs through process indicators.b) Projects, led by the PLs involved or by the MT, depending on thesignificance of the change for ZH. In cases of breakthrough changeaffecting the whole management system, e.g. management byprocesses or strategic planning, a team is formed of ZH leaders whowork alongside the MT to implement and monitor the change. In 2004,as a direct result of benchmarking Excellence organisations and themanagement systems of our partners, a new methodology for managingand monitoring projects was introduced in the hospital. This newmethodology reinforces the participation of our people, puts greateremphasis on scheduling the different project phases and on theprogressive delivery of project objectives.

Leaders take on a facilitator role in their teams to develop changeplans, acting as role models and becoming personally involved inchange management, i.e. preparing plans, analysing information onother organisations, reporting on developments to all affected people(3d) and stakeholders, securing the necessary investment, resourcesand training (4a, 4d & 4e), supporting and enabling those under theircharge, continuously monitoring the results of the change and takingcorrective action where necessary.Assessment: Changes are assessed through process and projectindicator monitoring, both in terms of their effective delivery and of theperceived quality of the change (through customer, people and Societysatisfaction surveys). These follow up activities enable us to establishappropriate corrective actions where variance from objectives isdetected. Change projects are considered to have been completedwhen the change involved has been fully integrated into the everydaymanagement dynamic of the hospital.

Fig. 1e-2 shows a selection of change projects conducted by ZH inrecent years.

Assessment and review of the effectiveness of leadership inthis area, both in terms of the exercise of leadership and of

the effectiveness of the system itself, are based on survey results(customers, suppliers and Society), indicator trends (9a & 9b),assessment against the EFQM model and on qualitative assessment bythe MT and, when applicable, support teams. These mechanismsenable us to measure and review the effectiveness of changes, and toshare the knowledge gained. Some of the projects undertaken by ZH

A

DAR

IdentificaciónIdentification

Prioritisation

Planning

Management (development & monitoring)

Assessment


have received external recognition (Management by Processes, theBaby Friendly Hospital Initiative, Environmental Management). Suchaccolades serve to confirm the appropriacy of the projects, and put us ina role model position for other organisations.

The people satisfaction survey contains a series of items whichenable us to broadly measure the degree of satisfaction of our peoplewith innovation and change. Results trends in this area are a measureof the effectiveness of our approach. The 2003 survey contained 11specific items on the management of change in ZH (Fig. 1e-3).

% A GREEMENTPEOPLE SATISFACTION SURVEY ITEM

99 01 03

Average score for items on Innovation - 63 74Organisation, leadership and people management in ZHhave improved.

- - 72

Figure 1e-3: RESULTS OF PEOPLE SATISFACTION SURVEY ITEMS

Quantitative and qualitative analysis by the MT of survey results (6a,7a & crit. 8) and suggestions, and the lessons learnt in this area have

enabled us to improve our approach. Examples of improvements aftersuccessive assessment and review cycles are shown in Fig. 1e-4.


YRIMPROVEMENTS

99 Creation of a support group of professionals forthe Management by Processes Project (1,3,5,6,7)

00 Systematic use of surveys to identify changes thatneed to be made (1,3,4,5,6).

01 Change Project documentation (Baby FriendlyHospital) (1,2,4,5,6).

02Assessment and selection (by a support group ofprofessionals) of areas that need to be changed inrelation to formulating the SP (1,4).

03

Use of the SP as the basis for selecting andmanaging change projects (1,2,3,4,6,7).Programming of Innovation Management usingthe Innovation Capital Model (1,7,8).

1. Assessment by MT2. Assessment by PL3. EFQM assessment4. Customer, People’sand Society Voice5. Training6. External experts7. Benchmarking8. Innovation CapitalModel

04 Introduction of a new methodology for ProjectManagement (1,6,7,8).

Figure 1e-4: EXAMPLES OF IMPROVEMENT CYCLES RELATED TO 1E

Change Identification Prioritisation Planning / Management Assessment

Laparoscopy Changes inTechnology Strategy Line

Scheduling, training and progressive implementation throughout theSurgical Unit of laparascopic (keyhole) surgery techniques, subsequentlyadopted in all other specialist areas.

