International Journal for Quality in Health Care 15:223-234 (2003)
© 2003 International Society for Quality in Health Care
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Progress in the implementation of Quality Management in Dutch health care: 1995–2000
NIVEL (Netherlands Institute for Health Services Research), Utrecht, The Netherlands
Objectives. Policymakers and researchers in all countries like to know whether the implementation of Quality Management (QM) in health care is proceeding satisfactorily. Longitudinal surveys can reveal whether sufficient progress is being made. The main objective of the study was to investigate the progress in QM in Dutch health care organizations during the period 1995–2000. A second objective was to explore whether the progress in QM was related to subsectors of care and/or to cultural characteristics of health care organizations.
Design and participants. The study has a descriptive longitudinal design, based on repeat measurements in 1995 and 2000. Empirical data about QM activities in health care organizations were gathered using a questionnaire. The analyses are based on data from the 474 health care organizations that participated in the study in 1995 and 2000.
Setting. Participants in the study were organizations from all subsectors of health care, including providers of home care, nursing homes, hospitals, and other care sectors.
Main outcome measures. Outcome measures are 46 distinct QM activities, which were listed in the questionnaire.
Results. Two-thirds of the organizations had made progress in the implementation of QM activities. A mean of 25 QM activities per organization was found in 2000 compared with 20 in 1995. More care providers had set up a client council and had carried out patient satisfaction surveys. Home care organizations had made twice as much progress as many other health care organizations. However, nearly one-third of the health care organizations showed a decline in QM activities. Patient organizations were less often involved in the development of quality criteria and protocols. Progress in QM was weakly related to the dedicated and flexible attitude of employees and a non-hierarchical decision-making structure.
Conclusion. The study demonstrates that the implementation of QM activities can be monitored at the national level and that differences between subsectors of care can be assessed. The decline in QM activities in one-third of the organizations needs to be researched further.
Keywords: country report, implementation, legislation, quality management
Many countries are involved in the implementation of Quality Management (QM) in health care. We can assume from this that policymakers and investigators would like to know whether the implementation of QM is proceeding satisfactorily in their country. In addition, comparisons between subsectors of care may reveal whether some subsectors are lagging behind in the implementation of QM. Such knowledge can be gained by longitudinal evaluations of the implementation of QM, which encompasses all subsectors of health care. The results of such an investigation are reported in this article. The object was to investigate to what extent health care organizations in The Netherlands have made progress in the implementation of QM in the period 1995–2000. The progress will be related to the various subsectors within care and to the cultural characteristics of the health care organizations.
The progress was assessed on the basis of a written questionnaire, which was sent to the directors of health care organizations in both years. The questionnaire measured the extent of the implementation of QM activities.
In this article, QM is broadly defined as ‘all the procedures explicitly designed to monitor, assess, and improve the quality of care’, for example peer review, patient satisfaction surveys, complaints handling, audits, and compiling a quality manual. A total of 46 such QM activities were listed in the questionnaire. An overall increase in QM was expected due to the stimulating effect of The Netherlands’ national quality policy and the Quality Acts implemented. This policy and the Quality Acts are explained below.
National Quality Policy in The Netherlands
The increased interest in quality assurance originated from government plans for deregulation and the introduction of more competitive elements into health care in 1986. In anticipation of such competition, the care providers initiated a national debate in 1989/1990 about quality assurance in health care [1]. All parties involved (health care providers, patient/consumer organizations, health insurers, and the government) participated. They made agreements concerning new efforts to assure the quality of care.
An important aspect, agreed upon by all health care partners, was the need for quality management systems in health care. These systems were to be implemented in all health care organizations and were to be accessible to external audit. The national government was to support the development of QM systems and to develop enabling legislation on quality assurance in health care [2]. As a consequence, quality requirements for health care organizations were laid down in the Care Institutions Quality Act in 1996. (Quality requirements for professional practitioners were incorporated in the Individual Health Care Professions Act, which came into effect towards the end of 1998.) We focus here on the quality requirements for health care organizations, because that is the subject of our research.
The Care Institutions Quality Act
The Care Institutions Quality Act (1996) applies to all care organizations, including commercial organizations such as private clinics. The core concept of the Act is that organizations provide appropriate care. This is ‘care of a high standard that is effective, efficient, and patient oriented’. To achieve appropriate care, the organizations must demonstrate that there is a planned effort to maintain and improve the quality of care in a systematic way. According to the Act, a systematic way means that at least three steps are to be followed: (1) the quality of care should be measured, for example by means of satisfaction surveys or quality indicators; (2) the results of such measurements are to be evaluated against explicit standards or goals; and (3) based on this evaluation, the organization is supposed to make the necessary changes in care processes or in their quality policy. Such a QM approach is intended to provide for a continuous process of quality assessment and improvement of care [3].
