1.

LEADERSHIP

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

1 LEADERSHIP MISSION
Zumarraga Hospital is a public hospital of Osakidetza / the Basque Health Service,
INTRODUCTION
providing specialised healthcare to improve the health of the population and meet the
Prior to 1998, the concept of leadership in Zumarraga Hospital (ZH) needs and expectations of its customers.
was that of the traditional chain of command over employees. In the To do so, we will follow and develop a philosophy of Continuous Improvement, in
course of 1998, as a direct consequence of self-assessment against terms of:
the EFQM Excellence model and strategic review, this concept was • The involvement and professional development of those who work in the
assessed and reviewed on the basis of what type of leadership ZH hospital;
would need to develop our strategy and deliver our Mission. As a result • Efficiency and financial equilibrium;
of this reflection, the Management Team (MT) developed a new • Promoting global improvement of the Health System through innovation,
approach based on shared leadership among our people. A ZH leader teaching and cooperation with other organisations.
was defined as a person who has other employees reporting to VISION
We aspire to being a hospital of Excellence, continuously improving in professional
him/her, and who involves and coordinates them to deliver the
and technical terms and fully satisfying the needs of Society, our people and
hospital’s goals and objectives to thus meet the needs and especially of our customers.
expectations of the customer and of the Health System. VALUES
In 1999, also as a direct consequence of self-assessment in 1998, We work for the patient Results focused
we adopted management by processes as a key element of change. Mutual respect Commitment to innovation
This system was chosen for its capacity to bring together and integrate Teamwork Sense of belonging
strategy, processes and results, and for the possibilities it offers in Open communication Consensus
terms of involving people in continuous improvement. At the same Figure 1a-1: MISSION, VISION & V ALUES (MV&V)
time, the concept of leadership in ZH was subject to another review the development of the ZH Mission and Values. The Mission and Vision are
cycle, culminating in the new concept of process leader (1a), referred to developed within the global management system, beginning with their
as PL, as the person responsible for continuous improvement of his/her definition and moving through to the stage where they are translated into
process. The immediate consequence of this was that 71 people goal-based strategies, which are themselves further detailed in terms of
became leaders, though 34 of these had no MT or Unit responsibility. Critical Success Factors (CSF), process objectives and indicators (2c).
Leadership is systematically assessed and reviewed through Processes are thus managed to deliver the Mission and Vision.
assessment against the EFQM Excellence model and through the
People’s Voice Process. This process is the vehicle through which Mission Stakeholders
Mission
people’s perception of leadership is measured and surveyed.
The development of a culture of Excellence in ZH is rooted in the Vision Customers
Vision Customers
commitment, belief, clear leadership and participation of our Chief
Executive (CE) and all other MT members in improvement activities. Values
Values
The acceptance of responsibility by all other ZH leaders, and the
leadership style adopted by the hospital enable our people to feel People
People
Strategic
Strategic
involved in improvement, to develop a sense of belonging and to Plan
Plan
actively contribute to the delivery of the hospital’s goals and objectives.
As the purpose of this criterion is to explain the role and system of Business
Business Health
Health
leadership in ZH management, it is essential to be familiar with the Plan
Plan System
System
content of the other 4 enabler criteria if this is to be fully understood.
1a. LEADERS DEVELOP THE MISSION, VISION, VALUES Processes
Processes Results
Results Society
Society
AND ETHICS AND ARE ROLE MODELS OF A CULTURE OF Strategic
Key Results
EXCELLENCE Key
Definition of leadership EFQM
Suppliers
Suppliers
A
Support Assessment
In ZH, leadership is understood as a series of attributes which
enable people to accept responsibility for improving the way the
Figure 1a-2: ZH MANAGEMENT S YSTEM
people, resources and processes of the hospital are managed. The
The ZH management system, and the integration of Total Quality into
profile of a middle manager, or Unit Head, is a person committed to the
it, promotes the establishing of improvement priorities, teamwork,
goals and policies of the hospital, who provides the necessary results measurement and the use of innovation and learning for the
resources and information to deliver them, who provides and assesses continuous improvement of our strategy and activities. Numerous
training, who devolves responsibility to others and duly recognises examples of this can be seen throughout this submission document.
them, and who acts as a role model for those who report to him/her. The The MT and all other leaders stimulate and encourage a culture of
profile of a PL, with or without direct leadership responsibility, has been continuous improvement by promoting training in the EFQM model, by
defined as a person with: the will to improve, as this is voluntary; taking active part in the assessment of other organisations, by sharing their
knowledge of his/her process and the quality management tools knowledge with other Health Centres and by participating in working groups
available to improve it; and empowerment, or the degree of self- and congresses or contributing articles for publication. All ZH leaders are
management and responsibility given to him/her to improve (5a). involved in establishing and developing the Mission and Strategic Plan (SP).
Any ZH employee can be a leader. At the current moment in time, we Different mechanisms are used to systematically stimulate and develop
have 74 leaders, 18% of the total number of staff and a pioneer figure in people participation and empowerment to ensure the highest possible level
the Health Sector. This figure is broken down as follows: of leadership in the hospital (crit. 2, 3 and 5). Fig. 1a-3 shows step-by-step
- Steering Committee (5) the role of ZH leaders in this process, and the criteria in this document in
- Unit Heads (40) which these actions are detailed.

D
- Process Leaders (74, of which 5 are Directors and 37 Unit Heads). Leaders’ involvement cascades down the established
4 process teams, made up of 24 people, are currently being trained and organisation chart and command chain (Figs. 0-4, 2d-5). All
leaders are involved at one step or another of the process, either in
developed. This will broaden the scope of leadership in the hospital.
terms of participation, communication or management and assessment,
Development of the ZH Mission, Vision and Values
whilst the delivery of the MV&V involves all ZH people.
As can be seen throughout this submission document, the
unequivocal commitment and personal involvement of the CE and MT
members have been the drivers of the Total Quality culture in ZH and of
AR Leadership effectiveness is assessed every year by the MT.
Various mechanisms are used:

