The Herdecke Community Hospital: Goals and Experiences

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By: Konrad Schily, M.D.
The Herdecke Community Hospital has been operating successfully since 1969, and there was a great deal of publicity when it opened. Medical circles questioned so much attention and voiced the suspicion that it represented some type of press campaign. No other explanation could be seen for so much press, radio and television coverage because, first, the hospital was too small to be used as a standard, and second, it operated under unique circumstances and thus, could not be considered as a real alternative to the existing system.

The radical left-wing political parties also were suspicious of the model for this hospital and the ensuing publicity. There was talk about "fraudulent self-administration" and weakening of "class-conscious colleagues who represent the interests of the working population."

The persons responsible for Herdecke never planned this publicity. From the start we were of the opinion that three to five years of operating experience were necessary before this model could be evaluated satisfactorily.

For ten years (1958-1968) we had tried to build a hospital run along Anthroposophical lines, somewhere in the Federal Republic of Germany. Finally, construction began in 1968 and was completed in 1969. The opening occurred at a time when the problems of hospitals were being widely discussed. It was a time, also, when Mr. Woythal, district councilman from Hanau, publicized the concept of the so-called "classless hospital." Since many of Mr. Woythal's criteria were met at Herdecke, the Herdecke model was often regarded as a prototype of the classless hospital.

The Herdecke hospital project makes no attempt to change the basic structure of hospital care, but it does try to combine material and human resources into a smoothly-running operation. Medical practice which claims to be scientific and judicious must be free of dogma. It can rely. only on experience and scientific thinking if it is to be scientific. The "Herdecke model" of the hospital therefore does not represent a particular philosophy of life. It would lose the character of a model if only persons with a certain philosophy could work there.

Thus, the goals of Herdecke are consistent with the modern practice of medicine; with the current "explosion of knowledge", with ever-evolving technology of medicine, we notice increasing specialization in clinical and laboratory medicine. Although there are many specialists with different amounts of experience working at Herdecke Hospital, no hierarchical administrative structure exists.

A non-hierarchic form of administration was chosen which requires that all individuals recognize the goals of the operation and that they be willing to share the responsibility for making decisions. This explains why the Herdecke structure does not include the so-called medical superintendant or chief-of- staff (Chefarzt, in German). It was necessary to set up Boards -- groups with distinct responsibilities -- responsible for the medical and administrative functions of the hospital; the operation is no longer organized vertically hierarchically, but horizontally, according to the flow of work.

This principle is applied not only to the medical staff but to all personnel within the hospital. It is not a question of egalitarianism. It rather addresses a clear delineation of professional authority obviating extraneous duties but also delineating clearly defined responsibilities. There is a hierarchy in Herdecke, but it is a professional one, built into the Board System. Authority means efficiency and dedication, not position. The individual responsible for a certain task cannot escape judgment by others and thus his performance is critically appraised by the group. The Herdecke model does not restrict but widens the opportunities for realizing individual potential.

We coined the term "differentiated system of boards" to describe our model, since boards encompassing diverse professions have to work together as a whole. The Herdecke model addresses itself to the independent citizen. The personnel have ample opportunity freely to develop their professional and personal initiative. The likelihood of arbitrary action is severely curtailed. Each colleague must be aware of the common goal, must recognize the work-flow in its whole cycle, and must be able to influence changes in the entire structure. As Professor Lievegoed (B. Lievegoed, M.D. Director and Founder of the Netherlands Pedagogical Institute (NPI) which studies and counsels organizations on group functioning.) says: "Purposelessness blocks individual thinking, isolation on the job erodes feelings, powerlessness paralyzes use of the will."

Such a structure specifies the following:

1. The individual must not be compelled to offer his human labor as a commodity, but must contribute his talents to the group. The group takes care of his private and professional needs. His work, so to speak, dissolves in the system, but the system takes care of him.

2. The power to decide on equipment and instruments must not rest with outsiders, but with those who responsibly use the equipment.

3. All employees must be equal before the law and precise democratic legal procedures must be set up.

The entire work force is divided into professional groups. Basically, they must organize themselves. The hospital is managed by an administration consisting of the delegates of the professional groups. The nursing-care unit is headed by four people, and two of these positions rotate every year. The corporate structure is a non-profit association. Membership in the association is voluntary (presently about 65 persons). Voting members must be employees of the hospital or other institutions of the association. This type of organization has no adverse effects on decision-making and has proven to be flexible and effective.

The Herdecke Community Hospital as of today has five full-time departments (Internal Medicine, Surgery, Pediatrics, Gynecology and Obstetrics, Neurology) and two departments (Ophthalmology and Ear, Nose, and Throat) staffed by doctors who are part-time in the hospital. For these seven specialty departments there are almost 200 beds and about 80 nurses. Presently, 12 specialist M.D.'s and 12 interns work in the hospital (1979).

The building was erected quickly and at unusually low construction costs, yet with first-class furnishings and equipment. The associated Teaching Hospital for Nursing now has sixty students. The present size of the hospital is not ideal; there is a plan to enlarge the facility to about 500 beds. (Since the writing of this article, the hospital has expanded to 500 beds as planned. - ed.) There are no plans for further enlargement after that, lest the hospital becomes too large to administer well.

The planning of the facility started six years ago and has proven that building rooms with only one or two beds did not increase construction costs. From the beginning, provisions were made for care in semi-private rooms for patients under RVO coverage (corresponding to Blue Cross/Blue Shield coverage in the U.S.). All patients are treated equally, whether rich or poor, although it is no secret that the payments of private patients in Herdecke enable us to maintain our high standards of service for all patients. The fact that full time doctors are on salary eliminates any financial relation between patient and individual doctor. We hope that the new laws on hospital rates pending in Germany will take the efficiency of individual hospitals into account, thereby enabling them to continuously improve their structure.

Many requests and recommendations from political and scientific-medical committees have been considered and realized in Herdecke. We believe one of the special advantages of our model to be our ability to apply medical knowledge and scientific results in a quick and unbureaucratic manner.

The Herdecke endeavor has tried to realize the goals described above and continues to pursue this aim. We do not claim to offer the only solution. Different models are available with the same qualifications but with many variations. Yet they all have one thing in common: there must be a willingness to change. We believe that the medical profession itself has to work out the reforms that become necessary with time; otherwise, outside forces will make their appearance and take over. The physician is the number one specialist of today and he must be able to work in this hospital with new and greater responsibilities. If the physician does not initiate the necessary reforms, someone else will.

In his practice and in the hospital, an independent and mature physician must be able to confront an independent and mature patient in such a way that neither will be degraded into a technical and bureaucratic puppet -- but both will preserve their character as free individuals. This is the goal of the efforts represented by the term, "Herdecke model."

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