THER2E2-MODEL©forTotalQualityManagement

HealthCareVersion

OCTOBER2018

EverardvanKemenade,PhD.

everard@onsnet.nu

Introduction

Dearfriend,TheR2E2-model©hasbeendevelopedusingtheMethodforImprovingtheQualityofHigherEducationbasedontheEFQMModel(Kemenade,editor,2006).Furtherinsightsregardingparadigmsinqualitymanagementareadded(Kemenade,2014).Theparadigmshavebeendefined,describedandhavetheirowncolor.R2E2standsforthenamesoftheReflective,theReference,theEmpiricalandtheEmergenceparadigm.Thisversionofthemodelisfocusedonhealthcareinstitutions.Theaimofthemodelistogiveorganizationstheopportunitytoimprovetheirquality.Itcanbeusedforself-assessmentaswellasforauditingbyanexternalteamofsurveyors.However,thetwoshouldnotbeconfused.Itdeliversa‘quickanddirty’scan.Still,weexpectorganizationstobenefitlargelyusingTheR2E2-Model©.Wecanprovidesupportbyauditing,consultancyandcoachingortraining.Iherebyliketothankthosewhocooperatedinthetheoriesused,especiallyprof.T.W.HardjonoandMartijnvanSchaik‡.EverardvanKemenadeIndependentExpertinTotalQualityManagementeverard@onsnet.nu

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1. RationaleThisR2E2-model©ismeantfororganizationstogetagripontheiradaptabilitytowardsemergentchange.Itisfocusedonhealthcare.ThemodelisuniqueinitscombinationofthecriteriaoftheEFQM-modelandfourparadigmslinkedtototalqualitymanagementinanorganization.ActuallytheR2E2-model©consistsoffiveconcepts:thePDCA-cycle,theEFQMExcellenceModel,theCaribbean©-model,theinput/impactmodelandthefourparadigmsforTotalQualityManagement.Leadershipandqualitymanagementrepresentativescanuseit,butinprincipleitisfitforuseforanyemployee.ThismodelhasbeenadaptedforuseintheCaribbean.Theinstrumentisamatrixmodelthatcanbescoredbyindividualsandthereafterdiscussedbygroupsofpeopleorteams.Thescoringmightcosthalfanhourofyourtime;reachingconsensuswithagrouptakeshalfaday,dependingontheabilityofthegrouptodialogue.

2. TheR2E2-Model©:TheEFQMModelIntroductionThechoicefortheExcellencemodel1developedbytheEuropeanFoundationforQualityManagement(EFQM)wasmadenotonlybecausethemodelisveryeasytounderstandandeasytouse,butalsobecauseitismorecompletethanothermodels.ThePDCA-cycledevelopedbyShewhartandDemingisthecoreoftheQualityManagementprofession.IntimesofemergentchangeothermodelsliketheCaribbean©-Modelareneeded.Itisalsoanattempttoadaptthemodeltothespecificcontext.Theresultsneedtobedividedintooutput,outcomeandimpact.ThesefourconceptsareappliedintheverticalaxesoftheR2E2–Model©.Theaxesaredescribedbelow.Fourparadigmsareaddedtoshowwhereanorganizationstandsandwhatisneededinthisparticularcontexttogrowandimprove.TheyformthehorizontalaxesoftheR2E2–Model©andaredescribedinchapter3.2.1. FundamentalconceptsoftheEFQMmodelBecausethisinstrumentisanaidtopeopleandpeopleworkonabasisofconcepts,imagesandvalues,weshallbrieflydiscusstheunderlyingconceptsoftheEFQMmodel.TheEmergenceModelborrowsagreatdealofitsmeritfromitsconceptualmodel2thatisapplicabletoallorganizationsregardlessoftheirsize,structureorthesectorinwhichtheyoperate.TheEFQMmodel,likeanyothermodel,isnotvalue-free.ForthisreasontheunderlyingconceptsanddimensionsareexplainedEightfundamentalconceptslieatthefoundationofthismodel.3

1. Addingvalueforcustomers2. Creatingasustainablefuture3. Developingorganizationalcapability4. Harnessingcreativityandinnovation5. Leadingwithvision,inspirationandintegrity6. Managingwithagility7. Succeedingthroughthetalentofpeople8. Sustainingoutstandingresults

1http://www.efqm.org/the-efqm-excellence-model2SeeSchaik†,Kemenade,HengeveldandInklaar(1998),andSchaik†(1998).3See:‘EightEssentialsofExcellence’(EFQM,1999)anditsrevisionathttp://www.efqm.org/efqm-model/fundamental-concepts

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2.2.PDCAIntheEFQMmodel,4theorganizationisdividedinninecriteria(seethefigurebelow)thataresubdividedintwosections:theOrganizationalsection(1-5)andtheBusinessResultssection(6-9).Eachoftheninecriteriaisdividedintoanumberofaspects.Theorganizationalcriteriaformthepreconditionsforeffective,efficientandinspiredworkandgoodresults.Thepositionofahealthcareinstitutioncanbedeterminedforeachofthesecriteria.

