Background: In 1989 a Dutch national policy was instituted to ensure that quality management is the responsibility of both health care professionals and management, with input from insurers and patients. In turn, quality management of medical specialists remained to a large extent self-regulatory, with accountability toward third-party payers and patients. Three programs for quality management-peer review, guidelines, and visitation-have sufficiently persuaded patient organizations and care insurers about medical specialists' ability to ensure the quality of the care they provide.
Peer review: Operational since 1976, the national program for peer review in hospitals has stressed the need for explicit evaluative mechanisms. This program led to the foundation of the National Organization for Quality Assurance in Hospitals (CBO), which conducts peer review activities but also support efforts aimed at quality assurance in hospitals. Once it is linked with the other two quality management programs, peer review will realize its full potential as a profession-based method for standardizing and rationalizing medical specialty practice.
Practice guidelines: Since 1982, more than 60 consensus guidelines have been developed for and by medical professionals, with input from patient organizations and third-party payers. Medical specialty associations have also created their own guidelines. Although the guidelines' impact has not been evaluated systematically, studies have shown effects on behavioral change and health outcomes. Solid, credible guidelines continue to be developed, although the successful implementation of these guidelines needs to be studied.
Visitation program: Visitation, or onsite assessment of specialty practice sites (in training and non-training hospitals), has been a hot issue in Dutch medical quality assurance. All 28 scientific societies have visitation programs, focusing on areas for improvement such as process management, use of guidelines, and evaluation of patient satisfaction and treatment outcomes. Closely linked to other medical quality assurance activities, visitation programs also incorporate clinical guidelines into evaluations.
Conclusions: Profession-driven peer review, practice guidelines, and visitation programs have been effective support tools for quality management in The Netherlands. Future challenges involve creating more synergy among these programs and between the profession-based quality management approaches and recently introduced hospital-based quality systems and maintaining the trust between third-party payers and patients.