High Performance

in Hospital
Management

A Guideline for Developing

and Developed Countries

Edda Weimann
Peter Weimann

123
High Performance in Hospital Management
Edda Weimann  •  Peter Weimann

High Performance
in Hospital Management
A Guideline for Developing
and Developed Countries
Prof. Edda Weimann, MD, MPH Prof. Peter Weimann, MSci, PhD
Commerce Faculty Commerce Faculty
Department of Information Systems Department of Information Systems
University of Cape Town University of Cape Town
Private Bag X3 Private Bag X3
Rondebosch 7701 Rondebosch 7701
Cape Town Cape Town
South Africa South Africa
Groote Schuur Hospital Beuth University
Academic Hospital Luxemburger Strasse 10
University of Cape Town 13353 Berlin
Cape Town Germany
South Africa

We are grateful for the support received from the CEO Dr. Patel and the Hospital Facility
Board of the Groote Schuur Hospital.

This book is based on the German Edition ‘High performance im Krankenhausmanagement’

by Edda Weimann and Peter Weimann © Springer, Berlin Heidelberg, 2012; ISBN 978-3-
642-25067-5 and was adapted for health systems in developing and developed countries.

ISBN 978-3-662-49658-9    ISBN 978-3-662-49660-2 (eBook)

DOI 10.1007/978-3-662-49660-2

Library of Congress Control Number: 2016960006

© Springer Berlin Heidelberg 2017

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Foreword

The task of delivering healthcare in a resource-constrained environment is

becoming a challenge in the South African context. Hospital managers are
­
expected to balance the burden of disease and the patient load against shrinking
resources, while still maintaining quality of care. The weight of this burden is
increasingly being felt in the public health care services, where there is a need
to support a growing population of uninsured citizens and immigrants from else-
where in Africa seeking care, and, for reasons both economic and related to the
design and delivery of healthcare, the trend is compounded by an ageing popula-
tion, a rising burden of infectious and chronic diseases and a global shortage of an
adequately skilled workforce. The leaders of today would need to do something
different to avoid a collapse of the system.
Leaders themselves will need to change in a transformational direction to
improve the quality of care provided. Such a change in strategy comes with the
realisation that there is no quick fix and that the transformation process takes time
to embed and institutionalise. Transformation involves much more than any single
event but instead is part of an overarching strategy, the core of which is to maximise
value for the patient. However, this focus should not deflect attention away from the
goal of ensuring that the staff who provide the service have the resources as well as
a safe and pleasant environment in which to perform these duties.
The expectation of good governance and management extends beyond merely
managing resources and people to include the challenge of understanding the con-
text within which those with executive responsibility will have to function, how they
will motivate and enable those from whom they seek a desired action, in addition,
to interpret the customers’ needs and how to satisfy them. A different model of lead-
ership is needed to respond to this rapidly changing environment, a model in which
leadership is shared amongst the employees, all working as a team towards a com-
mon vision through continuous improvement.
It is not uncommon for the leader of any organisation to embrace change so as
to create a better future. This future, however, will be more than simply an extrap-
olation of current circumstances, but instead is part of a complex and discontinu-
ous journey towards an unpredictable end. This end cannot be goal-less, but
should present a vision that drives change strategically. In addition, leaders and
managers need to achieve operational efficiency.

v
vi Foreword

This book provides a guide and tools that enable leaders, including managers,
to achieve the operational efficiencies necessary in order to work towards a
shared goal of change and transformation so as to secure the best results for the
organisation.

Dr Bhavna Patel
CEO
Groote Schuur Hospital
Cape Town, South Africa
Foreword

This book will be of interest to managers, clinicians, nurses and other staff in posi-
tions of leadership in the hospital and health-care environment in general. The style
of presentation, which includes case studies, diagrams and questions at the end of
each of the ten chapters, makes it accessible to clinicians who would generally not
have had any formal training in the science of organisational management. This
book covers the principles of business management as they apply to the health-care
environment. The intention of the authors is to make it relevant to both developed
and developing country settings.
The primary perspective presented in this book is relevant to the private sector
where profit, the competitive edge and market penetration are paramount. In Chap.
1, for example, on involving clinicians, nurses and patients to drive the hospital, the
concept of a market-driven hospital is presented. In public hospitals, addressing the
burden of disease rather than market share would be a paramount consideration. The
principles presented in this book can however be appropriated to the context of a
public hospital that is not only concerned with meeting the needs of the community
based on the burden of disease, but also in the improvement of the quality of care
and health outcomes among individual patients and public health.
A world with equitable and universal access to quality health care is one of the
central objectives of the Sustainable Development Goals that were adopted by
Heads of States at the United Nations in September 2015. This New Agenda, which
calls for the achievement of universal health coverage, including financial risk pro-
tection, access to quality essential health-care services and access to safe, effective,
quality and affordable essential medicines and vaccines for all by 2030, will not be
realised without high performance in the management of the health-care system.
The ten steps to success in high-performance hospital management that are outlined
in this book, if implemented, will contribute in no small measure towards the
achievement of the health-related Sustainable Development Goals.

Cape Town, South Africa Prof. Bongani M. Mayosi, DPhil, FCP(SA)

 Dean, Faculty of Health Sciences

vii
Author Biography

Prof Edda Weimann, MD, MPH

[email protected]

Professor Edda Weimann is a paediatric endocrinologist and public health professional

with international work experience. She obtained her medical degree at the Ludwig
Maximilians University of Munich (LMU), her habilitation in Paediatrics at the Goethe
University Frankfurt and her master’s degree in public health at the University of Cape
Town. She has served as head of departments and hospitals at tertiary care facilities
and is a faculty member of universities in Germany, Switzerland and South Africa.
She has published widely in international peer-­reviewed journals. Several of her books
have been translated into other languages. Currently, she heads the first Healthcare
Innovation Hub in Africa, is a member of the executive management team at Groote
Schuur Hospital and engages in green campus, climate change and health care initia-
tives. Her current research topics cover health care management, international health
systems, m-health, child and adolescent health and environmental health.

1. Groote Schuur Hospital and UCT Private Academic Hospital, University of

Cape Town, Private Bag, Observatory 7937
2. University of Cape Town, Faculty of Commerce, Department of Information
Systems, Private Bag X3, Rondebosch 7701 Republic of South Africa

ix
x Author Biography

Prof Peter Weimann, MSci, PhD

[email protected]

Peter Weimann is Professor of Information Systems at Beuth University in Berlin

and at the University of Cape Town (UCT). He holds a master’s degree in computer
science and obtained his PhD from UCT. His major professional experience lies in
the fields of business engineering, change management, project management and
the development and introduction of new IT-systems. He has broad experience as a
project manager, served as head of branch offices and has acted as senior consultant
for both private industry and federal ministries. He has written several books and
published his research in numerous journals. His research interests include the use
of technology in virtual project teams, information technology in Africa and in
health care.

1. University of Cape Town, Faculty of Commerce, Department of Information

Systems, Private Bag X3, Rondebosch 7701 Cape Town, South Africa
2. Beuth University, Luxemburger Straße 10, 13353 Berlin, Germany
Preface

There are two primary choices in life: to accept conditions as they exist, or to accept the
responsibility for changing them (Dennis Waitley)

Worldwide health care delivery and patients’ expectations have changed signifi-
cantly over the past few decades: Governments have realised that they need to
improve the health of the population for the country to be economically successful.
Meanwhile, the World Health Organisation proposes implementing universal health
care to close existing gaps in service delivery and access to care. However, there are
still huge disparities in health care delivery. Up until the present, numerous govern-
ments of developing countries have provided lower coverage for the costs of health
care than in most developed countries. Consequently, citizens of developing coun-
tries make a higher number of ‘out of pocket payments’, which counteracts financial
risk protection and can lead to disastrous financial situations for families.
In most European health systems patients are well looked after, although expec-
tations and the satisfaction of health care consumers do vary between countries.
Compared with countries such as the United States, European health systems show
advantages in equity, family-friendliness, regular check-ups, treatment options for
elderly people, therapy choices, approved treatment indications and no significant
treatment disparities between private and public patients. A welfare citizen or
migrant is entitled to receive a kidney or heart transplant if there is a medical indica-
tion. Likewise, while even at 80-years-old a patient can have a hip replacement.
Drug and treatment options are broad. Family insurance schemes guarantee that
children and a non-self-earning spouse do not pay a separate health care fee (e.g., in
Germany). Employers are required by law to earmark a portion of their employees’
monthly salary for health. Some countries have, however, restricted treatment
options: in Switzerland each family member is obliged to apply for their own insur-
ance; in UK hip replacements and transplants are not performed on elderly patients.
In addition, in hospitals a shift has taken place: the formerly near-almighty Head
of Department, who decided everything by himself, has had to cede authority to a
near-almighty CEO, who ensures that the hospital generates profits. Diagnosis-
related Groups (DRGs), Healthcare Resource Groups (HRGs), Payment by Results
(PbR) and improved quality standards have revolutionised hospital processes over
the last few years. Developing countries such as South Africa are on the cusp of
such changes, introducing DRGs into their new National Health Insurance (NHI).

xi
xii Preface

However, the changes have had costs attached to them. The new DRG require-
ments have added to the staff’s bureaucratic and administrative tasks. Expertise in
caring for patients has been lost as skilled personnel have chosen other, more attrac-
tive areas such as executive hospital management or quality assurance. Many health
systems are experiencing a severe brain drain of health care workers and doctors
who migrate to countries that offer better working conditions and compensation. On
the subject of length of work hours, significant improvements have been introduced
for nursing staff and recently also for doctors. What can we do to make hospitals
more attractive to patients and employees? What drives people to emigrate or move
to other fields where their expertise is more appreciated? What can be done to keep
experienced staff in our health care system and increase the satisfaction of patients
and of staff?
A paradigm shift is needed to align market orientation with professional ethics.
Patients have to be placed at the centre of all interests so that genuine ‘patient-­
centred care’ can be delivered. With all the profit orientation and resource con-
straints, an ethical debate must take place. Many employees, especially doctors and
nurses are worried about this paradigm shift from being curative-supportive to
becoming profit-orientated. Health care staff is in general very committed to look-
ing after patients, and show high work morale. Nevertheless, the economic condi-
tions in which health professionals work cannot be disregarded. In the future all
citizens globally will need to be provide with a sustainable, affordable and efficient
health systems. This can only be achieved if everyone is willing to contribute.
Hence, further fragmentation of the health system with the redundancy of diagnos-
tic procedures must be avoided as we have to use resources economically as well as
in an environmentally friendly way.
Many hospitals are not yet professionally managed and even now operate accord-
ing to a system that can only be called one of ‘trial and error’. Management tools are
not transparently applied at all levels. Visions and strategies are not developed
according to the requirements and the set priorities; the employees are not aware of
them and are therefore not motivated to buy-in.
The hospital staff needs to actively engage in change management processes and,
even taking a step back, in a change of strategy, if necessary.
To carry out strategy changes successfully, employees have to be informed about
the goals of the executive management. Processes must be sound, unobstructed,
outlined, understood and implementable by the staff. All too often, CEOs and HoDs
expect that a solely top–down approach will work. This is not the case. You have to
engage with your staff and your stakeholders. Employees need to be familiar with
the various tools of effecting change and trained in using them.
This book, entitled High Performance in Hospital Management addresses all
who assume responsibility in our health care system. It proposes an overarching
and integrative management and leadership approach as depicted in Fig. 1. Health
systems only function well if hospital processes run smoothly. This book should
serve as a guideline for developed and developing countries to highlight and apply
management tools in addition to the soft skills, such as communication, leadership
Preface xiii

Communication
and change
management
Staff
Patient
development,
centredness
and reliability

Strategic
Adherence to
development
health system
and continuous
framework
improvement
Leadership

Provision and
Clinical continuous
governance training of
management
tools

Quality Resilience and

assurance appreciation

Fig. 1  Holistic hospital management and leadership approach

and appreciation, on a regular basis. The aim is to achieve a high-performing hos-

pital that offers an effective and satisfactory service for all health care consumers,
with the available resources. Patients and referring doctors are important stakehold-
ers, hence, hospital processes should be made transparent for them and so facilitate
their contributing to the positive transformation of our health systems and our
society.
In the following book we illustrate with positive and negative examples from
everyday hospital life how business management tools can be successfully intro-
duced and employed. Do not be afraid of a successful hospital, even though it does
imply that you may have to give up power and your favourite habits and, instead to
share with others. Only somebody who is ready to do that can be ultimately success-
ful at transforming an organisation.
xiv Preface

The ten milestones on the roadmap for developing a high-performing hospital

are:

1. Engage your nurses, clinicians and patients to drive your hospital

2. Create a corporate identity
3. Develop your vision and communicate it
4. Face your competitors
5. Improve communication and appreciation
6. Creating positive attitudes towards change
7. Develop and communicate your strategy
8. Find the best staff and develop their skills
9. Manage your conflicts professionally
10. Be a visionary leader

Enjoy the journey. Edda and Peter Weimann

 Cape Town, South Africa
Contents

1 Engage Your Nurses, Clinicians and Patients to Drive

Your Hospital. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 What Do the Different Stakeholders Expect
from a Health System? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.2 What Can We Learn When We Compare Health
Systems Internationally?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.2.1 Merging of Funds. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.2.2 No Opt-Out Option for High Income Groups. . . . . . . . . . . . . . 4
1.2.3 Quality and Efficiency Increase . . . . . . . . . . . . . . . . . . . . . . . . 6
1.2.4 Leadership of the State and the Teaching of Values. . . . . . . . . 6
1.3 What Do Patients Expect from Health Systems and Hospitals?. . . . . . 6
1.3.1 European Health Systems as a Model
for Developed Countries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.3.2 South African Health System as a Model
for Developing Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.4 How Can You Become a Top Health Care Provider?. . . . . . . . . . . . . . 9
1.5 Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.6 Five Reflective Questions for Practical Application. . . . . . . . . . . . . . . 11
References and Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2 Create a Corporate Identity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.1 Corporate Identity: Bottom–Up Instead of Top–Down. . . . . . . . . . . . . 13
2.2 Work Motivation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.3 Positive Emotionality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.4 Recognising the Competitive Edge. . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2.4.1 The Competitive Standing of a Hospital. . . . . . . . . . . . . . . . . . 19
2.4.2 Competitive Advantages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.4.3 Role of the Value Chain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.4.4 Competitive Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.4.5 Core Competencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.5 Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.6 Five Reflective Questions for Practical Application. . . . . . . . . . . . . . . 25
References and Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

xv
xvi Contents

3 Develop Your Vision and Communicate It. . . . . . . . . . . . . . . . . . . . . . . . 27

3.1 From Vision to Processes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.2 SWOT Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
3.3 A Practical Approach to Business Engineering. . . . . . . . . . . . . . . . . 32
3.4 Hospital Strategy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.5 Business Processes in the Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . 35
3.6 How Is the Hospital Strategy Linked to Business Processes?. . . . . . 37
3.6.1 Evaluation of Business Processes in the Hospital. . . . . . . . . 37
3.6.2 ABC Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
3.6.3 Process Portfolio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
3.6.4 Success Factors Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
3.7 Business Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
3.7.1 Process Maps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
3.7.2 Integration of Business Processes into the Hospital . . . . . . . 42
3.8 Project Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
3.9 Project Portfolio Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
3.10  Lean Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
3.11 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
3.12 Five Reflective Questions for Practical Application . . . . . . . . . . . . . 58
References and Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
4 Face Your Competitors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
4.1 Improve Your Processes Daily and Align Them to Your
Benchmarking Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
4.2 Business Engineering. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
4.2.1 Reasons for Business Engineering. . . . . . . . . . . . . . . . . . . . . 63
4.2.2 Business Engineering: Business Process Management. . . . . 69
4.3 Business Process Re-engineering . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
4.3.1 Fundamentals and Objectives . . . . . . . . . . . . . . . . . . . . . . . . 71
4.3.2 Goals and Approaches. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
4.3.3 Problems, Opportunities and Risks. . . . . . . . . . . . . . . . . . . . 75
4.4 Process Improvement with Kaizen, CIP and Six Sigma. . . . . . . . . . 76
4.4.1 Continuous Improvement Process. . . . . . . . . . . . . . . . . . . . . 78
4.4.2 Kaizen and Muda. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
4.4.3 Six Sigma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
4.4.4 ISO 9000 Quality Management. . . . . . . . . . . . . . . . . . . . . . . 84
4.4.5 Comparison of Approaches. . . . . . . . . . . . . . . . . . . . . . . . . . 86
4.5 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
4.6 Five Reflective Questions for Practical Application . . . . . . . . . . . . . 88
References and Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
5 Improve Communication and Appreciation. . . . . . . . . . . . . . . . . . . . . . . 91
5.1 The Art of Appreciation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
5.2 The Art of Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
5.2.1 The Four Pillars of Communication . . . . . . . . . . . . . . . . . . . 94
5.2.2 Be Aware of the Overall Impression You Make. . . . . . . . . . . 96
Contents xvii

5.3 The Four ‘Ears’ of Communication. . . . . . . . . . . . . . . . . . . . . . . . . . 97

5.4 Childhood Experiences Influence the Present. . . . . . . . . . . . . . . . . . 98
5.4.1 Transactional Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
5.4.2 The OK Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
5.4.3 The Drama and the Winner Triangle. . . . . . . . . . . . . . . . . . . 100
5.5 Feedback Culture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
5.6 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
5.7 Five Reflective Questions for Practical Application . . . . . . . . . . . . . 103
References and Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
6 Creating Positive Attitudes Towards Change. . . . . . . . . . . . . . . . . . . . . . 105
6.1 Change Management of Hospital Processes . . . . . . . . . . . . . . . . . . . 106
6.2 What Resistance Can Be Expected During 
Change Processes?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
6.3 How Fit Is Your Hospital for Change Processes? . . . . . . . . . . . . . . . 108
6.4 How Can You Encourage Willingness to Change? . . . . . . . . . . . . . . 110
6.5 The Seven Phases of the Change Curve. . . . . . . . . . . . . . . . . . . . . . . 114
6.6 The Seven Steps of Successful Change Management. . . . . . . . . . . . 115
6.6.1 Assessment of the Sponsor . . . . . . . . . . . . . . . . . . . . . . . . . . 115
6.6.2 Installing Programme Management. . . . . . . . . . . . . . . . . . . . 117
6.6.3 Communicating the Programme . . . . . . . . . . . . . . . . . . . . . . 118
6.6.4 Analysing the Hospital Culture. . . . . . . . . . . . . . . . . . . . . . . 119
6.6.5 Programme Planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
6.6.6 Planning the Implementation. . . . . . . . . . . . . . . . . . . . . . . . . 123
6.6.7 Monitoring the Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
6.7 Which Strategy Can Be Applied When?. . . . . . . . . . . . . . . . . . . . . . 124
6.8 CIRS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
6.9 Change Management by Outsourcing. . . . . . . . . . . . . . . . . . . . . . . . 127
6.10 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
6.11 Five Reflective Questions for Practical Application . . . . . . . . . . . . . 130
References and Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
7 Develop and Communicate Your Strategy. . . . . . . . . . . . . . . . . . . . . . . . 131
7.1 From Vision to Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
7.2 Four BSC Perspectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
7.3 The Role of the Cause-and-Effect Chain in BSC . . . . . . . . . . . . . . . 137
7.4 Implementing the BSC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
7.5 The Financial Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
7.5.1 Objectives of Financial Perspective. . . . . . . . . . . . . . . . . . . . 143
7.5.2 Key Performance Indicators
of the Financial Perspective. . . . . . . . . . . . . . . . . . . . . . . . . . 144
7.6 Patient and Referrer Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
7.6.1 Objectives of Referring Doctors’
and Patients’ Perspective. . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
7.6.2 Key Performance Indicators of Referring Doctors’
and Patients’ Perspective. . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
xviii Contents

7.7 Internal Business Process Perspective. . . . . . . . . . . . . . . . . . . . . . . . 150

7.7.1 Innovation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
7.7.2 Treatment and Service Processes. . . . . . . . . . . . . . . . . . . . . . 151
7.7.3 Service for Patients and Referring Doctors. . . . . . . . . . . . . . 152
7.7.4 Internal and External Communication. . . . . . . . . . . . . . . . . . 152
7.8 Learning and Growth Perspective. . . . . . . . . . . . . . . . . . . . . . . . . . . 153
7.8.1 Objectives of Learning and Growth Perspective. . . . . . . . . . 153
7.8.2 Key Performance Indicators of the Learning
and Growth Perspective. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
7.9 Case Report on the Application of the BSC. . . . . . . . . . . . . . . . . . . . 156
7.10 Problems in the Development and Implementation of BSC . . . . . . . 158
7.11 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
7.12 Five Reflective Questions for Practical Application . . . . . . . . . . . . . 160
References and Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
8 Find the Best Staff and Develop Their Skills. . . . . . . . . . . . . . . . . . . . . . 161
8.1 The Future Starts Yesterday. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
8.2 Successful Hospitals Through Continuous Staff Development. . . . . 163
8.3 How Do You Experience Your Working Environment?. . . . . . . . . . . 164
8.4 Which Staff Fits Your Hospital? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
8.5 Various Types of Employees. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
8.6 Various Characteristics in Executive Positions . . . . . . . . . . . . . . . . . 170
8.7 Stages of Team Development. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
8.8 How Will a Team Become Productive?. . . . . . . . . . . . . . . . . . . . . . . 172
8.9 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
8.10 Five Reflective Questions for Practical Application . . . . . . . . . . . . . 175
References and Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
9 Manage Your Conflicts Professionally . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
9.1 Professional Conflict Management . . . . . . . . . . . . . . . . . . . . . . . . . . 178
9.2 When Should One Intervene in a Conflict?. . . . . . . . . . . . . . . . . . . . 179
9.3 The Various Stages of Conflict Escalation. . . . . . . . . . . . . . . . . . . . . 180
9.4 Support the Organisational Dispute Culture . . . . . . . . . . . . . . . . . . . 181
9.5 Conflict Analysis and Handling. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
9.6 How Do You Proceed in a Case of Conflict?. . . . . . . . . . . . . . . . . . . 184
9.7 Strategies for Resolving Conflicts. . . . . . . . . . . . . . . . . . . . . . . . . . . 186
9.8 The Golden Rules of Conducting Conversations. . . . . . . . . . . . . . . . 189
9.9 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
9.10 Five Reflective Questions for Practical Application . . . . . . . . . . . . . 190
References and Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
10 Be a Visionary Leader . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
10.1 How to Be a Good Leader. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
10.2 Leadership Styles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
10.3 Maslow’s Hierarchy of Needs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
10.4 Leadership Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Contents xix

10.5 Empathy, Authenticity and Anticipation . . . . . . . . . . . . . . . . . . . . . 198

10.6 How Do I Motivate My Colleagues?. . . . . . . . . . . . . . . . . . . . . . . . 200
10.7 How You Create a Meaningful Work Environment. . . . . . . . . . . . . 201
10.8 The First 100 Days in the Job . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
10.9 Prevent Burnout. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
10.10 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
10.11 Five Reflective Questions for Practical Application . . . . . . . . . . . . 206
References and Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Engage Your Nurses, Clinicians
and Patients to Drive Your Hospital 1

Goals
–– What can we learn from other health systems?
–– What do the different stakeholders expect from their health system?
–– How innovative is your hospital?
–– Which managerial attitudes are not sustainable?

This chapter introduces different health systems and health care costs. Over
the past few years a new market-driven orientation of hospitals has taken place.
We elaborate on the Kutzin framework to improve efficiencies of health systems
and highlight what the different stakeholders can anticipate with regard to a health
system. In addition, the expectations of health care users in developing and devel-
oped countries are debated. The chapter ends with a questionnaire to investigate
how innovative your hospital is and how you can engage in the innovation process.

When health systems are compared internationally, there is a huge variety among
them regarding equality, quality of care, service and accessibility. Also even within
countries, for instance in the USA and South Africa, service delivery, mortality and
even life expectancy vary depending on whether patients are treated as public or as
private patients. In South Africa, for example, the mortality rate among children
younger than 5 years differs by a factor of 10 between the private and the public health
care system. This is caused not only by the quality of service delivery and treatment
options, which differ significantly, but also by socioeconomic factors and co-morbid-
ities. Patients who are aged over 50 years have co-morbidities such as diabetes or
hypertension and those who live in a non-supportive socio-economic environment are,
for example, not eligible for dialysis in the public sector in South Africa.
The UK is one country that provides universal health care (‘universal health
­coverage’) for all citizens by applying the Beveridge model, a welfare model in which

© Springer Berlin Heidelberg 2017 1

E. Weimann, P. Weimann, High Performance in Hospital Management,
DOI 10.1007/978-3-662-49660-2_1
2 1  Engage Your Nurses, Clinicians and Patients to Drive Your Hospital

Fig. 1.1 Government 100

expenditure (in %) 90
regarding overall 80
healthcare costs in OECD 70
countries (OECD 2006) 60
50
40
30
20
10
0
nd ria y ce
US ag
e
st an UK
rla r an
itze ave Au er
m Fr
G
Sw D
EC
O

health care is provided for all and financed by the government through tax payments.
The British National Health System (NHS) is often cited as a model for a public health
system that offers good service delivery. However, long waiting times for medical
services and limitations (e.g., hip replacement, organ transplants) from a certain age
are often applied in the British NHS. In the World Health Organisation (WHO) annual
report of 2010 the implementation of comprehensive health care was identified as
a major objective in improving the health care of the population worldwide. This
should enable all citizens to have equal access to health service providers and ser-
vices, without facing catastrophic financial situations. Health care costs are financed
by payments in advance (‘prepayment’) as part of regular contributions; government
levies such as taxes and out-of-pocket payments (OOPs; Fig. 1.1). Health care users
in developing countries frequently have to cover health care costs as OOPs. South
Africa has embarked on a major health policy reform, the National Health Insurance
(NHI), to close the huge service delivery gap between public and private health care.
The performance expectations of health system consumers tend to increase over
time. This relates to medical advances, the demographic population development and
the increased life expectancy, which contribute significantly to higher expenditure. To
meet these requirements, there are various options: the state provides more financial
resources, the service users pay more for health service delivery or the services delivered
by the health system are reduced. A combination of all three options is also possible.

1.1  hat Do the Different Stakeholders Expect

W
from a Health System?

An analysis of the various stakeholders of a health system can highlight the poten-
tial policy options and constraints:

1. The state strives for a healthy population to drive the economy. Only healthy
people can contribute significantly to the economic outcome of a state. WHO
data clearly show that only a healthy population leads to prosperity (‘health
comes before wealth’). The percentage of gross domestic product (GDP) that
each country provides for health expenditure varies, in particular, the p­ ercentage
1.1 What Do the Different Stakeholders Expect from a Health System? 3

Table 1.1  Healthcare expenditure total (percentage of gross domestic product [GDP])a and rela-
tion between private and public healthcare expenditureb
Government Private expenditure
Country 2011 2013 Trend expenditure (2013) on health (2013)d
Australia 9.2 9.4 ↑ 66.6 33.4
Austria 10.9 11.0 ↑ 75.7 24.3
 Botswanac 5.2 5.4 ↑ 57.1 42.9
 Brazilc 9.2 9.7 ↑ 48.2 51.8
 Chinac 5.1 5.6 ↑ 47.4 52.6
 Cubac 10.8 8.8 ↓ 93 7
Denmark 10.9 10.6 ↓ 85.4 14.6
France 11.5 11.7 ↑ 77.5 22.5
Germany 11.2 11.3 ↑ 76.8 23.2
Greece 9.8 9.8 ≈ 69.5 30.5
 Indiac 3.8 4.0 ↑ 32.2 67.8
 Mozambiquec 6.6 6.8 ↑ 46.4 53.6
 Namibiac 8.6 7.7 ↓ 60.4 39.6
Netherlands 12.1 12.9 ↑ 79.8 12.9
 Nigeriac 3.7 3.9 ↑ 23.9 76.1
Russian Federation 6.7 6.5 ↓ 48.1 51.9
 South Africac 8.6 8.9 ↑ 48.4 51.5
Sweden 9.5 9.7 ↑ 81.5 18.5
Switzerland 11.1 11.7 ↑ 66 34
 Tanzaniac 7.5 7.3 ↓ 36.3 63.7
UK 9.2 9.1 ↓ 83.5 16.5
United Arab Emirates 3.1 3.2 ↑ 70.3 29.7
USA 17.1 17.1 ≈ 47.1 52.9
 Zimbabwec No data available No data available
The table compares healthcare expenditure in developed and developing countries. The bold fig-
ures depict higher values and trends. Developing countries are highlighted in grey.
a
Worldbank (2013)
b
WHO (2013)
c
Developing country
d
Out of pocket payments

of public health expenditure in comparison with the total expenditure (Fig. 1.1,

Table 1.1). Chronic under-funding of the health system should be avoided.
2. Patients seek high-quality health care with easy access to care. Financial risks
protection for all citizens is mandatory.
3. Doctors, nurses and other health care workers appreciate good working condi-
tions, fair compensation, an approving society and a low amount of bureaucracy.
4. The general goal of the pharmaceutical industry is to make profits. As in most
cases new therapies are more expensive than the established ones, an economic
evaluation of new drugs is performed by some health systems (e.g., in Australia,
Canada) before they are approved for general use. The application of e­ conomically
calculated cost–benefit reviews balancing common goals for the sake of indi-
vidual well-being is a topic of ongoing ethical considerations.
4 1  Engage Your Nurses, Clinicians and Patients to Drive Your Hospital

5. Hospitals can be divided into ‘not for profit’ companies, which reinvest their
profits back into the hospital, or in ‘for profit hospitals’, which can belong to
hospital chains that have to distribute their profits to their shareholders. In sev-
eral countries, a wave of privatisation of hospital care has led to the fact that most
hospital beds are provided by private suppliers (e.g., in Germany). Some coun-
tries, such as Canada or the UK, have so far avoided providing hospital beds by
for profit (private) companies. Table 1.1 highlights the fact that in developing
countries people often have to pay higher out of pocket payments for their health
in relation to developed countries. This results in financially disastrous situations
for many health care users. Over the past few years health care expenditure
related to the GDP has increased in most countries. The data depict the major
contributor and trends.

1.2  hat Can We Learn When We Compare Health

W
Systems Internationally?

Internationally, we find different approaches for the optimisation of care and effi-
ciency of a healthcare system for the population (Weimann 2013). The basic goals
of a health care system are: treating the sick, keeping people healthy and protecting
them against financial ruin caused by expensive treatment. The basic models to
finance health care are the Bismarck and Beveridge Model, the National Health
Insurance (NHI) Model, which combines the Bismarck and Beveridge Model, and
the Out-Of-Pocket-Payment Model. Only a few, mainly developed countries have
implemented health care systems. Up to the present most nations do not provide any
kind of mass medical care. Therefore the WHO is promoting universal health care
where citizens can access health care services without facing financial hazard.

1.2.1 Merging of Funds

More than 125 years ago, the Prussian Chancellor Otto von Bismarck invented the
welfare state and introduced the world’s first public health insurance scheme for
workers in Germany, which has in the course of subsequent decades developed into
a social health system with universal health care protection for all. The Bismarck
model still serves as a framework for health systems worldwide.
To achieve universal health care coverage for all citizens as prioritised by the
WHO, risk protection through mutual financial support from rich to poor is pro-
posed. Kutzin has developed a framework (Fig. 1.2) that depicts the main financial
building blocks of a health system and highlights reform options (Kutzin 2001).

1.2.2 No Opt-Out Option for High Income Groups

Those who can afford more should pay more to ensure the social justice of a health
care system. Market and economic considerations in some countries (e.g., Germany)
resulted in high earners with low health risk profiles being able to choose
1.2 What Can We Learn When We Compare Health Systems Internationally? 5

Health care Stewardship of financing

financing (governance, regulation and
arrangements provision of information)

Monopolistic vs competitive, not profit vs.

for profit health care providers, user fees, Health services
Provision of services
out of pocket payments

Market structure: one vs multiple providers,

Purchasing of Coverage
administrative costs, efficiency and quality
services

Population (individuals)
of service delivery

Pooling of financial resources (private and

public) and prepayments, balancing of risks, Coverage
Pooling of funds improved cash flow

Improved supply and better efficiency of

public funds (low admin costs), improved tax Contributions/
revenue, efficient administration, fixed user fees
Collection of funds health care premiums, high cost
transparency and responsibility, regulated
entitlement of claims

Fig. 1.2  Ways of financing health care (Modified according to Kutzin 2001)

cost-­attractive private health insurance and ‘opting out’, thus breaking the solidarity
pact and undermining risk pooling.
To encourage patients to use resources in a reasonable way and to generate additional
revenues, some countries have introduced service fees. The economic benefit is ques-
tionable, as the administrative costs are high, and the main burden lies with the providers
as private practitioners, clinics, and hospitals. Consequently, user-fees were largely
abolished in, for example, South Africa and Germany, as they have not proven to be
economically viable. Other measures, such as co-payments, as practised in the Swiss
health care system, would be another option for changing patients’ behaviour. All pol-
icy-holders have to pay a so-called franchise fee. In Germany, one public family insur-
ance scheme covers all family members at a base rate. In most countries each family
6 1  Engage Your Nurses, Clinicians and Patients to Drive Your Hospital

member has to pay their own fee. Sometimes, some health services, such as orthodon-
tics, psychotherapies, etc., are not even eligible for reimbursement. Service limits and
other co-payments can be covered by a separate voluntary insurance scheme (as in for
example in Switzerland and Canada). In a variety of health care systems, a co-payment
is requested for certain diseases and therapies, such as in vitro fertilisation.

1.2.3 Quality and Efficiency Increase

According to the WHO up to 40 % of health resources are wasted in health systems.
Austria, for example, has significantly fewer health insurance companies than other
countries, resulting in lower administrative costs and consequently lower financial con-
tributions. In almost all health systems, performance parameters and the cost of health
insurance funds needs to be improved. Owing to the high administrative costs, allow-
ances should be integrated into the existing system based on the Kutzin framework
(Fig. 1.2) and satellite systems should be avoided (e.g., for government employees in
Germany). The more efficient use of existing resources and improved integration of the
various health service providers could increase quality and efficiency. Health care costs
for service delivery should be made transparent for public and private health care users.

1.2.4 Leadership of the State and the Teaching of Values

Health systems in various countries, such as Thailand, Korea or in some former Eastern
Bloc countries, such as Kyrgyzstan and Moldova, demonstrate that much can be
achieved for the benefit of the population, when the requisite political will and leader-
ship are present. Despite often difficult economic conditions, general insurance cover-
age for the population has been established over the last few decades. Not that these
health systems have reached an ideal state. Success could have been achieved had there
been the political will and had those responsible drawn up an agenda for health and that
declared the general commitment to working towards this goal.
Even though Swiss citizens pay a large amount of their income into the health
system and have several restrictions in place, they are satisfied with their health care
system. The US health care reform, also known as Obamacare, tries to provide
equal access for all, in accordance with WHO recommendations. This reform has
been attacked by various political stakeholders, viewed as being too administrative
and bureaucratic, reducing individual choices, but can serve as an example where
the greater good is inhibited by a lack of a mandate needed for reforms.

1.3  hat Do Patients Expect from Health Systems

W
and Hospitals?

1.3.1 E
 uropean Health Systems as a Model for 
Developed Countries

Various studies have investigated the views of health care users on their health sys-
tem. Several studies have been published that analyse the National Health Services
1.3 What Do Patients Expect from Health Systems and Hospitals? 7

in the UK. Some years ago the British government engaged the public, patients and
staff into participating in redesigning family health and social care to meet the chal-
lenges of the twenty-first century. According to the results, patients asked for quick
access to good, free and equitable care, and they wanted to have a say in their care
(Coulter 2005).
European health service users, when surveyed, revealed that they expect good
communication skills from their treating doctor, they want to be included in the
decision-making regarding treatment options, and would like to choose the service
provider, either a GP or a hospital, although most Europeans are unaccustomed to
having a free choice. Often they do not feel sufficiently informed to make this
choice. Citizens in Poland and Spain are not satisfied with the still paternalistic
approach to decision-making (Coulter and Jenkinson 2005).

1.3.2 S
 outh African Health System as a Model for 
Developing Countries

The South African health system is characterised by a severe divide between the
public and private sectors. The proposed NHI aims to bridge the existing health
inequalities and offer equal access to affordable, quality health care to all citizens,
irrespective of their socioeconomic status (Frogner 2010). The South African health
system is characterised not only by a two-tiered system, but also by escalating costs.
Further, while the costs in the private health sector almost doubled between 1996
and 2003, spending in the public sector decreased. Annual expenditure per capita
on private care is estimated to be four times higher than in the public sector. In addi-
tion, a major part of public health sector spending is directed towards HIV/AIDS
and TB treatment, to the neglect of other medical areas (Coovadia et al. 2009).
Adding to the decline in the quality of public health services are the poor gover-
nance and management of hospitals, public underfunding, mismanagement, short-
ages of health professionals and deteriorating infrastructure (Keeton 2010). South
Africa needs to invest in the training of health professionals: this is currently under-­
developed, indeed it is neglected. The use of measures that optimise efficiency and
enable the treatment of patients according to their needs such as the triage score, are
also proposed for the country. The escalating gap between the rich and the poor in
South Africa is underlined by the increasing Gini index over the last decade (59.0 in
1993 and 65.0 in 2009), which indicates that the disparity is wider than under apart-
heid. The country spends 8.9 % of its gross domestic product (GDP) on its health
care system, with a poor outcome that is emphasised by a low life expectancy (57
years in men versus 60 years in women) and a high neonatal mortality rate (19 per
100 live births in 2011). Most financial and human resources in the health care sec-
tor are currently located in the private health sector, which covers only a relatively
wealthy minority of the population.
The NHI seeks to provide universal access to health care as promoted by the
WHO. This is a system of health care financing that is aimed at ensuring that
everyone has access to efficient, appropriate and good-quality health services in
South Africa. It will be phased in over a period of 14 years and will lead to major
changes in delivery structures, administration and management systems. South
8 1  Engage Your Nurses, Clinicians and Patients to Drive Your Hospital

Improved health
Governance

Medicines & Information

technologies
Responsiveness

Access, coverage,
Patients quality & safety

Social & financial

risk protection
Work force Financing

Service
delivery Improved
efficiency

Fig. 1.3  The World Health Organisation (WHO) health system framework (WHO 2007)

Africa could reduce the burden of disease by 14.2 million disability-adjusted life-
years (DALYs) and gain up to 184,085 lives by avoiding premature deaths under a
single payer system like the NHI. However, this goal can only be achieved if ser-
vice provision, equity and efficiency are improved. Thus, it is important to estab-
lish public support by reaching and including, as broadly as possible, the different
stakeholders. This entails professionalism on the part of members of the public
service, the functioning of government departments and agencies as well as the
absence of corruption.
The WHO proposes a building blocks framework (Fig. 1.3) for health systems
strengthening (HSS), the aim of such strengthening being to provide effective, equi-
table and good-quality health care and to maximise its accessibility for the popula-
tion (WHO 2007). Although the WHO building block framework does supply
health sector actions for strengthening health systems, the blocks in fact appear
static and not interrelated. Further, the framework specifically addresses neither the
role of the population in this process, nor the underlying social and economic deter-
minants, nor the interactions that exist across each component. The building blocks,
in short, provide an outline for the hardware, but not for the ‘software’ required to
apply ideas and interests, relationships and power, norms, values and human rights
to the strengthening process. A practical approach to HSS may, however, be applied
through the use of systems thinking, which is a means of gaining understanding of
the dynamics and the relationships of the various stakeholders that would be essen-
tial for successful interventions. Health systems are meant to be complex adaptive
systems that aim to provide improved health, social and financial protection, as they
respond to the expectations and current needs of the population.
Since public consultation and participation are valuable tools to be drawn upon
in support of the successful implementation of new policies, a survey was performed
to find out what these perceptions are (Weimann and Stuttaford 2014). The analysis
of the responses to the survey revealed the public requesting for improved service
1.4 How Can You Become a Top Health Care Provider? 9

efficiency, equity, affordability and the equal allocation of resources between the
public and the private sector. These findings substantiate the need for reform and fit
with the aims of the NHI. The current state of the health system is described as
neither accountable nor efficient. From the patient’s perspective, there is a shortage
of medicines, an uneven distribution of health services, and poor availability of
equipment and of intersectional services. Basic service management appears to be
inadequate. The respondents in this study are concerned about the quality of care
they are receiving. Most of the concerns and inefficiencies have been picked up in
the NHI’s plans. However, several themes are identified here that are not yet covered
by the NHI, these include, the need to fight corruption and have regular surveil-
lance, the implementation of underlying ethical values for health care professionals
and indicators for improved health services. In general, people judge the quality of
care to be better in private hospitals, with faster treatment and shorter waiting times.
The staff in private health care is described as being better organised, more attentive
and more patient-­orientated in comparison with staff in public health care.
The expectations of South African health care users accord with those of other
countries, with some exceptions particular to this country. South African health care
users regard it as vital to address the existing corruption in the public health care
system and to implement underlying core ethical values to which those working in
the health care sector must adhere. In addition, the lack of trust in government artic-
ulated by health care users should be addressed by policy makers and -implementers.
South African health care consumers also suggest advancing the intersectional
relationships within the health system for the benefit of the population. And, inter-
estingly, they ask for a more holistic approach and capacity enhancement to estab-
lish an efficient working health system (Weimann and Stuttaford 2014).

1.4 How Can You Become a Top Health Care Provider?

Management and staff have to be aware of the macro- as well as microeconomic

context in which their hospital is placed. They have to know their health system’s
constraints and possible solutions. The status quo must be analysed and evaluated to
improve current processes. External views and critical voices should be considered.
Self-reflection and innovation are two underlying main drivers in becoming a high
performing hospital. Besides, existing organograms should be evaluated so as to see
if they are effective, if they cover the needs of the various role players and if they
use those enhancing processes. The next nine chapters provide you with the neces-
sary tools to run your hospital or division successfully, thus avoiding the following
mistakes:

1. Provide clear evidence of who is the boss in the hospital and who has a say.
2. Decisions of the executive hospital management ought never to be questioned.
3. Never change a path that is being pursued.
4. You are only allowed to critique behind closed doors. Otherwise, commonly
articulated unhappiness and dissatisfaction is favoured.
5. Processes should not be changed as this only leads to confusion.
10 1  Engage Your Nurses, Clinicians and Patients to Drive Your Hospital

6. The satisfaction of staff is prioritised over the satisfaction of patients and refer-
ring doctors.
7. Everybody is replaceable, except for the hospital’s executive management.
8. We value our workplace as we earn money and receive incentives.
9. The duration of occupancy and stay affects the career more than the qualifica-
tions and efficiency of a person.
10. Before we cooperate with the competing hospital next door, we would rather
refer the patient to the nearest tertiary care or academic hospital.

If you adhere to these statements, your hospital will not advance to becoming a
high-performing and competitive hospital. The questions below will highlight your
ability to embrace innovation.

Questionnaire Innovation Yes No

1 Is your hospital/department the economically most successful hospital/
department in the region?
2 Are representatives of patients and referring doctors present on the hospital
board and do they have a say there?
3 Is your opinion considered and acknowledged in the decision-making process?
4 Is the continuous improvement process through transparent communication
and process optimisation incorporated into the everyday life of the hospital?
5 Are decisions that are taken by the executive hospital management made
transparent, are they comprehensible, and can they be implemented by you
and your staff?
6 Do you get social recognition for working in your hospital?
7 Does your hospital have a good reputation and do the patients feel well looked
after?
8 Does the hospital make enough profit and is it used to develop the hospital
further?
9 Are innovations and market-orientated developments carried out promptly
within a certain time frame?
10 Are you aware of the visions, strategies, processes, decision-making pathways
and behavioural codes in your hospital?

1.5 Summary

Hospitals are run within the broader microeconomic and macroeconomic contexts.
Staff members have to be aware of the health systems’ constraints and possible solu-
tions. Liaise with your stakeholders on a regular basis and explore what they expect
from your hospital. They are your target group. Engage your co-workers and subor-
dinates in a continuous improvement process. You will find useful and applicable
tools in the next chapters of the book, which will provide a holistic approach to
tackling current and future problems. Enjoy the journey!
References and Further Reading 11

Solution to Questionnaire Innovation

1. If you answered more than eight questions positively, our congratulations. You
are working for an innovative healthcare provider. Further improvements will
probably be well received and acknowledged.
2. If you have answered more than six questions positively, your hospital is a ser-
vice- and future-orientated provider. Support the further development by apply-
ing the steps outlined in the book.
3. If you answered fewer than six questions positively, do not be discouraged. Most
hospitals fall into this category. Together with a visionary and innovative leader,
you and your colleagues can improve the hospitals performance if you continu-
ously apply the relevant measures explained in our book. Bonne chance!

1.6 Five Reflective Questions for Practical Application

1. Analyse different hospital processes (admission, discharge, patient flow, dis-

charge management) and explore whether or not a patient-centred approach is
being followed.
2. Does the classical separation among management, nursing and clinical services
create obstacles to providing efficient and effective services?
3. Can you name three examples where you cooperate with other service

providers?
4. Which major constraints are you facing this year in your health system (budget
cuts, scarce skills, nursing etc.)?
5. How do private health care providers influence your business (e.g., depletion of
scarce skills that move to the private sector; less revenue; service cuts as patients
are using other service options)?

References and Further Reading

Coovadia DMH, Jewkes R, Barron P, Sanders D (2009) The health and health system of
South Africa: historical roots of current public health challenges. Lancet 374(9692):817–834
Coulter A (2005) What do patients and the public want from primary care? BMJ (Clin Res Ed)
331(7526):1199–1201
Coulter A, Jenkinson C (2005) European patients’ views on the responsiveness of health systems
and healthcare providers. Eur J Public Health 15(4):355–360
Frogner B (2010) Health and economic gains: what is at stake in South Africa’s Health Reform?
World Med Health Policy 2(3):25
Keeton C (2010) Bridging the gap in South Africa. Bull World Health Organ 88:803–804
Kutzin J (2001) A descriptive framework for country level analysis of healthcare financing arrange-
ments. Health Policy 56(3):171–204
OECD (2006) www.oecd.ilibrary.org/social-issues-migration-health/society-at-a-glance-2009
Weimann E (2013) Universal health coverage: warrantor for good health service provision. Dtsch
Ärztebl 110(3):A-69
12 1  Engage Your Nurses, Clinicians and Patients to Drive Your Hospital

Weimann E, Stuttaford M (2014) Consumers’ perspectives on National Health Insurance in South

Africa: using a mobile health approach. JMIR 2(4):8–21
World Health Organisation (2007) Everybody’s business. Strengthening health systems to improve
health outcomes. WHO’s framework for action. World Health Organization, Geneva
World Health Organisation (2013) http://www.who.int/health-accounts/tools/en/
Worldbank (2013) http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS
Create a Corporate Identity
2

Goals
–– What are hospital strategies from the top management?
–– Which group of employees damages the hospital deliberately?
–– What do employees need to be dedicated to a hospital?
–– How can Porter’s value chain be applied to creating a corporate identity for
the hospital?

In this chapter we differentiate among corporate identity, corporate design

and corporate image. This leads to the question: how can you motivate your co-
workers and subordinates? The entire chapter gives you the competence to
achieve a competitive advantage.

2.1 Corporate Identity: Bottom–Up Instead of Top–Down

Corporate identity reflects the character of a hospital. Its purpose is to make it

unmistakably recognisable both inside and from the outside (Balmer and Greyser
2006). A hospital’s corporate identity comprises a mission statement, the company’s
philosophy, operational guidelines and external symbols such as the logo (Stuart
1999). Corporate design (that is the external appearance of the hospital), refers to
conduct, communication, philosophy, language and culture, all are part of it too and
they are co-ordinated. By comparison, the corporate image is what is seen from the
outside, how the hospital is perceived in its community. Ideally, corporate identity
and corporate image correspond with one another (Andreassen and Lindestad
1998). However, only a few hospitals ever achieve this. When a private company is
a service provider, the success of an enterprise increases through its corporate iden-
tity (Gotsi and Wilson 2001). In particular, companies newly on the market that are

© Springer Berlin Heidelberg 2017 13

E. Weimann, P. Weimann, High Performance in Hospital Management,
DOI 10.1007/978-3-662-49660-2_2
14 2  Create a Corporate Identity

innovative and have clear goals, will appeal. They prompt staff, regardless of their
rank or income, to be dedicated to the company beyond their working hours and to
identify with its goals. Thus, corporate identity is lived by the staff bottom–up; it is
not ordered top–down through directives issued by management.
A successful hospital should be run with the same passion, enthusiasm and per-
fectionism as a five-star hotel. To achieve this, care and attention to detail are given
priority: untidy and run-down foyers and over-flowing ashtrays and waste baskets
should not be tolerated. When a patient is admitted to a ward or day clinic or outpatient
department, the admitting staff should have been previously informed about the patient
and the reason for his admission. Hence, a personal welcome with a certain amount of
background knowledge is mandatory: for example, the patient, Mr Samuels, 65 years
of age, admitted for cardiac arrhythmia, referring physician Dr Bradshaw.

Case Study
Mrs Simons is admitted to the ward because of recurring upper abdominal
symptoms. She is nervous and unsettled because this is her first time in hos-
pital. After she has been greeted personally and given a brief explanation of
what is planned and when her interview with the ward doctor will take place,
her anxiety disappears. She consequently relaxes because she has now expe-
rienced the pleasant feeling of being in competent hands. She remembers her
husband’s stay in hospital some years ago when a sister called across the ward:
‘Here is a Mr Simons. Does anyone know why he has been admitted today?’
As a result, Mrs Simons was not then able to place her trust in the staff.
Conclusion: Invest time in the admission process and give guidance and
information to the patient and the family. This should include the possible
challenges that can occur during the hospital stay. It saves having to deal with
complaints later.

In integrative corporate identity management various specific measures are con-

ceptually linked, are strategically synchronised, and serve to promote the identifi-
cation of the employee with the hospital. A corporate identity cannot be prescribed.
It must be lived, not just by the staff in direct contact with patients, but also by the
hospital management, the directorate, the Hospital Board and, in particular, the
administration. The corporate image will reflect how well a hospital is accepted in
the community it serves as well as how much appreciation the employees receive
from their social contact. Not only should the hospital be proud of its employees,
the employees should also be proud of the achievements of the hospital. If an
employee and his/her family keep getting negative feedback regarding their
employer in the community (‘Oh dear, is that where you are working? I would only
go there if there’s no other alternative’), then they may eventually go looking for
another job in the long run or give up on the job after a while and mentally resign
(Sect. 2.2). On the other hand it is very encouraging for staff to hear from patients
that they are satisfied with the treatment and with hospital processes.
Cardinal questions that are always asked include: what is good hospital manage-
ment? can what is purely management be transformed into leadership? Firstly, it
2.2 Work Motivation 15

seems to be important to have a good mix at the management level, thus, there should
be no one autocrat who has the say, but rather an executive management team of
which all the members have an equal say. Ideally, a supervisory board comprises exec-
utive hospital managers, health economists, a person who is in charge of ethical con-
siderations and a patient representative. Preferably, members of the executive hospital
management and the hospital board should have their family members treated at this
hospital if they are ill – and not only because they will have the advantage of receiving
special treatment but because they know that the level of care provided is high.
A further question that arises is, how can you set this hospital apart from its com-
petitors? To this end, positive emotionality plays an important part. The staff must
be able to have empathy with patients’ concerns and be able to take action. An emo-
tionless work-to-rule attitude is something that patients quickly pick up on. Another
important element is the way in which the staff are included and whether employees
can develop a sense of: ‘This is my hospital, I am feeling empowered to drive it as I
want to contribute to its success. These are our patients for whom we as a team are
responsible.’

