External Feedback

Improving Public Organisations through Self-Assessment

Improving Public Organisations through Self-Assessment

CAF External Feedback

January 2013

5

Table of Contents

Foreword 7

Executive Summary 9

PART 1: The CAF External Feedback 111. Effective use of the CAF model 112. The demand for external feedback 123. The objectives of the CAF External Feedback 124. The principles of the CAF External Feedback Procedure 135. The 3 pillars of the CAF External Feedback: ambitions and philosophy 13 Pillar 1: The process of self-assessment 14 Pillar 2: The process of improvement actions 15 Pillar 3: The TQM maturity of the organisation (the broader scope of excellence) 15

PART 2: How the CAF External Feedback works 171. Implementation of CAF External Feedback at national level 172. The role of the European CAF Resource Centre 173. Requirements to apply for the ‘Effective CAF User’ Label 184. The phases in the CAF External Feedback Procedure 18 Phase 1: Application for the Effective CAF User Label 18 Phase 2: Providing the feedback 19 Phase 3: Decision/Designation of the CAF Label 20

PART 3: The CAF External Feedback Actors 211. Roles, tasks and profile 212. Competences needed to conduct the CAF External Feedback 223. Training required 224. Code of Conduct and behaviour for the CAF External Feedback Actors 23

Appendix 1: Questionnaires on the different Pillars 24Appendix 1.1: The self-assessment process questionnaire 24Appendix 1.2: The improvement plan questionnaire 31Appendix 1.3: The TQM Maturity questionnaire 35

Appendix 2: The CAF External Feedback Scoring Guide 401. Scoring methodology 402. Evaluation scales 423. Scoring profiles 42 Appendix 3: Format of the CAF External Feedback Report 46 Appendix 4: Form for Applicant Organisation 53

Appendix 5: National Organiser Fact sheet 54

Appendix 6: Effective CAF User label example 55

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Foreword

At the end of the 1990s, quality management became an important issue for the public sector in the European Union. In order to coordinate their efforts and to start up a common European learning process, the EU

Ministers responsible for public administration invited their Directors-General (DG) to promote exchanges and cooperation between the EU Member States and to develop common instruments in the field of quality management. It was clear that there was a great need for European initiatives of this kind.

A first product of the cooperation among EU national experts was presented: the Common Assessment Framework (CAF), a real common European quality management instrument for the public sector, developed by the public sector.

The CAF is a total quality management tool developed by the public sector for the public sector, inspired by the Excellence Model of the European Foundation for Quality Management (EFQM®). It is based on the premise that excellent results in organisational performance, citizens/customers, people and society are achieved through leadership driving strategy and planning, people, partnerships, resources and processes. It looks at the organisation from different angles at the same time: the holistic approach to organisation performance analysis.

Public organisations invested a lot of efforts in using the CAF and many of them wanted to know if they were doing well, and wanted to learn about their CAF practice. They started to look for feedback, for recognition. Was their process of self-assessment done well? Did their improvement plan effectively reflect the conclusions of the self-assessment and had they taken the first steps on their journey for total quality management? How could they show this internally and externally?

Based upon their demand, reflection began on an external feedback scheme for CAF Users. As for the CAF itself, this was done in the spirit of European collaboration and developed in consensus between the different Member States. The core of the CAF External feedback Procedure is the feedback given by

peers or experts on three main issues (later called the ‘pillars’): the self-assessment process; the improvement planning; and the start of the journey amongst the 8 principles of excellence, the guiding principles towards an excellent organisation. This feedback constitutes the real added value of the CAF External Feedback Procedure. The peers and experts – called External Feedback Actors – will enter into dialogue with the different stakeholders of the organisation regarding the implementation of CAF give comments and formulate advice for the future. They will motivate the CAF Users to continue their efforts to further develop quality in all its aspects. To conclude their remarks, they will at the end of the procedure decide if the organisation has used CAF in an effective way and whether it deserves the Effective CAF User Label for the coming two years.

Many actual and potential CAF users have already shown their interest in the CAF External Feedback and the ‘CAF Label’. Both these new CAF related instruments constitute an extra stimulus to start using the CAF or to continue its use as part of the strategy for continuous improvement. A new impetus for the use of CAF is given and a growing number of CAF Users is expected for the future. Each Member State will have the responsibility to put the new system into practice, taking into account its own specificities. Yet, as they will follow common European guidelines, the Effective CAF User Label will have a clear European dimension. It creates an additional way to bring European CAF Users together, to exchange their practices and to raise the level of quality development once again.

The new CAF External Feedback Procedure was elaborated based upon the results of a number of pilot processes and in strong collaboration between the CAF National Correspondents Network within IPSG. Special thanks go in particular to the project group working on the procedure, composed of Belgium (Jean-Marc Dochot), Denmark (Mads Biering Sorensen & Hanne Dorthe Sorensen), Italy (Sabina Bellotti, Massimo Tronci & Italo Benedini), Slovenia (Gordana Zurga) and the European Institute of Public Administration – EIPA (Patrick Staes, Nick Thijs & Ann Stoffels), and supported by EFQM (Samuli Pruikkonen, Celal Seckin, Carla Guerra). They all worked together in the spirit of the common European interest and the conviction that their work will constitute a next step in the further development of a qualitative public sector in Europe.

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Executive Summary

The CAF External Feedback Procedure – which provides external feedback on the assessment that has taken place with CAF – aims to further support CAF users in their journey towards quality.

1. The CAF External Feedback Procedure

To enable public sector organisations applying CAF to see the results of their efforts and to obtain feedback, the CAF External Feedback Procedure provides external feedback on the introduction of total quality management with CAF. This feedback relates not only to the self assessment process, but also to the way forward chosen by organisations in order to attain excellence in the long run, and is based upon the principles of excellence.

The objectives of the CAF External Feedback ProcedureThe CAF External Feedback aims to achieve the following objectives:1. Support the quality of the CAF implementation and its impact on the organisation.2. Find out if the organisation is installing TQM values as the result of the CAF application.3. Support and renew enthusiasm in the organisation for continuous improvement.4. Promote peer review and bench learning.5. Reward organisations that have started the journey towards continuous improvement to achieve excellence in an effective way, without judging their obtained level of excellence.6. Facilitate the participation of CAF users in the EFQM® Levels of Excellence.

To that end, the CAF External Feedback Procedure is built upon three pillars.

Pillar 1: The process of self-assessmentThe quality of the self-assessment serves as a basis for the success of future improvements. In the first pillar of the CAF

External Feedback, the quality of the self assessment process is central. The CAF External Feedback Actors will look at the ability of the organisation to make an effective and well-planned self-assessment and will not be looking at the validation of the scores given in the CAF self assessment.

Pillar 2: The process of improvement actionsThe next important element in an effective CAF implementation is

acting upon the results from the self assessment. Suggestions for improvement need to be prioritised and translated into an improvement plan that will be carried out within a maximum timeframe of two years. In this second pillar of the CAF External Feedback Procedure, the Actors will look into the planning procedures adopted and the process followed for the implementation but they will not assess the results of the improvement actions.

1

2

Pillar 1

The process of self-assessment

Steps 1-6 in the 10 step plan

Questionnaire 1(Appendix 1.1)

Pillar 2

The process of improvement actions

Steps 7-9 in the 10 step plan

Questionnaire 2(Appendix 1.2)

Pillar 3

The TQM Maturity of the

organisation

Questionnaire 3(Appendix 1.3)

CAF External Feedback

10 Executive Summary

Pillar 3: The TQM maturity of the organisation (the broader scope of excellence)One of the aims of the CAF model is to

guide public sector organisations closer towards the important values of Total Quality Management. By applying the CAF model, these values should – over time – become part of the culture of the organisation. The questionnaire for TQM Assessment Maturity is therefore based on the eight fundamental Principles of Excellence. The evaluation concerns the maturity level achieved by the organisation as a result of the self-assessment and the improvement process.

2. The functioning of the CAF External Feedback Procedure

2.1 Implementation of CAF External Feedback of national levelThe CAF ‘National Organiser’ is appointed at national level to be in charge of the implementation of the CAF External Feedback in the country. The National Organiser selects a core group of CAF External Feedback Actors (the evaluators). The underlying principle of the CAF External Feedback is that organisations can make use of it at minimum costs.

General common guidelines for the CAF External Feedback are described in this brochure. By following these guidelines, Member States will be able to guarantee that the CAF External Feedback processes are organised in a qualitative way and that – as a consequence – the ‘Effective CAF User’ label enjoys a high standard across the European Union.

2.2. The role of the European CAF Resource CentreBesides managing the CAF database, the European CAF Resource Centre in EIPA Maastricht supports the Member States in the implementation of the CAF External Feedback Procedure through a number of initiatives: promoting the CAF External Feedback at European level, introducing the National CAF Correspondents to this procedure, offering a common European training scheme for CAF External Feedback Actors, coordinating support for Member States that do not have a National Organiser and organising the CAF External Feedback Procedure for non EU members and European institutions.

2.3 Application by CAF usersEach public organisation using CAF can apply for the CAF External Feedback under the following two conditions:1. The application should be made between 6 and 12 months after the CAF self-assessment has taken place and the self-assessment report has been concluded and delivered.2. The organisation registers, or is registered, as a CAF user in the online European Database of CAF users, hosted by EIPA.

The applicant organisation will then go through the different phases of the CAF External Feedback Procedure:Phase 1: the applicationPhase 2: the process of providing feedbackPhase 3: the final decision and awarding of theEffective CAF User label

3. Roles, tasks and profile of the CAF External Feedback Actors

The CAF External Feedback Actors play a crucial role in the CAF External Feedback Procedure. The main tasks of the CAF External Feedback Actors are to:1. analyse the implementation of CAF through a process of self-assessment and improvement actions and analyse whether the organisation is implementing TQM values;2. provide feedback and suggestions on strengths and areas of improvement regarding the process of CAF implementation;3. support and renew enthusiasm in the organisation to work with holistic quality development and self assessment with the CAF Model.

A CAF External Feedback Actor requires a balance of personal and professional skills, coupled with a commitment to timely and appropriate conduct. The CAF External Feedback Actor must have participated in the European or national training course to become a CAF External Feedback Actor.

Conclusion

The CAF External Feedback Procedure adds value to the use of the CAF and to its users. Public sector organisations will want to see the results of all their efforts and they require feedback about their efforts. This CAF External Feedback by peers and experts will help organisations take the next steps on their quality management journey towards making their efforts visible both internally and externally.

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PART 1: The CAF External Feedback

1. Effective use of the CAF model

The use of the CAF model provides an organisation with a powerful framework to initiate a process of continuous improvement. The CAF provides:• anassessmentbasedonevidence,againstaset of criteria which has become widely accepted across the public sector in Europe;• opportunities to identify progress and outstanding levels of achievement;• ameanstoachieveconsistencyofdirectionand consensus on what needs to be done to improve an organisation; • alinkbetweenthedifferentresultstobeachieved and supportive practices or enablers;• ameanstocreateenthusiasmamongemployees by involving them in the improvement process; • opportunities to promote and share good practice within different areas of an organisation and with other organisations;• a means to integrate various quality initiatives into normal business operations;• ameansofmeasuringprogressovertimethrough periodic self-assessment.The CAF External Feedback has been created to further support organisations in using the CAF

most effectively in their future quality management journey and to exploit to the maximum the features as described above. The three main reasons why it is important to use the CAF effectively and to receive feedback on this are the following:

Reason 1: Success of the CAF depends on the way in which it is applied As described in the CAF brochure, the guidelines for implementing the CAF in an organisation are not strict rules and regulations to be followed, but are to be regarded as recommended steps based on experience and successful applications during 10 years of working with the CAF. A successful implementation of the CAF strongly depends on the way in which the CAF model is used in an organisation. It can be useful for organisations receiving feedback on its usage to further improve their effectiveness in the future.

Reason 2: Working with CAF also means launching improvement actionsApplying the CAF model in an effective way not only means carrying out a self-assessment, but also involves creating an improvement plan and carrying out the actions in this plan. Receiving feedback on this

12 PART 1: The CAF External Feedback

plan and how it has been implemented can be one important way in which the CAF External Feedback Procedure can provide added value. Another important reason is the motivational aspect. As experience in many projects has shown, motivation and dynamics are usually quite high in organisations when starting the improvement plan. The challenge, however, is to continue these efforts. The external feedback can therefore help organisations keep up the momentum and avoid losing their motivation or dynamics.

Reason 3: Excellence is the beginning and the end of the CAFThe eight principles of excellence form the basis of the CAF model (as described in the previous part). Organisations that are starting to implement the CAF have the ambition to grow towards excellence in their performance and have introduced this culture of excellence in the organisation. Effective use of the CAF should, in time, lead to the further development of this type of culture and thinking within the organisation. Receiving feedback on this can help organisations develop this culture in future.

These three reasons form the drivers behind the CAF External Feedback Procedure.

The background and main features of the CAF External Feedback Procedure, its aims, objectives and underlying principles, will be described in this brochure.

2. The demand for external feedback

Public Sector organisations, which implement the CAF quality management system, will want to see the results of all their efforts and look for external feedback. This external feedback by peers and experts in TQM would provide such organisations with a clearer insight into what had been done, as well as opening up new perspectives for work on quality in the future. Furthermore, to make their successful efforts visible internally and externally, a Label of ‘Effective CAF User’ will be awarded to those organisations who use the CAF effectively.

3. The objectives of the CAF External Feedback

The CAF External Feedback has several important objectives:

• SupportthequalityoftheCAFimplementation and its impact on the organisation. The CAF model was launched as an instrument for self-assessment and organisational development. The CAF External Feedback provides organisations with the possibility to receive feedback on their CAF application and the quality journey launched in the organisation.

• Find out if the organisation is installing TQM values as the result of the CAF application. The CAF is based on a number of TQM values. Application of the CAF model should enable these values to become part of the organisation’s culture. Working with the CAF forces organisations to focus on certain important elements of TQM and makes them aware of the necessity to incorporate these values into the day to day running of the organisation.

• Support and renew enthusiasm in the organisation for continuous improvement. One important element in a good CAF self- assessment is the creation and implementation of an improvement plan. It is difficult for organisations to maintain the pace of change over a longer period of time. Many organisations pay less attention and lose track after a while. To keep their attention focused on improvements, the organisation receives external feedback at a perfect time to see if the organisation is still working on its improvements as planned.

• Promotepeerreviewandbenchlearning. One of the primary aims of the CAF is to help organisations learn from one another. The CAF External Feedback provides a new opportunity to learn from other organisations and to receive useful feedback from experienced users, colleagues and peers who have been through the same process and faced the same difficulties.

• Reward organisations that have started the journey towards continuous improvement to achieve excellence in an effective way, without judging their obtained level of excellence. The CAF provides many organisations with a starting point for working on quality in a structured manner. The CAF External Feedback aims at stimulating organisations who have taken

13PART 1: The CAF External Feedback

this path towards quality. The procedure recognises the attempts the organisation makes, the direction it has chosen and the way in which this is undertaken.

• Facilitate the participation of CAF users in the EFQM® Levels of Excellence, thus providing a bridge to the Committed to Excellence programme, since organisations that have been awarded the ECU label can demonstrate that they have carried out a reliable self-assessment and that they possess an effective action plan. (The feedback report which confirms the effective use of CAF will mention the possibility of applying for EFQM ® Levels of Excellence, including R4E).

4. The principles of the CAF External Feedback Procedure

The six general principles underpinning the CAF External Feedback Procedure are:1. The CAF External Feedback Procedure is a common European framework, to be implemented according to the national contexts on a voluntary basis.2. The CAF External Feedback Procedure promotes feedback of the implementation of CAF and its effects on the organisation.

3. This feedback is given by peers and/or external experts.4. The CAF External Feedback Procedure leads to the label of Effective CAF User which will be valid for two years.5. The CAF External Feedback Procedure is built upon three pillars: •theprocessofself-assessment •theprocessofimprovementactions •theTQMmaturityoftheorganisation (the broader scope of excellence)6. The decision and responsibility for implementing the CAF External Feedback Procedure at a national level belongs to each Member State. The national CAF correspondents are invited to cooperate with the European CAF Resource Centre at EIPA and the national EFQM contacts if needed.

5. The three pillars of the CAF External Feedback: ambitions and philosophy

The CAF External Feedback is built upon three pillars. These pillars are elaborated in detail in the next part of this brochure and also in the various questionnaires and scoring guides contained in the appendix.

The main features of the pillars are described below.

Pillar 1

The process of self-assessment

Steps 1-6 in the 10 step plan

Questionnaire 1(Appendix 1.1)

Pillar 2

The process of improvement actions

Steps 7-9 in the 10 step plan

Questionnaire 2(Appendix 1.2)

Pillar 3

The TQM Maturity of the

organisation

Questionnaire 3(Appendix 1.3)

CAF External Feedback

The CAF Model >> Enablers >> Criterion 1: Leadership14

Pillar 1: The process of self-assessment

The quality of the self-assessment serves as a basis for the success of future

improvements. In the first pillar of the CAF External Feedback, the quality of the self-assessment process is central. In order to obtain an in-depth look at the quality of the process, steps 1-6 of the 10-step process (as described in the CAF 2013 guidelines) will be analysed. A questionnaire has been developed for the assessment of these different steps. The questionnaire covers the six steps and is not meant for validating the scores given in the CAF self-assessment.

1

All these steps are translated into specific actions. Here we present the different actions defined for step 1 of the self-assessment process. For a detailed description of all the steps, see Appendix 1.1 Theself-assessmentprocessquestionnaire.

Scoring of the organisation is based on clear and simple evaluation scales.

The scheme recognises the ability to make an effective and well-planned self-assessment that increases the organisation’s understanding of the fundamental principles required to become excellent. The evaluation scale has five levels:

This evaluation scale has been detailed for each action in phrases, defining the interpretation of the real situation of the organisation with regard to the specific theme.

For a further explanation of the scoring and its use, please refer to the Scoring Guide (Appendix 2, sections 2.1 and 3.1).

Steps in Pillar 1

Step 1: Decide how to organise and plan the self-assessment (SA).

Step 2: Communicate the self-assessment project.

Step 3: Create a self-assessment group or groups.

Step 4: Organise training.

Step 5: Perform the self-assessment.

Step 6: Prepare a report describing the results of self-assessment.

Self-assessment process Pillar 1

Step 1: Decide how to organise and plan the self-assessment (SA).

1.1 Assure the commitment and ownership of the management for launching the process.

1.2 Assure a clear management decision regarding completion of the SA in consultation with the organisation, the scope of the SA (SA covers the whole organisation or only parts/units/departments...) and the overall objective of the SA.

1.3 Define the framework for SA process and the following actions, and plan the SA activities.

1.4 Appoint an SA process leader with a high level of knowledge of the organisation or form an SA Committee headed by the SA process leader.

1.5 Define the scoring panel to be used.

1.6 Allocate resources for SA and define how to prioritise the distribution of resources.

1 The activities have been carried out in a very limited way.

2 The activities have been carried out in a limited way.

3 The activities have been carried out in an acceptable way.

4 The activities have been carried out in a satisfying (satisfactory) way.

5 The activities have been carried out in an outstanding way.

Step 1: Decide how to organise and plan the self-assessment (SA).

Action 1.1 Assure commitment and ownership of the management for launching the process.

1 2 3 4 5

There is no evidence of commitment and ownership of the management.

There is some evidence of commitment of the management for launching the process, but limited to some of the managers involved.

There is evidence of commitment and ownership of the management for launching the process.

There is clear evidence of commitment and ownership of the management for launching the process, acting as guide and sponsor, and communicating the targets and advantages.

There is strong evidence of commitment and ownership of all the management involved for launching the process, acting as guide and sponsor, communicating the objectives and advantages and participating in the project definition.

