International Journal for Quality in Health Care 15:119-129 (2003)
© 2003 International Society for Quality in Health Care
Paper |
Supporting Dutch medical specialists with the implementation of visitatie recommendations: a descriptive evaluation of a 2-year project
Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
Objective. To improve the quality of patient care by supporting the implementation of practice-specific visitatie (external peer review) recommendations.
Design. A descriptive evaluation of an intervention strategy (Quality Consultation). Data collection through participatory observation, telephone interviews, and a postal survey.
Setting. Twenty-five specialist group practices (67 specialists) from the specialty societies of surgeons, paediatricians, and gynaecologists, supported in their implementation efforts by two experienced management consultants.
Intervention. Approximately 20 h of management consultancy. The Quality Consultation took a site-specific multifaceted implementation approach; its tool kit consisted of various management and quality improvement support methods.
Main measures. Choice of recommendations supported; type of interventions offered; degree of implementation; appreciation of implementation results and process; and impact of management consultants as assessed by participants.
Results. The level of participation was high and evaluation of the consultants and the impact of their support positive. Most implementation projects were related to strategic issues or the functioning of the specialist group. Every specialist group was offered multiple interventions, both participatory and non-participatory. The degree of implementation was rated 4.0 on a 5-point scale; the scores for the implementation result and process were 6.6 on a 10-point scale.
Conclusions. Visitatie seems to inherently enforce the development of management of medical specialist care. This might also be true for other external peer review models. The development of effective specialist groups deserves high priority in order to implement visitatie recommendations successfully. Management consultants can be instrumental in this process.
Keywords: implementation, management consultancy, medical specialists, peer review, quality consultation, specialist groups, The Netherlands, visitatie
Introduction
To assure and improve the quality of Europe’s health services, various systems of external peer review are used. Next to health care accreditation, the International Organization for Standardization’s ISO 9000 standards and the European Foundation for Quality Management’s (EFQM) Excellence Model, visitatie has been identified as one of the four main models of external peer review [1–4]. In 2000, the International Journal for Quality in Health Care dedicated an issue to the role of these four models in improving health care [5]. The visitatie model originated in The Netherlands (visitatie is a Dutch word meaning ‘to visit’). It was introduced in the late 1980s and early 1990s by the medical specialist community as a way of ensuring the quality of patient services and to reconfirm the trust of the public, financiers, and government in the self-regulating mechanism of the profession [6]. The 27 medical specialty societies in The Netherlands developed and executed the visitatie system: a doctor-led and doctor-owned peer review system aimed at assessing the quality of medical practice of hospital-based specialist groups. In Dutch hospitals, medical specialists, who mostly (>70% of all medical specialists) operate as independent entrepreneurs, are organized in groups by specialty.
Under the visitatie system, practices are surveyed every 3–5 years following strict procedures. Consequently, over the past decade all Dutch specialist groups have undergone one or more collegial quality surveys. The findings of these surveys are documented in a confidential report that for every practice concludes with recommendations for improvement [7,8]. With the report, the direct involvement of the surveyors with their reviewed peers usually ends; implementation of the recommendations is left to the medical specialists who underwent the review. Although there are as yet no formal sanctions for non-compliance with the recommendations, specialty societies expect that their members will act upon the recommendations and implement the suggested changes. Although positive implementation results have been reported by various specialty societies [9], implementation of the visitatie recommendations is not self-evident. Therefore three specialty societies have developed an intervention strategy to improve implementation of these recommendations. Members of the societies of surgeons, gynaecologists, and paediatricians received support for their implementation efforts from management consultants [10]. In the period 1999–2001 the intervention, called ‘Quality Consultation’, was offered to 25 medical specialist groups. This paper reports, in the format of a descriptive evaluation, the experiences with Quality Consultation, and discusses its wider implications for the visitatie model and the use of management support in implementing change.