2.2 Work Motivation

Don’t try to flog a dead horse. You cannot succeed. (Author unknown)

Gallup, the US research-based, global consulting company, carries out regular pub-
lic opinion polls on staff satisfaction in several countries. It has been shown over
and over again that a constant proportion of employees work against a company or
even actively damage it by their behaviour. This can be reduced by targeted mea-
sures even though it can never be eliminated. In a 2014 Gallup poll 31.5 % of
employees were engaged, whereas 51 % were not engaged and 17.5 % were actively
disengaged. Managers and executives showed the highest level of engagement
(38.4 %). The proportion of engaged people is responsible for the success of an
enterprise (Gallup 2014). The commitment of employees mirrors their emotional
attachment to the company. According to Gallup, emotional ties correlate positively
with the business indicators, fluctuation, or absenteeism. Dedication not only influ-
ences work performance, but also has an impact on patients’ safety. Certain man-
agement ‘soft skills’ (Chaps. 5, 9 and 10) influence these key data significantly.
Figure 2.1 shows results from the Gallup poll for selected countries.
What drives people to be either dedicated or not? Let us take a closer look at the
Gallup questions with regard to the hospital and reverse them. ‘If employees are a
company’s best asset, then their care and support should be a priority’.
The degree of agreement with the following 12 statements may reflect e­ mployees’
motivation and thus also the success of a hospital:

1. I know what is expected of me at work. Only a few employees and even manag-
ers really know precisely what their superior expects of them.
2. I have the necessary equipment to do my work properly. Often there is not
enough space and equipment for the hospital staff to complete the necessary
16 2  Create a Corporate Identity

80

70

60

50
Engaged
40
Not engaged
30
Actively disengaged
20

10

0
South USA UK Switzerland Germany
Africa

Fig. 2.1  Employees worldwide engaged in work (Adapted from Gallup Poll (2014))

administrative work. (Negative example: five interns and registrars share one
office in which there are two desks and one PC).
3. I have the opportunity to do what I am able to do every day. This is one of the
key issues raised by young doctors in particular, such as interns and registrars.
In the past, patient consultations and treatments were given priority, whereas
currently effectiveness is measured by the number of doctor’s discharge letters
and prompt submission of International Classification of Diseases 10 (ICD 10)
and diagnosis-related group (DRG) codes. Nowadays, the work is overloaded
with administrative tasks. Alienation from the original occupational profile has
taken place and can cause demotivation.
4. I have received appreciation or praise for doing a good job during the last 7
days. The motto: ‘No praise means no blame’ no longer applies.
5. My superiors show personal interest in me. Social appreciation in a hospital
should be applied at all levels. A departmental head, hospital director or consul-
tant who appreciates the staff and finds time and is interested in his employees
personally will, in the long run, only succeed if s/he in turn finds appreciation
for his/her work and engagement in the hospital from superiors.
6. There is someone at my workplace who supports my development. Mentoring
plays an increasingly greater role. If a new employee joins the hospital staff, a
mentor or coach (▶ Glossary) should be assigned who will accompany him/her
and support the employee in future training. Targeted continuing professional
development programmes, which are quite common these days, should be
offered more frequently in health care delivery.
7. My opinion seems to matter at work. How often do you hear the following
phrase in your hospitals: ‘I am only a small fly/tiny dog. My opinion doesn’t
count.’ Such an attitude has a negative impact on a hospital, for employees such
as secretaries, receptionists or security staff often do not feel appreciated, and
yet they have first contact with patients – and first impressions count. Hence,
you have to focus on the image presented on the patient’s first entrance: if a
2.3 Positive Emotionality 17

secretary or clerk continually puts on the answering machine, at some point

patients will stop calling during the specified and often very limited times
and look for alternatives. Poor service awareness is often encountered with
monopolist institutions such as university hospitals, provincial hospitals and
large regional hospitals.
8. The goals of the hospital make me feel that my work is important. It is a chal-
lenging task for hospital management to reach and talk to all employees. This
is only done in successful hospitals.
9. My colleagues are motivated to work to the highest standard. It is important
which structures new members of staff in particular encounter. How are mis-
takes and complaints handled? Does a team manage to implement change pro-
cesses that improve the operational output such as quality in addition to ensuring
patient satisfaction? Are the department and executive hospital management
teams actively engaged in creating a high work morale? (Chap. 6).
10. I have an important ‘go-to’ person in the hospital. Being grounded and
accepted plays an important part in the well-being of employees. On the other
hand, people who have mentally cut their ties may jointly work against the
hospital.
11. During the past 6 months someone in the hospital has discussed with me my
progress. It is important to the employee that performance reviews take place
regularly, and the employee’s achievements and evaluations are documented.
Employee should not experience such interviews as simply routine for their
superior. Standardised questionnaires for staff evaluations have already been
introduced in hospitals. However, often it is a matter of going through the
motions; the forms are simply filed and thus usually fail in their objective of
implementing targeted employee development.
12. I have had the opportunity to learn something new at work and to improve
myself over the past year. Professional development should play an important
part for both new and experienced hospital staff. A hospital should ensure in all
areas that staff can develop and will not at some point leave to join the competi-
tors because they offer better development opportunities.

2.3 Positive Emotionality

The factor of ‘empathy’, that is applied positive emotionality when treating patients,
is of crucial importance in order for a patient to feel accepted and well-cared for.
Casual remarks such as ‘No idea what Cardiology is thinking of to send you without
a prescription’ are quickly made, but stay with a patient for a considerable time and
create an image of incompetence and lack of care. Only if everybody works together
to achieve the common goal of treating patients at the best level can a health care
provider be successfully run. This does not necessarily require more staff, money or
other resources. You would have a similar experience with an almost empty coffee
shop: although the same number of staff is present, service and attention are occa-
sionally clearly worse than if all places are taken. If instead of one person, three
18 2  Create a Corporate Identity

people do not exactly know what is going on, the patient’s confidence in the treat-
ment is undermined.
When health systems are analysed and compared across the world, different qual-
ities of care are achieved, even when comparable budgets are used (Chap. 1). This
can be shown when infant mortality and average life expectancy are compared in
different health systems (WHO 2008). Huge amounts of money and resources can be
invested in malfunctioning systems without changing for the better.
The website is – to a higher or lower extent – user-friendly and professionally
designed. Usually, the most important feature is the mission statement, the self-­defined
task of the hospital. In most cases patient-centred care is advertised, patients finding
themselves apparently in first and central place. Yet, when the patient enters the hospital
s/he sometimes cannot get rid of the feeling that everything revolves around the staff’s
efficient work routines while the patient’s needs are hardly given consideration.
Hospitals spend large amounts of money on external and internal consultancy
contracts to create a corporate identity. Such corporate identity should ensure that
the patient feels well-­cared for in the hospital, but in fact this happens only in rare
cases. Patients notice very quickly the low value placed on them. Why is this the
case? The most moving words and well-advertised visions do not help at all if they
are not implemented as part of everyday-life. The hospital’s administration and
management are frequently referred to in derogatory terms. The management is
usually housed in a different building or at the top or ground floor of the hospital
and, compared with the rest of the hospital, it is best equipped. The reasons given
for this are the representative functions of the hospital, although a patient will only
very rarely find him/herself in the CEO’s office. From a kind of helicopter perspec-
tive, the top management issues directives while the Corporate Identity has been
prescribed top–down. The patient’s point of view is frequently only taken into con-
sideration when a complaint is written to the hospital’s CEO.

2.4 Recognising the Competitive Edge

It is better to be a big fish in a small pond than to be a small fish in a big pond. (South
African proverb)

It is important for a hospital to recognise and establish its own core competencies
by asking the question: compared with our competition, in which areas do we have
the competitive edge? To deal with this question we devote the following chapters
to recognising core competencies and the competitive edge.

Anecdote: The Farmer and the Tree Trunk

Han Fei Zi, the Chinese philosopher, born around 280 BCE
A young farmer was working in his field when a hare came running and crashed –
head first – into a tree trunk at the edge of the field. The hare died immediately.
Delighted, the farmer picked up the hare, took it home and prepared a delicious
meal. The next day, the farmer put aside his hoe and crouched next to the tree trunk.
He was hoping that another hare would come and run into the tree trunk, but in vain.
2.4 Recognising the Competitive Edge 19

And so he sat every day at the edge of his field and waited for a hare. In the mean-
time his field became covered in weeds.

This short story illustrates a very common attitude. After a chance success every
effort is made to repeat that success. In the meantime the real tasks are neglected
and actual competencies go unused.
A hospital’s vision must be implemented by using appropriate strategies.
Otherwise, both staff and patients will realise that the much vaunted vision on the
internet page is simply marketing. This is associated with loss of trust, both inside
and outside. Yet, trust is of central importance in medicine. Without trust in a hospi-
tal, in its doctors and nurses, patients are unable to commit themselves to a treat-
ment relationship and improve the condition of their health.
A successful hospital will analyse core competencies and competitive advantages
and use them as starting points for developing a strategy. The core competencies of a
hospital should be documented, thus enabling the processes on which the institution’s
competitive edge is based to be highlighted and analysed. The first step in documen-
tation is the so-called process map (Sect. 3.7.1), which visualises the processes in the
hospital. Identifying such a value chain illustrates the processes by which the hospital
stands out from its competitors to operate economically (Hines et al. 1998).

2.4.1 The Competitive Standing of a Hospital

Before a society becomes wealthier, it gets healthier. (Hans Rosling)

How companies or hospitals can achieve the competitive edge is illustrated in

Michael Porter’s concept of a value chain. Porter developed this concept as Professor
of Economics at Harvard Business School and published it in 1985. As a leading
economist in the area of strategic management he had already introduced his concept
in the 1970s. This approach introduced a fundamental change: whereas in the past
many decisions were taken based on gut feeling, more recently process orientation
and optimisation have developed to offer an essential approach to working in a com-
petitive and profit-orientated way. Only if the hospital works economically will it be
in a position to make the capital investments needed for its future development. This
applies not only to private hospitals, but also to public hospitals.

Definition
A process is defined as a temporal sequence of activities. For value creation a pro-
cess must be both efficiently and effectively structured. Efficiency means that the
result has to be better than the investment of factors. Flawed processes resulting in
poor quality imply that the treatment costs are too high and the service quality is
unsatisfactory for the patients and the referring doctors.
Compared with business processes in other companies, hospitals are repeatedly
facing problems in the three major hospital areas: administration and management,
medical departments, and nursing. Furthermore, the architectural structures of hos-
pitals often counteract integrated processes and hence value creation. For example,
20 2  Create a Corporate Identity

obstetrics, the neonatal unit, and the nursery may be situated in different buildings.
The coordination of treatment and interdisciplinary communication is seldom direct
and spontaneous, but has to take place via telephone and joint visits where not all
the staff involved can be present. Private hospital groups overcome this obstacle by
conceiving completely new hospital buildings with economically aligned care
structures.
The current situation must be ascertained and documented, focused on the essen-
tial parameters, depending on the processes that need to be analysed. This is helpful
in setting up a value chain and in recognising competitive advantages.
The following five forces influence the profitability of a business and determine
its appeal:

1 . Negotiating power of clients

2. Negotiating power of suppliers
3. Threat from alternative products
4. Threat from potential competitors
5. Competition within the branch of business

In the following, Porter’s value chain is aligned to a health care centre by apply-
ing the five forces model.

–– New competitors: new competitors require competition-orientated responses

that inevitably deplete a hospital’s own resources and thus reduce its profit
margin.
–– New products, alternative products and services: if genuine alternatives to hos-
pital services are offered elsewhere on the market or by a competitor, the scope
of one’s own pricing becomes constrained. In health systems that have to apply
DRGs, pricing outside of the budget is already very limited. The hospital may
apply alternatives by engaging in additional contracts outside of the budget. For
example, private patients could be offered individualised health services and
hence increase the attractiveness of the health care provider.
–– Negotiating power of clients: if clients can negotiate, they will do so. However,
this can reduce profits and as a result the profitability of the hospital. If services
are offered more cheaply in other health care centres or day clinics, this reduces
the competitiveness of the hospital.
–– Negotiating power of suppliers: if suppliers are limited and can enforce their
power (e.g., medical technology companies, pharmaceutical companies, and
medical supply stores) they will be able to increase prices and thus reduce
profitability.
–– Competition within the branch of business: competitive pressure, raises the
necessity of investing in marketing, research, and development or of reducing
prices – both consequently reducing profits. Depending on the particular special-
ist area, many inpatient services will be rendered mainly in outpatient facilities
within the next decade; thus, the range of services offered by hospitals is going
to change.
2.4 Recognising the Competitive Edge 21

2.4.2 Competitive Advantages

The competitive advantage is the result of establishing a profitable position together

with all the strengths offered by the hospital. In analysing competitive advantages
the following questions should be asked:

–– How can our hospital create competitive advantages and maintain them?
–– What is the underlying reason why other hospitals and hospital groups are being
more successful than us?
–– Which competitive strategies should be followed with regard to our position and
our expertise? The competitive position of a hospital is determined by the addi-
tional activities in innovative medicine, efficient treatment, marketing, waiting
times and the interaction with referring doctors (doctors in private practice,
health centres and other hospitals).

All activities contributing to the hospital’s relative cost situation form the basis
for being different from its competitors. For instance, a cost advantage can arise
because of the following:

–– Reduction to what is necessary and sensible in diagnostic processes (‘lean health

care’).
–– Efficient treatment processes (reducing levels of care from ‘intensive’ to ‘high
care’ to ‘low care’ with a reduced ratio of nurses and doctors per patient).
–– Continued treatment within the hospital group’s outpatient centres.
–– Cooperation with colleagues in private practice where services or support can be
offered by the hospital (e.g., support with administration, direct access with elec-
tronic interface to make appointments for patients).

According to Porter (1985) the competitive advantage grows fundamentally out

of the value a company is able to create for its buyers, value that exceeds the firm’s
cost of creating it. Meeting the competitive edge can be related to the following:

–– Purchasing medicines, equipment, and material at favourable prices.

–– Faster treatment with short waiting times.
–– Excellent reputation and high patient satisfaction.
–– Professional and organisational competence.

2.4.3 Role of the Value Chain

The value chain is a tool for systematically examining all processes in a hospital. It
clarifies how activities are related and the role they play in the competitive advantage.
The value-added chain divides the hospital into strategically relevant activities,
so as to analyse the costing and to understand the potential for differentiation
(Fig.  2.2). Your hospital achieves a competitive advantage by performing one or
22 2  Create a Corporate Identity

Management and support

Hospital infrastructure
processes

Strategy

Marketing/corporate identity

value creation
Controlling

Profit
Admission Diagnosis Therapy Treatment Discharge

Primary processes

Fig. 2.2  Porter’s value chain (Adapted for hospitals)

several strategically important activities more economically or better than your fel-
low competitors. Applied to a hospital, this could be described as follows:

–– A hospital’s value chain is part of a value creation system.

–– Suppliers who manufacture the products they purchase have a value chain and deliver
them with the relevant features (e.g., remedies, medicines, medical technology).
–– The client (patient, referring doctor/hospital) defines the requirements for the
hospital.
–– Achieving and maintaining a competitive advantage relates to the overall envi-
ronment you are working in (e.g., establishing a health centre if there is already
another one in existence).

2.4.4 Competitive Strategies

In Section 2.4.2 we explained how a hospital can achieve a competitive advantage

by being more cost efficient as well as more innovative than competitors. According
to Porter, the following strategies for achieving cost advantage exist:

–– Differentiation: a competitive strategy for creating customer loyalty by develop-

ing new services.
–– Focussed differentiation: a competitive strategy for developing and occupying
new market niches for specialised services.
–– Cost leadership: a competitive strategy with the goal of becoming the most rea-
sonably priced service provider on the market. To accomplish this, all possibili-
ties of achieving cost advantages must be identified, balanced and then utilised
(e.g., ‘high/medium/low care’, day clinics, separate facilities for outpatient ser-
vices and specialised ambulances).
–– Efficient consumer feedback: this includes the entire hospital. Inefficiencies
along the value creation chain are eliminated by taking into account the user
2.4 Recognising the Competitive Edge 23

requirements and a maximum client satisfaction level. The actions are related to
vision, strategy, and the pooling of technical procedures within the cooperation
that exists among patients, referring doctors and the hospital. This facilitates
advantages that could not be obtained single-handedly. Examples are private
hospital groups, private day clinics offering medical check-ups together with
wellness and ­optimisation of the personal lifestyle or specialised medical groups
for various diseases (fertility clinic, endocrinology and diabetes mellitus, life-
style diseases, cardiovascular diseases, etc.).

Compared with other business processes, there is little scope for pricing in health
care provision, in particular in public health care. Regulation is provided by the
legal framework, DRGs, budgeting and the prescribed scale of charges and fees.
Hospitals, day clinics, and private practices are limited in the measures they can
use to reduce costs. In the health care system the staff is the main expense. Therefore,
savings opportunities are implemented here first, and consequently, staff will then be
dismissed or reduced. In turn, this affects the quality of care and the working envi-
ronment. If this is implemented too harshly, then the hospital may quickly find itself
in a downward spiral. Specifically, well-qualified employees leave the ship first,
because they have found another, more attractive field of work with a competitor.

2.4.5 Core Competencies

As part of the development of competitive strategies, core competencies play an

important part. These are derived from the competitive abilities of a hospital that
have resulted from the pooling and linking of available resources.
When the business processes of a hospital represent core competencies or con-
tribute significantly to the development and expansion of the core competencies,
they are defined as core processes. Accordingly, core competencies are relevant in
increasing competitiveness and success. If your hospital performs core processes
better than the competitors, the hospital achieves a competitive advantage. Core
processes are characterised as follows:

–– They are based on specific knowledge and expertise.

–– They are not available on the market or are hard to imitate or replace.
–– They produce new services or procedures.
–– They generate an influx of new patients.
–– They create benefits for referring doctors and patients.

As a rule, core competencies cannot be introduced instantly, but a hospital can

use its competency and expertise as competitive advantages. This is why recognis-
ing core competencies is of strategic importance. Consequently, the following ques-
tions regarding processes and core processes must be asked:

–– High benefits for referring doctors and patients: can added value based on the
core processes be produced for referring doctors and patients?
24 2  Create a Corporate Identity

Fig. 2.3  Value creation

cycle
Hospital
strategy

Hospitals
business Vision
model

Value
creation

Core
Competencies
processes

Rules of
competition

–– Protection from imitation: is the process exclusive to the hospital or can the pro-
cess be easily imitated by competitors?
–– Differentiation: does the core process result in a sustainable advantage over
­competing hospitals?
–– Diversification: does the core process disclose new markets?

Even if core competencies cannot be introduced instantly, there are a number of

activities and skills that help to develop them:

–– Identifying patients’ and referring doctors’ requirements early

–– Being innovative
–– Efficiently offering services with a high degree of client benefit
–– Offering treatments with new and superior technologies
–– Satisfying patients and referring doctors quicker than the competitors
–– Reacting quickly to changes in the market.

As part of the planning process of a hospital’s strategy, it must be specified how

core competencies and business processes are interconnected. Besides, it is neces-
sary to define the business processes assigned to the development or support of core
competencies and how the implementation of core competencies is controlled and
preserved.
An overall picture of value creation is drawn based on Porter’s value creation
cycle (Fig. 2.3). Core and control processes, in addition to supporting and resource-­
developing processes, belong to the process landscape of the value chain.
References and Further Reading 25

2.5 Summary

Corporate identity cannot be prescribed top–down, but should be lived as a bot-

tom–up approach at all levels, throughout the entire hospital. It is not enough
and ­sustainable simply to place the hospital logo on all brochures, letterheads
and notices. Corporate identity is linked to coordinated communication, behav-
iour and a­ ppearance and reflects the entire ‘personality’ of a hospital. Some pri-
vate hospitals and hospital groups demonstrate leadership in this field. For this
purpose, business processes must be identified and, where necessary, changed.
Porter’s value chain constitutes an approach to optimising the core and business
processes and to aligning the strategies to that purpose, enabling a corporate iden-
tity to be established. Different tools, such as the five-forces model and recognis-
ing core competencies are available for improving the alignment of the hospital
with the market and generating the desired competitive edge. In this way, corpo-
rate identity and processes are synchronised. The various tools should be system-
atically applied and goals need be communicated to the hospital employees. These
measures contribute significantly to developing a corporate identity together with
the staff, by creating the feeling of being part of the business processes and of
playing an important role in the hospital, irrespective of individual responsibility.
It would be ideal if corporate identity and corporate image were to align with each
other.

2.6 Five Reflective Questions for Practical Application

1. What corporate identity do you have in your hospital? In what aspects is your
hospital better compared with the other hospitals in your community? What
would you mention to friends and acquaintances?
2. Which business processes can you identify in your hospital? How do you rate
their improvement potential?
3. How can you use Porter’s value added chain to facilitate the alignment of corpo-
rate identity and corporate processes?
4. How can you convey the corporate identity to your staff so that they will feel part
of the business processes and realise the important the role is they play in the
hospital?
5. Do corporate identity and corporate image correspond in the case of your hospi-
tal? Where do they conform, where do they differ?

References and Further Reading

Andreassen TW, Lindestad B (1998) Customer loyalty and complex services: The impact of cor-
porate image on quality, customer satisfaction and loyalty for customers with varying degrees
of service expertise. Int J Ser Ind Manage 9(1):7–23
Balmer JMT, Greyser SA (2006) Corporate marketing: integrating corporate identity, corporate
branding, corporate communications, corporate image and corporate reputation. Eur J Market
40(7/8):730–741
26 2  Create a Corporate Identity

Gallup Poll (2014) Employee satisfaction and engagement. www.gallup.com

Gotsi M, Wilson AM (2001) Corporate reputation: seeking a definition. Corp Commun Int J 6(1):
24–30
Hines P, Rich N, Bicheno J, Brunt D, Taylor D, Butterworth C, Sullivan J (1998) Value stream
management. Int J Logist Manage 9(1):25–42
Porter NE (1985) Competitive advantage: creating and sustaining superior performance. The Free
Press, New York
Stuart H (1999) Towards a definitive model of the corporate identity management process. Cor
Comm Int J 4(4):200–207
WHO (2008) The World Health Report 2008 – primary health care (Now more than ever). ­http://
www.who.int/entity/whr/2008/en/index.htm
Develop Your Vision and Communicate It
3

Goals
–– How do you develop a vision for a successful hospital strategy?
–– How and when do you conduct a SWOT or ABC analysis?
–– How do you develop successful project and project portfolio management?
–– How can you apply lean management processes in your hospital?

This chapter enables you to move from your vision to the processes of run-
ning a hospital efficiently. To do so we introduce the SWOT analysis, touch on
business engineering, business models and business processes. Hence, project
management and portfolio management with the various steps are highlighted.
The chapter ends with introducing lean management tools.

3.1 From Vision to Processes

Our deepest fear is not that we are inadequate. Our deepest fear is that we are powerful
beyond measure (Marianne Williamson, quoted by Nelson Mandela in his 1994 Inauguration
Speech)

Don’t be disappointed by unsuccessful projects and small or large failures. If you

are a visionary person, you are faced with a tough piece of work in convincing oth-
ers of your vision. It is even harder to put your vision into practice. In the long run,
hospitals cannot survive without a sustainable vision. However, it is also very
important not to lose touch but to remain grounded and realistic. Hospital manage-
ment becomes implausible if it professes to the outside world that it provides first-
class medicine and it pretends to be one of the best hospitals in the world, yet the
simplest processes aren’t working, and standard treatments are not even being
offered.

© Springer Berlin Heidelberg 2017 27

E. Weimann, P. Weimann, High Performance in Hospital Management,
DOI 10.1007/978-3-662-49660-2_3
28 3  Develop Your Vision and Communicate It

Case Study
At the get-together introducing a new head of department, the CEO of a
regional hospital announces that hospital management has the vision of offer-
ing medical services at the level of a tertiary academic hospital. Some staff
members and referring doctors are surprised about this ambitious project
because a glance at various benchmarking analyses reveals that the hospi-
tal falls within the lower range of patient and referring doctors’ satisfaction.
Furthermore, some standard treatments and procedures are not offered at
all. The general attitude of the attending staff is that the executive manage-
ment should first engage in improving existing processes before publically
­articulating currently non-achievable goals.

In formulating a vision, the goal can be ambitious, but it should be achievable

within a certain time frame. Competing hospitals should be seen as a challenge
to analysing your own hospital’s weaknesses and converting them to strengths
instead of, for instance, devaluing your competitors to appear better. Before the
executive hospital management presents its ambitious vision to the staff it has to
do its homework. Partly, this is to define a business strategy and coordinate the
processes needed. If the hospital is well positioned regionally, the staff will
understand and support the vision of becoming the regional expert in specific
areas within a certain period.
What enables you to develop a vision? On the one hand, you need to know and
understand the market. Relevant questions might be:

What do our referring doctors and patients want?

Who are our competitors?
What are our and their strengths and weaknesses?

You should envisage the present as well as the future. This is easier if one is alert
to developments in the region, in other cities, districts, provinces, or even interna-
tionally. Apart from that, contacts at the governmental level are important for execu-
tive managers. Advanced discussions of future developments should take place
before being made public.

3.2 SWOT Analysis

Vision without action is a daydream. Action without vision is a nightmare. (Japanese
proverb)

The first step in developing a vision is to analyse the present situation. A good
tool for doing this is a strengths, weaknesses, opportunities, threats (SWOT) analy-
sis. The strengths and weaknesses of a hospital or department become apparent by
3.2 SWOT Analysis 29

contrasting internal and external factors as well as contrasting your own enterprise
with the most important competitors. The purpose is to achieve competitive advan-
tages by determining unused potential in a hospital or department. In the course of a
situational analysis, a SWOT analysis can control the direction and development of
a hospital and its processes. Using SWOT guidelines and key performance indica-
tors (Chap. 7), hospital management can check whether the envisioned objectives
have been achieved. Furthermore, management are enabled to­evaluate by which
measures they may be fulfilled in the future.
Before going further into the SWOT analysis we refer to the history of strategic
analysis, using a quote from Sun Tzu’s The Art of War:
If you know the enemy and know yourself, you need not fear the result of a hundred battles.
If you know yourself but not the enemy, for every victory gained you will also suffer defeat.
If you know neither the enemy nor yourself, you will succumb in every battle.

The Chinese military strategist and philosopher Sun Tzu wrote the book The Art
of War more than 2500 years ago. His remarks have inspired many famous com-
manders. The book describes many possibilities regarding how you can prevail over
your enemies – not only in a battle – and be victorious. The quotation above can be
applied to many areas of life and business. Sun Tzu’s statements form the basis of
many strategies as well as the practical application of a SWOT analysis.

SWOT Analysis
Strengths: internal factors
–– On what are past successes based? What are their causes?
–– Which future opportunities do a hospital and department have?
–– What potential can be better utilised through new strategies?
Weaknesses: internal factors
–– Which weaknesses and weak spots can be avoided in future?
–– Which department and service produce the least revenue and have the highest
number of complaints?
Opportunities: external factors
–– What opportunities are offered within the health system?
–– How can a new technology be utilised in the hospital?
–– What opportunities are offered? For instance, what are our opportunities
when introducing diagnosis-related groups (DRGs) into the health
system?
Threats: external factors
–– What difficulties exist with regard to the overall economic situation and
development of the health system?
–– How are competing hospitals moving forward?
–– What acute threats exist?

These SWOT elements or steps should enable you to analyse the current and
future position in the market and to fine-tune your strategy. However, this is not a
one-off process. To sustain success, SWOT analyses have to be conducted regularly
30 3  Develop Your Vision and Communicate It

and conclusions should be drawn from changes. As a whole, the approach to a

SWOT analysis is as follows:

1. Hospital analysis: looking for strengths and weaknesses.

2. Community analysis: looking for strategically relevant opportunities and threats,
using moderating techniques and forming a group consensus. The results can
then be grouped, structured and weighted. The strengths and weaknesses are
listed in the relevant matrix fields.
3. Attempt to maximise the use of strengths and opportunities and minimise losses
from weaknesses and threats. To that end, the following information is specifi-
cally requested. Consideration is given as to which initiatives and measures can
be deduced from this information
–– Strengths–opportunities (S–O) combination: which strengths are linked to
which opportunities? How can strengths be utilised so that opportunities are
maximised?
–– Strengths–threats (S–T) combination: which threats can be countered by
which strengths? How can the current strengths be utilised to avoid specific
threats?
–– Weaknesses–opportunities (W–O) combination: where can weaknesses be
turned into opportunities? How can weaknesses be developed into strengths?
–– Weaknesses–threats (W–T) combination: where are our weaknesses? How
can we protect ourselves from harm?

The following example shown in Table 3.1 illustrates how the first two steps of
a SWOT analysis can be implemented.
Apart from the hospital and environment analysis, a third step has to follow, as
the SWOT analysis is meant to constitute the basis for restructuring and organisa-
tional measures.
Several strengths can certainly be used to realise an opportunity or avoid a threat.
The greatest threats can presumably be found where a combination of weaknesses
stands opposite one or several threats. Because of this combination, suitable strate-
gies must be developed and synchronised. This is the most demanding part of the
process. The core strategies are then entered into the four-area matrix (Table 3.2).
Figure 3.1 illustrates how an organisation can use its strengths to realise oppor-
tunities. Concrete and targeted measures that are consistently implemented are cru-
cial to success.
The following mistakes can often be seen in SWOT analyses:

–– Implementing a SWOT analysis without first having a vision. SWOT analyses

should always be made in relation to a vision and should not turn into an abstract
exercise. If there is no agreement regarding the target in the light of a common
vision, participants may follow their own assumption about the hospital’s vision,
leading to poor overall results.
–– External opportunities are often mixed up with internal strengths. They should
be rigorously separated.
3.2 SWOT Analysis 31

Table 3.1  Example of a strengths, weaknesses, opportunities, threats (SWOT) analysis

Internal factors External factors
Strengths Opportunities
Good infrastructure of buildings High population influx through new
residential area
Good ambience, high standard of facilities New bus line improves access to the
High proportion of private patients and out-of- hospital
pocket payments
High market share in the surrounding area
High number of cases with a broad professional
coverage
Solid financial situation
Young, highly motivated team
Strong monopoly in some specialist fields
Own hospital’s medical centre for private doctors
Weaknesses Threats
Competitor has better access to transport Results of lump compensation negotiations
for cases are uncertain and outstanding
High staff turnover Introduction of minimum volume
regulations in some surgical fields
Loss of confidence by the community because of
ambiguous staff politics
Low market share in the outskirts and other
districts
Strong local competition

Table 3.2  Matrix representation of a SWOT analysis

External analysis
(community analysis) Internal analysis (hospital analysis)
Strengths Weaknesses
Opportunities Strategic goals for S–O Strategic goals for W–O
Following up on new Eliminating weaknesses to make
opportunities that match the use of new opportunities
hospital’s strengths
Threats Strategic goals for S–T Strategic goals for W–T
Use strengths to avoid threats Develop strategies to prevent
existing weaknesses becoming the
target of threats
S–O strengths–opportunities, W–O weaknesses–opportunities, S–T strengths–threats, W–T
weaknesses–threats

–– SWOT analyses are often confused with possible strategies: SWOT analyses describe
conditions whereas strategies describe actions. To avoid this mistake, think of oppor-
tunities as ‘favourable conditions’ and of threats as ‘unfavourable conditions’.
–– Prioritisation is not part of a SWOT analysis. Hence, no concrete measures can be
deduced from it. The next step is developing strategies and implementing them.
32 3  Develop Your Vision and Communicate It

Opportunities

Adaption of
Vision SWOT analysis Goals and Performance
business
strategy review
process
Strengths

Fig. 3.1  Integration of strength, weaknesses, opportunities, threats (SWOT) analysis into strate-
gic development and implementation

3.3 A Practical Approach to Business Engineering

He who remains at the coast will never discover new oceans. (Fernando Magellan)

The development of a SWOT analysis is recommended when establishing a hospital’s

strategy, but also for realigning departments. This depends on the vision that exists for
the hospital. Business engineering (Chap. 4) is closely linked to the hospital’s strategy,
the demands of clients and the various interest groups (stakeholders). The strategy is
determined by the competitive position. Using the applied St Gallen approach to busi-
ness engineering, the connection between a hospital strategy and the business pro-
cesses is explained below.
The transformational process, i.e., the process of change in business engineering
is structured on three levels. These are the so-called ‘hard’ (structural) levels of busi-
ness strategy, business process models and the information and communication
technology. Then there are the ‘soft’ factors: leadership, behaviour and power. This
situation is illustrated in Fig. 3.2. It shows hospital strategy, which is described here
as business strategy. Changes based on this approach follow various principles:

–– Change processes must follow a model- and method-based approach so as to

structure all aspects with the necessary consistency and in a suitable sequence. The
propositions are complex and an interdisciplinary approach must be followed.
–– As part of integrated change management (Chap. 6 and ▶ Glossary), changes
need to be included in the hospital’s culture, together with the soft factors, such
as leadership, power, and behaviour.
–– Change processes must take into account the interconnectedness of clients and
the hospital’s stakeholders.
–– Only when implementing change at all levels the intended innovation will
become effective.
3.4 Hospital Strategy 33

“Hard” structural
levels “Soft” factors

Transformational process
Level of business strategy Leadership

Level of business process

models Behaviour

Level of information and

communication Power
technology

Fig. 3.2  A practical approach to business engineering

–– Restrictions due to technology must be considered when changing strategies and

business processes.

Let us first discuss the first two levels (business strategy, business processes) and
then analyse their role within business engineering (Chap. 4).

3.4 Hospital Strategy

Let us take a closer look at the business strategy or rather the hospital strategy.
Owing to new developments and demands, change is a process that is permanently
necessary. This often implies a change in strategy. The hospital’s vision (▶ Glossary)
plays an important part, in addition to its implementation in long-term (strategic),
medium-term (tactical) and short-term (operative) measures and objectives. This is
also referred to as strategy implementation (Fig. 3.3).
What do we mean by the term ‘strategy’?
34 3  Develop Your Vision and Communicate It

management
Strategic

Goals:
Strategic alignment of the
hospital
Identifying and developing
success potentials and
competitive strategies
Tactical management

Goals:
Transfer the desired strategic position
in measures on the structural business level
Alignment of the business processes
management
Operational

Goals: Realising the desired position by

implementing the relevant measures

Fig. 3.3  From the strategic to the operative management of business processes in the hospital

Historically, it was linked to a meeting of military commanders, known as the

college of strategists, in Athens in the fifth century BCE. At the beginning of the
nineteenth century the idea of a strategy was integrated into the military arena by
Clausewitz. Nowadays, the term ‘strategic’ is used as the opposite of operative.
Operative means short-term, based on day-to-day activities. Compared with this,
strategic implies long-term, not part of day-to-day activities. At times, strategy is
used as a means of fulfilling a (business) objective, or a vision.
According to Mintzberg (1978), a ‘strategy’ can have five different meanings:

–– A plan: intended, consciously planned guideline for one’s actions

–– A behaviour pattern: consistent action, whether planned or not
–– A position: positioning in a competitive environment
–– A perspective: a specific perception of the world – self-image and world image
–– A manoeuvre: a specific manoeuvre to outwit one’s competitors

We would like to define the term hospital strategy as the long-term planned
practices of a hospital for the purposes of reaching its objectives. In this sense, a
hospital strategy conveys how a medium- or long-term goal of a hospital is to be
reached.
Similar to Porter’s value chain and the five-forces model (Chap. 2), the focus is
primarily placed on positioning the hospital enterprise within its competitive
3.5 Business Processes in the Hospital 35

Strategic
Tactical management Operational
management
Target: management
Transfer the desired
Target: Strategic strategic position in Target: Realize the
positioning of the measures on the desired position by
hospital/clinic chain in its structural business level performing the necessary
Hospital competitive environment measures
vision Design of treatment and
Identify and develop Define and implement of
patient structure
success potentials treatment and therapy
offerings
Design of the treatment,
Identify and develop service & supplier
potential services Define and implement of
infrastructure
services
Derive competitive Align the hospitals
strategies for the hospital Involve referrers
business processes

Fig. 3.4  From vision to operational management

environment. This positioning is often referred to as strategic management and

must be distinguished from tactical and operative management, as shown in Fig. 3.3.
The measures shown in Fig. 3.4 can be implemented to achieve the hospital
vision.

3.5 Business Processes in the Hospital

Changes in hospital processes are initiated by various role players and often affect
other processes. Understanding business processes is the first step towards applying
business engineering in a certain setting. As mentioned above, a process can be
defined as a temporal sequence of activities. Beyond that, a business process in a
hospital may be characterised as follows:

–– It includes a repeatable sequence of activities with clearly defined input and out-
put (e.g., writing letters, ordering medication at the pharmacy).
–– It consists of several activities that are logically linked (e.g., admitting a patient).
–– It requires certain resources (e.g., staff, devices, materials).
–– It has a defined beginning and a defined end and should reach an economic
objective.
–– It possesses a certain operational organisation.
–– It can extend beyond departmental or hospital boundaries.
–– It fulfils the demands of patients and referring doctors.
–– It produces a positive result for both patients and stakeholders.

An example of a typical business process in a hospital would be the request by a

referring colleague for a hip replacement to be performed on a patient with a predis-
posing medical condition. The request would be followed by these steps: orthopae-
dics, communication of the findings to the referring doctor, recommendation of
further treatment, and finally the account statement.
36 3  Develop Your Vision and Communicate It

R P
e a
f Inter- t
Radiology Physio- Day
e disciplinary Wards i
diagnostic therapy hospital
r admission e
r n
e t

s
r s

se
es
/ /

oc
s s

pr
t t

ss
ne
a a

si
k k

Bu
e e
h h
o o
l l
d d
e e
r r

Fig. 3.5  Business processes in the hospital

Business processes vary from hospital to hospital. They should be efficient and
effective. The business process should be focused, on attaining a competitive advan-
tage for the hospital, e.g., by offering the patient and the referring doctor (practising
externally) the desired service quickly and efficiently.
Figure 3.5 shows that business processes can extend over various areas within
the hospital. Like the example above, they touch base not only with patients, but
also with referring doctors or other external institutions.
Different types of business processes interact as follows:

–– Service processes (or business processes in the narrow sense) produce services
‘to the environment’, i.e., for patients (e.g., pre-operative outpatients or day-
hospital patients).
–– Support processes support the service processes (pharmacy, bed-cleaning, pro-
curement, and kitchen).
–– Leadership/management processes coordinate the services, i.e., they measure the
goal fulfilment and support processes, intervene if there is delay and further
develop the entire system of services.

Service processes are often referred to as core processes. Core processes are
processes with a high degree of value creation for the hospital, i.e., with a direct
provision and marketing of services. The sum of all core processes in a hospital
defines its competitive advantage.
Leadership/management processes serve the planning, monitoring, and evalua-
tion of objectives, strategies and measures for the hospital.
Support services are activities necessary for the implementation of management
and core processes. These processes have no, or only limited value creation for the
patient. They serve to support the implementation of core processes and can partly
be outsourced. They have no strategic significance for the hospital.
3.6 How Is the Hospital Strategy Linked to Business Processes? 37

Analysing which processes are core processes and which are support and
­ anagement processes has led to outsourcing. Outsourcing can be defined as the
m
relocation of hospital processes. Reasons for outsourcing are the focus of core com-
petencies such as:

• Service processes
• Saving or making resources available
• Using the competencies of other health care providers or
• Obtaining greater financial flexibility (Chap. 7).

3.6  ow Is the Hospital Strategy Linked to Business

H
Processes?

Figure 3.4 depicts the creation of business process strategies as being located in the
area of tactical management and they are a result of strategic management. This
relationship is reciprocal and can be represented as described in the next few
paragraphs.
On the one hand, the hospital strategy influences the identification, scoping, tar-
geting, weighting, and control of business processes, in addition to their integration
into the organisational structure of the hospital.
On the other hand, business processes form the basis for the implementation of
the hospital strategy, that is for the implementation of a competitive strategy (dif-
ferentiation, focused differentiation, cost leadership, efficient consumer feedback
coupled with quick responses to clients’ needs; Sect. 3.8) and the development and
extension of core competencies.
Accordingly, a change in the hospital strategy results in changes in the business
processes. To reach the hospital’s objectives, processes have to be aligned to strate-
gies. For this purpose, they are often allocated to important business segments or
business units of a hospital.

3.6.1 Evaluation of Business Processes in the Hospital

The evaluation of hospital processes serves the purpose of establishing the specific
importance of the business processes. On this basis, the hospital can decide on sub-
sequent strategic and operational issues:

–– Improvement, adjustment, and renewal of business processes

–– Outsourcing of business or of sub-processes
–– Allocation of financial, staff, and technical resources

Different criteria influence the weighting of a business process, for example:

–– Achieving strategic business goals

–– Critical success factors
38 3  Develop Your Vision and Communicate It

–– Core competencies
–– Patients’ benefits and satisfaction
–– Referring doctors’ benefits and satisfaction
–– Potential for improvement
–– Effectiveness and efficiency
–– Relative competitive strength

The ABC analysis, the success factor analysis and the process portfolios are
among the methods to weight and prioritize processes. These methods are briefly
explained below and highlighted in an example.

3.6.2 ABC Analysis

So much to do and so little time. (Cecil John Rhodes)

The ABC analysis is part of the strategic planning and alignment of a hospital. You
could apply it to determine the service quality or the performance of doctors. For
example, a measure for improving the rate of referrals to a hospital could be to
regularly show the highest (A) and the lowest (C) rate of referring doctors. In con-
nection with this you could also analyse who, for instance, are your main referrers,
how you could satisfy them and how you can turn your lowest referrers into the
highest ones. You would liaise with them and ask for recommendations for how to
improve services. The ABC analysis can also be used for medication, examinations,
laboratory analyses etc.

3.6.3 Process Portfolio

The process portfolio is specifically focussed on weighting business processes, for

instance, to evaluate their effect regarding patient benefits and the hospital’s suc-
cess. A hospital’s business processes could be represented as set out in Table 3.3.

Table 3.3  Business process evaluation

Business processes Patient benefit Hospital benefit
Strategic planning process 1 5
Innovation process 4 5
Treatment process 5 4
Controlling process 1 3
Human resources management process 2 3
Financial management process 1 5
Quality management process 3 1
Service process 4 3
‘1–5’ corresponds to ‘low to high’
3.6 How Is the Hospital Strategy Linked to Business Processes? 39

High
B A
1 2

6 4 3
Hospital success

5 8

7
Low

D C
Low High
Patient’s benefit
1 Strategic planning process 4 Controlling process

2 Innovation process 5 Human resources management process 7 Quality management process

3 Treatment process 6 Financial management process 8 Service process

Fig. 3.6  Process portfolio

The evaluations from Table 3.3 are shown in Fig. 3.6 in a process portfolio.

In column A, business processes have the highest priority as they have the stron-
gest impact on both patient benefit and business success. Business processes in
column B are necessary for the hospital’s success, but do not directly contribute
to increased patient benefit. These are often secondary business processes (i.e.,
support processes). Business processes in column C are necessary for the patient’s
benefit, but do not directly contribute to an increase in the hospital’s success. The
business processes in column D provide evidence of possible areas that could be
outsourced.
If, besides the business processes, the sub-processes are also weighted, the
importance of a process portfolio increases. Since the process portfolio is flexible,
other criteria may also be included, e.g., improvement potential.

3.6.4 Success Factors Analysis

The success factors analysis is discussed as the third method of evaluating and
weighting your processes. Initially, the critical success factors of a business unit are
determined. This refers to a few features that are decisive for the success of a hos-
pital and a business unit (e.g., a department, day clinic, health centre). According
to the Pareto Principle (80/20) only a few factors influence the success of a busi-
ness unit and a hospital. Eighty percent of the results can be ascribed to 20 % of the
influences. Critical success factors are usually determined in the course of strategic
planning and accordingly appear in the hospital strategy, the business objectives,
40 3  Develop Your Vision and Communicate It

and hence in the business processes. Below, some critical success factors are listed
as examples:

–– Loyalty of patients and referring doctors

–– Short waiting times
–– Good external image and reputation
–– Patient centredness
–– Good interfaces with referring doctors
–– High flexibility
–– High degree of professional competence
–– Exceptional service behaviour
–– Good service agreements with cost providers
–– High quality of treatment
–– Innovative treatment procedures

A direct connection exists, particularly between the critical success factors of a

hospital and its business processes. The success factors analysis evaluates individ-
ual business processes according to critical success factors.
The approach to success factors analysis is:

–– Determining of critical success factors

–– Weighting of critical success factors, based on either paired comparison or
weighting from the clients’ point of view, such as referring doctors and
patients
–– Determining the influence of the individual business processes on critical suc-
cess factors, e.g., on the basis of an evaluation scale from 1 (weak) to 5 (strong)
–– Determining the scoring value per influencing factor by multiplying weight and
degree of influence
–– Determining the weighting sum per business process by adding together all the
weighting values for this factor.

The strategic importance and the rank order of business processes can be derived
from such scoring.
The example of a success factors analysis carried out by using a process success
factor matrix (Table 3.4) is shown below. In the success factors matrix process,
individual success factors are weighted according to their importance for the hospi-
tal (weight SF). Then, the business processes are evaluated with regard to their
contribution to individual success factors and this evaluation is multiplied by the
weight of the success factor. The sum of these amounts, defined as the contribution
of a business process to the various success factors, is significant to the business
process for the hospital. In the example below, business processes 5 and 6 (BP 5 and
BP 6) have the highest number of marks and are thus significant processes in the
competitiveness of the hospital.
In a next step, the relative competitive strength compared with that of a compet-
ing hospital could be determined by using the benchmarking process. The results
3.7 Business Models 41

Table 3.4  Process success factor matrix

Critical SF for a BP (degree of influence/weight)

hospital Weight SF BP 1 BP 2 BP 3 BP 4 BP 5 BP 6
Services offered 5 2 10 1 5 1 5 5 25 5 25 4 20
Quality of treatment 8 1 8 5 40 2 16 1 8 3 24 5 40
Price/performance 5 3 15 5 25 2 10 4 20 3 15 5 25
Flexibility 7 4 28 4 28 5 35 3 21 3 21 4 28
Innovations 9 2 18 1 9 1 9 4 36 5 45 3 27
Service 6 1 6 1 6 5 30 2 12 3 18 2 12
Waiting times 7 3 21 5 35 4 28 2 14 3 28 5 35
Sum BP 106 148 133 136 176 187
Ranking 6 3 5 4 2 1
SF success factors, BP business process

are then represented in a process weighting portfolio. This portfolio could provide
information on business processes, indicating the areas where performance should
be improved either to maintain the hospital’s competitive position or to improve it.

3.7 Business Models

The business models reflect the business process level (Fig. 3.2). At this level, the
hospital’s strategies have to be implemented. Apart from an analysis of business
processes, a representation at various levels of refinement and the use of various
perspectives, such as the perspective of procedures, data, and organisational struc-
tures, are necessary to achieve this.
The analysis of business processes and their systematic documentation in pro-
cess models provides the knowledge to successfully implement changes. This
becomes necessary on the basis of the business strategy. The analysis and docu-
mentation serve as a source of information and as communication medium to
support process-orientated change. The reasons for business engineering can be
diverse and are reflected in the goals for business process modelling.
On the one hand, business process modelling forms the basis of business engi-
neering. On the other hand, the hospital’s business processes are:

–– Documented for quality management and certification according to ISO 9000

–– Used for the training of staff
–– Utilised for transferring business processes to other locations or as a rulebook for
working instructions

In the hospital, documented business processes can serve as preparation for

change management, for instance, to introduce new organisational structures, out-
source hospital tasks or improve the hospital workflows. They support the prepara-
tion of the IT support of business processes (enterprise resource planning system,
42 3  Develop Your Vision and Communicate It

workflow management, ▶ Glossary). Moreover, they serve to determine the key per-
formance indicators of the process, to monitor process performance and to represent
a basis for benchmarking among hospitals, other health care providers, and partners.
Business models include the business processes of a hospital at various levels
and from different perspectives.

3.7.1 Process Maps

As mentioned previously, there are numerous business processes in a hospital.

These processes are structured according to different criteria (e.g., core (service),
support, and management processes, see above). If the processes in a hospital or
hospital group have been documented, they can be represented according to their
workflow sequences or allocated according to organisational or functional units.
The business processes in a hospital are often dependent on each other. This could
relate to the exchange of information or services. It is necessary to understand these
dependencies so that the business processes can be monitored, managed, and
improved.
Process maps are an important tool for showing dependencies and relationships
among processes, the flow of processes, the analysis of processes, and the connec-
tion with external partners (e.g., suppliers, patients, referring doctors, cost carriers,
banks, etc.). Process maps also help to depict the information and service exchanges
between processes.
All processes within an organisation, including their interfaces with the outside
world, are illustrated on a process map. Thus, a process map gives an overview of an
organisation’s processes. It will describe the structure of business processes of a
hospital and the interactions of the processes. The process map can also be used
when an overview of hospital workflows is to be developed and documented. The
creation of a process map requires an overview of all processes within an organisa-
tion without necessarily analysing them in detail.
The diagram of the process map exemplifies the core and support processes in a
hospital. It is expanded to produce further process maps for admission and treat-
ment (Fig. 3.7).
Different tools can be used to produce process maps or to create a refined repre-
sentation of specific processes.

3.7.2 Integration of Business Processes into the Hospital

The effectiveness and efficiency of business engineering strongly depend on how

the business processes are integrated into the organisational structure of the hospi-
tal. Indeed, the dictum says that the structure of an organisation should follow the
business processes and in turn the business processes follow the hospital’s strategy.
However, in practice, the organisational structure still dominates. In many hospitals
the management hesitates to implement the necessary organisational adjustments
3.7 Business Models 43

Support processes hospital

Human resource Financial

Accounting IT-Management
management planning

Core processes hospital

Admission Diagnostic Treatment Discharge

Core process admission

Preparation
Initial
Medical diagnostic
Register assessment
assessment & treatment
nursing
plan

Core process treatment

Patient- Final
Medical
Nursing physician interdisciplinary
treatment
discussion evaluation

Fig. 3.7  Sample process map of the core and support processes in a hospital

that result from process re-engineering. In doing so, they miss the potential for
improvement, for, these adjustments are necessary to increase efficiency and effec-
tiveness through business engineering.
The following forms of integration of business process management may be
distinguished:

–– Process-influenced organisational structure: expansion of the classic function-­

orientated organisational structure by process-orientated positions
–– Multidimensional organisational structure: creation of hybrid types of func-
tional and process organisation
–– Pure process-based organisational structure: replacement of functional organ-
isation by full integration of the business processes into the organisational
structure

The process-influenced organisational structure should not be the starting point

for structural changes in the hospital, as it does not give the potential of business
engineering the chance to develop. Furthermore, it may give the wrong impression
and inhibit the learning and adjustment process. In fact, a multidimensional organ-
isational structure is recommended to run side-by-side (business processes and clas-
sic departmental structure) for a limited amount of time so that the departmental
structure can gradually be aligned based on the improvement measures of business
engineering.
44 3  Develop Your Vision and Communicate It

New organisational structures must be carefully applied to hospitals. Questions

that arise in this context are: who is responsible for resolving conflicts? Who is
overlooking the whole process?
Within business engineering various roles with allocated duties, competencies,
responsibilities, and requirements are applied. Individuals and teams can take over
these roles. Business engineering differentiates between the introductory phase and
the implementation phase. In this process, the following roles have to be allocated:
project manager, process advisor, process manager, people in charge of a specific
business process, process controller, and process collaborator.

3.8 Project Management

If you limit your choices only to what seems possible or reasonable, you disconnect your-
self from what you truly want, and all that is left is a compromise. (Robert Fritz)

Over the last few years a veritable avalanche of projects has been rolled out across
hospitals worldwide. Some hospitals even provide a list of approved and planned
projects and their current status on their intranet. A great deal of resources and time
are invested in individual projects and a huge amount of written papers is produced.
However, in some cases the value added for the hospital is questionable and project
results often end up in a drawer, completely ignored. At best, project results are
occasionally reported, but do not have an effect on the overall day-to-day business.
There are many roadblocks in successful project management. Have you also
experienced improvement processes within the organisation regarding administra-
tive functions or procedures that later had no impact at all? After the project has
been concluded and despite many meetings and paper piles of detailed reports to
the hospital management, nothing has actually improved. Everything has continued
the way it was, because no-one had been appointed to initiate the necessary changes.
In the hospital, this would include involving the staff and getting their buy-in for
necessary changes. However, this is frequently related to difficult discussions and
interactions (Chaps. 6 and 9). The question remains: who is going to take on this
thankless task? The project manager, who often does not deal with staff? The head
of department? The consultant, who normally engages with the staff, but is not
responsible for the project and perhaps does not even agree with the predicted
results? The hospital management? Consequently, it is mandatory to specify before
the project is initiated who is going to implement the results and how this can be
done.
There are numerous reasons for conducting projects in hospitals. The competing
hospital has started a similar project. A new member of staff is specifically interested
in the subject. The hospital carries out fewer projects than other hospitals. Reasons for
launching projects are easy to find. However, are these really valid reasons for run-
ning a project? It is seldom that the project focus is placed on the hospitals strategy
alongside with its integration into the development of the hospital. Projects are
labour-intensive and costly. Therefore predictions must be clearly specified before the
3.8 Project Management 45

project begins. For example, what could be improved regarding hospital processes?
Could the project result in more profit, greater satisfaction or better patient care?
Before the possible start of a project and before various resources are committed
to it, the following question should be asked: is the project actually a project? A
project must possess a defined goal, it must create value for the hospital, and it must
be conducted just once in the hospital.
An example of the implementation of a project is described in this section con-
comitantly. It refers to the introduction of an emergency service of private practitio-
ners into the existing emergency unit of a hospital for the department of internal
medicine. The goals are defined to improving the quality of care, reducing waiting
periods for patients to a minimum and improving cooperation and communication
between the private practitioners and the hospital’s doctors. As shown in this sec-
tion, several steps are necessary to reach the objective.
A project has an objective within given circumstances (personnel, financial,
technical equipment, time constraints). If projects do not succeed, mostly the goals
and requirements were not clearly defined (Table 3.5).
In project management, a project is described as SMART if the project goals are
clearly defined and the following SMART conditions are all fulfilled: it is specific
(the project goal must be clearly defined), measurable (progress indicator), assign-
able (who will do it), realistic (the project goal must be implementable) and time
bound (the project goal must be implementable within a scheduled period of time).
Projects have the potential to fail if there are too many people involved, when
they run over a long period of time, when there are many interfaces with other
projects and external systems, and if there is a certain risk attached to implementa-
tion. Furthermore, many problems with implementation, such as uncertainty about
the time scale, cost planning, etc., only become apparent during the course of the
project and usually there is competition with other projects for scarce financial

Table 3.5  Reasons for failed projects (GPM and PA Consulting Group 2008)
Causes Percentage
Soft factors
Lack of qualified staff 45
Dispute over respective areas of authority 45
Poor communication 40
Lack of project management experience at the management level 33
Lack of project management method 28
Lack of support from top management 22
Start of project
Requirements and goals unclear 63
Lack of resources 54
Inadequate project planning 47
Others
Technical requirements too high 14
46 3  Develop Your Vision and Communicate It

and staff resources. This especially applies to hospitals. Exemption from their
day-to-day duties (although this would make sense for some projects) is rarely
possible. In addition, certain activities overlap and are repetitive. Finally, the high
degree of specialisation of many of the staff tasks with projects makes flexible
planning difficult. Even after projects have been concluded, measuring the impact
on productivity and quality is time-consuming or uncertain. Caused by these influ-
ences, there is a high risk of a project failing. Table 3.5 provides an overview of
the reasons for failure.
Careful project planning, continuous control of the project, and timely plan-
ning updates are important prerequisites for the successful completion of a proj-
ect. Time and cost estimates have to be drawn up for the entire project and not
only for certain activities. At the same time projects should be protected from
continuous change requests. Consequently the project manager must apply strin-
gent claim management. Requested changes are neither ignored nor automati-
cally integrated. Rather, awareness must be created that requests for changes can
lead to changed goals, new requirements or an amended project scope.
Furthermore, stakeholders must be informed about possible consequences for the
target figures during the project (costs/resources, time/deadlines, performance/
quality; Fig. 3.8).
In classical project management, a contextual analysis is recommended. This
process should include a stakeholder analysis (Varvasovsky and Brugha 2000) to
elucidate how much support or resistance can be expected for the project. Table 3.6
shows how a simplified stakeholder analysis can be conducted.

