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1.  How nurses and their work environment affect patient experiences of the quality of care: a qualitative study 
Healthcare organisations monitor patient experiences in order to evaluate and improve the quality of care. Because nurses spend a lot of time with patients, they have a major impact on patient experiences. To improve patient experiences of the quality of care, nurses need to know what factors within the nursing work environment are of influence. The main focus of this research was to comprehend the views of Dutch nurses on how their work and their work environment contribute to positive patient experiences.
A descriptive qualitative research design was used to collect data. Four focus groups were conducted, one each with 6 or 7 registered nurses in mental health care, hospital care, home care and nursing home care. A total of 26 nurses were recruited through purposeful sampling. The interviews were audiotaped, transcribed and subjected to thematic analysis.
The nurses mentioned essential elements that they believe would improve patient experiences of the quality of nursing care: clinically competent nurses, collaborative working relationships, autonomous nursing practice, adequate staffing, control over nursing practice, managerial support and patient-centred culture. They also mentioned several inhibiting factors, such as cost-effectiveness policy and transparency goals for external accountability. Nurses feel pressured to increase productivity and report a high administrative workload. They stated that these factors will not improve patient experiences of the quality of nursing care.
According to participants, a diverse range of elements affect patient experiences of the quality of nursing care. They believe that incorporating these elements into daily nursing practice would result in more positive patient experiences. However, nurses work in a healthcare context in which they have to reconcile cost-efficiency and accountability with their desire to provide nursing care that is based on patient needs and preferences, and they experience a conflict between these two approaches. Nurses must gain autonomy over their own practice in order to improve patient experiences.
PMCID: PMC4064111  PMID: 24923663
Patient experiences; Quality improvement; Nurses; Nursing work environment
2.  The consumer quality index anthroposophic healthcare: a construction and validation study 
Accounting for the patients’ perspective on quality of care has become increasingly important in the development of Evidence Based Medicine as well as in governmental policies. In the Netherlands the Consumer Quality (CQ) Index has been developed to measure the quality of care from the patients’ perspective in different healthcare sectors in a standardized manner. Although the scientific accountability of anthroposophic healthcare as a form of integrative medicine is growing, patient experiences with anthroposophic healthcare have not been measured systematically. In addition, the specific anthroposophic aspects are not measured by means of existing CQ Indexes. To enable accountability of quality of the anthroposophic healthcare from the patients’ perspective the aim of this study is the construction and validation of a CQ Index for anthroposophic healthcare.
Construction in three phases: Phase 1. Determining anthroposophic quality aspects: literature study and focus groups. Phase 2. Adding new questions and validating the new questionnaire. Research population: random sample from 7910 patients of 22 anthroposophic GPs. Data collection: survey, mixed mode by means of the Dillman method. Measuring instrument: experience questionnaire: CQ Index General Practice (56 items), added with 27 new anthroposophic items added and an item-importance questionnaire (anthroposophic items only). Statistical analyses: Factor analysis, scale construction, internal consistency (Chronbach’s Alpha), inter-item-correlation, discriminative ability (Intra Class Correlation) and inter-factor-correlations. Phase 3. Modulation and selection of new questions based on results. Criteria of retaining items: general: a limited amount of items, statistical: part of a reliable scale and inter-item-correlation <0,7, and theoretical.
Phase 1. 27 anthroposophic items. Phase 2. Two new anthroposophic scales: Scale AntroposophicTreatmentGP: seven items, Alpha=0,832, ICC=4,2 Inter-factor-correlation with existing GP-scales range from r=0,24 (Accessibility) to r=0,56 (TailoredCare). Scale InteractionalStyleGP: five items, Alpha=0,810, ICC=5,8, Inter-factor-correlation with existing GP-scales range from r=0,32 (Accessibility) to r=0,76 (TailoredCare). Inter-factor-correlation between new scales: r=0,50. Phase 3: Adding both scales and four single items. Removing eleven items and reformulating two items.
The CQ Index Anthroposophic Healthcare measures patient experiences with anthroposophic GP’s validly and reliably. Regarding the inter-factor-correlations anthroposophic quality aspects from the patients’ perspective are mostly associated with individually tailored care and patient centeredness.
