Practice management insufficiency: Diagnosis and treatment of the number one outpatient systemic disease in German medical practices

What it’s all about

In the search for development opportunities and future prospects for outpatient healthcare, one central starting point and design parameter is usually ignored: practice management. But its quality is currently poor. This white paper describes why practice management is so important and what GPs and specialists can do about their insufficiency.

1 Practice management and patient care

The term “practice management” refers to the totality of all regulations, instruments, measures and behaviours

which are used in the areas of planning, organisation, market research, leadership and cooperation, time and self-management, patient management, marketing and financial management of medical practices of all specialities and
The interplay of these factors ensures that the practice runs smoothly.

Practice management acts as a transmitter of medical expertise, the activities of medical assistants and the resources used in the actual care of patients.

The quality of its organisation determines

how comprehensively the expertise of doctors and the skills of staff are made available to patients in the form of comprehensive assistance,
it also determines how quickly practice teams can react to changes of any kind, implement them and benefit from them (example: digitalisation),
And last but not least, costs, turnover and profit are influenced.

Smoothly functioning practice management is based on the implementation of best practice standards, i.e. the systematic use of business management methods, tools and management behaviours that ensure that internal and external requirements for practice work are met.

2 The practice management insufficiency (PMI)

If practice management is not suitable for organising practice operations in such a way that they meet the requirements of day-to-day work and basically function smoothly, this is referred to as practice management insufficiency (PMI). The reason for its occurrence is that

the selection of precautions taken and measures realised is incomplete and/or incorrect, or
their implementation is inadequate and/or incorrect.

This creates a vacuum, as internal and external demands on practice work are not adequately met. Two examples:

Personnel management

The current Leadership Materialisation Score of German GP and specialist practices (LMS, use of leadership tools compared to the best practice standard) is 41.9% (optimum: >80%),
Its counterpart, the Leadership Impact Score (LIS, employee satisfaction in relation to requirements), is 32.7% (optimum: >80%).

Practice organisation

In medical practices – across all specialist groups and practice types and sizes – on average only just under 60% of the regulations and instruments necessary for a smoothly functioning practice organisation are currently used (Organising Quality Score),
the resulting patient satisfaction fulfils only 40% of the requirements and wishes (Organising Impact Score)
and even in companies where the teams do not experience any acute impairment of their work, there are often organisational risk factors that lead to problems in the medium to long term.

The low implementation and impact rates have a considerable impact on the quality of patient care, but also on the efficiency and productivity of work processes and, above all, on securing the future of medical practices.

3 Causes

Interviews and market research surveys with and of GPs and specialists revealed a number of reasons that – in isolation or in combination – cause practice management insufficiency and make it a systemic disease:

Inadequate expertise

Management techniques are still not a comprehensive part of medical training and physicians do not deal much with the topic on their own initiative. However, medical interest groups also do not vigorously pursue a corresponding transfer of knowledge; practice management is not given adequate importance. Since doctors in private practice pay a lot of attention to specifications and standards, they receive a completely false and unrealistic signal.

Missing system understanding

As already described, practice management is based on various areas of action that are interconnected and mutually dependent. Changes in one area have an impact on the other sectors of activity, but often also require corresponding adjustments there in order to have a synergistic effect. Practice owners are not aware of these interactions and hardly pay any attention to them. When problems arise, they usually think in monocausal terms, trying to identify “the” malfunction in practice management and eliminate it with the help of individual measures. However, practice management is a multifactorial process that must be analysed in its entirety.

Too little analysis activity

To date, only thirty per cent of GPs and specialists have carried out a professional practice analysis, and the realisation rate of other studies is even lower.
If analyses are carried out, the wrong methods are often used, for example with school grade scaling in satisfaction surveys, so that the results are misleading. Another mistake is to focus on symptoms rather than causes.
Overall, reliance on one’s own “gut feeling” dominates instead of the generation and utilisation of objective data. If patients or employees do not complain, it is assumed that no problems exist.
This results in extreme discrepancies between self-image and external image. For example, two thirds of practice owners are of the opinion that they manage their staff well, but only just under 20% of medical assistants confirm this assumption.
External influences – keyword “bureaucracy” – are also blamed for problems that occur. It is certainly annoying, but it is calculable and can therefore be planned into processes, so it is not a cause of PMI.
Another argument put forward is that the number of patients is too high. This impairment of practice operations can certainly occur on a seasonal basis, e.g. in times of flu or in regional monopoly situations. In the long term, however, the situation is an expression of a misalignment in practice management, triggered by inappropriate ordering behaviour or too few staff.
Furthermore, for many practice owners and medical assistants, the problem arises that the work overload caused by PMI does not offer any scope for carrying out optimisation analyses.

