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EFQM in the Basque Health Service

Country: 
Spain
Partner Institute: 
University of Barcelona
Survey no: 
(13) 2009
Author(s): 
Gen Badia, Joan
Health Policy Issues: 
Quality Improvement
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? yes yes yes no yes yes yes

Abstract

Since 1995 the Basque Country has gained experience with the implementation of the European Foundation for Quality Management (EFQM) excellence model. Until 1999 only self-assessment was done. Since 2000, the most advanced organizations concluded external evaluations and have achieved quality awards from the Basque governement. A change in government - a new non-nationalist party took office in May 2009 - may threaten the continuity of this successful program.

Purpose of health policy or idea

The purpose of the Basque Health Service is to provide healthcare services to the population under the principles of universality, equity, solidarity, efficiency and quality. Since 1995 and due to a movement towards integral quality promoted by the Basque Government, the Basque Health Service began to work with the European Foundation for Quality Management (EFQM) excellence model. Since 1998, total quality became a target objective in the pluriannual management plans for both the Health Service as a whole and its 31 organizations individually. Until 1999 only self-assessment was done. Since 2000, the most advanced organizations concluded external evaluations and have achieved quality awards from the Basque governement.

A new non-nationalist government took office in May 2009 after 30 years of the Basque Nationalist Party in power. The change may threaten the continuity of this successful program.

Main points

Main objectives

To promote quality in the Basque Health Service as a whole and in its 18 hospitals and 309 health centers through the use of the EFQM excellence model and its underlying tools.  

Type of incentives

An alliance between the Basque Health Service and the Basque Foundation for Quality Promotion, a public non-profit organization, organized a comprehensive training program for the health service personel.

Inside the Health Service, a Department of Care Quality was created in 1992. Individual organisations have also been progressively endowed with quality technicians and administrative resources. All of them have contributed to develop different tools which have facilitated the implementation of the EFQM model. Such tools are: surveys on customer satisfaction, coporate surveys to measure motivation and personnel satisfaction in healthcare organizations, indicators of patient's safety, accessibility and effectiveness of care, as well as guidelines adapting the EFQM model to the healthcare setting.

A specific training program on leadership in quality has been offered to directors.

Quality management was included in the strategic planning of the Basque Health Service for 1998-2002  and 2003-2007.

Iinvolving clinical personnel in management by the implementation of clincial management contracts in many healthcare services.

A new payment system for healthcare professionals established at the national level allowed to economically recognise personal contributions to quality improvements in the service.

Efforts have been made in the following resources area: optimization of material resources, improvements in information system technologies, implementation of health technology assessment systems, and support of healthcare research and knowledge.

A standard map of processes and the "key processes" for different healthcare organizations (hospitals, health centre, psychiatric centres, etc), were defined and a simple methodology to apply this approach in health centers.

ISO 9001:2000 certification has been promoted. Different programs were launched for improving main clinical processes. In association with groups of clinical leaders, clnincal guidelines have been developed, as well as standards and indicators on the quality of services. Some of these indicators have been incorporated into the clincial management contracts of healthcare services and are currently considered contractual requirements to receive public funding.

Groups affected

The Basque Health Service, 31 health care services organisations that manage 18 hospitals, 309 health centers, 28 mental health centers, 24,000 people working in these organisations and 2,200,000 inhabitants in the Basque Country

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Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual rather consensual highly controversial
Structural or Systemic Impact marginal fundamental fundamental
Public Visibility very low high very high
Transferability strongly system-dependent system-neutral system-neutral

The implementation of the quality management policy into every healthcare service in the region and its continuity in the time makes the Basque experience unique. The experience proves that it is possible to implement quality management in the public sector if quality becomes a real commitment of the healthcare managers. Support and training from the Basque Foundation for Quality Promotion has also been essential.

Political and economic background

The Basque Country is a Spanish Region with full autonomy in health since 1987. The Basque Country has the highest per capita health expenditure rate among the Spanish Regions. The Basque Nationalist Party had been in power in the regional government with different coalitions during the last 30 years. Nevertheless the current coalition lost the last election and a new coalition of the Socialist and the Conservative Spanish parties has taken office on May 5, 2009. Until then, the continuity of the government allowed the development and the implementation of the long term policy on quality of care.

Change of government

For the first time the Basque Nacionalist Party has not been able to make it into government. The change of governement might influence the future of the policy of promoting total quality through the EFQM model

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? yes yes yes no yes yes yes

Origins of health policy idea

Since 1995 and due to a movement towards integral quality promoted by the Basque government, the Basque Health Service began to work with the EFQM model. Since 1998, total quality became a target objective in the pluriannual mangement plans for both the Health Service as a whole and its 31 organizations. 