Zumarraga Hospital – Hospital de Zumarraga 3

 a) People satisfaction survey: A series of different items have been % Agreement
VALUES
progressively included since 1999 to assess the effectiveness of 1999 2001 2003
leadership in ZH from both a global and specific perspective. The layout We work for the patient 71 83 78
of the survey allows for middle managers to assess Management, and Mutual respect 67 86 90
for ZH people to assess middle management. Teamwork 47 61 63
Survey results are analysed in meetings with Management, Unit Heads and Open communication 48 58 67
healthcare professionals from different ZH Services. All relevant suggestions Results focused 25 77 91
from the survey are included in the BP (2a). The satisfaction ratings of a series Commitment to innovation - 63 74
of items from the survey are shown in Fig. 1a-4. As can be appreciated from Sense of belonging 35 81 91
this data, results in leadership effectiveness show a highly positive trend. Consensus - 59 69
SEQUENCE OF Figure 1a-5: % A GREEMENT WITH ZH VALUES
LEADERS’ ROLE REF.
MANAGEMENT ASSESSMENT TYPE /
YR IMPROVEMENTS
The MT and a team of ZH leaders and people review SOURCE OF LEARNING
the Mission, incorporating any previously undetected Participation of 3 leaders from the Technical
Mission stakeholder needs. Unit Heads and PLs disseminate 2a, 97 Committee in the formulation of the SP (1,3,4)
and check the validity of the Mission with team 2d Study of best practices in leadership, identifying
members. 1. Assessment by 98 the need to systematically assess and review
Management and a group of ZH people formulate the MT (1,3,6,7,8)
Vision. The contribution of non-leaders enriches the 2a, 2. Assessment by Inclusion of items on leadership effectiveness in
Vision
process in the respect that their perspective is different 2d PL people satisfaction survey (1,3,7)
from that of Management. Review of Mission (inclusion of suppliers) and
3. EFQM
Leaders work together to identify, review, 2a, 99 identification of values (1,5)
Values assessment
communicate and role-model ZH values. 2d Formulation of the Mission of each process (1,5,7,8)
4. Assessment by
The MT communicates hospital goals and reaches 2c, Dissemination of MV&V by leaders, with visual
Technical
Hospital Goals consensus agreement with Unit Heads and PLs for support (1,3,7)
2d Committee
their deployment in Units. Training of leaders in TQM (2,3,6)
The MT identifies the CSF for delivery of the goals, 2c, 5. People’s Voice 00 Mission included in in-house magazine to
CSF and Unit Heads and PLs develop the processes 2d 6. Training increase dissemination (2,5)
required to meet these goals. 7. Benchmarking Formulation of the Vision by more than 80 ZH
Leaders establish indicators and design the balanced 2d, 8. External expert people (1,7)
(Costa) 01 Modification of the people satisfaction survey to
BSC scorecards required for process monitoring and 5a
assessment, and inform their teams accordingly. 9. External expert assess leadership (1,2,5)
SWOT analysis The MT formulates the SP, and conducts a SWOT 2d, (Gesco) Formulation of the SP, involving the collaboration
10. Innovation 02 of over 80 ZH people (1,3,5,9)
and selection of analysis of internal and external factors to select the 5a
strategies most appropriate strategies to deliver ZH goals. Capital Model
03 Design of the leadership process (1,2,3,6,7,9)
The MT negotiates the Programme Contract with the Review of the ZH Mission (1,3,9)
Dept. of Health, communicates the Programme to
Programme 04 Study on incorporating the assessment of
hospital Units and monitors its progress. Unit Heads 2d personalised leadership (1,2,5,7,9,10)
Contract
and PLs are involved in the dissemination and delivery Figure 1a-6: E XAMPLES OF IMPROVEMENT CYCLES RELATED TO 1a.
of the Programme. One area for improvement identified through the 1998 assessment
The MT formulates and disseminates the Business against the EFQM Excellence model was the need to reflect the
Business Plan Plan (BP). Unit Heads and PLs participate in 2d organisation’s commitment to a quality culture in the form of a series of
establishing process objectives and indicators, and written Values. The following year, various items were included in the
inform their Units accordingly.
people satisfaction survey to measure our people’s perception of the
Management communicate the BP to all other ZH
Communication leaders, who in turn inform their people and drive 2d coherence of these values (Fig. 1a-5). 2001 and 2003 satisfaction ratings
improvement. are a reflection of the effectiveness of our management system.
Unit Heads and PLs ensure day-to-day management b) Qualitative assessment: contact with focus groups, with representatives
Monitoring and monitoring of plans, and establish any necessary 2d of ZH Services and the various communication channels used throughout
corrective actions. the hospital provide the MT with an instant snapshot of people’s perception
The MT and process teams and leaders coordinate at any given moment, thus enabling us to improve the approach and
and participate in process design, monitor and assess deployment of leadership.
process results against established targets and c) Sources of learning: Assessment against the EFQM model and expert
Process prioritise, lead, coordinate, participate in and provide 5 help provided by external assessors have enabled us over the years to
Management resources for improvements. Leaders participate
directly in specific improvement initiatives, such as check the implementation and effectiveness of our approach, and to
Clinical and Non-Clinical Committees, improvement establish improvement actions accordingly. Similarly, the contribution of
teams and working groups. external experts to improving our management system, benchmarking
Final assessment of the plans is conducted by the MT, leadership practices in other organisations such as ASLE, Irizar, Gasnalsa
Unit Heads and PLs, and documented in a report used (all 3 EQA Prize Winners) and Euskalit (The Basque Quality Foundation),
Assessment
to communicate the findings to stakeholders and as 2e and learning at technical seminars and from specialist publications have all
the basis for drawing up a new Plan. been instrumental in identifying and introducing improvements into our
Figure 1a-3: ROLE OF LEADERS IN THE MANAGEMENT S YSTEM management system (Fig. 1a-6).
% AGREEMENT * 1b. LEADERS ARE PERSONALLY INVOLVED IN ENSURING
P EOPLE S ATISFACTION S URVEY ITEMS
99 01 03 THE ORGANISATION’S MANAGEMENT SYSTEM IS
I trust in the decisions taken by the Management Team. 14 41 66
I trust in the decisions taken by the Head of my Unit. 44 64 71 DEVELOPED, IMPLEMENTED AND CONTINUOUSLY IMPROVED
The hospital’s strategy is being adjusted for improvement.
The Head of my Unit discusses with the team any projects
affecting our Unit.
16 51 69
--- 52 71
A Since 1992, on publication of the Osakidetza Integral Quality
Plan (Overview), Continuous Improvement has been
systematically established as the basis of management in ZH,
In my Unit, we cooperate with other Services to deliver the following the principles of Business Excellence. After analysing the
52 56 63
hospital’s goals experiences of other Health Centres and receiving encouragement
The Head of my Unit practices what he/she preaches 48 64 78 from Osakidetza itself, we decided in 1995 to adopt the EFQM
Figure 1a-4: RESULTS OF PEOPLE S ATISFACTION S URVEY ITEMS (* % agreement: % of Business Excellence Model as a reference framework for assessing,
people who responded “I totally agree” and “I agree”, discarding all neutral answers). learning, identifying and implementing areas for improvement into
our management system.
Zumarraga Hospital – Hospital de Zumarraga 4
 Continuous Improvement is embodied in the Mission and envelops the submission document. For example, the CE and other leaders give in-
whole management system (1a-1). It is, additionally, a strategic process, a house training every year to Unit Heads, PLs and other employees in
driver of improvement for the whole hospital (crit. 5). the EFQM model, management by processes, ISO certification and
The management system described throughout this submission TQM. The integration of a quality management culture in the hospital,
document is subject to improvement using the mechanisms shown in together with the training given to our leaders in management tools, has
Figs. 1b-1 and 1b-4. The improvement cycle begins with EFQM provided us with a solid base for improving our management system.
assessment, training and benchmarking, all of which contribute to
For example, in 2004, the hospital was chosen by Osakidetza to pilot
identifying areas for improvement. The first self-assessment exercise
their quick self-assessment model (Evalexprés).
was conducted towards the end of 1996, once the MT had been trained
The involvement of leaders in improving our management system also
appropriately in this activity, and proved to be a major source of
takes the form of actively stimulating and encouraging ZH people to
learning: 24 action plans were identified, incorporated into the BP and
participate in hospital improvement and work teams. All MT members
developed. The second self-assessment exercise was conducted in
take an active part themselves in these initiatives (Fig. 3c-2).
1998, as a result of which 5 areas for improvement were prioritised, one
of which was management by processes.
D The defined profile of ZH leaders (1a), coupled with their
involvement in the day-to-day business of the hospital, are the
essential ingredients for stimulating and encouraging our people to
RELEVANT participate in continuous improvement and the ZH management system.
EFQM SELF- INFORMATION All PLs and practically all Unit Heads drive improvement of the
BENCHMARKING
ASSESSMENT
Customer Voice processes which affect them. Deployment covers all the hospital’s
Primary Health processes. The methodology of management by processes
Care Voice
People’s Voice determines that a Mission statement be drawn up for each process,
Society’s Voice
TRAINING IN defining the “why, what and who” of each one (5a), and this has
LEARNING
MANAGEMENT Osakidetza Plan been done to cover all hospital activities. Over 90% of hospital
Dept of Health Plan
leaders participate in working groups and/or improvement activities.
This, together with the use of the model, training and benchmarking
have brought about the advances in our management system
MANAGEMENT AREAS FOR STRATEGIC PLAN described in Fig. 2-2.

AR
BENCHAMRKING IMPROVEMENT BUSINESS PLAN
In ZH, we use two systems to assess, review and
improve our performance in this area of management:
IMPROVEMENT
MANAGEMENT BY PROCESSES a)The system for assessing the approach itself helps to identify
MECHANISMS
IMPROVEMENT TEAMS areas for improvement and incorporate them into the management
system. This has led to improvements in self-assessment
Figure1b-1: MANAGEMENT S YSTEM & CONTINUOUS IMPROVEMENT methodology, increased participation in the Assessors Club and
After conducting another mini self-assessment exercise in 1999, broadened the scope of training for ZH leaders and people.
the MT decided to subject the ZH management system to external b)The system for leading and developing management-related
assessment. The submission document was prepared and compiled improvement. This has led to a wider definition of leaders in this
area (PLs, quality coordinators) and to an increase in the amount of
in the course of 2000 with the help and guidance of Osakidetza and
training in management for ZH people.
Euskalit, and this process in itself proved to be an important source
In this respect, in addition to qualitative assessment, a series of
of learning as this was a pioneer activity in the Health Sector. ZH
indicators are used to measure progress:
was subsequently awarded the Basque Govt. “Silver Q” for Quality
1. The people satisfaction survey includes items which enable us
(400-500 points after assessment against the EFQM model), and, 3
to measure the involvement of leaders in improvement (1b-2 & 7a-
years later, the “Gold Q” Award (500+ points against the EFQM
18).
model). These awards have proved to be a great stimulus for our
% AGREEMENT
people, and the submission documents are used as training material PEOPLE SATISFACTION SURVEY ITEM
01 03
both inside the hospital and externally for other healthcare
Considerable effort is being made to improve how the
organisations (Fig. 1c-6). 63 74
hospital is run.
Since 2000, the feedback reports from external assessment have 86 91
ZH people show an interest in working efficiently.
been used for prioritising and incorporating areas for improvement
Hospital users receive a high quality service. 83 83
into ZH plans. The findings of these reports were distributed to and Figure 1b-2: RESULTS OF P EOPLE S ATISFACTION S URVEY ITEMS
analysed by ZH employees, and were at the heart of the 2003 SP. 2. Assessment against the model has enabled us to assess our
The ever increasing number of ZH people who have trained as management in this area and identify areas for improvement (Fig.
assessors against the EFQM model and subsequently become 1b-3):
members of the Euskalit Assessors Club (6 people at the time of EFQM SELF -ASSESSMENT EXTERNAL ASSESSMENT
writing this document, all of whom conduct external assessments of 1997 371
other organisations), together with specific training and 1998 433 2000 401-450
dissemination activities of the model within the hospital and 1999 512 2002 450-500
participation of our people in benchmarking activities, have been 2004 643 2003 501-550
major factors in ZH people understanding and using the model. For Figure 1b-3: S CORES OBTAINED AFTER A SSESSMENT
example, prior to 2003, areas for improvement were prioritised by 3. The sources of learning used in this criterion have been
the MT on the basis of 4 criteria; impact on the customer, impact on covered in 1a (Fig. 1a-6). Some examples of improvements after
the organisation, viability and the need for improvement. Since assessment and review are shown in Fig. 1b-5.
2003, areas for improvement are prioritised according to their
impact on CSF and goals, and integrated into the SP and annual
BP.
Benchmarking and training in clinical, professional and management
related activities are considered essential for improving the
management system. Leaders are actively involved in developing these
activities, encouraging people to identify and implement best practices
and training initiatives, many examples of which can be found in this
Zumarraga Hospital – Hospital de Zumarraga 5
 MECHANISMS FOR IMPROVING THE MANAGEMENT SYSTEM
HOW ROLE OF LEADERS LEADERS EXAMPLES / EVIDENCE OF IMPROVEMENT
Conduct self-assessment against MT
Four self-assessment exercises since 1997 (Fig. 1b-3)
ASSESS

EFQM model Certification

EFQM

MENT

Prepare external assessment
Strategic Plan
Training of Management and
leaders in health management
MANAGEMENT
Coordinator Three external assessment exercises since 2000 (Fig. 1b-3)
MT / Others Use of the 2000 external assessment feedback report for formulation of SP
All Management and around 20 PLs have attended year-long training courses in management, and
PLs and Unit Heads specific training in management tools.

