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4. PARTNERSHIPS & RESOURCES

“The recognition you have been given places you amongst the best publicand private sector organisations in the Basque Country, and far ahead ofthe vast majority of them”. General Manager of Euskalit, the Basque CountryQuality Foundation

Zumarraga Hospital – Hospital de Zumarraga 34

4. PARTNERSHIPS & RESOURCES4a. PARTNERSHIPS ARE MANAGED

The concept of partnership at the hospital has developed from themere fulfilment of contractual agreements with suppliers into

voluntary co-operation in which both parties obtain added value,established with all stakeholders involved in our strategic goals.

Starting with assessment against the EFQM Excellence model in2000, the MT re-thought the management of partnerships based on thelayout shown in Fig. 4a-1, bringing existing partnerships into line withthis layout. In 2003 the External Relations macro-process was identifiedand described in order to improve management in this area in line withthe system described in 5a and 5b. Figure 4a-1: PARTNERSHIP PROCESS

PARTNERSHIP/PROCESS ORGANISATION ADDED VALUE 1) SuppliersPROCUREMENT Auzo-Lagun Supplementary satisfaction surveys / ISO 9001:2000/Training in the EFQM ModelMANAGEMENT BY PROCESSES Q2K (new, spin-off firm) Design of IT programme for management by processes

Ibermatica Innovation Capital Model & adaptation of this to the Health SystemCONTINUOUS IMPROVEMENT EUSKALIT Overall improvement of management systemWASTE MANAGEMENT Elirecon Training courses / Audits to monitor environmental quality / ISO 9001:2000CLINICAL ANALYSIS Roche Development of analytical & IT technologyPROCUREMENT Selection of suppliers Prosthetic material deposit / Support for key-hole surgerySTRATEGIC DEVELOPMENT Mas Innovación, Gesco, Implementation of BSC & high-performance equipment 2) Co-operation promoted under the Programme ContractIT EJIE & Bilbomática Customising of the hospital’s IT programmes: Unidosis, Infogen, InfoRx, Archelp

PROGRAMME CONTRACT MANAGEMENT Dept. of Health

A&E Unit: transfer by medicalised ambulance/Osatek & Clínica Asunción: NMR.Instituto Oncológico: diagnostic & therapeutic support for cancer sufferersPoliclínica Gipuzkoa: cardiovascular diagnosis & treatmentFundación Matía: admission of medium & long-stay patients

3) Osakidetza OrganisationsMANAGEMENT BYPROCESSES

Osakidetza Hospitals Joint preparation of clinical protocols

PRIMARY HEALTHCAREVOICE

PHCCM (Head of Health Centre) in Azpeitia & BeasainPrimary healthcare teachingNursing Heads

Joint timetables / Surveys / Agreement by Unit HeadsCentralised outpatient appointments / Availability of results of analysesImprovements in continuous care reports

BENCHMARKING Osakidetza Hospitals Knowledge pooling in best management practicesSURGICAL(ORTHOPAEDIC)

Centro Vasco de Trasplantes y Tejidos [Basque Centrefor Transplants & Tissues) Transplant Unit Extraction & preparation of bones for transplants

ACTIVITY PROGRAMMING Donostia Hospital Referral of patients with complex pathologies / Clinical sessionsCentral bed management

DIAGNOSTIC SUPPORT Osakidetza hospitals Referral of patients for endoscopic cholangiopancreatographyPRACTICAL CLINICALASSESSMENT

Osakidetza Hospitals Purchase of impactometer for measuring environmental pollution in operating theatresShared use of lithotriptor

4) Other OrganisationsLIBRARY Hospital libraries: Morales Meseguer, l’Hospitalet,

Fundación Hospital Alcorcon & Hospital Severo OchoaExchange of scientific articlesLibrary process map

BENCHMARKING Spanish national health service hospitals Sharing of experiences in best management practices & shared clinical practice (crit. 8)MANAGEMENT BYPROCESSES

University of the Basque Country Faculty of Sociology European study on development & assessment of systems of management by processes

INPATIENTS(PAEDIATRICS) La Caixa Opening of cyber-room & new playroom with facilitator for children’s programmes in

Paediatrics UnitEXTERNALRELATIONS

Zumarraga Town CouncilLocal & provincial development plans / Environment GroupMedical checks on municipal employees

HEALTHCARE Health Research Fund Project for assessment of management by processes.TRAINING Zumarraga Town Council Loan of premises / Basque language examinations

CONTINUOUSIMPROVEMENT

EuskalitObservatorio para la Calidad de los ServiciosPúblicos [“Public Service Standard Watchdog”]APTES (Association for Social Technology)SECA, ISQua, EASP, Carlos III

Methodological support in management & quality systems / Dissemination of best practicesCo-operation grants / External EFQM AssessorsBenchmarking & assessment of best practicesFounders of the Association for the development & encouragement of social technology(technology applied to social welfare)Co-operation in promoting quality in the health system

5) Teaching InstitutionsSchool, universities &private academies Teaching practices (nursing, medical nurses, pharmacy, anatomical pathology, documents, IT, psychology, administrative staff)

Ministry of Education Training for family doctors / training in assessment for National Agency for Assessment of Standards & Accreditation(Training in quality & assessment methods for 160 professors & lecturers at Spanish universities)

TEACHING

IT Faculty at Donostia R&D on IT system for management by processesFigure 4a-2: MAIN PARTNERSHIPS OF THE HOSPITAL

A Identification of

PossiblePartnerships

Establishment of Partnership

PartnershipManagement

PartnershipAssessment


1.-Identifying potential partnersThis is managed by the MT as one of the activities to further the strategicdevelopment of the hospital. The needs detected under strategicdevelopment are taken into account, goals are identified and potentialpartners who can help deliver those goals are pinpointed. The concept ofpartnership extends beyond written agreements and is based in somecases on a tacit relationship of mutual co-operation.

Partnerships are broken down into five different groups (Fig. 4a-2):a) Suppliers: We work with our suppliers to generate synergies that canadd value and achieve higher levels of mutual satisfaction. Suppliers whosevolume of invoicing is large are identified as key suppliers (taking the ABC ofsuppliers as our basis): they are critical in terms of technology or co-operatein the continuous improvement of the hospital (e.g. Elirecon and AuzoLagun) (1c & 8b).b) Co-operation under the Programme Contract (PC): The RegionalHealth Directorate establishes partnerships with providers of servicescommon to hospitals in Gipuzkoa for the provision of additional or alternativeservices in our value chain (diagnoses, referrals, social health services).These are induced partnerships, but we assume them as our own andmaintain them in a spirit of open co-operation (e.g. referral of patients toIntensive Care at the Tolosa clinic).c) Osakidetza organisations: Belonging to Osakidetza makes it easier toco-ordinate our resources and gives us a strategic advantage of undoubtedvalue. It enables us to refer and/or jointly study patients, to make centralisedpurchases, to work together in the formulation of protocols and in broaderquality studies, and facilitates the preferential sharing of best practices andknow-how (4e) (e.g. cardio-pulmonary resuscitation courses have beenoffered to other Osakidetza organisations since 2003).d) Other organisations: Partnerships are formed with organisations toexchange resources and information and pool experiences in managementwhen this can provide added value (e.g. in 2004 we set up a forum forexchanges between the 4 most advanced hospitals in the Spanish nationalhealth service in terms of management by processes).e) Teaching institutions: The hospital enters into agreements with teachinginstitutions for the training of healthcare specialists and to provide the hands-on training required to complete the syllabus of various areas of study (familydoctors, nurses, pharmacists, clinical documentation, etc.) (4e).2.-Forming partnerships

Formal agreements are established with the relevant organisations by amember of ZH Management, using a document that sets forth the terms andconditions agreed. In some cases, such as the sharing of experience, theagreement does not need to be set down in a document, but is based on amutual undertaking. Terms and conditions are established in advance bythe relevant PLs, based on the objectives set for the partnership and on ananalysis of consistency and compatibility with partners.3.-Managing the agreements

PLs are the key figures in monitoring and ensuring the conditions laiddown in the agreements are met. Monitoring takes place through indicatorschecked at a range of different, predetermined intervals. When the PLdetects any divergence he/she contacts or meets with the partner toestablish the necessary corrections.4.-Assessing & reviewing agreements

The results of agreements are also assessed and reviewed by therelevant PLs, and any corrections are set in place accordingly. Thedevelopment of ISO certification in some processes allows more detailedstudy and enables assessments deriving from audits and reviews to beformalised. Assessment is quantitative, through indicators (5a, 5b), except inthose cases where the difficulty of establishing quantitative indicators makesit preferable for qualitative assessments to be used. For instance, with AuzoLagun there is quarterly monitoring of progress. Following the last quarterlyreview nursing staff data were included to enrich the assessment.

The partnerships established cover all the areas that we haveidentified as significant in strategic terms.

As indicated above, monitoring and assessment of agreementsis the responsibility of PLs. After reviewing the partnership

agreements established and their results, PLs inform the CE at thebeginning of each year whether it is advisable to continue, modify or reviewthe terms of each agreement. In some cases surveys are used tosupplement these assessments, with results on the perception of the

organisations involved (Primary Care, suppliers, Spanish NHS hospitals,etc.). For example, a survey of primary healthcare doctors is used to assessthe policy of partnerships with those doctors. The results confirm theprogress achieved and the high degree of satisfaction of these doctors withthe agreements established (6a).

In its annual review of the Business Plan (BP) and the strategy of thehospital, the MT assesses the effectiveness of the partnership managementapproach and decides whether to enter into new partnerships, reinforceexisting ones or end collaboration. Time frames are also analysed to identifythe need for new partnerships. As a result of these reviews the necessaryempowerment was established for PLs to monitor and assess agreementsso that their suitability could be enhanced. An example of improvement in aspecific partnership agreement can be found in Elirecon, which started outas a mere supplier of hospital waste collection services, then began to givetraining courses and carry out audits, and by 2003 was actively working withthe hospital in certifying ISO 9001:2000 compliance of the WasteManagement Process. Other examples of change are shown below.

