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Quality Assurance Initiatives in Psychiatric and Psychotherapeutic Care for Depression Experiences from the South-German QA project and the German Competence Network on Depression Martin Härter and Petra Sitta Stuttgart, 15.03. 2002. Regulations for QI. SGB V § 135a (Abs. 1), 2000

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Quality Assurance Initiatives in

Psychiatric and Psychotherapeutic Care

for Depression

Experiences from the South-German QA project

and the German Competence Network on Depression

Martin Härter and Petra Sitta

Stuttgart, 15.03. 2002

Regulations for qi
Regulations for QI

SGB V § 135a (Abs. 1), 2000

Care providers have an obligation for quality assurance and improvement along standards of evidence based medicine.

SGB V § 135a (Abs. 2)

Health care providers are obligated toparticipate in external quality assurance measures, especially if improvement of outcome quality is intended.

SGB V § 135a (Abs. 2)

Hospitals and other health institutions should implement and improve internal quality management, that guarantees the quality of care by a system of precise procedures and systematic measures and helps to improve it continuously.

Quality Management Projects

in Psychiatry and Psychotherapy

I. Development of Inpatient Documentation Form (BADO)


II. Quality Circles in Outpatient Care


III. External Quality Assurance (Tracer Diagnoses)

a) Depression (Baden-Württemberg)

b) Schizophrenia (North Rhine Westphalia)


IV. Improvement of Inpatient Quality Management


V. Development of Guidelines (schizophrenia, affective disorders etc.)


VI. Competence Networks

a) Schizophrenia

b) Depression

c) Substance abuse

d) Dementia


Quality assurance in depression background
Quality Assurance in Depression- Background -

„Quality Assurance in Inpatient Treatment

of Depression in Baden-Württemberg“

(Study Period: 1998-2000)

Work Group:

Dr. R. Metzger, Bad Schussenried (speaker since 1997)

Prof. Dr. R.-D. Stieglitz, Basel (2. speaker, 1994-1999)

PD Dr. Dr. M. Härter, Freiburg (2. speaker since 2000)

Dr. Ch. Hornstein, Wiesloch

PD Dr. F. Keller, Ulm

Dr. G. Schell, Stuttgart

Dipl.-Psych. S. Stabenow, Karlsruhe (1994-1999)

Dipl. Psych. W. Wiegand, Zwiefalten

Prof. Dr. M. Wolfersdorf, Bayreuth (speaker, 1994-1996)

Initiator: Prof. Dr. M. Berger, FreiburgSupport: Landesärztekammer Stuttgart

Project 3Quality Management in

Treatment of Depression

Subprojects 3.5, 3.6 and 3.7

(Study Period: 2000-2004)


  • Improvement of diagnostic and therapeutic quality

  • Development of process and outcome quality indicators

  • Internal quality assurance and external comparison of hospitals (bench marking)

  • Implementation and evaluation of quality manage-ment structures

  • Transfer into regular care ?


South German QA project:n = 24

all psychiatric clinics in Baden-Württemberg

Competence Network Depression:n = 10

5 clinics in North Rhine Westfalia

5 clinics in Baden-Würrtemberg and Bavaria

Quality indicators / Patient Characteristics

  • Sociodemographiccharacteristics(e.g. age, sex,marital status, level of

  • education, job situtation, living conditions, mother tongue)

  • Diagnostics(ICD-10, indication for inpatient treatment, reason for relapse/ disorder,

  • family history of mental disorder)

  • Severity of disorder(HAMD, CGI, AMDP, BDI, GAF, attempted suicide, risk to others)

  • Chronicity of disorder(duration, number of in- and outpatient treatments)

Service Profiling


  • Diagnostics (blood tests, ECG, EEG)

  • Pharmacotherapy (substance, dosage indication, duration etc.)

  • Psychotherapy (units of individual or group psychotherapy)

  • Other treatments (e.g. occupational therapy, music therapy)

  • Incidents (compliance, problems in psychotherapy, threats, attempted suicide)


Course of treatment

  • Therapeutic effectiveness

  • Change of psychopatholoy (GAF, AMDP, CGI, HAMD, BDI etc.)

  • Patient satisfaction (ZUF- 8, BBA)

  • Duration of inpatient treatment

  • Changes (job situation, personal situation, living conditions etc.)



Study design


Day 1-3




Day X

ICD-10 Diagnosis of

depressive disorder

Yes No

Exclusion from the study


Therapist in charge: DOCU-A/ HAMD

Change in Diagnosis?


Therapist in charge: DOCU-P

Patient:BDI, BBA, ZUF-8

Therapist in charge:DOCU-D/ HAMD

Indication for inpatient treatment (%)

(Multiple choice)

Freiburg (2001), n= 383

Severity at Admission - CGI (%)

Indication correct ?

