An award for attractive doctors
Working conditions in hospitals as a tool against the shortage of doctors - results of a pilot study

One of the main reasons why many doctors turn away from medical care in Germany is proven to be poor working conditions with an unsatisfactory work-life balance, systematically excessive workloads and long and inflexible working hours (Via medici 2006). On the one hand, these result from the shortage per se (unfilled positions lead to overloading of compensating positions) but on the other hand, they can also be seen as a lasting consequence of the 80s and 90s. During that time of the “doctor glut”, a high workload for doctors was accepted because the job offer was very limited and the demand for jobs was high. Related violations of labor law or the Working Hours Act were and are often not reported or punished today (dpa 2017; Via medici 2014; Peters 2013). However, the high workload is not only caused by medical activities per se, but also increasingly by the increasing bureaucratization of the profession. In a physician survey from 2010, more than 50% of the physicians surveyed said that they use more than a quarter of their daily planned working time for administrative activities (IQME 2011). Since there were sufficient financial and human resources available during the “doctor glut,” in the past only limited emphasis was placed on efficiency or optimizing structures and processes. While the structural and process deficits partially remained, personnel and economic resources continuously decreased, so that this constellation can be viewed as the cause of the current workload. However, this also means that there is still immense potential for increasing efficiency in these structures and processes. There are wards and hospitals in which activities that can be delegated to non-medical staff, such as taking blood samples or organizing documents, continue to be carried out by medical staff.

>> In the near future, a further worsening of the shortage of medical workers is to be expected, as on the one hand the need is constantly increasing due to demographic change and the associated older and more morbid patient population, and on the other hand it is due to the increased importance of the work-life balance Demand for flexible working hours and part-time opportunities may lead to a further shortage.
Intense competition for young talent
As a result of the prevailing shortage of doctors, there is now strong competition for young talent. Most hospitals indicate in surveys that there are problems filling new positions (Meißner/Osterloh 2012). The significance of the deficiency varies greatly from region to region and from subject to subject. Some hospitals are trying to counteract this by hiring international medical staff (Bouncken et al. 2013).
Unfilled positions can pose a serious risk to hospitals. Since the number of patients usually remains constant when positions are unfilled or difficult to fill in the long term, there is an additional expense per medical employee, which makes the hospital in question even more unattractive as an employer. Better qualified employees with alternative offers leave the company due to poorer conditions or choose more attractive jobs during the application process. The less qualified or less flexible candidates are retained. This can cause a downward spiral that has a potentially significant negative impact on the quality of care and, in the long term, the hospital's economic situation. In 2010, Blum showed the negative influence of perceived poor working conditions on job filling problems for workload and working time organization (see Fig. 1).
Given the problems and risks presented, some employers are already trying to make working conditions more attractive. Changes that were once hardly thought possible are being introduced, such as more flexible working hours, overtime is reduced and paid through process optimization, above-standard remuneration is offered, more attractive service models are used, part-time positions are increasingly promoted and further training opportunities are expanded. However, these developments have so far been unstructured and not widespread.
Recording of working conditions and
Employee satisfaction
For hospitals with attractive working conditions and high employee satisfaction, the question arises as to how this information can be made transparent and communicated to the outside world. One possibility for this could be an award for attractive working conditions and high employee satisfaction, which is awarded after an external audit.
A methodology for recording the working conditions and employee satisfaction that makes such an award possible, as well as its application in a pilot study, is presented in this article. The aim of the testing methodology is to determine employee satisfaction and the working conditions for medical hospital staff in a largely standardized manner. An award can be given if working conditions are attractive and employee satisfaction is high. For this it is necessary to set the minimum requirements for the award. The working conditions and employee satisfaction of the hospitals or departments should be able to be compared objectively. It is known that working conditions and employee satisfaction in hospitals can vary greatly between individual departments. Therefore, testing should be possible on a departmental basis.
Examination methodology
Multidimensional concept of employee satisfaction and work facets
First, employee satisfaction was operationalized. For this purpose, the audit methodology draws on the multidimensional concept of employee satisfaction, which has already been established in several studies in work and organizational psychology (cf. Felfe 2006). The concept enables the specific investigation of the work facets corresponding to the dimensions.
The concept was adapted to the medical environment with definition of the work facets. To identify all relevant work facets, existing instruments for job satisfaction in general were taken into account, such as the “Job Satisfactory Survey” by Spector (Spector 1997) or the “Job Description Sheet” by Neuberger/Allerbeck (Neuberger/Allerbeck 1978). From this, working time organization, working atmosphere, leadership culture, compensation and further development were identified as relevant work facets. Literature was also taken into account that specifically deals with employee satisfaction among medical staff (cf. Kaiser 2005; Blum/Löffert 2010; Schmidt et al. 2011; Buxel 2012; Meißner/Osterloh 2012; MB-Monitor 2015, 2017). The following additional work facets were identified: fulfillment in the job, self-determination, fairness, appreciation and time for patients. All ten work facets identified and used in the audit methodology are presented in Table 1.
Instruments of the audit methodology and procedure
Four instruments were included for data collection: employee survey, department management self-assessment, department key performance indicators and audit.

