Transforming a healthcare organisation from good to excellent is not easy. If it were easy, every organisation would be great for treating all patients’ population, and as we know, few are. Most healthcare organisations are very good, but very good isn’t good enough. We don’t accept airlines being 99.99 per cent accident free in their landings, and we can’t accept that in healthcare either. The Institute of Medicine’s To Error Is Human report estimated as many as 98,000 people die in U.S. hospitals each year as a result of medical errors. The Centers for Disease Control and Prevention (CDC) has estimated for every person who dies from a hospital error or an infection, five to 10 others suffer a non-fatal infection. The Institute estimated the cost of all these medical errors at over US$20 billion annually. “With approximately 33.3 million hospitalisations in the U.S. each year, that means as many as 88 people out of every 1,000 will suffer injury or illness, and perhaps six of them will die as a result.”
Healthcare safety expert Lucian Leape compares the risk of entering an American hospital to that of parachuting off a building or bridge. The costs and frequency of the unintended harm and unnecessary death are unacceptable. The good news is analysis of the consistent application of best practices demonstrates that if the best science based medical practices were consistently followed, 80 to 90 per cent of these adverse events could be prevented. In my personal training practicum attended in Singapore in 2008 conducted by the Joint Commission International (JCI), the reality of healthcare was viewed to be a culture of low expectation due to many reasons such as wasting about 40 cents of each healthcare dollar spent, and being an environment that supports the tolerance of deviant behaviour. This kind of culture will not be tolerated when an organisation commits itself to excellence.
In a study quoted by JCI surveyor, Al Attal Z. in the quality and patent safety congress in Abu Dhabi in 2013, about what leaders in accredited facilities don’t hear about patient safety culture, he echoed the global anxiety of safe healthcare delivery where 56 per cent of 1,600 participants feel that their mistakes are held against them, and 71 per cent of staff are worried that mistakes are kept in their file despite that 74 per cent of hospital management show that patient safety is a top priority. On the contrary of stringent monitoring to errors reporting in order to meet accreditation requirements, in excellence environment, staff are empowered to practice correctly and report errors transparently. In my opinion, different types of national and international accreditations in the Middle East region have helped in improving healthcare practice and outcomes. It succeeded in emphasising on the necessity of reducing hospital acquired infections, raising awareness on international patient safety goals, reporting near misses, and addressing major medical errors that occurs at sharp end but still many years to come to see the impact on fixing broken processes and systems at blunt end, structuring realistic key performance indices, progressing toward value-based healthcare and following sustainable medical best practice to save lives and money.
The Institute of Medicine which was established in 1970 to provide independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public in the U.S. has produced two reports demonstrating healthcare has serious patient safety and quality problems and is in need of fundamental change (Institute of Medicine, 2000 and 2001). Care processes are poorly designed and characterised by unnecessary duplication of services and long waiting times and delays. Costs are exploding and waste is identified as an important contributor to the increase in healthcare expenditures. As a result, healthcare consistently does not succeed to meet patient’s needs. To better serve the needs of patients, healthcare systems have to be redesigned. By issuing the reports, the Institute of Medicine has put quality management strongly on the agenda of healthcare organisations. Delivering low quality of care was considered unacceptable. This obligation may cause more (financial) stress because, for example in The Netherlands, the hospital funding system pays fixed prices per patient regardless of the quality of care delivered. Hence, delivering high quality does not generate more income. However, the observations of the Institute of Medicine with respect to process optimisation and waste reduction offered opportunities for healthcare organisations with respect to cost containment.
Worldwide the cost of medical care is also increasing at an alarming and unsustainable rate. Admittedly, a significant percentage of these cost increases can be attributed to ageing populations and technological advances. Those two causes are inevitable facts of the technological and demographical developments of modern society. As such, they are largely beyond our control. However, another significant source of healthcare cost increases can broadly be characterised as unnecessary operational inefficiency. This we have more control over. Inefficiency we can change. If we do, we can provide more affordable and better healthcare for a large percentage of the population. Some operational inefficiencies are associated with the direct medical service delivery process. Others are associated with the administrative, logistical and operational side of the healthcare delivery system. I strongly believe that both areas in the Middle East healthcare delivery system can benefit from systematic process innovation activities that are offered by the excellence concepts and model.