ASSESSMENT TYPE /SOURCES OF

LEARNINGYR IMPROVEMENTS

99 ISO design & development in catering service withAuzo Lagun (1)

00 Establishment of system for identifying & managingpartnerships (1,2,3,4)

01Design & carrying out of surveys in PrimaryHealthcare to assess development of thispartnership & potential for improvement (1,2,3)

02

Joint project with IT Faculty in Donostia to developan IT programme for process management throughend-of-course projects (1,3)Partnerships with external libraries (2,6)Incorporation of survey of suppliers, town councils& external organisations to assess effectiveness ofpartnerships (1,2,3,4)

03 Assessment & redesign of Partnerships Process(1,3,4)

1. Assessment byMT

2. Assessment byPL

3. EFQMAssessment

4. External audit5. Elirecon training

courses6. ISO certification7. Strategic

planning

04 Redesign of system of partnerships (1,3,8)Figure 4a-3: EXAMPLES OF IMPROVEMENT CYCLES RELATED TO 4a.

4b FINANCES ARE MANAGEDThe remit of the Financial Management (Fig. 4b-3) is:1) To guarantee availability and optimisation of financial resources through

adequate planning and control so that the hospital can deliver its presenttargets. Indicator: financial balance (Fig. 9a-14).

2) To supply and draw up financial information as required to makedecisions that enable the targets set to be delivered. The degree ofattainment of those targets of the hospital is also reflected in the partialindicators of the relevant processes (Fig. 4b-10).

In recent years there have been changes in the financial managementapproach, especially as a result of a new structure for the financialdependency of the hospital on the Dept. of Health, which provides the publicfunding for our services to the public. The most noteworthy of thesechanges are shown in Fig. 4b-1.

1998

� Changes in the funding system: changeover from a system of budgetallocations based on past spending to funding linked to activity andsales of services. This means moving to a system with more autonomyin which the hospital manages its own income, so the PC andBudgetary Control processes take on greater importance.

� Changeover from budget accounting to financial accounting in line withthe principles of the General Accounting Plan, with the Accountingprocess being especially important.

� Change of information system to the SAP computer programme (4e)and application of the accounting principle of accrual so that thesituation of the operating account and balance sheet can always beknown in real time.

1999� Decentralisation of treasury operations so that collection, sales and

payments to suppliers and ZH people are managed from the hospitalitself, so that the Treasury/ Invoicing/ Payment Collection process hasbecome more significant.

2003 � Processes in the Financial Management area certified under ISO2002/2004

� Redesign of processes in the financial management area� Redefinition of indicators

Figure 4b-1: MAIN CHANGES IN FINANCIAL MANAGEMENT

DAR


In 1998 the Hospital became a Public Body subject to Private Law.Since then it has been possible to establish an annual balance sheetand income statement. Fig. 4b-2 shows the accounts for 2004.

(Thousands of euros) 2004People 21,419 Programme Contract 29,265Operations 8,225 Third parties 561Total outgoings 29,644 Other income 181Profit/ Loss 363 Total income 30,007

Figure 4b-2. BALANCE SHEET & INCOME STATEMENTIn line with this new situation, the MT defined five basic processes in

the area of economic & financial resources to develop the strategy ofthe hospital and deliver the goals set. The links between theseprocesses are shown in Fig. 4b-3.Strategic Processes: 1. Programme Contract ManagementSupport processes: 2. Budgetary Control

3. Accounts, Treasury & Invoicing

Figure 4b-3: BASIC STRUCTURE OF FINANCIAL MANAGEMENTAll the processes indicated are documented and have measurement

indicators, a person is designated as responsible for improving themand they are managed as per the methods developed in 5a & 5b.1.-Programme Contract (PC) Management

Taking as references the previous year’s PC, and the annual SPand BP, and setting balanced finances as our objective, we plan

our sales mid-way through the year, defining the activities and portfolioof services to be developed over the following financial year. Theportfolio of services and the sales plan are negotiated annually with theDept. of Health, and the results of the negotiations are set downbasically in the PC.

The PC is signed and renewed each year with the Dept. of Health. Itis a legal instrument that regulates relations between the Dept. of Healthand Osakidetza organisations for the provision of healthcare. It setsforth the goals established for activities, funding and quality, along withpre-set requirements in regard to supporting information, sending times,etc. Funding is thus linked to activities and to agreed quality goals, andthere are penalties and incentives established in line with the degree towhich they are delivered.

The layout of this process can be seen in Fig. 4b-4.

Figure 4b-4: PROGRAMME CONTRACT MANAGEMENTThe PC is executed monthly, and is implemented systematically

through the SAP computer programme. Implementation is reviewedmonthly by the MT, and the activities actually carried out are comparedto those forecast and to those of the previous year, so that thenecessary corrective measures and adjustments can be made to offsetany significant variance from the forecasts. Moreover, regular meetingsare held with the Dept. of Health to check implementation, at which the

terms and conditions of the contract (activities, prices) and the overallfunding provided on an authorised spending basis can be readjusted.

Implementation of the PC affects all invoiceable activities at theDept. of Health (98% of total ZH invoicing) and all the hospital’s

service lines. Examples are given below of PC objectives agreed for 2004in inpatient care (Fig. 4b-5) and quality requirements for births (Fig. 4b-6)

Generic Diagnosis Related Groups (DRG) 7,995Hip replacement -DRG 209 & 789 118Cataracts – DRG 39 688Births – DRG 373-372 307Nº A&E cases not admitted 24,881Figure 4b-5: AGREED INPATIENT ACTIVITY

% Caesarean sections <=16%% Epidural anaesthesia >=90%% Non instumentalised births w/o episiotomy & w/ epidural >=30%% Repeat caesarean sections in women with previous caesarean <=40%% Non instrumentalised vaginal births w/o episiotomy >=30%Figure 4b-6: BIRTH QUALITY REQUIREMENTS

An internal assessment is conducted by the PL based onthe indicators listed in Fig. 4b-10, supplemented by reviews

conducted at MT meetings. When significant variance is detected fromactivity forecast or carried out, the relevant corrective measures aretaken. Successive assessments have led to changes in approach as aresult of improvements in data collection.

Additionally, an external review resulted in the setting up of a workinggroup at the Department of Health in 2002, in which the ZH MedicalDirector took part. The aim was to analyse whether the approach of thePC (negotiation, monitoring, etc.) was the right one.

ASSESSMENT TYPE /SOURCES OF LEARNING YR IMPROVEMENTS

98 Preparation of IT support for PCmanagement (3,4)

99 Computerising of outpatients’ records (1,4,5)

00 Incorporation of rehabilitation, haemodialysis &pharmacy activities into PC IT support (2,3,4)

01 Computerising of occupational healthappointments & minor surgery (2,3,4)

02Assessment of effectiveness of proposals forimproving the system for establishing &monitoring the PC (1,5)

03 Computerising of day hospital &metabolopathies (2,4)

1. Assessment by MT2. Assessment by PL3. Health Dept. workinggroup4. Benchmarking w/other health centres5. PC study group

04 Computerising of high-resolutionappointments (2,3,4)

Figure 4b-7: EXAMPLES OF IMPROVEMENT CYCLES RELATED TO PC MANAGEMENTThe conclusion drawn from these reviews is that the process

approach is the right one, since the degree of contract fulfilmentexceeds 98.8 % (Fig. 9a-2). Even so, some adjustments have beenmade as a result of successive assessments and reviews (Fig. 4b-7).2.-Budget Control

The financial resources available to the hospital are limited by itsoperational and investment budgets, and a defined budget

structure exists. Taking the SP, the BP and the budgets from previousyears as references and setting financial balance with a balanced P&Lstatement as our objective (Fig. 9a-14), the MT establishes spendingforecasts to supplement the sales forecasts mentioned above (crit. 2).

The planning of expenditure for a financial year begins mid-way throughthe previous year with the drawing up of a P&L forecast that listsexpectations for expenditure and the funding and resources required tocover that expenditure. Forecasts are adjusted and updated month bymonth with expenses to be incurred being identified at book account level.

To increase people involvement and monitor and control trends inspending, the Heads of Finance and Human Resources draw upmonthly reports on trends in HR and operational expenses. Thisinformation is assessed by the MT and compared with actual activities.Variance is analysed as follows:♦ a given month with regard to the same month in the previous year (onboth book account and cost centre bases).♦ actual monthly expenditure compared to forecast figures.

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People Management

Facilities Management

Strategic Development

Business Plan

Budgetary Control

Accounts Treasury/Invoicing Procurement

PC Management

Preparingnegotiation PC Monitoring

Correctiveaction onvariance

PC Negotiation

Strategy PlanBusiness Plan

ZH Results


♦ unit cost per end product compared to forecasts at the hospital and atother organisations.

Other review and readjustment channels also exist.♦ Variance is also assessed quarterly at the management checks withOsakidetza Officials, at which causes are analysed and on the basis ofwhich the MT takes corrective measures to readjust plans and actions ifthis is deemed appropriate.♦ Meetings with Units (Laboratory, Pharmacy, Operating Theatres, etc.)to analyse causes of variance and make readjustments.

All areas of the hospital are subject to budgets. The relevantinformation is deployed systematically, and to that end balanced

scorecards have been drawn up with information obtained from the SAPprogramme that cover all major areas.

Since this is a process subject to 5a and 5b, it is subject toboth quantitative (Fig. 4b-10) and qualitative review by the

PL and the MT in their meetings. The planning approach and themonitoring of budgetary control can be considered adequate based onthe degree to which final expenditure coincides with authorisedexpenditure, since the results obtained at the year end coincide with theforecasts made (Fig. 9a-16).

Even though, on the basis of frequent process review, the process isconsidered to be adequate, small adjustments are made, some of whichare listed in Fig. 4b-8.