Rejection of business management perspectives

“I’m a doctor, not a businessman!”: Doctors in private practice have an extremely distanced relationship to the term “business management”. This is mainly due to a profound misunderstanding, because

Most associate this solely with financial management (“…my tax consultant will take care of that…”),
a primarily monetarily motivated medicine
and / or demands for a rigorous economisation of the healthcare system.

Overall, the term and everything associated with it is rejected as rather unethical. But this is a mistake, because 2/3 of the activities in medical practices follow the rules of business administration.Designed as an aid

it systematises the players involved in the economic process,
shows principles according to which they can act in accordance with their sector and field of activity and
Business administration provides methods, instruments and key figures to optimise work as far as possible, depending on the individually selected principle of action.

Business management is therefore free of requirements and specifications and provides assistance for the work content of the individual company, e.g. for a medical practice, in order to optimally fulfil the goals of the practice owners – both qualitatively (e.g. quality of care) and quantitatively (e.g. practice profit) (best practices).

Negotiation of entrepreneur status

In the business management system, medical practices are service companies, as opposed to production companies. In this context, the term “entrepreneurial practice management” refers to the systematic use of validated methods, instruments and behaviours in GP and specialist practices, which, taking into account the practice’s objectives, are both sustainable and flexible.

The best possible quality of medical care for patients,
a balanced and motivating quality of work for doctors and medical assistants and
ensure economic success.

This form of practice management is geared towards always acting proactively and successfully in the multi-layered events of the healthcare system with all its uncertainties – and not just reacting passively without greater freedom of decision. However, very few doctors adapt the entrepreneurial role for themselves and utilise the tools.

Low willingness to change

“We’ve always done it this way.” is a belief that characterises the German medical profession. This is also reflected in the results of employee surveys, in which medical assistants complain that their practice managers hardly respond to their suggestions for improvement and requests for change. A further indication is the fact that in most practices, the management has not been adapted or has only been adapted slightly since the foundation, takeover or co-operation.

4 Symptoms

The first symptoms of PMI appear gradually at the beginning in the form of anger, stress and dissatisfaction, both within the team and on the part of practice visitors. They are usually attributed to individual work situations, but increase significantly in intensity as they progress.The main symptoms of PMI are

Permanent lack of time
Frequent overtime
Increasing work pressure
An increasing error rate
Dissatisfied patients
Conflicts within the practice team
Demotivation.

There are also asymptomatic courses that are caused by hidden risk factors and only become effective in the medium to long term, but then suddenly.

5 Degrees of PMI

Based on the descriptions of doctors and medical assistants as well as patients and – in the case of specialist practices – referring physicians, PMI can be roughly divided into four PMI grades:

PMI grade I

Practice teams report no major problems occurring during their work, but there are risk factors that have not yet materialised.

PMI grade II

Doctors and employees are continuously exposed to recurring problems in their work. However, they are not yet perceived as very serious and only affect the quality of work to a lesser extent.

PMI Grade III

Practice management is characterised by a large number of daily problems which, when combined, have a lasting and noticeable effect on the quality of work, the practice team itself and the patients. The working atmosphere is characterised by alternating intensities of hectic and stress, the first patients complain, some work remains unfinished.

PMI grade IV

Practice teams are barely able to cope with the daily workload. There is a lot of overtime, patients are constantly leaving, and the number of new patients is disproportionately low.

