Description
Nowadays the efficient use of quality management systems and methods is becoming an important requirement in the institutions operating in the field of public services. The article deals with some elements of the quality efforts in public health, public administration and higher education.
„Club of Economics in Miskolc” TMP Vol. 4., pp. 75-80. 2007.
75
Quality Management in Public Service
JÓZSEF TOPÁR
SENIOR LECTURER
e-mail: [email protected]
SUMMARY
Nowadays the efficient use of quality management systems and methods is becoming an important requirement in the institutions
operating in the field of public services. The article deals with some elements of the quality efforts in public health, public
administration and higher education. My aim is to give an overview of the most important features and operational pieces of
experience of quality management systems in the public services in order to make the institutions of these sectors able to adapt those
quality management approaches, systems and methods which meet the requirements of their clients and of the organization.
INTRODUCTION
During the recent decades, raising quality to a strategic
level has become an essential condition of successful
operation in every field of the economy. No production or
service organization can avoid applying quality
management tools and methods on a system level. These
systems have developed parallel with the change of the
concept of quality and partly this change may have forced
the evolution and application of various quality
approaches and systems. (Topár, 2001)
What is called quality? There are numerous different
definitions of quality; however, pointing out its essence,
we can say that quality means meeting all expressed or
latent demands of a client (customer, partner). According
to this definition, in essence, the number of various
demands arising against services is the same as the
number of your partners or clients. (Tenner í De Toro,
2005)
To meet specific unique client demands, of course, a part
of public service institutions must consider the fact when
creating their quality management systems that the
majority of institutions fulfill authority functions. In these
cases, legal background and client demands do not
always fully comply. Of course, more extensive customer
demands stipulated by the law have priority in these
cases; these are the ones specified by the creator of the
law.
Talking about quality matters of public service, you must
not forget that basic quality management methods and
techniques have evolved in connection with industry
production. Creating or developing your quality
management systems, good results can be usually reached
with proper adaptation of these methods and considering
the special features of the applying sector and
organization when applying them.
The efficient application of modern quality management
systems and methods is a critical requirement also in case
of public service institutions. (Dudás, 2002)
As far as the work of these organizations is regarded, the
focus has been moving from fulfilling official functions
to service functions. Anyhow, the features of official
authority processes today also include service approach
and consulting, professional analyzing, after all,
supporting activities, as this means supporting the work
of the clientele and reaching client satisfaction, i.e.
quality. (Topár, 2002)
In the following, I summarize the efforts of some public
service sectors relating to quality management system
development and their experience. The detailed analysis
of these fields is far beyond the scope of this article so I
intend to cover some elements of the quality efforts of
healthcare, public administration and higher education in
the following.
QUALITY IN HEALTHCARE
No healthcare system can afford to disregard quality.
Quality in healthcare has come into the focus of the
public, healthcare professionals, managers, decision
makers of healthcare politics and subsidizers.
Limited sources, changing medical and nursing practice
as well as the evolution of management function have
resulted in a situation where, with the available sources
and circumstances, a widespread acceptance of quality
management systems and quality approach is required to
reach maximum results in the field of improving the state
of health of the population.
The Healthcare Act stipulates that all healthcare
institutions shall conduct various activities relating to
improving quality. However, it is not specified what
quality system shall exactly be operated in practice, what
specific processes shall be developed, what structure,
József Topár
76
process or outcome indicators shall be formed or used, or
how to measure and interpret the quality of medical
attendance using these indicators.
Quality assurance in healthcare makes healthcare
objectives and expectations explicit, analyses the current
situation and introduces required amendments. For that
very reason, it is a continuous operation, analysis and
improvement process. It still remains a problem that the
concepts of ’health’ and ’disease’ is often subjective and
difficult to specify. However, it is possible in many cases
and quality assurance activities can help in setting
objectives and criteria systematically. It is very
interesting to see that quality assurance in healthcare
experiences the same evolutional process as it occurred in
the field of industry. Following the period of handling
complaints and ’output control’, currently the processes
of healthcare services and the duties of all healthcare
workers relating to quality medical attendance get more
attention. The application of various systems meeting
these requirements has started recently in healthcare
attendance system.
After a decision regarding the necessity of a compatible
strategic development of quality is made in the specific
healthcare institution, the next question is how to start
this in an organized form. Usually the first question
arising is whether applying the certification against the
ISO 9000:2000 standard system or based on the EFQM
Model for Business Excellence or maybe based on the
Hospital Accreditation Standards (HAS) would be
appropriate in respect of the institution.
Institutions should choose the model or method that:
? meets the patients’ needs (demands) in the
specific field of attendance;
? ensures the obligatory quality level (minimum
requirements) stipulated by law in the healthcare
institutions;
? supports the institution both in the short and
long run to reach the expected (owners, subsidizers,
healthcare politics, national and local politics)
quality level (or to exceed it to a degree required by
the competition and other factors);
? promotes to accomplish aims set by the
management and the employees (mission and
vision).
This means that the appropriate system that should be
selected supports the strategic aims of the institution to
the maximum degree; specifically, it supports a critical
part of those: the long-term quality policy of the
institution.
The ISO 9000 Standard System in Healthcare
The guidelines helping the introduction of quality
management systems complying with the ISO 9000
standard system in healthcare were published by ISO in
September 2001: „IWA 1, Quality management Systems
– Guidelines for Process Improvements in Service
Organizations”. (Gulácsi, 2000)
IWA 1 Guidelines are based on the ISO 9004:2000
system and contain a major part of its text, expanded by a
direction regarding application in healthcare. The aim of
the development of guidelines was not the certification or
accreditation but to help the introduction and application
of the specific system. (Similarly, the ISO 9004:2000
standard also helps application and does not serve
certification.) The institutions can be certified according
to the general requirements set forth in the ISO 9001
standard.
