[Quality in statutory outpatient care: a modular system with varying approaches]. / Qualitätsentwicklung in der vertragsärztlichen Versorgung: ein Baukasten mit vielfältigen Ansätzen.

How is quality supported and what voluntary activities are there in the German statutory healthcare sector? Especially in outpatient healthcare, with a high proportion of chronic diseases treated that can significantly impair one's quality of life, quality of care is of utmost importance. We provide an overview of quality assurance measures that statutorily practicing doctors and psychotherapists (must) oblige to. Voluntary activities from third parties like doctor-specific associations and critical incidence reporting systems (CIRS) are presented alongside tools and services provided by the National and Regional Associations of Statutory Health Insurance Physicians as well as the implications of "Richtlinien" (directives) from the Federal Joint Committee and of "Qualitätssicherungsvereinbarungen" (quality assurance agreements) from the Joint Committee Quality Assurance. In summary, there is a wide spectrum of (in part voluntary) instruments and rules that is the cornerstone for the high quality present in the statutory outpatient healthcare system in Germany.

[Methodological Standard for the Development of Quality Indicators within Clinical Practice Guidelines - Results of a structured consensus process]. / Methodischer Standard für die Entwicklung von Qualitätsindikatoren im Rahmen von S3-Leitlinien ­ Ergebnisse einer strukturierten Konsensfindung.

BACKGROUND: Recommendations of evidence- and formally consensus-based clinical practice guidelines (CPGs) represent a valuable source of quality indicators (QIs). Nevertheless, a standardized methodological procedure for developing QIs in the context of CPGs does not yet exist in Germany for all CPGs. For this reason, a methodological standard for the guideline-based development of QIs (QI Standard) was developed based on a structured consensus process involving multiple key stakeholders. METHODS: The proposed content of the QI Standard was derived from evidence, drawing upon results of reviews and qualitative studies, and considered German manuals for guideline-based QI development of two guideline programs. A multi-perspective consensus panel, broadly representing key stakeholders from the German healthcare system with expertise in CPGs and/or quality management, was nominated to vote on recommendations for guideline-based development of QIs. The iterative, structured consensus process included a two-stage online survey based on the Delphi method ("preliminary voting") and a moderated final stakeholder conference where all those recommendations were definitely included in the QI Standard that received approval of more than 75 % (consensus criterion) of the consensus panel. RESULTS: Based on the agreed QI Standard, the QI development process starts with a criteria-based selection of "potential" QIs which - in case of adoption - are published in CPGs as "preliminary" QIs and can achieve the status "final" after successful testing. The QI Standard is composed of a total of 30 recommendations, which are allocated to six areas: A) preparatory work steps for the guideline-based recommendation of QIs, B) QI development group and cooperation with the CPG group, C) development of potential QIs, D) critical appraisal of potential QIs, E) formal adoption and publication as well as F) piloting/testing of preliminary QIs and conversion into final QIs. DISCUSSION: Before the QI Standard can be recommended for implementation in future CPGs, it should have been successfully tested in selected German CPG projects. In addition to methodological requirements for the QI development, it must be ensured that guideline groups have adequate resources for the implementation of the QI Standard. CONCLUSION: By using the QI Standard, scientifically sound and healthcare-relevant QIs can be expected.

Patient satisfaction with ambulatory care in Germany: effects of patient- and medical practice-related factors.

OBJECTIVE: The study aimed to illustrate the effect of the patients' sex, age, self-rated health and medical practice specialization on patient satisfaction. DESIGN: Secondary analysis of patient survey data using multilevel analysis (generalized linear mixed model, medical practice as random effect) using a sequential modelling strategy. We examined the effects of the patients' sex, age, self-rated health and medical practice specialization on four patient satisfaction dimensions: medical practice organization, information, interaction, professional competence. SETTING: The study was performed in 92 German medical practices providing ambulatory care in general medicine, internal medicine or gynaecology. PARTICIPANTS: In total, 9888 adult patients participated in a patient survey using the validated 'questionnaire on satisfaction with ambulatory care-quality from the patient perspective [ZAP]'. MAIN OUTCOME MEASURE(S): We calculated four models for each satisfaction dimension, revealing regression coefficients with 95% confidence intervals (CIs) for all independent variables, and using Wald Chi-Square statistic for each modelling step (model validity) and LR-Tests to compare the models of each step with the previous model. RESULTS: The patients' sex and age had a weak effect (maximum regression coefficient 1.09, CI 0.39; 1.80), and the patients' self-rated health had the strongest positive effect (maximum regression coefficient 7.66, CI 6.69; 8.63) on satisfaction ratings. The effect of medical practice specialization was heterogeneous. CONCLUSIONS: All factors studied, specifically the patients' self-rated health, affected patient satisfaction. Adjustment should always be considered because it improves the comparability of patient satisfaction in medical practices with atypically varying patient populations and increases the acceptance of comparisons.

Feasibility of 48 quality indicators in ambulatory care in Germany: a cross-sectional observational study.

