Evaluación de proyectos de empowerment en el área de los Servicios de Salud. Una metodología innovadora

8/14/2019 Evaluacin de proyectos de empowerment en el rea de los Servicios de Salud. Una metodologa innovadora

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Conducting an Empowerment Evaluation Project inthe Area of Health Care Services: An Innovative

Methodology

Evaluacin de proyectos de empowermenten el rea delos Servicios de Salud. Una metodologa innovadora

Monika Bobzien*

Empowerment evaluation, as a core concept in the elds of community psychology and healthpromotion, refers to the ways in which individuals, groups and/or communities gain inuence overthe activities in which they choose to work, and over the decision-making processes that these entail,augmenting the capacity to self manage their lives.

This article explores the concept of empowerment as a framework for managing projects in thehealth care services. The case study shows a two-year pilot project conducted in Hamburg, Germany,outlining an innovative approach towards combining experiential and professional expert knowledge

in the eld of clinical practice.We analyze and discuss the ways in which patient participation can be strengthened by makingpublic the criteria or standards by which hospital treatment is oriented; we also discuss theimplications of such a turn. Quality standards for self-help-friendly hospitals were developed,implemented and evaluated in collaboration amongst hospitals and patient organizations for thosewho suffer chronic diseases, and lead to a qualifying certicate (Self-help-friendly Hospital)awarded to those hospitals which succeeded in their performance.

Keywords. Empowerment, project management, health services, patient organizations, patientfocus, participation, quality standards.

Abstract

* Monika Bobzien, Dipl.-Psychologin, OrgLab Organizational Development Laboratory (http://www.orglab.de/), Universityof Duisburg-Essen, Germany ([email protected]).

La evaluacin del empowerment, como un concepto central en el campo de la psicologa comu-nitaria y de la promocin sanitaria, se reere a las formas en que los individuos, grupos y/o comu-nidades ganan inuencia sobre las actividades en las que eligen participar, y tambin sobre losprocesos de toma de decisin que stas incluyen, aumentando as su capacidad para autogestionarsus vidas. Este artculo explora el concepto de empowerment como marco para gestionar proyectosen los servicios de salud. Este caso de estudio muestra un proyecto piloto de dos aos de duracinque se llev adelante en Hamburgo, Alemania, sentando las bases para un enfoque innovador quecombina conocimiento de profesionales y de aquellos quienes han ido aprendiendo por su experien-

cia en el campo de la prctica clnica. Analizamos los modos en que la participacin de los pacientes

Resumen

Revista IRICE, 2009, 20, pp. 33-47

2009 IRICE (CONICET - UNR).


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Empowerment is a popular word and oftensubject to misperception. In the eld of organizationalconsulting, empowerment means a top-downmanagement tool for the improvement of individualand team performances to achieve better businessobjectives. Employees must initially be in a (high-

leverage) position to take advantage ofempowerment programs.

In community psychology, however,empowerment is an enabling and emancipatory toolmost commonly associated with political power anddecision-making processes geared towards peopleoutside the mainstream of economic and socialpower.

Central to the empowerment concept is the

importance of individuals and communitieshaving inuence and control over decisionsthat affect them (Israel et al., 1994, p. 3).

Characteristics of empowerment tools are theexchange of information, spreading of (bottom-up) knowledge to promote networking and to buildcapacity for theory, research and practice. Thismay also include international cooperation withinthe most relevant domains of intervention (e.g.health promotion and prevention, poverty andoppression, violence and drug problems) in areas ofsocial change and betterment in local, national andglobal politics (Rappaport, 1986; Stark, 1996).

The work of Fetterman and Wanders-man (1996, 2005) served as foundation forconducting the empowerment evaluation project.According to Fettermans and Wandersmans theoriesempowerment evaluation is dened as

An evaluation approach that aims to increasethe probability of achieving programsuccess by (1) providing programstakeholders with tools for assessingthe planning, implementation, and self-

evaluation of their program, and (2)mainstreaming evaluation as partof the planning and management of theprogram/organization (2005, p. 28).

The publication of Fettermans Ten principles1 ofempowerment evaluation coincided with the start of thetwo-year pilot project Development, implementationand assessment of quality standards of self-help-friendliness into hospital routines (Bobzien, 2006),which started in 2005. The objectives of the project

were dened in a exible way, and the publication ofthe 10 principles gave us dening parameters uponwhich to base the project. As a result, the descriptionof our methodology will apply Fettermans 10principles, even though this frame was not usedsystematically to conduct the study.

Introduction

We will start by providing a short overview on theinstitutional and political background on health carereform legislation. We shall also describe patientorganizations with experience in empowerment. It isimportant to note that from the start we encounteredfavourable conditions that were a prerequisite forthe success of this project. The coming together ofdifferent elements such as sponsors, knowledgeableproject managers, and the physical environment,including personnel, need be optimal to design theproject and to achieve the desired success. Ouranalysis of the case study presented in this piece willfocus on the following phases that were necessaryto get all parties together to begin the collaboration:

- Development of quality standards for self-help-friendliness in hospitals.

