Facts and Figures from the German Health Care System
What is at stake
In view of the shortage of medical assistants, the demand is growing louder to explore and quickly implement all possibilities to increase the attractiveness and appreciation of the profession of medical assistants in the public, since this group of people is one of the supporting pillars of the health system. However, one essential aspect is left out of this justified demand: appreciation by employers.
Performance is not seen
- „More recognition of our achievements!“
- „The boss could also praise once in a while!“
- „There is always an immediate debate about negative things, positive things are not mentioned at all!“
An evaluation of the employee statements from several hundred randomly selected practice management company comparisons shows: two thirds of the medical assistants complain about too little or completely absent appreciation and recognition of their performance.
However, it can be assumed that the number of medical assistants who are dissatisfied with this aspect of practice management is much higher.
The recognition mechanism in most medical practices follows a simple method from the employer’s perspective: if the employees do not hear any criticism, the boss is satisfied and their work is fine. With the payment of the salary, the motivational maximum is reached; from the perspective of the practice owners, nothing more is necessary.
Expectations are low
This also leads to the fact that kindness formulas such as „please“ and „thank you“ are virtually never used. „Find me the papers!“, „Get the blood pressure monitor“.“ or „Call Mr. W.“. Work pressure and lack of time shorten communication to the factually necessary, the motivationally necessary falls by the wayside.
For the staff members, this behaviour – even if they understand the mindset that justifies it – is demotivating and backsliding.
This is why practices with an „appreciation blank“ also have significantly lower work productivity and motivation than others with a stronger staff orientation. At the same time, the expectations of the assistants are not high: „…it would already be enough if once in a while someone said: you did that well…!“.
Appreciation promotes teamwork
But appreciation does not only take place in its pure form, but is embedded in a multitude of aspects that shape daily work. What specifically bothers the female staff and where do they see room for improvement in the cooperation with the practice owners in their practices? The answers to this question are important because the practice management comparisons also show that a large part of the problems observed in medical practices could be eliminated by improving the interactions between doctors and medical assistants. If this were to happen, the consequences could be directly felt and experienced by all involved: stress, hecticness, anger would be much less, patient care would be more intensive, work motivation would be higher and the success of the practice – both qualitatively and quantitatively – would be better.
In addition, there is a very decisive aspect: if the appreciation is right and the negative factors mentioned are eliminated, medical assistants work together as „real“ teams.
Teamwork is the gold standard of practice work
The team collaboration form is characterised by common goals, largely autonomous task completion, mutual complementation and support, as well as self-direction to solve problems and self-initiated measures to improve work results.This distinguishes it from the group form of cooperation. Their work is characterised by a low synergy of individual activities: the medical assistants work together, but always only within the framework given to the individual group member. Individual initiative or helping out with problems are rather rare. Moreover, the cooperation is often characterised by unresolved conflicts. Although each staff member strives to do her tasks well, there is no sustained joint commitment to constant improvement.
The group is the most common form of cooperation existing in GP and specialist practices.
For its part, the group differs positively from the special-purpose association, whose work performance is characterised by „service by the book“ and „lone wolf behaviour“.
What are the benefits of teamwork?
The cooperation of practice staff in team form offers a number of advantages:
- The quality of service provided by the staff is significantly better, both qualitatively and quantitatively, than in other forms of cooperation.
- They are relieved of significantly fewer management and control tasks and have more time for their patients.
- Increased productivity, efficiency and patient satisfaction result in better practice results.
For the staff
- A team environment increases work motivation and satisfaction.
- Each staff member can contribute her personal strengths and receives help with her weaknesses.
- Temporarily higher workloads are distributed among all staff members and create significantly less stress.
For the patients
- Teams are able to provide more intensive medical care compared to other forms of cooperation.
- The care of visitors to the practice can be more personalised.
- The balanced working atmosphere creates a feel-good atmosphere and higher satisfaction.
The wish list is long
The following overview outlines the deficits of their work most frequently criticised by medical assistants:
Missing work objectives
A prerequisite for productive teamwork in medical practices are concrete work objectives that are known to and understood by everyone. They enable each staff member to contribute her personal performance to the community of colleagues. However, according to the interviewees, such orientations are missing in many medical practices, as are implementation instructions that show which sub-goals apply when exceptional situations arise.