In Hungary, a guideline has been developed for the
application of the MSZ EN ISO 9001:2001 quality
system in healthcare service organizations with the
coordination of the Ministry of Healthcare, Social and
Family Affairs. This guideline consists of an explanation
relating to the standards and a guiding part supporting
their application.
EFQM Model for Business Excellence
The European Model for Business Excellence was
introduced by the European Foundation for Quality
Management (EFQM) after the model of Malcolm
Baldridge Model in 1991. The model was designed to
serve as the framework of organization self-assessment
and awarding the European Quality Award. The mission
of EFQM is the following: spreading the philosophy of
Total Quality Management (TQM) in business practice
and in the communication of companies with their
partners.
The improvement of EFQM model has made it possible
also for other entities than the companies of business
sector to join the organization. As of 1999, the model has
a new name lacking the former “business” attribute:
EFQM Excellence Model. Several public service
organizations attempted to implement the EFQM model
in the 90’s but they faced difficulties especially in the
field of education and healthcare. In 1994, EFQM
established the Public Sector Steering Group (PSSG) that
has drawn up a Public Sector Guideline promoting the
application of the model for organizations operating in
the three major segments of the public service sector
(education, healthcare and public administration). There
is already a possibility for applying for the European
Quality Award in the public service category. (Gulácsi,
2000)
The EFQM model consists of two equally important
parts: ’Enablers’ and ’Results’ containing 9 main criteria
and 32 subcriteria (Figure 1). The field of ’Enablers’
covers 24 subcriteria enabling organizations to assess the
process and method of approaching and solving
tasks/problems (Approach) and the way of application
broken down to specific tasks (Deployment). ‘Results’
defined by 8 subcriteria requires an objective assessment
based on facts and makes the comparison with other
organizations possible. Within the ‘Results’ section,
excellence of the results and coverage of the application
are assessed.
Quality Management in Public Service
77
ENABLERS RESULTS
Leadership
100 points
Human Resources
90 points
Policy and
Strategy
80 points
Partnerships and
Resources
90 points
Processes
140 points
People results
90 points
Customer results
200 points
Society results
60 points
Key
performance
results
150 points
INNOVATION and LEARNING
Figure 1. EFQM Excellence Model
In Hungary, the healthcare adaptation of the EFQM
model is in progress. So far, the Healthcare Quality
Awards based on the EFQM model have not been
announced in Hungary yet.
Accreditation Based on Hospital Standards
(Gulácsi, 2000)
The history of quality improvement based on standards
started with the establishment of the US accreditation
organization operating as a government organ in effect
(Joint Commission on Accreditation of Healthcare
Organisations, JCAHO) and the independent Canadian
accreditations center (Canadian Council on Health
Services Accreditation, CCHSA) in 1951. These two
countries have been followed by numerous other ones.
Standards are statements/declarations with professional
bases describing the ’state of the art’, planned, envisioned
state of the organization intended to reach. They
demonstrate the way experts imagine the operation of a
healthcare institution.
Comparing the accreditation systems, there are significant
similarities and differences in the field of operation and
objectives. However, all accreditation systems have the
following common features:
? an officially recognized organization establishes
standards and publishes them; conducts on-site
assessment in healthcare institutions and announces
its decisions,
? standards are created and the results of the on-
site assessment are evaluated by fraternal agreement
of the experts,
? they focus on continuous quality improvement
instead of control.
There are considerable differences between accreditation
systems as well. The most important ones are the
following:
? accreditation can be voluntary or obligatory,
? standards can be minimum versus optimal ones,
? accreditation can be subsidized by the
government or by other entities,
? the systems can be independent or under control
of a government organization,
? there are differences regarding the frequency of
on-site assessment and
? the role of consultation,
? there are also major differences between the
accreditation systems regarding how detailed the
published results are.
In the recent years, healthcare institutions in Hungary
have also received the Hospital Accreditation Standards
(HAS). These standards draw up the requirements
towards the applying institutions in a rather general form,
suggesting values in the following next chapters:
1. Admission and discharge of patients
2. Examining patients
3. Medical attendance
4. Patients’ rights, providing information and
education
5. Quality improvement
6. Leadership
7. Human resources management
8. Operation and safety of buildings and
equipments
The published Hospital Accreditation Standards draw up
general requirements concerning the above fields; these
requirements then serve as a base for institutions
specifying the directions and requirements of their own
systems. Essentially, a reasonable compliance with HAS
provisions moves the applying organization towards
TQM. Application of HAS provisions is not obligatory.
(Topár-Gulácsi, 2002)
Healing Based on Evidence
Medical activity today could not be conceivable without
the proper usage of reliable scientific facts. The primary
sources of information for scientific evidence are well-
planned and conducted randomized controlled clinical
trials (RCT). During RCT-s, participants are selected and
classified randomly. Usually, there is a therapy and a
control group formed and these groups are compared in
terms of the treatment in question and the outcome.
Randomizing ensures that the factors affecting the
outcome of the therapy be divided nearly evenly between
the therapy and control groups and so it helps avoiding
that these factors influence the judgment of the examined
therapeutic effect. However, the sources of scientific facts
are much more diverse that this. The concept of healing
with scientific basis is vaguer though; it includes the best
scientific facts available, the patients’ preferences and the
doctors’ professional experience. All decisions on
therapies or other treatments are made based on these
three components.