Care organizations are obliged to account for their QM system in a yearly quality report. According to the Act these reports are to be sent to the Ministry of Health, to the Public Health Inspectorate, and to the regional patient/consumer organizations. The idea is that patient/consumer organizations could inform patients about the quality of health care providers in their region, on the basis of these quality reports.
It is important to note that the Act only provides a framework for QM and that as yet no sanctions are imposed if such a framework is lacking. It is up to the organizations to develop their own QM system. Recently, however, many care organizations have begun using a blueprint or QM model developed by their umbrella organization. These blueprints or models are partly derived from ISO (International Organization for Standardization) and EFQM (European Foundation for Quality Management) systems, and encompass a large number of QM activities (such as protocols and guidelines, peer review, audits, need surveys, patient satisfaction surveys, quality manuals, and all kinds of preventive measures to reduce errors and improve safety) [4]. The organizations try to implement these activities step by step.
Involvement of patients in the implementation of QM
High quality of care implies patient centeredness and patient orientation of care. Therefore, improving the position of patients and strengthening their rights was and is a major issue in Dutch health policy [2]. The aims are to ensure the quality of care and to protect patients in a system with decreasing government regulation. To that end, and in addition to the Care Institutions Quality Act, three new Acts have been implemented by the Dutch Ministry of Health, Welfare and Sports. These Acts regulate patients’ right of complaint, informed consent, and patient participation.
The ‘Clients’ Right of Complaint Act’ came into effect in 1995. The Act requires that care providers and care organizations have an accessible complaints procedure in place and a complaints committee with an independent chair. Also in 1995, basic patients’ rights were laid down in the ‘Medical Treatment Agreements Act’ (incorporated in the Dutch Civil Code). The Act regulates patients’ right to be informed about their illness as well as the possible treatments and their consequences, the right to give (or not to give) consent to proposed treatment, and a number of procedures concerning privacy and protection of medical records.
The third Act took effect in 1996. This ‘Participation by Clients of Care Institutions Act’ enables patients to influence the care provider’s policy, including the quality policy. To this end, health care organizations are obliged to set up client councils. These client councils have considerable authority to make recommendations with regard to, for example, food, security, or mergers, and also with regard to the QM policy of the organization. In this way, client councils are intended to contribute to improving the quality and client-centeredness of care. Besides these Acts, a number of projects were, and are, funded by the Ministry of Health to improve the position of patients; for example, structural funding is available to support regional and national patient/consumer organizations.
The main assumption underlying this article is that the implementation of QM activities has increased in 2000 compared with 1995, and that the involvement of patients and their organizations in QM has increased.
Differences in QM between organizations
At the level of the organization, differences may exist in the progress that has been made in terms of the implementation of QM. Our earlier study in 1995 showed, for example, that more patient participation was seen in organizations providing long-stay care (e.g. nursing homes) compared with organizations providing short-term or ambulatory care (e.g. health centres) [5]. Differences in QM between organizations may also partly be due to cultural characteristics of the organization. In some studies, QM appeared to be positively related to an innovative attitude of the employees and a non-hierarchical decision structure in the organization [6]. It was also found that the implementation of QM was related to the degree to which organizations traditionally operated according to standardized methods [7]. Moreover, differences between organizations may exist in the extent to which management and health care professionals cooperate together in QM compared with situations in which these parties operate independently of one another. Cooperation may facilitate the implementation and presumably the effectiveness of QM [5].
In this article we will describe differences in progress in the implementation of QM between health care organizations, and analyse whether or not these differences are related to organization characteristics.
Methods
The data for this study were collected in the winter of 1994/1995 [7] and again in the winter of 1999/2000 [8]. At both times, the identical questionnaire was sent to all health care organizations in The Netherlands (a population survey). In 1995 a random sample of organizations was drawn from only two types of health care facility: nursing homes and residential care units. In 2000, all nursing homes in The Netherlands were included in the survey and the sample of residential care units was extended (by special request of the umbrella organization) (see Table 1). The addressee of the questionnaire was the director.