The CAF Model >> Enablers >> Criterion 1: Leadership 15

Pillar 2: The process of improvement actions

A self-assessment and a good diagnosis based on the CAF is one thing, but another important element of an effective CAF implementation relates to doing something with the results of the self-assessment. Conclusions have to be prioritised and translated into an improvement plan covering a (limited) list of well-chosen actions to be carried out in a maximum timeframe of two years. This second pillar of the CAF External Feedback procedure focuses on this phase of the CAF implementation and covers steps 7-9 of the 10-step process mentioned in the CAF 2013 guidelines. The steps all provide a detailed insight into the improvement plan, the quality of this plan, and how it is created, communicated and monitored.

The CAF External Feedback covers the planning and the process of improvement and is not meant for assessing the results of the improvement actions.

As in Pillar 1, all these steps are translated into specific actions and are evaluated against the same five point evaluation scale presented above. For a detailed presentation of the different actions in all the steps of Pillar 2, see Appendix 1.2 The improvement plan questionnaire and the Scoring Guide (Appendix 2, sections 2.1 and 3.1) for an in-depth explanation of the scoring on this pillar.

Pillar 3: The TQM maturity of the organisation (the broader scope of excellence)

The third pillar of the CAF External Feedback focuses on the eight Principles of Excellence and a shift in focus towards these principles after applying the CAF model.

The questionnaire for TQM Assessment Maturity is based on these eight Principles of Excellence. All eight principles must be checked by the organisation as a first step in order to gain an understanding of the TQM maturity within the organisation.

During the site visit, two Principles - as chosen by the applicant - will be assessed in depth (one of which must either be Results orientation or Customer focus).

The evaluation team assesses the maturity level achieved by the organisation as a result of the self-assessment and action plan. Evaluation of the TQM Maturity determines the extent to which the organisation has succeeded in implementing holistic quality development values through the self-assessment and improvement process. The aim is therefore not to assess the real results of the improvement activities and the quality of these, but to assess whether the self-assessment has stimulated the introduction and development of a culture of excellence within the organisation.

The evaluation scale has four levels:

These different maturity levels are illustrated with concrete statements for all eight principles. Here we present criteria 3 on ‘Leadership and constancy of purpose’ as an example. For a full description of all the principles see Appendix 1.3 The TQM Maturity questionnaire and the Scoring Guide (Appendix 2, parts 2.2 and 3.2).

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3

Steps in Pillar 2

Step 7: Draft an improvement plan, based on the accepted self-assessment report.

Step 8: Communicate the improvement plan.

Step 9: Implement the improvement plan.

0 = Initiation level has not been achieved

I = Initiation level

R = Realisation level

M = Maturity level

16 PART 1: The CAF External Feedback

1. Results orientation

5. People development and

involvement

8. Socialresponsibillty

7. Partnership development

6. Continuousinnovation andimprovement

2. Citizen/Customer focus

3. Leadershipand constancy

of purpose

4. Management of processes

and facts

PRINCIPLES OFEXCELLENCE

Principle of excellence

3. Leadership and constancy of purpose

0 I = Initiation R = Realisation M = Maturity

Definition Initiation level has not been achieved.

Leaders establish a clear mission statement.

Leaders establish vision and values. They drive and inspire people towards excellence.

Leaders demonstrate the capability to keep a constancy of purpose in a changing environment.

Examples Leaders provide the organisation with a well-defined mission according to legislation and regulation requirements, whilst taking into account the stakeholders’ expectations.

Leaders provide the organisation with the definition of a mission, vision and values and share it with the people in the organisation.

Managers at all levels are focused on bringing the mission, vision and values into practice.

Stakeholders are confident about the constancy of purpose and steadiness of management.

Managers are perceived to be role models.

The quality of management has been measured e.g. through management assessment or job satisfaction measurements.

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PART 2: How the CAF External Feedback works

1. Implementation of CAF External Feedback at national level

The Member States will consider and follow the general common guidelines for the CAF External Feedback as described in further detail in this part. By following these guidelines, Member States will guarantee that the CAF External Feedback Procedure is organised in a qualitative way and that – as a consequence – the ‘Effective CAF User’ label enjoys a high standard across the European Union. The concrete implementation of the CAF External Feedback Procedure in the different EU Member States will be their own responsibility and depending on national circumstances.

The ‘National Organiser’ (NO) is appointed at national level to be in charge of the implementation of the CAF External Feedback in the country. The organisation in charge depends on the national context and can be a separate organisational unit at the ministry in charge of public administration or at another organisation, a separate organisation or others. Irrespective of a concrete organisational solution, the National Organiser must be recognisable and promoted as such.

The National Organiser selects a core group of CAF External Feedback Actors (the evaluators providing external feedback), organises training for them at national and/or European level, distributes the workload amongst them and evaluates their functioning at regular times. The National Organiser awards the Effective CAF User label, based on the recommendations of the CAF External Feedback Actors and informs the European CAF RC of the labels awarded so that this information can be incorporated in the European database. The underlying principle of the CAF External Feedback is that organisations can make use of it at minimum cost.

2. The role of the European CAF Resource Centre

Besides managing the CAF database, the European CAF Resource Centre at the European Institute of Public Administration (EIPA) in Maastricht supports the Member States in implementing the CAF External Feedback Procedure through a number of initiatives: promoting the CAF External Feedback at European level, introducing the National CAF Correspondents to this procedure and offering a common European

18

training scheme for CAF External Feedback Actors, coordinating support for Member States that do not have a National Organiser and organising the CAF External Feedback Procedure for non EU members and European institutions.

The network of National CAF Correspondents regularly reports to the Directors-General of the European Public Administration Network (EUPAN), through the Innovative Public Services Group. In order to play its coordinating role, the CAF Resource Centre receives information from the Member States about the National Organiser in the different Member States.

3. Requirements to apply for the ‘Effective CAF User’ Label

Every public organisation using CAF – no matter how many times it has undertaken a self-assessment using the model – can apply for the CAF External Feedback.

CAF User organisations that believe they have done a good job in accordance with the model and require expert feedback on the quality of their CAF implementation within the organisation and its effects on the organisation can apply for the ‘Effective CAF User label.

The eligibility criteria for an organisation to apply are:

1. The application should be made not before the elapse of 6 months but not exceeding the 12 months after the CAF self-assessment has taken place and the self-assessment report has been concluded and delivered. Working with the CAF implies carrying out a self- assessment and launching concrete improvement actions. In order to receive sufficient feedback on this second part, the organisation needs time to set up these improvements. Immediately after the self-assessment, motivation and dynamics are high resulting in the organisation to be willing to implement any proposals put forward during the self-assessment.

After a few months, some organisations could enter a phase of reduced enthusiasm. This might be a good moment for CAF External Feedback Actors to come in and help maintain enthusiasm.

2. Thesecondrequirementisthattheorganisation must register or be registered as a CAF User in the online European database of CAF Users, which is hosted by EIPA at caf.eipa.eu.

The organisation can register itself or be registered through a registration process at national level, incorporated by the national CAF Correspondent in the European database, depending on the situation at national level. On the website of the European CAF Resource Centre at EIPA (www.eipa.eu/caf ), the organisation can find the location of the person or organisation responsible for the CAF in their country.

Organisations meeting these two requirements may apply for the Effective CAF User label.

The CAF External Feedback Procedure consists of three phases to be undertaken by the organisation:Phase 1: the applicationPhase 2: the process of providing feedbackPhase 3: the final decision and awarding of the Effective CAF User label

These phases are described in detail below.

4. The phases in the CAF External Feedback Procedure

Phase 1: Application for the Effective CAF User Label

In this first phase, preparations are made for the actual feedback process. In this phase, the actors are the applicant organisation on the one hand and the National Organiser on the other hand.

Four different steps need to be taken in this phase.

1

StartPhase 2

Applicant Organisation

National Organiser

Check documentsSTEP 3

STEP 4

Fill in documents

STEP 2

Send info packageSTEP 1

Request

PHASE 1

PART 2: How the CAF External Feedback works

19PART 2: How the CAF External Feedback works

STEP 1 The candidate public organisation contacts the National Organiser (NO) to request CAF External Feedback. To that end, it submits the statement (see Appendix 4) confirming its fulfilment of the two requirements.

STEP 2 The National Organiser while confirming receipt of application, will send a complete information package and invites the applicant to submit:• ashortpresentationoftheorganisation;• a brief description of the CAF self-assessment process;• the last self-assessment report(s) presented to the management;• the action plan(s) for implementation of improvements.

STEP 3 The applicant completes the requested information and returns it to the National Organiser in order to proceed towards the actual CAF External Feedback (Phase 2).

STEP 4 Once the required documents have been received by the National Organiser, the applicant organisation will receive a written acknowledgement, thereby signalling that the feedback procedure (Phase 2) could start.

Phase 2: Providing the Feedback

After the applicant organisation has fulfilled all the requirements in the first phase, the actual feedback procedure is launched in Phase 2.

This phase consists of six major steps and involves three different actors:• theapplicantorganisation;• theNationalOrganiser;and• theCAFExternalFeedbackActors.

These CAF External Feedback Actors are the persons who will judge the CAF assessment and its impact on the organisation and provide the organisation with useful feedback.

STEP 1 The National Organiser will designate two or more CAF External Feedback Actors which team number depend on the type, size and complexity of the applicant organisation.

The different aspects of the CAF External Feedback Actors’ role are described in the next part.

STEP 2 The National Organiser informs the applicant organisation of the CAF External Feedback Actors in charge and sends the three CAF External Feedback questionnaires. The applicant organisation is invited to complete the three questionnaires based on its own judgement and to submit them to the CAF External Feedback Actors designated and/or to the National Organiser (based on national context/arrangements):1. Questionnaire on the CAF self-assessment process;2. Questionnaire on the improvement process;3. Questionnaire on TQM Maturity.

STEP 3 The CAF External Feedback Actors will analyse the questionnaires submitted by the organisation.

STEP 4 Preparation of site visit: The CAF External Feedback Actors inform the organisation through an introductory meeting, common seminars or multimedia contacts on the main purpose of the site visit, in order to align expectations and decide upon the amount of documentation necessary and which persons, institutions and groups the CAF External Feedback Actors wish to have participate in interviews and workshops during the site visit. Part of this communication is to discuss the main themes and challenges of particular importance during the actual site visit. All participants in the CAF External Feedback should be aware of what they need to do to prepare for the site visit.

STEP 5 The site visit lasts a maximum of two days, depending on the type, size and complexity of the applicant organisation. The CAF External Feedback Actors examine whether the organisation has implemented the CAF model effectively:

2CAF Feedback

Actors

Applicantorganisation

Site visit

Checkdocuments

StartPhase 3

AnalyseQuestionnares

Preparesite visit

OralFeedback

Designation of CAF Feedback

Actors

STEP 1

STEP 2

STEP 3 STEP 3

STEP 6

PHASE 2

Fill in Questionaires

Send 3Questionaires

Feedbackreport & Recom-

mondation

STEP 4

STEP 5

National Organiser

20 PART 2: How the CAF External Feedback works

1. They analyse the quality of the self-assessment process, using the answers to the process questionnaire as a starting point for discussions (Steps 1 to 6 of the CAF guidelines) with different participants of the SA process than the person(s) who completed the questionnaire.2. They then discuss the drafting, communication and implementation of the improvement process, based on the answers to the improvement plan questionnaire (Steps 7 to 9 of the CAF guidelines), with a number of people involved in this process.3. In order to evaluate the extent to which a TQM culture has been installed, different stakeholders will be interviewed, based upon the questionnaire on TQM Maturity. 4. The CAF External Feedback Actors provide the organisation with an initial verbal impression of their findings.

STEP 6 Based on all the information gathered before and during the site visit, the CAF External Feedback Actors prepare a feedback report within one month. The CAF External Feedback Actors submit this report to the National Organiser together with a recommendation as to whether or not the applicant organisation qualifies for the label of an ‘Effective CAF User’ (a template of the feedback report is shown in Appendix 3).

Phase 3: Decision/Designation of the CAF Label

STEP 1 The National Organiser makes the final decision based on the report/recommendation of the CAF External Feedback Actors.

STEP 2 The National Organiser will send the feedback report together with the decision to the applicant organisation.

The organisation cannot appeal against the decision.

STEP 3 In the case of a positive decision, the applicant organisation receives the label ‘Effective CAF User’ in a timely manner.

STEP 4 The National Organiser informs the EIPA CAF Resource Centre when an organisation has been awarded the label. The CAF Resource Centre publishes the information (receipt of the label and date) in the online European database of CAF Users.

Remark 1:The ‘Effective CAF User’ label expires after two years and may be renewed after a new self-assessment based on CAF, followed by a new application for the label.

Remark 2:If the organisation is not awarded the label of ‘Effective CAF user’, it may apply again after completing a new self assessment based on CAF.

ApplicantOrganisation

National Organiser

Send feedback report

Step 1 finaldecision

Informs the CAF

Resource Centre

Send decision

STEP 2

STEP 3

STEP 4

Send label

PHASE 3

Yes No

3

21

PART 3: The CAF External Feedback Actors

The CAF External Feedback Actors play a crucial role in the CAF External Feedback. This part describes their role and tasks. In addition, the required competences; training; and Code of Conduct and behaviour are explained.

1. Roles, tasks and profile

The main task of the CAF External Feedback Actors in the Procedure is to:• analyse the implementation of CAF through the process of self-assessment and improvement actions and analyse whether the organisation is implementing TQM values;• provide feedbackand suggestionson strengths and areas of improvement regarding the CAF implementation process;• supportandrenewenthusiasmintheorganisation to work with holistic quality development and self assessment with the CAF Model.

One of the goals of the CAF External Feedback is to promote peer review and bench learning within the European public administration. It is for this reason that the CAF External Feedback Actors are peers from within the public sector.

Being a CAF External Feedback Actor requires a balance of personal and professional skills coupled with a commitment to timely and appropriate conduct. In order to conduct the CAF External Feedback process competently, the CAF External Feedback Actor needs to have a broad knowledge and experience of management processes and development and change processes within public sector organisations. The CAF External Feedback Actors can obtain the necessary competencies from a variety of sources including work experience (e.g. EFQM assessor), education and specialized training.

The CAF External Feedback Actor does not need to have been a manager and trained as an EFQM asses-sor or validator. The competencies achieved by such training are however highly useful in the feedback process. Instead, the CAF External Feedback Actor must have participated in the European or national training course required to become a CAF External Feedback Actor (acknowledged by the National CAF Correspond-ent). Highly experienced CAF Users in the public sec-tor are part of the target group for participation in the training courses for External Feedback Actors; this promotes exchange between organisations and increases knowledge within the organisations.

22 PART 3: The CAF External Feedback Actors

2. Competences needed to conduct the CAF External Feedback

In order to fulfil the role described, CAF External Feedback Actors need to possess some general competences. Such competencies are:

• Understand the CAF Model and its internal linkages. This includes understanding the structure and content of the CAF Model and the linkages between and within results and enablers.

• Practical experience with CAF and/or other TQM models as a framework for self-assessment and quality improvements. The CAF External Feedback Actor must have experience with implementation of the CAF model and/or other TQM models.

• Understanding of the fundamental TQM principles and values. The CAF External Feedback Actor must have a good understanding of the fundamental values of TQM and how the values and principles can be applied in practical quality development in organisations.

• Demonstrate an understanding of different public sector organisations and their varying demands and needs. The CAF External Feedback Actor must be able to understand the different demands and needs with regard to implementation of the self- assessment process and the improvement actions. The CAF External Feedback Actor does not use the examples and procedures contained within the CAF External Feedback material as a checklist, but understands that the approaches that are effective and appropriate in one organisation can be insufficient in other public organisations due to different values, leadership, people and internal processes.

• Practice good interpersonal skills and effective communication. The main task of the CAF External Feedback Actor is to provide precise and motivating feedback that supports the organisation’s continuing dedication to holistic and systematic quality development through self-assessment. The CAF External Feedback Actor should have skills and competences to ensure that the CAF External Feedback process is conducted in a way which supports learning, collaboration and dialogue. He/she must therefore be able to communicate effectively in the context of the specific type of institution and use non-abusive language.

• Able to work in a team. When approaching and working with the applicant organisation within the context of the CAF External Feedback, the CAF External Feedback Actor must act in a collegial way, sharing the workload and acting in a complementary manner.

3. Trainingrequired

As the CAF External Feedback is a common European initiative, the CAF External Feedback Actors need to share the most important principles, aims, values and methodologies of the Procedure. Training is therefore provided at national level by the National Organiser and/or the organisations responsible, and at European level by the European CAF Resource Centre at the European Institute of Public Administration (EIPA) in Maastricht. A minimum common core has been defined for this training. This two-day training course consists of five parts, each of them serving particular aims.

Part 1: The Common Assessment FrameworkGoals: Presentation of the main features of the Common Assessment Framework and the process of its implementation.Results: The CAF External Feedback Actors need to know the specificities of the CAF model, the context of public sector organisation and the different steps for applying the CAF model as described in the CAF guidelines.

Part 2: The CAF External Feedback: Philosophy and SystemGoals: The main features and pillars of the CAF External Feedback Procedure are presented.Results: The participants need to know the background behind the need for a CAF External Feedback Procedure, have an in-depth insight into

Work in a teamKnowledge ofthe CAF model

CAF External Feedback Actor Competences

Social andcomminication

skills

Public sectorknowledge

Practical CAFexperience

TQM values& principles

23PART 3: The CAF External Feedback Actors

the philosophy and ambitions of the system and be able to translate these, via the main features and pillars, to applicant organisations.

Part 3: How to Evaluate (applying the CAF External Feedback)Goals: Presentation of the detailed steps in the CAF External Feedback Procedure.Results: The participants know, understand and are able to work with the different questionnaires and scoring guides (theory). They know how to carry out a sound document analysis and conduct the site visit.

Part 4: Code of Conduct and behaviourGoals: Presentation of the Code of Conduct and behaviour for the CAF External Feedback Actors.Results: The Actors know their role as well as what to do and how to behave.

Part 5: Reporting and giving feedbackGoals: Presentation on how to report and give feedback.Results: The CAF External Feedback actors are able to provide feedback (orally and written) and report in a professional and satisfying manner.

4. Code of Conduct and behaviour for the CAF External Feedback Actors

The Code of Conduct is a common framework which states the values and principles of the CAF External Feedback and the requirements set for the conduct of the CAF External Feedback Actors. At national level, the national CAF Correspondent (and/or the National Organiser) may describe additional principles and requirements for the conduct of the CAF External Feedback Actors.

The CAF External Feedback Actors must maintain high standards of ethical behaviour, which means that he/she must maintain independence, conduct themselves in a courteous and respectful fashion, perform their duties diligently, competently and in a timely manner and maintain a personal position which is free from conflicts of interest.

• Independence They must maintain sufficient independence and always give appropriate, effective and correct feedback to the applicant organisation. This includes maintaining impartiality and guarding against bias at all times.

• Personalopportunityorgain They must not have past or future ties (financial or otherwise) with the applicant organisation, which could influence the feedback and validation process.

• Conflictofinterest They must identify and avoid any actual, potential or perceived conflict of interest with the applicant organisation which may throw doubt about the independence of the CAF External Feedback Actors. Any identified conflicts of interest must be brought to the attention of the National CAF correspondent or delegated organisation, which will act on the information.

A conflict of interest could, for example, be the fact that the CAF External Feedback Actor has been or is an employee of the organisation or is employed by an organisation with a conflicting interest towards that organisation. Furthermore, a CAF External Feedback Actor cannot participate in giving feedback to organisations where he or she has participated in the implementation of CAF (thereby validating his/her own work).

• Courtesyandrespect They must always conduct themselves in a courteous and respectful fashion, e.g. by responding promptly to requests for information, being punctual and not engaging in activities, which would bring the CAF External Feedback Actor, CAF External Feedback process or the CAF Model into disrepute.

• Diligence They must conduct themselves in a diligent, competent and timely manner. If the role as CAF External Feedback Actor cannot be carried out in such a manner, the assignment should not be taken on.

• Confidentiality Communication and the information gained during the CAF External Feedback process is confidential and may not be discussed or divulged to third parties (except to the persons/ organisation responsible for awarding the ‘Effective CAF User’ label).

• Positiveattitude To support/instil enthusiasm in the organisation.