Scope
(Quality)

Target dimensions
of the project planning

Fig. 3.8  Target figures for

the project-planning Time Cost
triangle (Resources)
3.8 Project Management 47

Table 3.6  Analysis of important stakeholders in the case study project

Stakeholder characteristics
Position Power
Role player Degree of Interest Will he Which Where are his Evaluation
involvement in support the instruments boundaries? influence/
contents project or of power power
intervene can he
negatively? bring to or
against the
project?
HoD of High +3 +3 support Good Clinical manager +2
Medicine relationship and consultant
with CEO oppose the
project as it
curtails their own
power and
resources
Consultant High +2 −3 Good Is hierarchically +1
emergency No support, relationship subordinate to
unit own power with consultant
and clinical
position is manager
threatened who does
by project not support
the project
Representative High +3 +3 Good No decision- +2
of doctors in support relationship making authority
private (initiator) with HoD and influence in
practice hospital
Remarks: +3 (high level of support) to −3 (lack of support or negative intervention)
HoD head of department, CEO Chief Executive Officer

In our example of the implementation of an emergency unit, a stakeholder analy-

sis should be undertaken at the start of the project. A detailed project plan should be
drafted for the duration of the project. The implementation of the new admission
process should be established. Figure 3.9 shows the admissions process in coopera-
tion between hospital and doctors in private practice according to the Australasian
Training Standards (ATS). Treatment modalities of ATS are shown in Table 3.7.
Additionally, a precise description of the duties of the individual people involved in
the project should be carried out as illustrated in Table 3.8.
48 3  Develop Your Vision and Communicate It

Fig. 3.9 Admissions
Triage of patients
process in cooperation according to severens
between the hospital and after the Australasian
private medical practitioner standard (ATS)

Triage 3-5: emergency

Triage 1-2: emergency
admission private
admission hospital
medical practitioner

Table 3.7 Urgency Triage level Category Urgency of treatment

according to the Australasian
1 Resuscitation Immediately
Training Standards (ACEM
2005) 2 Emergency ≥10 min
3 Urgent ≥30 min
4 Semi-urgent ≥60 min
5 Not urgent ≥120 min

Tools and guidelines for project management are available to enable critical situ-
ations to be visualised, to support communication with people, and to uncover prob-
lems. The planning and supervision of the project can be supported by such tools,
but cannot be replaced by them. Below, a number of important issues for project
management are discussed.
Project management processes are guided by two standards: the Project
Management Book of Knowledge (PMBOK) by the Project Management Institute
(PMI) and the Projects in Controlled Environments 2 (PRINCE2) by the British
Office of Government Commerce (OGC). Both standards serve to create a single
language and a common understanding of project management. A number of pro-
cess groups, processes, and activities help to organise the flow within projects more
efficiently. Specific topics and knowledge areas ensure that expertise and best prac-
tices can be applied.

Table 3.8  Description of duties of people involved in the project (selection)

Function Qualification Duty Responsibility Area of responsibility
Project Experience with Detailed Project execution, Successful conclusion
manager projects, knows project and informing of project within time
processes in the time planning persons involved frame
emergency unit
Nurse Experience with Plans the Responsibility Makes resources
manager projects and allocation of for budget in the available by new
responsibility for nursing care area of nursing acquisitions and
staff redistribution
3.8 Project Management 49

Although PMBOK is designed for the support of any kind of project, PRINCE
was initially developed for the management of IT projects. The current
PRINCE2:2009 standard is specifically characterised by the improved integration
of other methods. Extensive literature is available on both PMBOK (PMI 2013) and
on PRINCE2 (OGC 2009).
Below, project management is described in more detail. The various activities
of a project are allocated to various phases as roughly outlined in Fig. 3.10.
Efficient organisation is important for the successful implementation of a proj-
ect. A project possesses its own (albeit limited) personnel resources and its own
project organisation (Fig. 3.11). Different duties are assigned to the people involved
in the project. Within a hospital context, it is important that projects are integrated
into the hospitals everyday business. Otherwise, projects are in danger of becoming
rather a matter of mere window dressing. The figure illustrates an example of an
project organisation including the most important project roles: steering committee,
customer, team leader, and team members.
The steering committee monitors the implementation of the project with regard
to performance, its quality, use of resources and the time frame. It accepts the proj-
ect results in a responsible manner, takes firm decisions on the progress of the proj-
ect, and helps to clarify significant problems and conflicts. The steering committee
usually consists of people with decision-making powers, e.g., executive directors,
departmental or unit managers, possibly the customer and sponsors. It is important
for doctors and nursing staff to have a say in the steering committee.
The customer (e.g., the hospital manager) defines and evaluates the objectives as
well as the results of the project. He can request project updates and information if
there is a threat of time- or cost-overrun. He supports the project manager in opera-
tional matters and makes the necessary resources available. He must decide to
accept or reject the project outcomes and releases the project manager at the end of
the project.

Project initiation

Project definition and

planning

Project launch and

execution

Project performance
and control
Project close
Fig. 3.10  Various phases
of a project
50 3  Develop Your Vision and Communicate It

Steering committee Customer

Project manager

Team leader Team leader Team leader

Team member Team member Team member

Fig. 3.11  Project organisation

The most important role is that of the project manager. He should be assisted by
an experienced and effective team that is an integral part of the hospital and its pro-
cesses. The project manager coordinates all matters with the customer. At the start
he checks the feasibility of the project. He prepares the infrastructure for the team
and provides the best possible working conditions. He organises and moderates
project meetings and plans the project. He informs the customer of risks and devia-
tions from the project planning. In addition, he ongoing compare actual versus tar-
geted costs, schedules, and resources. All-in-all, he is responsible for the
implementation of the project to deliver the requested results in time and within
budget. The project manager must have adequate competencies and responsibilities
to fulfill his tasks and meet the project’s requirements. He must be informed and
supported by specific departments. For successful project management, he must
have the professional and managerial authority to lead his project team.
Project team members are allocated to the project preferably full-time or for a
fixed period of time. They independently carry out the assigned work packages,
document the results, and report back to the project manager on the progress of their
work. Should professional problems arise, they work together constructively as a
team. The project team should possess the relevant expertise in matters relating to
the hospital. The starting phase of a project is characterised by:

–– A preliminary investigation based on the project idea (usually including a feasi-

bility study with a contextual analysis and a stakeholder analysis)
–– Decision-making process for the implementation of the project
–– The objectives, requirements and the project scope set up in a project charter

These activities must take place before the formal start to the project. A project
can only be launched once the objectives have been fixed, and the requirements, the
scope of the project, the budget and time frame have all been determined.
Accordingly, the formal project start takes place only once the fully specified work
has been contracted with an internal or external project team.
3.8 Project Management 51

Planning is one of the central tasks of project management. Here, the following
activities can be distinguished:

–– Structuring the project. What needs to be done?

–– Milestone planning. What are the significant milestones of the project?
–– Planning resource requirements. How high is the workload and which resources
are necessary?
–– Process and time scheduling. In what sequence and when must work packages be
completed?
–– Cost planning. What are the costs of the different work packages?
–– Plan optimization. Does the project plan comply with the customers deadlines
and the availability of resources?
–– Risk management planning. Have the project’s risks been identified, evaluated
and taken into account?

A project is a complex undertaking. Primarily, structuring serves to ease the

complexity and improve transparency. The project tasks are divided into parts that
can either be planned or controlled. A structured planning phase is shown in the
work break down structure (WBS). The WBS includes all the project’s activities,
but does not contain their sequencing and timing. The advantage of a completed
WBS is that it highlights all activities necessary for achieving the project’s deliv-
erables. Figure  3.12 shows the WBS for the emergency unit project example.
The project team prepares the WBS as a team result. The most important item is
the complete listing of all activities. The activities must be clearly demarcated and
overlaps should be avoided. The WBS should show the work packages at the lowest
level. These can be allocated to a responsible person. Furthermore, the degree of

Project
"Emergency unit"

Analysis of the current status Implementation Trial operation

Design
and the requirements

Acquire the
Negotiate cooperation Manage Change
Identify weaknesses indicators
treaty

Evaluate the trial

Identify patient Plan the time schedule operation
Plan time and space
requirements

Plan reconstruction Optimize the

Calculate cost
Identify staff, resource activities processes
reimbursement
and space requirements

Establish majorities and Communicate both Assess cost/income

Identify referrer create project empathy internally and externally
requirements

Identify the Cost-Benefit-Analysis

requirements of other
hospital stakeholder

Fig. 3.12  Example of a work break-down structure for a hospital project

52 3  Develop Your Vision and Communicate It

detail should allow reliable costing of the work packages. However, it is not the aim
of the WBS to schedule the work packages.
If similar projects are frequently implemented in a hospital, the use of a stan-
dardised WBS is recommended. This secures the experiences in project manage-
ment and provides a planning template. To check the project’s progress, various
time points should be fixed by which certain main processes must be completed.
Typically, milestones are defined for development projects.
A detailed WBS is a suitable basis for cost estimates, e.g., what resources are
needed and in what quantities. Calculating the costs is the most important and most
difficult sub-item in planning the resource requirements. As human resources are
the major cost driver, these are particularly difficult and important to estimate.
The planning of resource requirements is the basis for cost planning and hence for
cost controlling. The resources required for completing each work package must be
determined (Table 3.9). In hospital projects, the requirement for staff is usually the
biggest single item. However, the cost calculation of the staff involved often does not
happen, as it is taken for granted that they will participate and neglect other duties.
The costs are underestimated in almost every project. This is caused by wrong
estimates but also by changes in the scope of a project. The complexity of projects
means that they are vague conceptions at the start of how the objective will be
reached. First estimates are thus highly uncertain. A bandwidth of accepted devia-
tions should be defined at the outset of the project. The following points should be
considered when making a cost estimate:

–– Cost estimates for new projects are usually too low.

–– Typically, staff members estimate the costs too low if they do not carry out the
work themselves.
–– Many staff members do not draw a clear line between cost and duration. Cost
depends on the content of the work to be done; thus, it cannot be directly influ-
enced. However, the duration can be influenced by more or less intensive work
on a work package.
–– There is no project management without costs. However, these costs are not
often included in the planning. Exactly the same applies to the costs for quality
management.
–– Experienced colleagues should be reponsible for cost estimations.

In the course of planning, activities are put into the correct sequence using net-
work planning techniques. Prerequisites are the project structure (WBS), planning

Table 3.9  Cost estimate

Work packet Operator Staff deployment Cost Duration
Define the project plan Dr Sisulu 50 % 4 MH 8 H
Specify the requirements Dr Jacob 100 % 90 MH 30 H
Ms Sass 100 % 90 MH 30 H
Mr Hertz 100 % 90 MH 30 H
Plan personnel and resources Ms Earl 50 % 4 MH 8 H
Analyse risks Dr Martens 20 % 10 MH 50 H
MH man-hours (total project effort in people hours), H hours (duration of the project in hours)
3.8 Project Management 53

of milestones and of resources and the cost estimate. Furthermore, it is necessary to

analyse the dependencies of the various work packages on one another. Two work
packages A and B could be linked by various kinds of dependencies, e.g., B could
only be started once A has been finished. The chronological progress of activities
can be depicted as a bar chart. Such a diagram, also known as a Gantt chart, docu-
ments the various links between work packages.
Figure  3.13 shows parts of a Gantt chart from the WBS of our sample project
‘Emergency Unit’. It highlights how the main activities are timed according to their
duration and dependencies.
The planning up to that point still shows a number of shortfalls because the availabil-
ity of staff has not been taken into account. However, in the early stages of planning this
may be hard to estimate, as various projects and departments may compete for the staff.
In principle, planning can be optimised by using the three most important plan-
ning elements: people, time and costs. The main focus in optimising a project plan
is generally on the required resources (staff). By using a so-called workload dia-
gram, the deployment of staff members is checked. A workload diagram consists of
two basic elements: the availability of people and the requirements for manpower.
People availability considers the expected availability of staff member for the
project. If a staff member is on holiday or on sick leave, the value for those who will
be available decreases. The manpower requirement results from previous planning
and the timing of the schedule. Matching availability and requirement makes it
evident whether the planned work can be completed in the calculated time frame. If
the requirements exceed availability in a given period of time, the plan cannot be
implemented and will have to be revised. Basically, there are two options.

–– Availability is increased by bringing in additional staff, e.g., by working overtime or

by engaging external staff. This should be carried out if ­there is a deadline to be met.

Fig. 3.13  Gantt chart

54 3  Develop Your Vision and Communicate It

–– Dates can be changed and tasks may be shifted either forwards or backwards to
increase availability. If free buffer periods exist, these may be used. Thus, man-
power surplus can be decreased by moving the work package forwards from the
earliest to the latest position.

Manpower (staff) availability is a critical issue, especially in a hospital. Doctors

and nurses have to be freed from their daily duties for effective participation in a
project. Frequently, it is not evaluated whether this would be possible as the hospi-
tal’s executive management often imposes projects top–down and adds them to the
current workload. Thus, many projects are condemned to failure right from the start
by not having adequate resources available.
Realistic project planning is necessary for the implementation and control of a
well-functioning project. Project planning may be used like a map that makes it pos-
sible to discover deviations from the plan at an early stage. Planning is an important
prerequisite for implementation of the project; however realistically speaking, plans
are not always adhered to. The project manager needs to be actively in control if the
project is to be implemented according to plan. If a deviation from the plan threat-
ens the project, he/she has to take measures to respond to this.
The comparison of the planned with the actual situation is probably the best
known and most frequently used instrument when controlling a project. This
makes differences transparent and helps to estimate their effects on the further
course of the project. If the comparison of planned and actual data shows a dif-
ference that makes a change of plan necessary, these updated planning dates are
described as target data. This method, referred to as the target or actual com-
parison, can be applied to all control parameters (deadlines, manpower, costs).
All target or actual comparisons and trend analyses serve the single purpose of
recognising variances in deadlines, performance, costs or quality as early as possi-
ble so as to introduce suitable counter-measures. However, such measures have side
effects. For instance, if the impending delay of a deadline is met by applying coun-
teractive measures, this is normally at the expense of performance, quality and costs.
Project completion is the official end of a project. The result of the project has
been accepted by the customer. No further expenses are necessary to fulfil the proj-
ect’s objectives.
Another approach of embedding a project into the overall strategy for the hospi-
tal is project portfolio management, which we briefly outline in the next section.

3.9 Project Portfolio Management

Project portfolio management is pooled project planning and management of the

projects in an organisation. It includes continuous planning, prioritisation, control
and monitoring of all projects in a hospital. In this regard it is important to choose
and develop the right projects according to the hospital’s strategic and economic
alignment. Persons directly involved in the processes must be included in the rele-
vant projects to enhance the successful implementation.
Within the scope of strategic alignment and market development, project portfo-
lio management can be used in conjunction with other management tools, e.g., the
3.10 Lean Management 55

Balanced Scorecard (Chap. 7). This pools activities in the hospital and effectively
depicts the necessary staff. Apart from that, cross-project synergies can be utilised
through project portfolio management. Particularly on the grounds of increasingly
scarce resources (people, time, money etc.) prioritising and slimming down of proj-
ects (lean management) should be implemented.
The aspect of time plays an important part in running a project. This means that
people or teams have to be freed up from other tasks to enable them to work on the
project. Partial results can be planned in short phases, e.g., by the week or month.
The project team must have the autonomy to make certain decisions and have per-
sonal responsibility. Short, direct lines of communication and reduction of hierar-
chic levels contribute to a project’s effective implementation and success. It is
important to set clear priorities and to avoid accustomed paths. An example habitu-
ally used by hospitals is a type of all-encompassing project planning worked out in
the greatest detail. It is better to run several short projects one after the other than to
implement many simultaneously.
The monitoring of the project portfolio must be conceptualised and responsibili-
ties described so as to anchor the project portfolio within the hospital’s organisation.
It is also important to set up the operational principles amongst participating indi-
viduals and teams as well as to formulate economic performance incentives, target
agreements and target compliance.

3.10 Lean Management

Lean management is applied as an approach to running organisations and hospi-

tals through a continuous improvement process in order to advance service deliv-
ery and efficiency. In the late 1980s and early 1990s, lean management ideas
developed by the Japanese car company Toyota were introduced into other inter-
national companies. A basic pillar of this concept is the avoidance of waste (Muda;
Sect. 4.4.2). The eight forms of waste in hospitals are: overprocessing, unneces-
sary movements, corrections, transport, waiting, stock, overproduction, incorrect
use of talent.
Furthermore, all the activities of an organisation can be divided into value added
tasks or non-value-added tasks. In other words: procedures can be carried out leaner
and faster when you abolish the non-value-added tasks.
Why is lean management particularly important in hospitals? During the last few
decades, organisational overheads have increased sharply in hospitals and health
systems worldwide. On the one hand, this is due to the legal requirements with
regard to quality management, patient safety, controlling and accounting. On the
other hand, according to the British sociologist Parkinson (1955), administrations
tend to expand. Examples 1 and 2 illustrate Parkinson’s law:

Example 1  Each task takes up exactly the time available for performing that task.
In an afternoon, a senior registrar or consultant can see either two or eight patients
in an outpatient clinic. With both two and eight patients he feels fulfilled by his
work and can confirm to himself that he has worked to his capacity.
56 3  Develop Your Vision and Communicate It

Example 2  A new hierarchical structure is planned to increase the number of his

subordinates. The department of surgery has, apart from the consultant, three senior
registrars. The consultant and the senior registrars all feel that they work to the limit
of their capacity. They succeed in reaching an agreement with the executive hospi-
tal’s management to convert the positions of the senior registrars to consultants and
the consultant to become the medical director of the hospital. The increase in the
hierarchical level should highlight and commend their extraordinary performance.
In addition, the elevation to a higher level within the hierarchy is meant as an incen-
tive to prevent them from applying for other external positions.
Conclusion: although this measure was initiated not to require additional staff, a
few months later the new consultants express their urgent need to recruit appropriate
deputies.
According to Womack and Jones (2003), lean management has five core princi-
ples that can be applied to hospitals. Admission, diagnostics, therapy, and discharge
can be structured according to these principles and modified for hospitals. They are
defined as follows (Fig. 3.14):

–– Define value: define services from the clients’ point of view (referring doctors
and patients). The client receives the best service, tailored to their needs.
–– Identify the value stream: sequence of value-creating processes to produce a ser-
vice. Subdivision of processes into value-added tasks and non-value-added tasks.
–– Implement flow: unobstructed flow of patients, laboratory analyses, examina-
tions, etc., from one point to the next.
–– Introduce pull-principle: the patient sets the pace. Waiting periods, also with
support services, should be avoided. The pull system calls in people, services,
and information precisely when they are needed.
–– Strive for perfection by applying continuous improvement process (CIP) or
Kaizen (Sect. 4.6). Conditions in health services change continuously. Standing
still means a step back; bad habits are quickly re-established (Chap. 6). It is the
frontline staff of a hospital who should be questioning processes on a regular basis
and making suggestions for improvements, as they are directly involved.

Lean management thus tries to achieve more with less and to offer an alternative
to the ‘more money, more staff, more rooms’ circle.
Backed up by lean management, flattened hierarchies and process-controlled
decisions are becoming increasingly en vogue. However, lean management also
means intensifying the work because the focus is on the work and not on the persons
doing it. However, the traditional separation of a hospital into nursing, medical and

Define services
from a Identify Implement flow Introduce pull- Strive for
customer processes principle principle perfection
perspective

Fig. 3.14  Five-factor model of lean management for the hospital

3.10 Lean Management 57

management discourages flat hierarchies and quick decisions. Small- and medium-
sized hospitals in particular place emphasis on care and economic considerations.
A representative example of a hospital that is aiming at excellent, patient-­
orientated medical care and consistently achieves this goal is the Mayo Clinic in
Rochester, USA. Mayo has successfully implemented lean management methods.
By applying these methods and structuring processes focussed on the patient, sig-
nificant improvement could be seen in the rate of staff absenteeism, the number of
patients treated, the time allocated for doctor–patient contact and waiting times
(Tanninecz 2010).
As is often the case, a critical number of participants had to be convinced to buy
in to the project and carry it forward. An example of the successful implementation
of lean management in a hospital is described in the case study.

Case Study
A day hospital for children and adolescents is managed according to lean
management methods. The goal is to provide the best treatment and care
of patients with the lowest conceivable number of staff to obtaining a high
degree of patient satisfaction. When patients are registered for admission,
their information and history are entered based on a standardised question-
naire. Further medical information is ascertained from the medical records
and the referring private practitioner. Only completed folders are accepted
for further processing. The doctor in charge of the day hospital determines
the necessary examinations (laboratory, equipment and imaging), which will
be coordinated and arranged by the administrative staff. The family is con-
tacted for an appointment and informed about the estimated length of stay in
hours. One week before the final admission, the treatment plan and neces-
sary modalities are discussed in detail by the team, which consists of nurses,
administrative staff, and doctors. As all information is available it is not nec-
essary to search for results or information. If there are unanswered questions,
one person is delegated to be responsible for providing the information within
the next 2 days and adding it to the database. Two days before admission, the
family is reminded of the appointment by a telephone call. During the stay
at the day hospital, the patient and parents are looked after by a doctor and a
nurse who are familiar with the medical history and the treatment plan. After
completion of all examinations, the doctor further advises the family and the
patient about the results obtained and specifies future actions. The patient
receives a discharge letter before leaving the day hospital. If necessary, the
treating doctor phones the referring doctor to discuss the case.
Conclusion: Based on this approach, the satisfaction of the patient, the
family, and referring doctor is very high. The hospital receives patients nation-
wide for specific treatments, even though it is only a regional hospital. Patients
know that they will be treated more efficiently, more competently and faster
than in any nearby hospital in their area.
58 3  Develop Your Vision and Communicate It

3.11 Summary

Visions are seldom developed sitting at a kitchen table. The development and
phrasing of a vision can be a tedious process. A clear strategy, precise defini-
tions and execution of processes are all needed before visions are made public
and can be implemented. The development of a business strategy and the strate-
gic implementation of projects are tools for realising visions. Initially, a SWOT
or ABC analysis should be conducted to analyse strengths and weaknesses and
set priorities. These are important prerequisites for coordinating the strategy
and the relevant processes. The entire process must be re-evaluated regularly to
ascertain whether the hospital or department has achieved what it aimed at. The
analyses of success factors are equally important. The project and the project
portfolio management have to align with the overall business strategy and must
provide benefits for patients and referring doctors through improved processes.
Projects are to be implemented according to a standardised scheme. It must be
clarified that they will effectively create benefits (added value) and which
objectives are to be attained (SMART). In this context, lean management plays
its part. Lean hospital management is conducive to making structures transpar-
ent and to successfully avoiding a negative cost loop. Processes and structures
aim to become lean and efficient. Only once this concept has been successfully
established the hospital’s vision can be conveyed to the different stakeholders.

3.12 Five Reflective Questions for Practical Application

1 . What is the vision for your hospital or department in 1, 2 and 5 years’ time?
2. Have you conducted a SWOT analysis for your hospital or department?
3. In which area do you see a need to improve hospital processes?
4. Which projects have you implemented during the past 6 months? Which projects
were successful, and which did not succeed? Outline what made them successful
or why they failed.
5. Which three opportunities do you see in your area that can be structured accord-
ing to lean management principles?

References and Further Reading

ACEM (Australasian College for Emergency Medicine) (2005) Guidelines for Implementation of
The Australasian Triage Scale in Emergency Depts. Revised 5 Aug 2005 http://www.acem.org.
au/media/policies_and_guidelines/G24_Implementation__ATS.pdf
Mintzberg H (1975) The manager’s job: folklore and fact. Harv Bus Rev 53(4):49–61
OCG (Office of Government Commerce) (2009) Managing successful projects with PRINCE2
manual 2009. TSO (The Stationery Office), London
Parkinson CN (1955) Parkinson’s law. Economist 177:635–637
References and Further Reading 59

PMI (Project Management Institute) (2013) PMBOK – a guide to the project management body of
knowledge, 5th edn. The Project Management Institute, Sylva
Tanninecz G (2010) Best in healthcare getting better with Lean. http://www.lean.org/
Varvasovsky Z, Brugha R (2000) How to do or not to do a stakeholder analysis. Health Policy Plan
15(3):338–345
Womack JP, Jones DT (2003) Lean thinking: Banish waste and create wealth in your cooperation.
Simon & Schuster, London
Face Your Competitors
4

Goals
–– Why is it necessary to do benchmarking?
–– Why is it so difficult for hospitals to do the right things right?
–– Which methods can improve processes?
–– How can you ensure continuous improvement in your processes?
–– How can Kaizen, CIP, Six Sigma, the PDCA cycle or the DMAIC cycle help you?

In this chapter we focus on process improvement. We highlight business engi-

neering and re-engineering, and how and when they can be applied. To be success-
ful and implement sustainable solutions you need to be familiar with Kaizen, the
continuous improvement process, Six Sigma and the avoidance of Muda (waste).

Benchmarking has gained a foothold in the everyday working life of hospitals. In

the benchmarking process, standards are set by comparing and analysing target
values. Services, processes, adverse incidents, infection rates and patient satis-
faction are compared with those of other, usually anonymised hospitals or other
health care providers to analyse and improve performance parameter. For
instance, the quality of n­ eonatal care is measured among hospitals. The number
of preterm infants of a particular gestational age, the rate of infections, duration
of ventilation, ­complications, survival rates etc. are compared and the hospital is
benchmarked against others.
In more recent years, the implementation of benchmarking processes for captur-
ing quality standards has become mandatory in many specialist areas. Alternatively
you can also volunteer to gain insight into quality assessment and to be present on
the platform. External benchmarking is commissioned and conducted too. Which
measures are evaluated or whether measures are taken is mostly decided by the
hospital management, the consultant or the head of department.

© Springer Berlin Heidelberg 2017 61

E. Weimann, P. Weimann, High Performance in Hospital Management,
DOI 10.1007/978-3-662-49660-2_4
62 4  Face Your Competitors

Case Study
For years, a certain hospital has participated in a country-wide survey that
­examines patients’ satisfaction. The hospital repeatedly has low scores in the
same categories. When a new consultant joins the staff and questions this, he
receives various answers and explanations: the timing of the survey is badly
chosen. Compared with other regions, the local community tends to give rather
negative answers. Although the survey takes place country wide, the staff is not
convinced of the effectiveness of the survey and the way questions are asked. Up
to that point, no steps have been taken to improve matters, even though it has
cost the hospital a considerable amount of money to participate in the survey.
Conclusion: Just taking part in a benchmarking process does not improve
the quality of the results. You must have exact ideas about how to make use of
the results.

Employees need to be informed about the underlying reasons for benchmarking

analyses. If you as a department or a hospital take part in a benchmarking process, you
have to be prepared to implement measures that your staff may initially see as being
negative. Benchmarking has a definite impact on staff. The handling and perception
of criticism and of change processes should be made familiar to staff, while these pro-
cesses have then got to be lived (Chap. 6). The collected data should not be interpreted
as simply serving as accolades and a mutual pat on the back: ‘Actually, we could have
done worse. In spite of our high workload we actually do good work.’ ‘Yes, you do
that but you could improve the results and in turn increase the quality of care.’

Case Study
Each year, evaluation surveys are carried out by the Committee for Continuous
Professional Development among the registrars in a hospital. Evaluations
regarding management, management of adverse incidents, staff development,
staff satisfaction, the leadership culture, etc. are conducted. In most categories
the hospital scores in the lower range. The doctors in senior positions accuse
the junior colleagues of depicting the hospital in an unfavourable light. The
respondents are asked to revise their evaluation and put in a request renounc-
ing the right to publish it on the internet. Internal structures and decision-
making processes are not evaluated, modified or changed. At the next
evaluation, only those employees whose work contracts expire before publi-
cation of the results answer the questions truthfully. The other registrars
answer as positively as possible.
Conclusion: Benchmarking results should not be used to exert pressure on
colleagues to answer questions more favourably due to that the results are
published externally. This contradicts the idea of benchmarking and defeats
the objective of using benchmarking towards continuous improvement.
4.2 Business Engineering 63

4.1 I mprove Your Processes Daily and Align Them

to Your Benchmarking Results

Good benchmarking results will highlight the service quality and efficient p­ rocesses
of the hospital. Processes play a central role in hospitals, hence a focus on them
will result in the standardisation of admission, discharge, and treatment manage-
ment. Costs can be saved when standardized procedures are implemented, how-
ever, workflows must be analysed on a regular basis and occasionally will have to
be ­substantially altered. Reorganisation concepts such as business engineering and
business process re-engineering (BPR; Chap. 3) adapted from the world of business
have gained a foothold in hospital management.
The change management anecdote outlined in Chap. 6 illustrates transformation
and change, which is normally associated with economic success. Economic suc-
cess or, in other words, the necessary competitive advantage of a hospital, is what
business engineering is about.

4.2 Business Engineering

4.2.1 Reasons for Business Engineering

Benchmarking provides information on performance and other parameters, such

as the rate of infection or rate of adverse incidents, compared with other hospi-
tals. Suboptimal benchmarking results can be the reason for implementing business
engineering measures. There are reasons for necessary change to obtain a competi-
tive advantage and thus ensure the economic success of the hospital. Before going
into details, we broadly describe and motivate business engineering.
Multiple changes in the local setting might have happened: for instance, there
may be a hospital close by that has been taken over by a private hospital group or is
expanding, or a new day hospital has opened where surgeons of different disciplines
work in private practice. At the day hospital profitable operations are performed
quickly and efficiently and may threaten the existence of various departments in the
hospital. Problems with current procedures may occur in high-risk areas, such as
admissions, discharge management, and emergency care. New legal requirements
ask for the introduction of quality standards, or request a minimum number of sur-
geries or treatments.
Problems, such as complaints, the infection rate, and long waiting periods, are
discussed in quality management. For this reason business engineering overlaps
significantly with quality management. Let us look more closely at the different
reasons for initiating a business engineering process (Fig. 4.1).

Changes in Business Environment

Many changes in the business environment have consequences for the hospital and
often require a change in business processes. Examples of such changes in the busi-
ness environment are:
64 4  Face Your Competitors

Changes in the region Benchmarking New therapies and

(e.g. new competitor) results treatments

Reasons for
business
Problems in the engineering New legal
hospital regulations

Problems with the

ISO 9000 New IT- systems/
current processes
certification innovations

Fig. 4.1  Reasons for business engineering

–– Certain services are no longer covered by the cost carriers.

–– A new hospital group employing private doctors has opened its doors. It is
located in a central position with easy access, good public transport, and suffi-
cient parking.
–– Surgical interventions and complex procedures are being performed by private
doctors in a newly opened day hospital.
–– A private hospital group gains a high market share with profitable procedures,
leaving less profitable areas such as outpatients and emergency care to the com-
peting hospitals.
–– A hospital chain opens a new day hospital in the proximity. This hospital only
treats private patients who are transported from their homes by the hospital’s
own taxi service.

The questions for the hospital management are:

–– What are the implications for the hospital? Which services are affected and have
to be adjusted?
–– What would be an appropriate plan of action?

Lack of effectiveness and reduced efficiency are two reasons for business
e­ ngineering, and thus to effect changes in processes. Be clear about the difference
between these two terms.

Definition
Effectiveness defines the degree to which something is successful. Effectiveness
measures the output. It can also be described as doing the right things.
4.2 Business Engineering 65

Efficiency is a subsidiary aim of effectiveness and is seen as a criterion of cost-­

effectiveness of resources. It compares input with output and is described as doing
the right things right.
These definitions are coined by Peter Drucker in his book The Effective Executive.
He distinguishes between efficiency (performance) and effectiveness (efficacy).
The executive is, first of all, expected to get the right things done. And this is simply saying
that he is expected to be effective…For manual work, we need only efficiency; that is, the
ability to do things right rather than the ability to get the right things done. The manual
worker can always be judged in terms of the quantity and quality of a definable and discrete
output, such as a pair of shoes. (Drucker 1967, p. 1)

It becomes evident in the benchmarking process that many hospitals lack effec-
tiveness, and have problems ‘doing the right thing’. Part of this is, for instance,
defining success factors, recognising core competencies or developing the right
treatment options.
The hospital, its environment, and the demands have changed over the years. For
instance, various hospitals are competing on the same platform, the demands of
patients and referring doctors have changed, or alternative methods of treatment
have been established. If the hospital did not respond adequately or not fast enough
to the changed circumstances, this could influence its effectiveness because hospital
vision, strategy, and objectives have not been adjusted. Examples of shortfalls in
effectiveness are:

–– Lack of a convincing and lived mission statement (e.g., the hospital is a church-­
owned institution; however, maximising profit is more important than ethical
principles).
–– Unclear strategic objectives (e.g., the hospital’s executive management dispar-
ages the competing hospitals both in front of the employees and in the commu-
nity. However, the hospital does not communicate its own strategies and
competencies).
–– Lack of knowledge of success factors and success potentials (e.g., the hospital
has not conducted a market analysis on how it is perceived in the community and
what the success factors are).
–– Unclear market objectives (e.g., only a few members of the hospital’s manage-
ment know which short-, medium- and long-term market objectives the hospital
is pursuing).
–– Lack of knowledge of problems, needs, requirements and expectations of patients
and referring doctors (e.g., hospitals and staff are working without customer orien-
tation and continuous evaluation as well as adjustments to the clients’ demands).
–– Lack of process goals and treatment options (e.g., the hospital offers a whole
spectrum of treatments; however, often there is little coordination with other
health care professionals and offers for follow-up treatment).

As outlined, business engineering is connected to the strategic management of a

hospital, which in turn, represents an important prerequisite for successful business
engineering.
66 4  Face Your Competitors

Doing the right things with a Doing the right things right.

High
too high effort -> Keep efficiency and
-> Improve efficiency effectiveness
Effectiveness

Doing the wrong things with a

Doing the wrong things with an
too high effort
Low

adequate effort
-> Change priorities and improve
-> Change priorities
efficiency

Low High
Efficiency

Fig. 4.2  Effectiveness and efficiency

The objective of BE consists in linking effectiveness (‘doing the right thing’) and
efficiency (‘doing things the right way’). Figure 4.2 illustrates the link between
effectiveness and efficiency.

Case Study
Typically, the head of department of radiology gets the instruction ‘to save
10 % this year’. That is no problem for radiology. The Picture Archiving and
Communication System (PACS) support of the departments is closed down. (This
is a standard procedure ensuring that pictorial, diagnostic and informational mate-
rials are distributed in the hospital.) If ‘10 % of costs’ are to be saved, this distribu-
tion can be stopped and 10 % is saved. There is even a sustainable and positive
effect for radiology, whose resources become more efficient. In the next business
cycle there is the instruction to save a further 5 %. This is also no problem for radi-
ology. Now, hard copies are no longer issued. Hard copies are films, CDs and print-
outs. Soft copy would be the distribution of the above-mentioned PACS. Patients
no longer get films, doctors are no longer provided with diagnostics reports and
everyone is forced to make their own provision for obtaining information. This
causes no problems for the radiology (Salomonowitz 2009, page 1).

In the case study, Salomonowitz (2009) describes a typical standalone solution

that has far-reaching consequences for the hospital. This is a question of doing the
right things the right way. Although the radiology department can cope with the
directives and can adjust its processes accordingly, the far-reaching impact of the
change on other departments and units has not been taken into account.

Use of New Technologies

Innovation and technology play a decisive role in maintaining and increasing the
hospital’s competitive advantage. Specifically, technologies in the area of informa-
tion and communication technology such as PACS, Orbis (▶ Glossary), the internet,
4.2 Business Engineering 67

smartphones, tablets, etc. strongly influence the administrative and medical

processes.
Using new technologies, various improvements have been made over the last
few years: the integration of tasks has been improved, working hours and place of
work have been made more flexible. This becomes particularly evident in areas
where there is no need for direct patient contact. Nowadays, the authorising doctor
can view and report on X-rays and other modalities at home; employees can answer
e-mails on smartphones; processes can be controlled more easily; the flow of infor-
mation is increased; information analyses have improved; geographical distance
can more easily be overcome; data can be exchanged between the hospital and the
referring doctors or between hospitals (telemedicine). A diagnosis can be made
from a distance, e.g., in the case of a suspected heart attack, the electrocardiogram
from the ambulance can be sent to a treatment centre. Apart from that, the collection
and distribution of knowledge is accelerated. A result is that staff’s skills should be
equal in different hospitals (e.g., tertiary care hospital versus large regional hospital)
because of the continuous learning and teaching process.
Such improvements can only lead to competitive advantage if procedures are
adjusted or occasionally revised completely. Processes in companies have been
radically re-organised using business process re-engineering. In the hospital con-
text, however, this approach has been implemented in only a few private hospitals
and hospital groups.

Definition
Business process re-engineering is the fundamental rethinking and radical reorgan-
isation of the processes within a company where the status quo is called into ques-
tion. BPR is often linked to significant cultural and technological changes (Hammer
and Champy 1993).
Which conditions would allow for BPR in a hospital? Let us illustrate this with
an example. A hospital group buys a hospital and moves later into a newly designed
building. In this case, structures should be reviewed and re-organised from a pro-
cess- and profit-orientated point of view. And, in this case, a radical approach such
as BPR is recommended, since the current hospital will continue to function until
the relocation and the hospital management has the time to train the staff in the
structures and processes. We will come back to the BPR a bit later (Sect. 4.4).

Problems with the Current Processes in the Hospital

Problems with current hospital processes make revisions necessary. Frequently, the
question is asked: why are processes suddenly insufficient? Processes were once
introduced for good reasons and have been used successfully over the years.
One reason is the continuously evolving information and communication technol-
ogy. Many processes were instituted before the introduction of certain technologies.
They were often provided to compensate for a lack of information. We still partly use
these old procedures, which in the meantime have been integrated into our digitalised
systems. Indeed, fax, e-mail, smartphones and the internet have dramatically changed
hospital procedures. But the adaptation process is still nowhere near complete, as
new technologies constantly become available on the market. Many hospitals have
gained a competitive edge by using new technologies quickly and effectively.
68 4  Face Your Competitors

If a hospital uses a new technology such as an electronic board to reduce waiting

times for patients, the competing hospital suddenly has a problem with extended
waiting times. Such problems are associated with inefficient processes.

New Statutory Regulations

The government influences processes in the hospital in many areas: new ­regulations
in consumer protection, new laws on privacy protection within the new govern-
mental frameworks, new quality assurance measures, and the introduction of a
practice fee or of an electronic medical card. Often these new regulations are
linked to changes or business engineering, resulting in business engineering mea-
sures. In turn, this introduces a new mode of accounting that entails endorsing an
altered treatment modality. Certain treatment options are no longer covered by
insurance companies/medical aids. The hospital must then consider initiating col-
laboration with other treatment facilities to ensure continuity of care (day hospital,
colleagues in private practice, step-down facility). This, too, entails changes in
hospital procedures.
Some hospitals design their treatment portfolio in such a way that they offer
mainly attractive and highly profitable treatment options and let competing hospi-
tals handle any other treatment. Thus, from year to year, changes have to be imple-
mented in hospitals. For example, a hospital has exceeded the treatment quota for a
particular condition or surgical intervention, such as hip replacements, and is not
being reimbursed for such operations. The hospital may, then, try to manage the
number of annual hip operations through instituting a waiting list or patients could
be handled as day-patients with integrated follow-up treatments.

New IT System
If an IT system or an electronic patient record is to be implemented successfully,
it is necessary to analyse the processes beforehand. Then they should be adapted
before the system is introduced. Adapted processes are the prerequisite for the
success of the new system. However, IT systems often fail because other hospi-
tal’s processes are inadequately considered. This causes the following
problems:

–– Inadequate support of processes from the new IT system (e.g., tiring and time-­
consuming admission procedures).
–– Cementing of inefficient processes (e.g., before an appointment is made it has to
be confirmed by various separate departments)
–– Lack of integration with other IT systems (e.g., many interfaces and compatibil-
ity problems).

The IT systems constitute an important component, supporting the structuring

and efficiency of processes. However, they do not lie within the focus of business
engineering, but are simply one of many reasons for applying it. Table 4.1 illustrates
an example of utilised and planned IT systems.
4.2 Business Engineering 69

Table 4.1  Information technology (IT) systems in the hospital

Administrative IT Operational IT Administrative IT
Medical IT support support support support (planned)
Therapy and Financial accounting Nursing care Resource planning
treatment
Laboratory Personnel, HR Prescription system Accounting, payroll
Outpatients DRG grouper Electronic imaging Electronic
archive procurement
Electronic patient Personnel Intensive medicine Electronic HR filing
record administration
HR human resources, DRG diagnosis-related group

4.2.2 Business Engineering: Business Process Management

Let us take a closer look at the different business engineering approaches. What
does business engineering mean? What are the tasks? How is business related to
concepts such as Kaizen, BPR, outsourcing and Six Sigma?

Definition
Business engineering is an integrated concept of management, optimisation, organ-
isation and controlling of business processes or hospital processes. Business engi-
neering in hospitals is aimed at fulfilling the needs of patients, referring doctors
and other interest groups (stakeholders) such as suppliers, staff, investors, and own-
ers. It contributes substantially to achieving the hospital’s strategic and operational
objectives.
The task of the executive hospital management is to create a business process
culture that is stakeholder-orientated. The responsible persons should be motivated
to improve the hospital's processes, establish necessary communication, and ensure
trust, especially in times of change (Chap. 6).
In the optimisation process, a continuous cycle of processes is assessed regard-
ing the improvement potential. This is the focus of business engineering. On the one
hand there is the radical approach of BPR that envisages a complete renewal of the
process landscape, on the other hand, evolutionary approaches such as the continu-
ous improvement process (CIP) and Kaizen implement a step-by-step improvement
of the business processes. As a further method, Six Sigma has the objective of
avoiding errors in processes and therefore sets statistical quality indicators. The
tasks of business process organisation consist in identifying business processes,
structuring and modelling them as well as prioritising them with regard to the hos-
pital’s strategy. Here, the roles and responsibilities must be determined that ensure
that the processes are integrated into the hospital (Chap. 3).
The tasks of business process control comprise determining the process objec-
tives and measurement parameters and documenting the results in addition to
implementing internal and external benchmarking (Chap. 7).
70 4  Face Your Competitors

Hospital strategy

R P
e a
f t
e Process management/ i
r business engineering e
r n
e t

s
r s

se
es
/ /

oc
s s

pr
t t

ss
a ne a
si
k k
Bu

e e
h h
o o
l l
d d
e e
r r

Hospital results
Garanteeing the future

Fig. 4.3  From hospital strategy to business result

In the hospital, business engineering has two central reference points:

–– The hospital’s strategy, which determines which business processes are required
in the hospital (‘What?’) and which objectives have to be implemented in the
business processes (‘How?’). The ‘What’ and the ‘How’ decide the alignment of
the business processes.
–– The demands of patients, referring doctors and the requirements of other interest
groups (stakeholders).

It is the task of business engineering to fulfil clients’ requirements and to struc-

ture the hospital’s strategies accordingly. You should be aware that hospital pro-
cesses can be geared too closely towards short-term operational goals. This lead to
insufficient measures for establishing and expanding core competencies as well as
success potentials. On the other hand, too much focus on the hospital’s strategy can
cause an imbalance between the needs of patients and referring doctors. The align-
ment of hospital strategies with patients and referring doctors is therefore aimed at
achieving good business results and at securing the hospital’s future. This situation
is illustrated in Fig. 4.3.
Finally, we can describe business engineering as follows: all activities within a
hospital are focused on the demands of clients (patients and referring doctors) and
other interest groups (stakeholders). Hence, the structure and control of business
processes can be divided into:
4.3 Business Process Re-engineering 71

–– Process orientation: the focus rests on business processes such as admission and
discharge management, treatment processes, and costs.
–– Orientation towards patients and referring doctors: structure and control of
business processes are focused on the requirements of patients, referring doctors,
and other stakeholders.
–– Orientation towards value creation: the focus rests on value-creating activities
as core processes.
–– Performance orientation: the effectiveness and efficiency of the business pro-
cesses are continually increased. Benchmarking processes are carried out on a
regular basis, and the improvement of the processes is adjusted towards the results.
–– Staff orientation: the staff is a crucial component of the hospital’s process man-
agement. Staff members are motivated to contribute to the improvement of the
hospital’s processes.
–– Orientation on learning: business engineering underpins organisational learn-
ing. You can learn from shortcomings.
–– Orientation on competencies: the business processes serve to build and expand
core competencies.

4.3 Business Process Re-engineering

In the following paragraphs we now describe the individual methods (BPR, CIP,
Kaizen and Six Sigma) that can be applied to improve processes.

4.3.1 Fundamentals and Objectives

In BPR the idea is to drastically re-engineer processes. The status quo is fundamen-
tally challenged (see definition in Sect. 4.2.1). The approach was invented by Hammer
(1990) and was successfully applied in various companies in the USA in the 1990s.
Hammer and Champy (1993, p. 32) define business re-engineering as follows:
Business Process Re-Engineering is the fundamental analysis and radical redesign of busi-
ness processes to achieve dramatic improvements in critical measures of performance such
as costs, quality, service and speed. (Hammer and Champy 1993, p. 32).

An example of the BPR approach is mentioned in Sect. 4.2.1. Further possibili-

ties may lie in a newly established day hospital, a new outpatient clinic, a health
centre or community health care centre. If re-structuring must happen, the hospital
management should take the time to consider whether a radical change in proce-
dures and processes would increase efficiency and create value. Possible starting
points for BPR are thus:

–– Processes are not efficient enough (e.g., on average, how long does it take for a
patient to be treated in the emergency room and admitted as an inpatient?)
–– There is a lack of referral information for doctors and patients.
72 4  Face Your Competitors

–– Some hospital procedures differ strongly from the requirements set by the health
system framework.
–– Reactions to changes in the community or market-driven changes are too slow,
caused by the increased complexity of hospitals.
–– Expectations of patients have increased and up to now the hospital has not taken
this into account sufficiently.
–– Standard solutions are offered that do not meet market requirements. There is a
lack of services that are specifically tailored to patients’ needs and demands.
–– Many services and treatments are only offered and rendered on an outpatient or
day-admission basis. Several private hospitals have been established in the vicin-
ity, resulting in an intensification of competition.
–– Constant changes and adjustments are necessary. The flexibility of processes
either does not exist or is inadequate.

Therefore, the objectives of BPR are as follows:

–– Alignment of hospital processes to referring doctors and patients

–– Alignment of the hospital to its core competencies
–– Realising costs, quality, speed and service advantages compared with the compe-
tition, e.g., by division of different levels of care such as ‘intensive/high care/low
care’
–– Intensive utilisation of information technology to support processes: all required
patient information is available at all points and does not have to be recaptured
–– Increased flexibility, e.g., higher staffing during epidemics, in the case of high or
low occupancy

The BPR is often compared with the ‘green meadow’ method. ‘If we have to
rebuild our hospital from scratch on a green meadow, how would we then structure
our processes?’ It is aimed at newly structured business processes in the entire hos-
pital. The driving force is the executive hospital management. Some private hospital
groups implemented BPR in their hospitals, resulting in the economic success of the
hospital group.
This type of optimisation characterises the radical and revolutionary method to
process transformation. Everything is questioned. The basic attitude is that the
existing processes are not necessary or do not function at all.
Such a radical approach is mandatory in hospitals when drastic measures
such as the introduction of diagnosis-related groups (DRGs) are implemented.
Hospitals have to adjust to new requirements, but are hesitant to change processes
fundamentally.

4.3.2 Goals and Approaches

The approach of BPR is fundamental in its concept; it is radical in how it has to be

applied in the hospital by the executive management team and it affects everyone in
the hospital. BPR projects run in roughly three phases: stocktaking, re-design and
4.3 Business Process Re-engineering 73

Identify business
processes

Redesign business processes

Challenge all and align them with
business processes referrer and patients

Identify stakeholder,
Referrer and
patients

Fig. 4.4  The three phases of business process re-engineering (BPR)

implementation (Fig. 4.4). When calling processes into question, the following

points must be borne in mind:

–– Basic assumptions
–– Division of work and procedures
–– Distribution of locations and rooms
–– Time schedules
–– Resource allocation
–– Responsibilities
–– Description of functions

In this step of the procedure, the 7-Question checklist is of great help. It is applied
in various areas, e.g., analysing texts, helping to define projects or work analysis.
The seven questions are:

–– What – needs to be done?

–– Who – will do it?
–– Why – is he doing it?
–– When – is it done?
–– Where – is it to be done?
–– Why – is it not done differently?
–– How – is it done?

The basic elements of BPR according to Hammer and Champy (1993) are
adapted to the individual hospital as follows:

–– Establishing process teams: selected staff members survey the entire process
along the process chain, co-ordinate it, and take the responsibility for quality and
efficiency.
–– The superior is relieved of co-ordination tasks and takes over a coaching role. In
this way, the performance range is increased and the hierarchy becomes flattened.
–– By varying the process, patients and referring doctors are treated based on their
current requirements.
74 4  Face Your Competitors

The implementation of BPR elements (especially in establishing business pro-

cesses) raises numerous issues, such as:

–– Which core processes (e.g., patient related processes) and which support pro-
cesses (supporting functions and/or processes) should be defined?
–– Are core processes conceived to be as autonomous as possible, i.e., independent
of supporting processes?
–– How is the segmentation of core processes to be implemented? Segmentation is
a central problem of BPR. It involves a decision on how well the staff is able to
attune to certain client requirements. Examples of segmentation in the hospital
are: seeing patients with abdominal pain in the nephrology ward instead in a
centre for abdominal diseases; neonatology and obstetrics are located in different
buildings within a hospital.

Below is a list according to Hammer and Champy (1993) that should be taken
into account in a process redesign that has been adapted to a hospital setting:

–– Do not organise processes around the tasks, but relate them to the results. The
former is often applied in hospitals.
–– The people who use the process results should also implement the process and be
responsible for it. Example: The implementation of a multi-disciplinary outpa-
tient department is restructured by medical and nursing staff.
–– Place information processing under the real activities generating the informa-
tion. Example: A letter is digitally dictated by a registrar. He electronically sends
it to the consultant to be signed off. As soon as the consultant has signed it off,
the system sends the letter to the referring doctor. The whole process is no longer
performed via a distant office where the file would have to be opened and pro-
cessed once more. In this case, distributed resources are utilised as though they
are centralised. For instance, if one office is off duty, another would take up its
tasks automatically.
–– Set decision measures where the work is being carried out and integrate monitor-
ing activities into the process. For instance, the consultant has signed off the
order for infusions and medication. Afterwards it is sent electronically straight to
the responsible pharmacist of the hospital.
–– Ensure process integration, i.e., the continuity of a process through various
organisational units. The interface from one organisational unit to another is
referred to as organisational interfaces and presents potential weaknesses in a
business process.
–– Capture data only once, namely at the point at which they originate. A pro-
nounced interface problem still exists in the medical field. Data are normally
captured repeatedly and this consumes resources. Information flow gaps can
develop.
–– Avoid media breaks and interfaces. A media break exists if, for instance, an
X-ray result is captured digitally and then is dictated or entered in letter format.
4.3 Business Process Re-engineering 75

4.3.3 Problems, Opportunities and Risks

The BPR process promises significant performance improvements (e.g., reduction

in waiting times, savings on staff), but it is also risky: up to 70 % of BPR projects
are identified as failures. Whether this can be attributed to BPR or whether it is also
related to the conditions under which the BPR was initiated is difficult to say.
However, more than 30 % of BPR projects are successful. Despite the success rate,
BPR has rarely been implemented in hospitals as the radical approach may clash
with smoothly running day-to-day hospital processes. Nevertheless, BPR could be
increasingly utilised if organisation, outpatients, day hospitals or entire hospitals
have to be completely redesigned.
In the course of BPR various difficulties tend to occur. For instance, the introduc-
tion of new processes often takes place in one go. However, in a hospital, changes
can normally only be implemented step-by-step because the care of patients must be
ensured. In line with the general resistance to change, the biggest obstacles are cre-
ated by the staff (Chap. 6). Unlike Kaizen, Six Sigma, and CIP, the different role
players are not included in the implementation, but are rather seen as part of the
problem. The result of BPR is often a different organisation with new personnel
structures and new ways of working. In addition, responsibilities are shifted.
In the case of successful implementation, however, the greatest effects can also
be generated. To implement a BPR successfully, the starting point is usually a crisis
in the hospital or a dramatically changed environment, e.g., the so called ‘burning
roof’ (Sect. 8.5). There are also areas that do not have direct patient contact (e.g.,
administration, accounts) that can greatly profit from BPR.
Apart from these difficulties, BPR has the following disadvantages. On the one
hand, it interferes with the social balance of an organisation because of its radical
and far-reaching approach and the lack of involvement of the affected employees,
on the other hand, the wealth of experience gained over many years is lost. Staff is
not included in the transformation process or is motivated to change processes. The
hospital and surrounding culture are not sufficiently taken into account.
This is associated with the following risks. Basically, BPR is in conflict with the
‘normal’ day-to-day operations. For that reason, BPR is difficult to put into practice
during normal ongoing hospital operations. Problems of acceptance, buy-in, and
resistance occur in employees who may often feel left out. Certain frictional losses
appear until the new structure has established itself. Frequent improvements are
necessary. During the implementation phase, there is a high degree of instability,
which can have the repeated effect of break-downs. In addition, there is no learning
process for the staff. Short-term, fast improvements are introduced at the expense of
long-term developments.
However, there are also opportunities. A modified BPR that takes hospital
requirements into account should be considered. Radical change ‘across the board’
is still possible. Concepts and solutions can be defined relatively easily. As it can be
implemented quickly, a time advantage can be gained in critical situations. Overall,
processes must not only be restructured and transformed in a patient-­friendly way,
76 4  Face Your Competitors

but continual improvements to administrative and managerial processes are also

necessary. Processes involving patients must be structured to be patient-friendly and
time-effective. This is shown in the following example.

