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1.  Investigating the Potential Contribution of Patient Rating Sites to Hospital Supervision: Exploratory Results From an Interview Study in the Netherlands 
Over the last decades, the patient perspective on health care quality has been unconditionally integrated into quality management. For several years now, patient rating sites have been rapidly gaining attention. These offer a new approach toward hearing the patient’s perspective on the quality of health care.
The aim of our study was to explore whether and how patient reviews of hospitals, as reported on rating sites, have the potential to contribute to health care inspector’s daily supervision of hospital care.
Given the unexplored nature of the topic, an interview study among hospital inspectors was designed in the Netherlands. We performed 2 rounds of interviews with 10 senior inspectors, addressing their use and their judgment on the relevance of review data from a rating site.
All 10 Dutch senior hospital inspectors participated in this research. The inspectors initially showed some reluctance to use the major patient rating site in their daily supervision. This was mainly because of objections such as worries about how representative they are, subjectivity, and doubts about the relevance of patient reviews for supervision. However, confrontation with, and assessment of, negative reviews by the inspectors resulted in 23% of the reviews being deemed relevant for risk identification. Most inspectors were cautiously positive about the contribution of the reviews to their risk identification.
Patient rating sites may be of value to the risk-based supervision of hospital care carried out by the Health Care Inspectorate. Health care inspectors do have several objections against the use of patient rating sites for daily supervision. However, when they are presented with texts of negative reviews from a hospital under their supervision, it appears that most inspectors consider it as an additional source of information to detect poor quality of care. Still, it should always be accompanied and verified by other quality and safety indicators. More research on the value and usability of patient rating sites in daily hospital supervision and other health settings is needed.
PMCID: PMC4972989  PMID: 27439392
patient rating sites; patient satisfaction; patient experiences; hospitals; quality of health care; supervision
2.  Influence of Intensified Supervision by Health Care Inspectorates on Online Patient Ratings of Hospitals: A Multilevel Study of More Than 43,000 Online Ratings 
In the Netherlands, hospitals with quality or safety issues are put under intensified supervision by the Dutch Health Care Inspectorate, which involves frequent announced and unannounced site visits and other measures. Patient rating sites are an upcoming phenomenon in health care. Patient reviews might be influenced by perceived quality including the media coverage of health care providers when the health care inspectorate imposes intensified supervision, but no data are available to show how these are related.
The aim of this study was to investigate whether and how being under intensified supervision of the health care inspectorate influences online patient ratings of hospitals.
We performed a longitudinal study using data from the patient rating site Zorgkaart Nederland, from January 1, 2010 to December 31, 2015. We compared data of 7 hospitals under intensified supervision with a control group of 28 hospitals. The dataset contained 43,856 ratings. We performed a multilevel logistic regression analysis to account for clustering of ratings within hospitals. Fixed effects in our analysis were hospital type, time, and the period of intensified supervision. Random effect was the hospital. The outcome variable was the dichotomized rating score.
The period of intensified supervision was associated with a low rating score for the hospitals compared with control group hospitals; both 1 year before intensified supervision (odds ratio, OR, 1.67, 95% CI 1.06-2.63) and 1 year after (OR 1.79, 95% CI 1.14-2.81) the differences are significant. For all periods, the odds on a low rating score for hospitals under intensified supervision are higher than for the control group hospitals, corrected for time. Time is also associated with low rating scores, with decreasing ORs over time since 2010.
Hospitals that are confronted with intensified supervision by the health care inspectorate have lower ratings on patient rating sites. The scores are independent of the period: before, during, or just after the intervention by the health care inspectorate. Health care inspectorates might learn from these results because they indicate that the inspectorate identifies the same hospitals as “at risk” as the patients rate as underperformers.
PMCID: PMC4967180  PMID: 27421302
rating sites; supervision; social media; online reviews; hospitals
3.  Unexpectedly long hospital stays as an indicator of risk of unsafe care: an exploratory study 
BMJ Open  2014;4(6):e004773.
We developed an outcome indicator based on the finding that complications often prolong the patient's hospital stay. A higher percentage of patients with an unexpectedly long length of stay (UL-LOS) compared to the national average may indicate shortcomings in patient safety. We explored the utility of the UL-LOS indicator.
We used data of 61 Dutch hospitals. In total these hospitals had 1 400 000 clinical discharges in 2011.