Quality Consultation: a project to support medical specialists with implementation of visitatie recommendations
Given the range of variables that impinge upon the implementation process, implementation of visitatie recommendations is complex. Which strategy is appropriate to a specific specialist group depends on the presence, absence, or extent of many factors. These include: the nature of the recommendation; acceptance of the recommendation by the specialists; the willingness and motivation of the specialists to change existing routines; their knowledge and skills to make changes; the specific local (organizational) context; and the time, resources, and management support available. An increasing number of researchers emphasize the importance of a ‘diagnostic analysis’ of the target group and target setting before initiating an implementation strategy [11,12]. Therefore, an implementation strategy was developed honouring the conviction that no one intervention should be used for all problems and specialist groups, and that interventions should be targeted where they are likely to effect change [13]. Consequently, the Quality Consultation (QC) implementation strategy is a site-specific multifaceted implementation approach offered to specialist groups. QC can be summarized as follows [10].
- QC starts with practice-specific recommendations for improvement, as formulated by peers on behalf of the specialty society.
- To support implementation of one or more visitatie recommendations, specialist groups are offered
20 h of management consulting. The consultants are familiar with the medical and quality improvement fields, and with the organizational and social development of hospital-based medical specialist groups.
- All recommendations are eligible. The participating specialist group and the consultant decide in a first meeting on which recommendation(s) the implementation efforts are to be directed toward.
- The QC tool kit consists of various management and quality improvement support methods. Which interventions are applied depends on the recommendations to be implemented and is determined in the first meeting with the complete specialist group.
- Participation in the QC project is voluntary and without cost; the specialty societies recommend that their members participate in the project.
- The practice-specific results of the QC are confidential.
This QC project took place under the auspices of the three participating specialty societies of surgeons, gynaecologists, and paediatricians, and was executed by two experienced management consultants, one of whom is an author of this paper (M.J.M.H.L.). The three specialty societies had well established visitatie programs: visitatie procedures were documented, surveyors were trained and relatively experienced, and participation in the visitatie program was obligatory for all members. The Dutch Ministry of Health supported the project financially.
Through a descriptive evaluation of the project we aim to capture the experiences; in particular we address the following questions.
- How was the intervention strategy introduced and received by the specialist groups?
- Which recommendations were selected for calling in professional support and why?
- What types of interventions were offered to support implementation of the chosen recommendations?
- How were these interventions looked upon by the participants?
Methods
Selecting, approaching, and meeting specialist groups
Selection of the specialist groups was directly linked to the regular visitatie planning of the three specialty societies involved. The project leaders randomly invited groups of surgeons, gynaecologists, and paediatricians, who had been surveyed by their respective specialty societies in the period September 1998 to November 1999, to participate in the QC project. The invitations continued until the maximum number of 25 participating groups had been recruited.
At the time of the visitatie, the survey team did not know whether or not a specialist group would be invited to participate. Not until the final visitatie report, as approved and laid down by the specialty society, was about to be sent to the visited specialist group was its participation status made known to the society. When the specialist group that had been visited received its visitatie report from the professional society, the project was announced and participation was recommended in an accompanying letter. An article published in the Dutch journal Medisch Contact introducing the QC project was also added to inform the specialists [10]. Two to 4 weeks after the letter announcing the project had been sent, one of the consultants contacted the specialist group to inquire about their interest in participating. If interest was expressed, a first meeting with the whole specialist group and the consultant was planned. This meeting was used by the consultant to introduce him- or herself, to explain the QC project in more detail, to stress the confidentiality of the consultancy process and results, to inquire about the specialist group’s visitatie experiences and their opinions about the recommendations, and to determine how to spend the 20 h of consultation available to the group. For both the selection process and the first meeting protocols were available. Detailed minutes were made of the first meeting and were available for analysis.
Data collection by the management consultants during the project
During the first meeting a practice-specific implementation project and strategy were chosen. The project was executed according to plan in the period thereafter. The process and progress were documented in diaries. Also, practice-specific reports, minutes, and correspondence between the consultant and the specialist group were available for analysis. Finally, the two consultants frequently discussed the progress of all projects among themselves and this sometimes led to adjustments in the project’s approach.
Data collection through a postal survey and telephone interviews
As part of a larger study on the effectiveness of visitatie, a postal survey was undertaken which included questions to determine the participants’ opinion on the implementation of the recommendations for improvement. The specialists were asked to assess the actual degree of implementation of the recommendations supported. The implementation rate was scored on a 5-point action scale, which stated that: (1) no action had been taken to implement the recommendation; (2) the recommendation had been discussed, but no actions were planned; (3) actions had been planned, but not yet executed; (4) the recommendations had been partially or (5) fully implemented. Respondents were also asked to express their appreciation of the implementation result as well as of the implementation process. Appreciation was rated on a 10-point scale. Finally, an open question was incorporated into the questionnaire inviting respondents to list perceived barriers to and encouraging factors for the implementation of recommendations. The questionnaires were sent 1 year after the first contact with the consultant; by that time all projects had been finished.
