Dutch Health Care Inspectorate Research Articles

S19: Using narratives to improve quality of long-term care for older people

Symposium OverviewInternationally there is a growing interest in evaluating experienced quality of care to better tailor care to resident’s needs. Narratives are a promising method to achieve this, because they capture experiences, identify conflicting values, and provide rich data that can be used to learn from and improve quality of care with. In the Netherlands, narratives are becoming a more substantial element within the quality improvement cycle of nursing homes. In this symposium, four Dutch research groups will present studies on how different narratives can be used and implemented in nursing homes to achieve and maintain high quality of care for residents.The first speaker will present how micro-narratives from care staff, residents and significant others enable the evaluation of long-term care. The second speaker will present how stakeholders improve care by reflecting together on rich narrative portraits of residents’ experiences. The third speaker will present the results of a study investigating how the narrative quality evaluation method ‘Connecting Conversations’ can be implemented in nursing home organizations. And, the last speaker will present findings on how the Dutch healthcare inspectorate is currently overseeing the quality of person-centred care in long-term care facilities and discuss the potential of a more reflexive approach using narrative methods.

Interpreting and evaluating open norms of person-centred care in daily regulatory practice of the Dutch nursing home care setting

Objective:The emphasis on person-centred nursing home care poses a key challenge for inspectors who regulate quality of care, because of its situated characteristics (i.e., for each client different and changing over time). This makes it difficult to assess with predetermined norms in contrast to for example requirements of medication safety. In this paper, we therefore empirically investigate how inspectors operationalize and evaluate open norms of person-centred care in the Dutch healthcare setting.Methods:Qualitative methods were used to study the work of inspectors who assess the quality of nursing home care within the Dutch Health and Youth Care Inspectorate. The first author7it observed the inspection process of nursing home care organizations (preparation, inspection visit, consults between inspectors and team meetings) and conducted semi-structured interviews with the observed inspectors and managers of the assessed organizations. Furthermore, different versions of the quality report were analyzed.Results:Easy made operationalizations of person-centred care (e.g., choice for meal) received more attention than other, less easily made, operationalizations of person-centered care (e.g., group dynamics). The following three exclusion mechanisms show why certain aspects of person-centred care got less attention than others: 1) not being able to triangulate information 2) doubting the trustworthiness of a person 3) not being able to deviate from the structure of the inspection program. Furthermore, there are two exclusion mechanisms that show how the assessment of person-centred care is ignored or overruled by other values in the assessment framework: 1) downplaying person-centredness by mitigating circumstances and, 2) prioritization of safety risks over risks of lacking person-centredness.Conclusion:In evaluating person-centred nursing home care using open norms, certain mechanisms are in place that exclude the assessment of quality of (certain aspects of) person-centered care. To overcome these mechanisms, a different, more reflexive approach for regulation might be needed to encourage stakeholders to engage in self-observation and self-criticism. Reflexive regulation using narrative methods can be especially helpful with complex issues, which are associated with uncertainty about standards and where different perspectives play a role. In further participative action research, we will experiment with and study the use of reflexive regulation using narrative methods in long-term care.

Correlations between care users' and the healthcare inspectorate's ratings of the quality of care in long-term care homes.

