[Quality labels and accreditation in German long-term care--a review]. / Qualitätssiegel und Zertifikate in der deutschen Langzeitpflege--ein Uberblick.

UNLABELLED: There are many quality certificates for ambulant and stationary nursing facilities obtainable in Germany. Yet there has been no systematic, topical survey in Germany since the Scientific Institute of the AOK (WldO) published "Qualitätssiegel und Zertifikate für Pflegeeinrichtungen--Ein Marktüberblick" (Gerste et al. 2004). The aim of this examination was to update the data on certification procedures and seals of quality for nursing institutions. We thus hopeto provide nursing homes, their staff, patients and their families with guidelines for assessing the various certificates. METHOD: Via literature and online searches as well as telephone interviews with the certificate providers we created an overview of the quality certificates and seals now being used by nursing facilities in Germany. RESULTS: Nine of the 17 certificates reported by Gerste and colleagues in 2004 are still being employed (as of spring 2011). We identified 11 additional certificates in use and examined a total of 20 seals of quality. Their providers claim to have certified about 3700 nursing facilities. CONCLUSIONS: The differences between the AOK WldO study by Gerste et al. in 2004 and ours seem to reveal considerable fluctuation in the quality-certification market. However, five of the six "large" certifiers (those having certified over 100 institutions) also existed in 2004. Thus the nursing-certification-market has also been somewhat stable. The market's "leaders" in 2004 were still essentially dominating the market in 2011.

Selection of hospital quality indicators for public disclosure in Germany.

OBJECTIVES: This paper introduces the QUALIFY instrument as an indicator assessment method used to select quality indicators suitable for public disclosure in Germany. METHODS: Fifty-five hospital quality indicators previously approved in routine use were systematically tested for suitability in public disclosure. A multi-disciplinary expert team including patient representatives used the QUALIFY instrument to assess the methodological quality of these indicators in detailed respect to their purpose. The team applied 14 of the 20 QUALIFY criteria to each indicator, the minimum acceptance level for public reporting was determined in advance. RESULTS: Thirty one indicators from eleven clinical conditions fulfilled all fourteen methodological criteria required for national reporting. They include eleven outcome and twenty process indicators. CONCLUSIONS: QUALIFY proved to be a useful tool for selecting quality indicators suitable for public disclosure and thus contributes substantially to proper information on German hospital quality. It ensures high transparency in a very sensitive context to all stakeholders.

[How to bring quality into the focus of health care--results of a delphi and stakeholder survey]. / Wie rückt Qualität in den Fokus der Gesundheitsversorgung? Ergebnisse einer Delphi- und Akteurbefragung.

Although plenty of statutory requirements, concepts and tools to promote the quality of health care exist, Germany's health care system seems far from being pervaded by a vivid quality culture. In order to show ways how to succeed in developing and implementing such a quality culture in the German health care system, the Bertelsmann foundation conducted a delphi survey of seven quality of care experts and an online survey of 239 stakeholders, encompassing health care providers and representatives of the self administration of the health care system, politicians, the health care industry, and patient representatives. Based on the delphi results 31 theses within 12 subject areas have been formulated and assessed, which describe building blocks to put quality in the center of Germany's health care system. After dichotomizing the answers (school grades 1-6 into 1-2 = best, and 3-6 = worse) > 66% of the stakeholders rated 28 of 31 theses with grades 1-2. The ten most accepted theses received grades 1 or 2 from more than 85% of the stakeholders. Following the main results of the surveys, establishing a vivid quality culture requires outcome oriented quality goals and quality indicators to be defined, quality management to be embedded better into the education of all health care providers, and quality promotion to be introduced which is build on quality incentives and objective quality transparency. Since experts and stakeholders agree to such a high degree in the steps necessary to establish a quality culture in the German health care system, the realization of these steps seems to be possible.

[The German program for disease management guidelines: evaluation by use of quality indicators]. / Nationale VersorgungsLeitlinien--Evaluation durch Qualitätsindikatoren.

The Program for National Disease Management Guidelines (German DM-CPG Program) in Germany aims at the implementation of best-practice recommendations for prevention, acute care, rehabilitation and chronic care in the setting of disease management programs and integrated health-care systems. Like other guidelines, DM-CPG need to be assessed regarding their influence on structures, processes and outcomes of care. However, quality assessment in integrated health-care systems is challenging. On the one hand, a multitude of potential domains for measurement, actors and perspectives need to be considered. On the other hand, measures need to be identified that assess the function of the diagnostic and therapeutic chain in terms of cooperation and coordination of care. The article reviews methods and use of quality indicators in the context of the German DM-CPG Program.

Goals in cardiac rehabilitation: influencing factors, relation to outcome, and relevance of physicians' illness perception.

PURPOSE: The study attempted to identify and define subgroups of patients participating in cardiac rehabilitation (CR) whose CR goal profiles were similar, what factors influence the definition of targets for these goals, and how the definition of goals influenced the short-term and medium-term effects of CR. METHODS: Data were obtained from 2,182 patients participating in 17 CR centers in Germany from 2001 to 2003. The data collection instruments included a patient questionnaire on general health status and a case report form completed by a physician. RESULTS: A latent class analysis led to a 3-cluster solution including a patient cluster of "risk factor patients" for whom the CR goals were primarily reduction of blood pressure and cholesterol level; a patient cluster of "multimorbidity patients" with numerous interdisciplinary CR goals; and a patient cluster for which the goals were relatively undefined. These clusters were derived only from the analysis of the CR goals defined by physicians rather than from the analysis of the baseline health status. Goal setting in the psychologic area was greater than 1.5 times more likely to occur for men than for women. The setting of goals had no independent influence on the effects of CR. CONCLUSION: Findings suggest that the cognitive illness perception of the treating physician affects goal setting in CR.

