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Purpose: Globally, healthcare managers continue to struggle with increasing demands for their services being delivered with limited or shrinking resources. It is, therefore, clear that systems, processes and practices need to change to meet these challenges. The purpose of this paper is to assess how integrating two improvement technologies, Lean and integrated care pathways (ICP) might help., Design/methodology/approach: Lean and ICP in healthcare provide a platform to develop conceptual frameworks for integrating two approaches., Findings: A conceptual integrated framework is provided to assist care pathway designers and implementers to consider the synergistic benefits of combining approaches to improvement., Research Limitations/implications: The authors provide a conceptual framework that requires empirically testing., Practical Implications: This research provides a conceptual framework to aid practitioners to improve healthcare design and delivery., Originality/value: For the first time, the authors bring together two approaches to improving patient care pathway design and consider how these are linked in relation to improving healthcare delivery.

Purpose The purpose of this paper is to study the effect of the implementation of Lean bundles on hospital performance in private hospitals in Jordan and evaluate how much the size of organization can affect the relationship between Lean bundles implementation and hospital performance. Design/methodology/approach The research is considered as quantitative method (descriptive and hypothesis testing). Three statistical techniques were adopted to analyse the data. Structural equation modeling techniques and multi-group analysis were used to examine the research's hypothesis, and to perform the required statistical analysis of the data from the survey. Reliability analysis and confirmatory factor analysis were used to test the construct validity, reliability and measurement loadings that were performed. Findings Lean bundles have been identified as an effective approach that can dramatically improve the organizational performance of private hospitals in Jordan. Main Lean bundles - just in time, human resource management, and total quality management are applicable to large, small and medium hospitals without significant differences in advantages that depend on size. Originality/value According to the researchers' best knowledge, this is the first research that studies the impact of Lean bundles implementation in healthcare sector in Jordan. This research also makes a significant contribution for decision makers in healthcare to increase their awareness of Lean bundles.

Purpose: The purpose of this paper is to describe changes and results obtained after implementation of a quality management system (QMS) according to ISO standards in a Hospital in the Home (HIH) Unit., Design/methodology/approach: The paper describes changes made and outcomes achieved. This took part in the HiH Unit, Clinico Hospital, Madrid, Spain, and looked at admissions, mean stay, patient satisfaction, adverse events, returns to hospital, no admitted referrals, complaints, compliance to protocols, equipment failures and resolution of urgent consultations., Findings: In June 2008, HiH Unit, Clinico Hospital obtained ISO certification. The main results achieved are as follows. There was an increase in patients' satisfaction--in June 2008, assessment of the quality of care provided by staff was scored at 4.7 (on a scale of 1 to 5); in 2010 it has been scored at 4.96. Patient satisfaction rate has increased from 92 percent to 98.8 percent. No complaints from patients were received. Unscheduled returns to hospital have decreased from 7 percent to 3 percent. There were no medical equipment failures. External suppliers' performance has improved. Material and medication needed by staff was available when necessary. The number of admissions has increased. Compliance to protocols has reached 97 percent. Inappropriate referrals have decreased by 8 percent. Six medications-related incidents were detected; in two cases the incident was not due to an error. In the other four cases error could have been detected before reaching the patient., Originality/value: Implementations of an ISO quality management system allow improved quality of care and patient satisfaction in a HIH Unit.

Purpose: The purpose of this paper is to determine the significant factors that cause delays in surgery operations in a hospital and factors that affect productivity of surgery clinics., Design/methodology/approach: Data are collected from surgery clinics of an international hospital to identify main factors that affect delays in surgery operation. A design of experiment is then performed and the significance of the effects of these factors is determined. A regression model was also developed to find a relation between surgery delays and the selected factors., Findings: The results show that such factors as the type of doctors and missing information significantly affect the delay in surgery operations as compared with some other factors, such as admission time considered in the study., Research Limitations/implications: The models developed and the results obtained in this paper are specific to the application presented. However, the procedures are general and can be applied to similar problems., Practical Implications: The results of the study can be used to control important factors to reduce the delays in surgery operations, reduce risks in patient health related to these delays, reduce hospital costs and improve the productivity of these clinics., Originality/value: The paper considers a management problem related to surgery delays which has not been considered before and presents a procedure to study the causes of the problem. It provides a methodology that could be used to study similar problems in health care management systems and to improve these systems by analyzing operations and activities with respect to the factors that affect productivity and efficiency of such operations.

