The publication of the SGAIM quality indicators for the inpatient sector provides an initial expert contribution to the quality development of inpatient internal medicine. The quality-oriented development according to Article 58 of the KVG is thus supported. Based on this law, the Federal Council established the Federal Quality Commission (EQK) for the first time in 2021. It coordinates and promotes national quality activities in the healthcare sector. In view of the current development, the initiative of the SGAIM seems to come at an appropriate time [1, 15]. Transparent quality indicators form an important basis for quality development for professionals, science and health policy. This is particularly important because the quality indicators available in Switzerland have been criticised by professionals of General Internal Medicine, but no alternative has yet been put forward for discussion [9].
Transmission of provisional discharge reports
The transmission of provisional discharge reports within 24 hours after discharge could be implemented in accordance with the recommendations. A seamless flow of information to post-treatment specialists and institutions is in line with the hospital's practical experience, as the prompt transmission of patient information relevant to treatment is expected. Donabedian [16] describes the importance of coordinating all healthcare providers involved as a crucial part of a comprehensive understanding of quality. In Hospital Männedorf, it became apparent in that there is still a need for training in the use of the application in reporting (reports were not correctly completed, sent and archived). A monthly analysis of this quality indicator also enables timely interventions if negative developments are detected. From a health economic point of view, it should be critically noted – with regard to provisional discharge reports – that two reports (provisional, definitive) must be taken into account in the post-treatment institution. Since both reports have to be consulted, additional costs are incurred. As part of the digital further development of all service providers in the outpatient and inpatient sector, digital, timely and complete information processes via the electronic patient dossier (EPD) should be strived for in the medium term. At the present time, however, the quality indicator makes a valuable contribution to improving treatment continuity and reducing avoidable complications [17].
New prescription of benzodiazepines and Transfusion with Hb value > 8 g/dl
The new prescription of benzodiazepines and transfusions with Hb values > 8 g/dl were included in quality reporting at Hospital Männedorf in accordance with the recommendations. Due to the broad acceptance among the medical staff as well as the comprehensible indicator descriptions, it became apparent in a short time that the preparation of results and the discussion led to sensitisation for these topics. However, the example of Hospital Männedorf showed that a monthly evaluation has a high variance due to the low patient volume and the associated few transfusions. This limits the statistical significance of the quality indicator considerably. Nevertheless, a monthly analysis of the indicators appears to make sense in order to enable short-term internal analyses in the event of anomalies.
CIRS case processing
According to the SGAIM, the quality indicator on the subject of CIRS is intended to promote an active error culture with discussion and analysis of CIRS cases [18]. In Hospital Männedorf, the recommendations were adopted on a trial basis. However, this quality indicator must be viewed critically from several perspectives. For example, the number of CIRS cases per patient does not allow any conclusions to be drawn about the qualitative case description and processing quality [19]. In addition, CIRS reports are based on voluntariness [20]. Furthermore, they cannot always be clearly assigned to a clinic or a specialty. On the one hand, this is because some patients are treated in other departments (e.g., geriatric traumatology); on the other hand, some CIRS cases are processed in support departments such as IT or medical technology (CIRS reporting groups). In addition, the potential of clinical risks, for example depending on the complexity of treatment and length of stay, as well as actual treatment errors resulting in liability cases, remain unconsidered. Employee satisfaction and team culture can also influence reporting behaviour [21, 22]. Based on the explanations, the quality indicator is not considered useful by the authors. High-quality case descriptions would be better suited to achieving the intended goal, as this allows for systematic case processing. This can be achieved through training for all employees and will contribute to an awareness of the employees for the reporting of CIRS cases (structural quality according to Donabedian) [23]. The experience of Hospital Männedorf with a CIRS that has been in place for many years shows that more well-founded and transparent case processing motivates reporters to report further cases. As a measure of the error culture, the proportion of CIRS cases reported by known reporters could be used throughout the hospital. This is important because, in the case of non-anonymous cases, the reporters can be involved in the case processing if necessary and thus a more well-founded case analysis is possible. The proportion of CIRS cases that are not reported anonymously also reflects the trust in CIRS and the safety and error culture within the hospital. For example, according to the national quality report by Vincent and Steines [24] and a meta-analysis by Manser [25], it is impossible to improve safety and quality problems without an open culture of conversation.