Worldwidereference ingastric surgery

Aldabide Osakidetza Corporative Breakthrough change in financial management system and IT support (SAP).Training for ZH people and investment in technology throughout the hospital.

Implemented andin use

Gizabide Osakidetza Corporative IT support for HR administration. Training for Unit Heads throughout thehospital, and investment in technology.

Implemented andin use

Security ofInformation Osakidetza Legal Adaptation of ZH IT systems to data protection requirements. Currently being

implemented

qZ+ Project SP/PartnershipsContinuousImprovement(Partnerships)

Research Project conducted with the IT Faculty of the University of theBasque Country, to develop an IT application for management byprocesses in the hospital.

Currently beingimplemented

PCH (IT application) SP SP 2003-07Computerisation in Outpatients and A&E, with online connection to otherdiagnostic areas to improve the availability of clinical data. Requirestraining and investment.

Indicators (%implementation)

Tech

nolo

gica

l

Patient Security SP/Benchmarking SP 2003-07

National Multi-centre Research Project (Health Research Fund) toimplement systems aimed at increasing the sensation of security forpatients under healthcare treatment.

Currently beingimplemented

Extension ofSurgical Unit, DMSH& LSRU

SP/Osakidetza SP 1997-2000Extension of an operating theatre, and the setting up of a new DMSH andLSRU with increased provision of service in response to healthcaredemands.

Facilities installed

Extension ofHaemodialysis Unit

Serviceimprovement Key processes New location, increased service and provision of state-of-the-art technology to

be able to provide treatment for all patients in our catchment area. Facilities installed

Safety Plan Osakidetza/SP SP 1997-2000Corporative

Project for the progressive adaptation of the ZH building and facilities tosafety standards. Training throughout the hospital and investment. Safety Plan

Infr

astr

uctu

re

Removal ofarchitectural barriers SP

ContinuousImprovement(Partnerships)

Project for the progressive adaptation of ZH facilities for use by all citizens,conducted under guidance from Patients’ Associations (4c). Ongoing

Assessment againstEFQM model Osakidetza SP 1997-2000

Use of the Excellence model in self-assessment and improvement cycles,external assessment (pioneer initiative in the health sector) anddissemination of submission document in health and business sector (1b,1d,8,9).

Silver Q forQuality (2000) &Gold Q for Quality(2003)

Management byProcesses EFQM Continuous

Improvement

Pioneer Project in the health sector to implement an integral system ofmanagement by processes in a hospital. Second phase of in-depth systemreview undertaken in 2004 (crit. 5).

System reviews(5a & 5b)

Baby FriendlyHospital Partnerships SP 2000-03

Specific project led by the MT and PLs, documented and programmedover 2 years with improvements to healthcare processes (increased breastfeeding), ZH infrastructure and equipment (5d & crit. 8).

Baby FriendlyHospital Award(UNICEF)

ISO Certification SP/Osakidetza SP 2003-2007 Introduction of ISO certification as support for management by processes,and pilot implementation in healthcare processes (5a & 5b).

14 processescertified

Strategy Planning SP/EFQM SP 2000-03Project to implement the BSC and advanced methodology of strategyplanning, with the participation of 80 ZH people and the support of a teamof professionals for deployment of the project (crit. 2)

Assessment ofSP

EnvironmentalManagement SP

ContinuousImprovementSP 2003-2007

Multi-phase project (waste management, IHOBE diagnosis, environmentalmanagement), with specific documentation and changes to theorganisation, to processes, in infrastructure and in equipment (4d).

Waste PlanISO 14.001

Man

agem

ent S

yste

m

Innovation CapitalModel

SP/Benchmarking

Pioneer use of the Innovation Capital Model in business organisations(through the 400 Club), and adaptation of the Model for use in healthcareorganisations.

