Development and validation of a questionnaire, the REST-Q Fire, to identify teamwork-related resources and stressors in firefighting operations.

In the complex work environments of firefighting teams, it is often human error or difficulties in teamwork that lead to dangerous situations. To prevent these, it is essential to know the teamwork-related stressors and resources in firefighting operations. A measurement tool is needed to evaluate these stressors and resources. A successive instrument development process was conducted to identify the relevant teamwork-related stressors and resources in firefighting operations. First, interviews with experienced firefighters, and second, a document analysis were conducted and evaluated to provide an overview of the teamwork-related stressors and resources. Thereupon, a questionnaire, the REST-Q Fire, was developed asking about the experienced frequency and intensity of the identified teamwork-related stressors and resources in firefighting operations. Afterwards, an online study with firefighters was conducted (N = 491). CFAs confirmed the assumed structure of the REST-Q Fire and a positive correlation of the intensity of stressors with stress was shown (r = .19 - .27). Further, the resources were overall more frequently and intensively perceived than the stressors. The most important stressors were 'behavior of leaders' (M (SD)frequency = 2.80 (0.83), M (SD)intensity = 3.59 (1.12)), and 'behavior of team members' (M (SD)frequency = 2.77 (0.75), M (SD)intensity = 3.59 (1.05)). The most important resources, on the other hand, were 'knowledge about skills and behavior of team members' (M (SD)frequency = 3.96 (0.63), M (SD)intensity = 4.24 (0.78)), 'watch out for/ check on each other' (M (SD)frequency = 3.96 (0.70), M (SD)intensity = 4.20 (0.80)), and 'reliability of team members' (M (SD)frequency = 3.96 (0.51), M (SD)intensity = 4.16 (0.73)). As a result, training needs for trainees in the fire service and experienced firefighters were derived.

The analysis of collective orientation and process feedback in relation to coordination and performance in interdependently working teams.

Effective teamwork is not only essential for teams themselves, but also for organizations and our society. To facilitate team processes and enhance team performance, feedback interventions are a widely used means. However, different types of feedback (i.e., individual vs. team-level feedback, performance vs. process feedback) can have various effects leaving the question of their effectiveness unanswered. This is especially important when team members' attitudes (namely collective orientation) are considered. Thus, understanding the interplay between types of feedback and team members' attitudes would reveal new opportunities for fostering reliable teamwork. The methodology of the present study is based on a laboratory approach. Teams (N = 142) of two worked together over four scenarios to extinguish forest fires in a microworld. We examined the effects of collective orientation on team coordination and team performance. To understand the interplay between feedback and attitudes we examined the effect of different feedback interventions on team performance and on a change in collective orientation. For analyzing multilevel mediation and changes over time, Bayesian multilevel models were applied. Results show a positive relationship between collective orientation and team performance mediated by coordination. Additionally, team-level process and performance feedback seem to be slightly more beneficial for maintaining performance over time with increasing difficulty of the task compared to individual-level process feedback. Feedback can lead to an increase in collective orientation if these values are low at the beginning. Our research highlights the importance of collective orientation and feedback interventions on team processes and performance for interdependently working teams.

Human-AI teams-Challenges for a team-centered AI at work.

As part of the Special Issue topic "Human-Centered AI at Work: Common Ground in Theories and Methods," we present a perspective article that looks at human-AI teamwork from a team-centered AI perspective, i. e., we highlight important design aspects that the technology needs to fulfill in order to be accepted by humans and to be fully utilized in the role of a team member in teamwork. Drawing from the model of an idealized teamwork process, we discuss the teamwork requirements for successful human-AI teaming in interdependent and complex work domains, including e.g., responsiveness, situation awareness, and flexible decision-making. We emphasize the need for team-centered AI that aligns goals, communication, and decision making with humans, and outline the requirements for such team-centered AI from a technical perspective, such as cognitive competence, reinforcement learning, and semantic communication. In doing so, we highlight the challenges and open questions associated with its implementation that need to be solved in order to enable effective human-AI teaming.

Off-label use in adult palliative care - more common than expected. A retrospective chart review.