24

ReferenceThe reference of the questionnaire is the ‘Ten steps to improve an organisation with CAF’ as defined. in the chapter entitled ‘Guidelines to improving organisations using CAF’ of the CAF 2013. The activities of each step have been adjusted and expanded to take into consideration the lessons learned from the relevant experiences at European level.

The following questionnaire includes questions relating to the first six steps, which focus on the planning and implementation of the self-assessment process.

Steps to be assessedThe questionnaire covers the first six of the ten steps defined in the ‘Guidelines to improving organisations using CAF’ and is not meant for validating the scores.

Evaluation scaleThe evaluation scale has five levels.

This evaluation scale has been detailed for each activity in phrases defining the interpretation of the real situation of the organisation with regard to the specific theme.

Evidence: definitionA various range of tangible and intangible documents/facts/information delivered before and during the site visits.

Appendix 1.1

Questionnaire on Pillar 1The self-assessment process questionnaire

Pillar 1

The process of self-assessment

Steps 1-6 in the 10 step plan

Questionnaire 1(Appendix 1.1)

Pillar 2

The process of improvement actions

Steps 7-9 in the 10 step plan

Questionnaire 2(Appendix 1.2)

Pillar 3

The TQM Maturity of the

organisation

Questionnaire 3(Appendix 1.3)

CAF External Feedback

1 The activities have been carried out in a very limited way.

2 The activities have been carried out in a limited way.

3 The activities have been carried out in an acceptable way.

4 The activities have been carried out in a satisfying (satisfactory) way.

5 The activities have been carried out in an outstanding way.

25

Step

1:

Dec

ide

how

to o

rgan

ise

and

plan

the

self-

asse

ssm

ent (

SA)

Leve

ls

1

23

45

Act

ions

1.1

Ass

ure

com

mitm

ent a

nd

owne

rshi

p of

the

man

agem

ent

for l

aunc

hing

the

proc

ess.

Ther

e is

no

evid

ence

of

com

mitm

ent a

nd o

wne

rshi

p o

f th

e m

anag

emen

t

Ther

e is

som

e ev

iden

ce o

f co

mm

itmen

t of t

he m

anag

emen

t fo

r lau

nchi

ng th

e p

roce

ss, b

ut

limite

d to

som

e of

the

man

ager

s in

volv

ed

Ther

e is

evi

denc

e of

com

mitm

ent

and

owne

rshi

p o

f the

m

anag

emen

t for

laun

chin

g th

e p

roce

ss

Ther

e is

cle

ar e

vide

nce

of

com

mitm

ent a

nd o

wne

rshi

p o

f th

e m

anag

emen

t for

laun

chin

g th

e p

roce

ss, a

ctin

g as

gui

de a

nd

spon

sor,

and

com

mun

icat

ing

the

targ

ets

and

adva

ntag

es

Ther

e is

str

ong

evid

ence

of c

om-

mitm

ent a

nd o

wne

rshi

p o

f all

the

man

agem

ent f

or la

unch

ing

the

pro

cess

, act

ing

as g

uide

and

sp

on-

sor,

com

mun

icat

ing

the

obje

ctiv

es

and

adva

ntag

es a

nd p

artic

ipat

ing

in th

e p

roje

ct d

efini

tion

1.2

Ass

ure

a cl

ear m

anag

emen

t de

cisi

on re

gard

ing

com

plet

ion

of th

e SA

in c

onsu

ltatio

n w

ith

the

orga

nisa

tion,

the

scop

e of

th

e SA

(SA

cov

ers

the

who

le

orga

nisa

tion

or o

nly

part

s/un

its/

depa

rtm

ents

...) a

nd th

e ov

eral

l ob

ject

ive

of th

e SA

.

Ther

e is

no

evid

ence

of a

dec

isio

n by

the

man

agem

ent.

The

deci

sion

ha

s b

een

take

n by

one

or m

ore

per

sons

with

out c

onsu

ltat

ion

with

th

e m

anag

emen

t

Ther

e is

som

e ev

iden

ce o

f con

sul-

tatio

n w

ith th

e m

anag

emen

t, b

ut

with

out a

dis

cuss

ion

of th

e cr

iteria

fo

r the

dec

isio

n an

d ch

oice

, a

form

al d

ecis

ion

and

a cl

ear

defin

ition

of t

he o

bje

ctiv

es

Ther

e is

evi

denc

e of

con

sult

atio

n w

ith th

e m

anag

emen

t tea

m a

nd o

f a

form

al d

ecis

ion,

but

the

crite

ria

for t

he c

hoic

e an

d th

e ob

ject

ives

ar

e no

t cle

arly

defi

ned

Ther

e is

cle

ar e

vide

nce

of th

e m

anag

emen

t dec

isio

n to

real

ise

the

eval

uatio

n, w

ithin

the

fram

e-w

ork

of th

e p

erio

dic

mee

tings

, in

volv

ing

the

head

s of

the

func

tions

. The

dec

isio

n ha

s b

een

form

alis

ed in

a d

ocum

ent a

nd th

e SA

ob

ject

ives

hav

e b

een

clea

rly

defin

ed, b

ut th

e cr

iteria

for t

he

choi

ce a

re n

ot c

omp

lete

ly e

vide

nt

Ther

e is

str

ong

evid

ence

of a

m

anag

emen

t dec

isio

n, ta

ken

afte

r a

wel

l-pon

dere

d di

scus

sion

invo

l-vi

ng th

e he

ads

of th

e co

mp

eten

t fu

nctio

ns, w

ith a

defi

nitio

n of

the

scop

e of

the

SA b

ased

on

wel

l-de

fined

crit

eria

. The

dec

isio

n an

d th

e sc

ope

have

bee

n fo

rmal

ised

in

a d

ocum

ent.

The

SA o

bje

ctiv

es

and

adva

ntag

es fo

r the

sta

keho

l-de

rs h

ave

bee

n cl

earl

y de

fined

1.3

Defi

ne th

e fr

amew

ork

for t

he

SA p

roce

ss a

nd th

e fo

llow

ing

ctio

ns, a

nd p

lan

the

SA a

ctiv

ities

.

Ther

e is

no

evid

ence

of a

real

pla

nTh

ere

is s

ome

evid

ence

of a

pla

n,

but

it p

artl

y co

vers

the

SA p

roce

ss

and

the

sub

sequ

ent a

ctio

ns

Ther

e is

evi

denc

e of

a p

lan

for t

he

SA p

roce

ss a

nd th

e su

bse

quen

t ac

tions

, but

it is

not

com

ple

tely

st

ruct

ured

(res

pon

sib

ilitie

s,

reso

urce

s, ti

me

sche

dulin

g)

Ther

e is

cle

ar e

vide

nce

of p

lann

ing

for t

he S

A p

roce

ss a

nd th

e su

bse

quen

t act

ions

, inc

ludi

ng

resp

onsi

bili

ties,

reso

urce

s, ti

me

sche

dulin

g an

d m

onito

ring

Ther

e is

str

ong

evid

ence

of p

lan-

ning

for t

he S

A p

roce

ss a

nd th

e su

bse

quen

t act

ions

, in

cohe

renc

e w

ith th

e p

lans

and

str

ateg

ies

of

the

orga

nisa

tion.

The

pla

n in

clu-

des

resp

onsi

bili

ties,

reso

urce

s,

time

sche

dulin

g

1.4

App

oint

an

SA p

roce

ss le

ader

w

ith a

hig

h le

vel o

f kno

wle

dge

of th

e or

gani

satio

n or

form

an

SA C

omm

ittee

hea

ded

by th

e SA

pro

cess

lead

er.

Ther

e is

no

evid

ence

of

form

alis

ed ta

sks

assi

gned

by

the

man

agem

ent

Ther

e is

som

e ev

iden

ce o

f a ta

sk

assi

gned

by

man

agem

ent,

but

no

t for

mal

ised

and

with

out c

lear

cr

iteria

for t

he c

hoic

e

Ther

e is

evi

denc

e of

a fo

rmal

ised

ta

sk a

ssig

ned

by m

anag

emen

t, b

ut th

ere

is li

mite

d ev

iden

ce o

f ap

pro

pria

te c

riter

ia fo

r the

cho

ice

(incl

udin

g th

e ap

pro

pria

te

know

ledg

e of

CA

F m

odel

)

Ther

e is

cle

ar e

vide

nce

of a

fo

rmal

ised

task

ass

igne

d by

the

man

agem

ent,

with

defi

nitio

n of

the

SA le

ader

on

the

bas

is o

f kn

owle

dge

of th

e or

gani

satio

n an

d ap

pro

pria

te k

now

ledg

e of

C

AF

mod

el

Ther

e is

str

ong

evid

ence

of a

fo

rmal

ised

task

ass

igne

d by

the

man

agem

ent,

with

defi

nitio

n of

the

SA le

ader

on

the

bas

is o

f kn

owle

dge

of th

e or

gani

satio

n,

exp

ertis

e of

the

CA

F m

odel

and

ac

know

ledg

ed le

ader

ship

1.5

Defi

ne th

e sc

orin

g pa

nel t

o be

use

d.Th

ere

is n

o ev

iden

ce o

f defi

nitio

n of

the

scor

ing

pan

el, i

n co

here

nce

with

the

mod

el

Ther

e is

som

e ev

iden

ce o

f de

finiti

on o

f the

sco

ring

pan

el b

ut

it is

not

fully

coh

eren

t with

the

mod

el a

nd th

e di

ffer

ence

s ar

e no

t co

mp

lete

ly a

ccep

tab

le

Ther

e is

evi

denc

e of

defi

nitio

n of

the

scor

ing

pan

el to

be

used

, co

here

nt w

ith th

e m

odel

, but

th

e co

here

nce

with

the

SA p

lan

(res

ourc

es, t

ime

sche

dulin

g) h

as

not b

een

verifi

eD

Ther

e is

cle

ar e

vide

nce

of d

efini

ti-on

of t

he s

corin

g p

anel

to b

e us

ed,

com

ple

tely

coh

eren

t with

the

mod

el a

nd th

e SA

pla

n (r

esou

rces

, tim

e sc

hedu

ling)

.

Ther

e is

str

ong

evid

ence

of

defin

ition

. The

sco

ring

pan

el is

co

mp

lete

ly c

oher

ent w

ith th

e m

odel

and

the

SA p

lan

(res

ourc

es,

time

sche

dulin

g). I

ts c

hoic

e ha

s b

een

eval

uate

d an

d is

bas

ed o

n th

e or

gani

satio

n co

ntex

t and

m

atur

ity

1.6

Allo

cate

reso

urce

s fo

r the

SA

and

defi

ne h

ow to

pri

oriti

se

dist

ribu

tion

of th

e re

sour

ces.

Ther

e is

no

evid

ence

of e

valu

atio

n of

reso

urce

s re

quire

d fo

r the

SA

Th

ere

is s

ome

evid

ence

of t

he

eval

uatio

n of

reso

urce

s re

quire

d fo

r the

SA

, but

the

allo

catio

n of

the

requ

ired

reso

urce

s is

not

evi

dent

Ther

e is

evi

denc

e of

eva

luat

ion

of

the

reso

urce

s re

quire

d fo

r the

SA

. Th

e al

loca

tion

of th

e re

sour

ces

has

bee

n de

fined

, but

the

avai

lab

ility

of

reso

urce

s is

not

evi

dent

for a

ll th

e ac

tiviti

es

Ther

e is

cle

ar e

vide

nce

of

eval

uatio

n of

the

reso

urce

s re

quire

d fo

r the

SA

. The

allo

catio

n of

the

reso

urce

s ha

s b

een

defin

ed

and

thei

r ava

ilab

ility

is e

ssen

tially

ev

iden

t, b

ut p

riorit

isat

ion

crite

ria

are

not e

vide

nt

Ther

e is

str

ong

evid

ence

of e

valu

-at

ion

of th

e re

sour

ces

requ

ired

for

the

SA. T

he re

sour

ces

have

bee

n al

loca

ted,

defi

ning

thei

r prio

ritie

s.

The

avai

lab

ility

of r

equi

red

reso

ur-

ces

and

the

prio

ritis

atio

n cr

iteria

ar

e ev

iden

t for

all

pos

ition

s

26

Step

2: C

omm

unic

ate

the

self-

asse

ssm

ent p

roje

ct

Leve

ls

12

34

5

Act

ions

2.1

Defi

ne a

com

mun

icat

ion

plan

, to

incl

ude

the

expe

cted

ben

efits

, th

e go

al a

nd th

e ac

tiviti

es o

f the

SA

.

Ther

e is

no

evid

ence

of a

com

mu-

nica

tion

pla

nTh

ere

is s

ome

evid

ence

of a

com

-m

unic

atio

n p

lan,

but

the

cont

ents

do

not

gua

rant

ee a

dequ

ate

info

r-m

atio

n ab

out t

he S

A (o

bje

ctiv

es,

goal

and

act

iviti

es, s

take

hold

ers

invo

lved

etc

.)

Ther

e is

evi

denc

e of

a c

omm

uni-

catio

n p

lan,

incl

udin

g su

ffici

ent

info

rmat

ion

abou

t the

SA

(ob

jec-

tives

, goa

l and

act

iviti

es, r

elev

ant

stak

ehol

ders

invo

lved

etc

.)

Ther

e is

cle

ar e

vide

nce

of a

co

mm

unic

atio

n p

lan,

incl

udin

g de

taile

d in

form

atio

n ab

out t

he

obje

ctiv

es, t

he g

oal,

the

exp

ecte

d b

enefi

ts a

nd a

des

crip

tion

of th

e ac

tiviti

es. T

he c

omm

unic

atio

n p

lan

is a

ddre

ssed

to th

e re

leva

nt

stak

ehol

ders

Ther

e is

str

ong

evid

ence

of a

co

mm

unic

atio

n p

lan,

with

a d

e-ta

iled

indi

catio

n of

the

obje

ctiv

es

and

goal

of t

he a

ctiv

ities

, the

ex

pec

ted

ben

efits

for t

he d

iffer

ent

stak

ehol

ders

and

a d

etai

led

desc

riptio

n of

the

activ

ities

. The

co

mm

unic

atio

n p

lan

is a

ddre

ssed

to

all

the

stak

ehol

ders

and

defi

nes

the

invo

lvem

ent o

f the

diff

eren

t p

artie

s in

the

pla

n

2.2

Impl

emen

t the

com

mun

ica-

tion

plan

usi

ng d

iffer

ent t

ools

Ther

e is

no

evid

ence

of i

mp

lem

en-

tatio

n of

the

com

mun

icat

ion

pla

n an

d/or

of t

he d

efine

d to

ols,

or

the

com

mun

icat

ion

is li

mite

d an

d ge

neric

Ther

e is

som

e ev

iden

ce o

f im

ple

-m

enta

tion

of th

e co

mm

unic

atio

n p

lan

and

of th

e to

ols

used

, but

the

pla

n is

imp

lem

ente

d in

a li

mite

d w

ay, o

r the

com

mun

icat

ion

is n

ot

com

ple

tely

ade

quat

e

Ther

e is

evi

denc

e of

imp

lem

en-

tatio

n of

the

com

mun

icat

ion

pla

n, u

sing

diff

eren

t too

ls; t

he

cont

ents

of t

he c

omm

unic

atio

n ar

e ad

equa

te

Ther

e is

cle

ar e

vide

nce

of im

ple

-m

enta

tion

of th

e co

mm

unic

atio

n p

lan,

usi

ng d

iffer

ent t

ools

in a

n ev

alua

ted

and

defin

ed w

ay. T

he

cont

ents

of t

he c

omm

unic

atio

n ar

e co

mp

lete

Ther

e is

str

ong

evid

ence

of i

mp

le-

men

tatio

n of

the

com

mun

icat

ion

pla

n, u

sing

the

app

rop

riate

tool

s in

the

diff

eren

t pha

ses

and

for d

if-fe

rent

par

ties

in a

n ev

alua

ted

and

defin

ed w

ay. T

he c

onte

nts

of th

e co

mm

unic

atio

n ar

e co

mp

lete

and

th

e eff

ectiv

enes

s of

the

com

mun

i-ca

tion

has

bee

n ve

rified

2.3

Com

mun

icat

e du

ring

the

diffe

rent

pha

ses

of th

e SA

pro

-ce

ss to

all

rele

vant

sta

keho

lder

s an

d st

imul

ate

the

invo

lvem

ent i

n th

e SA

of t

he to

p an

d m

iddl

e m

anag

ers,

sta

ff a

nd e

mpl

oyee

s

Ther

e is

no

evid

ence

of c

omm

u-ni

catio

n in

the

diff

eren

t pha

ses

of

the

SA a

nd to

rele

vant

sta

keho

l-de

rs, a

nd th

ere

are

no in

itiat

ives

fo

r inv

olve

men

t of i

nter

nal p

artie

s

Ther

e is

som

e ev

iden

ce o

f im

ple

-m

enta

tion

of th

e co

mm

unic

atio

n p

lan,

but

not

in a

sys

tem

atic

way

in

the

pha

ses

of th

e SA

and

/ or

no

t to

the

rele

vant

sta

keho

lder

s,

and/

or it

is n

ot a

dequ

ate

to

stim

ulat

e th

e in

volv

emen

t of t

he

inte

rnal

par

ties

Ther

e is

evi

denc

e of

imp

lem

enta

-tio

n of

the

com

mun

icat

ion

pla

n,

real

ised

in a

sys

tem

atic

way

in th

e m

ain

pha

ses

of th

e SA

and

to th

e ke

y re

leva

nt s

take

hold

ers,

in a

n ad

equa

te w

ay to

stim

ulat

e th

e in

volv

emen

t of i

nter

nal p

artie

s

Ther

e is

cle

ar e

vide

nce

of im

ple

-m

enta

tion

of th

e co

mm

unic

atio

n p

lan,

real

ised

in a

sys

tem

atic

way

in

all

the

pha

ses

of th

e SA

and

ad

dres

sed

to th

e re

leva

nt s

take

-ho

lder

s, a

nd it

is c

lear

ly a

ddre

ssed

to

the

invo

lvem

ent o

f the

inte

rnal

p

artie

s

Ther

e is

str

ong

evid

ence

of i

mp

le-

men

tatio

n of

the

com

mun

icat

ion

pla

n, re

alis

ed in

all

the

diff

eren

t p

hase

s of

the

SA a

nd a

ddre

ssed

to

all

the

rele

vant

sta

keho

lder

s,

and

it is

cle

arly

and

sp

ecifi

cally

ad

dres

sed

to th

e in

volv

emen

t of

all t

he re

leva

nt in

tern

al p

artie

s (t

op a

nd m

iddl

e m

anag

ers,

sta

ff

and

emp

loye

es)

27

Step

3: C

reat

e a

self-

asse

ssm

ent g

roup

(s)

Leve

ls

12

34

5

Act

ions

3.1

Dec

ide

if it

is n

eces

sary

to

crea

te o

ne o

r mor

e SA

gro

ups,

de

fine

thei

r num

ber,

crea

te a

nd

orga

nise

them

(cho

osin

g th

eir

chai

r, as

sign

ing

resp

onsi

bilit

ies

to e

ach

mem

ber a

s ne

eded

).

