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Healthcare
Organisational value of healthcare quality awards
quality awards in Andalusia
Vı́ctor Reyes-Alcázar, Belén Sotillos-González and
Antonio Torres-Olivera 475
Andalusian Agency for Healthcare Quality, Seville, Spain
Received May 2008
Revised October 2008
Accepted November 2008
Abstract
Purpose – The purpose of this paper is to develop and describe the symbolic value of quality awards
as a key indicator of recognition that public organizations have reached in the scope of quality
management and continuous improvement.
Design/methodology/approach – The paper provides a description of the evolution of the three
series of healthcare quality awards that have been held to-date in one of the biggest regions of Europe:
Andalusia.
Findings – Theoretical analysis of an instrument conceived as an institutionalised way of
recognizing quality assurance initiatives in the Andalusian Public Health System. At the same time,
the article focuses on the importance of using a reference model to ensure that the process of assessing
the projects is systematic and rigorous and therefore stands as a guarantee of transparency within a
public administration.
Research limitations/implications – The ultimate outcome is dependent of the geographical
context and the behaviours and perceptions of people that have participated as assessment panels.
Practical implications – The conceptual framework provides guidance on what methodology is
used to assess the quality projects (process to allocate projects to assessment panels and assessment
criteria required) in a complex healthcare system. It serves as a managerial framework to enhance
the continuous improvement in all health-related services.
Originality/value – The paper contributes to create a structured debate between researchers and
healthcare leaders regarding the assessment criteria to evaluate healthcare quality projects.
Keywords Leadership, Organizational culture, Quality management, Health services, Quality awards,
Spain
Paper type Case study