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The questionnaire was developed in The Netherlands in 1995. The reliability and validity of the questionnaire were tested in 1995 and are described elsewhere [9]. The questionnaire had a closed, Likert-type format with two to four ordinally scaled response options per item.
A non-response analysis was conducted by telephone in 2000 (as well as in 1995). On both occasions, it appeared that the non-respondents reported fewer QM activities compared with the respondents [7,8]. Therefore, a slightly positive bias in the results cannot be excluded.
Data collection
The data collected concerned, first, the extent of QM activities (as the dependent variable). The questionnaire listed 46 QM activities (Table 2). These items were empirically clustered into five focal areas, with reliability coefficients as follows [7,9]: (1) the availability of quality policy documents (six items; Cronbach’s alpha = 0.78); (2) human resources management (12 items; Cronbach’s alpha = 0.76); (3) using protocols and guidelines (eight items; Cronbach’s alpha = 0.71); (4) quality improvement procedures (14 items; Cronbach’s alpha = 0.80); (5) patient participation in QM (six items; Cronbach’s alpha = 0.86). For the items in the first four focal areas we used the affirmative answers (‘Yes, this QM activity is present in the organization’). For the fifth topic, the items had three response options as follows. ‘The quality improvement procedure: (1) is not present; (2) is present but not entirely operational; and (3) is present and operational’. Operational was defined as meaning that the information obtained from peer review, audits, or satisfaction surveys, for example, is systematically used to make improvements. For the purposes of this article we combined the responses to option 2 (present) and 3 (present and operational).
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Secondly, in the questionnaire, the following characteristics of the organization were surveyed (as independent variables). The size of the organization was asked for as an equivalent number of full-time staff. Six statements concerned cultural characteristics that could be related (positively) to the implementation of QM (e.g. standardized working methods, non-hierarchical decision-making, flexible attitude of employees). These statements were scored on a 6-point scale, ranging from 1 ‘not applicable’ to 6 ‘highly applicable’.
One question surveyed the collaboration between management and health professionals in QM (response options: ‘no’, ‘partly’, ‘yes’). One question surveyed the use of a QM blueprint or model (response options: ‘no’, ‘yes’). Finally, we asked whether the questionnaire had been completed by the director or by an administrator.
Analyses
The data from the 1995 and the 2000 surveys were put into one database. The organizations that had responded in 1995 as well as in 2000 were identified (paired cases). Six subsectors of care with >40 paired cases each were selected for further analysis per subsector. The analyses are based on a one-to-one equation per organization (paired cases).
The QM activities were grouped under five focal areas. A sum score was computed per focal area. The reliability per focal area was tested with Cronbach’s alpha (as reported above).
The overall progress in QM activities between 1995 and 2000 was expressed in the total sum score of the five focal areas. t-tests were used to test the overall progress and the progress per subsector.
The relationship between the progress in QM on the one hand (dependent variable) and the cultural characteristics of the organization on the other hand (independent variables) was investigated using step-wise regression analysis (overall and per subsector).
All missing values were recorded as zero, assuming that ‘missing’ implied that the QM activity was ‘not present’ in the organization. The level of significance was set at P < 0.01.
Results
Respondents
The number of respondents constituted 1182 health care organizations in 1995 and 1142 in 2000. In the time period between 1995 and 2000, many organization mergers took place, which caused a decline in the absolute number of organizations in The Netherlands. However, because more nursing homes and residential care units were included in the 2000 study, there is only a small decline in the total number of respondents. The overall response was 74% in 1995 and 66% in 2000. The number of respondents per type of health care facility is given in Table 1. The response rates differ per type of health care facility, ranging from 52% for social work services and 68% for hospitals to 89% for community health services.
Only 492 of the responding organizations were included in our analysis, because these were the only ones whose data for 1995 and 2000 could be linked exactly (paired cases). The data of the remainder could not be linked, for the greater part due to the many mergers of the organizations during the 5-year period, and for some part due to changed names or addresses. We excluded 18 cases with >10 missing values. The analyses are based on the remaining 474 paired cases (Table 1).
In 1995 and 2000, 58% and 54% of the questionnaires were completed by the organization’s director, respectively. The remaining questionnaires were completed by an administrator. Cross-matching showed that in 200 organizations the questionnaire was not completed by the same person in both years (P < 0.01). The possible influence of this change of respondent (director or administrator) will be analysed by means of regression analysis.
Progress in the implementation of QM activities
Table 2 gives an overview of the overall progress in the implementation of QM activities between 1995 and 2000 for each of the five focal areas. The figures represent the mean number of QM activities carried out by the organizations.