PMCID: PMC4230405  PMID: 24694288
Quality of care; Patient experiences; CQ-index; Anthroposophic healthcare; Validation of measuring instrument; Psychometric quality; Discriminating ability; Patient-centered care
3.  Improving cancer patient care: development of a generic cancer consumer quality index questionnaire for cancer patients 
BMC Cancer  2013;13:203.
To develop a Consumer Quality Index (CQI) Cancer Care questionnaire for measuring experiences with hospital care of patients with different types of cancer.
We derived quality aspects from focus group discussions, existing questionnaires and literature. We developed an experience questionnaire and sent it to 1,498 Dutch cancer patients. Another questionnaire measuring the importance of the quality aspects was sent to 600 cancer patients. Data were psychometrically analysed.
The response to the experience questionnaire was 50 percent. Psychometric analysis revealed 12 reliable scales. Patients rated rapid and adequate referral, rapid start of the treatment after diagnosis, enough information and confidence in the healthcare professionals as most important themes. Hospitals received high scores for skills and cooperation of healthcare professionals and a patient-centered approach by doctors; and low scores for psychosocial guidance and information at completion of the treatment.
The CQI Cancer Care questionnaire is a valuable tool for the evaluation of the quality of cancer care from the patient’s perspective. Large scale implementation is necessary to determine the discriminatory powers of the questionnaire and may enable healthcare providers to improve the quality of cancer care. Preliminary results indicate that hospitals could improve their psychosocial guidance and information provision.
PMCID: PMC3648393  PMID: 23617741
Consumer Quality Index (CQI); Focus groups; Healthcare evaluation; Healthcare quality; Patient experience; Quality indicators
4.  Free choice of healthcare providers in the Netherlands is both a goal in itself and a precondition: modelling the policy assumptions underlying the promotion of patient choice through documentary analysis and interviews 
In the Netherlands in 2006, a health insurance system reform took place in which regulated competition between insurers and providers is key. In this context, the government placed greater emphasis on patients being able to choose health insurers and providers as a precondition for competition. Patient choice became an instrument instead of solely a goal in itself. In the current study, we investigated the concept of ‘patient choice’ of healthcare providers, as postulated in the supporting documentation for this reform, because we wanted to try to understand the assumptions policy makers had regarding patient choice of healthcare providers.
We searched policy documents for assumptions made by policy makers about patient choice of healthcare providers that underlie the health insurance system reform. Additionally, we held interviews with people who were involved in or closely followed the reform.
Our study shows that the government paid much more attention to the instrumental goal of patient choice. Patients are assumed to be able to choose a provider rationally if a number of conditions are satisfied, e.g. the availability of enough comparative information. To help ensure those conditions were met, the Dutch government and other parties implemented a variety of supporting instruments.
Various instruments have been put in place to ensure that patients can act as consumers on the healthcare market. Much less attention has been paid to the willingness and ability of patients to choose, i.e. choice as a value. There was also relatively little attention paid to the consequences on equity of outcomes if some patient groups are less inclined or able to choose actively.
PMCID: PMC3548770  PMID: 23206601
Choice behavior; Patients; Patient satisfaction; Quality of healthcare; Healthcare reform; Netherlands
5.  Determinants of patient choice of healthcare providers: a scoping review 
In several northwest European countries, a demand-driven healthcare system has been implemented that stresses the importance of patient healthcare provider choice. In this study, we are conducting a scoping review aiming to map out what is known about the determinants of patient choice of a wide range of healthcare providers. As far as we know, not many studies are currently available that attempt to draw a general picture of how patients choose a healthcare provider and of the status of research on this subject. This study is therefore a valuable contribution to the growing amount of literature about patient choice.
We carried out a specific type of literature review known as a scoping review. Scoping reviews try to examine the breadth of knowledge that is available about a particular topic and therefore do not make selections or apply quality constraints. Firstly, we defined our research questions and searched the literature in Embase, Medline and PubMed. Secondly, we selected the literature, and finally we analysed and summarized the information.