Ther

e is

no

evid

ence

of t

he

deci

sion

to c

reat

e SA

gro

up(s

) and

to

ass

ign

the

chai

r and

resp

onsi

-b

ilitie

s

Ther

e is

som

e ev

iden

ce o

f the

de

cisi

on a

nd c

riter

ia to

cre

ate

an

SA g

roup

, but

the

crite

ria fo

r the

ch

oice

of i

ts s

ize

and

the

assi

gn-

men

t of t

he c

hair

and

resp

onsi

bili

-tie

s ar

e no

t cle

ar

Ther

e is

evi

denc

e of

the

deci

-si

on a

nd c

riter

ia to

cre

ate

the

SA g

roup

(s) a

nd to

defi

ne th

eir

size

, but

the

assi

gnm

ent o

f the

re

spon

sib

ilitie

s in

side

the

grou

p(s

) is

par

tial o

r has

not

form

ally

bee

n de

fined

Ther

e is

cle

ar e

vide

nce

of th

e de

cisi

on a

nd c

riter

ia to

cre

ate

the

SA g

roup

(s),

on th

e b

asis

of

an e

valu

atio

n of

the

num

ber

of

the

SA g

roup

s an

d th

eir s

ize;

the

crea

tion

of th

e SA

gro

up(s

) was

fo

rmal

ised

with

the

app

oint

men

t of

the

chai

r and

the

assi

gnm

ent o

f ta

sks

and

resp

onsi

bili

ties

Ther

e is

str

ong

evid

ence

of t

he

deci

sion

and

crit

eria

to c

reat

e th

e SA

gro

up(s

), on

the

bas

is o

f an

eva

luat

ion

of th

e nu

mb

er

of th

e SA

gro

ups

and

thei

r siz

e,

docu

men

ting

the

reas

ons

for t

he

choi

ces;

thei

r cre

atio

n w

as fo

rma-

lised

with

the

app

oint

men

t of t

he

chai

r and

the

assi

gnm

ent o

f all

the

requ

ired

task

s an

d re

spon

sib

ilitie

s to

eac

h m

emb

er

3.2

Dec

ide

if th

e m

anag

er(s

) sh

ould

be

part

of t

he S

A g

roup

(s).

Ther

e is

no

evid

ence

of a

n ev

a-lu

atio

n an

d de

cisi

on a

bou

t the

p

artic

ipat

ion

of th

e m

anag

er(s

) in

the

SA g

roup

(s)

Ther

e is

som

e ev

iden

ce o

f a d

eci-

sion

ab

out t

he p

artic

ipat

ion

of th

e m

anag

er(s

) in

the

SA g

roup

(s),

but

th

e ev

alua

tions

for t

he d

ecis

ion

are

not c

lear

Ther

e is

evi

denc

e of

an

eval

uatio

n an

d de

cisi

on a

bou

t the

par

ticip

a-tio

n of

the

man

ager

(s) i

n th

e SA

gr

oup

(s)

Ther

e is

cle

ar e

vide

nce

of e

valu

-at

ions

and

a d

ecis

ion

abou

t the

p

artic

ipat

ion

of th

e m

anag

er(s

) in

the

grou

p(s

), co

nsid

erin

g th

e cu

ltur

e of

the

orga

nisa

tion

and

indi

catin

g th

e p

ossi

ble

role

of t

he

man

ager

s

Ther

e is

str

ong

evid

ence

of

form

al e

valu

atio

ns a

nd a

dec

isio

n ab

out t

he p

artic

ipat

ion

of th

e m

anag

er(s

) in

the

grou

p(s

), co

n-si

derin

g th

e cu

ltur

e an

d tr

aditi

on

of th

e or

gani

satio

n an

d in

dica

ting

the

role

of t

he m

anag

ers

in th

e di

ffer

ent p

hase

s

3.3

Sele

ct th

e pa

rtic

ipan

ts o

f th

e SA

gro

up(s

) on

the

basi

s of

sp

ecifi

ed c

rite

ria

such

as

thei

r kn

owle

dge

of th

e or

gani

satio

n,

thei

r per

sona

l ski

lls a

nd th

eir

repr

esen

tativ

enes

s.

Ther

e is

no

evid

ence

of c

riter

ia fo

r se

lect

ion

of th

e p

artic

ipan

ts o

f the

SA

gro

up(s

)

Ther

e is

som

e ev

iden

ce o

f crit

eria

fo

r the

sel

ectio

n of

the

par

tici-

pan

ts o

f the

SA

gro

up(s

), b

ut th

ey

are

not o

r are

onl

y p

artl

y b

ased

on

know

ledg

e of

the

orga

nisa

tion,

p

erso

nal s

kills

and

rep

rese

nta-

tiven

ess

Ther

e is

evi

denc

e of

crit

eria

for t

he

sele

ctio

n of

mos

t of t

he p

artic

i-p

ants

of t

he S

A g

roup

(s),

bas

ed

on s

pec

ified

crit

eria

suc

h as

thei

r kn

owle

dge

of th

e or

gani

satio

n,

thei

r per

sona

l ski

lls a

nd th

eir

rep

rese

ntat

iven

ess

Ther

e is

cle

ar e

vide

nce

of c

riter

ia

for t

he s

elec

tion

of a

ll th

e p

arti-

cip

ants

of t

he S

A g

roup

(s),

bas

ed

on s

pec

ified

crit

eria

suc

h as

thei

r kn

owle

dge

of th

e or

gani

satio

n,

thei

r per

sona

l ski

lls a

nd th

eir

rep

rese

ntat

iven

ess.

The

sel

ectio

n cr

iteria

hav

e b

een

docu

men

ted

Ther

e is

str

ong

and

docu

men

ted

evid

ence

of c

riter

ia fo

r sel

ectio

n of

all

the

par

ticip

ants

in th

e SA

gr

oup,

bas

ed o

n kn

owle

dge

of th

e or

gani

satio

n, p

erso

nal s

kills

and

re

pre

sent

ativ

enes

s an

d p

artic

i-p

atio

n of

all

inte

rnal

func

tions

in

volv

ed; t

he c

hara

cter

istic

s of

th

e se

lect

ed p

artic

ipan

ts h

ave

bee

n ta

ken

into

acc

ount

in th

e de

finiti

on o

f the

role

s an

d in

the

orga

nisa

tion

of th

e gr

oup

(s)

28

Step

4: O

rgan

ise

trai

ning

Leve

ls

12

34

5

Act

ions

4.1

Org

anis

e in

form

atio

n/tr

aini

ng a

ctiv

ities

for l

eade

rs a

nd

man

ager

s (t

op a

nd m

iddl

e) to

pr

omot

e ow

ners

hip

and

com

mitm

ent.

Ther

e is

no

evid

ence

of i

nfor

mat

i-on

/ tr

aini

ng a

ctiv

ities

for l

eade

rs

and

man

ager

s

Ther

e is

som

e ev

iden

ce o

f inf

or-

mat

ion

/ tra

inin

g ac

tiviti

es b

ut it

do

es n

ot in

volv

e al

l the

pro

per

le

vels

and

/or i

t is

not a

dequ

ate

to p

rom

ote

owne

rshi

p a

nd c

om-

mitm

ent

Ther

e is

evi

denc

e of

info

rmat

ion

/ tra

inin

g ac

tiviti

es fo

r the

lead

ers

and

man

ager

s to

pro

mot

e ow

ner-

ship

and

com

mitm

ent

Ther

e is

cle

ar e

vide

nce

of in

for-

mat

ion

/ tra

inin

g ac

tiviti

es, b

ased

on

the

need

s of

the

diff

eren

t ma-

nage

men

t lev

els

and

to p

rom

ote

owne

rshi

p a

nd c

omm

itmen

t at

each

leve

l

Ther

e is

str

ong

evid

ence

of

info

rmat

ion

/ tra

inin

g ac

tiviti

es,

orga

nise

d to

take

into

acc

ount

th

e di

ffer

ent a

spec

ts (m

odel

, SA

p

roce

ss, m

etric

s, s

tep

s, e

tc.),

bas

ed

on th

e ne

eds

of th

e di

ffer

ent

man

agem

ent l

evel

s to

pro

mot

e ow

ners

hip

and

com

mitm

ent a

t ea

ch le

vel

4.2

Prep

are

a pl

an fo

r all

the

trai

ning

act

iviti

es o

f the

SA

gr

oup(

s).

Ther

e is

no

evid

ence

of a

pla

n fo

r tr

aini

ng a

ctiv

ities

Ther

e is

som

e ev

iden

ce o

f a p

lan

for t

he tr

aini

ng a

ctiv

ities

, but

the

cont

ents

are

par

tial a

nd n

ot a

de-

quat

e fo

r the

nee

ds o

f the

gro

ups

(com

ple

tene

ss, t

ime,

teac

hers

, ...)

Ther

e is

evi

denc

e of

a p

lan

for t

rai-

ning

act

iviti

es fo

r the

SA

gro

up(s

); th

e p

lan

has

bee

n fo

rmal

ised

and

th

e co

nten

ts a

re a

dequ

ate

for t

he

need

s of

the

grou

ps

(com

ple

te-

ness

, tim

e, te

ache

rs...

)

Ther

e is

cle

ar e

vide

nce

of p

lann

ing

for t

rain

ing

activ

ities

for t

he S

A

grou

p(s

); th

e ac

tiviti

es h

ave

bee

n p

lann

ed in

det

ail,

the

feas

ibili

ty

has

bee

n ve

rified

, the

pla

n ha

s b

een

form

alis

ed a

nd th

e co

nten

ts

are

adeq

uate

for t

he n

eeds

of

the

grou

ps

(com

ple

tene

ss, t

ime,

te

ache

rs, .

..)

Ther

e is

str

ong

evid

ence

of t

rai-

ning

act

iviti

es fo

r the

SA

gro

up(s

); th

ey h

ave

bee

n p

lann

ed in

det

ail,

the

feas

ibili

ty h

as b

een

verifi

ed,

the

pla

n ha

s b

een

form

alis

ed a

nd

the

cont

ents

are

ade

quat

e fo

r the

ne

eds

of th

e gr

oup

s (c

omp

lete

-ne

ss, t

ime,

teac

hers

,...);

the

pla

n in

clud

es s

tep

s to

ver

ify th

e eff

ec-

tiven

ess

of th

e tr

aini

ng a

ctiv

ities

4.3

Trai

n th

e m

embe

rs o

f the

SA

gr

oup(

s).

Ther

e is

no

evid

ence

of t

rain

ing

of

the

SA g

roup

(s)

Ther

e is

som

e ev

iden

ce o

f rea

lisa-

tion

of th

e tr

aini

ng, b

ut n

ot c

om-

ple

te w

ith re

spec

t to

the

pla

n or

no

t ade

quat

e fo

r the

nee

ds o

f the

m

emb

ers

of th

e SA

gro

up(s

), w

ith

rega

rd to

con

tent

s, p

artic

ipat

ion,

tim

e sc

hedu

ling

and

teac

hers

Ther

e is

evi

denc

e of

real

isat

ion

of

the

trai

ning

act

iviti

es. T

he tr

aini

ng

resp

ects

the

key

elem

ents

of t

he

pla

n an

d it

is a

dequ

ate

for t

he

need

s of

the

mem

ber

s of

the

SA

grou

p(s

), w

ith re

gard

to c

onte

nts,

p

artic

ipat

ion,

tim

e sc

hedu

ling

and

teac

hers

Ther

e is

cle

ar e

vide

nce

of re

alis

a-tio

n of

the

trai

ning

act

iviti

es. T

he

mem

ber

s of

the

SA g

roup

(s) a

re

adeq

uate

ly tr

aine

d ac

cord

ing

to

the

spec

ific

need

s of

eac

h m

emb

er

and

to th

e tr

aini

ng p

lan.

Ther

e is

str

ong

evid

ence

of r

ea-

lisat

ion

of th

e tr

aini

ng a

ctiv

ities

. Th

e m

emb

ers

of th

e SA

gro

up(s

) ar

e ad

equa

tely

trai

ned

acco

rdin

g to

the

spec

ific

need

s of

eac

h m

emb

er a

nd to

the

trai

ning

pla

n.

The

effec

tiven

ess

of th

e tr

aini

ng

has

bee

n p

ositi

vely

ver

ified

29

Step

5: P

erfo

rm th

e se

lf-as

sess

men

t

Leve

ls

12

34

5

Act

ions

5.1

Rele

vant

doc

umen

ts a

nd

info

rmat

ion

for S

A a

re c

olle

cted

an

d m

ade

avai

labl

e to

all

the

SA

grou

ps

Ther

e is

no

evid

ence

of r

elev

ant

docu

men

ts a

nd in

form

atio

n fo

r SA

bei

ng m

ade

avai

lab

le to

SA

gr

oup

(s)

Ther

e is

som

e ev

iden

ce o

f doc

u-m

ents

bei

ng m

ade

avai

lab

le, b

ut

they

do

not s

uffici

entl

y co

ver t

he

nece

ssar

y in

form

atio

n fo

r all

the

key

pro

cess

es a

nd re

sult

s of

the

orga

nisa

tion

and

for a

ll th

e ar

eas

of th

e m

odel

Ther

e is

evi

denc

e of

doc

umen

ts

and

info

rmat

ion

for S

A b

eing

co

llect

ed a

nd m

ade

avai

lab

le.

They

cov

er th

e ke

y p

roce

sses

and

re

sult

s of

the

orga

nisa

tion

and

mos

t are

as o

f the

mod

el

Ther

e is

cle

ar e

vide

nce

of

docu

men

ts a

nd in

form

atio

n fo

r SA

bei

ng c

olle

cted

and

mad

e av

aila

ble

. The

y co

ver a

ll th

e re

le-

vant

pro

cess

es a

nd re

sult

s of

the

orga

nisa

tion

and

all t

he a

reas

of

the

mod

el

Ther

e is

str

ong

evid

ence

of

docu

men

ts a

nd in

form

atio

n fo

r SA

bei

ng c

olle

cted

and

mad

e av

aila

ble

. The

y co

nsid

er a

ll th

e re

leva

nt p

roce

sses

/ p

roje

cts

and

resu

lts,

and

all

the

area

s of

the

mod

el. T

hey

pro

vide

info

rmat

i-on

on

pla

nned

act

iviti

es (p

lan)

, th

eir r

ealis

atio

n (d

o), v

erifi

catio

n (c

heck

) and

imp

rove

men

t (ac

t) fo

r al

l are

as o

f the

mod

el

5.2

The

mem

bers

of t

he S

A

grou

p(s)

mak

e up

a li

st o

f st

reng

ths

and

area

s fo

r im

pro-

vem

ent a

nd a

sco

re fo

r eac

h su

b-cr

iteri

on o

f CA

F.

Ther

e is

no

evid

ence

of l

ists

of

stre

ngth

s an

d ar

eas

for i

mp

ro-

vem

ent a

nd/o

r sco

res

bei

ng

pre

par

ed b

y th

e m

emb

ers

of S

A

grou

p(s

)

Ther

e is

som

e ev

iden

ce o

f in

divi

dual

inp

uts

bei

ng m

ade

avai

lab

le w

ith s

ome

indi

catio

ns o

f st

reng

ths,

are

as fo

r im

pro

vem

ent

and/

or s

core

s, b

ut th

ey a

re n

ot

avai

lab

le fr

om a

ll th

e m

emb

ers

and/

or a

re n

ot c

omp

lete

for e

ach

sub

-crit

erio

n

Ther

e is

evi

denc

e of

indi

vidu

al

inp

uts

bei

ng m

ade

avai

lab

le fr

om

all t

he m

emb

ers,

with

str

engt

hs,

area

s fo

r im

pro

vem

ent a

nd/o

r sc

ores

, com

ple

te fo

r eac

h su

b-

crite

rion

of C

AF

Ther

e is

cle

ar e

vide

nce

of in

divi

-du

al in

put

s w

ith a

list

of s

tren

gths

, ar

eas

for i

mp

rove

men

t and

sco

res

from

all

the

mem

ber

s of

the

SA

grou

p(s

), co

mp

lete

for e

ach

sub

-cr

iterio

n of

CA

F; th

e in

put

s ar

e st

ruct

ured

and

det

aile

d to

add

ress

th

e im

pro

vem

ent a

ctio

ns

Ther

e is

str

ong

evid

ence

of i

ndiv

i-du

al in

put

s w

ith a

list

of d

etai

led

and

suita

ble

str

engt

hs, a

reas

for

imp

rove

men

t and

sco

res,

ava

ilab

le

from

all

the

mem

ber

s of

the

SA

grou

p(s

) and

com

ple

te fo

r eac

h su

b-c

riter

ion

of C

AF;

the

indi

vidu

al

inp

uts

are

deta

iled

with

not

es a

nd

com

men

ts to

sup

por

t the

ana

lyse

s an

d th

e im

pro

vem

ent a

ctio

ns

5.3

The

chai

r col

lect

s th

e in

di-

vidu

al in

puts

and

pre

pare

s th

e co

nsen

sus

mee

ting

assu

ring

all

cond

ition

s fo

r its

suc

cess

.

Ther

e is

no

evid

ence

of c

olle

ctio

n of

the

indi

vidu

al in

put

s fo

r use

in

the

cons

ensu

s m

eetin

g. N

o ev

iden

ce o

f pre

par

atio

n fo

r the

co

nsen

sus

mee

ting

Ther

e is

som

e ev

iden

ce o

f col

l-ec

tion

of th

e in

divi

dual

inp

uts,

b

ut th

ere

is n

o ag

greg

atio

n an

d an

alys

is fo

r use

in th

e co

nsen

sus

mee

ting.

Lim

ited

evid

ence

of

pre

par

atio

n fo

r the

con

sens

us

mee

ting

Ther

e is

evi

denc

e of

col

lect

ion

of

the

indi

vidu

al in

put

s an

d ag

gre-

gatio

n fo

r the

con

sens

us m

eetin

g.

The

cons

ensu

s m

eetin

g is

pla

nned

Ther

e is

cle

ar e

vide

nce

of c

olle

-ct

ion,

agg

rega

tion

and

anal

ysis

of

the

indi

vidu

al in

put

s fo

r the

co

nsen

sus

mee

ting.

The

re is

cl

ear e

vide

nce

of p

rep

arat

ion

for t

he c

onse

nsus

mee

ting

(tim

e sc

hedu

ling

and

role

s, a

vaila

bili

ty

of re

leva

nt d

ocum

ents

)

Ther

e is

str

ong

evid

ence

of c

olle

-ct

ion,

agg

rega

tion

and

anal

ysis

of

the

indi

vidu

al in

put

s as

a b

asis

for

the

eval

uatio

ns in

the

cons

ensu

s m

eetin

gs. A

det

aile

d p

rep

arat

i-on

of t

he c

onse

nsus

mee

ting

is

evid

ent,

with

tim

e sc

hedu

ling,

as

sign

men

t of r

oles

col

lect

ion

and

avai

lab

ility

of r

elev

ant d

ocum

ents

, de

finiti

on o

f rul

es a

nd c

riter

ia to

fa

cilit

ate

the

cons

ensu

s et

c.

5.4

The

SA g

roup

reac

hes

con-

sens

us o

n st

reng

ths,

are

as fo

r im

prov

emen

t and

sco

ring

for

each

sub

-cri

teri

on.

Ther

e is

no

evid

ence

of a

real

con

-se

nsus

pro

cess

on

stre

ngth

s, a

reas

fo

r im

pro

vem

ent a

nd s

corin

g to

ob

tain

a fi

nal e

valu

atio

n

Ther

e is

som

e ev

iden

ce o

f the

co

nsen

sus

pro

cess

but

it d

oes

not c

over

all

the

sub

-crit

eria

for

stre

ngth

s, a

reas

for i

mp

rove

men

t an

d sc

ores

Ther

e is

evi

denc

e of

the

cons

en-

sus

pro

cess

, com

ple

te fo

r all

the

sub

-crit

eria

for s

tren

gths

, are

as fo

r im

pro

vem

ent a

nd s

core

s

Ther

e is

cle

ar e

vide

nce

of th

e co

nsen

sus

pro

cess

, eff

ectiv

e an

d co

mp

lete

for s

tren

gths

, are

as fo

r im

pro

vem

ent a

nd s

core

s w

ith a

de

fined

ap

pro

ach.

