1. Sustainability of Quality through Quality Management Prof. Dr. Dr. h.c. Hans-Günther Sonntag Medical School, University of Heidelberg

2. Quality Management in Healthcare, Medical Education and Research - where I come from -

3. History of the University of Heidelberg Founded in 1386, oldest University in Germany 4 Faculties – Faculty of Law, Theology, Philosophy/Arts, Medicine Today: 15 Faculties (without technical field), 13.000 employees ( 3500 Professors) and 30.000 students (> 20% foreign students from all over the world) Medical Faculty and University Clinic (1.200 Professors, 2.500 students, 8.000 employees)

4. Basic Data Medical School University of Heidelberg 13 Clinics (43 departments) 12 Institutes (23 departments) 6.650 Full Time Employees (8.000 real) 50.000 Inpatients 35.000 Daycare patients 350.000 Outpatients

5. Research and Health Care Profile Oncology Cardiovascular diseases Neurology and basic neuroscience (incl. Psychiatry) Transplantation Infections diseases Medical Genetics and Genomic

6. Research ranking At the list of the top 20 universities of the world (The Times Higher World University Rankings 2010) the Medical Faculty of Heidelberg is placed at position 1in Germany 5in Europe 48 worldwide

8. Ringstructure 1. ring: Inpatient area 2. ring: Treatment area 3. ring: Development 4. ring: Infrastructure / parking area

9. What is Quality - Definitions -

10. Definitions (1) Quality is a holistic approach which in its sum includes all parameters which guarantee an optimal requirement for industry and the public sector. Quality assurance means a continious committment of all persons involved in the business of industry and public sector to fulfill the expectancies of the stakeholders of those business and the whole society

11. Definitions (2) Quality Management (QM) is the sum of all activities (planning, regulating, assurance, improving), which are necessary to reach the goals of a quality policy. QM has to be realized by all leadership levels. Activities concerning QM which have to be established by the leadership levels are: Development of strategies, distribution of money, regulation of quality structures, quality influencing paramenters and assessment of quality.

12. Definitions (3) Total QM is defined as a method where all members of an organisation are committed on quality which is focused on satisfying stakeholders, longlasting success of business as well as benefit for the members of the organisation and the society. Quality control (Quality controlling) includes the controlling of working methods and measures which have to be installed to fulfill the requirements for quality.

13. How to establish Quality Management ? The different visions and methods for the introduction of quality management

14. NATIONAL STATUS +

15. THE EFQM EXCELLENCE MODEL

16. Purpose, Direction & Culture “Mission and vision” communicated by multimedia and personally by members of the executive board; Management system development Systematic development and implementation by executive board Support of change management by internal resources e.g. coordinator, facilitators Involvement Permanent involvement of members of executive board and heads of departments with institutions partners and customers Support & Recognition Motivation through adequate resources (time, people, means, money) Motivation through extra benefits 1. LEADERSHIP

17. Stakeholder information & involvement Stakeholders: federal government, public sector institutions Performance, learning and other information Guidelines (local) are developed, implemented and monitored by quality indicators Financial information gained from controlling and financing department Development & Updating Development through key processes Financial key processes are monitored Business plans are systematically implemented Implementation by board of directors and directors of units Communication & Implementation Proceedings of the executive board are communicated to all directors of business units Implementation is steered by the executive board Regular meetings and workshops with key persons 2. POLICY & STRATEGY

18. Resources planning & Management General management is done by central administration and executive board Each head of department and director of business units is in charge of planning and management Knowledge and Competencies People are encouraged to participate in permanent post-graduate training (external providers) Involvement & empowerment “Management by objective” is practised Quality circles empower the people to reengineer their workplace Dialogue (people, organisations) Intranet of the Unit Information about management plans People are encouraged to make comments (regular meetings of executive leaders with staff) Reward, Recognition & Caring for personal rewards (non monetary and financial benefits) offer for post-graduate training, supervision, special programs 3. PEOPLE

19. External Partnerships Unit for Strategy and Planning in charge of external partnerships multitude of institutional and personal relations, Finances Department of Finance and Controlling (finances from government, third parties,...) Building, Equipment & Materials Technology Technological innovations are actively pursued (telemedicine,..) Technical side managed by Information & Knowledge Technical aspects are managed by Centre for Information Management Intranet (Internet) 4. PARTNERSHIPS & RESOURCES

