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1 Exploring the Suitability of the European Foundation for Quality Management (EFQM) Excellence Model as a Framework for Delivering Clinical Governance in the UK National Health Service Sue Jackson* Centre for Excellence Development, University of Salford, Salford, UK Summary In December 1997 the United Kingdom (UK) government publicized its vision for the National Health Service (NHS) to become the best health care system in the world. In line with this vision a number of consultative and directive documents were circulated, one of which was Clinical Governance: in the new NHS. This particular document provided insight into the principles and proposed framework for delivering clinical governance. However, the document suggested that health care organizations create mechanisms for delivering clinical governance which implied that the government had failed to recognize that suitable mechanisms were already available. The author suggests that one such suitable mechanism/framework is the EFQM Excellence Model. The article therefore * Correspondence to: Excellence Development Facilitator, Centre for Excellence Development, University of Salford, Room 332a Maxwell Building, Maxwell Bridge, The Crescent, Salford, M5 4WT, UK. suejackson@excellence2000.freeserve.co.uk examines the similarities of the principles behind clinical governance and the EFQM Excellence Model and recommends the latter as a suitable tool for ensuring that the country s people have the best health care system in the world. Copyright 2001 John Wiley & Sons, Ltd. Key Words quality; clinical governance; EFQM Excellence Model Introduction In December 1997 the UK government publicized its commitment towards giving the country s people the best health care system in the world. To achieve this goal, the government maintained that it was to embark upon a 10-year programme that would result in big gains in quality and efficiency across the whole of the NHS. A number of specific actions were identified in the White Paper The new NHS modern.dependable [1]. For instance, the government made a commitment to issue consultation documents on quality and performance by the end of 1998

2 20 S. Jackson and to develop an infrastructure for local clinical governance by the end of 1999 [1]. In line with these promises a number of documents were distributed which began to outline the framework for quality. One such document was Health Service Circular (HSC) 1999/065 Clinical Governance: in the new NHS where clinical governance was defined as: A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish [2]. Also within that document were the statements: and The challenge posed by the new statutory duty of quality in the NHS is to transform the delivery of primary, hospital and community care so that consistently better outcomes are produced for patients It [Clinical Governance] will mean the creation of a systematic set of mechanisms that will support staff and develop all health organisations to deliver a new approach to quality [2]. If the second statement were to be taken literally achieving clinical governance would mean creating new mechanisms for ensuring its delivery and therefore fail to appreciate and benefit from existing frameworks that may be more than equipped to support the delivery of clinical governance. Moreover, much time would be wasted creating systematic sets of mechanisms at the expense of securing quality. This is particularly so when there appears to be a mechanism/framework already available for supporting the achievement of clinical governance. The mechanism alluded to is the updated version of the European Foundation for Quality Management (EFQM) Excellence Model [3] which can be applied throughout the whole of the health care sector including pharmacological research and development, pharmacological operations, clinical support services, estates, human resources, finance departments and rehabilitation services. The remainder of the article will therefore explore the similarities between clinical governance and the EFQM Excellence Model and recommend that the latter be used as a mechanism for ensuring that the UK has the best health care system in the world. EFQM Excellence Model The EFQM Excellence Model is a nonprescriptive framework that recognises there are many approaches to achieving sustainable excellence [4]. Non-prescriptive in this sense means that there is not one way of achieving excellence. Rather many approaches will attain similar outcomes because they are applied in different cultural, economic and social contexts. Nevertheless, EFQM maintains that there are a number of concepts deemed fundamental for attaining excellence which include customer focus, leadership, process management, people management, continuous learning, innovation, partnerships, public responsibility and results orientation. Moreover being focused on results (results orientation) means that organizations need to identify the measures that will demonstrate what they achieved and how they achieved it. The EFQM Excellence Model is based on nine criteria, of which five are enablers (describing how things are done in the organization) and four are results (describing what is achieved by the enablers). The five enablers are Leadership, Policy and Strategy, People, Partnerships and Resources and Processes, and the four results areas are Customers, People, Society and Key

