[Services for persons with mental illness in Germany from the perspective of the health and social system: current needs for development]. / Die Versorgung von Menschen mit psychischen Erkrankungen in Deutschland aus Perspektive des Gesundheits- und Sozialsystems: Aktuelle Entwicklungsbedarfe.

SUBJECT: The article provides an overview on the current state of service provision for people with psychiatric illnesses, financed by health-insurance companies, the rehabilitation and participatory systems, and the German Federal States. Over the last 20 years, service capacities have continually improved. Three areas that are in need of further development are highlighted here: the coordination of services for mentally ill persons with complex needs; the long-term placement of persons with severe mental illness and challenging behavior; and a growing shortage of specialists. CONCLUSIONS: The mental health system in Germany is largely well to very well developed. Despite this, specific groups do not benefit from the available assistance, and these often end up as "long-term patients" in psychiatric clinics. Models for coordinated and outpatient-oriented service provision for persons with severe mental illness exist, but are only sporadic. Intensive and complex outreach services in particular are lacking, as are service concepts that are able to cross the boundaries of social security responsibilities. The shortage of specialists, which affects the whole mental health system, requires restructuring toward a more outpatient-care focus. The first tools for this exist within the health insurance-financed system. They should be used.

[A Standard of Centers for Community Psychiatry in Lower-Saxonia - Checklist and Model Fidelity Scale]. / Ein Standard für Gemeindepsychiatrische Zentren in Niedersachsen ­ Checkliste und Modelltreueskala.

OBJECTIVE: Definition of a standard for structures and processes of Centers for Community Psychiatry (CCP) that aim at providing mobile, multiprofessional, complex and intensive outpatient care to patients with severe mental illness. METHODS: The standard was developed and consented using a mix-method approach and by involving all relevant stakeholders, including first hand experts and service providers of three CCP model-projects in Lower-Saxonia. RESULTS: The standard comprises a checklist with 12 binary and obligatory CCP features as well as a model fidelity scale with 45 scaled items in 9 dimensions. CONCLUSION: For the first time, a CCP-standard is available that offers a quantifiable and verifiable catalogue of features essential for CCPs. The standard orients at the S3 guideline "Psychosocial Therapies".

[Resilience after Flight: Perspectives of Refugees and Supporting Practice Actors]. / Resilienz nach der Flucht: Perspektiven von Geflüchteten und unterstützenden Praxisakteur*innen.

STUDY OBJECTIVES: The study aims to identify (aim 1) and relate (aim 2) refugees' and practice actors' perspectives on resilience after a flight to broaden the depth of understanding of postflight resilience and to provide insights into relationships between practice actors and refugees. METHODS: Three guideline-based focus groups with refugees (N=9) and practice actors (N=13) to assess the perspectives of both groups on resilience after flight were conducted in German. They were analyzed iteratively according to Constructionist Grounded Theory. RESULTS: Refugees and practitioners report the strains of uncertainty and limitation, the adaptation processes of commonality and endeavor, and the adaptation goals of stability, connectedness, and positive emotionality (goal 1). The statements of refugees and supporting practice actors on resilience after flight concur strongly regarding their content and complement each other. Refugees report more individualized and more specifically than practice actors (goal 2). DISCUSSION: The aspects of resilience mentioned by refugees and supporting practitioners replicate the results of previous qualitative studies on post-flight resilience conducted with refugees. Both the strain of partly not knowing adequate adaptation options locally and attempts to create resilience-promoting conditions seem to be specific to the resilience of refugees. The content-related similarities between refugees and practice actors might stem from experiences of the practice actors in the context of support processes or from similar life experiences of the practice actors. The less individualized approach to post-flight resilience of the practice actors may be caused by a higher level of abstraction, role expectations, or coping with emotional distress. CONCLUSION: The results of the study suggest that refugee resilience is characterized by universal and population-specific aspects. That practice actors who support refugees and refugees concur on the content of post-refugee resilience validates the findings of previous qualitative studies on post-refugee resilience. The study also identified different approaches to post-flight resilience among refugees and practitioners, whose causes require further research.

[The Impact of Treatment Volumes of Psychiatric Clinics on the Risk for Applying Seclusion or Restraint]. / Der Einfluss des Behandlungsvolumens psychiatrischer Kliniken auf das Risiko der Anwendung besonderer Sicherungsmaßnahmen.

