Development of a quality indicator set for day hospices in Germany - a multi-stage, quality-assured review of German guidelines and quality indicator sets.

Background

In Germany, the main aim of palliative care is to maintain and improve the quality of life of patients (and their relatives) with an advanced, life-limiting illness [ 1 ]. Palliative care can be provided in both, inpatient (palliative care units, hospices) and outpatient (outreach palliative care services for the home) settings, depending on need [ 1 ]. Day hospices are a relatively new type of outpatient palliative care facility in Germany, currently available in only a limited number of locations. Their primary goal is to enhance the independence and quality of life for individuals with advanced, life-limiting illnesses. This is achieved through interventions such as “social interactions (...), rehabilitation, physiotherapy, ergotherapy, artistic therapies (...) and/or medical care to control symptoms” [ 1 ]. Ensuring palliative nursing care and counteracting social isolation are particularly important for patients [ 2 , 3 ]. Additionally, day hospices aim to ease the burden on family caregivers, thereby enabling continued care for patients at home [ 4 – 6 ]. Especially the daily respite care provided by a day hospice is particularly important for relatives [ 2 , 3 ]. Patients typically attend day hospices on weekdays during standard working hours and return to their home environment afterward [ 3 ]. Research on the effectiveness of day hospices has reported high levels of patient satisfaction [ 4 , 7 ]. However, earlier quantitative studies—characterized by varying methodologies and difference in day hospice structures [ 1 ]—have produced inconsistent findings regarding their impact on quality of life [ 8 , 9 ]. Despite these mixed results, day hospices are anticipated to positively contribute to the German healthcare system [ 3 ]. Initial theoretical structural recommendations have already been published, proposing standardized criteria to guide the future establishment of day hospices in Germany [ 10 ].

Given that day hospices are a recent addition to the German healthcare system, specific measures for quality assurance and improvement have not yet been implemented. Establishing defined quality criteria and target values is essential for delivering high-quality medical and nursing care. These criteria provide a framework for evaluating specific aspects of care and identifying areas for improvement, particularly in newly developed care structures [ 11 , 12 ]. Quality indicators are particularly well-suited for this purpose, as they facilitate the differentiation between high- and low-quality. However, the global parameter “quality of a facility” is not measured directly as an individual single value. Instead, individual aspects are examined using various quality indicators relating to structures/organisations, processes/interventions and results of a facility as auxiliary parameters in the sense of a multidimensional approach. They do not directly measure quality but indirectly by comparing numerical ratios. This approach determines the degree to which specific target values are achieved [ 11 , 12 ]. By utilizing multiple quality indicators, various dimensions of a facility—such as structures, processes, or outcomes—can be evaluated [ 11 , 12 ]. For quality indicators to effectively assess care quality and identify potential improvements, they must meet specific criteria. These include the ability to collect data simply and cost-effectively, minimize subjective influence, and ensure the indicators are meaningful, relevant to the institution being evaluated, and reflective of healthcare quality. Furthermore, they should also measure those aspects that are particularly relevant for patients in the context of the analyzed institution. In Germany, the “QUALIFY” assessment tool is available to support this process. QUALIFY was developed by the German Federal Agency for Quality Assurance as a validated and operationalized evaluation tool for the structured, standardized and quality-assured evaluation of quality indicators. It comprises a set of clearly defined evaluation criteria divided into three categories: relevance, scientific validity and practicability [ 11 – 13 ].

The IMPULS study, a quality-assured investigation into day hospices (DRKS-ID DRKS00031613, Z-2022-1734-6 [ 14 ]), aims among others to identify potential quality indicators for monitoring and ensuring the quality of care in day hospices. These indicators may support the future development of day hospices and contribute to the growing importance of quality management in this field.

Methods

The development of a quality indicator set for day hospices followed the German Guideline Program in Oncology for creating guideline-based quality indicators [ 15 ] and the Program for National Care Guidelines–Quality Indicators [ 11 ].

Selected guidelines and quality indicator sets

To identify potentially relevant quality indicators [ 16 ] for day hospices, three German national platforms for validated quality indicators and with the best references to relevant topics for a day hospice like ambulant medical organisation/structure, palliative care and chronic or malignant diseases were used: the German-language S3 guidelines from the national guideline registry of the Association of Scientific Medical Societies in Germany (AWMF) [ 17 ], along with the German-language quality indicator sets from the National Association of Statutory Health Insurance Physicians (KBV) [ 18 ]: Outpatient Quality Indicators and Key Figures (AQUIK) and from the General Local Health Insurance Fund (AOK) [ 19 ]: Quality Indicator System for Outpatient Care (QISA). The S3 guidelines, developed by relevant professional societies, represent the highest methodological and qualitative state of the art standards for various diseases in Germany. The AWMF coordinates “the development of medical guidelines for diagnostics and therapy by medical societies and publishes them through the AWMF Guidelines Register” [ 20 ]. The KBV represents the interests of medical specialists in a practice and in outpatient care in Germany. AQUIK consists of 65 quality indicators for outpatient care, addressing a range of medical conditions and medical office management. It is intended as a tool for quality management control [ 18 ]. AOK is one of the largest health insurance companies in Germany. QISA offers a set of quality indicators to assess outpatient medical care, organized into 14 volumes, each addressing different clinical scenarios, healthcare models, and cross-sectional topics [ 19 ]. International quality indicators were excluded from the selection process due to different healthcare systems and the resulting challenges of adapting them to the German healthcare system without significant modification [ 11 ]. However, they were used as comparative or reference indicators in the discussion.

