Public reporting has multiple goals. In the first instance, it is intended to enable patients and referring physicians to make a well-informed choice of healthcare providers by facilitating comparison of the quality of care across providers [1, 2]. It is also meant to induce change in the clinical performance of healthcare providers by enhancing quality improvement activities [1, 2]. Furthermore, it intends to establish public accountability [2, 3]. Despite the widespread practice to publicly report healthcare providers’ performance data, little is known about its actual effects. In 2008, a systematic review by Fung et al.  revealed that hospitals’ public reporting is associated with a stimulation of quality improvement activities. Fung et al. could only find inconsistent associations between public reporting and hospital selection or improved effectiveness, respectively. Evidence on the impact of public reporting on patient safety and patient-centeredness is still scant .
The quality data collated by hospitals is frequently used for additional purposes. Hospitals routinely distribute their quality data among management, hospital board and medical staff (physicians and nursing staff), one fifth also among ancillary staff (e.g. laboratories) . They use the information to promote collaboration across departments and for internal monitoring of performance . Regarding the internal use of quality data, various effects have been detected; in particular, a stronger integration of best practice guidelines in patient care and improved documentation of treatment processes . Services not being provided before public disclosure have been instituted or planned afterwards . Some hospitals also highlight their outcomes as part of their marketing campaign ; some share their quality information with the public, for example via their web pages, internally produced report cards or newsletters .
Regarding public reporting in general, numerous positive effects on quality-oriented reorganization have been described, for example heightened attention to quality improvement, new or enhanced quality improvement activities [7, 8] and increased investment in hospital staff . Some studies also propose improved clinical outcomes due to activities initiated by public reporting [6, 7]. On the other hand, already in 1995 Smith warned of the careless use of performance data . He describes eight examples of unintended behavioural consequences on the part of the internal management of an organization caused by the publication of performance data. These behavioural changes are likely to be dysfunctional , i.e. by focussing on phenomena that are quantified and published (“tunnel vision”) and at the same time disregarding the remaining ones .
There is little detailed information on the costs of producing and publishing performance data. However, initial costs for the development of measures, analytical methods, and data management systems as well as ongoing costs for data collection, analysis, dissemination, and management of responses have to be considered . Generating physician level quality data is expensive  and constitutes a major burden to hospitals . There needs to be a balance between cost, effectiveness, and fairness to providers .
Hospitals in Germany are obliged by law to publish structured quality reports (QR) every two years since 2005. Detailed regulations regarding contents, structure and output format of these reports are specified legally. The reports currently contain chapters on structure and performance of the hospital as a whole as well as on each hospital department. Additionally, information on quality assurance and internal quality management is given. For the most part, data on the quality of structures and processes is included, only little information on the quality of outcomes is given. The prescribed data formats are PDF (for publication e.g. on the hospitals’ homepages or in a printed version) and XML/CSV (for the use of data in internet portals which provide hospital comparisons) .
However, in the recent version of QR - which was not yet available when data collection for this study began - far more quality data has to be published. Additionally, there are private initiatives on national level (e.g. the “hospital guide” of the TK, a German health insurance, ) as well as initiatives on international level (e.g. “Sundhedskvalitet” in Denmark ) to better integrate data of the quality of outcomes represented by patient satisfaction data into public reporting.
German QR have three legally defined goals. Firstly, they aim at supporting well-informed choice of hospitals by patients and other interested persons. Secondly, they are meant to guide and support referring physicians as well as sickness funds. And thirdly, German hospitals should be given the opportunity to demonstrate their performance by number, type and quality in a visible and transparent manner .
There’s a lack of systematic research on to what extent German hospital QR actually achieve the legally defined aims. Much research has been done on the attitudes and perspectives of patients and referring physicians [14–18] as the most common users of QR. But, to our knowledge, no research has been done on the perspective of hospitals so far. However, it is the hospitals that are burdened the most with collecting and processing data as required and may profit the least from it at the same time - apart from the self-chosen purposes hospitals use QR for as data is already available.
We therefore conducted a survey to assess hospital leaders’ attitude on mandatory quality reporting in Germany by questionnaire. We focused on the hospitals’ opinion regarding the suitability of the QR for meeting the statutory objectives, i.e. the representation of the number, type and quality of services and the cost-benefit ratio of preparing such reports.