Kirurgi i tulpanernas och väderkvarnarnas land

2014-05-07 / Svensk Kirurgi / Volym 72 / Nr 2 / 2014

Under det Internationella Året önskade huvudstyrelsen i Svensk Kirurgisk Förening utveckla vårt internationella nätverk. Vi ville se vad vi kunde lära av ett annat lands kirurgförening och gärna dela med oss av våra erfarenheter från Sverige. Med ett internationellt perspektiv på många av våra viktiga frågor så får vi en chans att se vad vi redan gör bra och vad vi skulle kunna göra bättre. I detta syfte träffades styrelserna för den svenska och nederländska kirurgföreningen 2013. Holländarna presenterar här sitt arbete med sin förening, utbildningssystem, kvalitetssäkring och patientsäkerhetsfrågor.

Association of Surgeons of the Netherlands


The Association of Surgeons of the Netherlands (Nederlandse Vereniging voor Heelkunde- NVVH) was founded 1902 in Amsterdam primarily as a scientific society. Nowadays our mission is to promote the quality of surgical care. Not only through the advancement of science, but also by defining guidelines, practices standards and norms, by measuring outcome through performance indicators, medical audits, site visits and by optimizing surgical training.

A broad interface

Furthermore the NVVH guards the professional interests of surgeons in the Netherlands. e NVVH monitors and analyzes developments in Dutch healthcare and has an ongoing intensive dialogue with the involved stakeholders, such as the Dutch Ministry of Health, Dutch Healthcare Inspectorate, healthcare insurance companies and Dutch University Hospitals and general hospitals, on quality and effcacy of care.

Structure of the association

The NVVH has an executive board of seven members (chair, vice-chair, secretary, treasurer, quality officer, safety officer). The general board consists of the executive board together with the chairmen of the seven daughter societies and a communication officer. Together they are responsible for defining the strategic policy of the society, which is approved by the members in the general assembly.

The NVVH has 1 950 members (of which 415 are surgical residents). All members receive the Journal of the Society, Nederlands Tijdschrift voor Heelkunde, nine times per year and are invited to the May and November scienti c meetings of the Society.

Societies in NVVH

The Association of Surgeons of the Netherlands has seven acknowledged societies:

1. Society of Gastro-intestinal Surgeons of the Netherlands (625)
2. Society of Lung Surgeons of the Netherlands (160)
3. Society of Surgeon Oncologists of the Netherlands(480)
4. Society of Pediatric Surgeons of the Netherlands (40)
5. Society of Trauma Surgeons of the Netherlands (600)
6. Society of Residents in Surgery of the Netherlands
7. Society of Vascular Surgeons of the Netherlands (330)

Surgical Training in the Netherlands


Training of surgeons in the Netherlands, as in most of the world, was formerly characterized by a high degree of autonomy for the Association of Surgeons of the Netherlands (ASN), the local training hospitals and its program directors. Since 2009, surgical training in the Netherlands has evolved from a traditional mastertrainee system to a competency based program with explicit responsibility for a whole training group, struc- tured courses and formalized assessments.

Structured training program

After six years of medical school, a University MD degree according to the individual Health Care Professional Act can be achieved. e Dutch postgraduate training is nowadays based on the presence of an elaborately regulated and closely monitored and approved training system. Regulations for surgical training concern requirements for the specialist in charge of the local training program and the surgical staff, the designated teaching hospitals or institutions and the duration, content and conditions of training. These requirements are proposed by the national organisation of all specialists to ensure a content validity and public support. In general the focus is practical training with structured feedback and assessment.

First two years

Nowadays surgical residency takes six years and is organized regionally in eight regions. Each region consists
of one academic hospital and several non-academic teaching hospitals. Residents spend in general four years in a non-academic hospital and two years in an academic hospital during different phases of their training. The first two years involve a basic surgical training. e residents follow a regionally, and nationally, organised teaching program including a boot camp with basic surgical skills, courses of basic laparoscopy, surgical anatomy, evidence based medicine, intensive and peri-operative care and Advanced Trauma Life Support. Most of these trainings are finished with an assessment and examination. This program is also applicable for residents in orthopaedic surgery, plastic surgery, urology and cardiothoracic surgery, before starting their specific training.

