Five years ago, I was on a sabbatical, and I returned to the medical university where I studied. I saw real patients and I wore the white coat for the first time in 17 years, in fact since I became a management consultant.
Pre 5 godina bio sam na plaćenom odsustvu i vratio sam se na Medicinski fakultet gde sam studirao. Video sam prave pacijente i nosio sam beli mantil po prvi put u 17 godina, zapravo od kada sam postao konsultant upravljanja.
There were two things that surprised me during the month I spent. The first one was that the common theme of the discussions we had were hospital budgets and cost-cutting, and the second thing, which really bothered me, actually, was that several of the colleagues I met, former friends from medical school, who I knew to be some of the smartest, most motivated, engaged and passionate people I'd ever met, many of them had turned cynical, disengaged, or had distanced themselves from hospital management. So with this focus on cost-cutting, I asked myself, are we forgetting the patient?
Postojale su 2 stvari koje su me iznenadile tokom mesec dana mog boravka tamo. Prva stvar je bila je to što su zajedničke teme diskusija koje smo imali, bili bolnički budžeti i smanjenje troškova, a druga stvar, koja me je stvarno brinula, zapravo bila je to što nekoliko kolega koje sam sreo, kolege iz srednje medicinske škole, za koje sam znao da su među najpametnijim, najmotivisanijim, najangažovanijim i najstrastvenijim ljudima koje sam ikada sreo, mnogi od njih su postali cinični i odvojeni ili su se distancirali od bolničkog upravljanja. Sa fokusom na smanjenje troškova, pitao sam se, da li zaboravljamo na pacijenta?
Many countries that you represent and where I come from struggle with the cost of healthcare. It's a big part of the national budgets. And many different reforms aim at holding back this growth. In some countries, we have long waiting times for patients for surgery. In other countries, new drugs are not being reimbursed, and therefore don't reach patients. In several countries, doctors and nurses are the targets, to some extent, for the governments. After all, the costly decisions in health care are taken by doctors and nurses. You choose an expensive lab test, you choose to operate on an old and frail patient. So, by limiting the degrees of freedom of physicians, this is a way to hold costs down. And ultimately, some physicians will say today that they don't have the full liberty to make the choices they think are right for their patients. So no wonder that some of my old colleagues are frustrated.
Mnoge zemlje koje predstavljate i odakle ja dolazim se bore sa troškovima zdravstvenih usluga. To je veliki deo nacionalnog budžeta. Mnoge različite reforme pokušavaju da uspore ovaj rast. U nekim zemljama pacijenti dugo čekaju na operaciju. U drugim zemljama, novi lekovi se ne refundiraiju i stoga ne dolaze do pacijenata. U nekoliko zemalja, doktori i medicinske sestre su u neku ruku mete za vlade. Uostalom, skupocene odluke u zdravstvenoj nezi donose doktori i medicinske sestre. Izaberete skupocen laboratorijski test, izaberete da operišete starog i bolešljivog pacijenta. Ograničavajući stepen slobode lekara, ovo je način da se troškovi smanje. Na kraju, neki doktori će danas reći da nemaju potpunu slobodu da naprave izbore za koje misle da su pravi za njihove pacijente. Nije ni čudo onda da su neki od mojih starih kolega isfrustrirani.
At BCG, we looked at this, and we asked ourselves, this can't be the right way of managing healthcare. And so we took a step back and we said, "What is it that we are trying to achieve?" Ultimately, in the healthcare system, we're aiming at improving health for the patients, and we need to do so at a limited, or affordable, cost. We call this value-based healthcare. On the screen behind me, you see what we mean by value: outcomes that matter to patients relative to the money we spend. This was described beautifully in a book in 2006 by Michael Porter and Elizabeth Teisberg.
