International Journal for Quality in Health Care 2006; Volume 18, Number 1: pp. 5865 10.

1093/intqhc/mzi077
Advance Access Publication: 10 November 2005

A descriptive study of the implementation

of the EFQM excellence model and
underlying tools in the Basque Health
Service
ELENA SNCHEZ1, JON LETONA2, ROSA GONZLEZ2, MARBELLA GARCA2, JON DARPN1 AND
JOSU I. GARAY3
1
Osakidetza/Basque Health Service, Hospital Basurto, Bilbao, 2Department of Care Quality, Osakidetza/Basque Health Service, and
3
Health Department, Basque Government, Vitoria, Spain

Abstract
Objective. To describe the implementation of the European Foundation for Quality Management (EFQM) excellence model
as a common framework for quality management in a regional health care service.
Design. Prospective, descriptive observational study.
Setting. Thirty-one organizations (hospitals, primary care organizations, mental health institutions, and emergency services) of
the Basque Health Service (serving a population of 2200000 inhabitants) in Basque Country, Spain.
Methods. Since 1995, the experiences with the EFQM excellence model were initiated by training, the design of quality tools
and application guidelines, and actions related to criteria of the EFQM model.
Results. Four assessment cycles in which most of the organizations have participated were completed. Scores for most of the
criteria improved, particularly in processes. The overall patients satisfaction was higher than 89% in all settings, in most of the
cases higher than 95%. Ten organizations (32%) exceeded 400 points in an external evaluation with the EFQM excellence
model, and 2 (6%) 500 points. Eighty-three percent of hospitals have some ISO-certified areas of activity. In the primary care
setting, 40% of people were attended in a certified center.
Conclusions. Stimulating actions towards quality have resulted in progressive implementation of the EFQM model, this approach
being possibly related to positive evolution of some outcomes. Key factors identified have been pursuing the objective of total
quality management during several years and the assignment of the resources for training and implementation of quality systems.
Keywords: clients satisfaction, clinical management, EFQM excellence model, quality

The European Foundation for Quality Management
(EFQM) excellence model [1] of which there is a public sec-
tor version has been especially accepted in Europe in recent
years. The EFQM excellence model is a non-prescriptive
framework based on nine criteria. Five of these are ena-
blers (leadership, people, policy and strategy, partnership
and resources, and processescriteria 15) and four are
results (people results, customer results, society results,
and key performance resultscriteria 69). There is a
dynamic relationship between enablers and the results, as
excellence in the enablers will be visible in the results.
EFQM promotes self-assessment by the institutions ini-
tially. This process allows the organization to discern clearly
its strengths and areas in which improvements can be made
and culminates in planned improvement actions. In a next
step, an external evaluation by an independent organization
accredited by the EFQM may be requested. Different publi-
cations have recommended the use of this model in the
health care [2,3].
In the Basque Country, a region in Northern Spain,
experience has been gained over many years into the imple-
mentation of the EFQM excellence model in the regional
health care service, formed by 31 health organizations. The
project was started in 1995. Until 1999 only self-
assessments were done [4]. Since 2000, the most advanced
organizations concluded external evaluations and have
achieved quality awards from the Basque government. In
this article, we describe the methodology used for the
implementation of the EFQM excellence model and the
results obtained so far.

Address reprint requests to Elena Snchez, Unidad de Docencia e Investigacin, Hospital Basurto, Avenida Montevideo-18,
48013 Bilbao, Spain. E-mail: esanchez@hbas.osakidetza.net

International Journal for Quality in Health Care vol. 18 no. 1

The Author 2005. Published by Oxford University Press on behalf of International Society for Quality in Health Care; all rights reserved 58

