Publikationen im Bereich Benchmarking


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Boundaryless Hospital -

Rethink and Redefine Health Care Management



Horst Albach

Wilfried von Eiff (HHL Leipzig Graduate School of Management)

Heribert Meffert (University of Muenster)

Andreas Pinkwart (HHL Leipzig Graduate School of Management)

Ralf Reichwald (HHL Leipzig Graduate School of Management)


Springer Publishers, Berlin Heidelberg.

Expected Release: First Quarter 2016


Foreword from the editors


The title of this book is taken from an article which was published in the Australian and New Zealand Journal of Medicine in 1994. The authors were J. Braithwaite, R. Vining, and L. Lazarus. They applied a vision of the organization that Jack Welch, the CEO of General Electric, had developed to make his company successful: boundarylessness[1]. In an annual report of GE Welch wrote: “Our dream for the 1990s is a boundaryless company, a company where we knock down the walls that separate us from each other on the inside, and from our key constituencies on the outside”[2].


For Welch, boundarylessness was the way to increase productivity. In GE’s 1991 annual report, Jack Welch wrote: “1991 did once again remind us how absolutely critical productivity growth is in the brutally Darwinian global market places in which virtually all of our businesses compete. … But to increase productivity, you first have to clear away all the impediments that keep you from its achievement – primarily the management layers, functional boundaries and all the other trappings of bureaucracy”[3].


Welch stressed boundarylessness as an instrument for productivity growth through cost-cutting, which is important in order to survive in highly competitive markets. The boundaryless hospital is facing a similar challenge called “The New Market Dynamics in Health Care”[4] which characterizes the dramatic change in managing hospitals: An increasing demand for state-of-the-art medical care for the entire population has to be served and the costs of health care should be contained simultaneously. As well as a company the boundaryless hospital is also considered as an organization which provides services in a highly competitive market where payers request a pay-for-performance reimbursement system. The factors critical to success in competition are the quality of structure (facilities, devices, experts), the process quality (minimal invasive diagnosis and treatment procedures; effective pain management) and the result quality (complication rate; mortality rate)[5]. However, the goal of managing a hospital is to secure a highly reliable medical quality in combination with highly effective and economic processes of care. For politicians it is the key to meeting the target triangle of access, affordability and quality of health care based on a sustainable reimbursement system. For hospital managers the objective is to ensure the provision of high-quality care combined with healing environment services despite of increasing financial limitations.


The HHL Center for Advanced Studies in Management (CASiM) attempts to meet this challenge. This requires more than planning and control of a firm. It is more than accounting and digitalization. The patient is more than a mere customer. Efficiency Management in a hospital is based on a profound under-standing of medicine and nursing on the side of the manager as well as a deep understanding of business economics and health services on the side of the medical scientists. And for both sides as well as for the regulator, a better understanding of the impact of the regulatory framework on the outcome of the health care system is indispensable. The traditional boundaries between medical scientists, administrators and nurses have to be removed in a new form of cooperation. Furthermore, the boundaries between the sectors of care should be vanquished and the boundaries between medical ethics and economic values have to be harmonized.


And above all, managing the hospital requires a deeper understanding of the patient. Patients are human beings who are looking for professional medical provision in a difficult psychological situation, characterized by pain and trepidation of what is lying ahead. Therefore, it is highly valuable for the patient to be diagnosed and treated by short-lasting, painless and fear-free procedures carried out in a “healing environment”. The next necessary step to patient-centeredness is to use the opportunities of “personalized medicine”. Personalized medicine is a vision for health care. There may be similar concepts in other fields, particularly in marketing of consumer products, where business economists talk about “markets of one” or “lot size one”, but in medicine the concept is different. M. Dietel defines personalized medicine as “the intention to diagnose and treat patients more precisely adapted to their individual needs”[6].


The health care systems all try to cope with the rising expenditures of health care but they all differ from country to country. Insurance – public or private - is one way to finance the costs of health care. Insurances may cover all expenses or they may require the sick person to pay his (or her) health expenditures himself (or herself). Regardless of the particular system Jan P. Beckmann provides in his introductory contribution a philosophical underpinning for our approach to reach more efficiency and better outcomes with new economic instruments.


Boundaryless in our understanding does not mean that there are no rules. On the contrary: The boundaryless hospital has to work on the basis of codes of conduct and contracts with regard to both internal and external relations. From Hirschhorn and Gilmore, we already know about the importance of internal “boundaries of the boundaryless company”, as they called it[7]. They argued that everyone in a boundaryless company “must figure out what kind of roles they need to play and what kind of relationships they need to maintain in order to use those differences effectively in productive work.”


Regarding the external boundaries Nobel Prize winner Alvin Roth gives a striking example of the impact of market design for a better supply of donor kidneys in his recently published book on matchmaking and market design[8]. His explanation of the entire process of establishing a kidney transplant network impressively shows the potential of synergies which can be exploited if the formidable obstacles caused by different logics on different sides can success-fully be overcome.