The link between Total Quality Management (TQM) and Business Excellence (BE)
I would not be surprised if some object to the concept of industrialised healthcare delivery.
However, industrialisation is essentially a conversion of artisan methods to more efficient, cost effective, streamlined systems for the delivery of products or services (Levitt, 1976; Heskett, Sasser, and Schlesinger, 1997). During the past century, industry deployed a large arsenal of tools and innovation approaches to achieve high levels of operational efficiency. Economic history indicates that efficiencies in industry were obtained primarily as the cumulative effect of a large number of incremental improvements (Rosenberg, 1982 and Bisgaard, 2006). What sets apart Total Quality Management (TQM) and Business Excellence (BE) models from other performance management models is that TQM/BE models are designed to address the whole management philosophy of an organisation and the activities it uses to pursue it. TQM/BE models aim to guide organisations to consistently exceed the current and future expectations of all stakeholders (i.e., customers, employees, shareholders and the community) through “continuous improvement in all processes, goods and services” (Sitkin, Sutcliffe, and Schroeder, 1994). Central to this realisation is the creation of a working culture (by the senior leadership) that uses data information and knowledge for every sphere of organisational activity, and evolution of a managerial system that fulfils the intrinsic and extrinsic needs of the organisation’s employees (Dean and Bowen, 1994; Hackman and Wageman, 1995; Kanji and Wallace, 2000). When an organisation applies for a national BE Award, the key areas of organisational capability are assessed against the model and points are allocated to each measurement item by a panel of trained independent evaluators using a scoring guideline based upon the level of evidence of actual performance. In my opinion, having quality experts in the external assessment and jury processes are vital to the success of any national quality award model because it will lead to healthy and transparent economy. Furthermore, those organisations with leadership that seed excellence culture in its daily performance, conduct vigorous self-assessment and grow internal assessors with quality values, behaviours and integrity that would defiantly with time contribute not just to its business growth but its national economy footprint and have evident proposition at the global market. Quality in healthcare like any other industry is an integral part of it and shall benefit from the excellence approach.
The concept of quality in healthcare and how regional healthcare delivery would benefit from the organisational excellence philosophy?
Quality in healthcare delivery has always been a primary aim for clinical physicians. But since the beginning of recorded medical history, physicians have always aimed to provide the best outcomes possible for each patient, a goal consistent with medical codes of ethics since at least the time of Hippocrates. This emphasis on quality of healthcare delivery forms the first and oldest part of a useful triad of concepts that cover much of what we mean by good healthcare delivery. The second part of the triad, access, and the third part, cost, reflect two additional goals of healthcare delivery that are manifesting increasingly today in medicine’s interaction with society as a whole. Quality of care (good outcomes for each patient, within the limitations of current medical knowledge) at the level of individual patients or small groups of patients has been the focus of medical research and publication since a long time, although in the last two decades new emphasis has been placed on measuring quality at the level of the practitioner (individual practitioner or hospital). The U.S. government has devoted much attention to healthcare delivery initiatives since the 2008 general presidential election, and one state (Massachusetts) has already enacted significant healthcare reform, making this topic a particularly appropriate one for discussion. The branch of the U.S. government most directly tasked with ensuring quality in healthcare delivery, the Agency for Healthcare Research and Quality (AHRQ), uses 19 distinct criteria to define successful healthcare delivery: (1) effectiveness, (2) safety, (3) timeliness, (4) patient-centeredness, (5) equity, and (6) efficiency, (7) acceptability (8) accessibility, (9) appropriateness, (10) care environment & amenities, (11) competency, (12) capability, (13) continuity, (14) improving health, (15) clinical focus, (16) expenditure or cost, (17) governance, (18) focus or responsiveness, and (19) sustainability.