The indicator is based on the percentage of patients with a prolonged length of stay of more than 50% of the expected length of stay and calculated among survivors.
No interventions were made.
Outcome measures
The outcome measures were the variability of the indicator across hospitals, the stability over time, the correlation between the UL-LOS and standardised mortality and the influence on the indicator of hospitals that did have problems discharging their patients to other health services such as nursing homes.
In order to compare hospitals properly the expected length of stay was computed based on comparison with benchmark populations. The standardisation was based on patients’ age, primary diagnosis and main procedure. The UL-LOS indicator showed considerable variability between the Dutch hospitals: from 8.6% to 20.1% in 2011. The outcomes had relatively small CIs since they were based on large numbers of patients. The stability of the indicator over time was quite high. The indicator had a significant positive correlation with the standardised mortality (r=0.44 (p<0.001)), and no significant correlation with the percentage of patients that was discharged to other facilities than other hospitals and home (r=−0.15 (p>0.05)).
The UL-LOS indicator is a useful addition to other patient safety indicators by revealing variation between hospitals and areas of possible patient safety improvement.
PMCID: PMC4054630  PMID: 24902727
4.  A pilot study on record reviewing with a priori patient selection 
BMJ Open  2013;3(7):e003034.
To investigate whether a priori selection of patient records using unexpectedly long length of stay (UL-LOS) leads to detection of more records with adverse events (AEs) compared to non-UL-LOS.
To investigate the opportunities of the UL-LOS, we looked for AEs in all records of patients with colorectal cancer. Within this group, we compared the number of AEs found in records of patients with a UL-LOS with the number found in records of patients who did not have a UL-LOS.
Our study was done at a general hospital in The Netherlands. The hospital is medium sized with approximately 30 000 admissions on an annual basis. The hospital has two major locations in different cities where both primary and secondary care is provided.
The patient records of 191 patients with colorectal cancer were reviewed.
Primary and secondary outcome measures
Number of triggers and adverse events were the primary outcome measures.
In the records of patients with colorectal cancer who had a UL-LOS, 51% of the records contained one or more AEs compared with 9% in the reference group of non-UL-LOS patients. By reviewing only the UL-LOS group with at least one trigger, we found in 84% (43 out of 51) of these records at least one adverse event.
A priori selection of patient records using the UL-LOS indicator appears to be a powerful selection method which could be an effective way for healthcare professionals to identify opportunities to improve patient safety in their day-to-day work.
PMCID: PMC3717450  PMID: 23872292
Public Health; Length of Stay; Colorectal cancer; Record reviewing; trigger tool
5.  Benchmarking and reducing length of stay in Dutch hospitals 
To assess the development of and variation in lengths of stay in Dutch hospitals and to determine the potential reduction in hospital days if all Dutch hospitals would have an average length of stay equal to that of benchmark hospitals.
The potential reduction was calculated using data obtained from 69 hospitals that participated in the National Medical Registration (LMR). For each hospital, the average length of stay was adjusted for differences in type of admission (clinical or day-care admission) and case mix (age, diagnosis and procedure). We calculated the number of hospital days that theoretically could be saved by (i) counting unnecessary clinical admissions as day cases whenever possible, and (ii) treating all remaining clinical patients with a length of stay equal to the benchmark (15th percentile length of stay hospital).
The average (mean) length of stay in Dutch hospitals decreased from 14 days in 1980 to 7 days in 2006. In 2006 more than 80% of all hospitals reached an average length of stay shorter than the 15th percentile hospital in the year 2000. In 2006 the mean length of stay ranged from 5.1 to 8.7 days. If the average length of stay of the 15th percentile hospital in 2006 is identified as the standard that other hospitals can achieve, a 14% reduction of hospital days can be attained. This percentage varied substantially across medical specialties. Extrapolating the potential reduction of hospital days of the 69 hospitals to all 98 Dutch hospitals yielded a total savings of 1.8 million hospital days (2006). The average length of stay in Dutch hospitals if all hospitals were able to treat their patients as the 15th percentile hospital would be 6 days and the number of day cases would increase by 13%.
Hospitals in the Netherlands vary substantially in case mix adjusted length of stay. Benchmarking – using the method presented – shows the potential for efficiency improvement which can be realized by decreasing inputs (e.g. available beds for inpatient care). Future research should focus on the effect of length of stay reduction programs on outputs such as quality of care.
PMCID: PMC2582034  PMID: 18950476

Results 1-5 (5)