Evaluation of the implementation of Value-Based Healthcare with a weekly digital follow-up of lung cancer patients in clinical practice.

OBJECTIVE: The aim of this study was to evaluate the implementation of Value-Based Healthcare principles for lung cancer patients in a large Belgian hospital. This hospital implemented a digital platform for the collection of patient-reported outcomes and the standardisation of care pathways. Also, a follow-up by the multidisciplinary care team was put in place. METHODS: Evaluation was done by employing a mixed method approach with data analysis of all included patients (n = 201), a pilot study (n = 30) and semi-structured interviews with the care team (n = 5). RESULTS: Overall, 95% of all lung cancer patients of two thoracic oncologists agreed to participate in the digital follow-up during the period January 2018 to September 2020 (201 participating patients). The response rates of those patients were high: 92% of the weekly questionnaires and 90% of the 6-weekly ICHOM questionnaires were responded. Based on the pilot study, we conclude that questions are clear and the platform is user-friendly for 90% of patients in the pilot. The interviews revealed that the weekly follow-up has a positive impact on the patient-provider communication and makes it easier to discuss psychological and palliative care needs. CONCLUSION: This study shows a successful implementation of Value Based Healthcare with weekly digital follow-up. Clinical trial registration is as follows: www. CLINICALTRIALS: gov, NCT04712149.

Challenges in organizing a Belgian reference hospital to respond to the COVID-19 pandemic: A case report.

The coronavirus disease 2019 (COVID-19) pandemic resulted in an enormous influx of seriously ill patients in the hospitals worldwide. After its initial impact in Asia, Europe also suffered greatly. Caring for COVID-19 patients whist maintaining treatment for patients with other conditions was a complex planning and management challenge. A series of interventions has been implemented to increase hospital capacity in response to the pandemic. Hospital provision interventions included the purchase of equipment, the establishment of additional hospital facilities and the redeployment of staff and other resources. Ensuring safe and high quality care to both COVID-19 patients and those with other conditions was a crucial aspect of the Belgian response in this current health crisis.

Clinical handover and handoff in healthcare: a systematic review of systematic reviews.

PURPOSE: The purpose of this systematic review is to appraise and summarize existing literature on clinical handover. DATA SOURCES: We searched EMBASE, MEDLINE, Database of Abstracts of Reviews of Effects and Cochrane Database of Systematic Reviews. STUDY SELECTION: Included articles were reviewed independently by the review team. DATA EXTRACTION: The review team extracted data under the following headers: author(s), year of publication, journal, scope, search strategy, number of studies included, type of studies included, study quality assessment, used definition of handover, healthcare setting, outcomes measured, findings and finally some comments or remarks. RESULTS OF DATA SYNTHESIS: First, research indicates that poor handover is associated with multiple potential hazards such as lack of availability of required equipment for patients, information omissions, diagnosis errors, treatment errors, disposition errors and treatment delays. Second, our systematic review indicates that no single tool arises as best for any particular specialty or use to evaluate the handover process. Third, there is little evidence delineating what constitutes best handoff practices. Most efforts facilitated the coordination of care and communication between healthcare professionals using electronic tools or a standardized form. Fourth, our review indicates that the principal teaching methods are role-playing and simulation, which may result in better knowledge transfer to the work environment, better health and patients' well-being. CONCLUSIONS: This review emphasizes the importance of staff education (including simulation-based and team training), non-technical skills and the implementation process of clinical handover in healthcare settings.

COVID-19 is having a destructive impact on health-care workers' mental well-being.