Diagnostics (Freiburg 2001, n= 401)





Psychopathology - Beck Depression Inventory

Admission Discharge

mean (SD) mean (SD)

Freiburg 24,7 (11,6) 12,1 (11,1)

(2001) N = 210

Baden-Württemberg 27,3 (11,2) 11,1 (9,8)

(1999) N= 1587

Baden-Württemberg 25,7 (11,4) 10,7 (9,4)

(2000) N= 1157

Evaluation of treatment by patients

The most important for me was .......

Baden-Württemberg: n=473,

categories >5%; BBA


structural quality

  • indicators fo inpatient treatment

  • stronger control for indication (inpatient treatment) necessary

    process quality

  • comparison of diagnostic procedures (necessity?)

  • long mean duration of inpatient treatment

  • remarkable differences in medication and psychotherapy

  • relevance of psychotherapy for patients

    outcome quality

  • high effectiveness for inpatient treatment

  • relevant percentage of „unchanged“ patients (chronic depression)

  • high patient satisfaction

Quality Management Projects

in Psychiatry and Psychotherapy


+ QA in psychiatry is possible

+ Attempt to implement QA area-wide / regional

+ Participation of all psychiatric hospitals in Baden-Württemberg

+ Development of documentation forms

+ Development and implementation of the concept of benchmarking

- no project evaluation

- representativity of data is limited (selection of patients?)

- data only at admission and discharge

- low establishment of QM-measures in clinics

- clinical relevance ?

- transfer in regular care ?

3.5/3.6 Time schedule - Main study

Step 3

Step 4

Step 5

Step 6



Initial Bench-


Post -intervention


Training; Involvement of QM-structures, areas of intervention (benchmarking based)

Continuous training

Ongoing benchmarkings



5 hospitals







n=150 pat./hospital

n=150 pat./hospital



5 hospitals




No intervention




n=150 pat./hospital

n=150 pat./hospital



Quality Management Projects

in Psychiatry and Psychotherapy

Preliminary Conclusions:

+ planned total-survey in clinics

+ reduced and adapted documentation materials

+ testing the effect of QM-structures

- motivation of staff, documentation load for physicians

- data for clinical decision making ?

Quality Assurance Initiatives in

Psychiatric and Psychotherapeutic Care

for Depression

Experiences from the South-German QA project

and the German Competence Network on Depression

PD Dr. phil. Dr. med. Martin Härter and Petra Sitta, Dipl. Psych.

[email protected]

Selected publications
Selected Publications

  • Härter, M., Vauth, R., Tausch, B. & Berger, M. (1996). Ziele, Inhalt und Evaluation von Trainingsseminaren für Qualitätszirkelmoderatoren. Zeitschrift für ärztliche Fortbildung und Qualitätssicherung, 90, 394-399.

  • Reuter, K., Mager, A., Härter, M., Kern, I. & Berger, M. (1999). Qualitätszirkel in der stationären Versorgung. Ein Pilotprojekt an der Universitätsklinik Freiburg. In M. Härter, M. Groß-Hardt & M. Berger (Hrsg.), Leitfaden Qualitätszirkel in Psychiatrie und Psychotherapie (S. 91-102). Göttingen: Hogrefe.

  • Härter, M., Stieglitz, R. & Berger, M. (1999). Qualitätsmanagement in der psychiatrisch-psychotherapeuti-schen Versorgung. In M. Berger (Hrsg.), Psychiatrie und Psychotherapie (S. 1001-1014).München: Urban & Schwarzenberg.

  • Klimpel, M., Schüpbach, H., Groß-Hardt, M. & Härter, M. (2000). Implementierung von Qualitätszirkeln im Krankenhaus aus arbeits- und organisationspsychologischer Sicht. Gesundheitsökonomie und Qualitäts-management, 5, 157-162.

  • Härter, M., Bermejo, I., Aschenbrenner, A. & Berger, M. (2001). Analyse und Bewertung aktueller Leitlinien zur Diagnostik und Behandlung depressiver Störungen. Fortschritte der Neurologie und Psychiatrie, 69, 390-401.

  • Tausch, B. & Härter, M. (2001). Perceived effectiveness of diagnostic and therapeutic guidelines in primary care quality circles. International Journal forQuality in Health Care, 13 (3), 239-246.

  • Keller, F., Härter, M., Metzger, R., Wiegand, W. & Schell, G. (2001). Prozess- und Ergebnisqualität in der stationären Behandlung ersterkrankter und chronisch depressiver Patienten. Krankenhauspsychiatrie, 12, S50-S56.

  • Härter, M. & Stieglitz, R.-D. (in Druck). Qualitätsmanagement in Psychiatrie und Psychotherapie. In H.J. Freyberger, R.-D. Stieglitz & W. Schneider (Hrsg.), Kompendium der Psychiatrie, Psychotherapie und Psychosomatischen Medizin. Basel: Karger.