József Topár
78
QUALITY MANAGEMENT IN PUBLIC
ADMINISTRATION
Basically, also the institutions of public administration
choose between two ways in Hungary. A part of them
steps towards a quality management system complying
with the requirements of the ISO 9001:2000 standard.
Other institutions consider the application of TQM
leadership philosophy efficient. As public administration
is controlled (in some cases, overcontrolled) by acts,
decrees and statutes, in my opinion, complying with the
requirements of ISO 9001:2000 is only reasonable if this
appears also as a tool of “making order”. To establish a
client-focused operation, I would suggest the application
of TQM leadership philosophy for the organizations
concerned. [4] A tool designed for measuring the results
reached during the application of TQM leadership
philosophy and defining the development tasks for public
administration organizations is the Common Assessment
Framework (CAF). The essence of the CAF system is
summarized in the following.
Common Assessment Framework (CAF)
The CAF system was established for the field of public
administration based on the EFQM model. The unified
European assessment framework was created and later
improved using the criteria of the EFQM model, taking into
consideration the special features of public administration
and simplifying the criteria. The creators of CAF also
emphasize that their aim was making the principles and
methods of TQM applicable and promoting the assessment
of the application in the field of the public administration.
CAF may not be deemed an individual quality management
system approach; instead, it is a special assessment tool that
endeavors to move the values of the applying organizations’
quality management systems towards the TQM leadership
philosophy, considering the special duties and values
appearing in public administration organizations.
Joining the self-assessment system recommended by CAF
is voluntary. It is not obligatory to use it in public
administration institutions in Hungary either. Following the
establishment of a proper quality culture base, however, it is
able to considerably support setting the organization’s
objectives and creating the system of tools required for
reaching those aims; furthermore it ensures the basis of a
continuous improvement. The application of the CAF
system and comparison of the results helps starting the
process of benchmarking, learning from each other as well
as in efficient implementation.
The criteria of the CAF system have been developed
according to the specific features of the sector and are
presented in Figure 2:
ENABLERS RESULTS
Leadership
Human Resources
Management
Strategy and
planning
Cooperation and
resources
Process and
change
management
People results
Client and citizen
results
Society results
Key
performance
results
INNOVATION and LEARNING
Figure 2. The criteria of the CAF system
All main and subcriteria for enablers and results expressly
take the specific features of public administration into
account.
The CAF system as a tool is efficiently applicable for the
improvement of the quality management systems of
institutions and organizations holding an ISO 9001
certification and for supporting the work of organizations
endeavoring to establish TQM values.
Quality Improvement Experience in Public
Administration
Recently I have had the possibility to examine in detail the
results and experience of 52 public administration
organizations in the field of quality improvement. All
institutions examined were granted government subsidy for
the improvement of their quality management systems. The
staff number in these 52 organizations varies as follows:
up to 20 employees 10 organizations,
20-100 employees 19 organizations,
over 100 employees 17 organizations
associations 6 organizations.
The quality improvement process was assessed based on
on-site interviews as well as written documents and self-
assessment of the organization. In the following I only
intend to point out some of the major findings.
Out of the 52 surveyed organizations, 9 ones have
developed ISO 9001:2000 systems; 38 of them have
developed CAF self-assessment systems and 5 of them
have applied some other quality improvement method
during the past two years.
In case of small organizations, only the CAF self-
assessment model has been used as a quality
improvement tool. This method is actually the one that
can support the work of these organizations the best. To
efficiently implement this task, the online system of the
Ministry of the Interior provides considerable support. It
is regrettable that these entities did not use the special
implementation tools and methods upon application of
the CAF system. For these organizations, an informal
conversation based on the assessment results and the
development of values and attitude may be a significant
Quality Management in Public Service
79
drive in improvement and cooperation processes. At the
same time, in case of an organization with autocratic
leadership, it might be impossible to make use of the
results, or even to conduct an objective self-assessment.
It is completely unfounded from a professional aspect
that, based on the results of the application of the CAF
system, some organizations came to the founding that the
development of a system in accordance with ISO 9001
means the future. In my opinion this is not the way of
development for an organization of this size.
In case of medium and large sized organizations, beside
unique results, it has to be noted that the reports and data
of county public administration bureaus present a high-
level CAF self-assessment project. This must be
explained by the fact that the application of CAF and
other quality improvement tools has had a tradition with
leaders and employees of public administration bureaus
already in the recent years.
In case of medium and large sized organizations the
number/ratio of those participating in the assessment was
defined rather timidly (in a low key). Undoubtedly, it
requires hard work from the participants but their
commitment to quality grows together with the number of
participants (if it is done well) and it is worth exploiting
this.
In the execution of the aims drawn up in the tender,
consultants played a too dominant role in some
organizations. Consulting organizations are interested in
selling their materials and methods as widely as possible.
As a result of this as well, only formal solutions came to
light instead of establishing actual leadership
commitment. It gives food for thought that the quality
management knowledge of some leaders is insufficient;
in many cases, it shows substantial mistakes.
The application of CAF self-assessment was usually
preceded by training. It is a general feature that the
training was focused only on the employees participating
in the assessment. From the aspect of developing quality
attitude, it is much more efficient if the training involves
all members of the staff.