Stage 1: Selection of potentially relevant guidelines and quality indicators sets

All S3 guidelines and all quality indicator sets/volumes from AQUIK, and QISA volumes were independently reviewed for their relevance for a day hospice by the authors KU, VKU, and KF (all three are specialists in palliative medicine with several years of experience in the care of patients in a day hospice). The screening criteria by keywords for Stage 1 are outlined in Table 1 . In a first joint meeting during Stage 1, the three authors discussed their findings and collectively decided on the acceptance or rejection of potential guidelines or quality indicator sets/volumes. To facilitate structured decision-making within the research team, the authors employed the nominal group process described by Dunham [ 21 ]. This process involves pooling analyses to gather and present the views and judgments of as many participants as possible in a clear and objective manner [ 21 ]. If a guideline or indicator set/volume was deemed relevant, all the quality indicators it contained were further screened for their applicability to day hospices in a second stage (Fig. 1 ). Fig. 1 Process for selecting quality indicators. QI, quality indicator

Table 1 Selection criteria: potentially relevant guidelines, indicator sets, and quality indicators Selection criteria for screening potentially relevant Guidelines/quality indicator sets (Stage 1) Selection criteria for screening potentially relevant quality indicators (Stage 2) Palliative care Relevance for the structure of day hospice Advanced, incurable disease Relevance for the organization of day hospice Progressive, chronic disease Relevance for equipment/staff of day hospice Geriatrics Relevance for interdisciplinary cooperation in day hospice Organisation/Structure Malignant disease Relevance for nursing tasks in day hospice Supportive care Relevance for medical tasks in day hospice Psychosocial illness/stress Relevance for psychosocial tasks in day hospice Quality indicators available Feasibility of a day hospice

Stage 2: Selection of potentially relevant quality indicators

All quality indicators from the guidelines and quality indicator sets/volumes selected in Stage 1 were independently screened by the three authors KU, VKU and KF as potential indicators for day hospices. Relevant screening criteria can be found in Table 1 . In a second joint meeting during Stage 2, the authors discuss their results and consolidated a final selection of potentially relevant quality indicators for a day hospice using a further nominal group process according to Dunham [ 21 ]. In a third stage, all final selected potentially relevant indicators were then sent to a panel of experts for further evaluation (Fig. 1 ).

Stage 3: Selection of the final quality indicator set

For further evaluation, an initial kick-off meeting was held with the expert committee. Prerequisites for participation as an expert were a specialist qualification in palliative medicine and/or quality management as well as several years of professional experience in palliative medicine and in hospices/day hospices mainly in Germany. Experts from various specialist disciplines were recruited (palliative care physicians, palliative care nurses and quality managers) in order to enable the widest possible range of different perspectives. Particular attention was paid to a balanced mix of participants with university and non-university experience, especially among the palliative care physicians. The final expert committee consisted of four palliative care physicians, two palliative care nurses, and two quality managers from the palliative care sector. The methodology [ 11 , 15 , 21 ], the existing German-language quality indicator sets/guidelines [ 17 – 19 ], and the planned steps were outlined here. Specifically, the committee examined the criteria for identifying and evaluating potential quality indicators for day hospices:

The possibility of internal and external supervision (monitoring, evaluation, and alert functions) of medical, nursing, and psychosocial care relevant for day hospices. The potential for ongoing quality improvement for day hospices: Internal: Optimizing patient care and internal structures and processes. External: Opportunities for certification, public relations, benchmarking between day hospices, and providing comparative decision-making tools for patients and cost units (quality and safety of care, cost efficiency).

Additionally, assessment criteria such as measurability, potential for improvement, clarity, and data collection effort were considered [ 15 ].

Based on these principles, the experts conducted a written evaluation of the selected quality indicators using a standardized evaluation form based on QUALIFY [ 13 ]. The evaluation included five criteria from the areas of relevance, scientific foundation, and practicability (identifying improvement potential, clear definition, describing an aspect that can be influenced; risk of misdirection; justifiable data collection effort). Additional comments were allowed on the focus of the quality indicators, external influenceability, and implementation barriers [ 13 , 15 ]. Each criterion was rated with a Yes/No response. Following the established guidelines, an indicator was considered accepted if ≥ 75% of the participating experts agreed on all criteria [ 15 ]. In a joint meeting, the expert group discussed the quality indicators using a nominal group process [ 21 ]. Based on these evaluations, the indicators were reevaluated if necessary, and a final set of quality indicators for day hospices was established. When indicators from different guidelines or sets overlapped, only one version was included. The selection prioritized the S3 guidelines as the highest quality guideline and the indicators best suited for day hospices.

