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Policy Document on
Responsible Ambulance Care
Colofon
Foreword
Ambulancezorg Nederland
PO box 489
8000 AL Zwolle
The Netherlands
phone: +31 (0)38 422 5772
info@ambulancezorg.nl
www.ambulancezorg.nl
We are delighted to present the new version of the Policy Document on Responsible Ambulance Care [Nota
Verantwoorde Ambulancezorg]. The policy document offers a captivating kaleidoscopic view of the current
situation within ambulance care, which forms an exceptional part of the healthcare sector.
Text
Ambulancezorg Nederland
Editorial board
Tekstbureau Taallent
Translation
Balance BV, Amsterdam & Maastricht
Design
Vormix, Maarssen
Illustrations
Studio Lakmoes & Anne van den Berg Illustraties
Printing
HSGB
Ambulance care is exceptional for a number of reasons. The first is the profound change our sector has
undergone over the past fifteen to twenty years, which is greater than that experienced by any other sector. We
have developed from a simple, vulnerable transport service into a high-quality, mobile care provider. We are now
accustomed to our current status, but take a look across the border and you will notice that the level of quality
within the Dutch ambulance care sector is very high.
Our sector is also unique because our work is conducted in two worlds. The first is the world of healthcare, in
which we are the mobile partner of all care services in principle. We are also a partner for parties active in the
domain of public order and safety. We therefore operate in two worlds, which requires our staff to be versatile.
They must possess an outstanding talent for cooperation and be able to deal with cultural differences.
Finally, ambulance care is also exceptional because the public places considerable trust in our care, according to
research. This is invaluable, especially at a time when trust in institutions is dwindling. It is imperative that we
not only cherish but also maintain this trust. We do so by taking a critical look at our own business every day to
see what we can do better and how we can elevate ambulance care to an even higher level.
This lies at the very heart of the Policy Document on Responsible Ambulance Care: providing an overview of the
status of the care we provide. Where are we, what issues do we face and what are the new challenges? It is also
a living document: new developments and initiatives demand adaptation and change.
For this reason we update this document at regular intervals. I hope that not only we but also all our chain
partners will join us in permanently exploring which amendments are needed - within our partnership too - to
provide patients with the best possible level of care. This is a crucial theme for the future. Necessary changes
are constantly required due to developments within the care sector and the domain of safety. But in these times
of economic crisis, the financial leeway for maintaining ambulance care is minimal. Anyone wishing to attain
a higher level with the same financial resources must therefore conclude that cooperation is needed more
than ever. Joining forces, working together and entering into new relationships will have to be a focal point that
transcends the personal interests of everyone.
We are open to this: open to intensifying the cooperation with our partners in both worlds of care and safety.
Using new social challenges as our starting point, we want to jointly find better answers to the needs of citizens.
That is the real challenge in the years ahead. The Policy Document on Responsible Ambulance Care offers
something to hold onto, provides direction and aims to encourage dialogue.
Finally, this is an appropriate opportunity to thank everyone who has helped draw up this policy document.
Hans Simons,
Chair, Ambulancezorg Nederland
Contents
Foreword
Guide
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11
1.1
1.2
1.3
1.4
Introduction
What is ambulance care?
Where does ambulance care begin?
Ambulance care as a binding factor
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12
13
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15
2.1
2.2
2.3
Introduction
Care Institutions (Quality) Act
2.2.1 Responsible care
2.2.2 Conscious policy
2.2.3 Quality system
2.2.4 Quality annual report
Monitoring and enforcement
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3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
Introduction
Available and accessible care
Transparency
Professional, high-quality and safe
Information, permission, documentation and privacy
Continuity of care and coordination with chain partners
Handling of complaints and client experience
Participation and good governance
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4.1
4.2
4.3
4.4
4.5
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9.1
9.2
Handling of complaints
Client experience
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Transparency
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5.1
5.2
5.3
5.4
5.5
5.6
5.7
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6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
Professionalism
Key positions
6.2.1 Nurse dispatch centre operator
6.2.2 Ambulance nurse
6.2.3 Ambulance driver
6.2.4 Ambulance unit
6.2.5 Job differentiation
Expertise and competencies
6.3.1 Expertise
6.3.2 Competencies
Protocol care
High-quality and functional equipment
Medical management
Continuous improvement
Safety
6.8.1 Patient safety
6.8.2 Safe working environment
6.8.3 Preventing incidents; safe incident reporting
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7.1
7.2
7.3
7.4
7.5
7.6
General information
Information for individual patients
Permission
Documentation
Privacy protection
Professional secrecy
8.1
8.2
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Appendices
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Appendix 2 - National Professional Code for Nurses and Carers [Nationale Beroepscode van
Verpleegkundigen en Verzorgenden]
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Guide
The Policy Document on Responsible Ambulance Care is structured as follows. Chapter 1 paints a picture of
ambulance care provision. What does ambulance care entail? Who provides ambulance care? Which chain
partners do Regional Ambulance Services work with?
Chapter 2 gives an overview of the Care Institutions (Quality) Act , upon which this policy document is based.
Responsible ambulance care is of course determined by a considerably wider range of acts. Appendix 1 contains
a summary of these acts. Where necessary, the policy document refers to this statutory framework.
Chapter 3 describes the essence of what responsible ambulance care means to the ambulance sector. The
description per theme is timeless and constitutes as it were the constitution for the sector when it comes to
responsible care.
The following chapters describe the various themes in greater detail. The text contains frequent references to
national frameworks and guidelines. These are listed per chapter in the reference list, which is in a separate
appendix to the policy document.
The appendices contain descriptions of the statutory framework, the professional code for ambulance care
providers and future developments within the sector. They form an intrinsic part of the policy document and
feature information essential for interpreting the document properly.
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11
1.1 Introduction
Over 700 ambulances are available in the Netherlands, ready to provide ambulance care 24 hours a day, 7 days
a week. More than 5,000 ambulance care professionals provide emergency and planned ambulance care. The
Ambulance Dispatch Centre deploys ambulances on more than one million trips every year. Approximately
740,000 of these involve emergency medical assistance and around 350,000 involve planned ambulance care.
A small percentage of emergency medical situations fall under medical assistance in the case of accidents and
disasters. This assistance is based on assistance provided in normal circumstances.
Ambulance care begins when the Ambulance Dispatch Centre receives a call. The Ambulance Dispatch Centre
is responsible for the process of intake, care needs assessment, care assignment, care coordination and care
instruction 7 days a week, 24 hours a day. The Ambulance Dispatch Centre is responsible for ensuring that the
right (ambulance) care is provided at the right moment and/or that the handover of the patient to other care
or emergency services proceeds as smoothly as possible. The Ambulance Dispatch Centre is the gateway for
ambulance care and also serves as a portal for other emergency services. It is also responsible for coordinating
the deployment of other care providers. The Ambulance Dispatch Centre is therefore the coordinator of
ambulance care.
Ambulance care has developed relatively quickly from a transport service into a care service that operates
as a fully-fledged link within the chain of emergency medical assistance. Ambulance care is provided by
the Regional Ambulance Service [Regionale Ambulancevoorziening, RAV]. In accordance with the Interim
Ambulance Act [Twaz], the Regional Ambulance Service is the legal entity designated to maintain the dispatch
centre and provide or arrange the provision of responsible ambulance care. This involves ambulance care in
normal situations as well as disasters and accidents. The Regional Ambulance Service is a care institution in
accordance with the Care Institutions (Accreditation) Act [WTZi].
The frameworks for ambulance care can be summarised as follows, based on the description above:
a need for medical care exists1;
the patient undergoes treatment, observation, nursing and/or care on site and/or while being transported;
the care needs assessment and deployment of care is performed by the Ambulance Dispatch Centre;
implementation is ensured by an organisation designated in accordance with the Interim Ambulance
Care Act.
Need for medical care: a medical reason exist that necessitates a particular type of care, treatment or medication.
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2.
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2.1 Introduction
The Policy Document on Responsible Ambulance Care is based on the Care Institutions (Quality) Act (KWZ)].
This chapter describes the key points of this act, which is applicable to all institutions in the healthcare sector
and therefore to the Regional Ambulance Service as well. The Care Institutions (Quality) Act is a framework
act, i.e. it only provides a general description of what a care institution must comply with. The individual care
institution is responsible for indicating how it satisfies these statutory requirements. An increasing number of
sectors are relying on umbrella organisations for this compliance. Since 1999, the ambulance sector has been
ensuring sector-wide compliance through national umbrella organisations for ambulance organisations and
professionals.
A care institution must monitor the quality of the care provided systematically and improve it where possible.
The care institution must have a quality system for this purpose in which all quality-related activities are
harmonised with one another. A quality system describes the standards that an institution thinks it should
meet. Systematically recording data relating to these activities and the quality of the care provided yields
an insight into the results of the pursued quality policy. A care institution can opt to allow an independent
organisation to assess and certify the quality system. Such an independent quality mark gives the organisation
a quality boost but also demonstrates to the outside world that the institution is serious about quality. This is
certainly applicable to the ambulance sector. Since the act came into force, the independent testing of Regional
Ambulance Services by an external body has received wide support. As a result, every single ambulance
organisation has been certified.
When the Interim Ambulance Care Act [Twaz] came into effect on 1 January 2013, a new statutory framework
also came into force. Appendix 1 therefore devotes a separate section to this act. Other acts also applicable to
ambulance care are outlined in Appendix 1.
