[Health services research : Definition, objective, method and perspectives]. / Versorgungsforschung : Definition, Gegenstand, Methodik und Perspektiven.

This overview article highlights the central role of health services research (HSR) for the further development of the healthcare system. As a young scientific discipline in Germany, HSR covers five important elements with different weighting in different definitions, which are elaborated in some detail in this article: patient orientation, results and outcome orientation at the patient and population levels, implementation perspectives and context relation, complex interventions and improvement, multidisciplinarity and multiprofessionalism. One of the fundamental pillars of HRS is related to the insufficient implementation of scientifically proven treatment methods and improvement strategies into routine patient care. Healthcare research is therefore the so-called second translation of clinical trials in the routine daily care (from bedside to practice) after the first translation from bench to bedside. The scientific methods used in HSR clearly extend beyond the spectrum of (clinical) epidemiology. The methodological standards are developed as consensus memoranda of members of the German network of HSR, which serve as orientation points for qualitatively good HSR. Finally, various perspectives for the long-term safeguarding and improvement of the quality of HSR in Germany are proposed.

[The Willingness to Consent to the Linkage of Primary and Secondary Data: An Analysis Based on a Survey of Patients with Primary Breast Cancer in Northrhine Westfalia]. / Die Bereitschaft zum Datenlinkage von Routinedaten und Primärdaten ­ Eine Analyse auf Basis der Befragung von Patientinnen und Patienten mit primärem Mammakarzinom in NRW.

Introduction: By linking data it is possible to merge, for example, survey data with routine data from statutory health insurance (GKV), to gain benefit from the advantages of both. As personal data is involved, it is necessary to obtain consent. Previous studies show that willingness to release this kind of data for scientific research is limited. This fact restricts the number of participants and can cause selection bias. The aim of our study was to analyze willingness to consent to the linkage of survey data with statutory health insurance data in patients with primary breast cancer. Associations between approval and socio-demographic characteristics were explored. Method: In the annual survey of patients with primary breast cancer in certified breast centers in North Rhine-Westphalia, all included patients were questioned concerning their willingness to consent to data linkage. We distinguished between patients insured by AOK Rhineland/Hamburg and all other patients: based on cooperation with AOK Rhineland/Hamburg, we obtained consent to actually link the data for all patients insured there. All other patients were questioned in terms of their insurance and their willingness to consent in general. Results: A total of 2,387 questionnaires were returned, giving a return rate of 49.3%. For the AOK Rhineland/Hamburg-insured patients, the consent rate was at 89.6%. At 75.7%, positive attitudes towards data linkage turned out to be a bit lower for patients with other insurers. Under the assumption that all non-responders disapprove data linkage, still 38.1% of patients showed a positive attitude towards data linkage. As a result of the multivariable model, insurance status (private vs. statutory) and first language turned out to be the only significant factors influencing the response. The consent of patients insured by AOK Rhineland/Hamburg is not significantly influenced by any of the measured socio-demographic factors. Conclusion: Currently, there is not much knowledge on the acceptance of data linkage in patients suffering from an acute illness. Although our results are restricted to breast cancer patients, they are able to uncover problems and chances concerning data linkage.

[Health services Research Faces New Challenges: Consequences for Definition and Concept]. / Versorgungsforschung vor neuen Herausforderungen: Konsequenzen für Definition und Konzept.

In Germany, Health Services Research (HSR) is undergoing rapid and impressive development. Starting from the translation of methods in individual health care (efficacy-effectiveness gap) and the social-scientific description as well as analysis of health care structures and processes, now it is the implementation of complex interventions on the organizational and system level that is the center of interest. This development is mainly triggered by the establishment of the so-called innovation funds by means of legislation in 2015, which has the task to evaluate structural changes and reforms in outpatient and integrated health care. Moreover, benefit and improvement at patient and population level is getting attention. Against this background, in this paper the current definition of HSR is modified so that the term "intervention" is extended to include organizational and system interventions, the focus on population is added to the patient perspective, and the orientation to appropriateness of care and improvement is integrated. Parallel to this, the theoretical throughput model as established by Pfaff in 2003 is updated, including 4 aspects: (1) the input factors of first order (resources of stakeholders) are expanded by complex interventions and active context as input factors of second order, (2) both undergoing modulation during the following throughput, (3) the final outcome is expanded by the population perspective, and (4) feedback loops from output and outcome to input and throughput are established. The "double complexity" of intervention and context as well as their interaction during throughput is the central and most important issue, because the interventions are highly context-sensitive and the complex context is most potent and poorly anticipated at the same time. Improvement science and implementation research represent fields of research from the perspective of improvement and the translation of knowledge and change of attitude, respectively, which are of great importance for HSR. Insofar as HSR is dealing with improvement and translation of complex interventions, the health care politics constitute an important transfer factor itself. Considering that, in the present situation, the political level represents both the main sponsor and the main demander of HSR results, improving methodological standards and further expansion of research structures of HSR are urgently needed.