MT, PLs and Unit Leaders receive and give training in management improvement tools (EFQM Model, management by
TRAINING IN

Heads processes, communication, prioritisation of problems, ISO Certification, strategy planning, 5S

Training in management tools
Dissemination of EFQM
submission document
Articles in media
Visits to other organisations
Visits by other organisations
Tutoring organisations
BENCHMARKING
MANAGEMENT
Certification methodology, Total Quality, etc.)
Coordinator Guide to Process Management, drawn up by the CE and Certification Coordinator
2000 and 2003 submission documents given to all ZH people and used by leaders in 2002, with the
MT
aid of a guidebook on the Model, as training material.
MT Publication of articles on management, continuous improvement and results assessment.
All Deeper knowledge of best practices of other organisations.
PLs and Unit Heads The experience of explaining our management system to other organisations and tutoring over 15
MT hospitals and numerous healthcare professionals is a rich source of learning and knowledge.

Attendance at Courses and

All Constant updating with respect to clinical and management tools.
Scientific Seminars
Participation in working groups All ZH leader participation in various working groups with Osakidetza
Membership of organisations such as Euskalit (6 EFQM assessors, members of the 400 Club,
Collaboration with Associations, PLs and Unit Heads promoters of 5S), Board Member of SECA (Spanish Society for Quality in Healthcare), of the
International Society for Quality in Healthcare and of the Observatorio Ciudadanía (Citizens’
etc. MT
Watchdog) enables ZH leaders to keep up-to-date with the latest advances in technology and
management and to incorporate them into our management system.
Encouragement for leaders to identify and implement best practices and training. Participation in
Continuous Improvement All
working groups and Committees (all Management and a significant number of leaders)
IMPROVEMENTS TO
MANAGEMENT

SP and BP MT and PLs Communication, monitoring and assessment of plans in their respective Units and processes.
Leaders analyse and prioritise improvement suggestions from these Committees and include them,
SYSTEM

Technical and other Committees All

where appropriate, in the BP.
Leaders analyse survey results with ZH people to incorporate areas for improvement into the
Analysis of surveys MT management system (5e, 6, 7, 8)
Use of the Innovation Capital Methodology for the assessment and management of continuous improvement and innovation in
MT
Model organisations. ZH is pioneering the validity and application of this model in the Health Sector.
Figure 1b-4: MANAGEMENT S YSTEM IMPROVEMENT MECHANISMS LED BY LEADERS
ASSESSMENT TYPE /
YR IMPROVEMENTS
SOURCE OF LEARNING
Technical Committee members included in the process for adapting the SP (1,3,4)
Setting up of the Library and Teaching Committee and absorption of the Central Quality Committee into the Technical Committee (1,3,6)
1. Assessment by MT 98
Greater impetus given to training in quality for all leaders (1,3,5)
2. Assessment by PL Improvement actions identified through self-assessment are included in BP (1,3)
99 Creation of a team of people to support the deployment of Management by Processes (1,3,6,7)
3. EFQM assessment External assessment against the EFQM model(1,2,3,6)
4. People’s Voice 00 Increase in the number of improvement teams (teams for analysing survey results, environmental management, implementation of
the Baby Friendly Hospital Initiative (UNICEF)) (1,2,3,4,6)
5. Training EFQM submission document distributed to all ZH employees (2,3)
6. Benchmarking 01 Inclusion of items in people satisfaction survey to assess performance of leaders in this area (1,3,6,7)
Creation of 5S implementation team, and of groups for strategy planning (1,2,3,6)
7. External experts
02 Creation of working groups for formulating ZH Vision statement, for ISO Certification and for compiling the next submission
document (1,2,3,5,6,7). 10 leaders participate in compiling the submission document (1,3,6)
8. Innovation Capital
Model 03 Increase in the amount of training for ZH people in processes and certification (2,3,4,5).
ZH becomes a member of the Group for Promoting 5S (5,6)
9. Mas Innovación Piloting of the Innovation Capital Model for use in health organisations (1,8)
(specialised company) 04 Creation of process teams and practical training (1,2,3,5,6,8)
Steering Committee training in high performance teams, as a pilot experience for implementation of process teams (1,9)
Figure 1b-5: E XAMPLES OF IMPROVEMENT CYCLES RELATED TO 1b. helps us to understand and appreciate the intensity of the personal
1c. LEADERS INTERACT WITH CUSTOMERS, PARTNERS involvement of our healthcare professionals and their relationship with
AND REPRESENTATIVES OF SOCIETY customers, and is, at the same time, an excellent source of information on

AD
To deliver the Mission, ZH leaders interact primarily with
customers, suppliers and representatives of Primary
Healthcare, the Health System and Society. ZH leadership
style promotes the proactive participation of our leaders in identifying
stakeholder needs and responding to them to improve our services
accordingly. This has meant that ZH has pioneered several services in the
health sector. Management by processes, together with complementary
factors such as empowerment, knowledge management and
communication create a synergy for our leadership in this area.
Though there are many channels through which ZH leaders
systematically interact with stakeholders, one of them stands out as
being particularly important and specific: contact with customers. The
special nature of the relationship between the hospital and its customers
Zumarraga Hospital – Hospital de Zumarraga
customer needs and service commitment. The need to coordinate our
actions with the Primary Healthcare Service to ensure continuity of patient
care, together with assessment and learning activities undertaken in this
respect, have led to the setting up of multiple communication channels and
collaboration initiatives with Primary Healthcare professionals, making ZH a
reference in this area of healthcare management.
Strong ties have also been established and developed with other health
centres and their people, with professional associations and social trusts
and with Excellence promoting bodies such as Euskalit. These relations are
fostered as sources of learning and knowledge sharing in the clinical and
management field.
Figs. 1c-1 to 1c-4 show multiple examples of interaction between ZH
leaders and the four key stakeholder groups involved. These channels of
6
contact also contribute key information for establishing our strategy and % A GREEMENT
P EOPLE S ATISFACTION S URVEY ITEMS
plans. Fig. 2a-1 shows how these channels are linked to processes, and 99 01 03
how they are used to improve our management system. Examples of The Head of my Unit considers customer satisfaction our 47 73 87
dissemination activities are shown in Fig. 1c-6. number one priority.