- Implementation of quality standards in standardoperating procedures (SOP) of hospital treatment,especially in routine delivery of health care and inthe institutional organization involved.

- Development of criteria for institutionalself-assessment, and the conduction of externaltests to evaluate the integrity of the self-assessmentprotocol. Success in the entire process qualied the

institution for a quality award.1. The Ten principles of empowerment evaluation are:Improvement, Community ownership, Inclusion, Democraticparticipation, Social justice, Community knowledge, Evidence-based strategies, Capacity building, Organizational learning,Accountability (Fetterman & Wandersman, 2005, p. 30).

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puede ser fortalecida al hacer pblicos los criterios a travs de los cuales se orientan los tratamien-tos hospitalarios. Tambin presentamos una discusin crtica de las implicancias que tiene dichaorientacin. Como resultado se han desarrollado Standards de Calidad para Hospitales Amigables,que se han implementado y evaluado en colaboracin entre los hospitales y las organizaciones depacientes que agrupan a quienes sufren de enfermedades crnicas. Esta implementacin llev aproducir y entregar certicados de calidad a aquellos hospitales que cumplen con los stndards.

Palabas clave. Empowerment, gestin de proyectos sanitarios, organizaciones de pacientes hos-pitalarios.


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and professionals. This knowledge often forms thebasis for recommendations about best practices, andreferrals to better clinics and treatment facilities. Asnonprot organizations they collaborate with healthresearch, health care institutions and lobby the phar-maceutical industry to invest more in research ofmore effective medicine. They also provide rst-handservices to other patients and professionals.

In the sense of Antonovskys concept ofsalutogenesis (1987) people in mutual aid groupsexperience a sense of coherence, which empowersthem and makes them feel less vulnerable to theeffects of their illness. They build up capacity totake charge of their environment with the resourcesavailable to them. As they become more self-determinated and aware of collective resourcesthey also establish a more critical attitude towardsprofessional help. It is an empowerment processin which people typically know their own problemsand are in a good position to generate their ownsolutions.

This exactly is the role and specic contribution ofpatient organizations in health promotion as denedin the Ottawa Charter for Health Promotion (1986):Health promotion is the process of enabling peopleto increase control over, and to improve their health(p. 1). If health promotion is applied to improvequality in hospitals, it increases the results of outcomesand has implications for hospitals structures andprocesses. Following the more explicit qualityphilosophy of hospitals, the outcome concept of

hospitals already has expanded to include, in additionto clinical outcomes, health-related quality of life andpatient satisfaction as well.

The concept of empowerment stresses thenecessity that individuals take control over theirhealth -which means in the context of the hospitalthat patients are not only seen as objects ofinterventions but also as active participants ofthese interventions. This kind of empowermentcannot be achieved by the clinical interventionsthemselves, but by communicative interventions

and shared perspectives with patients and patientorganizations / mutual aid groups.

- Implications in the Globe that fostered the

project idea

Some important changes in health care policy,research, quality control and the health careindusty have inuenced policy makers andstatutory health insurances to think about useful andsustainable approaches in health promotion. Animportant stimulus came from the German laws and

regulations which became effective in 2000. Theseregulations intended the overall modernization of thehealth care system. They affect almost every aspectof the health care system, from health promotionto after-care, and strengthened patients rights by

providing them the rights to participate in shared de-cision making in medical treatment and patient care.

Regulations require quality control in healthservices and mandate hospitals to provide evidencein quality. Their reports are published on thehomepage. Quality reports are an important aspectof competitiveness in the market place, and hospitals

implement quality management and undergoassessments by accredited certiers in order tostand out from the crowd in the healthcare market.

National and international economic constraintsare creating a competitive and shareholderdominated healthcare market. This triggerschanges in traditional patterns still prevailingin institutional treatment and patient care.Instead of exercising a paternalistic attitudetowards patients the climate became morecustomer-focused but at the same time moreprot-oriented as well.

Hospital stays have become shorter due to budgetcontrol that refers to Diagnosis Related Groups(DRG)4. This often results in the fact that a patientcannot recover from treatment adequately beforebeing discharged. On the other hand, hospitals areobliged to manage the interface between hospitalcare and after-care, for instance in rehabilitation, orto ensure ambulatory or family care. This situationmay also give patient organizations an importantrole in after care.

In the recent past, many hospitals have becomeunprotable; as a result, have either shut down,merged or have sold shares to private investors.During the project period one of the test hospitalsin the project was bought out twice and with everynew owner, there was a new mission and a turna-round in organization. However, being more efcientand being highly ranked can also be an impetus forbest practice in hospital management and patientcare. It is assumed that this new development wouldcreate the environment to listen to the patient -or tothe general patients needs.

From the beginning, the pilot project attractedgood reviews in professional healthcare circlesand self help groups. Articles about the core ideaof the project as well as about intermediary data ofcollaboration between patient organizations andhospitals were published in local, regional andprofessional journals. It was acknowledged thatthese activities supported sensibilization and crea-ted acceptance, which in turn led to interests andinquiries from other hospitals and patientorganizations all over Germany for the outcomes ofthe project, and, or the possibility for participation in

the project.