[Contribution of Health Care Research to Establishing Social Equality in Health and Health Care Opportunities]. / Der Beitrag der Versorgungsforschung zur Chancengerechtigkeit in der Gesundheit und in der Versorgung.

Social inequalities in health and health care services represent issues of major concern. Findings in this area reveal inequalities in health and health care indicating disadvantages for individuals with a low socioeconomic background. Although the health care system plays a marginal role in the explanation of inequalities in health, health services research can be an important part in the development of equal health opportunities. The current article describes the causal associations between social inequalities, health inequalities and the health care service. Health services research can make a contribution to increasing equal opportunities in health and health care service. Against this background, we discuss the existing potential and need of research in the area of health services.

Ten Years of Patient Surveys in Accredited Breast Centers in North Rhine-Westphalia.

Introduction: Patient surveys are an established tool for quality control in healthcare organizations. This report looks at the design and development of the annual patient surveys carried out among breast cancer patients treated in the Breast Centers of North Rhine-Westphalia and discusses selected findings from 10 consecutive years. Material and Methods: Since 2006 the Institute for Medical Sociology, Health Services Research and Rehabilitation Science (IMVR) of the University of Cologne has carried out an annual survey of breast cancer patients using the Cologne Patient Questionnaire for Breast Cancer. The patients included in the survey have been diagnosed with primary breast cancer and undergo surgery between February and July in one of the Breast Centers in North Rhine-Westphalia accredited by the medical association of Westphalia-Lippe. The questionnaire and the type of feedback given to the Breast Centers were comprehensively revised in 2014. Selected results collected over the survey period were analyzed descriptively. Results: The survey period of 10 years provides information on the actual medical care delivered in the Breast Centers based on the data obtained in this period from around 40 000 patients. Some areas showed positive developments over time. Conclusion: The approach used to survey patients, the Cologne Patient Questionnaire for Breast Cancer 2.0 and the benchmark-focused feedback provide an impetus for organizational learning in Breast Centers. The concept could also be used in other healthcare organizations to stimulate learning and improve healthcare services.

[Promotion of Young Scientists in Health Services Research - Evaluation of the Third Early Career Investigators Workshop in Health Services Research of the German Research Foundation (DFG)]. / Wissenschaftliche Nachwuchsförderung in der Versorgungsforschung - Ein Rückblick auf die DFG Nachwuchsakademie Versorgungsforschung 2014.

The third Early Career Investigators Workshop in Health Services Research (NWA) of the German Research Foundation (DFG) was initiated and hosted in 2014 by the Centre for Health Services Research Cologne (ZVFK) in cooperation with the Centre for Health and Society (CHS) in Dusseldorf and the Interdisciplinary Centre for Healthcare Research (IZVF) in Witten. The aim of the NWA participation was submitting a research proposal to the DFG. Young scientists were invited to apply with a draft proposal. A total of 100 applications were received. Out of these, 20 participants (15 women and 5 men) were selected. The disciplines most frequently represented were medicine, psychology, and sociology. After a one-day preparatory workshop, the preparation and evaluation of a project proposal, a 5-day academy and finalization of the proposal, a total of 19 research proposals were submitted to the DFG, out of which 10 were approved. The funded projects will be presented in 2015 at the German Conference of Health Services Research (DKVF).

[Prioritization and Consentation of Criteria for the Appraisal, Funding and Evaluation of Projects from the German Innovationsfonds: A multi-perspective Delphi study]. / Priorisierung und Konsentierung von Begutachtungs-, Förder- und Evaluationskriterien für Projekte aus dem Innovationsfonds: Eine multiperspektivische Delphi-Studie.

