title: Improving the quality of emergency medicine care by developing a quality requirement framework: a study from The Netherlands.
abstract: BACKGROUND
  In The Netherlands, mainly inexperienced physicians work in the ED on all shifts, including the evening and night shifts, when no direct supervision is available. In 2004 a report of the Dutch Health Care Inspectorate revealed that quality of care at Emergency Departments (EDs) was highly variable. Based on this report and international studies showing significant potential for quality improvement, stakeholders felt the need to improve the quality of EM care. Based on the literature, a baseline measurement and a panel of experts, The Netherlands recently developed a nationwide quality requirement framework (QRF) for EM. This article describes the content of and path to this QRF.
  
  
  METHODS
  To conduct a baseline measurement, the panel needed to identify measurable entities related to EM care at EDs. This was done by formulating both qualitative and partly quantitative questions related to the following competence areas: triage system, training of personnel (physicians and nurses), facilities and supervision of physicians.27 out of 104 Dutch EDs were sampled via a cross-sectional study design, using an online survey and standardized follow-up interview in which the answers of the survey were reviewed.
  
  
  RESULTS
  In the QRF, EM care is divided into a basic level of EM care and six competence certification areas (CCAs): (acute) abdominal aortic aneurysm, acute coronary syndrome, acute psychiatric behavioral disorder, cerebral vascular accident, pediatric critical care and infants with low birth weight. For the basic level of EM care and for every CCA minimum prerequisites for medical devices and training of personnel are established. The factors selected for the QRF can be regarded as minimum quality standards for EM care. A major finding of this study was that in The Netherlands, none of the 27 sampled EDs demonstrated compliance with these factors.
  
  
  CONCLUSIONS
  Our study shows that Dutch EDs fall short of what the expert consensus panelists considered minimum prerequisites for adequate EM care. The process of systematic enquiry allowed this information to come to light for the first time, which resulted in the implementation of a QRF for Dutch ED personnel, that is intended improve quality of EM care over time. This is an important development for the worldwide EM community as the QRF shows a way to generate interim standards to improve the chances of appropriate delivery of EM care when the gold standard of providing fully qualified EPs is not initially achievable.
authors.affiliation: Consultant at KPMG Plexus, Straatweg 68, Breukelen, BR 3621, The Netherlands. ikkersheim.david@kpmgplexus.nl.
authors.forename: David E
authors.initials: DE
authors.lastname: Ikkersheim
authors.forename: Harm
authors.initials: H
authors.lastname: van de Pas