The consequence is noticeable for the staff on a daily basis: according to the assistants, a lot of energy and time is wasted on things that do not serve the main goal of the work and / or even useless activities are carried out, often overlooking and neglecting important tasks.
The owners of practices without a goal system assume that the goals automatically result from the work assignment of their business. At the same time, the „aimless“ doctors complain disproportionately often that the assistants do not meet their requirements and that the performance level of their teams is poor.
But only about 10% of the problems related to the performance of medical assistants result from „real“ incompetence.
Above all, they are the result of a lack of goals and concrete implementation criteria. The same effect can be seen in overly high, unachievable targets in cases where the medical assistants lack the necessary qualifications to implement the targets.
Scarcely defining and delimiting areas of responsibility
In addition to the lack of work objectives, medical assistants also criticise the lack of clear competence assignments. They are the only way to ensure that each employee knows at all times whether she or a colleague must complete a task. Since this demarcation does not exist and the problems resulting from it are not discussed in many practices, the work flow repeatedly comes to a standstill.
Staff members complain that during the course of a working day they are constantly asked by colleagues to do different tasks at the same time. As a result, many activities overlap and in total nothing is done properly.
The unclear responsibilities also promote the development of conflicts, an aspect from which the staff sometimes suffer greatly.
The doctors‘ view on this point is very simple: they demand that the assistants organise themselves.
Too little freedom for independent action
The rigid instruction systems common in many practices are also considered inappropriate. The practice owners specify not only the tasks to be done, but also the way in which they are to be carried out. However, the medical assistants would like to be able to carry out their tasks as independently as possible, instead of being permanently harassed by instructions that leave no room for their own initiative and self-direction.
Again and again, one encounters doctors in private practice who are characterised by a deep mistrust of their medical assistants:
- „Are my staff working enough?“
- „Are all activities carried out carefully?“
- „Can the staff be relied upon even when I am not in the practice?“
As a result, they develop close-meshed control mechanisms and explain their behaviour mainly with the necessity of being able to ensure task completion and service quality only by means of a given framework of action.
But only in very few cases do bad experiences actually cause them to act in this way; rather, their decision is based on a fundamental conviction without concrete evidence.
If helpers are unable to carry out the tasks assigned to them on their own responsibility, there is usually a mismatch between skills and requirements. The reason is therefore to be found in inadequate delegation by doctors.
Unclear rules of cooperation
In addition to clear competences, medical assistants want clear rules that are binding for the entire practice team and that structure the cooperation: which work steps have priority for individual examinations, how to proceed when cooperating doctors call, in which cases may the doctor be disturbed in the patient conversation, who must pass on which information to whom, etc.?
Here, too, the practice owners, especially in smaller practices, are of the opinion that the staff can / should best establish this order themselves, because the basic framework would result – more or less by itself – from the daily work.
Some doctors also state that they refrain from establishing structures for motivational reasons, but the resulting problems and conflicts far outweigh the intended positive effect in terms of their negative impact. Moreover, rules and motivation do not contradict each other if the staff members are involved in the development of the rules, if they have enough „breathing space“ and if all staff members are treated equally according to the jointly agreed guidelines. But team self-controls quickly reach their limits when different abilities, perspectives and motivations clash. This is where – as the positive experiences in best practice companies show – a code of values and behaviour is needed that applies to all helpers.
If there are no basic rules – as complained about by the staff – there are always changing priorities for the same issues in everyday work.
If there is also a lack of explanatory information, chaos is inevitable.
Failure to provide assistance for necessary conflict solutions
Another consequence of a lack of rules is conflicts among the staff. If they are not resolved and persist, this has serious negative consequences for the practice work, because the work performance decreases and the quality of work drops, two aspects that also have a noticeable effect on the patients.
For the female staff, the personal consequences are just as serious: motivation, job satisfaction and team spirit dwindle and the working atmosphere deteriorates, the daily work becomes a torment.
However, according to the interviewed medical assistants, most practice managers do not even bother with conflicts and solutions („…come to an agreement and then it will be fine…“).