Introduction
As a result of the efforts undertaken, especially in the last two decades, quality awards
have become a consolidated tool for quality management, both in business companies
and in public government. In the latter context, the proliferation of such schemes in a
wide variety of geographical areas, government agencies or subject matters cannot be
seen as mere coincidence nor simply as a trend imported from the business world,
but rather as a globally accepted formula for acknowledging excellence.
The literature contains multiple references to these types of awards, which have
accumulated extensive knowledge about the practices of quality. Some progress has
been made in the usefulness and impact of this organizational tool, from multiple Leadership & Organization
approaches. As comparative studies, it can be highlighted the analysis of total quality Development Journal
Vol. 30 No. 5, 2009
awards in the European context and their critical success factors (Mavroidis et al., pp. 475-487
2007), an international review on business excellence framework in a sample of sixteen q Emerald Group Publishing Limited
0143-7739
countries (Grigg and Mann, 2008), or the study of relationships between underlying DOI 10.1108/01437730910968723
LODJ dimensions of service quality in models such as European Foundation for Quality
30,5 Management or Malcolm Baldrige National Quality Award (Palani Natha Raja et al.,
2007). Some empirical studies tackle the perceived organisational value of participating
in a quality award process, identifying benefits related to process orientation, customer
orientation and improvement work, committed leadership or wider involvement
(Eriksson, 2004; Eriksson and Garvare, 2005), and point out that the advantages of
476 participating go beyond descriptive scores as they also encompass organizational
commitment to excellence (Shirks et al., 2002). From an economic viewpoint, some
papers reflect on the impact of such awards on business variables (Balasubramanian
et al., 2005), with disparate results in terms of the significance level obtained, while
stressing the importance of intangible assets, a factor that is also identified as decisive
by a number of studies on strategic change (Caldwell et al., 2008).
A further dimension to be considered when analysing quality awards is related to
the agents that present the proposals. Parallel to the development of such awards, the
profile of possible prize-winners has also altered remarkably, so that nowadays
candidates may be teams, departments or even entire organisations. A positive
consequence of this is that quality and excellence are now perceived as achievable
targets at all levels of the organisation, which reflect the current complex web of
interrelationships on organisational life (McHugh, 2006). Bottom-up approaches have
underlined the role of front-line staff and middle managers (Borins, 2002) in the
creation of innovation, due to the position they hold that enable them to become
informal leaders. Participate in a quality award project provide professionals
the opportunity to share their experiences with other informal leaders, due that the
commitment with the project spread the engagement to all members of the teamwork.
Indeed, teamwork has been empirically demonstrated to be a factor closely related to
personal involvement in an organisation (Savic et al., 2007). Likewise, trust in the
organization and its leadership stands out as a key factor in all innovative change
(MacPhee, 2007).
However, there is still much research to develop with regard to the impacts
of quality awards. Indeed, given that existing awards vary significantly from the
point of view of their assessment method, coverage and focus (Hartley and Downe,
2007), one of the aspects to be covered in the research agenda is the extent to which
impact and effectiveness is contingent and context-dependent, or determined by
intrinsic factors.
In any case, the main functions of quality awards – acquiring each of these
functions different emphasis depending on the specific nature of the prize are the
following:
.
Awards become an explicit and public recognition of work done within the
organization in terms of quality and continuous improvement, and it serves as a
stimulus for further progress.
.
Awards help to disseminate the notion of quality assurance throughout the
different organisations and agents, inviting them to share how they have adapted
this management model to a specific situation. This function is especially
important when the quality model is still at the initial stage of implementation.
.
At the quality awards there is a seemingly contradictory effect; on the one hand
promote competition and on the other organizational learning (Löffler, 2001).
 Their competitive nature generally has a practical purpose – it is an attractive Healthcare
format for motivating public organisations with regard to quality, increasing quality awards
the visibility of their good practices and, on the other hand, such awards are
undoubtedly a stimulus for emulation and cooperative learning among the
different participants and for the whole organisation.
.
However, apart from this dialectic between competition and learning, these
awards can be seen as an important benchmarking tool such that projects are 477
presented voluntarily to a process of external assessment that enables them to
situate their position with regard to the initiatives of other organisations
(Eriksson, 2004).
.
Participation in quality awards, especially when candidates are preparing their
proposals, becomes a catalyst for change (Milakovich, 2004) that motivates
professionals to achieve increasingly ambitious performance targets.
.
From an instrumental point of view, certain widely recognised models of total
quality management can be said to be based on other prestigious quality awards
(Malcom Baldrige National Quality Award (USA), European Quality Award
(Europe), Deming Prize (Japan)). Review papers (Al Nofal et al., 2005) show how,
apart from the important recognition that winning a prize of this type entails,
organisations are also attracted by the methodology component, i.e. the
self-assessment stage that is compulsory during the preparation of the
documentation required to participate in the award and which helps them
to encompass their practices within widely validated methods.

Objective
The objective of this paper is to describe the evolution of the three series of healthcare
quality awards (2003, 2005 and 2007) that have been held to date as an institutionalised
way of recognising quality within the organisations and professionals that comprise
the Andalusian Public Health System (APHS).

Context
In October 2002, the Andalusian Agency for Healthcare Quality (AAHQ) was
presented to the public and health professionals as the entity set up by the regional
ministry of health to promote quality and continuous improvement in the provision of
healthcare services throughout the autonomous region. In this presentation ceremony,
the first edition of the healthcare quality awards was announced. Since its birth,
therefore, this institution has integrated into its mission, vision, values and activity, the
recognition of people and organizations that make up the APHS (AAHQ, 2005).
These awards are held every two years and aimed at professionals and
organisations within the APHS, who present initiatives for quality improvement
developed at any level of the healthcare administration.
The rules of these awards require that each project is accompanied by an
application form signed by the director of the organization presenting the initiative.
This requirement has not only an administrative purpose, but, within a complex
healthcare environment and with multiple agents, aims to strengthen the involvement
of not only the authors of the projects, but also of the formal leaders of the organization
to which they belong. Indeed, the process calls for the decision-maker level to assume
LODJ the commitment that participating in such awards implies and therefore to provide the
30,5 necessary facilities for the presentation of the proposal in terms of:
.
giving access to internal data of the organisation;
.
opening up channels of communication between those departments involved;
and
478 .
offering logistical support for the drafting of the project.