The Care Institutions (Quality) Act obliges institutions to publish a quality annual report. The act stipulates that
the care institution must focus in this report on the quality of the provided care and the pursued quality policy.
The institution must also devote special attention to how patients and their interest groups are involved in this.
No structure requirements are imposed on the quality annual report. It may form part of the general annual
report. However, the act does stipulate the period during which the report must be ready and the organisations
to which it must be submitted.
Institutions where people can stay longer than 24 hours must provide mental healthcare that corresponds to
patients beliefs. This requirement does not apply to Regional Ambulance Services, but does not detract from
the fact that ambulance care providers must respect patients beliefs.
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3.1 Introduction
The Care Institutions (Quality) Act defines responsible care as: care that is high quality, efficient and effective,
and coordinated and geared to the actual needs of the client. The further interpretation of these terms by
the ambulance sector is based on a number of categories. The patient is the focal point. This also ties in
with the vision and policy of the government laid down in legislation and with the vision of patients and
consumer organisations. It revolves around the accessibility and availability of care, the ability to choose and
compare types of care, the quality and safety of care, a strong legal position within the care relationship, good
coordination between care providers, a low-threshold and effective complaints and dispute procedures, the
right to participate in decision-making and good governance among care providers.
The sector also stands for sustainability, reliability and transparency. These core values are reflected in
the implementation of the cornerstones. Based on this framework, responsible ambulance care may be
summarised as follows:
The following sections describe the seven cornerstones of responsible ambulance care in greater detail.
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3.3 Transparency
Transparency for the client and the referrer
The Regional Ambulance Service provides as much information as possible to (potential) patients
and (potential) referrers about the care that is offered.
Transparent care process
The ambulance care process is clear to everyone involved (patients and chain partners).
Long-term policy plan
The Regional Ambulance Service has a long-term policy plan, which formulates its long-range
vision of responsible ambulance care and the specific details.
Management information
The Regional Ambulance Service has management information available, which highlights the
results of the ambulance care process and facilitates control of the process where necessary.
Annual report
Each year, the Regional Ambulance Service gives an account of its activities and the results it has
achieved by means of an annual report.
Sector report
The Regional Ambulance Service provides the agreed data for the sector report on an annual basis.
External assessment and certification
The Regional Ambulance Service has a certified quality system that guarantees and highlights the
quality of the care provided.
21
Cooperation with chain partners
The Regional Ambulance Service works closely with other care providers within the region to
guarantee the continuity of care.
Responsible care handover
The Regional Ambulance Service ensures that, if necessary, patients are handed over responsibly
to other care providers or that other care providers are engaged
22
Patient participation
The Regional Ambulance Service has a patient participation structure and procedure, which is
geared to the character of emergency care provision.
Good governance
The Regional Ambulance Service meets the requirements of good governance.
23
24
Ambulance Services can call on the ambulance capacity of a neighbouring region or regions for the deployment
of ambulances in specific areas. Every Ambulance Dispatch Centre has an insight into real-time ambulance
capacity and the positions of all available ambulances at that moment in order to ensure dynamic ambulance
management at a supra-regional level. Regional Ambulance Services use the national covenant to make
agreements on how to deal with open borders and on the conditions under which ambulances from other
Regional Ambulance Services can be deployed. The Ambulance Dispatch Centre plays a central role in the
process of dynamic ambulance management.
25
B urgency (B trip)
A trip on the instructions of the operator in response to a request for care without an A1 or A2 urgency, with an
agreed on time or time interval for pick-up and drop-off.
26
demands for care and match national competency profiles. The care ambulances design and equipment
complies with the national quality framework.
Emergency IC transport
Emergency IC transport is performed by a regular ambulance. Patients are usually unstable and urgently
require swift treatment elsewhere. Delaying transport in anticipation of the arrival of an MICU is irresponsible.
The patient requires IC-level care and the ambulance team is therefore supplemented by a specialist doctor
from the dispatching or receiving hospital. Emergency IC transport may not be delayed by discussions about
responsibilities and deployment. In accordance with ministerial instructions, every hospital must prepare for
this type of transport by making internal agreements about the availability of manpower and IC equipment.
27
years of age. The Neonatal Intensive Care Unit (NICU) provides the inter-clinic transport of a (newborn) baby.
The supervising doctor is usually a neonatologist.
Transparency
28
29
Patients must have a clear idea of the types of questions they can ask through the Ambulance Dispatch Centre
and the type of response they can then expect. This means, first of all, that the Regional Ambulance Service
must have clear information on hand for (potential) patients. When a patient approaches the Ambulance
Dispatch Centre with a request for acute care, the operator informs the requester whether or not help is on the
way and specifies the nature of this help. Ambulance care providers on site tell the patient what type of help he
or she will receive. It must also be clear to referrers what they can expect from the Regional Ambulance Service
and ambulance care providers. The Regional Ambulance Service uses the long-term policy plan to clarify its
vision, goals and activities. It also communicates these through regional partnerships. Finally, the Regional
Ambulance Service makes agreements with its chain partners that clearly define what partners may or can
expect from ambulance care.
The Regional Ambulance Service regularly draws up a long-term policy plan in which it describes its view on
responsible ambulance care and how it wishes to implement this. The Regional Ambulance Services ambitions
are formulated in objectives that help the organisation as it systematically works on making them a reality. The
role of chain partners and the way in which cooperation in the region takes shape is also expressed in the longterm plan. Finally, the long-term plan focuses on medical assistance during accidents and disasters.
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6.1 Professionalism
The ambulance sector and its ambulance care providers are a guarantee of professionalism. This term relates
to the professional manner in which individual care providers act, but also to the professional group and
organisations responsible for creating the conditions to act professionally and stimulate professionalism.
However, the essence of professional conduct lies with the individual professional and the definition of the
various professional roles that he or she must be able to fulfil. The essence of professionalism is the willingness
and ability of the individual professional to:
constantly ask himself/herself what good care is for this care requester in this situation;
make a well-considered assessment in this respect;
do this together with the care requester or others (depending on the situation);
act according to this consideration;
do this in such a way that the care requester feels that he or she has been acknowledged as a person;
account for his or her actions;
learn from experience.
34
Operators who are not nurses can also work in an Ambulance Dispatch Centre. They are deployed in the
2
logistical process of assigning ambulance trips .
evelopments concerning the deployment of dispatch centre operators who are not nurses are described in
D
paragraph 4.5.
35
Expertise
Ambulance care work is based on a specific medical and nursing actions. Patients who are or are not in a lifethreatening condition sometimes receive the care they require from the ambulance unit. An ambulance unit
comprises an ambulance nurse, either with or without an ambulance driver. Both professionals jointly provide
the required care on the basis of their own expertise and background, and their personal responsibilities. An
increasing number of ambulance nurses operate independently, such as the rapid responder. In such a case,
this independent ambulance nurse is the ambulance unit.
The quality of ambulance care that is provided depends largely on the expertise of care providers. This imposes
stringent requirements on the qualities of ambulance care providers. These requirements are laid down in a
statutory framework. The ambulance sector has also established several national frameworks. Specific expertise
is required for every key position within ambulance care. The sector has specified the desired minimal expertise
for key positions, in terms of (basic) training and required competencies. It has also defined recognition and
assignment criteria for training programmes relating to these key positions. The starting point within the
sector is that all care professionals active in the primary ambulance care process should enrol in a (continuing)
education programme recognised by the sector as quickly as possible upon entering service. Maintaining
expertise is essential for the provision of high-quality care. The ambulance sector has concluded national
agreements on the development and maintenance of expertise. The Regional Ambulance Service also offers
regional, additional training that corresponds to individual and organisational learning requirements. Sectorspecific agreements on professional development and registration in the quality register are applicable to
professionals pursuant to the Individual Healthcare Professions Act.
6.3.2 Competencies
The availability of skilled care professionals and equipment is adapted to the patients needs, now and in the
future. The treatment of patients within the ambulance care sector care is becoming increasingly focused on
target groups. This is causing differentiation within available care, which could also lead to differentiation in
care positions within the Regional Ambulance Service. This also applies to the Ambulance Dispatch Centre,
which has acquired increasingly complex duties due to social, professional and technical developments. This
necessitates differentiation at additional levels. Intake and dispatch are viewed as two separate processes that
each impose specific requirements on the operators competencies.
Ambulance care providers are governed by the Individual Healthcare Professions Act [Wet BIG]. The training
criteria and required competencies of individual ambulance care providers are geared to the content of their
professional practice (area of expertise) and the requirements of the Individual Healthcare Professions Act.
The job competencies of ambulance care providers are assessed partly through training and development
in accordance with national and regional standards. The individual professional, the medical manager for
ambulance care and the Regional Ambulance Service are personally responsible for the acquisition and
maintenance of this professionals competencies. The competency policy of the Regional Ambulance Service
complies with statutory requirements and sector-specific agreements.
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Ambulances
It is extremely important that vehicles used to transport patients meet the (quality) criteria imposed on them.
Ambulances and equipment are subject to statutory frameworks and (European) standards.