Increasing emphasis is being placed on person-centredness as a quality requirement for long-term care (LTC). Although healthcare inspectorates value the importance of care users' experiences, they struggle to address these experiences in regulatory practice. The aim of this study is to explore the correlations between care users' and the healthcare inspectorate's ratings of the quality of LTC in The Netherlands. The correlations between care users' ratings from a public Dutch online patient rating site and the Dutch Health and Youth Care Inspectorate's ratings of the quality of care were examined using Spearman rank correlations. The inspectorate's ratings cover three themes: 'attention to person-centred care', 'working towards sufficient and competent care staff' and 'focusing on quality and safety'. Ratings of the quality of care were obtained for 200 LTC homes in The Netherlands between January 2017 and March 2019. These LTC homes had 6 to 350 residents (M=89; SD=57) and belonged to organisations with 1-40 LTC homes in total (M=6; SD=6). Publicly available anonymous ratings of the perceived quality of care by care users were extracted from the Dutch patient rating website 'www.zorgkaartnederland.nl'. Care users' ratings were available for the 2 years prior to an assessment by the inspectorate for 200 LTC homes. We found a weak, significant correlation between the mean care users' ratings and the inspectorate's aggregated scores for the theme 'person-centred care' (r=0.26, N=200, padj<0.01); no other correlations were significant. This study showed only a weak correlation between care users' ratings and ratings of the Dutch Inspectorate of the quality of 'person-centred care' in LTC homes. Therefore, it may be fruitful to intensify or innovate approaches to involve care users' experiences in regulation to do them justice.

Protein intake during hospital admission; Dutch national data on protein intake in 339,720 malnourished patients from 2009–2019

<h2>Summary</h2><h3>Introduction</h3> To stimulate early recognition and treatment of malnutrition, the Dutch Healthcare Inspectorate obliged all hospitals from 2008–2019 to report the number of malnourished patients with an adequate protein intake on the fourth day of hospital admission. In this article we present results over the past 11 years and discuss success factors and barriers for adequate treatment of malnourished patients in hospitals. <h3>Methods</h3> The annual reports of hospitals on the numbers of patients with a screening result ‘malnourished' and an adequate protein intake on the fourth day of admission were analysed. Hospitals were categorized based on the percentage of malnourished patients with an adequate protein intake on the fourth day of admission as ‘poor' (<40% of patients in a hospital achieve an adequate protein intake), ‘moderate' 40–60% of patients in a hospital achieve an adequate protein intake), and ‘good' (>60% of patients in a hospital achieve an adequate protein intake). To identify success factors and barriers for adequate treatment and registration of malnourished patients in hospitals, three focus groups were held in June and July 2020. Participants were dietitians and quality employees or nurses who were involved in data collection for malnutrition indicators in their hospitals. <h3>Results</h3> Between 2008–2019, data were reported of 339,720 malnourished patients. The relative number of patients with adequate intake of protein on the fourth day in hospital ranges from 44%-53% between 2011 and 2019. Before 2013, the number of hospitals that reported data was too small to draw conclusions about results of treatment of malnutrition. Data from 2013 to 2019, show a decline in the number of hospitals with a ‘poor' score. The number of hospitals with a moderate score increased between 2015 and 2019 and the number of hospitals with a good score remained more or less stable, except for 2018 where more hospitals reached a ‘good' score. Sixteen professionals from ten different hospitals participated in the focus groups and revealed several determinants of adequate treatment of malnourished patients in hospitals such as awareness, feeling responsible and the need of clear instructions and good collaboration. <h3>Conclusion</h3> This inventory of the protein intake of 339,720 hospital malnourished patients over 11 years shows that in one out of five Dutch hospitals >60% of malnourished patients had an adequate protein intake on the fourth day of admission. This shows that meeting protein requirements remains a difficult challenge. Early recognition of malnutrition, optimal multidisciplinary treatment and continuous evaluation is necessary to provide optimal nutritional care in the hospital and beyond.

Sexual abuse of people with intellectual disabilities in residential settings: a 3-year analysis of incidents reported to the Dutch Health and Youth Care Inspectorate

ObjectivesTo explore characteristics of sexual abuse within residential settings for people with an intellectual disability and to map out measures undertaken and improvement plans made by healthcare organisations after sexual...