Case Study
A Department of Medicine embarks on establishing an emergency service
together with colleagues in private practice. The HoD has a specific interest in
integrating the emergency service of the private practitioners into the hospital
processes: he wants to improve the interface between private and hospital
doctors and to increase the standard of care. The CEO of the hospital also
favours this innovative approach. A contract is drafted and submitted to the
hospital’s legal advisor and then to the hospital administration. Several months
and many enquiries later, no further development is evident. The contract is
forwarded from one administrative staff member to the next. It is not apparent
to the main role players what exactly is happening and where the contract is
located. Holidays, workshops, seminars, and other absences delay processing
further. The deadline for starting the new service contract is imminent. As a
contract has not been prepared yet, the tension among the private doctors, the
HoD, and the CEO escalates. The head of administration is irritated by the
situation because according to his view everything went according to plan,
even though none of the involved parties is satisfied with the process. After a
meeting between the CEO, the HoD, a representative of the private doctors
and the head of administration, the pending contract is completed within a day
and is approved in a meeting of the executive hospital management.
Opportunity for improvement: To avoid the failure of a potentially suc-
cessfully project, the hospital administration should have focussed on the
requirements of the participants (the applying department and the private doc-
tors) and should have adapted their procedures to make the contract available
in due course. This would have enabled both sides to provide reliable infor-
mation. In this case, the problem arose caused by the classic three-part divi-
sion of the hospital where the administration processes are disconnected from
the medical processes and their requirements.

4.4 Process Improvement with Kaizen, CIP and Six Sigma

There are three ways to learn wisdom: Firstly, by reflection. That is the noblest. Secondly,
by imitation. That is the easiest. Thirdly, by experience. That is the bitterest. (Confucius)

Continuous improvement processes should be part of every hospital. They should

optimise organisational processes and the safety of patients. We will now describe
three approaches for continuous process improvement: Kaizen, CIP and Six Sigma.
All three approaches focus on identifying weak points, problems, and errors. Their
objective is to increase the effectiveness and efficiency of hospital processes. In the
4.4 Process Improvement with Kaizen, CIP and Six Sigma 77

Fig. 4.5  Plan, do, check,

P(lan) - plan a
act (PDCA) cycle
change to determine
its feasibility

A(ct) - determine D(o) - implement the

whether to adopt change and test it on
the change a small scale

C(heck) - assess the

test results of the
implemented change

course of doing this, all three approaches work according to the plan–do–check–act
(PDCA) cycle. This divides the improvement process into the following phases
(Fig. 4.5):

• Plan includes the identification of improvement potentials (normally by the

employee and/or the front-line manager), an analysis of the current situation, and
the development of a new improvement concept with the involvement of the
person performing the task.
• Do, does not indicate the introduction and implementation of the improvement,
but is rather a phase of testing and practical optimisation of the improvement con-
cept, including simple means that can be quickly implemented at a workplace.
• Check means that the results of the process tested in the previous phase are care-
fully checked and if the process is successful it is released as a standard for
implementation on a broader front.
• In the Act phase this new standard is introduced across the hospital, formalised,
and regularly checked for compliance. This phase is often very costly, as in indi-
vidual cases, extensive organisational activities can arise, such as changing work
schedules, the running of training courses, and the adjustment of the organisa-
tional structure and process organisation.

When this cycle is successfully implemented, the new business process is ratified
as the new standard so that errors are not repeated and the learning experience is
enhanced. It is referred to as the standardise–do–check–act (SDCA) cycle. Once an
improvement has been implemented in the business process, further weak points are
investigated and new objectives are set. This cycle never ends.
Apart from the PDCA cycle, teamwork is another pillar for Kaizen and Six
Sigma (Bothe 2003) as for CIP. The following benefits are applied:

–– Self-organisation and hence relief for the executive management

–– Activation of strengths and compensation for individual weaknesses
–– Gaining time by direct collaboration
–– Strengthening of innovative collaboration
–– Influencing attitudes and behaviours
–– Satisfying individual needs
78 4  Face Your Competitors

The PDCA cycle in process improvement is shown in the following example.

Case Study
There are frequent critical incident reports (Sect. 6.5) and ombudsman’s noti-
fications from a large, interdisciplinary outpatient and day hospital of a uni-
versity hospital. Patients regularly complain of having to wait too long,
continually changing contact persons, and the late arrival of letters to the
referring doctors who are in charge of further treatment. In the critical inci-
dent reporting system (CIRS) notifications of ‘near missed incidents’ in vari-
ous treatment areas, wrong applications of medication and infusions, and
delayed management of emergency treatments are mentioned. The hospital
manager, together with the head of nursing, calls a meeting. The topic is the
‘new organisation of the interdisciplinary outpatient and day hospital’. At this
meeting two groups for the areas ‘CIRS’ and ‘Complaints’ are formed that
consist of representatives from the various disciplines (nursing, administra-
tion, consultant, registrar). These people serve as representatives of their peer
group. Everyone else can make suggestions, which are regularly discussed
with regard to feasibility and efficiency. This approach intends to ensure the
buy-in of all team members. Newly structured processes and organisations are
scheduled within the next 4 months. A process representative is assigned who
will oversee the timely implementation of the project and support the various
team members. After another 6, 9, and 12 months, patient and staff satisfac-
tion as well as CIRS incidents are checked and monitored.
Conclusion: During the first months after implementation, a clear improve-
ment can be observed in all three areas. Regular improvements and adaptations
of existing processes are implemented by the teams ‘CIRS’ and ‘Complaints’.

4.4.1 Continuous Improvement Process

The Continuous Improvement Process (CIP) was developed by William Edward

Deming in the course of the quality improvement movement of the 1950s. The PDCA
cycle developed by Walter Shewhart describes the implementation of an improve-
ment process (see Fig. 4.3). CIP can be compared with the Japanese Kaizen approach
and because of their similarity the two terms are often used synonymously (Fig. 4.4).
CIP describes an inner attitude of all participants and implies a constant improve-
ment with maximum lasting impact. It relates to product, process, and service quality.
CIP is implemented by a process of steady, small improvement steps in continuous
teamwork. The CIP attitude of the hospital staff pervades the hospital’s activities.
The executive hospital management needs to implement the results of the CIP, to
authorise the CIP teams to implement their ideas, and make the necessary resources
available. The absence of management support or slow-moving implementation of
CIP leads to discouraged staff. If implementation is not possible in a specific case,
the staff must be given a plausible explanation. A prerequisite for the implementa-
tion of a successful CIP culture is the attitude that staff ideas and teamwork are
4.4 Process Improvement with Kaizen, CIP and Six Sigma 79

Defermine,
Determine as-is Problem description Generate and evaluate evaluate and
Project scoping implement Evaluate the sucess
and shall-be and analysis possible solutions
necessary
measures

Fig. 4.6  Steps in the continuous improvement process (CIP)

explicitly sought and that the staff is given effective support and public recognition.
The constructive involvement of the staff representative is also required.
The effects of CIP can be presented as follows: CIP discovers resources and
synergies, optimises work processes and business processes, improves treatment
processes, and the satisfaction of patients and the referring doctors. It reduces waste,
saves costs, and awakens abilities, creativity, and the commitment of those involved.
CIP improves teamwork and hospital culture and thus strengthens the CI (corporate
identity, Chap. 2). On the other hand, it increases the pressure on the staff to
perform.
In the course of CIP, staff members analyse their work area and, in groups,
develop concrete suggestions for improvements. They are usually trained in team-
work and group moderation in advance. The process is orientated towards the
PDCA cycle and usually follows this pattern (Fig. 4.6):

–– Identify and delimit the improvement process: what can be improved?

–– Describe the current and the target state using key performance data
–– Describing problems: frequency per time or object unit (patient, prescription,
task)
–– Evaluate problems: time, money, energy, stress per time unit
–– Analyse problems: causes, connections, interfaces, side effects
–– Collect ideas for solutions, evaluate, and decide
–– Deduce measures, costs, and returns
–– Agree on measures and clarify resources: who will do what until when?
Implement measures!
–– Check success.

Case Study
The interns and registrars repeatedly complain that they receive poor orienta-
tion when they join the hospital. The senior registrars and the consultants
point out that they did not get orientation and training either and had to gain
their knowledge and experience from their own efforts. One day a new con-
sultant is employed who sympathises with the concerns of the interns and
registrars. He mediates between the various groups and emphasises that they
depend on each other and have to act as a team. By applying CIP, a new train-
ing concept is designed according to the PDCA cycle, which is constantly
checked and improved.
Conclusion: The staff satisfaction, quality of patient care, and use of
resources clearly increases through CIP.
80 4  Face Your Competitors

4.4.2 Kaizen and Muda

Kaizen (Japanese for change for the better) is a Japanese management philosophy
focused on continual, systematic, and step-by-step improvement of business pro-
cesses, which includes the staff. A crucial aspect is the elimination of Muda, i.e.,
any kind of waste. Waste implies that resources are used without an increase in
value. Muda was first used by the car manufacturer Toyota. The seven kinds of
waste are summarised in the acronym TIMWOOD (transportation, inventory,
motion, waiting, overprocessing, overproduction, defects). The elimination of
Muda is part of lean management (Sect. 3.9) tools. In lean management another
kind of waste is added: available expertise is not used in an organisation (Womack
and Jones 2003).
Muda in a hospital context occurs mainly as waste of time, personnel, and diag-
nostic applications. For instance, consultants’ ward rounds last several hours; the
executive hospital management is more occupied with long meetings than with the
implementation of more efficient ways to run the hospital and using the existing
resources; staff is not available due to a lack of ‘meeting free’ time periods; events
are undertaken with the entire staff; diagnostic laboratory tests are ordered late, and
the results are only available long after a patient has been discharged and are there-
fore not considered in the treatment process.
The Muda list of the eight kinds of waste applied to a medical context are as
follows:

–– Medical processes tend to create waste. Almost anything can be made ‘better’.
Along the lines of ‘who wants to be written about in the newspapers because of
neglect or a treatment error?’, medical processes are arbitrarily expandable.
Diseases are overdiagnosed, unnecessary, and repeated laboratory tests and diag-
nostic procedures are carried out. With patients becoming more empowered,
they inform themselves via the internet and demand new and advanced examina-
tions. If they do not get what they want, they approach the next practitioner
(‘doctor shopping’).
–– Patient waiting times for procedures are often too long (e.g., in emergency or
radiology). Patients are lined up at the radiology department waiting to be
examined?
–– Complaints from patients and referring doctors result in the staff using valuable
time reacting defensively.
–– If staff satisfaction is low, this usually results in a considerable fluctuation of
staff. Hence, new staff must be orientated.
–– Distances within the hospital are too long (e.g., from the emergency unit to radiology).
–– There are unnecessary steps in the treatment process.
–– People in the hospital are moved unnecessarily because they have to change
wards and specialists (e.g., according to the intensity of their treatment, patients
have to change ward, nursing staff and the treating doctor if they need a higher
4.4 Process Improvement with Kaizen, CIP and Six Sigma 81

or lower degree of care), the discharge management is ineffective (e.g., discharge

takes place at any time during the day or night, therefore the cleaning staff has to
work nights and weekend shifts).
–– The knowledge available in the hospital is not used at its full extend.

There are numerous examples of Muda in a hospital. Medical staff knows the
typical kind of waste in the non-existent time management, as is entertainingly told
in a hospital novel.
Once more the ward round had been protracted and Lisa’s back was sore from standing so
long. After the discussion of the hospitalised patients Prof. Sanders got carried away in a
heated monologue about current health reforms. Adrian Illig, registrar on the general ward,
has entertained the conversation with emotive terms that Sanders used to philosophize
about. To everyone’s concern the ward clock stroke almost twelve when he ended the round
with his obligatory nod. (Mann 2006, p. 138)

Kaizen assumes that current situation can continuously be improved. Furthermore,

changes for the staff are desired. A high degree of staff satisfaction should be ensured
by constant training, and internal hierarchies are to be changed in such a way that
every member of staff is encouraged to participate in the change process.

Kaizen Process
The Kaizen process generally follows the PDCA cycle. Below, the relevant phases
(Fig. 4.7) are briefly described and the most important goals are explained.

Phase 1: planning the process. Within the scope of planning the action, several steps
are implemented by the responsible person:

–– Formulate the objectives together with the staff

–– Explain the steps of Kaizen at the introductory session
–– Introduce the concept of kick-off meetings and training workshops
–– Introduce Kaizen into the specific areas and for hospital processes
–– Create an appropriate organisational structure

Phase 2: project start. In the specific areas the staff is informed about Kaizen and
relevant training sessions take place emphasizing that:

–– Kaizen happens directly at the place of work

–– The scoping of problems is the starting point of improvements

Plan the Agree on Identify and Quantify the

Start the project
improvement objectives eliminate Muda improvement

Fig. 4.7  Kaizen process

82 4  Face Your Competitors

–– Every error and every bit of waste may occur – but only once.
–– Kaizen looks for and analyses the causes of waste and errors then removes
them.

Phase 3: agreeing on objectives. After the starting phase, the Kaizen team agrees on
the objectives. The Kaizen objectives are to be split into short-, medium- and
long-term goals and are separated from the objectives of hospital processes as
well as the hospital’s objectives.
Phase 4: identify waste and remove it. This phase is the core of the Kaizen project.
Errors and waste have to be discovered, for instance by applying the principle: ‘Go
to the source’ (Genkin-butso), which is related to the seven-question list (see Sect.
4.3.2). The principle stipulates that in the case of undesired results or errors the
‘Why’ question has to be asked five times to come to a solution. However, it also
means that management must get a picture of the situation (e.g., a specific treatment
process) on site by going to the source and not by making decisions from a distance.
The 7-M checklist deals with the seven most important factors that must be repeat-
edly checked when identifying waste:

–– Man/human
–– Machines
–– Material
–– Method
–– Milieu/environment
–– Management
–– Measurements/monitoring

Phase 5: measuring improvements. The effect of Kaizen improvements is made

transparent by determining key performance indicators on a regular basis. The
finance/controlling department supplies their indicators and develops them in
accordance with, e.g., a balanced scorecard approach (Chap. 7).

Kaizen and Business Engineering

At the beginning of the 1990s, Kaizen was mainly used for production and logistics
processes. With the introduction of business engineering, Kaizen can be utilised in
all functional areas of business and in hospitals to free capacities.
Kaizen enables incorporation into the improvement process of detailed knowledge
and operational staff skills. Small changes appear to be ‘normal’. There is little or no,
resistance to implementation caused by staff participation. Often only a few adjust-
ments or amendments are necessary. Based on a broadly-based preparation and imple-
mentation of changes, there are no surprises.
The risks of Kaizen lie in the time-consuming process of finding solutions for all
participants because each staff member has the right to be heard. This approach is
possibly too slow if the dynamics are too high. In spite of intensive information,
fairly long phases of uncertainty may occur. This can cause permanent unease.
Aside from this, support from the hospital’s management may decrease because
other problems appear and require attention. Kaizen is a gentler version of BE and
4.4 Process Improvement with Kaizen, CIP and Six Sigma 83

is usually controlled and implemented by middle management. The existing pro-

cesses are improved, flaws are fixed.

4.4.3 Six Sigma

Six Sigma is a statistical quality objective and at the same time a strategy for the
improvement of processes. The core elements are the description, measuring, analy-
sis, improvement and monitoring of business processes by statistical means. Six
Sigma is aligned with the important goals of organisation’s and customer’s needs
(Bothe 2003). The objective of Six Sigma consists in achieving the minimum devia-
tion from a predetermined target value. Similar to other methods of optimisation, Six
Sigma has its origin in a manufacturing industry: it was developed by Motorola in
the 1980s as a total quality management approach (Pande et al. 2000).
The term Sigma was invented by the German mathematician Carl-Friedrich
Gauss. Sigma (σ) is a mathematical term that measures how far a given process
deviates from the normal distribution. The objective is to achieve a minimum devia-
tion from the predetermined target value. This is the case with Six Sigma (6σ).
Six Sigma is thus a systematic, data-supported method of improving processes by
avoiding errors, with the objective of achieving zero errors. Six Sigma is a term used
in statistics to denote ‘zero-error-quality’: under certain basic conditions a process
fulfilling Six Sigma may have only 3.4 error logs for one million possibilities.
Six Sigma is not restricted to manufacturing and is equally utilised in service pro-
cesses. It can, for instance, support the change of a technical- and science-oriented
hospital into a process- and client-orientated hospital (Berry et al. 2002). Six Sigma
has already been implemented in optimising pre-­surgery preparation in high-risk
areas such as neuro-surgery. In some cases, all defined safety-related quality indica-
tors and the economic result could clearly be improved based on process changes.
Six Sigma focuses on indicators to optimize either the requirements of patients
and referring doctors or to optimize the results of treatments. Costs are reduced by
prevention. Quality consciousness and process orientation are promoted.
The disadvantages and risks are related to increased training. It is mandatory to
involve staff, professionally trained in the field of Six Sigma, who are familiar with
the hospital’s key performance indicators. An error analysis of the total process is
essential.
Six Sigma is interconnected with the various management levels through the role
players. These are:

–– Champions: champions ensure that all the hospital’s key functions are connected
to Six Sigma (hospital manager/CEO).
–– Black Belt Master: Black Belt Masters work with the Champions to coordinate
project choices and training (hospital and administration manager).
–– Black Belts: the Black Belts apply the methods and the knowledge of Six Sigma
to the projects (departmental heads, senior consultants).
–– Green Belts: the Green Belts are employees throughout the hospital who imple-
ment Six Sigma as part of their normal tasks.
84 4  Face Your Competitors

The systematic, phased approach of Six Sigma is known as the define–measure–

analyse–improve–control (DMAIC) cycle. The DMAIC cycle, which is used to
improve existing processes, constitutes the core element of the Six Sigma improve-
ment process. This is aligned to the PDCA cycle.

Phase 1: define. With regard to the success of the project, the definition phase is the
first and most important phase of the DMAIC cycle. A meaningful basis for the
control of the project is established. The problem and the customer should be
identified, the conditions must be clarified, the roles assigned, and objective,
project scope and time schedule fixed.
Phase 2: measure. The second phase serves to convey to all participants the environ-
ment in which the problem was observed. Control points for quantifying the
problem have to be determined. In addition, possible reasons for the origin of the
problem are collected. Bearing in mind potential causes, data gathering is subse-
quently planned. Data, figures, and facts provide the basis for a successful
improvement project according to Six Sigma.
Phase 3: analyse. The aim of the analysis phase is to identify the causes of errors,
verifying and quantifying them. This is the core of the Six Sigma improvement
process. First, the general conditions and results from phases 1 and 2 are evalu-
ated and the project is realigned. In this phase, the knowledge of the Black Belt
(method specialists) for the selection of the adequate method is required, e.g.,
value creation analysis or the cause–effect diagram. However, project teams
should avoid jumping from the ‘measured’ problems to the apparently obvious
solutions. At this stage, the solutions are not yet the focus; however, ideas for
solutions should be documented and then evaluated during the subsequent phase.
Phase 4: improve. In this phase, feasible and cost-effective solutions are selected,
evaluated, and implemented. Alternatives must be prioritized and options high-
lighted. Elementary steps are generating ideas for solutions, selecting a solution,
compiling a plan for implementing, and documenting a solution.
Phase 5: control. Finally, the identified improvements and new processes must be
anchored in the everyday processes. The new process is monitored using the
above-­mentioned statistical methods. It is important to hand the responsibility
for the process over, or back to, its owners.

4.4.4 ISO 9000 Quality Management

ISO 9000 (ff) is a set of standards that documents measures for quality management
(QM). Accordingly, quality management includes control, organisation, and quality
control. Quality management should ensure that the requirements of clients
(patients/referring doctors) and other stakeholders in a hospital are being fulfilled.
Over the last several years, ISO certifications have been implemented in numer-
ous hospitals, departments and private practices. This implementation has led
to structures and processes having been rethought, defined and made more effi-
cient (Fig. 4.8). Departments with well-structured processes (such as diagnostic
or i­nterventional radiology, hip replacement, eye laser surgery) are well suited for
4.4 Process Improvement with Kaizen, CIP and Six Sigma 85

Customer-orientation Leadership/Management Involvement of the staff

System-oriented
Process oriented approach Continuous improvement
management approach

Approach to decision Mutual advantages in

making stakeholder relationships

Fig. 4.8  Crucial points in International Standards Organisation (ISO) 9000 quality management
(QM) certification

Continuous improvement

Patients and
other
Responsibility stakeholder
of the
management
Referrer and
other
stakeholder
Management Measurement,
of ressources analysis and Satisfaction
improvement

Process
Requirements Results
implementation

Fig. 4.9  Model of process-orientated quality management

ISO 9000 certification, and Business Engineering itself is part of the quality man-
agement framework. Quality management in itself should be structured according
to the model of process-orientated quality management in ISO 9000:2000 (Fig. 4.9).
But all this is wasteful expenditure if it is not lived and applied in daily practice.
86 4  Face Your Competitors

Relationship to Business Engineering

A hospital or department that wants to obtain an ISO 9000 (ff) certificate has to
highlight the organisational measures that have been put in place for the continuous
process improvement (Fig. 4.8). The implementation of these measures and the
results must be monitored and documented on a regular basis. Apart from that, the
organisation has to prove how it ensures that identified errors do not recur. In this
way business engineering forms an integrated part of quality management. This is
also seen in the following requirements for quality management according to ISO
9000 (ff):

–– Quality management distinguishes between primary and secondary processes

and thus enables value-orientated control of hospital processes.
–– It defines process objectives, which derive from business objectives.
–– It continually measures and controls the efficiency of processes, monitors the
satisfaction of referring doctors, patients and other stakeholders, and compares
them with the process results.
–– It utilises performance measures and assessments as a basis for a continuous
cycle of improvements.
–– It creates transparency of the dependencies within and between business
processes.
–– It ensures that the business processes function as an effective and efficient
network.

Based on the close interdependence of quality management, business ­engineering,

and the various process improvement strategies, these systems must be seen and
treated as an integrated approach. For instance, CIP/Kaizen is an obligatory compo-
nent in standardised quality management for all areas of a hospital.

4.4.5 Comparison of Approaches

Table 4.2 shows a direct comparison of a revolutionary (BPR), a transformational

(Six Sigma), and an evolutionary approach (CIP/Kaizen).
Ideally, a combination of CIP/Kaizen with BPR should take place (Fig. 4.10).
This deviates from the pure BPR philosophy. It needs professional moderation,
excellent leadership, and strong become sponsors for its implementation. In addi-
tion, ‘thinking in processes’ should become an integrated part of the mindset of
all role-players and the hospital’s culture. Figure 4.10 shows an amended curve of
improvement methods. One approach is seldom the only right one; usually, it is a
mixture of BPR, Kaizen and CIP.
4.4 Process Improvement with Kaizen, CIP and Six Sigma 87

Table 4.2  Comparison of business process re-engineering (BPR), continuous improvement pro-
cess (CIP) and Six Sigma
BPR CIP/Kaizen Six Sigma
Degree of High in the short term Longer term Medium term
change
Concept of Revolutionary Evolutionary Transformational
improvement
Driving force in Process team, supported Management team Projects with experts:
the hospital by hospital management (Kaizen team); all Champion, Black Belt,
(employees) Green Belt
Starting point New structuring of Existing processes Existing processes
processes
Design Top–down Bottom–up Mixed
approach
Time-frame Limited, project work No time limitation No time limitation but
always in defined
projects
Objective Orientation to referring Removal of waste Reduction of variation/
doctors and patients, errors
focus on core
competencies
Cost High Low Medium (caused by
training and special
organisation)
Risk High Medium Medium

KAIZEN
CIP

BPR
improvement

KAIZEN
Change

CIP

BPR

Fig. 4.10  Alternating use

of CIP/Kaizen and BPR time
88 4  Face Your Competitors

4.5 Summary

The hospital should be designed around processes. The quality of processes has
to be compared with other health care providers in benchmarking processes. To
reach this goal, business process management and business engineering should be
utilised. Business engineering is understood to be an integrated concept of manage-
ment, organisation, and monitoring of processes. It seeks to fulfil the requirements
that patients, referring doctors, and other stakeholders have. Business engineering
contributes substantially to reaching the hospital’s strategic and operational goals.
In this way, business engineering forms an essential part of quality management.
Business Process Re-Engineering entails the fundamental re-thinking and the
radical new structuring of business processes to achieve drastic improvements in
costs, quality, service, and timeliness. This method is especially recommended
for application before establishing new buildings, departments or treatment cen-
tres. However, it is necessary to analyse in advance which processes would result
in value creation and which demands are being requested by referring doctors
and patients.
All three approaches for continuous process improvement (Kaizen, CIP and Six
Sigma) focus on identifying weak points, problems, and errors. The objective of
these approaches is to improve processes and thereby increase the effectiveness and
efficiency of hospital procedures. In the course of application, all three approaches
deploy more or less the PDCA cycle. The Muda list names eight forms of waste
that must be avoided with the support of Kaizen. Six-Sigma is a systematic, data-
supported method of improving processes by avoiding errors. An organisation
that wants to obtain a quality certificate according to ISO 9000 (ff) has to explain
which organisational measures have been put in place, so that focused continuous
improvement takes place on a regular basis. The implementation of these measures
and the results must be monitored and documented. Additionally, the organisation
has to prove how it ensures that the identified errors do not recur. This underpins
the close connection of quality management, business engineering and the various
approaches amongst continuous process improvement.

4.6 Five Reflective Questions for Practical Application

1. Name three areas in your hospital/department where you participate in bench-

marking processes.
2. If you compare your hospital with other hospitals, where is yours positioned
according to benchmarking? In the upper, medium or lower range? Does this
correspond to the ‘perceived view’? Would you also evaluate yourself in this
way, or do you feel the external assessment to be too positive or too negative?
3. In which areas would you consider it to implement BPR in your hospital? Give
reasons for that.
References and Further Reading 89

4 . Have you identified the success factors of your department and your hospital?
5. Which of the three methods – Kaizen, CIP or Six Sigma – could you use to
­optimise processes in your field?

References and Further Reading

Berry R, Murcko AC, Brubaker CE (2002) The Six Sigma book for health care-improving out-
comes by reducing errors. ASQ Quality Press, Chicago
Bothe KB (2003) The power of ultimate Six Sigma. Amacom, New York
Drucker PF (1967) The effective executive. Harper & Row, New York
Hammer M (1990) Reengineering work: don’t automate, obliterate. Harv Bus Rev 66:104–112
Hammer M, Champy J (1993) Reengineering the corporation: a manifest for business revolution.
Harper Collins Publ, New York
Mann C (2006) The hospital myth – disenchantment. Amazon KDP, Seattle
Pande P, Neumann R, Cavanagh R (2000) The Six Sigma Way: how GR, Motorola, and other top
companies are improving their performance. McGraw Hill, New York
Salomonowitz E (2009) Erfolgreiche Organisationsentwicklung im Krankenhaus. Mehr Personal
spart Kosten. Springer, Vienna
Womack JP, Jones DT (2003) Lean thinking: Banish waste and create wealth in your cooperation.
Simon & Schuster, London
Improve Communication
and Appreciation 5

Goals
–– Why are appreciation, transparency and open communication so difficult to
achieve in hospitals?
–– How can you create a culture of open communication and appreciation?
–– How can you ensure that the receiver understands the information ‘correctly’?
–– How can you use the transactional analysis in your daily communication?

This chapter points out how to carry out personal appraisal and how to com-
municate in an adequate manner by choosing the right tools. You will learn more
about the four ears of the addressee model, transactional analysis and how you
can apply it in your everyday work. Further, we highlight the characteristics of
the drama and winner triangle. The chapter ends by outlining the advantages of
establishing a 180° feedback culture.

Mutual appreciation and open communication are important pillars of a success-­

orientated hospital strategy. Mission statements and a transparent hospital cul-
ture are not only conveyed in workshops, closed-door meetings, and discussions.
They must be part and parcel of your everyday work and daily life. In a leader-
ship position you serve as a role model. If it is known that the CEO or head of a
department is short-tempered or disrespectful with others, appreciation and
respect will not play an important role in the organisation.
Although a corporate culture is a binding code of conduct in many companies, this
attitude still needs to be developed in many hospitals. The often patriarchal and auto-
cratic structure, together with the three existing hospital pillars of nursing, management,
and medical services, derive from historical hospital structures. To meet current
demands, the approach of working ‘together’ rather than that of ‘next to each other’

© Springer Berlin Heidelberg 2017 91

E. Weimann, P. Weimann, High Performance in Hospital Management,
DOI 10.1007/978-3-662-49660-2_5
92 5  Improve Communication and Appreciation

becomes mandatory. In this context a code of conduct, appreciation and open and trans-
parent communication are important components. Although it is no longer the preferred
practice to use the authoritarian-patriarchal leadership style, it continues to exist in the
everyday reality of many hospitals. Many decisions are made hierarchically ‘from the
top’ and are applied ‘top-down’. This includes routine medical work, where the consul-
tant or the head of a department decides whether and when a patient will be discharged
or which therapy or procedure is applicable. This usually happens for reasons of quality
assurance, since the departmental head carries the responsibility. Occasionally, however,
it is used merely to demonstrate who has the power to make decisions. The primus inter
pares (the first among equals) style of leadership requires a high degree of social com-
petence from both sides: a senior doctor is required to regard junior colleagues as equals
and the staff should understand that power-sharing must not be misunderstood as a
weakness, but rather a leadership strength.

5.1 The Art of Appreciation

Mutual appreciation and respect are expressed by, for instance, good manners,
greeting colleagues and patients, the structured flow of discussions and m ­ eetings,
timekeeping, and active listening. People who are busy on their smartphones ­during
meetings and making calls signal by their behaviour to those around them: ‘I have
more important things to attend to than listening to you.’
If an outsider would like to experience the mood, the appreciation and the working
atmosphere of a particular environment, s/he should attend an internal meeting such
as a ward round or the hospital’s executive management meeting. Unfortunately, only
very few employers offer this kind of transparency before a working relationship com-
mences. Yet, if such opportunities are offered in advance, they can be seen as a trans-
parent leadership tool for an applicant.
Please reflect during one of your next meetings how an outsider would sense
the attitude with which staff interacts. Which improvements might be suggested?
How could you yourself contribute to improving it? If a hospital wants to attract
good staff or even the best available, it has to offer a good work environment and
appreciation of staff. This approach might be too radical for many CEOs or heads
of departments (HoDs). For far too long they have enjoyed the position of having
numerous applicants enquire regularly when the next post will become available.
Hospitals in which appreciation and respect are prioritised are recommended by
their employees to friends and colleagues.

Case Study
The CEO urges the new HoD to give an inaugural lecture to which colleagues
in private practice, consultants from other hospitals and politicians are invited.
It takes several weeks to find a suitable date. Personal invitations are sent out
and the event is published in the daily newspaper. Before the lecture given by
the HoD commences, the CEO leaves the well-attended event after a brief
introductory with the excuse that he has other obligations to fulfil.
5.2 The Art of Communication 93

Conclusion: Caused by the absence of the CEO, neither the HoD nor the
attendees feel valued and respected. The CEO did not prioritise the task of
attending the lecture; otherwise, he would have rescheduled other appoint-
ments. The opportunity to communicate with other stakeholders of the hospi-
tal, such as doctors in private practice, consulting colleagues from other
hospitals, political representatives and the media, is wasted. The status of the
new HoD has been downgraded by the absence of the CEO.

5.2 The Art of Communication

If I had more time, I would write a shorter letter. (Mark Twain)

Visions, strategies and their implementation needs to be communicated on a regular

basis. Therefore, you must master the art of communication. Communication is the key
to informing your employees and motivating them. A large number of media options
are available: face-to-face conversation, telephone, e-mail, SMS, fax and social media.
However, the medium chosen should be handled modestly. Particularly in delicate situ-
ations, the personal, direct contact should be favoured over a written, indirect approach.
Especially for communicating unpleasant decisions personal contact should be pre-
ferred to communicating it via email. Especially in tense situations every word is
weighted and misunderstandings can easily occur. These situations can be avoided if
people master the art of communication.
Communication is an important tool in presenting the hospital’s objectives to the
staff. Both the internet and the intranet support communication as relevant informa-
tion can be sent to all employees with a mouse-click. However, the staff also becomes
overloaded with information. If by chance you are not working at your computer for
2 h, numerous high-priority e-mails will be waiting for you. Hence, e-mails are not
often read attentively, but skimmed and occasionally deleted immediately. Wooing all
employees with new information has somewhat lost its charm. Therefore, choosing
the right medium for communication is becoming increasingly important. It is possi-
ble to prioritise the use of the communication media.

–– Information should be put in writing, but brief (intranet, e-mail) and only if it is
relevant and intended for the receiver (be careful with circulars).
–– Anything personal or private should always be communicated in person (face-
to-­face) and not by e-mail. Otherwise the following interpretation could be
made: ‘He does not want to take the time to discuss the matter with me
personally.’
–– New strategies should be introduced to larger groups that include all
­hierarchical levels. It increases the credibility when the hospital management
personally explains new strategies, and does not delegate this task to an
external company or an administrative manager. In this way, faux-pas can be
avoided.
94 5  Improve Communication and Appreciation

Case Study
A hospital has purchased smartphones to replace pagers. Subsequently, in
each meeting and ward round doctors and nurses are phoned or read their
e-mails. Occasionally, several people are on the phone at the same time. This
leads to the distraction of the whole group. Finally, the consultant decides that
the use of phones is no longer allowed on ward rounds, except emergency
phone calls.
Conclusion: Meetings and ward rounds run faster and more purposefully
as the group is less frequently disturbed by outside influences.

5.2.1 The Four Pillars of Communication

Apart from the means of communication, the ‘how to communicate’ must be consid-
ered. Based on the Hamburg comprehensibility concept by Schulz von Thun (2010),
the enhancement of the understanding of information can be related to four pillars:

1 . Structure the sequence in a text

2. Phrase concisely
3. Phrase simply
4. Stimulate reading through the use of stylistic devices.

This sounds rather simple and straightforward. But are you able to present com-
plex facts in a simple way? And do you really want to do it? If the content sounds
rather complicated, fewer questions are asked and the respect increases. You might
improve your reputation, but still have not reached the objective: to inspire the lis-
tener with regard to a new idea. The four pillars of communication should be essen-
tial for communicating with your staff. Common mistakes can be avoided. Here are
some tips for a goal-orientated and successful exchange of information:

–– Communication covers all events: not only the positive, but also the negative
topics need to be addressed. Communication informs about processes, objec-
tives, strategies and goals.
–– There is an underlying communication concept, rules must be followed.
–– Opinions and recommendations by the staff are welcomed and appreciated. In
this way communication is authentic and achieves the desired result.
–– The staff is familiar with the hospital’s code of conduct (Sect. 5.2.2), which is
available on the intranet and is lived by the executive hospital management,
administration, doctors and nurses.
–– Communication takes place across departments. The hospital thinking is holistic and
not constricted by departmental thinking. The annual and project objectives of depart-
ments and divisions are available at any time to the staff members via the intranet.
–– General information is given regularly to prevent rumours and disinterest.
–– Information flow does not only occur top–down, but bottom–up as well. The
executive hospital management and departmental management depend on a two-­
way flow of information to function efficiently.
5.2 The Art of Communication 95

–– Staff members are personally informed of new strategies or current develop-

ments in the hospital by a member of the hospital management.
–– Staff members are fully informed. If special information is required, staff can
approach the hospital management or a superior.

However, how can you achieve the goal of keeping all staff equally well informed?
There are always people who withdraw from receiving information because of over-
load or absenteeism. They will shrug their shoulders when asked and complain that
they are never informed. The staff should be proactive in asking for information they
may have missed. They then should to take steps to catch up. Hospital communication
is not solely provided by the management and then consumed by the staff. It can only
work if there are bi-directional channels.

Empathic Communication
Empathy in the hospital setting is indispensable for a successful recovery of health.
Lack of empathy can affect the rate of adverse incidents. Empathy happens indepen-
dently of hierarchical levels. Importantly, non-verbal and verbal communication
should match each other. In addition, while the receiver must judge if the requested
information was given, the sender should ask her/himself if the information asked
for has been given.

Case Study
A doctor comes to the ward and enquires about a recently admitted patient.
The nurse looks first at the whiteboard, and then shrugs her shoulders: ‘I have
only just come on duty and was off for the last 2 days. You have to ask the
nurse responsible for that patient. We are only allocated the care of certain
patients.’
Conclusion: The introduction of zone nursing means that nurses are
responsible only for certain patients in the ward. This does not necessarily
meet ergonomic work requirements. It may well be that one nurse looks
after patients in rooms 1, 5, 7 and 8. This delays ward rounds and com-
munication. The underlying idea is to concentrate competencies and
responsibilities and to avoid exceeding the recommended number of
patients per nurse. Although a general handover is made per shift, nurses
often feel responsible only for their own patients. This attitude obstructs
the overview of processes and critical patients on the ward. The doctor
does not get the information he needs about the patient. The nurse does not
offer any help in getting the information, but refers to her own allocated
tasks.

There are many examples of codes of conduct and guidelines that have been
developed for all staff members. It is important, though, that they are lived on a day-
to-day basis and on all hierarchic levels.
Below we highlight an example of a successful and comprehensive code of
­conduct. Managers, especially function as role models in the organisation.
96 5  Improve Communication and Appreciation

Example of a Comprehensive Code of Conduct

1. Appreciation
–– We recognise and appreciate the performance of every individual member of
staff independent of their function or position.
–– We are sensitive to human and cultural differences in our hospital and see
them as a source of enrichment.
–– We practice good manners and an appreciative culture of communication.
–– We are open to criticism and other opinions and express them constructively.
–– We communicate openly, seek interactions, share our knowledge, and trust
one another.
2. Responsibility
–– We act responsibly in medical, social, and ecological matters and in an ethi-
cally correct manner.
–– We accept our individual responsibility, seek challenges, and take the initiative.
–– We are sensitive and respectful with one another and stand up for each other.
3. Performance
–– We recognise our goals, reach them efficiently, and allow ourselves to be
measured through the results.
–– In the interests of our internal and external clients we strive for the highest
quality and best service.
–– We combine our personal strengths to produce excellent team performance.
–– We are constantly working together to improve ourselves.
4. Adaptability
–– We have the courage to monitor ourselves and our actions, and we resolutely
explore new paths.
–– We know our internal and external clients, are sensitive to developments in
the market, and are one step ahead.
–– We think outside of the box and enjoy finding new solutions together.
5. Integrity
–– We are honest and make our actions transparent.
–– We act lawfully and in agreement with the interests and guidelines of the
hospital.
–– We are reliable, keep to our arrangements, and adhere to our word.
–– We treat personal and sensitive information with confidentiality.

It is appropriate to develop the code of conduct and the culture of communica-

tion in workshops together with the staff so that these values may be lived in the
day-to-day work of the hospital, independent of any hierarchies. In this area, new
staff should receive separate, specific training.

5.2.2 Be Aware of the Overall Impression You Make

As soon as you have accepted an executive position you are acting on stage. Your
gestures, your bearing, your activities and the way you dress together with the way
you speak are composed into a message by your listeners or observers. The verbal
5.3 The Four ‘Ears’ of Communication 97

Mimic

Eye contact Language, Pitch

Gesture Dress

Overall appearance

Fig. 5.1  Non-verbal communication

message is the smaller part. You should be aware of the overall impression you
make and of your role (Fig. 5.1). Ensure that the communication medium you
choose for sending messages (personally, by e-mail, SMS, Facebook or Twitter) is
adequate. The particular attention you pay to the person with whom you are com-
municating, your gestures and your behaviour also are important. Someone who
uses his smartphone while talking to others conveys a negative impression.

5.3 The Four ‘Ears’ of Communication

Messages and information are conceived and processed in four ways (Schulz von
Thun 2010). Essentially, it depends on how the addressee receives the message. We
as senders need to analyse how messages can be received:

–– The ‘ear’ for objective listening (the matter layer). The objective content of a
message is heard by the receiver and the factual issue is identified.
Example: A senior nurse to a junior nurse: ‘I have noticed that you consistently
don’t greet patients. The last time I noticed this it was when you met Mr.
Mortimer.’ Junior nurse: ‘I had seen that patient here before and greeted him
then.’ Factual communication becomes difficult when interpersonal problems
arise and are included.
–– The ‘ear’ for relationships (relationship layer). Neutrally intended messages are
interpreted and evaluated as if emanating from an individual. The sender expresses
how he gets along with the receiver, what s/he thinks of him. The receiver can feel
offended because he over-­interprets a message and evaluates it negatively.
Example: HoD, ‘You should have introduced yourself at the start of your presen-
tation.’ Consultant: ‘You need not tell me that. I was very well brought up and
know exactly how to appear in public.’
98 5  Improve Communication and Appreciation

–– The ‘ear’ of self-disclosure (self-revealing layer). The receiver hears the message in
the light of what it says about the sender (conscious or unconscious self-disclosure
by the sender).
Example: Consultant, ‘I did not see you today at the meeting when our new col-
league was introduced. Why didn’t you come? After all, he is employed to share
your workload.’ The addressee: ‘It is absolutely necessary to employ someone in
addition. I had so much work in outpatients that I couldn’t get away in time.’ The
doctor analyses his superior’s message with the ‘ear’ of self-revelation: he rein-
forces his superior’s bad conscience in implying that up to now he had not sup-
ported him enough to see to getting someone to share his workload.
–– The ‘ear’ of appeal (appeal layer). The receiver hears with the ‘ear’ of appeal, with
the idea to please everyone and fulfil unspoken expectations. According to Schulz
von Thun (2010) the receiver listens with the appeal ‘ear’ ‘practically hearing the
grass grow and is continually ready to act accordingly.’ The smallest signal by a
sender is analysed for its appeal and interpreted accordingly.
Example: On Monday morning, the secretary is not at work as usual, before her
boss arrives. When she wants to apologise, her boss interrupts her with the
remark: ‘I suppose it was late last night?’ Ever since, she is always at her desk
one hour before the official start of her working day.

Be conscious of the four ‘ears’. Be sensitive to how your message may be inter-
preted and how you could also be manipulated (see self-disclosure ‘ear’).
Be authentic and selective in your communication. Be conscious of what
you feel and think and match them to what you say and do (Schulz von Thun
2010).

5.4 Childhood Experiences Influence the Present

To enable you to understand the principles of communication, we briefly explain the

concepts of the transactional analysis, the ok positions and the drama triangle. What
we experience during our life influences us and our communication with others. It
determines how successfully we are able to realise our objectives on the level of
communication. Our way of communicating is often linked to childhood experi-
ences. As a child we wish to get the full attention of our parents. This role is adopted
over and over again. Depending on one’s own (childhood) experiences, those same
roles are replayed or, depending on circumstances, other roles are adopted or may
be changed as needed.

5.4.1 Transactional Analysis

To be able to analyse interpersonal dynamics and communication between two peo-

ple you should be aware of the mechanisms of transactional analysis (TA), which
originates from the American psychiatrist Eric Berne (1964).
5.4 Childhood Experiences Influence the Present 99

Every one of us has three ego states from which we may speak.

–– The child state (C) is the felt sense of living. Feelings and reactions from child-
hood are stored here. It can be split into three parts: the natural part (exuberant,
playful, spontaneous), the adapted part (well-behaved, submissive) and the rebel-
lious part (defiant, stroppy, fretful). If we allow the childhood state the necessary
freedom, it is the most valuable part of our personality. It gives us strength and
energy to be creative and spontaneous.
–– The parent state (P) is described as the learned model of life. What parents
have taught the child is stored here. Protection, help, wisdom, cautions, the
requirements and prohibitions and notions of how one ought to be. The parent
ego consists of two parts: the critical, judging, moralising part and the nurtur-
ing part.
–– The adult-state (A) is the constructed model of living: it analyses reality with the
impulses and the taught values from childhood and the adult state. The adult ego
is objective, assessing, analysing and informing. It addresses the other on the
same level.

All three states exist in one person, are activated according to context, and con-
stitute the adult personality (Fig. 5.2). In communication between equals, the
emphasis is on the adult state, the free child-like state, and the nurturing parent-like
ego (Berne 1964).
The transactional analysis can be used to analyse which behaviour is predomi-
nant in specific situations. This enables one to interpret and assess behaviour, and to
respond appropriately.

C C C C

A A A A

P P P P

Fig. 5.2  Objective, rational communication versus overlapping communication over various
levels
100 5  Improve Communication and Appreciation

5.4.2 The OK Position

Relationships to other people as taught during childhood are important. During

childhood one has already formed a life-long basic position with regard to the role
one occupies in relation to other people. This basic position determines the trust in
oneself and other people. It decides whether one:

–– Sees oneself as more valuable than others (I am ok, you are not ok)
–– As equally valuable (I am ok, you are ok)
–– As less valuable (I am not ok, you are ok)
–– Or seeing oneself and the other as of no value (I am not ok, you are not ok).

In communication, it is important to meet others on the same level. ‘I am ok, you

are ok’ is the win–win strategy, consequently one must attribute an equivalent
esteem to others. Problems arise when a negative basic position such as ‘I am ok,
you are not’ or ‘I am not ok and neither are you’ or ‘I am not valuable but you are’,
dominates (Harris 1969). In this way either the other or oneself is debased or exalted.
The following example shows how the knowledge of such basic positions can define
communication and the personal interaction with others.

Case Study
A consultant knows that a junior doctor grew up in a patriarchal-authoritarian
home where the basic position ‘I am ok, you are not ok’ was the order of the
day. When planning rosters and in cases of acute personnel shortages, he
applies his knowledge to manipulate the junior doctor into making decisions
that do not serve his personal interest, such as working on public holidays or
during the festive season.

5.4.3 The Drama and the Winner Triangle

Stephen Karpman introduced the drama triangle in 1968, deriving it from

Transactional Analysis. The suggestion is that we often adopt roles in expecta-
tion of some or other advantage. Roles may, in turn, be allocated. There are
three roles (Fig. 5.3), which are taken as relationship patterns and may change
as the situation requires.

–– Victim: this role (‘poor me’) is often found in the hospital. For instance, long-­
term employees indicate, about their working environment: ‘I am always here,
sacrificing myself daily for the hospital and giving up my spare time.’ Such peo-
ple demand attention and sympathy, spreading the general feeling that the hospi-
tal would not function without them.
Based on TA, the victim is in the adapted childhood state. Victims refuse to take
on responsibility.
5.4 Childhood Experiences Influence the Present 101

Fig. 5.3  Karpman’s drama Rescuer

triangle

Victim Persecutor

–– Rescuer: this role (‘Let me help you’) is taken in emergency situations only and
therefore prevents permanent solutions to problems.
Example: In an emergency unit there are no standard operational procedures
(SOPs) in existence as to how to act in specific cases (e.g., how to proceed with
a request for a consultation? How is a diagnostic test processed? Who is informed
when?) New employees must gather their own experience to know how to pro-
cess even simple procedures. The consultant opposes suggested changes in the
organisation of the emergency unit with the remark that he can be contacted at
any time. (‘When you don’t know what to do, call me.’) In this way he makes
himself irreplaceable. This has a negative effect, especially when s/he is on leave
or attending conferences. The holder of the rescuer role prevents improvement of
the organisation and restructuring of the emergency unit to make it more effi-
cient. According to TA, rescuers take on the role of the caring adult state. They
reinforce dependencies and wants to keep people dependent on them.
–– Persecutor: this role (‘It is all your fault’) is often adopted by managers and
superiors to prove their dominance and control.
Example: The CEO regularly checks after office hours if consultants are still in
the hospital. If he sees someone on the way home, he asks jovially: ‘Going
home early today again? ‘or remarks’ Yesterday the lights in your office were
still on, although you had already left.’ In addition, he gathers information about
the reputations of the various employees. He applies his knowledge, for instance,
if additional staff is requested because of a staff shortage. He rejects many
applications by taking advantage of his knowledge gained through his monitor-
ing of the employees. According to TA, the persecutor takes on the role of the
critical parent state.

Role-plays that take place in the drama triangle never have a positive outcome,
as they prevent constructive solutions and negatively affect a sustainable working
environment. In communication processes, you should always stay outside the
drama triangle and be aware of the different roles that may be taken. If you notice
that certain roles are being played, you should intervene. Otherwise, you will be
drawn into the emotional grid and an appropriate solution is prevented. Take note of
such behaviour patterns in your everyday life. You will be surprised how often they
are used, especially in a hospital setting.
102 5  Improve Communication and Appreciation

Remaining in the drama triangle prevents solutions; hence, it must be converted

into a winner triangle. It assumes that the attitude one has towards another can
change. The winner triangle according to Balling (2005) is solution-orientated.
Compared with the drama triangle it proposes the following changes:

–– The persecutor becomes the confronter. S/he, after stating an opinion, sets limits
and adjusts his/her behaviour according to observations made. Signalled to the
other is the message: ‘It is OK to make mistakes.’
–– The rescuer becomes the helper. S/he asks the participant what is needed, makes
clear agreements, all humans as being equal.
–– The victim becomes the needy one. S/he asks for support, assistance, and guid-
ance: clearly articulates what is needed and offers help in return.

When applying the winning triangle, old habits must be abandoned. Articulate
clearly what behaviour you have observed and what consequences can result. Share
what you expect in terms of change. In this way you can convert ‘psychological
games’ into open discussions and communication.

5.5 Feedback Culture

Systematic reflection about teams developed around the group of Kurt Lewin
(Sect. 6.4). Mutual disclosure, how members of the team see and are seen by oth-
ers, leads to mutual feedback (Lewin 1947). Feedback has the purpose of clarify-
ing both the one giving feedback and the one receiving it, how one’s behaviour
affects the other one person and what it means for him/her. In this way your feel-
ings and those of others become transparent, which can lead to a mutual process of
change. Cooperation and communication happens more smoothly because mutual
appreciation is made transparent.
Establish a culture of feedback to develop in your department and your team.
Respectful feedback is a management tool. Do not be discouraged if, at first, your
colleagues feel overwhelmed by the new and open communication culture. If teams
are not used to feedback they will initially be surprised and will try to repel it.
During feedback sessions, feelings and emotions are addressed and this can be pain-
ful. Creating a positive and empathetic feedback culture in a team is no easy task as
statements on the quality of a relationship are made and become transparent.
The goal is to offer an open and empathetic atmosphere, aspiring to interact
with each other and to articulate impressions and observations. This approach
therefore requires discipline, respect, and openness on all sides. What should you
pay particular attention to when giving feedback? Positives should be recognised;
however, negatives must also be discussed without hurting the other person.
Feedback should be formulated in a descriptive, appropriate, concrete, usable,
well-timed and clear way.
Personal messages and opinions should be phrased as ‘I’ messages in a feedback
interview: ‘I sense, I have noticed, I feel’. Concrete examples from the immediate past
may be added. However, the participants should not get lost in details. Reconstruction
5.7 Five Reflective Questions for Practical Application 103

efforts or “finding the truth” are not intended, because often a reinterpretation of what
was said takes place (Chap. 9). To make statements more meaningful, people often
hide behind group opinions. Instead of saying: ‘I have a problem when you assign
tasks without having discussed it with me first’ they often prefer to present it as a
group opinion, such as ‘the consultants have a problem’. In this way, they attempt to
give the statement more weight by citing a larger peer group and to be less personally
vulnerable. Don’t let yourself be intimidated or irritated: group opinions are seldom
homogeneous and a group larger than two people is seldom of one single opinion.
Eventually, the receiver has to decide whether to accept the feedback in a vote of
confidence based on personal maturity. If guidelines of transparent communication
are followed successfully, the team is on track to developing a positive attitude
towards change (Chap. 6).

5.6 Summary

Clear communication structures and guidelines as well as the lived appreciation of

individuals are key factors for a high performing hospital. The executive hospital
management, together with the HoDs, serves as role models for implementing ade-
quate communication pathways. The way in which communication takes place from
the top will be lived in the hospital. The various means of communication such as
conversations, telephone, and e-mail should be applied in a professional and appro-
priate manner. Face-to-face discussions should be given a higher priority than tele-
phone or e-mail correspondence. Hospital staff should be aware of important
interpersonal interaction theories such as the four ears of the receiver, transactional
analysis, and the drama and winner triangles. Only if communication pathways are
reliable and are used in an appropriate way, change processes can successfully take
place in a hospital.

5.7 Five Reflective Questions for Practical Application

1. How would you describe the communication culture in your hospital/department

(transparent, open, empathetic, etc.)? Elaborate on how, you believe, it can be
improved.
2. Do you implement internal workshops for your staff in your department or hos-
pital to foster a unified communication culture and code of conduct?
3. Can you remember conversations that were conducted within the drama trian-
gle? How would you have been able to transform the drama triangle into a win-
ning triangle?
4. Are you aware in your everyday work whether you receive messages with the
‘ear’ for objective listening, the ‘ear’ for relationships, the self-disclosure ‘ear’,
or the ‘ear’ of appeal?
5. Do you apply feedback sessions to promote the development of your department
or team? Which obstacles do you experience to implementing open communica-
tion with feedback sessions?
104 5  Improve Communication and Appreciation

References and Further Reading

Balling R (2005) Diagnosis of organisational cultures. Trans Anal J 42:199–208
Berne E (1964) Games people play: the psychology of human relations. In: The basic handbook of
transactional analysis. Grove Press, New York
Harris TA (1969) I’m OK, – you're OK. Harper & Row, New York
Karpman S (1968) Fairy tales and script drama analysis. TAB 7:39–43
Lewin K (1947) Frontiers in group dynamics: concept, method and reality in social science, social
equilibria and social change. Human Relations 1:5–41
Schulz Von Thun F (2010) Miteinander reden, vol 1–3. Rowohlt, Reinbek
Creating Positive Attitudes
Towards Change 6

Goals
–– Why are improvements associated with change?
–– Which methods are used by change management?
–– Which fellow campaigners do you need to cope with changes?
–– How can you use tools such as CIRS and complaint management to make
change happen?