OBJECTIVE: Off-label drug use seems to be integral to adult palliative care pharmacotherapy. Balancing potential risks and benefits in the context of limited therapeutic options is challenging. To provide specific support for clinicians in dealing with off-label use, it is essential to understand off-label use in everyday clinical practice. The aim of this pilot study was to quantify and describe off-label use in an adult palliative care unit. METHODS: Retrospective chart review of all adult patients treated on a palliative care unit in October 2017. All data on drug use (eg, indication, dose, route of administration) were extracted and matched with the prescribing information. Identified off-label use was subsequently compared with recommendations in the relevant literature. The main outcome measure was frequency and type of off-label drug use. RESULTS: Some 2352 drug application days and 93 drugs were identified for 28 patients. Of all drugs, 47 (51%) were used off-label at least once. Most off-label uses concerned indication (57%) followed by mode of administration. In drugs highly relevant to palliative care the rate of off-label use was as high as 67%. The extent to which off-label therapy was supported by literature was very variable and ranged from 0% to 88%. CONCLUSIONS: These data from a single unit confirm the high prevalence of off-label use in palliative medicine and demonstrate that off-label use in adult palliative care is multifaceted. The data presented allow for a more precise characterisation of various aspects of off-label use in order to derive concrete further measures for research and clinical practice.

Influence of presence in an inter-professional simulation training of the emergency caesarean section: a cross-sectional questionnaire study.

PURPOSE: Emergency training using simulation is a method to increase patient safety in the delivery room. The effect of individual training concepts is critically discussed and requires evaluation. A possible influence factor of success can be the perceived reality of the participants. The objective of this study was to investigate whether the presence in a simulated emergency caesarean section improves subjective effect of the training and evaluation. METHODS: In this observation study, professionals took part in simulated emergency caesarean sections to improve workflow and non-technical skills. Presence was measured by means of a validated questionnaire, effects and evaluation by means of a newly created questionnaire directly after the training. Primary outcome was a correlation between presence and assumed effect of training and evaluation. RESULTS: 106 participants (70% of course participants) answered the questionnaires. Reliability of the presence scale was good (Cronbach's alpha 0.72). The presence correlated significantly with all evaluated items of non-technical skills and evaluation of the course. The factor "mutual support" showed a high effect size (0.639), the overall evaluation of the course (0.395) and the willingness to participate again (0.350) a medium effect. There were no differences between the professional groups. CONCLUSION: The presence correlates with the assumed training objectives and evaluation of the course. If training is not successful, it is one factor that needs to be improved.

Structured evaluation of stress triggers in prehospital emergency medical care : An analysis by questionnaire regarding the professional groups.

BACKGROUND: Emergency medical services work in the environment of high responsibility teams and have to act under unpredictable working conditions. Stress occurs and has potential of negative effects on tasks, teamwork, prioritization processes and cognitive control. Stress is not exclusively dictated by the situation-the individuals rate the situation of having the necessary skills that a particular situation demands. There are different occupational groups in the emergency medical services in Germany. Training, tasks and legal framework of these groups vary. OBJECTIVE: The aim of this study was to identify professional group-specific stressors for emergency medical services. These stress situations can be used to design skills building tools to enable individuals to cope with these stressors. MATERIAL AND METHODS: The participants were invited to the study via posters and social media. An expert group (minimum 6 months of experience) developed a set of items via a two-step online Delphi survey. The experts were recruited from all professional groups represented in the German emergency medical service. We evaluated the resulting parameters for relevance and validity in a larger collective. Lastly, we identified stress factors that could be grouped in relevant scales. In total 1017 participants (paramedics, physicians) took part in the final validation survey. RESULTS: After validation, we identified a catalogue of stressors with 7 scales and 25 items for EMT (Emergency Medical Technician) paramedics (KMO [Kayser-Meyer-Olkin criterion] 0.81), 6 scales and 24 items for advanced paramedics (KMO 0.82) and 6 scales and 24 items for EMS (Emergency Medical Service) physicians (KMO 0.82). For the professional group of EMT basic, the quality parameters did not allow further processing of the items. Professional group-specific scales for EMT paramedics are "professional limitations", "organizational framework", "expectations" and "questions of meaning". For advanced paramedics "appreciation", "exceptional circumstances" and "legal certainty" were identified. The EMT physicians named "handling third parties", "tolerance to ambiguity", "task management" and "pressure to act". A scale that is representative for all professional groups is "teamwork". Organizational circumstances occur in all groups. The item "unnecessary missions" for EMT paramedics and "legal concerns with the application of methods" for advanced paramedics are examples. DISCUSSION: Different stressors are relevant for the individual professional groups in the German emergency medical service. The developed catalogue can be used in the future to evaluate the subjective stress load of emergency service professionals. There are stressors that are inherent in the working environment (e.g. pressure to act) and others that can be improved through training (teamwork). We recommend training of general resistance as well as training of specific items (e.g., technical, nontechnical skills). All professionals mentioned items with respect to organizational factors. The responsible persons can identify potential for improvement based on the legal and organizational items. The EMT basic requires further subdivision according to task areas due to its variable applicability.

