BMZ2024 – Improving Quality of
Care
8 behaald voor het tentamen
Inhoudsopgave
Task 1 – Caring for quality...................................................................................................................................3
1. Explaining the definitions of quality of care................................................................................................3
2. What is the Donebedian Model and are there other models?...................................................................5
3. What is the role of the six domains in the quality of care?.........................................................................9
4. Why is safety such a fundamental aspect of quality?.................................................................................9
5. What is meant with medical errors and adverse events?.........................................................................10
6. What factors might influent patients’ safety?...........................................................................................11
Task 2 – From quality assessment to quality improvement...............................................................................14
1. How can QoC be measured?.....................................................................................................................14
a. What kind of approaches exist? (qualitative/quantitative/indicators/etc)..............................................14
b. What kind of instruments exist?...............................................................................................................14
c. What are similarities and differences between these measurements?....................................................14
2. What kind of criteria should be selected to indicate QoC indicators?......................................................21
3. How can QoC-data improve the quality of care?......................................................................................23
4. (Advise nursing home how to assess QoC)................................................................................................29
Task 3 – The best available evidence.................................................................................................................31
1. What is evidence based practice (EBP)?....................................................................................................31
2. How can EBP be implied in practice (following the steps)?......................................................................34
3. What factors impede or facilitate EBP in healthcare?..............................................................................35
4. On what types of different research designs can EBP be based?.............................................................39
5. Explain the different levels of evidence.....................................................................................................41
6. Explain the GATE framework and its appliance.........................................................................................42
Task 4 – Developing and evaluating a complex geriatric intervention..............................................................44
1. What is a ‘complex intervention’ (definition)?..........................................................................................44
2. How is are the outcomes of a complex intervention measured?.............................................................45
3. What is Health Technology Assessment (HTA)?........................................................................................50
4. What is the MRC-framework?...................................................................................................................56
5. How can the MRC-framework be used to implement complex interventions?.......................................59
Task 5 – Good quality of integrated care...........................................................................................................61
1. What is integrated care?...........................................................................................................................61
2. Explain the PRISMA-model and what are other models?.........................................................................65
3. How can you achieve integrated care?.....................................................................................................69
4. What is the effect of integrated care on QoC?..........................................................................................71
5. What forms of integrated care are commonly used for dementia in the Netherlands? (example: case
management)................................................................................................................................................73
Task 6 – Optimising quality by integrated care pathways.................................................................................74
1. What are integrated care pathways..........................................................................................................74
2. How can these integrated care pathways optimise quality of care for patients (assumptions)?.............76
3. For what kind of conditions is there an integrated care pathway?..........................................................77
4. What is the LCP? Describe elements of this pathway...............................................................................78
4. Why was the LCP ended? (other resources)..............................................................................................80
6. How effective are integrated care pathways?...........................................................................................82
,Lectures....................................................................................................................................................... 85
Lecture 1 – Safety as quality domain.................................................................................................................85
Lecture 2 – Assessing quality of care.................................................................................................................87
Lecture 3 – Improving QoC.................................................................................................................................90
Lecture 4/5/6 – The role of EBP in improving QoC.............................................................................................93
Lecture 7 – Developing and evaluating interventions to improve QoC..............................................................97
Lecture 8 – Costs of QoC.....................................................................................................................................99
Lecture 9 – Integrated Care..............................................................................................................................101
Lecture 10 – Delivering integrated care for older adults.................................................................................103
Lecture 11 – Overview......................................................................................................................................108
Lecture 12 – Integrated care pathway.............................................................................................................110
,Task 1 – Caring for quality
1. Explaining the definitions of quality of care
IOM→ Quality of care (= the degree to which health services for individuals and populations
increase the likelihood of desired health outcomes and are consistent with current
professional knowledge) – Donabedian (1990)
- Safe
- Effective
- Patient-centered - Timely
- Efficient
- Equitable
Not one definition of quality of care Doing the right things right
John Z. Ayanian , & Howard Markel. (n.d.). Donabedian’s Lasting Framework for Health Care Quality. New
England Journal of Medicine, Vol. 375. https://doi.org/10.1056/NEJMp1605101
Underlying reasons for inadequate quality of care
1. Growing complexity of science and technology
2. The increase in chronic conditions
3. A poorly organized delivery system
o Evidence-based, planned care
o Reorganization of practices to meet the needs of patients who require more
time, a broad array of resources, and closer follow-up
o Systematic attention to patients’ needs for information and behavioral change
o Ready access to necessary clinical expertise
o Supportive information systems
4. Constraints on exploiting the revolution in information technology
5. Access to the medical knowledge-base
6. Computer-aided decision support systems
7. Collection and sharing of clinical information
8. Reduction in errors
9. Enhanced patient and clinician communication
First most important quality measure was patient centeredness and the second one was
efficiency; PC could be subsumed
Characteristics by quality of care
Structure refers to the organisational factors that define the health system under which care
is provided (Donabedian, 1980). We identify two domains of structure: physical
characteristics and staff characteristics, and Fig. 1 shows the dimensions of each of these
domains. Components of the dimension of resources include, for example, personnel,
equipment and buildings.