Purpose: The key factor for the success of total quality management programs in an organization is focusing on the customer. The purpose of this paper is to assess customer focus level following implementation of a quality improvement model in social security hospitals in Tehran Province., Design/methodology/approach: This research was descriptive-comparative in nature. The study population consisted of the implementers of quality improvement model in four Tehran social security hospitals. The data were gathered through a checklist addressing customer knowledge and customer satisfaction., Findings: The research findings indicated that the average scores on customer knowledge in Shahriar, Alborz, Milad, and Varamin hospitals were 64.1, 61.2, 54.1, and 46.6, respectively. The average scores on customer satisfaction in Shahriar, Alborz, Milad, and Varamin hospitals were 67.7, 65, 59.4, and 50, respectively. The customer focus average scores in Shahriar, Alborz, Milad, and Varamin hospitals were 66.3, 63.3, 57.3, and 48.6, respectively. The total average scores on customer knowledge, satisfaction and customer focus in the investigated hospitals proved to be 56.4, 60.5, and 58.9, respectively., Originality/value: The paper is of value in showing that implementation of the quality improvement model could considerably improve customer focus level.

Purpose: The purpose of this paper is to study the appropriateness of applying "manufacturing sector" quality management strategies to residential care homes sector and to analyze its influence on the quality of care., Design/methodology/approach: Observation and in-depth interviews were conducted with 41 Spanish care home top and middle managers, consultants and employees., Findings: The quality management paradigm based on ISO 9001 has certain shortcomings in the elderly residential care home sector. There is a need to fit general quality management models to the sector's specific characteristics and to integrate generic quality management with specialized models., Practical Implications: Research findings should be noted by different agents involved in the process of improving services., Originality/value: Useful, up-to-date conceptual overview for different agents interested in the sector (managers, consultants, academics, etc.) as well as interesting evidence for reflection.

Purpose: Medical and policy literature reports many six sigma applications at specific healthcare organizations. However, there is a lack of studies that investigate the broader status of six sigma in US healthcare systems. The purpose of this paper is to present the results from a national survey of six sigma programs in US healthcare organizations., Design/methodology/approach: Through the design, distribution, and analysis of a nationwide survey, this paper assesses the implementation of six sigma in healthcare facilities. Two sets of surveys were designed based on whether an organization has adopted six sigma or not., Findings: Findings from this paper indicate the common six sigma projects implemented in healthcare organizations, typical implementation durations, cost benefits, and major barriers in implementation, and so on., Research Limitations/implications: This paper is limited by the low-response rate owing to time and budget constraints. Through the dissemination of this paper, it is hoped that more organizations will become interested in this subject and participate in future studies., Originality/value: This work is the first study to investigate the implementation status of six sigma in US healthcare systems. It will share experiences amongst six sigma institutions and promote its application in many institutions. The findings will provide instructive information to six sigma practitioners and researchers, and particularly to health care management.

Purpose: The purpose of this paper is to suggest the fuzzy quality function deployment (QFD) method to assess LIFENET customers' spoken and unspoken needs in order to achieve the various objectives like: how to decide optimum portfolio for health services strategically; how to assess competitors' market position in order to reckon the market position of LIFENET; and how to set the revised target in order to satisfy the customers' demand and to fetch profit in order to satisfy managers' mission and vision in a competitive market., Design/methodology/approach: A fuzzy QFD method has been devised to take care of the various LIFENET objectives. Fuzzy logic's use has been recommended to remove the uncertainty, vagueness, and impreciseness from data obtained to assess customers' spoken and unspoken needs. Symmetric triangular fuzzy numbers (STFNs) may be used to assess various needs to enhance data accuracy. House of quality (HOQ), an in-built QFD matrix, may be constructed to take care of LIFENET's various requirements in order to satisfy internal and external customers., Findings: Fuzzy QFD plays a vital role in assessing customers' need in terms of WHATs. Various WHATs thus obtained can be accomplished by incorporating technical parameter HOWs'. The QFD HOQ offers various vital comparisons for instance, WHATs vs HOWs, HOWs vs HOWs, NOWs vs WHATs, etc. to obtain important inferences, which help to revise target to remain competitive in the market Fuzzy QFD helps devise a management strategy to follow customers' needs in health industry successfully., Originality/value: Accessing Indian customers' needs poses many challenges as the decision to opt for a given healthcare service is most uncertain because it varies from person to person. The set of parameters that influence individual decisions to opt for healthcare services are costs, treatment response time, disease/risk, and health service satisfaction. Fuzzy QFD may help LIFENET promoters to consider customers' favored health services thereby helping strategically in their attempt for major expansion, in order to get the most benefits of becoming first-movers in the sector. Fuzzy QFD may also help LIFENET to avert major investment decisions that looked attractive in short-term, but in fact were unfruitful, in long-term.

