Handlungsoptionen zur Krisen-Resilienz: Lehren für das Management des Medizinbetriebs in Krisenzeiten

Aim After three years of conflicting experiences with the Corona pandemic it is recommended to examine failures and consequences of the crisis management, but also to develop measures and concepts fostering the resilience of the health care system, especially in the areas of supply chain management, reimbursement, and digitalisation. Method A meta analysis pertaining the health service situation during the pandemic was conducted, complemented by an analysis of bottlenecks in the provision of medical products and pharmaceuticals. A research on working conditions and employee satisfaction of occupational groups working at the bedside was added. Results The resilience of supply chains can be strengthened by the reshoring of medical products critical to the the quality of medical services and by choosing suppliers and production facilities oriented to the „delivery reliability" as a selection criteria. Telemedicine services enable the at-home-care of patients and digital platforms offering virtual visits of familiy doctors as well as specialists contribute to reducing peer-to-peer contacts, and prevent from long-term effects of postponed diagnostic and therapeutic interventions. Telemedicine supports an intensive use of tight physician resources and improves the availability of medical expertise also in rural areas. Establishing attractive working conditions turned out to be a success factor in the fight against the lack of professionals. Conclusion In order to strengthen the resilience of the health care system and to be better prepared for future pandemic waves, a close co-operation between hospital managers, suppliers as well as politicians and federation representatives is needed. And, an holistic approach for redesigning health care is requested, especially in the areas of reimbursement, human resource management inside the hospital, digitalisation of medical service processes and the security of supply referring to medical products and pharmaceuticals.

Rehabilitations- und Vorsorgeeinrichtungen in der Corona-Krise: Situation und postpandemische Perspektive

Background During the early phase of the Corona pandemic (March to July 2020) rehab clinics were supposed to stop offering rehab treatment in order to be ready for admitting low-care patients from acute hospitals. On the other hand, acute care hospitals postponed elective interventions for the benefit of Corona patients and rehab patients denied treatment due to the fear of becoming infected. As a consequence a loss in revenue turns out while additional costs for infection protection management arose simultaneously. Methodology Aim of the study was to specify the economic risks of rehab facilities caused by the pandemic as well as the increasing medical requirements. Based on a structured questionnaire 97 rehab providers were polled referring to e. g. the „medical treatment situation", the „revenue development", the „cost pressure" and the „effects of supporting activities of the government". Results The revenue of rehab clinics collapsed intermittently up to 70 % compared to the previous year. Simultaneously, additional costs of 349 € per patient and employee per treatment cycle (21 days) accumulated due to decreed infection prevention arrangements. This unplanned cost burden corresponds roughly to 13 % of the revenue per case. The decline of rehab treatments under the pandemic will lead on to an exaggerated demand of medically necessary treatments in future. This congestion of non-performed rehab treatments is prognosed to exceed 20 % to 25 % of the rehab treatments performed in 2019. In 29 % of the facilities the shortage of personal protective equipment was associated with dysfunctional workflows and endangerment of patients suffering an infection. 71 % of the rehab facilities stated not to have benefitted from the procurement initiative of the German Ministry of Health. Discussion The Corona pandemic has reinforced the economic vulnerability of many rehab providers. This, due to additional costs for infection prevention activities, revenue losses owing to reduced occupancy and because of an investment bottleneck accumulated over years. Furthermore, the reimbursement system is complained not to cover the total costs of treatment in an economically sufficient way. Necessary investments in infection protection are a cost-driver but also lead to a factual impairment of treatment capacity. As a consequence, a piling up of medically essential rehab treatment is assumed to happen and will effect an increasing disease burden in the health system. Core Message The risk of insolvency has enhanced for rehab facilities due to the pandemic. Simultaneously, medical requirements have arisen and cost pressure has become more intensive. Because rehabilitation to play a pivotal role in public services the reimbursement system of the rehab sector is urged to be changed. One strong opinion requires to finance the costs of keeping rehab facilities. Indeed, this financing approach should be based on an assessment of the rehab demand. Furthermore, the operating costs are advised to be paid depended on medical quality, physical condition of the patient and the complexity of treatment. Zusammenfassung: Hintergrund Bereits in den ersten 6 Monaten der Pandemie erlitten die Rehabilitations- und Vorsorgeeinrichtungen massive Erlöseinbußen. Dies einerseits durch die Aussetzung von Heilverfahren und Nachsorgeangeboten sowie die Verpflichtung, im Bedarfsfall verlegbare Patienten aus Akutkrankenhäusern zu übernehmen;andererseits führte die Verschiebung elektiver Eingriffe zugunsten der prioritären Behandlung von Covid-19-Patienten in den Akuthäusern sowie die Angst von Reha-Patienten vor einer Infektion zu einem Nachfragerückgang. Demgegenüber entstanden erhebliche Zusatzkosten durch die Organisation infektionssicherer Arbeitsabläufe sowie die Beschaffung von Produkten der persönlichen Schutzausrüstung (PSA) auf einem überhitzten freien Markt. Das Insolvenzrisiko für die Reha-Einrichtungen erhöhte sich. Methoden Ziel der Studie war es, die ökonomischen und ablauforganisatorischen Konsequenzen sowie die Infektionsrisiken für Personal und Patienten einer Unterversorgung mit PSA-Produkten im Bereich der Rehabilitation zu ermitteln sowie die Effektivität staatlicher Eingriffe bei der Beschaffung von PSA-Produkten zu reflektieren. Durchgeführt wurde im Zeitraum 25. bis 28. Woche 2020 eine Online-Befragung unter 79 Einrichtungen mittels strukturiertem Fragebogen, u. a. spezifiziert nach den Erhebungsbereichen „Versorgungssituation bei PSA-Produkten", „Umgang mit PSA-Versorgungsengpässen", „Ertragssituation", „Zusatzkosten" und „Wirksamkeit staatlicher Hilfsmaßnahmen". In weiteren 18 Einrichtungen wurden Einzelinterviews zur Praxis des Pandemie-Managements vor Ort geführt. Die Erhebung wurde auf orthopädische, kardiologische und neurologische Einrichtungen konzentriert. Ergebnisse Der Umsatz der Einrichtungen ging um zeitweise bis zu 70 % gegenüber dem Vorjahr zurück, gleichzeitig erhöhten sich die Kosten für Infektionsprophylaxe um durchschnittlich 349 € pro Patient und Mitarbeiter pro Behandlungszyklus (21 Tage), was etwa 13 % des Fall-Erlöses bedeutete. Durch den Rückgang bei Patientenbehandlungen während der Pandemie baute sich ein Behandlungsstau auf, der zwischen 20 und 25 % der Reha-Leistungen des Jahres 2019 entspricht und die Krankheitslast im Gesundheitssystem zukünftig erhöhen wird. Der Mangel an Schutzausrüstung führte in 29 % der Einrichtungen zu erschwerten Arbeitsabläufen mit Infektionsgefährdung für Patienten und Mitarbeitende. Von der Beschaffungsinitiative des Bundesministeriums für Gesundheit fühlten sich 71 % der Einrichtungen nicht versorgt. Diskussion Die Corona-Pandemie hat die Anfälligkeit zahlreicher Reha-Einrichtungen für eine wirtschaftliche Schieflage verstärkt. Ursache dafür sind pandemiebedingte Zusatzkosten, Erlösausfälle aufgrund von Belegungsrückgängen und ein Investitionsstau in zahlreichen Einrichtungen. Notwendige Maßnahmen des Infektionsschutzes erhöhen nicht nur die Kostenbelastung, sondern vermindern faktisch die verfügbare Behandlungskapazität. Als Konsequenz ist ein Behandlungsstau zu erwarten, der mit erhöhter Krankheitslast im Gesundheitssystem verbunden sein wird. Kernbotschaft Das Insolvenzrisiko hat sich für Rehabilitations- und Vorsorgeeinrichtungen durch die Corona-Krise erhöht, gleichzeitig sind die Anforderungen an medizinische Qualität und Infektionsschutz ebenso wie die Vorhalte- und Behandlungskosten gestiegen. Eine Reform der Refinanzierung von Reha-Leistungen ist notwendig: Dies betrifft die Finanzierung von Vorhaltekosten von Reha-Einrichtungen als Teil der Daseinsvorsorge. Hier ist allerdings eine versorgungsstrukturelle und institutionenorientierte Bedarfsermittlung vorzuschalten, um Mitnahmeeffekten vorzubeugen. Weiterhin ist die Vergütung der Betriebskosten qualitäts- und aufwandorientiert am Krankheitsbild und am Patientenzustand vorzunehmen.