Medicine. (n.d.). Committee on Quality of Health Care in America. National Academy Press. ISBN:
Washington, D.C.:
Quality definition
Definitions of quality are either generic or disaggregated→approaches which are not
inherently incompatible but can be seen as opposite ends of a continuum. Generic
definitions of quality include excellence, expectations or goals which have been met.
Quality as the `degree to which health services for individuals and populations increase the
likelihood of desired health outcomes and are consistent with current professional
, knowledge'. Generic definitions are not easily operationalizable and trade both sensitivity
and specificity for generalizability.
Each individual component of quality provides a partial picture of quality when viewed on its
own, but other more specificity in defining quality when viewed in combination. However,
we propose that there are only two domains of quality→
- Access
- Effectiveness.
Access Do users get the care they need?
Whether individuals can access health structures and processes of care which they need.
- Geographic/physical like geographic barriers
- Availability with organizational access as a sub-component of availability.
➔ Organizational access if people are physically able to access a health facility, they may still
face barriers to accessing care in terms, for example the length and availability of
appointments or whether the health professionals can speak their language.
- Affordability like monetary costs
Effectiveness → Is the care effective when they get it?
Effectiveness is the extent to which care delivers its intended outcome or results in a desired
process, in response to need.
- Clinical care: Evidenced based, legitimate and knowledge based care. Knowledge-
based care incorporates the extent to which a treatment or service is consistent with
patients' reasonable expectations and contemporary professional standards of care,
reflecting both societal and professional norms.
- Inter-personal care: effective care requires appreciation of the patient’s personal
experience of illness, and must align the agendas of the professional and the patient.
Care should be planned for and with individual patients through negotiation between
doctor and patient and shared responsibility for care.
Individual→ patient access to health structure and process and if the treatment is efficient
Population→ equity added; people have the healthcare they need what also takes equity.
S.M Campbell , M.O Roland , & S.A Buetow. (n.d.). Defining quality of care. Social Science & Medicine, Vol.
51.
Care
8 behaald voor het tentamen
Inhoudsopgave
Task 1 – Caring for quality...................................................................................................................................3
1. Explaining the definitions of quality of care................................................................................................3
2. What is the Donebedian Model and are there other models?...................................................................5
3. What is the role of the six domains in the quality of care?.........................................................................9
4. Why is safety such a fundamental aspect of quality?.................................................................................9
5. What is meant with medical errors and adverse events?.........................................................................10
6. What factors might influent patients’ safety?...........................................................................................11
Task 2 – From quality assessment to quality improvement...............................................................................14
1. How can QoC be measured?.....................................................................................................................14
a. What kind of approaches exist? (qualitative/quantitative/indicators/etc)..............................................14
b. What kind of instruments exist?...............................................................................................................14
c. What are similarities and differences between these measurements?....................................................14
2. What kind of criteria should be selected to indicate QoC indicators?......................................................21
3. How can QoC-data improve the quality of care?......................................................................................23
4. (Advise nursing home how to assess QoC)................................................................................................29
Task 3 – The best available evidence.................................................................................................................31
1. What is evidence based practice (EBP)?....................................................................................................31
2. How can EBP be implied in practice (following the steps)?......................................................................34
3. What factors impede or facilitate EBP in healthcare?..............................................................................35
4. On what types of different research designs can EBP be based?.............................................................39
5. Explain the different levels of evidence.....................................................................................................41
6. Explain the GATE framework and its appliance.........................................................................................42
Task 4 – Developing and evaluating a complex geriatric intervention..............................................................44
1. What is a ‘complex intervention’ (definition)?..........................................................................................44
2. How is are the outcomes of a complex intervention measured?.............................................................45
3. What is Health Technology Assessment (HTA)?........................................................................................50
4. What is the MRC-framework?...................................................................................................................56
5. How can the MRC-framework be used to implement complex interventions?.......................................59
Task 5 – Good quality of integrated care...........................................................................................................61
1. What is integrated care?...........................................................................................................................61
2. Explain the PRISMA-model and what are other models?.........................................................................65
3. How can you achieve integrated care?.....................................................................................................69
4. What is the effect of integrated care on QoC?..........................................................................................71
5. What forms of integrated care are commonly used for dementia in the Netherlands? (example: case