We quote Alvin Roth: “Garet’s frustrations led him in late 2007 to form an exchange network he called the National Kidney Registry. It … aims to facilitate potentially quite long nonsimultaneous chains by recruiting hospitals and non-directed donars. If a hospital sends a non-directed donor, the NKR promises to end one of its chains at that hospital. That ensures that the hospital doesn’t “lose” a transplant by sharing its donor: Keep in mind that hospitals earn revenue on their transplants; they’re commercial enterprises as well as caregivers.” [9]


Cooperation and Big Data are the key words for the new development in health care. They are the topics of this book. Cooperation does not only refer to scientists from various disciplines and practitioners from different sectors working together, but also to the overall management of the value chain in the health care process, and a new form of relationship between the doctor and the patient. As an example, Hallek and his co-authors present a new form of organization which provides the medical services the patient needs: the Comprehensive Cancer Center (CCC). We quote: “The CCCs are the forefront to fight cancer. From an organizational perspective these large centers are highly complex. They cannot operate as standalone organizations but rely on cooperation in a network of hospitals and office-based physicians” [10].


Big Data is more than “number crunching” and repository management. Big Data aims to enhance diagnostic precision, intents to shorten the time between the first diagnosis and start of therapy and targets to increase therapeutic effectiveness as well as patient outcome. Big Data means the generation of decision-relevant information out of a tremendous mass of data. Especially in the field of diagnostics of malign tumours (e.g. pontine glioma) the capability of Big Data can be demonstrated.


The papers in this book are international and interdisciplinary. In chapter two and three, they are seizing the previously identified opportunities across countries and disciplines, and deal with the issue whether the new concept is suitable to meet future challenges better. They analyze and comment on the health care systems of Finland, Germany, Malta, Portugal, The Netherlands and Switzerland. They concentrate on different diseases such as cancer, heart diseases, epilepsy, inflammatory bowel disease, and chronic care. Maarten Janssen and his co-authors draw attention to the “physician assistant” in Holland. We quote: “Increasing experience, developed routines, specialization and trust among the medical and nursing staff enables Pas to gradually expand their occupational place, highlighting the fluidity of its boundaries.” [11] In the final chapter, the boundaryless hospital is particularly reflected from the patient’s perspective.


Book publications are always a result of a considerable collective effort and the successful completion of anthologies always requires additional coordination. We would like to use this opportunity to thank all contributors collectively for their important efforts in completing this project. Some contributors we would like to praise individually. We thank all authors for their highly stimulating papers and all reviewers for their critical and constructive feedback.


This book project also benefited greatly from numerous discussions with the members of the board of CASiM. We would like to acknowledge their important support. Special thanks go to Prof. Dr. Thomas Gehrig (University of Vienna) and Prof. Dr. Peter Letmathe (RWTH Aachen University) who also acted as reviewers in the double peer review process.


We would particularly like to thank our partners, Siemens AG, B. Braun Melsungen AG and McKinsey & Company, Inc.. Without their expertise and financial support the publication would not have been possible in the current form.


Furthermore, we would like to thank Dr. Martina Bihn, Editorial Director at Springer, for her professional guidance and numerous constructive discussions throughout the publication process.


Last but not least, we owe special thanks to Ms. Daniela Neumann and Dr. Lukasz Swiatczak from the Executive Office of CASiM who managed this book project, and successfully coordinated all activities of the authors, reviewers, and editors and provided continuous and enthusiastic support.


We hope this publication will not only provide interesting reading, but will also encourage further discussions and academic research on the boundaryless hospital and other innovative approaches to coping with the challenges and opportunities of health care in the 21st Century.


Selected articles (abstracts)


Infection Prevention and the Role of the Boundaryless Hospital


by Dennis Haking



Abstract Annually, there are approximately 900,000 nosocomial infections in Germany. These infections are often caused by multi-resistant bacteria like MRSA. The spread of these bacteria is fostered by the inappropriate and unnecessary use of antibiotics in the inpatient and outpatient, and also agricultural sector. In order to prevent the spread of multi-resistant organisms, cross-sectoral, concerted actions of health facilities and the community have to be forced. Therefore structures have to be implemented that motivate the players in a health care system to make efforts in infection prevention and patient safety. For countries with a relatively high MRSA rate as it is the case in Germany, it is necessary to have a benchmark with regions or countries like the Netherlands which show a significantly lower MRSA rate. The factors which determine the success of the Dutch prevention strategy have to be clearly evaluated and constructively adopted according to the requirements of the German health care system. The superior aim is to connect the service sectors in the health care system to establish concerted actions in terms of infection prevention. Established regional infection prevention networks show successfully how to overcome sector boundaries as well as internal boundaries, e.g. in hospitals.


Role and Function of the Emergency Department in a Boundaryless Hospital


by Maximilian C. von Eiff and Wilfried von Eiff


Abstract Over the last years an increase of patient demand in hospital emergency departments (ED) by at least 7 to 10 percent per year has been observed.