ASSESSMENT TYPE /SOURCE OF LEARNING

YR IMPROVEMENTS

98/02

Establishment & improvement of budget itemsdepending on activities (1,2)Adaptation of degree of use of materials asper healthcare processes (2)

03 Review & design of new balanced scorecardsfor budget monitoring (1,2)

1. Assessment byMT

2. Assessment by PL

04 Review & improvement of keyhole surgerymaterial kits (2)

Figure 4b-8: EXAMPLES OF IMPROVEMENT CYCLES RELATED TO BUDGET CONTROL3.-Accounts Managementa) Accounting

The objective of this process is to ensure that all financialoperations and transactions by the hospital are properly recorded,

and to provide adequate, accurate information in sufficient quantity and ingood time for decisions to be made that can help deliver the goals of thehospital. To that end, the SAP information system is used. This systemprovides the various reports that are used by the Head of Finance and theMT to analyse the situation and compare it with forecast objectives.

Analytical accounting uses SAP to obtain more detailed informationon the attribution of expenditure and income and to analyse variance. Asix-monthly report is drawn up on the unit costs of the final services, anda monthly report is drawn up showing increases in spending per Unitand analysing in more detail those cases in which significant variancehas been detected.

There is a single person in charge of attributing expenses in line withthe structured, predefined General Accounting Plan, which forms thebasis for generating reports and enables us to monitor and ensure that:� accounting periods are closed on time;� the resulting information is reliable. Reliability and the proper attributionof data are ensured by checking invoices and monitoring manual-entrybook accounts month by month.

Once records have been analysed corrective measures are taken asrequired to ensure that accounting principles are adhered to.

This process is used with all financial activities at the hospital.The audits conducted since Osakidetza became involved have

shown no non-compliance with these principles, so we consider that thedegree of fulfilment in the deployment of this process is 100%.

The audits conducted by the Audit Department and theBasque Auditors’ Court not only confirm fulfilment of the

system but also enable us to identify opportunities for improvement inthe use of the General Accounting Plan. We have never been penalisedunder this Plan or advised that we were implementing it incorrectly, sowe can consider the system to be adequate.

Along with this external assessment, a further quantitative assessment iscarried out by the PL through indicators (Fig. 4b-10) and a qualitativeassessment through self-assessment and the assessments of the MT. As aresult of all these assessments, a number of adjustments have been made,most of them when the cost attribution system is updated and reviewedeach year. The latest such adjustment involved a review of all cost centresand the cancellation of some of them in 2004.b) Treasury Management

The objective of treasury management is to manage thecollection of receivables in such a way as to ensure that sufficient

funds are available to meet payments to suppliers and employees asthey fall due. There is an agreement in place between the authorities ofthe Autonomous Community of the Basque Country and the financialinstitutions that operate in their territory which contains a list of thoseinstitutions and the conditions agreed upon with each. This agreementestablishes limitations on the number of institutions with which one canwork and on the number of book accounts held, does not allow for fundsto be drawn down freely and prohibits borrowing. In view of theseconstraints, the MT decided it was not necessary to draw up a systemfor managing risks and surpluses, since the only potential risk would belate payment of the PC invoice by the Dept. of Health. To prevent this,we have set the objective of ensuring that invoices are drawn up prior tothe 15th of the following month.

Treasury decentralisation took place at the hospital on 1-1-99. Prior tothis, studies were conducted of the workload involved, on planning forimplementation, on the training required, on the supporting documentsneeded and on computerising management (Aldabide project). SinceJanuary 1999, all payments to suppliers have been made viacomputerised instructions generated by the accounting system itself.Payments to salaried employees have also been made automaticallysince early 2000 via the computerised accounting system and electronicbanking. In line with instructions from Osakidetza, the standard paymentperiod for suppliers implemented via SAP is 60 days.

Collection of payments receivable consists basically of thereconciliation of bank accounts, the automatic downloading of bankstatements (from the BBVnetcash programme to SAP) and the updatingof the status of invoices (pending payment, etc.). Payments in and outare planned in the treasury budget, which covers all paymentsenvisaged in the year. The treasury budget is adjusted and updated inline with forecasts and payments made. Delays in payment promptanalyses to enable corrective measures to be applied as necessary.

The treasury budget covers all the financial transactions of thehospital. All these transactions are generated via computerised

instructions by the SAP programme.Indicators are in place (absence of complaints by ZH people& suppliers regarding delays in payment) for checking the

degree to which the treasury management process is delivered. Sincethe system is highly standardised, there is scant room for improvement,though some adjustments have been made: for example, the frequencyof payments to suppliers was changed as a result of assessmentsconducted by the PL.

Since 2002, supplier satisfaction surveys have been conducted to assessthe process (Fig. 8b-7, item 3). The survey results are analysed with a viewto meeting supplier needs more closely. This has led to improvements suchas the negotiation of discounts for cash with some suppliers.c) Invoicing

The remit of invoicing is first to identify invoiceable activities(under the PC and invoicing to third parties), then to issue the

relevant invoices and subsequently call for and collect payment.Planning of invoicing takes place mid-way through the year, based onthe SP and the BP. Levels of invoicing for the whole of the followingyear are defined and established on the basis of:

- activity in the previous year;- funding targets and financial balance;- the agreements signed by Osakidetza Officials and the various

companies: definition of invoiceable activity, price lists, etc.

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Invoicing is managed systematically through the SAP computerprogramme, which provides the indicators and information required formanagement, and monitored monthly by Management, based oncomparisons with other periods and with forecasts. Adjustments aremade if any variance shows up. Depending on the nature of thatvariance, the resulting changes may be incorporated into the forecasts.

The basis for invoicing is the information collected from hospitaladmissions. When we realised that invoiceable activities needed to bechecked against invoiced activities, a procedure for the review andmonitoring of discharges was drawn up (monitoring based on financialvolume was considered suitable) at the Invoicing Department. Thisprocedure was set in place early in 1999.

Fig. 4b-3 shows how this process is integrated with financialmanagement processes.

All invoicing in “invoiceable activities” is affected, be it under thePC or to third parties. All end services of the hospital are

covered. Contracts have been signed with various major organisations(e.g. Lagun Aro, Tráfico (Unespa), etc.), with conditions, activities andprices to be charged being established in each agreement.

In the case of invoicing to third parties, it is not important toassess the negotiation process and the suitability of each

contract, as this is not managed by ZH but by Osakidetza.We assess the degree of fulfilment of these contracts by monitoring

invoicing: all invoiceable discharges (of patients) are considered asinvoiced on the basis of the terms laid down in the contract.

Assessment is conducted by the PL on the basis of the indicators listed inFig. 4b-9, and supplemented by reviews and assessment by the MT.

INDICATORS FOR SUB-CRITERION 4B

PC management- % fulfilment of PC- Activity- Quality indicators- Funding

Accounting management :- Annual invoicing- Nº incidents due to payments incorrectly collected- Nº incidents due to payments incorrectly made- Nº incidents due to invoices returned- % invoicing not carried out due to incomplete data- Discrepancies on invoice- Activities invoiced/ carried out- Solvency: current assets/ short term receivables- Immediate liquidity: available/ receivable in the shortterm- Nº invoices accounted for per year- Nº invoices issued per year- Nº invoices not tallying with delivery notes- Bank interest- Nº areas for improvement in audit

Budgetary control - % variance between authorised/ actual spendingFIGURE 4B-9: FINANCIAL MANAGEMENT INDICATORSAware of the importance of monitoring incoming payments

outstanding, the drawing up of a claims procedure was included as anobjective in the BP. This claims procedure was implemented in 2000based on data obtained via the SAP programme. It has since beenextended, reviewed and adjusted. Since the documenting of protocolsfor ISO certification, the percentage of invoicing not carried out due toincomplete data has been taken as the quality indicator.

ASSESSMENT TYPE /SOURCES OF LEARNING

YEAR IMPROVEMENTS

97/02

Design & improvement of processes forAccounting, PC, Treasury/ Invoicing/Payment Collection, Purchasing, Stores,Waste Management & Maintenance (1,2,4)Adaptation & improvement of IT support toincorporate SAP (2,3,4,5)

03

Changes in information on payments sent tosuppliers (2,Computerising of all invoiceable activities(1,2,3,5,6)ISO 9000 Certification (5a & 5b) (1,2,7)

1. Assessment by MT2. Assessment by PL3. Courses in IT, SAP

etc.4. Seminars on

accounting,treasury, etc.

5. SAP circulars6. Audits by Audit

Dept. & BasqueAuditors’ Court

7. Benchmarking 04Review/ modification of indicators &incorporation of survey for medical insurancesocieties (2,3)

Figure 4b-10: EXAMPLES OF IMPROVEMENT CYCLES RELATED TO INVOICING

On the basis that at the end of the financial year all invoiceableactivities at the hospital are identified, and nothing is left pendinginvoicing, we believe that the approach used in this process is the rightone (though some improvements in invoicing affecting this process havebeen identified, Fig. 4b-10). The percentage of overall activitiesinvoiced/ carried out at the hospital is around 100%.

A new survey for medical insurance societies was incorporated in2004 to improve the assessment of this process.

Along with the changes and adjustments in each process, a number ofmajor changes have also resulted from the decision to adopt an integratedIT support system such as SAP throughout the Osakidetza network. Thesechanges have also affected all the processes described above (Fig. 4b-10).4c BUILDINGS, EQUIPMENT & MATERIALS ARE MANAGED

In this area the processes drawn up to develop strategy and deliverZH goals are the following:

1. Macro-process of Buildings & Equipment Management(maintenance, adaptation of structures and waste management)

2. Macro-process of Procurement (purchasing & stores).These processes are all documented, have assigned measurement

indicators and PLs and are managed in line with the methods describedin 5a & 5b.