6 PMI and its consequences for medical practices

The type and intensity of the effects of PMI vary from practice to practice depending on the respective causes and their manifestations, but the following five general consequences are the most common:

Patient care and support is worse than it could actually be, because the medical service does not fully benefit patients. For example, doctors who are under time pressure interrupt their patients’ descriptions of symptoms after just a few seconds and make decisions without knowing all the facts. In addition, there are information and communication deficits in co-operation with other service providers.
The team’s workload is greater than necessary, they work long hours, but the work results are below average in comparison, as the work cannot be managed. The efficiency and productivity of the practice team are reduced, creating a hamster wheel effect. Over time, staff develop mechanisms to deal with PMI and its consequences, but these ad hoc adjustments do not solve the underlying problems. In some cases, they even exacerbate the negative effects of PMI.
PMI generally restricts the performance and development opportunities of a practice, as important activities are neglected because there is no time for them (e.g. qualification of medical assistants, implementation of necessary changes, etc.), flexibility and responsiveness decrease, as does work motivation.
The assessment of the practice’s performance is deteriorating due to gradually increasing patient dissatisfaction, and the willingness to recommend the practice to others is also declining.
The practice result does not correspond to the possibilities.

7 The prevalence of PMI

Approximately 2/3 of German medical practices are affected by PMI to varying extents and degrees. This large number results from the fact that GPs and specialists do not utilise on average 50% of the precautions necessary for a smoothly functioning practice.

8 Diagnostics and therapy

The central problem for GPs and specialists is therefore primarily that “practice management” is a conglomerate of many different areas of action that are closely interlinked and to a large extent mutually dependent and influence each other. Only when these areas – from planning, patient management, leadership and organisation to marketing, market research and controlling – interlock like finely tuned cogwheels can management excellence be achieved.On a positive note, it should be noted in this context that most misalignments – once they have been recognised – can be rectified independently without outside help. The problem is therefore not the specific optimisation, but the identification of the causes of insufficiency.

Classical solutions only help to a limited extent

In this context, applying the tips, tricks and advice that are made available to practice owners from various sources does not lead to a noticeable change in their work, as this can only be achieved holistically, as described above.

Seminars sometimes impart knowledge on one or more of these interdependencies, but the content inevitably follows the principle of “one-size-fits-all”, so that the participating doctors – when they return to their practices – may have extended knowledge, but still have no plan for concrete action.The last option is to call in consultants, but a complete analysis of practice management is too expensive for many doctors and consultants are usually specialised in individual aspects of practice management, meaning that they cannot provide a 360-degree view.

Back to the beginning

A general practitioner or specialist who wants to improve, develop or reorganise their practice management in the context of their goals or simply improve their practice results first needs a status description of their work.

The concept of key performance indicators (KPI) is particularly suitable for this, as it

solves the aforementioned problem of the complexity of practice management by generating reference values,
offers the opportunity to determine the current state of practice management without a great deal of effort and
At the same time, strengths as well as deficits and unutilised opportunities and risk factors are identified.

The results of this initial analysis can be used to define specific target parameters for the practice’s work, which can then be monitored and controlled in a simple but comprehensive manner by means of follow-up analyses.

How the indicators are created

KPIs are parameters that are created by comparing the practice management data of a medical practice with objective and representative measurement parameters. For this purpose, a structured analysis is first used to describe the organisation of the practice management and make it quantifiable by means of scaling in the subsequent evaluation. In this way, not only the type and intensity of the regulations used for practice management are recorded, but also their effects, creating a kind of X-ray image of the practice’s work.

Insights through benchmarking

This data is then subjected to best practice and specialist group benchmarking. The best practice comparison shows whether all regulations, instruments and behaviours that ensure smooth practice operations have actually been implemented. The specialist group ratio provides additional information on the extent to which the analysed practice management meets the minimum market standard. The KPIs determined

results in a detailed status overview of the strengths, weaknesses, threats and opportunities of the analysed practice with a detailed action plan for improvements, changes and developments.
Individual practice management development goals can be created on the basis of the practice strategy and monitored with regard to progress in implementation.

A KPI status report thus corresponds to a balanced scorecard for practice management.

KPIs open up options

On the basis of a KPI status report and the associated action plan, practice owners are able to decide whether they want to implement the listed proposals themselves with their teams or call on external help. In the second case, the prior preparation of the balanced scorecard leads to significant cost savings, as the consulting objective can be precisely narrowed down and defined for external parties.

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