AIM: To determine the effect of treatment volumes on the frequency and duration of special safety measures (SSM) such as seclusion or restraint. METHOD: Register Data of the Lower Saxony Ministry of Social Affairs, Health and Equal Opportunities is analysed for the number of cases hospitalised under State Mental Health Act, the proportion of cases experiencing SSM, and the frequency and cumulative duration of SSM per case. RESULTS AND DISCUSSION: The larger the treatment volume of cases that are hospitalised under State Mental Health Act, the smaller the proportion of cases experiencing SSM. This result is robust, even if statistical outliers are exempted from analyses. CONCLUSIONS: In light of indications that also in mental health care treatment volumes may be related to the desired treatment outcome, discussion is need about the tension between hospital care that is provide.

[Necessity and Ways to Develop Care Goals for the Health System in Germany - a Position Paper of the DNVF]. / Notwendigkeit und Wege zur Entwicklung von Versorgungszielen für das Gesundheitssystem in Deutschland ­ ein Positionspapier des DNVF.

Goals for health and health care are an indispensable basic requirement for a functioning health care system. The dilemma of the German health care system is that it has not been designed in a planned way, but that it has grown historically. In recent years, it has developed through the free play of forces into what it is today. The OECD characterizes the current state as follows: The costs of the German health system do not correspond to the often only average health outcomes for the population. To meet the legal requirements (especially SGB V §§ 12, 27 and 70), health care/the health system in Germany needs concrete goals. An orientation towards health care goals entails measures on all levels of health care: on the macro level (overall system/total population), on the meso level (subdivided according to regions, specific population groups, etc.) as well as on the micro level (patients and health care providers). Based on national and international experiences, this position paper of the DNVF e.V. (German Network for health services research) shows the potential of how operationalised health care targets can ensure effective, affordable and high-quality health care. The coalition agreement of the current government propagates a reorientation with patient-related health care goals. Now it is important to derive concrete and realisable goals from this declaration of intent and to involve all important groups in the process. In addition, values and ethical standards for implementation shall be agreed upon in this process. The Health Ministry (BMG) should facilitate and promote the process of societal will-building for the definition of national health care goals. This requires a clear political will. As a result, the National Health Care Goals are available at the end of the process, which are published and maintained together with evidence-based facts as well as valid and resilient data in a Manual "National Health Care Goals". The operational responsibility for implementation could lie with the newly to be founded Federal Institute of Public Health, as already announced in the agreement of the governing coalition. The DNVF is willing to actively participate in the development of health care targets.

[The Strandet Ill: Long-Term-Inpatients in Psychiatric Hospitals and Departments]. / Die gestrandeten Kranken: Langzeitpatientinnen und -patienten in psychiatrischen Fachkrankenhäusern und Abteilungen.

In contrast to official mental health policy, psychiatric clinics accomodate long-term patients. AIM: To quantify this problem. METHOD: Cross-sectional assessment of the number of long-term patients in psychiatric clinics in Lower Saxony. RESULTS: 13 clinics of adult psychiatry report 60 long-term patients and one clinic for child and adolescent psychiatry reports 2 patients. Median duration of stay 9.5, maximum 215 months. Reasons for long-term hospitalisation include patients' challenging behaviour and, consequently, difficulties to find an accommodating long-term facility. DISCUSSION AND CONCLUSION: Housing willing to accommodate mentally ill persons with challenging behaviour is lacking, as well as local responsibility for the placement of these persons. Systematic transfer management from hospital to residential homes does not exist.

[Burden in parents of school-aged children during different phases of the COVID-19 pandemic in Germany: an analysis within the COVID-19 snapshot monitoring (COSMO) study]. / Belastung von Eltern mit Kindern im Schulalter während verschiedener Phasen der COVID-19-Pandemie in Deutschland: Eine Analyse der COVID-19-Snapshot-Monitoring-(COSMO­)Daten.

BACKGROUND: Parents face a variety of personal challenges during the COVID-19 pandemic, while simultaneously being confronted with additional, school-related pandemic containment measures. OBJECTIVES: To investigate burden in parents of school-aged children across different phases of the COVID-19 pandemic in Germany and to identify particularly affected subgroups. METHODS: The COSMO project is a repetitive cross-sectional survey monitoring the psychosocial situation of the population in Germany during the pandemic with a sample size of approximately n = 1000 respondents per survey wave. A quantitative analysis of COSMO data was conducted using closed survey questions on the item "burden" as the main outcome, and, if applicable, on parenthood-associated burden from March 2020 until January 2021. RESULTS: During the first COVID-19 wave, parents of school-aged children were significantly more burdened compared to the general study population. However, burden decreased significantly from March/April to June 2020. During the second COVID-19 wave in January 2021, burden was homogeneously high across all groups. Single parenthood, a low household income, having a chronic health condition, a COVID-19 infection and a migration background were associated with higher burden, although none of these factors was consistently significant across the survey waves. Mothers reported to be more affected by parenthood-related burden than fathers. CONCLUSIONS: School measures for infection control have to be weighed carefully against the psychological impact on parental burden with subsequent negative impact on the family system. An English full-text version of this article is available at SpringerLink as Supplementary Information.