Purpose: To examine the major factors affecting patients' perception of cumulative satisfaction and to address the question whether patients in Egypt and Jordan evaluate quality of health care similarly or differently., Design/methodology/approach: A conceptual model including behavioural dimensions of patient-physician relationships and patient satisfaction has been developed. As the empirical research setting, this study concerns three hospitals in Egypt and Jordan. The survey instrument in a questionnaire form was designed to achieve the research objectives. A total of 48 items (attributes) of the newly developed five quality dimensions were identified to be the most relevant. A total of 224 complete and usable questionnaires were received from the in-patients., Findings: Hospital C has above-average total and dimensional qualities and patients are the most satisfied in accordance with all dimensions of services. Hospitals A and B have under-average total qualities as the majority of patients are not satisfied with services. Comparing hospitals A and B, in the majority of dimensions (with the exception of Q5), the quality in hospital B is higher than in hospital A. Patients' satisfaction with different service quality dimensions is correlated with their willingness to recommend the hospital to others. A cure to improve the quality for health-care services can be an application of total relationship management and the 5Qs model together with customer orientation strategy., Practical Implications: The result can be used by the hospitals to reengineer and redesign creatively their quality management processes and the future direction of their more effective health-care quality strategies., Originality/value: In this research a study is described involving a new instrument and a new method which assure a reasonable level of relevance, validity and reliability, while being explicitly change-oriented. This study argues that a patient's satisfaction is a cumulative construct, summing satisfaction with five different qualities (5Qs) of the hospital: quality of object, processes, infrastructure, interaction, and atmosphere.

Purpose: The aim of this article is to show how Taguchi methods can be applied to health care., Design/methodology/approach: The quadratic loss function is at the heart of Taguchi methods. It is a powerful motivator for a quality strategy and can be used to adequately model the loss to society in health care. It also establishes a relationship between cost and variability. Therefore, it can be integrated with the performance and parameters of the design of medical applications. Signal-to-noise ratios give a sense of how close is the performance to the ideal. By maximizing the signal-to-noise ratio, quality-engineering activities can be aimed at identifying near-optimum levels of factors and making quality equal to zero., Findings: This article shows that, when the patients' requirements are consistently met, lower losses can provide an impetus to improve patient satisfaction., Originality/value: The article outlines areas in health care where Taguchi methods can easily be applied.

Purpose: This paper sets out to analyse the use of the Six Sigma methodology to improve quality in healthcare. It looks at how Six Sigma grew out of the concept of Total Quality Management (TQM)., Design/methodology/approach: Six Sigma is a quality improvement methodology that has been widely adopted by companies since the early 1990s and has grown exponentially in the healthcare industry during the past five years. Some of the main tenets of Six Sigma have emerged from the principles of TQM, including the notion that the entire organization must support the quality effort; that there should be a vigorous education effort; and that a quality improvement process should emphasize root cause analysis., Findings: In spite of its early success, TQM "crashed and burned" for several reasons including the fact that financial benefits were difficult to assign to TQM efforts, root cause was not always determined resulting in recurring errors, there was no common metric to measure the level of quality attained, and quality efforts were sometimes aimed at processes or operations that were not critical to the customer. Six Sigma filled the vacuums created by these TQM failures in several ways. Under the Six Sigma methodology, quality improvement projects are carefully defined so that they can be successfully completed within a relatively short time frame. Financials are applied to each completed project so that management knows how much the project saves the institution., Originality/value: On each project, intense study is used to determine root cause analysis; and in the end, a metric known as "sigma level" can be assigned to signify the level of quality. Six Sigma has a "critical to quality" dimension that keeps the quality effort focused on improving only those things that really matter to the customer.

Purpose: This paper aims to introduces a measure to assess the perceived effectiveness of multi-hospital organizations (MOs)., Design/methodology/approach: A sample of top managers of non-profit hospitals serves as the study setting. Data were collected via mail surveys. Usable responses were obtained from 189 hospitals. The measure was developed by considering the instrumentality and effect components of a set of relevant motives for joining an MO. During the course of the study, three alternative formulations were examined., Findings: Results show that the measures based on effect alone and a multiplicative combination of effect and instrumentality demonstrate sound psychometric properties. The recommendation here is to adopt the latter measure., Research Limitations/implications: The study was limited to a particular sample. Replications among other samples are needed to validate the current findings. Also, because the exact content of the objective function of a hospital for joining an MO is not necessarily constant over time, there is a need to conduct similar studies on a periodic basis., Practical Implications: The measure recommended here uses multiplicative/weighted instrumentality and effect scores as opposed to only the instrumentality or effect scores. This makes it possible to go beyond the mere "why" or "how" questions. Simultaneous consideration of instrumentality and effect dimensions affords a richer and more relevant understanding., Originality/value: Valid and reliable measures of performance are critical for both managerial and research purposes. The measure proposed in the current study could be used in structural equation models to investigate the effect of individual actions on performance and the impact of performance on other outcome measures (e.g. intentions to stay in an MO).