Using Text Mining Techniques to Identify Health Care Providers With Patient Safety Problems: Exploratory Study

BackgroundRegulatory bodies such as health care inspectorates can identify potential patient safety problems in health care providers by analyzing patient complaints. However, it is challenging to analyze the large number of complaints. Text mining techniques may help identify signals of problems with patient safety at health care providers.ObjectiveThe aim of this study was to explore whether employing text mining techniques on patient complaint databases can help identify potential problems with patient safety at health care providers and automatically predict the severity of patient complaints.MethodsWe performed an exploratory study on the complaints database of the Dutch Health and Youth Care Inspectorate with more than 22,000 written complaints. Severe complaints are defined as those cases where the inspectorate contact point experts deemed it worthy of a triage by the inspectorate, or complaints that led to direct action by the inspectorate. We investigated a range of supervised machine learning techniques to assign a severity label to complaints that can be used to prioritize which incoming complaints need the most attention. We studied several features based on the complaints’ written content, including sentiment analysis, to decide which were helpful for severity prediction. Finally, we showcased how we could combine these severity predictions and automatic keyword analysis on the complaints database and listed health care providers and their organization-specific complaints to determine the average severity of complaints per organization.ResultsA straightforward text classification approach using a bag-of-words feature representation worked best for the severity prediction of complaints. We obtained an accuracy of 87%-93% (2658-2990 of 3319 complaints) on the held-out test set and an F1 score of 45%-51% on the severe complaints. The skewed class distribution led to only reasonable recall (47%-54%) and precision (44%-49%) scores. The use of sentiment analysis for severity prediction was not helpful. By combining the predicted severity outcomes with an automatic keyword analysis, we identified several health care providers that could have patient safety problems.ConclusionsText mining techniques for analyzing complaints by civilians can support inspectorates. They can automatically predict the severity of the complaints, or they can be used for keyword analysis. This can help the inspectorate detect potential patient safety problems, or support prioritizing follow-up supervision activities by sorting complaints based on the severity per organization or per sector.

Can the Use of Health Insurance Claim Data Benefit the Risk-Based Supervision of General Practitioner Practices? An Exploratory Study in the Netherlands.

The Dutch Health and Youth Care Inspectorate has organized a study investigating whether there are benefits to using claim data in the risk-based supervision of general practitioner (GP) practices. We identified and selected signals of risks based on interviews with experts. Next, we selected 3 indicators that could be measured in the claim database. These were: the expected and actual costs of the GP practice; the percentage of reserve antibiotics prescribed; and the percentage of patients undergoing an emergency admission during the weekend. We corrected the scores of the GP practices based on their casemix and identified practices with the most unfavorable scores, 'red flags,' in 2015, or the trend between 2013-2015. Finally, we analysed the data of GP practices already identified as delivering substandard care by the Health and Youth Care Inspectorate and calculated the sensitivity and specificity of using the indicators to identify poor performing GP practices. By combining the 3 indicators, we identified 1 GP practice with 3 red flags and 24 GP practices with 2 red flags. The a priori chance of identifying a GP practice that shows substandard care is 0.3%. Using the indicators, this improved to 1.0%. The sensitivity was 26.7%, the specificity was 92.8%. The Dutch Health and Youth Care Inspectorate might use claim data to calculate indicators on costs, the prescribing of reserve antibiotics and emergency admissions during the weekend, when setting priorities for its visits to GP practices. Visiting more GP practices by the Health and Youth Care Inspectorate, and identifying substandard care, is necessary to validate the use of these indicators.

Publication of inspection frameworks: a qualitative study exploring the impact on quality improvement and regulation in three healthcare settings

BackgroundThe Dutch healthcare inspectorate publishes its inspection frameworks to inform both the public and healthcare providers about regulatory procedures and in the hope that publication will motivate healthcare providers to...

