Table 3 Citations of participants reformulating the problem of guidelines

‘People are not acquainted with it, they do not know it, they do not know what recommendations they have to know. It really depends on the interest of an individual professional whether it is used or not. I think that you need to look on system-level whether protocols are generally in line with guidelines. Quite often they are not even translated into practice. I think that it depends too much on the individual professional, and I think you should do much more on system level to implement it. And at the same time, I think, there is a problem with the system at organisational level.’

Norm developer 6

‘I did notice that there was a certain reluctance to reformulate an indicator, because the insurers may call them on account, and that was sensed immediately.’

Norm developer 9

‘Yes, if you look at the register, for example. We are asked to provide a tripartite now, including insurers. Thus, it is agreed that insurers play an even more important role. That was not the original question for guideline developers, by definition. Not because one is against it, but one looked at the content and how to deliver the best quality of care.’

Norm developer 2

‘I think it is a very difficult discussion, because I also realize what hospitals encounter. All parties awaken me to that. On the other hand, it is also true, that we have chosen a system in the Netherlands, where patients have an understanding of the quality in order to make the right choices. And yes, you will need information to do so.’

Norm developer 3

‘When I think of a quality label, I see it as a reward. I also notice that it happens in hospitals. Professionals say: we should keep this quality label.’ & ‘In psychology, not getting a reward is a punishment.’

Norm developer 3 & Norm user 6

‘It is questionable whether the field is really waiting for guidelines the way they are presented now.’

Norm user 8

‘And then you have the perverse incentives on all sides, and the control of the board of directors is fundamentally absent. Absolutely absent. There is no testing, nothing. For me, DICA is an example how it should not be done.’

Norm user 2

‘In the final phase, where you could start an improvement project, you cannot achieve it in practice, because you are hampered by so many factors. This is influenced by insurance companies, a patient, by available money or by management choices that must be made. So you have … What I am trying to say is that there is little room to establish improvement.’

Norm user 9

‘As a matter of fact, I would like to say that hospitals do want to provide good care. The resistance comes from the multitude and impossibility.’

Norm user 1

‘The challenge, therefore, is to provide the right information to the professional at the right time during the search. That is the big issue.’

Norm user 2

‘But a guideline, if I may call it that way, is a tool. It is an invitation. We, as a group, have determined that this is the best approach, and we can deviate from guidelines if we argue well. An indicator, on the other hand, encourages reflection, which stimulates the consideration: what is good for one specific patient, but not for the other?’

Norm user 1

‘… the whole exercise in the care sector was to deliver everything at one point in time for multiple purposes. But then you experience problems during realisation, as the insurers first said yes, but then they want to receive it at the first of October [which is a different date than earlier agreed on], because they need it for contracting. And then you have to work with the results from the previous year, so that is very difficult.’

Norm enforcer 1

‘The minute that all enforcing institutions, the patient, the insurers, and inspection, look over your shoulder in the doctor’s office, you might be more careful, perhaps you are going to make strategic choices instead of basing it purely on your professional expertise.’

Researcher/consultant/policymaker 5