As mentioned in 4b, SAP has brought about a radical change in allareas of financial management. It has also affected these processes asthe information they provide has been incorporated.1.1.- Maintenance Management

The objective is to maintain the hospital building, equipment andfacilities in optimum working order. The organisation of this

service is planned on the basis of two distinct plans of action, followinga viability analysis by the Head of Maintenance:� with hospital resources (people, machinery, materials, instruments,etc.). This applies to small-scale work and repairs, painting, etc.� with outside resources, when the hospital’s own resources areinsufficient, e.g. when specialist technicians are required or the lawrequires that this system be used.

Maintenance management is split into two sub-processes: preventivemaintenance and corrective maintenance. The complexity and cost ofclinical equipment and the safety requirements for its installation meanthat preventive maintenance predominates. There is a general facilitiesplan, and contracts exist with specialist firms for the development of thatplan, especially in electro-medicine.

In line with the requirements identified in each case, the MaintenanceUnit draws up preventive maintenance plans and implements themaccording to predetermined parameters:� resources required and asset to be maintained;� maintenance interval;� process & steps determined.

Corrective maintenance is based on the requirements and needs ofthe various Units. There is a predetermined protocol for notification andfor work orders that evaluates the main variables and uses an ITsupport application to assess and monitor the process.

Preventive and corrective activities alike are all conducted under workorders. On completion, they are recorded in the maintenance module ofthe SAP programme. This process is integrated with others:

� Procurement: acquisition & acceptance of equipment� Accounts: depreciation of equipment� Treasury/ Invoicing: blocking of invoices� Healthcare processes: adaptation of facilities to improve service� Adaptation of Structure: building & facility maintenance.

This method applies to all maintenance operations required. Allequipment and facilities at the hospital are subject to maintenance,

and all vital electro-medical equipment is under preventive maintenance.Assessment and review are conducted by the MT at itsmeetings and by PLs, using the indicators listed in Fig. 4c-7

and the procedure detailed in 5a & 5b (with certification for correctivemaintenance). There is also an internal customer survey to assess howthe various services of the hospital are perceived. Fig. 4c-1 showsexamples of improvements derived from review and assessment.

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ASSESSMENT TYPE /SOURCES OF LEARNING

YEAR IMPROVEMENTS

99 Definition of process indicators (1,2)

00Re-engineering of the maintenance process:organisational split into two sub-processes,incorporation of SAP IT module & changes incircuits for work orders (1,2,3,4,6,7)

01/02Improvements in maintenance process as aresult of improvement areas identified by PL(e.g. inclusion of endoscopy equipment inpreventive maintenance) (2)

03 ISO Certification (5a & 5b) (1,2,3)

04

Reorganisation of preventive maintenancebased IT inventory & situation diagnosis(1,2,3,5)Location of all maintenance personnel (1,2,6,7)Incorporation of internal customer survey (1,2 8)

1. Assessment byMT

2. Assessment by PL3. EFQMAssessment

4. SAP programme5. Training in SAP-maintenance

6. Review ofinformation &circuits

7. Meetings withUnits

8. ISO CertificationInnovation CapitalModel 05 Innovation project for improving availability &

quality of equipment (1,2,3,10)Figure 4c-1: EXAMPLES OF IMPROVEMENT CYCLES RELATED TO MAINTENANCE MANAGEMENT1.2.-Adaptation of Structures

Based on the plans for ZH requirements and information gatheredfrom meetings with the various Units, the MT draws up an annual

plan and list of priorities for investment requirements, with reference tothe strategy, the annual BP and the individual needs of each Unit.

Work and purchases depend on the annual investment budget, which isdivided into strategic investments (awarded and carried out byOsakidetza) and in-house investments in works and equipment with fundsfrom the hospital’s own investment budget. In the case of purchasesmade by the hospital itself, the Purchasing Area or the Maintenance Arearequests various estimates, and the Head of Finance (advised in mostcases by the CE, the Medical Director, the Head of Nursing and other UnitHeads or PLs) approves the investment required or the carrying out of thework, which is subsequently monitored by Purchasing or Maintenance.

Strategic investments generally concern work to refurbish majorbuildings, or equipment to be acquired by a number of hospitals overthe year, in which centralised purchasing means advantages in cost.

The building and its facilities are systematically maintained on a rotabasis to optimise operations and ensure safety for people and thecommunity. Fire safety regulations are scrupulously observed, effectivesafety devices and circuits are in place, and more than 147,000 euroshave been invested in this area since 2001. A safety and emergencyplan is also in place, and is disseminated and reviewed regularly.

This system applies to all investments made by the hospital.

The process is assessed at the meetings of the MT and by thePL through the indicators listed in Fig. 4c-7. Some examples of

improvements made through these mechanisms are shown below.ASSESSMENT TYPE /

SOURCES OF LEARNINGYR IMPROVEMENTS

99Study & definition of the work circuit (1,2)Rota-based all-round annual maintenance ofInpatients Units and their furnishings (1, 2)

00 Definition & management of the AdaptingStructures process (1,2,3)

01

Changes in structure of requests for investmentby Units (1,2,3,4)Provision of information on investments to Units(2,3,4, 6)Systematic adaptation & updating of fireprotection plans (1, 2, 5, 8)

02Review & improvement of criteria for assessinginvestments & incorporation of a prioritisationsystem (1,2,3)Review & improvement of the work circuit (2,4, 6)

03 Review & improvement of the investmentprioritisation system (1,2)

04Project to refurbish A&E Unit (1, 4)Updating & dissemination of safety plan (1, 2, 3,5, 7)

1. Assessment byMT

2. Assessment by PL3. EFQM

Assessment4. Working Groups5. External

assessment6. Benchmarking7. ISO 14001

05 MP programming (future needs for hospitalstructure) (1, 4)

Figure 4c-2: EXAMPLES OF IMPROVEMENT CYCLES RELATED TO STRUCTURES

1.3.-Waste ManagementThe need detected to manage hospital waste properly was dealtwith initially by drawing up a Waste Plan in 1999. The plan has

since been updated three times. It sets down the concepts, criteria andmeasures needed to ensure that waste is produced, sorted, treated anddisposed of properly, that the ZH people affected are properly informed(this objective is met in over 95% of cases), that an adequate workingenvironment is maintained, that the final amount of waste is reducedand that waste is properly sorted to protect the environment. This planwas approved by the Health Dept. in February 2004.

In accordance with Decree 76/2002, the waste produced by ZH issorted and specifically managed according to risk levels (Fig. 4c-3).

Group Materials included Management

I: MSWKitchen waste, paper,cardboard, clothing,nappies, bandages, etc.

Collected in black bags &managed as per MSWregulations

II: Specifichospital waste

Infectious, sharp &pointed waste

Collected in red bags or rigidcontainersStored for < 72 hours.Distinctly labelled

III: Chemical &other wastecovered byspecificregulations

Cytostatic products,developers & fixingagents, glutaraldehyde,formol, discardedmedicines etc.

Managed separatelydepending on type, anddistinctly labelled. Stored for< 72 hours

IV: Mixed waste Mixture of above groups Separate managementFigure 4c-3: CLASSIFICATION OF HOSPITAL WASTEWaste management is monitored systematically by the PL. Following

successive reviews of the process by the MT and the PL, the approachused in the process was changed. As a preliminary step on the way to ISO14001 Certification, an “Ekoscan” environmental & financial diagnosis,officially recognised by IHOBE (Basque Government) was conducted. Thisstudy sought to discover what potential there was for minimising productionof all types of waste (MSW, hospital waste, etc.), emissions and discharges,and for rationalising use of water and power. The diagnosis concluded withthe preparation of an action plan for 2002 that listed all the actions to betaken, appointed the people responsible for taking them and establishedtime frames and improvement indicators. This in turn provided the basis in2003 for the documenting and certification of our environmentalmanagement system under ISO 14001 in Feb. 2004.

All Units at the hospital apply this system of waste classificationand management. The first classified group dealt with was

specific hospital waste, the most significant group, but treatment andrecycling have subsequently been extended to other groups such as:

- hazardous hospital waste: X-ray plates & developing fluid containers;- non hazardous waste: paper in general, confidential papers,

cardboard, furnishings, plastic packaging, serum bags & packaging notidentified with orange labels;

- hazardous non-hospital waste: fluorescent light tubes, batteries &storage cells, aerosols, IT equipment, spent oils, mercury &plastic/metal packaging labelled as hazardous.

The Ekoscan diagnosis entailed setting up several improvementteams, in which more than 20 ZH people took part. For the certificationprocess a 12-person multi-disciplinary Environment Committee was setup. This committee meets every 4 months. By way of example, Fig. 4c-4lists some of the environmental objectives set for 2003 & 2004.

Environmental objective Level of fulfilmentMinimise risk of soil pollution 100 %Separate plastic waste produced 100 %Eliminate all equipment containing PCBs 100 %Heighten customer awareness of environmental matters 100 %Figure 4c-4: EXAMPLES OF ENVIRONMENTAL OBJECTIVES

Process assessment and review is undertaken by the MTand by the PL on the basis of the indicators listed in Fig. 4c-

7, reviews by the Environment Committee, the qualitative reviewreferred to in 5a & 5b and inspections by the Dept. of Health (Fig. 4c-5).

As a result of the training actions and audits carried out, the numberof kg of waste generated per bed per day has been reduced (Fig. 8b-2).

Fig. 4c-5 shows examples of improvements derived from review andassessment of waste management.