BACKGROUND: The National Association of Statutory Health Insurance Physicians develops quality indicators (QIs) for ambulatory care in Germany. This study explores the feasibility of a total of 48 QIs. METHODS: Cross-sectional observational study with primary data collection in writing from medical practices in 10 specialist fields of outpatient care. "Feasibility" covers 7 criteria for indicator assessment and data collection: applicability, availability, retrievability, complexity, relevance, reliability, and acceptance. A questionnaire consisting of 10 questions was used to evaluate these feasibility criteria for each indicator. Survey results were subjected to descriptive analysis. RESULTS: The analyzed sample comprises 103 participants who have been working as practice-based physicians for an average of 13 years. 40% only keep electronic medical records and 2% only paper records, and the rest uses both. The rating of QIs in the field-specific QI sets shows the following mean values: 67% of the participants consider the QIs assigned to them as corresponding to their practice care mandate. Data on these QIs deemed to be applicable are collected by 94% of respondents, documented by 91%, and by 51% electronically. 58% of the data required for the denominator, and 38% for the numerator are retrievable from the practice management system. The time required to access data on a QI is more than 30minutes for 84% of respondents, and 67% consider the effort involved as unacceptable. The rating received was 61% for the relevance of QIs to the assessment of a practitioner's own quality of health care, 69% for the estimated reliability of data collection, and 58% for the acceptance of being evaluated via QIs. CONCLUSIONS: In order to improve the feasibility of QI-based practice assessments it will be necessary to a) fine-tune the selection of QIs for the respective groups of specialist, b) to promote the use of computerized practice management systems, and c) integrate effective and user-friendly retrieval functions in the software. Another aspect to be explored is how the acceptance of QI-based practice evaluations can be improved in individual specialist fields.

[AQUIK®: starter set of ambulatory quality indicators developed by the German National Association of Statutory Health Insurance Physicians]. / KBV entwickelt Starter-Set ambulanter Qualitätsindikatoren - AQUIK®-Set.

AIM: Development of a starter set of quality indicators for application by general practitioners and specialists in the outpatient care sector. METHODOLOGY: The results of a systematic search for national and international quality indicators relevant to the outpatient care sector in Germany provided the basis for the indicator selection process. Outpatient care doctors rated the relevance and feasibility of the indicators according to the RAND/UCLA method. In a further step the indicators were tested in medical practices, focussing on data availability and accessibility. RESULTS: As a result, we established a set of 48 reliable, structurally developed and patient-oriented quality indicators which can be used for quality improvement in the outpatient care setting, both by specialists and general practitioners. DISCUSSION: The project provides important information with regard to the future development and use of quality indicators. Depending on the potential fields of application, the development of new indicators as well as a corresponding IT infrastructure is of high priority. Possible unintended effects of indicators will have to be considered.

[Self-assessment and quality development in primary care: results of the German pilot study using the International Maturity Matrix]. / Selbstbewertung und Qualitätsentwicklung in der primärmedizinischen Versorgung: Ergebnisse der deutschen Pilotstudie mit der Internationalen Maturity Matrix.

The International Maturity Matrix has been developed with the aim to provide a European instrument for a facilitated self-assessment of primary care organisations. It covers seven dimensions; their implementation is evaluated by the whole practice team on six theoretically-founded levels of organisational development. The present paper will report the results of the German pilot study with 22 participating primary care practices. The purpose of the study was to test the feasibility of self-assessment with the International Maturity Matrix which, in addition to the practice team's self-assessment, also contains the development of options for improvement on the basis of benchmarking the practice's individual achievements with the results of the other participating practices. To summarise, the survey shows positive results for the participating practices; in two meetings, the time-saving process allows for sharing the different perspectives of the practice team members, identifying relevant strengths and weaknesses and developing ideas for improvement motivated by the benchmarking. These results can be interpreted as first promising indications of the high feasibility of the self-assessment process with the International Maturity Matrix. First applications of the International Maturity Matrix in different medical disciplines have been started.

[A proposal of the medical profession for the prevention of medical errors]. / Konzept der Arzteschaft zur Behandlungsfehlerprävention.

In 2002 the Agency for Quality in Medicine developed an "action plan" to improve patient safety that can be summarized neatly as "Sensitize, inform, discuss and implement strategies". The following publication describes both the goals of this action plan and some of its implemented measures.

[Quality and quality development in medical practices--epidemiological results of the accompanying evaluation of the new KBV quality management system]. / Qualität und Qualitäts- entwicklung in Praxen--epidemiologische Ergebnisse der begleitenden Evaluation des neuen Qualitätsmanagementsystems der KBV.

The motivation for quality management has now reached medical and psychotherapeutic practices. This is partly due to exogenous factors, including regulatory requirements such as Sect. 135a SGB V (German Book of Social Code) demanding the implementation and further development of internal quality management from both out-patient and in-patient healthcare providers. The National Association of SHI-Accredited Physicians in Germany (KBV), along with several regional associations, responded to these internal demands and external requirements by developing the quality management system "Quality and Development in Practices (QEP)". Assisted by an independent institute, 61 selected practices participated in the pilot study. The pilot phase included five interview rounds held between April and November 2004 with 60 practices taking part. The results describe practitioners' expectations for the current state of and the demand for internal quality management. Only one in five practices expects improvements from the implementation of quality management in the area of healthcare processes and management. The improvement of organizational processes, patients' safety and patient outcomes are considered more important. In a self-assessment procedure which included 73 targets with 236 verifications from the quality target catalogue a distinct potential for quality improvement has been revealed. The greatest need for improvement has been identified in cases where quality management defines specific requirements for the practices. These include: treatment pathways, patient information, risk management, case discussions and instruction, quality improvement, regulations and quality measurement. Even practices with advanced quality development activities were able to detect some potential for improvement with the application of the QEP catalogue. In order to attain 15 selected quality targets with 45 verifications, the practices were provided with tools like sample documents and suggestions for internal regulations to be used for quality improvement and requiring relatively small efforts. The effectiveness of implementing a quality management system cannot be adequately demonstrated by an accompanying evaluation. However, established instruments (such as the quality target catalogue and verifications), complemented with suitable outcome indicators, allow the effects of the implementation of internal quality management to be measured in a comparative, or, ideally in a randomized study.