In addition, to evaluate the effect of QC on implementation of recommendations, as well as its added value to the specialist group, and the expertise, involvement, and service (defined as keeping one’s appointments) of the consultants, telephone interviews were conducted. One specialist from each of the specialist groups whose implementation projects had ended in the autumn of 2000 was contacted by the colleague representing their specialty society in the QC project. A protocol for the semi-structured phone interview and a standard report form were available.
Results
Participation
In total, 31 specialist groups were invited to participate in the QC project. They were geographically spread throughout The Netherlands. All of the 10 paediatric specialist groups, eight out of nine OB/GYN specialist groups, and seven out of 12 surgery specialist groups invited agreed to participate. The reasons for non-participation varied. The non-participating obstetrics/gynaecology (OB/GYN) specialist group did not reach consensus on participation within the specialist group. One surgery specialist group stated that no recommendations at all were formulated in the visitatie report. The other four specialist groups received one or a few recommendations, but, although positive about the QC project, none of these required professional help to implement them. Two of these specialist groups stated the opinion that ‘to call in professional consultants would be a waste of money and time, which would be better spent on supporting other specialist groups’. One specialist group commented ‘the recommendations do not make professional support necessary; it is just that a few colleagues are lacking the will to implement them’.
The consultants met with the remaining 25 specialist groups. All paediatricians in the groups were employed by a hospital; the gynaecologists and most surgeons (except for one specialist group) were paid on a fee-for-service basis. All specialist groups were non-teaching practices. They varied with regard to size of the specialist group, the number of patients seen, the number of recommendations for improvement formulated for their practice, and on a number of other factors (Table 1).
|
Introduction and reception of QC: sharing visitatie experiences
The first meeting of the specialist group with the consultant served three major goals. First, to explain the goal and design of the QC project to the participating specialists. The consultant noted that the selection process and the goal of QC were initially misunderstood by some specialist groups. Two specialist groups thought that they were selected based on their negative visitatie report. One had the impression that the QC project was being used by the specialty society to check on the degree of actual implementation, and another specialist group thought that the support was offered because of their lack of implementation progress. Secondly, the specialists were asked about their visitatie experiences. The statements made in reply were about the perceived meaning of visitatie as a quality assurance instrument, the process of visitatie, the atmosphere during the visitatie, the approach and focus of the survey team, and the results and impact of the visitatie. Reactions included welcoming as well as critical attitudes towards all aspects of the visitatie (Table 2). The third goal of the first meeting was to reach consensus on how to use the limited consulting time available to the specialist group.
|
Selecting recommendations: choice of implementation projects
In the process of choosing an implementation project, the specialist group and the consultant discussed the practice-specific recommendations for improvement at the first meeting. The reasons given for choosing a specific implementation issue were that: (1) the subject represented an acute problem/crisis situation; (2) the issue was formulated as a serious recommendation by the specialty society; (3) the specialist group had identified the subject as a high priority before, but had not implemented it as yet because of a lack of time, knowledge, skills, or consensus within the group; and (4) the subject was not identified as a high priority, but the QC project offered a good opportunity to now deal with the subject or solve the problem (Table 3).
|
The participation of one specialist group was ended after the first meeting, because professional support was deemed unnecessary given the practice-specific recommendations. This left 24 specialist groups to be supported.
The reason given for turning down a recommendation as subject for an implementation project was that the recommendation was not recognized. For example, one specialist group received the recommendation to improve their discharge letter to the referring general practitioner: ‘the previous visitatie report mentioned neat appearance of discharge letters. We don’t understand this recommendation’. Some recommendations they did not agree with, for example: ‘We don’t deem it necessary to have a daily morning report’. Others were not understood, not found relevant, not taken seriously (e.g. improving communication: ‘That’s kicking in an open door, it’s probably recommended to every specialist group’), not found suitable (e.g. improving attendance at patient-related meetings), or were found to be too extensive (e.g. merging of practices) for professional support. Also, implementation was felt to be beyond the control of the specialists (i.e. ‘lack of supporting personnel’) or implementation was not within the specialists’ responsibilities (e.g. to make sure the hospital formally contracts with the midwives working in the hospital). Many recommendations were said to have been implemented by the time the first meeting with the consultant took place.