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95 to99

Collection of anatomical pathology waste (3,4)Closure of incinerator (1,4)Hiring of approved waste disposer (1,3,4,5)Disposal of X-ray waste (1,2)

99 to02

Preparation of structures & equipment for wastemanagement (construction of new building,purchasing of bins, change of bags, etc.) (1, 2, 3)Introduction of staff training (1, 2, 4)Audits/ quality control of waste manager (1, 2, 6)Ekoscan diagnosis (1, 2, 3, 5)

2003to

2004

ISO 14001 Certification of environmentalmanagement system (1, 2, 3)ISO 9001_2000 Certification of “WasteManagement” process (1, 2, 3, 5)Extension & review of hospital waste separationcircuit (1, 2, 6)

1. Assessment byMT

2. Assessment by PL3. EFQMAssessment

4. Inspection visitsfrom Health Dept.

5. Working groupmeetings

6. EnvironmentCommitteemeetings

2005 Redesign of processes with definition ofenvironmental process (1, 2)

Figure 4c-5: EXAMPLES OF IMPROVEMENT CYCLES RELATED TO WASTE MANAGEMENT2.-Procurement2.1.- Stores Management

Stores management planning takes place in various areas:• Planning of material purchasing requirements at the beginning of

the year, and agreements with suppliers for regular deliveries over the year;• Planning of annual inventories;• Planning of annual agreements with Units for orders and consumption.This process is organised as follows:1) Identification and planning of purchasing requirements. Before agreeing

on regular deliveries with suppliers, the Head of Stores first conducts aproduct analysis, distinguishing between material that can be planned onthe basis of historical consumption and material to be purchased on thebasis of needs detected. The incorporation of the SAP IT system hasfacilitated planned purchasing. The system of planned orders covers around30% of goods consumed and 100% of programmable orders.

To optimise stores management, “consumer agreements” are entered intowith Unit Heads and supervisors in the various ZH Units to determine thequantities to be supplied at predetermined intervals. These agreements arereviewed on a cyclical basis and adjusted in line with changes arising fromnew requirements. There are currently 8 agreements which are reviewedannually. These agreements cover 80% of movements of materials,including all materials with significant volumes.

2) Monitoring of stocks and inventories to adjust the programme ofplanning for requirements. Inventories are currently conducted on a rotatingbasis on all materials, with an annual calendar of inventories being drawn upon the basis of the ABC classification of materials. To improve efficiency inmaterials management, indicators and targets for stock minimisation andincreased rotation were incorporated into the BP in 1999.

3) Monitoring of incoming and outgoing materials. This covers all materialsin stores.


99Monitoring of delivery times of urgent orders viaindicators (1,2,3)Incorporation of stock reduction & increasedrotation objectives into BP (1,2,4,6)

00Six-monthly reports on consumption by Units tonursing supervisors (1,2,4)Systematic rotating inventories (1,2 3,6)Introduction of product labelling system (1,2,4,5)

02

Direct receipt of orders by pharmacy (1,2,6)Return of signed delivery note for external orders(2)Partial implementation of 5S (1,2,3,8)Computerising of internal orders (1,2)

03Monitoring of urgent orders (1,2,4)Monitoring of orders served by supplier within >1 month (1,2,4)ISO Certification (5a & 5b) (1,2,7)

1. Assessment by MT2. Assessment by PL3. EFQM Assessment4. Working groupmeetings

5. Courses (stores,SAP programme)

6. Visits tobenchmark hospitals& companies

7. ISO Certification8. 5S methodology

04 Redefinition of process & monitoring indicators(1,2,7)

Figure 4c-6: EXAMPLES OF IMPROVEMENT CYCLES RELATED TO STORES MANAGEMENT

All these movements are reflected in SAP and integrated with theremaining financial processes.

This process is assessed by the MT and by the PL on the basisof the indicators listed in 4c-7, and using the method referred to

in 5a and 5b (with certification for procurements). An internal customersurvey is also conducted to assess how the various hospital services areperceived. Fig. 4c-6 shows examples of improvements derived from reviewand assessment of stores management.2.2.- Purchasing Management

The framework of reference in which we must act here is the StateContracts Act [“Ley de Contratos del Estado”], ensuring that all

management actions taken fall within the limits of the law. The regulationsunder which the Act is implemented establish various purchasingprocedures: which of those procedures must be applied under thislegislation to purchases envisaged throughout the year depends on thefinancial magnitude of the purchases involved. There is IT support for this.

Purchasing is handled by the hospital’s Procurement Panel, whichcomprises a chairperson, a secretary and two ordinary members. ThisPanel analyses and resolves on the adjudication of purchases. Purchasesare made under the following types of administrative contract:

• Direct purchasing or “minor contract”.• Negotiated procedures: consultation & negotiation with at least three firms.• Open procedure or public tender.Purchasing conditions are established in line with the needs of the Unit in

question, the quotes submitted and a comparison of prices insofar as ispossible with other similar hospitals. Supplier assessment is an implicitcriterion for purchasing decisions that is applied in all tenders, with thecriteria best suited to each type of purchasing being specified in each case.Purchasing is managed systematically, and is carried out according toestablished, standardised circuits with the support of the SAP system, whichenables purchasing to be integrated with the remaining financial processes.

All purchases at the hospital are made systematically under one orother of these processes, depending on the amount involved.

As with the accounting process, the purchasing process isassessed and reviewed externally through audits conducted

by the Basque Auditors’ Court. Corrective action is taken as necessarybased on the findings of their reports.

INDICATORS FOR SUB-CRITERION 4CManaging maintenance- Nº jobsheets for corrective work (ZH people)/ month / year- Nº jobsheets for corrective work (external services)/ month / year- Average completion time for in-house jobsheets- Average completion time for external jobsheets (for 2005)Adapting structures- Work/ actions carried outManaging waste- kg. of waste produced/ bed occupied/ day- kg. of waste produced/ type- Audit results- Nº of hours’ training/ yearProcurement- Stock-out- Annual turnover of stock assessed- Stock in stores as of 31st December- Urgent orders placed with stores by the various Units- Orders served by suppliers with delivery after more than 1 month- Processing time of orders for new materials- Result of supplier survey

Figure 4c-7: MATERIAL RESOURCES INDICATORSSupplier surveys are another mechanism used for process assessment.

These surveys are geared to measuring the degree of satisfaction of oursuppliers so that their needs can be met as far as possible by takingcorrective action as required. Surveys are sent to 200 suppliers (43% of thetotal, accounting for 90% of purchases). This survey has been conductedannually since 2002. The results are shown in Fig. 8b-7. Improvementsmade against survey findings include the faxing of orders to suppliers(introduced in 2003) for maximum clarity and the posting of specifications fortenders on the Internet (introduced in 2004).

The process is reviewed by the MT, by working groups set up to analysethe previous year’s purchasing report and by the PL on the basis of therelevant indicators (Fig. 4c-7) and the method described in 5a & 5b (ISO

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certification). The improvements implemented in all the processesdescribed in 4c as a result of the implementation of SAP, ISOcertification and 5S methodology are listed in Fig. 4b-1.

The people satisfaction survey includes items that enable assessmentof this section to be completed (Fig. 4c-8)

% AGREEMENTPEOPLE SATISFACTION SURVEY ITEM 99 01 03I have the resources I need to do my job 26 56 70

Figure 4c-8: RESULTS OF PEOPLE SATISFACTION SURVEY ITEMSFig. 4c-9 lists some examples of improvements implemented after review

and assessment cycles.ASSESSMENT TYPE /SOURCES OF LEARNING YEAR IMPROVEMENTS

99 Incorporation of SAP code into orders (1,2)

00 Definition of circuit for purchases of newproducts (1,2,3)

00-02 Processing of new files (1,2,4)

02 EAN coding for classification of materials(1,2,3)

03

Introduction into tender specifications ofenvironmental requirements forprocurement (1,2,4,5)Comparison of purchasing prices withother hospitals (1,2,3,4)ISO Certification (5a & 5b) (1,2,3,5)

1. Assessment by MT2. Assessment by PL3. EFQM Assessment4. Report on previousyear’s purchases

5. Working groups6. ISO 14001

04 Renegotiation of prices with suppliersbased on review of healthcare activity/consumption (1,2,)

Figure 4c-9: EXAMPLES OF IMPROVEMENT CYCLES RELATED TO PURCHASING MANAGEMENT4d. TECHNOLOGY IS MANAGED

Technology management is a macro-process closely linked withknowledge that involves information & communication

technologies (4e) and the management of health-related technology.The latter is part of a CSF (effective technology) for achieving effectivehealthcare under the strategic objective of customer care. Although thissection focuses on healthcare technology, due to its strategicimportance at the hospital, technology management is applied acrossthe board (IT, organisational technologies, non clinical equipment,personalised care, etc.), in line with a simplified form of the systemdescribed above. The technology management process is conductedalong the following lines (Fig. 4d-1):

PHASES ASSOCIATED PROCESSES

Detection ofneeds

Healthcare processesBenchmarkingStrategic developmentManagement by processesInnovation management

Implementationstudy

Budget controlTraining

Start-upPurchasingAdapting of structuresTraining

Assessment Healthcare processesImprovement Continuous improvement

Figure 4d-1: TECHNOLOGY MANAGEMENT1.-Detection of needs

ZH depends to a large extent on technological developments to be able tooffer efficient, quality services. Rapid developments in diagnostic andtreatment techniques are closely linked to developments in the technologyand use of equipment. The results in a continuous cycle of staff training,assessment of the effectiveness and safety of techniques and the valueadded for customers, and improvements in technology and equipment.

Detection of needs may originate from any ZH person, but the informationfor such detection and for the assessment and selection of newtechnologies comes from a number of sources:

a) Attending technical meetings and congresses, reading reports, theexperience of staff, working groups and knowledge gained from experiencesin other hospitals.

b) Technical reports from Osteba, O+IKER and other technologyassessment agencies world-wide, along with reviews and publicationsassessing scientific evidence.

In both mechanisms we take an active part in capture anddissemination by having staff members present in scientific forums and

through partnerships (e.g. participation in APTES, as described in Fig 4a-2,and the CE’s participation in the design of the Basque Government R&DPlan for 2010).

Detection of needs is intended to meet the priority strategic objective ofcovering needs and improving healthcare for customers, and affectsnumerous processes at the hospital:

1. Healthcare and clinical support processes (PLs and staff).2. Development of this hospital’s strategic development (SD) processes,

which takes customer needs into account (2a & 2b).3. Benchmarking, identifying best practices (Unit Heads/PLs).4. Management by processes, which standardises and implements

consolidated techniques (PLs).2.-Implementation studyA study is conducted into whether or not a technology is to be

implemented, taking the following factors into account:• Availability of resources (Budget Control process).• Health Dept. directives (2a).• Availability of staff with sufficient expertise.• Viability/ effectiveness of the new technology at the hospital.

