Bouwen aan een kwaliteitssysteem in de revalidatiezorg: Een poging tot constructive technology assessment van een kwaliteitssysteem in een gezondheidszorginstelling

In dit proefschrift staat de vraag naar de meerwaarde van (investeringen in) een kwaliteitssysteem in een revalidatiecentrum centraal. In de gezondheidszorg wordt vanaf het midden van de jaren tachtig toenemend gesproken over kwaliteit. De aandacht hiervoor groeide toen geleidelijk aan bleek dat de ontwikkeling van de zorgvraag en (met name de financiering van) het aanbod steeds minder op elkaar aansloten. Onder andere een toenemend beroep op zorgvoorzieningen door de verouderende en steeds meer eisende bevolking, én het door de overheid, met het oog op de collectieve lasten, noodzakelijk geachte kosten-beheersingsbeleid, zijn hiervoor belangrijke redenen. Binnen de sector groeit de bezorgdheid over de kwaliteit van de zorgverlening; de vanzelfsprekendheid waarmee men er vanuit ging dat een goed eindproduct geleverd zou worden, verdwijnt. In navolging van industrie en commerciële dienstverlening wordt het begrip kwaliteitszorg geïntroduceerd. In 1989 en 1990 werden - toen nog in verband met de door de commissie Dekker voorgestelde marktwerking en deregulering - door de KNMG (Koninklijke Nederlandse Maatschappij ter bevordering van de Geneeskunstl twee conferenties over een "landelijk kwaliteitsbeleid" georganiseerd; door de betrokken partijen in de gezondheidszorg werd toen, voor een periode van vijf jaar, een aantal afspraken gemaakt over uitgangspunten en gewenste ontwikkelingen. Onder andere werd vastgelegd dat de aanbieders van zorg het initiatief zouden nemen om "binnen een half jaar te komen tot het maken van afspraken over de ontwikkeling van kwaliteitssystemen" (zie bijlage 1). Op verzoek van de deelnemers is er door de Nationale Raad voor de Volksgezondheid een commissie Voortgang Ontwikkeling Kwaliteitsbeleid ingesteld, die de ontwikkelingen op dit terrein ging bewaken. In 1995 heeft, aangestuurd door die commissie, een evaluatie plaatsgevonden van de wijze waarop aan de eerder gemaakte afspraken vorm is gegeven en is er opnieuw een landelijke kwaliteitsconferentie geweest. Hier zijn afspraken voor de periode 1995-2000 vastgelegd over begripsverheldering, externe beoordeling, ontwikkeling van kwaliteitssystemen, informatie over de kwaliteit van zorg- en verzekeringsaanbod en prikkels en voorwaarden voor kwaliteitsbeleid. Bijvoorbeeld werd (opnieuw) afgesproken dat expliciet aandacht besteed zal gaan worden aan de organisatiebrede opbouw van kwaliteitssystemen

Development of MijnAVL, an Interactive Portal to Empower Breast and Lung Cancer Survivors: An Iterative, Multi-Stakeholder Approach

Background: MijnAVL (MyAVL) is an interactive portal being developed to empower cancer survivors. Literature review and focus groups yielded the selection of features such as access to the electronic medical record (EMR), patient reported outcomes (PROs) and related feedback, and a physical activity support program. Objective: Our aim was to present a final design of MijnAVL based on (1) health professionals' evaluation of proposed features, (2) cancer survivors’ evaluation of a first draft, and (3) cancer survivors’ evaluation of a functional online prototype. Methods: Professionals from various disciplines gave input to the content of and procedures related to MijnAVL. Subsequently, 16 cancer survivors participated in an interview to evaluate content and graphic design of a first draft (shown with screenshots). Finally, 7 survivors participated in a usability test with a fully functional prototype. They performed predefined tasks (eg, logging in, finding a test result, completing a questionnaire) while thinking aloud. Descriptive statistics and simple content analysis were used to analyze the data of both the interviews and the usability tests. Results: Professionals supported access to the EMR (eg, histology reports, lab results, and their letters to general practitioners). They also informed the development of PROs and the physical activity support program. Based on the first draft, survivors selected the preferred graphic design, approved the features and provided suggestions for the content (eg, explanation of medical jargon, more concise texts, notification by emails). Usability tests revealed that it was relatively easy to navigate the website and use the different features. Recommendations included, among others, a frequently asked questions section and the use of hyperlinks between different parts of the website. Conclusions: The development of MijnAVL, an interactive portal to empower breast and lung cancer survivors, was performed iteratively and involved multiple groups of end-users. This approach resulted in a usable and understandable final version. Its effectiveness should be determined in further researc

