The TQM JournalDesign of an integrated management system (IMS) in a government-run medicalevaluation organisationRafael Manzanera Josefina Jardí Xavier Gomila Joan Ramón Pastor Dolores Ibáñez Glòria GálvezConstança Albertí Albert Navarro Joaquín Uris Alicia Pomares Lluïsa López Cristina Zuazu Primitiva SabatéImmaculada Aguado Lidia Domingo Carolina Infante Josep Gomis Aurora Jover Jordi Iglesias AntoniMestres

Article information:To cite this document:Rafael Manzanera Josefina Jardí Xavier Gomila Joan Ramón Pastor Dolores Ibáñez Glòria GálvezConstança Albertí Albert Navarro Joaquín Uris Alicia Pomares Lluïsa López Cristina Zuazu PrimitivaSabaté Immaculada Aguado Lidia Domingo Carolina Infante Josep Gomis Aurora Jover Jordi IglesiasAntoni Mestres , (2014),"Design of an integrated management system (IMS) in a government-run medicalevaluation organisation", The TQM Journal, Vol. 26 Iss 6 pp. 550 - 565Permanent link to this document:http://dx.doi.org/10.1108/TQM-01-2012-0007

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Design of an integrated managementsystem (IMS) in a government-run

medical evaluation organisationRafael Manzanera

MC Mutual and Catalan Institute of Medical Evaluations (ICAMS), Barcelona, Spain

Josefina Jardı and Xavier GomilaCatalan Institute of Medical Evaluations (ICAMS), Barcelona, Spain

Joan Ram�on PastorPublic Health Agency and Catalan Institute of Medical Evaluations (ICAMS),

Barcelona, Spain

Dolores Ib�anez, Gloria G�alvez and Constanca AlbertıCatalan Institute of Medical Evaluations (ICAMS), Barcelona, Spain

Albert NavarroHealth Department, Barcelona, Spain

Joaquın UrisCatalan Institute of Medical Evaluations (ICAMS), Barcelona, Spain

Alicia PomaresHumannova and Catalan Institute of Medical Evaluations (ICAMS), Barcelona, Spain

Lluısa L�opezDepartment of Health, Catalan Regional Government and Catalan Institute of

Medical Evaluations (ICAMS), Barcelona, Spain

Cristina Zuazu, Primitiva Sabate, Immaculada Aguado,Lidia Domingo, Carolina Infante and Josep Gomis

Catalan Institute of Medical Evaluations (ICAMS), Barcelona, Spain

Aurora JoverHealth Department and Catalan Institute of Medical Evaluations (ICAMS),

Barcelona, Spain, and

Jordi Iglesias and Antoni MestresCatalan Institute of Medical Evaluations (ICAMS), Barcelona, Spain

Abstract

Purpose – The authors present the application of the L�opez-Fresno approach in designing an integratedmanagement system (IMS) for an aviation company to the development of an IMS in a government-runorganization responsible for the medical evaluation of work disabilities. The purpose of this paper is toshare the design process, with the intention of showing that this approach is applicable to other sectorsand proposing generalization and applicability strategies to other smaller government entities.

The current issue and full text archive of this journal is available atwww.emeraldinsight.com/1754-2731.htm

Received 27 January 2012Revised 11 February 2013Accepted 17 May 2013

The TQM JournalVol. 26 No. 6, 2014pp. 550-565r Emerald Group Publishing Limited1754-2731DOI 10.1108/TQM-01-2012-0007

The authors wish to thank the management team and the consultants working on theorganization’s quality model for their participation in this study as well as the employees of theICAMS, Board members, stakeholder representatives, and specially Palmira Lopez-Fresno,Maria Dolores Nunez, Eugeni Sedano, Virginio Gallardo, Josep Maria Costas, Jaume Ribera, RosaSunol and Joan Carles Cord�on, for their help, encouragement and cooperation.

The authors acknowledge the support and input from their unforgettable colleague XavierGomila, who sadly passed away a few months previously.

