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Financial risk protection from high costs for care is a main goal of health systems. Health system characteristics typically associated with universal health coverage and financial risk protection, such as financial redistribution between insureds, are inherent to, e.g. social health insurance (SHI) but missing in private health insurance (PHI). This study provides evidence on financial protection in PHI for the case of Germany's dual insurance system of PHI and SHI, where PHI covers 11% of the population. Linked survey and claims data of PHI insureds (n = 3105) and population-wide household budget data (n = 42,226) are used to compute the prevalence of catastrophic health expenditures (CHE), i.e. the share of households whose out-of-pocket payments either exceed 40% of their capacity-to-pay or push them (further) into poverty. Despite comparatively high out-of-pocket payments, CHE is low in German PHI. It only affects the poor. Key to low financial burden seems to be the restriction of PHI to a small, overall wealthy group. Protection for the worse-off is provided through special mandatorily offered tariffs. In sum, Germany's dual health insurance system provides close-to-universal coverage. Future studies should further investigate the effect of premiums on financial burden, especially when linked to utilisation. [ABSTRACT FROM AUTHOR]

Background: Health system performance assessment (HSPA) is a major tool for evidence-based governance in health systems and patient/population-orientation is increasingly considered as an important aspect. The IPHA study aims (1) to undertake a comprehensive performance assessment of the German health system from a population perspective based on the intermediate and final dimensions defined by the World Health Organization (WHO) and (2) to identify differences in HSPA between (a) common user characteristics and (b) user types, which differ in their interactions and patterns of action within the health system. Methods and Analysis: A cross-sectional survey was conducted between October and December 2018 with statutorily and privately health insured to assess the German health system from a population perspective related to the past 12 months. The random sample consists of 32 000 persons insured by AOK Nordost and 20 000 persons insured by Debeka. Data from the survey will subsequently be linked with health insurance claims data at the individual level for each respondent who has given consent for data linkage. Claims data covers the time period January 1, 2017 to June 30, 2018. The combination of the 2 data sources allows to identify associations between insured patient characteristics and differences in the assessment of health system performance. The survey consists of 71 items measuring all final and intermediate health system goals defined by the WHO and user characteristics like health literacy, self-efficacy, the attention an individual pays to his or her health or disease, the personal network, autonomy, compliance and sociodemographics. The claims data contains information on morbidity, care delivery, service utilization, (co)payments and sociodemography. Discussion: The study represents a promising attempt to perform a holistic HSPA using a population perspective. For this purpose, a questionnaire was designed that contains both validated and new items in order to collect data on all relevant health system dimensions. In particular, linking survey data on HSPA with claims data is of high potential for assessing and analysing determinants of health system performance from the population perspective. [ABSTRACT FROM AUTHOR]

Aim Design Methods Results Conclusion Implications for the Profession and Patient Care Impact Patient or Public Contribution To examine if and how selected German hospitals use nurse‐sensitive clinical indicators and perspectives on national/international benchmarking.Qualitative study.In 2020, 18 expert interviews were conducted with key informants from five purposively selected hospitals, being the first in Germany implementing Magnet® or Pathway®. Interviews were analyzed using content analysis with deductive‐inductive coding. The study followed the COREQ guideline.Three major themes emerged: first, limited pre‐existence of and necessity for nurse‐sensitive data. Although most interviewees reported data collection for hospital‐acquired pressure ulcers and falls with injuries, implementation varied and interviewees highlighted the necessity to develop additional nurse‐sensitive indicators for the German context. Second, the theme creating an enabling data environment comprised building clinicians' acceptance, establishing a data culture, and reducing workload by using electronic health records. Third, challenges and opportunities in establishing benchmarking were identified but most interviewees called for a national or European benchmarking system.The need for further development of nurse‐sensitive clinical indicators and its implementation in practice was highlighted. Several actions were suggested at hospital level to establish an enabling data environment in clinical care, including a nationwide or European benchmarking system.Involving nurses in data collection, comparison and benchmarking of nurse‐sensitive indicators and their use in practice can improve quality of patient care.Nurse‐sensitive indicators were rarely collected, and a need for action was identified. The study results show research needs on nurse‐sensitive indicators for Germany and Europe. Measures were identified to create an enabling data environment in hospitals. An initiative was started in Germany to establish a nurse‐sensitive benchmarking capacity.Clinical practitioners and nurse/clinical managers were interviewed. [ABSTRACT FROM AUTHOR]