Inequality of treatment
In the opinion of the interviewed medical assistants, every staff member – including trainees – should have the opportunity to express her opinion at meetings or in discussions. All contributions should – according to their wish – be treated equally and their key points taken into account. No one is to be excluded. Team disharmony arises when the opinions of individual colleagues are stifled or their suggestions ignored. Harmony is also reduced if the practice team only listens to certain members or if the practice owner always dictates the opinion alone. In this area, from the staff’s point of view, there is a clear failure of many practice managers and a desire for remedial action.
Too little unambiguity in decision-making
- „What we need from the boss is clear announcements, not this wishy-washy stuff where then nobody knows exactly what to do!“
- „More clarity in announcements!“
- „I wish the boss would say more precisely what she wants, then we could do our work better and faster!“
These three staff statements outline a widespread problem: the lack of clarity in decisions, instructions and requests from practice owners. „When the boss says something, the guesswork starts as to what he actually wants!“ is how one practice manager sums up the daily recurring problem. The reactions of medical assistants to imprecise orders are very different: some act in the way they think is most appropriate for the task and risk – depending on the temperament of the practice owner – anger and reprimands if their interpretations are not correct. The others keep asking until the task is defined in detail, a strategy that also leads to resentment on both sides.
„Let the bosses run a rail!“ A more difficult problem situation arises for medical assistants in doctor cooperations. Here it is not uncommon for individual doctors to have completely different working styles. One may be energetic, hands-on, business-oriented and demanding when it comes to the pace and quality of work, while the other is calm and deliberate, likes to have private conversations and is quite relaxed if not all the work is done immediately.
It follows almost automatically from such different working styles that the same work situations are also assessed differently.
For example, if one practice owner has no problem with a patient being pushed in without an appointment, the other finds it unacceptable. For the assistants, this constellation is a balancing act, because patients do not differentiate between doctors in routine processes such as making appointments, but see the practice as a whole.
In many cases, such constellations lead to a pronounced camp formation among the assistants, which in turn has a negative effect on team harmony and work motivation.
Too little internal communication
„We would like to have a short team meeting once a week!“ This suggestion for improvement represents a frequently voiced concern, because day-to-day business creates an acute need for information and communication, which must be met at shorter intervals – in large practices this is essential anyway.
But only about one-third of practising doctors rely on this exchange of ideas.
Doctors who do not hold meetings do not want to deal with the „small stuff“ (description of a practice owner) that they see as a result. Moreover, they consider urgently needed working time to be wasted.
But even in those cases where practice meetings are held, the quality of implementation is often insufficient from the point of view of the healers:
- the topics relevant to them are not taken into account enough,
- the doctors do not ensure a balance in the discussion, because there is a lack of any regulation of dominant female staff,
- binding agreements are rarely reached,
- the meetings are only slightly structured or not structured at all,
- later traceability is usually not guaranteed because no minutes are taken or they offer little substance in terms of content,
- discussed projects or decisions are not followed up in their implementation and suitability,
- the time frame available for the meetings and the need for discussion are not coordinated, the doctors – according to the staff – are usually only concerned with getting to the end as quickly as possible,
- the medical assistants complain about the doctors‘ monologue dominance instead of creative dialogue,
- discussions of mistakes or problems are conducted as negative discussions with blame, not as positive solution processes.
No promotion and development of skills
Another point of criticism is the low willingness of doctors to give their staff opportunities for further training. Staff members who express such wishes usually – according to the feedback from the interviews – have to pay for the necessary seminars and events themselves and take leave to attend them, if they take place on weekdays.
But also many instructions in the use of new devices or software, which the provider companies carry out in the practices and whose contents are essential for proper use, are reduced to a minimum („There must be a manual for that, just read it!“).
Suggestions are not listened to / accepted
In the context of the lack of recognition, ideas and suggestions for improvement from the medical assistants are often simply ignored: „We’ve told the boss so often, but he doesn’t listen to us! For the employees, whose commitment comes to nothing and whose working conditions do not improve due to ignorance, this behaviour is a central demotivating factor.
In this case, however, the practice owners are foregoing valuable help, because the female employees know exactly the weak points of the work processes, the „sand in the gears“, which could be removed at zero cost, to the benefit of all.