Automation as an equal team player for humans? - A view into the field and implications for research and practice.

The practical reality and feasibility of Human-Autonomy Teaming (HAT) are analyzed from an experts' point of view, considering current possibilities of various fields. We aim to find out whether the topics discussed scientifically are also practically relevant, to identify requirements for successful HAT, and to derive further research needs. Intensive guideline-based interviews with 28 experts from different industries are conducted and compared to the results of our literature review. The topics discussed scientifically are also practically relevant. Today's technology is far from being able to meet the practical requirements for successful HAT, as postulated in the literature. Contrary to the Human-Automation Interaction, the concept of HAT is hardly applied in the field. Identified key aspects for successful HAT are converted into a model. Future research needs with practical impact exist especially in the area of heterarchy, system knowledge, anticipation of mental states, and consideration of human needs and emotions.

Low self-reported stress despite immune-physiological changes in paramedics during rescue operations.

Despite the high stress levels, paramedics seem to ignore or even negate the stress. This can be detrimental and lead to stress-related diseases. Therefore, we investigated the divergence between physiological and psychological stress responses of paramedics. Participants were 16 paramedics and 17 white-collar workers. We assessed psychological stress parameters, cortisol awakening response (CAR), and quantified immune parameters. In paramedics, electrocardiogram (ECG) was measured during one complete 24-hour shift. Our results revealed that CAR was higher in paramedics compared to controls. An alteration of immune parameters was observed even during days of free time. Also, ECG recordings showed acute stress in paramedics during rescue situations. Questionnaires revealed that rescue-service specific stressors affect psychological outcomes. However, paramedics reported significantly less mental stress and higher levels of depersonalization than controls. Taken together, our results suggest higher stress in paramedics compared to controls. However, paramedics negate their daily stress. Our findings underline therefore the importance to develop stress-management interventions for paramedics including sensitization for their stress reactions.

Off-label drugs in palliative care: a Group Delphi treatment recommendation process.

OBJECTIVES: The use of drugs beyond their marketing authorisation, that is, off-label use, is common practice in palliative care with over 70% of off-label use having little or no scientific support. The lack of evidence makes recommendations for off-label use essential, in order to increase the safety of drug therapy and thus patient safety. The aim of this study was to develop a guide for preparing and consenting drug-specific recommendations for off-label use in palliative care. METHODS: Group Delphi Study with three rounds and a prior online survey to identify topics of dissent. Participants represented professional groups working in palliative care involved in direct patient care and/or drug management and various care settings. Furthermore, representatives of relevant professional associations, experts with academic, non-clinical background and experts with international expertise were invited. RESULTS: 18/20 invited professionals participated in the prior online-survey. 15 experts participated in the Group Delphi process. Six domains, including identification of drugs, drug uses, assessment of evidence, formulation, consensus and updating of recommendations were generated and respective statements were included in the Group Delphi process. The consensus process resulted in 28 statements forming the guide for recommendations. CONCLUSIONS: The resultant systematic approach for preparing and consenting drug-specific recommendations for off-label use will allow the development of recommendations with transparent and reproducible monographs. This will help to increase treatment quality and patient safety as well as security of decision-making in palliative care. The developed guide is part of a larger project aiming to provide therapy recommendations for areas that have little or no scientific evidence.

Training of airway management for anesthesia teams - Measurement of transfer into daily work routine by questionnaire.