Acharacteristicfeatureofthemodelisthestrongconnectionoftheenablercriteriatotheresults.Theaimsandeffectivenessofplansandactionsmustbedemonstratedbytheresultsachieved.The‘Learning,CreativityandInnovation’arrowarticulatesanessentialelementofthemodel:thetotalmodelisactuallyalearningcyclefororganizations.Asaconsequence,itcanberegardedasadynamicmodel.Theheartofthebasicmodelistherefore:learning.Inqualityassurance,oneoftenreferstothePDCAcycle(Plan-Do-Check-Act)towhichthenamesofShewhart(1939)andespeciallyDeming(1986)arelinked.Thislearningcycleformsthecoreofthemodelandshapestheeightunderlyingconcepts.

4 See also The EFQM Excellence Model (EFQM, 1999) and its revision http://www.efqm.org/efqm-model/criteria

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Plan:determinetheapproach:determinethedirection,choosethestrategyofapproach,specifythegoalsintoSMARTgoalsandplantheimplementation.Question:arethevariousactivitiesbasedonwell-underpinned,adequateandwell-communicatedplans?Do:elaboratetheapproach,distributeandimplementit.Thisstageincludestheallocationofpeople,resources,andtheimplementationofthework.Question:aretheseplansbeingcarriedoutproperly?Check(orStudy):assessyourapproach:measurewhetherornotthespecifiedSMARTgoalshavebeenrealized(resultsandprocesses).Question:aremeasurementsbeingtakentocheckiftheplanshavebeenwellimplemented?Isthisbeingdoneinavalidandreliablemanner?Act:analyzethemeasurements,reviewnewexternal(social)developments/trends,andmakelastingimprovements.Question:iftheevaluationindicatesthattheplansarenotbeingproperlyimplemented,arethereimprovementplansandcantheybeimplemented?Inreal-lifepractice,staffmembers,teamsanddepartmentsregularlyapplythiscyclebutprobablytheyarenotalwaysappliedequallyconsciously,systematically,andwithregardtoothermembersofstaffanddepartments.Byapplyingthecycleconsistentlyandatalllevelsandbywritingdowntheproceduresdevelopedforthispurpose,theorganizationgraduallydevelopsaqualityassurancesysteminconjunctionwithitscolleagues.Everyfewyearsyoure-determineyourpositiontoexaminewhetherornotyoursystemofworkinghasimproved.InturbulentsituationsthePDCA-cycledoesnotprovidethedesiredeffects.Thenanorganizationneedstoapplyothertools,likeCaribbean©,basedonACCRA©5(see:Kemenade,2013andKemenade,2014a).2.3.CaribbeanTheCaribbean©hasbeendevelopedbyEverardvanKemenade6tocopewithemergentchange,wherethePDCAmightbebetterequippedforplannedchange.Caribbeanisanacronymthatshows9aspectsthatarecrucialintimesofemergentchange:

1. ContextIntimesofemergentchangethecontextneedstobetakenintoaccount.Itdefinestoalargeextentwhatthecriteriaforqualityoftheorganizationare.

2. AttentionEmergentchangerequiresattentiontothecorebusiness,teamandindividual

3. ReflectionEmergentchangerequirescontinuousreflection

4. InspirationIntimesofchangeitiscrucialthatfirstleadershipandinfactasmanystaffaspossible,arecommittedtothechange.Leadershipneedstoinspirethestaffforthechange.

5. BreakthroughIncrementalchangeisnotenough;wearelookingforbreakthroughchange.

6. BenchmarkingInsituationlikethisweneedtocooperate,network,benchmarkwithorganizationsthatcansupportthechange.

7. ExperienceFinallywearenotsatisfiedwithcustomersatisfaction.Westriveforcustomerdelight,providingthecustomerwithanexperiencenevertoforget.