4. DRG Diagnoses Related Groups is an internationally developedclassication system on which a prospective payment system forhospitals is based upon.

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Fig. 1. Denition for Self-help Friendly Hospital

A Self-help-friendly Hospitalis dened as collaborating with patient organizations, by

enhancing the contact between patient / relatives and self-help groups

actively supporting self-help organizations

expanding expert knowledge in medical treatment and care by usingthe experiences and know how from self-help organizations

investing in the quality of patient focus in a structured and systematicway by using a patient-friendly quality standard.

Project framework

The idea and concept of the project Self-help-friendly Hospital (see Figure 1 for a summary ofits characteristics) came from the Kontakt undInformationstelle fr Selbsthilfegruppen KISSHamburg (the regional non-prot clearinghouse5in Hamburg) and the Department of MedicalSociology at the University Medical Center Hamburg-Eppendorf (UKE).

To promote the idea of a self-help-friendly hospital,

KISS and the Department of Medical Sociologyput together a group of stakeholders, includingthe patient organizations and the hospitals tocollaborate across. The Bundesverband derBetriebskrankenkassen BKK BV (The Germanumbrella association of Employees HealthInsurances) funded the project. However, BKKsrole in the project was not only nancial, but alsoinstrumental in establishing contacts and networksof organizations important for the project.

Clearinghouses, overall, have close connections

to patient organizations. In various presentationsduring regular meetings organized by KISSHamburg, we had the chance to discuss the projectidea and were able to invite patient organizationsto participate in the development of quality stan-dards and in the evaluation processes. Althoughthere were only a few organizations that felt ready toparticipate in a working group, all patientorganizations interested in the progress of theproject were regularly informed by the project

5. Clearinghouses professionally connect people to self-help,lobby for the idea of patient focus in professional health care

services, advocate resources and offer expertise to and aboutpeer-run groups and organizations that serve people who havebeen diagnosed with similar disease or share the same problem.Funding for these non-prot-organizations in general is obtainedfrom a local government health or social department and fromlocally-based government health insurances.

management in overall meetings and through pressreleases.

KISS Hamburg hired the author of this article asproject manager. Part of the project managers jobwas to be liaision to the relevant stakeholders andto select the project teams (evaluation team andconsulting committee). With the exception of theproject manager all other members of the projectteams worked on a voluntary basis for the pilotproject, which was especially true for the participantsof patient organization. The other stakeholders orparticipants in the project, such as hospital personelland other health care professionals contributed their

work time to the project.6

- Project Design

The project goals were dened as to

- develop and portray customized qualitystandards as a model of good practice incollaboration between hospitals and patient organi-zations;

- identify hospitals ready to participate in the pilotproject and to implement the quality standards intotheir daily standard operationg procedure (SOP);

- take part in the process leading to thequalication for the Self-help-friendly Hospitalaward.

To achieve our goals, we strived for a broadrepresentation of all stakeholders to be includedinto strategic development of the project. The ideawas that the benet of establishing consensus onviews, sharing expert knowledge and investing time

6. It is not generally expected in Germany that people eithervolunteer their time and efforts or use their work time to supportunpaid projects, so the fact that we had a mix of volunteers, paid,and unpaid workers in the same project created a very delicateworking environment.

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togetherwould result in a return on the outcomes(see Figure 2 for a representation of this idea).

Interventions by stakeholders based on mutualunderstanding and respect for one anotherscontributions tend to produce sustainable results,because each participating stakeholder is able totake responsibitly for the outcome of the results.Team building and mutual support is the key toempowerment evaluation process -and result-based accountability, as Wandersman notes (2003),the stakeholders are intertwined in a triple helix ofaccountability to one another to obtain results (pp.227-242).

For this purpose we rst put together an evaluationteam representing hospitals, patient organizations

and clearing-houses. Evaluation teams werecomposed by quality managers representing in turnthree large local hospitals (each with more than 1000beds for acute care), representatives from patientorganizations of chronic diseases (breast cancer,mental disorders, chronic eye diseases andprogressive muscle disease) and of twoprofessionals from local clearinghouse.

We next created a consulting committeerepresenting the same stakeholders as in theevaluation group, scientists from the eld of

medical and social sciences, a certier of qualitymanagement systems in hospitals and the healthinsurance to support the evaluation group withstrategies and ressources.

Both project teams met regularly as was needed toexchange ideas and brief each other on the progressof the project. Everyone was committed to workingas a team and sharing experiences with everyoneelse, regardless of position or who brought what tothe table.

Development of quality standards for

self-help-friendly hospitals

We used the principles of standard development(Fig. 3), as outlined by the international society forquality in healthcare (ISQua7) to develop the qualitystandards for self help. At our disposal we had theresults of a literature review and an alreadycompleted quality survey done by three hospitals in

Hamburg. Thus, we did not have to start from groundzero to develop a standard.