Na Bostonskoj grupi za konsultacije, pogledali smo ovo i zapitali smo se, ovo ne može da bude pravi način vođenja zdravstva. Stoga smo se vratili korak unazad i rekli: "Šta je to što želimo da postignemo?" U suštini, u sistemu zdravstvene nege, težimo da poboljšamo zdravlje naših pacijenata, i treba to da uradimo sa ograničenim ili pristupačnim troškovima. Mi ovo nazivamo zdravstvenom negom zasnovanom na vrednosti. Na ekranu vidite šta podrazumevamo pod vrednošću: ishodi koji se odnose na pacijente u odnosu na novac koji trošimo. Ovo je prelepo opisano u knjizi iz 2006. Majkla Portera i Elizabet Tajzberg.
On this picture, you have my father-in-law surrounded by his three beautiful daughters. When we started doing our research at BCG, we decided not to look so much at the costs, but to look at the quality instead, and in the research, one of the things that fascinated us was the variation we saw. You compare hospitals in a country, you'll find some that are extremely good, but you'll find a large number that are vastly much worse. The differences were dramatic. Erik, my father-in-law, he suffers from prostate cancer, and he probably needs surgery. Now living in Europe, he can choose to go to Germany that has a well-reputed healthcare system. If he goes there and goes to the average hospital, he will have the risk of becoming incontinent by about 50 percent, so he would have to start wearing diapers again. You flip a coin. Fifty percent risk. That's quite a lot. If he instead would go to Hamburg, and to a clinic called the Martini-Klinik, the risk would be only one in 20. Either you a flip a coin, or you have a one in 20 risk. That's a huge difference, a seven-fold difference. When we look at many hospitals for many different diseases, we see these huge differences.
Na ovoj slici se nalazi moj tast okružen sa svoje tri prelepe ćerke. Kada smo počeli da radimo istraživanja na BGK odlučili smo da ne gledamo toliko na troškove, nego na kvalitet, i u istraživanju, jedna od stvari koja nas je fascinirala bile su varijacije koje smo videli. Uporedite bolnice u zemlji, naći ćete neke koje su izuzetno dobre, ali ćete takođe naći veliki broj onih koje rade dosta lošije. Razlike su bile dramatične. Erik, moj tast, pati od raka prostate, i verovatno mu treba operacija. Živeći u Evropi, može da bira da ide u Nemačku koja ima sistem zdravstvene zaštite sa dobrom reputacijom. Ukoliko ode tamo i poseti prosečnu bolnicu, imaće rizik od dobijanja inkontinencije za oko 50 procenata, pa bi morao ponovo da počne da nosi pelene. Bacate novčić. 50% rizika. To je prilično mnogo. Da je umesto toga otišao u Hamburg, u kliniku po imenu Martini-Klinik, rizik bi bio jedan u 20. Ili bacate novčić ili imate rizik jedan u 20. To je velika, sedmostruka razlika. Kada pogledamo mnoge bolnice za mnoge različite bolesti, vidimo te ogromne razlike.
But you and I don't know. We don't have the data. And often, the data actually doesn't exist. Nobody knows. So going the hospital is a lottery.
Ali vi i ja ne znamo. Nemamo podatke. A podaci često zapravo ne postoje. Niko ne zna. Odlazak u bolnicu je lutrija.
Now, it doesn't have to be that way. There is hope. In the late '70s, there were a group of Swedish orthopedic surgeons who met at their annual meeting, and they were discussing the different procedures they used to operate hip surgery. To the left of this slide, you see a variety of metal pieces, artificial hips that you would use for somebody who needs a new hip. They all realized they had their individual way of operating. They all argued that, "My technique is the best," but none of them actually knew, and they admitted that. So they said, "We probably need to measure quality so we know and can learn from what's best." So they in fact spent two years debating, "So what is quality in hip surgery?" "Oh, we should measure this." "No, we should measure that." And they finally agreed. And once they had agreed, they started measuring, and started sharing the data. Very quickly, they found that if you put cement in the bone of the patient before you put the metal shaft in, it actually lasted a lot longer, and most patients would never have to be re-operated on in their lifetime. They published the data, and it actually transformed clinical practice in the country. Everybody saw this makes a lot of sense. Since then, they publish every year. Once a year, they publish the league table: who's best, who's at the bottom? And they visit each other to try to learn, so a continuous cycle of improvement. For many years, Swedish hip surgeons had the best results in the world, at least for those who actually were measuring, and many were not.
