Secretary General/Editor-in-Chief EAHM
Assistant to General Secretary EAHM
The hospital care environment is changing as our hospitals, under increased pressure and scrutiny, strive to maintain and improve quality of care with reduced budgets. For this reason the EAHM has been working hard to develop a new working model for the association to help shape future activities and to better serve its members. This article presents the model- IMPO: Inputs, Management, Processes, Outcomes.
Consultation and Workshop
The idea took shape in early 2013 and the long consultation and development process is still in progress. Following an initial presentation during a meeting in May 2013 (Amsterdam), the Executive Committee approved the IMPO model and a large consultation of the National Associations, the Subcommittees as well as the partners began. The IMPO model was presented to the Subcommittees in June and July and the national associations have been invited to discuss the IMPO model and provide their feedback via a questionnaire.
National associations were asked to discuss each aspect of IMPO in detail and inform us of they key inputs (both internal and external) and processes in hospitals in their country along with information on the current management models used and how hospitals measure their outcomes.
The consultation process culminated in the EAHM’s first internal workshop held on the 21st of October in the EAHM offices in Brussels. The workshop saw members of the Executive Committee and EAHM subcommittees (Scientific, European Affairs and Editorial Board) come together to discuss and refine the working model. A significant number of members attended the workshop representing a wide range of European countries and many fruitful discussions took place. The main results from the workshop can be found later in this article.
Speaking at the internal workshop, EAHM President Heinz Kölking explained how the IMPO model is a natural progression following on from the reflection process of 2010. The results of the reflection process highlighted four key focus areas for the EAHM: corporate identity, quality, tools and training. These areas dependent on the active involvement of the national associations and partnership agreements with the industry. With the model, these areas get the support of a framework which will help in the future development of those activities in a coordinated way.
Kolking stressed that IMPO must be not only a roadmap for the EAHM but also for the successful future management of our hospitals and so for our citizens and European society.
The Changing Hospital Environment
The hospital care environment has always been in a constant state of evolution; the changes seem never-ending. In recent times these changes have been intense, especially in light of the financial crisis with hospital budgets being significantly reduced. There is an appeal for healthcare reform across Europe and demographic change means hospitals are faced with the demands of an ageing population. At the same time patient expectations are increasing. Some of these changes in the hospital environment have a more direct impact on the management of the hospital.
Why a New Working Model?
EAHM is aware of the many changes in the healthcare sector and their impact on hospitals and hospital managers in particular. As our hospitals adapt and evolve so must our association. As we all know, the first objective of the EAHM is to promote the professional competence and responsibility of hospital managers (statutes article 1.3.a). The association fulfills this role through the
work of the Executive Committee, the Subcommittees, congresses and seminars and the publication of (E)Hospital. Throughout these activities the three main themes have been the mission, governance and quality:
• The mission of hospitals and related to this the mission of hospital managers;
• The governance of hospitals and particularly the relationship with doctors; and
• The management of quality in hospitals and healthcare
The theme of the 2010 EAHM congress in Zurich was “Roadmap to Top Quality” and discussion of quality has continued with last year’s seminar on crossborder healthcare. In terms of governance the EAHM conducted a European survey with Prof Kristof Eckloo and the Scientific Subcommittee is working on the mission of the hospital and of hospital managers in particular.
As in the IMPO model, the three main themes are connected. Each theme influences the other; the mission of hospital managers and the management of quality in hospitals are not separate worlds, on the contrary, quality is becoming more and more important in the missions of hospital managers. Furthermore the (changing) hospital environment has an impact on these themes, e.g. legislation on hospital governance and patient expectations on quality management. Future work on these themes will be integrated into the IMPO model.
Understanding the IMPO Model
As hospital managers we must first understand this changing hospital environment and the consequences. We must also learn from it. IMPO is a tool to learn from the changes for better management of our hospitals. In this way IMPO is a working model for the EAHM, to define its work programme and subsequent activities.
IMPO will be used to manage the activities of the association and also to reflect on the management of hospitals. IMPO is a working model for EAHM and its activities. It can also be used in managing a hospital, but this is not the first objective of IMPO. The model is not tailored to the context of a specific hospital but we are convinced that IMPO can help to reflect on the management of hospitals.
Nevertheless the objective of IMPO is not to evaluate the hospital management and thus it is not intended as a replacement for current evaluation methods but to examine the causalities between external and internal inputs and outcomes by taking into account management and processes.
Inspiration has been drawn from other models such as the Donabedian model (for evaluating quality of care) and the EFQM model (for encouraging excellence) but IMPO is different from these models.
The Donabedian model starts from structure, which includes all the factors that affect the context in which care is delivered. With IMPO, we prefer to start with inputs, which have a broader meaning and are more dynamic (like in terms of input-output systems). Furthermore, the term structure is often confusing e.g. with governance structure.
EFQM is a management model for organisations whereas IMPO is a conceptual model for healthcare organisations and its management. As in EFQM, we agree that leadership is an important element in the management of organisations. On the other hand, and as an association of hospital managers, we have to differentiate between management and processes. At the same time we have to emphasise the important interaction between the two.