The ndings of the survey indicated that, besidesthe benets for the patients, clinical staff assumedthat collaborating with patient organizations mayhelp optimize treatment and care, but they alsoshowed that clinical staff in general were not veryfamiliar with working with self help groups. Otherstudies conducted in Germany have also shown thesame results (Findei, 2000; Slesina, 2007; Stark,

7. ISQua, The International Society for Quality in Health Care,is a non-prot, independent organisation with members in over70 countries. ISQua works to provide services to guide healthprofessionals, providers, researchers, agencies, policy makersand consumers, to achieve excellence in healthcare delivery toall people, and to continuously improve the quality and safety ofcare.(http://www.isqua.org).

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Fig. 2. Collaborating in the Project

Collaborating in the Project:

Have all Partners around the Table

Self Help Clearinghouse

Health insurance

Patient Organizations

Scientists

Hospitals

Working together on

quality standards and asessment procedure

Project Manager (Moderator)

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2001; Trojan, 2004).

The evaluation team supported the idea to starta country-wide survey with the assistance of theDepartment of Medical Sociology at the UniversityMedical Center Hamburg-Eppendorf (UKE) - aproject stakeholders. Addresses were provided tous by NAKOS, an umbrella organization of Germanclearinghouses as well as by BAG Selbsthilfe, anumbrella organization for patient organizations of

chronic diseases, both important stakeholders in theproject, too.

The survey aimed to investigate the currentsituation of collaboration between hospitals andpatient organizations and to ask for the patientorganizations point of view. The questionnairescontained similar questions to those containedin the quality surveys done by three hospitals inHamburg, as well as proposals for standards. Thesurvey participants were asked to make commentsand suggestions on the standards proposed based

on their experience.

Fifty-eight percent of the patient organizationsinvited to participate in the survey consideredthe matter of introducing quality standards to bemeaningful and some organizations felt encouragedto attach individual reports to the questionnairesreturned, showing examples of good practice as wellas of bad experiences in collaboration with hospitals(Werner, Nickel & Trojan, 2006).

The data collected offered a valuable basis for theevaluation team to reect on mutual expectationsand community constraints8. We generated 16

8. It is important to note the due to the fact that this project involvedworking with people whose family members were personally ei-ther caregivers, family members of caregivers or sick people,most of the discussions and meetings, especially discussions of

preliminary standards and following severalreviews and discussions, we nally agreed on eightcore standards based on criteria and indicatorsthat had priority to the stakeholders (Fig. 4. QualityStandards).

The quality standards were understood as guide-lines to provide orientation to the hospitals as wellas to patient organizations and clearing houses withrespect to creating successful collaborations. The

results of the quality standards were published inprofessional journals for hospitals and became pivotalfor the upcoming steps in the project.

Implementing the quality standards in

hospital SOP

Most of the previous collaborations in the hospitalswere on ad hoc basis, nothing as systematic as whatwe were proposing. Based on anecdotal eviden-ce, it was evident to the hospitals to go forward to

incorporate our proposals in their SOP for example:

A hospital may make presentation spaceavailable to self-help groups and would, inmost cases, also make information yersavailable to interested patients or relatives,under the belief that this is all that wasneeded. However, in fact, reality surpassesthis description. We found that unlessit is some ones task to be responsiblefor giving out information, for example,the situation could worsen to theextent that patient organizations complainthat nobody is informed when yers runout, the hospital staff complains that runout yers are not timely replaced. Patientscomplain that they cannot nd material

results of surveys were sometimes emotional.

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Fig. 3. Principles for Standard Development.

Principles for Standard Development

Critical reviewof literature

Proposal forStandards

Review

PreliminaryStandards

Pilot testing

Final Standards

Implementation

Revision andAdjustment

WHO Health Promotion in Hospitals:Evidence and Quality Management(Groene et al., 2005, p. 64)



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because they are not placed in an easy to ndplaces. Sometimes the clinical doctor or thehospital nurse would pass on a yer but atanother time may forget to do so, etc.

In order to ensure that an SOP is implemented,the responsibility and commitment for this issueshould cover duties and competences assigned by

the hospital management. A self-help coordinatorenhancing the implementation of quality standardsin a structured and systematic way may act like abridge between hospital and patient organizationsin the process of collaboration.

- Aiming for Continuity and Sustainability

Today in Germany, most hospitals have to adaptto patients expectations of care, and a certainprofessional manner in regards to medica treatment,based on empirical evidence and research. Pa-tients rights are also becoming an increasing part ofhospital-patient-relationships. Several customizedquality management systems and accreditedcertiers refer to the current situations underwhich hospitals and patients have to deal with oneanother.

Kooperation fr Transparenz und Qualitt imKrankenhaus (KTQ) is one o the leading Germancertifers in the area of quality management system(they certify about sixty percent of all Germanhospitals). The hospitals collaborating in our project

also use the KTQ quality management system.

The KTQ model is inuenced by EFQM and otherquality management models such as ISO and JCIA.

The core element in certifying the process is astructured self-assessment process conductedby the hospitals and is intended to help inidentifying weaknesses in work processes. Itallows the hospitals to determine whetheraccreditation can be achieved the rst timeround and to determine what improve-ments, if any, are necessary. Self-assessment

is based on the assessment catalogue,which the hospital can follow in order to fullthe required criteria; it is not linked to subsequentcertication and can thus be carried out by a hospitalindependently of certication. If a hospital choosesto participate in certication, the results of theself-assessment are used in preparation for an ex-ternal survey.