The main prize is the “Healthcare Quality Award”, but other modalities also exist
(special prizes), in line with the vision of quality assurance as a multidimensional
concept, that affects all levels of the organisation.
Given that the healthcare sector is dynamic rather that static in nature, the different
categories of awards have undergone certain modifications over the three series in
which some have been eliminated while other new modalities have been incorporated.
Likewise, in some cases, the actual formula of certain modalities has been altered to
place more emphasis on certain aspects of quality assurance. In Table I, the modalities
areas marked with “U” have been awarded in all three editions of the prize held to date.
Both the main prize and the special prize modalities represent a series of features
that are the subject of special assessment during the project assessment stage. Table II
summarises the purpose and the valuable items in the 2007 edition.

Awards methodological process

1. Projects reception
Candidacies are formally presented to the AAHQ through an on-line application form
that provides personal details and attaches an executive summary of each proposal,
which has to adhere to a pre-established series of sections (introduction, aims,
methodology, results, discussion, conclusion and bibliography). A further pre-requisite
is that these summaries should be accompanied by an application form signed by the
head manager of the organisation where the project is implemented.
The existence of such general pre-requisites ensures, on the one hand, that all
proposals fulfil a homogeneous format with regard to the required content and
technical standards and on the other hand, that all projects are encompassed within the
organisational structure presenting them.

First edition Second edition Third edition

2003 2005 2007

Main prize
Healthcare quality award U U U
Modality
Professional development U U U
Continuous healthcare delivery and integrated U
Table I. process management
Evolution of modalities Innovation U U U
awarded in each edition Best answer to citizens U
of the Andalusian Humanisation of care U U
healthcare quality Transparency U U
awards Patient safety improvement U
 Healthcare
Modality Purpose Specially valued aspects
quality awards
Healthcare quality award This is the main prize which Value is given to efficiency
recognises an organisation that of such projects with regard to
maintains a quality-focused public satisfaction, the
culture and works with professional development,
systematic quality scope to innovation in healthcare 479
develop through its service management, resource
provision or management an management, application of
overall method of healthcare information technology systems,
quality scientific output and its transfer
to clinical practice
Professional development award A special prize given to the In this modality, value is given
project that outstandingly to those actions that strengthen
enhances the maintenance and continuous professional
improvement of professional development, competence
competences assessment, consideration of
gender-based approaches and
the design of on-going training
programs and schemes linked to
the professional’s performance
and which lead to reflection and
learning based on practical
experience
Award for the humanisation of This a special distinction given Merit is given to those solutions
care to the project that has made that best enhance continuous
significant steps towards healthcare, co-operation between
creating a more humanised medical institutions and
provision of healthcare services, implementation of integrated
thus making each patient treated healthcare processes. Likewise,
under the service feel unique and value is awarded to those
that all the professionals are mechanisms that guarantee not
working to improve his/her only that patient rights are
health respected and fulfilled but also
that patients are made to feel as
comfortable as possible while
receiving healthcare attention
Patient safety improvement Prize to the project that, in Value is attached to those
award accordance with the patient initiatives that have most
safety strategy of the regional remarkably contributed to
ministry of health, has made promoting patient safety among
significant progress in creating healthcare professionals by
and enhancing a patient safety identifying critical aspects and
culture developing good practices
related to medication,
preventing hospital or surgical
infection, among others. In the
same way, credit is also given to
measures that imply adequate
risk management or others that Table II.
enhance patient involvement in Purposes and main
safety strategies aspects evaluated in
(continued) the 2007 edition
LODJ Modality Purpose Specially valued aspects
30,5
Transparency award A special prize awarded to This modality evaluates the
measures taken to strengthen efforts made to improve the
transparency and accessibility image of the health service and
both its internal and external
to the health service by creating
guarantees and public communications, the
480 confidence and promoting the information given to the public
establishment of receptive regarding their rights and
obligations, the list of services
organisations that listen, report
and communicate available, timetables, access to
services and management of
claims and suggestions;
likewise, it considers the
training given to professionals
related to communication skills
and dialoguing with the public
to strengthen citizen
participation in clinical decisions
Innovation award A distinction designed to This evaluates the application of
acknowledge the most creative methods to improve
innovative solutions aimed at quality and efficiency, the
improving quality and the application of new technologies
establishment of new practices and the research of opportunities
and services capable of meeting for improvement
Table II. changing healthcare challenges