Model developed(MIOS)

Figure 1e-2: CHANGE PROJECTS IN ZH

Zumarraga Hospital - Hospital de Zumarraga 1

OVERVIEWThe remit of Osakidetza (The Basque Health Service), an adjunct of the

Basque Government Dept. of Health with its own independent legal status,is to provide healthcare to the people of the Basque Country. Theorganisational structure of Osakidetza consists of a Governance Board, thecentral organisation itself (administration and corporate management) andthe healthcare organisations providing services under the principles of self-management. These healthcare organisations are fundamentally of twotypes; Primary Health Care Centres and Specialised Healthcare Centres,and Zumarraga Hospital is classified under the second category. All thoseresiding in the Autonomous Community of the Basque Country have theright to public healthcare provided under principles of unity, universality,equal opportunity and solidarity.

Zumarraga Hospital (ZH) therefore forms part of this Basque publichealth service network, providing specialised healthcare for a populationof over 90,000 people resident in the Goierri and Urola Valleys in theBasque Country province of Gipuzkoa (crit. 1, Mission). After severalyears of public demand, the hospital was opened in 1984 by Insalud (TheSpanish Ministry of Health), with a staff of 250 healthcare professionalsproviding Accident and Emergency (A&E), Maternity-Postnatal, InternalMedicine, Surgical, Orthopaedic and Diagnostic services. ZH was the firstregional hospital to open in the province of Gipuzkoa.

In 1988, the hospital came under the governance of Osakidetza, afterfull competencies in health matters were transferred from the SpanishState to the Basque Government. Since then, the hospital has evolvedand increased the quantity and quality of its portfolio of services toprovide better healthcare for the population.

80% of the people within the hospital catchment area are concentrated inthree urban areas, namely Zumarraga-Urretxu-Legazpi, Beasain-Ordiziaand Azpeitia-Azkoitia. The remaining 20% are scattered over 17 ruralmunicipalities and farmhouses. Healthcare provision in our area consists ofa Primary Healthcare network of 71 doctors (44 General Practitioners, 11Paediatricians and 16 Accident and Emergency doctors) working in a total of18 Health Centres, two of which are purely for Outpatients. Thesehealthcare professionals refer their patients to us if they consider theyrequire specialised care, and we therefore consider these patients as ZHcustomers (crit. 2, 5 & 6). Patients can also come directly to the hospitalthrough the Accident and Emergency (A&E) Service.

The hospital itself is one large building (12,935 m2) divided into threeinter-connected wings. Since 1990, ZH healthcare professionals attendoutpatients and physiotherapy clinics in the Health Centres in the townsof Beasain, Azpeitia and Zumarraga. In this case, the objective is tomake these services more easily accessible for local inhabitants, andthese services are also considered as ZH services.

The hospital and its facilities have been modified and improved over theyears in response to changing healthcare and hotel/catering requirements.ZH has 4 Inpatient Units with a total of 106 beds, a Short Stay Unit with 12beds, a Medical/Surgery Day Unit with 8 beds (no overnight stay) and a LifeSupport/Resuscitation Unit with 8 beds for intensive care. ZH facilities alsohouse a Surgical Unit with four operating theatres and a delivery room, 39outpatient examination and medical diagnosis rooms, a physiotherapygymnasium, a body of Central Services (Clinical Analysis, Radiology,Anatomical Pathology, Haemodialysis, Pharmacy, etc.) and support services.

98% of hospital funding is through the Programme Contract (PC)agreed with the Department of Health, whilst the remaining 2% comesfrom Private Medical Insurance Associations or Insurance Companies.No distinction is made in terms of the healthcare offered ( 9a & crit. 4).

ZH currently offers the following specialist services:INTERNAL MEDICINEALLERGOLOGYCARDIOLOGYDERMATOLOGYGASTRO/INTESTINALENDOCRINOLOGYHAEMOTOLOGYNEPHROLOGY

RESPIRATORYNEUROLOGYRHEUMATOLOGYPAEDIATRICSGENERAL SURGERYGYNECOLOGYOBSTETRICSOPHTHALMOLOGY

EAR, NOSE & THROATORTHOPAEDICSUROLOGYANASTHETICSREHABILITATIONRADIOLOGYCLINICAL ANALYSISANAT. PATHOLOGY

Figure 0-1: PORTFOLIO OF SERVICES

At the current moment in time, 453 ZH people are working as a team todeliver the hospital’s goals and objectives: (Doctors: 93; Nursing staff:255; Administrative staff: 54; Miscellaneous: 46; Management: 5).