3 European Foundation for Quality Management (EFQM) Excellence Model 21 Performance. Therefore, the EFQM Excellence Model encourages organizations to understand the relationship between actions (enablers) and results. An example may be designing and delivering an induction programme (enabler) which has demonstrated a positive effect on the perceptions and experiences of new members of staff (result). Each criterion of the EFQM Excellence Model contains sub-criteria which an organization applies self-assessment and continuous improvement actions to, in order to work towards excellence status. Self-assessment means that the people within the organization or department (not an outside assessor or auditor) identify their own performance in relation to the sub-criteria. Once they have gathered and analysed the data regarding their performance they are able to determine whether they are performing well in this particular area (strength) or whether they are not performing as well as they could (area for improvement). Following on from the previous example it may be that the induction programme does result in all new members of staff feeling positive about the organization (strength). Alternatively it may be that some or all new members of staff have negative views of the organization (an area for improvement) which indicates the induction programme is in need of some corrective action in order to achieve the desired result. In order to achieve a culture of continuous improvement, a fundamental principle of the EFQM Excellence Model, an organization would need to undertake self-assessment on a regular (often six monthly or yearly) basis and demonstrate through a process of innovation and learning that its overall performance is getting better. All in all there are 32 sub-criteria with the EFQM Excellence Model that an organization would need to apply self-assessment to, 24 within the enablers and 8 within the results. By way of an example the leadership enabler encourages organizations to demonstrate how: Leaders develop the mission, vision and values and are role models of a culture of Excellence Sub-criteria 1a Leaders are personally involved in ensuring the organization s management system is developed, implemented and continuously improved Sub-criteria 1b Leaders are involved with customers, partners and representatives of society Sub-criteria 1c Leaders motivate, support and recognise the organization s people Sub-criteria 1d. [3] With regards to results, Customers, People and Society have two components; perceptions and indicators. By way of an example the People Results sub-criteria maintains that: Perception measures are those measures relating to the people s perception of the organization. Performance indicators are the internal measures used by the organization in order to monitor, understand, predict and improve the performance of the organization s people and to predict their perceptions. [3] The overall philosophy is that: Excellent results with respect to Performance, Customers, People and Society are achieved through Leadership driving Policy and Strategy, People, Partnerships and Resources, and Processes [4]. A diagrammatic representation of the model is shown in Figure 1. The percentages shown in the enablers and results boxes are those that the EFQM assign for the purposes of award applications for the European Quality Award which takes place each year. They emerged from the values and experiences of the 14 founder member companies of the EFQM and have remained the same despite a number of consultation exercises with all members of the EFQM (over 800 organizations are currently

4 22 S. Jackson members of the EFQM). Each criterion of the model has a number of sub-criteria which an organization has to address if they are to secure excellence status. All in all there are 32 model sub-criteria that an organization would apply self-assessment to in order to determine its strengths, areas for improvement and focus its action towards excellence which includes measuring progress towards that excellence (Figure 1) [3]. At the heart of the EFQM Excellence Model lies a logic known as RADAR [4]. The RADAR logic consists of the following elements: Results, Approach, Deployment, Assessment and Review. In order to fulfil the requirements of the logic an organization needs to: Determine the financial, operational and stakeholder perception Results it is aiming for; Plan and develop a sound Approach for achieving the proposed results; Deploy the approaches in a systematic way so that full integration of them is achieved; and Assess and Review the approaches by undertaking regular measurement which in turn promotes learning and leads to improvement activities where necessary. In essence, the EFQM model subscribes to Dr W.E. Deming s continuous improvement philosophy of Plan Do Check Act [5]. Moreover the process is driven by self-assessment which Porter and Tanner [6] maintain is not only a means for measuring continuous improvement, but also an excellent opportunity to integrate total quality management into normal operations [6]. The EFQM model defines excellent results as those which: show positive trends and/or sustained good performance, are meeting appropriate targets, compare well with other organizations and are caused by the enablers. Furthermore, the scope of the results needs to address the relevant areas of the organization. There is an appreciation that one-off good results, in a limited number of areas, is more readily achieved than sustained positive performance, but the latter is more indicative of an excellent organization. The benefits of undertaking a self-assessment against the EFQM Excellence Model are that it provides an objective measure of an organization s strengths and areas for improvement. Moreover, assessing against one overall framework means that organizations can compare their performance with similar organizations and other organizations Figure 1. Diagrammatic representation of the EFQM Excellence Model

