In the Dutch healthcare system, the emphasis is shifting from provider domination to client orientation [1
], where the role and position of clients have been strengthened in recent decades in a number of ways including legislation [3
]. For example, the Dutch 'Participation by clients of Care Institutions Act ('Wet Medezeggenschap Cliënten Zorginstellingen; WMCZ)' mandates every
healthcare organization to have a functioning client advisory council; a board whose members are recruited from the users of the organization and who will represent them [4
]. In practice, most councils have between five and ten members, depending on the size of the organization. In nursing homes and residential care facilities, spouses (of deceased clients) and volunteers are members of these councils along with clients themselves. Healthcare organisations facilitate these councils by providing resources such as office space and equipment, meeting rooms, budget, et cetera. [5
]. The WMCZ gives client councils the right to advise the management of the organisation about quality of care, and the law prescribes that the healthcare organisation asks for this advice.
More specifically, according to this law councils have been granted the following rights: to have meetings with management about organisation policy, to receive information, to request an investigation into mismanagement, to be consulted, and the right to consent [4
]. The right to be consulted allows councils to give their advice regarding issues on changing the aim and policy of the organisation, merger with another organisation, and financial matters, but the management can ignore this advice. The right to consent implies that councils need to formally approve plans concerning issues that affect the daily living of clients (food and drink, safety, recreation and leisure), hygiene, the quality of healthcare for residents, changes to the complaints procedure, and Consumer Quality Index (CQ-index or CQI) research. The management cannot carry out changes regarding these issues without approval of the client council [4
]. CQ-index is a standard methodology used in the Netherlands to measure, analyse, and report experiences of clients regarding the quality of healthcare. Besides this, the methodology includes also protocols for developing new CQI questionnaires. Questionnaires can be developed to assess the quality of care of a sector, professionals or treatment of a disease [7
The CQ-index for the nursing and caring sector -the CQI 'Long-term Care'- [9
] consist of several questionnaires targeting various client populations and domestic settings with tailored data collection: a face-to-face interview protocol for residents (1), a mail questionnaire for representatives of psychogeriatric clients (2), and a mail questionnaire for assisted-living clients (3). Outcomes of these questionnaires (also called client-related indicators) together with clinical indicators (e.g. incidence of skin ulcers, falls, malnutrition, and medication errors) form the national Quality Framework of Responsible Care [10
]. This information is also disclosed on the Internet, which creates transparent information about providers' performance [11
]. The framework consists of 19 indicators on four domains: a) quality of life, b) quality of caregivers, c) quality of care organization, and d) technical aspects. The CQ-index relates to indicators in the first three domains. Biennially, CQI data are collected, analysed, and reported by approved contractors. These contractors meet certain minimum performance standards based on ISO 20252, which is an international standard for market, opinion and social research. Healthcare organisations can choose any approved contractor. These contractors differ in price and the type of information products they provide. Some offer feedback reports that only report on the findings for one's own organisations, others offer benchmark reports in which one's own performance is compared to that of other organisations. Some contractors offer the opportunity to have an additional presentation of the findings, for instance, for the client council and/or for staff members. Because CQI research provides quality information regarding residents' daily living, councils have the right to consent to choose an approved contractor, but they have also a voice in pointing out improvement activities based on CQI results.
In 2004, an evaluation of the effect of client councils on decision-making of the organisation showed that councils influence on issues covered by the right to consent was small. According to a representative group of client councils in nursing homes, only half of these councils were given notice of decisions on which they had right to consent [12
Research about the role of client councils in the Netherlands is scarce and we do not know whether and to what extent client councils use their rights. Therefore, our first research question is: 'Do client councils exercise their rights to be consulted and to give their consent?' Because the CQ-index is relatively new, we were particularly interested in the role of client councils in the process of measuring client experiences and their opinion about the CQ-index. Therefore, our second research question is 'What is the role of client councils in the process of measuring clients' experiences with the CQ-index and what is their opinion about the CQ-index?