Implementation of a Total Quality Management System (TQM) according to the EFQM (European Foundation for Quality Management) at the Department of Ophthalmology - The pilot phase

PURPOSE: The EFQM business model was primary introduced into industry as a management tool to improve quality and is now going to be adapted in health care issues at our Department of Ophthalmology. METHOD: As a first step an initial self-assessment within the EFQM model was made by physicians, nurses and medical technicians by means of an adapted questionaire in November 2006. 9 main criterias were defined (5 enabler criterias i.g. leadership, partnership, resources and processes and 4 results criteria respectively e.g. people, customer and society results) and additional 20 subcriterias added (as adapted in our hospital). The PDCA cycle and the RADAR logic with quantification between 0 and 100 were applied. RESULTS: The results of the first EFQM self assessment showed a high degree of variation (e.g. in terms of people's satisfaction and need for improvement (between 25-75 scores). According to our initial self assessment improvement measures have been made and are going to be introduced. In January 2006 we defined 15 initiatives with improvement measures in the EFQM criteria people, partnership & resources, processes and key results. SUMMARY: Our first self assessment showed a high degree of variation. Reasons for the variation of the answers of our initial self assessment were the inhomogenity of the staff and questions that refer to general issues (leadership in general, politics, resources). According to our initial self assessment measures have to be introduced in due time.