In a comparison of the total sum of QM activities, the t-test showed a mean of 20 QM activities in 1995 and a mean of 25 in 2000. It may be concluded that overall progress in QM activities was achieved as expected. Quality documents and quality improvement procedures show the greatest increase. The other two focal areas show moderate increase. Contrary to expectations, the extent to which patients are involved in QM has decreased. To give more insight into the kind of QM activities under review, a breakdown of the QM activities listed in the questionnaire is given in Table 3. The table shows the percentage of organizations performing these activities in 1995 and in 2000.
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In 2000 the number of policy documents had increased compared with 1995. Also in 2000, more organizations reported that they had drawn up mission statements, that descriptions of their services (products) had been made, and that a quality policy had been developed. Considerably more organizations had published an annual quality report in 2000 than in 1995; in 1996 a law made publication of this form of report obligatory. A few organizations had compiled a quality manual in 2000.
Human resources management was relatively well developed in the organizations in 1995 as well as in 2000. In about two-thirds of the organizations, the professionals are motivated to participate in QM activities and to improve their skills and expertise. The data show that in 2000 nearly all organizations were conducting job assessment interviews (compared with 77% in 1995). However, two of the QM activities were being carried out less frequently in 2000 than in 1995. In 2000, fewer organizations reported selecting new personnel on the basis of a positive attitude towards QM, and staff received feedback on QM results less often.
All but one of the protocols listed in the questionnaire showed increased use in 2000 compared with their use in 1995. In particular, more organizations reported protocols for ‘protected interventions’, such as administering injections. The term ‘protected’ refers to interventions or procedures whose performance is restricted by law in The Netherlands to a limited group of professionals (e.g. doctors and nurses).
Quality improvement procedures are basically feedback procedures, characterized by a cyclic process (measure and evaluate the quality of care and make improvements if necessary). Care plan management and complaints registration are the ones most frequently reported in 1995 as well as in 2000. Of the 14 activities listed in the questionnaire, nine show an increase in 2000. In particular, more organizations reported performing ‘internal audits’ in 2000 and more client councils were set up. Patient satisfaction surveys were carried out more frequently.
Patient participation had changed in 2000 compared with 1995. In 2000, two-thirds of the organizations reported that the results of complaints registrations were discussed with patients (for example with the client council) and/or with patient organizations, a small increase over the data for 1995. However, patient participation in QM activities had decreased with respect to the remaining five items listed in the final section of Table 3. For example, fewer organizations were involving patients in the development of criteria or guidelines in 2000 compared with 1995.
The extent to which six subsectors of care differ in QM progress is shown in Table 4. These subsectors are: home care organizations, residential care units, nursing homes, hospitals, disability care, and mental health care facilities. The quality improvement progress per subsector is expressed as a difference score (i.e. the number of QM activities in 2000 minus the number of QM activities in 1995).
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Home care organizations and residential care units made the most progress in QM. The figures show that by the year 2000, on average, home care organizations had implemented >10 QM activities and had significantly increased the participation of clients in QM activities compared with the findings for 1995. Less but still significant progress had been made by the other five subsectors of care.
Table 5 presents the mean scores for the independent variables: the cultural characteristics of the organizations, collaboration between management and health professionals in QM, and the use of a QM blueprint or model. No large differences between the subsectors can be seen with respect to the cultural characteristics of the organizations. All scores are found to be around or slightly above the mean of the 6-point-scale. The largest difference between the subsectors concerns the dedicated attitude of employees, with the highest scores in residential care and disability care, and the lowest score in home care. Collaboration between management and health professionals in QM is found more frequently in mental health care and less frequently in hospitals. Nearly all nursing homes are using a QM blueprint or model. The correlations between the independent variables are given in Table 6.
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The cultural characteristics of the organizations are weakly interrelated; the strongest relationship exists between a non-hierarchical structure of the organization and decentralized decision making. Because these characteristics are conceptually interrelated, decentralized decision making was left out of the regression analysis.
Prior to the regression analysis, the organizations were divided into two groups: those who increased their QM activities and those who did not. The results showed that 313 (66%) organizations had increased their QM activities. No changes were found in 15 organizations and in 146 (31%) organizations a decline in QM activities was found. This decline was small in 80 organizations (one to five QM activities), moderate in 35 organizations (six to 10 QM activities), and substantial in 31 organizations (>10 QM activities).