Second phase

After these first two years the General Surgery residents enter the second phase of their general surgery training, again in conjunction with regionally and nationally organized courses. In the last two years they have to specialize in one of the major differentiations in surgery: surgical oncology, gastrointestinal surgery, trauma surgery, vascular surgery, paediatric surgery and pulmonary surgery. End points, competencies and key procedures are defined and recorded for every differentiation and the plan has passed national legislation. The program does not end with a formal national exam. The emphasis of the program was directed to the number and complexity of the procedures and on the level of independency to perform the procedure.

I denna idyll verkar 2000 kirurger för att hjälpa 16 miljoner holländare.

De två ordförandena, docent Agneta Montgomery och professor Rob Tollenaar, frankeras av sina respektive styrelser vid besöket i Amsterdam.

Working hours limitations

In 1993 the Working Hours Act restricted working hours for residents to 48 hours a week and this has chan- ged surgical training dramatically. In order to prevent extension of duration of training, the training program had to be reorganized and made more eficiently. Regional training courses, skills-lab sessions and national teaching programs were implemented. Potentially this could lead to substantial less surgical procedures and exposure time per resident and the surgical training coordinators were confronted with a challenge how to ensure continuity and quality in patient care but also high quality training for the residents.

Competency based training program

Furthermore, several aspects of the training needed to be improved to meet the requirements of modern training principles. Criteria of assessment and appraisal needed to be more explicitly de ned and standardized. In addition more room for reflection and feedback together with a regular monitoring of the residents performance was needed. These requirements prompted our Minister of Health to insist the National Registration Board of Medical Specialists (RGS) to urge the development of a competency based training program following the CAN- MEDS competences. A description of the competences of the trainee at the end of the training, modules of the training process, contents of the modules, structured training courses and quality enhanced for the trainers, were mandatory. A special surgical training committee proposed a program with 47 clinical themes; each of them consisted of specific CANMEDS competences and key procedures. Specific short clinical assessments during the training period and regular structured evaluations between the trainer and trainee were developed. In conjunction with this a national web-based digital portfolio was introduced with all details of the residents training program in order to follow the evolution of the residents training throughout several training programs and institutions.

Number of residents mirrors expected needs

Funding of this program and the expenses for residents is given by the government. As a result the number of residents, and the accreditation and quality control, is actually regulated and approved by a central governmental organization and delegated to and performed by the RGS and ASN. The total national number of residents accepted in this program is tailored to the expected need six years later, and the selection process is delegated to the ASN and its eight training regions.

Failing to meet requirements might end a program

Quality control is ensured by the fact that all local programs undergo at least every ve year a peer-organized and peer-conducted evaluation. A delegation of members of the ASN visits the hospital interviewing the board and residents concerning the program. In addition an intensive quality of care evaluation takes simultaneously place. The report of the evaluation visit is discussed in a special ASN teaching board, the Concilium Chirurgicum, which result in advices for improvement, but also in strict terms and conditions formulated to ensure the continuation of the training program. Not meeting these requirements could actually result in a temporary or permanent end of the training program in that specific training facility. e National Registration Board of Medical Specialists (RGS) ultimately performs formal approval for continuation of the training at a facility.

Recent developments include:

• Under pressure of the economic crisis and the sub- sequent required savings on the national budget, the educational and financial eficacy during the last differentiation years could be increased. While surgical training is still learning on the job, it is questioned whether or not this process could be more eficient. Should all residents in their last years be on call for general surgery? If compensation for their time being on call is needed less frequently this could result in more daytime training possibilities. Furthermore a more competitive market between training hospitals on the last two years of the training will be expected to increase the quality and eficacy of the training programs.

• Due to the increased needs for differentiated surgeons, the four year general surgery, two years differentiation system has been questioned and the discussion on a three year general and a three year differentiation or even a two year general and a four year differentiation system has started.

• Recently we started with a pilot for a national formative knowledge exam. Whether this will be an adapted system from another country, or a newly developed Dutch system needs to be decided.