The information sources for assessing and selecting new technologies arethose listed in the previous subsection.

In drawing up the BP, the MT takes into account the investment budget,the planned requirements of the Units and the contribution that newincorporations could make to customer service, and decides on aprogramme of investment based on a table of prioritisation of investmentsand a training programme to enable new technologies to be used.

In specific cases such as pharmaceuticals, high rates of innovation andspecificity make a specific mechanism necessary. Before a new drug isused a report requesting it must be submitted by the specialist, detailing itspotential indications and advantages. This report is studied by the PharmacyUnit to assess its effectiveness and efficiency and the advantages ofintroducing it. With these studies the Pharmacy Committee approves orrejects the request. If accepted, the drug is incorporated into the hospital’sguide to therapeutic drugs. The effectiveness of new drugs added to thisguide is reviewed annually. The PC also has indicators covering this area.

Knowledge and learning are closely linked in ZH, and are often developedsimultaneously with the implementation and assessment of technology (4e).There are numerous sources of learning for assessing innovations and theeffects of applying new technologies. These sources are used in thedetection of needs (DN) and in implementation studies (IS). Some of themare listed in Fig. 4d-2.

SOURCES OF LEARNING PHASE WHERE USEDAttendance at congresses & scientific meetingsAssessment of reportsSystematic searches for scientific evidenceReports by Osteba, O+IKER & other technologyassessment agenciesSpecialist databases: Cochrane, Evidence BasedMedicine.Hospital committeesJoint Technical CommitteeEquipment suppliersEFQM self-assessmentsAdvice from OsakidetzaLearning from experiences at other hospitalsExperience of our staff

DNDNDNDN/IS

DN/IS

DN/ISDN/ISDN/ISDNDN/ISDN/ISDN/IS

Figure 4d-2: SOURCES OF LEARNING & ASSESSMENT3.-Implementation

Equipment is purchased on a systematic basis (PurchasingManagement & Adapting of Structures processes) bearing in mind thetechnical evaluation of all the options submitted by the requesting Unitand a financial assessment by the Head of Finance. On that basis theMT or Osakidetza (if this is a strategic investment for them) determineswhich option gives the best value.

New technologies are applied with a process of staff training (3b),being implemented first as pilot schemes. If these schemes areassessed positively, the technology is then disseminated andconsolidated (4e).4.-Assessment

Assessments are carried out by the MT and the PL via the relevantprocess results indicators and the development of learning. If variance fromexpected results is detected (some cases are indicated in crit. 9, including

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effectiveness, outpatient surgery, medium-length admissions, etc.), thenecessary improvement actions are taken.

This method is applied systematically in all healthcare units (coveringover 95% of investment), and similarly in the remaining specialist

areas of ZH (IT, maintenance, health & safety, etc.). Some examples oftechnology changes in recent years are listed in Fig. 4d-3:

YRTECHNIQUE/SPECIALIST

AREATECHNOLOGY CHANGE

98Ophthalmic surgeryPatient monitoringCardiological testsDigestive system tests

FacoemulsificationCentral anaesthesia unitHolter blood pressure monitorVideo gastroscope

99 General surgeryPaediatrics

Laparoscopic surgery towerChildren’s neurology service

00

Digestive system testsCardiological testsInformation systemsGeneral surgery / ENTGynaecological testsTrauma treatment

Video endoscopeHolter heart monitorAdaptation of IT system for Y2KEndoscopic/ ENT surgeryLevel 3 gynaecological ultrasoundNegative assessment of hyaluronic acid treatment

01

RadiologyENTGynaecology/ surgeryEndocrinologyGynaecologyRehab. treatmentDigestive system testsAIDS treatment

Renovation of echocardiographEndonasal surgeryLaparoscopy (5c)Diabetes learning centreDiagnostic hysteroscopyFemale urinary I. rehab.Colonoscopy w/ sedationChanges in AIDS therapy

02

RadiologyGeneral surgerySurgical careUrology &haematology

Helical scannerCholedoscopeLigasur electric scalpelProsthetic surgery for male urinary incontinenceHaematological chemotherapy

03Orthopaedics/ NursingOrthopaedicsUrology

Growth factors in plasmaExtraction & implanting of bones & tissueEcho-directed prostate biopsy

04

UrologyOphthalmologyENTGynaecologyIT/ Laboratory

Urological laparoscopyAngiographStroboscopeExtension of ultrasound scans at outpatient clinicsin Beasain & AzpeitiaChange of network electronics

Figure 4d-3: TECHNOLOGICAL CHANGESResults are assessed by the PLs for each supporting process inClinical Practice Assessment, using the relevant process indicators.

There are numerous indicators for assessing the level of use and effectivenessof technology, some of which are listed in Crit. 9 (infections, outpatient surgery,etc.). For instance, cataract operations are assessed on the basis of twelveintermediate and final results process indicators that enable a relationship to beestablished between the technique used and its effectiveness in the patient.Other clinical practice assessment process indicators are:

Results for prevalence of infectionsAssessment of methods in oncological treatment of colo-rectal cancer at thehospitalAssessment of quality of referral document sent by Primary Healthcare toInternal Medicine appointments & specialist’s answer to sameAssessment of errors in requests and/ or samples in anatomical pathologyAssessment of effectiveness of punction with fine needle in studies of thethyroid glandAssessment of agreement of diagnoses in endometrial biopsies with surgicalfindingsAssessment of agreement of diagnoses in bronchial biopsies with surgicalfindingsCorrelation of diagnoses between abdominal ultrasound scan & anatomicalfindings in biliary surgical illnessesResults for incidence of infections in knee prostheses, abdominalhysterectomy, elective colon surgery & monitoring outside the hospitalResults for urinary infections in surgical patients fitted with cathetersResults of cataract sub-process, cerebral-vascular accidents, childbirth,keyhole colon surgery, colorectal neoplasia & cholecystectomy

Figure 4d-4: CLINICAL PRACTICE ASSESSMENT PROCESS INDICATORSThe various committees and the JTC assess the application of technologies

at the hospital, and also assess and monitor implementation in some cases.The MT uses the indicators and sources of assessment and learning

described to make general assessments of technology management atthe hospital and enable suitable plans of action to be drawn up forimproving it. For instance the review carried out for the SP resulted in a

working group of hospital staff being appointed to work on systemisingand reinforcing the assessment and dissemination of scientific evidenceand technology management.

Moreover, the 2003 people survey reflects the extent to which staffperceive technology at the hospital as adequate (Fig. 4d-5).

PEOPLE SATISFACTION SURVEY ITEMS % AGREEMENT2003

Changes in technology at the hospital are made in anorganised fashion and people are duly trained 65%In ZH efforts are made to improve technology and providebetter service 76%Working methods are in line with technology with a view tooffering good service 81%Figure 4d-5: ITEMS ON 2003 PEOPLE SATISFACTION SURVEYThe customer satisfaction survey is used to assess the degree of

customer satisfaction with technology management (Fig. 6a-28).Some of the improvements to the approach to technology derived

from assessment and review are shown in Fig. 4d-6.ASSESSMENT TYPE /

SOURCES OF LEARNINGYR IMPROVEMENTS

99 Incorporation of Clinical Practice Assessment& Library processes (1,3,5)

00 Outpatients therapeutic drug guide (1,4,5)

01 Changes in processes defined (1,3,5)Incorporation of Cochrane database (2,5)

02 Investment prioritisation table (1,3,5,6)

03Review & update of prioritisation criteria ininvestment table (1,5Design of technology management process(1,2,5,6)

04 New technology management macro-process(1,2,3,6)

1. Assessment by MT2. Assessment by PL3. EFQM assessments4. JTC / Committees5. Sources of learningFig. 4d-3

6. External experts

05 Multi-facility study by HRF on patient safety (1,5, 6)

Figure 4d-6: IMPROVEMENTS IMPLEMENTED FOLLOWING REVIEW & ASSESSMENT

4e. INFORMATION & KNOWLEDGE ARE MANAGEDIn ZH, information is a fundamental aspect of the management

system. Moreover, clinical information is the basis for clinical knowledgeand improvements in healthcare processes.1.-Management process of the major information systems

The information we use to develop our strategy and manage thehospital is that covering the following areas:

a) Personalised clinical information (5d): All clinically usefulinformation produced by any healthcare operation is collected in asingle dossier on each patient known as the Clinical Record. Thisdocument also provides the foundation the flow of information betweenthe various ZH healthcare professionals and processes. Management ofthis document, its attributes and the resulting information is regulated bythe Clinical Documentation process, which has a PL and processindicators as described in 5a & 5b.

The documents that make up this process are approved under Dept. ofHealth standards, and are updated and reviewed regularly by a monitoringcommittee made up of experts from Osakidetza. The confidentiality,traceability, access and security of this document are regulated by an in-houseregulation (Clinical Record Regulation) proposed by the Records Committeeand approved by the Dept. of Health. Compliance with this regulation ismonitored by the Medical Director. The central committee of Osakidetzaexperts also lays down the criteria for the periodic purging of records.

Since 1999 a number of IT software applications, such as Clinic and PCH,have gradually been made available to medical staff. These enable staff toobtain real-time computer access to most of the information contained inrecords, and to consult results of analyses and diagnoses (Fig. 4e-9). Accessis via passwords to ensure data privacy.

Clinical records include a final document (Discharge Report) that bringstogether the clinical data on the patient and facilitates the assessment ofresults and the grouping of pathologies via an IT system known as DRG(“diagnosis-related groups”), which enables comparisons with other hospitalsto be made (crit. 9). The Discharge Report is also the basis for continued careof the patient when they visit another healthcare service.b) Information on healthcare activities: This covers data and indicators onthe programming, quantity and quality of all healthcare activities. Various levels

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of aggregation are established for analysis. The most common activityindicators are collected using the same system at all hospitals, and Osakidetzaprovides both validation criteria and comparative results each month.