Validation and modification

Since the study was based exclusively on already validated quality indicators from guidelines or already tested quality indicator sets, no further separate validation of the selected indicators was carried out. Recommendations for possible modifications to enhance applicability to day hospices were also discussed and approved by consensus among the expert panel.

Ethical aspects

As part of the IMPULS-study [ 14 ], there is an ethics approval by the ethics committee of the University of Regensburg (Ethics Committee Number: 22–3012-101). As the researchers for the selection process were not themselves part of the study and no personal data was collected from the researcher, no separate consent forms were obtained from them.

Results

Selection of potentially relevant guidelines/quality indicator sets

In the initial screening, a total of 213 S3 guidelines, 1 AQUIK volume/quality indicator set, and 14 QISA volumes/quality indicator sets were reviewed. From these, 29 S3 guidelines ( n = 262 quality indicators), 1 AQUIK volume/quality indicator set ( n = 65 quality indicators), and 10 QISA volumes/quality indicator sets ( n = 155 quality indicators) were deemed potentially relevant for day hospices.

Of the 29 S3 guidelines, the majority related to various malignant diseases, as well as one guideline each on psycho-oncology, supportive care, and palliative care (Table 2 ). For chronic, life-limiting, non-malignant diseases, either no suitable S3 guidelines were available, or the inclusion criteria (Table 1 ) were not met. The latter also applies to the 184 non-selected S3 guidelines. Table 2 Development of quality indicators S3 guidelines Potential S3 guidelines Quality indicators in total Potential quality indicators Final quality indicators 213 Skin tumors (2022) 1 0 0 Colorectal carcinoma (2019) 11 1 0 Esophageal carcinoma (2023) 13 0 0 Gastric carcinoma (2019) 10 1 1 Pancreatic carcinoma (2024) 7 0 0 Hepatic cell and biliary carcinomas (2023) 9 0 0 Cervix carcinoma (2022) 10 0 0 Endometrial carcinoma (2024) 9 1 0 Ovarian tumors (2022) 9 0 0 Breast cancer (2021) 10 0 0 Laryngeal cancer (2019) 6 1 0 Oropharyngeal/hypopharyngeal cancer (2024) 13 1 0 Hodgkin lymphoma (2022) 9 0 0 Chronic lymphocytic leukemia (2018) 4 0 0 Follicular lymphoma (2020) 3 0 0 Monoclonal gammopathy of undetermined significance/multiple myeloma (2022) 1 0 0 Diffuse large B-cell lymphoma (2022) 7 0 0 Renal cell carcinoma (2023) 9 0 0 Anal carcinoma (2020) 13 0 0 Lung cancer (2024) 16 0 0 Bladder carcinoma (2020) 12 2 0 Soft-tissue sarcomas (2022) 14 0 0 Psycho-oncology (2023) 9 8 3 Supportive care (2020) 3 1 0 Oral cavity carcinoma (2021) 10 1 0 Palliative medicine (2020) 11 6 3 Prostate carcinoma (2024) 14 0 0 Penile carcinoma (2020) 8 1 0 Testicular cancer (2020) 11 0 0 S3 guidelines in total 213 29 262 24 7 AQUIK sets Potential AQUIK sets Quality indicators in total Potential quality indicators Final quality indicators 1 AQUIK (2013) 65 4 3 AQUIK total 1 1 65 4 3 QISA volumes Potential QISA volumes Quality indicators in total Potential quality indicators Final quality indicators 14 C1 asthma/Chronic obstructive pulmonary disease (2019) 15 4 0 C3 high blood pressure (2020) 11 0 0 Volume C6 depression (2020) 13 2 0 C8 heart failure (2024) 13 1 0 F2 multimorbidity (2022) 22 22 1 B regional healthcare models (2009) 28 10 5 C2 diabetes mellitus (2019) 11 3 0 C7 KHK (2023) 15 1 0 D pharmacotherapy (2019) 15 0 0 F1 palliative care (2021) 12 4 3 QISA total 14 10 155 47 9 Guidelines/Indicator sets in total Potential guidelines total Quality indicators in total Potential quality indicators in total Final quality indicators in total 228 40 482 75 19 Year of publication of the guideline/quality indicator set in brackets

Only one quality indicator set was available for AQUIK, so that no further screening process took place here.

Of the 14 QISA volumes, 4 volumes without relevance for a day hospice were excluded according to the inclusion criteria (Table 1 ): rational use of antibiotics, early detection of cancer, back pain, and prevention. The 10 volumes selected related to non-malignant, chronic, long-term potentially life-limiting diseases, palliative care, multimorbidity, pharmacotherapy, and models of care in medicine (Table 2 ).