Methods
Setting
State provision of Health Services are transferred in Spain to
the Autonomous Regions (total of 17), one of them is the
Basque Country, with some functions of coordination
remaining with the Spanish Health Ministry. The Basque
Health Service is the public body that provides health services
to the Basque Country population, about 2200000 inhabit-
ants. Universal, free health care is provided except for a part
of expenditures in medicines consumed at home. The Health
Service has the following resources: hospital care with 18 hos-
pitals, primary care including seven primary care regions with
309 health centres, mental care with 28 mental health centres,
and a network for emergency services. All these centres of
health care provision are grouped into 31 organizations, each
of which has management autonomy. The annual budget is
approximately 1.9 billion euro. Somewhat more than 24000
people are working in the Health Service.
Quality as a target objective of the Basque Health
Service
The purpose of the Basque Health Service is to provide pub-
lic care services in accordance with the principles of universal-
ity, equity, solidarity, efficiency, and quality. Since 1995 and
coinciding with a movement towards integral quality pro-
moted by the Basque government, this service began to work
with the EFQM model. Since 1998, total quality became a
target objective in the pluriannual management plans both
for the Health Service as a whole and its 31 organizations
individually.
Training with the EFQM model
A key factor for the progress of the EFQM model has been
the alliance between the Basque Health Service and the
Basque Foundation for Quality Promotion [5]. This is a pub-
lic, non-profit making institution which, since its introduction
in 1993, carries out different activities including training pro-
grams about the EFQM model for managers of private com-
panies, education centres, health care centres, and public
administration. In 1995, with the support of this Foundation,
we started the first training activities initially directed to exec-
utive teams and technicians of quality in the 31 organizations
of the Health Service. Training included a practical, case-
based approach, and practical experience in the self-assessment
process.
To achieve an advanced training level, we have promoted
that many professionals of the health centres will become
evaluators of the Basque Foundation for Quality Promotion.
They receive an advanced training and participate free in the
evaluations of this entity. Throughout this process, many
quality managers and technicians have acquired training and
experience, which has been very useful for the implementa-
tion of the EFQM model in our centres. Currently, there are
90 evaluators.
Implementation of the EFQM in a regional health care service
Structure and supportive tools
The Department of Care Quality was created in 1992 and
endowed with technical and human resources to promote and
facilitate total quality management in all components of the
Health Service. Individual organizations have also been pro-
gressively endowed with quality technicians and administra-
tive resources according to their needs.
All of them have contributed to develop different tools which
have facilitated the implementation of the EFQM model, such as:
1. Design, exploitation, and analysis of corporate surveys
for patients in different health care settings. These sur-
veys have been necessary to evaluate customer satisfac-
tion regularly and to supply to the Basque organizations
comparative data among them as the EFQM model
requires for criteria 5 and 6.
2. Design, exploitation, and analysis of a corporate survey
to measure motivation and people satisfaction in health
care organizations [6]. This initiative facilitates compar-
ative people satisfaction data between organizations,
which accomplish requirements of criteria 3 and 7.
3. Development of indicators and standards of patients
safety, effectiveness, accessibility [7], etc., and design
and exploitation of internal corporate care information
systems for the follow-up of indicators and benchmark-
ing (criteria 5 and 9).
4. Development of guidelines to adapt the use of method-
ologies related with different criteria of the EFQM
model, to the health care setting: self assessments, pro-
cess management methodology [8], 5S [9], etc.
Enablers criteria-related actions
Since 1995, different projects related to the five enablers cri-
teria of the EFQM model aimed to improve results have been
developed.
With regard to leadership, a specific training program in
health care management including quality has been offered to
directors and all other people in team leadership positions to
improve their roles as leaders. In addition, training activities
in quality care and the EFQM model for the remaining pro-
fessionals have been scheduled.
In relation to the second criterion of the model policy and
strategy, total quality management was included in the stra-
tegic planning of the Basque Health Service for 19982002
and 20032007 pluriannual cycles. In 2003, the 20032007
Quality Plan has been implemented with the objective of
improving both health service quality and management qual-
ity [10]. This approach has contributed to spreading out qual-
ity through all organizations of the Health Service to the
extent to which they had to implement management plans in
accordance with corporate directives.
In the area of people, two highly relevant projects were
developed: clinical management and professional develop-