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Design/methodology/approach – The study involves two phases. Phase I applies the L�opez-Fresnoapproach to design a basic IMS-I and ends with a European Foundation for Quality Management(EFQM) evaluation, whose suggestions were taken into consideration for the final design of IMS-IIduring phase II. The data were obtained from the organization’s own functioning. There was asignificant degree of personal involvement by the authors, external consultants and members of themanagement committee in areas ranging from the approach itself to the various components analyzed.Findings – The approach led to a better use of human and material resources and produced variousadvances in both internal and external communication and significant progress in employeemotivation in their dealings with users and stakeholders.Originality/value – The study offers guidelines and recommendations for designing an IMSadapted to small, compact, administrative organizations that operate with stakeholders with highlydisparate outlooks and interests, with different quality levels, in a context related to competitivenessand economic development.

Keywords Public sector, Quality management, European Foundation for Quality Management,Management systems

Paper type Case study

1. IntroductionOrganizations are strongly influenced by pressure from their clients and stakeholders,and even more so in a context of a deep economic recession. One of the greatestchallenges is to get organizational and management systems to work together toavoid inefficacies and inefficiencies. This need is particularly acute in complex,highly regulated sectors where professional groups have a high level ofindependence, empowerment and powerful corporate protection, as is the case of thehealthcare sector.

Integration is viewed as the only means to work adequately while obtainingbenefits from the large number of mandatory requirements. The need for thedevelopment of an integrated management system (IMS) dates back to the mid-1990sand since then, it has been extensively discussed in the literature, together withthe themes of quality, working climate, health and safety. However, the continuingdevelopment of requirements also requires constant expansion of these viewpoints.

In 2010, an article was published (L�opez-Fresno, 2010) on IMSs applied to anaviation company. This paper takes a systematic approach to a practical applicationof the integrated management model which has obtained excellent results. This case isapplied to an airline, with a significant number of guidelines and recommendations,and may be useful for sectors considered to have a high degree of complexity.

The Catalan Institute of Medical Evaluations (ICAMS) is a health organizationresponsible for evaluating the fitness for work from a medical viewpoint of patientshaving a clinically defined disease. The patients evaluated at the ICAMS work inspecific sectors and companies, with values and attitudes that are strongly focussed onthe individual. There is a high degree of complexity, in which clinical medicine,attitudes, social reality, the firm and employment coexist. The ICAMS works within anextensive body of health and economic regulations covering the Social Security,employment and mutual insurance companies, the productive economy, trade unionsand employers.

Given these distinctive features, the ICAMS Steering Committee decided tointegrate the management system in two consecutive phases. The first phase, in whichthe model’s basic elements were put in place as IMS-I, lasted from January to October2010. It concluded with the first external evaluation of the European Foundation forQuality Management (EFQM) model in November 2010. IMS-I includes organizational

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aspects, human resources, users and main stakeholders (the National Social SecurityInstitute, Occupational Injury and Disease Insurance Companies and others). Thesecond phase, from November 2010 to June 2012, consists of two stages, and concludedin December 2012 with a second EFQM evaluation.

These stages, focussed on the design and implementation of the IMS-II, werestructured as follows.

First stage: January-October 2011; on the clinical product (improvement in clinicalguides, peer agreement studies), users (rights and duties), processes (processesmapping) and the Strategic Plan 2011-2014.

Second stage: November 2011-June 2012, on management and objectives (fulfillmentmanagement, objectives evaluation, strategies impact) (Figure 1).

2. Existing research2.1 IMS: concept, principles and techniquesThe debate on the integration of management systems and how this should be done isongoing. For Hoyle (1996), it encompasses all disciplines and management processes,reaching all corners of the firm. For Karapetrovic and Willborn (1998), thesetwo concepts are systems that function as an integrated whole, thereby losing theirindependence. Karapetrovic (2002) acknowledges that each organization has its ownconcept of integration.

A number of authors provide detailed definitions of the concept of integration.Thus, Griffith (1999) expresses it as modules that act synergistically, providing mutualsupport that enables them to respond to each of the organization’s needs, while Bhutto(Griffith and Bhutto, 2009) propose an approximation to the business process model.