BACKGROUND: The German Innovationsfonds provides the chance for evidence-based developments of the German healthcare system. OBJECTIVE: Prioritization of recommendations for an effective, efficient, fair, transparent, and sustainable granting of funds through a transparent, evidence-driven consensus-process involving all relevant stakeholder groups. METHODS: Representatives from health and research policy, payers, patient representatives, healthcare providers, and scientists were invited to nominate participants for an electronic 3 round iterative Delphi-study to prioritize the thematic focus, requirements concerning study methods, the team of applicants, evaluation, utilization of study results, and for the selection of reviewers. Criteria considered as relevant by at least 60% of the panel (consensus definition) in the first 2 Delphi rounds were rated as facultative, preferable, or obligatory criteria for project funding. Data were analyzed descriptively. ( REGISTRATION: Datenbank Versorgungsforschung Deutschland VfD_15_003561). RESULTS: All invited stakeholder groups except payers participated. 34 (85%) of 40 nominated representatives participated in the Delphi-study. A total of 64 criteria were consented as relevant for project review and funding concerning the thematic focus (n=28), methodological requirements (n=13), requirements for applicants (n=4), for the evaluation (n=4), utilization (n=6), and selection of peer reviewers (n=9). DISCUSSION: It is the collective responsibility of all stakeholders to spend the designated funds as efficient and sustainable as possible. The consented recommendations shall serve decision makers as a resource for the granting of funds and the evaluation of the Innovationsfonds.

[Turnover of Non-medical Staff in Outpatient Oncology Practices: Is Building Social Capital a Solution?]. / Fluktuation bei nicht-ärztlichem Personal in onkologischen Schwerpunktpraxen: Sozialkapitalaufbau als Lösungsansatz?

STUDY AIM: While a lot is known about potential and actual turnover of non-medical hospital staff, only few data exist for the outpatient setting. In addition, little is known about actual instruments which leaders can use to influence staff turnover in physician practices. In the literature, the social capital of an organisation, which means the amount of trust, common values and reciprocal behaviour in the organisation, has been discussed as a possible field of action. In the present study, staff turnover as perceived by outpatient haematologists and oncologists is presented and analysed as to whether social capital is associated with that staff turnover. In conclusion, measures to increase the social capital of a practice are presented. METHODS: The present study is based on data gathered in a questionnaire-based survey with members of the Professional Organisation of -Office-Based Haematologists and Oncologists (N=551). The social capital of the practice was captured from the haematologists and oncologists using an existing and validated scale. To analyse the impact of the practice's social capital on staff turnover, as perceived by the physicians, bivariate correlations and linear regression analyses were calculated. RESULTS: In total, 152 haematologists and oncologists participated in the study which represents a response rate of 28%. In the regression analyses, social capital appears as a significant and strong predictor of staff turnover (beta=-0.34; p<0.001). CONCLUSIONS: Building social capital within the practice may be an important contribution to reducing staff turnover although the underlying study design does not allow for drawing causal conclusions regarding this relationship. To create social capital in their practice, outpatient physicians may apply measures that facilitate social interaction among staff, foster trust and facilitate cooperation. Such measures may already be applied when hiring and training new staff, but also continuously when leading employees and when organising work tasks, e.g., by establishing regular team meetings.

Can a stressed oncologist be good in a consultation? A qualitative study on the oncologists' perception.

The aim of this exploratory study was to examine how the working conditions and job stress of private practice oncologists (PPOs) affect their interaction with patients. Data for the study were collected through semi-structured interviews with PPOs selected based on purposeful sampling criteria. The data were evaluated using content analysis. Factors perceived by PPOs to influence their level of stress and patient care were some of their own personal characteristics as well as working conditions both within and outside their practices. Apart from being able to name specific stressors (e.g., dysfunctional organisational workflow and interruptions during medical encounters), the oncologists also mentioned individual and organisational resources (e.g., professional experience, well-educated nurses and good work organisation) for coping with job stress and improving interaction with patients. Within this study, we identified some obstacles on the individual and organisational level for good patient care, as working conditions which might lead to time pressure and stress, which subsequently have an impact on quality in patient care (e.g., less time for personal issues during patient consultations). Future stress research should conduct a more in-depth investigation of these and other interventions at both the individual and organisational levels in order to improve patient care.

Is having quality as an item on the executive board agenda associated with the implementation of quality management systems in European hospitals: a quantitative analysis.