The subsequent external survey is conductedby a team of professionals on the basis of theAnglo-American concept of peers. In addition tomedical, nursing or management qualications, thesurveyors must possess comprehensive knowledgeof quality management. External assessment hasan educational function: the surveyors are supposedto advise their colleagues during the surveys andalso learn about the hospitals problem solving andtrouble shooting mechanism. In addition, interviewsare conducted with patients, family members andhospital staff. The quality report represents theperformance achieved by the hospital and is publishedby both the certied hospital and KTQ. (see alsohttp://www.ktq.de)

We also needed to create a mechanism fortransparency and to nd an effective tool to controlthe implementation of the quality standards intoregular hospital working processes.

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Fig. 4. Quality Standards.

Quality Standards for a Self-help-friendly Hospital an Overview

Provide room, infrastructure and space for presentation to self-help groups

Provide regular information to patients about self-help

Support public relation work of self-help groups

Create a position that will be responsible for coordinating self-help in the hospital

Regularly exchange of information and experience between self-help groups and professionals

Implement self-help as part of qualication programs for hospital staff

Self-help groups to participate in quality circles, ethic commissions etc.

Formal commitment and documentation of collaboration

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The creation of the position of a self-helpcoordinator (as provided in the quality standards)showed the commitment of the top management tothe project. This was a milestone in the project sincefor the rst time, the project goals and objectivesbecame integrated into the everyday working of thehospital.

Then the pilot project gained approval from topmanagement of the hospitals to assign clinical

departments that were ready to act as testdepartments for conducting self-assessments andexternal assessments on the topic of self-help-friendliness according to their regular assessmentprocedure of the quality management systemalready in use in the hospital.

We revised and augmented ve major categoriesof the quality management system -patient focus,employee focus, Information and communication,leadership and quality management- with additionalquestions that would form part of the hospitalworking processes subject to quality control, therebyenhancing the implementation of quality standardsfor self-help-friendliness.

A questionnaire was generated by the evaluationteam for a trial run and after optimizing it, thedepartment leaders of seven clinical departments intwo hospitals were encouraged to take the chance ofevaluating with their staff the situation of fullment asa present state analysis.

Participatory assessment processes

We established two survey teams out of theevaluation team, each consisting of ve persons:three representatives of patient organizations, onerepresentative each from a hospital (quality

Fig. 5. PDCA Cycle

The PDCA-Cycle

manager), a self help clearinghouse in Hamburg.

Our task was to survey seven clinical departmentsin two hospitals. In order to avoid biased results,quality managers and patient organizations shouldnot evaluate their hospital but rather have mutual

insight. With quality managers as part of thesurvey team a cross evaluation process wasarranged. This required another commitmentbetween the surveyors and the management of

the hospitals to ensure that patients data to whichthe survey teams may have access to as well as toinsights experienced during the externalassessments are handled condentially.

To ensure that the survey will be completed asplanned, we invited ten additional members frompatient organizations of similar background as in thesurvey teams as extras.

All participating patient organizations went throughtwo training sessions before nally committing totaking part in the survey.

Especially supportive to the training was theexpertise the quality managers of the collaboratinghospitals brought into the survey teams. Selfassessments had been conducted already in theirhospitals and not only did they impart know-howabout running an assessment day, they also couldgive good advice as to time schedule and logisticpreparations.

The rst training session focused on communica-tion skills on how to conduct interviews with hospital

staff9. The second training session focused on

9. A surveyor should have a thorough know how about hospitalwork processes and have an open-minded attitude, i.e. he / sheshould not refer to his or her personal experience with the hospitalwhether good or bad, but should always remain neutral.

ACT- analyse difference- determine where

change will lead toimprovement

CHECK- compare resultsexpected andresults achieved

PLAN- process objectives- time frame and

responsability

DO- implement theprocess accordingto PLAN

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how to evaluate and interpret results using thePlan-Do-Check-Act (PDCA) technique (see Fig.5)10.

We used the PDCA-cycle as a base testing tooland augmented it to suite our purposes. We thenapplied the augmented PDCA-cycle to the categoriesin the self-assessment manual of KTQ. Every

process with a step in the PDCA-cycle was given amaximum score. How many points each step receivedwas based on the degree of completion of thatprocess.

With the numeric score system elaborated thesurvey team was able to judge the degree ofperformance, i.e. how quality standards were fullledin a coherent and consistent way.

The numeric parameters represented the fullmentof quality standards in the following level: 0 = did

not meet requirements; 1 = met requirementsrudimentarily; 2 = requirements fullled in someareas (about 50 %); 3 = requirements completelyfullled.

At the end, we developed indicators like

- targets of activities exemplied;- expected results in a given time frame;- scope of responsibility;- documentation and- structured methods of controlling

for analyzing whether and how the qualitystandards had been implemented into the clinicalwork processes of seven clinical departments.

We examined the results of the self-assessmentreports of the seven clinical departments and gave awritten report to the heads of the clinical departmentson the status quo of implementation of the qualitystandards.

