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Better documentation for quality circles in Germany


Quality circles (peer groups) in Germany were given a significant boost by legislation in the early 1990s. Many of the early quality circles were new groupings founded spontaneously by physicians, but others built on the work of existing groups. Surveys had looked at their emergence but there was little reliable information available on their work. But were quality circles making an impact? This question led to the creation of a project [1] to explore whether standardised information could be collected about the work being done in quality circles and used to support their continuing development.


Ferdinand M Gerlach and Martin Beyer. New concept for continuous documentation of development of quality circles in ambulatory care: initial results from an information system in Germany. Quality in Health Care 1998;7; 55-61.

How was the project tackled?

A team from the Department of General Practice and Quality Research Unit at Hanover Medical School worked with nine quality circle moderators (ie local volunteers who organised their quality circles) to design a report form which would allow comparison of the work of individual quality circles. The aim was to create a process to assemble and feedback the information to the moderators. The report form went through several stages of testing before it was issued to the moderators of quality circles within the regions of three (regional) Associations of Statutory Health Insurance Physicians (ASHIP) - Bremen, Schleswig-Holstein and Westphalia-Lippe.

The report form seeks information in seven fields:

  1. Number and qualification of participants
  2. Frequency and duration of meetings
  3. Topics and themes worked on
  4. Methods of data collection and presentation
  5. Problems and conclusions
  6. Self audit by moderator on the session (atmosphere, group satisfaction, factual gain etc)
  7. Other items such as the date and time of the meeting and 'invited' experts.

How did the project develop?

Between January 1995 and July 1996 the project team recruited moderators in a variety of ways, most particularly through the regular meetings (of quality circle moderators) organised by the three regional ASHIP. Over the 18 months, 56% of the quality circles in the three regions became involved. In total almost 500 forms (each reporting on a single quality circle session) from 120 different groups were received at the unit over the eighteen months. Each session had about 13 participants.

What did the project report?

1. Who are the participants and how often do they meet?

Development of quality circles was led initially by general practitioners, but now most ambulatory care specialities participate in quality circles. The quality circles met monthly and sessions lasted for about two hours. About 70% of members attended each session.

2. What was discussed?

Most of the time was devoted to work on a chosen clinical topic. Other issues tackled included: methodology for peer review and quality improvement; general discussion about ambulatory care; and formalities. See Table 1. Time spent on clinical topics increased as groups became more established. Most of the work was about clinical care and co-operation between physicians. Issues such as remuneration was given less attention, although some financial issues such as concern about sickness fund payments were discussed.

Table 1 Topics of discussion at quality circles


Proportion of time (%)

General professional qualifications, like doctor-patient relationships, co-operation across the health care team


Medical problems, like diabetes, diagnostic techniques or complex problems of care, psychosocial problems or patient complaints


Contractual problems, like legal and economic problems - who pays?, as well as professional politics


Other issues



3. What were the methods used in quality circles?

Most of the sessions used case reports as the basis for their discussion: others used summarised quantitative data. More objective methods, such as the presentation of computer based practice data, were used less often, but an increasing use of the collection of routine data was observed. Most new quality circles start by exchanging experiences without documentary evidence but gradually move to include objective data collection and analysis. For many German primary care physicians work in quality circles may be their first experience of quality improvement methods. Courses have since been established for new moderators on methods of quality improvement.

4. Do quality circles summarise their discussions?

About one third of the quality circles use their discussions to produce consensus statements and about a fifth produced clinical guidelines. Statements about future work in their practice and papers for publication to a wider audience were also produced. Some examples of the outputs are:

5. What information was fed back to the quality circles?

All moderators and associations received quarterly reports based on the data from the quality circles in their region. The Research Institute (an independent group) produced the reports. The reports were in two parts: Part A , an anonymous summary which was sent to moderators and regional associations and Part B , specified comparisons for each quality circle which was sent to the individual moderators. Moderators could then compare the work of their own quality circle with aggregated data from their region.

The initial format for these reports was created by the project team but over time, and based on reactions from moderators, the reports were condensed and supplemented with examples of the work of individual quality circles. Arrangements were made to allow moderators in each region to meet on a regular basis so that they could exchange experiences and learn from one another. These arrangements were later extended to enable moderators from quality circles in other regions to join in.

A study in one region (Schleswig-Holstein) showed that moderators welcomed the system and reports. The link with an independent scientific institute was valued. The study team were unable to find other examples of similar initiatives to support the development of quality circles and/or peer groups.

6. Moderators' view of the work of the quality circles.

Moderators were asked to rate five aspects of each session on a six point (Likert) scale: 1 indicating satisfaction and 6 dissatisfaction. The five aspects were: factual outcome; the 'atmosphere' in the group; their view on how participants felt about the session; their own performance as moderator; and an overall judgement about the session. Experience showed that the moderators gave the highest ratings to the group atmosphere, but also rated the factual outcome and participants satisfaction highly. They rated their own roles with some restraint!

What was learnt from the project?

There are important lessons here about the need to be incremental and to start development work simply. Complex systems and data collection is not necessary.

Limitations on the data collected proved not to be a problem. The incremental approach has been a success and building on this a new strand of activity has since been launched. This uses another questionnaire to assess how far groups meet established criteria for quality circle work.

Participation in quality circles is voluntary. Nevertheless, although the information collected was limited, many moderators were uncomfortable with the implicit infringement on professional autonomy and declined to get involved. Participation of all medical specialities suggests that problems about co-operation across boundaries are being addressed, for example about home care and outpatient surgery. Unfortunately, it remains however unusual for practice staff (nurses and other health professionals) to be involved.

It's an interesting piece of work, which has shown that a simple questionnaire can enable a continuous flow of useful information. There are some helpful lessons here as NHS organisations look for ways to provide practical support for clinicians as they build local arrangements for clinical governance. Co-operation across organisations may offer the breadth of debate helpful to clinicians as they look for ways to tackle the quality agenda.