[Quality assurance and improvement in healthcare: instruments and perspectives]. / Qualität in der Gesundheitsversorgung sichern und weiterentwickeln: Maßnahmen und Perspektiven.

In the German statutory health insurance system, quality healthcare is an imperative - healthcare must correspond to current medical knowledge. The central decision-making body, the Federal Joint Committee (G-BA), uses directives to regulate quality standards and instruments to ensure compliance. The Institute for Quality Assurance and Transparency in Health Care (IQTIG) supports the G­BA in this task with independent scientific recommendations. A central task of the institute is the development of quality indicators based on billing data, patient records, and patient surveys.With regard to instruments for the improvement of quality, the IQTIG distinguishes between improvement instruments, instruments based on selection decisions, and instruments based on incentives for providers. Quality improvement requires quality management and intrinsic motivation on the part of the providers. However, due to perverse incentives, intrinsic motivation and thus quality improvement alone are not always sufficient and must be supplemented by extrinsic incentives and other instruments. In particular, instruments enabling quality-oriented physician and hospital choice have not yet been implemented in Germany. The quality information required to enable patients to make such choices does not yet exist and should be based on billing data and patient surveys. Further, such quality information should be presented as simply and understandably as possible on online comparison platforms.To ensure high-quality healthcare, the various instruments for improving quality must be coordinated with one another and aligned with a system of healthcare targets. Such a system of overarching healthcare targets allows the limited resources to be focused on those areas in which the need for action is greatest.

Introduction of quality indicators in German hospital capacity planning - Do results show an improvement in quality?

In Germany, the use of quality data to support hospital capacity planning was introduced in 2017. On behalf of the Federal Joint Committee, IQTIG suggested 11 quality indicators and developed a program on how to collect, evaluate and report data for the clinical areas gynaecological surgery, obstetrics and breast surgery. By analysing data from 2015 to 2021, effects of the introduction of the program on indicator results, statistical discrepancies and impact on care quality are examined. Effects on capacity planning are discussed. Since the program started, indicator results improved in all clinical areas, and statistical discrepancies and the number of assessments with insufficient quality decreased due to enhanced adherence to quality standards and data validity. Effects on capacity planning or the allocation of hospitals have not occurred. Thus, a change of the legal basis to allow a better link between quality and hospital planning is recommended. The approach to use quality data on hospital regulation in Germany is evolving. The current hospital reform in Germany also addresses other approaches to quality-based regulation. Already now, there have been clear improvements in specific indicators as well as lessons for quality assurance and its link to capacity planning provided by the program, which are also applicable to other countries.

[One year of the Health System Modernization Act and its impact on the quality in medicine from the German Medical Association's point of view]. / Ein Jahr GMG--Auswirkungen auf die Qualität in der Medizin aus Sicht der Bundesärztekammer.

Both the demographic development in Germany and simultaneously expanding treatment options are creating an ever increasing need for medical care, despite stagnating health insurance contributions. By introducing competition, intensifying benefits assessment and improving patient participation the German legislator has tried to provide a fresh impetus through a recent Statutory Health System Modernisation Act (GMG) in order to release potential profitability reserves for the benefit of the statutory health insurance system. Just one year after the modernisation law came into effect, it is not yet possible to make conclusions about the potential effects of these regulatory instruments on the quality of healthcare because the measures set off by the GMG for restructuring the provision of care are still ongoing. However, the experience from other countries shows that introducing competition into the healthcare system may contribute to improving the allocation of resources in a very limited manner only.

[Individual healthcare services in the ambulatory sector]. / Individuelle Gesundheitsleistungen im ambulanten Bereich.

