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Open Access Study protocol

The effect and process evaluations of the national quality improvement programme for palliative care: the study protocol

Natasja JH Raijmakers1*, Jolien M Hofstede1, Ellen JM de Nijs2, Luc Deliens34 and Anneke L Francke14

Author Affiliations

1 Netherlands Institute for health services research (NIVEL), PO box 1568, 3500 Utrecht, BN, The Netherlands

2 Center of expertise Palliative Care, University Medical Center Leiden (LUMC), PO box 9600, 2300 RC Leiden, The Netherlands

3 End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Laarbeeklaan 103, Brussels 1090, Belgium

4 Department of Public and Occupational Health (EMGO+), VU University Medical Centre, PO Box 7057, 1007 MB Amsterdam, The Netherlands

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BMC Palliative Care 2014, 13:5  doi:10.1186/1472-684X-13-5

Published: 21 February 2014



The nationwide integration of palliative care best practices into general care settings is challenging but important in improving the quality of palliative care. This is why the Dutch National Quality Improvement Programme for Palliative Care has recently been launched. This four-year programme consists of about 70 implementation trajectories of best practices. A large evaluation study has been set up to evaluate this national programme and separate implementation trajectories.


This paper presents the protocol of the evaluation study consisting of a quantitative effect evaluation and a qualitative process evaluation. The effect evaluation has a pre-test post-test design, with measurements before implementation (month 0) and after implementation (month 9) of a best practice. Patients are eligible if they have a life expectancy of less than six months and/or if they are undergoing palliative treatment and provided they are physically and mentally capable of responding to questionnaires. Bereaved relatives are eligible if they have been involved in the care of a deceased patient who died after a sickbed between six weeks and six months ago. Three types of measurement instruments are used: (1) numerical rating scales for six symptoms (pain, fatigue, breathlessness, obstipation, sadness and anxiety), (2) the Consumer Quality Index Palliative Care - patient version and (3) the version for bereaved relatives.

The process evaluation consists of analysing implementation plans and reports of the implementation, and individual and group interviews with healthcare professionals. This will be done nine to eleven months after the start of the implementation of a best practice.


This mixed-method evaluation study gives more insight into the effects of the total programme and the separate implementation trajectories. However, evaluation of large quality improvement programmes is complicated due to changing, non-controlled environments. Therefore, it is important that an effect evaluation is combined with a process evaluation.

Trial registration


Palliative care; Terminal care; End-of-life care; Effect evaluation; Process evaluation; Quality improvement; Complex intervention; Implementation; Effectiveness