BACKGROUND: The coronavirus disease 2019 (COVID-19) may aggravate workplace conditions that impact health-care workers' mental health. However, it can also place other stresses on workers outside of their work. This study determines the effect of COVID-19 on symptoms of negative and positive mental health and the workforce's experience with various sources of support. Effect modification by demographic variables was also studied. METHODS: A cross-sectional survey study, conducted between 2 April and 4 May 2020 (two waves), led to a convenience sample of 4509 health-care workers in Flanders (Belgium), including paramedics (40.6%), nurses (33.4%), doctors (13.4%) and management staff (12.2%). About three in four were employed in university and acute hospitals (29.6%), primary care practices (25.7%), residential care centers (21.3%) or care sites for disabled and mental health care. In each of the two waves, participants were asked how frequently (on a scale of 0-10) they experienced positive and negative mental health symptoms during normal circumstances and during last week, referred to as before and during COVID-19, respectively. These symptoms were stress, hypervigilance, fatigue, difficulty sleeping, unable to relax, fear, irregular lifestyle, flashback, difficulty concentrating, feeling unhappy and dejected, failing to recognize their own emotional response, doubting knowledge and skills and feeling uncomfortable within the team. Associations between COVID-19 and mental health symptoms were estimated by cumulative logit models and reported as odds ratios. The needed support was our secondary outcome and was reported as the degree to which health-care workers relied on sources of support and how they experienced them. RESULTS: All symptoms were significantly more pronounced during versus before COVID-19. For hypervigilance, there was a 12-fold odds (odds ratio 12.24, 95% confidence interval 11.11-13.49) during versus before COVID-19. Positive professional symptoms such as the feeling that one can make a difference were less frequently experienced. The association between COVID-19 and mental health was generally strongest for the age group 30-49 years, females, nurses and residential care centers. Health-care workers reported to rely on support from relatives and peers. A considerable proportion, respectively, 18 and 27%, reported the need for professional guidance from psychologists and more support from their leadership. CONCLUSIONS: The toll of the crisis has been heavy on health-care workers. Those who carry leadership positions at an organizational or system level should take this opportunity to develop targeted strategies to mitigate key stressors of health-care workers' mental well-being.

Exploring and Evaluating Patient Safety Culture in a Community-Based Primary Care Setting.

OBJECTIVES: The primary aim was to measure patient safety culture in two home care services in Belgium (Flanders). In addition, variability based on respondents' profession was examined. METHODS: A cross-sectional study was conducted by administering the SCOPE-Primary Care questionnaire in two home care service organizations. RESULTS: In total, 1875 valid questionnaires were returned from 2930 employees, representing a response rate of 64%. The highest mean patient safety culture score was found for "organizational learning" (mean [SD] = 3.81 [0.53]), followed by "support and fellowship" (mean [SD] = 3.76 [0.61]), "open communication and learning from error" (mean [SD] = 3.73 [0.64]), and "patient safety management" (mean [SD] = 3.71 [0.60]). The lowest mean scores were found for "handover and teamwork" (mean [SD] = 3.28 [0.58]) and "adequate procedures and working conditions" (mean [SD] = 3.30 [0.56]). Moreover, managers/supervisors scored significantly higher on the dimensions "open communication and learning from error," "adequate procedures and working conditions," "patient safety management," "support and fellowship," and "organizational learning" than clinical and nonclinical staff. CONCLUSIONS: In conclusion, organizational learning is perceived as most positive. However, large gaps remain in the continuity of care as "handover and teamwork" is perceived as the most negative safety culture dimension. With knowledge of the current patient safety culture, organizations can redesign processes or implement improvement strategies to avoid patient safety incidents and patient harm in the future.

Systematic screening and assessment of psychosocial well-being and care needs of people with cancer.