Introduction: Many countries in Europe are facing a shortage of nurses and seek effective recruitment and retention strategies. The nursing workforce is increasingly diverse in its educational background, ranging from 3-year vocational training (diploma) to bachelor and master educated nurses. This study analyses recruitment and retention strategies for academically educated nurses (minimum bachelor), including intention to leave, job satisfaction and work engagement compared with diploma nurses in innovative German hospitals; it explores recruitment and retention challenges and opportunities, and identifies lessons on recruitment and retention taking an international perspective., Methods and Analysis: The study will apply a convergent mixed-methods design, including qualitative and quantitative methods. The qualitative study will include semistructured interviews among hospital managers, nurses, students and stakeholders in Germany. In addition, expert interviews will be conducted internationally in countries with a higher proportion of bachelor/master nurses in hospitals. The quantitative, cross-sectional study will consist of a survey among professional nurses (bachelor/master, diploma nurses) in German hospitals. Study settings are hospitals with a higher-than-average proportion of bachelor nurses or relevant recruitment, work environment or retention strategies in place. Analyses will be conducted in several phases, first in parallel, then combined via triangulation: the parallel analysis technique will analyse the qualitative and quantitative data separately via content analyses (interviews) and descriptive, bivariate and multivariate analyses (survey). Subsequently, data sources will be collectively analysed via a triangulation matrix focusing on developing thematic exploratory clusters at three systemic levels: microlevel, mesolevel and macrolevel. The analyses will be relevant for generating lessons for clinical nursing, management and policy in Germany and internationally., Ethics and Dissemination: Ethics approval was obtained by the Charité Ethics Committee.Several dissemination channels will be used, including publications and presentations, for the scientific community, nursing management, clinical nurses and the wider public in Germany and internationally., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Health literacy (HL) is a competence to find, understand, appraise, and apply health information and is necessary to maneuver the health system successfully. People with low HL are, e.g., under the risk of poor quality and safety of care. Previous research has shown that low HL is more prevalent among, e.g., people with lower social status, lower educational level, and among the elderly. In Germany, people with substitutive private health insurance (PHI) account for 11% of the population and tend to have a higher level of education and social status, but in-detail assessments of their HL are missing so far. Therefore, this study aimed to investigate the HL of PHI insureds in Germany, and to analyze their assessment of the health system according to their HL level. In 2018, 20,000 PHI insureds were invited to participate in a survey, which contained the HLS-EU-Q16, and items covering patient characteristics and the World Health Organization health systems framework goals (e.g., access, quality, safety, responsiveness). Low HL was found for 46.2% of respondents and was more prevalent, e.g., among men and insureds with a low subjective social status. The health system performance was perceived poorer by respondents with low HL. Future initiatives to strengthen health systems should focus on promoting HL.

Introduction: The increasing burden of mental distress reported by healthcare professionals is a matter of serious concern and there is a growing recognition of the role of the workplace in creating this problem. Magnet hospitals, a model shown to attract and retain staff in US research, creates positive work environments that aim to support the well-being of healthcare professionals., Methods and Analysis: Magnet4Europe is a cluster randomised controlled trial, with wait list controls, designed to evaluate the effects of organisational redesign, based on the Magnet model, on nurses' and physicians' well-being in general acute care hospitals, using a multicomponent implementation strategy. The study will be conducted in more than 60 general acute care hospitals in Belgium, England, Germany, Ireland, Norway and Sweden. The primary outcome is burnout among nurses and physicians, assessed in longitudinal surveys of nurses and physicians at participating hospitals. Additional data will be collected from them on perceived work environments, patient safety and patient quality of care and will be triangulated with data from medical records, including case mix-adjusted in-hospital mortality. The process of implementation will be evaluated using qualitative data from focus group and key informant interviews., Ethics and Dissemination: This study was approved by the Ethics Committee Research UZ/KU Leuven, Belgium; additionally, ethics approval is obtained in all other participating countries either through a central or decentral authority. Findings will be disseminated at conferences, through peer-reviewed manuscripts and via social media., Trial Registration Number: ISRCTN10196901., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Background: Many European countries experience health workforce skill-mix changes due to population ageing, multimorbidity and medical technology. Yet, there is limited cross-country research in hospitals., Methods: Cross-sectional, observational study on staff role changes and contributing factors in nine European countries. Survey of physicians, nurses and managers (n = 1524) in 112 hospitals treating patients with breast cancer or acute myocardial infarction. Group differences were analysed across country clusters (skill-mix reform countries [England, Scotland and the Netherlands] versus no reform countries [Czech Republic, Germany, Italy, Norway, Poland and Turkey]) and stratified by physicians, nurses and managers, using Chi-squared, Mann-Whitney U and Kruskal Wallis tests., Results: Nurses in countries with major skill-mix reforms reported more frequently being motivated to undertake a new role (66.5%) and having the opportunity to do so (52.4%), compared to nurses in countries with no reforms (39.2%; 24.8%; p < .001 each). Physicians and nurses considered intrinsic motivating factors (personal satisfaction, use of qualifications) more motivating than extrinsic factors (salary, career opportunities). Reported barriers were workforce shortages, facilitators were professional and management support. Managers' recruitment decisions on choice of staff were mainly influenced by skills, competences and experience of staff., Conclusion: Managers need to know the motivational factors of their employees and enabling versus hindering factors within their organisations to govern change effectively., (Copyright © 2018 Elsevier B.V. All rights reserved.)