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Quality Circles in ambulatory care in Germany:

Progress in their development


In 1993, federal legislation provided a new legal framework in the German health care system to implement quality assurance and quality improvement measures. These structures encouraged the development of quality circles (used in Germany for the term 'peer groups' used elsewhere). Federal funding supported the development of a handbook on quality circles and associated training. There was an unanswered question, how were the quality circles developing and what support was available for them? This prompted a national survey to establish a picture of the development of quality circles and to assess their future development.


Quality Circles in ambulatory care; state of development and future perspective in Germany. Ferdinand M. Gerlach and colleagues. International Journal of Quality in Health care 199810:pp35-42.

How was the question tackled?

A postal survey (June 1996) was used to assemble information from all 23 regional Associations of Statutory Health Insurance Physicians (ASHIP). Almost all physicians (over 98%) who care for patients insured by the statutory health insurance organisations in Germany are members of ASHIP. The key contact points were the quality improvement co-ordinators in the regional offices. The questionnaire sought information about the number of quality circles (participants etc), organisation (moderators, meetings and documentation), evaluation and future prospects. Internal consistency was used to check validity of the replies and in addition the replies were compared with data assembled through other sources. Some supplementary information was sought by telephone, for example to clarify unclear statements in the questionnaire. The personal approach to the quality co-ordinators enabled the team to achieve a near 100% response rate.

What did the survey find?

1. Establishment and development: number of quality circles and participants

Quality circles had grown rapidly from 16 in 1993 to 1633 by 1996. About 19,000 (17%) of all practising physicians were involved. The number of quality circles in each ASHIP region varied, from one region with only 6 (with 60 participants) to one with 252 (with over 3000 participants). This reflected, in part, the variation in size and membership of each ASHIP. While GPs had pioneered the development of quality circles, physicians from the full spectrum of specialities were participating. The regional quality co-ordinators estimated that about two thirds of the circles met the requirements outlined in guidelines issued by the National Association of Statutory Health Insurance Physicians.

2. Moderators and their training

Ambulatory care physicians with a special interest in quality improvement can volunteer to take on a moderator role. At the time of the survey about 2700 moderators were registered with ASHIP (with about 800 not leading quality circle at the time). Most moderators had completed suitable training with only a small proportion (about 200 physicians) who were acting as moderators without having completed some formal training. The majority of moderators (about 2400) had participated in training courses run by ASHIP. A number of other expert groups offer training courses for moderators.

3. Documentation and evaluation of quality circles by the regional ASHIP

Most ASHIP (19 of 23) collect information about the quality circles in their regions. The remainder had plans to do so. Comparative evaluation (based on documentation) has been undertaken by 10 ASHIP, with some of these seeking additional information to allow a more thorough evaluation. This has enabled local comparisons of methods used developments and results. Most of these evaluations took place on a regular basis. Some regions require lists of participants as a prerequisite for official recognition.

4. Facilitation and support of quality circles

Regional ASHIP support the quality circles in various ways, with different strategies to support and facilitate the work. Most provide organisational or financial support and materials but few help with supervision and/or advice. A few regions arranged regular meetings for moderators so that they could meet and share experiences. There were varying policies about quality circles seeking grants for drug companies to support their work: about a half reported receiving some such grants.

5. Future perspectives

The ASHIP were asked to rate the current and future importance of quality circles in the context of work on quality improvement. The majority of ASHIP rated the current importance of quality circles as 'moderate' with a few rating them 'low.' Most ASHIP predicted that the importance of quality circles would increase: non predicted that their significance would decrease.

What are the conclusions from the survey?

Involvement by physicians in quality circles is a voluntary activity that progressed rapidly in Germany in the period 1993 to 1996. It was a new development and was deemed a success. Further study is needed however to evaluate the impact of the initiative on medical practice. The research team has since led the development of a model for standardised documentation in partnership with four ASHIP: it could serve as a model for others.

The study concludes that further improvement in the performance of quality circles requires increased support and facilitation from ASHIP, professional organisations and academic institutions. Independent support for moderators, which allows them to share and learn from the experiences with others, may be the key to progress.

There are interesting lessons here for the development of clinical governance in England. While the theory may appear attractive the real test is, as ever, to help clinicians find time to get involved and not allow it to become simply another external pressure on valuable clinical time.