- Qualifying for the quality award self-help-

friendly hospital

Qualifying for an award requires an externalassessment and the results from the self-assessments formed the basis for the preparation ofthe external evaluation. The participating hospitalswere highly interested in qualifying for the award.The ndings documented in the self-assessmentreports of the clinical departments were broadlydiscussed in the hospitals across all levelsof hierarchy and in adjacent clinical departments.This was a motivating factor in getting hospitalstaff and management to comply with the quality

10 The PDCA-cycle originally elaborated by E. Deming is aniterative four-step problem-solving process employed inbusiness process-improvement. It was also adopted by the KTQquality management system for evaluating the fulllment of quality criteria.

standards and provided an impetus to the staff to winthe award.

The department heads used the period betweenself-assessment and external assessment forimprovements to further ne-tune the processes.Performance in the external assessment had toachieve at least fty-ve percent of the total scores

to be attained per category.

The hospitals and the survey teams agreed on adate for the external survey to begin. The hospitalsassigned the clinics and departments and providedus access to visit facilities and inspect documentationrelating to the results of the self assessment.

At the start of the survey, the survey team presentedthe project and asked questions that emergedfrom the results of the self assessment and whatchanges, if any were implemented between the endof the self assessment and beginning of the externalassessment. At the end of this dialogue phase, wemoved on to the individual clinics and departmentsto check the documentation process and to askhospital staff about specic processes.

At the end of the survey, we presented the results ofour ndings to the hospital staff. The reports includehighlights as well as well recommendations forfurther improvements.

The last step in the certication procedure requiresthat a quality report be written by the survey teams

together with the clinical departments. In addition tostatistical data such as how many beds the hospitalhas, how many doctors, etc, from the hospital, thequality report provides an overview of the categoriesevaluated as to the implementation of the qualitystandards of self-help-friendliness. All processesrepresenting the implementation of the qualitystandards are described. Since the quality report isgenerated in collaboration with the hospital and thepilot project based on the documentation providedby the survey teams, it is an important document inthe certication procedure.

Certication is successfully completed when thequality report is published on the Hospitals homepage as well as on the homepage of the pilotproject.

Finally, in August 2006 seven clinical departmentsin two hospitals were certied and qualied for theaward Selbsthilfefreundliches Krankenhaus self-help-friendly hospital. The award ceremony wasa reason to celebrate with all stakeholders of thepilot project and with hospital staff of the clinicaldepartments assessed and also promoted the image

of the hospitals in public media.

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Benefts and implications

of assessments

The set of quality standards were highly acceptedby the hospitals as well as in patient organizationsas they give orientation to both sides as to what hasto be achieved.

The ndings of the self-assessment and of theexternal assessment showed, that the hospitalscomplied only moderately with the standards. Thiswas not a surprise for the patient organizationsparticipating in the project, however it wasdisappointing for the hospital staff. Although thequality standards as suggested by the project wereaccepted in general by the clinical staff as innovative,they still claimed that they have been implementingthem all along. This contradictory view was truein one aspect: Many of the criteria showed goodscores in the parameter of Do of the PDCA-cycleand a plenty of the activities gathered seemed torelate to the requirements. However, few of themcomplied with the requirements in Plan or inCheck, because activities and results often turnedout to be an accidental occurrence. This led us toconclude in the external assessment that there wasconsiderable room for improvement in closing thegaps.

Since hospitals already have a systematic way ofcontrolling clinical tasks due to their existing qualitymanagement system it was clear that the task of

collaboration with patient organizations had to beimplemented and carried out in a systematic way,as well.

The hospitals put much emphasis on the

responsibility of leadership and the role clinical staffplayed during the assessment processes. It seemedthat during the external assessment an old practicesometimes disregarded in SOPs should be revivedthe personal communication between health

professionals and patients as a major factor in theirrelationship and an important factor to meet the

requirements of a patient focused treatmentand care. The hospital staff acknowledged thatthey received valuable inputs from from patientorganizations surveyors during the externalassessment, since they had personal experienceas real patients with knowledge about hospital andclinical processes and documentation.

The hospital management were inspired by theresults of the assessments to set new goals incollaboration with patient organizations. They werecommitted to various improvements in clinicaltasks that will have positive effects on internal

communicative processes since it initiated dialoguebetween clinical staff and management.

Lessons learned

Empowerment evaluation is a collaborative,

participatory and a user-friendly evaluationmechanism.

As stated at the beginning, the ten principles of

empowerment evaluation

- Improvement- Community ownership- Inclusion- Democratic participation- Social justice- Community knowledge- Evidence-based strategies- Capacity building- Organizational learning- Accountability

were not used as explicit guidelines for theevaluation process project. As a result, the casestudy does not describe the set of principles aspostulated by Fetterman and Wandersman (2005).However, the principles could and did act as aguide for conducting an evaluation process guidedby ethical standards.

A comparative analyses of the pure empowermentevaluation principles (eight out of ten principles)11with our project process as applied at the time of theproject highlights the deviations from Fettermans

and Wandersmans principles in some areas butshowed wide agreement in approach. This wasa surprising result, given that we did not have thebenet of the guidelines at the inception of theproject.