2. Method used to allocate projects to assessment panels

Once the projects applying for the awards have been received by the agency, they are
allocated among members of the assessment panel for evaluation. The following
requisites are implemented in this stage of the process:
(1) Each member of the assessment panel is sent the following documentation:
.
the projects allocated to him/her for assessment;
.
the assessment criteria to be applied; and
.
a spreadsheet on which the results of the evaluation of each allocated project
are to be recorded.
(2) Before starting the assessment process, each member of the panel should verify
whether he/she has any conflict of interest with regard to any of the projects
assigned.
As far as the method for allocating projects to the panel is concerned, in the 2007
edition the following criteria were applied:
.
Each project is assessed by five panels.
. Projects for assessment are allocated to the panels based on “volume of
information” or the number of words contained in each project, so that all panels
had a similar amount of information to deal with.
.
Once the weight (number of words) of the different projects to be assessed has
been adjusted, they are allocated at random among the panels.
3. Assessment criteria Healthcare
Giving public recognition through awards requires a structure that produces coherent
results (Meyer and Collier, 2001), so at least two issues must be examined: the existence
quality awards
of causal relations between different components of each project, and clarity in the
assessment criteria.
In the experience analysed in this article, panels are provided with a reference model
to ensure the assessment process of the projects presented for the awards is both 481
systematic and rigorous. The assessment criteria are given a specific weighting
percentage as shown in Table III.
In the event that a project running for the healthcare quality award is also presented
for a specific modality (special awards), the total criteria 1 to 7 is set as 75 per cent and
scoring for criteria 8 “modality” accounts for a further 25 per cent, so that this criterion
has a significant discriminating effect on the final score.

Results
Limitations
The paper presented herein has a number of limitations:
.
although the aim is to find out lessons learnt from it, the experience is developed
in a specific geographical context (Andalusia, Spain); and
.
the authors eligible to participate in the awards have to be in active employment
and working for the regional public health system.

Quantitative analysis
The success of an initiative such as the quality awards depends on the basic premise
of the existence of a suitable number of projects participating (Chuan and Soon, 2000)

Criteria Description of criteria Weighting (%)

1. Objectives Existence of clearly defined, precise objectives 15

coherent with the contents of the project
2. Methodology Quality of the design and development of the work, 15
coherency between sections, explicit aims and
description of the methodology design
3. Results Existence of a detailed description of main results, 25
which should be coherent with the proposed aims
and design
4. Discussion Inclusion of full and relevant discussion 15
5. Conclusions Detailed analysis of the conclusions, where negative 15
assessment is especially given to any lack of
conclusions, irrelevant conclusions, or conclusions
not in keeping with the study or results obtained
6. Applicability Extent to which the improvements described are 5
generally applicable to healthcare practice
7. Innovation Extent to which new methods, proposals or solutions 10
and opportunities for improvement are provided,
taking into consideration the originality and added Table III.
value of such proposed solutions Assessment criteria for
Total 100 projects in 2007 edition
LODJ in order to run the initiative. The presentation of the results of this specific experience
30,5 begins with two basic data: how many projects were presented for each edition and
how many institutions were behind them (Table IV).
Since the very first edition in 2003, the number of projects running for the awards
has grown steadily: 20 projects in 2003, 38 in 2005 and 54 in the third edition in 2007.
In percentage terms, the number of projects running for the awards has grown between
482 2003 and 2007 by 170 per cent. Likewise, the number of institutions participating has
gone up by 53 per cent over the same period of time.
Table V details the distribution of projects in all three editions for the main
prize and for each of the specific awards. In the 2007 edition, the maximum number
of modalities that any one project could opt for was restricted to two (main prize
and/or a specific modality), whereas in the first two editions, no such restriction was
imposed.
Specific analysis of the third edition in 2007 reveals that eight projects opted
exclusively for the main award, 11 projects opted exclusively for one of the specific
modalities and 35 projects were presented to run for two options (the main award and a
specific modality).
With regard to the scores given by the assessment panels, it has already been
mentioned that the assessment criteria were modified to make the process more
homogenous and systematic in the 2007 edition. The most relevant data concerning the
assessment values given for the 2007 awards are as follows:
.
all projects that won an award in 2007 had a score of over 8 out of 10;
.
the average score for all projects presented was 6.40 on a scale of 1 to 10; and