AR Assessment and review of the effectiveness of leadership in In my Unit, we work to meet the needs of our customers. 71 95 95
this area, both in terms of our approach to it (the system) In my Unit, we know who the end beneficiary of our work is. 80 85 85
and how it is practiced, is conducted through surveys (customers, My Unit understands the needs of its customers. 52 78 78
Figure 1c-5: RESULTS OF P EOPLE S ATISFACTION S URVEY ITEMS
suppliers and Society), assessment against the EFQM model and
Quantitative and qualitative analysis by the MT, through survey
qualitative analysis by the MT. The sources of learning related to this
findings (6a and 8) and learning activities, have enabled us to improve
sub-criterion are shown in Fig. 1a-6. The people satisfaction survey
includes several items which enable us to assess various aspects related our approach in this area of management. Examples of improvements
after successive assessment and review cycles are shown in Fig. 1c-7.
to the interaction of our leaders with stakeholders. Results trends
confirm the effectiveness of our approach (Fig. 1c-5).
LEADERS
C ONTACT TYPE LEADERS’ ROLE REF.
INVOLVED
Direct contact with Leaders maintain direct and daily contact with customers, providing services and identifying needs and 2a
All
customers expectations. 5d
Customer satisfaction Leaders assess results, communicate them to ZH people and propose improvements to be included in the BP All 6
surveys and/or the inclusion of new items in global and specific surveys for customers and those who accompany them.
C Complaints and Personalised complaints handling. Leaders propose improvement actions after assessing customer suggestions
U All 5e
suggestions and the follow-up report from the PALS.
S
Focus groups Leaders decide on the need for a focus group, participate in it, draw up action plans and report on conclusions. All 5e
T
Primary Healthcare Leaders assess findings and put forward improvement proposals. All Primary Healthcare doctors are informed of
O All 6
surveys the findings.
M
E Meetings with Primary The MT hold regular meetings with Primary Healthcare Management to monitor the delivery of common goals, MT 2a
R Healthcare Mg’ment and to identify, deploy and monitor joint improvement plans.
S Contact with Primary Leaders participate directly in problem solving and joint training activities with Primary Healthcare professionals,
Healthcare All 2a
as well as in Advisory Bodies and joint working parties (Technical Committee and Outpatients Process Team).
professionals
Meetings with PHCCM The MT and the Outpatients Process Team hold meetings with the PHCCM to identify areas for improvement and MT 2a
establish joint plans to improve customer care and the continuity of patient care.
Figure 1c-1: INTERACTION C HANNELS OF ZH LEADERS WITH CUSTOMERS
Collaboration of leaders in Quality Research Projects (Kaliker, Programme Contract), in Osteba (Technology
H Assessment Agency), O+IKER (Basque Institute for Health Research), the Process Group, the e-Osabide
E Stakeholders Group, the Quality Assurance Group (Osakidetza), the Working Group on Values, the Working Group on People
All 3c
A Management Strategy and various other Groups with the Dept. of Health for the assessment and improvement of
L management systems (Programme Contract, Clinical Management, Professional Career) and the Basque Govt.
T (R+D+I Programme).
H Programme Contract MT negotiates, communicates and monitors the Programme Contract. MT 4b
S Contact with Management hold follow-up meetings on plans, management control, collaboration on development lines and MT 2a
Y Osakidetza with working groups for general improvements to the Health System.
S Surveys Management identify the need for a survey and draw up questionnaires to measure stakeholder satisfaction. MT 4c,8a
T Publications, Leaders collaborate in studies and publications of Osakidetza, the Dept. of Health and Professional Associations All 2a
E submission documents to disseminate improvements in the clinical and management field.
M
Third Party Agreements Management identify their needs, inform them of our portfolio of services and mail them the ZH in-house MT 2a,8a
magazine.
Figure 1c-2: INTERACTION C HANNELS OF ZH LEADERS WITH THE HEALTH S YSTEM
Regular meetings with local Town Councils to identify their needs and expectations, to learn of any plans that may 2a,
Local Institutions have an effect on the demand for our services and to collaborate in training plans and environmental CE
8
management.
Dissemination of Active participation in information exchange, teaching and media initiatives to share our expertise and experience MT & 4 4e,
management expertise in TQM (Fig. 1c-5), and in Quality Associations such as SECA and ISQ. leaders 8a
Dissemination of Medical and nursing healthcare leaders contribute to the dissemination of clinical advances and to informing on the Health Care 4e,
clinical expertise results achieved by the hospital through practical demonstration, teaching and articles in specialist publications. Leaders 8a
Leaders promote and support the participation of ZH healthcare professionals in health care conferences, in 4e,
Health Education Various
schools, Professional Associations, on local TV (36 people) and in other media. 8a
S Environmental In addition to their involvement in specific work groups, leaders participate actively in communicating and 4c,
All
O Management managing the environmental policy of the hospital. 8b
C Recognition Interviews and/or written recognition for individuals and institutions in the ZH in-house magazine. MT 3e
I Survey Preparation and assessment of Society satisfaction surveys. All 8a
E Collaboration in Projects on Customer Research and Management by Processes (Univ. Miguel Hernández de
T Alicante, Informática Gipuzkoa, Faculty of Sociology of the Univ. Of the Basque Country), training in the EFQM
University CE 4a
Y Excellence Model (Engineering Faculty and Economics Dept. of the Univ. of the Basque Country) and training in
assessment in universities (National Association for the Assessment and Accreditation of Quality).
Professional Participation in professional bodies, organisation of and participation in technical seminars (National Congresses 2a,
All
Associations on Surgery, Urology and Radiology, and international conferences on Surgery, Paediatrics and Quality). 4e
Meetings with Patients Contact with representatives of Patients’ Associations to identify their needs and expectations and how best to 2a,
All
Associations respond to them. 8a
Training for Union representatives on a national level, and participation in a think tank in connection with the
Social Representatives CE 8b
Project for Sustainability in the Spanish National Health Service.
Collaboration as members of Euskalit, through the dissemination of ZH best practices in talks or publications, and 1b,
Euskalit MT
the participation of six ZH employees in the Assessors Club. 8a
Figure 1c-4: INTERACTION C HANNELS OF ZH LEADERS WITH S OCIETY
Zumarraga Hospital – Hospital de Zumarraga 7
S 4b,
Supplier survey Preparation and assessment of survey findings for detailed knowledge of their needs and the degree to which ZH meets them. MT
U 4c
P Supplier
P MT Review (with Unit Heads) of the efficiency of the partnership established with the supplier. All 4a
assessment
L
I Supplier Annual recognition by the MT of those suppliers considered as outstanding for their contribution to the development of the MT 1c
E recognition hospital (posted on the website)
R Meetings with ZH leaders and people are in direct and constant contact with suppliers to introduce improvements into our services. All 4a
S suppliers
Figure 1c-3: INTERACTION C HANNELS OF ZH LEADERS WITH S UPPLIERS
Year Presentations in Technical Seminars Visits Training-Publications
- Attendance in 6 Congresses, giving talks - Visit to ZH of MTs of - Support for 4 research projects into management, and consensus in the external
and papers (Congress of the Spanish Society 5 different hospitals to assessment of 2 organisations.
1999 for Quality In Healthcare). learn of our - Training seminars with 5 institutions (Universidad Complutense de Madrid,
experience in EFQM Cámara de Comercio, H. Monte Naranco and 2 others).
and management by - Publication of articles in various publications such as Osteba, Qualitas Hodie,
processes Diario Médico, Spanish Healthcare Quality Magazine, etc.
- Attendance at 3 Congresses, giving 5 talks, - Visit to ZH of MTs of - Support for 6 R&D projects on Quality Management Systems (Primary Healthcare
papers and workshops (Congress on Quality 5 organisations to Research Fund for process mapping, Escuela Andaluza de Salud Pública,
in Healthcare, Seminars on Healthcare Costs, share our experience adaptation of the Latin American Model of Excellence, a Think Tank from the
2000 etc.) in management Spanish Ministry of Health, etc.).
(Euskalit, Danobat, - Training in management and Quality given in 9 centres (Hospitals, University of
Oncological Institute the Basque Country, Tarragona Regional Council, Escuela Andaluza de Salud
of Catalonia, etc.) Pública, etc.).
- 2 publications on TQM
- National Congress of Hospitals, on the - Visit to ZH of 6 - Dissemination of our EFQM-based submission document to 140 centres.
occasion of being awarded the Golden Helix organisations to learn - Dissemination of ZH management tools (People and Primary Healthcare
Prize. of our management satisfaction surveys, process documentation and map, etc.) to over 20
- Healthcare Quality and Management system and share our organisations.
Congresses, giving a total of 8 talks and experiences (La Fe - Continuous tutoring for 2 centres on how to write an EFQM-based submission
2001 papers. Hospital, Fundación document.
- Workshop on Management By Processes in Matía, Universidad - Training workshops in 14 organisations in the healthcare, business and social
the International Congress of Quality in Católica de Chile, sectors.
Healthcare. etc.) - Articles and collaboration in Quality and Excellence publications (adaptation of the
EFQM model for the health sector, Spanish Healthcare Quality Magazine, best
practices of the Euskalit 400 Club, etc.).
- Link to the Basque Government Euskadikalitatea website.
- Presentation given on the occasion of - Visit to ZH of MTs of -Tutoring for 2 healthcare centres on how to write an EFQM-based submission
winning the Premio Ciudadanía 2002 Award. 6 healthcare centres document.
- Paper given in the II Meeting of Excellence (Hospital del Mar, - Participation in the ”Guide to process-based management”, published by Euskalit.
2002 Award Winners. Cruz Roja de - Training workshops on the EFQM model and processes for 6 healthcare
- Workshop presentation, 4 papers and poster Barcelona, Clínica La organisations (H. Clínico de Salamanca, Escuela Andaluza de Salud Pública, H.
display at the Congress of the Spanish Zarzuela, etc.) General de Asturias, etc.).
Society for Quality in Healthcare. - Collaboration in publications on ISO certification and knowledge management.
- 6 papers given in the Congress of the Visits to ZH by - Use of the ZH submission document for training in 4 healthcare centres and other
Spanish Society for Quality in Healthcare. Management from 8 healthcare organisations.
- Presentations given at the European different - Training in the EFQM model, TQM and management by processes in 13
Conference on Human Resources, a Seminar organisations. organisations and Regional Health Services (Autonomous Communities of Madrid,
on Hospital Administration, the National Navarre and Cantabria, the Engineering School, Hospital San Pablo, Hospital
2003 Congress on Clinical Documentation and the Ramón y Cajal, etc.).
National Congress on Surgery. - Dissemination of the ZH submission document, surveys and SP methodology to
27 organisations.
- Participation in a Think Tank with Osakidetza on Clinical Management and
assessment against the EFQM Excellence model.
- Preparation of training material for a Masters Course in Healthcare Management,
and collaboration in 2 such publications.
- 7 papers given in the Congress of the Visits to ZH by - Training in the EFQM model, TQM, Strategy Planning, Communication,
Spanish Society for Quality in Healthcare. Management from 4 Management by Processes and Environmental Management for 14 organisations
- Presentations given at National different and Regional Health Services (Autonomous Communities of Murcia, Madrid and the
Seminars, on the BSC, at the University of organisations. Canary Islands, the Spanish Ministry of Health, Escuela de Salud Publica, Instituto
Zaragoza, in the Spanish Ministry of Health, Carlos III, etc. )
for the Signo Project, at the National - Participation in a Think Tank with Osakidetza on the viability of the Evalexpres
2004 Radiology Congress, at Seminars on system, professional careers structures, People Management, etc.
Nursing, for the Regional Govt. of Castilla- -Training in Quality and Assessment given to 200 university academics from
León and at the Premio Ciudadanía Award Spanish universities (ANECA Project)
ceremony. - Dissemination of the ZH submission document, surveys and SP methodology to
25 organisations.
- Article published in the Qualitas Hodie magazine.
- Participation in the Science and Technology Plan of the Basque Government.
Figure 1c-6: E XAMPLES OF TQM DISSEMINATION A CTIVITIES