Our review shows that patients’ choices are determined by a complex interplay between patient and provider characteristics. A variety of patient characteristics determines whether patients make choices, are willing and able to choose, and how they choose. Patients take account of a variety of structural, process and outcome characteristics of providers, differing in the relative importance they attach to these characteristics.
There is no such thing as the typical patient: different patients make different choices in different situations. Comparative information seems to have a relatively limited influence on the choices made by many patients and patients base their decisions on a variety of provider characteristics instead of solely on outcome characteristics. The assumptions made in health policy about patient choice may therefore be an oversimplification of reality. Several knowledge gaps were identified that need follow-up research.
PMCID: PMC3502383  PMID: 22913549
Choice behavior; Patient freedom of choice laws; Patient satisfaction; Healthcare providers; Quality indicators; Quality of healthcare; Healthcare reform; Review literature
6.  Patients' experiences of the quality of long-term care among the elderly: comparing scores over time 
Every two years, long-term care organizations for the elderly are obliged to evaluate and publish the experiences of residents, representatives of psychogeriatric patients, and/or assisted-living clients with regard to quality of care. Our hypotheses are that publication of this quality information leads to improved performance, and that organizations with substandard performance will improve more than those whose performance is relatively good.
The analyses included organizational units that measured experiences twice between 2007 (t0) and 2009 (t1). Experiences with quality of care were measured with Consumer Quality Index (CQI) questionnaires. Besides descriptive analyses (i.e. mean, 5th and 95th percentile, and 90% central range) of the 19 CQI indicators and change scores of these indicators were calculated. Differences across five performance groups (ranging from 'worst' to 'best') were tested using an ANOVA test and effect sizes were measured with omega squared (ω2).
At t0 experiences of residents, representatives, and assisted-living clients were positive on all indicators. Nevertheless, most CQI indicators had improved scores (up to 0.37 change score) at t1. Only three indicators showed a minor decline (up to -0.08 change score). Change scores varied between indicators and questionnaires, e.g. they were more profound for the face-to-face interview questionnaire for residents in nursing homes than for the other two mail questionnaires (0.15 vs. 0.05 and 0.04, respectively), possibly due to more variation between nursing homes on the first measurement, perhaps indicating more potential for improvement. A negative relationship was found between prior performance and change, particularly with respect to the experiences of residents (ω2 = 0.16) and assisted-living clients (ω2 = 0.15). However, the relation between prior performance and improvement could also be demonstrated with respect to the experiences reported by representatives of psychogeriatric patients and by assisted-living clients. For representatives of psychogeriatric patients, the performance groups 1 and 2 ([much] below average) improved significantly more than the other three groups (ω2 = 0.05).
Both hypotheses were confirmed: almost all indicator scores improved over time and long-term care organizations for the elderly with substandard performance improved more than those with a performance which was already relatively good.
PMCID: PMC3305532  PMID: 22293109
7.  Legal rights of client councils and their role in policy of long-term care organisations in the Netherlands 
Legislation demands the establishment of client councils in Dutch nursing homes and residential care facilities. The members of those councils are residents or their representatives. Client councils have the right to participate in the strategic management of long-term care facilities. More specifically, they need to be consulted regarding organisational issues and a right to consent on issues regarding daily living of residents, including CQ-index research. CQ-index research concerns a method that measures, analyses and report clients' experiences about the quality of care. Research questions were: 'Do client councils exercise their rights to be consulted and to give their consent?' and '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?'
Postal questionnaires were sent to members of 1,540 client councils of Dutch nursing homes and residential care facilities. The questionnaire focussed on background information and client councils' involvement in decision-making and strategic management.
The response rate was 34% (n = 524). Most councils consisted of seven members (range: 5 to 12 members). One out of four members participating in the client councils were clients themselves. Although councils have a legal right to be consulted for organisational issues like finance, vision, annual report, and accommodation, less than half the councils (31-46%) reported that they exercised this right. The legal right to consent was perceived by 18 to 36% of the councils regarding client care issues like food and drink, complaints registration, respectful treatment, and activities. For CQ-index research, only 18% of the client councils perceived a right to consent. Their rights to choose an approved contractor -who performs CQ-index research- and indicating improvement priorities, were hardly used.