8. ActionThatrequirescontinuousaction.

9. NonegativityInanatmospherewheremistakestosomeextentmaybemade,wherepositivityistheattitude,wheregossipisnotaccepted.

5ACCRA©isdesignedbyVanKemenade(2013)andstandsforAttention,Context,Commitment,ReflectionandActionaskeystrategicfocus.6UndertheoriginaltitleofACCRA©

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3. TheR2E2-Model©:FourparadigmsTheR2E2-Model©workswiththeabovepresentedmodelsandfourparadigmsorvaluesystemsthroughwhichthequalitycanbemeasured.Thefourvaluesystemsaredescribedinseveralarticles(Kemenade2010;Kemenade2014;KemenadeandHardjono,2018,underreview).Example:Foursituationsinwhichahealthcareinstitutemayfinditself.Thissectionshowsthecharacteristicsofeachvaluesystemandthetheoriesbehind.Itgivesanexampleofhowahealthcareinstituteinacertainvaluesystemmayact.Itisimportanttorealizethattheorganizationitselfestablishesthevaluesystemorcombinationofvaluesystemsthatfitbest.

Fourparadigms:R2E2-Model©

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1:Control(Empiricalparadigm) Duringthe20’softhelastcenturythesystematicapproachofqualitymanagementstartstosurface.Inthebeginningthemaincharacteristicofthisqualityparadigmisthefocusontheendproduct.Whenmassproductionbecamecommon,itbecametoocostlytoinspecteverysingleproduct.WiththehelpofStatisticalProcessControl,samplingbecameavailableasawayofqualityinspection.TheAmericanSocietyforQuality(ASQ)andtheEuropeanOrganisationforQuality(EOQ)originatedinthatperiodandaredominatedbywhatwecalltheEmpiricalParadigm.TheEmpiricalParadigmderivesitsnamefromitsmethodology.Knowledgeabouttherealityisgainedbyexperiencinghereandnow,bysensoryperception.Itisevidencebased.Thequalityknowledgeconcernsobservablecharacteristics(aspects)ofentities(objects),likeproducts,servicesandprocesses.TheEmpiricalParadigmworksonactualandspecificproblems.Thesearetechnicalandcanbesolvedbyscience.Itisaboutobjectiveknowledge.Knowledgeisgathered(inductive)bymeasurementsanditsobjectiveresultsareexpressedinquantitieslikesizesandnumbers.TheEmpiricalParadigmfocusesonrules.Qualityisconformancetorequirements(Crosby,1979).TheEmpiricalParadigmregistersandcontrols.Itsmottois:“tomeasureistoknow”.JointCommissionInternationalAccreditationfitsinthisparadigmaswellasprotocolizationandEvidenceBasedMedicine.InHardjono’sFourPhaseModel©(1995)thewholecomplexofabsorbing,digestingandexudingenergyinorganizationsisexpressedthroughfourcompetencies:material,commercial,socializationandintellectual.Competencieswhichorganizationsneedtosurvive,competenciestheydrawonfromtheirenvironmentandwhichtheyexudetowardstheirdirectstakeholders(owners,financiers,members,personnel,businesspartnerssuchascustomersandsuppliersandthevarioustreasuries).Accumulationofthesecompetenciesmeansgrowthwhichisexperiencedasbeingsuccessfulandwhichcontributestothesurvivalchanceinthelongrun;competencieswhicheachofthesestakeholders,astheirownentities,needforsurvivalandgrowth.TheEmpiricalParadigmismainlyinterestedinthematerialcompetence.Theabilitytoincrease,maintainandoptimallyutilizetheresources(financialmeans,technologyandmaterialmeans).Leadershipisdirectiveandtechnical.Ametaphorforthiswayofthinkingisthearmy.Friedson(2001)discussedthreewaysoforganizing:inhisterminologythisparadigmfitswiththe“managerincontrol”.WerecognizetheEmpiricalParadigminQualityControlSystems.Theriskoftheempiricalparadigmisbureaucracy.Wegavethisparadigmthecolorblue.2:Continuousimprovement(Referentialparadigm)Noteverythingthatisimportantcanbeeasilymeasuredintemperature,kilograms,secondsoramperes.Or,ifyoudo,youdonotcatchtheessenceofwhattheentityis.Beauty,love,wisdom,empathy,trustareexamplesofthis;andthatgoesforanorganizationaswell.Tosolvethisdilemmaqualitymodelsweredesigned,frameworksofreferenceinwhichcriteriaorareastoaddressarementioned.WecallittheReferenceParadigm.Thisparadigmdoesnottakethereality(thisishowitis)asstarting-pointbutconvictionsabouthowtherealityshouldorneedstobe(thisishowitshould).Thisparadigmprescribeswhatnormsneedtobemettogetrecognition,orevenanaward.Insteadofrules,itprovidesguidelinesandmodels.TheReferenceParadigmvalues,certifiesandaccreditsusingmodelsliketheISO9000-series,theBalancedScoreCard,theEFQMExcellencemodelortheNationalMalcolmBaldrigeQualityAward.NationalAwardswereinstalledallovertheworldtomotivatecompaniestokeepimproving,sinceimprovementisitsaim.Thequalityknowledgeisgathered(deductive)searchingforobservable,realcasesthatprovethattheorganizationmeetsthenorms.Theoreticallyqualitycanbedefinedasfitnessforpurposeorfitnessforuse(Juran,1951).Vinkenburg(2006)statesthatwhatwecalltheReferenceParadigmseessuboptimalizationasproblem(diagnosis)andseeksthesolution(therapy)inatotalapproachofallprocesses,allstakeholdersinacyclicwayofworking(PDCA).Managementsciencesareinfavor.FamousgurusofthatmovementwereDeming,whodevelopedinthefiftiesthePDCA-cycle,basedontheideasofShewhart.AnotherrepresentativeofthismovementwasImai(1986)andhisKaizen-approach.InHardjono’sFourPhaseModel©theReferenceParadigmismainlyinterestedinthecommercialcompetence,thatistheabilitytohaveaccesstomarketsandtheabilitytoactonthem.IntermsofFriedson(2001)the“customerisincontrol”.Ametaphorforthiswayofthinkingisarobot.LeadershipintheReferenceParadigmissupportive,coachingleadership.Theriskofthisparadigmis‘pampering’.Wegavethisparadigmthecolororange.