THEORY: Problems in airway management are rare in anesthesia but when they occur, they have serious consequences for the patient. For this reason, training is recommended for professionals involved in anesthetic care. Here we investigated, if a newly developed technical/ non-technical hybrid airway training would be relevant for daily practice in a tertiary referral hospital. HYPOTHESES: We hypothesized that: (a) both parts of the validated questionnaires meet the quality criteria for the application in anesthesia teams, (b) even though the team regularly deals with airway management, airway management training is relevant to all professions and (c) contents of the developed training can be integrated into the behaviour of the teams. METHOD: In this observational study, 104 professionals took part in a one-day technical/non-technical hybrid airway training programme. Participants received a questionnaire six months after training, based on selected scales of the validated tools; "Training Evaluation Inventory" and "Transfer Climate Questionnaire". RESULTS: The scales of "perceived usefulness", "task cues" and "positive reinforcement" showed good internal consistency and all were rated higher than 3.9 on a 5-point Likert scale (1=complete rejection; 5=fullest approval). The scale "negative reinforcement and punishment" showed satisfactory internal consistency for physicians (rated 2.75 ± 0.8). By removing an item in each case, the scales "attitude towards training" (rated 4.93 ± 0.2) and "extinction" (rated 3.02 ± 0.8) showed satisfactory internal consistency for nurses and anesthetic technicians. "Social Cues" did not meet qualitative criteria. There was no difference in the assessment by the professional groups. CONCLUSIONS: The presented training course was perceived as useful by both professional groups equally, which supported the interprofessional concept. The content was positively reinforced in practice six months after training and is relevant for professionals who are regularly confronted with the topic "airway management". Scales which meet qualitative criteria for only one profession and the scale "social cues" should be reconsidered in the context of an interprofessional team.

Transfer of an interprofessional emergency caesarean section training program: using questionnaire combined with outcome data of newborn.

PUPROSE: An emergency caesarean section is a potentially life-threatening situation both for the mother and the newborn. Non-technical skills can be improved by simulation training and are necessary to manage this urgent situation successfully. The objective of this study was to investigate, if training of emergency caesarean section can be transferred into daily work to improve the outcome parameters pH an APGAR of the newborn. METHODS: In this pre-post study, 141 professionals took part in a training for emergency caesarean section. Participants received a questionnaire, based on the tools "Training Evaluation Inventory" and "Transfer Climate Questionnaire" 1 year after training. Outcome data of the newborn were collected from the hospitals information system. RESULTS: Except the scale "extinction", Cronbach's alpha was higher than 0.62. All scales were rated lower than 2.02 on a 5-point Likert Scale (1 = fullest approval; 5 = complete rejection). "Negative reinforcement" was rated with 2.87 (SD 0.73). There were no significant differences in outcome data prior. The questionnaire fulfils criteria for application except the scale "extinction". CONCLUSION: The presented training course was perceived as useful by the professionals and attitudes toward training were positive; the content was positively reinforced in practice 1 year after training. Parameters of the newborn did not change. It is conceivable that other outcome parameters (e.g. posttraumatic stress disorder) are addressed by the training. The development of relevant outcome parameters for the quality of emergency sections needs further investigation.

Impact of Simulator-Based Crisis Resource Management Training on Collective Orientation in Anaesthesia: Pre-Post Survey Study With Interprofessional Anaesthesia Teams.

THEORY: Individuals have different qualities, levels of willingness, and degrees of engagement for working in teams. This behaviour is termed 'Collective Orientation' (CO). Collective orientation can be trained and has a positive influence on team processes. Here, we investigated the effect of a simulator-based, Crisis Resource Management team training upon the participants' CO. HYPOTHESES: We hypothesized (1) the scales of CO and Presence for lab-based microworld research (PLBMR) are applicable to the German anaesthesia teams, (2) the CO can be influenced by means of simulation training, (3) the training effect is dependent on sex and/or profession, and (4) the change of CO depends on the perceived presence of the participants in the scenario. METHOD: In a pre-post study, 66 nurses and doctors from various anaesthetic departments took part in a 1-day training course to improve non-technical skills. The primary outcome was the mean difference between the CO measured (via questionnaires) immediately before (T1) and after (T2) training. The change was then tested for dependence upon other variables, such as sex, professional group, and immersion into the simulation scenarios. RESULTS: Collective orientation improved significantly after training (mean difference: 0.2; P < .001; dz = 0.53). Considering the subscales, affiliation increased significantly (P < .001; dz = 0.59), whereas dominance remained unchanged. Furthermore, no correlation was found regarding sex, professional group, or immersion into the simulation scenarios. CONCLUSIONS: Our study demonstrated that simulation-based training improves the participants' COs, primarily by increasing affiliation. Subjective scenario reality did not significantly influence this. Nonetheless, it remains unclear as to what factors categorically resulted in this benefit. The shared experience in the course by all team members might trigger the effects. However, further studies are needed to identify the modifiable factors that can improve teamwork attitudes.