Selection of potentially relevant quality indicators

The 40 selected guidelines/quality indicator sets contain 482 quality indicators. Of these 75 were identified as potentially relevant for day hospices according to the inclusion criteria (Table 1 ) (S3 guidelines, n = 24; AQUIK, n = 4; QISA, n = 47) (Table 2 ). The main reasons for excluding the 407 not selected quality indicators were: – Focus on haematological or oncological tumor therapy or therapy of non-malignant (chronic) diseases. – Focus on documentation and/or diagnosis of haematological or oncological tumors or non-malignant (chronic) diseases. – Focus on structures of a tumor centre. – Focus on structures/therapies, that a day hospice does not provide or that are not relevant for a day hospice. – Focus on the results of interventions/measures, that are not defined as the primary goal of day hospices or on which a day hospice has no or only an uncertain influence.

Selection of the final quality indicators

From the preselected 75 potentially relevant quality indicators, 56 preselected quality indicators were rejected. The main reasons for rejection were: A: Influence by external medical providers cannot be ruled out. B: Risk of mismanagement due to the day hospice (nursing) exceeding its competences, e.g. independent initiation of medication, therapeutic interventions or cross-competence medical consulting. C: Risk of mismanagement due to duplicate structures with external providers. D: No relevant potential for improvement possible through day hospice. E: Not relevant for the structure of a day hospice. F: Recording and documentation not appropriate. G: Duplication of quality indicators.

Of the 17 preselected quality indicators rejected from the S3 guidelines, three related to the quality of outcomes (reduction of pain/respiratory distress, use of laxatives for opioids; reasons for rejection: A, B), ten related to process quality (in particular, special counselling/support by specialists, e.g. stoma therapist, psycho-oncologist, social worker; reasons for rejection: A, C, D, G) and four related to structural quality (structural requirements, irrelevant for a day hospice; reasons for rejection: A, B, D, E).

One preselected quality indicator related to structural quality from AQUIK was rejected due to duplication (G).

Of the 38 preselected and rejected quality indicators from QISA, none related to outcome quality, 28 to process quality (medical and structural care of chronic diseases, hospital admissions, optimization and control of medication/side effects, definition of therapy goals, education on medical therapies; reasons for rejection: A, B, C, E, G), and 10 to structural quality (management of quality circle work, surveys among doctors, further training of doctors, coordination of care; reasons for rejection: D, E, F, G).