[QUALIFY--a tool for assessing quality indicators]. / QUALIFY: Ein Instrument zur Bewertung von Qualitätsindikatoren.

Quality indicators are used world-wide to control the quality of health care. To be effective these indicators have to meet quality criteria themselves. But until now there has been no fully operational method for assessing indicators. Using a systematic review of existing criteria and scientific analyses the criteria set QUALIFY was developed. Particular characteristics of QUALIFY include clear definitions of all criteria, consistent information as the basis of assessment and a standardized approach throughout the assessment process. QUALIFY comprises 20 criteria which are assigned to the three categories relevance, scientific soundness and feasibility. It was tested during the assessment of 55 indicators and served as the methodological basis for selecting those quality indicators that German hospitals are required to report publicly.

ICF Core Sets for low back pain.

OBJECTIVE: To report on the results of the consensus process integrating evidence from preliminary studies to develop the first version of a Comprehensive ICF Core Set and a Brief ICF Core Set for low back pain. METHODS: A formal decision-making and consensus process integrating evidence gathered from preliminary studies was followed. Preliminary studies included a Delphi exercise, a systematic review and an empirical data collection. After training in the ICF and based on these preliminary studies, relevant ICF categories were identified in a formal consensus process by international experts from different backgrounds. RESULTS: The preliminary studies identified a set of 503 ICF categories at the second, third and fourth ICF levels with 211 categories on body functions, 47 on body structures, 190 on activities and participation and 55 on environmental factors. Eighteen experts from 15 different countries attended the consensus conference on low back pain. Altogether 78 second-level categories were included in the Comprehensive ICF Core Set with 19 categories from the component body functions, 5 from body structures, 29 from activities and participation and 25 from environmental factors. The Brief ICF Core Set included a total of 35 second-level categories with 10 on body functions, 3 on body structures, 12 on activities and participation and 10 on environmental factors. CONCLUSION: A formal consensus process integrating evidence and expert opinion based on the ICF framework and classification led to the definition of ICF Core Sets for low back pain. Both the Comprehensive ICF Core Set and the Brief ICF Core Set were defined.

[Comparative assessment of rehabilitation centres]. / Einrichtungsvergleiche in der medizinischen Rehabilitation.

Comparative quality analyses of rehabilitation centres are required by the legislators and are the focus of the external Quality Assurance plans presently implemented. However, they are also highly relevant for internal Quality Management models (e.g. for the result criteria of the EFQM model). To control for confounders of rehabilitation success that cannot be influenced by the rehabilitation centre (e.g. age, co-morbidity), and thus to permit fair comparisons of clinics, regression analysis risk adjustment procedures are primarily used in the literature. The present paper explains the use of so-called Hierarchical Linear Models (HLMs) using example of data of N = 2.044 patients undergoing rehabilitation following hip and knee operations from the Quality Assurance programme of the statutory health insurance funds (QA-Reha-procedure). This procedure has the advantages of: a) taking into account the multi-level structure of the comparison problem; b) permitting the inclusion of predictors at the rehabilitation centre level; and c) permitting the modelling of variation in regression coefficients over the centres. The data presented show that the differences in achieved rehabilitation outcome among the rehabilitation centres - after control of the confounders by means of HLMs tend to be slight. In addition to patient-related predictors of rehabilitation outcome (baseline somatic, functional, psychosocial status, co-morbidity, rehabilitation motivation, gender, age), the mean functional disability of the patients in the centre is shown to be a confounder at the clinic level. In this respect, a centre that has little experience with severely affected rehabilitation patients achieves on average lesser effects on somatic, functional, and psychosocial levels.

[Effectiveness of rehabilitation with musculoskeletal diseases]. / Wirksamkeit der Rehabilitation bei muskuloskelettalen Krankheiten.

Multidisciplinary treatment focusing on impairments, activities and participation are an important component within the therapeutic regimen in musculoskeletal conditions. In Germany, for more than 95% of the patients multidisciplinary treatment is provided as inpatient rehabilitation. According to the results of a study from the Netherlands, inpatient rehabilitation is superior to usual care in terms of decreasing disease activity and improving emotional well-being in rheumatoid arthritis. Another randomized, controlled study gives evidence that rehabilitation is more effective as compared to usual care in ankylosing spondylitis. In patients suffering from fibromyalgia, after inpatient rehabilitation, symptoms improve significantly and this is true even one year after discharge. The results of a quality management project financed by the German health insurance and including several thousand patients with musculoskeletal diseases show an improvement in physical and emotional dimensions of health status at discharge and after a six month follow-up. Recent studies comparing inpatient with outpatient rehabilitation in patients with musculoskeletal diseases provide information that both forms are equally effective. Taking into account the high number of inpatient rehabilitation procedures in Germany, more outcomes research is required urgently.