ICT facilities
High-quality ICT facilities that function properly are essential for effectively supporting the ambulance care
process. Good communication and data exchange between the Ambulance Dispatch Centre and ambulance
care providers are crucial for ambulance care. ICT also plays a pivotal role in improving the exchange of
patient information between the various links of the (acute) care chain. The Regional Ambulance Service has
sound communication systems that comply with relevant national requirements. It also has good systems for
business processes and management information.
monitoring the implementation of the rights and obligations of the patient and care provider laid down in
the Medical Treatment Contracts Act [WGBO].
6.8 Safety
6.8.1 Patient safety
The provision of safe care within the ambulance care sector is a very important theme: responsible care is safe
care. The safety of patients must be guaranteed while ambulance care is being provided. Unsafe situations
must be avoided and accidental injury to patients during the entire ambulance care process must be minimised
from the moment the Ambulance Dispatch Centre receives the call up until the moment the patient is handed
over to other care providers. Ambulance care involves high-risk moments, regardless of the patient category.
It also has to deal with patient categories that entail additional safety-related risks. In other words: ambulance
care professionals have to be extra alert when patient safety is concerned. This relates to the physical
characteristics of these categories, the nature or complexity of the injury or how complaints are presented.
The ambulance sector is doing everything it can to minimise avoidable, accidental injury. But there is always
room for improvement, however, which is why ambulance care associations have developed a patient safety
programme. It goes without saying that the Regional Ambulance Service is personally responsible for ensuring
patient safety. In this, it complies with statutory requirements and sector-specific agreements. Individual care
providers are also personally responsible for providing safe patient care by implementing national guidelines,
for example.
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6.8.3
The quality system of the Regional Ambulance Service is also geared to preventing incidents during the
provision of ambulance care and responding effectively if an incident occurs. Part of the safety management
system involves reporting and registering incidents and near-incidents (Safe Incident Reporting [Veilig
Incidenten Melden (VIM)]) and developing a sound policy for this purpose. In the event of a disaster, the
Regional Ambulance Service acts in accordance with statutory requirements.
40
Information, permission,
documentation and privacy
41
7.1
General information
The Regional Ambulance Service provides information about ambulance care that is geared to patients.
This information is clear and easy to understand. It is also intended for potential patients.
7.3 Permission
The law stipulates that patients must grant permission for the provision of ambulance care. Ambulance care
providers give the necessary information that patients and/or their legal representatives use to grant such
permission. Ambulance care often involves situations where a patient is unable to give permission. In such
cases ambulance care providers act in accordance with professional standards and based on their responsibility
as a good care provider.
7.4 Documentation
The Ambulance Dispatch Centre operator and ambulance care providers record information during the
ambulance care process. This is important as it helps harmonise the provision of ambulance care as closely as
possible with the patients request for care. Information is also recorded to evaluate the care that was provided.
Finally, recording information helps ensure that care is transferred safely. Information recorded during the
ambulance care process is saved and stored in compliance with legal requirements.
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Chain agreements
Like a link in the (acute) care chain, the Regional Ambulance Service works closely together with other care
providers within its care area. It moves between the links of the (acute) care chain and plays a crucial role in
guiding patients through the care process as effectively as possible. On the one hand, the cooperation focuses
on guaranteeing and optimising the continuity of care provision within the chain. On the other hand, it focuses
on ensuring effective and demand-driven care: the right care at the right moment and tailored to the care
requesters needs. The Regional Ambulance Service makes agreements with its chain partners regarding the
coordination of care processes, duties and responsibilities, and the exchange of information. It also develops
concrete cooperation activities with its chain partners. Effective cooperation with the various disciplines (fire
brigade and police) within the safety chain is vital. The Regional Ambulance Service draws up covenants and
makes agreements with chain partners to ensure the continuity of patient care.
8.1.3
Scaled-up care
De RAV is ook verantwoordelijk voor het leveren van verantwoorde ambulancezorg in het kader van The
Regional Ambulance Service is also responsible for providing responsible ambulance care within the context
of disaster response and crisis management. It must meet requirements relating to the Ambulance Dispatch
Centre. Requirements relating to training and practice, deployment during events and preparation for
deployment during a disaster or crisis are also imposed on the Regional Ambulance Service. In addition, it
must satisfy requirements relating to ambulance assistance, casualty distribution and the casualty tracking
system. It is imperative for partners within the care and safety chain to work closely together during disasters
and crises. This cooperation is based on sound communication, a clear division of responsibilities and an
insight into available capacities. The Regional Ambulance Service and its partners make good agreements
in this regard based on the national covenant. It also complies with national agreements concerning the
education, training and practice [OTO] of staff.
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Appendices
Appendix 1 Ambulance care statutory framework
Appendix 2 National Professional Code of Conduct for Nurses and Carers
[Nationale Beroepscode van Verpleegkundigen en Verzorgenden]
Appendix 3 A sector in development
Composition of working group for the Policy Document on Responsible
Ambulance care List of abbreviations
49
This appendix provides a summary of legislation applicable to ambulance care. This legislation is an important
cornerstone of the Policy Document on Responsible Ambulance Care, which is evident in the numerous
references to statutory requirements. The reference list specifies all applicable legislation for each chapter.
The full legislative texts are available at www.overheid.nl, a website that provides access to information about
government organisations.
1.1
The Interim Ambulance Care Act [Tijdelijke wet ambulancezorg (Twaz)] came into force on 1 January 2013. It
replaced the Ambulance Transport Act [Wet ambulancevervoer (WAV)]. The Interim Ambulance Care Act will
remain in force for a period of five years, during which work will be carried out on a permanent statutory
regulation. Section 1, subsection 1d of the Act defines ambulance care and extends the definition thereof
compared to the Ambulance Transport Act. Ambulance care now entails:
a. providing medical assistance and transport by ambulance, or;
b. providing medical assistance via an ambulance nurse with a special vehicle equipped for that purpose and
clearly recognisable as such.
The definition of an ambulance comprises more than just an ambulance vehicle: it now includes a motor
vehicle equipped for patients as well as a craft or helicopter. The Ambulance Transport Act referred to a Central
Post for Ambulance Transport [Centrale Post Ambulancevervoer (CPA)] but the Interim Ambulance Care Act
now calls it a Dispatch Centre [meldkamer]. The new Dispatch Centre is still part of the general dispatch centre
referred to in Section 35, subsection 1 of the Security Regions Act [Wet veiligheidsregios]. Under the Interim
Ambulance Care Act, the Dispatch Centre is an integral part of the Regional Ambulance Service. Regional
Ambulance Services are designated by the Minister of Health, Welfare and Sport (Section 6 of the Interim
Ambulance Care Act). This Regional Ambulance Service is responsible for:
a. maintaining a Dispatch Centre;
b. providing or arranging the provision of ambulance care (Section 4 of the Interim Ambulance Care Act).
Ambulance care is care provided to ill or injured patients in order to treat their condition or injury and transport
them by ambulance, or medical assistance provided via an ambulance nurse with a special vehicle equipped
for that purpose and clearly recognisable as such (Section 1, subsection 1d of the Interim Ambulance Care Act).
The Dispatch Centre decides whether or not ambulance care will be provided, who will provide it and how it will
be provided (Section 5 of the Interim Ambulance Care Act). Section 6 stipulates who can be designated as a
Regional Ambulance Service in a region. Further requirements that a Regional Ambulance Service must comply
with are set out in the policy rules of the Minister of Health, Welfare and Sport (Section 6, subsection 3).
1.2
1.3
The Individual Healthcare Professions Act came into force on 1 December 1997. The purpose of the Act is to
improve and monitor the quality of professional practice and protect the client against inexpert and careless
actions performed by professionals. The Act applies to ambulance nurses, nurse dispatch centre operators
and doctors, with respect to the protection of titles within ambulance care. The basic principle of the Individual
Healthcare Professions Act is that care providers are free to practice within the area of individual healthcare.
However, this freedom does not apply to all practices. Some practices are deemed by the legislator to be
of such a high risk that they can only be performed by doctors, i.e. reserved procedures (Section 36 of the
Individual Healthcare Professions Act). The Act distinguishes between professionals who are independently
authorised to perform reserved procedures, such as doctors, and between professionals who are not
independently authorised to perform reserved procedures, such as nurses. Someone who is not independently
authorised may perform reserved procedures under certain conditions on the instructions of an independently
3
authorised individual (doctor) . Doctors authorised to issue an assignment (in this case recommendations
and instructions) to ambulance care providers are not present in ambulances and the Ambulance Dispatch
Centre. The nurse dispatch centre operator is the actual person who makes the care needs assessment for
the ambulance care to be provided, determines the urgency, or refers a patient directly to chain partners. The
ambulance nurse then decides on the care and treatment procedure (reserved or high-risk) that the patient
requires. The legally required instruction issued by the doctor to the Ambulance Dispatch Centre operator and
ambulance nurse to provide care and the manner in which this must occur is embedded within ambulance care
guidelines and protocols. This is decisive for the responsibilities of the Regional Ambulance Service board and
the Ambulance Dispatch Centre in relation to the proper implementation of these protocols and standards,
both nationally and regionally, and ensuring that this proper implementation is established, complied with and
monitored.