BACKGROUND: Receiving a diagnosis of cancer and the subsequent related treatments can have a significant impact on an individual's physical and psychosocial well-being. To ensure that cancer care addresses all aspects of well-being, systematic screening for distress and supportive care needs is recommended. Appropriate screening could help support the integration of psychosocial approaches in daily routines in order to achieve holistic cancer care and ensure that the specific care needs of people with cancer are met and that the organisation of such care is optimised. OBJECTIVES: To examine the effectiveness and safety of screening of psychosocial well-being and care needs of people with cancer. To explore the intervention characteristics that contribute to the effectiveness of these screening interventions. SEARCH METHODS: We searched five electronic databases in January 2018: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO, and CINAHL. We also searched five trial registers and screened the contents of relevant journals, citations, and references to find published and unpublished trials. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and non-randomised controlled trials (NRCTs) that studied the effect of screening interventions addressing the psychosocial well-being and care needs of people with cancer compared to usual care. These screening interventions could involve self-reporting of people with a patient-reported outcome measures (PROMs) or a semi-structured interview with a screening interventionist, and comprise a solitary screening intervention or screening with guided actions. We excluded studies that evaluated screening integrated as an element in more complex interventions (e.g. therapy, coaching, full care pathways, or care programmes). DATA COLLECTION AND ANALYSIS: Two review authors independently extracted the data and assessed methodological quality for each included study using the Cochrane tool for RCTs and the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool for NRCTs. Due to the high level of heterogeneity in the included studies, only three were included in meta-analysis. Results of the remaining 23 studies were analysed narratively. MAIN RESULTS: We included 26 studies (18 RCTs and 8 NRCTs) with sample sizes of 41 to 1012 participants, involving a total of 7654 adults with cancer. Two studies included only men or women; all other studies included both sexes. For most studies people with breast, lung, head and neck, colorectal, prostate cancer, or several of these diagnoses were included; some studies included people with a broader range of cancer diagnosis. Ten studies focused on a solitary screening intervention, while the remaining 16 studies evaluated a screening intervention combined with guided actions. A broad range of intervention instruments was used, and were described by study authors as a screening of health-related quality of life (HRQoL), distress screening, needs assessment, or assessment of biopsychosocial symptoms or overall well-being. In 13 studies, the screening was a self-reported questionnaire, while in the remaining 13 studies an interventionist conducted the screening by interview or paper-pencil assessment. The interventional screenings in the studies were applied 1 to 12 times, without follow-up or from 4 weeks to 18 months after the first interventional screening. We assessed risk of bias as high for eight RCTs, low for five RCTs, and unclear for the five remaining RCTs. There were further concerns about the NRCTs (1 = critical risk study; 6 = serious risk studies; 1 = risk unclear).Due to considerable heterogeneity in several intervention and study characteristics, we have reported the results narratively for the majority of the evidence.In the narrative synthesis of all included studies, we found very low-certainty evidence for the effect of screening on HRQoL (20 studies). Of these studies, eight found beneficial effects of screening for several subdomains of HRQoL, and 10 found no effects of screening. One study found adverse effects, and the last study did not report quantitative results. We found very low-certainty evidence for the effect of screening on distress (16 studies). Of these studies, two found beneficial effects of screening, and 14 found no effects of screening. We judged the overall certainty of the evidence for the effect of screening on HRQoL to be very low. We found very low-certainty evidence for the effect of screening on care needs (seven studies). Of these studies, three found beneficial effects of screening for several subdomains of care needs, and two found no effects of screening. One study found adverse effects, and the last study did not report quantitative results. We judged the overall level of evidence for the effect of screening on HRQoL to be very low. None of the studies specifically evaluated or reported adverse effects of screening. However, three studies reported unfavourable effects of screening, including lower QoL, more unmet needs, and lower satisfaction.Three studies could be included in a meta-analysis. The meta-analysis revealed no beneficial effect of the screening intervention on people with cancer HRQoL (mean difference (MD) 1.65, 95% confidence interval (CI) -4.83 to 8.12, 2 RCTs, 6 months follow-up); distress (MD 0.0, 95% CI -0.36 to 0.36, 1 RCT, 3 months follow-up); or care needs (MD 2.32, 95% CI -7.49 to 12.14, 2 RCTs, 3 months follow-up). However, these studies all evaluated one specific screening intervention (CONNECT) in people with colorectal cancer.In the studies where some effects could be identified, no recurring relationships were found between intervention characteristics and the effectiveness of screening interventions. AUTHORS' CONCLUSIONS: We found low-certainty evidence that does not support the effectiveness of screening of psychosocial well-being and care needs in people with cancer. Studies were heterogeneous in population, intervention, and outcome assessment.The results of this review suggest a need for more uniformity in outcomes and reporting; for the use of intervention description guidelines; for further improvement of methodological certainty in studies and for combining subjective patient-reported outcomes with objective outcomes.

Healthcare professionals' perspectives on the prevalence, barriers and management of psychosocial issues in cancer care: A mixed methods study.

This cross-sectional mixed methods survey explores healthcare professionals' perspective on their management of cancer patients' psychosocial concerns, and barriers to integrate the psychosocial approach in their work. An invitation for participation was sent to 4,965 inpatient and outpatient working professionals, of which 583 responded (12% response rate), and 368 fully completed the survey. The majority of respondents does not use a systematic approach to discuss patients' psychosocial concerns, 37.5% use the general question "How are you?," and 65.0% spontaneously addresses various psychosocial aspects. Most psychosocial topics are "sometimes" or "regularly" discussed. Sexuality and return to work are rarely mentioned. About half of the respondents are convinced that they pay enough attention to the psychosocial well-being of cancer patients: by listening, engaging in a deeper conversation, providing advice and through referral. Mostly, patients are referred to a psychologist, a general practitioner, a social worker, a specialised nurse or a centre for well-being and mental health. The barriers experienced, when providing psychosocial support, can be attributed to the patients, to themselves or other healthcare professionals, and to policy restrictions. These barriers should be addressed in order to enable healthcare professionals to improve the integration of the psychosocial approach in cancer care.

