Table 1

Determinants of PCC implementation related to the organisational level (inner setting)

Inner setting	Quotes
Strategies
Organisational incentives and rewards	‘We have introduced idea management in which all employees can participate. [description of innovation] is then acknowledged and the employee then receives […] a goodie for participation; it is then assessed in our QM steering committee, the idea and the employee, or if a team participates, they then receive a […] financial compensation’. ‘I mean, we also have some things go wrong, of course, someone or other makes a mistake sometimes here as well; you then go there and say, we made this mistake; we try to limit the consequences, but we handle it openly. […] Then the covering up, denying, etc., starts. I mean, I also used to have employees that exhibited those behaviors, but as I said, I used to have them’. ‘What we cannot do, we cannot evaluate whether the implementation has been successful. We can’t do that. So we can, I say, rather only give incentives and motivate and be supportive in the sense of as long as voluntariness… So if I am person-centered…. As long as they allow this in the organization’.
Learning	‘But the starting point are the cases, and in every quality circle, so every quarter of a year, the patient feedback – this includes not only complaints but positive things as well – it is then presented to us by the complaints officer […]. So they are specific patient assessments’. ‘Again, the patient is ultimately unable to assess that [medical treatment quality]. Rather, it tends to be the softer things. So, were you friendly to people; did the food taste good? Of course, those are also all things that play a much greater role for the patient because the patient can also assess them. So I always kind of claim that a hospital that has great food is popular with patients because the patient then says, well, if they can cook well, the rest will surely work well too’. ‘If an organization has longstanding employees who have not been permanently in learning status or have undergone changes, then they are rigid organizations, then it is difficult to break them open by new employees. They won’t stay either’.
Management of innovations and change	‘So I see the health care sector or the hospital sector as a very conservative sector, so the willingness to do things anew is not very pronounced. So because medicine is certainly also, I say, an experiential science, perhaps it is also connected with it. […] since so many people interact like gears in a machine, it is of course also extremely difficult to turn any adjusting screw without completely getting the overall system out of step. Well, that is. . as an executive director, you have to a little bit resist the temptation of saying, we will just do that now’. ‘[…] this works very well when an innovation promises advantages. So that’s the crucial thing you have to show the employees. have to prove to employees that what you bring to the market is an innovation that ultimately makes everyday life easier’. ‘And that is why change, of course, must be well managed. And it is also quite clear, probably just like in all other professions that young employees are better able to engage in change […]. And there you just have to convince in a completely different way and bring along some solutions so that these people can also be engaged’. ‘My problem is the team members, because they say “you don’t change anything, too”’.
Leadership behaviour and engagement	‘[…] then we are back to the management system again; how do I place people in certain functions and how do I design the tasks so that they can practice person-centeredness as well. Or can do so in their work’. ‘[…] And I find it very important, regardless of vacancy and personnel need, I find the application procedure extremely important. Very, very important. And only because I need someone does not mean that I will take anyone […]. And so I do that in every interview; I tell everyone, think about what is important to you. How would you want to be treated, or what if it was your mother? And to really stay alert with everyone and look’. ‘So because there are very different interests […]. This means that the nursing staff is subject to nursing services. And the doctors to the medical service. This means that the doctor is medically authorized to give instructions, but not with regard to the organization, which makes many processes inefficient. This has now become possible […] so here the head physician also conducts staff interviews with all non-medical staff. And we see ourselves as a team. All in all, this works very well’.
Conflict management	‘When there are conflicts, they must be discussed, but outside of patient care. And of course not in the presence of the patient. We really do not do that here’ . ‘The fact is, we of course have to ensure here that we have our heads clear for our work. And that means that we all [.] are very attentive in dealing with each other, that we do not allow any conflicts to drag on but think in terms of solutions in that area as well. In rapid solutions, that is’.
Process orientation	‘Of course, there are exceptions, but it should also be the case, I think, that this is already a little QM-orientated, of course, the procedures are controlled. Which we also monitor, help guide, and then again evaluate after the fact’. ‘[…] Here […] the issue is to efficiently care for routine patients, consistently at maximum medical quality’. ‘[…] we [doctors and nurses] feel we need more staff. […] the management always says “you must first try this by restructuring”, then also partly foreign management consultancies are brought in […] as an independent company, yes, they look at the processes, then make suggestions to the management as to how they see the moaning at our level is justified, yes or no’. ‘What is relatively rigidly specified, for example, is to keep to certain times. […] but with which elements […] that is then with us’. ‘But the perfect care is going wrong right now. Because we have far too many institutions around the patient that can no longer look at the actual core at all. Too many organizational structures’. ‘You can’t have a checklist on the patient. Because every patient comes completely different. The checklist is a great unit around structures and perfect management of a practice, structure in the case work, […] the structures that are not patient structures are right. So the whole thing around is perfectly organized’.