Zumarraga Hospital – Hospital de Zumarraga 8

 A SSESSMENT TYPE / empowerment, communication, training and recognition. All four factors
YR IMPROVEMENTS
S OURCE OF LEARNING together provide a synergy through which to deliver the hospital’s goals.
Creation with Primary Healthcare representatives The leaders involved in the day-to-day activities related to these factors
of the Joint Technical Committee. Focus group for have been selected for their operational efficiency in these areas. The
98
formulating the survey. Distribution of survey CE and MT provide guidance, and define and deploy the plans which
1. Assessment by MT results to leaders (1,3)
2. Assessment by PL enable us to deliver and assess these factors. Deployment at Unit level
Deployment of improvement actions identified
3. EFQM assessment is the responsibility of Unit Heads. Process teams and leaders manage
through Primary Healthcare survey (system for
4. People’s Voice locating ZH doctors more readily, assessment of continuous improvement and encourage their team members to
5. Primary Healthcare 99 the quality of outpatients reports) (1,5,7) participate in continuous improvement.
Voice Analysis of stakeholder needs with ZH leaders (1,3) Figs. 1d-1 to 1d-4 show the main channels used to develop each of these
6. Customer, Supplier, ZH in-house magazine mailed to stakeholders four factors, the role of ZH leaders in this respect, which leaders are
Health System and (1,3,9) involved, who is affected by this and the sub-criteria of this submission
Society Surveys 00 Establish system for supplier recognition document in which these points are detailed. The MT provides coordination
7. Technical (preferential supplier) (1,2,3,9) and support for the management system and for all other ZH leaders.
Committee Replacement of Joint Technical Committee with Empowerment: Devolved responsibility and self-direction are strong
01 meetings with PHCCM (1,5)
8. Training motivational tools systematically used in the hospital and coordinated
9. Benchmarking Extended range for gathering information on through our system of management by processes (crit. 3).
10. Innovation Capital 02 stakeholder needs, expectations and Communication: The “open doors” policy, by means of which all our
Model 03 perception, through surveys on suppliers, Town people have direct access to any leader, and the communication plans and
Councils, Health System and other
organisations (1,2,3,6,9) channels systematically developed in the hospital since 1999 are the main
tools used in this area (crit. 3).
04 Greater range of participative contact with Training: Training, both for specific job skills and in relation to
Society, and ISO 14001 Certification (1,2,3,6,9)
Figure 1c-7: E XAMPLES OF IMPROVEMENT CYCLES RELATED TO 1c improvements in management, is a basic pillar of our organisation. The
1d.LEADERS REINFORCE A CULTURE OF EXCELLENCE technical development of ZH people is a stated element of our Vision (Fig.
WITH THE ORGANISATION’S PEOPLE 1a-1). Training and personal tutoring are therefore key elements of
leadership widely deployed throughout the hospital (3b, 4e).
AD The measures taken and developed in ZH with respect to this sub-
criterion must be understood within the framework of constraints
described in crit. 3. Although all ZH systems must be coordinated and
Recognition: Recognition at an individual and Unit level takes many forms
(3e). The role of leaders is to be aware of the efforts and achievements of
interlinked to ensure our people are motivated and cared for, four our people and to recognise them accordingly.
systematically managed factors have been identified as key in this area:
EMPOWERMENT
LEADERS PEOPLE
HOW LEADERS’ ROLE REF.
INVOLVED AFFECTED
Leaders devolve responsibility and decision making powers through the command chain, e.g. Overview
Hierarchical MT and Unit
establishing BP action plans, changes in shift scheduling, recruitment, HR budgets and the All 3a, 3c, 4b,
empowerment Heads
design or modification of services. 4c
MT appoints PLs as a systematic element of empowerment for the continuous improvement of PLs
MT
Management by processes. All processes
5a, 5b
processes In turn, PLs empower their process team members, and describe, design, assess and improve PLs All
their respective processes.
Clinical self- All leaders encourage and support empowerment in terms of decision making in the clinical MT and Unit Healthcare 3c
management area, for improved face-to-face patient care in healthcare processes. Heads professionals (80%)
Leaders identify the need to create groups and participate actively in them, monitoring all MT, Unit
Working groups subsequent actions, providing the necessary resources and conditions, accepting the All 3c, 5a, 5b
Heads & PLs
conclusions of the group and supporting the decisions taken (Fig. 3c-2)
Knowledge Leaders stimulate and encourage people to identify their needs, and promote training and the MT and Unit All 3b
management acquisition of knowledge, taking active part in training initiatives. Heads
People satisfaction Leaders participate in the focus group for approving survey content, analyse and disseminate MT, Unit All 7a
survey survey results and support people to achieve their professional plans, objectives and targets. Heads & PLs
Figure 1d-1: MECHANISMS OF P EOPLE E MPOWERMENT DRIVEN BY LEADERS
COMMUNICATION
PEOPLE
HOW LEADERS’ ROLE LEADERS INVOLVED REF.
AFFECTED
General staff The MT communicates the ZH strategic structure, goals, plans and matters of general MT All 2d
meetings interest to all ZH people in general staff meetings.
Management and leaders meet with Unit representatives to inform them of Unit
Meetings with Units MT and Unit Heads All 2d
objectives, establish action plans and comment on any relevant matters.
Balanced Scorecards Leaders design content and layout of BSC, and assess process and/or Unit performance. MT, Unit Heads and PLs All 2d ,5b
Leaders inform new recruits of procedure, explain ZH goals and culture and introduce New
Induction procedure MT and Unit Heads 3a
them to their immediate leaders and colleagues. recruits
Leaders lead, take active part in and inform working groups on all relevant matters
Working groups MT, Unit Heads and PLs Various 3c
(Fig. 3c.2).
Leaders take part in designing the survey system, assess and communicate the
Surveys MT and Unit Heads All 3d, 7a
results, identify areas for improvement and propose action plans accordingly.
Leaders identify the need to create a focus group, take active part in them and assess
Focus groups MT and Unit Heads All 3d, 7a
the results.
Social events Leaders are involved in designing, organising and setting up social events and attend them. MT, Unit Heads and PLs All 3d
Accessibility All leaders are easily accessible on a day-to-day basis. MT, Unit Heads and PLs All 3d
Leaders design and participate in all types of communication channels for information
Miscellaneous MT, Unit Heads and PLs All 4e
of all kinds (Intranet, in-house magazine, etc., Fig. 3d-1).
Figure 1d-2: MECHANISMS OF COMMUNICATION DRIVEN BY LEADERS
Zumarraga Hospital – Hospital de Zumarraga 9
 TRAINING
PEOPLE
HOW LEADERS’ ROLE LEADERS INVOLVED REF.
AFFECTED
Leaders select training needs, are involved in drawing up training plans, monitor delivery
Continuing Training MT, Unit Heads & PLs All 3b 4e
and encourage people to take part in continuing training programmes.
Leaders train people through knowledge sharing and training in technique as part of day-
On-the-job training MT, Unit Heads & PLs All 3b 4e
to-day working life.
Self-training Leaders encourage self-training activities for people under their charge. MT and Unit Heads All 3b 4e
Leaders encourage and take active part in contributing to publications on technical and
Publications MT and Unit Heads All 3b 4e
management matters.
Research Projects Leaders organise, encourage and participate in research projects. MT and Unit Heads All 3b 4e
Clinical Sessions Leaders participate in, and encourage others to participate in clinical sessions. MT and Unit Heads Doctors 3b 4e
Congresses and Leaders participate in, advise on and encourage others to attend and present papers at MT and Unit Heads All 3b 4e
Seminars technical seminars and congresses.
Involvement in Management train other leaders and ZH people, especially healthcare professionals, in MT, Unit Heads & PLs All 3b 4e
teaching quality management tools.
ISO Certification Leaders organise, give and encourage people to take part in quality assurance training. MT, Unit Heads & PLs Various 5a 5b
Tutoring in
management by Management train and provide personal tutoring for PLs. MT PLs 5a 5b
processes
Leaders contribute to the magazine by publishing articles on quality management and
In-house magazine MT, Unit Heads & PLs All 3d
health education.
Figure 1d-3: MECHANISMS OF TRAINING DRIVEN BY LEADERS
RECOGNITION
PEOPLE
HOW LEADERS’ ROLE LEADERS INVOLVED REF.
AFFECTED
Meetings Leaders recognise individuals and Units in various meetings. MT, Unit Heads & PLs All 3e
New appointments MT appoints PLs or assigns special responsibilities (e.g. Quality Coordinator) MT PLs 3e, 5a
Hierarchical Leaders recognise people for a job well done. MT and Unit Heads All 3e
Promotion and Leaders define recognition criteria and select people for promotion and adjustment MT and Unit Heads All 3b, 3e
Adjustment proceedings (crit. 3).
Leaders concede to a flexitime policy for those with a proven record of
Timetable MT and Unit Heads Doctors 3e
responsibility.
Working conditions Leaders are sensitive to the conditions in which our people work, selecting MT, Unit Heads and All 3e
improvement actions and encouraging their deployment. PLs
Leaders give preferred status for the provision of support resources and training to
Resources MT and Unit Heads All 3e, 4b
those with a proven performance record, and to encourage improvement.
Leaders personally write and present ZH people with letters of recognition for MT, Unit Heads and
Letters All 3e
personal or team achievement. PLs
The Head of Human Resources, on behalf of the MT, personally congratulates all Head of Human
Congratulations All 3e
ZH people on their birthdays and on the birth of their children. Resources
Celebratory events Leaders organise and participate in retirement parties, events to celebrate external MT, Unit Heads and All 3e
recognition and leaving parties. PLs
Leaders identify the need to create a working group, are involved in selecting the
group members and take active part in these groups, stimulating and encouraging MT, Unit Heads and
Participation All 3b
people involvement and giving recognition for outstanding individual or team PLs
performance.
In-house magazine Leaders put forward individuals or Units for mention in the magazine, and publicly MT, Unit Heads and
congratulate them on receiving awards and accolades. All 3d
PLs
Figure 1d-4: MECHANISMS OF P EOPLE RECOGNITION DRIVEN BY LEADERS Training