Does simulation-based training in medical education need additional stressors? An experimental study.

The increased curricular integration of simulation-based training (SBT) in medical education is accompanied by researchers' calls to examine the effectiveness of SBT. We address conflicting results regarding effects of an added stressor on learning outcomes. In an experimental setting, one group of medical students (N = 20) performed cardiopulmonary resuscitation on a patient simulator. For a second group (N = 21) the scenario differed in that they encountered a defect defibrillator. We found participants of both groups to show increased biological stress-levels, independent of group allocation. Paradoxically, participants who encountered the equipment failure subjectively reported less stress. We discuss the implications of the comparable high stress levels in both groups with regards to future studies. We further discuss the result regarding subjective stress levels within the framework of attribution theory. Practitioner summary: The results of our experimental study underline the need for evidence-based choices of additional stressors for the design of simulation scenarios. We describe the choice of stimuli and setting in detail to maximise practical value for the construction of simulation-based medical trainings.

Changes of collective orientation through a medical student's anaesthesia simulation course - simulation-based training study with non-technical skills debriefing versus medical debriefing.

BACKGROUND: Non-technical skills (NTS) are known to have a positive impact on quality of medical care. The team performance enhancing behaviour, as an example for NTS, is termed "Collective Orientation" (CO). In this study, we investigated the effect of a simulator-based anaesthesia training upon student's CO in relation to medical and TeamGAINS (guided team self-correction, advocacy-inquiry and systemic-constructivist techniques) debriefing. We hypothesized (a) the scale collective orientation, as demonstrated in other team setting, is applicable to fourth year German medical students, (b) collective orientation increases by a four-hour anaesthesia simulation course, (c) the change in collective orientation can be influenced by type of debriefing. METHOD: All classes of an anaesthesia module (4th year medical students) were randomized into two groups. Students took part in a four-hour simulation course with team scenarios, supported by a simulated nurse. In group one the trainer focused on a debriefing on medical problems and in group two, a debriefing according to the specifications of the TeamGAINS concept was conducted. The primary outcome was the mean difference between the collective orientation measured (via questionnaires) immediately before (T1) and after (T2) training. RESULTS: Cronbach's alpha for all scales and measurement points was higher than 0.72. The scale "affiliation" decreases in the group medical debriefing MD = 0.1 (p = 0.008; r = 0.31) and was unchanged in the group TeamGAINS. "Dominance" increases in both groups. The values were MD = 0.19 (p = 0.003; r = 0.25) for medical debriefing and MD = 0.22 (p = 0.01; r = 0.40) for TeamGAINS debriefing. CONCLUSION: The collective orientation questionnaire can be applied to fourth year medical students. Simulation courses influence the attitude towards teamwork. The influence is negatively to the subscale "affiliation" by a "medical debriefing" and independently regardless of the nature of the debriefing for the subscale "dominance". We recommend a debriefing for medical students using the TeamGAINS approach to clarify the connection between the individual performance and non-technical skills. Anaesthesia simulation courses have the potential being a part of a longitudinal education curriculum for teaching non-technical skills.

Drug use beyond the licence in palliative care: A systematic review and narrative synthesis.

BACKGROUND: Drug use beyond the licence (off-label use, off-label drug use) is a common practice in palliative care and respective recommendations can often be identified in the literature. It is both risky and offers opportunities at the same time and, therefore, requires special attention in clinical practice. AIM: To determine the prevalence of off-label drug use in palliative care and to identify, evaluate and critically appraise studies describing the clinical practice, healthcare professionals' awareness, knowledge and attitudes towards off-label-use and management strategies. DESIGN: Systematic literature review following the guidance of the Centre for Reviews and Dissemination. DATA SOURCES: Medline, Embase, Web of Science and Current Contents Connect were searched in July 2018 as well as hand searches. The reference lists of pertinent studies were screened for further relevant publications, and citation tracking was performed. RESULTS: Eight studies met the inclusion criteria. Due to the variety in study designs and settings, no meta-analysis or meaningful statistical analysis was possible and a narrative synthesis of the data was performed. Frequency of off-label drug use ranged from 14.5% to 35%. Up to 97% of palliative care units did not have any policy or guidance on handling off-label drug use. About 20% of prescribers never obtain consent in the context of off-label use. CONCLUSION: Off-label use is common in palliative care with up to one-third of prescriptions affected. Challenges are often related to obtaining informed consent. Little is known about the decision-making process. More information and guidance for the prescribers are needed to enable safe handling of drugs outside their licence in palliative care.