Client councils play a rather passive role in determining the policy on quality of long-term care. Therefore, specific attention and actions are needed to create a more proactive attitude in councils towards exercising their rights, which are already supported by legislation.
PMCID: PMC3181203  PMID: 21910899
Consumer participation; empowerment; patients' rights; long-term care
8.  The Dutch Consumer Quality Index: an example of stakeholder involvement in indicator development 
Like in several other Western countries, in the Dutch health care system regulated competition has been introduced. In order to make this work, comparable information is required about the performance of health care providers in terms of effectiveness, safety and patient experiences. Without further coordination, external actors will all try to force health care providers to be transparent. For health care providers this might result in a situation in which they have to deliver data for several sets of indicators, defined by different actors. Therefore, in the Netherlands an effort is made to define national sets of performance indicators and related measuring instruments. In this article, the following questions are addressed, using patient experiences as an example:
- When and how are stakeholders involved in the development of indicators and instruments that measure the patients' experiences with health care providers?
- Does this involvement lead to indicators and instruments that match stakeholders' information needs?
The Dutch experiences show that it is possible to implement national indicator sets and to reach consensus about what needs to be measured. Preliminary evaluations show that for health care providers and health insurers the benefits of standardization outweigh the possible loss of tailor-made information. However, it has also become clear that particular attention should be given to the participation of patient/consumer organisations.
Stakeholder involvement is complex and time-consuming. However, it is the only way to balance the information needs of all the parties that ask for and benefit from transparency, without frustrating the health care system.
PMCID: PMC2864255  PMID: 20370925
9.  How do healthcare consumers process and evaluate comparative healthcare information? A qualitative study using cognitive interviews 
BMC Public Health  2009;9:423.
To date, online public healthcare reports have not been effectively used by consumers. Therefore, we qualitatively examined how healthcare consumers process and evaluate comparative healthcare information on the Internet.
Using semi-structured cognitive interviews, interviewees (n = 20) were asked to think aloud and answer questions, as they were prompted with three Dutch web pages providing comparative healthcare information.
We identified twelve themes from consumers' thoughts and evaluations. These themes were categorized under four important areas of interest: (1) a response to the design; (2) a response to the information content; (3) the use of the information, and (4) the purpose of the information.
Several barriers to an effective use of comparative healthcare information were identified, such as too much information and the ambiguity of terms presented on websites. Particularly important for future research is the question of how comparative healthcare information can be integrated with alternative information, such as patient reviews on the Internet. Furthermore, the readability of quality of care concepts is an issue that needs further attention, both from websites and communication experts.
PMCID: PMC2785792  PMID: 19930564
10.  Dutch healthcare reform: did it result in performance improvement of health plans? A comparison of consumer experiences over time 
Many countries have introduced elements of managed competition in their healthcare system with the aim to accomplish more efficient and demand-driven health care. Simultaneously, generating and reporting of comparative healthcare information has become an important quality-improvement instrument. We examined whether the introduction of managed competition in the Dutch healthcare system along with public reporting of quality information was associated with performance improvement in health plans.
Experiences of consumers with their health plan were measured in four consecutive years (2005-2008) using the CQI® health plan instrument 'Experiences with Healthcare and Health Insurer'. Data were available of 13,819 respondents (response = 45%) of 30 health plans in 2005, of 8,266 respondents (response = 39%) of 32 health plans in 2006, of 8,088 respondents (response = 34%) of 32 health plans in 2007, and of 7,183 respondents (response = 31%) of 32 health plans in 2008. We performed multilevel regression analyses with three levels: respondent, health plan and year of measurement. Per year and per quality aspect, we estimated health plan means while adjusting for consumers' age, education and self-reported health status. We tested for linear and quadratic time effects using chi-squares.
The overall performance of health plans increased significantly from 2005 to 2008 on four quality aspects. For three other aspects, we found that the overall performance first declined and then increased from 2006 to 2008, but the performance in 2008 was not better than in 2005. The overall performance of health plans did not improve more often for quality aspects that were identified as important areas of improvement in the first year of measurement. On six out of seven aspects, the performance of health plans that scored below average in 2005 increased more than the performance of health plans that scored average and/or above average in that year.