ment. The first strategy was developed with the objective of
involving clinical personnel in management by the imple-
mentation of clinical management contracts in numerous
59
E. Snchez et al.
care services. Professional development is currently being
approached by a new system of recognition of advances in
professional qualification.
In the fourth criterion of partnerships and resources,
efforts have been made in the following areas: optimization of
material resources, improvement of information systems tech-
nologies, implementation of health technology assessment sys-
tems, and support to health care research and knowledge.
Many actions associated with the processes criterion have
been developed. First of all, we have conducted different multi-
centre studies on processes management approach and imple-
mentation in the health care segment [11]. They allowed us, on
one side, to define the standard map of processes and the key
processes for different kinds of organizations (hospitals, primary
care, or psychiatric centres) and, on the other side, to establish
a simple methodology to apply this approach in health centres.
Afterwards, ISO 9001:2000 certification has been promoted
[12,13] as an effective way to deploy progressively processes man-
agement in our organizations. The most advanced primary care
centres and hospital services were the target of the ISO certifica-
tion. The number of them is indicated in the results paragraph.
To improve clinical processes, usually the key processes in
the health organizations, and to supply indicators for their
follow-up, we have developed different specific programmes.
These include standardization of the nursing process of care;
surveillance, prevention, and control strategies for nosoco-
mial infection; establishment and accreditation of bioethics
committees; strategies to improve the waiting lists for surgical
procedures and specialized care, etc. In association with clini-
cal leaders groups, clinical guidelines have been developed, as
well as standards and indicators of technical quality for the
care of patients with some diseases, such as cancer, diabetes
mellitus, hypertension, acute myocardial infarction, and hip
replacement surgery. Some of these indicators have been
incorporated into the clinical management contracts of health
care services and are currently considered contractual require-
ments to receive public funding.
Assessments and measurement
Since 1996, biennial assessments using the EFQM model have
been performed by the organizations. Self-assessments were
Table 1 Organizations (number and percentage of the total) of the Basque Health Service that have carried out EFQM assessments
Organizations assessed
.............................................................................................................................................................................................................................
Hospitals
Self-assessment and/or external auditing
External auditing
Primary care regions
Self-assessment and/or external auditing
External auditing
Other health care resources
Self-assessment and/or external auditing
External auditing
60
only initially performed but since 2000 some organizations, the
most advanced, underwent external auditing processes by the
Basque Foundation for Quality Promotion. The number of
organizations involved and the type of assessment (external or
self assessment) are shown in Table 1. Before each assessment
the Department of Care Quality in collaboration with the
Basque Foundation, provided training activities for participants
without sufficient knowledge of the EFQM model, and guide-
lines and criteria for the right implementation of the assess-
ment. Always an observer expert in the Model EFQM was
facilitated to support the assessment. In self-assessments, dif-
ferent criteria scores were obtained by consensus among the
participants (usually the management body integrated by 520
people, exceptionally more) according to the RADAR (Results,
Approach, Deployment, Assessment and Review) scheme of
the EFQM model [1]. When an external assessment was made,
the scores were assigned by consensus by 6 external assessors
of the Basque Foundation for Quality Promotion, using also
the RADAR scheme. The scores and the areas prioritized for
improvement were communicated to the Department of Care
Quality by each organization assessed, so a complete corporate
report was elaborated biennially. All the results were integrated
in the report, independently of the methodology (external or
self assessment).
Results
We present some relevant outcomes of our organizations:
scores obtained in the evaluations according to EFQM
RADAR system, and relevant figures of external assessments
and awards. Also, we show some corporate relevant available
tendencies related to 2 EFQM model results criteria: custom-
ers and key performance results. At the moment, we do not
have available corporate tendencies for criteria 7 (people
results) and 8 (society results); although individual organiza-
tions, mainly the most advanced, have them.
Scores obtained in the evaluations
Figure 1 shows the scores obtained from the different criteria
of the EFQM model in the four assessment cycles performed
19961997 19981999 20002001 20022003
12/20 (60%) 17/20 (85%) 18/18 (100%) 16/18 (89%)
None None 3/18 (17%) 5/18 (28%)
12/13 (92%) 3/7 (43%) 6/7 (86%) 7/7 (100%)
None None None 1/7 (14%)
None None 4/6 (67%) 4/6 (67%)
None None 1/6 (17%) 1/6 (17%)
 Implementation of the EFQM in a regional health care service