OBJECTIVE: To assess whether there is a relationship between having quality as an item on the board's agenda, perceived external pressure (PEP) and the implementation of quality management in European hospitals. DESIGN: A quantitative, mixed method, cross-sectional study in seven European countries in 2011 surveying CEOs and quality managers and data from onsite audits. PARTICIPANTS: One hundred and fifty-five CEOs and 155 quality managers. SETTING: One hundred and fifty-five randomly selected acute care hospitals in seven European countries (Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey). Main outcome measure(s) Three constructs reflecting quality management based on questionnaire and audit data: (i) Quality Management System Index, (ii) Quality Management Compliance Index and (iii) Clinical Quality Implementation Index. The main predictor was whether quality performance was on the executive board's agenda. RESULTS: Discussing quality performance at executive board meetings more often was associated with a higher quality management system score (regression coefficient b = 2.53; SE = 1.16; P = 0.030). We found a trend in the associations of discussing quality performance with quality compliance and clinical quality implementation. PEP did not modify these relationships. CONCLUSIONS: Having quality as an item on the executive board's agenda allows them to review and discuss quality performance more often in order to improve their hospital's quality management. Generally, and as this study found, having quality on the executive board's agenda matters.

Influence of Patient and Hospital Characteristics on the Performance of Direct Reconstruction after Mastectomy.

Aim: International studies have shown that the performance of a direct (or immediate) reconstruction (DR) after mastectomy is associated with patient (e.g., socio-economic status, insurance status, age) and hospital (number of cases, teaching status) characteristics. The present article addresses the question if such relationships also exist in Germany. Material and Methods: The results of a nationwide questionnaire to the patients of certified breast cancer centres were coupled with the clinical features of the patients and the characteristics of the hospital. Predictors for receiving a DR (vs. delayed or no reconstruction) were estimated by means of a logistic multilevel model for a sample of 1165 patients from 105 certified locations. Results: Substantial differences between the treating hospitals were found (intraclass correlation coefficient null model: 0.195) which can in part be explained by the total model (total model: 0.169). Patients with the following features are more likely to receive a DR: younger age, private health insurance, secondary school leaving certificate (vs. primary school leaving certificate), lower stage and acquisition of more information about reconstruction. ASA and partnership status are not statistically significantly related with DR. DR is more likely to be performed in hospitals with higher caseload of patients with primary breast cancer. Teaching status, operations per surgeon and urbanity of the location are not related to receiving a DR. Conclusions: Non-clinical features of the patients and the primary case number are associated with the performance of a DR, this poses questions concerning reasons and the equality of health care.

[Thrombolysis for acute stroke--a nationwide analysis of regional medical care]. / Thrombolyse des akuten Schlaganfalls--Eine deutschlandweite Analyse der regionalen Versorgung.

BACKGROUND: This study aims at investigating ischaemic stroke therapy in Germany by using secondary data. The focus lies on the performance of thrombolysis. METHODS: Statutory quality report data for 2010 were obtained. All hospitals (n = 1302) treating patients suffering from an ischaemic stroke either on a neurological, internal, geriatric or intensive care unit were analysed. The treatment situation, defined as the experience in performing thrombolysis, was displayed cartographically. Potential variables that may influence the thrombolysis rate were analysed. RESULTS: 78 % of the 198,500 ischaemic stroke cases were treated on a ward specialised in the stroke treatment (i. e., a stroke unit). The mean thrombolysis rate in neurological departments was 9.1 %. Thrombolysis rates between departments ranged from 0 to 38 %. Significant factors influencing the thrombolysis rate were the total number of ischaemic strokes treated as well as the existence of a stroke unit. DISCUSSION: In Germany, to date regional differences in the treatment of ischaemic stroke exist. Experience in the treatment of ischaemic stroke patients and the availability of a stroke unit both increase the thrombolysis rate. Data suggest that in Germany there is still room for improvement of appropriate ischaemic stroke treatment.

[The conflict between work and private life and its relationship with burnout - results of a physician survey in breast cancer centers in North Rhine-Westphalia]. / Der Konflikt zwischen Arbeit und Privatleben und sein Zusammenhang mit Burnout - Ergebnisse einer Studie bei Ärztinnen und Ärzten in nordrhein-westfälischen Brustzentren.

This study investigates the conflict between work and private life (work-life conflict and life-work conflict) and its relationship with burnout among physicians in breast cancer centers in North Rhine-Westphalia (n=378). With regard to the construct burnout, we differentiated between the 3 subscales emotional exhaustion, depersonalisation and personal accomplishment of the Maslach burnout inventory. In a structural equation model it was seen that above all the work-life conflict is positively associated with emotional exhaustion whereas the life-work conflict has a stronger positive correlation with depersonalisation and a negative relationship with personal accomplishment. Altogether, the results emphasise the importance of a successful interaction between professional work and private life ("work-life balance") for the health of medical personnel.

