Findings derived from both quantitative and qualitative process evaluation data are presented focusing on perceived relevance and applicability of the RESILARE indicators and covered domains, perception of outreach visit and feedback report, and management of crisis situations. Provided quotes from the qualitative data are presented with an indication of alias, transcript number and position (Pos.), and have been translated with due diligence.

Participant characteristics

A total of n = 57 GPs were initially interested in participation. N = 34 GPs and n = 34 MAs from n = 35 practices of varied sizes and located throughout Germany could be recruited to participate in the piloting and the process evaluation and signed a written consent. All other interested GPs declined participation due to workload. One GP cancelled participation shortly before the scheduled visit and past completion of recruitment due to exceptionally high workload and staff shortage. One practice participated with two sites but the same GP and MA, and completed questionnaires and interviews once each. N = 40 participants completed the first and n = 35 the second questionnaire. Between April 25 and September 05, 2023, a total of n = 65 telephone interviews with GPs (n = 33) and MAs (n = 32) were conducted (mean duration 21 min; range 11–42 min). During data collection, participants were either at their workplace, commuting or at home. One GP elaborated on questions supported by the practice manager and no MA from this practice was interviewed due to insufficient language skills. Table 2 details the participant characteristics.

Table 2 Characteristics of the participants in the piloting and the process evaluation (n = 34 general practices in Germany)

Participants stated they felt motivated to participate in piloting the indicators because they wanted to broaden and strengthen current efforts regarding crisis resilience and sustainable healthcare provision by learning about further approaches. They also felt motivated by the combination with accreditation of the obligatory quality management. A small number of GPs mentioned that remuneration for participation was a decisive factor. Some MAs described that the GP had asked them to jointly participate because of their specific roles in the team or prior efforts and they felt motivated by that.

Relevance and applicability of domains and RESILARE indicators

Survey questionnaire 1 asked the participants to indicate relevance they attributed to the four domains in general and referring to each single indicator. On a scale from 1 to 9 (1 = not relevant at all − 9 = very relevant), the domains regarding Individual resilience (mean 7.85; SD 0.81) and Organizational resilience (mean 7.82; SD 0.91) were rated the highest, followed by Crisis Prevention (mean 7.2; SD 1.29) and Climate Resilience (mean 6.49 SD 2.01). All indicators were rated above 6 with the exception of the one referring to measuring the ecological footprint of a practice (mean 4.72; SD 2.64)). Figures 2 and 3 visualize these findings.

Fig. 2

Relevance attributed by the participants (n = 40) in 2023 to the four addressed domains Scale from 1 to 9: 1 = not relevant at all − 9 = very relevant

Fig. 3

Relevance attributed to all RESILARE indicators by the participants (n = 37–40) in 2023 Scale from 1 to 9: 1 = not relevant at all − 9 = very relevant

On a scale from 1 to 5, relevance of sustainable ways of working in ambulatory care was rated neutral (mean 2.28; SD 1.01). The overall objective consistency of the indicators was rated similarly (mean 2.26; SD 0.55). Suggestions for specification of indicators in free text fields mainly referred to providing examples to facilitate transparency regarding content and intention of an indicator at first glance, for instance referring to safety concepts, measures of strengthening individual resilience, potential risks and the formation of local networks. Some participants indicated their individual and skeptical views on feasibility of some indicators, particularly referring to political or economic context, competencies and capacities in primary care, and ecological footprint of practices.

The qualitative data largely matched survey findings regarding perceived applicability and relevance of the indicators and the covered domains. Participants stated they considered the indicators to be “very well grounded and absolutely relevant for all practices” (GP08, Pos. 21) and feasible for implementation in mandatory quality management programs. Two GPs and two MAs mentioned that standardized indicators might be difficult to implement since practices differed individually and thus some indicators might not correspond with daily practice. Some participants recommended a gradual implementation to provide sufficient space and time for practices to design and prepare corresponding measures and processes. Generally, participants considered it important for practices to reflect on the domains, particularly on climate change resilience and sustainable care provision, and emphasized a need to individually consider what could be changed in the practice regarding climate action and be made aware of potential starting points.