Establishing a Mental Health Surveillance in Germany: Development of a framework concept and indicator set.

In the course of the recognition of mental health as an essential component of population health, the Robert Koch Institute has begun developing a Mental Health Surveillance (MHS) system for Germany. MHS aims to continuously report data for relevant mental health indicators, thus creating a basis for evidence-based planning and evaluation of public health measures. In order to develop a set of indicators for the adult population, potential indicators were identified through a systematic literature review and selected in a consensus process by international and national experts and stakeholders. The final set comprises 60 indicators which, together, represent a multidimensional public health framework for mental health across four fields of action. For the fifth field of action 'Mental health promotion and prevention' indicators still need to be developed. The methodology piloted proved to be practicable. Strengths and limitations will be discussed regarding the search and definition of indicators, the scope of the indicator set as well as the participatory decision-making process. Next steps in setting up the MHS will be the operationalisation of the single indicators and their extension to also cover children and adolescents. Given assured data availability, the MHS will contribute to broadening our knowledge on population mental health, supporting a targeted promotion of mental health and reducing the disease burden in persons with mental disorders.

Systematic review on women's values and preferences concerning breast cancer screening and diagnostic services.

BACKGROUND: There is still lack of consensus on the benefit-harm balance of breast cancer screening. In this scenario, women's values and preferences are crucial for developing health-related recommendations. In the context of the European Commission Initiative on Breast Cancer, we conducted a systematic review to inform the European Breast Guidelines. METHODS: We searched Medline and included primary studies assessing women's values and preferences regarding breast cancer screening and diagnosis decision making. We used a thematic approach to synthesise relevant data. The quality of evidence was determined with GRADE, including GRADE CERQual for qualitative research. RESULTS: We included 22 individual studies. Women were willing to accept the psychological and physical burden of breast cancer screening and a significant risk of overdiagnosis and false-positive mammography findings, in return for the benefit of earlier diagnosis. The anxiety engendered by the delay in getting results of diagnostic tests was highlighted as a significant burden, emphasising the need for rapid and efficient screening services, and clear and efficient communication. The confidence in the findings was low to moderate for screening and moderate for diagnosis, predominantly because of methodological limitations, lack of adequate understanding of the outcomes by participants, and indirectness. CONCLUSIONS: Women value more the possibility of an earlier diagnosis over the risks of a false-positive result or overdiagnosis. Concerns remain that women may not understand the concept of overdiagnosis. Women highly value time efficient screening processes and rapid result delivery and will accept some discomfort for the peace of mind screening may provide.

[Prevalences of Depression Among Adults: Comparative Analysis of a Nationwide Survey and Routine Data]. / Prävalenzen von Depressionen bei Erwachsenen ­ eine vergleichende Analyse bundesweiter Survey- und Routinedaten.

AIM: There are differences in the prevalence estimates of depressive disorders based on primary and secondary data. The reasons for this are, for instance, the use of divergent indicators and varying observation periods. This study examines the prevalence of depressive disorders using survey and routine data for a comparable survey period and age range. Effects of differences between data sources and indicators are estimated. METHODS: For 2010, 3 indicators are compared: in a population survey collected a) self-reported medical diagnosis of depression, b) diagnosis of depressive disorders identified by clinical interviews and c) administrative depression diagnoses collected from routine data of a statutory health insurance. In sensitivity analyses, privately insured participants of the population survey were excluded, and insured persons with care needs were excluded from routine data. The definition of administrative depression diagnosis was varied depending on the frequency of coded diagnoses and the specificity of the diagnoses. RESULTS: The highest prevalence (9.8%) was found for depression diagnoses from administrative data, the lowest prevalence (5.9%) in self-reported medical diagnoses of depression in the population survey. The prevalence of depression identified by clinical interviews was 8.4%. Differing age and gender-related courses of illness were found. The administrative prevalence dropped significantly if unspecific diagnoses (F3x.8, F3x.9) were excluded. DISCUSSION: Depending on the definition of depression diagnoses used in administrative data, there was a reduction in differences of prevalence compared to the self-reported medical diagnoses. Differences in prevalence based on a diagnosis of a depressive disorder identified in a clinical interview remained stable, which indicates different groups of persons.

