Table 4 Strategies of primary care teams for management of crises and selected representative citations

a) Crisis prevention

 Building awareness

B being informed about what might occur in the individual practice and be connected with warning systems such as local warning apps was named to increase awareness. Also, participating at different trainings about diseases, climate change impacts, or specifications (like care assistants or study nurses) were named as possible approaches

“In my opinion it is […] just as [other focus group participant] has already said: the practice must develop further and […] that we have to begin to develop strategies for ourselves so that we do not come unprepared in similar situations.” (SP1_FG_1)

 Gaining knowledge

Together with increasing awareness, gaining specific information about possible crisis situations and transmitting this knowledge to all team members was named as way to prepare for a crisis

“So, I think what has definitely helped us every time and also works is […] an early recognition and a sensitivity, there is something right now or there is something coming up, that could become of interest.” (SP1_FG_2)

 Planning scenarios

It was recommended that all practices define possible upcoming crises and plan different scenarios that might occur. For each scenario, a concrete action plan should be prepared. Some participants described to rehearse those scenarios and action plans to feel safe and evaluate feasibility of the action plans

“Good preparation. > laughs < Prophylaxis is everything, prevention is very important – anticipating as well – ideally, anticipate what could happen, and then be prepared for it.” (SP1_Int_23)

 Providing resources (staff)

Providing an adequate number of staff was seen as one of the most relevant aspects of crisis prevention. For this, working conditions should be improved to keep fluctuation rates low and avoid open job offers. Supporting this, trainees and internships were mentioned as helpful and “cheap workforce”. Training all employees to be able to roughly manage other team positions can help if an acute replacement is needed. Also, a pool of staff that is shared with other practices or within a joint practice is seen as beneficial. For the participants it was important that external staff already knew the practice in advance to avoid initial training during a crisis

“And you’re not crisis-resistant if you […] don’t have enough qualified staff, aren’t you?” (SP1_Int_22)

 Providing resources (material)

It was recommended that a practice includes enough storage space, just in case something has to be stored within a crisis. On top of that, it was asked by some participants that all practices always have a back-up in their most used items such as gloves, face masks, disinfectant, frequently used medication and medical devices

“[…] we then have really procured this personal protective equipment ourselves […] in a manageable amount – we were not a huge practice, but rather a medium-sized practice – but that we had such a basic equipment of these materials, we have stored in the practice and could then fall back on it in a new case […].” (SP1_Int_23)

 Providing resources (financial)

As crises were often linked with a financial burden for the practice, providing financial security for a certain time with no income was named as an important coping strategy

“[…] that was a period of four weeks, then the bosses fortunately still had some financial reserves for us and our salary and then we could bridge that.” (SP1_Int_03)

 Quality management

The overall conduction of quality management in practices as their participation in quality circles was seen as one way to improve organizational resilience already

"Well, I think what can definitely help a practice in such situations is quality management.” (SP1_FG1)

b) Individual resilience

 Satisfaction at work

Participants expressed their need for supporting their own mental health and satisfaction at work through a good and appreciative management, through inclusion of their mental health status and feelings in the communication within the practice team and, through creating a healthy working environment

“Well, I would tell the physicians: keep your team together. […] Have keen senses, ask how they are doing and take them on board, the medical assistants, because they are on the front line and they have to communicate and lead and organize. And I think that’s where a lot of people are stuck or there’s a lot of potential for errors or crisis potential.” (SP1_Int_17)

 Beneficial characteristics of individuals

As beneficial characteristics of individuals, the following personal qualities were named: creativity, flexibility, adaptability, openness, curiosity, personal commitment, working experience (in particular: knowing your patients for a long time), active confrontation with the crisis, seeing the crisis as a chance, staying and acting calm, keeping a distance to the crisis, self-protection. In this context, participants mentioned that a practice has to know and accept its limits:

„[…] and perhaps also to admit: we can’t accomplish everything. So (that you) have to admit to yourself as a practice, with our resources we can’t manage to vaccinate all the people who want it immediately. I1: Why do you think it is important to admit that? Int_2: Because otherwise it is a constant overload.“ (SP1_Int_2)

Individual attitude towards crises

Especially younger medical staff was rated to be less resilient than older staff. Two participants based this on the assumption that those persons were raised differently, in a “softer” way than themselves. Additionally, it was described, that especially physicians were likely to see crises as something positive and even tend to be happy when a crisis occurs:

“[…] but then doctors, well (…) they also find it kind of chic, a bit of a crisis… then it finally tingles in the stomach again.” (SP1_Int_12)

c) Team work

 Team meetings

As one of the most important strategies to cope with a crisis successfully, team meetings were named by all participants. Team meetings were described to be necessary in the regular patient care and needed to be held more frequently during a crisis (e.g. weekly or daily depending on how quickly a crisis situation is changing). To achieve a good team communication, it was seen as necessary to consider emotional aspects and the mental health state of the team members as well as the allocation of tasks and responsibilities during a crisis. Furthermore, all team members should have the same level of information about the crisis

"Certainly, communication within the team […]? It is clear, that the flow of information must be guaranteed, that there is clarity and that everyone is informed: what is the matter, what is the significance, what are the consequences and where do we have to set other priorities under certain circumstances?” (SP1_Int_23)

 Different levels of education

It was important for the participants to be aware of different levels of education within the team (physicians vs. medical assistants) and provide transparent and comprehensible information for all

“And what is also important, is that the employees come from different areas, for example there were some who are really close to the patients […], then also some from the administrative area […] a colorful mixture, so that everyone can really give his or her input.” (SP1_FG2)

 Atmosphere within the team

A constructive error management, diversity within the team (e.g. languages and nationalities, education level, specifications, age), and a good team atmosphere in general were also identified as beneficial. For a good team resilience, it was observed to be crucial to have a feeling of “moving in the same direction” (German “am selben Strang ziehen”)

“We need this wide range of people, we need young people, we need old people, and everyone has his or her right to exist. So, we also need a colleague who maybe knows another language […].” (SP1_Int_21)

 Leadership style

To support a beneficial team work, a good practice management with an officially trained manager was seen as crucial. Low hierarchies and delegation of tasks was welcomed by the participants but at the same time, the practice manager should not give the feeling of pulling himself back. If a conflict occurred within the team, the consultation of an external and neutral person was asked

Interviewer question: “Is there anything else you would say a medical practice needs to be more successful in dealing with a crisis?” Interviewee’s answer: “A good boss. > laughs < A good boss who really backs the team.” (SP1_Int_11)

d) Practice procedures

 Detection of crises and information acquisition

First, early detection of the crisis situation and immediate analysis of the occurring problem were described. After this, gaining information about the specific situation or problem and always stay up to date with the changing environment were named. Additionally, it was important that all information was shared within the team

"Well, I think it just needs a lot more awareness and information […] what could happen to us, which we perhaps have not even considered yet." (SP1_FG_1)

 Action plan

Another important strategy was to use existing action plans and, if no action plan was present, create an individual action plan. Within these action plans, all relevant steps, tasks, responsibilities and, if necessary, contact information of relevant institutes or persons needed to be included. Furthermore, the respective action plan needed to be feasible for the realisation within the individual practice environment. To respond to a crisis, this respective action plan needed to be implemented step by step to achieve structured and sensible proceeding. Especially during the covid-19 pandemic, this was seen as difficult due to a lack of consistent information and hardly feasible action plans for German practices

“There are plans how we are to behave, if it comes somehow to pandemic symptoms. Exactly, this already exists now and has also been established in our practice. And yes, you can orientate a bit on that […] Well, that’s a manual […] where things are simply laid down how you should behave […].” (SP1_Int_09)