5 European Foundation for Quality Management (EFQM) Excellence Model 23 deemed to be best performers in some or all the criteria within the EFQM Excellence Model. Therefore, the process of self-assessment is designed to stimulate improvement activities which positively impact on the overall organizational results and ultimately improve quality. The Suitability of the EFQM Excellence Model to Support Clinical Governance Given that HSC 1999/065 [2] mainly relates to the actions required for delivering clinical governance rather than specific results to be achieved, the following discussion concentrates on the principles behind both clinical governance and the EFQM Excellence Model and the individual enablers of the latter. The results areas of the EFQM Model are considered in their entirety rather than as separate elements. Principles behind Clinical Governance and the EFQM Excellence Model In terms of organizational culture, the UK government wants quality to become the driving force behind decision making at every level of the service [1], and wants everyone working within the NHS to take responsibility for improving quality [1,7]. It is in the area of quality that clinical governance and the EFQM Excellence Model are most closely aligned. For instance, the EFQM Excellence Model was designed with the belief that quality is fundamental to achieving organizational excellence. In line with this belief the model provides a practical tool to help organizations measure where they are on the path to excellence [4]. A further significant principle of clinical governance and the EFQM Excellence Model is that quality does not happen over night. The UK Government recognizes that it will take at least 10 years to attain a culture that reflects the many characteristics of quality. Likewise, using the EFQM Excellence Model suggests that organizations need to have embraced the concept of quality for at least 5 years before they are able to demonstrate sustainable, positive trends in their results, a requisite for being deemed excellent [3]. Enablers of the EFQM Excellence Model Leadership In order that efforts towards quality are successful Oakland [8] maintains that senior management commitment must be obsessional. However, commitment is not the only requirement of leaders as their skill base is also crucial. In recognition of this, the Department of Health (DoH) stated that the expectations of NHS Trusts (individual local provider units of hospital, community and/or primary health care) were so challenging that they required good leadership and the DoH also stated that a quality organization would ensure that leadership skills were developed [1]. With regards to clinical governance, leaders are expected to demonstrate: inclusivity, whereby all key groups within the organization are kept involved and fully informed; commitment from the top, resulting in free access of staff to the Chief Executive and Board when problems need to be resolved or barriers to progress have been identified; good external relationships, whereby robust working partnerships with health organizations and other agencies in the locality are forged; constancy of purpose, so as not to detract from the national agenda; progress, thereby having the evidence to demonstrate the organization s position in relation to clinical governance; and good communication, with all internal and external stakeholders [2].

6 24 S. Jackson The list therefore suggests that leaders need skills in all the above areas if they are to successfully secure the organizational cultural characteristics deemed appropriate for the new NHS. The EFQM Excellence Model assigns 10% of its award scoring weighting to leadership. In order to attain excellence status, organizations should demonstrate that they are applying the principles of the model (plan and develop approaches, deploy those approaches, assess and review approaches) to the following four sub-criteria: Leaders develop the mission, vision and values and are role models of a culture of Excellence; Leaders are personally involved in ensuring that the organization s management system is developed, implemented and continuously improved; Leaders are involved with customers, partners and other representatives of society (examples would be patients, general practitioners, government and voluntary organizations); Leaders motivate, support and recognize the organization s people [3]. When the sub-criteria of the EFQM model are compared with the DoH description of clinical governance characteristics of leaders, it can be seen that the latter does not specifically address how leaders demonstrate that they value the organization s people. For instance, similar to the EFQM Model, clinical governance supports inclusivity and commitment but unlike the EFQM Model it does not require organizations to plan, deploy, assess and review its approach towards motivating, supporting and recognizing its people. Stewart [9] believes that special skills are not needed to show people that they matter, rather an ability to treat each person as a distinct and valued individual is all that is required. However, it is so easy to overlook this vital element of leadership as has been demonstrated in the NHS clinical governance guidance which suggests specialist skills and attention may in fact be needed for ensuring that the organization s people are recognized and feel valued. This is especially so if there is credibility in the principle that what gets measured gets attention, thereby suggesting that a failure to make valuing people explicit means there is a risk of failing to value people. With regard to leadership skills described by the NHS such as good external relationships and good communications, these elements are all found within the People and Partnerships and Resources sub-criteria of the EFQM Excellence Model. Moreover, constancy of purpose and demonstrating progress are inherent within the RADAR logic of the Model. Hence, it would appear that the EFQM Excellence Model is fully equipped to match the leadership characteristics described in the NHS clinical governance guidance. Policy and Strategy Walburg [10] maintains that by planning a strategy from a quality perspective, the organization is emphatically oriented towards customer satisfaction and quality. The clinical governance guidance certainly appears to have been developed with the end customer and other stakeholders in mind. Some of the key policy principles of clinical governance are to: Provide an NHS that continually improves the overall standard of clinical care, whilst reducing variations in outcomes of, and access to services; Ensure that clinical decisions are based on the most up-to-date evidence; Ensure Trusts develop and maintain arrangements for monitoring and improving the quality of health care; Involve effective learning from leading edge services [2]. Examples of this would include benchmarking with other NHS organizations deemed best in class for certain clinical outcomes and possibly