Purpose: The purpose of this article is to present one example of how the strategies of total quality management (TQM) and continuous improvement are being used by US health care providers to meet the challenges of the future., Design/methodology/approach: This article presents an application utilizing the strategies of TQM and continual and rapid improvement in the area of assessing internal customer satisfaction in the health care arena. Satisfaction information concerning internal processes is critically important to the health care provider, and this article presents the development and application of an instrument designed to provide timely and relevant internal customer satisfaction information to individual health care providers. This provides information on problem identification and improvement opportunities for a world-class continuous improvement program., Findings: The article finds that customer satisfaction is increasingly being recognized as an appropriate measure for determining how well a particular organization is accomplishing its mission and, while customer satisfaction surveys provide valuable information and may be used to improve the entire operation, they provide limited insight into the details of the inner workings of each cost center. Each of the measures discussed in this article is potentially equally insightful and may provide more directly usable information when applied to internal customers., Originality/value: This article provides useful information on providing customer satisfaction in the health care arena.

This paper describes several approaches for implementing quality improvement initiatives to improve patient satisfaction, which enables health-care organizations to position themselves for success in today's global and increasingly competitive environment. Specifically, measuring the views of patients, improving patient satisfaction through a community-wide effort, and using a Six Sigma program are discussed. Each of these programs can be an effective mechanism for quality improvement. A key component to quality improvement techniques involves collaborative efforts by all health-care professionals and managers as they seek to increase patient satisfaction.

The purpose of this paper is to present the idea of a national health quality plan as a way of mobilising and organising effort towards quality improvement, and stimulate debate and interes in the West in the subject, showing how quality improvement can be developed and invigorated by engaging in issues arising from quality strategies in developing countries. Considers why developing countries are concerned to improve the quality of health care and the different methods which can be used. Stresses the importance of recognising the starting-point and what can help and hinder this work. Concentrates on improving the quality of health care, rather than the wider and important question of improving health. Concludes that developing countries do have the exerptise and that extra resources are needed, mostly for training and supervision. Opines that if implementation is not managed then the investment will be wasted.

Problem-solving teams, involving front-line staff, are widely used to achieve continuous process improvement. Approaches such as "plan-do-study-act" (PDSA) cycles, are now a core element of many health-care improvement initiatives. This paper evaluates the use of PDSA improvement cycles within the UK National Health Service, using emergency care improvement activity as a source of research evidence. It was found that, despite an abundance of information on how to implement this type of change, many senior professionals still misinterpret how this should work. This has implications for how such methodologies are implemented. There is a long way to go in allowing greater employee involvement, moving much further away from the "management committee" style of change. Care has to be taken to ensure that empowered employees are working to consistent and appropriate objectives. It is important that senior personnel develop process understanding alongside the workforce, rather than simply providing distant support.

In the face of increasing pressure to improve patient satisfaction, the health-care industry must continue to seek improved methods to measure the effects of its continuous improvement efforts. While measurement instruments in this area abound, most are global in perspective and inflexible in form, sometimes leading to less than optimally germane outputs. Patient satisfaction information is critically important to the health-care provider, and this paper presents the results provided by an instrument that was locally designed to provide the most utile aggregation and presentation of patient satisfaction information for individual health-care providers. These results provide substantial evidence to support the notion that local, rather than global, measurement instruments are needed to provide the most relevant and useful results when assessing patient satisfaction as part of a continuous improvement effort.

Reports on the authors' experience with a patient safety quality improvement program, intended to reduce the incidence and severity of adverse outcomes for emergency department (ED) patients aged > or = 75. The Identification of Seniors at Risk scale was used for screening, and those at high risk were referred for appropriate intervention. The plan-do-study-act improvement cycle was followed, conducting process evaluation to diagnose and correct implementation difficulties. Reports that: implementing an ED screening and referral program is deceptively difficult; process evaluation multidisciplinary working group meetings are an essential improvement tool; screening inclusion criteria had to be adapted to the subject population in order to make efficient use of staff time; the screening questions and process required ongoing assessment, revision, and local adaptation in order to be useful; and high-risk screening in the ED is critical to a hospital system's ability to anticipate clinical problems; the plan-do-study-act improvement cycle is a practical and useful tool for improving quality and systems in a real care setting.