To ne mora da bude tako. Postoji nada. Kasnih '70-ih, postojala je grupa švedskih ortopedskih hirurga koji su se sreli na svom godišnjem sastanku, i počeli su da diskutuju o različitim procedurama koje su koristili za operaciju kuka. Na levoj strani ovog slajda, vidite razne metalne delove, veštačke kukove koje biste koristili za nekoga kome je potreban novi kuk. Svi oni su shvatili da imaju sopstveni način operisanja. Svi su tvrdili: "Moja tehnika je najbolja," ali nijedan od njih zapravo nije to znao i to su i priznali. Stoga su rekli: "Verovatno treba da merimo kvalitet da bismo znali i mogli da naučimo od najboljeg." Oni su zapravo proveli dve godine u raspravi: "Kakav je kvalitet operacije kuka?" "Trebalo bi da merimo ovo." "Ne, trebalo bi da merimo ono." I konačno su se dogovorili. Kada su se jednom dogovorili, počeli su da mere i da razmenjuju podatke. Veoma brzo, otkrili su da ukoliko stavite cement u kost pacijenta pre nego što unutra stavite metalnu cev, to je trajalo mnogo duže, i većini pacijenata više nije bila potrebna ponovna operacija za života. Objavili su podatke i to je zapravo preobrazilo kliničku praksu u zemlji. Svako je primetio da ovo ima dosta smisla. Od tada, objavljuju radove svake godine. Jednom godišnje, objavljuju tabelu saveza: ko je najbolji, ko je na dnu? Sreću se međusobno kako bi pokušali da uče i nastave stalni krug poboljšanja. Godinama, švedski hirurzi za kuk su imali najbolje rezultate na svetu, barem za one koji su zapravo merili, a mnogi nisu.
Now I found this principle really exciting. So the physicians get together, they agree on what quality is, they start measuring, they share the data, they find who's best, and they learn from it. Continuous improvement.
Smatram ovaj princip izuzetno uzbudljivim. Doktori se okupe, dogovore se šta je kvalitetno, počnu da mere, razmenjuju podatke, otkriju ko je najbolji i uče iz toga. Stalno poboljšanje.
Now, that's not the only exciting part. That's exciting in itself. But if you bring back the cost side of the equation, and look at that, it turns out, those who have focused on quality, they actually also have the lowest costs, although that's not been the purpose in the first place. So if you look at the hip surgery story again, there was a study done a couple years ago where they compared the U.S. and Sweden. They looked at how many patients have needed to be re-operated on seven years after the first surgery. In the United States, the number was three times higher than in Sweden. So many unnecessary surgeries, and so much unnecessary suffering for all the patients who were operated on in that seven year period. Now, you can imagine how much savings there would be for society.
Međutim, to nije jedino zanimljivo. To je zanimljivo samo po sebi. Ali ako se vratimo na deo jednačine s troškovima i pogledate to, ispostavlja se da su oni koji su se fokusirali na kvalitet zapravo imali i najniže troškove, iako to nije bila prvobitna svrha. Ako ponovo pogledate priču o operaciji kuka, urađeno je istraživanje pre nekoliko godina gde su poređene SAD i Švedska. Videli su kom broju pacijenata je bila potrebna ponovna operacija nakon 7 godina od prve. U SAD broj je bio tri puta veći nego u Švedskoj. To je mnogo nepotrebnih operacija i mnogo nepotrebne patnje za sve pacijente koji su bili operisani u periodu od sedam godina. Možete zamisliti kolika bi to ušteda bila za društvo.
We did a study where we looked at OECD data. OECD does, every so often, look at quality of care where they can find the data across the member countries. The United States has, for many diseases, actually a quality which is below the average in OECD. Now, if the American healthcare system would focus a lot more on measuring quality, and raise quality just to the level of average OECD, it would save the American people 500 billion U.S. dollars a year. That's 20 percent of the budget, of the healthcare budget of the country.