Disruptive life event or reflexive instrument? On the regulation of hospital mergers from a quality of care perspective

PurposeDespite the continuation of hospital mergers in many western countries, it is uncertain if and how hospital mergers impact the quality of care. This poses challenges for the regulation of mergers. The purpose of this paper is to understand: how regulators and hospitals frame the impact of merging on the quality and safety of care and how hospital mergers might be regulated, given their uncertain impact on quality and safety of care.Design/methodology/approachThis paper studies the regulation of hospital mergers in The Netherlands. In a qualitative study design, it draws on 30 semi-structured interviews with inspectors from the Dutch Health and Youth Care Inspectorate (Inspectorate) and respondents from three hospitals that merged between 2013 and 2015. This paper draws from literature on process-based regulation to understand how regulators can monitor hospital mergers.FindingsThis paper finds that inspectors and hospital respondents frame the process of merging as potentially disruptive to daily care practices. While inspectors emphasise the dangers of merging, hospital respondents report how merging stimulated them to reflect on their care practices and how it afforded learning between hospitals. Although the Inspectorate considers mergers a risk to quality of care, their regulatory practices are hesitant.Originality/valueThis qualitative study sheds light on how merging might affect key hospital processes and daily care practices. It offers opportunities for the regulation of hospital mergers that acknowledges rather than aims to dispel the uncertain and potentially ambiguous impact of mergers on quality and safety of care.

Is there a volume-quality relationship within the independent treatment centre sector? A longitudinal analysis

BackgroundThe number of independent treatment centres (ITCs) has grown substantially. However, little is known as to whether the volume-quality relationship exists within this sector and whether other possible organisational factors mediate this relationship. The aim of this study is to gain a better understanding of such possible relationships.MethodsData originate from the Dutch Health and Youth Care Inspectorate (IGJ) and the Dutch Patients Association. We used longitudinal data from 4 years (2014–2017) including three different quality measures: 1) composite of structural and process indicators, 2) postoperative infections, and 3) patient satisfaction. We measured volume by the number of invasive treatments. We adjusted for three important organisational characteristics: (1) size of workforce, (2) chain membership, and (3) ownership status. For statistical inference, random effects analysis was used. We also ran several robustness checks for the volume-quality relationship, including a fractional logit model.ResultsITCs with higher volumes scored better on structure, process and outcome (i.e. postoperative infections) indicators compared to the low-volume ITCs – although only marginally on outcome. However, ITCs with higher volumes do not have higher patient satisfaction. There is a decreasing marginal effect of volume – in other words, an L-shaped curve. The effect of the intermediating structural factors on the volume-quality relationship (i.e. workforce size, chain membership and ownership status) is less clear. Our findings suggest that chain membership has a negative influence on patient satisfaction. Furthermore, for-profit providers scored better on the Net Promoter Score.ConclusionsOur study shows with some certainty that the quality of care in low-volume ITCs is lower than in high-volume ITCs as measured by structural, process and outcome (i.e. postoperative infection) indicators. However, the size of the effect of volume on postoperative infections is small, and at higher volumes the marginal benefits (in terms of lower postoperative infections) decrease. In addition, volume is not related to patient satisfaction. Furthermore, the association between the structural intermediating factors and quality are tenuous.

How to improve patient safety and quality of care in breast implant surgery? First outcomes from the Dutch Breast Implant Registry (2015–2017)

Although the use of breast implants is generally considered to be safe, breast implants are associated with short- and long-term complications. To evaluate and improve the quality of breast implant surgery, and increase our knowledge of implant performance, the national Dutch Breast Implant Registry (DBIR) was established in 2015. DBIR is one of the first up-and-running breast implant registries worldwide and follows an opt-out structure. This article provides an overview of the first outcomes and experiences of the DBIR. The national coverage of DBIR was studied using data from the Dutch Health and Youth Care Inspectorate. The incidence rate of breast implants was calculated for 2016 and 2017, and patient, device, and surgery characteristics were compared between cosmetic breast augmentations or reconstructive indications. Four infection control, measures were selected to demonstrate the variation in the Dutch clinical practice. In 2016, 95% of the hospitals and 78% of the private clinics participated in DBIR. Between 2015 and 2017, a total of 15,049 patients and 30,541 breast implants were included. A minimum breast implant incidence rate of 1 per 1,691 women could be determined for 2017. The majority of devices were inserted for a cosmetic indication (85.2%). In general, patient, device, and surgery characteristics differed per indication group. Substantial variation was seen in the use of infection control measures (range 0-100%). Preliminary results obtained from DBIR show high national participation rates and support further developments toward the improvement of breast implant surgery and patient safety.