[Adjusting for patient characteristics when evaluating questionnaire data]. / Adjustierung für Patientenmerkmale bei der Auswertung von Befragungsdaten.

INTRODUCTION: Patient questionnaires are a frequently used instrument within the framework of quality management in in- and outpatient care. Often such questionnaires enable a comparison of care suppliers with the consequence that one turns out to be visibly better or poorer than another. This process, in turn, makes it necessary to check whether differences found upon evaluation of the questionnaires are not merely the result of different compositions of the questioned populations. Although frequently demanded, such adjustments are not usually made. The present article describes the choice of variables for adjustments and the statistical procedures for a relatively homogeneous sample of breast cancer patients. In addition, the utility and limitations of adjustments are discussed. METHODS: On the basis of questionnaire data from 3 840 breast cancer patients of 52 breast cancer centres in North Rhine-Westphalia collected during 2010, we examined which patient characteristics can be employed for the adjustment of satisfaction ratings and to what extent the observed values for the centres differed from the expected results. Independent variables taken into consideration were age, educational level, native language, stage, grading, ASA classification, afffected breast, type of operation, insurance status, partnership status as well as time between operation and receipt of the filled out questionnaire. RESULTS: The variance revealed by the independent variables is low. The expected values showed minimal differences which can be attributed to the high homogeneity of the patients collectives and the centres. CONCLUSION: The use of adjustments remains limited in the study population. The variance of the independent variables revealed by the adjustors is small. Finally, in our opinion, no clear recommmendation for or against case-mix adjustments can be made in patient populations such as the one examined here. Thus, even when small, effects for a more correct reporting of patient questionnaires are faced with unresolvable methodological challenges. Also of importance but an as yet only rarely discussed factor is the factual intepretation of the association of patient characteristics with a better or poorer evaluation of questionnaires. An adjustment for the respective characteristics would eliminate these findings and not make any contribution to an improvement in health care.

[Elderly prostate cancer patients: patient information and shared decision making]. / Der ältere Prostatakrebspatient : Information und Einbezug in die Therapieentscheidung.

INTRODUCTION: Some data exist on information and decision-making preferences of elderly prostate cancer patients but little is known about whether communication needs are being met in urological practice. Therefore, it was the aim of this study to examine the information and shared decision-making experiences of prostate cancer patients over 75 years old. MATERIALS AND METHODS: The HAROW (hormonal therapy, active surveillance, radiation, operation and watchful waiting) study is a prospective, observational study designed to collect clinical data and patient reported outcome of different treatment options for patients newly diagnosed with localized prostate cancer under real conditions. At 6-month intervals general clinical data, PROs (e.g. quality of life, quality of physician-patient interaction) and individual costs are documented. Data from 2,482 patients at 4 time points from T0 (initial diagnosis) to T3 (24 months follow-up) were analyzed. RESULTS: T-tests and χ(2)-tests revealed no significant differences in terms of shared decision-making and information to different treatment options between patients aged over 75 years old and the rest of the sample. Regarding information on self-help groups, rehabilitation options and a second medical opinion, there were significant differences between prostate cancer patient age groups: patients aged over 75 years old received less information on these aspects at all points in time. CONCLUSION: Patients at all ages feel activated by urologists and are informed about different treatment options. However, there is room for improvement in terms of informing especially elderly prostate cancer patients about rehabilitation, second medical opinions and self-help groups. Special information tools and decision aids for prostate cancer patients aged over 75 years old should be developed and implemented to meet the specific information needs.

[The future issues of health services research: what do experts say?]. / Zukunftsthemen der Versorgungsforschung - Was meinen die Experten?