QUALITY MANAGEMENT IN HIGHER
EDUCATION
Higher education institutions have started applying
elements of quality management systems systematically
during the past decade. Similarly to other sectors of public
service, complying with the law is also typical for higher
education institutions, which is ensured as an external
quality system by the Hungarian Accreditation Committee
(HAC; Magyar Akkreditációs Bizottság, MAB). At the
same time, requirements drawn up by HAC include the
demand that a quality assurance system should operate also
within the institutions, enabling the continuous
improvement of institution processes.
Quality management systems developed according to the
ISO 9001:2000 standards can also be found in higher
education institutions, but in a smaller percentage as in
other fields of public service.
In my personal opinion, such a system should be developed
primarily in institutions where the development and
harmonization of processes requires operating a formalized
subsystem. I have seen positive results of the system
operating during the efficient implementation of
institutional integration efforts.
At the same time, in my professional opinion, the majority
of the main and supporting processes typical for higher
education institutions as well as the specific features of
these institutions give the grounds rather for establishing
and operating an own institution’s quality assurance system
taking the principles of TQM leadership philosophy into
account. Only the commitment of the leadership (on all
levels of the higher education institution) can ensure the
high-level operation expected from the institutions by
“customers” or partners.
A self-assessment system based on the TQM principles
makes it possible to define strengths and fields ready for
improvement on all leadership levels and, as a result, to
carry out continuous improvement in higher education.
Any self-assessment model may be suitable for this though,
but it will work efficiently only if the values of the self-
assessment are adapted to the specific features of the
institution.
Upon establishing this self-assessment culture, the system
of criteria drawn up in the Accreditation Guide of HAC
(MAB, 2005) can be of assistance, offering a usable
framework for the assessment of the institution’s (faculty’s)
potentials and the operating results.
SUMMARY
Giving an overview of the main features and some
operational experience of the quality management
systems applied in public service, I intend to promote
that, in order to improve their work and make it more
efficient, the institutions of these sectors can select a
quality management approach, a system and the relating
quality management methods fitting well to the demands
of their clientele and to the features of their organization.
Getting an overview of these systems is reasonable also
because, according to my experience, the application of
quality systems complying with the ISO 9000 standard
system has become too widespread with Hungarian
businesses, institutions and enterprises in the past decade.
Though I admit the advantages of the application of this
system, I still believe that it is the TQM leadership
philosophy and quality award models designed to assess
the successful application of this philosophy, primarily
the consistent application of the EFQM model for
example, or its version specifically developed for public
administration, the CAF system that would efficiently
support the execution of the long-term tasks of public
administration among others.
József Topár
80
I would like to make it absolutely clear that, in my view,
spreading quality culture and developing an attitude
required for the efficient application of quality
management systems is a process that cannot be
implemented rapidly. It cannot be implemented
efficiently without the commitment of the leaders. In
many cases, ordering the obligatory application of
different quality management systems (e.g. HACCP)
does more harm in forming the quality approach of a
specific institution than good. Due to the fact that they are
obligatory, they often move the organization applying a
formalized quality management system and its employees
towards unreasonable and formal solutions. And this can
become a significant obstacle to developing a long-term
quality approach.
The EFQM model can be a widely used tool in the
improvement of quality management systems of public
service institutions.
At the same time, quality award models in themselves
cannot be used efficiently for the improvement of quality
management systems, or to be more precise, the
organization’s business processes. It is not a good approach
if you only wish to meet the criteria. This does not result –
or results only in exceptional cases – in the development of
a system representing unified values. As a first step, you
have to create the bases of TQM and only then you can use
the models to define your strengths, weaknesses and, based
on this, the fields to be improved.
I am convinced that also in the field of public service there
are as many good solutions as institutions. There are no
general solutions applicable for every organization.
Efficiently applicable quality management philosophies,
models and methods always have to be selected taking the
organization’s organizational culture and conditions as well
as its tasks into consideration. The leader of the
organization has a key role in this; without leadership
commitment you can only operate formal quality
management systems that do not support real solutions.
This cannot be your aim. You have countless optional
solutions. You can do a lot of things expect one: neglecting
quality and disregarding the demands of your clients and
internal customers.
REFERENCES
TENNER, A. R. – DE TORO, I. J. (2005): Teljes kör? min?ségmenedzsment TQM, 4. kiadás, M?szaki Könyvkiadó,
Budapest
DUDÁS, F.: Közigazgatás-fejlesztési tendenciák a min?ség és a teljesítmény tükrében, Min?ség és Megbízhatóság 2002/5-
6. pp. 243-249., 346-349.
GULÁCSI, L. (2000): Min?ségfejlesztés az egészségügyben, Medicina, Budapest
TOPÁR, J.: A min?ségmenedzsment rendszerek szerepe és lehet?ségei a közszektorban Min?ségfejlesztés a
közigazgatásban a brit és a magyar gyakorlat tükrében, 2002. London-Budapest pp. 51-77.
TOPÁR, J. – GULÁCSI, L.: Min?ségfejlesztési-vezetési rendszerek, modellek, Egészségügyi menedzsment
IV. évfolyam (2002) 3.szám pp. 28-31.
TOPÁR, J.: A min?ségmenedzsment –rendszerek fejl?désének néhány jellemz?je a hazai vállalkozásoknál, Harvard
Business Manager, 4/2001, pp. 50-57.
