New concept for continuous documentation of development of quality circles in ambulatory care: initial results from an information system in Germany.

Introduction Requested by both governmental and professional organisations, quality circles for physicians involved with ambulatory care began in Germany in the late 1980s (box 1). Development of quality improvement through peer review suited the particular characteristics of the German ambulatory care system (box 2). Physicians who work predominantly in single handed practices and who can feel isolated value the opportunity to work in groups. Rules and guidelines published by the Federal Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung, which is an association of physicians caring for patients who are insured through statutory sickness funds) encouraged the role of quality improvment through voluntary instigation of quality circles. A comprehensive strategy for establishing quality circles and other quality improvement initiatives in ambulatory care was set up by the University Departments for General Practice in Hannover and Göttingen together with the Institute for Applied Quality Improvement and Research in Health Care, Göttingen. From this initiative alone over 750 providers of ambulatory care have been trained as group moderators to set up and coordinate local quality circles. Funding from the Federal Ministry of Health enabled development of an influential handbook on quality circles that included descriptions of experiences from other countries. Other aspects of the implementation strategy included research projects on quality improvement and the development of manuals, documentation materials, videos, symposia, and regular supervisory meetings for quality circle moderators. 6 In total there was an increase in the number of quality circles in ambulatory care from 16 in 1993 to over 1630. An unusual aspect of this project was that it was general practitioners rather than the usually dominating specialists who initiated this development. Surveys from regional associations indicated that quality circles are generally well accepted. Over half the physicians in ambulatory care are willing to participate in quality circles; one third remain uncertain; but only 10% are outwardly hostile to participation in peer review. Although various professional bodies and sickness funds support and encourage the development of quality improvement in ambulatory care,most quality circles have been founded spontaneously by physicians. Some have formed completely new peer review groups, others have transformed other groups such as Balint groups, specialty case conferences, continuing medical education groups, or informal meetings of physicians into quality circles. The particular status of private practice in German health care means that, compared with other European countries, little pressure is applied by purchasers of health care to control quality improvement activities. 11 12 Although this might have encouraged autonomous development of quality improvement little reliable information is available on appraisal of development and impact of the work of quality circles. We wanted to get standardised information on the work being done in quality circles from objective measurable criteria of groups at all stages of development. Such an instrument might provide useful information for the groups and be used to assess progress in quality improvement in ambulatory care. Getting such information is sensitive, and could be feared as a process of external control, so we describe here our system for obtaining this information. The system was based on feeding back only aggregated information to the associations, but providing more detailed information to the groups about themselves for their own use (fig 1). It is important for those keen to develop quality circles to understand current strengths and deficits as a basis for evaluation of the impact of quality improvement work on the quality of ambulatory care. This could also improve communication among those working in quality improvement.