AR The MT assesses and reviews the effectiveness of leadership by

analysing the results of the People’s Voice Process, of the
Communication and Training Plans and of self-assessment against the
The Head of my Unit encourages and supports me in the
area of continuing training.
25 48 78

Communication
EFQM Excellence model. People satisfaction surveys include several items The Head of my Unit discusses with the team any projects
which enable us to measure the effectiveness of our approach (Fig. 1d-5). --- 52 71
affecting our Unit.
P EOPLE S ATISFACTION S URVEY ITEMS % AGREEMENT The Head of my Unit encourages us to speak openly. 44 51 70
Leadership 99 01 03 Recognition
The Head of my Unit practices what he/she preaches. 48 64 78 The results I achieve are duly recognised. 17 31 48
Hospital Management is receptive to staff problems. --- 38 55 In my Unit, recognition is given for a job well done. 34 52 65
I have a satisfactory personal relationship with the Head of --- 79 85
my Unit.
Figure 1d-5: RESULTS OF P EOPLE S ATISFACTION S URVEY ITEMS
Empowerment
Improvements in leadership related to this sub-criterion are directly
The Head of my Unit encourages me to stretch my decision attributable to improvements in the personal skills of leaders and to
20 38 66
making powers.
improvements to the system itself. The sources of learning used in this
The Head of my Unit encourages me to contribute ideas on 36 51 71 respect are described in 1a (Training and Benchmarking). These
how to improve my work.
The Head of my Unit empowers me to take decisions. 37 63 learning sources, together with the study of best practices and
In ZH, we work largely on a consensus basis. --- 48 69 assessment exercises, have enabled us to implement numerous
My suggestions and contributions are listened to and taken improvement actions, the effectiveness of which is shown in the results
--- 43 63
into consideration. of satisfaction survey items (Fig. 1d-5). Examples of improvements after
assessment and review cycles are shown in Fig. 1d-6.
Zumarraga Hospital – Hospital de Zumarraga 10

A SSESSMENT TYPE /
YR IMPROVEMENTS
S OURCE OF LEARNING
Nursing staff budget management conducted by
Head of Nursing and her team (1,3)
98 Unit leaders and people meet to discuss survey
results (1,3,6)
Development of empowerment through PLs
(1,3,6,7)
99 Launching of the ZH in-house magazine (1,3,7)
Training for leaders in management by processes
1. Assessment by MT and improvement tools (1,3,5,6,7)
2. Assessment by PL Systematic development of ISO Certification
3. EFQM assessment 00 (1,2,6,7)
4. People’s Voice
Development of the Intranet (2,4,7)
5. Training Induction procedure (1,2,4)
6. External experts Transmission of knowledge in management
7. Benchmarking 01
through the in-house magazine and through
training in 5S (1,5,6,7)
02 Appointment of Certification Coordinators and
training in quality (1,2,3,5,7)
Involvement of 5 ZH employees in internal audits
03 for ISO 9001:2000 Certification (1,2,4,7)
04 Creation of 4 process teams, and training in high
performance team management (1,3,6,7)
Figure 1d-6: E XAMPLES OF IMPROVEMENT CYCLES RELATED TO 1d.
1e. LEADERS IDENTIFY AND CHAMPION ORGANISATIONAL CHANGE
A Changes to the ZH management system and to processes, geared
towards adapting our operations to current and future stakeholder
needs and to improved delivery of our Mission, is a pivotal aspect of our
activity. Similarly, commitment to innovation is one of the stated values of
our corporate culture (1a-1). In this respect, change management and the
involvement of leaders in it has been a distinguishing factor of ZH. Change
is managed as shown in Fig. 1e-1.
Identification of change: The changes required in the hospital, in our
management system and in our external relations were previously identified
through various information sources, through changes in technology, results
assessment, assessment against the EFQM model, the requirements of
Osakidetza, etc. Nowadays, the need for change is centred around the
demands of the SP and identified through strategic analysis and the drawing
up of ZH strategies. For example, the implementation of management by
processes was derived from an area for improvement included in an EFQM
external assessment feedback report. Similarly, through SWOT analysis
conducted as part of SP review, we concluded it was necessary to conduct
an in-depth review of our management by processes system in 2004.
Nowadays, the sources of information used to understand the internal
and external drivers of change in the hospital, and to anticipate current
and future stakeholder needs, are those described in 2a & 2b.
Identificación
Identification
Prioritisation
Planning
Management (development
& monitoring)
Assessment
Figure 1e-1: FLOW DIAGRAM OF CHANGE MANAGEMENT
Prioritisation: Many of the changes which take place nowadays in
ZH are decided against business criteria, i.e. on the basis of their
capacity to deliver business objectives, and are therefore prioritised
on the basis of the strategic structure of the hospital and SWOT
analysis (2c). The Continuous Improvement Process (1b) and key
process management (2c) are complementary guides to selecting
change. On the other hand, some changes which take place in ZH are
mandatory, either by law or through instructions received from the
Zumarraga Hospital – Hospital de Zumarraga
Dept. of Health or Osakidetza, and these changes affect all network
centres. In some cases, ZH has driven pilot change in Osakidetza and
in the Spanish Public Health System (ISO certification, assessment
against the EFQM Excellence model, etc.). Both types of change are
provided for in ZH planning.
Planification: On the basis of the definition and deployment of the SP,
change is managed in two ways:
a) Changes affecting one process only, or those changes with low
level repercussion in the hospital, are developed through processes and
managed using PDCA cycles (crit. 5).
b) Changes affecting many processes, changes requiring a long
implementation time and a lot of resources and breakthrough change
are managed as a unitary project. In this case, a global analysis is made
of the variables affecting change (people, customers, technologies,
etc.), the effect of this change on the organisation is calculated using
specifically conducted SWOT analysis, the potential risks involved are
evaluated and the ensuing project is designed.
Change project planning entails investment, the provision of financial
resources, whether specific information and training are necessary for
ZH people and assessment tools to measure the effectiveness and
impact of the change. Through applying the EFQM Excellence model,
we have discovered the benefits of using partnerships to implement
certain change projects (Gesco, Elirecon, UNICEF, etc.) and of
networking with other centres suffering similar problems to ours to learn
from them prior to implementing change (Euskalit, 400 Club,
benchmarking activities, etc.) (crit. 4).
Development, management and monitoring of change: After the
planning stage, change is implemented through:
a) Processes, following the system described in 5a & 5b. The
effectiveness of change is monitored by PLs through process indicators.
b) Projects, led by the PLs involved or by the MT, depending on the
significance of the change for ZH. In cases of breakthrough change
affecting the whole management system, e.g. management by
processes or strategic planning, a team is formed of ZH leaders who
work alongside the MT to implement and monitor the change. In 2004,
as a direct result of benchmarking Excellence organisations and the
management systems of our partners, a new methodology for managing
and monitoring projects was introduced in the hospital. This new
methodology reinforces the participation of our people, puts greater
emphasis on scheduling the different project phases and on the
progressive delivery of project objectives.
Leaders take on a facilitator role in their teams to develop change
plans, acting as role models and becoming personally involved in
change management, i.e. preparing plans, analysing information on
other organisations, reporting on developments to all affected people
(3d) and stakeholders, securing the necessary investment, resources
and training (4a, 4d & 4e), supporting and enabling those under their
charge, continuously monitoring the results of the change and taking
corrective action where necessary.
Assessment: Changes are assessed through process and project
indicator monitoring, both in terms of their effective delivery and of the
perceived quality of the change (through customer, people and Society
satisfaction surveys). These follow up activities enable us to establish
appropriate corrective actions where variance from objectives is
detected. Change projects are considered to have been completed
when the change involved has been fully integrated into the everyday
management dynamic of the hospital.
D Fig. 1e-2 shows a selection of change projects conducted by ZH in
recent years.
AR Assessment and review of the effectiveness of leadership in
this area, both in terms of the exercise of leadership and of
the effectiveness of the system itself, are based on survey results
(customers, suppliers and Society), indicator trends (9a & 9b),
assessment against the EFQM model and on qualitative assessment by
the MT and, when applicable, support teams. These mechanisms
enable us to measure and review the effectiveness of changes, and to
share the knowledge gained. Some of the projects undertaken by ZH
11
have received external recognition (Management by Processes, the enabled us to improve our approach. Examples of improvements after
Baby Friendly Hospital Initiative, Environmental Management). Such successive assessment and review cycles are shown in Fig. 1e-4.
accolades serve to confirm the appropriacy of the projects, and put us in A SSESSMENT TYPE / IMPROVEMENTS
YR
a role model position for other organisations. S OURCE OF LEARNING
The people satisfaction survey contains a series of items which Creation of a support group of professionals for
99 the Management by Processes Project (1,3,5,6,7)
enable us to broadly measure the degree of satisfaction of our people
with innovation and change. Results trends in this area are a measure 1. Assessment by MT 00 Systematic use of surveys to identify changes that
2. Assessment by PL need to be made (1,3,4,5,6).
of the effectiveness of our approach. The 2003 survey contained 11 Change Project documentation (Baby Friendly
3. EFQM assessment 01 Hospital) (1,2,4,5,6).
specific items on the management of change in ZH (Fig. 1e-3). 4. Customer, People’s
% A GREEMENT and Society Voice Assessment and selection (by a support group of
PEOPLE SATISFACTION SURVEY ITEM 02 professionals) of areas that need to be changed in
5. Training
99 01 03 relation to formulating the SP (1,4).
6. External experts
Average score for items on Innovation - 63 74 Use of the SP as the basis for selecting and
7. Benchmarking
Organisation, leadership and people management in ZH - 8. Innovation Capital 03 managing change projects (1,2,3,4,6,7).
- 72 Programming of Innovation Management using
have improved. Model the Innovation Capital Model (1,7,8).
Figure 1e-3: RESULTS OF P EOPLE S ATISFACTION S URVEY ITEMS
Quantitative and qualitative analysis by the MT of survey results (6a, 04 Introduction of a new methodology for Project
Management (1,6,7,8).
7a & crit. 8) and suggestions, and the lessons learnt in this area have Figure 1e-4: E XAMPLES OF IMPROVEMENT CYCLES RELATED TO 1 E
Change Identification Prioritisation Planning / Management Assessment
Scheduling, training and progressive implementation throughout the Worldwide
Changes in
Laparoscopy Strategy Line Surgical Unit of laparascopic (keyhole) surgery techniques, subsequently reference in
Technology
adopted in all other specialist areas. gastric surgery
Breakthrough change in financial management system and IT support (SAP). Implemented and
Aldabide Osakidetza Corporative
Training for ZH people and investment in technology throughout the hospital. in use
IT support for HR administration. Training for Unit Heads throughout the Implemented and
Gizabide Osakidetza Corporative
Technological

