Background
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Which specific situations are rated as “crises situations” by primary care practices?
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Which aspects need to be fulfilled in order to perceive a challenge as a crisis?
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Which strategies can be identified for managing these different situations successfully?
Methods
Study design
Study sample
Data collection and measures
Subject | Subthemes |
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Organizational resilience in primary care practices | - Starting points, criteria for medical practices, opportunities, challenges, aspirations - Experiences in previous crisis situations, disaster management - Previous strategies, action plans, resources - What can be transferred from previous experiences for preparing medical practices for future crisis situations? |
Resilience of primary care practices to climate change challenges | - Challenges in the context of climate change for primary care practices (current and future) - Meeting these challenges in the practice: possibilities, barriers, opportunities and risks, concrete starting points and strategies - Assessment of own role and attitude, attitude of experts in relation to the adaptation of the ambulatory health sector to health consequences of climate change |
Reduction of the ecological footprint of the ambulatory health sector | -Assessment of own role, attitude and attitude of the experts -Barriers and facilitating factors in the implementation of measures to reduce the ecological footprint of primary care practices -Change of care processes and structures with regard to their climate friendliness |
Data analysis
Results
N | % | |
---|---|---|
Total | 40 | 100 |
Sex | ||
male | 16 | 40.0 |
female | 24 | 60.0 |
Age | ||
18 – 24 years | 1 | 2.5 |
25 – 39 years | 14 | 35.0 |
40 – 59 years | 17 | 42.5 |
60 years or older | 8 | 20.0 |
Professional activity (multiple answers allowed) | ||
Working in a primary care practice as: | ||
physician | 14 | 35.0 |
medical assistant | 16 | 40.0 |
with additional training | 11 | 68.8 |
other | 3 | 7.5 |
Working in health system | ||
Research | 3 | 7.5 |
Health system (Politics/health insurance/…) | 4 | 10.0 |
others | 9 | 22.5 |
Which situations are perceived as crises by primary care practices?
a) Internal crises in practices | |
Breakdown of technical infrastructure | For example, caused by a blackout, technical devices like computer or telephone are out of order. Furthermore, failure of single technical devices such as the insurance card reader or a software used for electronic health record can cause a crisis for a practice. In this context a virus or hacker attack was named as well “[…] if this stupid card reader doesn’t work right now, then I don’t know what to do […] And of course that’s another crisis.” (SP1_Int22) |
Disputes with patients or within the team | This ranges from patients that show dissatisfaction or verbal complaints up to offences, abuse and even violence against the practice staff. Aggression of patients was described to be an increasing problem in practices. Besides this, lawsuits, medical errors and negative ratings of practices on the internet that cause patients to choose a different practice for treatment are named as crises Furthermore, personal differences may occur within the team and can lead to practice split-ups in the worst case “But you’ve also been spat at in the practice. […] Yes, well, there is also this kind of patients who don’t accept things, who then become really abusive and insulting.” (SP1_Int14) |
Damage to the building | Water damage, burglary or a damage/dysfunction of an elevator implying barriers of reachability for patients with walking disabilities can be seen as an internal crisis “water damage in endoscopy, yes, that’s a crisis.“ (SP1_FG2) |
Medical emergency | Medical emergency situations on patient level, like a heart attack or a stroke were mentioned. This was primarily named by practice staff that announced a lack of knowledge in handling these specific situations „Reanimation, resuscitation, in other words, life-threatening emergencies, […] Let’s summarize it like this. That is literally also a crisis.” (SP1_Int23) |
Inspections | Some participants described a visit for inspection, e.g. hygiene inspections conducted by a health department or similar, to be a crisis for them as these visits cause a high workload in advance and may bring organisational consequences for the practice when deficiencies are being identified “[…] but it actually also fits a crisis: the announced visit of the health department to check the practice.” (SP1_Int2) |
Staff shortage (temporary) | Temporary staff shortage may be caused by acute illness of staff, pregnancy and maternity leave or longer lasting illness. Some participants even described situations as a crisis that are actually not extraordinary, just because of a lack of staff to cope with it “[…] a few years ago quite a lot of medical assistants became pregnant [laughs] five at once, […] and it is generally, if important employees in each level suddenly leave the unit – that does not have to be a big crisis, but it can become one.” (SP1_FG2) |
b) Crises on health system level | |
Staff shortage (long-term) | Most of the participants mentioned a long-term and increasing staff shortage in medical professions as serious crisis for practices and on health system level. As crises on practice level, retirement of physicians resulting in open job offers and closure of the practice if no replacement can be found was named. This was described to be resulting in a shortage of practices, especially in rural regions, resulting in a higher workload for existing practices. Working conditions were described to be increasingly unattractive. Therefore, participants stated that especially younger staff would prefer to work in joint practices with a good infrastructure. Furthermore, participants mentioned that it is becoming increasingly difficult for them to find well-trained staff. This was specifically named for medical assistants Staff shortage not only occurs in the practice itself, but was also named to be relevant for nursing homes and ambulance service. Participants perceived that their own workload increases due to a lack of this external staff. This was named primarily by staff of general practices as they have to compensate staff shortage in nursing homes by a higher number of visits “Well, lack of personnel in the first place. Yes, I see it as quite a big problem everywhere. (SP1_Int_09) |