Three regressions analyses were carried out, one including all cases, and one for each of the groups of cases divided as defined above. Table 7 presents the results of these analyses. The progress in QM activities between 1995 and 2000 is partly explained by two subsectors of care: home care and residential care. In addition, collaboration between management and health professionals is related to the progress in QM activities. The decrease in QM can not be explained, because no significant relationships were found in the subgroup of organizations that decreased their QM activities between 1995 and 2000. The analyses show that the changes in QM are not related to the person (director or administrator) who completed the questionnaire (the same or different person in 1995 and 2000). The results of regression analyses within subsectors of care are given in Table 8.
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The cultural characteristics of the organizations are only weakly related to changes in QM in three subsectors of care, and the explanatory power is rather small. It appears that differences exist between the subsectors. In home care organizations, the progress in QM is related to a dedicated attitude among employees, and in nursing homes the progress is related to a flexible attitude among employees. The progress in hospitals is positively related to a non-hierarchical structure in the organization. In the other three subsectors no significant relationships were found.
Discussion
This article has shown that it is possible to monitor the implementation of QM in health care organizations at a national level. In addition, differences between subsectors in the extent to which QM activities are being performed can be assessed. Before discussing the main findings, the strengths and weaknesses of the study are summarized.
Strengths and weaknesses of the study
The main strength of the study is the measurement instrument, which was thoroughly tested in previous research [7,9]. The instrument provides for detailed information about QM activities, independent of specific characteristics of subsectors and independent of the quality model used by an organization (ISO, EFQM, or other models). The psychometric strength of the study is the one-to-one comparison by linking the data of 1995 to those of 2000 per case.
The study’s main weakness is inherent in investigations conducted by questionnaire. We measured whether or not a QM activity was present in an organization. The questionnaire approach did not permit us to assess the effectiveness of these activities in serving the purpose of quality assurance. As a second weakness the occurrence of social desirability in the responses could not be excluded. To diminish this effect we calculated difference scores between 1995 and 2000, assuming that if social desirability occurred it was to the same extent on both occasions. It seems unlikely that social desirability had increased in 2000 due to the Quality Act (1996): first because no sanctions were imposed on non-compliance with the Act, and secondly because the questionnaires were sent anonymously to NIVEL (Netherlands Institute for Health Services Research) as an independent research institute.
Overall progress at the national level
The main conclusion of the study is that the majority of health care organizations in The Netherlands made progress in the implementation of QM activities in the period 1995–2000. There are, however, large differences between the subsectors in the progress that has been made. The study has revealed that, contrary to our expectations, nearly one-third of the organizations showed a decline in QM activities, and some specific QM activities have decreased instead of increased. The results demand careful consideration of their implications.
A first assumption of this study was that overall progress in the implementation of QM activities at the national level could be expected for two reasons. First, all parties involved (health care providers, patient/consumer organizations, health insurers, and the government) had made agreements about the implementation of QM in health care. Together they had also agreed to evaluate compliance with these agreements every 5 years. To that end, national quality conferences were held in 1995 and again in 2000 (the so-called Leidschendam Conferences) [1]. Secondly, in line with these agreements, the national government had issued a Quality Act in 1996. The Act obliges health care organizations to develop a QM system and to publish an annual quality report. The Act is a general legal framework, leaving room for health care organizations to develop their own QM activities.
The results from 2000 compared with those of 1995 showed that progress in QM activities had been made by two-thirds of the organizations. It is not possible to draw conclusions about a firm cause-and-effect relationship between the Quality Act and this progress on the basis of this descriptive study. For many organizations the development of QM activities was an ongoing activity that had been initiated in the early nineties [1,10,11]. There are, however, indications that the law has had some influence. A remarkable degree of progress was made with respect to the publication of an annual quality report: from 13% of the organizations in 1995 to 84% in 2000. As yet, no sanctions have been imposed for non-compliance with the Act. Perhaps that is one of the reasons why some organizations had not yet published a quality report. In 2001 the national government evaluated whether implementation of the Act had been successful (a 5-year evaluation of new legislation is required by law in The Netherlands). It was concluded that implementation of QM was proceeding too slowly. The Ministry of Health therefore announced new measures to speed up implementation of QM. Accreditation of health care facilities will be strongly encouraged and health insurers will be obliged to contract with care facilities that demonstrate sufficient QM activities. Whether these measures will increase the pace of implementation remains to be seen.