Employee survey
The goals of the employee survey are to survey employee satisfaction, the individual work facets and to identify the optimization potential and design ideas from the employee's perspective (bottom-up). When designing the survey, items from existing questionnaires “Questionnaire for Work Analysis” (Frieling 1978) and “Instrument for Stress-Related Work Analysis” (Keller et al. 2013) were adopted and supplemented. The survey also contains items on organization, personnel and infrastructure. The employee survey is anonymous and takes place online. Processing for employees takes 15-25 minutes. The items are answered primarily using an agreement scale with a four-point response scale (Likert scale). The survey also contains items with free text as well as other items in which the respondents can indicate the personal importance of the individual work facets.
In a pretest, 23 hospital doctors were invited to the survey, 16 of whom (70%) took part in the survey. The reported processing time was around 20 minutes. Technically no problems were recorded. There were few abstentions at 4.1% (75 out of a total of 1,840 answers), which indicates that the items asked are understandable and that the respondents have an opinion on them and want to share them.

Self-assessment by the department head
The self-assessment of the department heads serves to find out what importance the individual work facets have in the department. It should be explained here whether the tested work facets are anchored in strategies, mission statements, etc. and whether measures or concepts exist regarding the work facets (e.g. a further training concept).

Department metrics
The key figures asked cover the subject areas of department structure, personnel structure and development, time management, workflow and compensation. Examples of the key figures collected are the fluctuation rate in the department, training days approved or taken and the drop-out rate (proportion of employees who start the position during specialist training and leave the position before the end of specialist training). It should be noted that employee satisfaction does not necessarily correlate with a single key figure, but with the construct of several of them.

Audit
The aim of the one-day audit is to verify the information obtained so far from the employee survey and employer information (self-assessment and key figures). This happens in semi-standardized interviews in which employees are specifically questioned. The items are largely formulated after receiving information from the employee survey and employer information before the audit. In addition, the workplaces are inspected and assessed according to suitability, atmosphere and ergonomics.

Evaluation of the information
The information collected is evaluated in two dimensions. On the one hand, a total of up to 100 points are awarded for all sections according to a scoring system. Up to 55 points are awarded for the employee survey, up to 25 for the employer information and up to 20 for the audit. Points may also be deducted from the audit if positive statements cannot be verified. Furthermore, the work facets are evaluated individually. For this purpose, all information relating to the respective work facet is taken into account. The items from the employee survey and the audit are given different weightings when evaluating a work facet. In addition, a standardized upward correction can be made using the key figures from the employer's information. At the end of the evaluation, each work facet is given a rating on a scale from 1 to 10, where 10 reflects the best rating, 1 the worst rating and 5.5 means a neutral rating. In addition, the work facets are subsumed and displayed in a department attractiveness diagram.
The minimum requirement for receiving the award was a minimum score of 60 points and an assessment of all individual work facets of at least 5.5/10. The rationale for this is that, based on the multidimensional construct of employee satisfaction, it is not the best-perceived influencing factors that determine satisfaction, but rather the worst-perceived factors. An influencing factor that is perceived as bad can significantly reduce the feeling of satisfaction.
Pilot study
Study site
The audit methodology developed was carried out in a hospital department in a city with approximately 120,000 inhabitants. At the time of the study, the department had 20 medical staff, 37 normal ward beds and 14 monitoring ward beds. The department is integrated into an academic teaching hospital with a focus on care with around 500 beds, 16 clinics and around 1,300 employees. 24,000 patients are treated every year.
Results
feasibility
The testing methodology was shown to be feasible in the pilot study. The information collection, processing and evaluation were possible without any problems. According to the specified minimum requirements for the awarding of an award, an award is not possible in the department examined here.