IMPO: A Working Model for EAHM
The working model is composed of four pillars:
I = Inputs
M = Management
P = Processes
O = Outcomes
The following considerations should be taken into account when speaking about IMPO and its pillars:
O: •The outcomes should be patient centered (containing all the effects of healthcare on patients or populations) and should be of societal or macroeconomic relevance.
•They should also be measured in terms of accountability and added value.
I: •Inputs are all that is brought externally & internally into the organisation.
•External inputs are for example regulation, finances, progress in medicine, relationship with companies in the health market etc.These external inputs are transformed into internal inputs by management, applying the regulations, by allocating financial priorities etc. P: •Denotes all the activities taking place directly or indirectly during the delivery of care to the patients (diagnosis, prescription). M: •Management defines priorities, the mission, the objectives and the strategy of the hospital as well as the inputs and the framework for the execution of processes steered by management.
•Management is a specific process. While processes of the daily work are performed by (medical) staff of the hospital management oversees the execution of those processes.
•Management includes leadership. It uses leadership but also followership in running the processes.
The 4 pillars are brought together in the following way: First of all, the pillars I P O are on the same level but with a different size and colour, showing that Inputs are to be converted into Outcomes through Processes. Attention should be first given to the Outcomes (biggest size and strongest blue), followed by Processes and then Inputs.
The M is not only covering the P, it is wider than the P and has one leg between the I and P, but is of course also involved in the outcomes.
These four pillars are interconnected in different ways, for example:
• As indicated, Management differs from Processes of the daily work. But there is a strong link and interaction between both in such a way that they cannot survive apart: they are the operational heart of the hospital.
• Inputs have an impact on the other pillars of model. For example, public expectations will influence the way we look to the outcomes. Disruptive change of technology will have an impact on the processes. Many more interconnections can be identified, but this goes beyond this introduction to the IMPO model.
The purpose of the workshop was to translate the IMPO-model and its concepts into the centre of activities of EAHM. This was done in two steps by three discussion groups; one for each official language of EAHM.
First we brought the management viewpoint to the foreground while looking to the other IMPO-pillars: Outcomes, Processes and Inputs. Secondly, we steered the discussion from the context of the hospital to the national, European level and finally to the level of EAHM. As a preparation for this workshop national associations were invited to give input to the workshop through a questionnaire.
Delegates broke into the language groups to discuss IMPO and how it relates to their experiences, respective countries and also Europe as a whole. After this, the chairs of each discussion group collated this information and presented it to delegates. The main findings are as follows:
Participants agreed that the most important outcomes for hospital management can be summarised in the "Iron triangle": quality, cost and access.
Patient satisfaction, perception of hospital in the media and innovation were also mentioned as examples of outcomes.
The discussion on processes highlighted that in order to ensure access to safe and high quality care, attention has to be devoted to structure, process, organisation, quality & capacity of staff.
Management has already a broad range of tools and approaches to steer the processes like project-, risk-, and workforce management. Monitoring is also an essential task for the management.
Given the impact on the outcomes, infection control and hygiene has become more and more of a priority on the national and European agenda. But in order to be successful, the direct participation of the hospital management is required.
Also logistics and supporting departments shouldn't be overlooked.
Many inputs of importance can be identified, from public health to trade unions, from immigration to changing demography without forgetting financing, public health policy making and health regulation. The discussion groups highlighted that inputs are not always positive, for example social fraud. Inputs can be strategically oriented, like planning or cooperation (private – public, in all its combinations). Also, through the implementation of Directives, the European Union is becoming more and more involved in healthcare.
Furthermore PEST (Political, Economic, Social, Technological) has been mentioned as a systematic framework for analysing external factors that are applicable to different countries.
Management has to ensure that the aims and objectives set are achieved. Professionality of the hospital director and the staff is crucial to guarantee this. This might include co-operation with external partners, private-public provision of healthcare and funding, leadership and co-operation within the hospitals, co-creation of adequate financing system etc.
Global IMPO model:
Participants agreed that the IMPO model helps to develop a common language. It will also help to improve the professionalisation
of healthcare managers.
The IMPO model may lead to a classic vision on how to organise healthcare but has to potential to look in a broader way. A global vision which looks at the particular illness/conditions of the patient from the beginning to the end and thus asking for integrated care will have an impact on the processes and outcomes. Therefore it was suggested to provide a plan for implementing the IMPO model, starting with the most crucial pillar, the outcomes.
Many recommendations have been formulated regarding the EAHM-activities using the IMPO model. These will be presented to the Executive Committee during its meeting in Luxemburg just before the EAHM congress. The outcome of the discussion and decisions by the Executive Committee will be shared with you during our congress in Luxemburg and in the next issue of this journal.
IMPO integrates the four components relevant in running hospitals and therefore underlines the need for a global approach to hospital management. By using this model we can prioritise topics to be elaborated or documented that arerelevant in terms of outcomes and that need to be approached under the scope of management and processes.