Enabler criteria

Percentages of maximum possible scores

100%

80%

60%

40%

20%

0%
Leadership Politics & People Partnerships Processes
Strategy &
Resources

1996-1997 1998-1999 2000-2001 2002-2003

Results criteria

Percentages of maximum possible scores

100%

80%

60%

40%

20%

0%

Clients People Society Key Performance

Results
Results Results Results

1996-1997 1998-1999 2000-2001 2002-2003

Figure 1 Evolution in the mean percentages (maximum possible score 100) for enablers and results criteria of the European
Foundation for Quality Management (EFQM) model in the four general assessment cycles of the BHS organizations.

biennially since 1995. With the aim of observing the criteria large range spread, which indicates a large variability of the
profile and the variability between organizations, a graphic percentages obtained for the nine criteria, particularly wide in
display of results obtained for the 20022003 period is customer results. The explanation of this finding is that
depicted in Figure 2. Mean highest scores, greater than 40%, some specific organizations such as psychiatric ones did not
were achieved for partnership and resources, customer start to use customer surveys until recently, so their punctua-
results, and key performance results. However, there was a tion was much lower than the rest. On the opposite side,

61
E. Snchez et al.

100%
Table 2 Progression of the ISO and the EFQM recognitions
in the Basque Health Service
Score (%) for each criterion
80%

(EFQM max = 100%) 60%

2001 2002 2003 2004
40% .............................................................................................................

20% ISO certifications

0%
Primary care
1 2 3 4 5 6 7 8 9
(number of centres)1
MEAN 37% 39% 36% 42% 38% 46% 37% 26% 46%
MAX 56% 56% 54% 58% 55% 86% 60% 45% 70%
Partial: only 15 30 34 42
MIN 18% 16% 17% 18% 13% 7% 6% 3% 25% administrative areas
Criteria
Global: administrative 4 12
and clinical areas
Figure 2 Mean and range (maximum and minimum) values Hospitals
of percentages (maximum score 100%) obtained in the 2002 (number of services)2
2003 assessments by Basque Health Service organizations for Central 3 11 25 35
the nine EFQM criteria: 1, leadership; 2, politics and strategy; administrative services
3, people; 4, partnerships and resources; 5, processes; 6, cus- Central 8 12 23 31
tomer results; 7, people results; 8, society results; and 9, key care services
performance results. Clinical services 1 1 1 8
Total 27 54 87 128
EFQM recognitions
some organizations had long tendencies and good data, organizations3
obtaining for these reasons remarkable results. Silver Q (400 points) 3 3 6 10
Gold Q (500 points) 1 2 2
External assessments and awards Total 3 4 8 12

Several organizations have passed external evaluations by the 1

BFQP according to criteria of the EFQM model and obtained
awards. At the moment, 10 out of them (32%) have reached 400
points (Q silver award of the Basque government), and 2 (6%),
Hospital Bidasoa [14] and Hospital Zumrraga [15], have scored
more than 500 points (Q gold award of the Basque government).
As a demonstration of the progress in the criterion pro-
cesses, now 54 primary care centres, the most advanced in
quality, attending 40% of the population, are certified by the
ISO standards. In the hospital setting, 74 services belonging
to 83% of the hospitals are certified.
Table 2 summarizes the progression of these external rec-
ognitions of quality during the last 5 years.
In primary care, the figures of ISO certifications refer to centres
certified.
2
In hospitals, the figures of ISO certifications refer to services certi-
fied: central administrative services (e.g. Admission, Clinical
Records Department), central care services (e.g. laboratory, radiol-
ogy, pharmacy), and clinical services (e.g. paediatric emergency,
home care, day psychiatric care, etc.).
3
The figures of the EFQM recognitions refer to organizations with
management autonomy (total of 31 in the Basque Health Service).
position of the Basque Country are summarized in Table 4.
Always, results of the Basque Country were largely above the
average, with a leadership position in some of them.