The Care Institutions (Accreditation) Act came into force on 1 January 2006. The purpose of the act is to
gradually create greater freedom and responsibility for care institutions by reducing government involvement
in the capacity and construction of care institutions. Care institutions must have an authorisation in order
to provide care that is covered by the Care Insurance Act [Zorgverzekeringswet] or the Exceptional Medical
Expenses Act [AWBZ]. This makes it possible to determine whether or not the institution complies with specific
requirements. The main requirements concern the accessibility of acute care and the transparency of the
governance structure and operational management (good governance). The key terms here are transparency,
independence, broad accountability and the close involvement of stakeholders. The Regional Ambulance
Service is subject to the Care Institutions (Accreditation) Act. The implementation decision designated the
Regional Ambulance Service as an institution that has received authorisation. This authorisation was in the
50
form of a permit issued by the province (Ambulance Transport Act). Now that the Interim Ambulance Care Act
has entered into force, this is a designation from the Minister of Health, Welfare and Sport. The policy rules
of the Admission of Care Institutions Act include an obligation for all providers of acute care to participate in
Regional Acute Care Consultations [Regionaal Overleg Acute Zorg (ROAZ)]. The Regional Ambulance Service is a
partner in these mandatory consultations on the acute care chain. The regional consultations survey acute care
available in the region and propose solutions to problems, at the initiative of the hospital with accreditation for
a regional trauma centre from the region concerned. Agreements stemming from these consultations must
be observed. The institution uses its annual report to account for the manner in which it has observed these
agreements. The Care Institutions (Quality) Act [Kwaliteitswet zorginstellingen (KWZ)] obliges the Regional
Ambulance Service to monitor its own quality and maintain and improve it in relation to responsible care and
qualitative policy by establishing a quality system.
Ambulance nurses occupy a unique position under Section 39 of the Individual Healthcare Professions Act
regarding the performance of reserved procedures. This is worked out in greater detail in the Decree on
Functional Independence [Besluit Functionele Zelfstandigheid]. This implies that the Act deems the expertise
of the nurses occupational group to be of such a level that they may perform certain procedures without any
supervision or intervention by the doctor. With a view to the functional independent performance of
Although the legislator has not considered all potentially high-risk procedures as reserved, this does not imply that the procedure concerned
does not require skilled and careful implementation. On the advice of the Individual Healthcare Provision Council, high-risk procedures are
in principle handled in the same manner as reserved procedures.
51
reserved (and other high-risk) procedures, the instruction issued by a doctor is still required, together with the
requirement that the nurse is competent. The functional independence of an occupational group does not
imply that supervision and intervention by the doctor are no longer possible. The principal and the contractor
retain their personal responsibility for the careful provision of care. The possibility remains that the contractor
may request supervision or intervention, or that the principal will personally decide to do so.
1.4
The Medical Treatment Contracts Act came into force on 1 April 1995. The act stipulates the rights and
obligations of the client and care provider arising from the agreement on medical treatment. It provides for
the obligation to give information, the consent requirement, the representation and position of minors, and
privacy. The Medical Treatment Contracts Act also defines the legal relationship between the care provider
and the client. One aspect of this is the obligation anchored in the act that requires the care provider to
comply with and work according to the professional standard, the norms that have been developed within
the occupational group. The care providers obligation to keep a medical file also merits further attention. The
professional standard is anchored as a norm for the actions of care providers within the Medical Treatment
Act, and under Section 7:453 of the Dutch Civil Code as follows: In providing medical treatment, the care
provider must observe the standards of a prudent care provider and, in doing so, must act in accordance with
the responsibilities laid upon him by the professional standard for care providers. The Medical Treatment
Contracts Act assumes that a treatment agreement exists between the care provider (operator, ambulance
nurse) and the patient. The patient who asks for assistance enters into a treatment agreement with the Regional
Ambulance Service. This organisation must ensure that this agreement has an effect on the operator-client
relationship and the ambulance nurse-patient relationship. The professional standard is used to determine
whether the Ambulance Dispatch Centre operator or ambulance nurse have provided the care of a good care
provider, or have failed imputably in this regard. Care providers are obliged to observe professional secrecy due
to the unique nature of their profession. That obligation also gives rise to a confidentiality requirement that the
professional must observe. Professional secrecy can be observed in two ways. Firstly, the care provider has an
oath of secrecy vis--vis everyone else. Secondly, the care provider has a statutory privilege of non-disclosure
that can be invoked during court proceedings. The oath of secrecy is also anchored in the Medical Treatment
Contracts Act under Section 7:457 of the Dutch Civil Code.
1.5 Clients Right of Complaint (Healthcare Sector) Act [Wet Klachtrecht Clinten
Zorgsector (WKCZ)]
The Clients Right of Complaint (Healthcare Sector) Act of 1995 contains a number of provisions with
obligations for the care provider with regard to the handling of clients complaints in the healthcare sector.
The act stipulates that the board of the Regional Ambulance Service is the care provider. The care provider is
responsible for the effective handling of clients complaints about the provided care. In short, this involves the
following: ensuring that clients complaints are handled by a complaints officer and setting up a complaints
committee that complies with all statutory requirements, defined in greater detail in Section 2 of the Clients
Right of Complaint (Healthcare Sector) Act. Pursuant to the act, every Regional Ambulance Service must have
an independent complaints committee or be affiliated to an independent complaints committee. In this way
patients complaints about the provided ambulance care (or lack thereof) can be assessed easily.
52
To this end, the act provides for the establishment of a client board in institutions and open access for clients to
relevant documents such as the annual report and complaints procedure.
1.7
The Medical Appliances Act specifies safety requirements for medical equipment used in the healthcare
sector in order to prevent injuries to the client as much as possible. The Regional Ambulance Service has a
responsibility in this regard, in addition to the medical device manufacturers responsibility and accountability.
The decree regarding the sterilisation of medical devices also falls under this act. The Medical Appliances Act
provides for the handling, storage, resterilisation, etc. of sterile products.
1.9
The Personal Data Protection Act came into force on 1 September 2001. The act stipulates the rights of
someone whose personal information is used and the obligations of organisations or companies that utilise
personal data. It lays down requirements for the processing of personal data. A Regional Ambulance Service
organisation:
may only collect and process personal data if it has a good reason to do so, or if the citizen concerned has
consented to the use of his or her data;
may not process more data than that strictly required for the purpose for which it has been collected;
may not keep the data longer than is necessary;
must take appropriate technical and organisational measures to protect data;
must, in principle, always inform the citizen concerned about processing of his or her data.
The registration of personal data by healthcare professionals falls under the Exemptions Decree
[Vrijstellingenbesluit] of the Personal Data Protection Act. If the conditions stipulated therein are complied with,
there is no need to report the processing of this data to the regulatory authority.
1.10 Road Traffic Act [Wegenverkeerswet (WvW)] and Traffic Code [Reglement
verkeersregels en verkeerstekens (Rvv)]
The Road Traffic Act and Traffic Code lay down general traffic rules and specific rules governing priority vehicles
as well as the use of signals. The use of flashing lights and sirens (Sector Guideline for Visual and Audio Signals
[Brancherichtlijn OGS]) is based on Section 29 of the Traffic Code of 1990. This Section stipulates that drivers of
motor vehicles used for the police and fire brigade, ambulances and motor vehicles of other emergency services
designated by the Minister of Transport, Public Works and Water Management, may utilise flashing lights and
sirens to indicate they are performing an urgent task. Pursuant to Section 91 of the Traffic Code of 1990, as
priority vehicles these vehicles may deviate from the rules of this Traffic Code in so far as this is required to
perform their task. The ambulance sector has drawn up a sector guideline to help Regional Ambulance Service
boards and drivers of priority vehicles apply these rules responsibly. This sector guideline specifies situations
53
where the use of flashing lights and sirens is permitted. The sector guideline also contains a code of conduct
for drivers of priority vehicles to ensure the safety of the client, the driver, other vehicle occupants and fellow
road users. Many of these requirements have now been laid down in law and the sector guideline is therefore
supplementary.
1.11
The Security Regions Act came into force on 1 October 2010. The new act replaces the Fire Services Act
[Brandweerwet] of 1985, the Medical Assistance during Accidents and Disasters Act [Wet geneeskundige
hulpverlening bij ongevallen en rampen (Wghor)] and the Disasters and Major Accidents Act [Wet rampen en zware
ongevallen (WRZO)]. It also stipulates the administrative context and basic requirements for the organisation of
emergency services, the tasks of the management board of a security region and the minimum requirements
for emergency services, such as the regional fire brigade and medical services, and for the equipment they
use. The Security Regions Decree [Besluit veiligheidsregios] imposes further regulations for security regions and
the fire brigade. Agreements have been made concerning the arrival times of the fire brigade. Key tasks and
minimum requirements have been defined for positions within the security regions (for regional fire brigades,
medical services and several multidisciplinary positions). The aim of personnel regulations is to provide a
nationwide guarantee for the quality of positions within the security region. The Security Regions Personnel
Decree [Besluit personeel veiligheidsregios] stipulates that the minister lays down rules for positions in the fire
brigade, within the Medical Assistance during Accidents and Disasters Organisation [GHOR] and within the
organisation of disaster response and crisis management. The positions are detailed in the Regulations for
Security Region Personnel [Regeling personeel veiligheidsregios].