Although the aim of the QC project was to support implementation of visitatie recommendations, the final choice of an implementation project was not always linked directly to one or more recommendations. Frequently, changes had occurred in the time span between the visitatie date and the date of the first meeting, for example the long-term absence of a colleague, the escalation of a conflict, or a situation of two or more merging hospitals, which put the recommendations in a different light or even superseded them. In choosing implementation projects, priority was given to the issues with the highest expected added value to the practice. In 15 cases, the implementation subjects chosen were related directly to one, two, or part of a practice-specific visitatie recommendation. In nine specialist groups, the choice of the implementation issue cannot be traced back to the list of recommendations.
As Table 4 shows, most implementation subjects concerned either strategic issues or issues related to the functioning of the specialist group. An example of the latter is a specialist group of four specialists (two full-time and two part-time) working together only recently as a group. Three of the specialists had joined the practice in the last 2 years. Priority had been given to the introduction of the new colleagues and the daily operations of the practice. Consequently, most non-acute and non-clinical problems were neglected or solved on an ad hoc basis. Meetings were inefficient and ineffective. Managerial and organizational tasks were unequally divided, with the full-timers taking care of most of the work and the longest serving specialist being the one to whom responsibility for these tasks was usually assigned. Personal ambitions were never exchanged. In short, the specialists expressed their dissatisfaction with the lack of structure and system within their practice as well as the need to develop team qualities. Another example of an implementation project, this time with a strategic character, was the forced integration of specialist groups (12 specialists in total) located in hospitals. The perceived quality differences between the groups (‘we deliver better care’), actual problems such as the shortage of staff at one location, and inherent personal differences hampered the development of a single, combined specialist group. Facilitating the realization of an integrated group was selected as the project’s goal. Other topics, chosen less often, included the improvement of practice registration, patient record keeping (the medical specialists’ records varied in completeness), or collaboration with others such as hospital management (the specialists wanted to address an existing discord with the hospital’s CEO) or Operating Room personnel (opinions differed about the organization and planning of the operating theatre). One specialist group requested that the consultant support them in a financial negotiation with the hospital (Table 4).
|
Type of interventions offered
Every specialist group participating in the QC project was offered multiple interventions (Table 5). Interventions could be either participatory or non-participatory. Non-participatory interventions were activities undertaken by the consultant directed towards the implementation of change, which did not require the specialist group to act or even to be directly involved. Five non-participatory interventions can be identified. (1) Some specialist groups received general educational materials on practice management or organization, e.g. on strategic planning, team collaboration, decision-making principles, or on ‘how to chair a meeting’. (2) For most specialist groups the consultant wrote practice specific documents such as strategic policy plans, practice agreement concerning the organization of the specialist group, discussion papers on regional collaboration, and integration plans for merging specialist groups. (3) Specialist groups were consulted on their project by letter or e-mail. (4) In a few cases the consultants would formulate detailed minutes of a meeting that had taken place with the specialists and send it to them. (5) Finally, the consultant met with someone other than one of the specialists as part of the implementation project, for example with the hospital’s Chief Executive Officer, regional midwives, or with the Operating Room manager.
|
Besides the non-participatory interventions, all specialist groups were offered participatory interventions, requiring the participating specialists to be actively involved in the implementation project, in the absence or presence of the consultant. Involvement was sought in the following ways. (1) By filling out evaluative questionnaires concerning the functioning of the practice or specialist group, or by reflecting on one’s own ambitions, goals, and values. (2) By making an inventory of one’s personal viewpoint on how to take action on topical practice and specialist group matters, for example developing subspecialties or the call for participation in hospital management. Both these activities took place in the course of preparing a practice-specific document or conducting a group meeting. (3) Specialists were involved in implementation projects by co-writing group-specific papers (see above). (4) Interactive interventions consisted of meetings with the specialist group and the consultant (who usually led the meeting) and (5) occasionally with the specialist group and participants from outside the group, such as the hospital’s Chief Executive Officer. Meetings could last 1 h or take up a whole day, discussing the future and/or organization of the practice/specialist group, trying to solve a problem, or giving each other feedback on professional behaviours. (6) The last participatory intervention was the phone conversation with the consultant, used as either a reminder (e.g. to fill out and return questionnaires) or an active consultation for advice, discussion, or feedback.