2004 Business Plan

2005 – Workers’ Opinion Survey

– 1 stage

2006 - EFQM Self -Evaluation

2007 - EFQM Improvement Plans

2008 - Social Responsibility Report

2009 - Start process development

2009 - Product Quality Evaluation

2009 - Opinion Polls

Integrated Management System

IMS-I

EvaluationEFQM 2010

IMS-II

EvaluationEFQM 2012

Stage I Stage II

Integrated Management System

Evaluation of clinical product quality and monitoring

Evaluation of leadership, communication plan

Strategic Plan

Knowledge and People Management Plan

Environmental and process management ISO

Evaluation of user policies and analysis of expectations

Evaluation of staff policies and Workers’ Opinion Survey-2 stage

Goals, Scorecard and MBO

Figure 1.Stages in the IMSdesign process

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Hall (1998) believes that non-integrated functions disappear when they are mostneeded, that is, when they must be used to address problems.

Jonker and Klaver (1998) suggest that the lack of methodology for integrationprocesses is one of the main reasons for their difficulty and advocate the use offrameworks such as the EFQM.

Jonker, together with Karapetrovic (2004), define two phases – analysis andconceptual model – for integration ( Jonker and Karapetrovic, 2004).

Thus, many factors come into play to make organizations different, so that itis not possible to define “the universal methodology” ( Jonker and Karapetrovic,2004). However, it is possible to define a series of guidelines and principles that may behelpful in the integration process. In our case, we use a broad integration conceptwhich involves the implementation of a quality management system with theprogressive integration of environmental and work-related components or furthercomponents when needed (Castillo and Sanasaloni, 2004).

2.2 Barriers for integrationAs in all management processes, there are many obstacles that must be taken intoaccount. Among the best known are outlined by (Shillito, 1995; Zutsi and Sohal, 2005;Heras et al., 2007):

. no understanding of the concept of integration, limiting it to documentation andrecord-keeping;

. no strategy, model or methodology;

. no engagement by management, particularly senior management;

. unsuitable organization culture;

. lack of resources and expert personnel;

. poor communication;

. wariness of people involved in previous processes, particularly among theirowners;

. different visions regarding the systems that must be integrated;

. different visions of the integration of systems; and

. frequent changes in regulations and guidelines.

2.3 Benefits from integrationThe literature identifies a number of benefits that can be attributed to integration(Hale, 1997; Lopez-Fresno, 2003; Griffith and Bhutto, 2009):

. better management decisions due to considering a larger number of aspects andhaving a more integrated vision;

. simplification of documents and audits;

. reduced costs due to a more efficient use of resources;

. increased employee motivation due to better staff leadership and less conflicts;

. effective improvements in internal communication, eliminating communicationbarriers;

. improvements in the provision of services and products to clients;

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. improvements in supplier confidence and corporate image; and

. improved responsiveness by employees to changes.

3. Model and methodologyThe L�opez-Fresno approach is based on the most solidly grounded quality models,empirical studies and the literature review. Figure 2 summarizes the main conceptualaspects used.

The criteria set forth in the L�opez-Fresno paper highlight the following aspects:

(1) Global approach to complexityOrganizations act as complex, dynamically adapting systems (Battram, 2001).The analysis must focus on their structure and components (cells) andhow they interact within the system as a whole. In this conceptual scheme, theintangible elements – information, communication and culture – are extremelyimportant. Thus, the IMS must be designed as a global model from asystemic perspective that addresses the whole organization, integrates rulesand requirements, and includes the improvement cycle as a response tostakeholders.

(2) ProcessesProcesses must be the primary elements of analysis rather than functions ordepartments.

(3) Cultural maturityWhether it will be feasible to apply the standards will depend, to a great extent,on the organization’s baseline situation as regards maturity and integration.

(4) FlexibilityThe model must be open to current and, especially, future requirements, andoffer opportunities for new horizontal and top-down integrations.

(5) SustainabilityBeing systems that are in a process of continual adaptation, organizations needmethodologies to constantly supervise their quality and the areas that needimproving. Accordingly, they need powerful internal continual assessmentmethods.