Inhaltsvalidierung einer kulturell adaptierten Checkliste zur Selbstbewertung für „Critical Incident Reporting System“ Meldekreise in einem Schweizer Universitätsspital

BackgroundCritical Incident Reporting Systems (CIRS) support the analysis of critical incidents and foster quality improvement in healthcare. The analysis of CIRS reports by designated CIRS teams enable organizational learning. To maintain a constructive work flow CIRS teams should be able to self-assess their work. We adapted the checklist used by the Dutch Healthcare Inspectorate to judge the quality of sentinel event analysis reports provided by hospitals. MethodThe 26 items of the Dutch checklist were translated into German and culturally adapted to be used in a Swiss university hospital. Relevance and comprehensibility were rated by experts applying the Content Validity Index on item level (I-CVI) and on the checklist level (S-CVI). Five CIRS team members tested the usefulness of the revised checklist and provided feedback which we used to further revise the checklist. ResultsComprehensibility of the 19 items ranged from 58.3 % to 100 %, and the I-CVI ranged between 0.17 and 1.0. The S-CVI achieved a good 0.80. For reasons of clarity we modified, deleted and added items. CIRS team members regarded this further adapted 15-item checklist to be of limited utility. DiscussionThe adapted checklist for self-assessment of the CIRS teams’ work flow received good ratings for content validity but its usefulness for CIRS teams was found to be limited. The checklist may benefit from further development.

Pedagogy of regulation: Strategies and instruments to supervise learning from adverse events

AbstractDiverse scholars have argued that standards and performance measurements are “instruments of control” that have a profound influence on the day‐to‐day lives of individuals and organizations, causing constitutive effects. Regulatory bodies increasingly use standards to oversee and monitor the regulated. This paper discusses the Dutch Health and Youth Care Inspectorate's use of both standards and a performance measurement system introduced to monitor how Dutch hospitals investigate and learn from serious adverse events. Rather than focusing on how standards affect regulated practices and organizations, our study examines how the use of these instruments affects the standard maker, that is, the Inspectorate. We explore how the Inspectorate's work practices, standards, and coupled performance measurement system influence its regulatory pedagogy, reviewing practices, and decisionmaking. We conclude that standards and performance measurement systems are not by definition “instruments of control” as their constitutive effects are (under)determined by the relationships in which they are enacted.

What are the perceived added values and barriers of regulating long-term care in the home environment using a care network perspective: a qualitative study

BackgroundChanges in Dutch policy towards long-term care led to the Dutch Health and Youth Care Inspectorate testing a regulatory framework focusing on care networks around older adults living independently. This regulatory activity involved all care providers and the older adults themselves.MethodsSemi-structured interviews with the older adults, and focus groups with care providers and inspectors were used to assess the perceived added value of, and barriers to the framework.ResultsThe positive elements of this framework were the involvement of the older adults in the regulatory activity, the focus of the framework on care networks and the open character of the conversations with the inspectors. However, applying the framework requires a substantial investment of time. Care providers often did not perceive themselves as being part of a care network around one person and they expressed concerns about financial and privacy issues when thinking in terms of care networks.ConclusionsThe experiences of the client were seen as important in regulating long-term care. Regulating care networks as a whole puts cooperation between care providers involved around one person on the agenda. However, barriers for this form of regulation were also perceived and, therefore, careful consideration when and how to regulate care networks is recommended.