Table IV.
Evolution of the number First edition Second edition Third edition
of projects and 2003 2005 2007
institutions participating
in each edition of the Total number of projects 20 38 54
Andalusian healthcare Total number of institutions 17 23 26
quality awards participating

First edition Second edition Third edition

2003 2005 2007

Main prize
Healthcare quality award 6 24 43
Modality
Professional development 6 8 5
Continuous healthcare delivery and integrated 7
Table V. process management
Evolution of project Innovation 9 25 19
distribution by modality Best answer to citizens 7
in the Andalusian Humanisation of care 9 9
healthcare quality Transparency 6 2
awards Patient safety improvement 11
 .
a high degree of consensus was achieved during the assessment process (each Healthcare
project is assessed by five panels), as standard deviation on the final scores for quality awards
all projects was # 1.3.

In the case of the main prize, this deviation dropped to only 0.7.

Qualitative analysis 483

The announcement, assessment and delivery of quality awards implies a
mobilization of resources and expectations so important to try to sketch, from a
qualitative approach, what is the usefulness of this visibility tool promoted by the
institutions.
The main benefit of the institutional recognition analysed herein lies in the fact that
these awards serve as efficient mechanisms for detecting improvement areas and
innovation, both at the organisational level (continuity of care across healthcare levels;
logistical matters, etc.) and in the relationship between providers of public services and
citizens (patient decision aids to support clinical decision making; communication
problems at healthcare centres, etc.).
Not only do award schemes help to identify areas for improvement and innovation
but also, indirectly, to disseminate them within the system, especially when it has
a large magnitude 2 eight million potential users involved, over 30 hospitals and 1,500
primary-care centers.
Table VI summarises the winning projects in the three editions held to date, as well
as the institution where the project has been implemented.
A series of basic reflections can be drawn from Table VI: the diversity of the subject
matters among the winning projects, the clear orientation towards healthcare practice,
especially at hospital level, the innovative nature of the projects while also revealing a
high degree of applicability in other healthcare sections within the public health
system. Likewise, it is interesting to note the significant number of projects aimed at
incorporating patients’ points of view into the equation, for example, through the
development of tools to aid decision making or involvement strategies.