Even in Germany where the majority of the population is insured under the Statutory Health Insurance system (SHI), there is an increasing need for taking more personal responsibility for healthcare services and more private participation in healthcare costs, which is due to continuously stagnating contributions to the German Statutory Health Insurances. "Medical services on individual demand" (IGeL) is the term used to denote a special choice of healthcare services that are available to SHI members, but not reimbursed by the SHI system. Despite the growing demand private healthcare services in the form of "medical services on individual demand" are not generally accepted, neither by all patients nor all physicians. Opponents criticise that "medical services on individual demand" are of less or no benefit to the patients. In 2006, the German Medical Assembly adopted a policy statement including ten basic principles that are intended to help doctors distinguish between useful and unnecessary private healthcare offers, and avoid conflicts with the professional code of conduct.

[The relevance of quality of life for the work of the Federal Joint Committee]. / Die Bedeutung von Lebensqualität für die Arbeit des Gemeinsamen Bundesausschusses.

As the highest decision-making body of the joint self-government of physicians, dentists, hospitals and health insurance funds in Germany, the Federal Joint Committee (G-BA) is responsible for determining the catalogue of benefits for those insured by statutory health insurance (SHI) funds. The G-BA uses patient-relevant, health-related quality of life outcomes as a decision criterion in the assessment of new examination or treatment methods, the benefit assessment of new pharmaceuticals, the quality assurance of services, and in determining treatment goals for disease management programmes and special forms of care. But the data generally available on quality of life are considered insufficient by the G-BA. Studies submitted for methods assessments or the benefit assessments of pharmaceuticals often lack findings on quality of life, or the data are of limited value due to methodological shortcomings. Because the burden of disease is shifting more and more towards chronic and oncological diseases due to demographic changes, the G-BA considers an improvement in the data available on health-related quality of life to be urgently necessary.

[Points of view: the role of quality measurement from the Federal Joint Committee's perspective]. / Perspektive: Rolle der Qualitätsmessung aus Sicht des Gemeinsamen Bundesausschusses.

The Federal Joint Committee (G-BA) is a central decision-making body that issues binding directives to ensure the quality of both inpatient and outpatient health care services within the German Statutory Health Insurance system. Quality measurement on the basis of quality indicators has proceeded furthest in the field of external quality assurance (QA) of inpatient services. Originally designed for quality development in a "protected environment" through learning from better practices, it has been faced with new expectations since competitive elements have been introduced into the health care system. The economisation of medicine is de facto the driving force of the development of QA measures. In terms of health policy, the 2013 coalition agreement includes "a renaissance of the concept of quality competition". In particular, this is meant to strengthen the decision-making options of insured persons by creating more transparency into the quality of not only inpatient but also outpatient care and, if necessary, to support the possibility of selective agreements with individual health insurance funds. The campaign planned to improve the quality of hospitals also provides for a quality-oriented advancement of hospital planning and funding; and the Federal Joint Committee, supported by the new Institute for Quality Assurance and Transparency in the Healthcare System in accordance with Section 137a of Book V of the Social Code (SGB V) in the GKV-FQWG version will be assigned new tasks within this context, too. On the whole, the measures already agreed upon in the Act to Improve the Financial Structure and Quality of the Statutory Health Insurance System (GKV-FQWG) and­as far as can now be anticipated­the proceedings of the working group set up between the German government and the German federal states indicate that there is a high need to improve the methods and tools of external quality assurance available, starting with questions about the validity of the quality indicators used and their relevance to patient care. Special issues and tasks require the development of new methods and tools. The need for paying more attention to the patient perspective will pose a particular challenge to future quality measurement. Additional information about the QA documentation of health care providers and the basis of social data that should be used preferentially can be gained from patient surveys. Despite the high political expectations (for example, concerning the development of online charts comparing the quality of inpatient care delivery), the Federal Joint Committee should not overlook the necessity of embedding quality measurement and public reporting into a comprehensive quality framework which can be used to promote continuous quality improvement through a structured feedback of the results to health care providers. In addition, we need a consistent patient orientation and a systematic evaluation of the QA measures employed. By networking more closely with evidence-based medicine and health services research, quality assurance may give rise to a systematic quality research from which genuine quality and care objectives can be derived and which, as an integral part of a "learning care", supports a patient-oriented advancement of care structures.

[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.