An explorative study on systematic assessment of QOL and care needs with the CARES-SF in the early follow-up of patients with digestive cancer.

PURPOSE: Systematic assessment of QOL and care needs was applied in two gastroenterology departments to support "Cancer Care for the Whole Patient." METHODS: Patients with digestive cancer were asked to complete the Cancer Rehabilitation Evaluation System-Short Form (CARES-SF) at the start of treatment and 3 months later. Both times CARES data were processed, and summary reports on the retained insights were sent to the reference nurse for use in further follow-up of the patient. Patients' and reference nurse's experiences with the systematic CARES-assessment were explored with several survey questions and semi-structured interviews, respectively. RESULTS: The mean age of the 51 participants was 63 years (SD11.17), 52.9% was male. With the CARES-SF, a large variety of problems and care needs was detected. Problems most frequently experienced, and most burdensome for QOL are a mix of physical complaints, side effects from treatment, practical, relational, and psychosocial difficulties. Only for a limited number of experienced problems a desire for extra help was expressed. All patients positively evaluate the timing and frequency of the CARES-assessment. The majority believes that this assessment could contribute to the discussion of problems and needs with healthcare professionals, to get more tailored care. Reference nurses experienced the intervention as an opportunity to systematically explore patients' well-being in a comprehensive way, leading to detection and discussion of specific problems or needs in greater depth, and more efficient involvement of different disciplines in care. CONCLUSIONS: Systematic QOL and needs assessment with the CARES-SF in oncology can contribute to more patient-centeredness and efficiency of care.

Similarities and differences in the associations between patient safety culture dimensions and self-reported outcomes in two different cultural settings: a national cross-sectional study in Palestinian and Belgian hospitals.

OBJECTIVES: To investigate the relationships between patient safety culture (PSC) dimensions and PSC self-reported outcomes across different cultures and to gain insights in cultural differences regarding PSC. DESIGN: Observational, cross-sectional study. SETTING: Ninety Belgian hospitals and 13 Palestinian hospitals. PARTICIPANTS: A total of 2836 healthcare professionals matched for profession, tenure and working hours. PRIMARY AND SECONDARY OUTCOME MEASURES: The validated versions of the Belgian and Palestinian Hospital Survey on Patient Safety Culture were used. An exploratory factor analysis was conducted. Reliability was tested using Cronbach's alpha (α). In this study, we examined the specific predictive value of the PSC dimensions and its self-reported outcome measures across different cultures and countries. Hierarchical regression and bivariate analyses were performed. RESULTS: Eight PSC dimensions and four PSC self-reported outcomes were distinguished in both countries. Cronbach's α was α≥0.60. Significant correlations were found between PSC dimensions and its self-reported outcome (p value range <0.05 to <0.001). Hierarchical regression analyses showed overall perception of safety was highly predicted by hospital management support in Palestine (ß=0.16, p<0.001) and staffing in Belgium (ß=0.24, p<0.001). The frequency of events was largely predicted by feedback and communication in both countries (Palestine: ß=0.24, p<0.001; Belgium: ß=0.35, p<0.001). Overall grade for patient safety was predicted by organisational learning in Palestine (ß=0.19, p<0.001) and staffing in Belgium (ß=0.19, p<0.001). Number of events reported was predicted by staffing in Palestine (ß=-0.20, p<0.001) and feedback and communication in Belgium (ß=0.11, p<0.01). CONCLUSION: To promote patient safety in Palestine and Belgium, staffing and communication regarding errors should be improved in both countries. Initiatives to improve hospital management support and establish constructive learning systems would be especially beneficial for patient safety in Palestine. Future research should address the association between safety culture and hard patient safety measures such as patient outcomes.

Seen through the patients' eyes: surgical safety and checklists.