In conclusion, surgical training has evolved in the last seven years from a traditional static autonomous mastertrainer centered local system based on the performance of procedures to a dynamic national approved, regulated and evaluated trainee centered competency based system.

Quality of Surgical Care in the Netherlands


One of the objectives of the Association of Surgeons in the Netherlands (ASN) is to improve the qua- lity of surgical care in the Netherlands. To reach this objective, the Association has several activities of which education and training, guideline development and consultation of surgical departments, were traditionally the cornerstones of our quality improvement policy.

Centralization and launching registries

In 2010 the Dutch Cancer Association published its report on the quality of cancer care in the Netherlands. A taskforce of experts in the eld of cancer, including surgical oncologists from the ASN, investigated variation in quality of care between Dutch hospitals. An extensive review of the literature showed a very consistent relationship between surgical volume and outcome for several complex cancer procedures. In addition, a study of variation in guideline adherence and surgical outcome, using data from the Netherlands Cancer Registry, showed marked variation between hospitals. Considering the situation in which nearly all tumour types were treated in every hospital in the Netherlands, the taskforce concluded that low-volume cancer procedures should be concentrated in a limited number of specialized centres. For this purpose, tumour-specific quality standards should be developed, concerning the infrastructure, procedural volume and expertise, necessary to provide optimal care for cancer patients. In addition, following the Swedish example, the development of clinical registries was recommended, with the objective to provide quality assurance for the treatment of each tumour type.

Amsterdams alla kanaler speglar att en fjärdedel av landets yta faktiskt ligger under havsnivån.

Quality standards for surgical procedures

In june 2011, the ASN was the rst medical specialty in the Netherlands that published quality standards for various surgical procedures, like esophagectomies, pancreatectomies and aortic replacement procedures, including a minimal volume standard of 20 procedures a year. These quality standards are enforced by the Health Care Inspectorate and used by Insurers contracting hospitals for these procedures. In addition, several clinical registries (audits) have been initiated, of which the Dutch Surgical Colorectal Audit was the first. All hospitals participate in these audits and data are entered in a web-based data-collection system. In return, surgical teams get feedback on their performance on an extensive set of quality aspects, including process and outcome indicators. Feedback is provided online, through a secured webpage, on which hospitals recieve benchmarked indicator-results, adjusted for differences in casemix and chance variation. This information is updated on a weekly basis. To assure its professionalism and continuity, the ASN founded the Dutch Institute for Clinical Auditing, that facilitates the development and maintenance of these clinical registries. At the moment, ten surgical audits have been initiated, not only for cancer procedures, but also for Abdominal Aneurysm repairs, Carotic Endarteriectomies, Pediatric and Bariatric surgery.

Holländska kirurger opererar förstås i denna typ av träskor.

Substantially improvement

After three years of auditing, guideline adherence and outcomes for colorectal cancer resections have improved substantially. e percentage of irradical resections has dropped 35 percent, severe complications 20 percent and postoperative mortality 30 percent, to 3.2 percent for colon and 1.5 percent for rectal cancer resections.

Basic training and recertification was altered

The introduction of quality standards and clinical audits has stimulated the ASN to revise its quality improvement policy, by integrating and synchronizing the various quality instruments. First, surgical training was revised by transforming six years of general surgery into four years of general and two years of specialized surgical education.

After their six year training surgical residents are specialized in surgical oncology, gastro-intestinal, vascular or trauma surgery and get a certificate for this domain, that has to be renewed every fth year. (Re)- certification is based on the procedures performed and CME-points earned in the preceding years. To perform complex surgical procedures surgeons need the right subspecialty certificate, which promotes specialization on a surgeon-level. Next to more specialized surgeons, quality is improved by setting conditions for the hospitals in which these surgeons perform surgical procedures, written down in the ASNs quality standards and enforced by the Health Care Inspectorate. Next to these preconditions for optimal surgical care, actual patient outcome is measured in the clinical audits. Performance on quality indicators is used in the consultation of surgical departments, accomplished every fifth year or earlier when a hospital has the status of a negative outlier in one of the audits.