Of the 24 projects, 22 were finished with the support of the consultant. In one case the consultant ended the collaboration due to a lack of commitment on the part of the specialist group; in the other case the specialist group repeatedly failed to keep its appointments and consequently the project was terminated.
Five specialist groups requested that the consultant’s support be prolonged after the limited number of subsidized hours had been used up. With these specialist groups the consultants entered a regular commercial consultancy process; the subsequent additional interventions are not included in Table 5.
Assessment of interventions by participants
To shed light on the actual implementation of recommendations and the contribution of the consultants in achieving the results, both a questionnaire survey and a telephone evaluation were undertaken (see Methods).
The 15 specialist groups whose implementation subjects were directly related to one, two, or part of a practice-specific visitatie recommendation assessed the actual degree of implementation of the recommendation supported. Thirty-eight specialists filled out a questionnaire; all specialist groups except one were represented by at least one respondent. The average score for the responding 14 specialist groups was 4.0 on a 5-point scale, where the score of 4 represented the fact that recommendations had been partially implemented (Table 6). The appreciation of this result was reported by the respondents in the form of a 6.6 score on a 10-point scale. The process of implementation was also rated with a score of 6.6. Furthermore, half of the specialist groups explicitly mentioned the professional support of the consultant as a facilitating factor in the implementation of the recommendations.
|
In addition, 15 specialist groups were approached for a telephone evaluation of the QC project. In the case of one specialist group, the consultant ended the collaboration as noted above, and so the telephone evaluation did not result in usable data. Of the 14 remaining specialist groups, 10 specialist groups stated that the QC had had a positive effect on the actual implementation of visitatie recommendations. Four specialist groups reported no direct implementation effects. Three of them said that this was due to the fact that most recommendations had already been implemented before the QC projected started. The fourth specialist group found that the recommendation was so complex that only serious time investments of the specialists involved might lead to measurable implementation effects. Although no positive implementation effects followed the QC for four specialist groups, all specialist groups were positive about QC in terms of the added value it had had for the practice/specialist group. The added value was described as the consultant thinking or writing along with the specialist group about its future, structuring meetings, gaining insight into the functioning of the specialist group, discussing and solving practical problems, setting up appointments, mediating difficult processes or conferences, setting priorities, and addressing performance or conduct issues. Positive effects were reported on the integration of the specialist group, the practice/specialist group organization, the division of tasks, and the conceptualization of plans for new practice policies. Two specialist groups explicitly mentioned that the authority and the presence of the consultant forced commitment on the part of the group and so led to results. The respondents evaluated both consultants very positively. They were unanimously positive about their involvement (‘good’, ‘stimulating’, ‘non obtrusive’) and the service they provided. All but one specialist group were positive about the consultants’ expertise.
Discussion and conclusions
Compared with other studies, the added value of the project evaluation outlined in this paper lies in the detailed description of getting medical specialists involved in an implementation strategy and the interventions offered to them. The nature of the evaluation is descriptive and exploratory, and due emphasis is therefore given to the views, experiences, and opinions of the participating medical specialists [14,15]. The study aims at a better understanding of the social phenomena of implementing change in specialist groups.
This study has its limitations. First, in the QC project one of the researchers also took on the role of consultant. The consultant was one of the many factors influencing the course and the success of the projects executed. Consequently, the researcher’s process of observation, including watching and recording what the participants said and did, was inevitably selective. Nevertheless, to profit from the advantages of participatory observation, several actions were undertaken to triangulate and validate the findings. The two consultants documented their projects’ progress separately and frequently exchanged their findings, which were discussed with the second researcher (second author) and were also fed back to the specialist groups during the projects. Also, telephone interviews were conducted by representatives of the participating specialty societies and an anonymous postal survey was undertaken to capture the participants’ opinions. Another restriction of the study was the limited resources available. More recommendations might have been implemented if more time had been available for each specialist group. Furthermore, we assume that the involvement of the three specialty societies and the fact that no costs were charged to the participating specialist groups were crucial in achieving the high degree of participation (25 out of 31 specialist groups).
