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.
五年前,我放咗一年假 之後我返去我以前讀過嘅醫學院 十七年嚟,自從我做咗顧問之後 我第一次見到病人同著住白袍 嗰個月裡面,有兩樣令到我好驚訝
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?
第一樣,嚟嚟去去都只係講同一樣嘢 唔係醫院預算,就係開源節流 第二樣,真係令我非常煩 就喺之前識得嘅幾個同事 以前讀醫學院嘅同學 佢哋都好醒目 好有鬥志、有承擔、滿腔熱血 但係,佢哋好多都睇穿人性嘅羞惡 已經無曬擔戴 又或者已經對醫院管理置之不理 所以呢,當醫院講緊節流 我就問自己 我哋係唔係忘記咗病人呢?
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.
在座各位你哋嘅國家,同我嘅國家 都要處理醫療嘅開支問題 呢樣係佔咗國家預算嘅一大筆 好多唔同嘅改革 都想限制醫療嘅開支增長 有啲國家,病人做手術要排好耐 有啲國家,新藥唔可以報銷 所以新藥病人用唔到 有啲國家,醫生同護士某程度上 係政府落手嘅對象 畢竟,醫療開支係由醫生同護士做決定 你揀好貴嘅實驗測試 你選擇幫又老又殘嘅病人做手術 就係咁,政府想限制醫生 從而削減開支 到最後,有啲醫生就話 佢哋就算覺得有啲決定對病人有益 佢哋都落實唔到 所以,都好難怪我有啲舊同事咁沮喪 喺 BCG,我哋討論到呢個問題
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.
我哋問自己 咁樣做醫療管理係行唔通? 所以我哋退後一步諗︰ 我哋想達到咩目標? 我哋希望喺醫療系統裡面 用有限或負擔得起嘅預算 最終可以改善病人健康 我哋叫呢個做 以成本效益為本嘅醫療 我身後嘅屏幕,大家可以見到何謂價值 既可以幫到病人 我哋開支又可以控制喺合埋水平 2006 年一本書描述得好好 書嘅作者係 Michael Porter 同 Elizabeth Teisberg
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.
呢張相,你見我岳父同佢身邊三個女 當時我哋喺 BCG 開始做研究 我哋決定唔好太介意使費幾多 反而要注重研究質量 研究裏面,有一樣嘢令我哋讚嘆嘅 係我哋見到分別 你比較一個國家嘅醫院 你會發現有啲醫院做得好好 但其他好多醫院就水皮 分別非常之大 Erik 我嘅岳父 佢有前列腺癌 佢需要做手術 佢宜家住喺歐洲,佢可以選擇去德國 德國有出名嘅醫療系統 如果佢選擇去嗰度 住一間中等水平嘅醫院 佢手術後大小失禁嘅機會係 50% 如果真係咁嘅話,佢就又要再著過尿片 你掟個銀仔,50% 風險都幾多 但係,如果佢決定去漢堡 一間叫 Martini-Klinik 嘅診所 風險就會降到 5% 一係你就 50% 風險 一係就 5% 風險 差別好大,兩者相差十倍 只有當我哋去睇好多醫院 睇唔同嘅病 我哋至知道有咁大嘅分別
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.
但事前你同我都唔知道。我哋冇數據 好多時,數據根本唔存在 從來冇人知兩間醫院有分別 所以去醫院就好似買六合彩咁
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.
宜家,已經唔使再估估下 我哋有希望 七十年代尾,有一班瑞典整形外科醫生 佢哋每年都開會 討論佢哋臀部手術過程中 用嘅唔同方法步驟 投影片左邊,你可以見到 唔同嘅金屬件、人造臀部 應用喺病人身上 佢哋都知道,佢哋各自有一套手術方法 個個都話佢嘅技術係最優秀 但冇一個知道佢哋自己嗰個係最好 所以佢哋就話︰「我哋要評估質素, 咁樣先知邊個最好,學最好嗰個。」 跟住,佢哋用咗兩年時間拗,譬如 臀部手術嘅質量點樣定義? 「我哋評估呢個。」 「唔係,我哋評估嗰個。」 最後佢哋至達成共識 有咗共識之後 佢哋就開始評估,開始交換數據 好快,佢哋就發現 如果先將膠接劑放入病人舊骨度 再將金屬桿放入去 咁樣會更加持久耐用 而且大部分病人有生之年 都唔需要再做手術 呢班人登咗呢啲數據 將佢哋國家嘅臨床診治模式 嚟個大革新 人人都覺得咁樣做更加合理 嗰次之後,佢哋就年年刊登一次 佢哋每年都會刊登一個表: 話畀人知邊個係最好同最差嘅醫生 而且佢哋會逐個拜訪、學習 所以至會不斷有改善 多年嚟,就算只有 少數瑞典臀部手術嘅醫生有評估結果 但佢哋做出嚟嘅手術結果 係全世界最好嘅 我發現呢個措施真係好好
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.