- Improvement

According to Fetterman and Wandersman,empowerment evaluators use the methods andtools of empowerment evaluation to help programs,

organizations and communities achieve results:This is in contrast to traditional evaluation,which values neutrality and objectivity andwants to examine programs in their naturalstate in order to determine a programseffect without the inuence of the evaluator.Many funding (agents) are interested inempowerment evaluation because they aretired of receiving evaluations that show noresults and would like evaluation to be helpfulto grantees in achieving results (Fetterman &Wandersman, 2005, p. 30).

11. Except from the principle of social justice and the principle ofcommunity knowledge, that will not be considered in this contextdue to the particularity of the project. The project itself strived forsocial justice and viewing the community members (stakeholders)as experts on their own community was a prerequisite of theproject idea.

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All stakeholders and the grant provider healthinsurance sought improvement in patient focusedhealth treatment and care. The project turned out tobe a successful intervention to improve collaborationbetween hospitals and patient organizations.

The quality standards dened best practice in

collaboration. The standards were in a way attractiveto all stakeholders. The quality standards were a goodt to the quality management system of hospitalsand provided a structured approach to improvingcollaboration processes.

Some improvements in the hospitals processes,like the assignment of a self-help-coordinator wereparticularly noteworthy. All clinical departments thattook part in the assessments commented on theircollaboration with patient organizations and providedlinks on their homepages to patient organizations.

At the end of the project, the hospitals as well asthe patient organizations suggested the continuationof the process of implementing the quality standardsby conducting quality circles to be moderated by theclearing-house.

One of the projects greatest accomplishments wasthat the quality standards for self-help-friendlinesswere adopted as a SOP by an accredited certier forhospitals and closely connected to the categories inan updated version of the self-assessment manual.

- Community ownership

Empowerment evaluators believe that

the community has the right to makedecisions about actions that affect theirlives. (..) Program stakeholders have theresponsibility of making critical decisionsabout the program and the evaluation. Thiscommitment to community ownership isin contrast to typical traditional evaluationapproaches, where decision-making power

regarding the purpose, design, and use ofevaluation results is held by the evaluatorsand the funding agent (Fetterman & Wanders-man, 2005, p. 31).

The health insurance as grant provider of theproject understood the idea of empowermentevaluation. They showed respect for communityownership exercised by the participants of theevaluation team and the consulting committee. Thepilot project itself turned out to be a collaborationprocess, and was a test of the motivation and abilityto improve mutual relations and team building of all

parties involved.

A great challenge for all participants was to learnto respect each others realms of personal andinstitutional resources as well as to tolerate

distinct points of view that emerged from functions,roles and experiences. The entire decision makingprocess during the project was based on consensus.This helped form a bond between the project teamand the stakeholder.

- Inclusion

To collaborate in diversity is a strong characteristicin empowerment evaluation projects.

Empowerment evaluators believe the

evaluation of a program or organizationbenets from having stakeholders and stafffrom a variety of levels involved in planningand decision making. (...) Not being inclusivecan be counterproductive to empowermentevaluation and often results in poorcommunication, undermining behaviour, anda lack of human resources for stakeholders tohelp one another in improving practices (Fet-terman & Wandersman, 2005, p. 33).

From the beginning the key stakeholders wereinvited to share their knowledge and participatein the project. Because they came from differingbackgrounds, it may create tensions, falseexpectations and skepticism. Subject matter orexpert knowledge often lead to prejudice andmisconceptions among the collaboration partners.Unequal resources may result in misunderstandingas well.

The project was characterized by the fact thatprofessionals from hospitals and clearing-housesare in the position to contribute their paid-workinghours to the project, whereas representativesfrom patient organizations worked as volunteers.Sometimes participants were unable to attendmeetings due to illness or because of to muchworkload outside of the project, neverthelesstheir commitment was valued. Addressing thosecultural differences helped a lot to avoidmisunderstandings and unrealistic expectations.

- Democratic participation

Democratic participation also (1) underscoresthe importance of deliberation and authenticcollaboration as a critical process formaximizing use of the skills and knowledgethat exist in the community and (2) emphasizesthat fairness and due process arefundamental parts of the empowermentevaluation process (Fetterman &Wandersman, 2005, p. 33).

When the project was proposed, some

stakeholders had the expectation that they couldexercise institutional power in relation to other

stakeholders. We were concerned that working with

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diverse partners prot, public and non-prot couldcreate a non-appropriate power issue within thegroup. To discourage this, we made it a priority andour goal solicit all stakeholders opinions in all levelsof planning and decision-making. We also madesure that everyone was equally represented in theworking groups and carried their own weight.

Democratic participation contributed to reasonablejudicious making when conducting the assessmentsin the hospitals.

- Evidence-based strategies

This value of using existing knowledge ispart of the commitment to avoid reinventingthe wheel and to build from existing literatureor practice (Fetterman & Wandersman, 2005,p. 35).

Ours was a seminal project, and we did not haveset frameworks from where to build our strategies.The evaluation team as well as the consultingcommittee sought out the best practices in strategyand practical steps; every adopted tool and strategyhad to be adapted to the needs of the project.