OBJECTIVE: We sought to explore the views patients have towards surgical safety and checklists. As a secondary aim, we explored if previous experience of error or other patient characteristics influence these views. DESIGN: A cross-sectional survey study design was applied. PARTICIPANTS: The Flemish Patients' Platform network and social media were used to recruit participants. MAIN OUTCOME MEASURE(S): An 11-item questionnaire was designed to assess the following constructs: perception of surgical safety, attitudes towards the WHO surgical safety checklist and attitudes regarding checklist usage. RESULTS: Respondents' view (N = 444) on the risk of an adverse event showed considerable variation. Respondents were positive towards the checklist, strongly agreeing that it would impact positively on their safety. However, this positive perception did not translate into an attitude where patients will actively inform themselves whether a checklist is used. The majority of respondents have no difficulty with repetitive verification of identity, procedure and location of the surgery. Respondents with a clinical background were the least anxious. Views were divided regarding hearing discussions around blood loss or airway problems. CONCLUSIONS: Patients perceive the checklist as a reliable safety tool. They do not mind repetitive verification of identity and procedure. However, hearing staff discussing specific, explicit, risks could cause anxiousness in some patients. Building a supportive and collaborative environment is needed to involve and empower patients to contribute in the realization of a safe hospital environment.

Systematic psychometric review of self-reported instruments to assess patient safety culture in primary care.

AIMS: To give an overview of empirical studies using self-reported instruments to assess patient safety culture in primary care and to synthesize psychometric properties of these instruments. BACKGROUND: A key condition for improving patient safety is creating a supportive safety culture to identify weaknesses and to develop improvement strategies so recurrence of incidents can be minimized. However, most tools to measure and strengthen safety culture have been developed and tested in hospitals. Nevertheless, primary care is facing greater risks and a greater likelihood of causing unintentional harm to patients. DESIGN: A systematic literature review of research evidence and psychometric properties of self-reported instruments to assess patient safety culture in primary care. DATA SOURCES: Three databases until November 2016. REVIEW METHODS: The review was carried out according to the protocol for systematic reviews of measurement properties recommended by the COSMIN panel and the PRISMA reporting guidelines. RESULTS: In total, 1.229 records were retrieved from multiple database searches (Medline = 865, Web of Science = 362 and Embase = 2). Resulting from an in-depth literature search, 14 published studies were identified, mostly originated from Western high-income countries. As these studies come with great diversity in tools used and outcomes reported, comparability of the results is compromised. Based on the psychometric review, the SCOPE-Primary Care survey was chosen as the most appropriate instrument to measure patient safety culture in primary care as the instrument had excellent internal consistency with Cronbach's alphas ranging from 0.70-0.90 and item factor loadings ranging from 0.40-0.96, indicating a good structural validity. CONCLUSION: The findings of the present review suggest that the SCOPE-Primary Care survey is the most appropriate tool to assess patient safety culture in primary care. Further psychometric techniques are now essential to ensure that the instrument provides meaningful information regarding safety culture.

A Factorial Survey on Safety Behavior Providing Opportunities to Improve Safety.

OBJECTIVES: To realize safe, high-quality treatment, employees should behave according to patient safety standards. Periodic measurement of safety behavior could provide management-relevant information to adjust the implementation of interventions and maximize improvement. Therefore, we constructed a factorial survey measuring safety awareness and intentions for behavior. METHODS: Cross-sectional results of the factorial survey were compared with results from the Hospital Survey on Patient Safety Culture, distributed in MAASTRO radiotherapy in 2010 to 2011. Respondents were presented 20 scenarios about incidents, randomly varying on work pressure, person causing incident, whether patient level was reached, severity of harm, notification by patient, and management support. After each scenario, questions were asked about safety awareness and behavior. χ and multilevel regression analyses were used. RESULTS: Response rates were 64% (n = 54) for the culture survey and 62% (n = 52) for the factorial survey on intentions. The culture survey reflected positive opinions regarding nonpunitive response and incident reporting, in accordance with high scores (factorial survey) on safety awareness (9.0; scale, 1-10) and reporting intentions (8.7). Whether an incident reached the patient level predicted safety awareness and intentions for safety behavior (ß = -1.3/-3.08) most strongly. Severity of harm showed minimal additional effects (ß = -0.24/-0.42). CONCLUSIONS: The factorial survey presented practical information on safety awareness and intentions for behavior. Therefore, it created additional opportunities for improving safety interventions. Because behavior is expected to change before values, one could hypothesize that factorial surveys would be more sensitive to change than culture surveys. Longitudinal research should further study the surveys' sensitivity to measure changes.

Seen through the patients' eyes: quality of chronic illness care.

