[Memorandum III, Part 3: Quality of Care and Patient Safety Research Methods]. / DNVF-Memorandum III "Methoden für die Versorgungsforschung", Teil 3: Methoden der Qualitäts- und Patientensicherheitsforschung.

The German Network for Health Services Research [Deutsches Netzwerk Versorgungsforschung e.V. (DNVF)] fosters the methodological quality of health services research studies by memoranda and other initiatives. Quality of care and patient safety research (QCPSR) form core areas of health services research. The present memorandum explicates principal QCPSR questions and methods. Based on the issues' particular relevance for health policy, the memorandum exemplifies methods for developing and testing indicators, risk adjustment techniques, methods for collecting patient safety data, tools to analyse patient safety incidents and methods for evaluating often complex and multicomponent QCPS interventions. Furthermore, we point out urgent research topics.

[Quality analyses of the development of preterm infants: results of the Lower-Saxonian preterm infant follow-up project and a comparison group of term infants]. / Qualitätsanalysen zur Entwicklung Frühgeborener: Ergebnisse des Niedersächsischen Frühgeborenen-Nachuntersuchungsprojekts und eines Vergleichskollektivs reif geborener Kinder.

Based on perinatal and neonatal quality assurance programmes, a follow-up project for the high-risk group of extremely preterm infants, unparalleled in Germany, was initiated in the federal state of Lower Saxony in 2004. Here we describe the new approach of examining a comparison group of term infants, which, for the first time, allows a valid interpretation of the collection of area-wide long-term outcome data on preterm children. The prospective long-term outcome project investigates the medical care situation for children born at less than 28 weeks of gestation up to school age. Based on the information obtained about the children's development the quality of health care will be optimised. A standardised examining concept with established development tests at defined follow-up intervals (at the age of 6 months, 2, 5 and 10 years) is used. At the age of five years 75 % of the examined premature children exhibited impairments. In order to better assess remarkable results, a comparison group of term infants (n=305) selected by a matched-pairs method was examined at the age of five using an analogous concept in kindergartens in Lower Saxony. The results were compared with the first two age cohorts of the follow-up-project (n=226) and quality analyses performed. As expected, significant differences have been found in the children's motor, cognitive and linguistic development between the preterm and term infants examined. This fact draws attention to the importance of early support for the majority of extremely premature infants. Feedback on the results given to the medical staff involved allows for the implementation of best practices and quality improvements. Identifying potential for improvement in everyday health care will help to develop specific optimisation measures.

[Requirements for the provision of healthcare to socially disadvantaged population groups: evaluation of 10 years of medical care provided to the homeless in Hanover]. / Anforderungen an die Gesundheitsversorgung sozialer Randgruppen: Eine Evaluation der medizinischen Versorgung für Wohnungslose in Hannover über zehn Jahre.

In 2007, the German Federal Government introduced a general health insurance obligation, but there are still vulnerable groups such as poor and homeless people without access to medical care. Especially for social fringe groups, a visit to the doctor involves many obstacles. Ten years ago the project "Outreach medical care for homeless people and people threatened by homelessness in Hanover" was established in order to reduce those gaps in healthcare provision. A continuously conducted evaluation of the project shows that low-threshold consulting hours are accepted and the transition to medical specialists is becoming increasingly easy. So the evaluation plays an important part in the development of the project. Since the healthcare reform in 2004, however, the number of cases has increased by 30 % while the actual homeless target group has remained the same. In order to guarantee access to the healthcare system for patients who cannot afford additional payments, the abolition of the quarterly practice fee and other additional payments for people on a low income is an important step. The growing requirements, resulting from a changing clientele and changes in the general conditions, are raising questions as to the nature of such projects and its future funding. In the long run it isn't the aim of this non-profit project to take on central tasks of a mutually supportive community. Therefore the data and results collected on the evaluation not only serve to improve the projects management, but also provide important information to other initiatives outside Hanover whether and how to support the respective groups of patients.