Customer results Key performance results

Surveys of customers satisfaction are carried out regularly
in organizations of the BHS according to questionnaires
specifically designed as a part of the supportive tools men-
tioned before. These surveys are conducted yearly or bien-
nially, and their results elaborated by the Department of
Care Quality and used for benchmarking amongst Basque
organizations. All questionnaires of customers satisfaction
include a final item of overall assessment, with a 5-point
categorical scale (excellent, very good, good, fair, and
poor). Table 3 summarizes the percentage of positive evalu-
ations (good, very good, and excellent responses) obtained
during 20002003.
The Spanish Ministry of Health, which conducted a survey
for inter-regions benchmarking using a different methodol-
ogy, has provided other data, for the first time in 2003. Some
of the most outstanding indicators as well as the ranking
Different indicators of processes and results, elaborated and
published by the Department of Care Quality, according to
their own methodology [7], are summarized in Table 5. Some
aspects, such as appointment delays for specialized care, are
objectives for improvement in the 20032007 quality plans.
Discussion
In recent years, there has been a debate about the advantages
and disadvantages of different quality models used in the
health sector. In our case, we have used the EFQM model as
a framework for all improvement activities. This includes the
use of ISO as an important tool integrated in the processes
criterion of the EFQM model. ISO standards were taken as a
reference for improvement of the processes. Technical

62
 Implementation of the EFQM in a regional health care service

aspects established in evidence-based medicine are included management of the health processes will be a key link
among requirements of the processes quality systems, so that between total quality management and evidence-based
medicine [16].
This study refers to a quality approach based in the EFQM
Table 3 Overall evaluations of the degree of satisfaction model as a quality framework for 10 years. The majority of
(excellent or very good or good) (%) obtained in the Basque EFQM criteria improved, especially noticeable in processes
Health Service Surveys (5-point scale used: excellent, very and people results. The first one in relation to numerous
good, good, fair, and poor) in the different health care set- actions oriented to improve processes carried out. The
tings during 20002003 second one was mostly due to the introduction of regular
peoples satisfaction and motivation measurements. How-
Setting 2000 2001 2002 2003 ever, a decrease in key performance results criterion was
....................................................... ....................................................... observed, which may be related to two factors: (i) an increase
Acute care hospitalizations 97.0 97.5 97.0 96.5 in the number of external evaluations, which are usually more
Outpatient clinics 95.5 95.8 96.2 96.2 demanding and strict regarding scoring and (ii) the conceptual
Emergency departments 91.0 93.0 92.2 93.1 change of the EFQM model for the identification of key per-
Day surgery admissions1 NI 98.9 97.6 formance results introduced in 2000.
Home hospitalizations1 NI NI 98.4 Some limitations of the study could be outlined. First of all,
Mothersfathers of 96.9 96.7 this is a descriptive study, so the causal relationship interpre-
hospitalized children1 tation between the methods described and the results
Mid- and long-stay hospitals 94.9 95.7 93.6 94.8 obtained is therefore restricted. Nonetheless, future reported
Primary care (family medicine) NI 96.4 94.9 95.4 experiences with similar results could reinforce the causal
Primary care (paediatrics)1 NI NI NI 96.9 link. Other limitations of the score evolution data are 2000
Acute psychiatric NI NI NI 89.5 changes in the EFQM model, although the changes were
hospitalizations1 minimal, or the different assessors along the study. In this
Outpatient psychiatric care1 NI NI 93.8 case, specific training of the assessors tried to guarantee
Breast cancer programme1 enough consistency between different self-assessments.
Detection 95.7 96.5 We want to remark on improvement in criteria processes.
Diagnosis and treatment 97.0 97.4 This can be largely attributed to efforts made towards systema-
tization of concepts, development of indicators, and stimulus
NI, surveys not implemented yet. for improvement. This criterion is usually one of the priority
1 areas for improvement detected in the self-assessment [17,18].
Biennial surveys.