This chapter highlights how you should engage in changing processes with
health care providers. It outlines how you will be successful and how you can
overcome resistance and how to support your staff in the change management
process. You will become familiar with the seven phases of the change manage-
ment curve. The chapter closes with a description of the critical incident report-
ing system (CIRS) and the advantages and disadvantages of outsourcing.

To change is difficult. Not to change is fatal. (William Pollard)

Businesses, and also hospitals, that want to align themselves with the daily chal-
lenge of the market need change processes – or, as Winston Churchill stated:
‘Improvement means change’. In many cases, employees understand the reasons for
change. However, during the implementation phase the change process is all too eas-
ily boycotted by some individuals. One reason is that people appreciate the environ-
ment they are accustomed to. They do not want detours or new routes because these
require re-­orientation and energy. Habits are deeply rooted in the evolution of man-
kind and the history of the organisation. People oppose change, ignore or undermine
it because it runs counter to their interests and habits (Guillebeau 2010). Usually,
long-lasting negative developments and counterproductive behaviour by staff are
tolerated simply because nobody dares to start a change process. One rather copes

© Springer Berlin Heidelberg 2017 105

E. Weimann, P. Weimann, High Performance in Hospital Management,
DOI 10.1007/978-3-662-49660-2_6
106 6  Creating Positive Attitudes Towards Change

with disadvantages than tries to initiate changes. How can you engage people in
change? How can you – according to the Chinese proverb below – build a windmill?
When the wind of change blows, some build walls and others windmills. (Chinese proverb)

It takes many windmills to carry, and carry through, change processes. An impor-
tant step in a change process is identifying resistance and implementing support.
To implement change, so-called change management is required. Change man-
agement supports the change process within the framework of business engineering.
It includes all planned, controlled and monitored changes in the structures and pro-
cesses of socio-economic systems (Thom 1998); it also addresses questions relating
to human resource management, sponsors, communication, and information.
Communication is a key element within a change process.
Why is it so difficult to engage people in change processes? Even clearly unsound
structures provide work and security for many people and employees. Willingness
to change is distinctly different in each individual. The willingness to change often
only increases when the current situation seems worse than the new one. The readi-
ness for basic changes only arises once the inconveniences of the status quo are
bigger than those of a transition (Belasco 1990). In most hospitals, this state is sel-
dom reached unless a successful competitor opens their doors in the direct vicinity.
However, by then it could be almost too late to initiate change processes.

Anecdote: Renovation for the Sparrows (Fable by G.E. Lessing)

An old church is completely renovated. In the walls, numerous sparrows have built
their nests, which they now have to leave. When the church is restored to its former
glory the sparrows return to find their old nests. They are surprised to find that their
old nests have all been destroyed. ‘What was the use of all that renovation?’ they cry
indignantly. ‘Come, we can’t live in this useless heap of stones!’ The sparrows flee,
scolding all the way.
Conclusion: The advantages of changes are not always evident to all concerned.
This is one of the underlying reasons why people are sceptical about changes.

6.1 Change Management of Hospital Processes

Progress is a nice word, but change is its motivator. And change has its enemies. (Robert
F. Kennedy)

If you want to adapt to market demands, you have to structure your business pro-
cesses accordingly. Two of the methods for achieving this are business engineering
and business re-engineering (BPR). BPR applies a radical approach. Although pro-
cesses can be amended and gradually improved with business engineering, BPR
questions all existing processes and re-structures them completely. An imaginary
new hospital is constructed from the ground up (Chap. 4).
Evolutionary business engineering can be divided into hard and soft factors.
Hard factors are the strategy of the executive hospital management, business pro-
cesses and the information and communication systems. Soft factors include leader-
ship, behaviour, and power (Sect. 3.3). Specifically, soft factors determine how
6.2 What Resistance Can Be Expected During Change Processes? 107

change processes take place and are experienced; they are the key to engaging in
change management.
The following negative example illustrates the role of power structures in process
and structural changes.

Case Study
The organisational structures outlined in the organogram result in delayed
hospital processes. A few years ago, the CEO changed the organisational
structure. These changes consolidated and increased his power. The hospital’s
vision of ‘patient-centred care’ is not lived in everyday processes. The hospi-
tal management continually defines future strategies that are not in accor-
dance with the real needs and requirements of the hospital. Necessary changes
do not take place and the staff is increasingly dissatisfied with the hospital
management’s decision-making culture. Overall, this leads to unfavourable
working conditions and worsens the financial output of the hospital. In con-
trast, patients and referring doctors are less satisfied because necessary
improvements are not implemented. When the CEO is asked by the heads of
various departments to restructure the current organisation to adapt them to
the requirements, he refuses to do so and seeks back-up from the executive
hospital board. As a result, long-term and knowledgeable hospital employees
finally leave the hospital. Patient satisfaction and financial output further drop.
Conclusion: Organisational structures often serve to maintain power.
Seldom are they in place to serve the patients and other important stakehold-
ers. Implementing continuous change management is important for the strate-
gic development of the hospital.

6.2  hat Resistance Can Be Expected During 

W
Change Processes?
Change will not come if we wait for some other person or some other time. We are the ones
we have been waiting for. We are the change that we seek. (Barack Obama/Mahatma Ghandi)

Why is the implementation of change processes so difficult? You can, in fact, facili-
tate change processes if you shift the focus and align your hospital strategymaking
orientated to processes and no longer to functions or to departments. In this case,
processes and patients are better attended to. It is no longer the head of department
(HoD) or CEO who is responsible for processes, but the people who implement the
processes. Now, the staff controls and improves the business processes, with a role
change between staff and management. The relevant control parameters are shifted
from the cost centre’s budget to the time, quality and cost of the business processes.
As this is associated with a loss of power and includes a change of habits, resistance
can develop. Resistance occurs in two ways: individual and organisational (Table 6.1).
When asked, many people cannot say precisely why they personally feel that the
change process is a threat to them – nor would they admit that it is a threat. They
108 6  Creating Positive Attitudes Towards Change

Table 6.1  Individual and organisational resistance

Individual resistance Organisational resistance
The necessity for change is not Existing incentive systems strengthen the existing
understood situation (processes, power, and managerial structures)
Approach, objectives, and results of the Threat to power balance of the hospital
change process are not understood
Fear of what is new and unknown Conflicts between groups prevent collaboration
Loss of status Organisational structure and change process are not
compatible
Threat to existing relationships (among Resources bound to previous decisions and activities
colleagues, members of staff, superiors)
Threat to existing work flows and habits

may have an unpleasant gut feeling about what is new and different, but they cannot
articulate what this feeling is.
Rooted in the historical development of hospitals and the accompanying organ-
isational structures, innovations frequently meet with resistance. Often hospitals
were not started or run as profit-earning enterprises but nowadays they have to adapt
to market conditions. Many hospitals that were founded by a church or the local
government offered patients whatever care and support were available. In addition,
these hospitals served as non-profit organisations.
Furthermore, many hospital employees still have only obtained experience in
one organisation. Some of them have been trained at the hospital and then have
worked their way up in the organisation. They have had little or almost no experi-
ence in other organisational structures.
Hospital CEOs often have an economics-focused degree; some have had previous
experience in hospitals or even have a medical degree. It is still not common practice that
they have combined qualifications in a medical field and health economics. Occasionally,
they come from businesses associated with hospitals and have gained their managerial
knowledge there. The mind-set and values of hospital staff may be unknown to them.
Even if hospitals are managed more efficiently today than in the past, they are
­different from companies, which are run exclusively along business lines. Although
similar management principles apply to both, they cannot simply be transferred whole-
sale and without adaption. Hospitals still must work within a health policy framework,
apply ethical considerations, and be empathetic about patients’ concerns. Hence, the
points of view of management and the staff can be very different. In particular, this can
occur in for-profit hospitals and private hospital groups. It is a fact that must be consid-
ered when change management processes are planned.

6.3 How Fit Is Your Hospital for Change Processes?

Life consists of many closed doors. The needed skill is not to give up looking for an open
one. (Author unknown)

Have you ever heard remarks like: ‘We have always done it like this’, when you
suggest something different? How frequently do you hear comments like these?
6.3 How Fit Is Your Hospital for Change Processes? 109

Companies, including hospitals, where such an opinion is continuously

expressed, are doomed to fail sooner or later (Belasco 1990). You can analyse
how well your hospital is prepared for change by answering the following
questions.

Question–Answer Catalogue for Assessing Willingness to Change

Question 1. A new consultant asks the personal assistant (PA) of the CEO to person-
ally discuss a recent decision taken by management. What would normally happen
in your hospital? Please tick your answer(s).

Possible answers:
(a) As soon as the CEO is available, he will answer the question in a face-to-face
discussion.
(b) The PA asks the employee to discuss the topic with his superior.
(c) The CEO instructs his secretary to give the employee’s HoD a call so that he
can personally take up the matter.
(d) The employee is rescheduled by the secretary and told that he will be called
back at a later stage.

Question 2. A recently employed consultant realises after a few weeks that certain
admission procedures are redundant and could be improved. What would normally
happen in your hospital?

Possible answers:
(a) The consultant submits an application to the executive management of the hos-
pital and asks for certain changes.
(b) The consultant speaks with his HoD so that he can discuss the matter with the
executive management.
(c) The consultant personally attends to the matter until it has improved.
(d) The consultant is told that he needs to obtain in-depth knowledge of the hospital
structure before he can make suggestions.

Question 3. A neighbouring hospital in your referral area offers an integrated care

concept with their day-care-hospital operations and subsequent nursing at home in the
highly contested and profitable market of implants. How would your hospital react?

Possible answers:
(a) The hospital’s public relation officer reports in the regional press on patients’
satisfaction at being treated under the existing system.
(b) The hospital management instructs a consulting company to examine the
issue.
(c) A multidisciplinary working group is formed that consists of members of the
department of orthopaedics. The group is asked to submit a detailed proposal
within 30 days.
(d) The executive hospital management refers to its own good financial results and
lets the neighbouring hospital gather their experience in the matter.
110 6  Creating Positive Attitudes Towards Change

Question 4. Over the last year, the number of births in the obstetrics unit is clearly
decreasing. However, the neighbouring hospital shows an increase in births every
year. How would your hospital handle this situation?

Possible answers:
(a) The long-serving consultant is dismissed after two warnings if he cannot show
improved figures within a given time.
(b) The executive hospital management forms a working group to examine this
problem.
(c) The labour ward is upgraded as it is assumed to be the cause of the problem.
(d) The consultant of the unit is given the mandate and autonomy necessary to
propose and implement a new concept within three months.

Be honest and assess which answer relates most closely to your hospital. Then
add together the marks of the answers.

–– Question 1: 2/0/0/0
–– Question 2: 1/0/2/0
–– Question 3: 0/0/2/0
–– Question 4: 0/1/0/2

The total indicates your hospital’s willingness to change:

–– 0–2 marks: you have a great deal of work ahead to make your hospital fit and
open to change processes.
–– 3–5 marks: your hospital is moderately able to change, but needs a boost. There
are lots of red carpets around.
–– 6–8 marks: in your hospital change processes can be implemented successfully.
Carry on and demonstrate the changed practices through your actions.

6.4 How Can You Encourage Willingness to Change?

It is not the strongest who survives but the one that is able best to adapt. (Carly Fiorina)

Now we will move on to the questions: how do you encourage willingness to change
and which obstacles have to be overcome? Many people are overwhelmed by the
oft-repeated ‘we have always done it like this’. Change processes are like clearing a
thicket. If you neglect the task for a couple of days, it grows back again and the
earlier efforts are hardly visible.
The following guiding principles can encourage the willingness to change
(Belasco 1990):

–– Convey a sense of urgency.

–– Sketch a clear picture of tomorrow.
–– Develop a new path.
–– Display the new values in the way you yourself act.
6.4 How Can You Encourage Willingness to Change? 111

John Kotter and Holger Rathgeber’s penguins anecdote offers a good illustration
of the various steps of change management (Kotter and Rathgeber 2006).
The example below highlights how half-hearted implementation of these princi-
ples can, however, lead to failure of the change process.

Case Study
The CEO of a large regional academic teaching hospital conveys to his
staff the possibility of the hospital being taken over by a private hospital
group that is already in the neighbouring town. To highlight the urgency
of the matter, he cancels bonuses for additional duties such as the teach-
ing allowance for students who are being trained for entering the nearby
university. He defends these steps to his staff by reasoning that the addi-
tional money is urgently needed for the cash-flow of the hospital. A fur-
ther step is staff reduction. The remaining staff willingly accepts the
additional workload of their colleagues whose fixed-­term employment
contracts are not renewed. Over time, cost saving becomes the dominant
motto of the hospital; individual and outstanding performance are appre-
ciated less and less (‘everyone is replaceable’). The executive hospital
management celebrates its financial successes and increasingly takes on
external speaking and representative engagements. Some of the staff
members can no longer identify themselves with the hospital’s strategy
and move to competing hospitals where they are offered better develop-
ment potential.
Conclusion: In this case, the executive management creates a sense of
urgency (‘your job is in danger’), but neglects behavioural changes that go
beyond saving costs. Furthermore, no new values or new hospital strategies
have been implemented to address questions such as: how can we set our-
selves apart professionally from competing hospitals? What are our competi-
tive advantages? No examples of implementing new goals have been shown.
Some staff members felt alienated from their initial job description and no
longer identify themselves with the hospitals strategy. Furthermore, the staff
have become rather sceptical as to whether the executive hospital manage-
ment is capable of developing a suitable strategy that will ensure the hospi-
tal’s viability in the long run.

Further difficulties in the successful implementation of changes will be ­illustrated

by a few examples:

Lack of Commitment or Impatience of the Initiator:  The project’s initiator has

instructed the senior outpatient nurse to conduct a patient survey to determine
their satisfaction with the outpatient department. Based on the results, she is
asked to complete an action plan. When they meet again after two weeks, the
initiator cannot understand why the outpatient staff have not been informed about
the project and the first results are not yet available (e.g., questionnaire, time
frame etc.).
112 6  Creating Positive Attitudes Towards Change

Resistance to Change: Too Little Understanding of the People Concerned:  The

staff of an outpatient department is asked to record the waiting times in both the
medical and nursing areas and reduce these by 20 %. However, the nurses and doc-
tors working in this area are convinced that they are already working close to capac-
ity and cannot work any faster to shorten waiting times.

Lack of Qualified Staff:  The nurse in the outpatient department is responsible

for the project ‘Outpatients’ waiting times’. But she does not have the necessary
professional competence to judge the performance and quality of the doctor on duty.

Lack of Communication Between the Initiating and Participating Groups:  There

was no meeting time that was convenient for the relevant role-players such as nurses
and doctors to have the opportunity to discuss with the project leader the project’s
objectives and timeframe. Subsequently, either the support of the participating staff
was lacking or the person responsible for the project was missing.

Lack of Consideration of the Hospital’s Culture:  The nursing staff of a hospital

that is run by one of the churches receive more appreciation than do the nursing staff
in a government hospital. An initiative to optimise treatments of private patients in
the church-run hospital initiated by an HoD threatens to fail because the nursing
staff were not consulted beforehand. As the nursing staff were not included in the
project from the beginning, they feel offended and are now blocking the process.

Lack of Sponsors:  Due to the poor flow of information, only a few staff members know
what the project’s objectives are; as a result, the project is not supported by the staff.

Lack of Willingness to Change:  Most members of staff have been working in the
hospital for a long time and by now constitute a well-attuned team. As changes have
rarely been initiated over time they are often ignored or undermined.

One often forgets that change requires perseverance. There is also the instance in
this case of neglecting to inform the involved staff adequately about content, time-
frame, and personal job security.
Change processes do not only imply changes affecting departments or the entire
hospital. They can also include small projects, such as the way to do ward rounds or
reduce the waiting time in the Emergency Unit. In change processes, the interests of
the various stakeholders must be understood (Chap. 3) and analysed, while the staff
involved must be engaged and should participate. Soft skills and social competence
are required to achieve the set goals (Chap. 10).
Change processes run through various phases. According to Kurt Lewin (1947)
the phases are ‘unfreeze’, ‘move’ and ‘freeze’. As shown in Fig. 6.1, the existing
processes and structures must be unfrozen to allow the entry of change processes.
Then the enterprise has to be moved: new values will develop, but insecurity also
arises. The path becomes rough and seems uncertain; the vale of tears is traversed.
Remarks such as ‘Everything was better in the past’ are heard on a regular basis. In
6.4 How Can You Encourage Willingness to Change? 113

“Old” existing
“New” changed
processes and
(improved) processes
structures
and structures

Unfreeze Move Freeze

Fig. 6.1  Change processes according to Lewin (1947)

the freeze phase, the process has been completed and new behaviours, values, and
norms are anchored and, most importantly, lived by everyone.
The team should familiarize themselves with the change curve so that feelings
and experiences are recognised as among the normal reactions to a change process.
In contrast, change saboteurs use these phases to emotionally influence the
change process. Troublemakers can exploit people’s basic needs (e.g., for the safety
of the work place) to deliberately unsettle them while simultaneously strengthening
their own power and influence.
In implementing change in a hospital culture, it is necessary to ensure that being open
to changes is experienced as an opportunity. Furthermore, understanding and anticipa-
tion are needed rather than mere reactions to events. The executive hospital management
should be able to accept criticism and should avoid listening only to the people who
agree with them. If they allow only their existing opinions to be confirmed, this will
entrench stagnation and result in a step backwards. On all levels, permanent, personal,
and organisational learning should be regarded as self-evidently essential. Further, team-
work must be lived. A CEO, a head of department (HoD) or medical director should
retain the ability to listen actively and to change their point of view (Chap. 10). This is
shown in the following negative example.

Case Study
The hospital management invites consultants and HoDs to attend a workshop.
Various topics are discussed in the different groups. The CEO of the hospital
is a member of one of the groups. Only when he has voiced his ­opinion do the
others take part in the discussion and they support him.
Conclusion: This hospital will develop only along lines that the CEO
envisages. A free expression of opinions is neither appreciated nor asked for
by the executive hospital management.
 114 6  Creating Positive Attitudes Towards Change

Apart from the above-mentioned guiding principles formulated by Belasco

(1990) and Kotter and Rathgeber (2006), we wish to show in the following section
how successful change management can be implemented by using a systematic
approach.

6.5 The Seven Phases of the Change Curve

It often takes more courage to change one’s opinion than to stick to it. (Friedrich Hebbel)

To facilitate change processes in your hospital, you have to educate your staff
about the different phases of the change curve. The defence mechanism is a nor-
mal part of it. Structural changes proceed according to a uniform scheme. In a
change process everybody should be aware of the current and future phases.
Figure 6.2 shows the perceptions of, and the reactions to the different stages of
structural changes.

–– Phase 1 – all in agreement: the interior perception conforms to the exterior.
Attitudes are aligned with the information received from the outside world.
–– Phase 2 – shock and disbelief: a sudden change occurs. We are informed that we
must change. At first, we deny this message. Dismay prevails. It is the task of the
change leader to listen to your concerns with empathy.

New behaviour, self

confidence
Consequences and effects to the employee

Resistance, aggression
(input)

Understanding Insight,
curiosity

Shock, disbelief

Farewell to the old

Acceptance of the new

Time

Fig. 6.2  Change curve, staff perceptions of changes

6.6 The Seven Steps of Successful Change Management 115

–– Phase 3 – resistance and aggression: the familiar attitude is defended by the team.
The team still denies that change is unavoidable. It is the task of the change leader
to consistently communicate in order to raise awareness of the new realities.
–– Phase 4 – understanding: individuals try hard to pretend that change does not
exist. In spite of that, the team begins to understand that change has to happen
and to feel the effects.
–– Phase 5 – farewell to the old and acceptance of the new: there is closure with the
old and a dignified parting from it. Discussions come to a close.
–– Phase 6 – insight and curiosity: a change in attitudes, beliefs and values takes
place. The road is clear for new behaviours and skills. The task of the change
leader is to permit mistakes and discuss them in an atmosphere of empathy. The
new becomes routine. Assurance sets in.
–– Phase 7 – new behaviour and self-confidence: the new goal can be visualised
both inside and outside. The task of the change leader is to praise teamwork and
plot successes.

6.6 The Seven Steps of Successful Change Management

The change process can be divided into seven steps:

–– Assessment of the sponsor

–– Analysing the hospital culture
–– Planning the programme
–– Planning the implementation
–– Communicating the programme
–– Installation of the programme management
–– Monitoring the process

Apart from management, changes also demand leadership. The part played by man-
agement is to plan and pursue management objectives. Among them are: monitoring
whether measures are being carried out; communication within the hospital and with the
separate departments and staff; managing operational and human resources. As a leader
you establish a vision and a strategy for a long-term direction. You motivate and inspire
your staff and define a hospital culture. You reinforce this by actively living it.

6.6.1 Assessment of the Sponsor

In a change process, you need fellow campaigners who will support your project,
vision, hospital culture, etc. and carry it further. They can be divided into the follow-
ing groups:

–– Sponsors: persons or group of persons with the power to reorganise (usually

executive hospital management, HoDs).
116 6  Creating Positive Attitudes Towards Change

–– Agents: person or group of persons who are responsible for the implementation
of change (e.g., senior doctors, consultants, managers).
–– Affected persons: persons who have to change (e.g., doctors, nursing staff,
administrative staff)
–– Advocates: persons or groups who want the change, but don’t have power (e.g.,
doctors, nursing staff and administrative staff).
–– Camp followers: persons who are affected without being particularly convinced
and play subordinate roles.
–– Blockers: persons who work against change.

The best sponsors want the change themselves and at the same time feel them-
selves to be both agents and affected persons. This is illustrated in the following
case:

Case Study
The CEO of a hospital wants to implement the concept of patient centered
care. He is not a medical doctor himself and is not familiar with hospital pro-
cesses. However, he tries to put himself in the role of patients and considers
how patient centred care could be implemented in the hospital. Spontaneously
and without advance notification he attends daily activities in various units
(ward rounds, discussions, outpatients, admissions, discharges) as he wants to
get a realistic, uncontrived impression (‘management by walk-in’). One eve-
ning he attends the trauma unit to experience how the hospital functions from
the patients’ point of view.

Success is dependent on good and reliable sponsors. The sponsor is the key fac-
tor for successful changes. If the CEO wants to change the hospital culture without
actively supporting change processes, the project is not going to succeed.
If the hospital board wants to implement changes, they should support the
CEO and the executive management team in developing the necessary skills and
management tools. If the CEO remains resistant to change, the hospital board
should consider replacing him. Effective change management from the top can-
not be delegated or ignored.
A successful sponsor has to have various tools at hand: for instance, the
resources and formal power to enable acting autonomously. Furthermore, s/he
must be empowered to influence the persons involved and the organisation.
Integrity, the ability to develop vision, foresight and consistency in actions are
important characteristics. A sponsor is critical to the successful launch of a change
management process. Agents cannot take over the role of sponsors, as they have to
implement the change.
The following case study highlights the importance of consistent action in a
change management process.
6.6 The Seven Steps of Successful Change Management 117

Case Study
For several years, the HoD and the hospital management pursue the plan to
rebuild the hospital in another location to improve access and patient flow. It
has already invested a lot of time and money in the planning. However, after
the building plan has been officially submitted, the CEO withdraws the proj-
ect. He then disseminates the goal of building a new outpatients treatment
centre because this is faster to set up and would relieve certain hospital and
treatment processes.
Conclusion: To initiate projects such as the urgent construction of a new
hospital and then to pursue, instead, the development of an outpatient treat-
ment centre wastes resources, and confuses the staff and other stakeholders. If
urgent business reasons make such a change in strategy necessary, this must
be communicated appropriately: these reasons should be made transparent
and understandable to the staff and all other stakeholders.

6.6.2 Installing Programme Management

Change management must be planned and coordinated with measures and tools.
The organisation and planning process is known as programme management, the
activities accompanying it, as change management.
Among the objectives and tasks of programme management is the overarch-
ing ­planning of the change management. It also includes planning of points-of-
decision-making as well as feedback control on existing processes. Key
activities are setting up interfaces to BE projects or other projects, the methods
and tools of change management and ensuring information flow. An early warn-
ing system for problems should be installed so that they do not accumulate. A
professional press officer to f­ acilitate communication plays an important part.
As an interface, he should be familiar with the hospital, the public, and other
role-players.
The person responsible for change management is primarily a communicator. He
must keep his eye on the entire change process. The style of change management is
important. A democratic-cooperative leadership style has good chances for success
(Chap. 10). This approach is based on the appreciation of employees, as is signalled
by including their knowledge and abilities. Drafts of decisions need to be developed
and presented, from which the superior may choose.
The necessary steps of programme management could be outlined as follows:

–– Mobilising for the programme: ‘We cannot continue as we are.’

–– Workshop I, ‘situational analysis’: ‘We realise that we have to take the new path.’
–– Workshop II, ‘solution concept’: ‘We know where we are heading.’
–– Workshop III, ‘planning the implementation’: ‘We know how we are going to get
there.’
118 6  Creating Positive Attitudes Towards Change

Fig. 6.3  Five W questions

Why change? When to change? Who changes?

The context The period the
participants

What to
change? Which way?
The content The process

It is important to explain the various steps to staff members ahead of time and
inform them in various workshops.

6.6.3 Communicating the Programme

The best way to obtain information is to give information. (Machiavelli)

Communication is the decisive instrument for successful change. In the following

example, we show how communication could be implemented during a change
management programme.
As shown in the above example, the progress of change management is to
be communicated by the ‘W’ questions: what, when, who, and which way?
(Fig. 6.3).

Case Study
The executive hospital management is planning a new surgical outpatient
building. On several occasions the CEO invites all staff to attend short in-
house presentations with opportunities for questions and answers. He per-
sonally outlines the most important milestones and calls for active
participation by way of contributing creative ideas. He explains to the
staff why this project is so important for the hospital, informs them who
is involved and which departments will profit from it. He sketches the dif-
ferent phases of the new building as well as addressing the departments
and administrative areas that are affected by it.
Conclusion: All levels of staff feel well informed and included in the pro-
cess. By being able to make suggestions that are considered and taken up, the
executive hospital management, too, gets their buy-in.
6.6 The Seven Steps of Successful Change Management 119

In communicating information about the programme or project, the following

process can be applied. The reasons and the current status of the programme are
repeatedly and briefly communicated. Apart from that, the programme and the vari-
ous steps including the various reasons and goals are presented on the intranet. The
press officer who aligns the communication holds a key position in this process.
Furthermore, the time frame and the changes to it are reported. Explanations are
given as to who is affected and involved, when the change is being implemented and
what the effects will be.
Every opportunity for feedback should be used, e.g., in a questionnaire for ‘Workshop
I – situational analysis’, a question could be: ‘In your opinion, what are the advantages
to pursuing the new goals?’ A four block matrix with a time dimension could be
provided-short-term/long-term and an importance dimension-direct/indirect.
The staff’s reactions to the different phases within the change process should be
discussed and considered. They could be used to modify strategies and ensure the
necessary support.

6.6.4 Analysing the Hospital Culture

During change management, training and workshops will become necessary to over-
come resistance to change (Krueger 1994). In the first place, the hospital’s culture should
be analysed to identify and understand possible opposition to the change process.
Analysing the hospital’s culture to assess willingness to change, various methods
in organisational and cultural analysis can be applied. Among them are the map of
power assessment of executives, the support-influence matrix, and the web of cul-
tural analysis.
In a map of power assessment, executives are analysed and grouped according to
their roles. The hierarchy within the hospital can be marked with ‘+’ or ‘−’. This will
give you an overview of who is supporting or opposing the change, who are the involved
employees and who has been identified as a sponsor, blocker or advocate (Fig. 6.4).
In the framework of the support–influence matrix the employees are grouped
according to their willingness to support change as well as according to their influ-
ence. This can be done by grading them into the dimensions of ‘influence: low/high’
and ‘support: low/high’ (Table 6.2).
Before you start far-reaching change processes, you should realistically assess
and analyse how change processes have been handled in the past. What were the
characteristics of earlier projects? Which problems arose? How were they handled?
Did the projects result in new structures, organisational changes, and processes
which are being lived in the daily work? Which groups have been successful in this?
How high were the costs of the previous project?
A comprehensive organisational and cultural analysis (web of cultural analysis)
can be drawn up by applying the following twelve parameters. This will help you to
determine ahead of time what resistance you could possibly encounter and in which
areas problems can be expected (Pfeffer 2010).
120 6  Creating Positive Attitudes Towards Change

Dr. Matumba, CEO

(+ Sponsor)

Mrs. Rule,
Head of Nursing
(- Blocker)

Prof. Miller Dr. Brunner Prof. Salomon

Head of Internal Medicine Head of Radiology Head of Perinatal Medicine
(- Blocker) (- Camp follower) (+ Advocate)

Fig. 6.4  Example of a map of an assessment of executives

Table 6.2  Support and influence of the employees involved

Support Influence high Influence low
High Sponsors: Advocates:
Prof Dowling (HoD) Dr Johnson (Senior Registrar)
Dr Steyn (Consultant) Sr Jeffrey (Nurse)
Mrs Bosson (Nurse Manager)
Low Blockers: Camp followers:
Prof Blockman (Deputy HoD) Dr Gilbert (Consultant)
Dr Picker (Consultant) Sr Abrahams (Senior Nurse)
Sr Spikes (Senior Nurse)
Dr Beth
HoD Head of Department

1. Drive for improvement. How intense is the individual drive for improvement
within the team? Is the team striving for excellence or do most of them just try
to get through the day? How many improvements have been made in the hospi-
tal during the last twelve months that were successfully implemented and have
advanced the operational work?
2. Willingness to collaborate. How developed is this attitude in your team/depart-
ment/hospital? Do the team members work well together? Does the team work
with other specialists and departments or do they prefer to work among
themselves?
3. Need for cooperation. Does the team feel a need to work together with others?
6.6 The Seven Steps of Successful Change Management 121

4. Need for continuity. Is there a wish to leave everything the way it is – in accord
with the old saying: ‘a new broom sweeps clean, but the old one knows all the
corners.’
5. Dependence on others. Is the team autonomous, authorised to make decisions,
or are they dependent on others? Is there an alpha dog in the team?
6. Aversion to risk. Does the group accept risks or are they averse to risks? Is the
team prepared to head into a new direction and experience new things?
7. Oppositional stance. How much opposition should you expect from individuals
or from the team?
8. Orientation to power. On the executive level, is the main focus on staying/
retaining power?
9. Internal competition. How much internal competition exists, and how much is
allowed?
10. Perfectionism. Is there a desire for perfectionism that prevents innovation or
can people tolerate degrees of imperfection enabling them to move on?
11. Results-focused thinking. Does results-focused thinking dominate? This is the
key to successful change processes.
12. Team dynamics. How dynamic are the individual members and the team as a whole?

The criteria measuring the culture of learning, willingness to change and aggres-
sion can help you to estimate the risk for the change process:

–– Culture of learning (willingness to learn new ways of acting): criteria 1, 2, 11

and 12
–– Willingness to change: criteria 3, 4, 5 and 6
–– Aggression (intention to block or harm the change process): criteria 7, 8, 9 and 10.

The following example illustrates an operational process in change management.

This will lead us to the next step in programme planning.

Case Study
The executive hospital management, the HoD for orthopaedics, and the HoD
for the trauma unit have decided to establish a surgical day hospital. This will
include aftercare in collaboration with private orthopaedic specialists and sur-
geons working in the outpatients department. The day hospital will be housed
in a new hospital wing. The colleagues in private practice will jointly work
together with their hospital colleagues in both surgery and outpatients. The
objective is to offer patients better treatment options and improved aftercare
services. Furthermore, the treatment costs for the hospital have to be reduced,
as the number of negotiated procedures exceeds the limit and are therefore not
reimbursed by the health care insurances.
122 6  Creating Positive Attitudes Towards Change

The following steps are necessary. The environment (i.e., the hospital staff,
colleagues in private practice, purchases and patients) must be aligned to the
goal of ‘new integrative care in outpatient surgery with optimised aftercare
treatment’. To achieve this, an interdisciplinary project group comprised of
members of various stake holders is formed to outline a vision and create
awareness of the goal.
The current attitudes of those concerned are analysed to identify barriers,
find sponsors and to include opponents and blockers. At the same time, the rel-
evant information must be disseminated. In addition, training is offered to high-
light the necessity for changes as well as to inform about further developments
and the envisaged goals. It is also helpful to share experiences of other hospitals
with similar projects. After the buy-in from the role players, an attitude in favour
of change must be established. Those concerned should be actively involved in
the project, and play a part in it. The various steps have to be recorded. Ensuring
continued support is an important task, as the process continues.

6.6.5 Programme Planning

If you want to build a ship, don’t drum up people to collect wood and don’t assign them
tasks and work, but rather teach them to long for the vast and endless ocean… (Antoine de
Saint Exupéry)

Two aspects of programme planning are the design of the concept and the imple-
mentation of the change process. The strategy needs to be separated from the plan-
ning (‘initiate the change, i.e., build participation and convince people to get
involved’) and the implementation (‘manage the change, i.e., in each phase, imple-
ment each stage quickly and manage the risks’). Programme planning comprises
the set goals within a certain time frame and the way to proceed further, depending
on what has been achieved.
There are various approaches to leading the change process. Improvements that
can be made in the short term must be implemented immediately because your
­colleagues and the management need to see results. Then even notorious blockers
will look unreasonable as time goes on.
No major change can be achieved in one go. Intermediate stages – plateaus – are
necessary. They can be structured according to different principles, but the hospital
must be able to function at each plateau. Each level has its guiding principle and is
balanced in itself.
In health systems, i.e., hospitals, day clinics, private practices, the visualised
objective must be analysed repeatedly and if necessary, be adapted as continuous
changes and modifications take place. The transformation programme of change
should benefit from a combination of ‘push’ and ‘pull’ factors: Push should be
6.6 The Seven Steps of Successful Change Management 123

understood as stimulus given by management and pull as the participation and buy-
in from colleagues. ‘Learning by doing’ transforms affected persons into advocates.
This can become a ‘pull’ factor, i.e., those concerned will pull others along.
The lessons learnt from the change processes will create innovative work struc-
tures. ‘Making mistakes’ must be permitted as long as there is the willingness to
correct them and learn from them. The willingness to take on risks (responsibility)
promotes development. Resistance to change management and innovation pro-
cesses is normal, partly predictable, and measurable if you take the time to analyse
it (Chap. 5).

6.6.6 Planning the Implementation

To implement change successfully, there are various approaches, as described

above. Start with projects that have a short- to medium-term time line and a high
probability of success. For this, select the most suitable colleagues in the hospital
as initiators. In the implementation phase, the snowball principle, building on the
push and pull factors, has been proven to be effective. Furthermore, changes are not
only initiated top–down, but also, since the staff is included, bottom–up. For each
hierarchical level the mind-set of its occupants must be considered, moved and
changed.
It is necessary to analyse how staff members react relative to the relevance and
speed of the particular change process. The four-field matrix with the dimensions
speed (high/low) and participation (high/low) can be used to make the analysis. The
readings are to be interpreted as follows:

–– Low speed, low participation: lack of interest, resignation (apathy). At every

regular meeting you have to point out the importance of taking part, even if no
significant progress has been made since the last meeting. The targeted innova-
tion process shows a high risk of failure.
–– High speed, low participation: restlessness, uncertainty, opposition. Since the
last meeting, the project has advanced without those involved having participated
actively. They feel that they are not being adequately consulted and involved.
–– Low speed, high participation: frustration, implausibility. The staff members
participate actively in the change process and contribute actively. However, the
progress is very slow. As time goes on, they are frustrated and no longer con-
vinced that enough support is being given by the sponsor.
–– High speed, high participation: motivation, creative thinking. This is the ideal
situation. The group is prepared for the flight of the flamingo (Chap. 8).

As outlined, you as the project sponsor need to find the appropriate speed that
will ensure the high involvement of your team. Depending on that speed, you will
have to set goals and deadlines and adjust them.
124 6  Creating Positive Attitudes Towards Change

6.6.7 Monitoring the Process

The entire change programme must be continuously monitored and controlled.

Progress across all stages of the transformation requires much patience. The agents
and sponsors must be prepared to encounter resistance on all levels. If resistance is
not taken seriously, success will be endangered. Even if the change process is
broadly accepted, this does not automatically imply satisfaction of all the staff
involved. People who resist the change should be given the opportunity to articulate
their doubts. However, blockers need to know from the beginning that they are
expected to actively support the change.
The web of cultural analysis (Sect. 6.8) shows the chance for a successful change.
During the change process this must be continually updated to assess how far the
change has been embraced by the involved staff.
Even if the change process slows down, there are ways and means of getting the
process into gear again. It calls for a change of strategy.

Example Change of Strategy

Change of strategy: a man was standing outside a building with a sign that read:
I am blind, please help. A ‘creative publicist’ was walking by him and stopped to
observe. He saw that the blind man had only a few coins in his hat. He dropped in a
few more coins and, without asking for permission, took the sign, turned it around
and wrote another announcement. He placed the sign by the blind man’s feet and
left. That afternoon the creative publicist returned to where the blind man sat and
noticed that his hat was full of bills and coins. The blind man recognised his foot-
steps and asked if it was he who had re-written his sign; he wanted to know what he
had written on it. The publicist responded: ‘Nothing that was not true, I just wrote
your sign out a little differently.’ He smiled and went on his way. The new sign read:
Today is the first day of spring and I cannot see it. (unknown author)

The following options for a change of strategy exist: more time can be assigned
to staying on a level, especially if it is on the first plateau; goals can be modified; the
‘pain’ of the present situation can be increased (e.g., ‘The new consultant will only
be employed once the innovation process of restructuring the department has been
implemented.’). In addition, instruction, training, and coaching can be intensified.

6.7 Which Strategy Can Be Applied When?

Depending on the requirements, changes can be introduced at various stages.

Collaborating, advising, instructing and active decision-making are options and
should be applied in a specific situation specific manner (Table 6.3). The strategy
depends on the degree to which your colleagues support the various steps and how
urgently changes need to be implemented.
Change processes include small changes, step-by-step application, modular trans-
formation, or the reorganisation or restructuring of an entire department or hospital.
6.8 CIRS 125

Table 6.3  Conditions for various change strategies

Step-by-step Transforming
Collaborative/ Participative: Only small Charismatic transformation: The
advising changes are necessary in the hospital/department needs changes
hospital/department. The groups urgently. There is little time to ensure
support the change general participation. Important
role-players in the hospital support the
intended changes
Direct/mandatory Forced change: For the hospital/ Directive transformation: The need to
department smaller and bigger change is urgent. There is neither the
changes are necessary and there time nor the support for radical
is enough time available in order changes. The changes are necessary so
to do so. Although interest that the hospital/department recovers
groups are resistant to change and quality of treatment improves
Modified according to Dunphy and Stace (1990)

6.8 CIRS

The Critical Incident Reporting System (CIRS) is a system for controlling pro-
cesses and initiating changes (Fig. 6.5). How does CIRS work and how is it evalu-
ated? CIRS reports originated in the field of air traffic control. For decades, a
systematic data analysis of incidents (accidents/events) and near miss incidents
(‘almost’ accidents) have been carried out and officially published. This process
has significantly increased flight safety worldwide because mistakes were made
transparent to the wider community who could all learn from it. In hospitals an
internet platform in which data can be entered anonymously would be ideal. Job
details (medical services/nursing/administration/security/others) should be entered.
Anonymity must be granted, related to other departments and to the hospital
­management. The designated CIRS person of the department/hospital evaluates
the data regularly. The different topics are summarised and subdivided into various
­subgroups; the topics are discussed at least once a month together with the HoD/
consultant and the head of nursing. In turn, the executive CIRS team regularly
presents the findings and measures passed on to their peer groups (medical ser-
vices/nursing). Problems and measures taken of the departments/hospital should
be documented in the intranet to advise new or absent staff. The nominated CIRS
person of a department/hospital will forward the relevant reports to the head of
CIRS in the hospital who then collates the anonymised report for the executive
hospital management. An open, trusting and transparent atmosphere in the hospital
promotes participation in CIRS. This enables risks and problems to be communi-
cated to higher levels, since it is imperative that hospital management and risk
manager be informed about current problems.
Whereas the nursing staff tend to use CIRS on a regular basis, doctors are more
hesitant. The higher the hierarchical level, the greater the hesitation to provide
critical information. A contributing factor is the traditional concept of the medical
126 6  Creating Positive Attitudes Towards Change

a Insufficient Unclear docu- Nurse on duty

communication mentation of does not know
the insulin the patient and
dosage applies the Patient develops a
wrong dosage severe
hypoglycamia

b
Provision of insulin by
Insufficient Unclear docu- the night nurse;
communication mentation of inconsistent with the
the insulin patient’s statement,
dosage therefore, feedback
from the consultant
Correct
requested
dosage of
insulin

Fig. 6.5  Swiss cheese model. (a) Depicts when no back-up and checking system is in place, caus-
ing incidents. (b) Shows the incidents avoided because there are back-up and double-checking
systems in place

expert: ‘Who will admit to making mistakes if he is supposed to know everything

related to his expertise and managerial level? What are the consequences for me,
as a doctor? What must I expect if I admit to having made a mistake?’ Within the
hospital a mind shift has to take place: the staff must recognise that criticism is
6.9 Change Management by Outsourcing 127

something that can be used in a positive way. And that it drives the hospital for-
ward if it is treated constructively and is a part of the work environment. Doctors
often voice support for CIRS as a good and efficient tool to external stakeholders.
The internal reporting from clinicians tells a different story.
Medicine is still perceived as a zero error zone. Unfortunately this perception does
not mirror the everyday reality of hospitals. The following anecdote illustrates this:

Anecdote
“Let us take Mrs Moore as an example. She is the wife of the multi-millionaire
Moore, the creator of Moore’s Law. Once she was admitted to John Hopkins
Hospital. Around midnight a night nurse makes her ward round: ‘Mrs. Moore, your
injection!’ Mrs. Moore asks: ‘Which injection?’ The nurse: ‘I have to give you your
injection.’ ‘I am not supposed to get injections.’ ‘Here is my instruction; you are to
have an injection.’ ‘I don’t want to get an injection.’ ‘Oh well’, says the nurse, ‘I’ll
call the doctor. He has documented it clearly but if you insist. After all it is after
midnight, he won’t be pleased, but I’ll ask him.’ Mrs Moore finally gave in: ‘No, we
don’t want to disturb him. Give me the injection.’ The injection was insulin. It was
not intended for Mrs Moore. The lady in the bed next to her was asleep. Mrs Moore
fell into a coma, but luckily survived.
Mr Moore, a wise man, did not sue the hospital but instead implemented a qual-
ity management improvement programme known now as the ‘Moore Foundation of
Nursing’. His view was: whose fault is it? Is it the behaviour of the nurse that
deserves criticism? The doctor for his wrong documentation, and that he was not to
be woken up? The nursing manager? The consultant on call? The HoD? The phar-
macist who put Mrs Moore’s name on the medication? The Chief Operating Officer
(COO) who is responsible for the medical departments? The CEO? The head of the
holding? The vice-president of the Medical Association? The Minister of Health?
The biggest problem factors exist in the variability, the irregularity of processes,
broken processes and the uncertainty of processes. We experience them in our
everyday life and accordingly also in the hospital” (Salomonowitz 2009).

However, CIRS is also used as a tool to express ‘gripes’ and current tensions.
Consequently, CIRS reports separate incidents ‘without injury to patients’ (medica-
tion swopped, wrong infusion mixed before administration to the patient, mother’s
milk exchanged etc.), from those incidents that result in injury to patients and those
arising from interpersonal problems. Transparent reporting is required for the
patient’s benefit. Even if the patient has not been injured, s/he must be informed if a
breach of rules has occurred. If patients or relatives were to be informed via another
source, trust in the hospital would be damaged forever.

6.9 Change Management by Outsourcing

This chapter discussses outsourcing of processes as an alternative form of change

management. In outsourcing, work or business processes of a hospital are given
totally or partially to external service providers. These services present a special
128 6  Creating Positive Attitudes Towards Change

form of external procurement of services that have previously been handled in-
house. The duration and the subject of the service are fixed by contract. This dif-
ferentiates outsourcing from other forms of collaboration. The most often used
departments for outsourcing are laundry, IT, security, outpatients and, where an
emergency an external medical centre is attached to the hospital, laboratory, radiol-
ogy, and, pathology or there could be strategic hospital development through exter-
nal consultants.
Hospitals can improve their image by outsourcing processes. If the catering and
canteens are serviced by an outstanding caterer, this could also attract non-patients
to use it, particularly in small towns.
Outsourcing includes in-house or external allocation:

–– In internal outsourcing, a partial area of the hospital or the hospital group is

assigned to another provider in the same group (e.g., hip replacements will be
carried out by casualty surgeons instead of orthopaedic surgeons; neonatology
and birth medicine will be transferred to another hospital within the hospital
chain; the hospital establishes another hospital, such as an outpatient health cen-
tre, to optimise after care and shorten the duration of services; a service is sub-
contracted in-house (e.g., all hospitals/departments of the entire group are
charged by the in-house cleaning firm for cleaning according to the floor area).
–– External outsourcing takes place when services are given to external regional or
global companies (typically: cleaning, laboratory, radiology, pathology). Over
the last few years, outsourcing of services has become strategically important in
hospitals due to cost constraints (Sect. 3.7). For successful outsourcing, modern
service and logistics concepts must be applied. Some hospitals send all their
hospital laundry to a neighbouring country for washing, although this approach
is not in accordance with green hospital goals (www.greenhospitals.net). An
alternative could be to join a group of hospitals and have the laundry done at the
same place. The hospital is then less vulnerable to bottlenecks caused by events
such as strikes, the onset of winter, and epidemics. A collective arrangement also
reduces the carbon footprint of each hospital and so contributes to protecting the
environment (Sect. 7.8).

There are a number of reasons for outsourcing:

–– The hospital is able to concentrate on its actual core competencies (service pro-
cesses) and it is therefore optimally adjusted and focussed on market requirements.
–– There is a lack of qualified staff or technical knowledge in the hospital.
–– Efficiencies improve, by, for instance, the external company collecting labora-
tory samples directly from the wards.
–– Caused by the reduction of costs, the hospital is financially more flexible and can
react faster to changes.

However, there are also difficulties and challenges involved with outsourcing.
The cost-­effectiveness can sometimes not be correctly calculated in advance. With
6.10 Summary 129

regard to pricing and price increase, the hospital is more dependent on an outside
company. The quality of the outsourced processes can only be influenced indirectly
(e.g., if the IT maintenance and support of the entire hospital was outsourced and
the obtained support remains below standard). Furthermore, the specific expertise
of the hospital is not protected if services are given to third parties.
Further problems of outsourcing include quality requirements, interruptions in
the communication structure and shortage of resources (lack of linen at the outbreak
of an epidemic, missing devices, lack of surgical tools, etc.).
Experience has shown that occasionally extensive effort is needed for commu-
nicating and coordinating matters between the outsourcing entity and the contrac-
tor. The secondary costs arising are usually not calculated by the hospital because
they are compensated for the existing staff. This is illustrated in the following case
study:

Case Study
A COO has decided to outsource the emergency department including radio-
logical modalities, as the low reimbursement rate per case does not cover the
incurred costs. To provide these services, the emergency department has
been outsourced and subcontracted to another location. Over the next months,
the hospital staff (porters, nurses, support staff and doctors) are engaged in
answering logistic and external inquiries without being able to charge for this
service.
Conclusion: The hospital management cannot understand the reason why
staff still has to work overtime even though the emergency processes have
been outsourced.

If a hospital is looking at possibilities to outsource, the long-terms risks must be

carefully considered and calculated. Returning to the previous situation is almost
impossible or only at very high costs.

6.10 Summary

Change management includes all planned, controlled, and monitored changes in

structures, processes, and the hospital’s culture. A hospital run by a church would
presumably possess a different culture from a public hospital or a private hospital
group. The methods of change management are business engineering, BPR, Kaizen
and CIP (Chap. 4). An integrated change management approach combines human
resource management and communication of change. Change management includes
the entire time frame of the change process. It can be divided into seven steps: from
assessing the sponsor to monitoring the process. Sponsors, agents, affected persons,
and advocates are typical roles adopted in effecting the change process. Possible
causes of failure are organisational or personal opposition. These need to be
130 6  Creating Positive Attitudes Towards Change

considered in advance and relevant countermeasures must be taken accordingly.

Outsourcing is another method of change management. The strategic advantages
and risks must be carefully analysed beforehand.

6.11 Five Reflective Questions for Practical Application

1. How open-minded is your department/hospital towards change? Would you

describe it as low, medium or high?
2. Which changes have you implemented during the last twelve months? What type
of opposition did you encounter? What form of resistance led to failure?
3. Can you define who the sponsors, agents, affected persons, and advocates are for
a current project in your department/division or hospital?
4. Have you established CIRS in your department/hospital? Describe three positive
results in your hospital processes. If none, give reasons.
5. How is CIRS being received? Which forms of resistance do you encounter in its
implementation and its daily use?

References and Further Reading

Belasco JA (1990) Teaching the elephant to dance. Crown Publications, New York
Dunphy D, Stace D (1990) Strategies for organizational transition. McGraw Hill, New York
Guillebeau C (2010) The art of non-conformity. Penguin Books, New York
Kotter J, Rathgeber H (2006) Our Iceberg is melting – changing and succeeding under any condi-
tions. Macmillan, London
Krueger RA (1994) Focus groups: a practical guide for applied research. Sage, Thousand Oaks
Lewin K (1947) Frontiers in group dynamics. Human Relat 1:5–41
Pfeffer J (2010) Power – why some people have it – and others don’t. Harper Collins, New York
Salomonowitz E (2009) Erfolgreiche Organisationsentwicklung im Krankenhaus. Mehr Personal
spart Kosten. Springer, Vienna
Thom N (1998) Change management – basic elements for a differentiated and integrated change
management. Manage J Contemp Manage 3:9
Develop and Communicate
Your Strategy 7

Goals
–– Which performance indicators can you apply to analyse and develop the
­various departments and the hospital further?
–– Why do financial performance indicators have only limited relevance?
–– What can you expect from the Balanced Scorecard?
–– Why must the Balanced Scorecard cycle be continuously repeated?

This chapter guides you in developing goals from your vision statement. It
outlines in detail the Balanced Scorecard (BSC), the different perspectives and
the approach to applying it. Problems that may occur are described. Measures of
communication are briefly explained.

“Your most unhappy customers are your greatest source of learning.” (Bill Gates)

Diagnosis-related groups (DRGs) were developed in the 1980s by a collaboration

between the Yale School of Management and the School of Public Health. Hospital
cases are classified into groups based on International Classification of Diseases
(ICDIO) coding and co-morbidities. This method replaces cost-based reimburse-
ment. Important parameters are the case mix index, which highlights the complexity
of cases, the underlying base rate for cases, the maximum duration of stay for each
DRG and the readmission rate. In the UK called Healthcare Resource Groups
(HRGs).
Diagnosis-related groups enhance the transparency of the financial situation of
health care providers. Hospitals have now to publish the number of services, treat-
ments, modalities, hospital-acquired infections, surgical interventions, bed occu-
pancy rate etc. in their annual reports. Frequently, special emphasis is put on the
presentation: well-designed glossy brochures picture caring hospital staff treating

© Springer Berlin Heidelberg 2017 131

E. Weimann, P. Weimann, High Performance in Hospital Management,
DOI 10.1007/978-3-662-49660-2_7
132 7  Develop and Communicate Your Strategy

satisfied patients. A genuine comparison and benchmarking of hospitals, as is propa-

gated and aimed at, is still seldom possible.
However, the hospital’s most important performance indicators are known only
to a few insiders in the executive management team. The director of finance holds
the money and the power associated with these resources. Only a few staff members
in the hospital have a sound economic business knowledge, although everybody –
including interns, registrars and nurses – is being asked to work economically. How
this can be achieved was not taught during their training. Whether the year has been
a good or a bad one will mostly be outlined in the annual New Year’s speech given
by the CEO. The new year is always rated as difficult, partly because of the annual
budget negotiations with the various health insurance funds and with the local and
national government as well as health care purchasers.
The knowledge of the financial indicators and the allocation of funds is fre-
quently abused in power struggles between different departments. If more people in
the hospital possessed sound economic knowledge, they could use this expertise to
demand higher transparency and pursue common goals to drive the hospital for-
wards in a bottom-up approach.

7.1 From Vision to Objectives

The Balanced Scorecard (BSC) offers a good path for developing sustainable future
strategies beyond the key performance indicators. In addition, the BSC furnishes all
staff with valid decision criteria. It was developed in the US for businesses during the
1990s by Robert Kaplan and David Norton (Kaplan and Norton 1996). Their studies
investigated what a performance measurement system should be like in the future.
One of the major underlying questions was whether monetary indicators are sufficient
or whether non-monetary indicators are just as important for the long-­term operation
of an enterprise such as a hospital. They said that only one instrument (for instance,
financial data) was not adequate for controlling an enterprise. Consequently, they
developed the BSC and suggested using three other types of indicators, apart from the
financial ones (financial perspective):

–– Indicators related to the clients (patients/referring specialists): client perspective

–– Indicators related to the processes: internal business process perspective
–– Indicators related to learning and growth: learning and growth perspective

7.2 Four BSC Perspectives

However, Kaplan and Norton (1996) do not see these four perspectives as fixed
parameters appropriate to every kind of enterprise, but instead, as a template for
developing one’s own BSC. First used in a classic business environment, BSCs are
now gaining importance in hospital settings (Stewart and Bestor 2000; Zelman et al.
2003). The outline below no longer refers to the business environment generally but
to hospitals specifically. Norton and Kaplan applied the client’s perspective to
­businesses. We now subdivide a hospital’s clients into referring doctors and patients,
7.2 Four BSC Perspectives 133

Fig. 7.1  From mission via Our mission

strategy and balanced
Why do we exist?
scorecard (BSC) to the
objectives (Pyramid) Fundamental values
What do we believe?
Our strategy
Map to success
Balanced score card
Focus and Implementation
Strategic measures
What do we have to do?
Personal goals
What do I have to do?

