Quality management of medical specialist care in the Netherlands : an explorative study of its nature and development

In January 1985, the author of this study was employed as a scientific staff member at CBO, the Dutch National Organisation for Quality Assurance in Hospitals. His main job was to support peer review committees of medical specialists in hospitals. The task proved to be challenging and was broadened to an active involvement in the consensus development programme run by CBO'S scientific council. Both peer review and guideline development through consensus conferences turned out to be far more complex activities than might be expected at first sight. Hence over the years the ambition emerged to study these phenomena more thoroughly. From the beginning it was clear that peer review and guideline development are only two of the various systematic activities the medical profession has developed to manage the quality of specialist care. This study is rooted in the curiosity to understand these activities and in its essence the study tries to provide an answer to two questions: • What is quality management of medical specialist care? • How does it develop

Flying with doctors: Experiences with the application of 6 techniques from aviation industry in the Rotterdam Eye Hospital

Intoduction. Aviation industry is often put forward as an example in creating safer health care. Comparing aviation and health care, there are similarities in using technology, working with highly specialized professional teams and the need for dealing with risk and uncertainties (Sexton 2000; Powell 2006; Kao & Thomas 2008). Rhetorical use of the resemblance however, does not directly contribute to the safety of the health care system. To measure the added value of the experiences in aviation for the health care sector, it is preferable to study in detail the use of aviation based principals in daily practice

Influences of hospital information systems, indicator data collection and computation on reported Dutch hospital performance indicator scores

Background: For health care performance indicators (PIs) to be reliable, data underlying the PIs are required to be complete, accurate, consistent and reproducible. Given the lack of regulation of the data-systems used in the Netherlands, and the self-report based indicator scores, one would expect heterogeneity with respect to the data collection and the ways indicators are computed. This might affect the reliability and plausibility of the nationally reported scores. Methods. We aimed to investigate the extent to which local hospital data collection and indicator computation strategies differ and how this affects the plausibility of self-reported indicator scores, using survey results of 42 hospitals and data of the Dutch national quality database. Results: The data collection and indicator computation strategies of the hospitals were substantially heterogenic. Moreover, the Hip and Knee replacement PI scores can be regarded as largely implausible, which was, to a great extent, related to a limited (computerized) data registry. In contrast, Breast Cancer PI scores were more plausible, despite the incomplete data registry and limited data access. This might be explained by the role of the regional cancer centers that collect most of the indicator data for the national cancer registry, in a standardized manner. Hospitals can use cancer registry indicator scores to report to the government, instead of their own locally collected indicator scores. Conclusions: Indicator developers, users and the scientific field need to focus more on the underlying (heterogenic) ways of data collection and conditional data infrastructures. Countries that have a liberal software market and are aiming to implement a self-report based performance indicator system to obtain health care transparency, should secure the accuracy and precision of the heath care data from which the PIs are calculated. Moreover, ongoing research and development of PIs and profound insight in the clinical practice of data registration is warranted

Testing the construct validity of hospital care quality indicators: a case study on hip replacement

BACKGROUND: Quality indicators are increasingly used to measure the quality of care and compare quality across hospitals. In the Netherlands over the past few years numerous hospital quality indicators have been developed and reported. Dutch indicators are mainly based on expert consensus and face validity and little is known about their construct validity. Therefore, we aim to study the construct validity of a set of national hospital quality indicators for hip replacements.METHODS: We used the scores of 100 Dutch hospitals on national hospital quality indicators looking at care delivered over a two year period. We assessed construct validity by relating structure, process and outcome indicators using chi-square statistics, bootstrapped Spearman correlations, and independent sample t-tests. We studied indicators that are expected to associate as they measure the same clinical construct.RESULT: Among the 28 hypothesized correlations, three associations were significant in the direction hypothesized. Hospitals with low scores on wound infections had high scores on scheduling postoperative appointments (p-value = 0.001) and high scores on not transfusing homologous blood (correlation coefficient = -0.28; p-value = 0.05). Hospitals with high scores on scheduling complication meetings, also had high scores on providing thrombosis prophylaxis (correlation coefficient = 0.21; p-value = 0.04).CONCLUSION: Despite the face validity of hospital quality indicators for hip replacement, construct validity seems to be limited. Although the individual indicators might be valid and actionable, drawing overall conclusions based on the whole indicator set should be done carefully, as construct validity could not be established. The factors that may explain the lack of construct validity are poor data quality, no adjustment for case-mix and statistical uncertainty