We found mixed results concerning the effects of managed competition on the performance of health plans. To determine whether managed competition in the healthcare system leads to quality improvement in health plans, it is important to examine whether and for what reasons health plans initiate improvement efforts.
PMCID: PMC2761896  PMID: 19761580
11.  Psychometric Properties of the Dutch Version of the Hospital-Level Consumer Assessment of Health Plans Survey® Instrument 
Health Services Research  2006;41(1):284-301.
To assess the reliability and validity of a translated version of the American Hospital-level Consumer Assessment of Health Plans Survey® (H-CAHPS) instrument for use in Dutch health care.
Data Sources/Study Setting
Primary survey data from adults aged 18 years or more who were recently discharged from two multispecialty city hospitals in the Netherlands.
Study Design
We used forward and backward translation procedures and a panel of experts to adapt the 66-item pilot H-CAHPS into a 70-item Dutch instrument. Descriptive statistics and standard psychometric methods were then used to test the reliability and validity of the new instrument.
Data Collection
From late November 2003 to early January 2004, the survey was administered by mail to 1,996 patients discharged within the previous 2 months.
Principal Findings
Analyses supported the reliability and validity of the following 7-factor H-CAHPS structure for use in Dutch hospitals: on doctor's communication, nurses' communication, discharge information, communication about medication, pain control, physical environment of hospital, and nursing services. The internal consistency reliability of the scales ranged from 0.60 to 0.88. Items related to “family receiving help when on visit,” “hospital staff introducing self,” and “admission delays” did not improve the psychometric properties of the new instrument.
These findings suggest that the H-CAHPS instrument is reliable and valid for use in the Dutch context. However, more research will be needed to support its equivalence to the United States version, and its use for between-hospital comparisons.
PMCID: PMC1681536  PMID: 16430612
CAHPS®; hospitals; Dutch health care; patient experiences of care; cross-cultural translation
12.  The road to tuberculosis treatment in rural Nepal: A qualitative assessment of 26 journeys 
The fact that tuberculosis can be treated with the DOTS strategy (Directly Observed Treatment, Short-course) is not enough to control the disease. Patients have to find their way to tuberculosis treatment first. To better understand the route to tuberculosis treatment in rural Nepal we interviewed twenty-six patients under treatment.
In semi-structured interviews patients shared their disease history and health seeking behaviour. The analysis focused on the encounters with the health care system before enrolment in the tuberculosis treatment program.
Patient routes often started in the medical shop and led via intricate routes with multiple providers to facilities with higher qualified and more competent staff where tuberculosis was diagnosed. Several factors influenced the route to tuberculosis treatment. Besides known patients factors (such as severity of complaints, the ability to pay for services, availability of services and peer support for choosing a provider) specific health services factors were also identified. These included the perceived quality, costs and service level of a provider, and lack of provider initiated referral. Self referral because of waned trust in the provider was very common. In contrast, once tuberculosis was considered a possible diagnosis, referral to diagnostic testing and tuberculosis treatment was prompt.
Patient routes towards tuberculosis treatment are characterised by self referral and include both private and public health care providers. Once tuberculosis is suspected referral for diagnosis and treatment is prompt. Given the importance of the private practitioners in the patient routes, quality improvement initiatives need to address not only the public sector but the private health care sector as well.
PMCID: PMC2257948  PMID: 18190698
13.  The Consumer Quality Index Hip Knee Questionnaire measuring patients' experiences with quality of care after a total hip or knee arthroplasty 
The Dutch Consumer Quality Index Hip Knee Questionnaire (CQI Hip Knee) was used to assess patients' experiences with and evaluations of quality of care after a total hip (THA) or total knee arthroplasty (TKA). The aim of this study is to evaluate the construct validity and internal consistency reliability of this new instrument and to assess its ability to measure differences in quality of care between hospitals.
Survey data of 1,675 subjects who underwent a THA or TKA were used to evaluate the psychometric properties. Exploratory factor analyses were performed and item-total correlations and inter-factor correlations were calculated to assess the construct validity of the instrument. Reliability analyses included tests of internal consistency (Cronbach's alpha coefficients). Finally, multilevel analyses were performed to assess the ability of the instrument to discriminate between hospitals in quality of care.