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3:Theprofessional(Reflectiveparadigm)Vinkenburg(2006)introducedwhatwecalltheReflectiveParadigm.TheReflectiveParadigmstartsfromtheexistenceofdifferentrealities,likeperceptions(thisiswhatIseeandthatiswhatyousee)andinterpretations(thisiswhatyouthinkandthatiswhatIthink).Everyonehashisownrealitythatcanbedifferenttomorrowfromtoday.Thisparadigmlooksforthedifference,makesitexplicitandreflectsonit.Knowledgeisgathered(inductive)bytellingandlisteningtostories,byconversations,groupmeetings,andinnerconversations.Thisparadigmreflectsandphilosophizes:WhatdidIdowellandwhatdidIdowrongandwhy?TheReflectiveParadigmconsiderspeople,theirinteractionsandconceptionsasitsentityandmorespecifictheirworldviewandtheircapabilitytoreflectonthat.Itismainlyaboutnon-observableaspects,subjective.BasedonZenandtheArtofMotorMaintenancePirsig(1972)isoftenquotedasproofthatqualitycannotbedefined,butjustdiscussed.Theadageis,that“Qualityisnotathing,itisanevent”.Thescienceinfavorisphilosophy.AmetaphorforthisparadigmisthestatueofRodincalled‘Lepenseur’.Vinkenburg(2006)statesthatwhatwecalltheReflectiveParadigmsees‘wrongattitudes’(psychicalaspect)and‘unfruitfulinteractions’(thesocialaspect)assymptoms,‘insufficientself-criticism’asproblem(diagnosis)andseeksthesolutionin‘detachingmechanisms’(therapy).Thisisdone(treatment)byshadowing,modeling,secondopinion,intervision,timeout,stories(tellandlisten),anddiscussion(Vinkenburg,2006).WerecognizetheReferenceParadigminaninstrumentlikepeerreviewasitisusedinHealthcareusingvisitations.Friedson(2001)talksaboutthethirdlogic:“theprofessionalincontrol.”IntermsofHardjono’sFourPhaseModel©theReflectiveParadigmisinterestedinthesocializationcompetence.Leadershipisdelegating,sincetheprofessionalknowsbestwhattodo.Theriskofthisparadigmisarrogance.Wegavethisparadigmthecolorgreen.