Information on healthcare activities is managed via the Statistics process,which has a PL and indicators as described in 5a & 5b. Information onprogrammed activities regarding appointments and operating theatres, andactivities at doctors’ surgeries, A&R Units, operating theatres and inpatientunits is available on a day to day basis to all authorised personnel (Fig. 4e-9).

The healthcare information needed for management is collected on balancedscorecards that provide data broken down by healthcare areas or Units onmonthly, annual and cumulative bases, and as comparisons with previousperiods (2d). These scorecards have been distributed to ZH Unit Heads since1998 to facilitate the monitoring of their Units, and to PLs since 1999. They areupdated monthly via the Intranet and are accessible for all ZH people.

The complexity of measuring healthcare products, especially in regard topersonalisation, means that a certain level of aggregation is required for datato be analysed, otherwise there would be as many products as there arecustomers. Activities in inpatient care are summarised in a database known asCMBD (Minimum Basic Data Set, MBDS) which is collected from all nationalhealth service hospitals, and which enables overall comparisons to be made.The encoding and IT processing of clinical record data provides a basis forgrouping data by pathologies dealt with, using the DRG system (Explo-DRG).This system also enables us to compare pathologies between hospitals. Datais distributed to PLs and working groups for use in the assessment andmanagement of the relevant processes.

Supplementary databases are also available for the assessment andimprovement of the most frequently used and most significant healthcareprocesses (cataracts, childbirth, colon cancer, etc.).c) Financial Information (4b): Following the implementation of the AldabidePlan (which covers changes in the IT system for management andaccounting) in 1998, all financial events in ZH are reflected in the SAP ITsystem. This system can be used to obtain real-time data on the status of ourincome and expenditure accounts, up to book account and cost centre level.There are also specific modules of the SAP system (Pharmacy, Maintenance,Stores, etc.) that not only allow financial analysis but also facilitate theprogramming and management of the service.

Monthly analysis of data and the results of analytical accounting and DRGenable the MT to supplement the hospital management process. Hospital andOsakidetza Officials have permanent access to overall system data.

Financial information is also analysed monthly with the Heads of Pharmacyand Stores to facilitate decision-making. Prosthesis, laboratory and theatrecosts, Unit by Unit pharmaceutical consumption and consumption by nursing,library and teaching areas, as the main elements, are monitored with thevarious Unit Heads.d) Information on ZH people (3a): The information needed for HRmanagement is provided through the SAP system. Since the implementationof Gizabide in 2000 this has enabled an overall analysis of the administrativesituation of ZH personnel to be drawn up, and further management moduleshave been incorporated.

Like financial data, this information is also available in real time, and isanalysed by the MT and by Unit Heads. The shift scheduling software,regulations and significant information affecting ZH people are freely availableand publicised.e) Documentation of processes and protocols (5a): Processes aredescribed and assessed using an IT application given the name QZ+, whichprovides support documentation to the ZH management by processessystem. This is available on the Intranet and updated when changes occur.Protocols for healthcare and procedure manuals for the processes involved inISO Certification are available and are kept up to date. Nursing protocols arebacked by a specific IT application that provides knowledge of activities andenables treatment procedures to be personalised for each patient (Zaineri).

All five systems described above have IT support managed as described in5a and 5b via the IT process, whose objective is to ensure integrity, structure,reliability and access for all ZH people who require it. At the same time, theprocess manages system maintenance, training requirements and systemintegration. Its objectives are included in management plans that have beendelivered year-on-year.

Osakidetza has an IT development plan for detecting, selecting andcustomising the applications best suited to the sector. This enables us to accesspowerful IT tools and rely on the support of Osakidetza’s methodological guides.

To ensure data security, anti-virus programmes with daily updates are used,daily, weekly and monthly back-up copies are made systematically within ourown LAN and by the Osakidetza central unit, in line with the relevant regulationson data storage and custody, and the system is protected against power cutsand voltage fluctuations by a UPS. In line with the sensitive nature of the data wehandle, the system ensures confidentiality via passwords that are changedregularly and registration of access to sensitive information so as to allowtraceability. With confidentiality in mind, a Security Committee was set up at thehospital in 2003. This committee has improved assurances and control circuits inthis area.

Fig. 4e-9 gives a list of information systems and systemisedknowledge facilitators, the programmes that implement them and

the people who have access to them. The scope of our systems andaccess for consultation by authorised personnel are shown in Fig. 4e-1.

SYSTEM INFORMATION PLANNEDDEPLOYMENT

ACTUALDEPLOYMENT

Personalisedclinical data

Clinical recorddocuments All clinical actions 100%

Programming All non urgentclinical activities 100%Healthcare

activities Quantity/ qualityindicators

All healthcareprocesses 100%

Financial Financial indicators(4b)

All financial eventsat the hospital 100%

Employment records/ financial data onpersonnel (3b)

All ZH people 100%HRShift schedules (3b) All ZH people 100%

ProcessesDescription/assessment ofprocesses

100%Processes &protocols Protocols/

proceduresDescription ofprotocols

% main medical100% nursing100% certifiedprocesses

Figure 4e-1: SCOPE OF INFORMATION SYSTEMSOur information systems, IT support and access criteria arereviewed at least once a year by the MT and the person

responsible for the overall improvement of the system in line with theirimportance for P&S development, increasing management autonomy andthe availability of developments in IT applications.

Several sources of information are used. People satisfaction surveys andthe analysis of their findings with Units, plus indicators and assessments byPLs have enabled us to obtain an in-depth knowledge of the informationrequirements of our people and of the effectiveness of our informationsystems (Fig. 7a-3).

The JTC, the Records Committee and the Library and Teaching Committeeare further valuable sources of review in their respective areas of responsibility.

The standard of clinical record keeping is assessed annually by theRecords Committee using specific documents for medical, surgical andnursing reports (see 9b). Systematic reviews of records are also used toassess infections at the hospital, the results of some techniques and thedevelopment of some frequent or significant pathologies.

SOURCES OF LEARNING & INFORMATIONKnowledge of experiences at other Osakidetza & Spanish NHS hospitalsKnowledge of experiences of firms outside the sectorAdvice & support from OsakidetzaAdvice & support from the IT Unit at Donostia HospitalAdvice & support from IT development firms hiredRegulations on Clinical RecordsCentral Committee on Clinical RecordsAttendance at courses & congresses on IT, clinical records & librariesISO development at library & ITIT training for staffFigure 4e-2: SOURCES OF LEARNING/ INFORMATIONThe signing of the first Programme Contract with the Health Dept. in

1995 led to a critical need to develop our information systems formanagement. Systematic reviews of balanced scorecards since 1996have enabled us to adapt gradually to needs in strategic developmentand management by processes.

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In order to learn of other approaches and tools for developing informationsystems, visits have been made to other hospitals and non healthcareorganisations. This has enabled us to introduce improvements and checkthe consistency of our own system (Fig. 4e-2).

The MT conducts reviews, assesses the effectiveness of the system andincorporates lessons learnt in the process and from the sources ofknowledge indicated. Fig. 4e-4 shows some of the improvements made toour information systems as a result of these reviews. The assessment andreview of financial, HR-related and process/protocol information is describedin 4b, 3b & 5b. The people satisfaction survey also reflects how staffperceive the way in which information is managed (Figs. 4e-3 & 7 a-3).

% AGREEMENTPEOPLE SATISFACTION SURVEY ITEMS 99 01 03I am provided with all the information I need to do my jobproperly 36 59 70

Information given to staff has improved considerably inrecent years -- -- 70

Figure 4e-3: PEOPLE SATISFACTION SURVEY ITEMSASSESSMENT TYPE /

SOURCE OF LEARNINGYR IMPROVEMENTS

98 New balanced scorecards for healthcare activities& incorporation of financial data via SAP (1,3,7)

99System of information by processes (1, 3, 6)DRG system (1, 6)Zaineri system (1, 6)New appointments programme (1, 2, 3, 6)

00Gizabide system (1, 2)Management programme for infants (1, 2, 4, 6)Clinical reports (1, 2, 4)Computerised daily balanced scorecard (1, 2)

01Clinic programme (clinical data) (1, 2)Changes in balanced scorecards by processes (1, 2,3, 7)Medical Visual (management of clinical images) (1, 2)

02PCH (integration of clinical processes) (1, 2, 3)Digitised passive archive (1, 2, 6)New Intranet (1, 2, 3, 7)

03 Strategic balanced scorecard (1, 2, 6)IT system for management by processes (1, 2, 3, 6)

04 Technology assessment group planning (1, 2, 3, 4)Personal data protection plan (1, 2, 3,7)

1. Assessment by MT2. Assessment by PL3. EFQM assessment4. JTC5. Clinical committees6. Strategic planning7. Sources of learning

Figs. 4d-2 & 4e-2

05 Incorporation of Clinical Search Engine forassessing healthcare results (1, 2, 7)

Figure 4e-4: IMPROVEMENTS IMPLEMENTED FOLLOWING ASSESSMENT & REVIEW2.-Knowledge management

Knowledge management is fundamental for us, as knowledge is anecessary resource for all ZH people and is essential for medical and

nursing staff, who base their actions on developments in clinical science. Itcomprises a complex system of relationships by which knowledge iscaptured, fixed and distributed through our organisation. Knowledgemanagement is closely linked to technology management and to peopletraining and upskilling. Fig. 4e-5 outlines the knowledge managementsystem in ZH and the main relationships established with the processes thataffect it at each stage.

Detecting the need for improvement begins with an analysis of theinformation systems described in the previous section, and assessmentof processes, contributions from ZH people, committees and workinggroups and benchmarking work.

The capture of best practices is a process in which ZH people seekout experiences and technologies that can improve the results of clinicalpractice. The fact that the hospital belongs to Osakidetza is a greatstrategic advantage: knowledge can be exchanged and experiencepooled through a variety of different mechanisms. The processes andsystems listed in Fig. 4e-5 and 4e-6 are used as support.