IMS

Integrated Management System

QualityISO 9001

Environment ISO 14001

Safety/Health OHSAS 18001

European Foundation for Quality Management EFQM

Corporate Social Responsibility CSR

PROCESESS

CHANGE

Figure 2.Conceptual aspects usedfor the IMS approach

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Although it is true that L�opez-Fresno acknowledges that the methodology forimplementing an IMS must be specific for each organization if it is to achieve a robust,internally consistent integration, it is also possible to identify certain guidelines thatfacilitate universal implementation, for example, implementation by units (cells),apoptosis criteria, management team commitment and cooperative leadership.

4. Field study. The ICAMS case study4.1 Background and context to the caseAs a public organization controlled by the Catalan Department of Health, ICAMS issubject to the rules governing the operation of public organizations and submitted tofinancial and functional control by the Catalan Regional Government’s Audit Agency.Furthermore, the Steering Committee decided to perform a set of studies (showed asinitial activities in Figure 1) and reviewed the quality-related standards:

. Organizational consulting process and Information System Plan (2003).

. Business Plan (2004-2007).

. Workers’ Opinion Survey 1 stage (2005).

. EFQM Self-Evaluation (2006).

. Development of Improvement Plans based on the findings of the EFQMSelf-Evaluation (2007).

. Corporate Social Responsibility Report: environmental, economic and socialaspects (2008).

. Development of processes (2009): Processes mapping and procedures definition.

. Evaluation methodologies and quality of the clinical product (2009): clinicalguides and peer-agreement study.

. Survey of user and stakeholder satisfaction (2009): Qualitative and quantitativestudies about stakeholders’ satisfaction.

. Stakeholder opinion poll (2010): Qualitative and quantitative studies aboutstakeholders’ opinion.

The studies are performed to the extent and in the sequence that ICAMS considersnecessary to implement its approach, as is shown in Figure 3. It starts with theorganizational consulting process, information system plan and business plan as toolsfor organizational consolidation. The workers’ opinion survey focusses on the internalclient. The EFQM self-evaluation and the improvement plans generated from thisbroaden the vision to users, processes and quality of the clinical product.

The ICAMS’ entrepreneurial approach has led to the creation of an InformationSystem Plan (2003), which analyses, defines and programs the different parts of theorganization with a view to implementing a broad information system that could becomea genuine “lever for change.” The Business Plan (2004-2007) broadens the analysis of ourorganizational state to other aspects more closely linked with the functioning rules of theSocial Security in Spain and the provision of work disability benefits.

The focus on the professionals and employees working in the institution wasconsidered essential from the outset. Accordingly, a first Workers’ Opinion Surveywas performed in 2005, which pinpointed the deficiencies and capacities indicated bythe internal clients. Basically, more and better organization, more organized quality and

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more effort in communication and leadership were suggested. More policies focussed oninnovation and on motivation were requested, whilst at the same time taking intoaccount the significant and well-known limitations posed by the public services sector.

Improving the quality of the service provided was considered a priority task and,with this aim self-evaluation applying the EFQM model was done in 2006. As a result,six lines of improvement were defined, with the participation of a quarter of theorganization’s employees. These lines addressed communication strategies, userservice, process methodology, improvement of the clinical product, focus on theinternal customer and quality improvement from a general viewpoint. These processeswere developed during 2007 and 2008.

The “Activities Report 2008” presents a vision of the organization as sociallyresponsible through including financial equilibrium and environmental protection.

During 2008 and 2009, the user service strategy was formalized and intensive,systematic work was undertaken on process methodology (processes and proceduresmap), quality strategy and evaluation of the clinical product (reports, guidelines andagreement analysis). These activities were performed simultaneously, providingresults in 2008, 2009 and 2010.

In 2008, the User Service Unit was created. This decision was based on two reasons:to provide an effective response to the highly negative view held of the organization bysome patients and to achieve user satisfaction as an essential action program. Withinthis process, in addition to creating a complaints’ window, the user would become theorganization’s leitmotiv, defining rights and responsibilities that are integrated in theorganization’s clinical and technical processes.

Thus, over a period of ten years, powerful and systematic participation processesand organizational quality improvements have been developed, related with systems,users, internal and external clients, and a greater social balance has been achieved withusers and professionals, within a more efficient economic framework and with agreater degree of environmental protection.

4.2 Need for an IMSFrom its creation, the organization demonstrated a powerful focus on improvingquality, shown, among other actions, by the implementation of an organization andsystems’ consulting process (2002).