In a “boundaryless hospital” the ED plays a pivotal role as a gatekeeper and has a hub function because 30 to 50 percent of all inpatients are admitted as emergency patients first. The ED is challenged to overcome four typical boundaries: the management boundary of being forced to enhance medical quality and contain costs simultaneously, the primary-acute care-boundary, the boundary between ED management and hospital management (management level) and the boundary between ED patient service and acute care service (clinical level). Tearing down these boundaries by optimizing the process of ED-patient flow can contribute to shorten average length of stay in the ED, to lower patient risks and to reduce treatment costs. In two independent randomized, prospective two-center cohort studies (with 184 and 260 patients) evidence could be verified that process optimization for the treatment of patients suffering from acute coronary syndrome (ACS) contributes significantly to both cost savings and enhanced medical quality. Moreover, point-of-care-testing (POCT) technology leads to speeded up turn-around-times for lab test results of critical parameters (high-sensitive troponin = cTnI). As a consequence, crowding effects could be reduced and an exoneration of ED capacity could be stated.


Network Management as a Strategic Option for the Boundaryless Hospital


by Wilfried von Eiff


Abstract Due do to the phenomenon of the aging society, the number of patients suffering from multi-morbidity and/or chronic diseases has rapidly increased. Simultaneously, the cost-intensive progress in medical technologies leading to more precise diagnostic and innovative surgical interventions, enables treating patients with complex illnesses, as well as elderly people, more effectively.


Bearing this development in mind, it is fair to comment that patient-centered, successful medical services based on sustainable financial sources have to be organized in cross-sectoral medical networks consisting of primary care physicians, specialized clinics and rehabilitation facilities. The concept of the boundaryless hospital, in combination with the value chain approach, provides the theoretical basis for an effective and efficient network design. In this article, the nature, aims and impacts of network management in medicine are described. Furthermore, the traps and pitfalls of insufficient and inefficient network structures are discussed, and different types of network configurations, as well as limiting factors of network design are discussed. In addition, selected network concepts like the portal clinic approach, cross-sectoral contracting, managed care opportunities and emergency network designs are depicted. Ultimately, there are convincing facts and findings enabling us to recommend network concepts as the most effective and efficient way to provide medical services for the broader population.

International Benchmarking and Best Practice Management:


In Search of Health Care and Hospital Excellence




Wilfried von Eiff




Purpose: Hospitals worldwide are facing the same opportunities and threats: the demographics of an aging population; steady increases in chronic disesaes and severe illnesses; and a steadily increasing demand for medical services with more intensive treatment for multi-morbid patients. Additionally, patients are becoming more demanding. They expect high quality medicine within a dignity-driven and painless healing environment.

The severe financial pressures that these developments entail oblige care providers to more and more cost-containment and to apply process reengineering, as well as continuous performance improvement measures, so as to achieve future financial sustainability. At the same time, regulators are calling for improved patient outcomes. Benchmarking and best practice management are successfully proven performance improvement tools for enabling hospitals to achieve a highler level of clinical output quality, enhanced patient satisfaction, and care delivery capability, while simultaneously containing and reducing costs.


Approach: This chapter aims to clarify what benchmarking is an what it is not. Furthermore, it is stated that benchmarking is a powerful managerial tool for improving decision-making processes that can contribute to the above-mentioned improvement measures in health care delivery. The benchmarking approach described in this chapter is oriented toward the philosophy of an input-output model and is explained based on practical international examples from different industries in various countries.


Findings: Benchmarking is not a project with a defined start and end point, but a continuous initiative of comparing key performance indicators, process structures, and best practices from best-in-class companies inside and outside an industry.

Benchmarking is an ongoing process of measuring and searching for best-in-class performance:


Measure yourself with yourself over time against key performance indicators

Measure yourself against others

Identify best practices

Equal or exceed this best practice in your institution

Focus on simple and effective ways to implement solutions


Comparing only figures, such as average length of stay, costs of procedures, infection rates, or out-of-stock rates, can lead easily to wrong conclusions and decision-making with often disastrous consequences. Just looking at figures and ratios is not the basis for detecting potential excellence. It is necessary to look beyond the numbers to understand how processes work and contribute to best-in-class results. Best practices from even quite different industries can enable hospitals to leapfrog results in patient orientation, clinical excellence, and cost-effectiveness.


Originality/value: Despite common benchmarking approaches, it ist pointed out that a comparison without "looking behind the figures" (what it means to be familiar with the process structure, process dynamic and drivers, process institutions/rules and process-related incentive components) will be extremely limited referring to reliability and quality of findings.

In order to demonstrate transferability of benchmarking results between different industries practical examples from health care, automotive, and hotel service have been selected.

Additionally, it is depicted that international comparisons between hospitals providing medical services in different health care systems do have a great potential for achieving leapfrog results in medical quality, organization of service provision, effective work structures, purchasing and logistics processes, or management, etc.


This article is published in:


International Best Practices in Health Care Management.



Sandra C. Buttigieg (University of Malta)

Cheryl Rathert (Virginia Commonwealth University)

Wilfried von Eiff (HHL Leipzig Graduate School of Management)


Managing Editor: Jim Goes (University of Phoenix)


Emerald Group Publishing Ltd., Bingley, 2015