The

eva

luat

ions

ar

e fo

rmal

ly d

ocum

ente

d an

d ag

reed

Ther

e is

cle

ar e

vide

nce

of th

e co

nsen

sus

pro

cess

, eff

ectiv

e an

d co

mp

lete

: the

indi

vidu

al a

sses

s-m

ents

are

doc

umen

ted

and

the

cons

ensu

s is

form

ally

agr

eed

by a

ll th

e p

artic

ipan

ts, w

ith s

tren

gths

, ar

eas

for i

mp

rove

men

t and

sc

ores

. The

eva

luat

ions

and

the

deci

sion

s ta

ken,

and

the

varia

tions

fr

om in

divi

dual

eva

luat

ion

and

cons

ensu

s ar

e fo

rmal

ly re

gist

ered

an

d an

alys

ed

30

Step

6: P

repa

re a

repo

rt d

escr

ibin

g th

e re

sults

of s

elf-

asse

ssm

ent

Leve

ls

12

34

5

Act

ions

6.1

Edit

a fin

al re

port

con

tain

ing

the

follo

win

g el

emen

ts fo

r eac

h su

b-cr

iteri

on:

•streng

ths

•area

sforimprov

emen

t•score

Ther

e is

no

evid

ence

of a

form

al

final

rep

ort f

or th

e ac

tiviti

es o

f SA

or t

he fi

nal r

epor

t doe

s no

t in

clud

e in

form

atio

n on

str

engt

hs

and/

or a

reas

for i

mp

rove

men

t an

d/or

a s

core

Ther

e is

som

e ev

iden

ce o

f a fi

nal

rep

ort f

or th

e ac

tiviti

es o

f SA

, in

clud

ing

som

e in

dica

tions

on

stre

ngth

s, a

reas

for i

mp

rove

men

t an

d sc

ores

, but

the

indi

catio

ns a

re

not c

omp

lete

or d

o no

t cov

er e

ach

sub

-crit

erio

n of

the

mod

el

Ther

e is

evi

denc

e of

a fi

nal r

epor

t co

verin

g al

l the

sub

-crit

eria

of t

he

mod

el, a

nd in

dica

ting

stre

ngth

s,

area

s fo

r im

pro

vem

ent a

nd s

core

s.

Ther

e is

cle

ar e

vide

nce

of a

fina

l re

por

t cov

erin

g al

l the

sub

-crit

eria

of

the

mod

el, a

nd in

dica

ting

stre

ngth

s, a

reas

for i

mp

rove

men

t an

d sc

ores

. The

rep

ort c

onta

ins

info

rmat

ion

and

com

men

ts to

ad

dres

s th

e or

gani

satio

n in

ord

er

to e

valu

ate

corr

ectiv

e an

d im

pro

-ve

men

t act

ions

Ther

e is

str

ong

evid

ence

of a

fina

l re

por

t cov

erin

g al

l the

sub

-crit

eria

of

the

mod

el, a

nd in

dica

ting

in

deta

il th

e st

reng

ths,

are

as fo

r im

-p

rove

men

t and

sco

res.

The

rep

ort

cont

ains

info

rmat

ion

and

com

-m

ents

to a

ddre

ss th

e or

gani

satio

n in

ord

er to

eva

luat

e eff

ectiv

e co

r-re

ctiv

e an

d im

pro

vem

ent a

ctio

ns

and

thei

r wei

ght a

nd p

riorit

y

6.2

Pres

ent t

he fi

nal r

epor

t to

the

Seni

or M

anag

emen

t of t

he

orga

nisa

tion

Ther

e is

no

evid

ence

of p

rese

ntat

i-on

of t

he fi

nal r

epor

t to

the

seni

or

man

agem

ent

Ther

e is

som

e ev

iden

ce o

f pre

sen-

tatio

n of

the

final

rep

ort t

o th

e se

-ni

or m

anag

emen

t but

ther

e is

no

evid

ence

of p

rese

ntat

ion

in fo

rmal

an

d do

cum

ente

d m

eetin

g(s)

Ther

e is

evi

denc

e of

pre

sent

atio

n of

the

final

rep

ort t

o th

e se

nior

m

anag

emen

t of t

he o

rgan

isat

i-on

in fo

rmal

and

doc

umen

ted

mee

ting(

s)

Ther

e is

cle

ar e

vide

nce

of p

re-

sent

atio

n of

the

final

rep

ort t

o th

e se

nior

man

agem

ent o

f the

or

gani

satio

n. It

has

bee

n p

rese

n-te

d an

d di

scus

sed

in fo

rmal

and

do

cum

ente

d m

eetin

g(s)

, with

a

deta

iled

anal

ysis

of s

tren

gths

and

w

eakn

esse

s

Ther

e is

str

ong

evid

ence

of

pre

sent

atio

n of

the

final

rep

ort t

o th

e se

nior

man

agem

ent o

f the

or-

gani

satio

n. It

has

bee

n p

rese

nted

an

d di

scus

sed

in fo

rmal

and

do-

cum

ente

d m

eetin

g(s)

, in

whi

ch a

de

taile

d an

alys

is o

f str

engt

hs a

nd

wea

knes

ses

and

a fir

st e

valu

atio

n of

the

pos

sib

le in

terv

entio

n ar

eas

have

bee

n m

ade

6.3.

Com

mun

icat

e th

e m

ain

resu

lts

to p

eop

le in

the

orga

nisa

tion

and

othe

r rel

evan

t sta

keho

lder

s.

Ther

e is

no

evid

ence

of c

omm

uni-

catio

n of

the

SA re

sult

sTh

ere

is s

ome

evid

ence

of c

omm

u-ni

catio

n of

the

mai

n re

sult

s, b

ut it

do

es n

ot in

volv

e al

l the

rele

vant

in

tern

al a

nd e

xter

nal p

artie

s

Ther

e is

evi

denc

e of

com

mun

ica-

tion

of th

e m

ain

resu

lts,

add

ress

ed

to th

e p

eop

le in

the

orga

nisa

tion

and

to a

ll ot

her r

elev

ant s

take

-ho

lder

s

Ther

e is

cle

ar e

vide

nce

of c

om-

mun

icat

ion

of th

e m

ain

resu

lts,

w

ith d

etai

led

info

rmat

ion,

in a

fo

rmal

way

and

with

ap

pro

pria

te

tool

s. T

he c

omm

unic

atio

n w

as

addr

esse

d to

the

peo

ple

of t

he

orga

nisa

tion

and

to o

ther

rele

vant

st

akeh

olde

rs

Ther

e is

cle

ar e

vide

nce

of c

om-

mun

icat

ion

of th

e m

ain

resu

lts,

w

ith d

etai

led

info

rmat

ion,

in a

fo

rmal

way

and

with

ap

pro

pria

te

tool

s. T

he c

omm

unic

atio

n w

as

addr

esse

d to

the

peo

ple

in th

e or

gani

satio

n an

d to

all

othe

r rel

e-va

nt s

take

hold

ers.

The

info

rmat

ion

was

cle

arly

add

ress

ed to

invo

lve

inte

rest

ed p

artie

s in

the

corr

ectiv

e an

d im

pro

vem

ent a

ctio

ns

31

Appendix 1.2

Questionnaire on Pillar 2The improvement plan questionnaire

ReferenceThe reference of the questionnaire is the ‘Ten steps to improve an organisation with CAF’ as defined in the chapter on ‘Guidelines to improving organisations using CAF’ of the CAF 2013. The activities of each step have been adjusted and expanded to take into consideration the lessons learned from the relevant experiences at European level.

The questionnaire covers the steps from seven to nine.

Steps to be assessedCAF External Feedback covers the planning and the process of improvement and is not meant for assessing the results of the improvement actions.

Evaluation scaleThe evaluation scale has five levels.

This evaluation scale has been detailed for each activity in phrases defining the interpretation of the real situation of the organisation with regard to the specific theme.

Evidence: definitionA various range of tangible and intangible documents/facts/information delivered before and during the site visits.

Pillar 1

The process of self-assessment

Steps 1-6 in the 10 step plan

Questionnaire 1(Appendix 1.1)

Pillar 2

The process of improvement actions

Steps 7-9 in the 10 step plan

Questionnaire 2(Appendix 1.2)

Pillar 3

The TQM Maturity of the

organisation

Questionnaire 3(Appendix 1.3)

CAF External Feedback

1 The activities have been carried out in a very limited way.

2 The activities have been carried out in a limited way.

3 The activities have been carried out in an acceptable way.

4 The activities have been carried out in a satisfying (satisfactory) way.

5 The activities have been carried out in an outstanding way.

32St

ep 7

: Dra

ft a

n im

prov

emen

t pla

n, b

ased

on

the

acce

pted

sel

f-as

sess

men

t rep

ort

Leve

ls

12

34

5

Act

ions

7.1

Colle

ct a

ll pr

opos

als

for a

c-tio

ns fo

r im

prov

emen

t, in

clud

ing

the

idea

s fo

rmul

ated

dur

ing

the

SA.

Ther

e is

no

evid

ence

of c

olle

ctio

n of

idea

s an

d p

rop

osal

s fo

r im

pro

-ve

men

t act

ions

Ther

e is

som

e ev

iden

ce o

f col

lec-

tion

of p

rop

osal

s fo

r im

pro

vem

ent,

but

with

out t

he in

volv

emen

t of

the

inte

rest

ed fu

nctio

ns a

nd/o

r w

ithou

t a c

omp

lete

ana

lysi

s of

the

resu

lts

of th

e SA

Ther

e is

evi

denc

e of

col

lect

ion

of

pro

pos

als

for i

mp

rove

men

t ac-

tions

, fro

m th

e in

volv

ed fu

nctio

ns

and

for a

ll th

e re

sult

s of

the

SA,

taki

ng in

to c

onsi

dera

tion

the

idea

s fo

rmul

ated

dur

ing

the

SA.

Ther

e is

cle

ar e

vide

nce

of c

olle

c-tio

n of

pro

pos

als

for i

mp

rove

men

t ac

tions

, fro

m a

ll th

e in

volv

ed

func

tions

, in

a fo

rmal

way

, sta

rtin

g fr

om a

nd ta

king

into

con

side

ra-

tion

the

idea

s fo

rmul

ated

dur

ing

the

SA. T

he p

rop

osal

s ar

e de

rived

fr

om a

com

ple

te a

naly

sis

of a

ll th

e re

sult

s of

the

SA

Ther

e is

evi

denc

e of

col

lect

ion

of p

rop

osal

s fo

r im

pro

vem

ent

actio

ns, i

n a

form

al w

ay, s

tart

ing

from

and

taki

ng in

to c

onsi

dera

tion

the

idea

s fo

rmul

ated

dur

ing

the

SA. T

he p

rop

osal

s ar

e b

ased

on

a de

taile

d an

d do

cum

ente

d an

alys

is

(mee

tings

, etc

.) of

all

the

resu

lts

of th

e SA

, with

in e

ach

func

tion

invo

lved

7.2

Prio

ritis

e im

prov

emen

t ac

tions

with

rega

rds

to th

eir

effec

tiven

ess

and

feas

ibili

ty.

Ther

e is

no

evid

ence

of p

riorit

isat

i-on

of i

mp

rove

men

t act

ions

or u

se

of p

riorit

isat

ion

crite

ria

Ther

e is

som

e ev

iden

ce o

f pri-

oriti

satio

n of

the

imp

rove

men

t ac

tions

, but

the

crite

ria a

re n

ot

clea

r or c

oher

ent

Ther

e is

evi

denc

e of

prio

ritis

atio

n of

the

imp

rove

men

t act

ions

, on

the

bas

is o

f defi

ned

and

cohe

rent

cr

iteria

Ther

e is

cle

ar e

vide

nce

of p

riori-

tisat

ion

of th

e im

pro

vem

ent a

c-tio

ns, o

n th

e b

asis

of d

efine

d an

d co

here

nt c

riter

ia. T

he p

riorit

isat

ion

crite

ria a

re d

ocum

ente

d, ta

king

in

to c

onsi

dera

tion

the

imp

act o

n st

rate

gy a

nd o

bje

ctiv

es o

f the

or

gani

satio

n, a

nd th

e fe

asib

ility

of

the

actio

ns

Ther

e is

str

ong

evid

ence

of

prio

ritis

atio

n of

the

imp

rove

men

t ac

tions

, on

the

bas

is o

f defi

ned

and

cohe

rent

crit

eria

. The

ana

lysi

s of

pos

sib

le a

ctio

ns, t

he p

riorit

isa-

tion

crite

ria a

nd th

e ev

alua

tions

ar

e do

cum

ente

d, ta

king

into

co

nsid

erat

ion

a qu

antiz

ed e

valu

a-tio

n of

the

imp

act o

n st

rate

gy a

nd

obje

ctiv

es o

f the

org

anis

atio

n, a

nd

the

feas

ibili

ty o

f the

act

ions

7.3

Defi

ne a

str

uctu

red

actio

n pl

an fo

r the

sel

ecte

d im

prov

e-m

ent a

ctio

ns b

ased

on

the

PDCA

Cy

cle

(Pla

n-D

o-Ch

eck-

Act

).

Ther

e is

no

evid

ence

of a

n ac

tion

pla

n or

the

actio

n p

lan

cann

ot

defin

e th

e m

ain

pha

ses

of th

e ac

-tiv

ities

(sta

rt, p

hase

s of

act

iviti

es,

inte

rmed

iate

che

cks,

fina

l che

ck(s

) et

c.)

Ther

e is

som

e ev

iden

ce o

f an

actio

n p

lan,

but

the

mai

n de

fined

p

hase

s ar

e no

t bas

ed o

n th

e PD

CA

cy

cle

(ap

pro

ach,

dep

loym

ent,

chec

k an

d re

view

s, fu

rthe

r im

pro

-ve

men

t act

ions

)

Ther

e is

evi

denc

e of

an

actio

n p

lan

for t

he s

elec

ted

imp

rove

men

t ac

tions

, bas

ed o

n th

e PD

CA

cyc

le

(ap

pro

ach,

dep

loym

ent,

chec

k an

d re

view

s, fu

rthe

r im

pro

vem

ent

actio

ns)

Ther

e is

cle

ar e

vide

nce

of a

str

uc-

ture

d ac

tion

pla

n fo

r the

sel

ecte

d im

pro

vem

ent a

ctio

ns, d

efini

ng

the

sche

dulin

g fo

r the

ap

pro

ach,

th

e de

plo

ymen

t of t

he a

ctio

ns,

the

chec

ks a

nd re

view

s du

ring

the

deve

lop

men

t of t

he a

ctio

ns

Ther

e is

str

ong

evid

ence

of a

st

ruct

ured

act

ion

pla

n fo

r the

se

lect

ed im

pro

vem

ent a

ctio

ns,

defin

ing

for t

he s

ingl

e p

hase

s an

d ac

tiviti

es a

det

aile

d sc

hedu

ling

for

the

app

roac

h, th

e de

plo

ymen

t of

the

actio

ns fo

r the

targ

et a

reas

, th

e ch

ecks

and

revi

ews

durin

g th

e de

velo

pm

ent o

f the

act

ions

. Th

e p

lan

cont

ains

the

defin

ition

of

furt

her i

mp

rove

men

t act

ions

and

fo

llow

-up

7.4

Esta

blis

h w

ays

to m

easu

re th

e pe

rfor

man

ce o

f the

act

ions

and

th

e re

sults

.

Ther

e is

no

evid

ence

of a

defi

niti-

on o

f ind

icat

ors,

targ

ets

or m

etric

s fo

r all

or m

ost o

f the

imp

rove

men

t ac

tions

Ther

e is

som

e ev

iden

ce o

f a

defin

ition

of i

ndic

ator

s, ta

rget

s or

met

rics,

but

not

com

ple

te o

r ad

equa

te to

mea

sure

the

per

for-

man

ce a

nd re

sult

s of

the

actio

ns

(lack

of i

ndic

ator

s an

d/or

targ

ets;

la

ck o

f defi

nitio

n of

met

rics,

...)

Ther

e is

evi

denc

e of

a d

efini

tion

of in

dica

tors

, tar

gets

and

met

rics,

ad

equa

te to

mea

sure

the

per

for-

man

ce a

nd re

sult

s of

the

actio

ns

Ther

e is

cle

ar e

vide

nce

of in

dica

-to

rs, t

arge

ts a

nd m

etric

s of

the

imp

rove

men

t act

ions

, defi

ned

in

a co

mp

lete

, qua

ntita

tive

and

con-

sist

ent w

ay fo

r eac

h ac

tion.

The

in

dica

tors

and

targ

ets

cons

ider

th

e ex

pec

ted

resu

lts

in te

rms

of

outp

uts

and

outc

ome

Ther

e is

str

ong

evid

ence

of i

ndi-

cato

rs, t

arge

ts a

nd m

etric

s of

the

imp

rove

men

t act

ions

, defi

ned

in

a co

mp

lete

, qua

ntita

tive

and

con-

sist

ent w

ay fo

r eac

h ac

tion.

The

in

dica

tors

and

targ

ets

cons

ider

the

exp

ecte

d p

erfo

rman

ce a

nd re

sult

s in

term

s of

out

put

s an

d ou

tcom

e,

effec

tiven

ess,

effi

cien

cy a

nd e

xter

-na

l ben

chm

arki

ng

7.5.

Inte

grat

e th

e ac

tion

plan

in

to th

e no

rmal

str

ateg

ic

plan

ning

pro

cess

.

Ther

e is

no

evid

ence

of c

orre

-la

tion

bet

wee

n th

e ac

tion

pla

n an

d th

e st

rate

gic

pla

nnin

g of

the

orga

nisa

tion

Ther

e is

som

e ev

iden

ce o

f int

egra

-tio

n of

the

actio

n p

lan

(but

with

lim

ited

corr

elat

ion

of ti

me

sche

du-

ling

and/

or p

lann

ing

of re

sour

ces

and/

or im

pac

t of t

he a

ctio

ns o

n st

rate

gic

obje

ctiv

es)

Ther

e is

evi

denc

e of

inte

grat

ion

of

the

actio

n p

lan

into

the

stra

tegi

c p

lan

of th

e or

gani

satio

n (t

ime

sche

dulin

g, re

sour

ces,

imp

act

of th

e ac

tions

on

the

stra

tegi

c ob

ject

ives

)

Ther

e is

cle

ar e

vide

nce

of in

tegr

a-tio

n of

the

actio

n p

lan

into

the

stra

tegi

c p

lan

of th

e or

gani

satio

n (t

ime

sche

dulin

g, re

sour

ces,

im-

pac

t of t

he a

ctio

ns o

n th

e st

rate

gic

obje

ctiv

es, c

heck

s an

d re

view

s an

d re

late

d re

spon

sib

ilitie

s)

Ther

e is

str

ong

evid

ence

of i

nte-

grat

ion

of th

e ac

tion

pla

n in

to th

e st

rate

gic

pla

n of

the

orga

nisa

tion

(tim

e sc

hedu

ling,

reso

urce

s, im

-p

act o

f the

act

ions

on

the

stra

tegi

c ob

ject

ives

, che

cks

and

revi

ews,

in-

volv

emen

t of l

eade

rs, e

tc);

the

SA

activ

ity

and

the

cons

eque

nt a

ctio

n p

lan

are

form

alis

ed a

s p

art o

f the

st

rate

gic

pla

nnin

g an

d co

ntro

l

33

Step

8: C

omm

unic

ate

the

impr

ovem

ent p

lan

Leve

ls

12

34

5

Act

ions

8.1.

Defi

ne a

com

-m

unic

atio

n pl

an

- the

app

ropr

iate

in

form

atio

n w

ith th

e ap

prop

riat

e m

edia

to

the

appr

opri

ate

targ

et

grou

p, a

ddre

ssed

to

all t

he s

take

hold

ers

- of

the

impr

ovem

ent

actio

ns.

Ther

e is

no

evid

ence

of a

com

mun

icat

ion

pla

n fo

r mai

n st

akeh

olde

rs a

nd/o

r with

ap

pro

pria

te in

form

atio

n

Ther

e is

som

e ev

iden

ce

of a

com

mun

icat

ion

pla

n (b

ut n

ot a

ddre

ssed

to th

e m

ain

stak

ehol

ders

and

/or

limite

d in

form

atio

n)

Ther

e is

evi

denc

e of

a c

omm

uni-

catio

n p

lan,

add

ress

ed to

the

mai

n st

akeh

olde

rs, w

ith a

pp

rop

riate

info

r-m

atio

n an

d ap

pro

pria

te m

edia

. The

co

mm

unic

atio

n p

lan

cons

ider

s a

few

p

hase

s of

the

imp

rove

men

t act

iviti

es

Ther

e is

cle

ar e

vide

nce

of a

co

mm

unic

atio

n p

lan,

add

ress

ed

to a

ll th

e st

akeh

olde

rs, w

ith

app

rop

riate

info

rmat

ion

and

with

th

e us

e of

ap

pro

pria

te m

edia

. The

co

mm

unic

atio

n p

lan

cons

ider

s th

e m

ain

pha

ses

of th

e im

pro

vem

ent

activ

ities

Ther

e is

str

ong

evid

ence

of a

com

mu-

nica

tion

pla

n: th

e p

lan

is c

omp

lete

and

de

taile

d, a

ddre

ssed

to a

ll th

e st

akeh

olde

rs,

with

ext

ensi

ve in

form

atio

n an

d w

ith th

e us

e of

the

app

rop

riate

med

ia fo

r the

dif-

fere

nt ta

rget

gro

ups.