ICAMS

OrganizationInternal Client

I.N.S.S.Mutual InsuranceCompanies

UsersSocietyEmployersTrade unionsOccupational HealthEnvironment

Integrated Management System

Baseline

IMS-I IMS-II

Figure 3.Agents involved inthe IMS design

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This led to the various studies, reports and self-evaluations which are individuallysupported and articulated in the organization’s annual reports. However, the SteeringCommittee and the 150 members of the working groups for improvement identifiedseveral aspects that required an integrated quality management approach:

. excessive fragmentation of the goals achieved;

. relative lack of connection between these goals;

. excessive workload of the organization’s active members;

. lack of internal communication;

. insufficient communication with agents and stakeholders;

. lack of development of individual and department strategic goals; and

. lack of alignment with the above-stated individual and department strategic goals.

Consequently, in 2010 a decision was made to undertake an integration exercise in anIMS with the primary goal of reducing the detected problems of dispersal, lack ofsynergy and lack of communication among agents, together with an excessivelydiverse leadership, while at the same time improving the objectives and theirarticulation as management tools.

The decision to create a first IMS called “ICAMS Quality Model” includeddeveloping policies, creating guidelines and establishing unified requirementstargeting all levels, professions and areas of the organization, both in its internaloperations and in its interactions with external stakeholders. The overriding goalhere was to overcome limitations, remedy defects and move forward as a sociallyresponsible entity.

4.3 Designing an IMS-I adapted to the ICAMS caseIn designing the IMS-I, the five steps described thereafter have been followed.

Step 1. Analysis of the baseline situation. In general lines, the ICAMS’ activities aredefined within the framework of the regulations governing the Catalan Civil Service,which are highly concentrated on economic aspects and human resourcesmanagement, and those concerned with the monetary benefits provided by theSocial Security, such as the type and nature of the benefits evaluated in thisorganization.

In the same way, its clinical activities are based on regulatory medical criteria andthe profession’s good general practices.

Both the regulations and medical practice are subject to specific audits, which areapplied to a greater or lesser degree. Those concerning budget management comeunder the responsibility of the Catalan Regional Government’s Audit Agency, whilethose concerning human resources are governed by the Civil Service regulations.

Regarding the Business Plans, the work climate studies, the surveys and otherstudies and plans, these have all fostered the development of different types of actions,disconnected from previous actions and with relatively formalized audits.

Step 2. Definition of the scope of integration. The integration should allowalignment of the strategy with the requirements of the different stakeholders,the organization’s status as a public entity, the efficiency and management needs of amodern organization, the medical nature of the activity, and the economic impact of thedecisions made.

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Step 3. Detection of the organization’s requirements. As a result of the preparation ofthe report based on the EFQM model, the implementation of the management byprocesses methodology, the optimization of the clinical work and the evaluation ofits quality, it was possible to systematize the organization’s basic requirements.

One of the goals of this three-pronged analysis was to detect the organization’sessential requirements as a prior step to creating the framework for the IMS,identifying:

. Universal rules, which the entire organization must follow: Budgetary Law,Public Contracts’ Law, Civil Servant Regulation.

. Specific rules for a particular area, department or process: Medical Ethical Code,Law for the Patient’s Autonomy, Law for Personal Data Protection.

. Rules without a target standard that the organization needs to apply to optimizemanagement or ascertain the expectations or needs of stakeholders: regulationsfor applying Social Security Benefits.

Step 4. Relationship between rules and defined processes. Public health serviceorganizations have tended to pay more attention to their functions or services than totheir processes. Implementation of the IMS in the ICAMS was perceived as anopportunity to improve the processes’ focus and to increase efficiency andcompetitiveness. It was also seen as an opportunity to increase the engagement ofprofessionals and employees, provided that the implementation was gradual and tookinto account their needs, culture and criteria.

First of all, the organization identified the “macro” processes that did not entailparticularly dramatic changes as they were already acknowledged to some extentthough very independently. Thus, clinical evaluation, legal management, user service,teaching and offsite training and studies, research and publications processes weredefined. These “macro” processes showed a correlation between the people owning theprocesses and each process.