4:Context(Emergenceparadigm)TheEmergenceParadigmfitsinthecurrenteraofcontinuouschange(asMillerandCangemi,1993request).Emergenceisaconceptfromsystemstheory.Itrelatestothedevelopmentofcomplexorganizedsystemsthathavecharacteristicsthatarenotvisiblebyreductionofthecomposingparts.“Whilesomeexpertsarefamiliarwithdevelopmentsinonefield,suchasartificialintelligence,nanotechnology,bigdataorgenetics,nooneisanexpertoneverything.Nooneisthereforcapableofconnectingallthedotsandseeingthefullpicture“(Harari,2015).Emergenceistheprocesswherenewcharacteristicscometoexistencethroughinteractionbetweensimple,smallentitiesthatdonothavethesecharacteristicsliketheselforganizationofants.Manyantstogethershowacollectiveintelligencethatindividualantsdonotposses.Itprovidesgreaterbuy-inbyemployeesanditcontinuouslyrelatestothecontext,soitwilloffercontextspecificdesigns(asAsifetal,2009request).Systemstheoryisfocusedontheinteractionbetweenthesystemanditsenvironment(asMosaghrad,2014requests).

IntheEmergenceParadigmsystemsthinkingisintegratedinqualitymanagementtheoryandpractices(Conti,2010;Chenetal,2014).BarouchandPonsignon(2016)giveanoverviewofqualitymanagementconceptsfromasystemicperspective.AlsointermsofWhittington’sstrategicperspectives,wearetalkingaboutthesystemicperspective(Whittington,2000).TheEmergenceParadigmisbasedonJohnDewey(1859-1952)andhispragmatism.TheEmergenceParadigmrelatestoWilber’squadrantoftheexteriorcollective.Thisisratheraboutchaos,ofwhichwecontinuouslyhavetomakesenseintersubjectively.TheEmergencyParadigmdefinesqualityinadialogueofallstakeholders,notjustmanager,customerorprofessional,knowingqualitycanbedifferenttomorrow.Itisaboutmakingdecisionsbasedonthebestknowledgeoftoday,havinginvestigatedeverything,tothebestofourknowledge.Qualitydoesnotexist,butarises.Inthatinvestigation,inthatstudywerelyonvirtues,onmorals,onsharedvalues.Pirsig(1991)inhissecondbookLilaknewquitewellwhatqualityis.Qualityisadynamicconcept.Itisvalue,hesays,givinghisbooktheundertitleaninquiryintomorals.TheEmergenceParadigmseescrises,likebankruptciesandethicalmisconductassymptoms.Tobeabletounderstandtheseproblemsandsolve

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themweneedtostudythecontext.Theinabilitytocopewithchangesinthecontextistheproblem(diagnosis);theEmergentParadigmseeksthesolutioninfixesintheprocesses,adjustingtothecontext,sometimesbreakthrough(ShibaandWalden,2006)ortotalreorganization(therapy).Thisisdone(treatment)bychangesinthewaywework,bynetworkingandcreatingaqualityculture.“Thetruthis,whatworks”,saysDewey.Thereisnotonerightwaytoorganizeabusiness(seealsoBurnes,1996),nosinglerightwaytomanagepeopleortomanagequality.Andwhatworkstoday,mightnotworktomorrowanymore.WhatworksintheNetherlands,mightnotworkonSintMaartenintheCaribbean.Ratherthanasymphonywithanorchestraconductor(Crosby,1992:14,15),wetalkaboutajazzcombothatcontinuouslyimproviseswithinthecontext.Toolscanbequalitycircles,appreciativeinquiry,SocraticCafe,whilenewtoolslikeACCRA©(Kemenade,2013and2014b)arebeingdeveloped.Leanfitshere(butSixSigmafitsintheEmpiricalParadigm).Leadershipisparticipativeorshared(PearceandConger,2002).IntheHardjonoFourPhaseModel©thisparadigmbelongstothequadrantexteriorchange.Hardjonomentionsthiscreativity,witharelationtodisruptiveinnovation,lateralthinkingandinvestingintellectualcapacity.Wegivethisstagethecolorteal.

ThefourparadigmsarecomparedonthenextpageintheParadigmsoftheR2E2-model©.TogethertheyformTotalQualityManagement.

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EmpiricalParadigm ReferenceParadigm ReflectiveParadigm EmergenceParadigm

Qualityis Conformancetorequirements Qualityisfitnessforuse Qualityissubjective Qualityisnotstatic,butdynamic.