The

com

mun

icat

ion

pla

n co

nsid

ers

all t

he d

iffer

ent p

hase

s of

th

e im

pro

vem

ent a

ctiv

ities

8.2.

Impl

emen

t the

co

mm

unic

atio

n pl

an.

Ther

e is

no

evid

ence

of i

mp

lem

enta

tion

of a

com

mun

icat

ion

pla

nTh

ere

is s

ome

evid

ence

of

imp

lem

enta

tion

of

a co

mm

unic

atio

n p

lan

(the

com

mun

icat

ion

pla

n th

at h

as b

een

app

lied

in

par

t or t

he e

xten

t to

the

stak

ehol

ders

and

to d

iffe-

rent

pha

ses

has

not b

een

resp

ecte

d)

Ther

e is

evi

denc

e of

imp

lem

enta

-tio

n of

the

com

mun

icat

ion

pla

n ad

dres

sed

to th

e di

ffer

ent s

take

hol-

ders

, with

ap

pro

pria

te in

form

atio

n an

d w

ith a

pp

rop

riate

med

ia, a

s p

lan-

ned

or w

ith li

mite

d m

odifi

catio

ns

Ther

e is

cle

ar e

vide

nce

of im

ple

-m

enta

tion

of th

e co

mm

unic

a-tio

n p

lan

addr

esse

d to

diff

eren

t st

akeh

olde

rs, w

ith a

pp

rop

riate

in

form

atio

n an

d w

ith a

pp

rop

riate

m

edia

, as

pla

nned

. The

imp

lem

en-

tatio

n is

doc

umen

ted

Ther

e is

cle

ar e

vide

nce

of im

ple

men

tatio

n of

the

com

mun

icat

ion

pla

n, a

nd th

e eff

ec-

tiven

ess

of th

e co

mm

unic

atio

n (t

o di

ffer

ent

stak

ehol

ders

, with

ap

pro

pria

te in

form

atio

n an

d w

ith a

pp

rop

riate

med

ia) h

as b

een

verifi

ed a

nd im

pro

ved.

The

imp

lem

enta

tion

is fu

lly d

ocum

ente

d

8.3.

Info

rm th

e re

leva

nt s

take

hold

ers

regu

larl

y –

espe

cial

ly

the

peop

le o

f the

or

gani

satio

n - o

n th

e st

atus

and

pro

gres

s,

incl

udin

g ev

alua

tions

an

d ex

peri

ence

s.

Ther

e is

no

evid

ence

of i

nfor

mat

ion

for

rele

vant

sta

keho

lder

s on

the

stat

us,

pro

gres

s an

d re

late

d ev

alua

tions

and

ex

per

ienc

es

Ther

e is

som

e ev

iden

ce o

f in

form

atio

n on

the

stat

us,

pro

gres

s an

d re

late

d ev

a-lu

atio

ns a

nd e

xper

ienc

es,

but

the

info

rmat

ion

is n

ot

pro

vide

d re

gula

rly,

or i

s lim

ited

to th

e st

atus

and

p

rogr

ess,

or l

imite

d to

few

st

akeh

olde

rs

Ther

e is

evi

denc

e of

info

rmat

ion

to

the

peo

ple

of t

he s

tatu

s, p

rogr

ess

and

rela

ted

eval

uatio

ns a

nd e

xper

ienc

es.

The

info

rmat

ion

is p

rovi

ded

regu

larl

y to

the

peo

ple

of t

he o

rgan

isat

ion

and

limite

d fo

r oth

er re

leva

nt s

take

hol-

ders

(onl

y so

me

pha

ses,

as

star

t, en

d of

act

iviti

es, .

..)

Ther

e is

cle

ar e

vide

nce

of in

for-

mat

ion

to a

ll th

e st

akeh

olde

rs o

n th

e st

atus

of a

ctiv

ities

, pro

gres

s,

eval

uatio

ns a

nd e

xper

ienc

es, f

or a

ll th

e re

leva

nt p

hase

s of

the

imp

ro-

vem

ent p

lan.

Ther

e is

str

ong

evid

ence

of i

nfor

mat

ion

to a

ll th

e st

akeh

olde

rs o

n th

e st

atus

of

activ

ities

, pro

gres

s, e

valu

atio

ns a

nd e

xpe-

rienc

es, f

or a

ll th

e re

leva

nt p

hase

s of

the

imp

rove

men

t pla

n. T

he le

sson

s le

arne

d an

d th

e op

por

tuni

ties

to e

xten

d th

e ex

pe-

rienc

es a

re in

vest

igat

ed, d

ocum

ente

d an

d co

mm

unic

ated

34

Step

9: I

mpl

emen

t the

impr

ovem

ent p

lan

Leve

ls

12

34

5

Act

ions

9.1

Defi

ne c

lear

ow

ners

hip

of th

e im

prov

emen

t pro

gram

and

the

proj

ects

, and

ens

ure

tran

spar

-en

cy in

task

and

resp

onsi

bilit

y de

lega

tion.

Ther

e is

no

evid

ence

of d

efini

tion

of o

wne

rshi

p o

f the

pro

gram

and

th

e p

roje

cts

Ther

e is

som

e ev

iden

ce o

f defi

niti-

on o

f ow

ners

hip

for t

he p

rogr

ams

and/

or fo

r the

pro

ject

s, b

ut th

e le

vel o

r the

coh

eren

ce o

f the

role

s fo

r the

ass

igne

d re

spon

sib

ilitie

s ar

e no

t dem

onst

rate

dLi

mite

d ev

iden

ce o

f tra

nsp

aren

cy

and

resp

onsi

bili

ty d

eleg

atio

n

Ther

e is

evi

denc

e of

defi

nitio

n of

ow

ners

hip

for t

he im

pro

vem

ent

pro

gram

and

for t

he p

roje

cts.

Th

e ow

ners

hip

is c

omm

unic

a-te

d, e

nsur

ing

tran

spar

ency

and

re

spon

sib

ility

del

egat

ion.

The

leve

l of

ass

igne

d re

spon

sib

ilitie

s is

ade

-qu

ate

and

the

role

s of

the

owne

rs

are

cohe

rent

with

the

activ

ities

to

be

real

ised

Ther

e is

cle

ar e

vide

nce

of d

efini

ti-on

of o

wne

rshi

p fo

r the

imp

rove

-m

ent p

rogr

am a

nd th

e p

roje

cts.

Th

e le

vel o

f ass

igne

d re

spon

si-

bili

ties

is a

dequ

ate

and

the

role

s of

the

owne

rs a

re c

oher

ent w

ith

the

activ

ities

to b

e re

alis

ed. T

he

dele

gatio

n of

resp

onsi

bili

ties

is

form

ally

defi

ned

and

com

mun

ica-

ted

to g

uara

ntee

tran

spar

ency

Ther

e is

str

ong

evid

ence

of d

efi-

nitio

n of

ow

ners

hip

for t

he e

ntire

im

pro

vem

ent p

rogr

am a

nd fo

r th

e si

ngle

pro

ject

s an

d ac

tiviti

es,

at a

pp

rop

riate

leve

l and

coh

eren

t w

ith th

e ac

tiviti

es to

be

real

ised

. Th

e de

lega

tion

of re

spon

sib

ilitie

s is

form

ally

defi

ned

and

com

mun

i-ca

ted

to a

ll th

e in

tere

sted

sta

ke-

hold

ers

to g

uara

ntee

tran

spar

ency

an

d to

pro

mot

e in

volv

emen

t and

co

llab

orat

ion

9.2

Impl

emen

t the

impr

ovem

ent

plan

as

sche

dule

d.Th

ere

is n

o ev

iden

ce o

f im

ple

men

-ta

tion

of th

e im

pro

vem

ent p

lan

Ther

e is

som

e ev

iden

ce o

f im

ple

-m

enta

tion

of th

e im

pro

vem

ent

pla

n, b

ut re

leva

nt d

efici

enci

es a

re

evid

ent i

n te

rms

of c

omp

lete

ness

, ex

tent

of d

eplo

ymen

t, co

ntro

ls,

mon

itorin

g, c

hang

es to

the

pla

n-ni

ng d

ue to

lack

of r

esou

rces

or

chan

ges

to p

riorit

ies

etc.

Ther

e is

evi

denc

e of

imp

lem

en-

tatio

n of

the

imp

rove

men

t pla

n,

with

a s

ubst

antia

l alig

nmen

t to

the

sche

dulin

g. T

he d

evia

tions

fr

om th

e sc

hedu

led

pla

n ar

e do

cum

ente

d an

d m

otiv

ated

. No

rele

vant

defi

cien

cies

are

evi

dent

in

term

s of

com

ple

tene

ss, e

xten

t of

dep

loym

ent,

cont

rols

, mon

itorin

g,

chan

ges

to th

e p

lann

ing

due

to

lack

of r

esou

rces

or c

hang

es to

p

riorit

ies

etc.

Ther

e is

cle

ar e

vide

nce

of im

ple

-m

enta

tion

of th

e im

pro

vem

ent

pla

n, w

ith a

str

uctu

red

cont

rol.

The

devi

atio

ns fr

om th

e sc

hedu

led

pla

n ar

e lim

ited

and

do n

ot re

duce

th

e co

mp

lete

ness

, ext

ent o

f de-

plo

ymen

t, co

ntro

ls o

r mon

itorin

g;

they

are

ana

lyse

d, d

ocum

ente

d an

d m

otiv

ated

Ther

e is

str

ong

evid

ence

of i

mp

le-

men

tatio

n of

the

imp

rove

men

t p

lan,

with

a s

truc

ture

d co

ntro

l. Th

e de

viat

ions

from

the

sche

dule

d p

lan

are

anal

ysed

and

doc

umen

-te

d, a

nd a

re c

lear

ly fi

nalis

ed to

im

pro

ve th

e sc

hedu

ling

and

to

assu

re th

e at

tain

men

t of t

he b

est

pos

sib

le o

bje

ctiv

es (c

omp

lete

ness

of

the

activ

ities

, ext

ent o

f dep

loy-

men

t, co

ntro

ls, m

onito

ring

etc.

)

9.3

Invo

lve

empl

oyee

s in

the

diffe

rent

impr

ovem

ent a

ctio

ns to

en

sure

anc

hori

ng o

f the

impr

o-ve

men

t pro

ject

s th

roug

hout

the

inst

itutio

n.

Ther

e is

no

evid

ence

of i

nvol

ve-

men

t of e

mp

loye

es in

the

imp

ro-

vem

ent a

ctio

ns

Ther

e is

som

e ev

iden

ce o

f in

volv

emen

t of e

mp

loye

es in

the

imp

rove

men

t act

ions

and

of a

n ap

pro

ach

to a

ncho

r the

pro

ject

s th

roug

hout

the

inst

itutio

n

Ther

e is

evi

denc

e of

invo

lvem

ent

of e

mp

loye

es in

the

imp

rove

men

t ac

tions

, not

lim

ited

to re

alis

atio

n of

the

pro

ject

s, b

ut a

lso

final

ised

to

anc

hor t

he p

roje

cts

thro

ugho

ut

the

orga

nisa

tion

Ther

e is

cle

ar e

vide

nce

of

invo

lvem

ent o

f em

plo

yees

in th

e im

pro

vem

ent a

ctio

ns, n

ot li

mite

d to

real

isat

ion

of th

e p

roje

cts,

but

al

so fi

nalis

ed to

anc

hor t

he p

ro-

ject

s th

roug

hout

the

orga

nisa

tion,

w

ith d

efini

tion

of in

volv

emen

t an

d ro

les

of d

iffer

ent p

artie

s in

the

follo

w-u

p

Ther

e is

str

ong

evid

ence

of

invo

lvem

ent o

f em

plo

yees

in th

e im

pro

vem

ent a

ctio

ns, n

ot li

mite

d to

real

isat

ion

of th

e p

roje

cts,

but

al

so c

lear

ly a

ddre

ssed

to a

ncho

r th

e p

roje

cts

thro

ugho

ut th

e or

ga-

nisa

tion,

with

defi

nitio

n of

invo

lve-

men

t and

role

s of

diff

eren

t par

ties,

p

lans

for f

ollo

w-u

p, d

eplo

ymen

t, ob

ject

ives

and

resp

onsi

bili

ties

9.4

Defi

ne a

con

sist

ent a

ppro

ach

for m

onito

ring

and

ass

essi

ng th

e im

prov

emen

t act

ions

.

Ther

e is

no

evid

ence

of a

defi

ned

app

roac

h fo

r mon

itorin

g an

d as

sess

ing

the

imp

rove

men

t pla

n

Ther

e is

som

e ev

iden

ce o

f mon

ito-

ring

and

asse

ssin

g th

e im

pro

ve-

men

t pla

n, b

ut th

e ap

pro

ach

is n

ot

clea

r or c

onsi

sten

t

Ther

e is

evi

denc

e of

mon

itorin

g an

d as

sess

ing

the

imp

rove

men

t p

lan,

and

the

app

roac

h is

defi

ned

in a

con

sist

ent w

ay

Ther

e is

evi

denc

e of

mon

itorin

g an

d as

sess

ing

the

imp

rove

men

t p

lan,

in a

defi

ned

and

form

alis

ed

way

, with

a c

lear

and

con

sist

ent

app

roac

h fo

r the

mai

n p

hase

s of

th

e ac

tiviti

es

Ther

e is

evi

denc

e of

mon

itorin

g an

d as

sess

ing

the

imp

rove

men

t p

lan,

in a

defi

ned

and

form

alis

ed

way

, with

a c

lear

and

con

sist

ent

app

roac

h fo

r all

the

mai

n p

hase

s of

the

activ

ities

, defi

ning

the

resp

onsi

bili

ties

and

invo

lvin

g th

e m

ain

stak

ehol

ders

9.5

Mon

itor o

n a

regu

lar b

asis

th

e im

plem

enta

tion

of th

e im

prov

emen

t act

ions

.

Ther

e is

no

evid

ence

of m

onito

-rin

g of

imp

lem

enta

tion

of th

e im

pro

vem

ent a

ctio

ns

Ther

e is

som

e ev

iden

ce o

f m

onito

ring

of im

ple

men

tatio

n of

th

e im

pro

vem

ent a

ctio

ns, b

ut it

do

es n

ot g

uara

ntee

mon

itorin

g of

the

mai

n p

hase

s of

the

pro

cess

(m

ain

inte

rmed

iate

ste

ps,

end

of

pro

ject

s, s

urve

ys o

f res

ults

)

Ther

e is

evi

denc

e of

mon

itorin

g of

th

e m

ain

pha

ses

of th

e im

ple

men

-ta

tion

of th

e im

pro

vem

ent a

ctio

ns,

(mai

n in

term

edia

te s

tep

s, e

nd o

f p

roje

cts,

sur

veys

of r

esul

ts e

tc.)

Ther

e is

cle

ar e

vide

nce

of

mon

itorin

g of

all

the

rele

vant

p

hase

s of

the

imp

lem

enta

tion

of

imp

rove

men

t act

ions

, with

form

al

feed

-bac

k on

pro

gres

s an

d in

ter-

med

iate

and

fina

l res

ults

Ther

e is

str

ong

evid

ence

of m

oni-

torin

g of

all

the

rele

vant

pha

ses

of

the

imp

lem

enta

tion

of im

pro

ve-

men

t act

ions

, inv

olvi

ng th

e m

ain

stak

ehol

ders

and

with

form

al

and

com

mun

icat

ed fe

ed-b

ack

on

pro

gres

s an

d in

term

edia

te a

nd

final

resu

lts

35

Appendix 1.3

Questionnaire on Pillar 3The TQM Maturity questionnaire

ReferenceThe questionnaire for TQM Assessment Maturity is based on the eight EFQM® Fundamental Concepts of Excellence as formulated in the Excellence model version 2003. In the context of the CAF External Feedback Procedure, these principles of excellence were translated into four maturity levels adapted to the public sector environment.

Areas of assessmentAll eight principles are to be checked by the organisation as a first step, in order to gain an understanding of the TQM maturity within the organisation. During the site visit, two principles – as chosen by the applicant – will be assessed in depth (one of which must either be Result orientation or Customer focus).

Assessment procedureThe evaluation relates to the maturity level achieved by the organisation as a result of the self-assessment and the action plan. The evaluation scale has four levels:

Pillar 1

The process of self-assessment

Steps 1-6 in the 10 step plan

Questionnaire 1(Appendix 1.1)

Pillar 2

The process of improvement actions

Steps 7-9 in the 10 step plan

Questionnaire 2(Appendix 1.2)

Pillar 3

The TQM Maturity of the

organisation

Questionnaire 3(Appendix 1.3)

CAF External Feedback

0 = Initiation level has not been achieved

I = Initiation level

R = Realisation level

M = Maturity level

36

Prin

cipl

e of

exc

elle

nce

1. R

esul

t ori

enta

tion

0I =

Initi

atio

nR

= Re

alis

atio

nM

= M

atur

ity

Defi

nitio

n

The

initi

atio

n le

vel h

as n

ot b

een

reac

hed

The

orga

nisa

tion

iden

tifies

rele

vant

sta

ke-

hold

ers

and

resu

lt a

reas

.Th

e or

gani

satio

n de

fines

a s

et o

f tar

gets

an

d re

sult

s to

be

achi

eved

in re

latio

n to

th

e re

leva

nt s

take

hold

ers’

need

s.

The

orga

nisa

tion

syst

emat

ical

ly m

onito

rs

the

resu

lts

it ac

hiev

es a

nd u

ses

it fo

r con

ti-nu

ous

imp

rove

men

t.

Exam

ples

Th

ere

is a

focu

s on

dev

elop

ing

a re

sult-

orie

nted

cul

ture

in th

e or

gani

satio

n.

The

orga

nisa

tion

has

iden

tified

the

diff

e-re

nt s

take

hold

ers

and

segm

ente

d th

em

into

diff

eren

t cat

egor

ies.

It h

as d

efine

d re

leva

nt re

sult

are

as li

nked

to

the

mis

sion

of t

he o

rgan

isat

ion.

A re

sult-

orie

nted

cul

ture

is s

yste

mat

ical

ly

pro

mot

ed in

the

orga

nisa

tion.

A fi

rst s

yste

mat

ic a

sses

smen

t of t

he

stak

ehol

ders

- as

wel

l as

thei

r cur

rent

and

fu

ture

nee

ds a

nd e

xpec

tatio

ns -

has

bee

n ca

rrie

d ou

t.

A fi

rst s

et o

f cor

resp

ondi

ng ta

rget

s ha

s b

een

defin

ed fo

r rel

evan

t sta

keho

lder

s in

re

latio

n to

the

resu

lt a

reas

.

Stak

ehol

ders

are

invo

lved

in s

ettin

g an

d re

view

ing

resu

lts

and

targ

ets.

The

orga

nisa

tion

has

defin

ed re

sult

ta

rget

s fo

r all

key

pro

cess

es. T

hese

targ

ets

are

conn

ecte

d w

ith th

e di

men

sion

ing

and

pla

nnin

g of

the

assi

gnm

ents

.

Emp

loye

es k

now

the

targ

ets

rela

ting

to

thei

r wor

k ta

sks

and

pro

cess

es.

Man

agem

ent s

uper

vise

s th

e or

gani

satio

-na

l dev

elop

men

t in

term

s of

resu

lt ta

rget

s fo

r key

pro

cess

es a

nd fi

nanc

es.

