Quality improvement in Germany

THE GERMAN HEALTH CARE SYSTEM: Recent law has provided for increased competition among public insurers ("sickness funds"). Hospitals are also finding increasing competition as lengths of stay shorten and excess capacity grows. THE EVOLUTION OF QUALITY IMPROVEMENT: Quality improvement in Germany, mostly as quality assurance, has progressed slowly since its beginnings in the 1970s. A majority of medical associations and societies now support quality improvement, by dint of the public's increasing demand for performance data, the potential threat posed by declining financial resources to the quality of medical care, competition among providers for payer purchases of health care, and financial concerns of third parties. INTERNAL QUALITY MANAGEMENT (QM) ACTIVITIES: In Germany quality improvement activities are conducted either as external quality assurance or as internal quality management (QM). Payers, who increasingly prefer to work with those hospitals that provide information on the quality of treatment offered, are interested not only in the structure and outcome dimensions of quality, but in the process dimension--as practice guidelines and clinical pathways. More than a few hospitals in Germany have implemented or have started to implement QM systems. Key processes in the hospital should all be described, examined, and considered by project groups (once referred to as quality circles) in terms of potential efficiencies to be gained through improvement. QUALITY ASSURANCE: Federal and state hospital associations and sickness fund associations agreed on a new contract in 1995 that included a provision to introduce new external quality assurance measures.