Introducing a formal quality system in a medical department: case study of the ENT(ORL)-Department at the Catholic University Leuven

This paper describes the experience of introducing a formal Quality System in the ENT (Ear - Nose - Throat - Head & Neck surgery) department of the Medical Faculty at K.U.Leuven. This department is a typical medical unit in a university environment with responsibilities for education, research and patient service. Today, formal Quality Systems are well introduced in production organisations and they also emerge in service organisations, but they are much less common in university medical departments. Quality systems are used as a tool for quality assurance and continuous improvement. This paper describes the different phases in the development of the ENT-quality system. After describing the origin and history of the project, we elaborate on the structure of the formal Quality System (based upon a quality handbook, procedures, measurement of performance indicators, corrective and preventive actions). Finally, we comment on implementation issues and plans for future development.