Exploratory factor analyses indicated that the survey consisted of 21 items measuring five aspects of care (i.e. communication with nurses, communication with doctors, communication with general practitioner, communication about new medication, and pain control). Cronbach's alpha coefficients ranged from 0.76 to 0.90 indicating good internal consistency. The survey's ability to discriminate between hospitals was partly supported by multilevel analysis. Two scales (i.e. communication with nurses and communication with doctors) were able to measure differences between hospitals with respect to patients' experiences with quality of care. Logistic multilevel analyses indicated that hospitals explained part of the variation between patients in receiving information.
These findings suggest that the CQI Hip Knee is reliable and valid for use in Dutch health care. Health care providers or health plans can use this survey to measure patients' experiences with hospital care and to identify variations in care between hospitals.
PMCID: PMC1876799  PMID: 17462084
14.  Collaborating while competing? The sustainability of community-based integrated care initiatives through a health partnership 
To improve health-care delivery, care providers must base their services on community health needs and create a seamless continuum of care in which these needs can be met. Though, it is not obvious that providers apply this vision. Experiments with regulated competition in the health systems of many industrialized countries trigger providers to optimize individual organizational goals rather than improve population health from a community perspective. Thus, a tension exists between the need to collaborate and the need to compete. Despite or because of this tension, community health partnerships are being promoted, and this should enforce a needs-based and integrated care delivery.
In this single case study, we retrospectively explored how local health-care providers in Amsterdam collaborated for more than 30 years, interacting with the changes to the national health-care system. In-depth analysis of interviews, documents and literature focused on the complex relationship between the activities of this health partnership, its nature and its changing context.
The findings revealed that the partnership itself was successful and sustainable over time, although the partnership lost its initial broad explorative nature and narrowed its strategic focus towards care of the elderly. Furthermore, the realized projects – although they enforced integrated care – lost their community-based character. This declining scope of community-based integrated care seems to have been influenced by the incremental introduction of regulated competition in Dutch health care. This casts doubts on the ability of health partnerships to apply a vision of community-based integrated care within the context of competition.
Collaborating health-care providers can build seamless continuums of care in a competitive environment, although these will not automatically maximize community health with limited resources. Active policies with regard to health system design, incentive structures and population-based performance measures are warranted in order to insure that community-based integrated care through health partnerships will be more than just policy rhetoric.
PMCID: PMC1464130  PMID: 16549028
15.  Intermediate care: for better or worse? Process evaluation of an intermediate care model between a university hospital and a residential home 
Intermediate care was developed in order to bridge acute, primary and social care, primarily for elderly persons with complex care needs. Such bridging initiatives are intended to reduce hospital stays and improve continuity of care. Although many models assume positive effects, it is often ambiguous what the benefits are and whether they can be transferred to other settings. This is due to the heterogeneity of intermediate care models and the variety of collaborating partners that set up such models. Quantitative evaluation captures only a limited series of generic structure, process and outcome parameters. More detailed information is needed to assess the dynamics of intermediate care delivery, and to find ways to improve the quality of care. Against this background, the functioning of a low intensity early discharge model of intermediate care set up in a residential home for patients released from an Amsterdam university hospital has been evaluated. The aim of this study was to produce knowledge for management to improve quality of care, and to provide more generalisable insights into the accumulated impact of such a model.
A process evaluation was carried out using quantitative and qualitative methods. Registration forms and patient questionnaires were used to quantify the patient population in the model. Statistical analysis encompassed T-tests and chi-squared test to assess significance. Semi-structured interviews were conducted with 21 staff members representing all disciplines working with the model. Interviews were transcribed and analysed using both 'open' and 'framework' approaches.
Despite high expectations, there were significant problems. A heterogeneous patient population, a relatively unqualified staff and cultural differences between both collaborating partners impeded implementation and had an impact on the functioning of the model.
We concluded that setting up a low intensity early discharge model of intermediate care between a university hospital and a residential home is less straightforward than was originally perceived by management, and that quality of care needs careful monitoring to ensure the change is for the better.
PMCID: PMC1168893  PMID: 15910689

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