- Capacity building

Evaluation capacity was developed by conductingthe assessments when provided with the necessary

conditions in the organizational environment of thehospitals and with appropriate tools (e.g. outcomemeasures). Every one learned that evaluation isan ongoing integrated process. The participantsacquired new tools to plan, implement, evaluate andproduce results.

Empowerment evaluation helps peoplehelp themselves and in the process acquirenew skills and knowledge. (Fetterman andWandersman, 2005.105)

This approach helped to demystify evaluation andthe participants became more self-sufcient.

After many years of experience in hospital staysa member of a patient organization is often familiarwith hospital processes, language usage, idiomsand medical acronyms used in treatment anddocumentation protocols. Hospital professionalsand patient groups gained new insights into oneanothers thinking when it became clear that bothreally understood each others language. Thisprovided a breakthrough and mutual respectbetween both parties.

- Organizational learning

Argyris (1999) concludes that in order for

organizational learing to occur organizationsmust do the following:

1. Support learning and not just be satisedwith business-as-usual (i.e., organizationsmust be open to change).

2. Value continuous quality improvement and

strive for ongoing improvement.

3. Engage in systems thinking. Organizationallearning involves inquiring into the systemicconsequences of actions rather than settlingfor short-term solutions that may providea temporary quick x but fail to address theunderlying problem.

Promote new knowledge for problem solving(Fetterman & Wandersman, 2005, p. 36).

The clinical departments participating in theassessments used the evaluation feedback to createactivities in various organizational areas and toprovide resources that would improve collaborationwith patient organizations. Implementing the qualitystandards in the quality management system ofthe hospital probably shows long term positive andsustainable effects.

The evaluation team and the consulting committeerepresenting the key stakeholders were encouragedto form a learning community working together,

although the stakeholders had competing political

agendas.

The open structure of the pilot project andproject processes by itself encouraged theparticipants to acquire, apply and master new toolsand methods to improve the collaboration betweenpatient organizations and hospitals.

- Accountability

Although the pilot project placed a high priority on

process accountability, it also focused on the naloutcomes to be achieved.

A description and assessment ofprogram processes enables program staff andparticipants to create a chain of reasoning.This helps establish mechanisms foraccountability on both process and outcomelevels (Fetterman & Wandersman, 2005, p.37)

The goal of the project was to create a set ofprocesses with guidelines and parameters that

when applied in hospital settings, adjusting forparticularities in each situation will yield resultssimilar to what was observed in the project.

Linking the quality standards of self-help-

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friendliness to the quality management systemapplied by the hospitals may augment the chancefor sustainable effects. To this extent, we are ableto say that we have achieved the goal to providefor continuous improvement in collaboration withinthe two-years project period. Thus more longitudinalstudies still have to be made to nd out whether andto which extend the interventions were suitable to

activate changes in hospitals as well as in patientorganizations.

Conclusions

The development, implementation and assessmentof quality standards of self-help-friendliness inhospital processes was a seminal project involvingpatient organizations, clearing-houses and hospitals all key stakeholders from the healthcare system inGermany.

The project management played a key consultingrole in identifying and selecting critical elements toachieve the projects goals in two years. To the extentthat the project management team was committed toworking within the time and budgetary constraints ofthe grant provider, certain activities of the evaluationteam and the project management were restricted.Further more, it was not always easy to obtaintimely approval from hospital top management fornecessary steps during the inception anddevelopment of the project.

In discussions with the entire stakeholder team,we all realized how important to us all it was toachieve positive results in the pilot project rst timeround. Not backing the project was not an optionfor any one since it would have been difcult toencourage the key stakeholders to participate in furtherprojects.

The interdependence of the grant provider BKK,project management and other stakeholders wasinstrumental to the fact that the project was widelyaccepted by the relevant communities. The results

of the project urged the health insurance BKK tocontinue to support hospital treatment and programswith patient focus. It has continued to fund otherstudies in self-help friendliness in other hospitals inGermany.

The transparency and the structure ofdocumentation of the assessments made itpossible to trace the scores received in the selectedcriteria and made outcomes credible. As a result, thecertier KTQ - one of the stakeholders -, implementedthe quality standards for self-help-friendliness asa standard format in their assessment manuals,

revised and edited in 2009. All stakeholders involvedin the project were satised with results of theproject and approved the use of the projectevaluation results. The implementation of the qualitystandards and the assessment criteria into a widely

deployed quality management system for hospitalswould enhance the goals of the project - to achieve a sustainable, structured and systematic patientfocused collaboration in hospitals.

Not only did the patient organizationsparticipating in the pilot project in Hamburg benetfrom the outcomes, but they also gained a higher

acceptance from hospitals in other regions. Inaddition patient organizations to be more condent intheir abilities and effectiveness as a voice for changein patients treatment and care.

The clearing-houses also realized theirvalue as coordinators and a bridge between patientorganizations and hospitals. The clearing houseshave intensied their role as match-makersbetween hospitals and patient organizations. Theyalso showed interest in working together on futureprojects.

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Evaluación de proyectos de empowerment en el área de los Servicios de Salud. Una metodología innovadora