So, it’s very important, and I thought it was truly good to pause for a moment and of course the environmental aspect is very important, in many things your hands are tied, but in some things, I think, […] if you just knew. (GP04, Pos. 25).

Some GPs and MAs mentioned that they had been considering and engaging regularly in aspects covered by the indicators for some time, particularly in connection to quality management in the practice, but also in their private lives. Few participants self-critically reflected to neglect these important topics sometimes during daily routines. While considering three of the domains relevant, one GP stated that resilience to climate change would not play a role in the particular region where the practice was located and that sustainable care was inept. One MA noted that “Environment and climate are a bit difficult and a double-edged sword in medicine” (MA33, Pos.13) since so many single-use items were present. Regarding implementation and use of the indicators, critical views referred mainly to existing hygiene regulations as well as uncertainty about relevance for primary care in general or for the particular practice.

At first, I thought it was a bit excessive, I have to say, to add this to basic medical care, but over time, to be honest, the deeper you delve into this subject, the more sense it makes to think about it. (MA06, Pos. 23).

Outreach visit and feedback report

Outreach visits were conducted via video calls (n = 22), on-site (n = 10), and over telephone due to technical difficulties (n = 2). The quality management experts who conducted the visits indicated their positive perceptions regarding resonance in the practice teams and general acceptance of the indicators (9.4 and 8.6; scale 1–10). They also considered implementation of key messages into daily practice very probable (9.2) and attributed a high influence of the indicators on future decisions in the practices (9.1). In the survey, overall expenditures for preparation, attendance and follow-up of the outreach visit were classified with a mean of 2.45 (scale 1–5; SD 0.81). Regarding the feedback reports, 57% of participants indicated full comprehensibility, 77% confirmed clarity. 80% welcomed the benchmarking information and indicated that they had initiated improvement measures based on their visit and report. Free text fields were used to detail measures implemented after the visit and feedback on incident and crisis management, team building, conservation of energy, patient information material and negotiations with landlords.

Interview participants generally described the outreach visit as a very targeted, informative and useful tool for piloting the indicators. The time invested was mostly considered adequate and corresponding to perceived benefits of the assessed status quo and impetus for reflection, planning and implementing necessary measures. Some practices opted to combine the piloting with quality management accreditation to be mindful of resources. Participants reported that this made a separate contemplation of the piloting somewhat difficult for them and the visitor.

We not only took part in the RESILARE study during the visitation, but it was also part of our [quality management] certification, so it was a bit difficult for both, the visitor and us to separate the two, because some of the content simply overlapped […], I think we understood the impact of the questions very well. (GP22, Pos. 5).

GPs and MAs explained they thought it was a good idea to pursue sustainability thinking not only during an ongoing crisis, but also focus on it in a preparatory way during the outreach visit. It was mentioned that the visit and feedback report provided confirmation for being on the right path regarding potential improvement measures. Most participants described their expectation to receive additional impulses and learn about best practices via the feedback report. While some GPs expected to benefit from the benchmarking, others mentioned they would appreciate specific suggestions, instructions for implementation of adequate measures and an exchange of ideas with other practices. Few GPs had no expectations regarding the feedback report. Some GPs and MAs had not accessed the first part of the online feedback report at the time they were interviewed, thus the second part which included the benchmarking was mailed by postal service to avoid an information gap.

Based on insights gained through outreach visits and feedback reports, GPs and MAs alike reported that they had started to compile to-do lists for their planning of improvement measures and discussed them during their regular team meetings. It was considered important to include the whole team in corresponding efforts. Some participants described that the visit had taken place shortly before a vacation period and planning for improvement measures had yet to be initiated. Measures already planned or implemented referred to active transportation for house calls and getting to work, team building and communication, appreciative interaction and individualized working hours, sustainable and climate resilient care provision, supply management and reduction of single-use materials, safety concepts and heat protection plans, patient information, emergency planning and potential power outages, digitalization of health services, energy resources, waste sorting, incident handling, adaptation of practice hours, solar shading and energy-saving air-conditioning during summer months, ventilation during winter months, energy-saving light sources, and data storage. Some GPs planned to implement new measures after moving to different premises.