Background: Most well-developed healthcare systems are facing the challenge of managing the increasing prevalence of patients with chronic diseases. Comprehensive frameworks, such as the chronic care model (CCM), receive widespread acceptance for improving care processes, clinical outcomes and costs. Objective: The purpose of this study was to explore chronic patients' perceptions of the quality of chronic care and the alignment with the CCM. Since previous research indicated that a patient's assessment may depend on socio-demographic or disease-related characteristics, the relationship between the mean Patient Assessment of Chronic Illness Care (PACIC) score and possible aforementioned predictors was also explored. Methods: An observational, cross-sectional study design was applied, and participants were recruited from the Flemish Patients' Platform (Belgium). An online questionnaire was designed to assess chronic patients' socio-demographic characteristics, medical consumption, quality of life (EuroQol-5D survey) and the perspective of chronic illness care PACIC survey. Results: The mean overall PACIC score was 2.87 on a maximum score of 5. The highest mean score for the PACIC subscales was found for 'patient activation' (3.26), followed by 'delivery system design/decision support' (3.23), 'problem solving/contextual counselling' (2.86), 'goal setting/tailoring' (2.70) and 'follow-up/coordination' (2.59). Quality of life, as measured by the EuroQol Visual Analogue Scale, had a significantly positive correlation with the mean PACIC score (P = 0.005). Conclusion: The CCM is considered an important step towards improved care for patients with chronic diseases. However, the findings of this study showed that elements from the CCM have not yet been fully implemented. Aspects such as dealing with problems which interfered with achieving predefined goals, helping patients to set specific goals for their care delivery and arranging follow-ups are less common in today's care of chronic diseases.

The SCOPE-PC instrument for assessing patient safety culture in primary care: a psychometric evaluation.

INTRODUCTION: Primary healthcare differs from hospitals in terms of - inter alia - organisational structure. Therefore, patient safety culture could differ between these settings. Various instruments have been developed to measure collective attitudes of personnel within a primary healthcare organisation. However, the number of valid and reliable instruments is limited. OBJECTIVES: Psychometric properties of the SCOPE-Primary Care instrument were tested to examine the instrument's applicability in home care services in Belgium. METHODS: A cross-sectional study was conducted by administering the SCOPE-PC questionnaire in a single home care organisation with more than 1000 employees, including nurses, midwives, healthcare assistants, diabetes educators and nursing supervisors. First, a confirmatory factor analysis was performed to test whether the observed dataset fitted to the proposed seven-factor model of the SCOPE-PC instrument. Second, Cronbach's alphas were calculated to examine internal consistency reliability. Finally, the instrument's validity was also examined. RESULTS: In total, 603 questionnaires were retained for further analysis, representing an overall response rate of 43.9%. Most respondents were nursing staff, followed by healthcare assistants and nursing supervisors. The results of the confirmatory factor analyses satisfied the chosen cut-offs, indicating an acceptable to good model fit. With the exception of the dimension 'organizational learning' (0.58), Cronbach's alpha scores of the SCOPE-PC scales indicated a good level of internal consistency: 'open communication and learning from error' (0.86), 'handover and teamwork' (0.78), 'adequate procedures and working conditions' (0.73), 'patient safety management' (0.81), 'support and fellowship' (0.75), and 'intention to report events (0.85). Moreover, inter-correlations between the seven dimensions as well as with the patient safety grade were moderate to good. CONCLUSIONS: The present study indicated that the SCOPE-Primary Care instrument has good psychometric properties for home care services in Belgium. No modifications are required to the original questionnaire in order to allow benchmarking between primary healthcare settings.

Seen through the patients' eyes: Safety of chronic illness care.

OBJECTIVE: Due to the increasing burden of chronic diseases, a considerable part of care delivery will continue to shift from secondary to primary care, and home care settings. Despite the growing importance of primary care, concerns about the safety of patients in hospitals have thus far driven most research in the field. Therefore, the present study sought to explore patients' perceptions and experiences of the safety of primary chronic care. DESIGN: An observational, cross-sectional study design was applied. PARTICIPANTS: Participants were recruited from the Flemish Patients' Platform, an independent organization that defends patients' rights and strives for more care quality. MAIN OUTCOME MEASURE(S): An online questionnaire was designed to assess: socio-demographic characteristics, medical consumption and patients' perspectives of the quality and safety of chronic care. RESULTS: Respondents (n = 339) had positive perceptions of the safety of primary chronic care as they indicated to receive safe care at home (68.1%), receive enough care support at home (70.8%) and experience good communication between their healthcare professionals (51.6%). Almost one quarter of respondents experienced an incident, mainly related to self-reported fall incidents (50.4%), wrong diagnoses or treatments (37.8%) and adverse drug events (11.8%). Also, more than half of respondents who experienced an incident (64.9%) indicated that poor communication between their healthcare professionals was the main cause. CONCLUSIONS: Information on patients' experiences is critical to identify patient safety incidents and to ultimately reduce patient harm. More research is needed to fully understand patient safety in primary chronic care to further improve patient safety.