By consensus during the detailed evaluation, a final set of 19 indicators (S3 guidelines, n = 7; AQUIK, n = 3; QISA, n = 9) was chosen (Fig. 1 ; Tables 2 and 3 ). Summarizing, 13 quality indicators are related to process quality, and 6 quality indicators are related to structural quality (Table 3 ). The process quality indicators focus on areas such as patient care, co-care by relatives, psychosocial support, symptoms tracking, and the collection of clinical, medical, and psychosocial data/complaints, as well as the organization within the day hospice. The structural quality indicators cover topics such as staff training, networking, and satisfaction. Furthermore, many of the quality indicators could not be directly applied to day hospices. In most cases, adjustments were made to better align with the specific needs and structure of day hospices (Table 3 ). Table 3 Final set of quality indicators Source Quality indicator Final evaluation Implementation barriers Focus Modification S3 guideline for palliative medicine QI 7: Oral care (numerator, number of patients with oral care; denominator, patients with diagnosis “incurable cancer” and dry mouth) Acceptance with modification None Process quality (patient care) Expand “dry mouth” to include other oral issues: “Oral problems: dry mouth, mouth ulcers” S3 guideline for palliative medicine QI 8: Assessment of malignant wounds (numerator, number of patients with exulcerating tumor assessed using a specific tool; denominator, patients with a diagnosis “incurable cancer” and exulcerating tumor) Initially rejected, accepted after modification Requires physician prescription; in TH physician not always present, influence by externals possible. Process quality (data collection/patient care) Modify numerator: “Patients with assessment of the ulcerating tumor using a specific assessment tool according to the guidelines and co-care by physician order” S3 guideline for palliative medicine QI 10: Symptom recording using MIDOS or IPOS (numerator, number of patients with symptom recording using MIDOS or IPOS; denominator, all patients with diagnosis “incurable cancer”) Accepted None Process quality (recording) No modification required S3 guideline for gastric cancer QI 4: Nutritional status (numerator, number of patients with nutritional status assessed using the Nutritional Risk Score and body mass index; denominator, all patients with gastric/esophagogastric cancer) Acceptance with modification QI applies only to specific cancer patients Process quality (recording) Modify denominator: “All patients with diagnosis ‘incurable cancer’” S3 guideline psycho-oncology QI 3: Screening and diagnostic methods (numerator, patients of the denominator who underwent psycho-oncological screening; denominator, primary case patients + patients with new (local) recurrence and/or distant metastasis) Acceptance with modification QI applies only to certain patients Process quality (recording) Modify numerator and denominator: Numerator, “All patients screened for psychosocial support needs”; Denominator, “All day hospice patients” S3 guideline psycho-oncology QI 4: Diagnostic procedures (numerator, patients in the denominator with a diagnostic conversation to clarify psychosocial stress and mental comorbidity; denominator, all cancer patients with initial diagnosis, recurrence or first distant metastasis and positive screening for psychosocial stress) Acceptance with modification Numerator: diagnostic conversations by nursing staff at the day hospice not feasible; Denominator: applies only to specific cancer cases Process quality (psychosocial support) Modify numerator and denominator: Numerator, “All patients who receive supportive conversations from the day hospice staff and/or referred for further professional psychosocial support”; Denominator, “All day hospice patients with positive screening for psychosocial support needs” S3 guideline psycho-oncology QI 7: Patient-centered communication: training measures to improve the communicative competence of practitioners and their effectiveness (numerator, all physicians and nurses with quality-assured communication skills training to improve their communication skills; denominator: all physicians and nurses working in oncology) Primary rejection, acceptance after modification Risks of unbalanced training Structure quality (training) Modification title, numerator, and denominator: Title, “Training measures”; Numerator, “All specialist nursing staff at the day hospice with quality-assured further training in palliative care”; Denominator, “All specialist nursing staff at the day hospice” KBV: AQUIK Indicators Drug therapy safety: long-term medication (numerator, proportion of patients with four or more long-term medications whose medication was reviewed in the last 12 months and documented in their file; denominator, number of patients with four or more long-term medications) Initially rejected, accepted after modification Day hospices can only suggest reviews; it cannot review the medication plan itself Process quality (recording) Modify numerator and denominator: Numerator, “All patients of the day hospice whose medication plans are regularly recorded and updated according to physician´s orders”; Denominator, “All patients of the day hospice” KBV: AQUIK Indicators Clinic management: debriefing of critical events (At least three debriefings of critical events were conducted within the team in the last year in the clinic) Acceptance with modification None Process quality (organization) Replace “clinic” with “day hospice” KBV: AQUIK Indicators Clinic management: emergency medication (A standard procedure is used to test the stability of emergency medication in the clinic at least once a year) Acceptance with modification QI applies only if medications are stocked Process quality (organization) Replace “clinic” with “day hospice” AOK: QISA Volume F1. Palliative care in general practice Indicator 3: Proportion of palliative care patients for whom a contact person is documented (numerator, number of palliative care patients with a contact person/representative documented in an electronic file; denominator, number of palliative care patients in the clinic) Acceptance with modification None Process quality (recording) Replace “clinic” with “day hospice” AOK: QISA Volume F1. Palliative care in general practice Indicator 11: Proportion of palliative care patients whose relatives are included in the care provided by the clinic (numerator, number of palliative care patients with documented discussion with relatives or family in the clinic administration; denominator, number of all palliative care patients in the clinic) Initially rejected, accepted with modification Relatives must attend the day hospice, if needed. Content of the conversation predetermined (especially the course of the disease) ->rejection, modification with focus on care/QoL/spiritual + end-of-life aspects Process quality (co-care of relatives) Modify title, numerator, and denominator: Title, “Clinic” is replaced by “Day hospice”; Numerator, “Proportion of palliative care patients whose relatives have received (specialist)advice and/or supportive/palliative conversation from the day hospice about the palliative (healthcare/illness) situation (after physician consultation). Initial conversations about the palliative situation or physician information conversations are not included here.” Denominator, “All patients in the day hospice” AOK: QISA Volume F1. Palliative care in general practice Indicator 12: Proportion of palliative care patients with palliative counseling/information (numerator, number of palliative care patients for whom a discussion of the treatment and prognosis of the disease is documented in the practice management system; denominator, Number of all palliative care patients in the clinic) Initially rejected, accepted with modification QI for information on therapy and prognosis ->not suitable for TH content ->alternatives QI, focus: palliative care/social/coping with illness Process quality (psychosocial support) Modify title, numerator, and denominator: Title, “Informative discussion” replaced by “supportive discussion”; Numerator, “Proportion of palliative care patients with (specialist)counseling and/or supportive discussion on the palliative (healthcare/illness) situation by specialist nurses at the day hospice (after physician consultation). Initial discussions about the palliative situation or physician’s consultations are not included here.”; Denominator, ”Clinic” replaced by ”Day hospice” AOK: QISA Volume B. General Indicators Quality circle work. Indicator 7: Proportion of physicians participating in at least four quality circles per year (numerator, number of network physicians who attended at least four quality circles; denominator, all network physicians) Acceptance with modification None Structure quality (further training/networking) Modify title, numerator, and denominator: Title, “Participation in palliative, regional quality circles”; Numerator, “Participation of day hospice staff in palliative, regional quality circles”; Denominator, not applicable. Additional explanation: The highest possible participation in quality circles. Minimum to achieve the QI are 4 participations/year AOK: QISA Volume B. General Indicators Information for the insured. Indicator 9: Quality and availability of information for the insured persons on the healthcare model and on topics specific to their illnesses Acceptance with modification None Structure quality (networking) Modify Table 3 (criteria): include only criteria 1, 2.1, 2.2, 2.4, and 6; replace “network” with “day hospice” . Title: “and on disease-specific topics” is omitted. AOK: QISA Volume B. General Indicators Satisfaction of the insured. Indicator 13: Proportion of satisfied policyholders in the network (numerator, number of satisfied survey participants; denominator, number of all survey participants) Acceptance with modification None Structure quality (satisfaction) Title modification: replace “network” with “day hospice” AOK: QISA Volume B. General Indicators Satisfaction of the insured. Indicator 14: Proportion of insured persons who would recommend the health care model to others (numerator, the number of respondents who would recommend the network; denominator, the total number of respondents) Acceptance with modification None Structure quality (satisfaction) Modify the title and numerator: in each case, replace “network” with “day hospice” AOK: QISA Volume B. General Indicators Physician satisfaction. Indicator 15: Proportion of physicians satisfied with the results of the healthcare model in the past year (numerator, the number of survey participants who are satisfied with the network results; denominator, the total number of survey participants) Acceptance with modification None Structure quality (satisfaction) Modify title and numerator: replace “physicians” with “referring physicians” and “healthcare model” with “day hospice” ; numerator, replace “network results” with “results of the day hospice” AOK: QISA Volume F2. Multimorbidity Patient-centered parameters. Indicator 5: Evaluation of the subjective quality of life (numerator, number of patients with whom their subjective quality of life was discussed; denominator, number of patients aged 65 and over with three or more chronic diseases) Acceptance with modification None Process quality (recording) Modify the denominator: “All patients of the day hospice”