Napravili smo istraživanje sa podacima organizacije za ekonomsku saradnju i razvoj. Ova organizacija veoma često posmatra kvalitet nege gde mogu naći podatke o zemljama članicama. Za mnoge bolesti SAD zapravo imaju kvalitet koji je ispod prosečnog u OEES. Ukoliko bi se američki sistem zdravstvene nege fokusirao više na merenje kvaliteta, i podigao kvalitet na nivo prosečnog u OEES, to bi američkom narodu uštedelo 500 milijardi dolara godišnje. To je 20% budžeta, budžeta za zdravstvenu negu zemlje.
Now you may say that these numbers are fantastic, and it's all logical, but is it possible? This would be a paradigm shift in healthcare, and I would argue that not only can it be done, but it has to be done. The agents of change are the doctors and nurses in the healthcare system.
Možda ćete reći da su ovi brojevi fantastični i to je sve logično ali da li je moguće? Ovo bi bila promena paradigme u zdravstvenoj nezi, i ustanovio bih da to ne samo da može da se uradi, već i mora da se uradi. Agenti promene su doktori i medicinske sestre u sistemu zdravstvene nege.
In my practice as a consultant, I meet probably a hundred or more than a hundred doctors and nurses and other hospital or healthcare staff every year. The one thing they have in common is they really care about what they achieve in terms of quality for their patients. Physicians are, like most of you in the audience, very competitive. They were always best in class. We were always best in class. And if somebody can show them that the result they perform for their patients is no better than what others do, they will do whatever it takes to improve. But most of them don't know. But physicians have another characteristic. They actually thrive from peer recognition. If a cardiologist calls another cardiologist in a competing hospital and discusses why that other hospital has so much better results, they will share. They will share the information on how to improve. So it is, by measuring and creating transparency, you get a cycle of continuous improvement, which is what this slide shows.
U svojoj praksi kao konsultant, srećem verovatno stotinu ili više od stotine doktora i medicinskih sestara i ostalog bolničkog i zdravstvenog osoblja svake godine. Jedna stvar koja im je zajednička je da oni zaista paze na to šta postižu u smislu kvaliteta za svoje pacijente. Doktori su, poput mnogih vas u publici veoma takmičarski nastrojeni. Uvek su bili najbolji u generaciji. Bili smo najbolji u grupi. Ako neko može da im pokaže da rezultat koji pokazuju za svoje pacijente nije bolji od onog koji postižu drugi, uradiće bilo šta što je potrebno za poboljšanje. Ali većina njih ne zna. Ali doktori imaju drugu karatkeristiku. Oni zapravo napreduju kroz prepoznavanje uspeha od strane kolega. Ako kardiolog zove drugog kardiologa u suparničkoj bolnici i razmatra zašto ta druga bolnica ima toliko bolje rezultate, oni će to podeliti. Deliće informacije o tome kako se poboljšati. Dakle, kroz merenje i stvaranje transparentnosti dobijate ciklus stalnog usavršavanja, što je ono što vam ovaj slajd pokazuje.
Now, you may say this is a nice idea, but this isn't only an idea. This is happening in reality. We're creating a global community, and a large global community, where we'll be able to measure and compare what we achieve. Together with two academic institutions, Michael Porter at Harvard Business School, and the Karolinska Institute in Sweden, BCG has formed something we call ICHOM. You may think that's a sneeze, but it's not a sneeze, it's an acronym. It stands for the International Consortium for Health Outcome Measurement. We're bringing together leading physicians and patients to discuss, disease by disease, what is really quality, what should we measure, and to make those standards global. They've worked -- four working groups have worked during the past year: cataracts, back pain, coronary artery disease, which is, for instance, heart attack, and prostate cancer. The four groups will publish their data in November of this year. That's the first time we'll be comparing apples to apples, not only within a country, but between countries. Next year, we're planning to do eight diseases, the year after, 16. In three years' time, we plan to have covered 40 percent of the disease burden. Compare apples to apples. Who's better? Why is that?