In the Middle East, different accreditations models and bodies were introduced in the last two decades as a remedial approach to improve quality of care in healthcare services by local authorities. Recently, different countries in the region including the Kingdom of Saudi Arabia, Jordan and UAE created their national accreditation scheme and started mandating it to foster national standards of quality of care. Similar to AHRQ, each hospital, authority or accreditation scheme adopted different dimensions to measure and assess its quality. In my personal opinion, as a lesson learned from the sole adaptation of the accreditation approach of any size of healthcare institution is that “structuring healthcare delivery algorithm on safety and quality is way beyond complying with the accrediting bodies’ requirements.”
I strongly believe that what determines how great a healthcare organisation will become is how well its leadership system creates a culture of excellence and safety, improves the enterprise system and effectively implements best practices. I look forward to the day where quality, infection control and safety become the DNA of healthcare services in the Middle East region and the quality department becomes just a facilitation arm that helps leadership make informative decisions. The day shall come where every healthcare provider is morally engaged in the delivery system without monitoring.
What are the excellence models available worldwide and regionally… which model works for you?
There are two well recognised excellence award models worldwide, the Business Excellence Model which was launched in 1991 by the European Foundation of Quality Management (EFQM) and the Malcolm Baldrige National Quality Award, which was introduced in the early and mid-1980s recognises U.S. organisations in the business, healthcare, education, and non-profit sectors for performance excellence. The EFQM is an innovative approach that is currently popular in all industries, whether manufacturing or services, based on a belief of leaders from 14 companies, based in Europe, who were convinced that a new membership organisation (EFQM) was necessary to promote higher standards of management through knowledge sharing and recognition. Both awards provide a platform for systematic approach to facilitate leadership, culture, systems, and incremental process innovations. The models help organisations in building robust enablers to achieve sustainable results, which can be self-assessed internally or by peers externally using the RADAR (Results, Approach, Deployment and Assessment and Review) philosophy. Each model has excellence concepts that renewed emphasis on quality as necessary for doing business in an expanding and competitive world market. The EFQM just recently launched its 2020 Excellence model in Helsinki. The model takes a complete view of the organisation, which emphasises the role continuous improvement has in creating sustainable success. In the Middle East, the EFQM has made stronger footprint since the majority of governmental awarding bodies have adopted its approach while the Baldrige award remained within the boundaries of U.S.
Since early 2002, many quality awards were established and launched in the Middle East region including the Dubai Quality Award, followed by the King Abdullah Excellence Award of Jordan, King Abdulaziz Quality Award of the Kingdom of Saudi Arabia, and Abu Dhabi Excellence Award. It is not the aim of this paper to compare between the national or international quality/excellence awards but to emphasise on the benefit of adopting the business excellence approach in healthcare performance. For example, the Baldrige criteria asks about healthcare processes, support processes and innovation. The examiners look for the use of best practices in the application and during a site visit. In today’s competitive environment, Baldrige award recipients and others that have chosen performance excellence are reaping the benefits of financial stability, staff retention, prevention-based culture, safe and quality care, and a compassionate, ethical environment where staff, patients and physicians thrive. In 2005, 33 healthcare organisations applied for the Baldrige award, making healthcare the fastest growing segment. Even though the excellence awards in the region were targeting the private sector, it has recently expanded to the public sector with strong focus on customers’, stakeholders’ and community needs and expectations. I strongly believe that quality awards are instrumental in deploying the smart government vision when it comes to quality improvement in public services.
In conclusion, the senior leadership team in any healthcare organisation shall create the strategies, systems and methods for reaching performance excellence by seeding excellence culture, stimulating innovation, building knowledge and capabilities and ensuring organisational sustainability. Every organisation has the potential to achieve performance excellence, and there are several ways to get started: first, a good step is to learn about the excellence concepts and criteria whether national or international, which are based on world-class practices and provide a model for integrating clinical and business processes to drive performance excellence throughout the organisation. This shall enable the organisation to improve productivity and profitability while increasing patient, employee and community satisfaction. Second, conducting an annual assessment using the excellence criteria is an excellent way to measure your organisation’s pace of improvement.
References available on request.