ZH employees are mostly women (76%), have an average age of 40.5and over 65% of them have a permanent contract. Employment in ZH isof administrative status, more akin to that of local government workersthan an employment contract, with all the implications that this conditionconfers. Despite this, the ZH management system and the commitmentof our people to continuous improvement both encourage and ensurethat the degree of people involvement is very high.

Facilities management (catering, cleaning, laundry, gardening,messaging and security services) is outsourced. The hospital’s servicesare, for the main part, distributed as follows:

SERVICEInvoicing as per PC2004 (thousands of

euros)% invoicing Attendances

/ year

Inpatients 15,899 61 7,300A&E 2,239 8 31,000Outpatients 6,259 24 40.000Haemodialysis 1,272 5 40Physiotherapy 671 2 2,000Figure 0-2: SERVICE LINES, INVOICING AND ATTENDANCESZH is a teaching hospital for family doctors. We also collaborate in

practical training activities for a number of professional collectives (crit. 4 & 8).Governance by Osakidetza provides several major competitive

advantages, such as prestige, culture and strategy lines, the joint use ofdifferent types of tools and the encouragement and support offered tous by the Basque Health Service. Knowledge transfer and participationin working groups composed of people from different health centres ofthe network represent a continuous and invaluable source of learning.

The changes which the Basque Health System has undergone inrecent years have made Osakidetza a focal point of reference for theSpanish National Health Service and for Basque society, as its qualityratings are best-in-class on a national scale (for example, waiting listtime). Key milestones towards this situation have been:- Osasuna Zainduz: strategies of reform for the Basque Health Service,with three lines of action; 1) Total Quality, 2) Separation of funding(Department of Health) and provision of services (Osakidetza), with theProgramme Contract as a regulatory tool, and 3) Closer relationsbetween clinical and management cultures.- Healthcare Act: constitution of Osakidetza as a Public Body subject toPrivate Law, bringing about a greater degree of autonomy inmanagement terms for Health Centres.- Development of new IT software and tools to support management(Gizabide, Zaineri, other Information Systems, etc.)- 2003-2010 Health Plan: in which the health needs of the populationand action strategies are developed.

The Chief Executive (CE) has overall management responsibility. Thebody with decision-making powers is the Management Team (MT),composed of the CE and four other members. The Steering Committee (SC)is composed of the MT, the Assistant Head of Nursing, the ManagementSecretary and the Certification Coordinator, these last three people havingbeen incorporated into the team in 2004. As a direct consequence of the ZHculture of teamwork, most daily strategic and management decisions aretaken by consensus. The organisation chart (Fig. 0-3) shows howinformation is cascaded through the different hierarchical levels.

The period 1984-1992 was a period of consolidation for the hospital’sstructure and staff. The command chain was hierarchical, and thecentre was organised through services and Units. Quality was primarilyseen and understood from a technical-clinical perspective, andcoordinated through committees.

There have been various stages on our path towards Total Quality. In1992, the Osakidetza Integral Quality Plan was a driver of change and areference framework for the hospital, and in 1993, the ZH Quality Planwas formulated. This Plan, in addition to containing the first draft of theMission, established customer satisfaction, ensuring technical quality

Zumarraga Hospital - Hospital de Zumarraga 2

and avoiding non-quality as basic strategy lines. The Central QualityCommittee was formed to promote, together with Management, stafftraining in quality management tools and to develop indicators, actionlines and operational protocols.

Figure 0.3 ZH ORGANISATION CHARTIn 1996, ZH management commitment to Total Quality became

unequivocal, and we adopted the European Business Excellence modelas a reference framework. Training was undertaken in the model, andthe first self-assessment exercise was conducted in 1997, as a result ofwhich a Strategic Plan was drawn up (including a Mission statement)and the first people satisfaction survey was conducted.

