Zinnige Zorg (appropriate care)

Working method for the Zinnige Zorg (appropriate care) Programme

Points of Departure

The Zorginstituut designed a systematic working method for the Zinnige Zorg Programme in order to examine the degree to which care in the insured package is used. The key is to identify and combat ineffective and/or unnecessary care, thus improving the quality of care for patients, increasing health gains and avoiding unnecessary costs. We carry out a systematic assessment for a field of disorders as defined in the ICD- 10 classification system. A systematic assessment is carried out based on a number of points of departure.

Central role for patients

When assessing care, we give patients and the care path they follow a central role. The underlying question is always how much do patients benefit from the care supplied? Do they receive care that is appropriate to their situation, or perhaps too little care (under-treatment) or too much care (over-treatment)?

Shared decision-making

Care must be in keeping with the personal circumstances of patients. Apart from the established indication, patient-related matters also play a role in the choice of treatment, such as patients’ expectations, their professional situation, impact on social functioning, pain perception, motivation, etc. For some diagnoses it is clear which treatment options have to be deployed. Often, however, various treatment options exist, each with their pros and cons and the choice of a given treatment will depend more on the preferences of patients and their carers. Shared decision-making is a way of arriving at an optimum treatment pathway together with a patient. Various instruments exist that can support shared decision-making of doctors and patients effectively, such as decision aids, option grids and patients’
versions of guidelines; these can increase the quality of the decision-making process.

Stepped care

We assume that courses of treatment are started based on the stepped care principle. According to this principle, care is offered based on a step-by-step plan: the least burdensome effective treatment is used first, and only when this gives insufficient results are more complex or more invasive interventions offered. Stepped care is a general point of departure, not a mandatory requirement. The ‘start moment’ is not necessarily step 1, as steps may be skipped as necessary, according to the symptoms with which a patient presents.

Parties in health care are involved throughout the entire proces

The objective of the Zorginstituut is to realise active agreement with the parties in health care. This will benefit the quality of the analyses and the basis of support for improvement measures. We involve the
parties responsible in all phases of the systematic assessment. The parties are invited to attend various consultations via umbrella arrangements. They are also given an opportunity to participate in supervising the research of external research bureaus. Lastly, we ask parties for comments on the draft versions of reports.

Phases of systematic assessment

In order to promote good care, we carry out a systematic assessment according to a quality circle, or improvement
circle. This circle is comprised of four sequential phases:

1. Screening phase
   The objective of the screening phase is to select a number of topics for in-depth analysis with a possible potential for improving the quality and effectiveness of care by using care more appropriately.
2. In-Depth Analysis phase
   The screening phase is followed by the in-depth phase. The objective of this phase is to give as concrete as possible an indication of which potential improvements can be achieved.
3. Implementation phase
   The implementation phase is primarily a task for the parties in health care: patients, care professionals, institutions and health insurers. It takes place based on agreements made in the in-depth phase.
4. Evaluation phase
   During the evaluation phase, the Zorginstituut examines, together with the parties involved, whether the results mentioned in the Improvement Report have been achieved. Based on this, we determine whether a new circle of improvement should start, possibly using different instruments for improvement.

More information about the programme can be found in the brochure 'Working method for the Zinnige Zorg (appropriate care) Programme'.