Next, the system’s strategic processes were defined: documentation, improvementactions and internal audits, and then the services’ strategic processes: service planning,information, people and complaints. Likewise, the support processes were defined:people support, general services, budgets, contracts and purchases, ICT and records.

Subsequently, the most significant processes and sub-processes were classified insix strategic processes, five key processes, with 38 dependent sub-processes, and foursupport processes, with eight dependent sub-processes.

This systematic description enabled the definition of a matrix that correlatedprocesses, sub-processes and requirements.

Step 5. Model design: framework and modules. In designing the IMS-I, certaincriteria were highlighted:

. global approach to the organization as a whole and to the interrelation of itsparts;

. focus on processes;

. paper-free, easy-to-update documentation;

. outreach to coexisting cultures (medical, clerical, primary care, Social Securityand mutual insurance companies, users);

. management responsibilities and skills;

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. flexibility in adaptation to changes;

. sustainability and updating of the IMS;

. integrative element for improving quality; and

. the EFQM evaluation as a measuring instrument and for detecting areasrequiring improvement.

The IMS has been called the “ICAMS’ Quality Model,” with quality as a basic,management-linked strategy. Taking these criteria into account, it was structured asfollows:

. General framework.The general framework, defined in the ICAMS’ Quality Model, encompasses thebody of policies and guidelines as essential elements that describe keymanagement aspects and offer a broad view of the organization. Its primary goalis to offer staff an overview of the main interrelations between differentmanagement aspects, systems and subsystems within the organization.

. Modules.The ICAMS’ Quality Model Manual is structured in three modules to facilitateunderstanding, follow-up and review: Operational, Strategic and Support(Figure 4).

. Monitoring and evaluation tools.

The ICAMS’ Quality Model has been built on the PDCA quality improvement cycle andis structured as follows:

. Introduction

. Organization and Policies

. Planning

. Resource management

. Process and activity management

. Evaluation of the activity

. Ongoing development

STRATEGIC MODULE

SUPPORT MODULE

OPERATING MODULE

Products

Medical EvaluationTraining and TeachingInvestigation

Occupational Health and Safety Environment Figure 4.

The ICAMS’ QualityModules within the

IMS-I framework

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. Relations with the Catalan authorities

. Relations with other authorities and international organizations

. Appendices

4.4 Need to evaluate the IMS-I with EFQM prior to its applicationThe methodology for implementing the ICAMS’ Quality Model should be based on:

. commitment at the highest level of the organization;

. implementation in each organizational unit;

. definition of signs of apoptosis (or signs of inadequate implementation);

. senior management commitment and cooperative leadership;

. high level of communication;

. provision of training at all levels of the organization;

. implementation with self-generated resources; and

. cross-organization improvement teams.

Being aware of the project’s complexity, compounded by shortcomings in thepreparation of phase l of the implementation of the IMS, it was decided to change thefocus in the implementation of IMS-I, and the preparation of the organization’sreport was modified to align it with the EFQM model and its corresponding externalevaluation.

This realigning of the general strategy was driven by three basic factors:

(1) Need to reflect on the quality projects currently in progress.

(2) EFQM evaluation as an analysis and measuring tool.

(3) Interest in external recognition (getting the EFQM mark 400 þ ).

Thus, the development and implementation strategy of the IMS (now called IMS-II)would be expanded, improving its technical quality and performing a newself-evaluation (and external evaluation) in accordance with the EFQM model, at theend of 2012.

4.5 Findings from the EFQM evaluation of the IMS-IExecution of the classic EFQM review procedure generated highly positive opinionsand improvement proposals: Leadership (process and evaluation), Strategic Plan,Satisfaction and People Management Plan, Process Consolidation (ISO-14001,environmental, already implemented and ISO-27001, occupational health in workingprocess), Objectives and Balanced Scorecard, Review and Improvement of User ServicePolicies, Communication and External Image Plan, Training Plan, KnowledgeManagement, Expectations and Needs of the Organization’s People, EnvironmentalManagement and Acknowledgements and Awards.

A series of actions were programmed on the basis of the recommendations received:

. Evaluation of the quality of the clinical product and ongoing monitoring.