Employee satisfaction
Around 93% of employees answered the item “I am satisfied with my job” with “true” or “somewhat true”. General employee satisfaction was rated at 6.8 according to the available standardized methodology. 93% of employees also stated that they would like to stay with the employer in the next few years. The alarm items asked (items that indicate a great need for action) show that 29% of those surveyed often think about changing jobs, 0% actively pursue a job change and 14% often think about quitting medical practice due to dissatisfaction.
Overall, the department achieved 61 points. The survey was awarded 34 points, the employer information 15 and the audit 12 points. The developed concept for further training of medical staff in specialist training was also positively received in the evaluation. Information about this concept was taken from the self-assessment and the free-text questions in the employee survey and verified in the audit. The regular use of longer-term employment contracts was also rated positively. Another positive factor in the evaluation was that the training opportunities were explicitly mentioned positively several times in the free text information. The awarding of points from the key figures was based on existing electronic working time documentation, a low fluctuation rate (< 10 %), a low drop-out rate (< 15 %) and the existing medical assistance from non-medical staff. The rooms proved to be suitable and ergonomic. There were no deductions in the awarding of points because there were no contradictions in the audit and the information already obtained could be verified.

Work facets
When employees prioritized the work facets, the working atmosphere and working time organization were found to be the most important work facets, while self-determination and remuneration were stated to be the comparatively least important work facets. The work facets were evaluated according to the standardized methodology. With a rating of 7.6, leadership culture was the best-rated work facet, followed by appreciation (7.4) and work atmosphere and fairness (6.8 each). The individual work facets were subsumed into a user-friendly department attractiveness diagram (Fig. 2) showing the ratings of employee satisfaction, leadership culture, working conditions, further development and work-life balance.
With the prioritization of the work facets by the employees on the one hand and the individual assessments of the work facets in the methodology on the other hand, it is possible to identify weaknesses. These are the poorly rated work facets that are at the same time given high priority. In the department examined, the organization of working hours proved to be a weakness. The rating was relatively low at 5.7 and at the same time it was cited by employees as the second most important work facet.
Effects of an award for attractive medical working conditions in hospitals
Improvement of working conditions
In an era of skilled labor shortages, working conditions have already improved. Doctors in hospitals are currently assessing their working conditions better than they did years ago. While in a Marburger Bund survey in 2010, 42% of respondents reported their working conditions as “bad” or “very bad”, in 2017 there were only 24% (IQME 2011; Marburger Bund 2017).
Against the background of the shortage of doctors and the growing awareness of the importance of workplace attractiveness, an award for attractive working conditions and high employee satisfaction can be an ideal instrument for hospitals to survive in the competition for skilled workers. Such an award represents an incentive to improve working conditions due to the competitive advantage it offers. With such an award, hospitals can meet the demands of the younger, self-confident generation of doctors for improved working conditions and retain the talents from this generation. The award increases the scope of the improved working conditions and not only reaches the employees who are already employed. It enables hospitals to communicate attractive working conditions to the outside world without any additional effort, so that the number and quality of applicants is likely to increase significantly. For example, the department attractiveness chart can be used for publicity in job advertisements and on the hospital's website.
In addition to the expected improvement in working conditions for medical hospital staff resulting from the incentive effect of such an award, a direct improvement in working conditions is also likely. The established concept of multidimensional employee satisfaction used in the audit methodology allows strengths and weaknesses in employee orientation to be identified and measures to be derived from this. In addition, employees have the opportunity to formulate concrete suggestions for improvement using suitable free text items in the employee questionnaire and the audit in the interview. By weighting the work facets by employees, employers can also assess the need for action to improve individual work facets. Simply taking part in an employee survey can have a positive impact on employee satisfaction if they feel that the employer values their opinion.