Adage “Tomeasureistoknow” “Weneedtoimprovecontinuously”

“Qualityisnotathing,itisanevent”

“Thetruthiswhatworks”

Focus Rules,standards Models,guidelines Principles Sharedvalues,virtues

Aim Control Continuousimprovement

Professionalism Contextflexibility

Problem Unpredictabilityofproductanduncontrollabilityofprocesses

Suboptimalization Insufficientselfcriticism Inabilitytocopewithchanges

Solution Takecausesofvariationaway PDCA Detachingmechanisms Adjustingtothecontext,breakthrough

Tools SPCSeventoolsSixSigmaJointCommissionInternationalAccreditationEvidenceBasedMedicine,Protocols

ISO9000-seriesEFQM-modelMalcolmBaldrigeAwardQualitycircles

Secondopinion,Intervision,Timeout,DiscussionStoriesInnerconversations,Shadowing,Modeling,Peerreview

Contextanalysis,QualitycirclesACCRA©LeanAppreciativeInquirySocraticCafe

Gurus Shewhart Deming,Juran,Imai Pirsig(1976),Vinkenburg(2006)

Pirsig(1991)DemingConti

Competence Material Commercial Socialization Intellectual

Sciences Statistics,‘Hard’sciences Managementsciences Philosophy Systemstheory

Whittington(2000)

Classicstrategicperspective Processualstrategicperspective

Evolutionarystrategicperspective

Systemicstrategicperspective.

Leadership Directive,technical Supportive,coaching Delegating Participative,Sharedleadership

Metaphor Army Robot LePenseur(Rodin) Improvisingjazzcombo

Friedson(2001) Managerincontrol Customerincontrol Professionalincontrol Allstakeholders

Risk Bureaucracy Pampering Arrogance Chaos

ParadigmsoftheR2E2-model©.

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4. Workingwiththemethod:step-by-stepplanandscoring

4.1.Self-assessment

TheR2E2-Model©offersatriedandtrustedstructurefordeterminingthepositionofaninstitute–which

isalsoreferredtoas‘internalaudit’or‘self-assessment’.Inthisdeterminationofposition,the

management,doctors,nurses,supportingstaffandmaybeevenpatientsexaminethequalitymanagement

withintheinstitute.Theoutcomeindicatesthevaluesysteminwhichtheorganizationcurrentlyfinds

itselfintermsoftotalquality,andformstheimpulseforthegenerationofimprovementplans.Whatone

shouldalwayskeepinmindis,thatthisconcernsaself-evaluation,aself-assessmentaimedataprocessof

continuousimprovementandnotanexternalcheckorajustificationofone’sactivitiestotheMinistryof

Healthoravisitationcommittee.Theessentialnatureofa‘self-assessment’shouldremainintact(see

Kemenade,2010).

Thedeterminationofpositioniscarriedoutbyagroupofstaffmembersandmaybesomepatientslikein

apatientinterestgroup,whoarewellacquaintedwiththeprocedureswithintheinstitute.Asa

consequence,theresultsoftheinvestigationgiveatruepictureofthestateofthingswithinthe

departmentororganization.Thisisapositiveelementincreatingabroadsupportbase.

Inprinciple,alllayersofthestaffareinvolvedinthescoring:themanagementandasampleofthemedical

andnursingstaffandtheauxiliarystaff.Ifarelativelysmallnumberofstaffdoesthescoring,theworkcan

bedonequicklyand–provideditisagoodsample–agooddeterminationofpositioncanberealized.

However,inthatcase,moreattentionwillhavetobedevotedtoexplaininganddiscussingthescoresand

tryingtoreachconsensus(theconsensusmeeting).

Theadvantageofusinga(large)samplefromalllayersisthatmutualexchangesandadjustmentofideas

takeplace.Inthisway,communication,participationandinvolvementarefavorablyinfluenced.Thisalso

producesfuturebenefit.Itisimportantthat,whateverelsehappens,eachpartisfilledinbypeoplewho

haveexperienceorknowledgeoftherelevantcriterionwithintheorganization.

Intheabbreviatedversion,onlythemanagementdoesthescoringandthatisthebasisforthestrategyto

bedeveloped.Workingproperlywiththemethodmightrequireexpertsupervisionandsomesupportin

theapplicationofthemodel.Thisshouldbeparticularlyapplicableontheveryfirstoccasion.

Weshallnowbrieflyexplainthefivestepsofthemethod.