In more detail, of the 7 indicators in the S3 guideline, 3 came from the palliative medicine guideline, 1 from the gastric cancer guideline and 3 from the psycho-oncology guideline. Of these, 6 indicators could be assigned to process quality. The focus was on clinical and psycho-oncological symptom assessment, including nutritional status and the nursing and psycho-oncological measures carried out. 1 indicator was assigned to structural quality with a focus on the specialized training of day hospice nursing staff. Except the indicator “Symptom recording using MIDOS or IPOS”, 6 indicators required modification to adapt them to the special structures of a day hospice.

All 3 indicators from AQUIK were assigned to process quality and modifications were necessary for all of them. They related to the handling of critical events, the regular review of emergency medication and the medication plans of the day hospice guests.

Of the 9 indicators from QISA, 3 were from volume F1 “Palliative care in general practice”, 5 from volume B “General Indicators” and 1 from volume F2 “Multimorbidity”. All indicators required modifications. The indicators from volumes F1 and F2 were all assigned to process quality. They related to the documentation of a contact person, the evaluation of quality of life and the implementation of supportive/counseling discussions on the palliative situation for patients and relatives. The indicators from volume B were assigned to structural quality. They focused on participation in regional palliative care quality circles, the information provided and the satisfaction of patients and referring physicians with the day hospice.

Discussion

As day hospices are still a relatively new palliative care model in Germany, there are currently few scientifically grounded recommendations for their implementation and design [ 10 ].

The goal of this work was to develop a set of quality indicators for day hospices, drawing on validated quality indicators from guidelines for chronic or malignant diseases and quality indicator sets for outpatient care. A total of 482 quality indicators from 40 guidelines/quality indicator sets were analyzed, leading to the development of a final set of 19 quality indicators for day hospices.

In the analyzed guidelines and quality indicator sets for both malignant and chronic, non-malignant diseases that often lead to death, several potential quality indicators were identified. However, only a few were deemed suitable for palliative care/day hospices in the final evaluation. This is mainly due to the fact that the majority of the analyzed quality indicators focus on the diagnosis and treatment of diseases and/or the necessary medical and disease-specific structures and less or not on palliative care aspects [ 15 , 16 ]. Specifically, only one indicator each from the multimorbidity set and the S3 guideline on gastric cancer were included in the final quality indicator set. Most of the selected indicators came from guidelines/indicator sets focused on (oncological) palliative medicine/psycho-oncology or on organizational/structural topics. This pattern is also evident in the international literature [ 16 ] and reflects, on one hand, the growing distinction of palliative medicine and psycho-oncology as separate specialties. However, it highlights the ongoing need for continuous education and interdisciplinary collaboration between palliative medicine and the specialties of hematology/oncology, particularly for chronic non-malignant diseases [ 22 ]. This is important because, currently, day hospices, like the rest of the palliative care system, primarily treat patients with advanced malignant diseases [ 23 , 24 ], although they are technically open to all patients, including those with advanced non-malignant diseases. This should be considered in the future development of quality indicators for day hospices.