There is an increasing need of a model for the process-based performance measurement of multispecialty tertiary care hospitals for quality improvement. Analytic hierarchy process (AHP) is utilized in this study to evolve such a model. Each step in the model was derived by group-discussions and brainstorming sessions among experienced clinicians and managers. This tool was applied to two tertiary care teaching hospitals in Barbados and India. The model enabled identification of specific areas where neither hospital performed very well, and helped to suggest recommendations to improve those areas. AHP is recommended as a valuable tool to measure the process-based performance of multispecialty tertiary care hospitals.

In this article, the total quality programme in the Spanish healthcare system (1986-1992) and the subsequent quality improvement steps that have led to definition and implementation of such an integrated framework, seeking a quality management system and patient safety, are discussed.

Voluntary organisations are an integral part of community care, and the available research indicates the value of their social support role. However, surprisingly little is known about the forms and functions of this support, or the links to the formal support provided by the National Health Service (NHS), so hampering quality improvements. Therefore, a small sample of voluntary service organisations in one English county participated in a pilot study. This involved the staff and users of these organisations, and a geographically linked sample of NHS mental health professionals. Interview data indicated that the voluntary sector users and staff held similarly positive views of the appropriately varied forms and functions of the provided social support, and all participants held unusually similar and positive views of their links, although areas for improvement were suggested by both groups (e.g. links to GPs).

States that finding an effective method for helping teams to make better use of time is critical to the delivery of the current policy agenda within the UK National Health Service (NHS). Details the introduction of a communication technology into the work of the NHS, piloted by the Learning Alliance, a virtual team of development staff providing support to over 100 organisations, which hopefully will help solve the problem of time wastage. Concludes that the key to successful technology supported collaboration depends not only on the technology, but also on the organisation's ability to adopt an entirely new way of working.

Explores whether the EFQM Excellence Model provides a suitable framework for quality management within the pharmacy department at Hope Hospital, Salford Royal Hospitals NHS Trust. Research involved a literature search of the work of authors in the field of quality, generically and in healthcare, the development of quality awards, and practical cases of implementation of the model in NHS Trusts. Common themes were identified from this search. Interviews with staff and customers showed high levels of customer awareness, customer satisfaction and generic training. This was compared with the data from the literature search and the researcher's observations. The Excellence Model was seen to be a suitable framework for quality management provision, although there was little knowledge of it in the pharmacy department. A quality service was still being provided in spite of this, but the model could build further on this good work and provide a more structured approach.

The aim of this study was to assess whether clinical guidelines complied with the instructions for writing structured care management tools in a French university hospital. A cross-sectional study of guidelines for appropriate antimicrobial agent use in the authors' institution was carried out. A total of 221 guidelines were retrieved in 62 hospital units. The number of guidelines by unit ranged from one to 22 and 198 guidelines (90 per cent) had been developed at the local level. None of the guidelines fully complied with the ten criteria of the instructions. Each guideline met, on average, 4.2 criteria (3.9-4.5). The partial compliance rate was 75 per cent (68-80). In two-level multivariate analysis, factors associated with partial compliance were: dissemination of guidelines after implementation of the instructions (odds ratio = 6.25 (2.41-16.21)), existence of more than one storage site for guidelines in each unit (OR = 3.26 (1.03-10.32)), and hospital unit (variance of the intercept = 1.54).

Even though the balanced scorecard (BSC) has become a highly popular performance management tool, usage in local public sector National Health Service (NHS) organisations is still rare. This paper conditionally outlines some grounds in supporting such usage. In particular underlying conceptual concerns with the BSC system and its implementation pitfalls require full consideration. This paper then outlines some factors to be taken into account for "successful" BSC implementation in a NHS multi-agency setting. These findings emerged from a series of focus groups that took place with contributors drawn from all the key organisations within the Bradford Health Action Zone. Finally, this paper argues that if key criteria are met, successful implementation of the BSC may then proceed. However, "blind" BSC implementation without consideration of these factors may result in potential "failure".

The new realities of the healthcare marketplace are forcing healthcare decision makers to implement innovative operational philosophies, techniques, and tools that were proven in other industries to enhance the effectiveness of their organization. This study examines the acceptance and effectiveness of these philosophies, techniques, and tools in a hospital operational setting. The impact of implementation on operational and strategic outcomes is examined for 108 hospitals. Overall, the results of this study appear to indicate that certain quality improvement philosophies, techniques, and tools have been successful when applied in a hospital operational setting.