Transforming clients into experts-by-experience: A pilot in client participation in Dutch long-term elderly care homes inspectorate supervision

As experts-by-experience, clients are thought to give specific input for and legitimacy to regulatory work. In this paper we track a 2017 pilot by the Dutch Health and Youth Care Inspectorate that aimed to use experiential knowledge in risk regulation through engaging with clients of long-term elderly care homes. Through an ethnographic inquiry we evaluate the design of this pilot. We find how the pilot transforms selected clients into experts-by-experience through training and site visits. In this transformation, clients attempt, and fail, to bring to the fore their definitions of quality and safety, negating their potentially specific contributions. Paradoxically, in their attempts to expose valid new knowledge on the quality of care, the pilot constructs the experts-by-experience in such a way that this knowledge is unlikely to be opened up. Concurrently, we find that in their attempts to have their input seen as valid, experts-by-experience downplay the value of their experiential knowledge. Thus, we show how dominating, legitimated interpretations of (knowledge about) quality of care resonate in experimental regulatory practices that explicitly try to move beyond them, emphasizing the need for a pragmatic and reflexive engagement with clients in the supervision of long-term elderly care.

De- and Recoupling and Public Regulation

The concept of decoupling refers to the gap between the formal and the actual world in organizations in which a policy is formally introduced but not actually implemented and effective. Although the phenomenon of decoupling in organizations has been studied widely since the late 1970s, little is known about the reverse process of recoupling. Little is also known about the abilities of public regulators to discover decoupling in regulated organizations and to promote the recoupling that is necessary to diminish the gap between the formal and the actual world. In an experimental project of the Dutch Health and Youth Care Inspectorate, we ethnographically followed how this public regulator changed the focus from prescriptive regulation based on quality and safety indicators to the supervision of the management system of a regulated organization. We call this type of regulation system-based regulation. We found that, by using system-based regulation, a regulator can identify several forms of decoupling that have not been recognized in earlier research. Interestingly, we found indications that, by applying SBR and thus recognizing decoupling, a process of recoupling was supported. With SBR the government can reclaim its influence on the meta level while maintaining the level of freedom of management at the organizational level. Instead of aiming for more or stricter regulation, the government could shift its role to meta-regulation, meaning that the public regulator redefines its role as an assessor and stimulator of the quality of governance in terms of self-regulation. Implications for theory and practice are discussed.

Governance and performance measurement in integrated care. An Evidence Based Integrated Care Approach

Introduction: Healthcare institutions in The Netherlands are faced with the facts of increasing extent of internal and external accountability. This is related to the fact that healthcare institutions and their professionals are obliged to register a full set of indicators which are required input to effect this accountability. This is also known as governance. One of the definitions is: to control and to account for Minderman 2008 or controlling accountability Hoek 2007. On the one side in integrated care, care pathways are characterized by the delivery of care interventions proof of concept and on the other side pathways are characterized by the organization of the delivery of care interventions proof in context. Both concept and context of care are related to governance and performance measurement in healthcare. In general governance in healthcare in The Netherlands focuses on control, accountability and controlling the boards, mostly within one care organisation. However in integrated care governance and performance measurement should ideally be on cooperation and trust between the organizations. Governance therefore includes various forms of accountability, concerning several areas: from government national and local, to organizations and commissioners, to organizations and their supervisory boards, to organizations and their financiers and the patient. Healthcare organisations must be accountable to e.g.: The Dutch Healthcare Inspectorate, The care insurance companies and The National Healthcare Institute. Furthermore, healthcare institutions have to account for their efforts to deliver quality of healthcare. The way this is done is through a system administrating their internal performance indicators. In this respect, one can ask how indicators are administrated within healthcare organisations and how external accountability is designed. Different gaps of governance and accountability can thus be found e.g.: A gap between what accountancy data in care institutions is collected, their network and what is externally justified to the involved parties. The gap between governance and is the ones accountable to people and municipals are involved in decentralization. Gap of citizens and governance. Theory/Methods: A systematic review of literature on what is the current knowledge on governance in integrated care, and an extensive case study which will be conducted in Dutch healthcare organisations and healthcare network organisations. One of the characteristics of case study method is: a narrow domain with several research units, in depth rather than a broad view, the supposed concerns in many cases the entire research area instead of a few variables like in a survey study. Discussion: What should governance as an accountability tool look like within the context of evidence-based integrated care and what knowledge is gained and how can this knowledge be used to meet accountability issues?

