RESUMEN
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.