Study Notes: Certified Business Specialist in Health and Social Care - Spring Exam 2020

Organizational Context: Soziale Dienste der Stadt Schwalbenburg AG

• History and Ownership: The "Soziale Dienste der Stadt Schwalbenburg AG" is located in the city of Schwalbenburg and dates back to the $11^{th}$ century. The sole shareholder is the Municipality of Schwalbenburg.
• Specialization (Approx. 10 years ago): Under the city's direction, the company specialized into two primary entities:
  • Klinikum St. Barbara gGmbH: Focuses on medical, outpatient, and semi-residential services across $18$ clinics. This includes specialized departments, institutes, treatment centers, emergency rooms, day clinics, and services in forensic commitment ($\text{Maßregelvollzug}$).
  • Klinikum St. Heinrich gGmbH: Focuses on therapeutic and medical-social housing, forensic psychiatry, drug aid, and specialized facilities for nursing and persistent vegetative state ($\text{Wachkoma}$) patients.
• Hospital Classification: Both clinics are classified as "Plankrankenhäuser" (planned hospitals) providing "Schwerpunktversorgung" (priority care).
• Cooperation Partners (Non-profits/e.V.): The group initiates and cooperates with several non-profit organizations:
  • Kindertagesstätte e.V.
  • Förderverein der Klinik für Kinder- und Jugendmedizin e.V.
  • Drogenhilfe e.V.
  • Betriebs- und Breitensport e.V.
  • Rehabilitation e.V.
• Internal Education: Klinikum St. Barbara gGmbH operates its own internal training and further education center ($\text{Aus- und Fortbildungszentrum}$).
• Current State: The group recently recovered from a period of mismanagement that led to near insolvency. Under new management, a strict restructuring course was implemented, restoring profitability and liquidity. Medium-term goals include expanding into neighboring Eastern European countries (specifically Poland).

Information Sourcing for International Market Expansion

To explore new business fields in the Republic of Poland, the management utilizes both primary and secondary information sources:

• Primary Information Sources (Direct Data Collection):
  • Surveying internal medical staff with Polish migration backgrounds: Provides detailed knowledge about the medical profession in Poland and potential local contacts.
  • Interviews with university members connected to Polish health systems: Useful for identifying development trends from a research and teaching perspective.
  • Surveying nursing staff with Polish migration backgrounds: Offers target-group-specific insights into the Polish nursing sector, which may differ significantly from the medical sector.
  • Interviews with cooperation partners and suppliers: Includes stakeholders like pharmaceutical companies to understand market dynamics.
• Secondary Information Sources (Existing Data):
  • Technical Literature: Provides medium-to-long-term development trends, though it may lack the latest political updates due to publication intervals.
  • Medical and Nursing Trade Journals: Offers journalistically processed articles and columns on specific niche topics.
  • Ministry of Health of the Republic of Poland (Press Office/International Policy Dept.): Provides the most up-to-date data, political frameworks, and legal conditions.
  • External Chambers/Associations: Includes Economic Chambers ($\text{Wirtschaftskammern}$), health insurance funds ($\text{Krankenkassen}$), and professional associations.

Legal Framework: Professional Training and Youth Protection

• Legal Basis for Training:
  • Commercial/Industrial training (e.g., "Kaufleute im Gesundheitswesen") is governed by the Vocational Training Act ($\text{Berufsbildungsgesetz - BBiG}$), which applies nationwide in Germany.
  • The Crafts Code ($\text{Handwerksordnung - HWO}$) does not apply to hospitals as they are not craft-based businesses.
  • Nursing professions follow state-level legislation ($\text{Länderrecht}$) as they are school-based training programs.
• Prerequisites for Minor Trainees:
  • Consent: The vocational training contract must be signed by a legal guardian.
  • Medical Examination: According to the Youth Employment Protection Act, a youth health examination ($\text{Jugendarbeisschutzuntersuchung}$) by a licensed physician is required to ensure no health concerns regarding the chosen profession.
• Trainer Qualifications: Trainers must be approved by the responsible Chamber (IHK) and possess:
  • Technical Suitability: Demonstrated through completed vocational training and professional experience.
  • Personal Suitability: Proven via an extended certificate of good conduct ($\text{erweitertes Führungszeugnis}$); no criminal record.
  • Pedagogical Suitability: Proven by passing a written and practical examination before an IHK commission to demonstrate the ability to convey knowledge and skills.
• Mandatory Training Contract Content:
  • Exact name of the vocational title.
  • Specialization or focus area (if applicable).
  • Duration of training (standardly $3$ years for health scouts; possible reduction for prior knowledge).
  • Probation period ($1$ to $4$ months).
  • Training location(s) (internal and external sites).
  • Regular daily working hours.
  • Vacation entitlement in working days per calendar year.
• Accident Prevention (UVV) Guidelines:
  • Initial instruction for all trainees at the very start.
  • Adults: General instruction at least once per year.
  • Minors: General instruction at least every $6$ months.
  • Specialized Instruction: Required when entering a new department or operating a new machine.
• Training Record Book ($\text{Ausbildungsnachweisheft}$):
  • Must be maintained daily by the trainee.
  • Serves as evidence during disputes regarding the delivery of learning content defined in the curriculum.
  • Trainees record daily activities ($\text{Tagesberichte}$) signed weekly; trainers check and sign regularly.
  • Monthly reports ($1-4$) require detailed text/drawings to deepen technical knowledge.