Initiators of idea/main actors

  • Government
  • Providers

Approach of idea

The approach of the idea is described as:
renewed: The achievements are based on the continuity and the consistence of the management policy during the last 14 years.

Innovation or pilot project

Local level - Some health centers and some services of the region are used as benchmarks. In 2004 10 achieved a EFQM score higher than 400 points (silver award of the regional government) and 2 scored over 500 (Gold award of the regional government)

Stakeholder positions

The process has been implemented in a clear top down policy. The government through the Basque Foundation for Quality Promotion and the Health Services published the policy paperrs, the guidelines for evaluation, trained health professinals and evaluators, caried out external evaluations and offered the awards.  

Actors and positions

Description of actors and their positions
Government
Basque Health Servicevery supportivevery supportive strongly opposed
Basque Foundation for Quality Promotionvery supportivevery supportive strongly opposed
Providers
Hospitalsvery supportivevery supportive strongly opposed
Primary care centresvery supportivevery supportive strongly opposed

Influences in policy making and legislation

The process is a management strategy without changes in legislation.

Actors and influence

Description of actors and their influence

Government
Basque Health Servicevery strongvery strong none
Basque Foundation for Quality Promotionvery strongneutral none
Providers
Hospitalsvery strongstrong none
Primary care centresvery strongstrong none
Basque Foundation for Quality PromotionHospitals, Primary care centresBasque Health Service

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

Currently 89% of hospitals carried out a self assessment and 28% received an external audit. 100% of primary care areas have fulfilled a self assessment and 14% got an external evaluation. 128 services got the ISO certification for health centers.

Monitoring and evaluation

Despite the EFQM being a non-health specific open questionnaire, the Basque Health Service developed guidelines to adapt the use of the methodologies related with different criteria of the EFQM model to the healthcare setting. At the same time, corporate surveys for patients in different healthcare settings are periodically administered, as well as surveys for professionals aimed to measure motivation and satisfaction with the organization. The Health Service also periodically monitors corporate indicators and standards of patients' safety, accessibility to the service and performance effectiveness for the health centres follow-up and benchmarking.

Results of evaluation

Among the Spanish regions consumer surveys, the Basque country ranks first in "satisfaction with the information provided", second in "satisfaction with the healthcare system", and third in agreeing that "the primary care services and the spezialised care improved in recent years". Health Indicators improved since the year 2000. The mean consultation time in primary care increased from 7.4 minutes to 8.5, the length of stay in acute hospital beds sank from 6.1 to 5.9 days and the mean delay in surgical wainting lists decreased from 57.1 days to 53.8 days.

Expected outcome

The policy proved its acceptability among the providers, mostly public, of the Basque Country Health Services. Evaluations show its positive impact on the health service performance and in patient's satisfaction.

The continuity of the management policy is the most impressive aspect of the experience. It is difficult to maintain a global quality management policy for several years inside a public non-competitive health service. In Spain a change in the regional government means a change of the top level Health Service general managers and also a change of many directors of Hospitals and Health Centers. The recent political change is a real threat for the continuity of this successful project.

Impact of this policy

Quality of Health Care Services marginal rather fundamental fundamental
Level of Equity system less equitable four system more equitable
Cost Efficiency very low high very high

Evaluation shows that the experience positively influenced the performance of every healthcare center and improved patient and professional satisfaction as well as performance indicators.The EFQM model has been a useful tool for the  cultural change towards a total quality management strategy in the healthcare services

References

Sources of Information

  • Sánchez E, Letona J, González R, García M, Darpón J, Garray J. A desriptive study of the implementation of the EFQM excellence model and unferlying tools in the Basque Health Service. Internationa Journal for Quality in the Health Care; 2006;18:58-65
  • Arcelay A, Sánchez E, Hernández L, Bacigalupe M, Letona J, González RM, Martínez Conde AE. Self-assessment of all the health centres of a public health service through the European Model of Total Quality Management. International Journal of Health Care Quality Assurance. 1999;12:54-59 
  • Basque Foundation for Quality. Euskalit. /www.euskalit.net/ingelesa/indexingles.htm. Accessed March 2009.

Author/s and/or contributors to this survey

Gen Badia, Joan

Suggested citation for this online article

Gen Badia, Joan. "EFQM in the Basque Health Service". Health Policy Monitor, May 2009. Available at http://www.hpm.org/survey/es/a13/4