Value-based leadership in turbulent times: lessons from the Corona crisis and recommendations for post-pandemic management in the health sector

The Corona crisis not only exposed the causes of supply disruptions for system-critical medical products and pharmaceuticals, and made the consequences of the digitalization gap in the health care system transparent, but in particular, revealed the consequences of fundamental leadership deficits in hospital personnel management, professional profiles and ethics, professional policies, and procurement management. However, Corona has also triggered a rethinking of the values, meaning and purpose of work content and behavioral norms. This paper aims to identify and analyse management failures observed and experiences made during the Corona pandemic. Based on these findings recommendations for good leadership practices are given. By literature research reported experiences from physicians and nurses were analysed related to working conditions, motivation-to-work, and satisfaction with incentive systems. Furthermore, interviews with clinical staff working under Corona conditions were realised based on a structured questionnaire. The workload of nursing has increased significantly due to economization: from 2005 to 2017, the number of treatment cases increased by 12%, while at the same time, the number of beds decreased by 9.4% and the length of stay shortened from 8.4 to 7.3 days. The accumulated nursing overtime in German hospitals alone is equivalent to 17,800 full-time employees. During the Corona crisis the working situation especially for nurses facilitating patients ventilated on the intensive care unit has dramatically worsened: additional overtime, high patient mortality, resource-intensive and stressful care requirements lead to prostration and mental exhaustion. As a consequence of this tremendous work burden for nurses and physicians during the Corona pandemic up to 30% of these occupational groups gave voice to inadequate working conditions and utter their intention to quit their jobs. Demotivation and a flight into professions remote from medicine are a reaction of many physicians and nurses to years of leadership failures in hospitals and politics, as well as an increasing economization of medicine. Between 68 and 82% of physicians cite the cost pressure associated with rationing as a source of dissatisfaction with their professional situation. It is up to management to learn from these findings, implement the necessary measures and provide family-friendly working conditions for occupational groups working “at the bed-side”. A “value-based leadership model” that takes into account the specific conditions prevailing in the healthcare industry was developed and serves as a compass in meeting and overcoming this challenge. This paper transfers practical experiences made during the Corona pandemic and pertaining to motivation-to-work under stressful working conditions, the meaning of “purpose”, the try-out of so far unknown working practices and types of inter-occupational co-operation into a leadership model that is unique for the health care sector.