Appendix 2 N
ational Professional Code of Conduct for
Nurses and Carers [Nationale Beroepscode
van Verpleegkundigen en Verzorgenden]
Introduction
The professional conduct of ambulance care providers is based on the National Professional Code of Conduct
for Nurses and Carers [Nationale Beroepscode van Verpleegkundigen en Verzorgenden] of the Dutch Nurses
and Carers Association [Verpleegkundigen & Verzorgenden Nederland (V&VN)]. This code defines professional
standards and values for professional practice. It provides ambulance care providers with guidelines and
support for day-to-day professional practice. The code clarifies what society as a whole and individual patients
and clients in particular can expect from nurses and carers. It has been formulated against the backdrop of the
Universal Declaration of Human Rights, the Convention on the Rights of the Child and the Dutch Constitution. The
Individual Healthcare Professions Act, Contracts in respect of Medical Treatment from the Dutch Civil Code,
Book 7, Title 7, Chapter 5, and the Care Institutions (Quality) Act have also been used.
54
55
2.7 As a nurse/carer, I seek consent from the care requester (and/or this persons representative) before I
start providing care.
2.8 As a nurse/carer, I act responsibly in relation to the reporting of information about the care requester in
the nursing or care file.
2.9 As a nurse/carer, I am aware of the care requesters rights in relation to the nursing or care file and handle
these in a responsible manner.
2.10 As a nurse/carer, I treat confidential information about the care requester scrupulously.
2.11 As a nurse/carer, I respect and protect the care requesters privacy.
2.12 As a nurse/carer, I respect the professional boundaries of my relationship with the care requester.
2.13 As a nurse/carer, I have the right to refuse engaging in certain activities on the grounds of conscientious
objection.
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Introduction
The Policy Document on Responsible Ambulance Care describes what responsible ambulance care means to
the ambulance sector. The policy document contains a number of general starting points and describes how
these are developed by means of national and sector-specific agreements. The starting points in this policy
document are also applicable to new, future developments. And these are plentiful. The entire care sector is in a
state of flux, and the ambulance sector therefore finds itself in an similar position. New opportunities and new
challenges are arising. This appendix discusses several key developments. These may be within the ambulance
sector itself, or developments within the care sector that concern the ambulance sector. The appendix describes
these developments and how the ambulance sector responds to them on its own or in cooperation with
chain partners. It does so, for example, by drawing up vision documents and policy agendas, formulating
views or setting up pilots. Appendix 3 contains the reference list for documents that detail the developments
(future studies by advisory bodies, policy memoranda from the government), and documents in which the
ambulance sector sets out its vision and plans for the future (position papers and future agendas). These vision
documents, memoranda or pilot results will become part of the policy document the moment they result in
sector-specific agreements.
2.1
Tailored care
The demand for tailored care is growing due to demographic trends such as low birth rates, the ageing
population, interculturalisation, the increasing number of single persons and medical-technical treatment
options in various care settings. In addition, the ageing population will cause an increase in the number of
people with chronic illnesses. The demand for care will grow accordingly. More and more regions and Euregios
such as South Limburg, North-East Groningen and Zeeuws-Vlaanderen have to or will have to deal with a
declining population. However, other regions will also face this problem in the years ahead. Population decline
affects economic dynamism, the demand for goods and services, the labour market and the use of space.
Significant changes are also taking place in the healthcare market itself, such as the shift from a supply-driven
approach towards a demand-driven approach. Secondary care is experiencing a shift towards more treatment
and less nursing: the number of hospital beds is clearly decreasing in favour of outpatient consultations and
day treatment. This trend is also causing changes in the demand for care and the composition and duties of
healthcare personnel. All of these developments also have an effect on ambulance care: in terms of the demand
for ambulance care, but also in the nature of this demand.
The ambulance sector wants to anticipate these trends and is already making every effort to do so. It is
increasing care capacity and continuing to develop differentiated care, ranging from high complexity to low
complexity. Examples include the Mobile Intensive Care Unit (MICU), the rapid responder and the care
ambulance. The shift towards demand-driven care is also creating scope within ambulance care for the
deployment of care professionals with specific knowledge and competencies for providing this care. In addition,
this is enabling differentiation in the supply of work within the context of sustainable deployment.
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2.2
A number of measures were initiated during the previous cabinet period that have had a major impact on
developments in the Ambulance Dispatch Centre:
the coalition agreement of the first Rutte cabinet stipulated that existing dispatch centres will be reduced to a
single dispatch centre organisation with three sites;
the Ministry of Health, Welfare and Sport has listed bottlenecks in the development and organisation of
acute care, which ambulance care is part of;
the cabinet has decided to reorganise the police force by reducing the 25 police regions to ten districts under
one national police organisation;
the Ministry of Security and Justice, in coordination with the Ministry of Health, Welfare and Sport and after
consulting practitioners in the field, decided in February 2012 to establish one national dispatch centre
organisation with a maximum of ten sites.
in line with the Security Regions Act, the Dutch Government has decided to implement the regionalisation of
the fire brigade in all regions;
in the Interim Ambulance Care Act, the Government has stipulated that the Regional Ambulance Service is
responsible for maintaining the Ambulance Dispatch Centre. This act came into force on 1 January 2013.
The creation of one national dispatch centre organisation is the most important step in the entire process that
has an effect on the Ambulance Dispatch Centre.
In February 2012 the Ministry of Security and Justice set out the vision of the Dispatch Centre of the Future in
a letter to the Dutch House of Representatives. This letter defines the direction in which the dispatch centre of
the future will develop. In principle, a maximum of ten supra-regional dispatch centres will be created and will
all fall under one national management organisation. Two such dispatch centres have already been established
in anticipation of this development: the East Netherlands Dispatch Centre and the North Netherlands Dispatch
Centre.
The white column (Ministry of Health, Welfare and Sport, the ambulance care sector and the Medical
Assistance during Accidents and Disasters Organisation [GHOR] has expressed its vision of developments
relating to the dispatch centre. It is important for the white column that several starting points are used to
formulate a vision of the dispatch centre of the future. Firstly, quality and effectiveness are leading to ensure the
best, uniform care is provided to whoever requests it. Secondly, a careful transition process towards economies
of scale must be selected to facilitate the implementation of changes. Thirdly, it must be clear for each column
which requests can and must be multidisciplinary in nature. Two factors are essential for the ambulance care
sector: intake by a nurse dispatch centre operator within the Ambulance Dispatch Centre and control over the
competence and working method of staff who work there. This is the only way the Regional Ambulance Service
can ensure responsibility for the quality and effectiveness of ambulance care (and statutory responsibility for
maintaining the Ambulance Dispatch Centre). Fourthly, developments relating to the dispatch centre of the
future may not affect the integration of the Ambulance Dispatch Centre within the chain of acute care. Finally,
it is essential that the white column can participate in setting up multiple processes and that the director of the
Regional Ambulance Service has control over his mono-disciplinary dispatch centre processes as well as over
staff and resources.
The common starting points for this transition towards to the dispatch centre of the future and the path
taken to make this a reality will be laid down in a Transition Agreement on the Dispatch Centre of the Future
[Transitieakkoord meldkamer van de toekomst] and signed by the parties concerned. Independent data
and pilots will be used to assess the effects of multidisciplinary intake so that the scope of the request by a
multidisciplinary operator centralist can be determined in greater detail. Within eighteen months after the
transition agreement has been signed, it must be clear how intake, extended intake and dispatch collectively
ensure that emergency requests are handled properly. It is important to clarify the effect of multidisciplinary
58
and mono-disciplinary requests. The ambulance care sector also wishes to create opportunities during the
coming period for setting up pilots in the Ambulance Dispatch Centre, with or without the cooperation of chain
partners in order to continue improving the provision of (acute) care. The conditions for these pilots will be
jointly specified by the sector.
2.3
Working and thinking in care chains provides a greater choice in treatment for care requesters, a more
job-specific approach and more extensive cooperation between chain partners. The development of a triage
method for the acute care chain is a concrete example of cooperation within the chain. Within the trauma
region, Regional Acute Care Consultations (ROAZ) are also responsible for ensuring the continuity of acute care
provision. This will ultimately lead to chain agreements on the specific content of available care across the chain
and the responsibilities of various parties. Transparency, optimal communication and information exchange,
with clients privacy being guaranteed, are also important themes that chain partners (must) agree on. Finally,
the joint initiation and implementation of scientific research is a key development in cooperation within the
chain. The Dutch Government has stimulated this through research programmes, but practitioners in the field
are also increasingly being called on to take the initiative. The ambulance sector has responded to this call by
starting development on a research agenda in cooperation with the chain partners.
Developments in quality
3.1
Quality policy
Several developments are also evident within the quality policy of care institutions, which are influenced by
government choices. These developments focus on the following priorities:
making quality visible and measurable;
increasing the influence of clients;
making care safer.
59
intends to entrench these rights in a new law called the Patients Rights (Care Sector) Act [Wet clintenrechten
zorg (Wcz)]. The purpose of this act is to strengthen and clarify the clients legal position. The underlying idea
is that the inclusion of rules on the relationship between the care provider in a single statutory regulation
will help harmonise the rights and obligations of both parties more effectively. Although it is unclear whether
this proposal will actually be realised, the train of thought that clients play a key role in the provision of
care through freedom of choice and participation is acquiring greater form and content. It is and remains a
challenge with ambulance care to involve patients more actively in the provision of care. Despite this, Regional
Ambulance Services are not shying away from the challenge and are continuing to look for opportunities.