Monitoring of stable glaucoma patients

A high workload for ophthalmologists and long waiting lists for patients challenge the organization of ophthalmic care. Tasks that require less specialized skills, like the monitoring of stable (well controlled) glaucoma patients could be substituted from ophthalmologists to other professionals (substitution in person). In addition, care could perhaps be provided in an ambulatory setting (substitution in location of care). To date, little is known about substituting care in ophthalmology, the organizational and professional dynamics involved and any consequences for both the quality of care and cost effectiveness. Glaucoma is the name given to a group of eye diseases characterized by damage to the optic nerve yielding gradual, irreversible loss of visual field. Glaucoma is often related to too high an intraocular pressure (IOP) and is age related. The usual care for glaucoma patients consists of diagnosis, lifelong monitoring, and treatment and is provided by ophthalmologists. However, monitoring stable glaucoma patients will presumably not require the specialist expertise of an ophthalmologist and may be carried out by less specialized professionals. Therefore, the quality of care given to stable glaucoma patients was evaluated when provided by ophthalmic technicians or optometrists based on pre-set protocols and under supervision of ophthalmologists in a Glaucoma follow-up unit (GFU) within The Rotterdam Eye Hospital (REH). The objective of this study is to evaluate an organizational intervention, a GFU for monitoring stable glaucoma patients in a hospital setting, staffed by non-physician Health Care Professionals instead of ophthalmologists. Furthermore, conditions will be formulated that need to be fulfilled to successfully substitute the monitoring care for stable glaucoma patients to a primary care optometrist (substitution in person as well as in location). The conditions will be b

Is the readmission rate a valid quality indicator? A review of the evidence

Conclusions: Although readmission rates are a promising quality indicator, several methodological concerns identified in this study need to be addressed, especially when the indi

Diffusing Aviation Innovations in a Hospital in the Netherlands

Background: Many authors have advocated the diffusion of innovations from other high-risk industries into health care to improve safety. The aviation industry is comparable to health care because of its similarities in (a) the use of technology, (b) the requirement of highly specialized professional teams, and (c) the existence of risk and uncertainties. For almost 20 years, The Rotterdam Eye Hospital (Rotterdam, the Netherlands) has been engaged in diffusing several innovations adapted from aviation. Methods: A case-study methodology was used to assess the application of innovations in the hospital, with a focus on the context and the detailed mechanism for each innovation. Data on hospital performance outcomes were abstracted from the hospital information data management system, quality and safety reports, and the incident reporting system. Information on the innovations was obtained from a document search; observations; and semistructured, face-to-face interviews. Innovations: Aviation industry-based innovations diffused into patient care processes were as follows: patient planning and booking system, taxi service/valet parking, risk analysis (as applied to wrong-site surgery), time-out procedure (also for wrong-site surgery), Crew Resource Management training, and black box. Observations indicated that the innovations had a positive effect on quality and safety in the hospital: Waiting times were reduced, work processes became more standardized, the number of wrong-site surgeries decreased, and awareness of patient safety was heightened. Conclusion: A near-20-year experience with aviation-based innovation suggests that hospitals start with relatively simple innovations and use a systematic approach toward the goal of improving safety

Using quality measures for quality improvement: The perspective of hospital staff

Research objective: This study examines the perspectives of a range of key hospital staff on the use, importance, scientific background, availability of data, feasibility of data collection, cost benefit aspects and availability of professional personnel for measurement of quality indicators among Iranian hospitals. The study aims to facilitate the use of quality indicators to improve quality of care in hospitals. Study design: A cross-sectional study was conducted over the period 2009 to 2010. Staff at Iranian hospitals completed a self-administered questionnaire eliciting their views on organizational, clinical process, and outcome (clinical effectiveness, patient safety and patient centeredness) indicators. Population studied: 93 hospital frontline staff including hospital/nursing managers, medical doctors, nurses, and quality improvement/medical records officers in 48 general and specialized hospitals in Iran. Principal findings: On average, only 69% of respondents reported using quality indicators in practice at their affiliated hospitals. Respondents varied significantly in their reported use of organizational, clinical process and outcome quality indicators. Overall, clinical process and effectiveness indicators were reported to be least used. The reported use of indicators corresponded with their perceived level of importance. Quality indicators were reported to be used among clinical staff significantly more than among managerial staff. In total, 74% of the respondents reported to use obligatory indicators, while this was 68% for voluntary indicators (p<0.05). Conclusions: There is a general awareness of the importance and usability of quality indicators among hospital staff in Iran, but their use is currently mostly directed towards external accountability purposes. To increase the formative use of quality indicators, creation of a common culture and feeling of shared ownership, alongside an increased uptake of clinical process and effectiveness indicators is needed to support internal quality improvement processes at hospital level

Creating patient value in glaucoma care

Purpose: The purpose of this paper is to explore in a specific hospital care process the applicability in practice of the theories of quality costing and value chains. Design/methodology/approach: In a retrospective case study an in-depth evaluation of the use of a quality cost mode