Table 4 Population satisfaction with the Spanish National Health Care system, measured by a Survey, coordinated by the
Spanish Health Ministry. Comparison of the results obtained in 2003 in the 17 autonomous communities (regions) for some
indicators selected

Concept (scale) Basque Health National Health Basque Health

Care Service Care system Service ranking1
mean (range)
.............................................................................................................................................................................. ..............................................

Satisfaction with the health care system 7.2 6.1 (5.37.2) 2/17
(010 points), mean
Care provided in his/her community is better 56% 20 (4.479) 2/17
than in other autonomous communities (%)
Satisfaction with the information provided by 6.5 4.8 (3.56.5) 1/17
the administration (010 points), mean
Satisfaction with primary care (very good 93% 82.6 (71.394) 3/17
or good) (%)2
Consider that primary care has improved in 64.9% 50.7 (4368) 3/17
recent years (%)
Satisfaction with specialized care (very good 81.8% 67.6 (5085) 5/17
or good) (%)2
Consider that specialized care has improved 56.1% 40.7 (29.862.9) 3/17
in recent years (%)
1
Position of the Basque Health Service among the 17 autonomous communities.
2
Five-point scale used by the Spanish Ministry of Health in this question: very good, good, fair, poor, and very poor.

63
E. Snchez et al.

Table 5 Some key performance results obtained in the Basque Health Service during 20002003

Areas evaluated 2000 2001 2002 2003

........................................................................................................................ .......................................................................................................

Duration of the medical consultation in primary care, minutes, mean 7.4 8.1 8.2 8.5
Length of stay in acute care hospitals, days, mean 6.1 6.0 6.1 5.9
Delay in surgical waiting lists, days, mean 57.1 53.7 55.2 53.8
Patients waiting less than 1 month for specialized care (%) 63.1 65.8 55.5 60.1
Prevalence of patients admitted with an infection episode (%) 6.7 6.0 5.8 6.6
Minimally invasive tumours detected in the Early Detection Breast 43.3 46.5 47.0 40.9
Cancer programme (%)

This study shows other positive results in health care sector
such as customers satisfaction and key performance indicators
related with the EFQM model criterion 9. Customers satisfac-
tion has had a high-sustained performance and offers favoura-
ble comparisons with other regional Spanish health services.
Some of the key performance indicators have not been so
good, such as waiting delay for specialized consultation, this
related in part with an increase in the health services demand.
As suggested before, we could ask if the quality politics
have influenced the results presented. Really we cannot be
certain that other quality politics would have been conducive
to obtaining similar or better results. Nevertheless, experi-
ences reported in the health sector related to the use of the
EFQM model in Europe [1921] or the Malcolm Baldrige
framework in USA [22,23] emphasize that these approaches
help organizations to perform better. Studies published have
identified success factors and best practices of self-assess-
ment, as well as limitations, barriers, and lessons learned [24].
For us, the methodological support of the Basque Foundation
for Quality Promotion, facilitating training and experience
with the use of the EFQM model and promoting the quality
Basque awards, has been a relevant factor for success. The
influential effect of this type of activities on quality improve-
ment plans has also been recognized in other countries
[25,26]. On the other hand, understanding the EFQM
approach may be found difficult by health care professionals,
given that it is a non-specific model. In our experience, like
others [27,28], it was considered important to develop guide-
lines for the practical application of the model [29]. The com-
mitment of the Basque government on management
excellence has been another crucial factor. This EFQM model
implementation experience is one of the longest duration
reported. The administrative support for quality, extended to
governing bodies of the Basque Health Service and most of
the directors of health care organizations, resulted in multiple
initiatives along the years [30]. This support has facilitated the
assignment of the necessary resources for training and consul-
tancy services, which are indispensable for the long-lasting
maintenance of a quality improvement project.
Acknowledgements
We are indebted to the Basque Foundation for Quality Pro-
motion for valuable support and unconditional help in the
implementation of quality management programmes; directors
and experts in quality methodology of the Basque Health
Service for personal encouragement, constructive comments,
and suggestions on methodology; all professionals of the
health centres who represent an added value to our daily
activities; and Marta Pulido, MD, for editing the manuscript
and editorial assistance.
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Accepted for publication 7 August 2005
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