In recent decades, quality management in general and the measurement of quality in particular have become increasingly important. Quality management in today's sense originated in the manufacturing industry in the 20th century and it has since spread to numerous sectors and professions (Timmermans & Angel, 2001; Timmermans & Berg, 2003). The health care sector, among many other (public) sectors, represents a key example where the importance and measurement of quality seems to become increasingly important (see also Power, 1997, 2000, 2021, 2022). Quality measurement in health care has become a central issue for many different actors, such as governments, providers, researchers, and patients, which is expressed in numerous reforms in various health care systems (see also Jordan et al., 2020; Wörndle, 2022).

While many recent health care reforms have targeted cost containment and efficiency, justified by rising costs in the face of an aging population and ever-evolving medical innovations (Chua, 1995; Chua & Degeling, 1993; Gebreiter, 2017; Lapsley, 1999, 2007; Preston et al., 1997), other explicit goals of these reforms have been improved transparency and quality of health care services. Recent health care reforms, therefore, increasingly combine cost and efficiency considerations with quality management ideas and technologies (e.g., Pflueger, 2016, 2020). Concerns about maintaining and improving the quality of health care are often expressed in this context in terms of aspirations for transparency and the "empowerment" of patients and professionals (Chua, 1995; Kurunmäki & Miller, 2006; McGivern & Ferlie, 2007; Pflueger, 2016).

In this context, controlling authorities are increasingly creating metrics and performance indicators to measure the quality of care within a health system on an ongoing basis, and health care providers must be held accountable for the quality of their care accordingly. Patient:s also increasingly expect transparency in medical services and treatments (e.g., Reilley, 2019; Reilley & Scheytt, 2019). However, the use of quality indicators is not without controversy, as there are different definitions of "quality in health care," the measurement of quality itself is not without problems, and last but not least, because the use of indicator systems always has an influence on the actions of actors, such as physicians and nurses, that cannot be fully calculated (Espeland & Sauder, 2007).

Austria represents such an example in light of the international trend of increasing importance of quality metrics. The recent Austrian health care reform illustrates this trend, as it explicitly aims to contain health care spending and improve the quality and transparency of health care services. The measurement of outcome quality indicators is intended to make the services provided by different providers comparable and transparent for payers, health professionals and patients.

A core aspect of this health reform is the introduction of a mandatory quality indicator system, the Austrian Inpatient Quality Indicators (A-IQI) (Fuchs, 2015; see also Health Reform Act, 2013). These indicators are produced as standard for all public hospitals. The basis for this is the billing data based on the coding of services and diagnoses, the Diagnosis-Related-Groups (DRG or in Austria: Leistungsorientierte Krankenanstaltenfinanzierung - LKF). A-IQI depict the relative outcome of a single inpatient stay by means of traffic lights in the colors red, yellow, and green, in various categories, such as mortality, intensive care frequency, or complication rates (BMASGK, 2019a, 2019b; BMG, 2016). In the case of inexplicable negative results, there is the possibility of a peer review, in which external physicians assess the situation and, if necessary, make recommendations for quality improvement.

The results of the A-IQI surveys, the A-IQI reports, are sent to the medical directors of each hospital. It is up to them how they share the results within their hospitals. An annual A-IQI report with aggregated data from all hospitals is published. Some outcome indicators of all hospitals, e.g., treatment volume, surgical techniques, or length of stay, are also published on the Internet on the website kliniksuche.at (BMASGK, 2019a, 2019b).

In research, we generally see, on the one hand, an ever-increasing importance of quality management and, on the other hand, a rise in (mandatory) quality indicators in healthcare. However, the application practice of healthcare actors has often not been studied in detail. Therefore, we know relatively little about how employees of health care institutions deal with these quality indicators. Previous research in this regard focused more on the Anglo-Saxon area, and studies on the application practice of quality indicators are rare in the continental European context (Malmmose, 2019).

Since 2018, an FWF-funded project at the University of Innsbruck led by Prof. Silvia Jordan has focused on the application practice of the A-IQI in Austrian hospitals. On the one hand, this project investigated the (political) discourse and the genesis of the A-IQI (Neff et al., 2021); on the other hand, the application practice of the A-IQI in Austrian hospitals was analyzed (Wörndle, 2022). To investigate the application of the A-IQI, ethnographic studies were conducted in which the creation, sharing, and discussion of the A-IQI were observed in two hospitals, each over a period of several weeks. A-IQIs are discussed and used only to a limited extent despite their mandatory status. On the one hand, this means that these quality data are only made available to a limited group of people, mostly medical directors and primary physicians. For numerous other professional groups in hospitals, the A-IQI system is quite foreign. On the other hand, even those who receive A-IQI reports attach little relevance to them and consider them only to a limited extent as a basis for quality improvement measures.

The reasons for the limited distribution and use are manifold. A-IQIs, unlike clinical registries, cannot be used for scientific purposes or for legitimacy purposes, e.g., similar to certifications and accreditations. Numerous other quality management tools are also perceived to be more accurate compared to A-IQI. A-IQI information also comes too late from the perspective of medical staff, so it is often difficult to relate it to specific medical actions. A-IQI reports for a past year are not available until the following summer because the Federal Ministry of Social Affairs, Health, Long-Term Care and Consumer Protection (BMSGPK) does not make the updated version of the A-IQI computer program used to generate the reports available to hospitals until the following year. Another reason for the limited use is the low effort required to create the A-IQI based on DRG data. This is a disadvantage in that it results in medical staff being unable to relate to A-IQI in their daily practice. Other reasons can be located in the application of A-IQI by the Ministry of Health. Peer reviews are conducted relatively rarely (total of all peer reviews Austria-wide in 2012 - 2020: 170; BMSGPK, 2020, p. 6-7) and consequences in case of negative results are very limited. One of the reasons peer reviews are so infrequently conducted is that there are so-called focus indicators each year and peer reviews take place almost exclusively within these annual themes. There are neither budgetary nor disciplinary consequences, and due to the lack of publicity of the results, there is no need to fear negative consequences in terms of loss of reputation.

Future studies should focus on the influence of specific political cultures, such as the Austrian consociational democracy, on the governance of quality in health care, as well as on the influence of professional organizations and professional associations on performance measures. The "audit society" (Power, 1997) - a phenomenon describing the rapid rise of auditing and accountability practices since the end of the 20th century - has not yet gained too much acceptance in the Austrian context, compared to Anglo-Saxon countries, and (publicly available) quality measurements of medical treatments in general are not very common in the Austrian health care system. Furthermore, it seems interesting to investigate to what extent intra-organizational factors in hospitals contribute to the low use of A-IQI by health care staff.

The healthcare sector is undergoing rapid change and digitalization will transform many areas. With the support of digital methods and software, it will be even easier in the future to capture various processes and outcomes and to bring forth additional forms of quality measurement. It is therefore important to continue to investigate the application practice of quality indicators in the future and to critically question the flood of quality measurement systems and performance indicators.

This project was funded by the FWF (P 30072-GBL).