The finding that nearly one-third of the organizations in the study showed a decline in QM activities in 2000 compared with 1995 is contrary to our expectations and could not be explained. It might be that the decline was caused by stagnation in the implementation of QM, as was reported by some managers. They told us that in 1995 many quality instruments had been developed and were thus reported in the 1995 questionnaire, but some of the instruments were not implemented and thus were missing from the 2000 questionnaire. Further research is needed to investigate these and other tentative explanations of decreasing QM activities.
Differences between subsectors
The results showed that subsectors differ in the extent to which they have made progress in the implementation of QM. Home care organizations and residential care units had implemented twice as many QM activities during the 5-year period between the two surveys compared with nursing homes, hospitals, disability care, and mental health care settings. As yet it is unknown what caused the differences between the subsectors. A tentative explanation can be sought for home care in the specific circumstances of home care (but does not, however, explain the progress in residential care units). In the mid-1990s, home care organizations in The Netherlands were criticized because of long waiting lists and doubt arose about the efficiency of home care. These criticisms resulted in two radical interventions by the home care umbrella organization. First, to retain membership of the umbrella organization, the home care organizations had to implement a large number of QM activities. Audits were carried out by the umbrella organization to monitor compliance with their list of demands. Secondly, nearly all home care organizations participated in a benchmarking project in home care. In this project comparisons between the organizations were made with respect to efficiency and quality of care [12]. This benchmarking may have provided a further impetus to QM in home care [13]. In the other subsectors, such membership requirements and benchmarking have not been instituted. Currently, on the initiative of the national government, benchmarking is being prepared for a number of other subsectors in health care and the results have yet to be seen.
Change in the involvement of patients in QM
It was hypothesized that the involvement of patients in QM had increased in 2000 in all respects, and for two reasons. In 1995 special legislation was enacted, which obliged every health care organization to set up a client council. The council was to be involved in the quality policy of the organization. Secondly, at the national quality conference in 1995 the parties agreed that extra attention should be paid to the involvement of patients and their organizations in QM in the years to come.
The results show that the number of client councils did indeed increase from 53% of organizations in 1995 to 77% in 2000. By 2000 nearly all of the organizations that provide long-stay care had set up such a council. Fewer councils were seen in organizations that provide short-term or ambulatory care. Compared with 1995, more organizations conducted satisfaction surveys among patients in 2000.
In contrast to our expectations, the involvement of patients and their organizations in other respects did not increase, but instead decreased in 2000. Patients were less often involved in the establishment of criteria or the development of protocols and guidelines compared with 1995. Explanations for this finding are tentative. There are indications that a representative of patients or patient organizations with sufficient knowledge about the matter at hand could not always be found. In this connection, it could be that some organizations consider the feedback of client councils and satisfaction surveys the most effective way to involve patients or their organizations in QM. More research is needed to establish how patients or patient organizations can most effectively contribute to the quality and patient-centeredness of care in health care organizations [3].
Cultural characteristics related to the progress of QM
Other research has found that cultural characteristics of the organizations may facilitate (or hinder) the implementation of QM activities [6]. We therefore investigated whether or not such characteristics were also related to the progress that had been made by the organizations. Our results showed that the progress could partly be explained by collaboration between management and professional care givers. Only weak relationships/correlations between progress and other cultural characteristics were found. Moreover, these differed by subsector. In home care the progress in QM was related to dedicated employees. In nursing homes a correlation was found with the flexible attitude of employees. In hospitals, however, it was the organizational structure that was related to progress in QM. In hospitals with a non-hierarchical organizational structure, more progress in QM was seen than in those with a hierarchical structure. It could be that delegation of responsibilities to lower levels in the organization motivates the employees with regard to the implementation of QM [3]. Currently, hierarchical structures are changing in Dutch hospitals due to a so-called ‘break through series’ [14]. ‘Break through’ means a new clustering of, and cooperation between, all professionals involved in the care of specific diagnostically related groups, with the purpose of redesigning and streamlining the total care process from the patients’ point of view.
We must conclude that as yet much is unknown about factors that may either facilitate or hinder the implementation of QM activities in health care organizations. Much work needs to be done to unravel the mechanisms underlying the successful implementation of a quality system in health care organizations in the different subsectors of health care.
Address reprint requests to Emmy M. Sluijs, NIVEL (Netherlands Institute for Health Services Research), Postbox 1568, 3500 BN, Utrecht, The Netherlands. E-mail: e.sluijs{at}nivel.nl 
Accepted for publication February 3, 2003.
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