Working atmosphere, job satisfaction and individual characteristics of community mental health professionals in integrated care.

Working requirements of community mental healthcare professionals in integrated care are complex. There is a lack of research concerning the relation of job satisfaction, working atmosphere and individual characteristics. For the current study, a survey evaluating job satisfaction and working atmosphere of mental healthcare professionals in integrated care was performed. About 321 community mental healthcare professionals were included in the survey; the response rate was 59.5%. The professional background of community mental healthcare professionals included nursing, social work and psychology. Community mental healthcare professionals reported the highest satisfaction with colleagues and the lowest satisfaction with income. Moreover, it could be shown that more responsibility, more recognition and more variety in job tasks lead to an increase of overall job satisfaction. Healthcare for mentally ill patients in the community setting is complex and requires well-structured care with appropriate responsibilities within the team. A co-operative relationship among colleagues as well as clearly defined responsibilities seem to be the key for the job satisfaction of community mental healthcare professionals in integrated care.

Intensive follow-up for women with breast cancer: review of clinical, economic and patient's preference domains through evidence to decision framework.

BACKGROUND: Women treated for breast cancer are followed-up for monitoring of treatment effectiveness and for detecting recurrences at an early stage. The type of follow-up received may affect women's reassurance and impact on their quality of life. Anxiety and depression among women with breast cancer has been described, but little is known about how the intensity of the follow-up can affect women's psychological status. This study was undertaken to evaluate the effects of intensive vs. less-intensive follow-up on different health outcomes, to determine what are women's preferences and values regarding the follow-up received, and also assess the costs of these different types of follow-up. METHODS: A systematic review following standard Cochrane Collaboration methods was carried out to assess the efficacy of intensive follow-up versus non-intensive follow-up in breast cancer patients. Two additional reviews on women's preferences and economic evidence were also carried out. The search was performed up to January 2016 in: MEDLINE, EMBASE, PDQ, McMaster Health Systems Evidence, CENTRAL, and NHS EED (through The Cochrane Library). The quality of evidence was assessed by GRADE (for quantitative studies) and CerQUAL (for qualitative studies). Several outcomes including mortality, breast cancer recurrences, quality of life, and patient satisfaction were evaluated. RESULTS: Six randomised trials (corresponding to 3534 women) were included for the evaluation of health outcomes; three studies were included for women's values and preferences and four for an economic assessment. There is moderate certainty of evidence showing that intensive follow-up, including more frequent diagnostic tests or visits, does not have effects on 5- or 10-year overall mortality and recurrences in women with breast cancer, compared with less intensive follow-up. Regarding women's preferences and values, there was important variability among studies and within studies (low confidence due to risk of bias and inconsistency). Furthermore, intensive follow-up, as opposed to less intensive follow-up, is not likely to be cost-effective. CONCLUSIONS: Less intensive follow-up appears to be justified and can be recommended over intensive follow-up. Resources could thus be mobilised to other aspects of breast cancer care, or other areas of healthcare.

Development of indicators for a nationwide cross-sectoral quality assurance procedure for mental health care of patients with schizophrenia, schizotypal and delusional disorders in Germany.