[Quality management in implementing specialist pediatric palliative home care in Lower Saxony, Germany]. / Qualitätsmanagement bei der Einführung der Spezialisierten Ambulanten Pädiatrischen Palliativversorgung in Niedersachsen.

BACKGROUND: To provide comprehensive high-quality health care is a great challenge in the context of high specialisation and intensive costs. This problem becomes further aggravated in service areas with low patient numbers and low numbers of specialists. Therefore, a multidimensional approach to quality development was chosen in order to optimise the care of children and adolescents with life-limiting conditions in Lower Saxony, a German federal state with a predominantly rural infrastructure. METHODS: Different service structures were implemented and a classification of service provider's specialisation was defined on the basis of existing references of professional associations. Measures to optimise care were implemented in a process-oriented manner. RESULTS: High-quality health care can be facilitated by carefully worded requirements concerning the quality of structures combined with optimally designed processes. Parts of the newly implemented paediatric palliative care structures are funded by the statutory health insurance.

[State-wide follow-up of extremely preterm infants: a model of cross-sectoral quality analysis]. / Landesweite Nachuntersuchung extrem unreifer Frühgeborener: Ein Modell sektorübergreifender Qualitätsanalyse.

A long-term outcome project for the special high-risk group of extremely preterm (ELBW) infants has been established in the federal state of Lower Saxony, which is unique in Germany. All departments of neonatology and all divisions of paediatric neurology are participating. Since October 2004 children who were born at <28 weeks gestation are examined using a standardised concept at defined follow-up intervals (at the age of 6 months, 2, 5 and 10 years). The aim is to achieve a cross-sectoral improvement of quality in healthcare on the basis of neurodevelopmental outcome parameters (the right therapy for the right child, at the right time). So far 739 extremely preterm infants (81% of the survivors) were examined at the age of six months, 513 ELBW infants (74% of the survivors) at the age of two years, and 99 children (59% of the survivors) at the age of five years. The comparison of the follow-up intervals has demonstrated an increase of children with minor and major impairment, which indicates the importance of the long-term scheme. At the age of five years 27% of the children exhibit normal development, 49% minor impairment and 24% major impairment. Many ELBW infants need therapy. The model of the project can be transferred to other federal states or regions and other high-risk groups.

[Process orientation as a tool of strategic approaches to corporate governance and integrated management systems]. / Prozessorientierung als Instrument strategischer Unternehmensführung und integrierter Managementsysteme.

The concept of general process orientation as an instrument of organisation development is the core principle of quality management philosophy, i.e. the learning organisation. Accordingly, prestigious quality awards and certification systems focus on process configuration and continual improvement. In German health care organisations, particularly in hospitals, this general process orientation has not been widely implemented yet - despite enormous change dynamics and the requirements of both quality and economic efficiency of health care processes. But based on a consistent process architecture that considers key processes as well as management and support processes, the strategy of excellent health service provision including quality, safety and transparency can be realised in daily operative work. The core elements of quality (e.g., evidence-based medicine), patient safety and risk management, environmental management, health and safety at work can be embedded in daily health care processes as an integrated management system (the "all in one system" principle). Sustainable advantages and benefits for patients, staff, and the organisation will result: stable, high-quality, efficient, and indicator-based health care processes. Hospitals with their broad variety of complex health care procedures should now exploit the full potential of total process orientation.

[In-house team seminars: working together as a team--from data and statistics to quality development]. / Inhouse-Teamschulungen: Gemeinsam mit dem Team--von den Daten und Statistiken zur Qualitätsentwicklung.

The concept of the "ZQ In-house Seminars" provided by external trainers/experts pursues the specific aim to enable all healthcare staff members of hospital departments to analyse statistical data--especially from external quality measurements--and to initiate in-hospital measures of quality improvement based on structured team work. The results of an evaluation in Lower Saxony for the period between 2004 and 2008 demonstrate a sustainable increase in outcome quality of care and a strengthening of team and process orientation in clinical care.