Cross-Border Social Security and Healthcare Regulations

• Foreign Posting ($\text{Entsendung}$): According to $\S 4$ paragraph $1$ SGB IV, German social insurance obligation remains active for employees temporarily sent abroad by a German employer.
• Healthcare for Tourists in the EU: Under Directive $2011/24/EU$, German tourists in Poland have a right to treatment if it prevents a medically necessary premature return home. The European Health Insurance Card (EHIC), located on the back of the health card, must be presented.
• Planned Treatment Abroad:
  • Individuals can choose medical treatment in other EU countries under the reimbursement principle ($\S 13$ paragraph $4$ SGB V).
  • Planned hospital services require prior approval from the health insurance fund ($\S 13$ paragraph $5$ SGB V).

Operational Management and Communication Strategy

• Operative Goals for Internal Group Integration:
  • Organize experience exchanges between middle management and related facilities by a specific deadline.
  • Adopt group-wide mission statements and leadership tasks.
  • Launch an electronic platform for specialist contributions for executives.
• Supportive Measures:
  • Practical internships for executives (e.g., Polish nursing staff in special senior housing in Germany).
  • Closed-door meetings with personnel representatives to align different perspectives.
  • Establishment of Quality Management (QM) circles between Polish and German entities to discuss common standards.
• Communication Instruments (Intranet):
  • Functions: Targeted information delivery without delay, vertical/horizontal exchange, uniform internal appearance, and discussion platforms for scientific findings.
  • Implementation Measures: internal campaigns to increase acceptance, feedback loops in service meetings, and providing mobile devices.

Federal Health Oversight: The G-BA and Physician Types

• Federal Joint Committee ($\text{Gemeinsamer Bundesausschuss - G-BA}$): The highest body of shared self-governance between service providers and health insurance funds. It defines the benefit catalog of statutory health insurance via guidelines ($\text{Richtlinien}$).
• Legal Force: Beschlüsse (resolutions) of the G-BA are subject to legal supervision by the Federal Ministry of Health and are published in the Federal Gazette ($\text{Bundesanzeiger}$).
• Physician Types:
  • Contract Physician ($\text{Vertragsarzt}$): Licensed to treat statutory insurance patients and bills through the Association of Statutory Health Insurance Physicians ($\text{Kassenärztliche Vereinigung}$).
  • Private Physician ($\text{Privatarzt}$): Bills patients directly and independently.

Personnel Onboarding Concept

A 5-phase plan to reduce turnover during probation (estimated currently at $50\%$ in the MVZ):

1. Phase 1: Contract to Start: Send welcome info, mission statement, and organigram.
2. Phase 2: First Day: Welcome, workstation hand-off, discussion of the specific training plan, and introduction to colleagues.
3. Phase 3: First Weeks: Instructions on QM manuals, software, hygiene rules, and department rotation.
4. Phase 4: Mid-Probation: Discussion with direct supervisor to assess progress and adjust the plan.
5. Phase 5: End of Probation: Final performance evaluation and decision on permanent employment (notice period is usually $14$ days before the end of a $6$-month probation).