Employee orientation in the current economic pressure
Hospitals in Germany are under increasing economic pressure. While hospitals have experienced optimization in many areas in recent years (for example in the areas of performance and coding processes), the potential for optimization of the important success factor of employee satisfaction and loyalty in German hospitals still appears to be very high. Given the shortage of skilled workers and the need to tap all potential for optimization, employee orientation and retention are becoming increasingly important. It is essential for hospitals to identify the inefficient processes and structures that lead to employee dissatisfaction, as dissatisfaction leads to lower productivity.
The connection between employee motivation and company success has already been examined in companies in various economic sectors. A distinction was made between companies with high (upper 25%) versus low (lower 25%) employee commitment. Companies with high employee engagement experienced 21% higher productivity and 22% higher profitability. There were also 48% fewer safety incidents in companies with high employee engagement (Sorenson 2013). It is also conceivable that increased acceptance of the hospital through good working conditions for the medical staff leads to an increased willingness to support the hospital among donors and sponsors. The explanation for such a positive effect on the increasingly important source of financing, fundraising, is the ability to influence funding behavior through a positive image of the hospital. An externally communicated award of attractive working conditions can further strengthen this effect.
Another approach for assessing the economic viability of employee orientation is the conflict cost model, in which costs due to frictional losses such as employee fluctuation, but also counterproductive or company-damaging behavior by employees are examined (Insam 2009). If employee satisfaction is low, there is a higher potential for conflict. These costs can be reduced through conflict resolution. The prevailing economic pressure should therefore not serve as an argument against, but rather as an argument for strengthening the importance of employee orientation and satisfaction in the healthcare system. Measures to increase employee satisfaction should be viewed as investments.
Ensuring medical care
The current trend towards greater demand and a simultaneous shortage of medical professionals makes decisive, sustainable countermeasures necessary. On the one hand, measures that increase the number of medical staff must be taken into account, as well as measures that lead to increased efficiency in medical work.
The common starting point is to increase the number of students. It should be noted, however, that there are drop-out rates of 14% during the course of study and 12% of graduates after completing their medical degree (Kopetsch 2010). Another approach is to recruit international medical staff. In addition to the language barrier for patients and doctors, what needs to be viewed critically here is the global “brain drain” that the recruitment of international doctors has as a domino effect. There is usually also a need for medical professionals in their country and the deficit there is further increased by people moving away. This further deteriorates medical care in those states.
By awarding attractive medical working conditions in hospitals, the shortage of doctors can be counteracted on several levels. In particular, due to its incentive effect, it can lead to fewer doctors quitting their medical practice through a widespread improvement in working conditions. It is also likely that fewer doctors will move abroad to practice medicine there as the difference in working conditions between countries becomes less significant. This means that more doctors will probably stay in German hospitals and practices and continue their medical practice.
For the first time, such an award represents an explicit incentive to improve working conditions in German hospitals and can thus help to accelerate the improvement process. The testing methodology presented is geared equally to the needs of hospitals and medical professionals. The work-life balance taken into account in the methodology is playing an increasingly important role for the younger generation of doctors with a simultaneous desire for meaning. The doctors of Generation “Y” are intensively concerned with the question of whether they live in an environment that makes them happy and in which they would like to spend the rest of their professional lives (Bund 2014; Schürmann 2014). Self-realization is seen as a greater good than loyalty to the employer. Appreciation is an important health factor (Matyssek 2011), promotes work ability (Ley/Kaczmarczyk 2013) and reduces anxiety and the risk of depression (Hawkins 1999). Time for patients and the patient-doctor relationship is a central factor for satisfaction in the medical setting (Maio 2016).
Many doctors would like more transparency when looking for a job. The previous options for finding out about the working conditions of a possible new position are usually limited to the statements made by current employees during an internship or experience reports that are published on the Internet. However, applicants may have doubts about the validity of the statements, as the motivation of current employees and the authors of experience reports can greatly distort the assessment. The advantage of the audit methodology is the standardized, objective review of working conditions, which not only relies on the subjective representation of department management or employees, but also on objective key figures that indicate attractive working conditions. In order to meet the desire for more transparency, hospitals can, for example, communicate the department attractiveness diagram described in the methodology to the outside world. This allows interested parties and applicants to see the strengths of a department and to compare the working conditions of different departments. <<