What clinics want from the government

23. October 2018

How do hospitals successfully implement lower personnel limits or digitalisation and what assistance do they need with this? The 41st. German Hospital Day is concerned with burning topics for representatives of the inpatient sector.

What do clinics want from the government? And what course does the Federal Ministry of Health take? Already at the beginning of his term of office, Spahn concentrated on the inpatient sector. Under the motto “Hospital policy for better care”, he will open the 41st German Hospital day. His initiatives are the subject of lively discussions among experts.

This also includes the issue of lower personnel limits. This has long been on the political agenda, nationwide. Spahn had asked the German Hospital Association (Deutsche Krankenhausgesellschaft – DKG) and the GKV association (Spitzenverband der Gesetzlichen Krankenversicherung) to agree binding figures for areas requiring intensive care, albeit without success. A sufficient supply is, according to Johann Magnus von Stackelberg, deputy chairman of the board of the GKV association, by no means self-evident. “In order for the situation to change in the future, we would have liked to have agreed lower limits for nursing staff with the DKG at the negotiating table and regret the refusal of the DKG Board of Management.” The Minister of Health subsequently intervened by ordinance.

Lower personnel limits: this will change

As of January 2019, binding lower limits will initially apply to intensive care medicine, geriatrics, cardiology and accident surgery. These are provided differently for each area: nurses in intensive care units may care for a maximum of two patients during the day shift. During the night shift this is three patients, even on weekends.

In accident surgery, the ratio is 1:10 (day shift) or 1:20 (night shift) on weekdays and 1:11 (day shift) or 1:21 (night shift) on weekends. For geriatrics, 1:10 (day shift) or 1:24 (night shift) is planned for weekdays. On weekends, the quotas are 1:11 or 1:24. And in cardiology 1:11 (day shift) and 1:24 (night shift) will apply in the future. On weekends the quota is 1:13 or 1:23. Failure to comply with these requirements could result in the clinics being discounted from their remuneration.

Clinics would like to see a more practical implementation of the project. Rigid requirements would not allow people to act in a situation-dependent manner. “The requirements for staffing intensive care units are unrealistically high”, commented DGK President Dr Gerald Gaß. “The lower limits now set by the ministry are at the level required by professional societies for good quality care.” In intensive care units, patients with very different care needs are cared for. “If at least one nurse is prescribed as a rigid norm for every two patients, the treatment capacities in intensive care units will be drastically reduced,” Gaß continues. “Numerous clinics with intensive care units will no longer be able to admit additional patients because they will no longer be able to meet the staff requirements.”

What works in the clinic – and what doesn’t

Which areas in hospitals work well, and which urgently need to be improved? A recently published report of the Institute for Quality Assurance and Transparency in Health Care (IQTIG – Instituts für Qualitätssicherung und Transparenz im Gesundheitswesen) provides answers to these questions. Aspects of quality assurance were examined on behalf of the Federal Joint Committee (G-BA – Gemeinsamen Bundesausschusses). The survey was based on 2.5 million data records from 1,516 clinics. Researchers worked with 242 quality indicators. The indicators are very different and depend on clinical topics. These can be infections after surgery, poorly healing wounds, post-operative length of stay or decubitus in nursing care. IQTIG has published an overview online. Although the list is constantly being expanded, it currently only covers a fraction of all inpatient procedures.

Regarding the results: 182 indicators (67 %) remained unchanged compared to the previous year, a further 45 (17 %) improved significantly and 13 (5 %) deteriorated significantly. Experts found deficits in decubitus prophylaxis in the nursing sector, which strongly indicates bottlenecks in personnel. Experts also see a need for improvement in outpatient acquired pneumonia, in pancreas and pancreas-kidney transplants, in the area of breast surgery, of obstetrics, for hip joint fractures femoral fractures with osteosynthetic care and for treatment with hip endoprostheses.

Gaß is nevertheless euphoric: “Such a result is outstanding when you consider that we treat around 20 million patients in hospital every year. Just as positive is the fact that despite the high level of quality that has been maintained for years, improvements are still being made.”

Billing: More control, more bureaucracy

As far as transparency is concerned, not only IQTIG but also the Federal Audit Office is exerting pressure. According to the Handelsblatt, many health insurance funds voluntarily refrain from examining hospital bills. In return, they receive discounts from the respective hospital on a voluntary basis. “The Federal Audit Office regards special agreements as a violation of the statutory obligation of the health insurance funds to subject certain accounts to an audit,” the Handelsblatt quotes the audit report. “The fact that there are agreements between health insurance funds and hospitals on flat-rate invoice reductions instead of individual audits is an expression of the fact that the entire billing audit procedure is not in order,” commented DKG Managing Director Georg Baum. Hospitals would a priori be in a loser position in audit procedures.

“If 15,000 possible diseases (ICD code) are pressed by 30,000 possible treatment steps (OPS code) in 1,200 flat rate payments per case (DRGs), taking into account six degrees of severity, there is room for complaints in each billing.” With regard to the demand for further audits, Baum says that billing conditions must first be changed so that hospitals “are no longer victims of any auditing and assessment options available to payers”. Spahn clearly stands behind the Federal Audit Office and rates special agreements on discounts as “legally highly critical”. However, the Federal Minister of Health does not seem to be planning any legislative initiatives at present.

Digitisation: Everyone wants more

When it comes to digitisation, the German Hospital Association takes a clear stance. Among other things, the opinion of 2017 speaks of the necessity of a digitisation surcharge, in addition “existing hurdles for telemedical services must be dismantled”, “cross-sector standardisation” and “patient-oriented data protection” are needed. Another wish: “The introduction of IT innovations must be simplified and excessive regulations and complex approval procedures must be abolished.”

Spahn also found plain words for modern technologies in health care: “I am a convinced advocate and want to develop digitisation with you.” With conhIT he admitted that there was a lot of catching up to do. Dr Carla Kriwet, Chief Business Leader for Connected Care and Health Informatics at Philips, sees this similarly: “If you look at the structures and processes in many hospitals, they are essentially the same today as they were 50 years ago,” she told the Handelsblatt. “Patient records on paper, traditional hierarchies, shortcomings in cross-departmental communication, and rising costs.”

The “Hospital study” by Roland Berger shows where possible problems lie. Almost 90% of all managers surveyed said that they had their own in-house digitisation strategies. That’s all well and good, only 91% spent less than 2% of their total budget on modern infrastructure. Only every tenth hospital in the sample had more than 2 %. “In the opinion of the study participants, digitisation in hospitals is desirable, but expensive and time-consuming,” says the report.

But there is a silver lining on the horizon, related to one of the original demands of hospitals. In September, the GKV association and the DKG agreed on framework conditions for financing the agreed telematics infrastructure. For the hardware and for technical adaptations, cash registers will initially make more than 400 million euros available. A further 18 million euros will cover the annual operating costs.

We do some straight talking

Many topics, one conclusion: clinics are facing great challenges. Approximately seven months after the formation of the government, German Hospital Day offers good opportunities to discuss trends for the first time. This also applies to MEDICA, which is taking place simultaneously.

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