eHealth is most effective when integrated into conventional health care in a “hybrid” health care model. In order to achieve high-quality hybrid health care, eHealth must benefit patients and must... Show moreeHealth is most effective when integrated into conventional health care in a “hybrid” health care model. In order to achieve high-quality hybrid health care, eHealth must benefit patients and must be effectively integrated and organized within regular health care. This thesis describes the evaluation of eHealth from both a patient perspective and an organizational perspective. Chapters 2 and 3 present patients’ views of an online patient portal. Chapters 4 and 5 describe the factors that affect the organization of high-quality hybrid health care and use these as inputs to develop a tailored quality management model and accompanying self-assessment questionnaire: the Hybrid Health Care Quality Assessment (HHQA) (Chapter 5). Health care organizations can use the model and questionnaire to gain insight into ways of improving the quality of their hybrid care. Show less
This thesis shows that quality of colorectal cancer care is irrevocably associated with hospital costs. Although surgical auditing is a cost and time-consuming exercise, it has a strong potential... Show moreThis thesis shows that quality of colorectal cancer care is irrevocably associated with hospital costs. Although surgical auditing is a cost and time-consuming exercise, it has a strong potential to improve outcomes in healthcare and simultaneously reduce hospital costs. Comparing hospital performances on both quality and costs makes identification of ‘best practice’ hospitals possible. Moreover, providing combined quality-cost outcomes of frail patients or operation techniques provides valuable insights where to start quality improvement initiatives. Finally, rewarding healthcare providers based on operative risk could be a first step in developing powerful reimbursement systems. This all might catalyze the continuous improvement of value leading to a more sustainable healthcare system in the future. Show less
De Dutch Surgical Colorectal Audit (DSCA) evalueert sinds 2009 op landelijk niveau de kwaliteit van colorectale zorg via clinical auditing. In dit proefschrift wordt het principe en effect... Show more De Dutch Surgical Colorectal Audit (DSCA) evalueert sinds 2009 op landelijk niveau de kwaliteit van colorectale zorg via clinical auditing. In dit proefschrift wordt het principe en effect van clinical auditing beschreven en wordt gekeken waar aangrijpingspunten voor kwaliteitsverbetering zijn en welke verbeteringen er zijn gerealiseerd in Nederland. Show less
The essence of VBHC is to improve patients' outcomes at lower costs. This thesis attempts to construct the value quotient (vQ) for IBD: a metric for value which incorporates patient value, defined... Show moreThe essence of VBHC is to improve patients' outcomes at lower costs. This thesis attempts to construct the value quotient (vQ) for IBD: a metric for value which incorporates patient value, defined as a combination of disease control, quality of life, and productivity in the numerator, and divides it by the associated IBD-related costs in the denominator. In this thesis we showed the feasibility of monitoring clinical disease control remotely using a mobile app, we showed the impact of IBD on work productivity, and we developed a patient-centric composite score that incorporates all three outcomes as well as individual patient preferences. However, metrics for long term outcomes still need to be incorporated in the vQ. Although ideally this would be done by measuring disease outcomes long-term, this is not practical for short-term improvements. Process measures that are associated with long term outcomes and that are well-grounded in the medical literature offer a feasible short term alternative. Future research is needed to assess which process measures would be appropriate in this context, and to develop a quantifiable way to include these in the vQ. Show less
Quality of care- and of surgical oncology in particular- is gaining momentum. In this thesis the scientific bases of minimal volume standards and quality indicators are evaluated. Also the impact... Show moreQuality of care- and of surgical oncology in particular- is gaining momentum. In this thesis the scientific bases of minimal volume standards and quality indicators are evaluated. Also the impact of centralization of pancreatic surgery is investigated as is the influence of comorbidity on patient outcomes after colorectal surgery Show less
As the de facto industry standard for software modeling, the Unified Modeling Language (UML) is used widely across various IT domains. UML__s wide acceptance is partly because the language offers... Show moreAs the de facto industry standard for software modeling, the Unified Modeling Language (UML) is used widely across various IT domains. UML__s wide acceptance is partly because the language offers flexibility and freedom in modeling software systems: 1) UML provides an extensive set of modeling notations that can be used to model various concepts; 2) UML can be used both in a casual and formal manners. In the context of model-driven software development, the degree of freedom in which UML is used raises an important issue related to model quality. Different styles and rigors in using UML affect the quality of the resulting models. It is then logical to think that the level of quality of the UML model may affect the quality of the resulting software. This thesis reports on a series of empirical studies performed to address a pivotal question concerning the benefits of UML modeling in software development, particularly from a quality perspective. The results of these empirical studies show that the use of UML provides benefits in terms of increased quality and productivity in software development. The availability of UML models also allows early prediction of defects in software systems. Such prediction is potentially useful for identifying and fixing defects early during software development, and for prioritizing testing. Show less
This research is a socio-legal study of developments in the profession of notaries. The enactment of a new act in 1999, aimed at enhancing competition and abolishing the guilt-like structure of the... Show moreThis research is a socio-legal study of developments in the profession of notaries. The enactment of a new act in 1999, aimed at enhancing competition and abolishing the guilt-like structure of the profession of notaries, is a first pillar of this research, The study focuses as well on developments in the ethics of notaries and the qualities of their services. Liberalization, through the abolition of fixed fees as well as regulated establishment, would bring about the flux of young notaries, innovation and dynamics in the profession and better prices for the customers. Making up the balance after eight years of enhanced competition in the notaries’profession one must say, that not all of the intentions and goals of the legislator were translated into the practice of notaries. The flux of new firms run by young notaries, lagged behind. Price differentiation entered the stage, but so did higher prices in the consumer’s sector. The guilt-like and old fashioned flavour of the profession is a thing of the past. Scaling up, specialization and innovation enter the stage. Franchises of firms of notaries arise. Ratings of notaries’firms and their tariffs appear on the Internet and the services of notaries become more consumers friendly. While a more entrepreneurial orientation can be traced, one cannot speak of an ethical decay. Liberalisation is rather a catalyst for new thoughts on quality and ethics on firm level. Show less
Quality of surgical procedures in the treatment of cancer patients is of utmost importance. This thesis focuses on two large prospective randomised trials on gastric and rectal cancer. Important... Show moreQuality of surgical procedures in the treatment of cancer patients is of utmost importance. This thesis focuses on two large prospective randomised trials on gastric and rectal cancer. Important feature in both trials was the standardisation and quality control of surgery, enabling the reliable assessment of the rol of adjunctive therapies. The trial on gastric cancer showed no benefitit of extensive lymph node dissection in gastric cancer. However, if postoperative morbidity is reduced, extended surgery may be of benefit. Various ways of reducing the likelihood of postoperative complications are considered. The trial on rectal cancer patients showed that short term preoperative radiotherapy is capable of reducing the risk of local recurrence, which however does not lead to improvement of survival. Moreover, there are important side effects of radiotherapy, the most important one being the increased incidence of fecal incontinence in irradiated patients. Show less