7 European Foundation for Quality Management (EFQM) Excellence Model 25 industry for outpatient queuing strategies. (Benchmarking with Royal Mail has been undertaken by some NHS organizations in the past for improving queuing processes within outpatient departments). The EFQM Excellence Model requires organizations to self-assess against the following sub-criteria of the Policy and Strategy enabler, how: Policy and Strategy are based on the present and future needs and expectations of stakeholders; Policy and Strategy are based on information from performance measurement, research, learning and creativity related activities (a health care example would relate to a clinical change that has been implemented or would require implementing because of the availability of new technology and its proven benefits); Policy and Strategy are developed, reviewed and updated; Policy and Strategy are deployed through a framework of key processes (this may involve identifying the key processes for achieving the organization s policy and strategy and determining who would be responsible for ensuring their delivery); and Policy and Strategy are communicated (to key stakeholders) and implemented in the organization [3]. The similarities between clinical governance and the EFQM Excellence Model should be apparent. For instance, both concepts rely on learning, performance measurement, utilizing up-to-date information and knowing and predicting customer needs and expectations. Moreover, when the deployment element of the EFQM Excellence Model is considered (i.e. systematic implementation throughout the whole organization), it would appear that this model provides a framework for ensuring that everyone working within a NHS organization takes responsibility for improving quality, a vital component for clinical governance, the new NHS and quality as a whole. People Health care organizations are required to design separate human resource strategies that will support clinical governance [2] and maximize the contribution of staff for attaining a modern and dependable NHS [11]. In line with this requirement a further government document was issued entitled Working Together [11], which identified specific actions recommended by the NHS Executive (governing body of the NHS). For instance NHS organizations are to: Have in place an annual workforce plan; Have in place training and development plans for the majority of health professional staff; Demonstrate yearly improvements in staff retention (nurse retention has been a particular problem in the NHS as many qualified nurses have left to take up posts outside the NHS because of concerns regarding pay and work conditions within the NHS), and sickness absence rates; Have developed and reviewed mechanisms for involving staff in the planning and delivery of health care; Have undertaken an annual staff attitude survey to act as a benchmark against which improvements to the quality of working life can be measured [11]. According to the Working Together [11] document, all of the above were to be in place by April However, the above list is not exhaustive as there are at least nine other activities that NHS organizations must take on board in order to fulfil the requirements of the Government s Human Resources Strategy (Working Together document). Some of the other requirements of Working Together are:

8 26 S. Jackson Organizations need to have in place systems for recording and monitoring workplace accidents and violence against staff; Organizations need to have reviewed their induction arrangements and agree local improvements with particular reference to doctors on rotational training; and Organizations need to have Occupational Health Services and counselling available for all staff [11]. There is evidence of an alignment between the Working Together document [11] and the RADAR concept of the EFQM Excellence Model as some of the above actions relate to the desired results as well as to some of the desired approaches designed to attain those results. For instance, demonstrating year on year improvement in staff retention and sickness absence is a result, whereas having occupational health departments and good induction programmes are enablers which can impact positively on those results areas. Moreover, the EFQM Excellence Model encourages organizations to identify and continuously improve the perceptions of its people and not solely rely on indicators for satisfaction like staff turnover and sickness absence levels. This is further evidence of alignment between Working Together [11] and the EFQM Excellence Model.With regards to the EFQM Excellence Model the enablers for the sub-criteria People are to self-assess how: People resources are planned, managed, and improved; People s knowledge and competencies are identified, developed and sustained; People are involved and empowered; People and the organization have a dialogue; and People are rewarded, recognized and cared for [3]. When the above sub-criteria are compared