醫生可以走埋一齊,傾好質素嘅定義 佢哋量度同交換數據 跟最好嘅學習,不斷咁改善 呢個唔止令人開心
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.
佢本身就係一樣好嘢 你諗返起計算開支嘅方程式 就會發現之前嗰啲關注質素嘅人 雖然冇將開支擺喺首位 但佢哋嘅使費都係最低 所以,你睇返幾年前 一個臀部手術嘅研究 比較美國同瑞典 研究人員統計 幾多個病人需要喺第一次手術之後 七年內要再做手術 美國嘅數字比瑞典高出三倍 咁樣講 好多病人做咗好多不必要嘅手術 經歷過好多不必要嘅痛苦 你又可以想像社會可以慳返幾多錢
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.
我哋做過一個研究 觀察經濟合作與發展組織 OECD 嘅數據 OECD 定期調查成員國嘅生活質素 佢哋集合成員國嘅數據 美國好多病嘅治療水平都係 低於 OECD 嘅平均 咁樣講 如果美國醫療系統 專注多啲喺質素上面 將水平提高到 OECD 嘅平均水平 就可以幫到美國人 每年慳返五千億美元 亦即係慳返國家醫療預算嘅兩成 你可能話
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.
呢啲數據好好,非常合邏輯 但係,有冇可能做到? 呢個會係醫療嘅改革示例 我堅信,不單止可以做到 而且必須要做 而改革者係醫療系統嘅醫生同護士 我做諮詢咁耐
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.
年年都會見過百個 甚至更多嘅醫生、護士 同其他醫護員工 佢哋有一個共同點: 佢哋真係好緊張 為病人服務嘅質素 醫生,正如在座咁多位一樣 非常拼搏 佢哋一直都係班內最優秀 我哋一直都係班內最優秀 如果有人可以話畀佢哋知 佢哋醫人嘅結果比其他人差 佢哋會用盡一切方法改善 但係,佢哋大部分 都唔知道比其他人差 但係醫生有另一個特點: 佢哋渴望得到行內認同 如果一個心臓科醫生 打電話畀對手醫院嘅一個心臓科醫生 問佢點解佢間醫院有更好結果時 嗰個醫生會分享俾佢聽 佢哋會分享改善方法 所以,因為有透明度,你可以不斷改善 正如投影片所講一樣 咁你可能會話,諗法唔錯
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?
但係呢個唔止係諗法 呢樣嘢真係發生咗 我哋嘗試令到全世界 都可以評估同比較醫療結果 BCG 聯同兩間學術機構 哈佛商學院嘅 Michael Porter 同瑞士嘅卡羅林斯卡醫學院 已經成立咗一個叫 ICHOM 嘅機構 你可能以為我打乞嗤 呢個唔係乞嗤,而係一個縮寫 全名係︰健康成果測量國際聯盟 我哋令頂尖醫生同病人 一齊討論每一種疾病 咩為之質素 我哋應該量度啲乜嘢 務求令標準國際化 佢哋都做緊 舊年有四個工作小組做梗 白內障、背痛 冠心病,例如心臓病 同前列腺癌 四個小組會喺今年十一月 刊登佢哋嘅數據 呢次會係第一次 我哋真正比較到同類嘅嘢 唔止係比較國內 而係比較唔同國家 下一年,我哋計劃研究八種疾病 再下一年,研究十六種 三年內,我哋計劃覆蓋 疾病總數嘅四成 比較同類型邊個好啲? 同埋點解?
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."
五個月前,我喺北歐最大嘅大學醫院 主持一個工作坊 怇哋請咗新 CEO,佢有一個願景: 令醫院注重多啲病人嘅 醫療質素同醫療成果 嗰日,我哋喺工作坊 同一啲醫生、護士同其他員工一齊坐 討論兒童白血病 我哋討論咗: 我哋應該點樣評估質素? 現有評估方法可唔可以改善? 我哋討論:點樣醫好呢啲兒童 有咩重大嘅進步? 我哋又討論:啲病人要使幾多錢 我哋可唔可以更有效咁治療? 當時房裏邊啲人好積極 有好多想法、好熱情 會議結束時,系主任企起身 佢望下小組 佢舉手,緊握拳頭 然後對小組嘅人講: 「多謝你哋,今日我哋終於可以討論 呢間醫院應該點樣做。」
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.
通過評估醫療成效 其中不單止費用,仲包括治療嘅成果 我哋會令到醫院嘅員工 以至醫療系統其他崗位 唔再係煩惱 而係解決方案嘅重要一部分 我相信,評估醫療成效會帶嚟革命 我相信現代醫學嘅始祖 希臘嘅希波克拉底 一位永遠將病人放喺第一位嘅人 會喺上天覺得欣慰
Thank you.
多謝
(Applause)
(掌聲)