Strategic success factors

thus forming two sub-groupings of the client’s perspective, being the referring doc-
tors’ and the patients’ perspectives.
The BSC is a method that increases the probability of a planned strategy reaching
implementation: it starts from a mission statement, derives objectives from strategies,
and substantiates these objectives by means of measured values, goals and actions.
This refining and substantiating of objectives can be represented as a pyramid, as
shown in Fig. 7.1, which depicts how the hospital’s strategy can be converted into
concrete activities on the individual level. Every department and every staff member
will know how they can contribute to the company’s success. The goals of BSC usu-
ally relate to performance indicators, and for these key data indicators specific goals
are defined, in particular what precisely has to be achieved (Banker et al. 2004).
In business management, performance indicators can be used to evaluate compa-
nies and hospitals. They also play an important role in the BSC, serving as the basis
for decisions (problem recognition and presentation in addition to the acquisition of
relevant information), for monitoring (target versus actual performance compari-
son), for documentation or coordination (behaviour control) of important facts and
interdependencies within the hospital. Performance indicators can be subdivided
into categories, some of which are shown in Fig. 7.2.
In controlling and monitoring processes within a hospital, traditionally the focus
rests on financial key data, such as profitability or liquidity. In health systems that
apply DRGs the case mix index and the base rate are important financial indicators.
Financial key indicators give an indication of the financial success of a hospital, but
for the following reasons they are insufficient for its strategic orientation.
Financial performance indicators often refer to the past. This diminishes their
helpfulness when positioning a hospital appropriately for the future. It is not possible
to derive a reliable prognosis of the performance for the next year from the turnover
and profit of the previous year. Therefore, financial performance indicators can give
only limited help regarding a good or a less favourable development of a hospital.
134 7  Develop and Communicate Your Strategy

Indicators

Absolute Relative
indicators indicators

Index value Dimensioned Relationship

indicators numbers

Fig. 7.2  Classification of performance indicators

Performance indicators can be used to measure business processes and improve

them. They include information on technical and business management matters as
well as on processes, stakeholders, shareholders, staff or clients (patients, referring
doctors; Fig. 7.3).
The vision and strategy of the hospital or a hospital group form the key fac-
tor to measure the performance indicators. They provide the management execu-
tives with a comprehensive overview of the performance and effectiveness of the
hospital and its business processes. BSC is based on the assumption that a one-
dimensional description and control of a hospital is not realistic. With the help of
the BSC, other crucial parameters of a hospital can be illustrated and the informa-
tion necessary for controlling the hospital can be made available. Thus, the BSC
facilitates a holistic management and key data system, which, in addition to the
financial perspective, includes non-monetary performance indicators. Based on the
BCS concrete actions can be taken and monitored to align the performance of
the staff with the hospital’s vision and goals. In a BSC, key data with a different
chronological reference are needed, such as early (performance drivers) as well as
late indicators (result key data):

Leading (early) indicators give an impression of the course the hospital is taking.
They can facilitate the development of the hospital and indicate whether the objec-
tives will be achieved. They are therefore called performance drivers. A good
example of a performance driver is the number of recourse claims and complaints.
Admittedly, they do not mirror treatment results but they give an indication of the
7.2 Four BSC Perspectives 135

Vision
Goals
Strategy

Strategic success factors

Enthusiastic
Satisfied Effective
patients & Motivated staff
shareholder processes
referring doctors

Referrer and Learning and

Financial Process
patients growth
perspective perspective
perspective perspective

Fig. 7.3  Cross-linkage of individual perspectives to vision and strategy

quality of service deliveries in the hospital. A change of this performance driver is

going to affect the hospital’s results (lagging indicators) in the foreseeable future.
Lagging (late) indicators show whether the hospital has reached its objectives. A
typical example of such an indicator is the number of patients treated. This
number indicates whether a hospital has reached its goals. This key indicator
does not, however, provide insight into any future development of the hospital.
In some health systems the number of cases are budgeted and hence limited.
Hospitals are then unable to thrive economically by increasing the number of
cases, since additional cases will not be reimbursed. The prescribed aspects of
the national health system framework affect hospitals and influence their eco-
nomic and strategic alignment.

Combination of leading and lagging indicators  Both kinds of indicators are only
valuable when they are looked at together. It is the combination of performance
indicators relating to the past and to the future that makes the BSC most useful:

• Lagging indicators on their own only indicate which objectives the hospital
wants to achieve in the long run (turnover). They do not indicate how these
objectives will be accomplished (lowering of error rate).
• Leading indicators on the other hand, enable only short-term, operative improvements
(lowering of complaint rate; recourse claims). However, one cannot see whether, and
how, the financial results have been changed by these performance drivers.
136 7  Develop and Communicate Your Strategy

Patient and referrer

Financial perspective
perspective

How do patients and referrer see us?

How do our shareholder see us?
What do we want to achieve on the market?
What financial results do we want to achieve?

Vision
Goals
Strategy

Internal business Learning and growth

process perspective perspective

Where do we have to improve our

performance? How can we continue to improve, create value and
How can we improve our internal processes? innovate?

Fig. 7.4  Standard perspectives of BSC

Accordingly, leading and lagging indicators are defined for each of the four perspec-
tives. This makes it possible for the hospital to be guided in such a way that its strategic
objectives for all four perspectives may be reached in a balanced way (Fig. 7.4).

–– The Financial perspective serves as an orientation for the other perspectives. It

includes information about a hospital’s financial position and performance. For
this purpose, the key data of efficiency (e.g., process costs) and effectiveness
(e.g., savings) can be utilised.
–– The Patients’ and referring doctor’s perspective provides information about
the services by which current and future patients and referring doctors can be
attracted to the hospital. A possible key figure for this would be the patient’s
satisfaction rate.
–– The Internal business process perspective describes the most important charac-
teristics of the business processes and assesses them according to costs, time, and
quality. The focus is less on the improvement of existing hospital processes, but
rather on the identification of potential client requirements, such as referring
doctors and patients. Process perspectives include key data such as patient wait-
ing times, average length of stay, case mix index, etc.
–– The Learning and growth perspective defines the necessary infrastructure to
enable growth and improvement of the hospital’s competitive position. In these
areas only ‘soft’ performance indicators are utilised (e.g., staff qualifications in
the field of managerial and economic processes.)
7.3 The Role of the Cause-and-Effect Chain in BSC 137

7.3 The Role of the Cause-and-Effect Chain in BSC

The BSC helps to visualise hospital performance indicators for the staff. Thus stra-
tegic objectives become evident for the people involved. The strategies are anchored
in every-day operations and the budget and, if necessary, are adjusted to the chang-
ing environment. In this way, the visions and the derived strategic objectives are
measurable.
It is not so much a matter of grading the performance of the past but also of monitor-
ing the variables that strongly influence the performance of your hospital in the future.
Therefore you should use the BSC as a tool for implementing strategic objectives.
Through the cause-and-effect-chain, the hospital’s strategy is linked to the cli-
ents’ perspective (patient and referring doctors’ perspective). This is connected to
the hospital’s processes and in turn to indicators on the learning and growth per-
spective. The challenge lies in choosing fewer but at the same time relevant perfor-
mance indicators which influence each other in the various perspectives. For
instance, a client performance indicator should be selected in such a way that its
achievement has a positive effect on the associated financial indicator.
The development of a BSC is at least as valuable as the resulting objectives, perfor-
mance indicators and their measures. In developing the BSC, you and your staff gain
deeper insight into the future alignment between key indicators and performance. It
results in a stronger identification with the hospital’s objectives. Consequently, the
motivation of the staff increases to play a part in a hospital’s business processes and
contribute to them (Fig. 7.5).
The introduction of BSC forces management and staff to reflect on the hospital’s
vision and strategy and, where applicable, revise it. The BSC links a hospitals’ past
with its future. The communication at traditionally difficult interfaces, for instance
between the hospital management and the medical staff or between accounting,
procurement and operational business, can be distinctly improved by the common
‘language’ of the BSC.
The BSC serves as a leadership tool for aligning the organisation to the strategic
goals in the various perspectives (finance, patient and referring doctors, processes,
learning and growth). Unlike guiding principles and other fuzzy formulations, the BSC
tries to make the goals tangible and implementable by deriving measures from it.

Facilitaon of a connuous
Measures and projects to
strategic learning and
realize the hospital's strategy
development process
Main advantages
of the BSC

Focus on the most relevant Transparent communicaon

strategic performance of the hospital’s strategy to all
Fig. 7.5  Advantages of indicators staff members
BSC
138 7  Develop and Communicate Your Strategy

Vision
Goal
Strategy

Goal Analysis

Returns Internal business

process perspective Learning and
Effect Cause growth
perspective
Market success

Effect Cause

High performance

Effect Cause
Financial Patient-referrer-
perspective perspective Competency

Cause-Effect-Chain Effect

Fig. 7.6  Functioning of the cause–effect chain

The above-mentioned perspectives are interlinked by a logical cause–effect

chain that is described as a cause–effect diagram. Not all links are set out here, only
the strategically intended cause–effect ones (Fig. 7.6), i.e., connections that are
important for the hospital’s goals and strategies.
The core element of the BSC is the establishing of this complex web of reciprocal
relationships. The participants often have very different perceptions about cause and
effect. However, intensive and open communication between the hospital’s various
stakeholders can bring about the necessary process of reaching consensus.
By thinking in terms of perspectives and the various links, you can highlight the
essential interdependencies in one system to support the implementation of your
strategy. While you document the cause-effect chain on three or four pages, your
strategy is described entirely. Therefore, the cause–effect chain is also called a strat-
egy map. Every change in one of the BSC performance indicators has thus an effect
on other indicators. This underlines how the entire hospital is reflected in the
BSC. Although individual perspectives are balanced among themselves, the financial
perspective plays a kind of leadership role. In the long run, the other perspectives
must eventually improve the hospital’s financial situation.
The connection between key performance indicators and the cause–effect chain
(strategy map) is depicted in Fig. 7.7 (modified according to Kaplan and Norton
1996).
Within the BSC, the following points for the cause–effect chain must always be
kept in mind:

–– When interlinking all key data, this often results in a kind of spider’s web. Within this
net, no performance indicator can change without having an effect on the others.
7.3 The Role of the Cause-and-Effect Chain in BSC 139

Financial perspective Return on equity

Patients/Referrer
loyalty

Customer
perspective

Reliability

Internal Business
Treatment quality Treatment time
Process perspective

Learning and growth Staff skills and

perspective knowledge

Fig. 7.7  Example of a cause–effect chain (strategy map) with the different perspectives

–– The cause–effect chain connects the entire hospital with its objectives. In this
way you achieve a more in-depth discussion of the performance indicators within
the hospital.
–– The hospital’s strategy is expanded to the entire hospital because every individ-
ual directly influences the results of the BSC.
–– The hospital can better utilise their change potentials through the cause-effect
chain. You can explain the effects of single changes for the entire hospital.
140 7  Develop and Communicate Your Strategy

Financial
Creation of
perspective financial reserves
for investments

Increase in the
Cost reduction
number of cases

Customer Good market position

perspective due to harmonized Patient satisfaction
processes between
referrers and hospital

Good cooperation Good patient care

with referrers

Internal
pusiness
process
perspective Interdisciplinary Shortened treatment
cooperation processes

Transparent
treatment
processes

Learning and
growth
perspective High patient
centeredness

High professional
competency of the
staff High staff
motivation

Fig. 7.8  Strategy map interconnecting the various perspectives

A further example of the implementation of a strategy into a cause–effect chain

is shown in Fig. 7.8.

Case Study
The BSC has been utilised in various hospitals and departments. An example
is Duke’s Children’s Hospital in Durham (North Carolina, USA) (Kaplan
2001). This hospital introduced the BSC to react to a number of changes in the
environment, such as
7.4 Implementing the BSC 141

–– The average length of stay is too high and above the national average.
–– The hospital is uncertain about their service provision.
–– There are no goals to which management, doctors and nursing staff agreed on.
–– Communication and cooperation with private paediatricians is inadequate
and unsatisfactory.
–– The hospital’s position on the market is threatened by competing medical
facilities.

Despite all these difficulties the hospital pursues the vision of becoming a
‘centre of excellence’. Patients, parents and referring doctors should be
offered the best possible, empathic treatment with outstanding communica-
tion. The following goals are set: patients should experience a high degree of
satisfaction, a high rate of recommendations, excellent information and the
best admission and discharge management. The referring doctors should be
provided with a high degree of communication and have consistent contact
persons in the hospital.
These goals were reached by applying the BSC. Within the first years, the
average length of stay decreases and a higher case-mix is achieved as intended.
In addition, loyalty and satisfaction increases in both patients and staff.

7.4 Implementing the BSC

Budgeting: a method of being annoyed before, rather than after spending the money.
(Voltaire)

The introduction of the BSC is not a process that is concluded after one run-­through
cycle. The implementation is a continuous cycle that is repeated again and again.
This approach transforms the BSC into a strategic operational framework for the
hospital. Each strategic decision falls within the course of the BSC. As an integrated
and comprehensive management approach, the BSC provides a continuous cycle
with the following phases (Fig. 7.9):

–– Development of a strategy: setting up the hospital’s vision and strategy; formulating

the BSC based on an analysis of the environment and hospitals potentials.
–– Communicating the strategy and initiating the objectives: communicating the
vision and mission statement and connecting the objectives with individual per-
formance parameters in specific areas, departments and teams by applying BSC
key performance indicators.
–– Setting up and implementing plans: integration of BSC key performance indica-
tors into regular controlling (reporting, budgeting and forecasting).
–– Strategic feedback, learning, adapting: regular revision of the BSC, and monitor-
ing the BSC key performance indicators with regard to their relevance to success.
142 7  Develop and Communicate Your Strategy

Fig. 7.9  BSC cycle

Development of the
strategy

Communicating the
Strategic feedback,
strategy and setting up
learning and adaptation
the associated objectives

Setting up and
implementing the
initiatives

To summarise the above, a hospital that employs a BSC will first have to be
c­ ertain about its vision and strategy. Then the vision and strategy are transformed
into the hospital’s objectives and circulated within the hospital. The objectives must
then be implemented. In the planning phase, this needs to be separated from budget-
ing. It should rather meet the strategic planning and alignment of the hospital with
the objectives. The strategic feedback, results and new knowledge closes the BSC
cycle and leads to the review of vision and strategy (Fig. 7.9). Currently, a frequent
limiting factor is that the strategy is based on the budget instead on the vision of the
hospital.
The BSC links the development of a hospital strategy with its implementation.
At the same time, the objectives are specified and monitored by the performance
indicators. In this way deviations from the specified goals by non-adherence to key
data will become evident at an early stage.
We will now discuss in possible goals for the four perspectives of the BSC, such
as key performance indicators, the target values and possible measures. Accordingly,
each perspective should provide information (Fig. 7.10) on:

Objectives (strategies): in general, long-term economic success and medical–

strategic alignment will secure the survival and the development of the
hospital.
Key performance indicators (dimensions): after the objectives have been set up, you
have to deduct indicators that permit measuring the degree of success in reaching
a goal in each area.
Target parameters (values): in the context of implementing the objectives, you have
to specify concrete target values for each of the measures taken. These targets
should relate to the actual values.
Measures (initiatives): you specify your initiatives to achieve the objectives.
7.5 The Financial Perspective 143

Vision

Goals

Internal business
Patient and referrer
process perspective Learning and growth
Financial perspective perspective
perspective
Which business processes
To which financial results How are we to act towards
related to patients and How can you enable your
shall our strategy our patients and referring
referring doctors do we staff to implement the goals
contribute? doctors in order to realise
have to change to achieve derived from our vision?
our vision?
the set goals?

Objectives Objectives Objectives Objectives

Performance Performance Performance Performance

indicators indicators indicators indicators

Target parameters Target parameters Target parameters Target parameters

Measures/ Measures/ Measures/ Measures/

Initiatives Initiatives Initiatives Initiatives

Fig. 7.10  The different perspectives of the BSC

7.5 The Financial Perspective

In the BSC approach, the following questions cover financial perspective: How do
we as a private or non-profit hospital have to visualise our success? How can we
demonstrate the financial success of our vision? In the development of the BSC, the
following specific steps must be implemented:

–– Define financial objectives

–– Determine key performance indicators (leading and lagging indicators)
–– Specify target parameters/values for the key performance indicators
–– Introduce measures and initiatives (including responsibility and time frame)
–– Organise feedback (continuous development of the strategic goals; Fig. 7.11)

7.5.1 Objectives of Financial Perspective

Although the different perspectives of the BSC are of equal importance, financial
success is the primary goal of every enterprise, including a hospital. Even a public
144 7  Develop and Communicate Your Strategy

1. Transform vision, strategy and

goals into BSC

BSC
objectives

2. Plan the
strategic Measure Short-
Adapt 4. Feedback
initiatives and target term
BSC learning and
operational values reporting
Adaption
measures

Re-
adjust
Quarterly

3. Communicate strategy
and implement the Yearly
respective controlling
processes

Fig. 7.11  Control processes of the BSC (Modified according to Kaplan and Norton (1996))

or non-profit hospital has to work economically so that future capital investments

can be made to ensure the continued development of the hospital according to the
demands of the market. The key indicators of the other perspectives are inter-
linked and therefor influence improves the financial performance of a hospital or
a h­ ospital group.
By introducing the BSC, or in the course of strategic planning, part of the
profits can be sacrificed for the sake of promoting certain things. However, it is
expected that eventually these will contribute to an increase in profits. Examples
are: members of staff are trained so that the knowledge they have gained will
later be used for improving the business results, or a hospital department that is
not profitable is supported and promoted by other departments to increase future
performance.

7.5.2 Key Performance Indicators of the Financial Perspective

Most hospitals usually have a large number of key indicators for the financial perspec-
tive. Therefore, the right ones must be chosen for the BSC. In contrast to key indica-
tors of the other perspectives, the key indicators of the financial perspective are well
known to the hospital management and the finance department. The financial triangle
(Fig. 7.12) depicts the key indicators and objectives of the financial perspective of a
BSC. The following objectives could form the basis of the financial perspective in the
hospital:
7.5 The Financial Perspective 145

–– Growth of profitability and mix of earning sources, i.e.,

–– Extension of services to reach new patients and new medical fields
–– Change to services with higher value creation
–– Decreasing costs and increasing productivity, i.e., by reduction of the direct and
indirect costs of services
–– Utilisation of assets and investment strategies
–– Better utilisation of the hospital’s resources, e.g., subletting of unused train-
ing facilities to third parties during weekends, evenings, and holidays
–– Reduction of current assets

Possible key indicators for profit growth and various earning sources.  With
regard to the above-mentioned objectives, the following key indicators are relevant
for the growth of a hospital:

–– Proportion of revenues from new services

–– Turnover in new treatment areas
–– Enlargement of the target market share
–– Profitability of patient groups or treatments
–– Turnover regarding new patients and referrer

Possible key indicators for decreasing costs and improved productivity 

Potential key indicators for reducing costs and/or increasing productivity in a hos-
pital are:

–– Costs of the hospital compared with competitor (benchmarking): costs per case
–– Reducing costs: comparing costs in various departments
–– Increased productivity: profit per department/patient/referring doctor

Liquidity

Fig. 7.12  Key indicators

of the financial perspective Rentability Stability
146 7  Develop and Communicate Your Strategy

Table 7.1  Examples of the implementation of goals from the financial perspective
Key performance Target
Objectives indicators parameters Measures/initiatives
Competitive cost Reduction of Annual Outsourcing or privatisation of
structure costs reduction by certain services (outpatients,
10 % laboratory, radiology, pharmacy)
Reduction of tied Increase in Additional General overhaul, shorter
capital utilisation periods 2 years maintenance intervals
of facilities

Possible key indicators for utilisation of assets and/or investment ­strategies.  The
alternatives for key indicators for the utilisation of assets and/or investment
­strategies, are:

–– Shareholder value
–– Cash flow
–– Growth of turnover
–– Increased service life of devices
–– Utilisation of assets depending on turnover (investment rate, investments in
research and development)

The implementation of goals in objectives, key indicators, target values and mea-
sures could, for example, look as described in Table 7.1.

7.6 Patient and Referrer Perspective

From the patients’ and referring doctors’ perspective, the following questions cover
the BSC approach: how do we act towards our patients and referring doctors to
realise our vision? In the development of the BSC, the following specific steps must
be implemented:

–– Develop objectives for the different target groups

–– Define key indicators (early and lagging indicators)
–– Specify target parameters/values for the key performance indicators
–– Introduce measures and initiatives (including responsibility and time frame)
–– Organise feedback (continuous development of the strategic goals)

7.6.1 Objectives of Referring Doctors’ and Patients’ Perspective

For the layout the referring doctors’ and patients’ perspective, the following consid-
erations must be made:

–– The hospital must satisfy the requirements of referring doctors and patients.
7.6 Patient and Referrer Perspective 147

Leading indicators Lagging indicators

Treatment and service Patient and referrer

characteristics satisfaction

Patient and referrer Acquisition of new Patient and referrer

Profitability
relationships referrer and patients loyalty

Image and reputation Market share

Fig. 7.13  Leading and lagging indicators of the referring doctors’ and patients’ perspective

–– The hospital must determine the focus in which medical fields it wants to be
competitive.
–– The hospital must clarify in which way it offers the services to the patients and
the referring doctors.

7.6.2 K
 ey Performance Indicators of Referring Doctors’
and Patients’ Perspective

Lagging indicators are already commonly used in many hospitals. In their basic
form, they are unique for all hospitals but still have to be adjusted to the specific
requirements. Many of these lagging indicators can be turned into early indicators
by changing the angle from which they are viewed: Patient loyalty and patient satis-
faction can quickly turn into early indicators in case of forward-looking treatments
and therapies (e.g., laser operations, minimal invasive techniques, interventional
endoscopy, day-hospital treatments and outpatient surgeries). Figure 7.13 illustrates
early and lagging indicators as well as the different interrelations.

Leading Indicators of Patients’ and Referring Doctors’ Perspective  They

enable observations about future treatments and are valuable indicators for the
future market.

Leading Indicator – Satisfaction of Patients and Referring Doctors  The

satisfaction of referring doctors and patients is an important factor for a hospi-
tal. Satisfied patients will return to the hospital for other medical conditions.
They are a credit to the hospital and will tell others of their positive experiences
(multipliers). The following e­ xamples of key indicators for patient satisfaction
can be established by questionnaires:

–– Survey results of general patient satisfaction

–– Recommendation rate
–– Number of positive feedbacks from patients’ and referring doctors’
148 7  Develop and Communicate Your Strategy

Leading Indicator – Patients’ and Referring Doctors’ Loyalty  The loyalty indi-
cator provides information on how well the hospital looks after the patients and
referring doctors. Many hospitals only concentrate on new patients. Existing rela-
tionships are not fostered and referring doctors and patients might turn to other
competing health care providers such as hospitals, day hospitals and colleagues in
private practice. It is often forgotten that it is more cost-effective, and thus more
profitable, to foster a customer base than to acquire new customers. The following
example illustrates that loyalty indicators for referring doctors and patient are com-
paratively easy to ascertain in-house:

–– Share of turnover of ‘long-standing’ referring doctors and ‘long-standing’

patients
–– Growth of ‘long-standing’ referring doctors and ‘long-standing’ patients
–– Allocation and referral frequency

Leading Indicator – Treatment and Service Characteristics  The quality of

medical treatments and services a hospital offers in the following three areas is
important for referring doctors and patients:

–– Personal and individual attention

–– Quality of care
–– Waiting and treatment time

The following key indicators can – if used correctly – give an early indication of
whether the hospital is on the right track in fulfilling its clients’ requirements:

–– Accessibility and availability

–– Proportion of re-admissions for the same diagnosis
–– Complaint rate - rate of adverse incidents
–– Medical services and additional health services

Leading Indicator – Image and Reputation  An early indicator for the patients’
and referring doctors’ perspective is given by the public image of a hospital. Patients
will more easily choose a hospital with an excellent reputation. Monopolists have an
advantage; however, this can quickly disappear once there are competitors on the
market. The press and public relations office can significantly contribute to an
improvement of a hospital’s image. Some indicators are

–– Growth of advertising budgets of the press office

–– Number of positive comments/reviews in the media
–– Number of articles in the press
–– Number of visitors at hospital events (regular and new visitors)

Leading Indicator – Relationships with Patients and Referring Doctors 

Relationships with patients and referring doctors influence the success of a hospital
to a large extent. If a hospital cannot build up positive relationships with the ­referring
7.6 Patient and Referrer Perspective 149

doctors and patients, it will lose them sooner or later. The important points in this
context relate to:

–– Accessibility of the hospital

–– Time to address enquiries, complaints and appointments
–– Number of complaints
–– Patient satisfaction

Examples for key indicators are:

–– Friendliness and customer service awareness of the staff. Surveys among patients
and referring doctors are helpful to provide the relevant data.
–– Waiting times for admission, at the patient administration, until a telephone call
is picked up, requests for appointments are dealt with, etc.

Lagging Indicators from the Referrers’ and Patients’ Perspective

Lagging indicator – acquisition of new clients. The acquisition of new clients such
as patients and referring doctors is important for a sound financial performance. The
following key figures for new acquisitions can be ascertained internally:

–– Proportion of new patients within the total number of patients

–– Growth rate for new patients and referring doctors
–– Ratio of newly referring doctors to the number of potential new referring doctors
who were contacted

Lagging indicator – profitability. A hospital needs to measure its profitability

on a regular basis. In order to recognize if the relationships with other stakeholders
are valued, the various contracts with the service providers must be analysed.
Occasionally, there might be strategic reasons to exempt an individual service pro-
vider from making profit but this should be the exception. As a rule, contracts should
make profit. The following key indicators can be utilised:

–– Profitability per patient/patient group

–– Contribution margin per patient/patient group

Lagging indicator – market share. The market share is also important because
it can measure its success with the desired target group. The following target figures
can be utilised:

–– Market share in a specific market (e.g., regional)

–– Market share in a specific target group (e.g., youth, families, senior citizens, old
age homes)

Within a specific target group, key indicators measure the share within the
total number of patients (‘account share’ or ‘share in the number of referred
patients’).
150 7  Develop and Communicate Your Strategy

Table 7.2  Examples of goals from the perspective of the patients and referrers
Key performance Target
Objectives indicators parameters Measures/initiatives
Development of a Number of new Annual increase Marketing campaign
higher price segment for private patients in of 10 % Sponsoring
private patients treated in the ‘comfort class’
wards offering ‘comfort wards
class’
Most patient-friendly Customer Annual increase Regular feedback from
hospital in the region satisfaction index of 5 % test persons
Continuous service
training for staff

–– Example: The total share of a target group covered by one referring doctor (e.g.,
share of patients suffering from diabetes mellitus and co-morbidities such as
hypertension and neuropathy).

The implementation of goals, i.e., the parameters of objectives as key indicators,

target values and initiatives could for example be described as in Table 7.2.

7.7 Internal Business Process Perspective

When you apply the BSC to the process perspective, you should ask the following
questions: which business processes related to patients and referring doctors do we
need to change and how must we change them to achieve the set goals? By develop-
ing the BSC, the following specific steps must be implemented:

–– Defining the objectives for innovation, treatment processes and patient services
–– Determine key indicators (early and lagging indicators)
–– Specify target parameters/values for the key performance indicators
–– Introduce measures and initiatives (including responsibility and time frame)
–– Organise feedback to continuously develop the strategic goals

When you apply the BSC in hospital processes, avoid to put the emphasis on a
certain part of the process. Rather, the total process should be analysed from the
strategic point of view to identify those processes that are critical for achieving the
objectives for patients, referring doctor and shareholder. This step is in line with
business engineering. For example, the entire process can be subdivided into four
different aspects for the relevant key indicators.

–– Innovation describes the identification of the market and the requirements of

patients’ and referring doctors’ in addition to new services to be offered.
–– Treatment describes the therapy and treatment offers.
–– Service includes all services intended for patients. This comprises the service for
in-patient and outpatient treatments. In addition can serve to secure patient
7.7 Internal Business Process Perspective 151

s­ atisfaction, e.g., talks of health professionals on certain diseases, diet and fitness
for cardiac and stroke patients.
–– Internal and external communication: communication is a process that can con-
tinuously be improved because weaknesses need to be detected and removed and
new technology needs to be considered and applied.

In the process perspective you cannot differentiate between leading and lagging
indicators as the relevant business processes are sequences that are passed through
continuously (cycle).
Example: The key indicator ‘post-operative care patients’ actually appears to be
a typical lagging indicator as it provides information on whether patients are satis-
fied with the services in the hospital. If one uses them to indicate new patient
requirements, it turns into a leading indicator.

7.7.1 Innovation

The best way to predict the future is to create it. (Alan Key)

This process cannot be delegated to colleagues, the departments or the head of the
innovation hub. Rather, every staff member, irrespective of his level in the hierarchy,
must become actively involved in the hospital’s innovation processes to solve
­problems, e.g.,

–– Identification of patients’ requirements

–– Creation of appropriate services to fulfil the patients’ and referring doctors’
requirements.

Possible key indicators for the innovation process are:

–– Number of newly identified patients’ and referring doctors’ requirements

–– Degree of implementation of identified patients’ and referring doctors’
requirements
–– Project success rate – how many ideas are successfully implemented?
–– Time to market (time until practical implementation of the innovation)

7.7.2 Treatment and Service Processes

In all hospital services and treatment processes, each step from procurement to
treatment, discharge, and accounts has to be structured in such a way that the ser-
vices fulfil the patients’ requirements in the following respects:

–– Quality
–– Costs
–– Time
152 7  Develop and Communicate Your Strategy

Then key indicators can be utilised for the processes:

–– Time until appointment

–– Number of appointments kept
–– Number of complaints and recourse claims

7.7.3 Service for Patients and Referring Doctors

In order to obtain satisfied referring doctors and patients who are to recommend
your hospital to other patients, it is necessary to provide support for the patients
after the discharge. Some key indicators illustrate how capable these patient
services are:

–– Number of patients treated after being discharged in collaboration between the

­hospital and private practitioners
–– Lead time to reply and settle queries and complaints
–– Waiting times
–– Billing and collection times regarding private patients and service providers

One of the most important strategic objectives is a continuously high standard

of treatments and services. All patients should be cared for and treated courteously,
not only those who know the executive hospital management or the HoD or who
complain about their concerns: if patients are successful in bypassing staff, they
will increasingly talk to the hospital’s management first without having the matter
discussed with the people in charge. Consequently, the executive hospital manage-
ment should redirect decisions and complaints to those responsible for dealing
with them: this will ensure that management do not face a loss of competence and,
at the same time, they are empowering their co-workers.

7.7.4 Internal and External Communication

A hospital’s internal and external communication must be seen as a business pro-

cess that plays a key role in the hospital.
Internal communication is vital for the BSC, i.e., the dissemination of strategic
goals throughout the hospital. This can be measured by the following key
indicators:

–– Internal dissemination of news in the hospital’s bulletin: Are staff member inter-
ested in the contents? How many staff members read the paper regularly? Which
content is read? Are the matters related to the interests of the staff or is the con-
tent published by and for the hospital management?
–– Number of staff contributors to the hospital paper. Is the paper intended to
enhance internal communication? Are the concerns of the staff taken up in the
7.8 Learning and Growth Perspective 153

bulletin? Or is it instead seen as a prescribed and persuasive medium working on

behalf of the hospital management? Blogs could also present an innovative way
of communication enabling staff to express internally, in the hospital, their opin-
ions on projects and strategies; it is also a method that avoids matters being
broadcasted outside the hospital, via social media.

External communication, important for defining the hospital’s image and reputa-
tion, usually comprises three areas:

–– Public relations
–– Advertising
–– Hospital events

They can be evaluated using the following performance indicators:

–– Number of positive reviews/articles in external media such as the daily newspa-

pers or television
–– Number of participants in hospital events (number of regular and new visitors)
–– Number of participants attending ‘open days’

7.8 Learning and Growth Perspective

This perspective, which is frequently regarded as the staff perspective, is aimed at

transforming the hospital into an organisation with a culture of learning and growth.
To achieve the goals of organisational growth and development, the necessary infra-
structure must be set up.

7.8.1 Objectives of Learning and Growth Perspective

The objective is to empower staff so that tasks will be carried out as best as possible.
In addition, relevant information technologies must be available to provide the
organisation with the necessary information. How can you enable your staff to
implement the objectives derived from this vision?

7.8.2 K
 ey Performance Indicators of the Learning and Growth
Perspective

For the performance indicators of this perspective, it is particularly important to

define how the results can be determined. It might be difficult to express these
objectives in key indicators and related target values. However, if this task is taken
up by a mixed team from all involved departments, it could lead to an overarching
awareness of the organisational culture in the hospital (Fig. 7.14).
154 7  Develop and Communicate Your Strategy

Leading indicators Lagging indicators

Training of staff
Satisfaction of the staff

Motivation of the staff

Staff loyalty Staff productivity

Informal infrastructure

Fig. 7.14  Early and lagging indicators for the learning and growth perspective

Lagging Indicator – Staff Satisfaction

Satisfied staff is the requirement of a well-functioning hospital. Satisfied colleagues
perform better than unsatisfied. The following factors influence positively staff sat-
isfaction (Sect. 10.6):

–– Responsibility assigned to the employees

–– Performance appraisal
–– Pleasant and trusting work environment
–– Reliability in the hospital and the different departments
–– Open and trusting working relationship with one another

The following examples of key indicators can be used for measuring staff
satisfaction:

–– Average sick leave

–– Willingness to work (unpaid) overtime
–– Number of applicants by whom the hospital was recommended by staff members
–– Willingness to take on tasks that are beyond normal work routine (e.g., participa-
tion in student teaching and supervision).

Lagging Indicator – Staff Loyalty  A high degree of staff loyalty can contribute to
the success of a hospital for various reasons:

–– The training of new employees is costly and does not render a ‘return on invest-
ment’ if the employee is going to leave the hospital after a short time.
–– Every employee gains knowledge and experience while working at the hospital,
which will be lost when they leave the hospital.

The following key indicators can be used for determining staff satisfaction:

–– Average affiliation with the hospital in years

–– Resignation rate
–– Number of absentees and days absent
7.8 Learning and Growth Perspective 155

However, there is a potential risk when the long term affiliation of employees is put
in the centre of hospital strategy. In spite of long affiliation with one organisation,
employees should be able to repeatedly face new and changing tasks. A regular influx
of new staff from other health care providers must be the goal to maintain the competi-
tiveness of a hospital and the enthusiasm for innovation. Vacant positions should be
promoted in an official process and filled preferably with external candidates.

Lagging Indicator – Staff Productivity  The productivity of staff members

depends on their job satisfaction: on whether their abilities match their present posi-
tion and whether their work is appreciated. The following key indicators can be
applied:

–– Number of patients
–– Rate of regress claims, complaints and ‘critical incidence reporting system’
reports. (Caution: the reports may decrease if staff feel that their reports do not
add value. They will then save themselves the effort of posting a report.)
–– Additional qualifications that serve the completion of a task
–– Number of consultants and HoDs cooperating with other health care providers,
such as hospitals, doctors in private practice, day hospitals, treatment centres

Leading Indicators of the Learning and Growth Perspective

Leading indicator – staff training. The training level of staff is a typical early indi-
cator. If the expertise of staff increases, they must be given the opportunity to apply
their new knowledge. It is necessary to plan training courses: these should be varied,
for instance, compulsory specialised courses, and to evaluate if that serve mainly the
general interest of the staff or are in the interest of the hospital. For a hospital that
wants to further position itself in the market it is vital to continually improve the
qualifications of its employees. Key indicators for staff training, such as the total
number of training events can hardly be linked to tangible success in the short term.
Only in the long run will newly gained knowledge contribute to a hospital’s success.
Leading indicator – staff motivation. Besides being satisfied with their current
work task, employees must identify themselves with the hospital’s goals and strategy to
further improve results. The following measures could be applied for staff motivation:

–– Centre (e.g., innovation hub) that allows staff to contribute to the hospital
development
–– Possibility for teamwork
–– Hospital management that attends to the needs and demands of the staff

Possible performance indicator could be:

–– Suggestions for improvement per employee

–– Payment of incentives for improvement suggestions and implementations
–– Number of suggestions submitted by a team
–– Implementation of improvements (e.g., measured via paid incentives)
156 7  Develop and Communicate Your Strategy

Table 7.3  Examples of the implementation of goals from the learning and growth perspective
Key performance Target
Objectives indicators parameters Measures/initiatives
Increased staff Number of training 3 per staff Continuous qualification; targeted
competency units per staff member training programmes
member
Increased rate of New service and 25 % Improved website and communication
innovations treatment offers with private doctors via social media
Increased staff Rate of 3 % Mentoring programme, incentives
motivation resignations

Informal infrastructure: using information technologies such as the internet,

intranet or the hospital’s in-house software solutions is indispensable. But how is it
possible to ascertain whether these technologies are, in fact, being used? Key per-
formance indicators for the usage of these technologies could be the following:

–– Percentage of software solutions and apps used

–– Accessibility of available data or evaluations
–– Number of IT usage hours by management and employees

Availability of medical/management reports. The implementation of goals, i.e.,

objectives, key indicators, target values, and measures, could be described as
depicted in Table 7.3.

7.9 Case Report on the Application of the BSC

Rochester Heights (RH) is a large regional general hospital. Like many hospitals in
the neighbourhood, RH is facing the following problems:

–– Proximity of several competitors

–– Low bed occupancy rate
–– Low financial revenue
–– Unmotivated staff, shortage of skills
–– Duration of stay too long

To tackle these issues, RH develops the following mission: ‘Personalised patient

centred care providing a high satisfaction level’.
Rochester Heights follows the vision ‘what we want to achieve in future’: ‘We
want to raise the rate of private patients to 30 %.’
Consequently RH promotes the following strategies:

–– High degree of patient satisfaction

–– Highest degree of patient centredness in the market
–– Short waiting periods before admission
–– Vision: In 3 years we are the major regional provider serving private patient.
7.9 Case Report on the Application of the BSC 157

Financial perspective Significant

increase of the
operating results

Build up a
Revenue
competitive cost
leadership
structure

New treatment Attractive pricevalue

Reliability
offers relationship

Patient and Referrer

perspective

Internal business
process
perspective Increase and
Shortening of the
Expansion of the
treatment
treatment offers and
processes
knowledge

Growth and
learning perspective

Improve the staff Improve the Increase the staff

qualification growth potential motivation

Fig. 7.15  Strategy map of Rochester Heights

In several workshops the executive management developed a strategy map

(cause–effect chain; Fig. 7.15).
Based on these results RH decides to outsource the treatment services for private
patients as an independent hospital branch and calls it ‘Health Center of Excellence
Rochester Heights’.
The executive hospital management looks for an investor in the market and
approached the neighbouring headquarters of the car company Mobi-De. The vision
and implementation for a Health Centre of Excellence are presented there: the staff
of Mobi-De will receive improved medical care. The hospital management prom-
ises fast treatment processes, individualised care, enhanced recovery time through
combined medical services, and optimized support by cooperating with colleagues
158 7  Develop and Communicate Your Strategy

Table 7.4  Sample case: Rochester Heights

Key performance
Objectives indicators Target parameter Measures/initiatives
Financial Increased Turnover of Annual increase Financial cooperation
perspective profits patients of 15 % with Mobi-De
Perspective High Satisfaction Annual increase Use of software and
of patient reliability index of 20 % marketing programmes
and Waiting time Online tools Granting Interfaces and online
referring requested tools
doctors appointments
increased by 15 %
Internal New services Time first to 100 days Marketing by hospital
business market management. Improved
process implementation
perspective Number of Turnover of 30 % Marketing measures
private private patients
patients
Learning Staff Number of 3 per staff Continuous qualification
and growth competence training units per member process.
perspective staff member Targeted training
programmes
Service Greater client 25 % Targeted training of staff
competence satisfaction,
lower rate of
complaints
Staff Reduced 3 % Mentoring programme
motivation absenteeism and
resignation rate

in private practise. Financial support and the profit share are agreed upon. As a long
time result, the hospital increases the number of private patients and could achieve
the set goals. The goals, key indicators, and measures are displayed in Table 7.4.
Through staff training and scheduled implementation of the new vision and busi-
ness goals, the Center of Excellence RH is able to establish itself in collaboration with
its stake- and shareholders in a niche market as well as to provide improved service
provisions. By creating new income resources, the financial revenue improves so that
future-orientated capital investments can be made throughout the year. As a result, not
only the private hospital, but also RH gains a better financial revenue.

7.10 P
 roblems in the Development and 
Implementation of BSC

We want to briefly address various problems in the development and implemen-

tation of the BSC. The BSC carries the risk of implementing wrong or unrealistic
goals. However, even ‘bad’ strategies can be managed professionally.
7.11 Summary 159

Furthermore, a BSC can be overloaded with too many objectives that are too
complex. If the BSC is developed too superficially, a one-sided focus on key
indicators, particularly on lagging performance indicators, can result. When this
happens the intention of the BSC to align actions to strategic goals and the sus-
tainable future development of potentials is lost. If you attend mainly to key
indicators, an unbalanced ‘optimisation’ of key indicators can take place – espe-
cially if remuneration or incentives are linked to the fulfilment of key indicators.
Therefore, the individual targets must be balanced, to avoid undesirable effects.
If a hospital strategy is implemented by applying the BSC, it is necessary to
monitor compliance with the relevant key indicator to ensure long-term accep-
tance. However, you cannot always hold people accountable for every deviation
that occurs. Particularly, in cases of external interventions such as the implementa-
tion of top-down saving measures in the health system, the reason for departing
from the plan cannot be placed with the person responsible for key indicators.
Thus, it is a fundamental principle that ‘responsible for’ and ‘not responsible for’
deviations from the plan are clearly separated. The best chance of achieving this is
to explore risks related to a specific target figure when the BSC is being developed.
Precisely these risks should clearly describe a ‘not responsible for’ deviation from
a planned and expected value. By using this approach, strategic management and
risk management are integrated and the efficiency and logical consistency of both
systems can increase.

7.11 Summary

The control and definition of key performance indicators are an important part of,
but should not be the major focus of, business decisions made by a hospital’s man-
agement. Key performance indicators play a central part in the hospital’s concept.
If the focus rests only on financial key indicators, the bigger picture gets lost. The
balanced scorecard is a holistic management approach that provides a key indicator
system of non fi­ nancial and financial perspectives for the monitoring process. It
serves to ensure the consistent alignment of actions, processes, and measures
within a team/organisation (hospital, departments, project groups, etc.) to a com-
mon goal. In contrast to the classical key data systems, the BSC also focuses the
attention on non-financial indicators via the assumed interrelationship of the
cause–effect links. By means of the BSC, the different perspectives are analysed
and help to establish competitive advantages for a hospital so that the various key
indicators and measures can be aligned to it. Apart from the classic financial key
indicators, the BSC includes referring doctors, patients, treatment processes, and
staff. Relevant key indicators must be defined for each of them. Consequently, the
hospital can be developed in such a way that the strategic objectives for all four
perspectives may be reached in a balanced manner. Unlike guiding principles and
other fuzzy formulations, the BSC enables that measurable goals can be
implemented.
160 7  Develop and Communicate Your Strategy

7.12 Five Reflective Questions for Practical Application

1. What is the strategy of your hospital or department? Outline your 1-, 2-, 5-year
plans.
2. Why do you regard the BSC as useful/not useful for your hospital or

department?
3. Which areas can you envision implementing a BSC?
4. Can you apply the pyramid depicted in Fig. 7.1 to your hospital or department?
5. What resources and which people would you need to realise your mission?

References and Further Reading

Banker RD, Chang H, Pizzini MJ (2004) The balanced scorecard: judgmental effects of perfor-
mance measures linked to strategy. Account Rev 79(1):1–23
Kaplan RS (2001) Strategic performance measurement and management in non-profit organiza-
tions. Nonprofit Manage Lead 11(3):353–370, Jossey & Bass
Kaplan RS, Norton DP (1996) Using the balanced scorecard as a strategic management system.
Harv Bus Rev 1–2:75–85
Stewart LJ, Bestor WE (2000) Applying a balanced scorecard to health care organisations. J Corp
Account Finance 11(3):75–82
Zelman W, Pink GH, Matthias CB (2003) Use of balanced score card at health care. J Health Care
Finance 29(4):1
Find the Best Staff and Develop
Their Skills 8

Goals
–– Which fundamental changes have taken place in hospitals over the last
decade?
–– Why structured staff development is important for hospitals?
–– What are the typical features of characters you can find in hospital?
–– What is the ideal composition of a team? What would be the ideal fit for a
team composition?

This chapter gives you guidance on how to achieve a highly competitive team.
It depicts how to engage in continuous staff development and highlights key
characteristics of clinicians and managers. An outline of leadership is given in
addition to characteristics of team bonding and how to achieve it.

8.1 The Future Starts Yesterday

Learn from yesterday, live for today, hope for tomorrow. (Albert Einstein)

Thirty years ago there were sufficient nurses and doctors available on the market.
Apart from a few leadership positions, regional hospitals mainly recruited local
staff. Most of the employees would already have known the hospital for many years,
and had possibly been born there. They and their families had some good and some-
times not so good encounters with the hospital. The hospital was part of the local
community and people went there whenever they needed hospital treatment. At that
time, the hospital had no website on the Internet and quality assessments of hospi-
tals or doctors did not yet exist. Economic aspects played a minor part because most
hospitals were financially supported by the community, province or church. Deficits

© Springer Berlin Heidelberg 2017 161

E. Weimann, P. Weimann, High Performance in Hospital Management,
DOI 10.1007/978-3-662-49660-2_8
162 8  Find the Best Staff and Develop Their Skills

were mostly balanced by the public sector. If a family member had to stay longer in
hospital because there was no-one at home who could care for them, the ward doc-
tor would extend the stay. If the referring doctor wanted to have a patient observed
in hospital because he could not classify the disease, this was often not a problem.
The regional hospital dealt with routine cases; complicated cases were referred to a
tertiary centre for further diagnosis and treatment.
This was before financial measures such as diagnosis-related groups (DRGs)
were implemented. Now, there are treatment splits if patients have to be transferred
to another hospital, fees are reduced if patients have to be readmitted within a cer-
tain time period. For every disease, there is a maximum length of stay and fixed
treatment costs. Hospital treatments are seen as unnecessary referrals if the patient
could have been treated more cheaply in an outpatient department or primary/sec-
ondary health care facility. In such a case, hospitals are not reimbursed for the treat-
ment they provide. For a sustainable financial situation, hospitals should treat a
broader variety of cases and be able to look after complex cases as well to achieve
a high case mix index. Treatments and diseases have become more complex and
patient co-morbidities have increased. Often, capacity limitations prevent the trans-
fer of patients to another c­ entre. Referring doctors prefer to have their patients
treated at the place of residence rather than in a distant hospital that the referring
doctor and family members are not familiar with. Many complicated cases that were
transferred to other centres in the past are now dealt with in the regional or local
hospital. Referrals are handled differently depending on the country; national com-
petence centres might exist only in some m ­ etropolitan areas, and patients need a
referral from a primary or secondary centre (‘gate keeper’) to be treated there (‘pri-
mary, secondary, tertiary care’).
Improved treatment results and increased life expectancy have consequences: life
expectancy after cancer treatment has improved, although admittedly the long-term
side effects of radio- and chemotherapy have increased; babies can survive from the
24th week of pregnancy, although often with severe long-term effects; angiograms,
bypass surgery and joint replacements are routinely done in many hospitals. This high-
lights the fact that the demands on doctors and nursing staff have increased consider-
ably. A hospital needs well-trained and highly motivated staff to deal with the new
demands and the market-orientated service delivery (Coomber and Barnball 2007).
All these improvements necessitate equipment, expertise and staffing. In hospitals,
personnel costs account for at least 60 % of the budget. If a hospital wants to save
money, the quickest way to do this is to reduce the staff. And yet staff remains the most
important basis for a competent, patient-orientated and economically run hospital.
On a first impression, patients will be impressed by contemporary standards in
the health care facility. A hospital can always impress with these. But given time to
observe more deeply, patients will notice that there are more important matters than
an impressive entrance hall and comfortable one-bed wards. Service delivery relies
on people. Empathetic and patient-orientated staff is crucial, even if some executive
hospital managers still like to reiterate that everyone is replaceable and that one
person is as good as another. How a successor works is a different matter and will
only be evident after some time. This is illustrated in the following case example.
8.2  Successful Hospitals Through Continuous Staff Development 163

Case Study
The new HoD restructures the neurological department and within 3 years it
develops strategically well. The occupancy and revenue figures improve sig-
nificantly over time. Through a high standard of treatment and service deliv-
ery more referring doctors and patients are attracted by his department. The
various insurance companies could have been convinced to increase their
reimbursements for service delivery and the overall budget allocation. When
the consultant approaches executive management requesting an increase in
the staff in proportion to the increased services, they deny this request. An
external consulting company that the CEO approaches states that no addi-
tional staff is needed. The HoD is told that further expansion of services is not
necessary. A few months later the HoD hands in his resignation as he has
received another, more rewarding job offer. His successor is a previous senior
registrar of the hospital who became a consultant in another hospital. Three
years later only a small part of the previous range of treatments remains. The
referring doctors now increasingly use other competing hospitals so that the
number of treatments and the revenue figures have significantly declined.

8.2  uccessful Hospitals Through Continuous

S
Staff Development
Train people well enough so that they can leave, treat them well enough so that they don’t
want to. (Richard Branson)

In contrast to medium-sized and large companies, staff development in hospitals

has, in the past, played only a minor role. However, concepts such as appreciation
or staff planning have gained in importance over the last few years. Initially, this
took place in nursing care, and was caused by the health care crisis, which led to
more attractive working and development conditions being created for nursing
staff (Willis-Shattuck et al. 2008). Furthermore, nurses are often part of the hos-
pital’s executive management board and have a say in the decision making pro-
cess. In many hospitals nurses are offered various hospital-related development
programmes that are financially supported.
Many doctors leave the daily hospital routine for new areas or foreign countries.
One of the underlying reasons are the changes in the job description that overload
them with bureaucracy. In addition, life priorities have changed. Compared with the
past, the life focus is no longer solely on “being a doctor” rather, family and leisure
activities take precedence (known as a Generation X characteristic). This is fre-
quently equated with the so-called ‘feminisation’ of medicine, although the concept
of ‘family-friendly work environment’ (‘combining family and professional tasks’)
would describe the trend better. There are increasingly more mothers working full-
time and fathers who stay at home to look after the children. Fathers also work less
164 8  Find the Best Staff and Develop Their Skills

so as to have more time for their families. This is a trend that has to be taken into
account together with the current emphasis on ‘work–life balance’.
Increasingly, there are fewer medical specialists available for direct patient care.
Hence, the competition among hospitals for well-trained and experienced doctors
that started some time ago. When choosing a position, doctors want to know what
professional and social development opportunities are available (working atmo-
sphere, work load and duties, roster, leadership quality of HoD and executive hos-
pital management). Employers who are quick to dismiss staff are increasingly
avoided. Hospitals in unattractive or rural locations have to be especially commit-
ted and should offer applicants development opportunities with good social inte-
gration (i.e., nursery schools or child care facilities, search for employment for the
spouse or life partner, housing, etc.), regular feed-back discussions (Sect. 5.11),
accessibility and empathy of superiors (Chap. 10), review meetings and options for
further development that are discussed regularly with superiors. Such opportuni-
ties should be part of the standardised development and support programme of a
well-run hospital.
The hospital management should also be prepared to reflect on itself and conduct
surveys on a regular basis as to how the staff sees their job. This would help to evalu-
ate the potential for improvement and development (Willis-Shattuck et al. 2008).
You will be surprised at the quality of the innovative ideas that staff members can
produce when their opinion is consulted. Consequently, ideas must be followed up.
Interns, registrars and nurses often come up with practical suggestions, which then
ought to be implemented if you do not want to stop this flow of ideas in the future.
As far back as 1949, Ferdinand Drucker, a famous US economist of European
origin and pioneer of modern management science, said:
Any institution has to be organised so as to bring out the talent and capabilities within the
organisation; to encourage men to take initiative, give them a chance to show what they can
do, and a scope within which to grow. (Ferdinand Drucker)

8.3 How Do You Experience Your Working Environment?

It is a well known fact that motivated and committed staff thrive in an open-minded,
appreciative working environment. Hospitals conduct regular staff surveys, but it is
rare that a hospital is so transparent that these results are published in detail, for
instance on the intranet. Surveys are seldom used to initiate specific changes and as
a result valuable potential is wasted.
Engage in a brief survey on how the current working environment, in your
department is experienced. Don’t be afraid of the results! Take it as advice that will
enable you to analyse how to implement potential changes. A further step could be
to work out suggestions for change and then implement them. In this way, you can
assess which further steps are necessary for effecting changes.
You could use the brief questionnaire shown in Table 8.1. This provides a reason
to focus on special areas more intensively. Use it as orientation for recognising
problem areas.
8.4  Which Staff Fits Your Hospital? 165

Table 8.1  Brief questionnaire on the working atmosphere

Does not
Correct Neutral apply
General questions about the working atmosphere
Staff enjoys working in our hospital/department
Each staff member has a say in the hospital processes and
his suggestions are heard, considered and, if possible,
implemented
Questions about colleagues
The working atmosphere appreciates each staff member
If someone experiences problems, there are colleagues
around prepared to help
We work in superficial politeness
Everyone can openly state his opinion without having to
be afraid of negative consequences
Questions regarding supervisors
The mood in the hospital/department is independent of the
mood of the superior
Good work is appreciated by my superior, the HoD,
the CEO
Our superiors respond to our concerns, problems and
complaints
The superiors know how to create an environment in
which everyone can reach their true potential
Questions regarding the hospital/organisation
Tasks are allocated according to the abilities and potential
of staff
In our organisation the different departments work
together in an open and transparent way
The units/departments concerned adhere to the agreements
We often have to do additional work and work overtime
Questions regarding communication and having a say
We are informed about important matters in our
department/hospital
The hospital management considers staff ideas and
suggestions on a regular basis
The information we get is often contradictory

8.4 Which Staff Fits Your Hospital?

When analysing staffing, it has been observed that frequently staff members are not
positioned according to their abilities and talents. In staff planning, the ability of
employees should get the highest priority. However, it may happen that a candidate
is suitable for a position, but his working style differs to other team members. When
he challenges existing processes to improve them, he must be supported by
166 8  Find the Best Staff and Develop Their Skills

executive management. Simply having worked at the hospital for many years cannot
be the crucial deciding factor for the next career step. New employees should be
selected in accordance with the hospital’s objectives; although they might clash in
the case of long-standing employees, who resist change and refuse to act in line with
the new strategic goal of the hospital. The supervisor has the responsibility of ana-
lysing in advance which objectives are being pursued and of supporting the staff
according to their abilities and plans. When career advancement is discussed at the
regular evaluation session, the employees need to be adequately prepared if they are
meant to take on a new role, rather than being put into their new position with the
encouraging words: ‘You’ll manage’, and a pat on the back.
In summary, the three following issues must be analysed in advance:

–– What are the long-term goals for the department/hospital? Are we aiming to
continue with minor changes or are we aiming at a major change in direction?
–– Which types of employees and which head would be best suited?
–– Which leadership qualities do we need if we want to change and restructure the
department/hospital? What support will the new consultant or head of depart-
ment receive from the executive hospital management, or other superiors?
–– How can we best reach our goals?