Prin

cipl

e of

exc

elle

nce

2. C

itize

n/Cu

stom

er fo

cus

0I =

Initi

atio

nR

= Re

alis

atio

nM

= M

atur

ity

Defi

nitio

n Th

e in

itiat

ion

leve

l has

not

bee

n re

ache

dTh

e or

gani

satio

n fo

cuse

s on

the

need

s of

ex

istin

g an

d p

oten

tial c

itize

ns/c

usto

mer

s.Th

e or

gani

satio

n in

volv

es c

itize

ns/c

usto

-m

ers

in th

e ev

alua

tion

and

imp

rove

men

t of

its

per

form

ance

.

The

orga

nisa

tion

resp

onds

to th

e ne

eds

of

citiz

ens/

cust

omer

s by

dev

elop

ing

and

de-

liver

ing

activ

ities

, pro

duct

s an

d se

rvic

es.

Exam

ples

M

anag

emen

t and

em

plo

yees

hav

e a

com

-m

on u

nder

stan

ding

of w

ho th

e cu

stom

ers

are

and

whi

ch s

egm

ents

the

orga

nisa

tion

is s

ervi

cing

.

Emp

loye

es u

nder

stan

d th

e de

man

ds a

nd

exp

ecta

tions

defi

ned

in le

gisl

atio

n an

d re

gula

tion

rega

rdin

g ci

tizen

/cus

tom

er

serv

ice.

The

first

sys

tem

atic

mea

sure

men

t of

cust

omer

sat

isfa

ctio

n, e

xpec

tatio

ns a

nd

need

s ha

s b

een

carr

ied

out,

and

the

inst

itutio

n is

wor

king

on

imp

rove

men

ts

rela

ted

to th

is.

Man

agem

ent a

nd e

mp

loye

es d

evel

op

and

deliv

er s

ervi

ces

resp

ondi

ng to

the

need

s an

d ex

pec

tatio

ns o

f citi

zens

/cu-

stom

ers.

Resu

lts

from

citi

zen/

cust

omer

sat

isfa

ctio

n m

easu

rem

ents

and

dia

logu

e ar

e us

ed- t

o re

view

and

dev

elop

str

ateg

ies

and

actio

n p

lans

for t

he e

ntire

org

anis

atio

n;- t

o re

spon

d ad

equa

tely

whe

n th

ings

go

wro

ng (e

.g. c

omp

lain

ts m

anag

emen

t).

Emp

loye

es h

ave

a m

ulti-

face

tted

pic

ture

of

citi

zen/

cust

omer

nee

ds -

incl

udin

g ad

-di

tiona

l nee

ds to

thos

e th

at re

late

dire

ctly

to

key

pro

duct

s/se

rvic

es (e

.g. t

rans

par

en-

cy, i

nvol

vem

ent)

.

Both

man

agem

ent a

nd e

mp

loye

es s

how

co

ncer

n fo

r cur

rent

and

futu

re c

usto

-m

er n

eeds

thro

ugh

thei

r beh

avio

ur a

nd

attit

udes

.

37

Prin

cipl

e of

exc

elle

nce

3. L

eade

rshi

p an

d co

nsta

ncy

of p

urpo

se0

I = In

itiat

ion

R =

Real

isat

ion

M =

Mat

urit

y

Defi

nitio

n Th

e in

itiat

ion

leve

l has

not

bee

n re

ache

dLe

ader

s es

tab

lish

a cl

ear m

issi

on s

tate

-m

ent.

Lead

ers

esta

blis

h vi

sion

and

val

ues.

Th

ey d

rive

and

insp

ire p

eop

le to

war

ds

exce

llenc

e.

Lead

ers

dem

onst

rate

the

cap

abili

ty to

m

aint

ain

cons

tanc

y of

pur

pos

e in

a c

han-

ging

env

ironm

ent.

Exam

ples

Lead

ers

pro

vide

the

orga

nisa

tion

with

a

wel

l-defi

ned

mis

sion

acc

ordi

ng to

legi

sla-

tion

and

regu

latio

n re

quire

men

ts, a

s w

ell

as ta

king

into

acc

ount

the

stak

ehol

ders

’ ex

pec

tatio

ns.

Lead

ers

pro

vide

the

orga

nisa

tion

with

th

e de

finiti

on o

f a m

issi

on, v

isio

n an

d va

lues

and

sha

re it

with

the

peo

ple

in th

e or

gani

satio

n.

Man

ager

s at

all

leve

ls a

re fo

cuse

d on

b

ringi

ng th

e m

issi

on, v

isio

n an

d va

lues

in

to p

ract

ice.

Stak

ehol

ders

are

con

fiden

t ab

out t

he

cons

tanc

y of

pur

pos

e an

d st

eadi

ness

of

man

agem

ent.

Man

ager

s ar

e p

erce

ived

as

role

mod

els.

The

qual

ity

of m

anag

emen

t has

bee

n m

easu

red

e.g.

thro

ugh

man

agem

ent

asse

ssm

ent o

r job

sat

isfa

ctio

n m

easu

re-

men

ts.

Prin

cipl

e of

exc

elle

nce

4. M

anag

emen

t of p

roce

sses

and

fact

s0

I = In

itiat

ion

R =

Real

isat

ion

M =

Mat

urit

y

Defi

nitio

n Th

e in

itiat

ion

leve

l has

not

bee

n re

ache

dPr

oces

ses

are

iden

tified

and

man

aged

.Th

e im

ple

men

tatio

n of

the

stra

tegy

and

p

lann

ing

of th

e or

gani

satio

n is

ena

ble

d an

d as

sure

d th

roug

h th

e p

roce

sses

.

Proc

esse

s ar

e co

ntin

uous

ly im

pro

ved

for

effec

tiven

ess

on th

e b

asis

of i

nter

nal p

er-

form

ance

mea

sure

men

t, b

ench

lear

ning

an

d/or

ben

chm

arki

ng.

Exam

ples

A p

roce

ss-o

rient

ed w

ay o

f thi

nkin

g ha

s b

een

initi

ated

with

in th

e or

gani

satio

n.

The

key

pro

cess

es -

linke

d to

the

rele

vant

re

sult

are

as -

have

bee

n id

entifi

ed.

The

orga

nisa

tion

has

com

ple

ted

the

iden

tifica

tion

of a

ll ke

y p

roce

sses

.

Key

pro

cess

es h

ave

a cl

ear o

wne

rshi

p.

Targ

ets

for k

ey p

roce

sses

are

defi

ned

in

line

with

the

stra

tegy

and

pla

nnin

g of

the

orga

nisa

tion.

The

orga

nisa

tion

mea

sure

s re

sult

s of

key

p

roce

sses

in re

latio

n to

the

targ

ets.

The

orga

nisa

tion

has

defin

ed th

e b

asis

for

an in

form

atio

n sy

stem

to s

upp

ort p

roce

ss

man

agem

ent.

The

orga

nisa

tion

has

a de

taile

d vi

ew o

f all

pro

cess

es th

roug

h an

info

rmat

ion

syst

em

(incl

udin

g m

anag

emen

t, op

erat

iona

l and

su

pp

ort p

roce

sses

).

All

thes

e p

roce

sses

are

mon

itore

d re

latin

g to

resu

lts

and

imp

rove

d on

a re

gula

r bas

is.

Peop

le k

now

the

pro

cess

es th

ey a

re in

vol-

ved

in a

nd th

e ta

rget

s of

thes

e p

roce

sses

.

Proc

edur

es a

re in

pla

ce to

ens

ure

that

ta

rget

s ar

e b

roke

n do

wn

and

resu

lts

are

used

for i

mp

rove

men

ts.

38

Prin

cipl

e of

exc

elle

nce

5. P

eopl

e de

velo

pmen

t and

invo

lvem

ent

0I =

Initi

atio

nR

= Re

alis

atio

nM

= M

atur

ity

Defi

nitio

n Th

e in

itiat

ion

leve

l has

not

bee

n re

ache

dTh

e or

gani

satio

n ta

kes

initi

ativ

es fo

r de

velo

pin

g an

d in

volv

ing

peo

ple

.Th

e or

gani

satio

n de

velo

ps

com

pet

enci

es

and

invo

lves

peo

ple

in a

str

uctu

red

way

to

imp

rove

pro

duct

s, s

ervi

ces

and

pro

cess

es.

The

orga

nisa

tion

crea

tes

a w

orki

ng e

nvi-

ronm

ent o

f sha

red

valu

es a

nd a

cul

ture

of

trus

t, op

enne

ss, e

mp

ower

men

t and

re

cogn

ition

.

Exam

ples

A tr

aini

ng p

ortf

olio

is p

rese

nt, w

hich

take

s in

to a

ccou

nt p

eop

le’s

dem

and

for f

urth

er

deve

lop

men

t of t

he e

xist

ing

com

pet

en-

cies

.

The

orga

nisa

tion

reco

gnis

es th

e im

por

tanc

e of

invo

lvin

g p

eop

le in

the

deci

sion

-mak

ing

pro

cess

.

Peop

le a

re in

vite

d to

exp

ress

thei

r op

inio

n on

the

orga

nisa

tiona

l dev

elop

men

t.

The

orga

nisa

tion

iden

tifies

and

dev

elop

s th

e re

quire

d co

mp

eten

cies

; the

reby

p

rep

arin

g p

eop

le to

mee

t and

ada

pt t

o ch

ange

s.

The

orga

nisa

tion:

- c

arrie

s ou

t diff

eren

t kin

ds o

f tra

inin

g an

d co

mp

eten

ce d

evel

opm

ent;

- mea

sure

s an

d im

pro

ves

emp

loye

e sa

tisf-

actio

n an

d m

otiv

atio

n;- p

rom

otes

inte

rnal

mob

ility

; - i

nvol

ves

emp

loye

es a

ctiv

ely

in th

e p

roce

ss o

f im

pro

ving

pro

duct

s, s

ervi

ces

and

pro

cess

es.

The

orga

nisa

tion

rew

ards

and

reco

gnis

es

peo

ple

in a

way

that

bui

lds

com

mitm

ent

and

enco

urag

es th

eir l

oyal

ty to

the

orga

nisa

tion.

The

orga

nisa

tion:

- for

mul

ates

the

hum

an re

sour

ce p

olic

y ac

cord

ing

to th

e st

rate

gy a

nd p

lann

ing

invo

lvin

g th

e p

eop

le;

- est

ablis

hes

a re

gula

r cyc

le re

gard

ing

peo

ple

dev

elop

men

t (ap

pra

isal

, tra

inin

g an

d di

alog

ue);

- inv

olve

s em

plo

yees

in th

e de

velo

pm

ent

of s

trat

egie

s an

d ac

tion

pla

ns, i

nviti

ng

them

to g

ener

ate

and

imp

lem

ent i

deas

fo

r im

pro

vem

ent.

Prin

cipl

e of

exc

elle

nce

6. C

ontin

uous

inno

vatio

n an

d im

prov

emen

t

0I =

Initi

atio

nR

= Re

alis

atio

nM

= M

atur

ity

Defi

nitio

nTh

e in

itiat

ion

leve

l has

not

bee

n re

ache

dTh

e or

gani

satio

n le

arns

from

its

activ

ities

an

d p

erfo

rman

ce a

nd lo

oks

for o

pp

ortu

-ni

ties

for i

mp

rove

men

t.

Con

tinuo

us im

pro

vem

ent i

s p

rom

oted

in

the

orga

nisa

tion,

thro

ugh

shar

ing

know

-le

dge

and

taki

ng in

to a

ccou

nt p

eop

le’s

sugg

estio

ns.

The

orga

nisa

tion

syst

emat

ical

ly c

halle

n-ge

s th

e st

atus

quo

, enc

oura

ges,

acc

epts

an

d in

tegr

ates

inno

vatio

n an

d re

gula

rly

com

par

es it

s p

erfo

rman

ce to

oth

er o

rga-

nisa

tions

.

Exam

ples

Th

ere

is a

n as

sess

men

t of p

erfo

rman

ce in

re

leva

nt re

sult

are

as.

Man

agem

ent h

as s

tart

ed a

dia

logu

e w

ith

othe

r org

anis

atio

ns o

n ho

w th

ey w

ork.

Imp

rove

men

ts b

ased

on

inte

rnal

ass

ess-

men

ts a

nd e

xter

nal o

bse

rvat

ion

have

b

een

initi

ated

.

The

orga

nisa

tion

star

ts to

inco

rpor

ate

the

prin

cip

les

of th

e PD

CA

cyc

le w

hen

wor

king

with

imp

rove

men

ts.

The

orga

nisa

tion

exch

ange

s ex

per

ienc

es

with

oth

er o

rgan

isat

ions

.

The

orga

nisa

tion

iden

tifies

op

por

tuni

ties

and

obst

acle

s to

inno

vatio

n an

d le

arni

ng.

Con

tinuo

us im

pro

vem

ent i

s su

pp

orte

d by

the

peo

ple

on

a re

gula

r bas

is e

.g. b

y ca

rryi

ng o

ut s

elf-

asse

ssm

ents

.M

anag

emen

t enc

oura

ges

emp

loye

es

to ta

ke re

spon

sib

ility

for i

mp

rove

men

t ac

tions

.

Man

agem

ent a

ckno

wle

dges

the

sign

ifi-

canc

e of

str

ateg

ic re

new

al a

nd m

oder

ni-

satio

n in

ord

er to

acc

omm

odat

e fu

ture

ch

alle

nges

rega

rdin

g e.

g. c

usto

mer

nee

ds,

recr

uitm

ent,

mai

nten

ance

and

pol

itica

l de

man

ds.

The

orga

nisa

tion

carr

ies

out b

ench

-lear

-ni

ng, b

oth

inte

rnal

ly a

nd e

xter

nally

.Pr

ojec

ts/e

ffor

ts a

re c

arrie

d ou

t acc

ordi

ng

to th

e p

rinci

ple

s of

the

PDC

A c

ycle

. Th

e or

gani

satio

n us

es c

reat

ive

met

hods

to

car

ry o

ut c

oncr

ete

imp

rove

men

t ini

tia-

tives

gen

erat

ing

adde

d va

lue.

39

Prin

cipl

e of

exc

elle

nce

7. P

artn

ersh

ip d

evel

opm

ent

0I =

Initi

atio

nR

= Re

alis

atio

nM

= M

atur

ity

Defi

nitio

n Th

e in

itiat

ion

leve

l has

not

bee

n re

ache

dTh

e or

gani

satio

n id

entifi

es it

s p

artn

ers.

The

orga

nisa

tion

form

alis

es p

artn

ersh

ips

to re

ach

mut

ual a

dvan

tage

s.Th

e or

gani

satio

n m

anag

es p

artn

ersh

ips

in

a w

in-w

in s

ituat

ion

to e

nab

le d

eliv

ery

of

enha

nced

val

ue a

nd to

op

timis

e th

e us

e of

reso

urce

s.

Exam

ples

M

anag

emen

t is

awar

e of

the

sign

ifica

nce

of th

e ex

tern

al re

latio

nshi

ps

and

par

tner

-sh

ips

held

by

the

orga

nisa

tion.

The

orga

nisa

tion’

s m

ost i

mp

orta

nt e

xter

-na

l rel

atio

nshi

ps

and

par

tner

ship

s ha

ve

bee

n id

entifi

ed.

The

orga

nisa

tion

enjo

ys d

iffer

ent k

inds

of

coop

erat

ion

with

ext

erna

l act

ors.

Man

agem

ent h

as a

cle

ar v

iew

of t

he m

ost

imp

orta

nt e

xter

nal r

elat

ions

hip

s an

d p

art-

ners

hip

s an

d th

e de

velo

pm

ent p

ossi

bili

-tie

s of

thes

e, b

ased

on

a cl

earl

y id

entifi

ed

mut

ual b

enefi

t.

The

orga

nisa

tion

is e

ngag

ed in

form

alis

ed

key

par

tner

ship

s.

Emp

loye

es a

re a

war

e of

the

exte

rnal

re

latio

nshi

ps

and

par

tner

ship

s, w

hich

are

im

por

tant

to th

eir p

ositi

on a

nd ta

sks.

The

orga

nisa

tion

ensu

res

syst

emat

ic p

art-

ners

hip

s w

ith a

ll si

gnifi

cant

par

tner

s.

Regu

lar e

valu

atio

n of

the

effec

tiven

ess

and

effici

ency

of e

xist

ing

par

tner

ship

s an

d th

eir i

mp

rove

men

t is

carr

ied

out.

The

orga

nisa

tion

enga

ges

in th

e se

arch

fo

r new

par

tner

s.

Prin

cipl

e of

exc

elle

nce

8. S

ocia

l res

pons

ibili

ty0

I = In

itiat

ion

R =

Real

isat

ion

M =

Mat

urit

y

Defi

nitio

n Th

e in

itiat

ion

leve

l has

not

bee

n re

ache

dTh

e or

gani

satio

n is

aw

are

of it

s im

pac

t on

soci

ety

(soc

ial a

nd e

nviro

nmen

tal).

The

orga

nisa

tion

is a

ctiv

ely

invo

lved

in

activ

ities

rela

ted

to s

ocia

l res

pon

sib

ility

an

d ec

olog

ical

sus

tain

abili

ty.

The

orga

nisa

tion

mee

ts o

r exc

eeds

the

maj

or e

xpec

tatio

ns a

nd re

quire

men

ts o

f th

e lo

cal a

nd -

whe

re a

pp

rop

riate

- th

e gl

obal

com

mun

ity.

Exam

ples

Th

e or

gani

satio

n m

akes

a d

istin

ctio

n b

et-

wee

n its

mis

sion

and

its

corp

orat

e so

cial

re

spon

sib

ility

as

a p

ublic

inst

itutio

n.

The

orga

nisa

tion

iden

tifies

the

area

s of

imp

act i

n te

rms

of s

ocia

l, ec

onom

ic

and

ecol

ogic

al is

sues

and

imp

act o

n th

e m

edia

.

The

orga

nisa

tion

wor

ks o

n m

utua

lly b

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40

Appendix 2

The CAF External Feedback Scoring Guide

Background

The purpose of the guide is to act as a guide for the CAF External Feedback Actor with regards to assessing the level of achievement reached in the CAF External Feedback and whether an applicant organisation is qualified to receive the label ‘Effective CAF User’.

The scoring guide describes the basic principles for an assessment by the CAF External Feedback Actor and scoring of the organisations working with CAF.

The scope of the assessment comprises three pillars:• Assessmentoftheself-assessmentprocess,which covers the first six steps of the ten steps defined in the ‘Guidelines to improving organisations using CAF’ (not an assessment of the scores given in the self-assessment process).• Assessment of the planning and the process of improvement, which covers the steps from seven to nine defined in the ‘Guidelines to improving organisations using CAF’ (not an assessment of the results of the improvement actions). • Assessment of the TQM maturity of the organisation by examining the maturity level it has attained as a result of the self-assessment and the action plan that is installed. The assessment of maturity with regard to TQM values is based on the eight Principles of Excellence (the broader scope of excellence).

The questionnaires completed by the applicant cover these pillars and serve as the main frame of reference for an assessment by the CAF External Feedback Actor. Each of the pillars will be scored through the appropriate evaluation scale (see further below), and the pillars have specific scoring profiles (profiles which must be met to obtain the label – see further below).The first section on Scoring methodology will outline the basic principles with regard to scoring by the CAF External Feedback Actor.

1. Scoring methodology

The main purpose of the procedure is to serve as a framework for the provision of systematic external feedback to CAF users requiring it. The assessment process and the examination during the site visit must therefore be provided in an open and respectful manner, which supports learning and dialogue. The CAF External Feedback Actor should behave in such a manner that the site visit is not perceived as a one-way gathering of evidence, but as a possibility for discussion and feedback.

The CAF External Feedback must be flexible enough to handle many types of organisations in terms of complexity and size. The actions described in all three pillars, and their correlation to the scores, should therefore not be used as a checklist, but as a guide. In addition to the actions described here, other actions not included may also be appropriate for certain organisations. This means that the scoring should not be perceived as a mechanical exercise, but should be based on both the overall impression of the organisation when the site visit has been concluded, as well as the various evidence gathered with regard to specific steps, actions and changes.

