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Quality & Patient Safety

Naturally our patients expect qualitative and safe care. But care implies working with people. Through research and hands-on experience we learn how best to contribute to good care, improve in a proactive way, and learn about care that did not turn out as we had intended. If an incident or major incident occurs, we investigate thoroughly what factors contributed to the fact that something in the care process did not go according to plan. We also look at how we can prevent this from happening again in the future, and work actively on improvements.

Quality-management system

In 2022 we started with a new approach to test, improve and guarantee quality: Quality Cooperation. In this we continue to build on the solid foundation that we have developed in the past fifteen years and that was tested three times in this period by an external body, the Joint Commission International (JCI) . We reached the conclusion that a fourth external assessment by JCI would not per definition contribute to further improvement of quality and safety for patients. Since the hospitals in the Netherlands have agreed with each other in a field standard to have their safety management system reviewed externally at least once a year, UMC Utrecht is getting assessed according to the NEN8009-2018 standard in which the requirements are defined. An external assessment took place in September 2022 which showed that UMC Utrecht meets the requirements for a safety-management system.

With our new Quality Cooperation method, we can be more in line with caregivers’ intrinsic motivation to improve, and with patients’ own experience. After all, they know better than anyone where there is still room for improvement in care. Quality Cooperation is based on five pillars, where we move from monitoring to trust:

In keeping with this movement, we started in 2022 to draw up a department-specific quality agenda in several departments. Besides countrywide IGJ improvement goals and and UMC Utrecht-wide priority areas, it leaves room for department-specific improvement goals.

In 2022 we also gained further experience through what we call value discussions, where experience experts and caregivers gather around a clinical picture and talk about what they see as quality in care. This remains an important source of inspiration for our improvement goals and contributes to an equal discussion between caregivers and experience experts. In 2023 we will expand on this experience to form a guideline for other departments.

In 2022 we furthermore started in the scope of NFU to draw up a guideline for ‘horizontal learning’ as a quality instrument: sharing best practices between departments, divisions, UMCs in the region, or other professional categories.

Adrienne Cullen lecture

The annual Adrienne Cullen lecture plays an important role in opening discussion and learning about things that go wrong, so that we can avoid making similar mistakes again and so that patients can feel supported. The fourth Adrienne Cullen lecture took place on Friday, March 25, 2022. The lecture focused on the experience of a family member of a patient with regard to our communication. The lecture can be seen online and is also available with live English interpreting and Dutch subtitles . The lecture is named after Ms Adrienne Cullen who contracted terminal uterus cancer due to a medical error at UMC Utrecht. She died on December 31, 2018.

Discharge communication further improved

In 2022 we continued to improve our discharge communication. Our ambition is to send a discharge report to the general practitioner/referrer within 24 hours for 90% of all transfers to the patient’s home or to another institution. We thereby guarantee care continuity, also after a patient has left UMC Utrecht. In December 2022 we sent 65% of all discharge letters on time (53% in 2021). Through more detailed analyses we have identified actions with which we can make further significant improvements in 2023.