Complex Problem Solving in Teams: The Impact of Collective Orientation on Team Process Demands.

Complex problem solving is challenging and a high-level cognitive process for individuals. When analyzing complex problem solving in teams, an additional, new dimension has to be considered, as teamwork processes increase the requirements already put on individual team members. After introducing an idealized teamwork process model, that complex problem solving teams pass through, and integrating the relevant teamwork skills for interdependently working teams into the model and combining it with the four kinds of team processes (transition, action, interpersonal, and learning processes), the paper demonstrates the importance of fulfilling team process demands for successful complex problem solving within teams. Therefore, results from a controlled team study within complex situations are presented. The study focused on factors that influence action processes, like coordination, such as emergent states like collective orientation, cohesion, and trust and that dynamically enable effective teamwork in complex situations. Before conducting the experiments, participants were divided by median split into two-person teams with either high (n = 58) or low (n = 58) collective orientation values. The study was conducted with the microworld C3Fire, simulating dynamic decision making, and acting in complex situations within a teamwork context. The microworld includes interdependent tasks such as extinguishing forest fires or protecting houses. Two firefighting scenarios had been developed, which takes a maximum of 15 min each. All teams worked on these two scenarios. Coordination within the team and the resulting team performance were calculated based on a log-file analysis. The results show that no relationships between trust and action processes and team performance exist. Likewise, no relationships were found for cohesion. Only collective orientation of team members positively influences team performance in complex environments mediated by action processes such as coordination within the team. The results are discussed in relation to previous empirical findings and to learning processes within the team with a focus on feedback strategies.

Does teaching non-technical skills to medical students improve those skills and simulated patient outcome?

Objectives: The purpose of this study is to evaluate the effects of a tailor-made, non-technical skills seminar on medical student's behaviour, attitudes, and performance during simulated patient treatment. Methods: Seventy-seven students were randomized to either a non-technical skills seminar (NTS group, n=43) or a medical seminar (control group, n=34). The human patient simulation was used as an evaluation tool. Before the seminars, all students performed the same simulated emergency scenario to provide baseline measurements. After the seminars, all students were exposed to a second scenario, and behavioural markers for evaluating their non-technical skills were rated. Furthermore, teamwork-relevant attitudes were measured before and after the scenarios, and perceived stress was measured following each simulation. All simulations were also evaluated for various medical endpoints. Results: Non-technical skills concerning situation awareness (p<.01, r=0.5) and teamwork (p<.01, r=0.45) improved from simulation I to II in the NTS group. Decision making improved in both groups (NTS: p<.01, r=0.39; control: p<.01, r=0.46). The attitude 'handling errors' improved significantly in the NTS group (p<.05, r=0.34). Perceived stress decreased from simulation I to II in both groups. Medical endpoints and patients´ outcome did not differ significantly between the groups in simulation II. Conclusions: This study highlights the effectiveness of a single brief seminar on non-technical skills to improve student's non-technical skills. In a next step, to improve student's handling of emergencies and patient outcomes, non-technical skills seminars should be accompanied by exercises and more broadly embedded in the medical school curriculum.

Key Aspects of a Sustainable Health Insurance System in Germany.

BACKGROUND: The main goals of health-care systems are to improve the health of the population they serve, respond to people's legitimate expectations, and offer fair financing. As a result, the health system in Germany is subject to continuous adaption as well as public and political discussions about its design. OBJECTIVE: This paper analyzes the key challenges for the German health-care system and the underlying factors driving these challenges. We aim to identify possible solutions to put the German health-care system in a better position to face these challenges. METHODS: We utilize a broad array of methods to answer these questions, including a review of the published and grey literature on health-care planning in Germany, semi-structured interviews with stakeholders in the system, and an online questionnaire. RESULTS: We find that the most urgent (and manageable) aspects that merit attention are holistic hospital planning, initiatives to increase (administrative) innovation in the health-care system, incentives to increase prevention, and approaches to increase analytical quality assurance. CONCLUSION: We found that hospital planning, innovation, quality control, and prevention, are considered to be the topics most in need of attention in the German health system.