Finally, because of the non-experimental character of this study, the limited number of specialist groups involved, and the great number of variables relevant to implementation of the recommendations, no general conclusions can be drawn on the effectiveness of management consultancy for these implementation tasks.
In reviewing the four research questions formulated at the beginning of this paper, we may summarize our findings with two conclusions. The first is that specialist groups overall showed welcoming attitudes to the management support that was offered to them. The level of participation was high, the evaluation of the consultants and the impact of their support positive, and the atmosphere in which consultants and specialists worked together was mostly friendly and constructive. It is likely that many specialists were not familiar with the variety of services offered by a management consultant. The free introduction to the consultants’ work and the experience of benefiting from their interventions may have contributed to a clearer view of the value of management consultants’ specific knowledge and skills. More importantly, the willing collaboration of most specialists suggests that the consultants responded to a need. Reflection on the 24 projects reveals that no two were the same. Depending on the issue selected, the local context of the specialist group, and the combination and characteristics of both the specialists and the management consultant, all specialist groups were offered a unique mix of participatory and non-participatory interventions. Routine application of specific management tools or interventions was not deemed suitable by the consultants; it seems there was no room for standardized management consultancy practice. Instead problems were tackled by developing a tailor-made multifaceted approach for each specialist group. In terms of implementing change, it is not clear which barriers were removed by the interventions offered. The support may have counteracted a lack of time, a lack of specific implementation knowledge or skills, the absence of a coordinating person, or other barriers to implementation of visitatie recommendations. It is important to investigate further which factors limit and which encourage implementation.
The second conclusion is that at this period in time the key element in professional quality improvement lies in the development of effectively run specialist groups. Explicit attention to clinical processes and outcomes failed to occur in the QC project. In our view this can be ascribed to the visitatie model, and to the managerial and organizational problems hospital-based medical specialists face today.
What sets visitatie apart from other models used in improving health care services (accreditation, EFQM, ISO) is its exclusive professional ownership. The professional claim on visitatie is accepted by other parties in the health care industry in the expectation that self-regulation will ultimately lead to better clinical care. Underlying this is the assumption that physicians will focus on clinical issues when they are given the lead in quality assurance activities. The experiences in the QC project suggest that this is an incorrect assumption. None of the projects, selected by medical specialists and based on the collegial assessment of their specialist group, addressed the improvement of clinical care. Instead, practising specialists focussed on managerial and organizational topics. In large part this can be put down to the design of the visitatie model. Visitatie was never set up to address clinical outcomes. Right from the start the systems approach to quality improvement was embodied in the definition of visitatie, which was written down in the early 1990s and still stands today: ‘...to assess the circumstances under which clinical practice takes place’ [16]. The specialty societies were encouraged in their choice by the Dutch Institute for Healthcare Improvement.
At the time visitatie was introduced, the medical specialist community may have felt more comfortable in leaving the clinical performance of individual medical specialists out of the model. Nowadays, many medical specialists express the opinion that the value of visitatie would be increased by focussing on clinical processes and outcomes. The question is whether or not visitatie, and external peer review in general, can be an appropriate method for systematic clinical evaluations. Or should it be better reserved for measuring the organizational processes underpinning clinical practice? Other models, such as accreditation, have proven themselves successful in this area. In The Netherlands, it is likely that over time clinical indicators will be part of the visitatie system so that this also includes clinical outcomes. In a joint effort, Dutch medical specialists, hospitals, financiers, and the Department of Health are ambitiously aiming at the year 2006 for achieving this.