Min?ségértékelési szempontrendszer, Ajánlások az önértékelés készítéséhez, Magyar Akkreditációs Bizottság,
Budapest 2005.
doc_795593022.pdf
Nowadays the efficient use of quality management systems and methods is becoming an important requirement in the institutions operating in the field of public services. The article deals with some elements of the quality efforts in public health, public administration and higher education.
„Club of Economics in Miskolc” TMP Vol. 4., pp. 75-80. 2007.
75
Quality Management in Public Service
JÓZSEF TOPÁR
SENIOR LECTURER
e-mail: [email protected]
SUMMARY
Nowadays the efficient use of quality management systems and methods is becoming an important requirement in the institutions
operating in the field of public services. The article deals with some elements of the quality efforts in public health, public
administration and higher education. My aim is to give an overview of the most important features and operational pieces of
experience of quality management systems in the public services in order to make the institutions of these sectors able to adapt those
quality management approaches, systems and methods which meet the requirements of their clients and of the organization.
INTRODUCTION
During the recent decades, raising quality to a strategic
level has become an essential condition of successful
operation in every field of the economy. No production or
service organization can avoid applying quality
management tools and methods on a system level. These
systems have developed parallel with the change of the
concept of quality and partly this change may have forced
the evolution and application of various quality
approaches and systems. (Topár, 2001)
What is called quality? There are numerous different
definitions of quality; however, pointing out its essence,
we can say that quality means meeting all expressed or
latent demands of a client (customer, partner). According
to this definition, in essence, the number of various
demands arising against services is the same as the
number of your partners or clients. (Tenner í De Toro,
2005)
To meet specific unique client demands, of course, a part
of public service institutions must consider the fact when
creating their quality management systems that the
majority of institutions fulfill authority functions. In these
cases, legal background and client demands do not
always fully comply. Of course, more extensive customer
demands stipulated by the law have priority in these
cases; these are the ones specified by the creator of the
law.
Talking about quality matters of public service, you must
not forget that basic quality management methods and
techniques have evolved in connection with industry
production. Creating or developing your quality
management systems, good results can be usually reached
with proper adaptation of these methods and considering
the special features of the applying sector and
organization when applying them.
The efficient application of modern quality management
systems and methods is a critical requirement also in case
of public service institutions. (Dudás, 2002)
As far as the work of these organizations is regarded, the
focus has been moving from fulfilling official functions
to service functions. Anyhow, the features of official
authority processes today also include service approach
and consulting, professional analyzing, after all,
supporting activities, as this means supporting the work
of the clientele and reaching client satisfaction, i.e.
quality. (Topár, 2002)
In the following, I summarize the efforts of some public
service sectors relating to quality management system
development and their experience. The detailed analysis
of these fields is far beyond the scope of this article so I
intend to cover some elements of the quality efforts of
healthcare, public administration and higher education in
the following.
QUALITY IN HEALTHCARE
No healthcare system can afford to disregard quality.
Quality in healthcare has come into the focus of the
public, healthcare professionals, managers, decision
makers of healthcare politics and subsidizers.
Limited sources, changing medical and nursing practice
as well as the evolution of management function have
resulted in a situation where, with the available sources
and circumstances, a widespread acceptance of quality
management systems and quality approach is required to
reach maximum results in the field of improving the state
of health of the population.
The Healthcare Act stipulates that all healthcare
institutions shall conduct various activities relating to
improving quality. However, it is not specified what
quality system shall exactly be operated in practice, what
specific processes shall be developed, what structure,
József Topár
76
process or outcome indicators shall be formed or used, or
how to measure and interpret the quality of medical
attendance using these indicators.
Quality assurance in healthcare makes healthcare
objectives and expectations explicit, analyses the current
situation and introduces required amendments. For that
very reason, it is a continuous operation, analysis and
improvement process. It still remains a problem that the
concepts of ’health’ and ’disease’ is often subjective and
difficult to specify. However, it is possible in many cases
and quality assurance activities can help in setting
objectives and criteria systematically. It is very
interesting to see that quality assurance in healthcare
experiences the same evolutional process as it occurred in
the field of industry. Following the period of handling
complaints and ’output control’, currently the processes
of healthcare services and the duties of all healthcare
workers relating to quality medical attendance get more
attention. The application of various systems meeting
these requirements has started recently in healthcare
attendance system.
After a decision regarding the necessity of a compatible
strategic development of quality is made in the specific
healthcare institution, the next question is how to start
this in an organized form. Usually the first question
arising is whether applying the certification against the
ISO 9000:2000 standard system or based on the EFQM
Model for Business Excellence or maybe based on the
Hospital Accreditation Standards (HAS) would be
appropriate in respect of the institution.
Institutions should choose the model or method that:
? meets the patients’ needs (demands) in the
specific field of attendance;
? ensures the obligatory quality level (minimum
requirements) stipulated by law in the healthcare
institutions;
? supports the institution both in the short and
long run to reach the expected (owners, subsidizers,
healthcare politics, national and local politics)
quality level (or to exceed it to a degree required by
the competition and other factors);
? promotes to accomplish aims set by the
management and the employees (mission and
vision).
This means that the appropriate system that should be
selected supports the strategic aims of the institution to
the maximum degree; specifically, it supports a critical
part of those: the long-term quality policy of the
institution.
