Government supervision on quality of smoking-cessation counselling in midwifery practices: a qualitative exploration.

BACKGROUND: The Dutch Healthcare Inspectorate supervises care providers in order to improve quality of care. Recently the inspectorate assessed and promoted the use of a guideline on smoking-cessation counselling in midwifery practices. The supervision programme consisted of an announcement of the enforcement deadline for the guideline and site visits. The purpose of our qualitative study was to identify factors related to guideline adherence after the supervision programme, and investigate whether the programme had helped improve adherence. METHODS: We conducted semi-structured interviews with inspected and non-inspected midwives. Additionally, we studied documents and observed the inspection process. The sampled midwives all work in primary care midwifery practices providing care to pregnant smokers. The questions included the current provision of smoking-cessation counselling, support to the midwife in counselling, recent changes in provision of counselling, reasons for recent changes, knowledge about the supervision programme, and experiences with supervision by the inspectorate. RESULTS: Our results show that guideline adherence depends on several factors. Awareness and familiarity with the guideline are important, as is outcome expectancy. Additionally, motivation, guideline factors and environment factors were mentioned. Besides these previously documented factors, we found that professional collaboration also determined guideline adherence. Increased collaboration in counselling is associated with greater adherence to the guideline, such as provision of counselling and taking required training. The supervision programme helped improve stop-smoking counselling, by making midwives aware of the counselling and giving them an extrinsic motivation to provide counselling. CONCLUSION: Motivation and environmental aspects were the most important factors related to guideline adherence, and professional environment was added as significant factor. The improved guideline adherence is partly attributable to the supervision programme.

Effects of Government Supervision on Quality of Integrated Diabetes Care: A Cluster Randomized Controlled Trial.

OBJECTIVES: The quality of integrated diabetes care is important for reducing the burden of diabetes. Therefore, we have evaluated the effect of a supervision program on the quality of integrated diabetes care in the Netherlands in the 2011-2012 period. METHODS: In this cluster RCT, the supervision program was assigned to randomly selected care groups providing care to diabetes patients. The supervision program included announcements of inspections, site visits, and sending individualized reports. Indicators of effectiveness were derived from the structures, processes, and outcomes of care. These indicators were collected from patients' files, before and after the supervision program. Hierarchical linear and logistic regression models were used to analyze data from 356 patients of 10 intervention and 8 control care groups. RESULTS: Structures and processes of care did not improve more in the intervention groups than in the control care groups. Moreover, health outcomes did not improve more in the intervention groups than in the control care groups. Although structures of care improved over time in the total population of intervention and control care groups, there were no changes in process of care or health outcomes. CONCLUSIONS: In this cluster RCT, we could not demonstrate improvements in quality of integrated diabetes care resulting from the supervision program. Although structures of care did improve over time, other quality-improvement initiatives are necessary to substantially strengthen integrated care for diabetes patients.

Provision and effect of quit-smoking counselling by primary care midwives.

OBJECTIVE: we aimed to evaluate the provision of quit-smoking counselling by midwives in the Netherlands and its effect on smoking behaviour and birth weight. DESIGN: quasi-experimental study in which we collected information from pregnant women who smoke throughout their pregnancy by extracting data from electronic patient files. SETTING: primary care midwifery practices. PARTICIPANTS: 851 pregnant women who smoke, treated between 2011 and 2014. INTERVENTION: quit-smoking counselling. MEASUREMENTS AND FINDINGS: the midwives decided to provide quit-smoking counselling to the participant or not. Non-counselled women were used as the control group. The primary outcome parameter was quit smoking, defined as 'quit smoking by end of pregnancy'. At intake, 67% of the women smoked 1-9 cigarettes a day, 23% smoked 10-20 cigarettes a day and 4% more than 20 cigarettes a day. The midwives began counselling with 42% of the participants, but seldom completed all the counselling steps. The average quit rate was 10% and average birth weight of the babies was 3200g. We found no difference in quit rate or birth weight between counselled women and those who were not. However, the data suggested that counselling is more effective when more steps of counselling are completed. KEY CONCLUSIONS: no effect was found of quit-smoking counselling on quit-smoking rate or birth weight. Possibly, counselling is effective when provided extensively throughout pregnancy. IMPLICATIONS FOR PRACTICE: our study shows that provision of counselling can be improved.

Does government supervision improve stop-smoking counseling in midwifery practices?

INTRODUCTION: Smoking-cessation counseling during pregnancy is important to prevent smoking-related harm in pregnant smokers and their children. Therefore we evaluated the effects of an Inspectorate's supervision programme on the provision of smoking-cessation counseling by midwifery practices in the Netherlands. The supervision programme consisted of 3 elements: A) A deadline was announced by which all practices should comply with professional norms on such counseling (2011); B) A set of randomly selected practices were assessed using a questionnaire and a personal feedback report (2010); C) Another set of randomly selected practices were assessed through a site visit and a personal feedback report (2012). METHODS: Programme A was evaluated in a before-after study, Programmes B and C were evaluated in a randomized controlled trial (RCT) with only a post-intervention measurement. Primary outcome was provision of smoking-cessation counseling through a minimal-intervention strategy (V-MIS). Linear and logistic regression models were used to analyze data from 233 primary-care midwifery practices. RESULTS: A) After announcement of the deadline, Dutch midwifery practices reported significantly more provision of smoking-cessation counseling. For example, the use of V-MIS increased substantially from 28% to 80%; B) In practices that were assessed with a questionnaire, the provision of counseling improved partially compared to controls; C) The provision of counseling did not differ between practices that were visited and their controls. While the training participation rate in counseling by midwifery practices did not differ between the intervention and control groups, the rate increased significantly in all practices after the start of the supervision programme. CONCLUSIONS: The provision of smoking-cessation counseling improved spectacularly in Dutch midwifery practices. Despite some limitations of our study, the Inspectorate's supervision programme is likely to have contributed to the improvements in provision of counseling.

An examination of the Dutch Health Care Inspectorate's supervision system for suicides of mental health care users.

OBJECTIVE: This study examined characteristics of suicides among mental health care users reported between 1996 and 2006 to the Dutch Health Care Inspectorate and the inspectorate's follow-up responses. The aims were to determine whether follow-up was associated with particular characteristics and whether the responses could be improved in accordance with guidelines for treatment of suicidal patients. METHODS: Information about patient and treatment characteristics was collected from a sample of 505 of the 5,483 suicide notifications between 1996 and 2006. The 1996-2005 sample included an equal number of cases to which the inspectorate did and did not respond. The 2006 sample included the first 205 notifications in that year. RESULTS: For 2006 notifications the response rate was 37%. The responses most frequently addressed how and whether the suicide was evaluated and the adequacy of treatment for the psychiatric disorder. A follow-up response was more likely when the suicide involved a young patient or a patient treated in a mental health care setting for less than a year or when the notification was accompanied by the mental health institution's plans for improving its policies. A response was less likely when the patient was discharged from inpatient care in the three months before the suicide. Since 2002 responses have more frequently emphasized the importance of suicide risk assessment, in accordance with guidelines. CONCLUSIONS: The inspectorate might improve its supervision system by placing greater emphasis on addressing suicidal impulses and treating older and chronically suicidal patients and patients soon after inpatient discharge.