Secondly, in explaining the lack of emphasis on clinical evaluation in professional quality improvement, we find that the managerial and organizational problems medical specialists are facing today may be dominant to such a degree that they hinder systematic clinical improvement. The reality of many specialist groups can still be characterized by such features as ad hoc decision-making, lack of consensus, burn-out or otherwise unhappy doctors, complaining support staff and patients, inefficient meetings, chaos, or too much bureaucracy [17–19]. Administrative pressure is increasing and the customary informal work methods and communication are no longer satisfactory. In the media and various legal cases, the lack of effective collaboration within specialist groups and its (presumed) negative impact on patient care have been stressed [20]. Obviously, improving the managerial infrastructure of specialist groups deserves high priority. In the development of effectively run group practices, the individualistic orientation and behaviour of doctors [21] needs to make room for a more collaborative approach to medicine [22,23]. At the same time medical specialists are challenged to incorporate management skills into their professional lives. These transitions should not be dismissed as small achievements. The group’s members need to reconcile decisions about organizational, social, and financial matters, personal (lifestyle) preferences, personality, and ethics [19,24]. As we described above, in the QC project much has been invested in dealing with these issues.
The QC project is not the first and not the only initiative in the field of management of specialists. However, its explicit focus on specialist groups is quite unique and seems to fill a gap. But what should the future hold with regard to the development of effective specialist groups? Structural support of specialist groups as a standard follow-up service of a visitatie is not attainable and not necessary in the long run. Turning to independent professional consultants might, however, remain useful in particular situations and for specific problems, e.g. when mediation skills are required or when strategic interests are at stake. Besides practice-specific interventions offered by expert consultants, specialist groups might benefit from management training. In the future, adding this sort of training to the medical curricula should be considered. Finally, specialist groups need to be able to rely and build upon sufficient managerial and secretarial assistance [25].
We feel that the further enhancement of the managerial and organizational qualities of medical specialist groups is a joint responsibility of specialists and hospital management. Their empowerment might very well be a prerequisite for enhancing the achievement of professional and organizational goals, and thus for the successful running of a hospital [26]. The role of hospital administrators can be a facilitating one: others have stressed that the best way to manage professionals is to support them in managing themselves [27,28].
The ultimate goal of the QC project was to improve the quality of patient care by implementing visitatie recommendations. As outlined in this paper, professional quality improvement through visitatie does not focus on clinical issues but rather emphasizes the realization of well run specialist groups. Although this might be seen as an important step towards quality improvement, more research is needed to understand if and how the management of care affects patient outcomes [29–31]. We assume that other external peer review models also inherently enforce the development of management of medical specialist care. For these models to be effective, specialists need to have the necessary minimum knowledge and skills to implement change.
The authors would like to thank G. H. Damhuis, management consultant, for his input and collaboration in the QC project. The project was supported by a grant to DamhuisElshoutVerschure (management consultants in ’s-Hertogenbosch, The Netherlands) from the Dutch Department of Health. During the period of the QC project, one of the researchers and management consultants (M.J.M.H.L.) was employed by DamhuisElshoutVerschure.
Address reprint requests to Kiki Lombarts, Breestraat 35, 5256 ED Heusden, The Netherlands. E-mail: k.lombarts{at}hetnet.nl 
Accepted for publication December 13, 2002.
References
- Shaw C. External quality mechanisms for health care: summary of the ExPeRT project on visitatie, accreditation, EFQM and ISO assessment in European Union countries. Int J Qual Health Care 2000; 12: 169–175.
[Abstract/Free Full Text] - Shaw C. External assessment of health care. Br Med J 2001; 322: 851–854.
[Free Full Text] - Heaton C. External peer review in Europe: an overview from the ExPeRT Project. Int J Qual Health Care 2000; 12: 177–182.
[Abstract/Free Full Text] - Klazinga N. Re-engineering trust: adoption and adaptation of four external quality assurance models in Western European health care systems. Int J Qual Health Care 2000; 12: 183–189.
[Abstract/Free Full Text] - Special Issue: External evaluation of health care. Int J Qual Health Care 2000; 12.
- Lombarts MJMH, Klazinga NS. A policy analysis of the introduction and dissemination of external peer review (visitatie) as a means of professional self-regulation amongst medical specialists in The Netherlands in the period 1985–2000. Health Policy 2001; 58: 191–213.[Medline]
- Lips JP, Wildschut HIJ, Calvert JP. Lessons from Holland: hospital visiting as an instrument to assess the quality of obstetrics and gynaecological care. Eur J Obstet Gynecol Reprod Biol 2001; 97: 158–162.[Medline]
- Lombarts MJMH, Klazinga NS. Inside self-regulation: attitudes of Dutch surgeons, pediatricians and gynaecologists towards the peer review programs of their specialty societies and the resulting medical practice recommendations. Br J Clin Gov (in press).