Describes a process to assess facilities management (FM) process capabilities: the structured process improvement for construction environments--facilities management (SPICE FM) approach. The SPICE FM framework is a method that FM organizations can use to monitor continuously and subsequently improve their performance. The SPICE FM framework is being tested in a series of case studies to ensure that its outputs are appropriate to the FM sector and of value in the real world. Documents the outcomes of a study undertaken at a facilities directorate of a healthcare NHS trust, in searching its applicability within the NHS. Further describes the study methodology and the key activities undertaken and reviews the key communication and management processes that are in place to support the implementation of the strategic FM objectives within the specific NHS facilities directorate.

The RAF method for regulation, assessment, follow-up and continuous improvement of quality of care was developed in Israel in the late 1980s by the Quality of Care Unit at the JDC-Brookdale Institute. The goal of the RAF method is to continuously increase the level of quality of organizations providing any kind of a service. This article presents the developmental processes for the method's adaptation to a specific regulatory service--its structuring, implementation and assimilation--based on our experience in developing and implementing the RAF method in Israel. It describes how the RAF method encourages the development of reliable data bases, adaptation of the organizational structure, and introduction of a positive ideology that together promote changes leading to continuous improvement in quality of care.

In response to residents' reports of inefficiencies in the Veterans Administration (VA) system, a temporary task force of quality control circles was implemented at a VA hospital. A total of 25 internal medicine residents, on rotation at the VA, were subdivided into four groups. Each group was presented with a different problem, given the components and constraints of the problem, and asked to identify possible solutions. Program results were submitted to the hospital administration. Efforts are now being made to improve the working environment for medical residents.

The RAF method for regulation, assessment, follow-up and continuous improvement of quality of care was developed in Israel in the late 1980s by the Quality of Care Unit at the JDC-Brookdale Institute. During the past decade the RAF method has been adapted to and implemented successfully in a number of government regulatory systems operated by services in the Ministry of Health and the Ministry of Labor. This article presents the conceptual framework of the RAF method. It describes the three theoretical approaches that have been integrated--the tracer approach, the model for quality assurance and the introduction of organizational change--to create a broad conceptual framework. It then presents the key operational principles at work in the field that drive the RAF mechanism in its efforts to achieve a constant improvement in quality of care.

The UK NHS quality proposals require all NHS organisations to develop an "integrated approach " to quality. In other countries, health care organisations are also working to ensure that the many different quality methods and systems used in health organisations do not duplicate or conflict with each other. The question this paper addresses is "what would an integrated approach to quality look like and how might managers and clinicians develop such an approach in their organisation?" The findings from the Norwegian total quality management experiment in six hospitals were that TQM could not be applied in its pure form in public health care services to ensure integration. The paper draws on this research to describe these hospitals' approach to integrate the different projects and systems which were stimulated by their initial quality programmes. The paper describes the "integrated quality development" approach which characterised these programmes.

One of the most important instruments for gathering information and processing data relating to professional and organisational quality in health systems is "healthcare processes classification". The authors found that a typical problem of many European countries is a lack of reliable information in the field of healthcare, mainly because the development of quality instruments, including healthcare processes classification, is not a priority for medical and other health professions. Additionally, it is difficult to update this instrument coherently with organisational changes and developmental achievements. This article describes the approach used by the University Medical Centre in Ljubjana, Slovenia, to redesign its healthcare processes classification in order to improve the quality of healthcare.

With a defined population served, contracted provider panels and the nature of care delivery integration, managed care has provided a solution, though not a panacea, to provide equitable services, standardized and prevention oriented cares to its enrolled members. Combined with the earmarked capitation reimbursement system and a series of cost containment and utilization review techniques, managed care has also demonstrated potently its capacity in cost-saving and quality promotion. Presents steps and measures related to managed care that federal government has taken to manage care and contain cost. It is crucial to identify and promulgate best practices continually, while managing utilization of resources for improving health care, containing cost, and equalizing medical care access to a greater proportion of the population. Concludes that it may take time for a universal adoption of managed care. However, Americans may actually benefit more from having a standard level of health care that managed care could achieve and provide.

Society now expects more from its doctors and dentists, and these increasing demands can be summed up in one relatively new term for the medical profession: "quality management" (QM). Doctors and dentists formerly took the view that their performance could be assessed solely on the basis of their technical skills, ethics and expertise, but are now confronted with a new social imperative, from outside the profession--quality management. The author, prize-winner of the European Quality Award 2000 describes his approach to introduce the European Foundation for Quality Management (EFQM) Excellence Model in his dental practice. He shows that the EFQM model is well suited as a basis for a quality management system in healthcare.