PURPOSE: This paper describes the development of quality indicators for an external statutory and cross-sectoral quality assurance (QA) procedure in the context of the German health care system for adult patients suffering from schizophrenia, schizotypal and delusional disorders (F20-F29). METHODS: Indicators were developed by a modified RAND/UCLA Appropriateness Method with 1) the compilation of an indicator register based on a systematic literature search and analyses of health care claims data, 2) the selection of indicators by an expert panel that rated them for relevance and for feasibility regarding implementation. Indicators rated positive for both relevance and feasibility formed the final indicator set. RESULTS: 847 indicators were identified by different searches. Out of these, 56 were selected for the indicator register. During the formal consensus process the expert panel recommended another 45 indicators so that a total of 101 indicators needed to be considered by the panel. Of these, 27 indicators rated both relevant and feasible were included in the final set of indicators: this set included 4 indicators addressing structures, 19 indicators addressing processes and 4 indicators addressing outcomes. 17 indicators of the set will be reported by hospitals and 8 by psychiatric outpatient facilities. Two indicators considered to be cross-sectoral will be reported by both sectors. DISCUSSION: F20-F29 and its treatment show some specific features which so far have not been addressed by any procedure within the statutory QA program of the German health care system. These features include: Schizophrenia and related disorders a) are potentially chronic conditions, b) are mainly treated in outpatient settings, c) require a multi-professional treatment approach and d) are treated regionally in catchment areas. These specific features in combination with the peculiarities of some legal, political and organizational characteristics of the German health care system and its statutory QA program have strongly influenced the development of indicators. The result was a seemingly "imbalanced" set of indicators with a greater number of indicators for inpatient than for outpatient care despite the fact that clinical reality is otherwise. CONCLUSIONS: The circumstances of the German health care system that restricted the development of this cross-sectoral QA procedure addressing care for F20-F29 are also most likely to emerge with the development of cross-sectoral QA procedures for other (potentially) chronic conditions that are mainly treated in the outpatient setting by multi-professional teams or by networks of different providers. In order to be able to develop a QA procedure that mirrors the reality of service provision for (potentially) chronic diseases such as F20-F29 we need to explore further current and new data sources, diminish sectoral borders, and implement health care responsibility on the level of catchment areas.

["Hope Dies Last  " - Cross-Sectoral Cooperation in Integrated Care]. / "Die Hoffnung stirbt zuletzt  " ­ sektorenübergreifende Kooperation in der Integrierten Versorgung.

Objective Multiple models of Integrated Care (IC) have been implemented in German mental health services in the last decade in order to improve cross-sectoral, interdisciplinary cooperation. This study investigates an IC network model providing home treatment, case management and a 24/7 hotline. The aim of the study was to explore how health professionals working in this service model perceive both cooperation within their facilities and with external stakeholders. Methods 5 focus groups with 39 health professionals working in an IC mental health network were conducted and analyzed with qualitative content analysis. Results Focus groups participants reported on excellent cooperation within their facilities. The cooperation with external stakeholders, i. e. physicians, psychotherapists and psychiatric clinics, leaves room for improvement. Conclusions Until now little consideration has been given to the perspectives of health professionals. Cooperation within IC mental health networks seems to be effective. Cooperation with stakeholders outside the networks needs to be enhanced.

[Studies to Evaluate Outpatient Mental Health Services: Are Patients' Priorities Considered?] / Studien zur Evaluation ambulanter psychiatrischer Versorgung: Werden die Prioritäten psychisch kranker Menschen berücksichtigt?

Objective: To evaluate whether outcome measures in studies to evaluate outpatient mental health services reflect patients' priorities. Methods: Two systematic literature reviews were conducted to identify, 1) patients' priorities and 2) outcome measures that are used for evaluating outpatient mental health care. 3) The findings from the literature review for patients' priorities were contrasted with the findings from the literature review for outcome measures. Results: 19 patients' priorities and 48 outcome measures were identified. Only eight priorities were directly assessed by an outcome measure in evaluations of outpatient mental health care. Conclusion: The majority of studies that evaluate outpatient mental health care do not consider patients' priorities as an outcome.

Mandatory national quality improvement systems using indicators: An initial assessment in Europe and Israel.

INTRODUCTION: Quality improvement systems (QIS) that are based on empirical performance assessment have increasingly been implemented as a mandatory part of health systems across countries. This study aims to describe national mandatory QIS in Europe in 2014. MATERIALS AND METHODS: Relevant national agencies for national mandatory QIS in Europe were identified through online searches and key informants. A questionnaire was compiled during a workshop with these agencies and filled out by representatives from these particular agencies. RESULTS: Agencies in charge of national mandatory QIS in seven countries (Denmark, France, Germany, Israel, Scotland, Sweden and Switzerland) were included in the study. An analysis of QIS revealed similarities, such as the use of routine data for performance assessment and the aim to hold healthcare providers accountable. Differences relate to the different forms of feedback systems and improvement mechanisms used. Trends include the development towards greater implementation of QIS within health systems, the inclusion of the patient's perspective in performance assessment, and experiments with pay for performance-related measures. CONCLUSION: On a country level, for health systems striving for newly implementing QIS it is recommended to start where routine data is available, add qualitative methodologies once the QIS is getting more complex, report performance data back to service providers and be patient centred. On the inter-country level exchange of information between agencies commissioned with implementing national QIS is very much needed for.