Financial Analysis and Liquidity Management

• Illiquidity ($\text{Illiquidität}$): Meaning the inability to meet due payment obligations, which legally leads to insolvency.
• Costs of Liquidity:
  • Low Liquidity: Interest expenses for overdrafts, conversion costs for money market papers, and risk of insolvency.
  • High Liquidity (Opportunity Costs): Lost profits from alternative investments (interest income). In low-interest phases, these costs are relatively low.
• Liquidity Ratios for Klinikum St. Barbara (as of September 30, 2019):
  • Data: Cash/Bank = $475\,\text{TEUR}$; Receivables = $890\,\text{TEUR}$; Inventory = $700\,\text{TEUR}$; Short-term Liabilities (Provisions + Trade Payables + Other) = $900 + 150 = 1\,050\,\text{TEUR}$.
  • Cash Ratio (1st Degree): $\frac{475}{1\,050} \times 100 = 45\%$ (Benchmark: $31\%$).
  • Quick Ratio (2nd Degree): $\frac{475 + 890}{1\,050} \times 100 = 130\%$ (Benchmark: $97\%$).
  • Current Ratio (3rd Degree): $\frac{475 + 890 + 700}{1\,050} \times 100 = 197\%$ (Benchmark: $122\%$).
• Management Strategies:
  • Liquidity Planning: Continuous monitoring of inflows/outoflows to detect bottlenecks or surpluses.
  • Optimal Cash Holding: Setting upper and lower limits. Surpluses should be invested in short-term interest-bearing assets; if limits are undercut, assets should be liquidated.

Corporate Identity (CI) and Leadership Guidelines

• Corporate Identity Objectives: Strengthen group identity to prevent silo-thinking between Klinikum St. Barbara and St. Heinrich.
• Leadership Guidelines (Selection of 12 Points):
  1. Consistent goal setting.
  2. Timely and comprehensive information.
  3. Fairness and respect.
  4. Cooperative work climate.
  5. Maximum freedom and backing for staff.
  6. Success of staff is group success.
  7. Supporting employee development.
  8. Continuous improvement of leadership competence.
  9. Criticism as growth opportunity.
  10. Behavior as a role model.
  11. Promoting team spirit.
  12. Sensitivity to family and life stages.
• Corporate Fashion Benefits: Beyond recognition, it strengthens team spirit, ensures compliance with safety/hygiene standards, and conveys professionalism to patients.

Complaint Management Process (Standardized Instruction)

• Intake: Forms available at reception/cafeteria. Verbal complaints are transcribed by staff into forms.
• Collection: Quality Officers (QB) empty suggestion boxes weekly.
• Immediate Action: QB decides if immediate measures (e.g., diet change, case conference) are needed.
• Central Management: All complaints go to the Central Complaint Manager (BM).
  • Legal cases: Forwarded to lawyers/insurance.
  • Non-legal cases: BM may request statements from departments, leading to factual assessment and patient feedback.
• Evaluation: Monthly analysis sent to station/nursing management and Head Physicians for improvement measures.

Cost and Performance Accounting: HNO Department Variance Analysis

• DRG Case Parameters (HNO):
  • Base Case Value ($\text{Landesbasisfallwert}$) = $3\,360\,€$.
  • Plan CMI = $1.03$; Actual CMI = $0.95$.
  • Plan Case Quantity = $500$; Actual Case Quantity = $450$.
  • Fixed Costs = $900\,000\,€$ per half-year.
  • Variable Costs = $40\%$ of revenue.
• Variance Calculation Table:

• Key Results:
  • Employment Variance: Due to lower occupancy ($450$ cases vs. $500$), $90\,000\,€$ in fixed costs remain uncovered.
  • Actual Result: The department moved from a planned profit of $138\,240\,€$ to an actual loss of $-62\,100\,€$. This eliminates the ability to cross-subsidize new DRG groups.

The Principle of Subsidiarity

• State Structure (Federalism): Competencies are distributed between Federal (Bund) and State (Länder) levels. States handle local interests (citizens' proximity), while the Federal government handles matters of the common good for all citizens.
• EU Level: The EU sets minimum standards (e.g., Medical Device Law), while member states regulate national implementation (e.g., social insurance details).
• Social Benefits: Recipients have rights to subsistence, housing, and medical care if insurance is insufficient. They have duties to prove need and take active initiatives to escape dependency.
• Application in Schwalbenburg:
  • Investment Financing: The state (Land) provides funds based on the Federal Hospital Financing Act ($\text{KHG}$).
  • Medical Device Act: Originates from EU directives but applies to all internal group operations.
  • Social Assistance: Subsidizes nursing home costs only after private assets and professional insurance are exhausted.