20. Design & Management key processes are designed and managed by the business units and departments, monitored by controlling units and improved by means of quality management Improvement & Evaluation key processes are monitored by controlling (financial indicators), results (outcome), consumer satisfaction and discussed with stakeholders (Improvement is carried out by directors of units with help of quality management) Products & Services design Customers needs and expectations are monitored by regular surveys and personal interviews Products & Services, production & delivery Delivery of services is based on information from customers, partners and stakeholders Customer relationship regular meetings with customer groups personal interviews regular customers´ surveys complaints handled by executive board 5. PROCESSES

21. PERSONAL MANAGEMENT development of a vision and mission decision exec. board TOP- DOWN BOTTOM UP task force draft discussion revision approval dissemination discussion implementation

22. Vision deployment translate the vision explain the vision find congruence Communicate & Integrate publish and instruct connect with gratification & efficiency measurement Feedback and learning Articulate common values give strategical feedback Stimulate strategic review business plan set a specific target Strategical positioning Allocate resources Define milestones An organisation is streamlined, when each single task is linked to the mission and vision

23. ORGANISATIONAL DEVELOPMENT Q top-down leadership executive board units bottom-up involvement customers Coordinator for Quality Management

24. THE FUNDAMENTAL CONCEPTS OF EXCELLENCE

25. The Quality Improvement Cycle

26. SUSTAINABILITY IN QUALITY EXAMPLE EDUCATION

27. Inquiry by the Federal Ministry of Education in Germany Main negative criteria of education Bad quality of teachers concerning teaching methods No active participation of students in lectures, courses and seminars No communication between students and teachers No guidance of the students by the teachers (tutoring) Information of grades of test results without extensive information about content of tests and exams No communicative learning, no discussions No readiness by the teachers for criticism

28. History of implementing the new curriculum for medical education 1999 to a yearly admission of medical students, start with external evaluation of old curriculum 1999 Cooperation with Harvard Medical University to establish new teaching methods 1999 and 2000 Training of 15 teachers each at Harvard Medical University for 2 weeks 1999 Creating the new model of medical education (HEICUMED) by a core group of teachers in Heidelberg 2001 start with the new curriculum for all students and external evaluation 2002 HEICUMED is the only curriculum which meets the requirements of the new German law (2003)

29. Framework Step 1 : The Leadership Role Top down : Dean, Dean of Studying affairs, Core group – teachers trained in Harvard Directors of the departments – responsible for medical education Decision of the Executive Board of the Medical Faculty Bottom up : Teachers from the second line – trained as tutors Students involved in the planning and establishing of the new curriculum

30. Framework step 2 : Key Milestones on the Journey Acceptance of the curriculum by the students Motivation of the teachers Best results according to extern evaluation Corporate identity of the students (their institutes,their clinics, their patients, their teachers) New curriculum fits into the new law of medical education Until now >600 young teachers trained as tutors International acceptance of the new curriculum (Germany, Bosnia & Herzegovina, Slowenia, Budapest)

31. Framework Step 3 : Building Blocks to Excellence Tools used: Communication, personal talks, Training – core group in Harvard, Young teachers in „Train the trainer „ courses New teaching /learning methods (CBT, Skills Lab, organisation of bedside teaching, POL ) New methods for examinations (OSCE, artists, oral examinations) Athena – intranet for communication between students and teachers

32. Framework step 4 : Integrating the Programme into normal Operation New curriculum introduced for all students Teaching organized according to the new curriculum Assistance for the whole project by the deans office of studying affairs, the core group, the deans office and all directors of departments Financial support for the new curriculum through the budget of the Medical Faculty Extern evaluation and adaption of the results into further activities Self assessment as a basic requirement for further development

33. Framework step 5 : Measurement and Review Extern and intern evaluation of the new curriculum (students, teachers satisfaction) Besides Excellence in Health Care and Research Medical Education one of the main columns of duties of the University Medicine Feed back of the teachers according to intern evaluation, meetings with the core group and the tutors High commitment of teachers and students Better communication between students and teachers Outcome of learning

34. Evaluation Results before after Quality of education 11% 73% Content coordination 5% 54% Practical relevance 6% 87% Lecturer contact 2% 76% Competition between stud. 48% 10% Support of history taking 8% 84% Support of examination tech. 5% 60% Support of ethical compet. 6% 35%