Qualitative research on the Belgian Cancer Rehabilitation Evaluation System (CARES): An evaluation of the content validity and feasibility.

RATIONALE, AIMS, AND OBJECTIVES: The systematic assessment of cancer patients well-being and care needs is internationally recommended to optimize comprehensive cancer care. The Cancer Rehabilitation Evaluation System (CARES) is a psychometrically robust quality of life and needs assessment tool of US origin, developed in the early 1990s. This article describes Belgian patients' view on the content validity and feasibility of the CARES for use in current cancer care. METHODS: Participants were cancer patients recruited through media. Data were gathered in 4 focus groups (n = 26). The focus group discussions were facilitated with key questions. A moderator and an observer conducted and followed up the discussion. The audio file was transcribed verbatim and afterwards analyzed thematically. RESULTS: Participants experience concerns and needs in a wide range of life domains such as physical, emotional, cognitive, social, relational, sexual, financial, and work-related and in the interaction with care professionals. According to participants, the items of the CARES are all relevant to capture the possible life disruption that cancer patients and survivors experience. One important theme is missing in the CARES, namely, the well-being of loved ones. The completion time of the CARES was judged to be feasible, and according to participants, only a few items need a reformulation. CONCLUSIONS: In general, the results of this study support the content validity and feasibility of the CARES. However, little adjustments in formulation and a few extra items are needed. The instrument can be used to obtain a comprehensive assessment of a cancer patients' overall well-being and care needs to take dedicated action in care.

The impact of stakeholder involvement in hospital policy decision-making: a study of the hospital's business processes.

INTRODUCTION: In many health care systems, strategies are currently deployed to engage patients and other stakeholders in decisions affecting hospital services. In this paper, a model for stakeholder involvement is presented and evaluated in three Flemish hospitals. In the model, a stakeholder committee advises the hospital's board of directors on themes of strategic importance. OBJECTIVES: To study the internal hospital's decision processes in order to identify the impact of a stakeholder involvement committee on strategic themes in the hospital decision processes. METHODS: A retrospective analysis of the decision processes was conducted in three hospitals that implemented a stakeholder committee. The analysis consisted of process and outcome evaluation. RESULTS: Fifteen themes were discussed in the stakeholder committees, whereof 11 resulted in a considerable change. None of these were on a strategic level. The theoretical model was not applied as initially developed, but was altered by each hospital. Consequentially, the decision processes differed between the hospitals. Despite alternation of the model, the stakeholder committee showed a meaningful impact in all hospitals on the operational level. As a result of the differences in decision processes, three factors could be identified as facilitators for success: (1) a close interaction with the board of executives, (2) the inclusion of themes with a more practical and patient-oriented nature, and (3) the elaboration of decisions on lower echelons of the organization. CONCLUSION: To effectively influence the organization's public accountability, hospitals should involve stakeholders in the decision-making process of the organization. The model of a stakeholder committee was not applied as initially developed and did not affect the strategic decision-making processes in the involved hospitals. Results show only impact at the operational level in the participating hospitals. More research is needed connecting stakeholder involvement with hospital governance.

Economic Impact of Integrated Care Models for Patients with Chronic Diseases: A Systematic Review.