Monitoring mental healthcare on a system level: Country profiles and status from EU countries.

AIMS: Routinely collected data can be used to monitor the performance and improve the quality of mental healthcare systems. Data-based and system-level Quality Monitoring Programmes in Mental Health Care (QMP-MHC) are increasingly being implemented in EU countries. They are believed to be indispensable for the sustainable improvement of the quality of mental healthcare. However, there is a paucity of comparative research on national strategies in quality monitoring. This study explores the status of system-level Quality Monitoring Programmes in Mental Health Care (QMP-MHC) in EU countries. It aims to provide a descriptive overview, which is intended to be the first step for comparative research in this field. METHODS: Case studies of system-level QMP-MHCs were gathered from eight EU countries. Experts from each country were asked to describe their approach using a template. These experts were all members of a Europe-wide network of researchers and members of public institutions involved in quality assessment and performance monitoring of mental healthcare. RESULTS: Country profiles were gathered from England, Denmark, France, Germany, Italy, the Netherlands, Portugal, and Sweden. All these countries have - or are in the process of implementing - system-level QMP-MHCs. Implementation seems to be facilitated when a national performance monitoring programme for general healthcare is already in place, although in the Netherlands, a QMP-MHC was established without being attached to a general monitoring programme. All the monitoring programmes described use various quality and performance indicators; some systems enhance this methodology with the addition of qualitative assessment methods such as peer reviews linked to accreditation processes. CONCLUSIONS: Research is needed to better understand the historical, political and technical backgrounds of the different national cases and to explore the effectiveness of different improvement mechanisms on the actual quality of healthcare. Policy makers and those designing performance measurement programmes are recommended to look across the borders of their own healthcare systems as there are many ways to assess performance and many ways to feedback results to service providers. No evidence is available whether one of these methods is superior to the others in improving the quality of mental healthcare.

Integrated care in German mental health services as benefit for relatives--a qualitative study.

BACKGROUND: As mental health services undergo the process of deinstitutionalization, this is resulting in a higher burden of care for relatives. Evidence suggests that interventions for carers have a beneficial impact on their psychological health. A reduction of responsibility for relatives is linked with a significantly improved outcome for the severely mentally ill. The aim of the study was to explore the relatives' experiences with severely mentally ill patients in different integrated care service providers. METHODS: Semi-structured focus groups and interviews were conducted with 24 relatives of patients receiving community based integrated care for severe mental illness. The collected data was transcribed and evaluated using qualitative content analysis. A deductive-inductive approach was used in generating thematic categories. RESULTS: Four main categories were found related to the structural aspects of the integrated care services and for the experiences of the relatives within these services. Relatives reported that the services offered significant relief and substantial support in daily life. In addition, relatives felt a reduced burden of carer responsibility and therefore that they were provided with more protection and stability. This resulted in a sense of encouragement and not feeling left alone to face challenges. CONCLUSION: Relatives are a critical resource for patients suffering from mental health problems and benefit from formal structures and interventions to support them in carer role. An important need is to ensure continuity of care for patients and the bridging of gaps concerning information and support needs for relatives when providing integrated mental health services in the community.

[Integrated Quality Management System (IQMS): a model for improving the quality of reproductive health care in rural Kenya]. / Integrated Quality Management System (IQMS): ein Modell zur Förderung der Qualität der reproduktiven Gesundheitsversorgung im ländlichen Kenia.

OBJECTIVES: To develop a model aiming to improve the quality of services for reproductive health care in rural Kenya and designed to measure the quality of reproductive health services in such a way that allows these services to identify measures for improving their performance. METHODS: The Integrated Quality Management System (IQMS) was developed on the basis of a pre-existing and validated model for quality promotion, namely the European Practice Assessment (EPA). The methodology for quality assessment and feedback of assessment results to the service teams was adopted from the EPA model. Quality assessment methodology included data assessment through staff, patient surveys and service visitation. Quality is assessed by indicators, and so indicators had to be developed that were appropriate for assessing reproductive health care in rural Kenya. A search of the Kenyan and international literature was conducted to identify potential indicators. These were then rated for their relevance and clarity by a panel of Kenyan experts. RESULTS: 260 indicators were rated as relevant and assigned to 29 quality dimensions and 5 domains. The implementation of IQMS in ten facilities showed that IQMS is a feasible model for assessing the quality of reproductive health services in rural Kenya. IQMS enables these services to identify quality improvement targets and necessary improvement measures. Both strengths and limitations of IQMS will be discussed.