The ISO 9000 Standard System in Healthcare
The guidelines helping the introduction of quality
management systems complying with the ISO 9000
standard system in healthcare were published by ISO in
September 2001: „IWA 1, Quality management Systems
– Guidelines for Process Improvements in Service
Organizations”. (Gulácsi, 2000)
IWA 1 Guidelines are based on the ISO 9004:2000
system and contain a major part of its text, expanded by a
direction regarding application in healthcare. The aim of
the development of guidelines was not the certification or
accreditation but to help the introduction and application
of the specific system. (Similarly, the ISO 9004:2000
standard also helps application and does not serve
certification.) The institutions can be certified according
to the general requirements set forth in the ISO 9001
standard.
In Hungary, a guideline has been developed for the
application of the MSZ EN ISO 9001:2001 quality
system in healthcare service organizations with the
coordination of the Ministry of Healthcare, Social and
Family Affairs. This guideline consists of an explanation
relating to the standards and a guiding part supporting
their application.
EFQM Model for Business Excellence
The European Model for Business Excellence was
introduced by the European Foundation for Quality
Management (EFQM) after the model of Malcolm
Baldridge Model in 1991. The model was designed to
serve as the framework of organization self-assessment
and awarding the European Quality Award. The mission
of EFQM is the following: spreading the philosophy of
Total Quality Management (TQM) in business practice
and in the communication of companies with their
partners.
The improvement of EFQM model has made it possible
also for other entities than the companies of business
sector to join the organization. As of 1999, the model has
a new name lacking the former “business” attribute:
EFQM Excellence Model. Several public service
organizations attempted to implement the EFQM model
in the 90’s but they faced difficulties especially in the
field of education and healthcare. In 1994, EFQM
established the Public Sector Steering Group (PSSG) that
has drawn up a Public Sector Guideline promoting the
application of the model for organizations operating in
the three major segments of the public service sector
(education, healthcare and public administration). There
is already a possibility for applying for the European
Quality Award in the public service category. (Gulácsi,
2000)
The EFQM model consists of two equally important
parts: ’Enablers’ and ’Results’ containing 9 main criteria
and 32 subcriteria (Figure 1). The field of ’Enablers’
covers 24 subcriteria enabling organizations to assess the
process and method of approaching and solving
tasks/problems (Approach) and the way of application
broken down to specific tasks (Deployment). ‘Results’
defined by 8 subcriteria requires an objective assessment
based on facts and makes the comparison with other
organizations possible. Within the ‘Results’ section,
excellence of the results and coverage of the application
are assessed.
Quality Management in Public Service
77
ENABLERS RESULTS
Leadership
100 points
Human Resources
90 points
Policy and
Strategy
80 points
Partnerships and
Resources
90 points
Processes
140 points
People results
90 points
Customer results
200 points
Society results
60 points
Key
performance
results
150 points
INNOVATION and LEARNING
Figure 1. EFQM Excellence Model
In Hungary, the healthcare adaptation of the EFQM
model is in progress. So far, the Healthcare Quality
Awards based on the EFQM model have not been
announced in Hungary yet.
Accreditation Based on Hospital Standards
(Gulácsi, 2000)
The history of quality improvement based on standards
started with the establishment of the US accreditation
organization operating as a government organ in effect
(Joint Commission on Accreditation of Healthcare
Organisations, JCAHO) and the independent Canadian
accreditations center (Canadian Council on Health
Services Accreditation, CCHSA) in 1951. These two
countries have been followed by numerous other ones.
Standards are statements/declarations with professional
bases describing the ’state of the art’, planned, envisioned
state of the organization intended to reach. They
demonstrate the way experts imagine the operation of a
healthcare institution.
Comparing the accreditation systems, there are significant
similarities and differences in the field of operation and
objectives. However, all accreditation systems have the
following common features:
? an officially recognized organization establishes
standards and publishes them; conducts on-site
assessment in healthcare institutions and announces
its decisions,
? standards are created and the results of the on-
site assessment are evaluated by fraternal agreement
of the experts,
? they focus on continuous quality improvement
instead of control.
There are considerable differences between accreditation
systems as well. The most important ones are the
following:
? accreditation can be voluntary or obligatory,
? standards can be minimum versus optimal ones,
? accreditation can be subsidized by the
government or by other entities,
? the systems can be independent or under control
of a government organization,
? there are differences regarding the frequency of
on-site assessment and
? the role of consultation,
? there are also major differences between the
accreditation systems regarding how detailed the
published results are.
In the recent years, healthcare institutions in Hungary
have also received the Hospital Accreditation Standards
(HAS). These standards draw up the requirements
towards the applying institutions in a rather general form,
suggesting values in the following next chapters:
1. Admission and discharge of patients
2. Examining patients
3. Medical attendance
4. Patients’ rights, providing information and
education
5. Quality improvement
6. Leadership
7. Human resources management
8. Operation and safety of buildings and
equipments
The published Hospital Accreditation Standards draw up
general requirements concerning the above fields; these
requirements then serve as a base for institutions
specifying the directions and requirements of their own
systems. Essentially, a reasonable compliance with HAS
provisions moves the applying organization towards
TQM. Application of HAS provisions is not obligatory.
(Topár-Gulácsi, 2002)
Healing Based on Evidence
Medical activity today could not be conceivable without
the proper usage of reliable scientific facts. The primary
sources of information for scientific evidence are well-
planned and conducted randomized controlled clinical
trials (RCT). During RCT-s, participants are selected and
classified randomly. Usually, there is a therapy and a
control group formed and these groups are compared in
terms of the treatment in question and the outcome.