 Adaption to mental and physical health of staff

As the crises usually implied a higher workload for the practice team, spending overtime hours, cancelling vacation time, increasing working time of part-time staff, or giving staff a time out to protect their health were named as strategies. For this, it was seen as crucial to adapt the specific strategy to the mental and physical health of the individuals. Another strategy to support resilience of a practice was to provide periodically reflection/evaluation sessions with all team members. “What went well? What didn’t? And what needs to be changed for the next step?” were important questions, the teams were discussing. This can be linked to the team meetings and should be part of the error management

“[…] and also to recognize who is reaching his or her limits. We have a doctor […] who also reached her limits because she worked more, and she then got two days off in between. […] I think motivation is very important.”

 Pro-active approach and immediate action

In general, a pro-active approach and immediate action was seen as beneficial in responding to a crisis successfully. Some participants described that their practice managers have waited too long so that it was more difficult to respond to the crisis, others praised their practice managers if they were acting immediate and were able to catch up the situation or prevent certain problems that became visible in other, non-prepared practices (e.g. buying enough face masks and disinfectant during the covid-19 pandemic)

"[…] whereas what I think has really helped us a lot – regarding our basic attitude and our strategy – is that we have always tried to deal with these issues proactively." (SP1_FG2)

 Networking

Information exchange and networking, not only within the team, but also with other external institutions such as other practices, hospitals, health departments, political or funding institutes (e.g. health insurances, associations of statutory health insurance physicians), professional associations, local authorities, nursing homes, pharmacies, disaster control authorities, and similar are rated as crucial to build resilience. In this context, exchanging information and experiences with the implementation of coping strategies (f.e. via E-Mail, Whats-App, personal meetings, online meetings, quality circles) or the exchange of resources (like staff or medical devices) was described as helpful

“I think what is helpful in such ordinary everyday crises or also when it’s about business-threatening issues and so on, […] or also in the doctors’ network, is, yes, to reveal yourself to others, to talk about things, to ask for help, to ask others how they are doing. Have you ever had the same thing? I am in a certain situation, I can’t get out of it. Well, not to look for facts in the first place, but to identify where I can get support quickly and easily?” (SP1_FG1)

 Changes in practice procedures

First, prioritizing of tasks and patients’ needs was named as a possibility to allocate resources efficiently. Second, changes in managing patient flows included the separation of infectious patients from non-infectious patients (especially within the covid-19 pandemic) and implementing specific consultation hours just for potentially infectious patients was named by almost all participants. Together with this, the participants described that they have implemented the need for patients to call and make an appointment before coming into the practice. Most participants rated this change as highly beneficial and wanted to stay with this in the future. Some participants described that they implemented other, specific time slots within their practice like a time slot for processing prescriptions, slots for vaccination, and other. It was also of importance to not plan workflows too tight so that they will include enough time to deal with unexpected issues

"These are all very big and very urgent things that have to happen quickly, but we can’t react to everything, we have to set hierarchies, prioritizations. And, above all, we have to make sure that we can work as a team." (SP1_Int_02)

 Communication with patients

Communication with patients needed to be transparent, comprehensible and patient-friendly. It was seen as crucial to provide all information to patients to make them understand certain changes in care provision and catch up their fears and needs adequately. Along with this, management of complaints and periodical patient surveys were named as beneficial. Furthermore, patient compliance was described higher when they were informed. As compliance was described to decrease within longer-lasting crises, communication needed to be “refreshed” periodically. For specific crisis situations that affected certain patient groups (like heat waves), it was necessary to inform those vulnerable groups about the occurring crisis and coping strategies. The following concrete communication strategies were named within the interviews: a homepage with highlighted news and a contact form, contact opportunity via e-mail, a specific telephone hotline, information brochures/flyers, signs, information provided on social media (e.g. Facebook page of the practice) or an action sheet especially for patients

„Well, the more we communicated, the better it worked out, if I’m honest.“ (SP1_Int_05)