Quality Assurance (QS)

In order to ensure patients' safety and medical treatment in accordance with the current state of scientific knowledge and to be able to provide it in the required professional quality, hospitals must participate in quality assurance procedures.

As a hospital approved under Section 108 of the Social Code Book V, the MHH is legally obliged to participate in external quality assurance in accordance with Sections 135a ff. of the Social Code Book V.

The aim of external quality assurance is to consistently improve the quality of treatment for patients by measuring medical services and making them comparable.

As a patient, you can find further information on data collection for the individual procedures here under 'Further information'.

The legislation has legitimised the G-BA (Federal Joint Committee) as the highest decision-making body for joint self-administration in the German healthcare system in the German Social Code.

The G-BA (Gemeinsamer Bundesausschuss) determines the basic requirements for external quality assurance in the form of guidelines.

The following guidelines (according to Section 137 of the Social Code Book V) currently regulate external quality assurance in healthcare:

plan. QI-RL - Guideline on planning-relevant quality indicators

DeQS-RL - Guideline on data-based cross-institutional quality assurance

QFD-RL - Guideline Quality promotion and enforcement

The measured medical performance data are analyzed using defined quality indicators. At the federal level, this task is carried out by the IQTIG (Institute for Quality Assurance and Transparency in the Healthcare Sector) in Berlin. At the state level, the process has been managed by the Lower Saxony State Working Group for Quality Assurance in Medical Care (LAGN QSmV) since January 1st, 2020.

The core element of the external quality assurance process is a statement procedure with the help of which valid and comparable findings on the quality of care can be determined. The quality of care is ensured and, if necessary, improved by means of target agreements.

We publish a yearly quality report with the structured data for quality assurance and improvement, which are continuously analyzed in accordance with legal requirements.

To ensure compliance with the requirements for structural, process and outcome quality in hospitals authorised under Section 108 SGB V, the G-BA was given the task of regulating the quality controls of the Medical Review Board (MD) with the Act on the Reform of Hospital Care Structures (KHSG). The principles of these inspections in accordance with Section 275a SGB V are defined in the MD Quality Control Guideline (MD-QK-RL).
The inspections of the G-BA guidelines specified in the MD-QK-RL are coordinated and monitored by the MHH QA team.

Contact: If you have any questions or suggestions, please contact us at: eqs@mh-hannover.de