Resource orientation	‘[…] We have a good rate of skilled employees; we are at, I think, [>65] percent right now […]. That is good. Nevertheless, if I advertise a nursing assistant position because I cannot only hire specialists, because then I do not have enough people because they are more expensive than the assistants. Sure, I have to find a good mix’. ‘Well, here, we always tend to choose medical quality over money here. But if I wanted to run it that profitably, then I could not maintain the medical quality’. ‘Patients are at the center, as well as I understand it now, and everything else is orientated around them. It really isn’t such a small effort, if you consider how many not very inexpensive people then virtually take care of a patient. […] And the whole thing then works where you also focus on certain things, yes, centered or concentrated. And does not claim to treat almost all clinical pictures in the same way with such a complex and complete treatment or to treat patients with these many clinical pictures in this way. […] Beds in the hallways. Yeah? But then you cannot provide adequate care at all with the same resources. That is the same way. Yeah? Then we have to say, either we stop taking more patients’.
Employee retention and satisfaction	‘And to that extent […] you have to also […] consider, well, working conditions you create for employees. And that, too, I would say, leads to, when employees feel comfortable, when they are not rushed, them ideally being able to be patient-oriented in their work or communicating differently with patients’. ‘Anyway, I believe that patient centeredness does not work without employee centeredness. Because especially in a job where you work so closely with people […]. When people are not well, they cannot take good care of patients. And we try to manage that somehow through numerous small and medium-sized measures, whatever we can afford (grins). […] [E]very Monday, there is a fruit basket, for instance. […] And that is a little measure, that does not cost a whole lot, but as far as the responses we get, it is pretty well received’. ‘Of course, the salary is part of that, but this is actually no longer the decisive factor. [.] It is really the team, the reliable off-duty time, can I have that or not? And the less or the more vacancies I have, the harder it becomes to ensure reliable off-duty time, weekends off’.
Add-on services	‘Well, working with family and friends, that simply happens. And this work is important to us, but it is nowhere to be found in the expert opinion to determine the long-term care dependency level; it does not ask whether you constantly have to talk with the wife or whether you have a friend or family member […] all that does not exist at all. But lots of friends and family members do need to talk with us. Whether because of a bad conscience or worries or whatever. That is not reflected anywhere’. ‘In the rooms area, I will say, or everything that has to do with the quality of lodging, all the way to entertainment, well, those are really the hotel components that play a great role too. […] But the patients clearly have hotel-like expectations from the hospital. […] And particularly when patients are feeling better, when the level of suffering recedes, the hotel-like expectations are there, and that I believe is something that patients would clearly perceive as patient orientation too because these topics, if you look at [Hospital assessments website] or things like that, very often are, well. . [the] medicine is assumed to be OK’.
Structures
Staffing and workload	‘[…] we are always fully staffed to our nurse-to-patient ratios. And it is still always tight. A week like this, where five are sick, that is extremely high; we do not have a high illness rate. […] Then I am truly almost at my wit’s end […] As long as no staff is added, no new clients, no new individuals in need of care can be admitted’. ‘That gives you an idea of how many residents are being cared for by one caregiver. And this inevitably often already really leads to an assembly line care’. ‘This means that the number of employees depends on the number of patients. And there is just a staff index, if it is overfilled it is nice for the patient, bad for us, because we don’t get paid’.
Technical infrastructure
Equipment	‘Or someone comes in from the hospital and suddenly requires oxygen. And stands here without an oxygen unit. But I don’t have something like that sitting in the basement’. ‘I also work with flip charts, still. Gladly. Because I noticed that what you can see is quite different to what is merely said. Patients take pictures of it, or sometimes, they take the flip chart paper with them. Yeah. So there are quite a few things. I work with chairs or with postcards, with cuddly toys, with drawing, with stones. So with everything that makes it more tangible. And somehow helps to translate the words and make them palpable’.
(Health) Information technology	‘When referring a patient from A to B […], well, when someone comes from the outside […], I would say, we physicians in Germany mostly communicate by letter or by fax. The fax is truly still the standard. And I find that so creepy’. ‘When we have generated the nursing plan, this standardized nursing plan, which we of course individually complete with the needs of the guest, we add measures here […]. [W]e use IT-supported documentation here so that we can go to the various levels at any time […], in each shift, whether the early shift, late shift, or night shift, ultimately to have reminders of what is to be done now’.
Rooms and buildings	‘It is a little cramped here (laughing) for some exercises I do. But I am lucky in that my colleague toward the front of the building has a larger room. Right? Right. So there are solutions for that’. ‘We then tried by means of the TVs you saw in the waiting rooms, by offering drinks […] To try, although you cannot directly reduce the waiting time, to make it as tolerable as possible. That works to some extent, and to some extent it does not’. ‘We mostly have double-occupancy rooms. We do not have bathrooms in the rooms but have to take the respective measures […] across the hallways to the showers and such. So in terms of the […] environment, this is really not ideal’.