I’m currently building a new practice, and I’m already able to implement a lot of the energy aspects and optimize CO2 savings. And the fact that we are actually addressing the issue of bicycles more, our role model function, and that we’re also making sure that we motivate patients to come to the practice on foot or by bike, that the issue of sustainability is more important than parking spaces. (GP16, Pos. 31).

Managing critical situations

Survey 1 asked participants’ self-perception regarding their ability to manage critical situations. The minimum rating across items was 1, the maximum was 7 (1 = not applicable at all − 7 = fully applicable), and the mean score ranged from of 5.61 to 6.2. A mean score of 6 and above was registered for a total of 6 items. Table 3 details these items, mean scores and standard deviations.

Table 3 Participants’ self-perception of handling crisis situations (n = 38–40)

Regarding current crises, participants in the interview study felt resilience was a daily essential. They outlined approaches to coping with medication shortages. Time-consuming communication efforts were described, both with patients and pharmacies when a specific medication was not available and prescriptions had to be re-issued. For most practices, this was perceived as a daily occurrence, resource-intensive for the team and frustrating for patients. Most GPs and MAs stated to routinely communicate with pharmacies in the region to assess availabilities on a daily basis. Some practices phoned pharmacies before patients went there with a prescription, others received daily availability updates from pharmacies or information was passed on through patients. One GP perceived a positive side effect when fewer antibiotics were available since less prescribing contributed to reducing the risk of antimicrobial resistance. Another GP felt that medication shortages changed perceptions regarding sustainability aspects when people realized they could manage with less. One practice asked patients to deposit unused nonexpired medication with them to be able to pass them on to patients in need. GPs were also aware that medication shortages could result in non-guideline-compliant therapy, potential harm for patients, and otherwise avoidable hospitalization.

The sheer number of patients we look after means we have an enormous administrative burden because about every second prescription comes back corrected by the pharmacy, or we have to make phone calls to pharmacies. We really experienced an almost pandemic level of bacterial tonsilitis, and almost no penicillin was left in the entire district. […]. So, it is difficult to provide very good care in line with guidelines if the medication is simply unavailable. And to explain this to the patients, who are usually truly nice anyway, but the frustration increases, you have to be honest. (GP21, Pos. 31).

Only a few participants felt that they were not confronted with crisis situations related to energy supply and costs, patients affected by war and migration, and inflation while most GPs and MAs felt affected daily and could detail their handling of related crisis situations. It was mentioned that crisis situations were addressed and discussed calmly with patients when they were brought up or when an impression arose that counseling was indicated. GPs voiced concerns regarding the economic well-being of their practice and teams and stated that it was important to be aware of employer responsibilities and the protective role of a GP practice. It was also noted that with higher cost of living, some patients might not be able to afford necessary medication. One GP mentioned that MAs often learned more about traumatizing crisis situations from patients when they changed a wound dressing than GPs did during a consultation. As crisis response, such incidents were then discussed in team meetings to share the burden and develop coping strategies.

Well, it is demonstrated to you every day how important resilience is. Because it is so omnipresent, you’re confronted with these crisis issues every day […] I have to be prepared if things do not work out. […] And that we actually pass this on to the patients. (GP16, Pos. 39).

Regarding inflation and rise of costs, participants shared to apply cost-cutting strategies such as increasing the use of renewable energy sources, reducing overall energy consumption for instance by switching off ultrasound and other devices, sustainable supply management and the use of electromobility for house calls. Participants also contemplated the bigger picture beyond their own practices, patients and teams and voiced that regarding current crises they noticed a feeling of helplessness, insecurity and anxiety about future developments, overstraining, depression, and loss of a carefree world around them and for themselves.

Ultimately, we have to assess what this means for us, for example the blasting of a dam, the water does not get here directly, but it has an impact, […] we are talking about electric cars and CO2, and what happens there in one day - I exaggerate - is sometimes what happens in Germany in a year, but we are talking about environmental disasters and similar things, and what is happening there is a sheer environmental disaster, and it all has to do with us, also in the long term, it does not pass us by. (GP20, Pos. 23).