Future-proof quality policy

By modernizing its quality instruments, the ASN is convinced to have a future-proof quality policy. Within a few years, further specialization of surgeons, concentration of complex surgical procedures and a continuous quality improvement cycle has been accomplished with the introduction of certification, quality standards and clinical audits.

The first signs of improved patient outcome are visible, stimulating surgeons in their continuous e orts to improve quality of the care they deliver.

Implementing a patient safety culture in the Dutch surgical departments

Professor Dr. J.F. LANGE, Drs A. NUTMA

In 1999 the famous report To err is human of the American Institute of Medicine was published, indicating that a signi cant number of errors, often related to individual failure of the healthcare worker (doctors, nurses), are made in healthcare.

Netherlands was no exception

Unfortunately also in the Netherlands these data could be con rmed: about six percent of all hospital-admitted patients su er from an adverse event of which 8 percent are lethal and 40 percent preventable (2008). About half of these errors are made in the surgical setting. ese impressive data incited the Netherlands Society of Surgery to install a new committee of surgeons, supported by a quality officer, specifically focused on patient safety.

Blame free safety culture

The philosophy of this committee is founded on the principle of an up-to-date patient safety culture in each surgical department, facilitating a blame free setting for identification, reporting, analyzing and preventing errors. For this purpose ten recommendations to all surgeon-members were formulated and accredited by the Netherlands Society of Surgery (2008):

  1. Peri-operative checklist
  2. Participation of a safety o cer in each surgical


  3. Compensation for duty hours (‘Fit to perform’)
  4. Electronic patient report
  5. 24/7 care by a certi ed specialist-surgeon
  6. Guidelines-directed surgical care
  7. Resident training with regard to patient safety
  8. Team training such as crew resource management


  9. Selection of surgical trainees also with regard to

    communication talents

  10. Safety climate attitude questionnaire on a structural


Implementation phase

As for now the majority of these recommendations have been implemented or are being developed. Some of these are still being discussed like the participation of a specific safety officer in each surgical department. As it seems the format of a safety officer pro hospital organization will be explored first. Also the concept of CRM is still evaluated for evidence as this instrument, tranlated from aviation, is timecostly and expensive. With regard to the training of surgical residents a pilot study is awaited in which residents are preoperatively assessed on specific safety aspects of their own patients they will operate under supervision. Furthermore from 2014 the surgical educators from all teaching hospitals will be specifically trained on patient safety issues.

Campaign for patient safety

Coming up is a new practical four point-safety campaign that will be voted by the members: S.A.F.E. comprizing: Safety climate (blamefree climate), Acting PDCA (quality cycle), Fit to perform (compensation for nightwork), Excellent 24/7 (certified specialist) care. is campaign will be kicked o in a special ‘Week of Patient Safety’, organized by the Dutch surgery residents. Also several specific surgical themes, as proposed by the government (infection prevention, wrong site surgery), will be addressed within this campaign. Other aspects of quality improvement like concentration of specific surgical care with operation quora and involvement of outcome indicators have proved to be a great stimulus developing a safety culture in Dutch surgical practice.

Hierarchi is replaced by horizontal teamwork

As most errors are made by the autonomous individual surgeon or resident gradually the traditional hierarchi- cal organization structure of the surgical departments is being replaced by a horizontal teamwork-directed format, implicating the equal participation of other specialities and functions like nurses in the new patient- centered surgical team. Like in aviation, this process is not easy, and will certainly take many years to be completed. However, the Society of Surgery, in the Netherlands, compared to other disciplins is frontrunner in the patient safety eld. In that respect it has largely passed the stage of mere reactivity to safety issues, and has clearly progressed to a very well motivated, proactive mindset. Also looking forward to cooperation with the Swedish Society on these important matters, like the Dutch S.A.F.E. campaign, as it has also just started up with Johns Hopkins Medical Faculty patient safety group (Pronovost, Weaver).

Nederländska konstnären Rembrandt (1606–1669) är en av landets mest kända historiska personer och pryder frimärken från en rad länder.