Randomizing ensures that the factors affecting the
outcome of the therapy be divided nearly evenly between
the therapy and control groups and so it helps avoiding
that these factors influence the judgment of the examined
therapeutic effect. However, the sources of scientific facts
are much more diverse that this. The concept of healing
with scientific basis is vaguer though; it includes the best
scientific facts available, the patients’ preferences and the
doctors’ professional experience. All decisions on
therapies or other treatments are made based on these
three components.
József Topár
78
QUALITY MANAGEMENT IN PUBLIC
ADMINISTRATION
Basically, also the institutions of public administration
choose between two ways in Hungary. A part of them
steps towards a quality management system complying
with the requirements of the ISO 9001:2000 standard.
Other institutions consider the application of TQM
leadership philosophy efficient. As public administration
is controlled (in some cases, overcontrolled) by acts,
decrees and statutes, in my opinion, complying with the
requirements of ISO 9001:2000 is only reasonable if this
appears also as a tool of “making order”. To establish a
client-focused operation, I would suggest the application
of TQM leadership philosophy for the organizations
concerned. [4] A tool designed for measuring the results
reached during the application of TQM leadership
philosophy and defining the development tasks for public
administration organizations is the Common Assessment
Framework (CAF). The essence of the CAF system is
summarized in the following.
Common Assessment Framework (CAF)
The CAF system was established for the field of public
administration based on the EFQM model. The unified
European assessment framework was created and later
improved using the criteria of the EFQM model, taking into
consideration the special features of public administration
and simplifying the criteria. The creators of CAF also
emphasize that their aim was making the principles and
methods of TQM applicable and promoting the assessment
of the application in the field of the public administration.
CAF may not be deemed an individual quality management
system approach; instead, it is a special assessment tool that
endeavors to move the values of the applying organizations’
quality management systems towards the TQM leadership
philosophy, considering the special duties and values
appearing in public administration organizations.
Joining the self-assessment system recommended by CAF
is voluntary. It is not obligatory to use it in public
administration institutions in Hungary either. Following the
establishment of a proper quality culture base, however, it is
able to considerably support setting the organization’s
objectives and creating the system of tools required for
reaching those aims; furthermore it ensures the basis of a
continuous improvement. The application of the CAF
system and comparison of the results helps starting the
process of benchmarking, learning from each other as well
as in efficient implementation.
The criteria of the CAF system have been developed
according to the specific features of the sector and are
presented in Figure 2:
ENABLERS RESULTS
Leadership
Human Resources
Management
Strategy and
planning
Cooperation and
resources
Process and
change
management
People results
Client and citizen
results
Society results
Key
performance
results
INNOVATION and LEARNING
Figure 2. The criteria of the CAF system
All main and subcriteria for enablers and results expressly
take the specific features of public administration into
account.
The CAF system as a tool is efficiently applicable for the
improvement of the quality management systems of
institutions and organizations holding an ISO 9001
certification and for supporting the work of organizations
endeavoring to establish TQM values.
Quality Improvement Experience in Public
Administration
Recently I have had the possibility to examine in detail the
results and experience of 52 public administration
organizations in the field of quality improvement. All
institutions examined were granted government subsidy for
the improvement of their quality management systems. The
staff number in these 52 organizations varies as follows:
up to 20 employees 10 organizations,
20-100 employees 19 organizations,
over 100 employees 17 organizations
associations 6 organizations.
The quality improvement process was assessed based on
on-site interviews as well as written documents and self-
assessment of the organization. In the following I only
intend to point out some of the major findings.
Out of the 52 surveyed organizations, 9 ones have
developed ISO 9001:2000 systems; 38 of them have
developed CAF self-assessment systems and 5 of them
have applied some other quality improvement method
during the past two years.
In case of small organizations, only the CAF self-
assessment model has been used as a quality
improvement tool. This method is actually the one that
can support the work of these organizations the best. To
efficiently implement this task, the online system of the
Ministry of the Interior provides considerable support. It
is regrettable that these entities did not use the special
implementation tools and methods upon application of
the CAF system. For these organizations, an informal
conversation based on the assessment results and the
development of values and attitude may be a significant
Quality Management in Public Service
79
drive in improvement and cooperation processes. At the
same time, in case of an organization with autocratic
leadership, it might be impossible to make use of the
results, or even to conduct an objective self-assessment.
It is completely unfounded from a professional aspect
that, based on the results of the application of the CAF
system, some organizations came to the founding that the
development of a system in accordance with ISO 9001
means the future. In my opinion this is not the way of
development for an organization of this size.
In case of medium and large sized organizations, beside
unique results, it has to be noted that the reports and data
of county public administration bureaus present a high-
level CAF self-assessment project. This must be
explained by the fact that the application of CAF and
other quality improvement tools has had a tradition with
leaders and employees of public administration bureaus
already in the recent years.
In case of medium and large sized organizations the
number/ratio of those participating in the assessment was
defined rather timidly (in a low key). Undoubtedly, it
requires hard work from the participants but their
commitment to quality grows together with the number of
participants (if it is done well) and it is worth exploiting
this.
In the execution of the aims drawn up in the tender,
consultants played a too dominant role in some
organizations. Consulting organizations are interested in
selling their materials and methods as widely as possible.
As a result of this as well, only formal solutions came to
light instead of establishing actual leadership
commitment. It gives food for thought that the quality
management knowledge of some leaders is insufficient;
in many cases, it shows substantial mistakes.
The application of CAF self-assessment was usually
preceded by training. It is a general feature that the
training was focused only on the employees participating
in the assessment. From the aspect of developing quality
attitude, it is much more efficient if the training involves
all members of the staff.