hospital, and investment in technology. in use

Security of Currently being
Osakidetza Legal Adaptation of ZH IT systems to data protection requirements.
Information implemented
Continuous Research Project conducted with the IT Faculty of the University of the
Currently being
qZ+ Project SP/Partnerships Improvement Basque Country, to develop an IT application for management by
implemented
(Partnerships) processes in the hospital.
Computerisation in Outpatients and A&E, with online connection to other
Indicators (%
PCH (IT application) SP SP 2003-07 diagnostic areas to improve the availability of clinical data. Requires
implementation)
training and investment.
National Multi-centre Research Project (Health Research Fund) to
SP/ Currently being
Patient Security SP 2003-07 implement systems aimed at increasing the sensation of security for
Benchmarking implemented
patients under healthcare treatment.
Extension of Extension of an operating theatre, and the setting up of a new DMSH and
Surgical Unit, DMSH SP/Osakidetza SP 1997-2000 LSRU with increased provision of service in response to healthcare Facilities installed
& LSRU demands.
Infrastructure

Extension of Service New location, increased service and provision of state-of-the-art technology to
Key processes Facilities installed
Haemodialysis Unit improvement be able to provide treatment for all patients in our catchment area.
SP 1997-2000 Project for the progressive adaptation of the ZH building and facilities to
Safety Plan Osakidetza/SP Safety Plan
Corporative safety standards. Training throughout the hospital and investment.
Continuous
Removal of Project for the progressive adaptation of ZH facilities for use by all citizens,
SP Improvement Ongoing
architectural barriers conducted under guidance from Patients’ Associations (4c).
(Partnerships)
Use of the Excellence model in self-assessment and improvement cycles, Silver Q for
Assessment against external assessment (pioneer initiative in the health sector) and Quality (2000) &
Osakidetza SP 1997-2000
EFQM model dissemination of submission document in health and business sector (1b, Gold Q for Quality
1d,8,9). (2003)
Pioneer Project in the health sector to implement an integral system of
Management by Continuous System reviews
EFQM management by processes in a hospital. Second phase of in-depth system
Processes Improvement (5a & 5b)
review undertaken in 2004 (crit. 5).
Management System