There are various approaches to recruiting personnel. An external human

resources consultant may be employed. Based on his/her expertise, the hospital
would then rely on his/her making the right decisions. Often, the consultant will
make decisions according to the requirements the hospital has formulated, even
although he/she does not possess all the relevant details. Assessment sessions would
be organised for executive positions.
Another approach to recruiting staff is to apply a detailed job description that
includes evaluating and ranking criteria based on the job’s requirements. The appli-
cants are evaluated according to their submitted documents and a personal inter-
view. These results are transferred to a spider’s web (Fig. 8.1). The diagram depicts
a job profile for a post: the candidate’s attributes are marked in the solid line with
the ideal required profile traced by the dotted line. In the given example, the appli-
cant has a high degree of patient-orientation, professional expertise, social compe-
tence and networking capability as well as good networking abilities. In the areas of
leadership and organisational competence he/she is less qualified. The spider’s web
highlights the gap between the job profile and the applicant’s qualifications. Very
seldom is complete conformity reached. Initially the priorities of the department
and hospital must be identified. Furthermore, the composition of the selection com-
mittee has to be determined. It may be appropriate for the person who has the
responsibility to make the final decision. In most cases, this would be the hierarchi-
cal superior. Selection committees must be a well-balanced and neutral, but this
should not obscure the fact that agreements and block decisions can happen during
the selection process. Be aware that bias will always be present in the process.
As the institution’s requirements and those of personal development change,
measures for further personnel development should be carried out periodically.
A hospital needs staff with diverse character traits. Characters can be divided
into the following main groups:
8.4  Which Staff Fits Your Hospital? 167

Medical/Professional
competence
5

Behaviour towards other 4 Patient

stakeholder centeredness
3

Networking Social
capability 5 1 2 3 4 5 competence
4 3 2 1

Leadership
Management competence
competence

Economical
competence

Fig. 8.1  Example of a possible job profile

Doers (‘What new thing can I implement today?’)

Compliers (‘I complete all tasks that I am asked to do without asking’)
Enthusiasts (‘Striving for excellence’)
Opposers (‘Nothing happens here without my say-so!’)

Successful hospitals and departments have a good balance of the different char-
acter groups. However, it is mandatory to attract staff that a hospital can choose its
ideal candidate from amongst several applicants.
The most obvious mistakes are often made in the beginning of the selection pro-
cess. Either the job profile was outlined in the wrong way, the hospital focuses on
the wrong targets or the staff member has other expectations when he/she joines the
hospital, which are not fulfilled in the long run. The basic trust between employer
and employee is also created in the beginning of an employment relationship. If one
side hears that the working conditions are significantly different from what was
indicated at first or major problems were not mentioned, this inevitably causes a loss
of trust. At a later stage corrections are very costly and emotionally difficult.
It is seldom possible for future staff members to get a reliable view of the hospi-
tal, the duties and the existing problems before starting in a new organisation.
Existing problems are rarely mentioned openly by the future employer and solu-
tions and support seldom offered. Both sides should aim for mutual frankness.
168 8  Find the Best Staff and Develop Their Skills

Case Study
An applicant for an executive position is sitting in the reception area of the
hospital management, where his interview is to take place. It is already 5 p.m.
He has previously received an e-mail from the personal assistant of the CEO,
telling him to take a seat in the waiting area when he arrives and he will be
called when it is his turn. When he arrives, the area is deserted, there is no-one
to speak to, all doors are closed. After half an hour he starts to feel increas-
ingly uneasy. Suddenly voices in one of the rooms are raised, then they calm
down. A man emerges from a door and leaves without looking up. Ten min-
utes later a gentleman who, he recognizes, is the CEO, exits through the same
door and approaches the applicant, whom he greets in a friendly manner. ‘We
had a business meeting, which, unfortunately, took longer than anticipated
and the secretary has already left.’ Although their subsequent meeting and
interview are very positive and he is offered the post, he does not accept it
because he feels warned by an indefinable gut feeling. Two years later he
hears that the executive who was subsequently chosen has resigned because
of the tense work climate.
Conclusion: The nature of the work climate is often picked up by outsiders
through subtle gestures and remarks. Frequently, it becomes evident in the
appreciation shown to individuals.

It would be ideal to apply a reciprocal information policy in the job application

process. Not only the applicants should be obliged to answer questions and hand in
references, but the employer also should reveal important information, as a sign of
transparency and openness. The top applicants could, for instance, be given the
opportunity of obtaining unvarnished information from the future employer and be
entitled to spend a day observing behaviour there. Current problems and difficulties
could then be discussed. In this way, the applicant is given the opportunity to evalu-
ate whether s/he is willing to cope with these problems and whether s/he wants to
enter a potential conflict environment at all. However, being honest with each other
by putting the cards on the table requires mutual trust on both sides. Mutual confi-
dentiality about the obtained information is mandatory in this situation.

8.5 Various Types of Employees

A team is composed of a group of people who will, typically, manifest a variety of char-
acteristics. You need a good team mix to develop a hospital/department strategically well.
A job interview must consider how a particular applicant would fit in with the current
team or whether the applicant is the right person to head for new shores. Too many ‘keep-
ers’, ‘opposers’ and ‘rationals’ can counteract any change in the hospital. It is just as
potentially contentious if a new colleague who is creative, innovative and autonomous
8.5  Various Types of Employees 169

should be placed in a long-standing, well attuned team. After a thorough analysis of the
current situation, certain characters should be placed in other areas so that the hospital can
thrive according to its strategy. Inter alia, there are the following types of personalities:

–– The keeper prefers to continue using functions and structures that support him/
her. S/He sees her/himself as traditional, conscious of values, and often has been
working in the hospital for a long time. S/He will only pursue innovations after
having been convinced of the advantages in many detailed discussions. If you
want to initiate a renewal process, it is best to get keepers on board by giving
them their own project. They respond well to being helped to believe that they
are basically implementing their own ideas.
–– The opposer is critical of everything and everyone. If a project is being imple-
mented after a majority decision, it is the opposer who, at the last minute, can
still make the project fail. Opposers are often employees who function as ‘old
bulls’ or ‘grey eminences’. Opposers, too, should be part of the process from the
beginning and their personality should, ideally, be presented as innovative, that
is, reframed as such.
–– The helpers will, self-sacrificially, support wherever possible and the help they are
able to provide is needed. If no-one can be found for a weekend duty or if patients
come too late to a pre-surgery discussion and as a result overtime must be worked,
helpers will typically step in. This will be done with moaning and complaints of
their kindness being exploited. Helpers are stop-gaps in unexpectedly tight spots
that crop up during daily work. Support them with appreciation and compensate
them with incentives such as bonuses and congress attendance.
–– The innovative and creative members of staff are always prepared to take up and
implement the newest research outcomes or congress innovations. Seldom do
they accept a verdict of ‘later’ or ‘impossible’. They make the ideal partner for
new projects, the introduction of new therapies or new treatment methods.
–– The autonomous members need their own tasks and decision-making areas and
love working independently. If direction and control from others or superiors are
too tight they will experience this as an intrusion and having had a loss of com-
petency. Placed in an appropriate position, however, they are able strategically,
and successfully, to develop a hospital or a department.
–– The rational members wish to harmonise their professional and leisure activities.
Whatever does not bring them any advantage, will not excite their interest and a
response can hardly be expected of them.
–– The social members live in a group and are carried and validated by the group. If
birthday presents have to be bought, signatures collected or holidays organised they
are always very happy to comply. They are important for the social cohesion of a team.

If a hospital wants to move in a new direction it must be possible to restructure,

reorganise and mix old and new staff members. If new, innovative employees who
want to develop a department meet up with members of staff who have been
employed there for many years and who see their task as defending their vested
rights, conflict is likely.
170 8  Find the Best Staff and Develop Their Skills

Case Study
Mrs Mutius was frequently quoted by Professor Sanders as one of his
unwanted legacies. She was close to retirement and vehemently defended,
tooth and claw, the accumulated and personal privileges she had attained over
decades. With the exception of intermittent and brief frictions that arose from
time to time, even the confrontational Sanders dared not approach her. If there
was an acute problem, as would arise particularly with younger colleagues
who resented her imperious and know-it all kind manner, Sanders would
respond, usually smugly: ‘The problem Mutius can only be resolved with
time.’ He would then point to her close retirement (Mann 2006, p. 46).

8.6 Various Characteristics in Executive Positions

An analysis of the types of leaders and their likely behaviour in with staff members
can help to identify the potential for possible conflict and can act as guide to possi-
ble solutions. For instance, a new, innovative HoD is allocated a conservative con-
sultant as his deputy. This arrangement has a high potential for conflict. The
following list of stereotypes and their characteristics serves as a rough guide:

–– The autocrat: he is an executive of the old school. Where he appears, he expects

due respect as well as patience with his notions of time. He accepts no contradic-
tion and is used to shouting his demands. What he says is law. His type is fre-
quently encountered in surgical disciplines.
–– The slob: without his able secretary, who protects him, as well as a consultant,
who deputises for him, things would get out of hand. He is always impressive in
his specialisation and detailed knowledge. Matters of operational hospital rou-
tine are of less priority for him.
–– The fully committed: he runs from appointment to appointment, but is always
late. In meetings he works on his smartphone and sends out SMS messages or
e-mails. However, he does not always apply himself to matters with the neces-
sary focus. If one could check his diary, one would be surprised to see that this is
not as full as he usually claims.
–– The conservative: he acts according to the motto: ‘Never change a running sys-
tem’ and is wary of innovations. He only gets involved when the executive hos-
pital management demands it for him or the smell of the burning roof can no
longer be ignored (Sect. 6.3). He does not make decisions quickly and prefers to
delay making them. His colleagues seldom hear a clear ‘yes’ or ‘no’, but rather
‘perhaps’, ‘one could’ or ‘let’s see’.
–– The powerful type: He is a key player, gatekeeper and member of important com-
mittees. All relevant information is concentrated in him. No-one gets past him.
In order to gain more power, he is prepared to use unconventional ways, leave
official channels behind and is prepared to accept unorthodox solutions to reach
8.7  Stages of Team Development 171

his goals. He is happiest when he can juggle all balls at once. He receives much
recognition by virtue of the fact that nothing would work without him. He will
do anything to gain more power.
–– The complier: He fulfils everyone’s wishes and complies with everybody (the
laissez-faire style of leadership). For leadership tasks, he needs a representa-
tive as a grey eminence who will keep the team together. He appears selflessly
devoted to hospital matters but creates generously free spaces for his own
interests.
–– The reliable type: He seems to have read all available management books and
applies them in everyday life. If you have made an agreement with him you can
rely on him implementing it. However, he also assumes such reliability in his
colleagues and is very disappointed when this is not the case. Power people
occasionally play him off, especially if they use unexpected ways of doing
things.

The above-mentioned character sketches are slightly exaggerated to highlight

typical characteristics. Obviously, there are numbers of combinations.

8.7 Stages of Team Development

The various conditions of team adherence are described by the words ‘­ individualized
teams – next to each other’, ‘team spirit – better together’ and ‘brotherhood – one
for another’. They describe the values of team spirit, to active coexistence, and of
coping with one another.
The first phase in team-building has the members merely being next to each other.
The team is characterized by a polite relationship. Contacts with each other are
reduced to a minimum. There is a certain degree of superficiality. There are hardly
ever any conflicts because the group does not really interact. They are in a state of
tolerant co-existence. Discussions end in the gossip factory. Controversies are
avoided. Occasionally snide and disparaging remarks occur, but generally harmony
is exercised. The energy in the group is rather low, although everyone does what has
to be done. There is much tolerance of other team members. If a team in this stage
were to be judged from the outside, others, especially those on higher hierarchical
levels, would describe them as in a harmonious state. Innovation and change have not
happen for several years. The style of leadership is often one of laissez-faire. Many
departments in hospitals function like this. This situation can also be found in a
department or hospital after a longish period under an acting head.
If a group is more mature, its members enter a state of connection. The members
deal with one another sensibly, keep within boundaries and act in a task-orientated
way. Most of the professional boundaries are known and are mutually accepted.
Communication is a matter-of-fact; personal matters are generally avoided. The
energy in the group is average, everyone does what is necessary. Relationships at
work are organised in such a way that everyone can work largely undisturbed in his
field; clear rules exist regarding interfaces. Groups in this condition are managed.
172 8  Find the Best Staff and Develop Their Skills

Such teams can be found in departments and hospitals that are well attuned to the
available resources.
The third stage is the commitment to a leader. The members of the group respect
each other professionally and personally. Each one aims at giving and achieving his
best. The energy is high and characterised by motivation and passionate concern for
optimisation and change. The working relations are such that each can give the best
according to the individual strengths. The team redefines itself continuously and it
has a positive attitude to changes. Its members are convinced that the sum of their
individual energies is greater than merely adding them up. Innovative departments
and hospitals fall within this category.

8.8 How Will a Team Become Productive?

Tuckman defines a team as a group of people having the same goal, who are put
work together for a certain period and show mutual responsibility (Tuckman 1965).
Whether a team is productive depends on the mix within the team, the ability of
team members to solve conflicts, the process of team building and leadership.
To develop teams and organisations such as hospitals, goal-orientated personal
development is a necessity. Under these conditions, development, learning and
change processes can thrive. If you want to empower your employees, they must be
willing to act, be entitled to act and be able to act.
To summarise: it would be ideal to analyse ahead of a work relationship what
resources and characteristics exist within a team, what is missing and what is domi-
nant. Furthermore, the hospital’s management should assist to back up new pro-
cesses, and new goals.
In aligning teams, the leaders recruit available colleagues with similar charac-
teristics. A powerful or committed leader probably chooses staff members who are
rational or innovative; others prefer autonomous or socially committed people to
work with. A balanced mix in a hospital/department exists only in an ideal world.
It is more likely that there will be certain groups that will fit in with a larger team.
This aspect is often neglected when executive positions are to be filled. If a hospital
is to continue to run with only slight changes, it is wise to choose someone whose
characteristics suit the existing team. If a hospital is to be restructured from scratch,
a candidate should be chosen who matches the job profile as closely as possible. If
there are economic reasons for aligning the hospital with a new direction, the new
head must have the opportunity of choosing his closest colleagues, such as the
senior doctor and his secretary, himself. These days, even hospitals cannot wait for
years until the one or other person retires before change processes can take place.
The team is either prepared to attempt something entirely new or those on the team
who oppose change might be advised to take up another post.
It is important that new executives not only get verbal, but also active support
from the hospital management. As soon as the first problems and opposition occur,
8.8  How Will a Team Become Productive? 173

Warming-up Storming Norming Performing Adjourning

Fig. 8.2  Team-building process (Tuckman 1965)

the hospital management frequently retracts. But without receiving support from
superiors, the consultant is doomed to fight against windmills. An innovative and
communicative head who is confronted by a group of keepers and opposers, who,
on top of everything else, are supported by management, will not be able to realise
his ideas. Either he looks for a new position and leaves the hospital or he withdraws
to inner isolation and resignation (Chap. 2) and will then also no longer be actively
available to the hospital.
How can you build high performing teams? In the first place, you have to be
entitled to make decisions without constantly checking with your superior. If your
goals are different to your team and you do not have the support and back up of the
hospital management, your chances of success are diminished. The best advice is to
continue as before with slight modifications along the way.
If you as head or consultant have a defined concept and this is backed-up by the
hospital management, you can start the team-building process as follows (Fig. 8.2)
(Tuckman 1965).
There are four phases: the warming-up phase of polite interpersonal relations;
the phase of storming, where polarisation becomes evident and disputes arise; the
norming phase, where new behaviours and manners are regulated; and the per-
forming phase, where the new team has found itself, people value each other and
communicate openly. The aim is to reach the performing phase as soon as
possible.
174 8  Find the Best Staff and Develop Their Skills

Based on the phrase ‘you’ll always meet twice in life’ it is sensible to organise
the parting process in good terms. The following example illustrates how important
proper adjourning really is.

Case Study
The HoD has employed a consultant to become his deputy. After a couple of
months, the senior doctor realises that hardly anything he was promised in the
beginning has actually materialised. He discusses this with his superior in
feed-back sessions. The HoD puts him off taking any serious action, saying
that everything needs time and he shouldn’t lose patience. When nothing
changes in the following months and he sees no action from the HoD indicat-
ing that the situation will change in the near future, he explores the market and
takes up a position in another hospital. When he informs the HoD of his deci-
sion he is accused of a breach of confidence. The HoD relieves him of his
duties forthwith and forbids him to ever enter the hospital again. Staff and
colleagues in the hospital are informed in the evening by circular letter that the
consultant has been relieved of his duties with immediate effect. This behav-
iour astonishes the other colleagues. However, as the consultant was depicted
by the HoD as being a very difficult character, they accept his approach. A few
years later the HoD applies for a post in a larger hospital. He is unpleasantly
surprised to find that his former deputy is a member of the executive manage-
ment of the hospital.
Conclusion: An amicable adjourning process could have facilitated their
next meeting with very different feelings.

In a team-building process, the team must be made aware on a regular basis of

the pursued overarching goal.
Based on the South African Mont Fleur Scenario that took place between 1991
and 1992 (http://futuristablog.com/the-mont-fleur-scenarios) the following condi-
tions can also be applied in health care setting:

–– Ostrich strategy: burying your head in the sand. Power and privilege remain
unchanged. Problems and areas of conflict are ignored.
–– Lame duck: although every opinion is considered and complied with, no-one is
satisfied.
–– Icarus: money is spent hand over fist – until all crash together.
–– The flight of the flamingos: the entire team heads for new shores and rises above
all that is established and no longer up to date.

Many people have experienced burying one’s head in the sand and the lame duck
attitude in their everyday work and will encounter it in other departments and hospitals.
It mirrors our health services: large sums are paid to the health system by tax payers,
employers, employees, the state and every individual. In spite of this, we often do not
References and Further Reading 175

get the quality of care comparable to the economic input. To balance this out is one of
the great challenges of our time.
Occasionally, someone aspires to the flight of the flamingos for his department
or hospital, but it is a rare feat to achieve. If success is too striking and the attention
paid becomes unbearable for others, there is always the danger of an opponent or
another powerful rival wanting to shoot the flying flamingos down. In a leadership
position there is no time and leisure for relaxing and resting.

8.9 Summary

An important prerequisite for becoming a high achieving hospital is to choose mem-

bers of staff who are committed to the hospital, the patients and public welfare
rather than merely to their own interests. Another requirement is to place staff into
the correct positions according to their abilities. The executive hospital manage-
ment should be aware of the goals and strategies, and choose the staff according to
the resultant requirements. Members of staff and their expertise remain the most
important assets of a hospital. Continuous staff development is an important func-
tion of successful hospital management. The ideal composition of the team and the
deployment of employees in the right position and workplace to match their abilities
and expertise are crucial for the success of a hospital.

8.10 Five Reflective Questions for Practical Application

1. What percentage of staff in your hospital/department has working experience

with one or two other employers?
2. Do you possess a structured programme for promoting and developing your staff?
3. Do you regularly carry out review meetings where your employees are able to
formulate their wishes and career goals?
4. How do you characterise your colleagues in terms of the composition of the
team? Have you found the ideal staff mix? If not, how could you achieve this?
5. What type of bonding exists between members of your team? Is it a bond of
politeness, process or of authority?

References and Further Reading

Coomber B, Barnball KL (2007) Impact of job satisfaction components on intent to leave and
turnover for hospital based nurses: a review of the research literature. Int J Nurs Stud
44(2):297–314
Gordon T (1955) Group centred leadership. The Riverside Press, Cambridge, MA
Mann C (2006) The hospital myth – disenchantment. Amazon KDP, Seattle
Tuckman BW (1965) Developmental sequences in small groups. Psychol Bull 63:384–399
Willis-Shattuck M, Bidwell P, Thomas S, Wyness L, Blaauw D, Ditlopo (2008) Motivation and
retention of health workers in developing countries: a systematic review. BMC Health Serv Res
8:247
Manage Your Conflicts Professionally
9

Goals
–– Why is a positive attitude towards a conflict resolution culture good for a
hospital?
–– Why does a hospital need an internal dispute culture?
–– Why should you avoid discussions in the drama triangle?
–– What are the golden rules for conducting conflict resolution?
This chapter introduces you to the various steps of professional conflict man-
agement and advises you when to intervene in a conflict. We highlight the differ-
ent escalating levels and encourage you to establish a constructive atmosphere of
debate. An analysis and solution framework for conflicts is described, in addition
to the golden rules of negotiation.

Large and medium-sized businesses are increasingly realising the necessity of man-
aging conflicts professionally, as they are part of everyday work life (‘you can’t
make an omelette without breaking some eggs’). On the contrary, in most hospitals
conflicts are often ‘solved’ by gut feeling in the course of daily management and are
frequently enhanced by personal power struggles. This often leads to an inner resig-
nation of many employees. Internal warfare brings about energy loss, fronts divide
the hospital, and in the long run the external image is affected. The Case Study
describes a typical example of an escalated conflict.

Case Study
The children’s hospital and its surgical department share one senior registrar.
When the registrar is off duty, he has to be replaced by a registrar from the chil-
dren’s hospital, although their staff pool is very restricted in numbers. One day
during the holiday period several staff members from the children’s hospital

© Springer Berlin Heidelberg 2017 177

E. Weimann, P. Weimann, High Performance in Hospital Management,
DOI 10.1007/978-3-662-49660-2_9
178 9  Manage Your Conflicts Professionally

are on sick leave. The surgeon insists on consistent compliance with the agree-
ment. The head of the children’s hospital, however, decides that in this case
no registrar is able to help out in the surgical outpatient department; since this
will affect the service delivery of the children’s hospital. The surgeon has to
conduct his outpatient clinic on this day without the support of a registrar.
The paediatric surgeon, who is not on the best of terms with his colleague,
approaches the CEO of the hospital and complains that the agreement was
deliberately violated. As a result, the head of the children’s hospital receives a
written warning from the CEO for having arbitrarily overruled the agreement.
Conclusion: A conflict that is basically simple to solve escalates to such a
degree that further constructive co-operation is significantly affected.

The first step towards professional conflict management consists of the insight
that an internal dispute culture is encouraged. Employees and their superiors may
have different opinions and still be in a position to be on good terms later. When
formally contradicting a superior this should not mean having to expect animosity.
Below we take a closer look at the methods of professional conflict management.

9.1 Professional Conflict Management

In the example above we describe a typical conflict situation. Neither of the two
parties could change their point of view in such a way that the requirements of the
other are met. Such conflicts are part of everyday work life. Conflict management
does not suppress conflicts; rather, it shows how they can be managed profession-
ally and ‘routinely’ dealt with. If, however, each conflict is brought straight to ‘the
boss’, who makes gut-feeling decisions about which head has to roll – this cannot
be described as professional conflict management.
By definition, a conflict is a disruption in interpersonal or professional areas.
Conflicts can arise between individuals or within a team and have many causes. For
instance, there are conflicts between high-performance and low-performance group
High

High Low

ts
Divergences of interests

lic
onf
o rc
lf
ia
y

nt
nc

e
te

ot
pe

P
m
co
al
ci
So

Fig. 9.1  Source of conflict

Ressource availability
potential Low
9.2  When Should One Intervene in a Conflict? 179

Table 9.1  Indications for Factual controversy takes place with great intensity
potential conflicts
Formation of groups within the team who do not want to give in
Derogatory remarks or hostile behaviour towards team members
Distrust among staff members
Members of the team do not mention their own ideas and avoid
conflicts

members, power conflicts between senior registrars and the heads of departments,
and conflicts fed by such fuel as contradictory or deficient information, rivalry and
jealousy, conflicts of interests as well as a lack of social competence (Fig. 9.1).
Typical types of conflicts are over objectives, solutions, resources, roles, values
and interpersonal conflicts (De Dreu and Weingart 2003). For instance, role con-
flicts may be based on different role expectations, e.g., that women must behave
subordinately in a patriarchal society. Conflicts may derive from different underly-
ing values and norms between varieties of nationalities, religious groups or even
different organisational values.
Conflicts can arise on a subjective level – especially, if a discrepancy arises
between tasks and personal orientation or there is a refusal to comply with working
methods in the case of specific behaviours – or conflicts may arise on the level of
relationships (e.g., affective conflicts caused by the forming of cliques, or the fight
for power and status). Within the scope of conflict management, it is important to
recognise an arising conflict in due course.
Consider the situation in your team, and tick the applicable points in Table 9.1. In the
next paragraph we shall discuss whether, and when, one should intervene in a conflict.

9.2 When Should One Intervene in a Conflict?

May you have the strength to change what can be changed. May you have the serenity to
accept what cannot be changed. And may you also have the wisdom to recognise the differ-
ence. (Gregory Bateson)

A conflict requires intervention when it becomes necessary in order to prevent dam-

aging results, if, for instance, quality of work or of patient care is suffering or going
to suffer. There is a difference between conflict management and conflict resolution.
Although conflict management does not categorically prevent every conflict, con-
flict resolution implies the reduction, elimination, and termination of conflicts.
Can it be called a matter of success if there are only a few conflicts and these are
solved immediately? Probably not: a positive dispute culture is an important part of
the functioning of an innovative hospital. Proactive conflict management furnishes
the hospital with tools for dealing with conflicts in a positive way; it enables the
hospital to use conflicts as social capital. Furthermore, focused conflict manage-
ment enables learning from the conflict situation and thus contributes to the devel-
opment of a team culture (Amason et al. 1995).
In short, conflicts are valuable for the hospital if they are professionally dealt
with and the hospital teams can learn from them (De Church & Marks 2001). The
value that it can add to the continuous learning process of an organisation is an
essential feature of conflict management.
180 9  Manage Your Conflicts Professionally

So, which conflicts require intervention? On the one hand there are group con-
flicts in a hospital that may interfere with the working atmosphere. But, there are
also interpersonal conflicts where colleagues fail to communicate with each other.
This, too, affects the working environment, but also affects efficient and trusting
patient care. In such cases, you may not ignore the situation if you are responsible
for the staff (‘They’ll sort it out amongst themselves’, ‘That’s a hopeless case’,
‘Let’s just ignore it.’). As one who has as a consultant, HoD, COO or CEO, manage-
rial responsibility, you are directly involved and challenged.
In addition, there are substantive or affective conflicts. If conflicts can be divided
into ‘good’ and ‘bad’ ones, substantive would be seen as ‘good’ and affective as
‘bad’ conflicts.
Substantive conflicts relate to conflicts between team members and can be linked to
topics, but also to quality of work. They could stem from differences in the basic con-
cept of ideas and in convictions held. Substantive conflicts may be assessed as entirely
positive and as a part of the desired organisational conflict culture. Conflict manage-
ment may not be necessary should the conflict remains on the substantive level.
Affective conflicts are the result of interpersonal differences. These differences
may be related to the incompatibility of individual team members (Sect. 8.7). This
type of conflict has damaging effects on the quality of the team and its work. Hence
the task of successful conflict management consists of avoiding staff members’ frus-
tration, withdrawal, indifference and diminished work performance.
What would the first steps be? Ask the individual opponents to suggest possible
solutions, what they expect from the other, and what they are prepared to give. Often
empathetic listening opens the way to problem solutions.

9.3 The Various Stages of Conflict Escalation

Dealing with conflicts professionally is a key qualification for any head of a depart-
ment or executive. It is important for such a managerial figure not only to get to
know what has caused the conflict, but also to engage to resolve the situation. There
are several stages in the escalation of conflict (Fig. 9.2).
An executive must have the ability to realise when conflicts exist, to analyse
them and to resolve them. In order for the relevant steps to be applied, the normal
course of a conflict should be understood. In addition, the necessary competency
and range of action for efficient conflict resolution has to be established. The back-
ing up and support of higher hierarchy levels in the hospital should be brought into
play, depending on the stage of escalation and the type of conflict. You have to act
carefully: group conflicts are frequently used by people to entrench and expand their
own power. If team conflicts are scaled up and taken to the next hierarchical level,
room for manoeuvring could be lost and a further escalation of the conflict could
take place. However, if the upper executive level is constantly approached in cases
of disagreement, the conflict is then being ‘resolved’ only at a higher level. This
scenario does not conform to professional conflict management. Besides, the con-
flict team will not have learnt anything they could apply in future.
9.4  Support the Organisational Dispute Culture 181

• Cooperative efforts with occasional frictions and tensions: a normal process

1.-2. stage
• Polarization and debate already causing disturbances in team

• Actions instead of words: the parties are no longer talking, coordination deficits arise
3.-4. stage
• Concern for reputation, looking for support: the conflict detaches from the initial problem

• Lack of willingness to compromise, struggle to loose the face

The decision is "victory or defeat" "him or me"
5.-6. stage • Threats

• Systematic strikes against the enemy

7.-8. stage
• Targeted attacks on the opponent's nervous system

• Total destruction of the enemy at the cost of self-destruction

9. stage

Fig. 9.2  The various stages of conflict escalation

9.4 Support the Organisational Dispute Culture

All things come into being by conflict of opposites. (Heraclitus)

Some hospitals have a high degree of personnel turnover: instead of managing conflicts
professionally and promoting a culture of dispute, they instead act according to notions
such as: ‘You can’t change people.’ and ‘Those who don’t fit in must leave.’ In such
cases, conflicts in departments are exploited as instruments for maintaining power. Such
hospitals are constantly engaged in finding new employees. If they run out of applicants
who would like to come and work there, an external consultant be brought in to find
adequate staff, often by sugar-coating the current situation to applicants. Alternatively,
the consultant could advise, for instance, that the management subdivide one depart-
ment into various sub-departments, as it would make a post more attractive if it was
attached to becoming head of a department, as outlined in the case study. This enables
the executive hospital management to reinforce their power (“Divide et impera”; divide
and rule). Problems are not solved in this way, but instead are suppressed. Frustration
and resignation spread among the staff. The establishing of an organisational dispute
culture would have led instead to a competitive advantage for the hospital.

Case Study
A hospital is looking for senior registrars, but can find hardly anyone who is
suitable and has the necessary experience. The hospital management is well
known for its ‘hire and fire’ methods. Besides, the hospital’s location and
working conditions are not very attractive. After talking to an external
182 9  Manage Your Conflicts Professionally

consulting company, each of the departments is divided into smaller sub-

departments headed by HoDs. In this way, doctors may be attracted by promise
that they will become a “head of department”. Furthermore HoDs have no
regulations for working hours and they can take on duties without restrictions.

Some hospitals have hardly any staff turnover. In such hospitals it could happen quite
frequently that a long-time staff member can make “faux pas” without having to fear
severe consequences (see the following case study). Both hospitals have one thing in
common, even though their strategies differ. They do not manage conflicts profession-
ally. In the one case a ‘hire and fire’ mentality is applied, in the other conflicts are swept
under the carpet and ignored. Neither adopts an approach that seeks a solution.

Case Study
The consultant in a department discharges a private patient without having
discussed it first with the new HoD. He receives a warning from the HoD. It
is pointed out to him that a second warning would result in actual dismissal.
In another hospital, the consultant regularly treats and discharges patients
without having previously discussed it with the new HoD. On a regular basis,
the HoD requests that he wants to be involved beforehand, but always gets the
answer that this process has been followed in this hospital for years. One day
a patient who was treated by a senior registrar dies several hours after having
been discharged from the hospital. The head of the department receives a
written warning from the CEO that is intended to reassure the public and the
press. Apart from this, everything continues as before.
Conclusion: In the first example, the case was overstated and the warning
was inadequately expressed; in the second one, everything went on as before,
underlying reasons were neither addressed nor resolved and an iceberg of
problems was ignored. Neither a change of conduct nor the gaining of insight
into the cause of misconduct was requested, hence they did not take place.

Bringing in an external advisor is a well-used method resorted to in cases of conflict.

Often the advisor does not know either the hospital or its internal processes: a lot of
noise can be made; money spent, disturbance and uncertainty spread. The decision is
taken to sacrifice a king and to constitute new principalities – yet everything continues
as before. The hospital management conveys the impression to the outside world that
everything possible was done and that the conflict has been resolved by mediation.
The care of patients suffers because pseudo conflict resolution is often combined
with internal power struggles. Are doctors in one department not consulting col-
leagues in the department next door? Either they do not want to lose face or they do
not have a good relationship with their colleagues: but the effort was not made to
find out, the false ‘resolution’ has papered over the cracks, and another opportunity
has been missed to improve patient-centred care.
Below, we look at analysing and solving conflicts professionally.
9.5  Conflict Analysis and Handling 183

9.5 Conflict Analysis and Handling

Even from stumbling stones something beautiful may be built. (Johann Wolfgang von
Goethe)

When problems arise, they have to be discussed and solved. The saying: ‘shut your
eyes and push through’ should not be applied. A strong team must develop the ability
to be resilient. Resilience means the ability to withstand stress and to overcome adver-
sity. Resilience enables people to rebuild their lives, even after severe incidents and
events. It can be learnt from having coped with crisis situations and criticism by using
personal and socially determined values. Where as in the past, ‘no praise means no
censure’, these days much praise is verbalised. However, coping with criticism is sel-
dom taught. Nevertheless, it is only through constructive, positive evaluation of a pro-
cess that attitudes can be changed and hospitals, departments, and teams can develop
further. Employees and managers need to realise this. Resilience is a skill that is train-
able and learnable. It is a basic condition for successful conflict management as it
supports thinking in terms of resolution rather than solely questioning the underlying
reasons. The process shown in Fig. 9.3 can be applied for conflict management.
Adopting roles in the drama triangle (Sect. 5.5) must be avoided because then a
focused and resolution-orientated discussion becomes impossible. There, within the
triangle, roles are assumed that need to be defended. Such as: ‘I have been sacrific-
ing myself for this hospital for years, have worked countless hours of overtime, and
now you are blaming me?’ If discussions are held at this level, it is difficult to come
to a constructive, mutually acceptable solution.
The mechanisms of managing conflicts as well as the impact of conflicts on the
working environment should be systematically taught (De Dreu and Weingart 2003).

1. Conflict perception

2. Conflict localization

3. Root cause analysis

4. Solution strategy

5. Finding a solution

6. Document the solution

Fig. 9.3  The various stages of conflict resolution

184 9  Manage Your Conflicts Professionally

To acquire this knowledge and use it with skill, an external coach could be
consulted.
A conflict usually presents three distinct parts: one’s own, the opponent’s and the
situational part. And usually what happens is that any blind spot is turned towards
one’s own part. This is evident in the following example.

Case Study
Some senior doctors complain that a new colleague is reluctant to take on
team tasks. Furthermore, compiling the staff duty roster with him is reported
to be difficult. The team approaches the HoD asking him to dismiss the col-
league during his probation period, otherwise they will resign – there are
enough attractive job offers for them available on the market. They are unable
either to consider or analyse the role they have played in the development of
the situation. The new colleague is characterised as being ‘difficult’, further
collaboration is seen as impossible. They go further and approach the CEO.
He dismisses the new colleague during the probation period without even hav-
ing heard the HoD.
Conclusion: The HoD feels bypassed and not valued by the CEO. The cli-
nicians are at first satisfied that their demand has been met, but they subse-
quently become dissatisfied because their workload has increased. Applicants
for the post back off when hearing of the dismissal. In summary, no construc-
tive solution was attained for the staff and the hospital. Furthermore, the team
did not learn how the conflict could have been managed professionally to
achieve a win–win situation for both sides and without a loss of face.

The above example shows the consequences if an organisational dispute culture

has not been established. Extreme decisions such as dismissals by the executive hos-
pital management, but also staff resignations, are a last resort. They bring about a loss
of knowledge and experience for the hospital. Furthermore, long-term employees
should not insist on the rights of top dog. They, too, should realise, are part of an
adaptable decision-­making system within the hospital, with responsibility for the con-
sequences of decisions made. Both parties in a conflict should be aware of the poten-
tial danger of escalation (Fig. 9.2). Emotionalism positions and opinions must be
avoided. Step back and try to see the problem from a distance. This is often difficult
to do when in the midst of a situation. Distance is frequently truly achieved only after
a period of time. ‘We always know better afterwards!’
Generally speaking, the options listed in Table 9.2 exist for solving disputes. You
should aim for a win–win situation since it offers a problem-solving result for a team.

9.6 How Do You Proceed in a Case of Conflict?

Let us take a closer look at the above-mentioned quality of resilience. We act with
emotional intelligence if we are experienced in planning our actions and emotions
in advance. Personal crusades, emotional action, and taking offence are the greatest
9.6  How Do You Proceed in a Case of Conflict? 185

Table 9.2  Various options for solving disputes

Strategy Winner/loser Loser/loser Winner/winner (win–win)
Principle A wins what B loses Each one lowers his Overall best solution
sights
Means Power, competition Negotiation, compromise Common definition of
problem and solution
Fundamental Who wins? How many concessions? What is best?
issue
Process Person-orientated Resolution-­orientated Problem orientated
Reaction Fight Tricks Understanding

stumbling blocks. ‘The heart’s blood’ should only be shed to resolve conflicts in an
‘unbloody’ way. It implies, in this context: resolve conflicts without hurting per-
sonal sensitivities and without losing face. This holds independently of any hierar-
chical levels: someone in leadership does not have the right to speak bluntly or
offend others simply because their hierarchical level is higher.
The noisier your opponent gets, the calmer your reaction should be; otherwise
the conflict will invariably escalate. Nevertheless, from a certain point on you have
to stop your opponent, regardless of hierarchical levels. Similarly, personal bound-
aries should be granted and respected. Most of us tend to avoid conflicts, to avoid
being personally attacked and hurt. Hence you should always try to stay on the
factual level regarding what the conflict is about and enable your opponent to save
face.
A hospital should have clear strategies for resolving conflicts – not only on paper
but lived out, by example. A conflict arose in the past and is being resolved now – in
the present – and it should not negatively influence the future. This stance cannot be
attained in a short period of time, and one needs perseverance to reach it; but, in
fact, many positive examples can provide important corner stones. Not only does
the fish stink from the head, but good examples, too, are lived by and from the head,
in the person of the CEO or the HoD.
If a conflict is to have a solution, the three C’s should be applied: be concise,
concrete, and constructive. Don’t allow your voice to be led by emotion. Look
for a future-orientated resolution. Let the past be the past and look to the future
(“Wat verby is, is verby” , Nelson Mandela). Do not try to reconstruct every-
thing in detail, because with enough ‘evidence’ anyone can be made out to
have won.
Further method that may be applied in the case of a conflict is reframing. With
the help of reframing it is possible to, for instance, reinterpret unpleasant or unde-
sirable character traits to view them in a positive light. Instead of describing your-
self as chaotic, you can present and describe yourself as being creative and
forward-looking. In this way, and in relation to the conflict, you will be signalling
your willingness to discuss the matter. Apart from that, reframing diminishes the
tension of a situation and enables staff members to see each other in a (more) posi-
tive light.
When you analyse conflicts, you should remember that conflicts are like icebergs
(Fig. 9.4): only one third is above the water, while the rest is hidden under the surface.
186 9  Manage Your Conflicts Professionally

Visible part of the iceberg (20 %)

= factual problem (rational part of
the conflict)

Fears
Invisible part of the iceberg (80 %)
= Emotional and cultural conflict part Emotions Needs Values

Communication problems Cultural differences Interests

Sense of justice Relationship problems

Motivation Experiences

Fig. 9.4  The iceberg conflict

Successful departments and hospitals ensure that the mass under the water does not
grow to huge proportions and that the hospital and department remain manoeuvrable.
A typical example of an iceberg conflict is described in the following case:

Case Study
The HoD has problems with a consultant, who repeatedly challenges his posi-
tion in front of others. After a number of personal conversations with the col-
league and attempts to solve the problem, the HoD asks for an appointment
with the CEO of the hospital to discuss the way forward. Since the CEO does
not know the HoD very well, he uses the time prior to the appointment to
gather opinions from various hierarchy levels about the two opponents. On
the one hand, the staff members being consulted feel valued because their
opinions are asked. On the other hand, they are confused (‘Is the CEO only
able to have an opinion by asking others? Is my opinion helpful in resolving
the conflict? Do I need to know about the conflict?’). The HoD also gets irri-
tated when he unofficially hears about the various inquiries.
Conclusion: The interaction (HoD – consultant – CEO) is already bur-
dened before the actual discussion takes place. This makes it difficult to find
an amicable solution for all involved. This is a typical example of an iceberg
conflict where much conflict potential is hidden under water and will proba-
bly lead to other conflicts in future.

9.7 Strategies for Resolving Conflicts

For future team-building, the results of conflicts and the ways in which conflicts are
experienced are important. This determines how future collaborations will take
place. A win–win situation not only strives for the overall best solution, it also
9.7  Strategies for Resolving Conflicts 187

Fig. 9.5 Conflict
resolution by considering
the interests of third parties
versus self-interest

High
High
Integration Accomodation

parties
third parties
of
Interest of
Interest
Compromise

third

Low
Low
Dominanz Avoidance

High Low

Self-interest

enhances the acceptance of all parties and the maintenance of good working rela-
tionships. Crucially, no-one loses face.
In connection with conflict resolution, everyone follows their individual pattern.
The question of whether the concern, while resolving the conflict, is primarily for
oneself (self-interest) or for others (of benefit to others) is vital. The various styles
opponents adopt can be divided into dominant, integrative and accommodating, and
avoiding (Fig. 9.5).
For settling disputes constructively, it is necessary to agree on a common
approach without anyone dominating and the other party giving in. If a team knows
in advance that a conflict is being settled professionally, constructively, and without
a power struggle, the team will emerge stronger than before.
For staff and new staff members, the resolution of past conflicts is an important
indicator of the sustainability and reliability of a team. Pay careful attention to
teams claiming to be working harmoniously and without conflicts. The composition
of teams is discussed in detail in Chap. 8.
To resolve conflicts constructively, the following approach should be used.
Initially, the superior and the team should try to solve the conflict internally, without
bringing it to the notice of anyone outside the hospital or outside the department. If
this does not succeed, those concerned could consult an internal, trained mediator.
The mediator should develop a problem analysis together with the opposing parties
and look for a common solution. In the negotiations process, the mediator remains
neutral and is obliged to maintain confidentiality.

Case Study
On a yearly basis an external consultancy company carries out a survey of how
the clinicians in a hospital perceive their working environment. These evaluations
are published on the internet and are accessible countrywide for a benchmarking
process. In the view of the external consultants the registrars have assessed their
188 9  Manage Your Conflicts Professionally

training facility too critically in the officially published report. As a result, the
two groups do not speak to one another. Even important patient data is not passed
on during ward rounds and the consultants impose an unofficial information
blockage. When the conflict further escalates, an appointment is arranged for a
discussion. In advance of the meeting the HoD speaks to both groups and tries to
moderate. The HoD succeeds in convincing the registrars to take this first impor-
tant step so that the relationship between the groups can be re-established. Slowly
at first, but then more intensively a debate and discourse follows.
Conclusion: To reach a win–win solution, it is often necessary to use a
mediator to help overcome stumbling blocks. In the above case, the HoD
facilitated the function of a mediator.

If the conflict cannot be resolved through an internal mediator, an external coach

may be consulted. This, too, may have disadvantages. Since the coach is often paid
by the hospital, he may not adhere to a neutral position. In addition, the coach is not
familiar with the hospital; thus, he could sometimes cause more harm than good. He
may leave behind mayhem, with the team then experiencing a marked loss of confi-
dence. Table 9.3 highlights suggestions for the style of conflict management to be
adopted in relation to the situation.

Table 9.3  Conflict management strategies appropriate to various situations

Conflict
resolution Appropriate situations Inappropriate situations
Integrate Complex factors Task or problem is simple
Synthesis of ideas is necessary to offer Immediate decision is necessary
a better solution
Support by others necessary Other parties are not affected by
the outcome
There is time available for resolving Other parties have no problem-­
the problem solving skills
The team cannot resolve the problem
on its own
To resolve the problem, others are
needed
Concessions You consider that you might be wrong The subject is important to you
The subject has more importance to You believe that you are right
others
You are prepared to give something as The position of the opposing
compensation for something you will party is wrong or they are not
receive in future from the opposing acting in an ethically correct
party manner
You act from a weak position
Maintaining the relationship is
important
9.8  The Golden Rules of Conducting Conversations 189

Table 9.3 (continued)
Conflict
resolution Appropriate situations Inappropriate situations
Dominance The contentious point is trivial Both parties are equally strong
A quick decision is necessary The subject is not important to
you
It is necessary to make an unpopular The subject is complex
decision
It is necessary to dispose of dominant The decision does not have to be
staff members taken quickly
An unfavourable decision by the The staff members possess a high
opposing party has negative effects for measure of competence
you
The staff members lack the expertise
needed to come to a decision
The subject is important to you
Avoidance The subject is trivial The subject is important to you
The negative effect of confronting the It is your responsibility to make a
opposing party cancels out the decision
advantages
A cooling-off phase is necessary The parties do not want to defer
the problem, a solution must be
found
Immediate attention is necessary
Compromise The objectives of both parties are One party dominates or is
compatible with each other stronger than the other
Both parties are equally strong The problem is sufficiently
Neither an integrative nor a dominating complex to require a problem-­
style is successful solving approach
A provisional solution for a complex
problem is called for
Modified according to Rahim (2002)

9.8 The Golden Rules of Conducting Conversations

The parties involved in a dispute ought to know how important it is to communicate.

The objective is to find a good solution, not only for both parties involved in the con-
flict, but also for the hospital and the department. In the case of conflicts, it is important
to repeatedly stress that there are no winners and no losers; both sides have to make
concessions and meet each other. The golden rules of conducting conversations and
mediations are essential and should be known and applied by all hospital employees.
The golden rules of conducting conversations to bring about conflict resolutions
are together with your opponent:

–– Clarify the relationship with your opponent (if possible in mediation)

–– Avoid emotions
190 9  Manage Your Conflicts Professionally

–– Do not arouse fear

–– Respect your partner in the conversation and avoid a loss of face
–– Avoid escalation of conflicts
–– Show esteem and respect
–– Allow free spaces and do not drive the opponent into a corner
–– Do not offend the opponent and respect his personal boundaries
–– If the problem seems to be too large, divide it into smaller sections
–– Listen empathetically and ask if a fact is not clear
–– Summarise the key factors and the way forward before you close the meeting

9.9 Summary

In hospital settings, professional skills in the use of conflict management tools are
still rare. Whereas in many enterprises professional strategies and measures are in
place, in hospitals conflicts are frequently managed intuitively and in terms of gut
feelings. They are also often ignored, are swept under the carpet or are ‘solved’ as
top–down decisions. By involving an external consultant, conflict resolution can
often be achieved. This approach, though is not always the best one for the hospi-
tal. It is more advisable to establish a culture of conflict management and conflict
solution within a team. If hospital managers and heads of department are able to
create a positive organisational culture of conflict resolution, and enable the staff
to cope with criticism and practice resilience, the conflicting parties often will
emerge strengthened from a conflict. It would be ideal to establish organisational
and preventative strategies for conflict management and conflict resolution ahead
of time, as teams and the hospital can then learn and gain from transparent and
solution-orientated management of conflicts.

9.10 Five Reflective Questions for Practical Application

1. How do you handle adverse opinion and conflicts in your team? Are conflicts
stigmatised as being bad for the department or the hospital?
2. How high do you estimate the number of conflicts to be that are not noticed, are
played down or are deferred? High/middle/low
3. Briefly summarise the various steps that are used in your department and within
the hospital if conflicts arise?
4. Who is responsible for conflict management? Does it always become a matter
for the boss? What are the stages of conflict escalation in your department/
hospital?
5. Is there an established conflict and dispute culture in your d­ epartment/hospital?
References and Further Reading 191

References and Further Reading

Amason AC, Thompson KR, Hochwater WA, Harrison AW (1995) Conflict: an important dimen-
sion in successful management teams. Organ Dyn 24(2):20–35
De Church LA, Marks MA (2001) Maximizing the benefits of tasks conflict: the role of conflict
management. Int J Confl Manag 12:4–22
De Dreu CKW, Weingart LR (2003) Task versus relationship conflict, team performance, and team
member satisfaction: a meta-analysis. J Appl Psychol 88(4):741–749
Rahim MA (2002) Toward a theory of managing organisational conflict. Int J Confl Manag
13:206–235
Schulz von Thun F (2008) Talking to each other, vol 1–3. Rowohlt, Reinbek
Be a Visionary Leader
10

Goals
–– How can you become a visionary leader?
–– How can you avoid frequent errors in leadership?
–– How can you motivate your colleagues and co-workers?
–– How do you prevent identity crises for yourself and your subordinates?

This chapter outlines the key characteristics of a good leader. It depicts lead-
ership styles and describes methods of leadership, empathy, authenticity and
anticipation. To understand how you can motivate your co-workers, Maslow’s
hierarchy of needs and other motivational theories are explained. The term
‘noetive dissonance’ is described, as are measures to avoid it. The hassles of the
first 100 days in a new workplace are outlined. We describe how a burn-out syn-
drome can be detected and avoided.

10.1 How to Be a Good Leader

Two things prevent advances in medicine: authorities and systems. (Rudolf Virchow)

As early as the 16th century, Niccolò Machiavelli challenged the Republic of Florence
with his book The Prince. Much of what he said is still valid today and applicable in
hospitals. In contrast to purely market economy–orientated service providers, hospi-
tals have an ethically-orientated focus. Nevertheless, the everyday hospital routine
occasionally tells a different story: in historically established autocratic structures,
power and influence still play an important – sometimes even the central – role.
To the modern way of thinking, the ideal leader does not exist and is seen as represent-
ing a permanent goal that one can only strive for. To become a good leader you should be

© Springer Berlin Heidelberg 2017 193

E. Weimann, P. Weimann, High Performance in Hospital Management,
DOI 10.1007/978-3-662-49660-2_10
194 10  Be a Visionary Leader

familiar with the different management instruments and be able to apply them accord-
ingly. The underlying theory, in addition to practical experience, should enable you to
make decisions based on evidence. You should not be tempted to give in to certain inter-
est groups without being convinced that to do so would be best for the hospital.
Being the CEO of a hospital or the head of a medical department means to balance
responsibilities and interests for the sake of the institution. A head of a department
(HoD) may be highly regarded by his colleagues because he prioritises their interests
and subordinates everything else to that. Accordingly, staff fluctuation and resigna-
tions are low. However, he will not have properly fulfilled his role if this is achieved
at the expense of the patients’ interests or at the cost effectiveness or efficiency of the
hospital. A leader must free him- or herself of wishing to be ‘everybody’s darling’ –
of the desire to be popular, loved, and acknowledged. Executives need to have the
ability to face opposition – even storms – to enforce unpopular but necessary changes.
The following mistake is often made on all executive levels – including politi-
cal leaders: despite representing a rationally understandable proposition for
change, the initiator buckles at the first sign of opposition, which usually comes
from some interest groups. The leader backtracks, perhaps tries ‘to put things into
perspective’. Finally, the good idea is watered down or not implemented at all.
More courage and the necessary backbone are needed when implementing change
(see Chap. 6). Here are some key abilities that are expected of executives:

• Integrity towards colleagues and the employer

• Confidentiality (e.g., treat confidential and personal documentation or conversations
as such and do not pass them on to third parties for tactical or strategic reasons)
• Transparency of decisions and the decision-making process
• Loyalty to colleagues and subordinates, patients, and referring doctors
• Good communication skills
• Appropriate behaviour and action

Ethical behaviour plays a central part in medicine. Medical staff is not only
bound by the Hippocratic Oath when treating patients. Ethical behaviour is also
associated with correct behaviour towards colleagues and staff members. In this
context, it is of particular importance that words and deeds match. The entire com-
portment of an executive should follow ethical principles. Executives have to be
open to new information and must be able to change opinions and attitudes. Beyond
that, they should accept that subordinates might disagree with the decisions of their
superiors. This attitude also affects successful conflict management (Chap. 9).