management)................................................................................................................................................73
Task 6 – Optimising quality by integrated care pathways.................................................................................74
1. What are integrated care pathways..........................................................................................................74
2. How can these integrated care pathways optimise quality of care for patients (assumptions)?.............76
3. For what kind of conditions is there an integrated care pathway?..........................................................77
4. What is the LCP? Describe elements of this pathway...............................................................................78
4. Why was the LCP ended? (other resources)..............................................................................................80
6. How effective are integrated care pathways?...........................................................................................82
,Lectures....................................................................................................................................................... 85
Lecture 1 – Safety as quality domain.................................................................................................................85
Lecture 2 – Assessing quality of care.................................................................................................................87
Lecture 3 – Improving QoC.................................................................................................................................90
Lecture 4/5/6 – The role of EBP in improving QoC.............................................................................................93
Lecture 7 – Developing and evaluating interventions to improve QoC..............................................................97
Lecture 8 – Costs of QoC.....................................................................................................................................99
Lecture 9 – Integrated Care..............................................................................................................................101
Lecture 10 – Delivering integrated care for older adults.................................................................................103
Lecture 11 – Overview......................................................................................................................................108
Lecture 12 – Integrated care pathway.............................................................................................................110
,Task 1 – Caring for quality
1. Explaining the definitions of quality of care
IOM→ Quality of care (= the degree to which health services for individuals and populations
increase the likelihood of desired health outcomes and are consistent with current
professional knowledge) – Donabedian (1990)
- Safe
- Effective
- Patient-centered - Timely
- Efficient
- Equitable
Not one definition of quality of care Doing the right things right
John Z. Ayanian , & Howard Markel. (n.d.). Donabedian’s Lasting Framework for Health Care Quality. New
England Journal of Medicine, Vol. 375. https://doi.org/10.1056/NEJMp1605101
Underlying reasons for inadequate quality of care
1. Growing complexity of science and technology
2. The increase in chronic conditions
3. A poorly organized delivery system
o Evidence-based, planned care
o Reorganization of practices to meet the needs of patients who require more
time, a broad array of resources, and closer follow-up
o Systematic attention to patients’ needs for information and behavioral change
o Ready access to necessary clinical expertise
o Supportive information systems
4. Constraints on exploiting the revolution in information technology
5. Access to the medical knowledge-base
6. Computer-aided decision support systems
7. Collection and sharing of clinical information
8. Reduction in errors
9. Enhanced patient and clinician communication
First most important quality measure was patient centeredness and the second one was
efficiency; PC could be subsumed
Characteristics by quality of care
Structure refers to the organisational factors that define the health system under which care
is provided (Donabedian, 1980). We identify two domains of structure: physical
characteristics and staff characteristics, and Fig. 1 shows the dimensions of each of these
domains. Components of the dimension of resources include, for example, personnel,
equipment and buildings.
Medicine. (n.d.). Committee on Quality of Health Care in America. National Academy Press. ISBN:
Washington, D.C.:
Quality definition
Definitions of quality are either generic or disaggregated→approaches which are not
inherently incompatible but can be seen as opposite ends of a continuum. Generic
definitions of quality include excellence, expectations or goals which have been met.
Quality as the `degree to which health services for individuals and populations increase the
likelihood of desired health outcomes and are consistent with current professional
, knowledge'. Generic definitions are not easily operationalizable and trade both sensitivity
and specificity for generalizability.
Each individual component of quality provides a partial picture of quality when viewed on its
own, but other more specificity in defining quality when viewed in combination. However,
we propose that there are only two domains of quality→
- Access
- Effectiveness.
Access Do users get the care they need?
Whether individuals can access health structures and processes of care which they need.
- Geographic/physical like geographic barriers
- Availability with organizational access as a sub-component of availability.
➔ Organizational access if people are physically able to access a health facility, they may still
face barriers to accessing care in terms, for example the length and availability of
appointments or whether the health professionals can speak their language.
- Affordability like monetary costs
Effectiveness → Is the care effective when they get it?
Effectiveness is the extent to which care delivers its intended outcome or results in a desired
process, in response to need.
- Clinical care: Evidenced based, legitimate and knowledge based care. Knowledge-
based care incorporates the extent to which a treatment or service is consistent with
patients' reasonable expectations and contemporary professional standards of care,
reflecting both societal and professional norms.
- Inter-personal care: effective care requires appreciation of the patient’s personal
experience of illness, and must align the agendas of the professional and the patient.
Care should be planned for and with individual patients through negotiation between
doctor and patient and shared responsibility for care.
Individual→ patient access to health structure and process and if the treatment is efficient
Population→ equity added; people have the healthcare they need what also takes equity.
S.M Campbell , M.O Roland , & S.A Buetow. (n.d.). Defining quality of care. Social Science & Medicine, Vol.
51.