Examples of this are the development of the patient card within the patient safety programme and the
development of a Consumer Quality index for ambulance care.
3.2
Scientific research
In the pursuit of continuously improving the quality of care provision, it is important that care standards
and care-related guidelines are evaluated methodically and developed and amended on the basis of the
latest insights. Scientific research is used for this purpose. This especially applies to ambulance care as well,
where care providers work with professional, national standards and guidelines. The sector acknowledges
the importance of scientific research for the further (substantive) development of ambulance care and is
increasingly taking the initiative in this regard. New care professionals such as the nurse specialist play an
important role here. Partnerships with research institutes and care chain partners are being sought on a
national and regional level in order to develop evidence-based guidelines and protocols, which can be used to
provide optimal care. A research agenda for ambulance care, which the sector is currently working on together
with chain partners and other stakeholders, must support this development.
The need to respond to societys changing demands for care with greater speed and flexibility has given rise
to a new occupational structure for nursing. This structure only contains the occupational levels of nurse and
nurse specialist. In addition to this vertical classification into two areas, there is also a horizontal, job-specific
classification into sub-areas: preventive care, acute care, intensive care and chronic care. In each sub-area a
distinction is made between the nature of the condition: somatic, mental and/or behavioural. This results
in nursing care clusters. Further differentiation (ambulance care) is possible for each cluster. The horizontal
classification makes a clear distinction between generic competencies within a sub-area (acute care) and
specific competencies for differentiation (ambulance care). The new structure increases the deployability and
flexibility of nurses within a sub-area, and stimulates chain thinking.
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4.2
Task reallocation
Another development is the reallocation of tasks and the deployment of a new type of professional (not a
doctor) who is authorised to perform limited medical tasks. This has resulted in several new positions within
the healthcare sector, such as the nurse specialist (formerly nurse practitioner) and the physician assistant
(PA). The nurse specialist performs tasks relating to cure and care: medical and nursing tasks are combined.
In the new classification for nursing professions, the nurse specialist falls under Section 14 of the Individual
Healthcare Professions Act. The title of nurse specialist is therefore protected, which means that nurse
specialists are independently authorised to diagnose and perform a number of reserved procedures on their
own. Examples of this include carrying out minor surgical interventions and prescribing medication. In addition
to independent, medical tasks, the nurse specialist plays a role in innovation and applied scientific research.
The PA supports a doctor during clinical work and is therefore primarily active in medical patient care. The
ambulance sector will have to focus on how to deploy these new positions within the Regional Ambulance
Service. At Regional Ambulance Service level, initiatives relating to this theme are already being developed, such
as the deployment of the nurse specialist as a rapid responder, within the partnership with general practitioners,
as a consultant for fellow ambulance nurses and in research activities.
4.3
Another development in line with the one mentioned above is the Bachelors Degree Programme for Medical
Assistance [Bacheloropleiding Medische Hulpverlening (BMH)]. The programmes profile is based on a solid
medical foundation linked to practice-based specialisations. The intention is that this study programme will
supplement the existing in-service training system for the positions and professions concerned. It distinguishes
between the following specialisations for the time being: ambulance care provider, emergency care provider,
triage specialist and anaesthesiology assistant. The programmes first students started in 2010 and its first
graduates are expected in 2014. The ambulance sector is open to new ways of recruitment for the provision of
ambulance care. It is important, however, that a new position such as the Bachelors Degree Programme for
Medical Assistance be legally safeguarded (in the Individual Healthcare Professions Act). Furthermore, this
programme must be able to independently provide ambulance care in the broadest sense.
4.4
The Individual Healthcare Professions Act sets out minimum requirements for the quality of professional
practice. The professional must have the required training in order to be registered. The professional will then
have to demonstrate every five years that he or she has worked a minimum number of hours (quantitative
requirement). Registration and re-registration occurs within the register maintained under the Individual
Healthcare Professions Act and is mandatory. But work experience alone is not enough to help patients
and clients in a professional manner and guarantee quality. Nurses and carers must actively work on their
professional development to keep abreast of the latest developments within their profession. This is supported
at national level from professional associations, united within the Dutch Nurses and Carers Association
[Verpleegkundigen & Verzorgenden Nederland (V&VN)], using the Quality Register V&V [Kwaliteitsregister V&V].
This quality register enables (specialist) nurses to maintain their expertise in an demonstrable and transparent
manner by taking accredited training courses and allowing these to be registered. Since June 2009, areas of
expertise have been added to the Quality Register V&V in phases. Ambulance care is one of these areas of
expertise. Nurse specialists have their own, statutory quality register.
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5.1
The growing demand for care and imminent shortage of personnel will compel the care sector to take further
steps within the labour market in the near future. Various studies from 2010 reveal that the care sector will
require more than 400,000 additional staff over the following fifteen to twenty years if the policy remains
unchanged. In addition to this extra demand for labour, there will also be a need for replacements. The number
of ageing care staff and the retirement of elderly staff will increase. All of this means that care will continue
placing a huge demand on the labour market while the ageing and declining population will reduce the number
of available employees in this labour market in the near future. The existing labour market position for care
staff is generally favourable, but meeting the demand for care in the future will be highly challenging. There is a
risk of labour market shortages due to these developments, even in an attractive sector such as the ambulance
sector. The shortages are expected primarily among nurses and dispatch centre operator nurses. Less
information about drivers (and other positions) is available, but no problems are apparent at this moment.
Nevertheless, the ambulance sector also faces the challenge of having enough, qualified and healthy staff to
cope with the demand for care. This requires an active labour market policy at national and regional level. At
sector level, labour market policy is being developed to provide a sufficient supply of labour for nurses now and
in the future. This is in addition to what is already happening within the various Regional Ambulance Services in
this area. The sectors strategic policy focuses on several aspects:
stimulating recruitment;
retaining and promoting staff.
5.2
5.3
Themes such as good employership and sustainable deployment are important for retaining existing staff for
the care sector. This entails the efficient and effective deployment of staff and keeping them employed up to an
increasingly higher age, within or outside the sector itself. The following activities in this area are more concrete:
sustainable deployment: focus on the sustainable deployment of staff and work together with the chain in this
regard;
mobility in the sector: stimulate mobility in the acute care sector through career guidance policy, the creation
of career paths across sector boundaries and the exchange of staff within the care sector;
benchmark for staff commitment (using an employee satisfaction survey, for example).
Magnet institutions is a notable development within labour market policy.
These institutions have several (organisational) features that make them more appealing to staff, increase
job satisfaction and also enhance the quality of care. The Federation of Patients and Consumer Organisations
in the Netherlands [Nederlandse Patinten Consumenten Federatie (NPCF)] and the Dutch Nurses and Carers
Association [V&VN] are busy adapting this American concept of magnet hospitals to the situation in the
Netherlands.
Stimulating recruitment
Job vacancies in the ambulance sector are filled relatively easily at the moment. However, this does differ from
region to region. That is why it is important to stimulate the recruitment of students within the care sector and
of staff into the ambulance sector. The sectors policy focuses on the following activities:
labour market communication: promote the ambulance sector on the labour market and align it with the
cross-sector labour market agenda;
expand recruitment opportunities: develop new recruitment processes for specialist nurses and nurse
specialists in cooperation with other chain partners and examine lateral recruitment (with the help of
Accreditation of Prior Learning policy);
job differentiation: formulate a policy for job differentiation and possible task reallocation.
This can increase the career prospects of care providers and make the profession more appealing to them and
new students.