- Boer ML de, Pelleboer RAA, Drewes JG. Five years of paediatric visitatie (in Dutch). Med Contact 2000; 55: 1605–1607.
- Lombarts MJMH, Damhuis GH, Holl RA et al. Supporting quality improvement. The Quality Consultation project (in Dutch). Med Contact 1999; 54: 238–240.
- Grol R, Wensing M. Implementation. Effective change in patient care (in Dutch). Maarssen: Elsevier, 2001.
- Grol R. Successes and failures in the implementation of evidence-based guidelines for clinical practice. Med Care 2001; 39 (suppl. 2): II46–II54.[ISI][Medline]
- Grimshaw JM, Shirran L, Mowatt G et al. Changing provider behavior: an overview of systematic reviews of interventions. Med Care 2001; 39 (suppl. 8): II2–II45.[ISI][Medline]
- Pope C, Mays N. Qualitative Research in Health Care. London: BMJ Publishing Group, 2000.
- Swanborn PG. Case studies. What, When and How? (in Dutch). Amsterdam/Meppel: Boom, 1996.
- CBO. Visitatie of Specialist Groups (in Dutch). Utrecht: CBO, 1993.
- Arnetz BB. Psychosocial challenges facing physicians today. Soc Sci Med 2001; 52: 203–213.
- Stevens RA. Public roles for the medical profession in the United States: beyond theories of decline and fall. Milbank Q 2001; 79: 327–353.[CrossRef][ISI][Medline]
- Damhuis G, Lombarts K. Managing the Partnership (in Dutch). ‘s-Hertogenbosch: DamhuisElshoutVerschure, 2001.
- Kahn, P. The Legal Relationship Hospital: Medical Specialist and Quality of Care (in Dutch). Dissertation. Lelystad: Koninklijke Vermande, 2001.
- Freidson E. Professionalism Reborn. Cambridge: Polity Press, 1994.
- Plochg T, Klazinga NS. Community-based integrated care: myth or must? Int J Qual Health Care 2001; 14: 91–101.
- van ‘t Klooster R, Schipper E. Balance between outcome and development of professionals (in Dutch). Holland Manage Rev 1999; 69: 78–84.
- Kelley MJ. Physician practice and organization. In: Wolper LF, ed. Health Care Administration, third edition. Chapter 18, pp. 468–491. Gaithersburg, MD: Aspen Publishers, Inc.
- Lombarts K. Surgical practice ‘avant la lettre’ (in Dutch). Kwaliteit in Beeld 2002; 1: 13–15.
- Lasker RD, Weiss ES, Miller R. Partnership synergy: a practical framework for studying and strengthening the collaborative advantage. Milbank Q 2001; 79: 179–205.[CrossRef][ISI][Medline]
- Broekhuis M. Quality Management in the Professional Service Sector (in Dutch). Dissertation. Capelle a/d IJssel: Labyrint Publication, 2001.
- Weggeman M. Culture and management style in knowledge intensive organizations. Holland/Belgium Manage Rev 1997; 54: 62–72.
- West E. Management matters: the link between hospital organisation and quality of patient care. Qual Health Care 2001; 10: 40–48.
[Abstract/Free Full Text] - Shortell SM, Jones RH, Rademaker AW et al. Assessing the impact of total quality management and organizational culture on multiple outcomes of care for CABG surgery patients. Med Care 2000; 38: 207–217.[CrossRef][ISI][Medline]
- Walshe K, Rundall TG. Evidence-based management: from theory to practice in health care. Milbank Q 2001; 79: 429–457.[CrossRef][ISI][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  T. W J Schulpen and K. M J Lombarts Quality improvement of paediatric care in the Netherlands Arch. Dis. Child., July 1, 2007; 92(7): 633 - 636. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 H. Hofhuis, C. H. M. Van Den Ende, and D. H. De Bakker Effects of visitation among allied health professionals Int. J. Qual. Health Care, December 1, 2006; 18(6): 397 - 402. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||