10.2 Leadership Styles

Visionaries will always meet opposition from weak minds but the seeds they plant save the
world. (B. Habyarinama)

To fulfil the functions of a head and executive, you need to apply the various leader-
ship styles to the context.
10.2 Leadership Styles 195

The major leadership styles can be grouped as autocratic-hierarchic, democratic-­

cooperative, and laissez faire. Although many executives declare themselves to be a
cooperative leader, their style is often a mixture of autocratic-hierarchic and demo-
cratic-cooperative. People with a mixed leadership style are situational leaders. An
authoritarian decision is, in fact, required for certain problems and critical situations
in a hospital. It is not always possible to discuss everything in great detail; hospitals
would then become unmanageable.
Staff members experience the greatest freedom with the laissez faire leadership
style. The leader does not intervene in the processes. However, due to a lack of
discipline (for example, staff in a department take leave or attend a conference at
the same time), conflict of competence or the forming of cliques, this style can lead
to decreased cost effectiveness and a decline in the quality of care offered to
patients.
Leadership qualities can be further split into four main behaviours:

Driver (example: Hilary Clinton): competitive, experimental, focussed, direct,

tough-minded
Pioneer (example: Steve Jobs): energetic, spontaneous, brainstormer, innovator,
networker
Integrator (example: Nelson Mandela): diplomatic, empathetic, helpful, consensus-­
orientated, relationship-orientated, big picture thinker
Populist (example: Donald Trump): tells the mass what they want to hear and pur-
sues his own interests behind the scene
Guardian (example: Angela Merkel): loyal, realistic, methodical, structured,
cautious

The staff must be able to rely on the HoD or CEO making the right decisions by
showing leadership qualities. Above all, decisions should be situation-specific and
comprehensible (Carter et al. 2005).
You should avoid the following leadership flaws:

–– Successes are attributed only to the head or CEO

–– Decisions are taken top–down and are not explained
–– Discussions with staff members do not take place unless they concern a particu-
lar interest of the HoD or CEO
–– The boss interferes with task and competency areas
–– Competencies are not or only inadequately assigned
–– Instructions are distributed in an autocratic manner
–– Controlling habits that demotivate the staff
–– Offensive and confrontational behaviour
–– Personal problems and difficulties that colleagues are experiencing are not taken
care of
–– Preference is given to certain interest groups
–– There is an atmosphere of moods, arbitrariness, and harassment
–– There is a lack of confidence in colleagues
–– Actions by others are always regarded with great scepticism
196 10  Be a Visionary Leader

Self-actualization Growth needs

(talent, living one’s vision
and mission)

Esteem
(independence, status,
recognition, freedom)

Social Needs
(such as love and belonging as group membership,
contact and recognition by other people)
Deficiency needs
Safety Needs
(fear, secure employment, protection)

Physiological Needs
(sleep, hunger, thirst, and recreation)

Fig. 10.1  Maslow’s hierarchy of needs

10.3 Maslow’s Hierarchy of Needs

The motivation of staff is a major pillar of effective leadership. A good and reliable
boss tries to address the needs of the staff and keeps them motivated. This can be
achieved by creating an adequate work environment, incentives, expressing appre-
ciation of their work, good working conditions and acceptable working hours, and
facilitating self-actualisation.
Abraham Maslow, a US American psychologist, conducted his basic studies on
the hierarchy of needs and motivation in 1943. He drew a holistic picture: human
beings are usually motivated and seek self-fulfilment; but only once physiological
needs are satisfied a high degree of self-fulfilment can be achieved.
Maslow organised the different needs in the shape of a pyramid, which is called
Maslow’s hierarchy of needs. The individual needs must be met from the bottom
up. On the first level, physiological needs like sleep, hunger, thirst and recreation
are addressed. On the second level, safety needs must be met (fear, secure employ-
ment, protection). The third level depicts social needs such as love and belonging (as
group membership, contact and recognition by other people). The fourth level cov-
ers esteem, being respected and valued by others (independence, status, recognition,
freedom). This is followed by self-actualization ‘What you can be, you should be.’
(talent, living one’s vision and mission) at the top of the pyramid. The first four levels
of needs are named as deficiency need, the self-­actualization level is categorised as
response to growth need. The different levels blend into each other (Fig. 10.1).
The following quote from a hospital novel illustrates that hospital staff can
­neither achieve self-actualization nor a high degree of motivation without first satis-
fying their basic needs.
10.4  Leadership Methods 197

Case Study
Staff shortages have become so extreme over the last few months that doctors
in the Emergency Department and the Day Clinic had to cover tasks previ-
ously done by nurses and secretaries whose vacant posts have not been filled:
making appointments, writing letters, admitting patients, creating new fold-
ers, drawing blood and many other of the small tasks that are necessary when
careing for patients.
The HoD, Professor Sanders, complains regularly about decreasing
patient numbers. He opposes any carefully placed remarks about the inef-
ficiencies of the organisation of his department. He wants to maintain the
good working relationship to Mrs Adlmaier, the head of nursing. He shields
away from dealing with her directly, preferring to delegate direct commu-
nication to his colleagues. ‘If you don’t like the way nursing is organised
in the hospital, go and speak to Mrs. Adlmaier’, was his standard answer to
all complaints.
Conclusion: Colleagues will be motivated to work to the best of their
abilities only if their basic needs, such as good working conditions, tasks
appropriate to their professional status, and appreciation of their work are
met. Without these, self-actualization and thus professional perfection
will not be achieved and performance will reach only an average level at
best.

10.4 Leadership Methods

Leadership is the capacity to translate vision into reality. (Warren Bennis)

Performance agreements can effectively measure staff accomplishments, and they

belong to the leadership tools. These agreements are binding. You can support their
acceptance when you draw them up together with your subordinates: carry out regu-
lar reviews with your subordinates and apply agreed-upon procedures and measure-
ments. Set dates in advance when these reviews will take place. However, if you can
praise someone, do it immediately. Praise wherever possible, especially with new
team members so that they feel acknowledged and welcome, only dispraise when
necessary. Praise in a tangible way by going into detail. Convey the message ‘Keep
it up!’ However, praise and reprimand must be genuine. Express your own positive
emotions, authentically. Encourage your colleagues! Look for opportunities to
praise. Praising staff members in front of others doubles the effect, as it motivates
staff who overhear to work harder.
If you have to reprimand someone, do it immediately. Reprimand in a concrete
way by going into detail, yet do it without accusing or harassing. Always show your
colleagues that you value them. Then discuss the next steps in their professional
career and, whenever possible, give support.
However, the choice of your leadership style, whether you are delegating, par-
ticipating or training, depends on the degree of maturity of your subordinates
(Table 10.1). A registrar delegates and trains interns differently from a consultant
198 10  Be a Visionary Leader

Table 10.1  Type of leadership dependent on the degree of maturity of the employees
Degree of maturity Type Implementation
High Delegation Hands over responsibility for decisions and
implementation
Moderate Participation Shares ideas and supports decision-making
Average Training Explains decisions and gives the opportunity for
questions
Low Delegation Gives precise instructions and strictly monitors
performance

who allows his senior registrars to participate and delegate relevant tasks. Do not
allow responsibilities you have delegated to revert back to you: your staff is
employed to solve problems!
Besides having the responsibility to lead, your role is to motivate others to get
active and do things; manage and coach your subordinates.
The management function requires that you monitor tasks, manage complex situ-
ations, and ensure that there is a good work flow. Managing also entails achieving
results through your subordinates and colleagues. Leadership consists in imple-
menting change processes, developing visions, setting goals, and inspiring others to
strive for completion of common goals (Cook and Hunsacker 2001). This illustrates
why only a few CEOs and politicians can also call themselves true leaders. By
coaching you are supporting your staff in their development and fulfilment of their
duties, so ensuring that the standard of work is constantly raised.
For each of the three tasks (managing, leadership, and coaching) different skills
come into play. Apart from analytical capabilities, an executive needs to under-
stand human nature. This can best be gained by working for different employers
and in various work settings. Furthermore, an executive should be able to develop
the potential of staff members enabling them to unfold their best abilities. You, as
an executive, have to believe in the potential of your employees and help them to
develop their potential.
For coaching – i.e., supporting staff to reach their best performance – you need
skills such as selflessness, the ability to encourage people, credibility, and well-­
developed communication and behaviour patterns.
Have the courage to lead people and to stand by your decisions, even if you are
facing headwinds. Don’t immediately bend and leave things the way they were, on
familiar, worn-out tracks. Repeatedly illustrate the process of change to your col-
leagues and subordinates. In this way you can gather an increasing number of peo-
ple who support you.

10.5 Empathy, Authenticity and Anticipation

Make your actions look like your words. (Severn Cullis-Skukuzi)

When you are dealing with your staff, you should show empathy, authenticity, and antic-
ipation. Empathy means the ability to walk in another person’s shoes and sympathise
with him. Authenticity in your own behaviour implies that words and actions match. You
are reliable in your actions your behaviour today being no different from your behaviour
10.5  Empathy, Authenticity and Anticipation 199

yesterday. Anticipation describes an ability to foresee, an alertness to, what is likely to

be required in any situation.
These characteristics give you the ability to recognise calls for help and other signals:
if you are confronted with criticism or requests for changes in a discussion, take these
points seriously. Substantiate, discuss, and summarise them. After the dialogue, both of
you should have a clear picture of the underlying problem and how it can be solved. Ask
for the solution that your colleague or subordinate would suggest. Do not delegate prob-
lems to other colleagues, but hold yourself responsible for them (Sutton 2010). Assume
that a colleague may be under psychological strain before s/he articulates problems in a
face-to-face interview. Emphasise that you will definitely tackle this problem and look
for a constructive solution. If you expect something in return, be as specific as possible
in formulating what the colleague has to do within a specific time period.
The higher you are placed in the hierarchy the more critically people will moni-
tor you (Pfeffer 2010). Be conscious of the fact that your manner, your remarks and
gestures are carefully weighed (Sect. 5.2.2). Even if appearance isn’t your primary
interest, it starts with your clothes and hairstyle, as simple as that may sound. And
the less you conform to the usual and accepted standards, the more critically every-
thing about you will be questioned. Women in leadership positions or executives of
foreign origin will feel this in particular. Nevertheless, be authentic in your actions
and behaviour. You will not be credible if you constantly change your behaviour
because of external advisors. Deliver an authentic image and consider beforehand
how your actions might appear to others.

Case Study
Two patients are in their ward, waiting for the morning round. Suddenly a
large group enters the room. A gentleman in a dark suit approaches them,
greets them by handshake and asks if they are satisfied with the services.
Slightly befuddled, they nod. One minute later the group leaves. They look at
one another and ask themselves: ‘What was that?’ To a later question the
nurse explains that this was the CEO, who uses an unannounced ‘walk in’
strategy to find out how satisfied patients are.
Conclusion: The image you deliver must be appropriate and should not
cause consternation.

The empathy you have for your staff will be carefully analysed, as other aspects of
your behaviour. Who do you greet? Do you greet others first? How do you behave towards
your subordinates? How do you react in meetings? How do you act towards people who
are placed higher than you in the hierarchy? Are you mentally present in meetings or do
you spend your time sending messages and e-mails on your smartphone? How do you
react when someone disagrees with you? Do you insult people with your comments? Do
you allow your displeasure to be felt the next time you meet that person?
Empathy and anticipation are important characteristics and determine how you
are accepted by your staff. Let your staff know that you appreciate their work. Allow
them to enjoy your optimism and the pleasure you take in their work. In this way
you can motivate your staff to enjoy doing their work. This should result in a self-
fulfilling prophecy: what many say and do will eventually become true.
200 10  Be a Visionary Leader

10.6 How Do I Motivate My Colleagues?

Motivated staff will engage in their work with keenness and enthusiasm, and so will
benefit the development of the hospital. They should enjoy coming to work. Sharing
work motivation is another important tool in management, and it is also one that
responds to training. As a leader you have to engage in building up trusting relation-
ships and open communication between staff members. Besides, members of staff
have to become involved in decision-­making and need to be informed about what is
happening in the hospital (Chap. 5).
Motivation develops from intrinsic and extrinsic factors. Intrinsic describes
holistic and self-generated motivation. It originates around a sense of responsibility
and the feeling that the work is important. It presupposes that you have control over
your own area and a certain degree of autonomy in your work; you are able to
develop and increase your competence and know that you have an exciting and chal-
lenging job (Chap. 9). Extrinsic motivation is the result of external influences.
Among them are incentives, praise, support, promotion, or, as negative factors, dis-
ciplinary measures, criticism and lack of praise (Herzberg et al. 1959).
John Stacy Adams, a behavioural and workplace psychologist, developed the
equity theory of motivation (Fig. 10.2). Everyone pays attention to a balanced degree
of equality and harmony (Adams 1965). The balance can be judged by what one
receives as an output (salary, appreciation, etc.) in exchange for one’s own input
(work). Ideally, this should feel fair and balanced. Otherwise, balancing acts will be
performed to counteract the imbalance. Yet the weighting of input and output are sub-
jectively sensed values and depend on an individual’s personality and experiences.
According to Frederick Herzberg, the two-factor theory or dual factor theory
presents another approach to explaining motivation and work satisfaction (Herzberg
et al. 1959). It includes the hygiene factors (factors that do not give positive satisfac-
tion or result in a higher motivation) and motivators (factors causing satisfaction),
which compete with each other. Hygiene factors are created by general conditions;
motivators originate from the content of the task. Hygiene factors include work
conditions, status, relationships within the team, team culture, security, pay, benefits
and access to information and sources of knowledge. Among the motivators are
responsibility, challenging work, recognition, and job opportunities.
How can the needs of staff be met? Working conditions will have to improve, and
solutions are not to be delegated to others, as is illustrated in the above example
referring to the head of nursing (Sect. 10.3). Staff should have access to department
and hospital information, for example, by enabling them to access minutes of meet-
ings via the intranet. Engage in an appropriate communication culture in meetings.

Output

Fig. 10.2  Theory of Input

equity or fairness
10.7  How You Create a Meaningful Work Environment 201

To improve motivation, individuals should be given the chance to receive regular

feedback on their performance (Sect. 5.6).
The inner resignation of staff (Chap. 2) has to be avoided because it is counter-
productive for the hospital. A frequent reason for this mechanism is the feeling of
not being involved. This may be reflected in remarks such as ‘In any case, decisions
about my unit are being taken over my head’. Other reasons may be that staff mem-
bers cannot identify themselves with the hospital’s mission statement. Furthermore,
they may not feel able to fully apply their abilities at their workplace and therefore,
feel under-challenged.
Self-actualisation at the workplace only happens when you can use your profes-
sional competence, demonstrate your effectiveness, and are given the opportunity
for creating your own tasks. This will only take place if you can (pro-) actively
practise your social and self-competence and feel accepted (Graf 2007). This can
make a big difference to the competitive advantages of organisations and hospitals.
If there is a strong focus on cost cutting, as it is frequently the case, staff are often
regarded as the main cost factor that can be replaced at will. In the health care sys-
tem, appreciation and development of staff are still rare. However, nursing, organ-
isational structures and management tools are frequently much better implemented
than for clinicians.

10.7 How You Create a Meaningful Work Environment

Live as if you were to die tomorrow. Learn as if you were to live forever. (M. K. Ghandi)

A number of studies have shown that staff members are usually only 60 % produc-
tive. Hence, many abilities and talents are not utilised to the hospital’s advantage.
One reason might be that staff members are facing noetive dissonance (Graf 2007).
The concept of noetive dissonance portrays the intensive endeavour by a person to
work towards a goal, to implement projects, and to put ideas into practice. But
­external circumstances, such as harmful competitiveness within the department
(e.g., various divisions within the department are fighting for dominance) and
­parties pitting against others, are jeopardising the ambitious goals of individuals.
A meaningful work environment remains the biggest motivator. Most objectives
set by decision-makers are aligned to economic considerations. Nevertheless, a boss
is not going to develop himself to become a good leader if he sees the main objec-
tive in his work only to be earning a good salary and getting the annual bonus. On
the other hand, meaningful self-recognition cannot be simply prescribed or
instructed, but must be developed and striven for.
Most employees start their new work with a lot of enthusiasm and goodwill. As
a leader you should attempt to maintain this commitment, support and promote it,
and consequently counteract the effects of noetive dissonance. Employees often
perceive their superior to be hazy about or uninterested in ethical ideas and beliefs.
However, frequently, it is not satisfying for the staff to pursue the only goal they
have in common, to make a profit and frame the margin for the next year. In the long
run, motivating your staff in this manner will not succeed. You, as the leader, have
202 10  Be a Visionary Leader

to be able to describe meaningful work apart from economic considerations, and

especially in a health care setting. Goals, values, and ethics have to be discussed
and implemented with regard to: What is important for health care workers, nurses,
and doctors? How can the hospital as an organisation enable them to apply ethical
considerations? How would they describe the current quality of their interpersonal
relationships within the team? To achieve a high level of motivation, the general
conditions provided by the hospital should enable exciting, meaningful, and valued
work. For this reason, leaders have to be authentic and real. Words have to be fol-
lowed by actions. If you demand transparency, but sweep problems under the car-
pet, fail to discuss matters, and carry on as normal assuming that nobody will notice
you’ve done this or if you leave problems to solve themselves, you are creating an
authenticity problem for yourself.
One dilemma is that many people only tolerate people around them who confirm
their opinions. For your personal development, but also for the development of any
organisation, it is crucial to permit critical voices to emerge around you, to listen to
them, and consider them. This is why ‘think tanks’ are so successful. In leadership
positions there are a considerable number of people who try to hide a lack of self-
esteem by adopting a particularly aggressive manner. This produces a bad mix. On
the one hand, openness is demanded; everyone is invited to have their say. But par-
ticularly when those who demand openness are unable to live the values they expect
from others contention may arise (Graf 2007). Propagating a transparent leadership
model does not guarantee that this model will really be lived. Paper is patient, how-
ever, ultimately leaders are evaluated by their peers on what they do and not simply
by what they say.
Even today, an interdisciplinary treatment approach is still not common in hospi-
tals. Resources are wasted and staff is not appropriately involved. Only a few people
are capable of working in an interdisciplinary team since opinions may have to be
subordinated and agreement to be found. Motivational approaches are aligned to
power, needs, and the idea of self-actualisation (‘live your dream’). By manipulating
feelings (e.g., with rewards) you can control, stimulate, and motivate colleagues.
Around 1930, the Austrian psychiatrist and neurologist Viktor Frankl founded a
neo-dynamic approach, which is spirit and meaning-orientated. Power struggles in
or among departments often dominate the daily activities and may result in noetive
dissonance. They may also be partly consciously and partly unconsciously enter-
tained by the executive hospital management. If the performance and the require-
ments of the customers (referring doctors and patients) no longer motivate the staff,
they will be more concerned with defending benefits than market orientation, and
when this happens, the striving for power and pleasure has won over the striving for
deeper meaning. The result is existential frustration, leading to an inner emptiness
and a sense of meaninglessness. The motivation committing you to a goal disap-
pears. This is especially difficult for staff members who are committed to pursuing
these goals. This commitment has been destroyed by external circumstances, inter-
nal quarrels, and power struggles to secure vested rights. People in leadership posi-
tions and staff members for whom a meaningful work environment, team spirit,
service, and client orientation are important values are particularly vulnerable. This
10.8  The First 100 Days in the Job 203

is especially the case when the facilitation of their goals is prevented by their supe-
riors. This leads to existential frustration (Graf 2007). At this stage, communication
workshops or changes in organisational structures are no longer sufficient. Their
identity crisis can only be solved with meaningful work and a holistic concept.
In summary, some basic principles for staff motivation can be recommended:

–– Place meaningful work higher in value than financial aspects.

–– A department and hospital can only function well if all work as a team. It is the
task of the departmental heads and CEO to support the staff in finding their self-
fulfilment and to make sure they are involved in the team process.
–– Create a work environment where creativity and interdisciplinary work are sup-
ported, so as to counteract the growth of noetive dissonance.
–– Give people space, but also clearly define existing boundaries (e.g., ‘You can
make the decision on one training course that you would like to complete; the
other courses I would like to select with you and advise you.’).
–– Create a network of appreciation. It may cause inner conflict if, for instance, the
head of a department endeavours to express appreciation of the work of his staff,
but his own work is not acknowledged by the executive management. Exemplify
transparency and openness.
–– Give your staff the opportunity to find self-fulfilment in the work place.

Depending on your dominant characteristics (e.g., www.enneagramm.com), you

will make your decisions. They will also guide your reaction in inter-personal con-
flicts. Everyday life is certainly made easier if crises affect you like “water off a duck’s
back” rather than you feeling you are “wearing shoes that don’t fit”. Nevertheless, in
certain situations it can be helpful to be more sensitive than others. In this way, weak-
nesses can become strengths. Sensitivity or a lack thereof is not what distinguishes a
good boss from a bad boss. In critical situations, be continually aware of your particu-
lar ‘strengths’ and your ‘weaknesses’. This will enable you to be a good leader.

10.8 The First 100 Days in the Job

The difference between the impossible and the possible lies in a person’s determination.
(Tommy Lasorda)

The first 100 days in a new working environment are often called the ‘window of
opportunity’. The challenge is to innovate, set goals or get the department or the
hospital back on track. It is a sensitive time for initiating change, to address people,
to carry them along with you, and not to put them off. Changes are often accompa-
nied by the question: ‘What’s in it for me?’ You should address this concern and
engage staff in the new process.
Joining a new organisation or taking on a new hierarchical role is a critical
period. Your statements, comments, your gestures, and expressions will all be scru-
tinised. It is important when issuing a mission statement to remember that the
204 10  Be a Visionary Leader

organisation existed and functioned before you joined it. If processes are running
smoothly, you should take the time to observe, analyse, and familiarise yourself
with your new environment before developing your own strategies. This approach
will give you the opportunity to assess and evaluate things appropriately.
However, settling into a new job is not always as smooth and harmonious as
described in books and articles. Due to previous long-term tenure there may be an
urgent need for innovation and change. Sometimes, the staff has waited years for a
new superior to take over and make imminent improvements. Alternatively, a laissez
faire style may have become established during a period when there was an acting
executive manager or acting head of department (Chap. 9). Consequently, you cannot
spend the first 100 days merely observing, but will have to start acting fairly quickly.
This could lead to conflicts because different management styles and visions clash,
while the staff may have developed a longterm bond and therefore are well-attuned to
each others. In such a situation, conflicts can be expected. A visionary hospital execu-
tive or your superior would ideally have drawn your attention to such potential prob-
lems and will offer help and support. However, you cannot expect other people to
make the effort to understand your troubles and concerns. Empathy may be a virtue,
but it is not a widespread trait. Imagine, instead, colleagues who enjoy the sorrows of
others without offering any constructive help. All too often, the messsage is: take care
of your problems yourself; don’t expect help from anyone else. It might help to get
external support. In this case, make sure that the values and views of the coach or
facilitator are similar to yours. Sometimes, the involvement of external coaches can
cause more calamity than salvation.

Case Study
One evening around 6 p.m. the CEO of the hospital comes along to have an
informal talk with the new HoD. After a few introductory words he volunteers
to provide some local background information, since the new head has worked
abroad for some years. The CEO emphasises that he wants to distribute the
‘right’ information by avoiding influences from other ‘sources’. First, he tells
of the seemingly unbridgeable problems with his predecessor, who eventually
had to be evicted. Little by little and almost by-the-way he mentions that dur-
ing the last 5 years several departmental heads have had to leave. They all
appear to have been complicated characters. He closes the conversation with
the conclusion that all difficulties have been overcome, the hospital is now in
good shape, and he as the CEO is facing the future with confidence. After an
hour, he leaves a rather puzzled HoD behind, who asks himself whether he
would have accepted the position if he had had this information beforehand.
His position now seems far less glamorous than before.

How would you react to this situation? Decide on an answer that is closest to
your likely response:
10.9  Prevent Burnout 205

1. That happened all in the past. There have been some personality clashes between
people who had to work together. But I’m smarter than they were and get along
well with people. I won’t let anyone have the power to force me to leave this job.
2. Oh dear, they seem to enjoy showing people who the boss is. I’m sitting in an ejec-
tion seat. I’ll have to look for a new post as soon as possible. I can’t expect my fam-
ily to live under such uncertain circumstances. I could be the next to go.
3. They don’t seem to be particularly concerned about trust. How am I supposed to
build a relationship of mutual trust if I’m only told such important information
after already starting the new job? Could all of those HoDs have been difficult
people. Or is it the CEO who’s the difficult one? I’ll have to be very careful and
watch my step to survive here.

An interpretation to the question of the case study is given at the end of the
chapter.

10.9 Prevent Burnout

The burnout syndrome describes a condition of emotional exhaustion due to work

overload, which causes reduced performance. The burnout syndrome is increas-
ingly seen in hospitals, independently of hierarchies. Nursing staff and doctors are
at elevated risk as they are continually confronted with highly emotionally-charged
life and death situations. In their every day work they often feel externally driven
and not self-determined. Treatment processes are subdivided into small sub-steps
and the patient is no longer seen holistically. Doctors and nurses no longer partici-
pate in the recovery process of a patient and often do not get to experience the
patient’s joy and gratitude.
Symptoms of burnout are an emotional state of exhaustion, detachment, and
ineffectiveness (Maslach 2001) and are listed in the Maslach and Copenhagen
Burnout inventory (Table 10.2). The Burnout Syndrome includes, too, feelings of:
depersonalisation and the sense of being a failure. Many small events can cumula-
tively result in a state of exhaustion, which cannot be fixed by a free week-end. A
contributing factor is the above-mentioned noetive dissonance. There could be con-
flicts on various levels: role and goal conflict (lack of autonomy) or relationship and
expectation conflicts (discrepancy between one’s own demands and expectations
and the everyday work). Additionally, an overburdened situation due to a lack of
resources may be a contributing factor.
When it comes to recognising the signs of threatening burnout, everyone is
responsible not only for him/herself but also has a responsibility towards others.
The lowering of self-esteem is a first sign, which may be expressed in repeated
remarks such as: ‘In any case, what I say doesn’t matter’, ‘Everyone makes deci-
sions without me’, ‘I always make the same mistakes’. Such signs should not be
ignored and professional help should be sought although it should not be organised
behind the back of the person causing concern. To do so would risk a breakdown in
trust.
206 10  Be a Visionary Leader

Table 10.2  The Maslach and Copenhagen Burnout inventory

Type of
burnout Dimension Symptoms Example
Related to Depersonalisation Indifference ‘I find it hard to focus on my
patients Detachment patients.’
Cynicism
Personal Emotional exhaustion Poor motivation ‘I no longer enjoy my work.’
Irritability
Tension
Task-related Experiencing failure Feeling of futility ‘I seldom feel that I can really
Ineffectiveness help someone else or that I
Hyperactivity relevantly contribute to the
system.’

10.10 Summary

You can only pass on your values to your staff if you are in harmony with yourself.
This is not all that easy to achieve, especially in a demanding and busy working
environment. For this, self-confidence is needed, but also reflection and a critical
distance from your own actions. You should ask yourself regularly whether you are
on track together with your hospital or your department. Avoid being surrounded
only by people who count the remaining years to their pension, have always stayed
in the same position. Do not tend to eliminate critical voices. A good boss should
have the ability to manage, coach, and lead. Furthermore, empathy, anticipation and
authenticity are sought after characteristics in leaders. In the long run, staff can only
be motivated successfully if both the leader and the staff can define their work
beyond the limits of financial aspects and in this way counteract identity crises and
noetive dissonances.

10.11 Five Reflective Questions for Practical Application

1. Who belongs to your peer group? Are they people that you have known for a
long time and are in tune with or is the group repeatedly re-constituted?
2. How do you react to criticism? Do you possess a systematic way of coping with
it? In what respects are you influenced by extrinsic motivation?
3. Which points do you consider to be important for your first 100 days in a new
position?
4. What proportion of your time at work is taken up by each of the three tasks of
managing, coaching and leading?
5. What strategies do you have for preventing noetive dissonances and identity cri-
sis for yourself and your staff?
References and Further Reading 207

A possible interpretation of the case study question from Sect. 10.8. Agreement
with:

–– Answer 1: You are an optimist. You have the good fortune to see the world
through rose-tinted spectacles and you don’t concern yourself with matters that
don’t affect you.
–– Answer 2: You have a pessimistic approach to life; you dwell on matters that
have been reported to you from second-hand and anticipate rain clouds even
though others don’t yet even see rain on the horizon.
–– Answer 3: You are a realist. You see differences between yourself and others and
don’t automatically relate everything back to yourself. However, a relationship of
mutual trust is very important for you and enables you to work well with others.

References and Further Reading

Adams JS (1965) Inequity in social exchange. In: Berkowitz L (ed) Advances in experimental
social psychology. Academic Press, New York, pp 267–299
Carter L, Ulrich D, Goldsmith M (2005) Best practices in leadership development and organiza-
tion change. Wiley, San Francisco
Cook CW, Hunsacker PL (2001) Management and Organisational Behaviour. McGraw-Hill Irwin,
Boston
Graf H (2007) Die kollektiven Neurosen im Management. Linde, Wien
Herzberg F, Mausner B, Snyderman BB (1959) The motivation to work. Wiley, New York
Mann C (2006) The hospital myth – disenchantment. Amazon KDP, Seattle
Maslach C (2001) Job Burnout. Annu Rev Psychol 52:397–422
Maslow AH (1943) A theory of human motivation. Psychol Rev 50(4):370–396
Pfeffer J (2010) Power: Why some people have it – and others don’t. Harper Collins, New York
Sutton R (2010) Good boss, bad boss. How to be the best and learn from the worst. Little Brown,
Boston
Glossary

ABC Analysis  Prioritises the tasks, problems, products, and other similar elements
on three levels: A = very important, B = important, C = less important.
Activity  Task that is focused on achieving a specific outcome in a project.
Advocates  Individuals or groups who desire change through business engineering
but have no power in the organisation.
Affected persons  People who have to change and are affected by change manage-
ment processes.
Agents  Persons or a group of people who are responsible for the implementation
of change management.
Architecture  Structure of a system and the rules on which such a structure is based.
Balanced scorecard (BSC) A holistic management and performance indicator
system that includes financial and non-financial key data in the control process.
It aligns the actions (processes, measures) of a group of people (organisations,
companies, institutions, fields, departments, project groups etc.) to a common
goal.
Base rate  Established by dividing the hospital budget by the case mix index. The
hospital-specific base rate is founded on a benchmarking process between hospi-
tals. It provides information about how economically efficient the hospital is in
comparison with other hospitals.
Benchmarking  The implementation of a competitive comparison analysis.
Normally, this is done by using a system of performance indicators that defines
the criteria being compared and their quantitative definitions.
Best practices ‘Objective’ empirical values that help to carry out a project.
Successful methods, tools or measures are applied.
Business architecture  A business system or partial system and the result of plan-
ning the structure of the business. It includes the general structure of a business
and the necessary design rules.
Business engineering/business process management  An integrated concept of
control, organisation, and monitoring that enables an objective-orientated con-
trol of business processes. It is geared towards fulfilling the needs of clients
(patients, referring doctors) and other interest groups (stakeholders), such as sup-

© Springer Berlin Heidelberg 2017 209

E. Weimann, P. Weimann, High Performance in Hospital Management,
DOI 10.1007/978-3-662-49660-2
210 Glossary

pliers, partners, staff and owners, and contributes to achieving the strategic and
operative goals of the hospital.
Business engineering map  A map that describes how change processes can be
implemented throughout various areas of a business. It is based on information
and communication technology developed during the past few decades and the
new economic system resulting from it.
Business model  The business processes of a company on various levels and from
different viewpoints: structure, functions (operations), data, and performance
(processes).
Business process  A logically connected chain of activities that have to be per-
formed in a given sequence and aims at a certain process performance. Initiated
by a defined event, specific input is transformed into output by considering regu-
lations and using various resources.
Business process management An integrated concept of leadership, organisa-
tion, and controlling that enables the objectively-orientated control of business
processes. It is geared towards fulfilling the needs of clients and other interest
groups (stakeholders), such as suppliers, partners, staff, and owners, and con-
tributes materially to achieving the strategic and operative goals of the business.
Business process model  Usually hierarchically modelled, purpose-orientated, and
simplified representations of business processes.
Business process re-engineering (BPR)  The optimisation of business processes.
It is the fundamental re-thinking and the radical new structuring of business pro-
cesses to achieve a dramatic improvement in costs, quality, service, and speed.
BPR is often linked to significant cultural and technological changes.
Business strategy  A long-term plan of action designed to achieve a particular goal
or set of goals or objectives. In this sense, the business strategy of management
indicates the way in which a medium-term or long-term goal can be achieved.
Case mix index  A parameter that relates to the severity of cases and reflects the
amount of complex cases being dealt with at a hospital.
Cash flow  An economic measure presenting the cash flow generated by business
activities during a certain period of time.
Change management  The management and design of planned change processes
within an organisation.
Critical incident reporting system (CIRS)  A voluntary report by hospital staff
of critical incidents or violations of processes where a patient has been or could
have been harmed. The aim is to increase patient safety.
Client orientation  Operational thinking and action focused on clients, i.e., their
needs, wishes and problems.
Competitive advantage  Realised by a business by offering one or several strategi-
cally important activities at a cheaper rate or at improved service delivery than
one’s competitors.
Conflict management  Professional dealing with conflict according to in-­hospital
standards so that conflict teams can independently develop workable solutions
and profit from the solutions.
Conflict resolution  Reduction, elimination, and ending of any type of conflict.
Glossary 211

Continual improvement process (CIP)  A core value and attitude of participants

that implies constant improvement with long lasting impact. This staff attitude
ideally permeates all areas of business activities. CIP relates to product, process
and service quality. CIP is implemented by a process of steady small improvement
steps in a continuous teamwork process. CIP can be compared with the Japanese
Kaizen. Because of its success, it is often used synonymously with Kaizen.
Controlling  A goal- and profit-orientated activity. Controlling may take the form
of self-controlling (the manager exercises the controlling duties himself) or in
the form of institutional controlling (the controlling is exercised by a specialised
body that supports management). Controlling functions include planning, moni-
toring, co-ordination and information dissemination.
Core competencies  The abilities or activities that lead to a competitive advan-
tage. They are achieved by consolidating and linking the company’s resources to
improve its position with regard to competitors and hence achieving a competitive
advantage. If the business processes of a company represent core competencies
or contribute significantly to the structure or upgrading of core competencies,
they are also called core processes.
Core processes  Business processes with a high degree of added value for the cli-
ent. All core processes within an organisation are taken together and into account
for its competitive advantage.
Critical success factors  Features that significantly contribute to the success of a
company and/or a business unit.
Current assets  Items on an entity’s balance sheet that are cash or a cash equivalent,
or which can be converted into cash within one year.
Customer relationship management (CRM)  The alignment of processes within
a company to its clients and consequently the outline of customer relationship
processes. A CRM system is application software supporting CRM.
Data integration  Combining data residing in different sources and providing users
with a unified view of these data. All data for a business process should be inte-
grated. If this does not take place, media breaks occur.
DMAIC cycle The systematic, phased procedure of Six Sigma is known as a
DMAIC cycle. The DMAIC cycle is used to improve existing processes and con-
stitutes the core element of the Six Sigma improvement process. The DMAIC
cycle is related to the PDCA cycle and stands for: ‘define, measure, analyse,
improve, control’.
Effectiveness  The degree to which the achieved goal fulfils the desired outcome is
evaluated independently of the required input.
Efficiency  The cost–benefit ratio is generally the effectiveness and the suitability
of the actions by which the specified goals were achieved. It is defined as the
economic achievement of set goals (resource utilisation).
Enterprise resource planning system (ERP system) A complex programme
integrating a common data base into several standard business applications.
Consequently, only business-consistent transactions are carried out. Data con-
sistency is maintained. Cross-company business processes are supported and
repeated and redundant data capturing is avoided.
212 Glossary

Equilibrium theory The return of input (work performance) balanced against

­output (salary, recognition).
External benchmarking  Uses comparative values not originating in the business
itself. If these standards result from the comparison with competitors it is known
as competitive benchmarking.
Feasibility study  It assesses whether suggested solutions(s) can realistically be
implemented under the specific business conditions.
Five forces model  Developed by Porter, the model asserts that competition in any
branch of business is determined by five factors: (1) new competitors, (2) new
products and services, (3) clients’ scope to negotiate, (4) suppliers’ scope to
negotiate, (5) traditional competitors.
Functional benchmarking Occasionally, it is an advantage to conduct com-
parative analyses beyond one’s own business and study the successes of
­non-competitors and role-models. This is described as functional benchmark-
ing, as typically one is looking at optimal organisational solutions or processes
(e.g., best of country). Functional benchmarking is also used if no reference
values are available.
Gantt chart  It is a type of bar chart that illustrates a project schedule. A Gantt chart
shows the start and finish dates of the tasks of a project. It helps the project man-
ager to visualize the project timeline and completed work over a period of time.
Gross domestic product (GPD)  The monetary value of all goods and services pro-
duced inside a country’s borders within a specific time period, usually calculated
on an annual basis.
Globalisation  A development trend in the global economy. Globalisation is
the strategic alignment of companies and financial markets operating inter-
nationally; utilising the respectively feasible advantages of cost and loca-
tion in various countries so that an increase in competitive opportunities is
achieved.
Internal benchmarking  Comparison within a company (best of company).
Ishikawa diagram (cause–effect diagram)  Also known as the fishbone or cause–
effect diagram, it serves to visualise a problem-solving process where the pri-
mary causes of a problem are sought.
ISO 9000ff.  A coherent set of norms documenting the basis of measures for quality
management. Within the ISO 9000:2000 norms, process orientation has a special
significance. In many places, the role of process management within a quality
management system is indicated.
Kaizen  Meaning ‘change for the better’, a Japanese management philosophy
focused on continuous, systematic and step-by-step improvement of business
processes with the involvement of employees. The continuous improvement pro-
cess (CIP) can be compared with the Japanese Kaizen. Because of the success of
Kaizen, it is often used synonymously.
Lagging indicator  Key data of results. These are performance indicators in a b­ alanced
scorecard and show whether the organisation was able to achieve its goals.
Leading indicators  They provide information of the course the organisation is tak-
ing and highlight how the organisation will develop and whether it will achieve
its objectives. They are therefore also called performance drivers and are perfor-
mance indicators used in a balanced scorecard.
Glossary 213

Leadership  Provision of a guiding principle, a vision and a long-term goal and

their realisation.
Leadership processes/management processes Business processes serving the
planning, monitoring and evaluation of objectives, strategies and measures for
an organisation or hospital.
Lean management  Methods and principles applied to the entire company for effi-
cient operations. Lean management is aimed at increasing efficiency.
Management processes  Within a company, they serve the planning, monitoring
and the control of goals, including strategies and measures.
Marketing  A concept of the company’s management that aligns all aspects and
activities of a company to the requirements of the market. In this sense, market-
ing includes all activities of a business that are sales-related; specifically, the
policies that address products and the product range, price and conditions, sales,
communications and service policies.
Media breaks  The lack of integration of all data necessary for a business process.
Media breaks should be avoided. For instance, a media break exists if an order is
captured in an ERP system. To calculate one day’s turnover, the volume of orders
must also be captured in an Excel table.
Mentor  An experienced and trustworthy advisor and teacher. Odysseus entrusted
his son Telemachus to a man called Mentor, who could act as his advisor and
confidante during his absence in the battle for Troy.
Milestone  The control points of a project. They are important constituents of proj-
ect management as they conclude phases or present project reviews.
Mind map  A mind map is a map of thoughts, i.e., a graphic representation of the
relationship of concepts and key words relating to a complex topic.
Mission  The reason and goal for a hospital is stated in a promise for its stakehold-
ers (patients, referring doctors). The function, market and competitive advan-
tages, together with the business goals and company policy, are outlined briefly
and concisely in a short statement.
Motivation, extrinsic  Influence from an external source (e.g., by salary, status,
social acknowledgement).
Motivation, intrinsic  Holistic, self-generated motivation.
Non-profit organisation (NPO)  Also called not-for profit, as they are allowed to
work for profits. These must be reinvested in the organisation and do not serve to
make a profit as this would be the case in for-­profit organisations.
Organisation of economic cooperation and development (OECD)  At present,
34 member states of developed countries with a high per capita income that
­follow democratic and market economy goals.
Out of pocket payment (OOP)  Individual health service contribution.
Orbis  Software for hospitals and other health care professionals.
Organisational management  All tasks related to the organisational structure of
a company. Core tasks of organisational management are conceptualisation and
implementation of the structural and operational organisation.
Organisational structure This outlines relationships and authorities within an
organisation and indicates how they function. The organisational structure speci-
fies: communication structure (how information is distributed) and authorities
(which authorities and powers exist).
214 Glossary

Outsourcing  The allocation of company processes to an external enterprise.

Reasons for outsourcing could include: concentration on core competencies
(operating processes), savings and/or freeing up of resources, utilisation of the
competencies of other companies, greater financial flexibility.
Picture archiving and communication system (PACS)  Used in radiology to store
images electronically.
Pareto principle  The name is derived from the Italian economist Vilfredo Pareto,
who postulated the 80–20 rule. This constant probability distribution describes
a static phenomenon, that 80 % of influence can be traced to 20 % of the cause
variable. These ratios have been confirmed in various studies. Examples: 80 %
of product defects are caused by 20 % of all possible causes of defects. 20 % of
tasks block 80 % of working time.
Parkinson’s law Bureaucratisation: the bureaucratic administration in offices
and businesses grows at a predictable rate, regardless of whether the work load
remains the same, increases or decreases.
PDCA cycle (Deming cycle)  An iterative four-step management method used in
business for the control and continuous improvement of processes and products.
It orders the improvement process of business processes in four phases: ‘plan,
do, check, act’.
Performance indicators  Values (key data) providing quantitative information with
specific significance for the performance of an organisation.
Portfolio  Collection of objects (projects), tools, methods and options for
activities.
Potential analysis  Analysis of the resources of a business when it becomes avail-
able for strategic decisions. It reflects the strengths and weaknesses of the
business.
Process  A temporal and logically coherent sequence of functions necessary for
carrying out an activity. A process consists of a sequence of steps producing
output from a series of inputs.
Process benchmarking The business processes of different companies are
compared.
Process flow chart  Summarises and shows the flow of economic processes. Process
flow charts depict operations, points of decision-making and the sequence of
executing tasks.
Process map  Depicts all processes carried out by an organisation (including inter-
faces to the outside). It gives an overview of all the essential processes of a busi-
ness. The process map is thus a higher level view (meta level) of the p­ rocesses
within an organisation. It describes the structure of business processes of a
­company and the interaction of individual partial processes.
Process organisation  Process organisation describes the business processes of an
organisation on various levels, right down to the level of operations. The indi-
vidual processes and their dependencies and interactions are analysed.
Process portfolio  An analytical tool specifically focussed on business processes.
The process portfolio can be used as a method for prioritising; for instance, to
evaluate business processes according to client benefits and business success.
Glossary 215

Project  A project is a complex plan by which a clearly defined goal is to be

achieved, considering all circumstances (such as time, costs and resources).
Project management A leadership concept that serves the goal-orientated and
efficient implementation of projects. This includes organisational, methodical
and interpersonal aspects.
Project portfolio management  Overarching project planning within multi-­project
management. Projects are selected and developed in terms of the strategic and
economic alignment of a hospital.
Quality management  This includes all activities of management that determine
quality policy, the goals and responsibilities within the framework of quality
management. It implements them by means such as quality planning, quality
control, quality assurance and quality improvement.
Resilience  Mastering crises and criticism by recourse to personal and socially
mediated values for personal development.
Resources  The amount of personnel and material necessary to carry out actions,
processes or projects.
Return on Equity  Return on equity (ROE) is the amount of net income returned as
a percentage of shareholders equity. Return on equity measures a corporation’s
profitability by revealing how much profit a company generates with the money
shareholders have invested.
Risk management  The systematic capture and evaluation of risks and the sub-
sequent reaction to identified risks. It contributes to the improvement of pro-
ductivity and efficiency of a hospital and is aimed at increasing patient safety.
Indicators are, for instance, the rate of complaints and legal–medical cases.
SDCA cycle When the PDCA cycle is successfully implemented in a business
engineering project, the new business process is ratified as the new standard
so that errors are not repeated and the learning experience is enhanced. This is
referred to as the standardise–do–check–Act (SDCA) cycle.
Service process Business processes producing external services, i.e., for the
respective clients. Performance processes are frequently called core processes.
Shareholder  Owner of shares in a hospital or a business.
Shareholder analysis  The value of a process from the point of view of the owner
or shareholder.
Situational analysis  Forms the basis for future concepts. It provides a detailed
description of the initial situation of a business. The situational analysis includes
a survey of the framework, a description of the actual situation and an analysis
of the data.
SMART method  Serves to unequivocally define goals (smart = clever). SMART
stands for: ‘specific, measurable, achievable, and relevant, time bound’.
Sponsors  Persons or a group of persons who have the power to restructure the
framework of business engineering and/or change management.
St Gallen approach  Developed in the early 1990s at the University of St Gallen.
It includes the basics and methods for business transformation caused by infor-
mation technology. The approach encompasses three levels of design: strategy,
process (organisation) and information system.
216 Glossary

Stakeholder  A person or a group (i.e., colleagues, CEO, patients, referring d­ octors,

suppliers, cost carriers) whose interests are affected by events or the results of the
project or processes.
Standard software  A term used for programmes that offer a pre-set solution for
a clearly defined area of application. Normally, this software must be purchased
or leased.
Strategic management  A way of conducting business in terms of goals, principles
and strategies. In the past, conducting business was largely a matter of principles
of liquidity or profitability; strategic management is guided by existing (or new)
success or market potential.
Support process  Business processes required for the successful completion of ser-
vice processes through subsequent actions or functions. Support services are all
the activities necessary for the implementation of management and core pro-
cesses (invisible and meaningless to the clients); these are processes producing
no, or low added value for the client; they serve to support the implementation
of core processes, have no strategic value for the business and can be partially
outsourced.
SWOT analysis  Serves to highlight internal strengths and weaknesses, external
opportunities and threats. A SWOT analysis can guide the direction and develop-
ment of business processes in a situational analysis.
Time to market  The time it takes for a product to be developed before being put
on the market. During this time period the product creates costs, but does not
generate income.
Two factor theory  Motivation theory according to Herzberg. It highlights job sat-
isfaction and consists of hygiene factors (dissatisfaction factors) as well as moti-
vational factors.
Value-added chain Divides the business into strategically relevant activities to
understand their role and to identify their potential to gain a competitive advan-
tage. The value-added chain is a simple aid for investigating all activities (pro-
cesses) in a business. In this way, you get an understanding how activities are
related and the roles they play within one’s competitive advantage.
Vision  An imagined concept of a specific future situation. In business, this is often
identical with a strategic aim. Vision is one of the management instruments in the
change management processes.
Weak-point analysis  An investigation for the purposes of identifying weaknesses,
errors and reasons for errors in a process or a system.
Work-breakdown structure (WBS) This documents all activities of a project;
it is a deliverable-orientated subdivision of the project into smaller tasks and
describes the plan for the structure of a project. It serves to divide a project into
controllable, manageable and plannable tasks.
Workflow  A sequence of process steps through which an automated business pro-
cess passes from initiation to completion.
Workflow management Support of business processes through automation or
information technology. This enables to support business process ­management
by means of technology.
Index

A CIRS. See Critical Incident Reporting System

ABC-analysis, 38, 59 (CIRS)
Advocates in CM, 116, 120, 123, 129, 130 Coaching, 73, 124, 198, 207
Agents in CM, 116, 124, 129, 130 Competitive advantage, 19–23, 29, 36, 63, 66,
Australasian Training Standards (ATS), 47, 48 67, 111, 159, 181, 201
Conflict management, 177–180, 183, 188,
190, 194
B Conflict management strategies, 188
Balanced Score Card (BSC), 56, 82, 131–144, Conflict resolution, 177, 179, 180, 182, 183,
146, 150, 152, 156–160 187–190
Base rate, 5, 131, 133 Continuous Improvement Process (CIP), 10,
Benchmarking, 28, 40, 42, 61–63, 65, 69, 71, 11, 56, 57, 61, 69, 71, 75–79, 86–88,
88, 132, 145, 187 129
Blockers in CM, 116, 119, 120, 122, 124 Core competencies, 18, 19, 23–25, 37, 38, 65,
BPR. See Business Process Re-Engineering 70–72, 87, 128
(BPR) Core process, 23, 24, 36, 37, 71, 74
British National Health System (NHS), 2 Corporate design, 13
BSC. See Balanced Score Card (BSC) Corporate identity (CI), xiii, 13–25, 79
Burnout, 205–206 Corporate image, 13, 14, 25
Burnout inventory, 205, 206 Critical Incident Reporting System (CIRS),
Business engineering, 27, 32–33, 35, 41, 42, 78, 105, 125–127, 130
43, 44, 61, 63–71, 82–83, 85, 86, 88,
106, 129, 150
Business model, 42–44 D
Business process, 19, 23–25, 27, 32–44, 63, Define-measure-analyse-improve-control-
67, 69–77, 79, 80, 83, 86–88, 106, 107, (DMAIC)-cycle, 61, 84
128, 132, 134, 136, 137, 150–152, 158 Diagnose related groups (DRGs), xi, xii, 16,
Business Process Re-Engineering (BPR), 63, 20, 23, 29, 69, 72, 131, 133, 135, 162
67, 69, 71–76, 86–88, 106, 129 Drama triangle, 98, 100–103, 177, 184
DRGs. See Diagnose related groups (DRGs)

C
Camp followers in CM, 116, 120 E
Cause-effect-chain in BSC, 138–140, 157 Effectiveness, 16, 38, 42, 43, 62–64, 71, 76,
Change management (CM), xii, 32, 41, 63, 88, 128, 134, 136, 194, 195, 201
105–108, 111, 114–124, 127–130 Efficiency, 1, 4, 6–8, 10, 19, 22, 38, 42, 43, 55,
CIP. See Continuous Improvement Process 64–66, 68, 71, 73, 76, 78, 86, 88, 128,
(CIP) 136, 159, 194

© Springer Berlin Heidelberg 2017 217

E. Weimann, P. Weimann, High Performance in Hospital Management,
DOI 10.1007/978-3-662-49660-2
218 Index

Empathic communication, 95 Maturity of employees, 198

Equity theory of motivation, 200 Mission, 13, 18, 65, 91, 133, 141, 156, 160,
196, 201, 202
MUDA, 56, 61, 80–83, 88
F
Feedback culture, 102–103
Five forces model, 20, 25, 34 N
Flight of the flamingos, 123, 174, 175 Noetive dissonance, 193, 201–203, 205–207
Four BSC perspectives for hospitals, 132–136 Non-verbal communication, 95, 97
Four ears of a receiver, 103
Four pillars of communication, 94–96
O
OOP. See Out of pocket payment (OOP)
G Organisational dispute culture, 181–184
GANTT chart, 54 Organisational resistance to change, 108
Out of pocket payment (OOP), xi, 2–4
Outsourcing, 37, 69, 105, 127–130, 146
H
Health care expenditure, 4
Health system, xi, xii, xiii, 1–10, 18, 20, 29, P
55, 72, 122, 133, 135, 159, 174 Pareto principle, 39
Parkinson’s law, 57
Performance indicators, 29, 42, 82, 83,
I 131–139, 141–150, 153–156, 158, 159
Iceberg conflict, 186 Plan-do-check-act (PDCA)-cycle, 61, 77–79,
Individual resistance to change, 108 81, 84, 88
Innovation, 9–11, 32, 38, 41, 66, 108, 121, PMBOOK, 47
123, 124, 150, 151, 155, 156, 169–170, Porter’s value chain, 13, 20, 22, 24, 25, 34
204 Process
ISO 9000 quality management, 42, 84–86, 88 maps, 19, 42–43
portfolio, 38–39
Project
K management, 27, 44–55
Kaizen, 57, 61, 69, 71, 75–87, 88, 129 organisation, 49, 50
Key performance indicators, 29, 42, 82, 83, planning triangle, 46
132, 138, 141–150, 153–156, 158, 159 portfolio management, 27, 54–55, 58
Kutzin framework on health care financing, 6 Projects in Controlled Environments 2
(PRINCE2), 48, 49

L
Lagging indicators, 134, 135, 143, 146, 147, Q
149–151, 154, 155 Quality management, xii, 38, 39, 41, 52, 55,
Leadership 63, 83–86, 88, 127
flaws, 195
styles, 92, 117, 171, 193–197
Leadership-/management process, 36 R
Leadership types, 198 Readmission rate, 131
Leading indicators, 135, 147–149, 151, 155 Resilience, 183, 185, 190
Lean management, 27, 56–60, 80
Levin’s change processes
S
Service process, 36–38, 83, 128, 151–152
M Seven-W-checklist for BPR, 73
Managing, 47, 115, 177, 181, 184, 198, 207 Six sigma, 61, 69, 71, 75–88
Maslow’s hierarchy of needs, 193, 196–197 SMART project goals, 46
Index 219

Source of conflict potential, 179 Two Factor Theory of Motivation, 200

South African National Health Insurance Type of employee, 198
(NHI), 2, 7
Spider’s web of a job profile, 166
Sponsors in CM, 115–117, 119–122, 124 U
Stages of conflict escalation, 180–181, Universal access to health care, 7
183, 190
Stakeholder, xii, xiii, 1–4, 6, 8, 10, 32, 35,
46–48, 50, 51, 58, 69–71, 84, 86, 88, V
93, 107, 112, 117, 127, 134, 138, 149 Value creation, 19, 22, 24, 36, 71, 84, 88, 145
Standardize-do-check-act (SDCA)-cycle, 77 Vision, xiii, 19, 23, 27–60, 65, 107, 115, 122,
Strategy, xii, 11, 13, 19, 21–25, 27–42, 44, 45, 131, 132, 134, 135, 137, 141–143, 146,
54, 58, 65, 69, 70, 83, 86, 91, 93–95, 153, 156–158, 196, 197
100, 106, 107, 111, 115, 117, 119, 122,
124–125, 131–160, 169, 174, 175, 182,
185–190, 199, 204, 207 W
Strategy map of the BSC, 138 Web of cultural analysis, 119, 124
Success factor analysis, 38–42 WHO Building Blocks for Health System
Success of a hospital, 15, 38, 39, 133, 148, strengthening, 8
154, 175 Winner triangle, 91, 100–103
Support-influence-matrix in CM, 119 Win-win-situations, 100, 184–186, 188
Swiss cheese model, 126 Work Break Down Structure (WBS), 52–54
SWOT-analysis, 27–32, 59 Work motivation, 15–17, 200
W-Questions in CM, 118

T
Transactional analysis, 91, 98–100, 103
Tuckman’s team building process, 172, 173