Supply shortage | Participants named a shortage of vaccines (influenza, covid-19 and other), medication and medical devices as a periodically reoccurring crisis for practices. Especially in the context of the first phase of the covid-19 pandemic, a massive shortage of face masks, disinfectants and other protective equipment was named “The first major crisis is always supply bottlenecks. We have seen this quite a few times for example with influenza [vaccines] or other important drugs.” (SP1_Int_05) |
Increasing care needs | Care needs are described as increasing steadily and are predicted to keep increasing in the future. This was mentioned in the context of demographic change, an increase in chronically ill and geriatric patients, as well as an increase in patients with mental illness that tend to require a higher need for consultation. Along with this, participants described the increasing care needs to become a crisis especially in the context of increasing staff shortage Besides these long-term developments, an acute disaster affecting many persons at the same time was also described as possible crisis for practices as they cannot cover to treat an extremely high number of patients |
Changes in health system infrastructure | As changes in the infrastructure of the health system, centralization of health facilities and local relocations were named. Because of these, specific areas might be perceiving a shortage of care facilities (especially in rural areas and districts with high poverty). Few participants described that for example a practice in their neighbourhood decided to discontinue home visits as they bring no financial benefit to the practice. This led to the own practice having to additionally care for these patients by making home visits “[…] there are of course also, let’s say, structural crises at the local level. Doctors joining forces or pharmacies getting bigger, retail or, let’s say, frequency structures changing, a large medical centre being built somewhere, the clinic spreading out into outpatient care in some form or other, that can of course also be difficult.” (SP1_Int5) |
Digitalization | Digitalization was named as crisis for practices on three different levels. First, participants perceived the transformation itself as a crisis when their technical affinity was described as low. Some mentioned that especially older physicians and medical assistants refused to deal with and implement technical approaches in order to “sit this one out” until they retire. Second, technical affinity was also described as low in some older, chronically ill patients who were said to “get left behind” by the digital transformation process in healthcare. Third, digitalization was named as a crisis whenever the technical devices implemented in the practice failed (see “Breakdown of technical infrastructure”). One medical assistant expressed concern about being replaced by machines in the future “If you like, this is an approach to solving crises – but the path until digitization is properly implemented can still be a crisis.” (SP1_Int6) |
Social crises | Social crises in general could also affect primary practices. In particular, migration and the care of refugees were named as crises for practices as they perceived a high workload. Along with this, participants named that they had to treat diseases that they have never been confronted with yet, which resulted in a crisis for them “[Another participant from focus group] mentioned the refugee crisis, because we were very much involved in the care. Partly communication was not possible, I think that some colleagues were also quite afraid when they had to go to the refugee accommodations. So, I think there were actually different things that felt like a crisis […].” (SP1_FG02) |
c) Overarching crises | |
Epidemic/pandemic | For most participants, the current pandemic of covid-19 was the first and most significant crisis that came to their mind. Besides covid-19, Ebola, H1N1, influenza, gastrointestinal diseases and local outbreaks of paediatric diseases (e.g. in schools or day care) were named. Most of the participants expect further disease outbreaks like the covid-19 pandemic or other, new viruses in the future „I think that through the climate crisis, […] through the pandemic as a whole, so a lot of things in medicine will change as well.” (SP1_FG1) |
Economic crises | As economic crisis on health system level, a shortage or shift in the payment of health care was feared. Due to social insurances, funding might lack with increasing poverty and unemployment. Besides this, participants concerned that they had to cope with the increasing care needs but will perceive payment cuts at the same time which might lead to redundancies of practice staff. Furthermore, concerns about financial losses due to a predicted decrease of treatments that require out-of-pocket-payment (IGeL), or due to restrictions of funding were described (increasing care needs and decreasing funding rates at the same time) “An economic crisis may occur.” (SP1_Int5) |
Local disasters | Local disasters such as damage in a nuclear power station or a fire of industrial companies located in the neighbourhood of the practice were named as possible occurring crisis situations “[…] these fears, well, for example nuclear power plants – we have one in 60 km distance – what else is going to happen? Can this also erupt like Chernobyl? (SP1_Int1) |