1.1 EvidenceThe questionnaires completed by the applicant serve as the main frame of reference for the CAF External Feedback Actor. Evidence gathered at the site visit and through written accounts should determine whether the self-description in the questionnaires gives a correct assessment of the organisations working with CAF. Evidence will be gathered through interviews and workshops with all (internal) relevant stakeholders from the organisation, and through various existing written accounts.

Written documents include self-assessment report(s), improvement plans and other relevant documents.

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It is important to stress that ‘evidence’ does not have to be materialised in written form, but can take the form of interviews and opinions of the stakeholders, and a comparison of these statements between the different groups. Secondly, the organisation is not supposed to prepare a lot of new written accounts in the process of the External Feedback scheme; the examination should, where possible, use materials that are already available.

1.2 ScoringOrganisations are scored on the basis of evaluation scales (see part 2 of this scoring guide). A sophisticated scoring tool – such as Radar in the Excellence recognition scheme – has not been developed because the CAF External Feedback scheme is for CAF users who are just starting their journey towards holistic and systematic quality development. At this level, most organisations will not have written accounts that support this more sophisticated type of assessment.

The scheme recognises the ability of an organisation to make an effective and well-planned self-assessment that increases its understanding of the fundamental principles needed to become excellent. A more sophisticated scoring tool at this level would risk shifting the focus from a dialogue between the CAF External Feedback Actor and the organisation regarding important discussions and lessons learned, to a more one-sided gathering of facts to support an assessment.

Scoring of the self-assessment process and improvement actions (Pillars 1-2) Instead of a scoring tool, some basic principles are available to guide the CAF External Feedback Actor. In order to make the decision as to whether a step should be assessed as acceptable (3) or satisfactory (4), for example, the CAF External Feedback Actor should use the PDCA as a guideline For each step, the CAF External Feedback Actor considers whether the organisation has planned, developed, checked and adjusted the actions, where reasonable, in an effective way. Important questions could be:• Has the applicant organisation planned the step effectively and included relevant issues and contingencies?• Hasthestepbeendevelopedand implemented according to the plan? If not, were changes to the implementation reasonable and based on solid arguments?• Hastheorganisation,ifappropriateforthestep, checked whether the chosen approach has achieved the intended results?

• And finally, did the organisation adjust actions during the process or plans in order to change the approach in the next self-assessment, based on checks and lessons learned?

The PDCA should not be used as a scoring tool, but as a framework for reflection with regard to the planning and implementation of the self-assessment and improvement actions. The CAF External Feedback Actor should therefore not provide a mechanical assessment of the individual activities for all aspects of PDCA (e g by judging an otherwise satisfactory activity as merely acceptable just because checks (C) and adjustment (A) are missing). In other words, not all activities will require checks and adjustment, for example, to receive the assessment ‘satisfactory’.

The questionnaires completed by the applicant serve as the main frame of reference for the CAF External Feedback Actor when scoring. The first two pillars (self-assessment process and improvement plan) are scored at the level of the nine steps and not the 35 underlying actions. The CAF External Feedback Actors are thus invited to use the questionnaires as a framework for scoring by giving the individual actions a rating and examining what the ratings add up to on the level of the nine steps (see Part 3 of this scoring guide).

Scoring of TQM values (Pillar 3)To support the scoring of maturity, the questionnaire provides a range of examples that indicate which possible actions constitute different levels of maturity (see Part 3 of this scoring guide). Again, the examples serve as a guide only and the context and type of organisation can impact which and how many actions are appropriate for reaching different levels of maturity.

To achieve the label of ‘Effective CAF User’, the organisation must reach initiation level in all eight principles of Excellence. It is not possible to discuss all eight principles in depth during the site visit. During the site visit, the CAF External Feedback Actor will focus on the two principles chosen by the organisation for a more in-depth examination and feedback.

The questionnaire on TQM values completed by the applicant serves as the main frame of reference for the CAF External Feedback Actor. In addition to the Pillar 3 document, the CAF External Feedback Actors examine the self-assessment report(s) and the improvement plan(s) in order to make an overall assessment of the level of maturity reached for all eight principles. The aim is to decide whether the report(s) and the improvement plan(s) show that

42

actions are either in place or under development, making it reasonable to judge that the first level of maturity has been reached. The CAF External Feedback Actors may also include other principles during the site visit interviews if there is any doubt as to which level of maturity the organisation has reached.

2. Evaluation scales

2.1 Evaluation scales for the self-assessment process and the improvement actions (Pillars 1-2)The self-assessment process and the improvement actions are assessed through the same evaluation scale from 1-5 points: The assessment does not look at the scores generated during the self-assessment (i.e. PDCA-evaluation of actions performed under each sub-criterion in the CAF model), nor does the assessment examine the actual proven results of the improvement actions. What is examined is the way the self-assessment and the improvement process have been planned, developed, checked and adjusted.

All steps in both pillars (steps 1-9) must be assessed by the CAF External Feedback Actor

2.2 Evaluation scales for the TQM valuesThe assessment of the TQM values relates to the maturity level achieved by the organisation as a result of the work with the self-assessment and the improvement process. The TQM values consist of the eight Principles of Excellence.

The evaluation scale has four levels:

The evaluation of the TQM Maturity determines the extent to which the organisation has succeeded in implementing holistic quality development values through the self assessment and improvement process. The aim is therefore not to assess the real results of the improvement activities and the quality of these, but

to assess whether the self-assessment has changed basic values with regard to quality development in the organisation. The applicant chooses two concepts from the eight Principles of Excellence to be assessed in depth during the site visit (one of which must either be Customer Focus or Result Orientation).

3. Scoring profiles

3.1 Scoring profile for the self-assessment process and the improvement actions (Pillars 1-2)These scoring profiles cover:• Assessment of the process of self-assessment which covers the first six of the ten steps as defined in the ‘Guidelines to improving organisations using CAF’ (not an assessment of the scores given in the self assessment process) • Assessment of the planning and the process of improvement which covers the steps from seven to nine as defined in the ‘Guidelines to improving organisations using CAF’ (not an assessment of the results of the improvement actions).

The assessment made by the CAF External Feedback Actor will be based on evidence gathered by interviewing different groups in the workplace and the self-assessment report(s), the improvement plan and other relevant documents. A score from 1 to 5 is given for each of the nine steps globally.

To obtain the label, the minimum requirements are as follows: • ThetotaloverallscoreoftheassessmentofPillars 1 and 2 must be at least 28 points.• Steps1,5and9mustbedeemedtobeat least satisfactory (score of 4) i.e. a minimum score of four must be achieved.

All steps must be assessed by the CAF External Feedback Actor.

The CAF External Feedback Actor can choose to use the questionnaire as a framework for scoring by giving the individual actions a rating and examining whether the actions add up to the score given on the level of the nine steps. The final decision as to whether the organisation obtains the label is based on the scoring profile for the nine steps, not the individual actions.

The scoring profile is marked with grey for steps 1, 5 and 9, where a minimum of 4 is deemed necessary. The score is given for the nine steps (marked with a red border in the questionnaire), not the individual activities of which the step is comprised.

The total overall score for the assessment of the nine steps in Pillars 1 and 2 must be at least 28 points.

0 = Initiation level has not been achieved

I = Initiation level

R = Realisation level

M = Maturity level

1 The activities have been carried out in a very limited way.

2 The activities have been carried out in a limited way.

3 The activities have been carried out in an acceptable way.

4 The activities have been carried out in a satisfying (satisfactory) way.

5 The activities have been carried out in an outstanding way.

43

Scoring profile Pillar 1 1 2 3 4 5

Step 1: Decide how to organise and plan the self-assessment (SA).

Step 2: Communicate the self-assessment project.

Step 3: Create a self-assessment group(s).

Step 4: Organise training.

Step 5: Perform the self-assessment.

Step 6: Prepare a report describing the results of self-assessment.

Scoring profile Pillar 2

Step 7: Draft an improvement plan, based on the accepted self-assessment report.

Step 8: Communicate the improvement plan.

Step 9: Implement the improvement plan.

Minimum score needed ( incl. three steps with 4) = 28

Self-assessment process Pillar 1 1 2 3 4 5

Step 1: Decide how to organise and plan the self-assessment (SA).

1.1 Assure the commitment and ownership of the management for launching the process.

1.2 Assure a clear management decision with regard to carrying out the SA in consultation with the organisation, the scope of the SA (SA covers the whole organisation or only parts/units/ departments....) and the overall objective of the SA

1.3 Define a framework for the SA process and the subsequent actions, plan the SA activities

1.4 Appoint an SA process leader with a high level of knowledge of the organisation or constitute an SA Committee headed by the SA process leader

1.5 Define the scoring panel to be used

1.6 Allocate resources for SA and define how to prioritise the distribution of resources

Self-assessment process - Overall score - Step 1:

Step 2: Communicate the self-assessment project.

2.1 Define a communication plan, to include the expected benefits, the goal and the activities of SA

2.2 Implement the communication plan using different tools

2.3 Communicate to all relevant stakeholders during the different phases of the SA process and stimulate involvement of the top and middle managers, staff and employees in SA

Self-assessment process - Overall score - Step 2:

Step 3: Create a self-assessment group(s).

3.1 Decide whether it is necessary to create one or more SA groups, define their number, create them, choose their chair, assign responsibilities to each member as needed

3.2 Decide whether the manager(s) should be part of the SA group(s)

3.3 Select the participants of the SA group(s) on the basis of specified criteria, such as their knowledge of the organisation , their personal skills and their representativeness

Self-assessment process - Overall score - Step 3:

Step 4: Organise training.

4.1 Organise information/training activities for leaders and managers (top and middle) to promote ownership and commitment

4.2 Prepare a plan for all the training activities of SA group(s)

4.3 Organise training for the members of the self-assessment group(s)

Self-assessment process - Overall score - Step 4:

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Step 5: Perform the self-assessment.

5.1 Relevant documents and information for SA are collected and made available for all the SA groups

5.2 The members of the SA group(s) compile a list of strengths and areas of improvement and provide a score for each sub-criterion of CAF.

5.3 The chair collects the individual inputs and prepares the consensus meeting, assuring all conditions for its success

5.4 The SA group reaches consensus on strengths, areas for improvement and scoring for each sub-criterion.

Self-assessment process - Overall score - Step 5:

Step 6: Prepare a report describing the results of self-assessment.

6.1 Prepare a final report containing at least the following elements for each sub-criterion: - strengths, - areas for improvement and - score

6.2 Present the final report to the Senior Management of the organisation

6.3 Communicate the main results to people in the organisation and other relevant stakeholders

Self-assessment process - Overall score - Step 6:

Improvement plan (Pillar 2) 1 2 3 4 5

Step 7: Draft an improvement plan, based on the accepted self-assessment report.

7.1 Collect all proposals for actions for improvement (including the ideas formulated during the SA)

7.2 Prioritise improvement actions with regards to their effectiveness and feasibility

7.3 Define a structured action plan for the selected improvement actions based on the PDCA Cycle (Plan-Do-Check-Act )

7.4 Establish ways to measure the performance of the actions and the results

7.5 Incorporate the action plan into the normal strategic planning process

Self-assessment process - Overall score - Step 7:

Step 8: Communicate the improvement plan.

8.1 Define a communication plan - the appropriate information with the appropriate media to the appropriate target group, addressed to all stakeholders - for the improvement actions

8.2 Implement the communication plan

8.3 Regularly inform the relevant stakeholders– especially the people of the organisation - on the status and progress, including evaluations and experiences

Self-assessment process - Overall score - Step 8:

Step 9: Implement the improvement plan.

9.1 Define clear ownership of the improvement programme and the projects, and ensure transparency in task and responsibility delegation.

9.2 Implement the improvement plan as scheduled

9.3 Involve employees in the different improvement actions to ensure anchoring of the improvement projects throughout the institution

9.4 Define a consistent approach for monitoring and assessing the improvement actions

9.5 Monitor implementation of the improvement actions on a regular basis

Self-assessment process - Overall score - Step 9:

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3.2. Scoring profile TQM values (Pillar 3)

These scoring profiles cover: • Assessment of the TQM maturity of the organisation by examining the maturity level it has attained as a result of the self-assessment and the action plan that is installed. The assessment of maturity with regard to TQM values is based on the eight Principles of Excellence (the broader scope of excellence). • All of the eight principles will be examined briefly. Two principles chosen by the applicant will be systematically assessed in depth during the site visit (one of which must either be Customer Focus or Result Orientation).

A score signifying the level of TQM maturity (initiation, realisation and maturity) is given for each of the eight Principles of Excellence. To obtain the label, the minimum requirements are as follows:• Alleightprinciplesmustreachthelevel of Initiation (I).

The assessment by the CAF External Feedback Actor will be based on evidence gathered by interviewing different groups in the workplace. The interviews examine whether and to what degree the self-assessment has resulted in positive changes, and the maturity level that has been achieved with regards to the eight Principles of Excellence.

All of the eight Principles of Excellence will be examined briefly. Two concepts chosen by the applicant will be systematically assessed in depth (one of which must either be Customer Focus or Result Orientation).

To support the self-assessment and the examination by the CAF External Feedback Actor of the eight Principles of Excellence, examples describing the level have been included in the questionnaire. The examples should be seen as a guideline for the CAF External Feedback Actor’s examination of the eight principles. For a detailed description of the principles, please refer to Appendix 1.3 ‘The TQM Maturity questionnaire’.

8. Principles of Excellence

1. Result orientation

2. Citizen/Customer focus

3. Leadership and constancy of purpose

4. Management of processes and facts

5. People development and involvement

6. Continuous innovation and improvement

7. Partnership development

8. Social responsibility

Maturity level

O I R M

46

Appendix 3

Format of the CAF External Feedback Report

Feedback reportEffective CAF User

[Name of organisation][Date]

CAF External Feedback Actors[Name of Actor], [Organisation] [Name of Actor], [Organisation]

47

Feedback report

Name of the organisation:

Address:

Contact person:

Telephone:

Fax:

E-mail:

Date:

Team of CAF External Feedback Actors:

48

Section 1: General comments

Main themes in the report [Insert ½ page describing the main themes in the feedback report].

Identified key strengths•[Insert3-4findingsonkeystrengths].

Key areas of improvement

•[Insert3-4findingsonkeyareasofimprovement].

Main recommendations [Insert ½-1 page on main recommendations].

Label has been obtained: Label has not been obtained:

49

Section 2: Feedback on the self-assessment process

General comments about the self-assessment process:Step 1: Decide how to organise and plan the self-assessment (SA).Strengths•[Insertstrengths]

Areasforimprovement•[Insertareasforimprovement]

The activities have been carried out in a:

very limited way limited way acceptable way satisfying way outstanding way

Step 2: Communicate the self-assessment project.Strengths•[Insertstrengths]

Areasofimprovement•[Insertareasofimprovement]

The activities have been carried out in a:

very limited way limited way acceptable way satisfying way outstanding way

Step 3: Create a self-assessment group(s).Strengths•[Insertstrengths]

Areasofimprovement•[Insertareasofimprovement]

The activities have been carried out in a:

very limited way limited way acceptable way satisfying way outstanding way

Step 4: Organise training.Strengths•[Insertstrengths]

Areasofimprovement•[Insertareasofimprovement]

The activities have been carried out in a:

very limited way limited way acceptable way satisfying way outstanding way

Step 5: Perform the self-assessment.Strengths•[Insertstrengths]

Areasofimprovement•[Insertareasofimprovement]

The activities have been carried out in a:

very limited way limited way acceptable way satisfying way outstanding way

Step 6: Prepare a report describing the results of self-assessment.Strengths•[Insertstrengths]

Areasofimprovement•[Insertareasofimprovement]

The activities have been carried out in a:

very limited way limited way acceptable way satisfying way outstanding way

50

Section 3: Feedback on the improvement plan

General comments about the improvement plan:Step 7: Draft an improvement plan, based on the accepted self-assessment report.Strengths•[Insertstrengths]

Areasforimprovement•[Insertareasforimprovement]

The activities have been carried out in a:

very limited way limited way acceptable way satisfying way outstanding way

Step 8: Communicate the improvement plan.Strengths•[Insertstrengths]

Areasofimprovement•[Insertareasofimprovement]

The activities have been carried out in a:

very limited way limited way acceptable way satisfying way outstanding way

Step 9: Implement the improvement plan.Strengths•[Insertstrengths]

Areasofimprovement•[Insertareasofimprovement]

The activities have been carried out in a:

very limited way limited way acceptable way satisfying way outstanding way

51

Section 4: Feedback on TQM values

General comments about the TQM values:[Insert first chosen Principle of Excellence]

Strengths•[Insert2-4strengths]

Areasofimprovement•[Insert2-4areasofimprovement]

The organisation: has not reached the Initiation level

has reached the initiation level

has reached the realisation level

has reached the maturity level

General comments about the TQM values:[Insert second chosen Principle of Excellence]

Strengths•[Insert2-4strengths]

Areasofimprovement•[Insert2-4areasofimprovement]

The organisation: has not reached the initiation level

has reached the initiation level

has reached therealisation level

has reached thematurity level

52

Section 5: Scoring profile

Scoring profile Pillar 1 1 2 3 4 5

Step 1: Decide how to organise and plan the self-assessment (SA).

Step 2: Communicate the self-assessment project.

Step 3: Create a self-assessment group(s).

Step 4: Organise training.

Step 5: Perform the self-assessment.

Step 6: Prepare a report describing the results of self-assessment.

Scoring profile Pillar 2

Step 7: Draft an improvement plan, based on the accepted self-assessment report.

Step 8: Communicate the improvement plan.

Step 9: Implement the improvement plan.

Minimum score needed ( incl. three steps with 4) = 28 Score = [Insert score]

8. Principles of Excellence

1. Result orientation

2. Citizen/Customer focus

3. Leadership and constancy of purpose

4. Management by processes and facts

5. People development and involvement

6. Continuous innovation and improvement

7. Partnership development

8. Social responsibility

Maturity level

O I R M

All eight principles must reach at least Initiation level (I)

Label has been obtained: Label has not been obtained:

53

Appendix 4

Form for Applicant Organisation

Contact detailsApplicant

Name of the organisation:

Address:

Contact person:

Telephone:

Fax:

E-mail:

Date:

The CAF has been applied in 20___ (year) CAF has been implemented in the organisation as a whole CAF has been implemented in part of the organisation, namely: _______________________________________________

The CAF self-assessment report was concluded and delivered to the management of the organisation on _____________ (dd/mm/yyyy)

Please note that the application should be completed between 6 and 12 months after the CAF self-assessment has taken place and the self-assessment report has been concluded and delivered.

Registration as a CAF User The organisation (or department) is registered as a CAF User in the European online database of CAF Users (caf.eipa.eu)

Signature by the management of the organisation (e.g. General Director)

Name: ___________________________________________________ Title: ________________________________________

Place: ____________________________________________________ Date: ________________________________________

Signature:

This signature confirms that the information provided is correct and that you agree to the conditions for applying.

The application must be sent to: [Adress of the CAF National Organiser]

54

Appendix 5

National Organiser Fact sheet

Name Name of National Organiser in the Member State

Logo Logo used by the National Organiser

Person responsible Person responsible within the organisation

Address Full postal address

E-mail E-mail address

URL URL address

Phone

Fax

The fact sheets of the Member States will be published on the CAF website (www.eipa.eu/caf ).

55

Appendix 6

Effective CAF User label example

56

57

The Common Assessment Framework (CAF) is a result of the co-operation among the EU Ministers responsible for Public Administration.

The CAF is offered as a common tool to assist public sector organisations to use quality management techniques in public administration. It provides a general, simple, easy-to-use framework, which is suitable for a self-assessment of public sector organisations and their development towards Excellence!

European CAF Resource CentrePatrick Staes, Head of the European CAF Resource Centre

European Institute of Public AdministrationP.O. Box 12296201 BE MaastrichtThe NetherlandsTel.: + 31 43 32 96 317Fax: + 31 43 32 96 296E-mail: caf@eipa.eu

www.eipa.eu/CAF