Education and training of nurses in the use of advanced medical technologies in home care related to patient safety: A cross-sectional survey

Background: To use advanced medical technologies (AMTs) correctly and safely requires both specialist knowledgeand skills, and an awareness of risks and how those can be minimized. Reporting safety concerns aboutAMTs in home care can contribute to an improved quality of care. The extent to which a health care organizationhas integrated the reporting, evaluation and learning from incidents is a key element of that organization’spatient safety culture.Objectives: To explore nurses’ experiences regarding the education followed in the use of AMTs in the homesetting, and their organizations’ systems of reporting.Design: Descriptive cross-sectional design.Methods: 209 home care nurses from across the Netherlands who worked with infusion therapy, parenteralnutrition and/or morphine pumps responded to the online questionnaire between July 2018 and February 2019.The analysis of the data was mainly descriptive.Results: Educational interventions that are most often used to learn how to use AMTs were, as an average over thethree AMTs, instruction by a nurse (71%), practical training in the required skills (71%) and acquiring informationto increase theoretical knowledge (69%). Considerable attention is paid to patient safety (88%) and thehome setting (89%). However, a substantial proportion of the nurses (up to 29%) use AMTs even though they hadnot been tested on their skills. 95% of the respondents were well acquainted with the incident reporting protocolof their organization, but only 49% received structural or regular feedback on any actions taken as a result ofevent reporting.Conclusions: This study revealed aspects of nurses’ education that imply risk factors for patient safety. Practicaltraining is not always given, additional or retraining is often voluntary, and the required skills are not alwaystested. However, the results show that nurses do have a good awareness of patient safety. Incidents are mainlydiscussed within the team, but less at the organizational level

Reporting incidents involving the use of advanced medical technologies by nurses in home care: a cross-sectional survey and an analysis of registration data

Background  Advanced medical technologies (AMTs), such as respiratory support or suction devices,  are increasingly used in home settings and incidents may well result in patient harm.  Information about risks and incidents can contribute to improved patient safety, provided that those are reported and analysed systenaticaly. Objectives  To identify the frequency of incidents when using  AMTs in home settings,  the effects on patient outcomes and the actions taken by nurses following identification of incidents. Methods  A cross- sectional study of 209 home care nurses in the Netherlands working with infusion therapy, parenteral nutrition or morphine pumps,  combining data from a questionnaire and registration forms covering more than 13 000 patient contacts.  Descriptive statistics were used. Results  We identified 140 incidents (57 adverse events;  83 near misses).  The frequencies in relation to the number of patient contacts were 2.7% for infusion therapy,  1.3% for parenteral nutrition and 2.6% for morphine pumps. The main causes were identified as related to the product (43.6%),  the organisation of care (27.9%),  the nurse as a user (15.7%) and the environment (12.9%).  40% of all adverse events resulted in mild to severe harm to the patient.  Incidents had been discussed in the team (70.7%),  with the patient/informal caregiver(s) (50%),  or other actions had been taken (40.5%).  15.5% of incidents had been formally reported according to the organisation’s protocol. Conclusions  Most incidents are attributed to product failures.  Although such events predominantly cause no harm,  a significant proportion of patients do suffer some degree of harm. There is considerable underreporting of incidents with  AMTs in home care. This study has identified a discrepancy in quality circles:  learning takes place at the team level rather than at the organisational level