Climate change | Some participants already named climate change as an upcoming crisis by themselves and few were even using the term “climate crisis” instead of “climate change”. Some saw consequences of climate change but did not perceive them to be a crisis and a few did not see any consequences for practices at all as they haven’t yet thought about possible impacts of climate change. But generally, climate change was associated with effects on practices on many levels. In this context, heatwaves were mentioned primarily. Many participants already perceived periods of extremely high temperature in their practices. Described consequences were: patients that could not come into their practice during that time, damage on medication that was stored in a badly ventilated room, dehydration or bad health condition of patients and staff, worse health outcomes of patients after (ambulatory) surgery and a slow recovery after sedation, failure of medical technique such as ultrasound, higher workload due to extra home visits and visits of nursing homes with patients suffering from heat-related illnesses, up to the need for an acute shutdown of the practice. Besides heat waves, other extreme weather events such as floods, storms, cold spells, heavy rain or snow, black ice were named as possible consequences of the climate change. Those extreme changes of weather were predicted to increase symptoms of migraine, back pain, gout and arthrosis (weather changes), asthma and COPD (higher humidity) and longer and more intense allergy seasons. An increase of mental illness was named in the context of climate change as well. Only few participants named the occurrence of tropical diseases, but many named an increase of vector-borne diseases and saw a link between new occurring viruses like covid-19 and climate change. A general change in the range of diseases because of changing environment was prognosed. This was also named in the context of forced migration due to climate change. As further consequences of climate change, a shortage in resources such as water, nutrition and power were mentioned „Climate change or the climate crisis will certainly have an impact on practices.“ (SP1_Int2) |
Which aspects need to be fulfilled in order to perceive a challenge as a crisis?
“When crises come, no matter in what form, weaknesses always reveal themselves everywhere, which were actually already visible for a long time theoretically and (…) were fallow. That actually nothing was ever done against it, and, if then such a crisis comes, like the pandemic for example, then such a thing becomes quite often to the disadvantage, I noticed.” (Int. 15, medical assistant)
“Yes, the time pressure is certainly one of the central characteristics of crises, definitely!” (Focus Group 1, Part. 1, physician)
Strategies to enhance resilience of practices
a) Crisis prevention | |
Building awareness | B being informed about what might occur in the individual practice and be connected with warning systems such as local warning apps was named to increase awareness. Also, participating at different trainings about diseases, climate change impacts, or specifications (like care assistants or study nurses) were named as possible approaches “In my opinion it is […] just as [other focus group participant] has already said: the practice must develop further and […] that we have to begin to develop strategies for ourselves so that we do not come unprepared in similar situations.” (SP1_FG_1) |
Gaining knowledge | Together with increasing awareness, gaining specific information about possible crisis situations and transmitting this knowledge to all team members was named as way to prepare for a crisis “So, I think what has definitely helped us every time and also works is […] an early recognition and a sensitivity, there is something right now or there is something coming up, that could become of interest.” (SP1_FG_2) |
Planning scenarios | It was recommended that all practices define possible upcoming crises and plan different scenarios that might occur. For each scenario, a concrete action plan should be prepared. Some participants described to rehearse those scenarios and action plans to feel safe and evaluate feasibility of the action plans “Good preparation. > laughs < Prophylaxis is everything, prevention is very important – anticipating as well – ideally, anticipate what could happen, and then be prepared for it.” (SP1_Int_23) |
Providing resources (staff) | Providing an adequate number of staff was seen as one of the most relevant aspects of crisis prevention. For this, working conditions should be improved to keep fluctuation rates low and avoid open job offers. Supporting this, trainees and internships were mentioned as helpful and “cheap workforce”. Training all employees to be able to roughly manage other team positions can help if an acute replacement is needed. Also, a pool of staff that is shared with other practices or within a joint practice is seen as beneficial. For the participants it was important that external staff already knew the practice in advance to avoid initial training during a crisis “And you’re not crisis-resistant if you […] don’t have enough qualified staff, aren’t you?” (SP1_Int_22) |
Providing resources (material) | It was recommended that a practice includes enough storage space, just in case something has to be stored within a crisis. On top of that, it was asked by some participants that all practices always have a back-up in their most used items such as gloves, face masks, disinfectant, frequently used medication and medical devices “[…] we then have really procured this personal protective equipment ourselves […] in a manageable amount – we were not a huge practice, but rather a medium-sized practice – but that we had such a basic equipment of these materials, we have stored in the practice and could then fall back on it in a new case […].” (SP1_Int_23) |
Providing resources (financial) | As crises were often linked with a financial burden for the practice, providing financial security for a certain time with no income was named as an important coping strategy “[…] that was a period of four weeks, then the bosses fortunately still had some financial reserves for us and our salary and then we could bridge that.” (SP1_Int_03) |