QUALITY MANAGEMENT IN HIGHER
EDUCATION
Higher education institutions have started applying
elements of quality management systems systematically
during the past decade. Similarly to other sectors of public
service, complying with the law is also typical for higher
education institutions, which is ensured as an external
quality system by the Hungarian Accreditation Committee
(HAC; Magyar Akkreditációs Bizottság, MAB). At the
same time, requirements drawn up by HAC include the
demand that a quality assurance system should operate also
within the institutions, enabling the continuous
improvement of institution processes.
Quality management systems developed according to the
ISO 9001:2000 standards can also be found in higher
education institutions, but in a smaller percentage as in
other fields of public service.
In my personal opinion, such a system should be developed
primarily in institutions where the development and
harmonization of processes requires operating a formalized
subsystem. I have seen positive results of the system
operating during the efficient implementation of
institutional integration efforts.
At the same time, in my professional opinion, the majority
of the main and supporting processes typical for higher
education institutions as well as the specific features of
these institutions give the grounds rather for establishing
and operating an own institution’s quality assurance system
taking the principles of TQM leadership philosophy into
account. Only the commitment of the leadership (on all
levels of the higher education institution) can ensure the
high-level operation expected from the institutions by
“customers” or partners.
A self-assessment system based on the TQM principles
makes it possible to define strengths and fields ready for
improvement on all leadership levels and, as a result, to
carry out continuous improvement in higher education.
Any self-assessment model may be suitable for this though,
but it will work efficiently only if the values of the self-
assessment are adapted to the specific features of the
institution.
Upon establishing this self-assessment culture, the system
of criteria drawn up in the Accreditation Guide of HAC
(MAB, 2005) can be of assistance, offering a usable
framework for the assessment of the institution’s (faculty’s)
potentials and the operating results.
SUMMARY
Giving an overview of the main features and some
operational experience of the quality management
systems applied in public service, I intend to promote
that, in order to improve their work and make it more
efficient, the institutions of these sectors can select a
quality management approach, a system and the relating
quality management methods fitting well to the demands
of their clientele and to the features of their organization.
Getting an overview of these systems is reasonable also
because, according to my experience, the application of
quality systems complying with the ISO 9000 standard
system has become too widespread with Hungarian
businesses, institutions and enterprises in the past decade.
Though I admit the advantages of the application of this
system, I still believe that it is the TQM leadership
philosophy and quality award models designed to assess
the successful application of this philosophy, primarily
the consistent application of the EFQM model for
example, or its version specifically developed for public
administration, the CAF system that would efficiently
support the execution of the long-term tasks of public
administration among others.
József Topár
80
I would like to make it absolutely clear that, in my view,
spreading quality culture and developing an attitude
required for the efficient application of quality
management systems is a process that cannot be
implemented rapidly. It cannot be implemented
efficiently without the commitment of the leaders. In
many cases, ordering the obligatory application of
different quality management systems (e.g. HACCP)
does more harm in forming the quality approach of a
specific institution than good. Due to the fact that they are
obligatory, they often move the organization applying a
formalized quality management system and its employees
towards unreasonable and formal solutions. And this can
become a significant obstacle to developing a long-term
quality approach.
The EFQM model can be a widely used tool in the
improvement of quality management systems of public
service institutions.
At the same time, quality award models in themselves
cannot be used efficiently for the improvement of quality
management systems, or to be more precise, the
organization’s business processes. It is not a good approach
if you only wish to meet the criteria. This does not result –
or results only in exceptional cases – in the development of
a system representing unified values. As a first step, you
have to create the bases of TQM and only then you can use
the models to define your strengths, weaknesses and, based
on this, the fields to be improved.
I am convinced that also in the field of public service there
are as many good solutions as institutions. There are no
general solutions applicable for every organization.
Efficiently applicable quality management philosophies,
models and methods always have to be selected taking the
organization’s organizational culture and conditions as well
as its tasks into consideration. The leader of the
organization has a key role in this; without leadership
commitment you can only operate formal quality
management systems that do not support real solutions.
This cannot be your aim. You have countless optional
solutions. You can do a lot of things expect one: neglecting
quality and disregarding the demands of your clients and
internal customers.
REFERENCES
TENNER, A. R. – DE TORO, I. J. (2005): Teljes kör? min?ségmenedzsment TQM, 4. kiadás, M?szaki Könyvkiadó,
Budapest
DUDÁS, F.: Közigazgatás-fejlesztési tendenciák a min?ség és a teljesítmény tükrében, Min?ség és Megbízhatóság 2002/5-
6. pp. 243-249., 346-349.
GULÁCSI, L. (2000): Min?ségfejlesztés az egészségügyben, Medicina, Budapest
TOPÁR, J.: A min?ségmenedzsment rendszerek szerepe és lehet?ségei a közszektorban Min?ségfejlesztés a
közigazgatásban a brit és a magyar gyakorlat tükrében, 2002. London-Budapest pp. 51-77.
TOPÁR, J. – GULÁCSI, L.: Min?ségfejlesztési-vezetési rendszerek, modellek, Egészségügyi menedzsment
IV. évfolyam (2002) 3.szám pp. 28-31.
TOPÁR, J.: A min?ségmenedzsment –rendszerek fejl?désének néhány jellemz?je a hazai vállalkozásoknál, Harvard
Business Manager, 4/2001, pp. 50-57.
Min?ségértékelési szempontrendszer, Ajánlások az önértékelés készítéséhez, Magyar Akkreditációs Bizottság,
Budapest 2005.
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