Visitation (inspection) of the practice

In 1998, I (my practice) was 'visitated' (inspected) by our professional association, the Dutch Association for Dermatology and Venereology (NVDV). A visitation is 'an examination to be carried out on the spot, in which members of the NVDV, in an organized context, assess the conditions under which dermatologists practice the profession, where possible on the basis of the standards laid down in the most recently adopted standards report. In order to be able to assess the quality of dermatological and venereological professional practice, attention will be paid in particular to the dermatologist's methodical and technical conduct, his or her attitude, and the organization of care. The purpose of the visitation is to monitor and promote the quality of care provided by dermatologists'.


An important part of the visitation involved reviewing a number of patient records pulled at random from the filing cabinet. Back then, all data was still collected in paper statuses, including, of course, my notes and all results. Each discipline had its own status for each patient. At one point the unholy plan was launched for one patient status for all departments in the hospital in a central archive. I resisted this vehemently, because of course it would become impossible to find the status when it was not in the archive. The plan was, quite rightly, called off.             


On the left, Corina searching for a patient record in the filing cabinet

Currently, the visitation committee consists of 8 members, in 1998 there were only two, accompanied by an official secretary from a Dutch organization for visitation of medical practices, who was responsible for reporting. As instruments for making an assessment, reaching conclusions and formulate opinions, the committee had the following tools at its disposal: 1. The answers to a very broad questionnaire, in which all aspects of the practice were documented in extenso; 2: interviews with me during the visitation; 3: visits to the outpatient clinic and the hospital, and 4: interviews with my secretary and physician's assistant, with a representative of the local general practitioners' association (which had conducted a survey among 12 general practitioners for this purpose in advance), with the chairman of the Board of directors (medical director) Frank Vernooy and with the chairman of the medical staff, Albert Smeets. The conclusions and recommendations of the visitation committee are presented below (translated in English below the original documents, italics). A few more items from the report are discussed thereafter.

7. Evaluation

7.1 Conclusions

1.   The committee is impressed by the efficient, structured practice of dr. De Groot and his decisiveness to
       resolve organizational problems immediately.

2.   The Committee has the impression that dermatology is practiced in its full breadth, with an emphasis on allergology.         Dermatosurgery is limited; referrals for surgical interventions are adequately arranged.

3.   The Committee notes that dermatological practice is conducted satisfactorily despite the limitations of space and                 staff support.

4.   The Committee notes that the dermatologist, as solo practitioner, closely monitors continuity, for example by

       reporting absences to referring GPs and arranging replacements.

5.   The committee considers the reporting of data in patient files and to GPs to be adequate; the reporting is quick                   and short, but contains all relevant information for the GP.

6.   The committee notes that the Board of Directors has concerns about the continuity of De Groot's dermatological                 care now and in the future when of any form of collaboration with other dermatologists is lacking.

7.   The committee notes De Groot's great activity in the field of further training and refresher courses, but considers his           conference visits to be minimal.

8.   The committee notes the high level of satisfaction among referring GPs with regard to the practice reviewed and the           good relationships within the hospital.

9.   The committee is very pleased with the extensive information provided by dr. De Groot to the committee in                           preparation for the visitation.

7.2 Recommendations

Based on these conclusions, the committee has also made several recommendations for improving the dermatological practice of A.C. de Groot.

1.     The committee recommends that the assistant take the course for doctor's assistant dermatology, as well as a                     resuscitation course to be able to provide first aid.

 2.    The committee advises De Groot to pay attention to the forthcoming obligation with regard to further training and             refresher courses, as the conferences will also count.

3.      The committee advises De Groot to publish the protocols he has developed (diagnosis registration and oncology                 call system) in the Dutch Journal of Dermatology and Venereology so that other dermatologists can also benefit                 from them.

4.     The committee recommends that De Groot draw up an annual report and write a medical policy plan.


What have I done with the recommendations?

As I'm sure you can imagine, I was very happy with the conclusions of this report, and I didn't have much trouble with the recommendations. Collaborating with other dermatologists was fortunately not necessary. In June 2002, when I ended the practice, the Carolus-Liduina Hospital and the merger hospital of Groot Ziekengasthuis and Willem-Alexander Hospital (Bosch Medicentrum) had already formally merged to become Jeroen Bosch Hospital, but we still had our own location and de facto nothing had changed.

As far as congress attendance is concerned, that was indeed minimal in 1998: 1 day and an evening. In 2000 I attended conferences for 2.5 days, while half a day would have been enough to meet the accreditation requirements because I had so many publications. Apparently I had taken the advice of the visitation committee to heart after all. Incidentally, I am convinced that very little is learned during conferences. There are very few speakers who can give a decent presentation, people can only really concentrate for 10 minutes, the amount of information available in 1 day is far too large and many conference attendees (including me) often doze off in a dark and warm room. Those conferences are great for people who like to travel and make trips, network and in the evening all sit down to a copious meal with a good portion of wine. All these things except I abhor.


Conclusion 1 regarding my 'decisiveness to solve organizational problems acutely' made me chuckle a bit, I knew what that meant. During lunch, the chairman of the review committee asked me if I had a protocol for treating shock, for example due to an allergic reaction to a local anesthetic or aethoxysclerol, which is used for injecting varicose veins. I had to answer 'no'. I then said 'Excuse me for a moment', walked away from the lunch table and hurried to the cardiology department, where I bumped into Hoc Tan, one of the cardiologists. I said that I was in a visitation session at the time and asked if he had such a protocol. He also had to sell 'no'. 'Shall we write a protocol together soon', I suggested, and his answer was 'fine'. So within 8 minutes I was sitting next to the chairman of the visitation committee again and said that I had agreed with the cardiologist that we will soon write a protocol (which we indeed did later, I seem to remember). He was visibly impressed, and that must have led to conclusion 1.

In addition, I have indeed published my own protocols, on the recommendation of the visitation committee (recommendation 3), in 3 articles:

  • De Groot AC, Warmerdam C. Het registreren van diagnosecodes: een protocol en ervaringen. Ned Tijdschr Derm Venereol 1999;9:218-224
  • De Groot AC, Warmerdam C. De patiëntenpopulatie in een perifere dermatologische praktijk. Mogelijkheden en beperkingen van registratie. Ned Tijdschr Derm Venereol 2000;10:281-284
  • De Groot AC. Beoordeling van verdachte gepigmenteerde afwijkingen. Het vastleggen van relevante gegevens. Ned Tijdschr Derm Venereol 2001;11:238-241
I do not know whether the protocols have been adopted by other dermatologists and I do not believe that I have subsequently drawn up a medical policy plan (recommendation 4). However, I did start drawing up annual reports after that, which had become a lot easier due to the further development of digitization and automation.

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