The conversation with the patient is essential for good pharmacotherapeutic care

Frail elderly with polypharmacy are at greater risk of preventable medication-related health damage. To improve medication safety, the healthcare field prepared, in consultation with the Dutch Health Care Inspectorate, anumber of guidelines and standards containing conditions for safe prescribing. According to these standards the active involvement of patients by health care professionals is essential for good pharmacotherapeutic care. However, two studies with patients show that there is still room for improvement. According to patients, they can be (even) better informed about changes in their medication. Also the caregivers could communicate more clearly who is the central contact point and who is ultimately responsible for the medication. Patients are not sufficiently informed on this. Furthermore, there is uncertainty about how and why medication reviews are performed. More explanation to patients about this is desirable. In addition, patients experience that keeping their medication list up to date and transferring medication data between health care providers could be improved. Finally, agroup of patients welcomes the opportunity to co-decide on changes in their medication. In order to prescribe safely, it is crucial that caregivers actively involve patients in pharmacotherapeutic care and really enter into conversation with them about their medication.

Is There a Mismatch Between the Perspectives of Patients and Regulators on Healthcare Quality? A Survey Study.

Internationally, healthcare quality regulators are criticized for failing to respond to patients' complaints. Patient involvement is, therefore, an important item on the policy agenda. However, it can be argued that there is a discrepancy between the patients' perspective and current regulatory approaches.This study examines whether a discrepancy exists between the perspectives of patients and regulators on healthcare quality. A questionnaire was sent to 996 people who had registered a complaint with the Dutch Healthcare Inspectorate to measure expectations of and experiences with the Inspectorate. A taxonomy was used to classify their complaints into the clinical, relationship, or management domains. The response was 54%. More complaints about clinical issues (56%, P = 0.000) were investigated by the regulator than complaints about organizational (37%) and relational issues (51%). Patients with complaints about management issues less often indicated (13%, P = 0.002) that healthcare is improved by making their complaint than patients with complaints about clinical or relationship issues did (22%-23%). Patients who reported about relational issues with care providers attached more importance to issuing sanctions against the care provider than other patients (mean score 2.89 versus 2.62-2.68, P = 0.006). The predominant clinical approach taken by regulators does not match the patients' perspective of what is relevant for healthcare quality. In addition, patients seem to be more tolerant of what they perceive to be clinical or management errors than of perceived relational deficiencies in care providers. If regulators want to give patients a voice, they should expand their horizon beyond the medical framework.

Nationwide prospective audit of pancreatic surgery: design, accuracy, and outcomes of the Dutch Pancreatic Cancer Audit

BackgroundAuditing is an important tool to identify practice variation and ‘best practices’. The Dutch Pancreatic Cancer Audit is mandatory in all 18 Dutch centers for pancreatic surgery. MethodsPerformance indicators and case-mix factors were identified by a PubMed search for randomized controlled trials (RCT's) and large series in pancreatic surgery. In addition, data dictionaries of two national audits, three institutional databases, and the Dutch national cancer registry were evaluated. Morbidity, mortality, and length of stay were analyzed of all pancreatic resections registered during the first two audit years. Case ascertainment was cross-checked with the Dutch healthcare inspectorate and key-variables validated in all centers. ResultsSixteen RCT's and three large series were found. Sixteen indicators and 20 case-mix factors were included in the audit. During 2014–2015, 1785 pancreatic resections were registered including 1345 pancreatoduodenectomies. Overall in-hospital mortality was 3.6%. Following pancreatoduodenectomy, mortality was 4.1%, Clavien–Dindo grade ≥ III morbidity was 29.9%, median (IQR) length of stay 12 (9–18) days, and readmission rate 16.0%. In total 97.2% of >40,000 variables validated were consistent with the medical charts. ConclusionsThe Dutch Pancreatic Cancer Audit, with high quality data, reports good outcomes of pancreatic surgery on a national level.