Most of the quality indicators in the final set were highly suitable for palliative medicine but could not be directly applied to the specific needs of day hospices without modifications. This misalignment is why a significant number of quality indicators, primarily from palliative medicine guideline/indicator sets, were not included in the final set for day hospices. Day hospices are primarily focused on palliative nursing care with an emphasis on social interaction and quality of life [ 1 , 10 ]. Physician involvement is not mandatory in day hospices and is only an additional option. Furthermore, day hospices provide outpatient care, while many of the quality indicators mentioned earlier require physician involvement and/or an inpatient stay to be fully applicable. Although day hospices can carry out physician orders on the nursing side, the resulting benefits cannot be solely attributed to the day hospice setting. But since high-class quality indicators should measure dimensions that can be directly influenced by the analyzed facility, many of the (palliative) quality indicators are not suitable for evaluating day hospices [ 25 ]. However, given their specialized palliative training, nursing staff at day hospices are highly capable of recognizing issues or crises in patients and, if necessary, their relatives and can recommend or organize further actions. By adapting the indicators to account for these aspects, many quality indicators could be made suitable for use in day hospices. Due to the complex and sometimes different forms of care in palliative medicine, it is considered sensible to adapt quality indicators to the requirements of the respective form of care [ 25 , 26 ]. The new set of quality indicators for day hospices is based on already validated quality indicators. However, most of these indicators had to be modified by the expert committee to meet the special requirements of a day hospice. These modifications have not yet been empirically validated in a day hospice as part of this study.

Quality indicators are intended to specifically evaluate and monitor the quality of care provided by medical institutions. A comparison of the new quality indicator set with the contractual requirements for day hospices in Germany (the contract cannot be published due to data protection laws; see also Sect. 113, Social Security Code (SGB) XI [ 27 ]) revealed that most of the required objectives and quality assurance criteria could be met. The primary mission of day hospices is to provide palliative nursing care to guests of a day hospice, including social, therapeutic, and spiritual services, as well as end of life and bereavement support for both patients and their families. The main goal is to enhance quality of life [ 1 , 4 – 6 ]. These central tasks of day hospices, in particular the quality of life and the relief of relatives, are not measured as direct quality indicators. The collection and evaluation of this data as part of quality management may be impracticable for day hospices due to a very high/too high effort. But specifically, the quality indicators in areas such as patient care, co-care with relatives, psychosocial support, and the recording of symptoms and clinical, medical, and psychosocial data/complaints can cover these objectives very well in the sense of an indirect measurement. These are core topics that also play an important role in international quality indicator sets on palliative care [ 25 , 28 , 29 ]. The new set of quality indicators also covers important internal and external structural criteria, such as the integration of day hospices into a regional (hospice and palliative) network, as well as regular case discussions and ongoing training [ 27 ]. Furthermore, the documentation and quality system in day hospices should remain within a reasonable and justifiable scope [ 27 ]. The quality indicator set, consisting of 19 individual indicators, aligns with previous German-language indicator sets on specialized topics [ 30 , 31 ], particularly since some indicators only need to be collected once or a few times per year. However, certain contractually defined quality requirements for day hospices are not fully covered by the new set. These include specific care measures, the evaluation of special support services (e.g., music therapy, breathing therapy, volunteer helpers), and day-structuring activities (e.g., shared meals, walks). This omission can be attributed to the unique and new nature of the “day hospice” care model, which has not yet been fully addressed in existing guidelines and quality indicators. It should also be considered that in day hospices, the special support and day-structuring measures are usually handled very individually and patient-centered. Too strict standardization carries the risk of undermining the idea of personalized hospice-care. In principle, future quality indicators for these topics should be more flexible and more general than too specific. Although the development of quality indicators in palliative care is in a constant state of flux [ 32 ], it is important to consider that the quality requirements remain within a reasonable and practicable framework. Many day hospices are small and have only a few employees. Extending the documentation requirements entails the risk of excessive demands and a lack of implementation. This must be taken into account when adapting the current quality indicator set, which will likely need further updates in the future.

Due to structural differences—for example, in Austria, where fixed physician coverage in day hospices is mandatory [ 33 ]—a comparison with international quality indicators is limited [ 11 ]. However, there is some overlap, particularly in the goals of day hospices, such as enhancing quality of life and social integration, as well as providing care with an emphasis on palliative nursing care [ 33 ]. A comparison with the new quality indicator set could offer an initial indication of its quality. International collections of quality indicators mainly address areas such as psychosocial care for patients and their families, palliative nursing care measures, and general aspects like the documentation of contacts/emergency contacts or networking [ 25 , 28 , 29 , 32 – 36 ]. The quality indicator set developed in this study covers these topics broadly, though, as mentioned earlier, some subaspects are not included in the new set. This includes, in particular, the specific services provided by a day hospice, such as the daily activities offered, the outcomes of palliative nursing/medical measures including symptom management, social integration efforts, and general aspects like documentation/determination of therapy preferences at the end of life, as well as care planning. Indicators that evaluate the activities offered and social integration measures will likely play a significant role in the quality management of day hospices in the future. However, other aspects, such as medical planning and determining the medical treatment of symptoms, and the determination of therapy preferences, fall outside the scope of day hospices in Germany or cannot be fulfilled due to the non-mandatory presence of physicians. Taking this into account, the new set of quality indicators primarily focuses on process quality, with a lesser emphasis on structure quality. There are no indicators for quality of outcomes. This may be because day hospices are typically integrated into an interdisciplinary palliative care network [ 37 ], making it difficult to attribute expected outcomes solely to the effect of the day hospice. The international literature also categorizes the measurement of outcomes of a day hospice, particularly on the basis of patient-reported outcomes, as difficult [ 23 ] and localized them more in the area of process or structural quality indicators [ 25 ]. An optimal tool does not yet exist, and previous studies have not yet been clearly successful or conclusive [ 9 , 23 ]. The quality of outcomes in a day hospice is certainly multidimensional and includes social, psychological, and interpersonal aspects and not only medical objectives [ 8 , 23 ]. A potential recording within the framework of a quality management system as well as the differentiation from external influences could be associated with a disproportionate amount of effort, which could make possible development and establishment more difficult [ 25 ]. This is also reflected in the low number of indicators on quality of outcome in the guidelines/indicator sets on palliative care analyzed [ 1 , 30 ]. Therefore, this does not necessarily capture the full qualitative value of day hospices.