. Evaluation of the Leadership and the Communication Plan.

. Strategic Plan 2011-2014.

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. Knowledge and People Management Plan.

. Environmental and process management International Standards Organization(ISO).

. Evaluation of user service policies and analysis of expectations.

. Workers’ Opinion Survey-2 stage and evaluation of the policies with the peopleinvolved.

. Objectives, Scorecard and Participative Management by Objectives.

The people responsible for these lines and their working groups, with their respectivetimelines, were defined. Those responsible for administrative quality (administrationmanager) and clinical quality (clinical care manager) were also defined andpreparation of the IMS-II began.

4.6 Redesigning the IMS-I after EFQM: IMS-IIThe construction of the IMS-II takes advantage as much as possible of the effort madein designing the IMS-I and incorporates the reports and evaluations carried out duringthe EFQM process, as already mentioned and shown in Figure 5.

The process concluded with the presentation of the IMS-II for the second externalEFQM evaluation (September 2012-December 2012).

4.7 Benefits from designing and evaluating the IMS-I prior to its application as IMS-IIThe results – the tangible and intangible benefits – achieved during construction of theIMS-I, which concluded with obtainment of the EFQM mark 400þ , can besummarized as follows:

. Increased efficiency in the use of resources: more and better medical evaluationactivity and improvement in peer-agreement.

The ICAMS’ IMS-II

Documentation

Strategic Proceduresof the Management System

Strategic Proceduresof the Service

EnvironmentISO 14001

Occupational Hazards OHSAS 18001

Identification Evaluation Planning Action

Integrated Management Manual

Key Procedures

Medical Evaluation ManagementTraining and TeachingInvestigation

of the Disability

QUALITY ISO 9001

Support Procedures

EF

QM

400

+ R

EP

OR

T

CS

R/G

RI R

EP

OR

T

Figure 5.Redesigning the IMS-I

after EFQM: IMS-II

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. Implementation of the organization’s strategic vision: renewed Strategic Plan2011-2014.

. Implementation of management by processes: processes mapping, proceduresand quality management system.

. Improved staff motivation: improved workers’ opinion when comparing first andsecond Workers’ Opinion Surveys.

. Consolidation of the focus on the user: Letter of Rights and Duties.

. Focus of the culture on social responsibility: report on Corporate SocialResponsibility and adhesion to the Global Reporting Initiative.

. Improved corporate image, acknowledgement of the sector and its professionals:several prizes and certifications acknowledged the quality improvement process.

The results that were hoped to be achieved with the implementation of the IMS-II,which was revised in the light of the results of the EFQM evaluation at the end of 2012,were the following:

. implementation of a Strategic Plan;

. global vision of the organization, with precisely defined objectives and personalduties assigned to each employee, evaluated on an ongoing basis;

. improvements in internal communication;

. consolidation of the improvements in staff motivation;

. continuity of the efficiency improvements in the use of resources;

. strengthening of the focus on the user and guarantees of compliance; and

. corporate image as a benchmark in organization in its field, in Spain and abroad.

This revision has been recently done achieving an excellent mark of 500þ .

5. Conclusions and managerial implicationsThis article presents the experience of the creation, in two phases, of an IMS, in apublic health organization specializing in medical evaluation.

In the authors’ opinion, this paper is particularly useful because it discusses a casestudy of a situation that is relatively common in Spain, namely, there are a number ofmedium-sized government-run enterprises that have a high degree of complexity andare governed by different bodies or regulations, with mandatory or recommendedcontrol systems, but experience certain difficulties such as a certain lack of integration,excessive employee workload, communication problems between the different players,and with certain areas of strategic interest that are less valued than others.