Diagnostic tests are widely used in many areas of modern technological society, but they are of particular importance in medicine, where early and accurate diagnosis can decrease morbidity and mortality rates of disease. How the quality of diagnostic information and decisions should be measured in a meaningful way has become increasingly important in recent years as an abundance of new diagnostic tests have been introduced. A number of seemingly independent indices are studied for evaluating diagnostic performance such as the receiver operating characteristic curves and signal-to-noise ratios. Designing robustness into diagnostic tests can only be achieved by minimizing the variation in the total number of false diagnosis. This article has undertaken a comparison of signal-to-noise ratios developed by Taguchi in quality engineering and system performance in manufacturing industry. A hybrid is also computed and its relevance to physicians as an efficient assessment method is proposed and strongly encouraged.

This article examines the appropriateness of the Business Excellence Model in developing a strategy for Bolton Hospitals NHS Trust to measure organisational performance. The need for a strategy to measure organisational performance and to improve organisational performance was highlighted with the production of the Government White Paper, The New NHS: Modern and Dependable. At the heart of recommendations there is emphasis on improving quality and driving efficiency. Greater emphasis will be placed on organisations measuring their performance. By utilising the conceptual framework, which consisted of The European Foundation for Quality Management (EFQM) Model, it became evident that, although tools were in existence within Bolton Hospitals to measure organisational performance, several critical areas needed addressing. By addressing these key areas, the organisation could begin to work towards its goal of business excellence. The conclusions drawn from this project demonstrated that there was scope for Bolton Hospitals to improve on organisational performance. It was highlighted that the Trust was functioning well in some areas of the EFQM Model, but not in others. For Bolton Hospitals NHS Trust to improve organisational performance, the EFQM Model should be adopted.

Wakefield and Pontefract Community Health NHS Trust uses the European Business Excellence Model self-assessment for continuous improvement. An outline of the key aspects of the model, an approach to TQM, is presented. This article sets out the context that led to the adoption of the model in the Trust and describes the approach that has been taken to completing self-assessments. Use of the model to secure continuous improvement is reviewed against Bhopal and Thomson's Audit Cycle and consideration is given to lessons learned. The article concludes with a discussion on applicability of the model to health care organisations. It is concluded that, after an initial learning curve, the model has facilitated integration of a range of quality initiatives, and progress with continuous improvement. Critical to this was the linking of self-assessment to business planning and performance management systems.

Different approaches to improve quality are used in organizations delivering health care. Donabedian introduced structure, process and outcome, from which other approaches like self-assessment, accreditation, visitation, International Standards Organisation (ISO) and European Foundation for Quality Management (EFQM) can be aligned. The EFQM model is one such approach that has been adopted and adapted by the Dutch Institute for Quality Management. This article describes the background and progress relating to the use of the EFQM business excellence model within Dutch health care organizations. In addition the process for applying for the European Quality Award and the Dutch Quality Award are described in detail. Finally, the reader is enlightened regarding the work of the European ExPeRT research group who are promoting the use of quality models within health care.

Measuring organisational effectiveness in a health care delivery context is a challenging task. Although there are numerous performance assessment models, audit tools and managerial diagnostic tools, they all tend to fall short in their attempts to closely scrutinize how health care organisations deploy their capabilities to deliver optimum quality in service provision and what performance levels they achieve as a result of their approach. The project reported here attempted to address the aforementioned issues. It set out to examine health care providers from an integrated perspective and to assess the key drivers of effective organisational performance using an adapted model based on the 7s' principles. The research project culminated into a major report highlighting best practices found to be inherent in 18 well performing health care providers. This paper reflects the experience of one of a series of Trusts whose approach to organisational effectiveness was closely examined.

Objective/design: An increase was noted in the incidence of needlestick injuries in our institution. A retrospective study was carried out analyzing the accident reports and medical records of needle-stick injuries from January 1995 to July 1996. Study variables included monthly incidence; location; injury site; mechanism; staff vocational status; source virological status; staff immunity; and serological conversion to hepatitis B and C viruses and the human immunodeficiency virus (HIV)., Setting: 350-bed general hospital in Western Saudi Arabia employing 2,083 employees of many different nationalities., Results: 126 injuries were identified. Thirty percent of injuries occurred in the operating room and 28% on general wards. Twenty-five injuries occurred during a surgical procedure in the operating room, 22 injuries were caused by undisposed sharps, 11 occurred during suturing, 11 occurred during injection, and 10 occurred while disposing of refuse. At least 38% of the injuries were avoidable. Sixty percent of those injured were nurses, 30% were medical staff, and 6% were housekeeping staff. Nine of the identifiable sources were hepatitis B surface antigen-positive, nine were hepatitis C antibody-positive, and none were anti-HIV positive. Eighty-nine percent of injuries involved the hands. None of our injured employees had seroconverted at 3, 6, or 9 months follow-up to HIV, hepatitis C, or hepatitis B. Eighty-four percent of injured staff were hepatitis B immune., Conclusion: Steps taken to reduce the future incidence of injuries included the provision of readily accessible sharps boxes, a hospitalwide education program focusing on safe handling and disposal of sharps, and the development of clear policies and procedures for dealing with sharps injuries. A further study will be conducted 12 months after the introduction of these measures.