Quality management | The overall conduction of quality management in practices as their participation in quality circles was seen as one way to improve organizational resilience already "Well, I think what can definitely help a practice in such situations is quality management.” (SP1_FG1) |
b) Individual resilience | |
Satisfaction at work | Participants expressed their need for supporting their own mental health and satisfaction at work through a good and appreciative management, through inclusion of their mental health status and feelings in the communication within the practice team and, through creating a healthy working environment “Well, I would tell the physicians: keep your team together. […] Have keen senses, ask how they are doing and take them on board, the medical assistants, because they are on the front line and they have to communicate and lead and organize. And I think that’s where a lot of people are stuck or there’s a lot of potential for errors or crisis potential.” (SP1_Int_17) |
Beneficial characteristics of individuals | As beneficial characteristics of individuals, the following personal qualities were named: creativity, flexibility, adaptability, openness, curiosity, personal commitment, working experience (in particular: knowing your patients for a long time), active confrontation with the crisis, seeing the crisis as a chance, staying and acting calm, keeping a distance to the crisis, self-protection. In this context, participants mentioned that a practice has to know and accept its limits: „[…] and perhaps also to admit: we can’t accomplish everything. So (that you) have to admit to yourself as a practice, with our resources we can’t manage to vaccinate all the people who want it immediately. I1: Why do you think it is important to admit that? Int_2: Because otherwise it is a constant overload.“ (SP1_Int_2) |
Individual attitude towards crises | Especially younger medical staff was rated to be less resilient than older staff. Two participants based this on the assumption that those persons were raised differently, in a “softer” way than themselves. Additionally, it was described, that especially physicians were likely to see crises as something positive and even tend to be happy when a crisis occurs: “[…] but then doctors, well (…) they also find it kind of chic, a bit of a crisis… then it finally tingles in the stomach again.” (SP1_Int_12) |
c) Team work | |
Team meetings | As one of the most important strategies to cope with a crisis successfully, team meetings were named by all participants. Team meetings were described to be necessary in the regular patient care and needed to be held more frequently during a crisis (e.g. weekly or daily depending on how quickly a crisis situation is changing). To achieve a good team communication, it was seen as necessary to consider emotional aspects and the mental health state of the team members as well as the allocation of tasks and responsibilities during a crisis. Furthermore, all team members should have the same level of information about the crisis "Certainly, communication within the team […]? It is clear, that the flow of information must be guaranteed, that there is clarity and that everyone is informed: what is the matter, what is the significance, what are the consequences and where do we have to set other priorities under certain circumstances?” (SP1_Int_23) |
Different levels of education | It was important for the participants to be aware of different levels of education within the team (physicians vs. medical assistants) and provide transparent and comprehensible information for all “And what is also important, is that the employees come from different areas, for example there were some who are really close to the patients […], then also some from the administrative area […] a colorful mixture, so that everyone can really give his or her input.” (SP1_FG2) |
Atmosphere within the team | A constructive error management, diversity within the team (e.g. languages and nationalities, education level, specifications, age), and a good team atmosphere in general were also identified as beneficial. For a good team resilience, it was observed to be crucial to have a feeling of “moving in the same direction” (German “am selben Strang ziehen”) “We need this wide range of people, we need young people, we need old people, and everyone has his or her right to exist. So, we also need a colleague who maybe knows another language […].” (SP1_Int_21) |
Leadership style | To support a beneficial team work, a good practice management with an officially trained manager was seen as crucial. Low hierarchies and delegation of tasks was welcomed by the participants but at the same time, the practice manager should not give the feeling of pulling himself back. If a conflict occurred within the team, the consultation of an external and neutral person was asked Interviewer question: “Is there anything else you would say a medical practice needs to be more successful in dealing with a crisis?” Interviewee’s answer: “A good boss. > laughs < A good boss who really backs the team.” (SP1_Int_11) |
d) Practice procedures | |
Detection of crises and information acquisition | First, early detection of the crisis situation and immediate analysis of the occurring problem were described. After this, gaining information about the specific situation or problem and always stay up to date with the changing environment were named. Additionally, it was important that all information was shared within the team "Well, I think it just needs a lot more awareness and information […] what could happen to us, which we perhaps have not even considered yet." (SP1_FG_1) |