Lack of solidarity towards the patients
- „Decisions that are clearly defined should stay that way and not be reversed in front of patients!“
- „When decisions are made, they should be carried out that way (e.g. patient’s request for medication is refused by the boss, then when the patient comes to the surgery, he gets it after all)!“
- „…occasionally more support and backing by the doctors in implementing their orders, i.e. also standing by the things that were ordered by themselves and have to be implemented by us. When discussions arise, the doctors are not fully behind us, but neither are some colleagues, in order to avoid unpleasant situations…!“
The complaint of medical assistants about bosses who belong to the group of pushover doctors („Umfaller“) appears regularly in the survey results. The non-compliance with what has been discussed and decided is not only frustrating and disorienting for the assistants (what should one actually adhere to, what applies in case of doubt?), but also humiliating. For they are usually the ones who have to inform the patients about unpleasant decisions. If they then turn to the doctor, the doctor acts contrary to what has been decided and thus „stabbed the doctor’s assistants in the back“. This casts doubt on their competence and creates embarrassing situations. For the doctors, this is not a problem, they take the path of least resistance and do everything to avoid trouble with their patients.
Censure in the presence of patients
Another behaviour of practice owners that is perceived as drastic, negative and humiliating is reprimanding practice staff in the presence of patients.
Half of the interviewed medical assistants complain about such „expressions of criticism“ by their bosses.
„If I have made a mistake, the doc should tell me, then I can explain, but please always without patients around!“.
The practice owners do not think about their behaviour, they have gotten rid of their anger and expect that the reprimanded behaviour will not occur again. The consequence: female staff members who are exposed to this form of criticism practice „duty by the book“ in order to avoid mistakes as much as possible.
From the doctor’s point of view, it is also not taken into account that patients do not want to be involved in the „internal affairs“ of medical practices. Their wish is for individual medical care in a calm and friendly atmosphere. The experience of reprimands works against this and lowers both patient satisfaction and willingness to recommend.
„Every day starts with uncertainty: is the boss in a good mood? If so, we all breathe a sigh of relief. But unfortunately this happens rather rarely and then nothing counts: neither rules nor agreements. Sometimes such a working day is a real horror trip!“
If practice owners continue to bring problems, worries and anger into the practice and act them out there, the working atmosphere immediately sinks to zero. Such practices are quickly recognisable from the outside:
- On the one hand, there is a very high staff turnover. When asked about this, the doctors usually refer to the difficulty of getting good staff at an affordable salary or play down the negative effects of their behaviour („…they can handle it…“),
- On the other hand, all work is strictly doctor-centred, the medical assistants often appear closed and dismissive, the working atmosphere is depressing.
Every day, they help their patients to reduce, eliminate or even avoid health problems, but when it comes to the health of their own staff through adequate health-preserving and health-promoting design of working conditions, registered doctors fail almost completely. This is shown by a look at the suggestions for improvement found in the employee satisfaction surveys:
- „Adherence to break times on a more than 10-hour day would be beneficial for regeneration!“
- „Acceptance that certain work processes require a circumscribed period of time and not senseless rushing from activity to activity!“
- „At least an ergonomically shaped office chair for a healthy back and an improvement of the shoulder-neck area!“ (Quote from an employee survey conducted in an orthopaedic (!) practice)
- „Reasonable, bright workplace lighting instead of semi-darkness!“
- „Time off in lieu for overtime or should we work until we drop?“
- „A new PC monitor so that we don’t ruin our eyes!“
- „Better positioning of equipment, e.g. the printer at reception is too low, bending down 100 times a day is bad for the back!“
These kinds of problems are found in every second doctor’s office. They add to the daily, not insignificant workload the additional personal impairment of the staff due to the inadequate working conditions. Above all, cost reasons keep many practice owners from taking health-promoting measures in their businesses (…why should I replace the monitor if it still works…?“). A look at the absenteeism of staff, the productivity-limiting effects and the resulting costs would open the eyes of many doctors to the short-sightedness of their actions.
Optimising practice management and teamwork quality with the convenience approach
Regardless of whether general practitioners and specialists want to reduce daily work pressure with their teams, improve the efficiency of their processes or develop practice success, practice management is always the central control variable.
But only very few know how to put their goals into practice; external consultants are often too expensive for them. As a result, the situation usually remains unchanged. But there is a simple solution.
Convenience in the analysis of practice management
The Practice Management Comparison© is a convenience practice analysis specially developed for this situation with the following performance features:
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