Discussion
The experience described in this article highlights the role of quality awards as a form
of institutional recognition to the organizations and professionals who share their
quality initiatives with the rest of the system which includes, in this case over 90,000
professionals and more than 1,500 organisational units. Such recognition encompasses
two relevant factors: the feeling of “professional pride” among members of the
award-winning organisations (Bourgault and Gusella, 2001) and the multi-agent
approach, which acknowledges the enormous potential for improvement that lies in the
staff at all levels of the organisation.
Furthermore, it is important to note that in the process analysed, the competitive
component is less prominent than the role of organizational learning and dissemination
of best practices, often innovative.
The approaches based on continuous improvement extends to the awards promoter
itself, as the experience gained in the course of the editions facilitated the introduction
of some concrete improvements in the last call, especially with regard to addressing
concerns for greater objectivity and methodological accuracy:
LODJ
First edition 2003 Second edition 2005 Third edition 2007
30,5
Main prize
Healthcare quality Evaluation of quality Mammary pathology: Development of a serum
award standards in integrated before and after their bank: safety against
healthcare processesa implementation at the pathogens in the
484 clinical management monitoring of patients
unit for mammary with haemophiliac
disorders at the Puerta
del Mar University
Hospital (2002-2005)b
Modality
Professional SIGES £ COMP Intern reception Program to review and
development competence-based scheme: programme for update clinical
integrated adaptation to new protocols in oncology.
management environmentd, e Year 2006f
systemd
Continuous healthcare Development of
delivery and integrated healthcare process
process management software (SIPA)
for management
sharing across
levelsg
Innovation Implementation of a Internal logistics aimed Development of web-
quality group in the at “continuous based software to
intensive care unith improvement” in facilitate incorporation
healthcare processesi of new healthcare
technologies in
centres belonging to the
APHSe
Best answer to citizens A hospital without
barriersj
Humanisation of care Managing quality, Design of a tool aid
caring for patients, for decision making in
caregivers and families the integrated
at homek healthcare process for
breast cancer:
“alternatives for
treating breast cancer:
which option do
I prefer?”l
Transparency The front door is
transparentm
Patient safety Assessment of safety
improvement measures in the
cytostatic circuit at the
Puerta del Mar
University Hospitalb
Notes: aAndalusian health service; bPuerta del Mar University Hospital; cCarlos Haya Regional
Table VI. University Hospital; dIavante Foundation; eVirgen del Rocı́o University Hospital; fVirgen Macarena
Winning projects in the University Hospital; gJaén Public Hospital Complex; hPoniente Hospital; iPuerta Real University
Andalusian healthcare Hospital; jSan Juan de la Cruz Hospital; kAljarafe Health District; lMinistry of Health, Directorate for
quality awards Quality, Research and Knowledge Management; mAxarquı́a Health District
 .
increasing the number of panels assessing each project; Healthcare
.
monitoring and eliminating from the start any possible conflict of interest for the quality awards
panels with regard to the projects allocated to them;
.
using a reference model to guarantee that the project assessment process would
be systematic and rigorous; and
.
including emerging initiatives as new specific modalities. 485
In this sense, the patient safety improvement award is coherent with an initiative
promoted by the World Health Organization (2004) through the World Alliance for
Patient Safety.
This paper defends the organisational value that these quality awards hold, a value
which stretches beyond the winning candidates. It is a question of looking at this initiative
in an integrated way, i.e. by attending to the tangible results (awards) but also to
the process which encourages participation by everybody and thereby turns quality into a
multi-dimensional objective shared by all. The quality awards, especially during the
proposal elaboration stage, represent a learning experience, an exercise of reviewing,
systematising and reflecting on the day-to-day activities. This educational component is
strengthened by the project managing to blend the expertise, free will and effort of people
from different levels within the same organisation (intra-organisational dynamics) or even
who come from different institutions (inter-organisational relationship).

Conclusions
This paper provides theoretical analysis of an instrument conceived as an
institutionalised way of recognizing quality assurance initiatives by organisations
and professionals in the APHS. It examines the role played by the different modalities
comprising the healthcare quality awards as a guide to improving public healthcare
services, not only by indicating initiatives of an innovative nature but also by
demanding through the assessment criteria that they be applicable to other healthcare
centres and formats within the public health system.
Likewise, an element of special value in this paper is the recognition of the
commitment and dedication given to these healthcare quality awards by prominent
centres in the public health system and certain managerial teams, which is illustrated
by the growing number of professionals and institutions that participate in drafting the
proposals presented as candidates for the awards.
At the same time, the paper focuses on the importance of using a reference model to
ensure that the process of assessing the projects is systematic and rigorous and
therefore stands as a guarantee of transparency within a public administration.
The experience described herein demonstrates that recognising formal and informal
leadership is an essential part of these quality awards, especially when the
presentation of the projects is designed from an interdisciplinary and
cross-disciplinary approach. This open scheme enables front-line staff and middle
managers to disseminate their best working practices to the rest of the organisation.

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Corresponding author
Vı́ctor Reyes-Alcázar can be contacted at: victor.reyes@juntadeandalucia.es

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