35. Evaluation Results (2) Ranking of students after 6 years education: 2nd of 36 Medical Faculties in Germany Students failing exams: 3.5% instead of normally >35%

36. EVALUATION THROUGH PATIENTS Example Sustainability of Quality in Patient Care

37. PATIENT (CUSTOMER) FOCUS - “traditional“:- interaction of one particular physician with one particular patient - “objective expert“ - “modern“:- interdependent action of a number of various professionals - customer / consumer satisfaction “subjective non-experts“ satisfaction of individual patient and patient groups

38. Evaluation through Patients 1. Step: Asking for expectations when patients are admitted to the hospital (items with high and with low priority) 2. Step: Asking for satisfaction when leaving the hospital

39. importance satisfaction PATIENT SATISFACTION SURVEYS importance/ satisfaction of one item key weaknesses weak points zero weaknesses weak points zero strenghts strong points key strenghts strong points

40. Performance of physicians at the Women's Hospital (rating by the patients) „Die medizinische Behandlung durch die Ärzte ist gut.“ „Die Ärzte informieren mich ausreichend über meine Befunde und die Behandlung.“ „Die Ärzte nehmen sich Zeit für mich.“ „Die Ärzte gehen auf mich und meine Bedürfnisse ein.“ „Ich habe das Gefühl, bei den Ärzten in guten Händen zu sein.“ “ The medical treatment by the doctors is good.“ “ The doctors inform me well on my examination, results and my treatment“ “ The doctors have time for me.“ “ The doctors listen to me and are responsive to my needs.“ “ I believe I am in good hands with my doctors.“ expectance actual state

41. PATIENT SATISFACTION SURVEYS trend analysis (departement x) Total items 15, sub items 5-8 in each item Item: physicians 4,3 3,84,0 4,5

42. Sustainability through COMPLAINT MANAGEMENT

43. COMPLAINT MANAGEMENT REPORTING CATAGORIES OF COMMENTS Physicians Nursing staff Other staff Staff in general Accomodation Catering Orientation Organisation

44. Sustainability in Quality using BENCHMARKING INDICATORS

45. research, teaching, care input / output analyses (evaluation by clinical research, controlling (HIS), quality management) state of health PROCESSES (diagnosis / therapy “Outcome” Q = “quality” “risk profile” } SUSTAINABILITY OF QUALITY APPLIED TO UNIVERSITY CLINICS OF HEIDELBERG

46. Excellence TeamworkLeadership Excellence – Delivering what we promise and adding value beyond what is expected Teamwork – the best solutions come from working together with colleagues and clients Leadership – leading with clients, leading with people and thought leadership Sustainability in Quality will be the guarantee at every working place to be a great place to work for all our people

47. Thanks for your attention Independent of what will come, we will always survive

48. Sustainability in Quality through IMPLEMENTING AND ACCEPTING CHANGES

49. Readiness for Change Planning Leadership & Direction Implementing Change PROCESSES Organisation & Resources Behaviours Systems & Controls Need for Change External Events        © Oakland Consulting 2004 Successful improvement in competitiveness requires “Readiness” and “Implementation” Strategic Operational

50. Need for change Leadership & Direction Planning Need for change Leadership & Direction Planning Need for change Leadership & Direction Planning Readiness for Change Successful change possible Need for change Leadership & Direction Planning No urgency and no action Never leave the start False starts and wrong directions   

51. Process of Change … d c b a Ease of implementation € Cost Reduction e f g Prioritisation Problem Rules Assumptions revised rule Revise Assumption Busting … involving skilled facilitation with a precise mix of analytical and creative thinking Sub-process changes eliminating simplifying combining rearranging Select easily changed sub-processes through, e.g … Creative thinking Brainstorming Related Worlds Re-expressionWhat-If Random Links Identify processes to change Options for redesign Prioritise for implementation analysis analysis diversified idea generation Using a carefully experienced approach to maximise the opportunities for change …

52. Processes Organisation & Resources Systems & Controls Behaviours Processes Organisation & Resources Systems & Controls Behaviours Processes Organisation & Resources Systems & Controls Behaviours Processes Organisation & Resources Systems & Controls Behaviours Implementing Change Successful change probable Effort wasted on non-core Driving blind Processes Organisation & Resources Systems & Controls Behaviours     Paralysis and frustration Resistance endangers success