Given this situation, the authors have endeavored to convey certainrecommendations for organizations having similar features that may be interested indesigning an IMS considering the clear evidence of synergy in the use of standardizedmanagement systems in our country (Casadesus et al., 2011) and the importance of thelevel of integration (Bernardo et al., 2012). On the basis of the experience described,the following are considered indispensable:

. combine the systemic vision of the organization with an analysis of itscomponents;

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. maximum and visible commitment from the senior management;

. have the necessary resources to integrate the different systems;

. overcome the resistance to change through training techniques, group work andpeer review;

. guarantee vertical and horizontal communication within the organization:communication plan based on social network, including evaluation and policiesfor recognition;

. facilitate integration of the organization’s people: newcomers’ integrationplan, practical training and fulfillment management of individualobjectives;

. systematically applying the PDCA quality improvement cycle as a basis forimprovement and for moving the model’s reach forward;

. be alert to the main risks (apoptosis criteria);

. incorporate flexibility as an essential element of the model; and

. integrate the audit as an instrument for continual improvement of theorganization and driver of the model.

Our case study has several limitations related to the organizational size, the generallack of flexibility in the Public Administration, the recent implementation of ourinitiatives, the broad and ambitious project requiring serious and permanentevaluation and the current rigid Social Security rules which may, however, changeabruptly in the context of the present economic crisis in Spain. Further studies areneeded to monitor whether or not the changes that could take place in the near futurein the Social Security rules, the Public Administration, the Steering Committees and soon, have an effect in our organization and require further actions.

References

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Bernardo, M., Casadesus, M., Karapetrovic, S. and Heras, I. (2012), “Integration of standardizedmanagement systems: does the implementation order matter?”, International Journal ofOperations & Production Management, Vol. 32 No. 3, pp. 291-307.

Casadesus, M., Karapetrovich, S. and Heras, I. (2011), “Synergies in standardized managementsystems: some empirical evidence”, The TQM Journal, Vol. 23 No. 1, pp. 73-86.

Castillo, J. and Sanasaloni, J. (2004), “Sistemes Integrats de Gesti�o”, CIDEM (Center forInnovation and Business Development), Department of Work and Industry. Generalitat deCatalunya. Barcelona.

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Hall, R. (1998), “An individual’s perspective on IMS’s”, Quality World, Vol. 24 No. 8,pp. 14-16.

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About the authors

Dr Rafael Manzanera is former Director of the ICAMS, and is currently based at the MC Mutual,Barcelona.

Dr Josefina Jardı is former General Manager at the ICAMS and a Member of the ICAMSManagement Committee.

Dr Xavier Gomila (1963-2014) was Medical Director at the ICAMS and a Member of theICAMS Management Committee.

Joan Ram�on Pastor is a former Administration Manager at the ICAMS and is currently basedat the Public Health Agency (ASPCAT), Generalitat de Catalunya.

Dr Dolores Ib�anez is a Medical-Legal and Knowledge Management Manager at the ICAMSand a Member of the ICAMS Management Committee.

Gloria G�alvez is a User Service and Qualitative Methodologies Manager at the ICAMSand a Member of the ICAMS Management Committee.

Dr Constanca Albertı is a Research and Quantitative Methodologies Manager at theICAMS. Dr Constanca Albertı is the corresponding author and can be contacted at:constanca.alberti@gencat.cat

Albert Navarro was employed at the ICAMS from 2002 to 2010 and is currently based at theHealth Department, Generalitat de Catalunya.

Joaquın Uris is a Quality Expert and Advisor to the ICAMS in EFQM methodology.Alicia Pomares is an Organizations Expert and Advisor to the ICAMS on the MBO project.

She is currently based at the Humannova.Dr Lluısa L�opez is a Manager of the Care Quality and Accreditation Service, Department

of Health, Catalan Regional Government, and Team Member of participative projects atthe ICAMS.

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Dr Cristina Zuazu is a Member of the ICAMS Management Committee.Dr Primitiva Sabate is a Member of the ICAMS Management Committee.Dr Immaculada Aguado is a Member of the ICAMS Management Committee.Dr Lidia Domingo is a Member of the ICAMS Management Committee.Dr Carolina Infante is a Member of the ICAMS Management Committee.Dr Josep Gomis is a Member of the ICAMS Management Committee.Dr Aurora Jover is a former Member of the ICAMS Management Committee and is currently

based at the Health Department.Jordi Iglesias is a Member of the ICAMS Management Committee.Antoni Mestres is a Member of the ICAMS Management Committee.

To purchase reprints of this article please e-mail: reprints@emeraldinsight.comOr visit our web site for further details: www.emeraldinsight.com/reprints

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