with the action checklist from the Working Together [11] strategy, it becomes evident that the Government has once again overlooked the important area of demonstrating that it values its people. Moreover, the EFQM Excellence Model encourages organizations to compare their performance with other organizations (not necessarily within the NHS) deemed best in class (an example would be an organization with the lowest sickness absence level) and continuously strive to match that performance. In contrast Working Together [11] encourages health care organizations to compare and make improvements with internal benchmarks of the NHS, which may not necessarily be best in class. This is further evidence that the EFQM Excellence Model is structured in such a way that it can support the delivery of clinical governance. Partnerships and Resources Developing and maintaining robust working partnerships is of particular importance to the UK Government. For example, the White Paper The new NHS modern.dependable [1] asserted that there would be a third way (the previous two being centralized control and an internal market initiated by the previous conservative government) of running the NHS which would be a system based on partnership and driven by performance. However, the performance element mainly relates to the overall organizational outcomes, rather than measuring the impact of any individual partnership. Nevertheless, the document maintained that achieving quality was reliant upon a positive approach to partnership unlike the previous internal market initiative which created competition as opposed to collaboration [1]. With regard to resources, the Government promised that national reference costs (a more recent initiative whereby NHS organizations submit their individual costings for certain treatments to the NHS Executive)

9 European Foundation for Quality Management (EFQM) Excellence Model 27 be prepared to allow NHS Trusts to benchmark their performance. This initiative was developed to further fuel the drive for continuous improvement and thereby strengthen the message that efficiency and quality go hand in hand [1]. Finances were not the only resources to be considered as the Government maintained that harnessing the knowledge and expertise of staff providing the service would be one of the cornerstones of quality improvement. Similarly transforming the knowledge from research into information that clinicians can relate to would also be important [2]. The sub-criteria for the Partnerships and Resources element of the EFQM Excellence Model require organizations to self-assess how their: External partnerships are managed; Finances are managed; Buildings, equipment and materials are managed; Technology is managed; and Information and knowledge are managed [3]. When compared to the UK Government agenda, the EFQM Excellence Model would again appear more than adequate, particularly as the impact that individual partnerships have on overall organizational outcomes would be planned, measured, reviewed and improved within a context of best in class performance. Moreover, the management of finances, technology, buildings, equipment, materials, and information and knowledge would also be subject to the same rigorous process, thereby supporting an organizational culture whereby continuous improvement is the norm. Processes According to the NHS Executive [12], the common thread linking clinical governance and controls assurance is risk management. Moreover, risk management is defined as the culture, processes and structures that are directed towards effective management of potential opportunities and adverse effects. In particular, NHS organizations will need to risk manage both the clinical and non-clinical aspects of health care delivery [12]. With regards to the clinical aspect, one specific aim of clinical governance is to recognize problems of poor clinical performance at an early stage. Hence, the need to implement clear mechanisms for identifying and managing poorly performing clinicians [2]. At the national level, a number of standards are being promoted and/or developed to support the clinical governance. However, there is a risk with agreeing on common national and local standards as this may stifle innovation, and more importantly eliminate continuous improvement in organizations attaining the standard. For instance, a national standard for outpatient waiting times is 13 weeks, hence an organization achieving this may not strive to lessen the wait to 11 or 12 weeks, for example, because the standard is being met. Moreover, national standards may not align well to local needs and worse still may divert people s attention from identifying standards that would be better suited for the local population. With regards to the EFQM Excellence Model, it is no accident that the Processes criteria carries the highest percentage weighting (14%) of all the five the enablers [4], particularly as achieving excellence is dependent upon sound processes which are regularly reviewed and updated in accordance with customer expectations and experiences [3]. The sub-criteria for the Processes element of the EFQM Model are to self-assess how their: Processes are systematically designed and managed; Processes are improved as needed, using innovation (maybe ideas from staff and/ or customers) in order to fully satisfy and generate increasing value for customers and other stakeholders;

