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Cross Sectoral Quality Assurance

Country: 
Germany
Partner Institute: 
University of Technology, Berlin
Survey no: 
(14) 2009
Author(s): 
Markus Wrz, Ewout van Ginneken
Health Policy Issues: 
System Organisation/ Integration, Political Context, Quality Improvement
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes no no

Abstract

German health care is known for its rather strict and historically evolved separation between the various sectors. A new cross sectoral quality assurance QA)system aims to overcome this fragmentation. After a European wide tender, the Joint Federal Committee commissioned the AQUA-Institute with implementing a new QA system. From 2010, AQUA will also take over the task of external QA in the hospital sector, which so far was the responsibility of the Federal Office for Quality Assurance BQS).

Purpose of health policy or idea

Since July 2008, measures passed by the Federal Joint Committee (FJC) with regard to quality assurance should in principle be cross sectoral. Previously, explicit external quality assurance was confined to the inpatient sector.

The German healthcare system is characterized by a rather strict and historically evolved separation between the various sectors. Implementing a cross sectoral quality assurance system is one instrument to overcome this separation. In order to put cross sectoral quality assurance into practice the FJC has issued a Europe wide tender in order to commission an independent institution with cross sectoral quality assurance. In February 2009, against many expectations, the FJC decided to commission the AQUA-Institute (www.aqua-institut.de/) with the implementation of the new cross sectoral quality assurance system. Furthermore, from 2010 the AQUA Institute will also take over the task of external quality assurance in the hospital sector, which so far was the responsibility of the BQS-Federal Office for Quality Assurance (Diel & Klakow-Franck 2009).

Main points

Main objectives

1. Improve cross sectoral quality assurance
2. improve quality of health care in general

Groups affected

Joint self government, Providers in health care (in particular hospitals and ambulatory physicians), Federal Office for Quality Assurance (formerly responsible for QA)

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Characteristics of this policy

Degree of Innovation traditional traditional innovative
Degree of Controversy consensual controversial highly controversial
Structural or Systemic Impact marginal rather marginal fundamental
Public Visibility very low low very high
Transferability strongly system-dependent neutral system-neutral

QA is a widely used concept in international health care and therefore the degree of innovation can be characterised as rather traditional. However, the choice for AQUA turned out to be highly controversial, the choice for the system per se was not controversial.

Political and economic background

In 2007, Germany's 'Grand Coalition' between the Christian Democrats (CDU) and the Social Democrats (SPD), adopted a reform ("Act to Strengthen Competition in Statutory Health Insurance" - GKV-WSG) to strengthen competition in the statutory health insurance system. The core elements of the reform include:

  • central pooling of contributions in a health fund (c.f. HPM report "Health fund now operational", May 2009),
  • introduction of a morbidity-oriented risk structure compensation scheme for allocating payments from the health fund to the sickness funds acting as third-party payers (c.f. HPM report "Morbidity-based risk structure compensation", April 2009), 
  • a uniform contribution rate, for the first time set by the government and not by sickness funds individually.

The GKV-WSG also dictated the introduction of an independent institution for cross sectoral quality assurance. This institution would become responsible for:

  • Measuring and demonstrating quality in different sectors using cross sectoral quality indicators and instruments
  • developing the necessary documentation for cross institutional quality assurance while respecting data protection laws
  • participating in the implementation of cross institutional quality assurance
  • making the results available to the public in an apprehensible manner

It is important to bear in mind that at this point, it is unclear what the new coalition of Christian Democrats (CDU) and liberals (FDP), which came into power on 28 Ocober 2009,  will alter or leave intact in their new plans for the german health care system.

Change of government

Introduced as part of the GKV-WSG reform drafted by the then governing Grand Coalition

Change based on an overall national health policy statement

Coalition paper of the grand coalition - Koalitionsvertrag zwischen CDU, CSU and SPD: Gemeinsam für Deutschland. Mit Mut und Menschlichkeit, 11 November 2005

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes no no

Origins of health policy idea

External quality assurance (in contrast to internal quality assurance of single hospitals) has been made obligatory in the 1990s. Since 2001, the Federal Office for Quality Assurance has implemented and managed this system. It involves the documentation of quality indicators. These indicators are gathered by the individual hospitals and then handed over to one of the sixteen state offices for quality assurance (one for each of the sixteen federal states). The state offices then pass the data on to the Federal Office for Quality Assurance (c.f. HPM report "External quality assurance for hospitals", December 2004). This old system was restricted to the inpatient sector only. The new approach will have to trace the way of the patient through the different sectors of health care (e.g. ambulatory, inpatient and rehabilitation).

