183-1095 / External quality assurance program “MRSA”

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
anderes Formular benutzen


Quality indicators
Quality improvement project
Infection control / Prevention of surgical site infections
Surveillance of Patient Safety
GOP Description
Implementation level
Clinical settings
All hopsitals 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 Methicillin-resistant Staphylococcus aureus (MRSA) load in Baden-Württemberg. All hospitals receive individual results twice a year. If the results indicate that MRSA screening or handling might need improvement, an expert group meets with the hospital in a protected setting to discuss the situation.
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 (Regional Office for Quality Assurance in Hospitals Baden-Württemberg / Germany) 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. Individual answers are transmitted to the hospitals.
Timeframe implementation
about 6 months
Implementation tools available
Data collection concerning MRSA-screening and nosocomial infections/colonizations with MRSA from all hospitals in Baden-Wuerttemberg, benchmarking of these data and discussion of the insufficient results with each hospital.
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 figures. This allows the hospitals to rank their individual efforts compared to all other hospitals in the region. For each performance figure the expert team is defining limits. If these limits are exceeded or not reached, 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 frame the rate of nosocomial infections has decreased continuously.
Analysis of the results
Results from the screening activities of the hospitals show a large amount of heterogeneity. Quality assurance is obtained by starting a dialogue with medical providers, such as those whose screening activities were too low or showed high nosocomial infections rates. Since the implementation of the quality assurance program the screening activity has increased remarkably. Nevertheless these pioneer measures are considered a learning processes whose determinants are continuously discussed.
Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
Initially the mandatory data delivery was incomplete.
Describe the strategies used to overcome the barriers (If needed)
Regional regulations (Baden-Wuerttemberg) and feed-back helped to reach complete data delivery.
Other information
Other information about the GOP that you would like to add (Link or attached document)
Detailed results of the project were recently 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)
further information: http://www.geqik.de/index.php?id=1081