The introduction of new healthcare techniques once their validity has beenproven at other hospitals normally entails staff upskilling, which is attainedthrough study and/or practical learning (crit. 3), and sometimes involves pilotschemes to check the validity, safety and effectiveness of a technique in ZH.

Depending on strategic goals, especially on customer needs and financialbalance and, to a lesser degree, on efforts to improve the system, learningobjectives are set for clinical and management staff.

Once a technique has been shown to be valid and safely applicable, andis considered appropriate for strategic development of the hospital, plansare made to incorporate the relevant knowledge for use by other ZH people.

This is done through theoretical and practical training, which is the mainmechanism through which knowledge is fixed. Technology is also adaptedas necessary, sometimes through close co-operation with technologysuppliers. Finally, the relevant protocols are drawn up to facilitate thedissemination and communication of new techniques to the relevant people.The incorporation of protocols in IT formats also helps ensure andpersonalise their application, which in turn helps the system to be graduallyadopted by other processes. On-the-job training (learning curve) and sharedlearning among our people ensures that knowledge is fixed in place.

Knowledge management in non clinical areas such as hospitalmanagement follows the same system, but is usually implemented morequickly because no risk to patients is involved. For instance, to improve theuse of management tools and encourage ZH people participation, coursesare held in management tools and methods for PLs and other members ofstaff. This promotes a significant sharing of experiences and results in bestpractices being extended through the different processes (Fig. 5b-7).

Figure 4e-5: KNOWLEDGE MANAGEMENT & ASSOCIATED PROCESSESTo disseminate knowledge at the hospital and share it with the rest of the

health system (an overall system improvement goal, 2c & 8), the MT andthe Library and Teaching Committee promote and facilitate the publication,reporting and sharing of experiences within ZH Units and with otherhospitals. For example, the annual agreement with clinical units includes thepublication of at least one scientific article per year. The organising ofcourses and thematic congresses is also encouraged by allowing thehospital’s infrastructure to be used and even providing financial assistance.All the relevant information is collected each year in a Scientific Report, theformat of which was designed by the Library & Teaching Committee. Thisreport is distributed to all hospital Units and to other Osakidetza hospitals.

SOURCES OF LEARNING IN HEALTHCAREKnowledge of experiences at other hospitals in the network and in theSpanish NHSAdvice & support from the central organisationTraining for staff in IT and biomedical databasesTechnology assessment agencies (Osteba, O+IKER, international agencies)Presentation of papers at congresses & scientific meetings (Scientific Report)Practical clinical assessmentClinical sessions & clinical auditsAudits of clinical recordsPeer training of staffTeaching of trainee staffTraining periods for staff at other hospitalsClinical search engineFigure 4e-6: SOURCES OF HEALTHCARE LEARNINGThe assessment of results through audits of clinical records, clinical sessions,

assessment of clinical practice and the analysis of information systems helpsdetect new areas for improvement and encourages the search for best practices.

Figs. 4e-1 & 4e-9 show the extent of the deployment of the informationsystems and protocols used to manage knowledge in ZH. Diagnostic

and therapeutic techniques are shared by all staff at the same Unit as a way ofpooling knowledge. For other day-to-day activities, such as peer training,

A

D

Captaciónmejores prácticasContraste validez

Objetivos

ProtocolosFijación

conocimiento

Comunicación

Cambios en prácticas

Resultados

Áreas deMejora

• Grupos de tra bajo /Comisiones• Benchmarking • Biblioteca • Procesos asistenciales

• Formación • Adiestramiento • Evaluación Práctica Clínica • Sistemas de Información • Documentación Clínica • Mejora Continua

• Estrategia

• Formación • Tecnologí a a • Documentación clínica Mejora Continua

Comunicación Interna

GESTION DEL CONOCIMIENTO

PROCESOS ASOCIADOS

•

•

Capture ofbest practicesCheck on validity

Objectives

ProtocolsFixing of

knowledge

Communication

Changes in practices

Results

Areas forImprovement

• Working groups /Committees• Benchmarking • Library • Health care processes

• Theoretical training • Practical training • Assessment of clinical practice• Information systems • Clinical records • Continuous improvement

• Strategy

• Training • Technology a • Clinical records Continuous improvement

In-house communication

KNOWLEDGEMANAGEMENT

ASSOCIATED PROCESSES

•

•


consultation of specialist literature and databases, specific training is provided(crit. 3).

By way of an example of knowledge planning & development, in 1990 planswere established for the learning and implementation of keyhole surgerytechniques with a view to cutting inpatient times and costs and reducingcomplications arising from gall-bladder surgery. The first such operation inGipuzkoa took place at the hospital in 1993. All surgeons in this Unit now usekeyhole surgery as their first choice technique. Reviews of results and learninghave enabled the hospital to attain low levels of complications, stay times andcosts that are benchmarks in Europe. Moreover, since 1997 we haveperformed a higher percentage of laparoscopic cholecystectomies than anyother Osakidetza hospital, and we have the second best series of totalgastrectomies by keyhole surgery in Europe. In view of the good resultsobtained, other Units such as Gynaecology and ENT adopted similartechniques in 1996 and 1999 respectively, followed by Urology in 2004.Hysteroscopies, gynaecological ultrasound examinations, scans, nursingtechniques, arthroscopies and other medical and surgical techniques havesubsequently followed suit.

Knowledge management is assessed by the MT and by UnitHeads on the basis of the results of its application and the

assessment/learning elements described in Fig. 4e-2. Following theassessments carried out, improvements have been introduced in sources ofknowledge acquisition (Figs. 4e-2 & 4e-6) and the assessment of results has

been reinforced by using analysis based methods (evidence-based medicine,meta-analysis).

Along with the points mentioned in 3b & 3d, the people satisfaction surveyenables us to complete our assessment in this area.

% AGREEMENTPEOPLE SATISFACTION SURVEY ITEMS 99 01 03The work and responsibility I am given allow me to makethe most of my professional ability. -- -- 68Average score of items on training 35 36 50ZH people show an interest in working efficiently -- 91 91Figure 4e-7: PEOPLE SATISFACTION SURVEY ITEMS

As a result of all this, several improvements to our approach have beenimplemented (Fig. 4e-8).


99 Library & Teaching Committee: criteria for attendingcourses (1,2,4)

00Scientific Report for distribution (1,3,6)Training in databases to facilitate access toinformation sources (2,6)

01 Use of Intranet to distribute protocols (1,2,3,6)02 System of scientific evidence as assessment method

(1,2,4,5)03 Design of knowledge management process (1,2,3,6)

1. Assessment by MT2. Assessment by PL3. EFQM assessment4. Working groups/

committees5. Clinical sessions6.Benchmarking

04 Programming of diagnosis of training needs (1,2,3)Figure 4e-8: IMPROVEMENTS IMPLEMENTED FOLLOWING ASSESSMENT & REVIEW

Figure 4e-9: SOURCES OF INFORMATION & IT SUPPORT

AR

SOURCES OF INFORMATION & IT SUPPORT USE M N Ad O MD = Doctors N = Nurses Ad = Admin. workers O = Others M = Management staff

INFORMATIONAS-400 IT system Acquisition & processing of all healthcare activities + + + + +Waiting lists Detailed information on waiting lists: surgical, appointments & tests + + + +Balanced scorecard Daily, weekly & monthly healthcare activities +Hospital annual report Annual report detailing main events & results + + + + +List of inpatients Location of inpatients for Units + + + + +MBDS (encoding of inpatients) Full data on each former inpatient discharged + +PALS Record of complaints, claims & procedural steps of Units + +Gestalón Information on prescriptions for pharmaceutical management + +RED system On-line connection to social security system + +SAP-Gizabide-Aldabide Schedules, payrolls, financial activities & operational reports + + + + +

INFORMATION & KNOWLEDGEClinical records All relevant data on clinical processes + + +Archelp Digitised support for passive records + +Clinical report programme Assistance in drawing up & processing discharge reports + +Clinical search engine Grouping of healthcare process results to facilitate clinical assessment + +DRG (encoding of diagnoses) Grouping of inpatient processes on the basis of isoconsumption of resources + + +Reports on results Results of diagnostic tests + + +Rehabilitation programme Monitoring of therapy profile & techniques of each patient + + +Infant care management programme Collection & use of specific data on new-born infants + + +Catering programme Therapeutic diets & menus for each patient + +Laboratory programme Record of analyses & results of each test + + + +Anatomic pathology programme Record of diagnostic tests in anatomic pathology + + + +Pharmacy programme Single dose treatments for each patient + + + +Day hospital programme Day hospital patient management + + + +PCH & Clinic Integration of records, diagnostic results in patient management + +Guide to healthcare products Guide to products approved & used at the hospital + + + +Occupational health Information on activities & occupational health programmes +Business plan Plans, indicators & goals for the annual plan + + + + +Satisfaction surveys Customer & people satisfaction surveys + + + + +Reports by Osakidetza Specific reports on each main area + + + + +Balanced scorecards Daily & cumulative activity tables + + + + +Regulations – Instructions & circulars Specific regulations in different areas + + + + +Manuals for SAP-Aldabide-Gizabide Financial & staff information programme + + +Micro-IT Workstation IT development + + + + +QZ+ (IT application) Management by processes IT support + + + + +

KNOWLEDGEZaineri Nursing protocols for inpatient care + + +Protocols for action Procedures & protocols for the various processes + + + + +Teaching & training In-house & external training programmes + + + + +Hospital pharmacological guide Guide to drugs approved by the Pharmacy Committee + + +Outpatients’ pharmacological guide Guide to drugs for outpatient use + + +External reports Reports from other hospitals & assessment agencies + + + + +Biomedical databases Updating of scientific evidence in medicine + + +EFQM submission doc. 2000 & 2003 Management practices at the hospital + + + + +

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