10 28 S. Jackson Products and Services are designed and developed based on customer needs and expectations; Products and Services are produced, delivered and serviced; and Customer relationships are managed and enhanced [3]. It can be seen from the above that there is a focus on applying innovation to fully satisfy the needs of customers and other stakeholders, which suggests that the approach is superior to that of standard setting, especially when it has been argued above that nationally agreed standards could stifle continuous improvement and the identification of appropriate local improvement initiatives. Furthermore, when the RADAR logic is applied to the above criteria a robust system emerges for managing and improving the organization s processes. For instance, if a department were to develop an integrated care pathway for a certain patient group they would have to: determine the Results they wanted (customer satisfaction, more efficient use of resources); plan an Approach to achieve the desired results (the integrated care pathway); Deploy that approach (ensure that everyone who ought to is following the care pathway); and Assess and Review the approach (check whether the care pathway is the correct approach for the results required and that it is being implemented as intended). Given this to be the case, the EFQM Excellence Model can again be viewed as a suitable framework for delivering clinical governance. Another feature emerging from the White Paper The new NHS modern.dependable [1] is an enthusiasm for sharing best practice. Evidence of this can be found in the following quotes: it [the NHS] has to share best practice and eliminate poor performance so that the patients have a guarantee of excellence particular emphasis will be put on benchmarking and on sharing of good practice The Government will spread best practice and drive clinical cost effectiveness in a number of ways [1] The EFQM Model maintains that excellent organizations compare favourably with those that are best in class. With regards to health care an example would be that a particular health care organization or specialty (i.e. surgery or pharmacy) could demonstrate that its performance compares favourably with those known to be the best in that field. To achieve this, benchmarking is an inherent feature of the EFQM Excellence Model. Thus the suitability for utilizing the Model as a framework for clinical governance is again apparent. Results In terms of results, the aim of clinical governance is to: Improve people s health; Make services quick and convenient for people to use; Improve consistency of services; Break down barriers within health and social care; Modernize the NHS [2]. In order to achieve these results/benefits, performance measurement needs to be implemented in all areas of care delivery. However, the Government recognizes that the way in which performance is measured directly affects how the NHS acts and that the wrong measures produce the wrong results [1]. In line with this thinking the Government initiated the new Performance Framework which was set up to focus on

11 European Foundation for Quality Management (EFQM) Excellence Model 29 more rounded measures like: health improvement, fairer access to services, outcomes of care and patient/carer experiences [13]. An important aspect of the performance measurement framework is that the quality of the data collected must be of a high standard [13], as incomplete and/or insufficient data tends to detract health care personnel from applying all their efforts towards continuous improvement. An example would be when data indicates that clinical outcomes are worse at one hospital than another, and yet the reasons for this are due to patient mix rather than poor hospital performance. For instance, high smoking prevalence in one area of the country may impact on cardiac outcomes. In this type of scenario clinicians may spend their efforts explaining the meaning behind the data to the detriment of their continuous improvement efforts. When the EFQM Excellence Model is examined, it can be seen that an organization is expected to achieve excellent results in the perception measures of their Customers, People and Society in addition to improvements in actual performance indictors. Perception measures relate to the views of customers, people (employees) and society, the latter being defined as all those people who are, or believe they are affected by the organization, other than its employees, customers and partners. Performance indicators for customers, people and society are the internal organizational measures used to monitor, understand and improve performance [3]. In addition to customers, people and society, the EFQM Excellence Model includes a fourth results criterion known as Key Performance Results. Key Performance Results carries the highest weighting of the results criteria (15%) and covers the financial and non-financial, strategic and operational aspects of the organization [3]. It is here where results are found that relate to the clinical elements of clinical governance. Therefore, it can be seen that the four results criteria of the EFQM Excellence Model more than meet the requirements of clinical governance, especially when organizations are not only encouraged to demonstrate sustainable continuous improvement but are encouraged to improve to the level of best in class performing organizations whether they be internal or external to the NHS. Discussion According to Crosby [14] a quality culture can be characterized by: demonstrable commitment from the Chief Executive; everyone recognizing it is their responsibility to deliver quality; good communications; and an environment whereby staff feel valued and are recognized. Further features include: teamwork [15] participation, empowerment, and a focus on continuous improvement for the benefit of the customer [16]. Core to the attainment of a quality culture is performance measurement and the recognition that quality cannot be achieved from a one-off activity. It takes time [14] and a multitude of progressive continuous improvement efforts. Given that achieving excellence with regards to the EFQM Excellence Model implies that an organization must demonstrate all of the aforementioned characteristics, the Model is ideal for supporting organizations in their pursuit of a quality culture. Moreover, if an organization wants to see quality at the heart of its decision-making, then quality cannot be seen as an add-on initiative [1,15]. One of the major strengths of the EFQM Excellence Model is that it is able to integrate many other quality frameworks that may already be utilized by the organization. For instance the ISO standards fit readily into the processes and key performance results criteria of the EFQM Excellence Model. A situation that will still apply to the new ISO standards. Hence, it has been demonstrated that by utilizing the concept of self-assessment, the