In 1998, as a direct consequence of the second self-assessmentexercise, the MT began to look into management by processes as aworking methodology which would create a quality culture in the hospitaland increase people participation and hospital efficiency. Although thiswas unprecedented in the Spanish Health Network, this methodologywas adopted the following year as a quality management system. ThisProject was led by the Chief Executive and the MT (crit. 1 & 5).

Management by processes was chosen as a continuous improvementproject to make it easier for people to understand and appreciate whatneeds to be improved, to increase their involvement, to empower themwith the appropriate tools and decision making powers, to bring aboutgreater hospital/people synergy and to globally increase the efficiency ofour services. This system has been further enhanced through the use ofa robust system for planning and deployment, and through thedevelopment of multiple channels for gathering stakeholder information.In turn, this has enabled us to harness the natural leadership potentialof our people and fully engage their commitment and knowledge ofquality management. Additionally, management by processes hasproved an excellent tool for disseminating the ZH Mission, Vision andstakeholder needs. The concept of quality is integrated with that ofmanagement, and learning and continuous improvement have beenestablished as the day-to-day culture of the hospital.

The ZH management culture and how it has been developed, theintensive use of innovation and benchmarking and the involvement ofour healthcare professionals are all factors which have contributed tothe hospital’s prominent position in terms of results. These same factorshave also enabled us to pioneer the use and development of variousmanagement tools, and to be seen as a reference in the field of qualitymanagement. Since 2000, ZH has been recognised for itsachievements in the field of management more than any other hospitalin the Spanish Health System.

This EQA submission document, like the previous 3 used forassessment against the model, is seen by us as another source oflearning and continuous improvement, another step on our path towardsExcellence. The document has been drawn up by the MT and a groupof ZH healthcare professionals.

Key milestones in the development and improvement of the ZHmanagement system are shown in Fig. 0-4.

KEY MILESTONES IN MANAGEMENT & TOTAL QUALITY1992 - Osakidetza Integral Quality Plan

1993

- ZH Quality Plan (Total Quality)- Definition of ZH Mission- Central Quality Committee- Osasuna Zainduz document (strategy to reform the Basque

Health Service)

1994 - Satisfaction surveys for customers to fill out themselves- Training in Quality Management

1995 - First Programme Contract

1996- Decision to adopt the EFQM Excellence Model and training

to undertake self-assessment- Formulation of the 1997-2000 Strategic Plan and Mission

1997

- Healthcare Act- First self-assessment against EFQM Excellence model in ZH- Application of QFD in Accident and Emergency Unit- Customer satisfaction surveys by telephone- First people satisfaction survey- Staff training in quality management tools

1998

- Constitution as a Public Body subject to Private Law- Second self-assessment against EFQM Excellence model- Primary Healthcare satisfaction surveys- Review of the Strategic Plan, and formulation of the

Business Plan.- Improvement teams- Scheduling of management by processes

1999- Review of the Mission, and definition of corporate values.- Leadership and people satisfaction survey- Development of management by processes- ISO 9000

2000- Review of management by processes, and Business Plan

integrated into processes.- Preparation of submission document for assessment against

EFQM Excellence model (Silver Q Award, > 401 points)

2001

- Formulation of Vision- Global environmental diagnosis of the hospital (Ekoscan)- People Satisfaction survey- Golden Hélix Award- Baby Friendly Hospital Initiative Accolade (UNICEF)

2002

- Development of Goals and CSF- ISO Certification Project (16 processes)- Primary Healthcare, Society and Supplier satisfaction surveys- Second external assessment against EFQM Excellence

model (> 451 points)- Ciudadanía Award

2003

- Innovation Capital Model- ISO 9.000 and 14.001 Certification Project- 2003-2007 Strategic Plan- External assessment against EFQM Excellence model (Gold

Q Award, > 501 points)

2004

- Process teams- Internal customer surveys- Balanced scorecard- Training in teamwork- Evalexprés self-assessment (crit. 1)- ISO 14.001 Certification- Review of the management by processes system

Figure 0-4: MILESTONES IN ZH MANAGEMENTOur commitment to Total Quality and the path towards Excellence are

ever-present in our work. The end goal is seen as continuousimprovement in all areas of our organisation, especially in ourcontribution to social welfare through the provision of healthcare to ourcustomers.

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