This article looks to review recent practice undertaken within the UK hotel sector to improve customer service, and suggests ideals that could be implemented within National Health (NHS) Trust hospitals. At a time of increasing competition, hotel firms are using service enhancement as a means to gain competitive advantage, and therefore developing a range of techniques to measure levels of service quality improvement. With continued change in the health service, where greater focus now lies with patient satisfaction, so there is a requirement for managers to adapt techniques presently being offered in other service industries to improve levels of customer service and ensure patients are targeted to define their levels of satisfaction.

This article describes the journey of managing the change from seven separate health providing units to one overall team providing a range of services. To facilitate the change the Malcolm Baldrige National Quality Award self-assessment model was used. The benefits and limitations of the model are described as are the activities undertaken to achieve a goal of delivering quality care within a customer driven rather than service driven focus. Finally the learning gained from the change is shared in an attempt to help others undertaking a similar journey.

The EFQM model for organisational excellence is used in the health care sector as a tool to diagnose and assess the starting position for the effective QM programme. Feedback reports cover the fields of acute medical care, rehabilitation and ambulant care and contain strengths areas for improvement. Building on the EFQM feedback reports, the Modular Concept for Quality in Health Care ("Heidelberg Model") improves QM both holistically and specifically by implementing so-called "Modules for Excellence". The implementation process follows principles of project management covering medical, nursing and managing issues and the performance is periodically evaluated against targets. QM projects that are designed in the dichotomic way follow three goals. Organisational diagnosis and therapy lead to numerical health care improvements in "Prevention of nosocomial infections" and "Optimising out-patient treatment". Different assessment approaches lead to a diagnosing feedback report for QM in health care. The Modular Concept for Quality in Health Care ("Heidelberg Model") clusters, priorities, implements and evaluates the organisation's key areas for improvement.

A reappraisal is made of the relevance of industrial modes of quality management to the issues of medical care. Analysis of the nature of medical care, which differentiates it from the supplier-client relationships of industry, presents the main intrinsic characteristics, which create problems in application of the industrial quality management approaches to medical care. Several examples are the complexity of the relationship between the medical action and the result obtained, the client's nonacceptance of economic profitability as a value in his medical care, and customer satisfaction biased by variable standards of knowledge. The real problems unique to hospitals are addressed, and a methodology model for their quality management is offered. Included is a sample of indicator vectors, measurements of quality care, cost of medical care, quality of service, and human resources. These are based on the trilogy of planning quality, quality control, and improving quality. The conclusions confirm the inadequacy of industrial quality management approaches for medical institutions and recommend investment in formulation of appropriate concepts.

The introduction of critical paths, generically referred to as clinical paths, into the planning, delivery, documentation, and evaluation of patient care provided a tangible method for clinical experts to identify elements they collaboratively perceived to represent a stable, predictable, patient-care episode. Variance is the difference between the planned, stable process for a homogeneous group of patients and the actual, individual, unique care delivery experience. Building the formal use of both task (intervention) and outcome variance into a clinical path approach is fundamental to the individualization of care given concurrently and the creation of an aggregate database for retrospective evaluation, continuous quality improvement, and research. As clinical paths have become more accepted and sophisticated over the last decade, the use of variance also has evolved, albeit one step behind. Variance from length of stay and task (intervention)/resource still predominates clinical path application and literature. Real progress in healthcare practice will not be made until variances from measurable intermediate goals and patient responses and outcomes are combined with other data and transformed into knowledge. The use of variance, from past to future stages, provides a mirror of the transformation of healthcare delivery in the United States and other countries.

Patient satisfaction is becoming increasingly important for the successful operation of private and public hospitals. The quality of the service provided can be improved if internal and external customers' opinions are taken into account during the definition of hospital operating objectives. This research presents a new methodology, called the simulation service quality system (SSQS), developed to improve operating performance measures in the light of customer preferences. The motivation for the development of the SSQS methodology arose from the need to achieve timeliness standards at United States Veterans' Hospitals. The Harry S. Truman Memorial Veterans' Hospital in Columbia Missouri served as the validation and initial application site for the SSQS methodology. Details one such project: the objective of reducing customer waiting times to 30 minutes or less at an outpatient treatment clinic. Through the identification of relationships and interactions, discrete-event simulation techniques are applied to model and experiment with the system to ultimately arrive at recommended changes in hospital operating policies which achieve the objective.