Step1 Preparation

- Defineaspreciselyaspossibleanumberofkeyconcepts,suchas‘management’,‘organization’

tomakeclearwhatyouaretalkingabout.

- Determinewhatwillhappenwiththeresults.

- Planthecommunicationaroundtheresult(who,when,what,how).

- Trainthepersonwhoco-ordinatestheprocess.

- Preparethestaffmembersparticipatinginthedeterminationofposition(explanation,

meetingforinstruction).

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Step2 Fillinginthemethod

Theindividualmembersofstaff(orarepresentativesample)readtheentiremethodthoroughlyand

assessallcriteriaandconstituentaspectstodeterminethesituationinwhichtheorganizationcurrently

findsitself.Eachparticipantfillsinthescoreontheirown;therearenomutualconsultations.

Step3 Theconsensusmeeting:determiningtheposition

Themembersofstaffinventoryanddiscussthedifferencesintheindividualscoresataconsensus

meeting.

Theaimistoseekconsensusonthestrengthofargument,nottoreachanaverageortoacceptthevalue

systemthatwasmostscored.

Step4 Improvement

Assoonasthereisaviewofthetotalscore,theorganizationcanorientitselftopossiblemeasuresfor

improvement.

- Theformulationandprioritizationofalimitednumberofattainableimprovementmeasures.

- Theregularpolicycycle.Includetheprioritiesinthe(short,mediumandlong-term)policyof

theorganizationalunitandintheplanningandcontrolcycle.

Optional:Step5 The(external)auditteam(everyyear)

- Analysisofdocuments

Theinstitutesendsmaterial,suchaspolicydocuments,toanauditteamconsistingofexternal

experts.Theoutcomesoftheconsensusmeetingneednotbesent.Theauditteamstudiesthe

writtendocumentationandinformationandassessesthestageinwhichtheorganizationalunitis

currentlysituated.

- Visitoftheauditteamtotheinstitute.

Theauditteamvisitstheinstituteandholdsdiscussionswithindividualmembersofstaff,patients

andrepresentativesofthefamily.Thediscussionsareheldinlinewithanagenda.

Afeedbackreportcontainingthefinalresultsisthenformulated.Thisreportcontainsveryconcise

recommendations.Theorganizationcanusethisreportfortheformulationandprioritizationofthe

improvementmeasures.Ifnecessary,externalexpertsareinvolvedinthatprocessintheformofa

workshop.

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4.2. Scoringtheorganizationalcriteria

Determiningthevaluesystemoftheinstituteshouldbedoneinthesamemannerforallorganizational

aspects.Thevaluesystemsarelistedfromlefttorightonthehorizontalaxis.Theconstituentaspectsof

thecriterionunderinvestigationaregivenontheverticalaxis.For‘Leadership’,anexampleofanaspectis

‘Styleofleadership’.Eachcellofthematrix(i.e.theintersectionofavaluesystemandaconstituent

aspect)containsashortdescriptionoftheparticularaspectthatischaracteristicforanorganizationin

thatvaluesystem.Thesedescriptionsaregivenbywayofexampleanddonotcoveralldimensionsthat

shouldbeconsideredwhenscoring.

Howtoscore

Thescoringshouldbedoneforeachconstituentaspectofeachcriterion,inthefollowingmanner:

1. Readthedescriptionsinthecellsofthematrixforthecriterionyouaredealingwith(fromlefttoright)

2. Tickthebox(es)thatapplytoyourorganization(morethanonescoreispossible,thereisnohierarchy

inthescores).

3. Individualscoresmaybetransferredtothereportinstrumentsdescribedintheappendix.

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1.

LEADERSHIP

Control

Continuous

improvement

Theprofessional

Context

1. Values,

mission,vision

Values,missionand

visionareexplicitin

oneormore

documents.Rulesare

leading.

Values,missionand

visionare

communicatedinside

andoutsidethe

organization.Norms

areleading.

Values,missionand

visionaresharedbystaff.

Values,missionandvisionare

sharedbystaffandtheoutside

network.Positivityisacore

value.

2. Leadership

Style

Directive(telling)

Coaching(selling)

Delegatedleadership

Participativeincluding

externalstakeholders

4.Attention

Managementattention

isgivento(it)the

primaryprocess

(evidencebased

medicine).

Managementattention

isgivento(we)the

patientandfamily.

Managementattentionis

givento(I)the

professional.

Managementattentionisgiven

toallstakeholdersandthe

context(its).

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