Specific project led by the MT and PLs, documented and programmed Baby Friendly
Baby Friendly
Partnerships SP 2000-03 over 2 years with improvements to healthcare processes (increased breast Hospital Award
Hospital feeding), ZH infrastructure and equipment (5d & crit. 8). (UNICEF)
Introduction of ISO certification as support for management by processes, 14 processes
ISO Certification SP/Osakidetza SP 2003-2007 and pilot implementation in healthcare processes (5a & 5b). certified
Project to implement the BSC and advanced methodology of strategy
Assessment of
Strategy Planning SP/EFQM SP 2000-03 planning, with the participation of 80 ZH people and the support of a team
SP
of professionals for deployment of the project (crit. 2)
Continuous Multi-phase project (waste management, IHOBE diagnosis, environmental
Environmental Waste Plan
SP Improvement management), with specific documentation and changes to the
Management ISO 14.001
SP 2003-2007 organisation, to processes, in infrastructure and in equipment (4d).
Pioneer use of the Innovation Capital Model in business organisations
Innovation Capital SP/ Model developed
(through the 400 Club), and adaptation of the Model for use in healthcare
Model Benchmarking (MIOS)
organisations.
Figure 1e-2: CHANGE PROJECTS IN ZH
Zumarraga Hospital – Hospital de Zumarraga 12
OVERVIEW
The remit of Osakidetza (The Basque Health Service), an adjunct of the
Basque Government Dept. of Health with its own independent legal status,
is to provide healthcare to the people of the Basque Country. The
organisational structure of Osakidetza consists of a Governance Board, the
central organisation itself (administration and corporate management) and
the healthcare organisations providing services under the principles of self-
management. These healthcare organisations are fundamentally of two
types; Primary Health Care Centres and Specialised Healthcare Centres,
and Zumarraga Hospital is classified under the second category. All those
residing in the Autonomous Community of the Basque Country have the
right to public healthcare provided under principles of unity, universality,
equal opportunity and solidarity.
Zumarraga Hospital (ZH) therefore forms part of this Basque public
health service network, providing specialised healthcare for a population
of over 90,000 people resident in the Goierri and Urola Valleys in the
Basque Country province of Gipuzkoa (crit. 1, Mission). After several
years of public demand, the hospital was opened in 1984 by Insalud (The
Spanish Ministry of Health), with a staff of 250 healthcare professionals
providing Accident and Emergency (A&E), Maternity-Postnatal, Internal
Medicine, Surgical, Orthopaedic and Diagnostic services. ZH was the first
regional hospital to open in the province of Gipuzkoa.
In 1988, the hospital came under the governance of Osakidetza, after
full competencies in health matters were transferred from the Spanish
State to the Basque Government. Since then, the hospital has evolved
and increased the quantity and quality of its portfolio of services to
provide better healthcare for the population.
80% of the people within the hospital catchment area are concentrated in
three urban areas, namely Zumarraga-Urretxu-Legazpi, Beasain-Ordizia
and Azpeitia-Azkoitia. The remaining 20% are scattered over 17 rural
municipalities and farmhouses. Healthcare provision in our area consists of
a Primary Healthcare network of 71 doctors (44 General Practitioners, 11
Paediatricians and 16 Accident and Emergency doctors) working in a total of
18 Health Centres, two of which are purely for Outpatients. These
healthcare professionals refer their patients to us if they consider they
require specialised care, and we therefore consider these patients as ZH
customers (crit. 2, 5 & 6). Patients can also come directly to the hospital
through the Accident and Emergency (A&E) Service.
The hospital itself is one large building (12,935 m2) divided into three
inter-connected wings. Since 1990, ZH healthcare professionals attend
outpatients and physiotherapy clinics in the Health Centres in the towns
of Beasain, Azpeitia and Zumarraga. In this case, the objective is to
make these services more easily accessible for local inhabitants, and
these services are also considered as ZH services.
The hospital and its facilities have been modified and improved over the
years in response to changing healthcare and hotel/catering requirements.
ZH has 4 Inpatient Units with a total of 106 beds, a Short Stay Unit with 12
beds, a Medical/Surgery Day Unit with 8 beds (no overnight stay) and a Life
Support/Resuscitation Unit with 8 beds for intensive care. ZH facilities also
house a Surgical Unit with four operating theatres and a delivery room, 39
outpatient examination and medical diagnosis rooms, a physiotherapy
gymnasium, a body of Central Services (Clinical Analysis, Radiology,
Anatomical Pathology, Haemodialysis, Pharmacy, etc.) and support services.
98% of hospital funding is through the Programme Contract (PC)
agreed with the Department of Health, whilst the remaining 2% comes
from Private Medical Insurance Associations or Insurance Companies.
No distinction is made in terms of the healthcare offered ( 9a & crit. 4).
ZH currently offers the following specialist services:
INTERNAL MEDICINE RESPIRATORY EAR, NOSE & THROAT
ALLERGOLOGY NEUROLOGY ORTHOPAEDICS
CARDIOLOGY RHEUMATOLOGY UROLOGY
DERMATOLOGY PAEDIATRICS ANASTHETICS
GASTRO/INTESTINAL GENERAL SURGERY REHABILITATION
ENDOCRINOLOGY GYNECOLOGY RADIOLOGY
HAEMOTOLOGY OBSTETRICS CLINICAL ANALYSIS
NEPHROLOGY OPHTHALMOLOGY ANAT. PATHOLOGY
Figure 0-1: PORTFOLIO OF SERVICES
Zumarraga Hospital - Hospital de Zumarraga
At the current moment in time, 453 ZH people are working as a team to
deliver the hospital’s goals and objectives: (Doctors: 93; Nursing staff:
255; Administrative staff: 54; Miscellaneous: 46; Management: 5).
ZH employees are mostly women (76%), have an average age of 40.5
and over 65% of them have a permanent contract. Employment in ZH is
of administrative status, more akin to that of local government workers
than an employment contract, with all the implications that this condition
confers. Despite this, the ZH management system and the commitment
of our people to continuous improvement both encourage and ensure
that the degree of people involvement is very high.
Facilities management (catering, cleaning, laundry, gardening,
messaging and security services) is outsourced. The hospital’s services
are, for the main part, distributed as follows:
Invoicing as per PC
Attendances
SERVICE 2004 (thousands of % invoicing
/ year
euros)
Inpatients 15,899 61 7,300
A&E 2,239 8 31,000
Outpatients 6,259 24 40.000
Haemodialysis 1,272 5 40
Physiotherapy 671 2 2,000
Figure 0-2: SERVICE LINES, INVOICING AND ATTENDANCES
ZH is a teaching hospital for family doctors. We also collaborate in
practical training activities for a number of professional collectives (crit. 4 & 8).
Governance by Osakidetza provides several major competitive
advantages, such as prestige, culture and strategy lines, the joint use of
different types of tools and the encouragement and support offered to
us by the Basque Health Service. Knowledge transfer and participation
in working groups composed of people from different health centres of
the network represent a continuous and invaluable source of learning.
The changes which the Basque Health System has undergone in
recent years have made Osakidetza a focal point of reference for the
Spanish National Health Service and for Basque society, as its quality
ratings are best-in-class on a national scale (for example, waiting list
time). Key milestones towards this situation have been:
- Osasuna Zainduz: strategies of reform for the Basque Health Service,
with three lines of action; 1) Total Quality, 2) Separation of funding
(Department of Health) and provision of services (Osakidetza), with the
Programme Contract as a regulatory tool, and 3) Closer relations
between clinical and management cultures.
- Healthcare Act: constitution of Osakidetza as a Public Body subject to
Private Law, bringing about a greater degree of autonomy in
management terms for Health Centres.
- Development of new IT software and tools to support management
(Gizabide, Zaineri, other Information Systems, etc.)
- 2003-2010 Health Plan: in which the health needs of the population
and action strategies are developed.
The Chief Executive (CE) has overall management responsibility. The
body with decision-making powers is the Management Team (MT),
composed of the CE and four other members. The Steering Committee (SC)
is composed of the MT, the Assistant Head of Nursing, the Management
Secretary and the Certification Coordinator, these last three people having
been incorporated into the team in 2004. As a direct consequence of the ZH
culture of teamwork, most daily strategic and management decisions are
taken by consensus. The organisation chart (Fig. 0-3) shows how
information is cascaded through the different hierarchical levels.
The period 1984-1992 was a period of consolidation for the hospital’s
structure and staff. The command chain was hierarchical, and the
centre was organised through services and Units. Quality was primarily
seen and understood from a technical-clinical perspective, and
coordinated through committees.
There have been various stages on our path towards Total Quality. In
1992, the Osakidetza Integral Quality Plan was a driver of change and a
reference framework for the hospital, and in 1993, the ZH Quality Plan
was formulated. This Plan, in addition to containing the first draft of the
Mission, established customer satisfaction, ensuring technical quality
1
and avoiding non-quality as basic strategy lines. The Central Quality KEY MILESTONES IN MANAGEMENT & TOTAL QUALITY
Committee was formed to promote, together with Management, staff 1992 - Osakidetza Integral Quality Plan
training in quality management tools and to develop indicators, action - ZH Quality Plan (Total Quality)
lines and operational protocols. - Definition of ZH Mission
1993 - Central Quality Committee
- Osasuna Zainduz document (strategy to reform the Basque
Health Service)
- Satisfaction surveys for customers to fill out themselves
1994
- Training in Quality Management
1995 - First Programme Contract
- Decision to adopt the EFQM Excellence Model and training
1996 to undertake self-assessment
- Formulation of the 1997-2000 Strategic Plan and Mission
- Healthcare Act
- First self-assessment against EFQM Excellence model in ZH
- Application of QFD in Accident and Emergency Unit
1997
- Customer satisfaction surveys by telephone
- First people satisfaction survey
- Staff training in quality management tools
- Constitution as a Public Body subject to Private Law
- Second self-assessment against EFQM Excellence model
Figure 0.3 ZH ORGANISATION CHART - Primary Healthcare satisfaction surveys
In 1996, ZH management commitment to Total Quality became 1998 - Review of the Strategic Plan, and formulation of the
unequivocal, and we adopted the European Business Excellence model Business Plan.
as a reference framework. Training was undertaken in the model, and - Improvement teams
the first self-assessment exercise was conducted in 1997, as a result of - Scheduling of management by processes
which a Strategic Plan was drawn up (including a Mission statement) - Review of the Mission, and definition of corporate values.
and the first people satisfaction survey was conducted. - Leadership and people satisfaction survey
1999
In 1998, as a direct consequence of the second self-assessment - Development of management by processes
exercise, the MT began to look into management by processes as a - ISO 9000
working methodology which would create a quality culture in the hospital - Review of management by processes, and Business Plan
and increase people participation and hospital efficiency. Although this integrated into processes.
2000
was unprecedented in the Spanish Health Network, this methodology - Preparation of submission document for assessment against
was adopted the following year as a quality management system. This EFQM Excellence model (Silver Q Award, > 401 points)
Project was led by the Chief Executive and the MT (crit. 1 & 5). - Formulation of Vision
Management by processes was chosen as a continuous improvement - Global environmental diagnosis of the hospital (Ekoscan)
project to make it easier for people to understand and appreciate what 2001 - People Satisfaction survey
needs to be improved, to increase their involvement, to empower them - Golden Hélix Award
with the appropriate tools and decision making powers, to bring about - Baby Friendly Hospital Initiative Accolade (UNICEF)
greater hospital/people synergy and to globally increase the efficiency of - Development of Goals and CSF
our services. This system has been further enhanced through the use of - ISO Certification Project (16 processes)
a robust system for planning and deployment, and through the - Primary Healthcare, Society and Supplier satisfaction surveys
2002
development of multiple channels for gathering stakeholder information. - Second external assessment against EFQM Excellence
In turn, this has enabled us to harness the natural leadership potential model (> 451 points)
of our people and fully engage their commitment and knowledge of - Ciudadanía Award
quality management. Additionally, management by processes has - Innovation Capital Model
proved an excellent tool for disseminating the ZH Mission, Vision and - ISO 9.000 and 14.001 Certification Project
stakeholder needs. The concept of quality is integrated with that of 2003 - 2003-2007 Strategic Plan
management, and learning and continuous improvement have been - External assessment against EFQM Excellence model (Gold
established as the day-to-day culture of the hospital. Q Award, > 501 points)
The ZH management culture and how it has been developed, the - Process teams
intensive use of innovation and benchmarking and the involvement of - Internal customer surveys
our healthcare professionals are all factors which have contributed to - Balanced scorecard
the hospital’s prominent position in terms of results. These same factors 2004 - Training in teamwork
have also enabled us to pioneer the use and development of various - Evalexprés self-assessment (crit. 1)
management tools, and to be seen as a reference in the field of quality - ISO 14.001 Certification
management. Since 2000, ZH has been recognised for its - Review of the management by processes system
achievements in the field of management more than any other hospital Figure 0-4: MILESTONES IN ZH MANAGEMENT
in the Spanish Health System. Our commitment to Total Quality and the path towards Excellence are
This EQA submission document, like the previous 3 used for ever-present in our work. The end goal is seen as continuous
assessment against the model, is seen by us as another source of improvement in all areas of our organisation, especially in our
learning and continuous improvement, another step on our path towards contribution to social welfare through the provision of healthcare to our
Excellence. The document has been drawn up by the MT and a group customers.
of ZH healthcare professionals. (
Key milestones in the development and improvement of the ZH
management system are shown in Fig. 0-4.
Zumarraga Hospital - Hospital de Zumarraga 2