BACKGROUND: The expectations of health services research are growing with its recognition and acceptance as an independent field within health research. What are the issues that health services research should deal with in future to perform the tasks it will be confronted with? Different health-care players like physicians, scientists, sponsors, and third-party payers were invited to give answers to these questions which was the aim of the workshop held in Cologne on the 8th November 2010. The IMVR (Institute for Medical Sociology, Health Services Research, and Rehabilitation Science, University of Cologne) and WINEG (Scientific Institute of TechnikerKrankenkasse for the Benefit and Efficiency in Health Care) jointly hosted the 'Expert Workshop - Future Issues of Health Services Research' in order to get closer to meeting this goal. METHODS: Experts met in 4 focus groups to identify the future issues of health services research in the one-day workshop in Cologne in November 2010. The participants discussed their proposed issues in a moderated session and decided on the key future issues of health services research in a double voting procedure. RESULTS: 36 experts accepted the invitation. Of these 6 were experts of the medical profession, 4 of the group of sponsors, 13 scientific experts and 13 experts of the groups of third-party payers. According to their rating, "intersectoral networking", "patients' preferences", and "the evaluation of innovations, processes, and methods" are the 3 key future issues of health services research. CONCLUSIONS: The experts developed the key future issues for health services research according to their opinion. They answered the question on the issues, health services research should be occupied with in future, i.e. a broad range of topics. To a certain extent, they returned to former issues and problems for which satisfactory solutions have not yet been found.

[Relationship between organisational structure and worksite health management in the information technology and communications sector]. / Zusammenhänge zwischen der Betriebsstruktur und Betrieblichem Gesundheitsmanagement in der Informationstechnologie- und Kommunikationsbranche.

AIM OF THE STUDY: Worksite health management (WHM) can positively influence employee health and performance. However, it has not yet been comprehensively implemented in companies. This study aims to identify the role of organisational structures in the implementation of WHM. METHODS: In this cross-sectional study, data were collected on the companies' WHM and the organisational structure. Out of 522 randomly selected companies within the German information technology and communication (ITC) sector, one managing director for each company was being questioned through telephone interviews. Bivariate and multivariate logistic regression analyses were conducted. RESULTS: The results of the study reveal that the implementation of WHM is positively correlated with a large company size (OR 2.75; 95%-CI 1.10-6.88) and with the existence of an employee representation (OR 2.48; 95%-CI 1.54-3.98). Other structural characteristics, such as the employment of a company physician, the percentage of temporary workers as well as the staff's age and sex distribution do not seem to have a significant impact on the implementation of WHM. CONCLUSIONS: The results indicate that the implementation of WHM can only be explained to a certain degree by organisational structures. However, the findings highlight the fact that companies with few structural resources are in particular need of tailored support when implementing WHM.

The Patients' View On Accredited Breast Cancer Centers: Strengths and Potential for Improvement.

Breast Care Centers that were accredited according to the German Cancer Society criteria were offered to participate in a standardized patient survey in 2010, which was conducted by the Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Human Science and Faculty of Medicine, University of Cologne. Patients were included consecutively between March and November 2010. The Cologne Patient Questionnaire-Breast Cancer (CPQ-BC) was used, which assesses a number of aspects of hospital care as perceived by the patients, among them provider-patient interaction, the disease-specific information provided, the quality of organization, and room amenities. 128 of 195 Breast Care Centers and 160 of 251 hospitals participated in the study. 8226 patients consented to the survey. The questionnaires of 7301 patients could be included in the analyses (89 %). Overall, the results showed that patients are satisfied with their hospital stay and that the accreditation criteria are implemented in a way that serves the patients. However, there is room for improvement for a number of issues, for example with regard to the provision of information and patient involvement in decision making. In addition, for a number of indicators substantial differences were found between the hospitals. The results of the survey provide information on the breast centers' development and can be used by the centers' surgery locations for benchmarking purposes, to identify strengths and weaknesses, and to take actions.

Key Informants' Perspectives on Accredited Breast Cancer Centres: Results of a Survey.

This paper presents the results of a survey among key informants that was conducted between June and September 2011 in Breast Cancer Centers that were accredited according to the criteria of the German Cancer Society (DKG). The survey intended to assess the degree to which the breast cancer center concept was accepted among the key informants as well as to gain an overview over structures and processes in the centers. The Questionnaire for Breast Cancer Centres Key Informants 2011 (FRIZ 2011) was used with two reminders having been sent out. Questionnaires were sent back from 149 of the 243 initially contacted hospitals (response rate: 61.3 %). The vast majority of respondents indicated to be part of the Breast Cancer Center management. 110 of the 149 hospitals did also participate in the patient survey conducted in 2010. Among the key informants surveyed, the concept is highly accepted with regard to improvements in patient care. Overall, the concept is regarded as "good" or "very good" by almost all respondents. Both contact to resident doctors and the hospitals' reputations improved since the implementation of the concept. Quality and patient safety were more often on the agenda than financial performance in the quality circles with the main co-operation partners of the Breast Cancer Centers.