Action plan | Another important strategy was to use existing action plans and, if no action plan was present, create an individual action plan. Within these action plans, all relevant steps, tasks, responsibilities and, if necessary, contact information of relevant institutes or persons needed to be included. Furthermore, the respective action plan needed to be feasible for the realisation within the individual practice environment. To respond to a crisis, this respective action plan needed to be implemented step by step to achieve structured and sensible proceeding. Especially during the covid-19 pandemic, this was seen as difficult due to a lack of consistent information and hardly feasible action plans for German practices “There are plans how we are to behave, if it comes somehow to pandemic symptoms. Exactly, this already exists now and has also been established in our practice. And yes, you can orientate a bit on that […] Well, that’s a manual […] where things are simply laid down how you should behave […].” (SP1_Int_09) |
Adaption to mental and physical health of staff | As the crises usually implied a higher workload for the practice team, spending overtime hours, cancelling vacation time, increasing working time of part-time staff, or giving staff a time out to protect their health were named as strategies. For this, it was seen as crucial to adapt the specific strategy to the mental and physical health of the individuals. Another strategy to support resilience of a practice was to provide periodically reflection/evaluation sessions with all team members. “What went well? What didn’t? And what needs to be changed for the next step?” were important questions, the teams were discussing. This can be linked to the team meetings and should be part of the error management “[…] and also to recognize who is reaching his or her limits. We have a doctor […] who also reached her limits because she worked more, and she then got two days off in between. […] I think motivation is very important.” |
Pro-active approach and immediate action | In general, a pro-active approach and immediate action was seen as beneficial in responding to a crisis successfully. Some participants described that their practice managers have waited too long so that it was more difficult to respond to the crisis, others praised their practice managers if they were acting immediate and were able to catch up the situation or prevent certain problems that became visible in other, non-prepared practices (e.g. buying enough face masks and disinfectant during the covid-19 pandemic) "[…] whereas what I think has really helped us a lot – regarding our basic attitude and our strategy – is that we have always tried to deal with these issues proactively." (SP1_FG2) |
Networking | Information exchange and networking, not only within the team, but also with other external institutions such as other practices, hospitals, health departments, political or funding institutes (e.g. health insurances, associations of statutory health insurance physicians), professional associations, local authorities, nursing homes, pharmacies, disaster control authorities, and similar are rated as crucial to build resilience. In this context, exchanging information and experiences with the implementation of coping strategies (f.e. via E-Mail, Whats-App, personal meetings, online meetings, quality circles) or the exchange of resources (like staff or medical devices) was described as helpful “I think what is helpful in such ordinary everyday crises or also when it’s about business-threatening issues and so on, […] or also in the doctors’ network, is, yes, to reveal yourself to others, to talk about things, to ask for help, to ask others how they are doing. Have you ever had the same thing? I am in a certain situation, I can’t get out of it. Well, not to look for facts in the first place, but to identify where I can get support quickly and easily?” (SP1_FG1) |
Changes in practice procedures | First, prioritizing of tasks and patients’ needs was named as a possibility to allocate resources efficiently. Second, changes in managing patient flows included the separation of infectious patients from non-infectious patients (especially within the covid-19 pandemic) and implementing specific consultation hours just for potentially infectious patients was named by almost all participants. Together with this, the participants described that they have implemented the need for patients to call and make an appointment before coming into the practice. Most participants rated this change as highly beneficial and wanted to stay with this in the future. Some participants described that they implemented other, specific time slots within their practice like a time slot for processing prescriptions, slots for vaccination, and other. It was also of importance to not plan workflows too tight so that they will include enough time to deal with unexpected issues "These are all very big and very urgent things that have to happen quickly, but we can’t react to everything, we have to set hierarchies, prioritizations. And, above all, we have to make sure that we can work as a team." (SP1_Int_02) |
Communication with patients | Communication with patients needed to be transparent, comprehensible and patient-friendly. It was seen as crucial to provide all information to patients to make them understand certain changes in care provision and catch up their fears and needs adequately. Along with this, management of complaints and periodical patient surveys were named as beneficial. Furthermore, patient compliance was described higher when they were informed. As compliance was described to decrease within longer-lasting crises, communication needed to be “refreshed” periodically. For specific crisis situations that affected certain patient groups (like heat waves), it was necessary to inform those vulnerable groups about the occurring crisis and coping strategies. The following concrete communication strategies were named within the interviews: a homepage with highlighted news and a contact form, contact opportunity via e-mail, a specific telephone hotline, information brochures/flyers, signs, information provided on social media (e.g. Facebook page of the practice) or an action sheet especially for patients „Well, the more we communicated, the better it worked out, if I’m honest.“ (SP1_Int_05) |