OBJECTIVES: To assess the costs and potential financial benefits of integrated care models for patients with chronic diseases, that is, type 2 diabetes mellitus, schizophrenia, and multiple sclerosis, respectively. METHODS: A systematic search of the literature was performed using EMBASE, MEDLINE, and Web of Science. Studies that conducted a cost analysis, considered at least two components of the chronic care model, and compared integrated care with standard care were included. RESULTS: Out of 575 articles, 26 were included. Most studies examined integrated care models for type 2 diabetes mellitus (n = 18) and to a lesser extent for schizophrenia (n = 6) and multiple sclerosis (n = 2). Across the three disease groups, the incremental cost per patient per year ranged from - €3860 to + €613.91 (x¯ = - €533.61 ± €902.96). The incremental cost for type 2 diabetes mellitus ranged from - €1507.49 to + €299.20 (x¯ = - €518.22 ± + €604.75), for schizophrenia from - €3860 to + €613.91 (x¯ = - €677.21 ± + €1624.35), and for multiple sclerosis from - €822 to + €339.43 (x¯ = - €241.29 ± + €821.26). Most of the studies (22 of 26 [84.6%]) reported a positive economic impact of integrated care models: for type 2 diabetes mellitus (16 of 18 [88.9%]), schizophrenia (4 of 6 [66.7%]), and multiple sclerosis (1 of 2 [50%]). CONCLUSIONS: In this systematic literature review, predominantly positive economic impacts of integrated care models for patients with chronic diseases were found.

Validation of the flemish CARES, a quality of life and needs assessment tool for cancer care.

BACKGROUND: The Cancer Rehabilitation Evaluation System (CARES) is a quality of life (QOL) and needs assessment instrument of US origin that was developed in the 90's. Since November 2012 the copyright and user fee were abolished and the instrument became publicly available the present study aims to reinvestigate the psychometric properties of the CARES for the Flemish population in Belgium. METHODS: The CARES was translated into Flemish following a translation-back translation process. A sample of 192 cancer patients completed the CARES, concurrent measures, and questions on socio-demographic and medical data. Participants were asked to complete the CARES a second time 1 week later, followed by some questions on their experiences with the instrument. Internal consistency, test-retest reliability, content validity, construct validity, concurrent validity and feasibility of the CARES were subsequently assessed. RESULTS: The Flemish CARES version demonstrated excellent reliability with high internal consistency (range .87-.96) and test-retest ratings (range .70-.91) for all summary scales. Factor analysis replicated the original factor solution of five higher order factors with factor loadings of .325-.851. Correlations with other instruments ranging from |.43|-|.75| confirmed concurrent validity. Feasibility was indicated by the low number of missing items (mean 2.3; SD 5.0) and positive feedback of participants on the instrument. CONCLUSIONS: The Flemish CARES has strong psychometric properties and can as such be a valid tool to assess cancer patients' QOL and needs in research, for example in international comparisons. The positive feedback of participants on the CARES support the usefulness of this tool for systematic assessment of cancer patients' well-being and care needs in clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02282696 (July 16, 2014).

Assessing cancer patients' quality of life and supportive care needs: Translation-revalidation of the CARES in Flemish and exhaustive evaluation of concurrent validity.

BACKGROUND: The prevalence of cancer increases every year, leading to a growing population of patients and survivors in need for care. To achieve good quality care, a patient-centered approach is essential. Correct and timely detection of needs throughout the different stages of the care trajectory is crucial and can be supported by the use of screening and assessment in a stepped-care approach. The Cancer Rehabilitation Evaluation System (CARES) is a valuable and comprehensive quality of life and needs assessment instrument. For use in Flemish research and clinical practice, the CARES tool was translated for the Dutch-speaking part of Belgium (Flanders) from its original English format. This protocol paper describes the translation and revalidation of this Flemish CARES version. METHODS: After forward-backward translation of the CARES into Flemish we aim to recruit 150 adult cancer patients with a primary cancer diagnosis (stage I, II or III) for validation. In this study with a combination of qualitative and a quantitative approach, qualitative data will be collected through focus groups and supplemented by two phases of quantitative data collection: i) an initial patient survey containing questions on socio-demographic and medical data, the CARES and seven concurrent instruments; and ii) a second survey administered after 1 week containing the CARES and supplementary questions to explore their impressions on the content and the feasibility of the CARES. DISCUSSION: With this extensive data collection process, psychometric validity of the Flemish CARES can be tested thoroughly using classical test theory. Internal consistency of summary scales, test-retest reliability, content validity, construct validity, concurrent validity and feasibility of the instrument will be examined. If the Flemish CARES version is found reliable, valid and feasible, it will be used in future research and clinical practice. Comprehensive assessment with the CARES in a stepped-care approach can facilitate timely identification of cancer patients' psychosocial concerns and care needs so it can contribute to efficient provision of patient-centered quality care. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02282696 (July 16, 2014).