12 30 S. Jackson EFQM Excellence Model is more than equipped to support an organization in the process of determining its strengths and areas for improvement in relation to national standards, local needs and best in class performance. In recognition of this, the UK government via the NHS Executive commended the use of the EFQM Excellence Model within the NHS [12]. More recently two NHS Learning Centres (Salford and South Tees) have been set up to support NHS organizations wishing to utilize the EFQM Excellence Model for securing quality. Both Learning Centres are NHS provider hospitals situated within the North of England and have been utilizing the EFQM Excellence Model for over five years. Therefore the emphasis is on sharing the learning. In line with this sharing of the learning Jackson [17] observed that many organizations identify in excess of 100 areas for improvement as a result of self-assessment against the EFQM Excellence Model. Consequently there is a danger of biting off more than you can chew and so it is advisable to have a mix of improvement initiatives that secure both short and long-term paybacks (easy and more difficult projects), otherwise motivation can be adversely affected [17]. Finally, Brannan [16], Crosby [14] and the EFQM [18] maintain that self-assessment does not in itself produce continuous improvement only acting on the outcomes will, a vital characteristic when striving for clinical governance and quality in the new NHS. Conclusion Throughout this article it has been demonstrated that the EFQM Excellence Model is a more than adequate tool for supporting the implementation of clinical governance. The concepts of the EFQM Excellence Model can only be achieved in a culture of performance measurement and continuous improvement, whereby quality lies at the heart of an organization and drives all of the decision-making. Features of the EFQM Excellence Model that strongly support clinical governance are that it encourages organizations to: set targets, develop and utilize robust information systems, compare performance against targets and best in class, involve customers and other stakeholders wherever appropriate and develop its people to achieve organizational excellence. Moreover, the EFQM Model ensures organizations assess and develop their leaders so that the needs of customers and stakeholders are accommodated and employees are supported, motivated and valued. Additionally, the Model is able to incorporate a number of initiatives and accreditation frameworks already being utilized by an organization. Further similarities between the clinical governance agenda and the concepts of the EFQM Excellence Model are their focus on partnership working, good use of resources, full deployment (everyone responsible for quality), lifelong learning and the application of continuous improvement rather than the attainment of fixed standards. In conclusion, the EFQM Excellence Model is specifically suited for securing a change in culture that embraces total quality management and therefore should be the recommended mechanism for meeting the demands of clinical governance. References 1. Department of Health. The new NHS modern. dependable, Department of Health, December. 2. NHS Executive. Clinical Governance: in the new NHS, Health Service Circular 1999/065, 16th March. 3. EFQM. The EFQM Excellence Model. Public and Voluntary Sector Version. The European Foundation for Quality Management: Brussels, EFQM. European Foundation for Quality Management (1999),

13 European Foundation for Quality Management (EFQM) Excellence Model Deming WE. Quality, Productivity and Competitive Position. Massachusetts Institute of Technology: MA, USA., Porter L, Tanner SJ. Assessing Business Excellence. A Guide to Self-Assessment. Butterworth Heineman: Linacre House, Jordan Hill, Oxford, Department of Health. A First Class Service. Quality in the new NHS, Department of Health, July. 8. Oakland JS. Total Quality Management. Heinemann Professional Publishing: Oxford, Stewart R. Leading the NHS. A Practical Guide (2nd Edition). Macmillan Business Press Limited: Basingstoke, UK, Walburg JA. Integrale kwaliteit in de Gezondheidszorg. Van Inspecteren naar Leren. Kluwer BedrijfsInformatie B.V. Deventer: The Netherlands, Department of Health. Working Together. Securing a Quality Workforce for the NHS, 1998b. Department of Health, September. 12. NHS Executive. Governance in the new NHS, 1999b. Health Service Circular 1999/123, 21st May. 13. Department of Health. The NHS Performance Assessment Framework, Department of Health, April. 14. Crosby P. Quality is Free: The art of making quality certain. Mentor Books Penguin: New York, Dale BG, Boaden RJ, Lascelles DM. Total quality management: an overview. In Managing Quality (2nd Edition), Dale BG (ed.). Prentice Hall: London, Brannan K. Total quality in health care. Hospital Material Management Quarterly 1998; 19(4): Jackson S. Achieving a culture of continuous improvement by adopting the principles of self-assessment and business excellence. International Journal of Health Care Quality Assurance 1999; 12(2): EFQM. Self-Assessment. Guidelines for Companies. The European Foundation for Quality Management: Brussels, 1997.