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63
List of abbreviations
ALS
AWBZ
BSA
Basic Set Ambulance Care [Basisset Ambulancezorgezorg]
BOPZ Psychiatric Hospitals (Compulsory Admissions) Act [Wet bijzondere opneming in psychiatrische
ziekenhuizen]
BSN
Citizen Service Number [Burger Service Nummer]
BMH
Bachelors Degree Programme for Medical Assistance [Bacheloropleiding Medische Hulpverlening]
CPA
CQi
EVC
GGZ
Mental Healthcare Services [Geestelijke Gezondheidszorg]
GHOR Medical Assistance during Accidents and Disasters [Geneeskundige Hulpverlening bij Ongevallen en
Rampen]
ICN
IGZ
KWZ
MI
MICU
NICU
MKA
MMA
MMT
Management Information
Mobile Intensive Care Unit
Neonatal Intensive Care Unit
Ambulance Dispatch Centre [Meldkamer Ambulancezorg]
Medical Manager Ambulance Care [Medisch Manager Ambulancezorg]
Mobile Medical Team
OGS
Sector Guideline for Visual and Audio Signals [Brancherichtlijn Optische en Geluidssignalen]
OTO Education, Training and Practice [Opleiden, Trainen en Oefenen]
PA
PICU
Physician Assistant
Paediatric Intensive Care Unit
RAV
Regional Ambulance Service [Regionale Ambulancevoorziening]
RI&E
Risk Inventory and Evaluation
RIVM National Institute for Public Health and the Environment [Rijksinstituut voor Volksgezondheid en Milieu]
RVV
Dutch Traffic Code [Reglement Verkeersregels en Verkeerstekens]
ROAZ Regional Acute Care Consultations [Regionaal Overleg Acute Zorgketen]
SHE
64
65
Twaz
UBK
VIM
VWS
WAV
Ambulance Transport Act [Wet ambulancevervoer]
WAZ
Ambulance Care Act [Wet ambulancezorg]
WBP
Personal Data Protection Act [Wet bescherming persoonsgegevens]
Wcz
Patients Rights (Care Sector) Act [Wet clintenrechten zorg]
Wet BIG Individual Healthcare Professions Act [Wet op de Beroepen in de Individuele Gezondheidszorg]
WMCZ Participation (Clients of Care Institutions) Act [Medezeggenschap Clinten Zorginstellingen]
WGBO Medical Treatment Contracts Act [Wet op de Geneeskundige Behandelingsovereenkomst]
Wghor Medical Assistance during Accidents and Disasters Act [Geneeskundige Hulpverlening bij Ongevallen
en Rampen]
WKCZ Clients Right of Complaint (Healthcare Sector) Act [Wet Klachtrecht Clinten Zorgsector]
WTZi
Care Institutions (Accreditation) Act [Wet Toelating Zorginstellingen]
Wvr
Security Regions Act [Wet veiligheidsregios]
WvW
Road Traffic Act [Wegenverkeerswet]
ZvW
Chapter 2
2.1
2.2
2.3
Chapter 3
3.1
Rights of patients and clients in the healthcare sector
www.rijksoverheid.nl
3.1 Programme Seven Rights for the Client in the Healthcare Sector: Investing in the Care Relationship [Zeven rechten voor de clint in de zorg: Investeren in de zorgrelatie]
Ministry of Health, Welfare and Sport, 2008
Chapter 4
4.2.1 Reference Framework for Distribution and Availability [Referentiekader Spreiding en Beschikbaarheid Ambulancezorg] 2008
National Institute for Public Health and the Environment [Rijksinstituut voor Volksgezondheid en
Milieu] 2008
4.2.2
Interim Ambulance Care Act [Tijdelijke wet ambulancezorg]
Ministry of Health, Welfare and Sport, 2012
Policy Memorandum and National Covenant for Dynamic Ambulance Management [Beleidsnotitie en landelijk convenant Dynamisch Ambulancemanagement]
Ambulancezorg Nederland, 2009
66
67
Chapter 5
Transparency
5.2
5.4
68
Chapter 6
6.1 Guideline for Nurses and Carers: Individual Professionalism [Handreiking voor verpleegkundigen
en verzorgenden: individuele professionaliteit]
Nurses and Carers Netherlands [Verpleegkundigen en Verzorgenden Nederland], June 2012
National Professional Code of Conduct for Nurses and Carers [Nationale Beroepscode van
verpleegkundigen en verzorgenden]
Nurses and Carers Netherlands, 2007
6.2
CanMED framework
http://knmg.artsennet.nl/Opleiding-en-Registratie/Modern-opleiden/CanMEDS.htm
6.2.1 Triage System Schedule of Requirements for Ambulance Dispatch Centres [Plan van eisen
MKA-triagesysteem]
Ambulancezorg Nederland and Dutch Association of Medical Managers [Nederlandse Vereniging van
Medisch Managers]
Ambulancezorg Nederland, 2011
Ambulance Care Training Policy [Opleidingsbeleid ambulancezorg]
www.ambulancezorg.nl/werken en leren
Manual for Accreditation Request Educational Programmes CZO
Netherlands Board of Hospital Education [College Zorgopleidingen], 2010
6.2.2 Individual Healthcare Professions Act [Wet Beroepen op de Individuele Gezondheidszorg]
Ministry of Health, Welfare and Sport, 1993
Decree 524 on Functional Independence within the Context of the Individual Healthcare
Professions Act [Besluit 524 functionele zelfstandigheid in het kader van de Wet BIG]
Ministry of Health, Welfare and Sport, 1997
Area of Expertise and Attainment Targets for Ambulance Nurse Educational Programme
[Deskundigheidsgebied en eindtermen ambulanceverpleegkundige]
Netherlands Board of Hospital Education, 2012
69
Attainment Targets for Subject-Related Activities for the Structure of the Ambulance Nurse
Educational Programme [Eindtermen van het vakinhoudelijk handelen voor de inrichting van de
opleiding tot ambulanceverpleegkundige]
Dutch Association of Medical Managers and Ambulancezorg Nederland 2012
Ambulance Care Training Policy
www.ambulancezorg.nl/werken en leren
Manual for Accreditation Request Educational Programmes CZO
Netherlands Board of Hospital Education, 2010
Area of Expertise and Attainment Targets for an Ambulance Nurse
Netherlands Board of Hospital Education, 2012
6.2.3
Ambulance Care Training Policy
www.ambulancezorg.nl/academievoorambulancezorg
6.2.5
Interim Ambulance Care Act [Tijdelijke wet ambulancezorg]
Ministry of Health, Welfare and Sport, 2012
Individual Healthcare Professions Act
Former Ministry of Welfare, Public health and Culture and the Ministry of Justice, 1993
Decree on Temporary Independence of Nursing Specialists [Besluit tijdelijke zelfstandigheid
verpleegkundig specialisten]
Ministry of Health, Welfare and Sport, 2011
Quality Framework for Ambulance Care [Kwaliteitskader Zorgambulance]
Ambulancezorg Nederland and Dutch Association of Medical Managers Ambulancezorg
and V&VN Ambulancezorg, 2012
6.3.1
Interim Ambulance Care Act [Tijdelijke wet ambulancezorg], section 12
Ministry of Health, Welfare and Sport, 2012
Individual Healthcare Professions Act
Former Ministry of Welfare, Public Health and Culture and the Ministry of Justice, 1993
Ambulance Care Training Policy
www.ambulancezorg.nl/werkenenleren
Area of Expertise and Attainment Targets for Ambulance Nurse Educational Programme
[Deskundigheidsgebied en eindtermen ambulanceverpleegkundige]
Netherlands Board of Hospital Education, 2012
Quality Registry for Nurses and Carers [Kwaliteitsregister Verpleegkundigen en Verzorgenden]
www.kwaliteitsregistervenvn.nl
6.3.2
Individual Healthcare Professions Act
Former Ministry of Welfare, Public Health and Culture and the Ministry of Justice, 1993
Decree 524 on Functional Independence within the Context of the Individual Healthcare Professions Act
Ministry of Health, Welfare and Sport, 1997
Decree on Periodic Registration within the Context of the Individual Healthcare Professions Act
[Besluit periodieke registratie Wet BIG]
Ministry of Health, Welfare and Sport, 2008
Ministerial Decree on Periodic Registration [Ministeriele regeling periodieke registratie]
Ministry of Health, Welfare and Sport, 2009
Description of the Medical Management Job Structure [Beschrijving functiegebied Medisch Management]
Ambulancezorg Nederland, 2009
70
71
6.8.1 Programme for Patient Safety and Ambulance Care [Programma patintveiligheid Ambulancezorg] 2010-2013
Ambulancezorg Nederland and Dutch Association of Medical Managers Ambulancezorg
and V&VN Ambulancezorg, 2010
Interim Ambulance Care Act Decree [Tijdelijke wet ambulancezorg], Section 8
Ministry of Health, Welfare and Sport, 2012
Administrative Agreements on Patient Safety and Ambulance Care [Bestuurlijke afspraken
patintveiligheid ambulancezorg]
Ambulancezorg Nederland and Dutch Association of Medical Managers Ambulancezorg
and V&VN Ambulancezorg, 2010
Hygiene Guidelines for Ambulance Services [Hyginerichtlijnen voor de ambulancediensten]
Working Group for Infection Prevention [Werkgroep Infectiepreventie], 2012
Sector Guideline for Visual and Audio Signals [Brancherichtlijn optische en geluidssignalen] in case
of emergency medical assistance
Ambulancezorg Nederland and V&VN Ambulancezorg, 2009
Directive on Incident Management on Rush-Hour and Buffer Lanes/First Safety-Related
Measures During Incidents [Richtlijn Incidentmanagement bij spits- en bufferstroken/eerste
veiligheidsmaatregelen bij incidenten]
Ministry of Transport, Public Works and Water Management [Ministerie van Verkeer en Waterstaat],
2003
National Ambulance Care Protocol 7.2
Ambulancezorg Nederland, 2011
6.8.2
Working Conditions Act [Arbeidsomstandighedenwet]
Ministry of Social Affairs and Employment [Ministerie van Sociale Zaken en Werkgelegenheid], 2007
Health and Safety Catalogue for Ambulance Care
Social Partners in the Ambulance Care Sector
NEN standard 1789 and 1865
Netherlands Standardisation Institute, 2007
