Elsevier

Health Policy

Volume 42, Issue 3, December 1997, Pages 255-267
Health Policy

Quality systems in Dutch health care institutions

https://doi.org/10.1016/S0168-8510(97)00071-7Get rights and content

Abstract

The implementation of quality systems in Dutch health care was supervised by a national committee during 1990–1995. To monitor the progress of implementation a large survey was conducted in the beginning of 1995. The survey enclosed all subsectors in health care. A postal questionnaire—derived from the European Quality Award—was sent to 1594 health care institutions; the response was 74%. The results showed that in 13% of the institutions a coherent quality system had been implemented. These institutions reported, among other effects, an increase in staff effort and job satisfaction despite the increased workload; 59% of the institutions had implemented parts of a quality system. It appeared that management pay more attention to human resource management compared to documentation of the quality system. The medical staff pay relatively more attention to protocol development than to quality-assurance procedures. Patients were hardly involved in these quality activities. The research has shown that it is possible to monitor the progress of implementation of quality systems on a national level in all subsectors of health care. The results play an important role in the discussions and policy on quality assurance in health care.

Introduction

In 1990 the Dutch organisations for health care providers, patients and insurance companies reached agreement about a coherent, joint policy on the quality of care [1]. This policy was deemed necessary because of government plans to make the Dutch health care system more market-oriented and self-regulated, which in turn meant that the quality of care had to be assured in a system with less government regulation. One aspect agreed upon by the health care partners was the need for quality systems in health care institutions. These systems were to be introduced and implemented in all health care institutions within 5 years and were to be accessible to external audit. A national committee made up of representatives of all parties involved supervised implementation of these systems and counselled the government about health care policy.

Under the auspices of this committee three surveys were held by the Netherlands Institute of Primary Health Care (NIVEL). The first survey showed that in 1992 nearly all national associations of health care providers were formulating criteria for the quality of care in their sector [2]. The second survey was held in 1994 among 36 health care institutions. This survey profoundly focused on factors that promoted or obstructed the implementation of quality systems by in-depth interviews with the management [3]. Positive factors were the perceived effects of the quality system, involvement of all employees in quality activities, and management-guided monitoring of progress. Negative factors were the longer than expected time taken to implement the system, a heavy workload, the autonomy of health care staff, and the lack of cooperation between (hospital) departments [3]. The third survey was held among all Dutch health care institutions in the beginning of 1995. Its aim was to assess the stage of development of quality systems on a national basis. Preliminary data have been published in a research report [4].

To our knowledge, this is the first time such a survey has been conducted among all health care sectors. A small-scale study with a broader scope was reported by Shortell et al. in 1995 [5]. They assessed whether a total quality management approach had an impact on quality improvement activities in 61 hospitals in the USA. Implementation of quality improvement activities was assessed by using a questionnaire based on the Malcolm Baldrige National Quality Award Criteria, which is comparable to the European Quality Award 6, 7. Shortell et al. found a relationship between the implementation of quality improvement activities and the perceived impact on patient outcomes (patient satisfaction) and staff satisfaction. Klazinga [8]evaluated a Concerted Action Programme on Quality Assurance, also in hospitals, in 15 European countries. Large differences between the countries were found. Although many effects were reported, he concluded that the time span of the project (3 years) was too short to reach its full potential. Implementation of quality assurance requires much more time.

Monitoring the development of quality systems at a national level requires the development of a questionnaire that is applicable to all subsectors of health care. We developed such a questionnaire that was designed to provide answers to the following questions: Which activities have been undertaken by health care institutions to manage and improve the quality of care? How many institutions have completed a quality system and at what stage of development are the remaining systems? And, finally, what are the perceived effects of the quality systems? The progress of implementation should indicate the feasibility of self-regulation in health care.

Section snippets

Study area

The data used in the analyses were derived from a large nationwide study of 15 different subsectors of the Dutch health care system. For 13 of these subsectors, all health care institutions that were registered as a member of the relevant national associations were sent a postal questionnaire. For two remaining subsectors, we drew a random sample of 157 homes for the elderly (=10%) and a random sample of 159 nursing homes (=50%). A total of 1594 institutions was approached: 315 institutions for

Results

The overall response was 74% (1182 of the 1594 institutions returned the questionnaire in good order; Table 1). The percentage response differed per subsector, ranging from 55% for homes for the elderly to 91% for the sheltered housing institutions. Seventy-six percent of the hospitals completed the questionnaire.

Table 2 gives an overview of the items of each focal area and the percentage of institutions that applied the procedures listed. The data show that, as regards quality systems, nearly

Discussion and conclusions

This research has shown that it is possible to assess the stage of development of quality systems in all subsectors of health care. The impact of the results on health care policy will be discussed. But first, we consider the main findings of the survey and some limitations of the research methods.

The main conclusion of this study is that, although health care institutions are working on the introduction of quality systems and quality management, only 13% have a coherent, complete system in

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