Processes
Continuity of care	‘This means that we try to manage in terms of the duty roster in such a way that the next days of the same shift, the same staff member always sees the resident. So that the resident does not constantly… . he already has to get used to the early shift, late shift, night shift, to different faces. But to ensure that, if possible, the same staff member goes in’. ‘[…] most of them […] know that they get all-round care here […] that we take care of patients even after discharge; they then come to us again for outpatient wound checks, for consultations. Of course, that is very time-intensive, and it costs the management more than if they were sent away immediately afterward, but that is what patients applaud here and why they like to come here’. ‘I believe that many patients benefit from having someone to look after them over a longer period of time. Especially since many patients also have many psychosomatic problems. I think it is important to stay in touch and not always cover all sorts of things directly with examinations’.
Timeliness of care	‘Professional competencies [have] specified that within 24 hours, a corresponding, adequate medical device must be available […]. That means you have to submit an application to get this alternating pressure mattress. Then the person responsible for the budget has to check if that is in the budget or not, OK? Then I might have to ask the management board. In the meantime, the user who actually needs it has developed a skin injury’. ‘This means that we are pleased that we have visits twice a week and that the laws ensure that if you have SAPV, cooperation, you can reach a doctor 24 hours a day. And that is of course also the case here. And the residents benefit from this because as soon as the condition or symptoms change, we can react immediately and very quickly’. ‘It is simply illogical for me, if there is an insurance card, why not let the card be given and send the patient directly to a treatment room. […] And then you can say “thank you for the card, you get it right back, now go to the treatment room”, it doesn’t matter whether he is Roman Catholic and whether he signs the treatment contract […] at the moment. We want the patient to be well. The patient, he is in pain’.
Flexibility	‘We have a very young man with [neurodegenerative disease]. […] Very advanced already. For him, I need completely different services than for an 85-year-old who was a wife and mother […]. They are worlds apart. And I find that totally important, and it is our job to see who needs what’. ‘[…] what else is really important is that depending on the way the individual feels that day, you can also respond to changing needs, right? That you don’t say, well, you get a partial bath five times a week and a complete bath once a week, and on that one day, the person does not want to or cannot get into the bathtub or shower, and, well, how do you respond then, right?’
Formal communication	‘We do case conferences regarding the residents. We say, there is a problem, or a resident has a wish, how can we respond to it? The social support service participates in team discussions’. ‘And the aim is basically to present pretty much every patient to the tumor board once […] to obtain a recommendation that is based not on the opinion of only one physician but on the opinion of many’. ‘The one in the back must know what the one in front is doing. Either through continuous communication, or as we have just done, through communication via computer. It says: the patient is there, you have to call there immediately, please pay attention to this or if someone is in a bad way. And also on call. Some kind of emergency. A pick-up and drop-off service is organized. The patient is […] transferred to the ward. In my time, […] we went down to the intensive care unit as a team of doctors and nurses, […], the doctor spoke with the doctor, the nurses with the nurse, we exchanged, we exchanged crosswise […]. […] a transport service […] has no exchange at all. This means that one must orientate oneself according to the file situation, documented file situation. How much more work, how much more time and how much more insufficient is this?’
Informal communication	‘[…] those are actually short paths […] [Y]ou talk to each other a lot, you do a lot unofficially too, that can have advantages and disadvantages […]. You just call your colleague; well, for QM, a lot of what we do may not be official enough, but (laughing) on the other hand, it is also very effective, rather than always sticking to these, well, otherwise regulated pathways’. ‘Well another obstacle is certainly, of course, the hierarchy at the hospital, which is, of course, extremely pronounced in comparison with other sectors. That is changing to some extent. But it certainly through […] separate departmental structures […] and the collaboration between the three professional groups in the hospital’.
Culture and climate	‘The patient feels whether it harmonizes and functions in a practice or not immediately. These are looks, this is the tension, this is the vibration in a practice, the patient immediately notices this. […] And the moment he opens the door, the radar is on, “is everything is okay here, can I stay here, am I really in a good care here”. And when the patient feels tension, in a hospital, in a practice, and realizes that they are already grumbling at each other, the fear is actually already there for the patient, well, if they are already yelling at each other here, “where am I? I hope I get out of here all right”’. ‘Well, for me, that has a lot to do with values as well. And I think that due to the fact that we are an enterprise serving ideological ends and are affiliated with enterprises purely serving ideological ends, we do encounter different attitudes, among staff members too […] I do experience great willingness too. In the general setting, to really commit to focusing on the patient’. ‘And the rest is really cultivated and also lived corporate culture, simply to say that there is a good spirit here’. ‘Because here in a manageably large house a relatively good togetherness prevails, this usually also succeeds, I say, to get people into this mainstream somewhere’.

PCC, patient-centred care.