Practical Guidelines for Physical Workload in Ambulance Care [Praktijkrichtlijnen fysieke belasting
ambulancezorg]
LOCOmotion, commissioned by SOVAM and BBC-A, 2005
Practical Guidelines for Physical Workload in Ambulance Care
Smits and Beerends, commissioned by SOVAM and BBC-A, 2006
Directive on Incident Management on Rush-Hour and Buffer Lanes/First Safety-Related
Measures During Incidents
Ministry of Transport, Public Works and Water Management, 2003
Sector Guideline for Visual and Audio Signals in case of emergency medical assistance
Ambulancezorg Nederland and V&VN Ambulancezorg, 2009
Driving Guidelines for Ambulance Care [Rijtechnische richtlijnen ambulancezorg]
Ambulancezorg Nederland, 2009
National Ambulance Care Protocol 7.2
Ambulancezorg Nederland, 2011
6.9
Certification System for Ambulance Care
Foundation for Harmonisation of Quality Assessment in the Care Sector, 2011
Administrative Agreements on Patient Safety and Ambulance Care
Ambulancezorg Nederland, 2011
Healthcare Institutions Quality Act, section 14a
Ministry of Health, Welfare and Sport, 1996
72
Chapter 7
7.2
Medical Treatment Act [Wet op de geneeskundige behandelingsovereenkomst]
Ministry of Health, Welfare and Sport, 1994
National Professional Code of Conduct for Nurses and Carers [Nationale Beroepscode van
verpleegkundigen en verzorgenden]
Nurses and Carers in the Netherlands 2007
7.3
Medical Treatment Act
Ministry of Health, Welfare and Sport, 1994
National Ambulance Care Protocol [Landelijk Protocol Ambulancezorg ] 7.2
Ambulancezorg Nederland, 2011
7.4
Medical Treatment Act [Wet op de geneeskundige behandelingsovereenkomst]
Ministry of Health, Welfare and Sport, 1994
Personal Data Protection Act [Wet bescherming persoonsgegevens]
Ministry of Justice [Ministerie van Justitie], 2001
Citizen Service Number [Burger Service Nummer]
Ministry of Health, Welfare and Sport, 2008
Directive on Data Processing Ambulance Dispatch Centre [Richtlijn gegevensverwerking
meldkamer ambulancezorg]
Ambulancezorg Nederland and Dutch Association of Medical Managers
Ambulancezorg Nederland and V&VN Ambulancezorg, 2009
7.5
National Professional Code of Conduct for Nurses and Carers
Nurses and Carers in the Netherlands 2007
Social Media Guideline for Nurses and Carers [Handreiking Sociale Media voor verpleegkundigen
en verzorgenden]
Nurses and Carers in the Netherlands 2012
7.6
Medical Treatment Act [Wet op de geneeskundige behandelingsovereenkomst]
Ministry of Health, Welfare and Sport, 1994
Personal Data Protection Act
Ministry of Justice, 2001
Individual Healthcare Professions Act
Former Ministry of Welfare, Public Health and Culture and the Ministry of Justice, 1993
Guideline for Professional Secrecy and Data Exchange between Ambulance Care, Police and
Public Prosecution Service [Richtlijn beroepsgeheim en uitwisseling gegevens tussen ambulancezorg,
politie en openbaar ministerie]
Ambulancezorg Nederland and Dutch Association of Medical Managers
Ambulancezorg Nederland and V&VN Ambulancezorg, 2009
Guideline for Processing of Noise Data in the Ambulance Dispatch Centre [Verwerking Geluidsgegevens in de MKA]
Ambulancezorg Nederland and Dutch Association of Medical Managers Ambulancezorg
and V&VN Ambulancezorg, 2009
Chapter 8
8.1.1 Interim Ambulance Care Act Decree [Regeling Tijdelijke wet ambulancezorg], Section 11
Ministry of Health, Welfare and Sport, 2012
Guideline for Data Exchange Between General Practitioner- Ambulance Service-Emergency
Care [Richtlijn gegevensuitwisseling huisarts-ambulancedienst-spoedeisende hulp] Ambulancezorg
Nederland, Dutch College of General Practitioners [Nederlands Huisartsen Genootschap], (National
73
ICT Institute for Healthcare [Nationaal ICT Instituut in de Zorg], Netherlands Society of Emergency
Physicians [Nederlandse Vereniging van Spoedeisende Hulp Artsen], 2009
Guideline for Ambulance Care on Water [Richtlijn ambulancezorg op het Water]
Ambulancezorg Nederland, 2009
Model Covenant between Ambulancezorg Nederland and the Ambulance Care and Medical
Assistance in Accidents and Disasters Organisation [Model convenant ambulancezorg en GHOR]
Ambulancezorg Nederland, GHOR Nederland, 2010
Directive on Incident Management on Rush-Hour and Buffer Lanes/First Safety-Related
Measures During Incidents [Richtlijn Incidentmanagement bij spits- en bufferstroken /richtlijn
eerste veiligheidsmaatregelen bij incidenten]
Ministry of Transport, Public Works and Water Management, 2003
First Responder Policy Document and National Directive [Beleidsnotitie en landelijke richtlijn First
and Rapid responder]
Ambulancezorg Nederland, 2005
8.1.2
Healthcare Institutions Admission Act [Wet toelating zorginstellingen]
Ministry of Health, Welfare and Sport, 2005
Memorandum and Covenant on Regional Acute Care Consultations [Notitie en Convenant
Regionaal Overleg Acute Ketenzorg]
Ministry of Health, Welfare and Sport, 2005
Interim Ambulance Care Act Decree [Regeling Tijdelijke wet ambulancezorg], Section 10
Ministry of Health, Welfare and Sport, 2012
8.1.3
Security Regions Act [Wet veiligheidsregios]
Ministry of Security and Justice, 2010
GHOR Knowledge Publications
GHOR Nederland, 2012
Interim Ambulance Care Act Decree [Tijdelijke wet ambulancezorg], Sections 17, 18, 20 and 21
Ministry of Health, Welfare and Sport, 2012
National Covenant between Ambulancezorg Nederland and the Medical Assistance in
Accidents and Disasters Organisation [Landelijk convenant ambulancezorg en GHOR]
Ambulancezorg Nederland, GHOR Nederland, 2011
National Covenant on Education, Training and Practice [Landelijk Convenant Opleiden, Trainen
en Oefenen]
Ambulancezorg Nederland, GHOR Nederland, GGD Nederland, Dutch Association of Out-OfHours Clinics [Vereniging Huisartsenposten Nederland], Dutch Association of Hospitals [Nederlandse
Vereniging van Ziekenhuizen], National Association of Trauma Centres [Landelijke Vereniging van
Traumacentra], National Network for Acute Care [Landelijke Netwerk Acute Zorg], National Association of General Practitioners [Landelijke HuisartsenVereniging], Federation of Dutch Academic
Medical Centres [Nederlandse Federatie van Universitair Medische Centra], 2009
National Policy Framework for Education, Training and Practice [Landelijk Beleidskader OTO]
Ambulancezorg Nederland, GHOR Nederland, GGD Nederland, Dutch Association of Out-OfHours Clinics [Vereniging Huisartsenposten Nederland], Dutch Association of Hospitals [Nederlandse
Vereniging van Ziekenhuizen], National Network for Acute Care [Landelijke Netwerk Acute Zorg],
National Association of General Practitioners [Landelijke HuisartsenVereniging], Federation of Dutch
Academic Medical Centres [Nederlandse Federatie van Universitair Medische Centra], 2012
8.2 Model Guideline and Model Authorisation Information Material for Access to E-Speed dossier
[Modelrichtlijn en model voorlichtingsmateriaal autorisatie voor toegang tot het e-spoed dossier],
version 1.0
74
Ambulancezorg Nederland, Royal Dutch Medical Association [Koninklijke Nederlandse Maatschappij ter bevordering der Geneeskunst], Dutch College of General Practitioners, National ICT Institute
for Healthcare, Dutch Patients and Consumers Federation [Nederlandse Patinten Consumenten
Federatie], 2007
Citizen Service Number [Burger Service Nummer]
Ministry of Health, Welfare and Sport, 2008
Guideline for Data Exchange between General Practitioners- Ambulance Service-Emergency
Care [Richtlijn gegevensuitwisseling huisarts-ambulancedienst-spoedeisende hulp] Ambulancezorg
Nederland, Nederlands Huisartsen Genootschap, Nationaal ICT Instituut in de Zorg, Nederlandse
Vereniging van Spoedeisende Hulp Artsen, 2009
Chapter 9
9.1
9.2
Clients Right of Complaint (Healthcare Sector) Act [Wet klachtrecht clinten zorgsector]
Ministry of Health, Welfare and Sport, 1995
Healthcare Institutions Quality Act [Kwaliteitswet zorginstellingen]
Ministry of Health, Welfare and Sport, 1996
Chapter 10
10.1 Participation of Clients of Care Institutions Act [Wet medezeggenschap clinten zorginstellingen]
Ministry of Health, Welfare and Sport, 1995
10.2
Healthcare Institutions Admission Act [Wet toelating zorginstellingen]
Ministry of Health, Welfare and Sport, 2005
Appendix 3
A sector in development
Developments in the care sector
2.1
Name and Utilise Population Decline [Bevolkingskrimp benoemen en benutten]
Social and Economic Council [SER], 2011
2.2
Letter from Minister of Security and Justice regarding Ambulance Care Dispatch Centre
Ministry of Security and Justice, February 2012
Letter from Minister of Health, Welfare and Sport regarding Ambulance Care Dispatch Centre
Ministry of Health, Welfare and Sport, March 2012
Position Paper on Ambulance Care Dispatch Centre
Ambulancezorg Nederland, 2011
Explanation to Position Paper on Ambulance Care Dispatch Centre
Ambulancezorg Nederland, 2011
Policy Agenda for Out-Of-Hours Clinics+Regional Ambulance Service [Beleidsagenda HAP+RAV]
2013-2014
Ambulancezorg Nederland and Dutch Association of Out-Of-Hours Clinics, 2012
2.3
Netherlands Triage System
www.nederlandstriagesysteem.nl
75
76
77