The AQUA-Institute has to develop a method paper, which describes the approach when implementing the new cross sector quality assurance. After this, specific quality instruments have to be developed (Diel & Klakow-Franck 2009).

Initiators of idea/main actors

  • Government
  • Providers: The Federal Chamber of Physicians and the German Hospital Federation (which are shareholders of the Federal Office for Quality Assurance on the side of the providers) were originally oppossed to the decision of the JFC.

Approach of idea

The approach of the idea is described as:
renewed: QA is a widely used concept in international health care. However, due to the fragmented nature of German health care, QA was applied using different methodologies for different sectors. The new approach mainly seeks to remedy this fragmentation.

Stakeholder positions

Commissioning the AQUA Institute for implementing a cross sectoral QA system caused a high degree of controversy in Germany. Both the Federal Chamber of Physicians and the German Hospital Federation (shareholders of the Federal Office for Quality Assurance on the side of the providers) opposed to the decision of the FJC. The FJC justified its decision to commission the AQUA Institute and not the established Federal Office for Quality Assurance (BQS) with the argument that the concept of cross sectoral quality assurance of the latter was too focused on the inpatient sector. The Federal Office for Quality Assurance filed a lawsuit. This proved to be unsuccessful and in August 2009 an agreement was signed between the FJC and AQUA on the development of a new cross sectoral quality assurance system. The new responsibilities mean that the Federal Office for Quality Assurance (BQS) will no longer play a role in mandatory quality assurance.

In addition, there are uncertainties amongst hospitals since hospital employees fear that they will have to adjust to new methods of collecting data by the AQUA Institute, which will result in higher administrative burdens

Actors and positions

Description of actors and their positions
Government
Ministry of Healthvery supportivesupportive strongly opposed
Providers
Federal Office for Quality Assurance (BQS)very supportiveopposed strongly opposed
Federal Chamber of Physiciansvery supportiveopposed strongly opposed
German Hospital Federationvery supportiveopposed strongly opposed

Actors and influence

Description of actors and their influence

Government
Ministry of Healthvery strongstrong none
Providers
Federal Office for Quality Assurance (BQS)very strongstrong none
Federal Chamber of Physiciansvery strongstrong none
German Hospital Federationvery strongstrong none
Ministry of HealthFederal Office for Quality Assurance (BQS), Federal Chamber of Physicians, German Hospital Federation

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

Since the implementation is currently underway, it is too early to comment on adoption and implementation.

Expected outcome

The main aim of cross sectoral QA is improving the quality of health care in Germany. Whether this will succeed depends on many factors. 

  • Much will depend on the system that AQUA will develop. Although AQUA has extensive experience with optimising quality in health care, introducing a QA model for the whole of  Germany (named a "Herculean task" by a the Federal Joint Committee chairman) may pose challenges with regard to capacity and logistics

  • Whether the new model will become successful also strongly depends on the cooperation AQUA will encounter. The policy process so far may not bode well and showed quite some reservations from the side of mainly the Federal Chamber of Physicians and the German Hospital Association. It will be crucial for AQUA to involve all stakeholders early in the process of developing their QA system, in a transparent manner. The head of the AQUA Institute is currently trying to reach out to providers by taking part in many public debates and events on cross sectoral quality assurance, in an attempt to gain their confidence.

Impact of this policy

Quality of Health Care Services marginal marginal fundamental
Level of Equity system less equitable neutral system more equitable
Cost Efficiency very low low very high

References

Sources of Information

  • Reinhard Busse, Nimptsch,U., & Mansky,T. (2009). Measuring, Monitoring, And Managing Quality In Germany's Hospitals. Health Affairs, 28(2), w294-w304.
  • Franziska Diel and Klakow-Franck,R. (2009). Sektorübergreifende Qualitätssicherung. Gestaltungsspielräume für regionale Besonderheiten. Deutsches Ärzteblatt, 106(11), A491-A494.
  • Sebastian Hesse,Weinbrenner, S. and Schlette, S. (2004). External quality assurance for hospitals". Health Policy Monitor, 12/04. Available at www.hpm.org/survey/ger/a4/1.
  • Helena Legido-Qugley, McKee,M., Nolte,E., & Glinos,I.A. (2008). Assuring the Quality of Health Care in the European Union. A Case for Action. Copenhagen: Word Health Organization on behalf of the European Observatory on Health Systems and Policies.

Author/s and/or contributors to this survey

Markus Wrz, Ewout van Ginneken

Suggested citation for this online article

Wörz, Markus, Ewout van Ginneken. "Cross Sectoral Quality Assurance". Health Policy Monitor, October 2009. Available at http://www.hpm.org/survey/de/a14/3