Fall biography of the last 12 months
In Hospital Männedorf, as in many other hospitals in Switzerland, the survey of fall biographies is already standardised for all inpatients as part of the electronic nursing assessment in the acute care sector. The survey ensures part of the process quality in order to be able to prevent future falls through preventive interventions. However, whether and in what quality the fall history and the fall prevention measures are discussed and implemented in the interprofessional treatment team remains unconsidered. The SGAIM recommendations do not define which professional group is recommended to conduct the survey [26]. However, it is in the interest of the patients that existing information from other professional groups is used. Since the electronic nursing assessment previously provided for recording the fall history of the last two months, the assessment processes in Hospital Männedorf were adapted to twelve months and the nursing staff, who primarily work with the assessment, were trained in this regard. Without electronic nursing assessment, the indicator appears to support quality. However, if the fall history is systematically collected on admission, the quality indicator does not provide any added value due to a lack of variance. In this case, it would be relevant to analyse whether preventive measures were initiated based on any history of falls.
Hepatitis B vaccination protection
This involves recording the sufficiency of hepatitis B vaccination protection among employees with potential contact with blood or contaminated material. This quality indicator is a spot measurement once a year based on the number of employees. The respective delimitation of the staff proves to be difficult, since many employees work for several clinics, for example, employees of the housekeeping service or the nursing staff of interdisciplinary wards. Further challenges are so-called "non-responders" (persons who do not respond to vaccination or only respond to a limited extent), vaccine-critical persons, and the high turnover, especially among staff undergoing training. External partners, such as medical consultants, are also not taken into account. In Hospital Männedorf, the first step was therefore limited to the salaried physician staff of the Clinic for Internal Medicine and the cut-off date of December 31 was chosen. An extension to other professional groups will be evaluated after the pilot phase. There is also the question of whether hepatitis B vaccination protection allows a statement to be made about the health of employees. For example, the STRAIN study "Work-related stress among health professionals in Switzerland" by the Bern University of Applied Sciences describes numerous other factors that have an impact on the health of healthcare professionals [27]. For example, moral stress or physical and psychological workload are not considered in the SGAIM recommendations. An institution-wide survey of the quality indicator may be useful. From the authors' point of view, however, other factors, such as workload according to the STRAIN study, appear to be more relevant in the field of employee health [27].
Overall: The quality indicators defined by the SGAIM proved to be largely feasible in practice. The data for all indicators were available and, thanks to a high degree of digitisation, could be exported completely and in a structured manner from the various systems and evaluated at Hospital Männedorf with little effort. Only the data for the quality indicator of hepatitis B vaccination protection had to be evaluated manually. All indicators are comprehensible to physicians and nurses. Only the quality criterion of comprehensibility and interpretability of the indicator for the interested public and patients is not consistently met. However, the criteria applied by the SGAIM do not have the same claim of comprehensibility for the public as the QUALIFY evaluation model [11]. According to the SGAIM, the quality indicators aim to support the measurement of a structured quality improvement process and not to provide quality transparency to stakeholders. For this purpose, the professional association was guided by the criteria of the American College of Physicians (ACP) and also subjected them to an external review [9, 28, 29]. Based on the results of this study as well as the previous discussion, the question arises as to whether the quality criteria for relevance and scientific soundness delineated in this study are always given [11]. In the case of the CIRS quality indicator, for example, the question arises as to whether validity is given: Does the indicator measure what it purports to measure? In addition, there should be a statistical discriminatory ability of the results with potential for improvement for each indicator, so that quality development is possible and recognisable in the course. In this study, for example, this was not the case for the quality indicator on fall history.
Individual quality indicators are not only suitable for internal medicine, but also across specialties. In the interest of quality orientation that goes beyond inpatient internal medicine, it would be ideal for the quality indicators to be recognised by all actors in the healthcare system.
The quality indicators of Swiss acute hospitals (CH-IQI) of the FOPH remain unconsidered and undiscussed by the SGAM. In the sense of standardised quality transparency for all stakeholders in the healthcare system and comparable quality development, it would be welcome if the SGAIM were to contribute its knowledge and experience to the further development of the national quality indicators. This is particularly recommended, since the FOPH accepts suggestions from service providers, professional medical societies and individuals according to a publicly visible change process, carries out a risk adjustment and enables comparisons between institutions. Such suggestions would enable sustainable improvement based on quality transparency [6, 30]. Expansion by means of a peer review process following the example of the Initiative Quality Medicine (IQM) would also be a conceivable option [31].