182-1095 / External quality assurance program “MRSA” (Landesspezifisches Verfahrens QS-MRSA)

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
Regional Office for Quality Assurance in Hospitals Baden-Württemberg /Germany
Geschäftsstelle Qualitätssicherung im Krankenhaus Baden-Württemberg)


Quality improvement project

GOP Description
Implementation level
Clinical settings
All hospitals in Baden-Württemberg have to deliver accumulated data twice a year concerning certain clinical characteristics and information from legally required laboratory documentations (“IfSG-lists”).
The objective is to establish screening structures and to reduce the MRSA load in Baden-Württemberg. All hospitals receive indivdual results twice a year. If the results indicate that MRSA screening or handling might need improvement the case is discussed inbetween an expert group and the hospital in an procteced setting.
All hospitals in Baden-Württemberg with in house patients.
The data collection is mandatory for all hospitals in Baden-Württemberg since 2010. The delivered data contains information such as number of patients screened, number of patients in total, number of patients with first record of MRSA, number of patients with nosocomial MRSA etc. The data is delivered to the GeQiK twice a year. Statistical results are calculated and discussed on a protected level with an expert team. In case the need for improvement is seen by the expert team indivual statements of the medical providers are requested and discussed. Indivudual answers are transmitted to the hospitals.
Timeframe implementation
about 6 months
Implementation tools available
The data sheet, the calculated performance figures and the data analysis are published on our homepage (http://www.geqik.de/index.php?id=1083 and http://www.geqik.de/index.php?id=1082)
Implementation cost
not determined
Method used to measure the results
Performance figures for each hospital are calculated. The hospitals are provided with graphic benchmarks for all performance figure. This allows the hospitals to rank their individual efforts compared to all other hospitals in the region of Baden-Wuerttemberg.
For each performance figure the expert team is defining thresholds. In case these limits are passed a dialogue to discuss the result with the medical provider is started. The expert team formulates individual answers to each statement.
The average screening activity in Baden-Württemberg / Germany has increased from 6,5% to 18,1% since the program was launched. Within the same time the rate of nosocomial infections has decreased continuoulsy.
Analysis of the results
The screening activities inbetween the hospitals show a big heterogeneity. Qualilty assurance is obtained by starting a dialogue with medical providers, which e.g. show screening activities under a defined rate or high nosocomial infections rates.
Since the implementation of the qualitiy assurance program the screening activity has increased remarkably. Nevertheless these pioneer activity is considered a learning process whose determinants are coninuously discussed and adapted.
Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
In the first year almost a quater of all hospitals did not deliver data despite delivery is mandatory by regional regulations. The hospitals were reminded and requested to deliver the data.
Now all hospitals deliver the requested data in time.
Describe the strategies used to overcome the barriers (If needed)
The barriers were overcome by the existence of mandatory regional (Baden-Wuerttemberg) regulations.
Other information
Other information about the GOP that you would like to add (Link or attached document)
Detailed results of the project were previously published in a German journal:
Giehl J. et al: Seit 2011 in Baden-Württemberg etabliert: Landesspezifisches QS-Verfahren MRSA (Since 2010 in Baden-Württemberg / Germany established: External quality assurance program “MRSA”. HygMed 2014, 39-4 (133-138)
for further information: http://www.geqik.de/index.php?id=1081