Možete reći da je ovo dobra ideja, ali ovo nije samo ideja. Ovo se dešava u stvarnosti. Stvaramo globalnu zajednicu, veliku globalnu zajednicu, gde ćemo biti u mogućnosti da merimo i poredimo ono što smo postigli. Zajedno sa dve akademske institucije, Majkl Porter na Harvardskoj poslovnoj školi, i institutu Karolinska iz Švedske BGK je formirala nešto što zovemo IKMZI. Možda ćete pomisliti da je to kijavica, ali nije, to je skraćenica. To je skraćenica za Internacionalni konzorcijum za merenje zdravsvenih ishoda. Mi spajamo vodeće doktore i pacijente da zajedno diskutuju jednu po jednu bolest šta je zapravo kvalitetno, šta bi trebalo da merimo i da ti standardi postanu globalni. 4 radne grupe je radilo tokom prošle godine: katarakte, bol u leđima, bolest koronarnih arterija, što je, na primer, srčani udar, i rak prostate. Četiri grupe će objaviti svoje podatke u novembru ove godine. To je prvi put da ćemo porediti babe sa babama, ne samo unutar zemlje, već između zemalja. Sledeće godine, planiramo da uradimo 8 bolesti, a one tamo godine, 16. U trogodišnjem periodu planiramo da pokrijemo 40% opterećenja bolesti. Poređenje baba sa babama. Ko je bolji? Zašto to?
Five months ago, I led a workshop at the largest university hospital in Northern Europe. They have a new CEO, and she has a vision: I want to manage my big institution much more on quality, outcomes that matter to patients. This particular day, we sat in a workshop together with physicians, nurses and other staff, discussing leukemia in children. The group discussed, how do we measure quality today? Can we measure it better than we do? We discussed, how do we treat these kids, what are important improvements? And we discussed what are the costs for these patients, can we do treatment more efficiently? There was an enormous energy in the room. There were so many ideas, so much enthusiasm. At the end of the meeting, the chairman of the department, he stood up. He looked over the group and he said -- first he raised his hand, I forgot that -- he raised his hand, clenched his fist, and then he said to the group, "Thank you. Thank you. Today, we're finally discussing what this hospital does the right way."
Pre 5 meseci, vodio sam radionicu u najvećoj univerzitetskoj bolnici u severnoj Evropi. Imaju novog izvršnog direktora, a ona ima viziju: želim da svoju veliku instituciju više fokusiram na kvalitet, ishode koji se tiču pacijenata. Tog posebnog dana, sedeli smo na radionici, zajedno sa doktorima, medicinskim sestrama i ostalim osobljem, diskutujući o leukemiji kod dece. Grupa je diskutovala, kako merimo kvalitet danas? Možemo li da ga merimo bolje nego što to sad radimo? Razgovarali smo o tome kako lečimo tu decu, koja su bitna poboljšanja? Diskutovali smo o tome šta su troškovi tih pacijenata, možemo li obavljati tretman efikasnije? Bila je ogromna količina energije u sobi. Bilo je toliko ideja, toliko entuzijazma. Na kraju sastanka, predsedavajući odeljenja je ustao. Pogledao je grupu i rekao - prvo je podigao ruku, zaboravio sam to - podigao je ruku, stegnuo pesnicu, a zatim je rekao grupi: "Hvala vam." Hvala vam. Danas, mi konačno diskutujemo o tome šta ova bolnica radi na pravi način."
By measuring value in healthcare, that is not only costs but outcomes that matter to patients, we will make staff in hospitals and elsewhere in the healthcare system not a problem but an important part of the solution. I believe measuring value in healthcare will bring about a revolution, and I'm convinced that the founder of modern medicine, the Greek Hippocrates, who always put the patient at the center, he would smile in his grave.
Mereći vrednost zdravstvene nege, ne samo troškova već ishoda koji se tiču pacijenata, od osoblja u bolnicama i svuda u sistemu zdravstvene nege napravićemo ne problem, nego važan deo rešenja. Verujem da će merenje vrednosti u zdravstvenom sistemu doneti revoluciju, i uveren sam da bi se osnivač moderne medicine, Grk Hipokrat koji je uvek stavljao pacijenta u centar, verujem da bi se osmehivao u grobu.
Thank you.
Hvala vam.
(Applause)
(Aplauz)