In the future, the new quality indicator set could be a further decision-making aid for health insurance companies in the context of quality assessments and approval procedures for day hospices. The set could also be used in certification procedures in accordance with a standardized quality management system and could serve as an orientation aid for providers when founding and setting up new day hospices. Even if there is currently no nationwide establishment of day hospices in Germany, the new indicator set could enable patients and their families to compare day hospices in the future - in particular the quality of structures and processes. The extent to which outcome-focused measures will improve this comparability remains unclear, especially in view of the difficulty of recording and evaluating the quality of outcomes and the interdisciplinary and sometimes individualized working methods of day hospices.

Limitations

A significant portion of the identified quality indicators could not be directly applied due to the unique structure and objectives of day hospices, requiring necessary modifications by experts. The final set of adapted quality indicators has not been undergone specific validity testing in day hospices due to these modifications. This may limit the applicability and may require further research. However, they are based on recommendations from an interdisciplinary expert committee and still reflect the core principles of the original, validated quality indicators. While the new quality indicator set covers a wide range of quality criteria outlined in the care contract, some required aspects (both nationally and internationally) are not included. This should be considered when evaluating the relevance of the indicator set. International quality indicators were not examined for the final quality indicator set. This was due to the different structures of the international healthcare systems and the resulting problems of transferability to the German healthcare system. Nevertheless, certain relevant aspects may not have been taken into account. Furthermore, physicians, nurses, and quality managers were involved in the development of the final quality indicator set, but no patients or guests of the day hospice and no relatives. They were not included, firstly because of the development and evaluation process of the quality indicator set extended over many months and the life expectancy of the patients concerned was usually shorter. Secondly, the development of the quality indicators took place at a very early stage of the IMPULS study [ 14 ]. At this time, the final structures of the day hospice under investigation had not yet been conclusively established. Therefore, the experience and knowledge of patients and relatives with day hospice structures had to be considered limited at this time. This represented a further exclusion criterion. The ‘consumer’ perspective is therefore missing and should be taken into account in the future development of the indicator set. Finally, the paper describes the work of a small number of German experts. Whether a larger number of - possibly international - experts could have identified further important quality aspects for a day hospice cannot be excluded.

Conclusions

In conclusion, the newly developed set of 19 quality indicators for German day hospices represents the first compilation of indicators for the assessment and monitoring of day hospices within Germany in a verified and comparable manner. As recommendations for practice and research the new indicator set can already be used to assess the quality of day hospices and allows individual day hospices to be compared with one another. It can also provide guidance for funding organisations when reviewing the relevant basic requirements and quality of a day hospice. Particularly in the start-up phase of new day hospices, the indicator set can provide assistance in establishing the necessary structures. However, this set requires further research, clinical evaluation and the development of additional quality indicators to more fully and accurately address the specific needs of day hospices.

Abbreviations

General Local Health Insurance Fund

Outpatient Quality Indicators and Key Figures

Association of Scientific Medical Societies in Germany

National Association of Statutory Health Insurance Physicians

Quality Indicator System for Outpatient Care

Social Security Code

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Acknowledgements

None.

Authors’ contributions

UK, UVK, and FK designed the study; UK, UVK, AH, MR, MF, and FK developed the methodology; UK, UVK, and FK implemented the methodology; AH, FK, EK, RC, and MF carried out the data analysis; FK wrote the original manuscript; UK, UVK, FK, MR, EK, MF, and FK reviewed the manuscript.

Funding

The study is funded by the Bavarian State Ministry of Health and Care, Ref.Nr.

G46e-K9200.1-2022/35 − 2.

Data availability

All relevant data are within the paper. The raw data analyzed in this study are available upon reasoned request to the corresponding author.

Declarations

Ethics approval and consent to participate

The project was approved by the Ethics Committee of the University of Regensburg (No. 22-3012-101) and was registered in the German Register of Clinical Studies (DRKS-ID: DRKS00031613) and the Display portal of the Center for Clinical Studies of the University Hospital Regensburg (Z-2022-1734-6).

Consent for publication

Not applicable.

Competing interests

UK, UVK, AH, FK, MR, EK, RC, and MF declare no competing interests; FK has conducted consulting work for Abbvie, Astellas, BeiGene, Gilead, GSK, Janssen, Lilly, Novartis, Pierrre Fabre, Sanofi, Servier, and Elsevier.

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