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.
五年前我放了一段給薪假 回到醫學院 我的母校 實際看到病人,而且我還穿著白袍 已經17年沒有這種經驗 我成為管理顧問以後就停止了
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?
在醫學院的那個月 有兩件事令我訝異 第一件是我們討論的主題 常常圍繞著醫院預算 和削減成本 第二件事真的令我不安 有關我遇到的幾位同儕 我讀醫學院時交的朋友 我知道他們是我所認識的人中最聰明 最積極、最投入 也最有熱誠的人 但其中許多人變得悲觀、消極 或者不願與醫院管理沾上邊 所以強調削減成本 我捫心自問:我們是否忽略了病人
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.
很多你們所代表的國家 以及我的國家 都忙於應付保健的成本 該成本佔了國家大量的預算 許多改革專注於控制成本增長 在許多國家,得等上很長一段時間 病人才能動手術 其他國家,病人須自費買新藥 因此無法使用新藥 有些國家的醫生和護士 或多或少成了政府的標靶 畢竟保健的重大花費 掌握在醫生和護士的手中 他們選擇昂貴的檢測 他們選擇為體弱的老人動手術 因此,限制醫生選擇的自由 是壓低成本的一種方式 終於有些醫生如今表示 他們不能完全自由地 替病人的福利把關 難怪我的一些舊同僚會感到挫敗 難怪我的一些舊同僚會感到挫敗
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.
我們在BCG(波士頓顧問公司)探討了該現象 我們捫心自問 這種保健管理是行不通的 所以我們退一步思考 那我們的目標是什麼 保健體系終究是 為了改善病人的健康 並且在此目標下還須節制成本 至少要能夠負擔得起 我們稱之為「價值為主的保健」 螢幕上是我們所定義的價值 螢幕上是我們所定義的價值 病人關心的成效 相對於花費 2006年一本書對此有極佳的描述 作者是波特與泰斯伯格 (Michael Porter and 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.
這張照片是我的岳父 和圍繞他的三個女兒 我們在BCG開始研究時 決定不要著重於成本 而是要重視品質 研究當中有一件事讓我們相當感興趣 那就是各家醫院素質的參差不齊 比較同一國家的醫院 會發現有部分表現極佳 但還是有很大一部份的醫院素質差許多 優劣之間的差距驚人 我的岳父艾瑞克 罹患了攝護腺癌 可能需要動手術 他現居歐洲,可以選擇去德國就醫 德國的保健體系聲譽卓著 他如果去德國一家普通的醫院 手術後尿失禁的風險 大約是百分之五十的可能性 不幸的話,他就必須再度穿尿褲 一半的風險,等於擲硬幣,機率相當大 如果他去德國漢堡就醫 去當地的馬丁尼診所(Martini-Klinik) 風險只有二十分之一 看你是要擲硬幣 還是要冒那二十分之一的風險 二者差距之大,是十倍之差 我們檢視了許多醫院 觀察許多不同疾病 我們看到這種極大的差異
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.
但是一般人不會知道 因為我們沒有這些資料 而且通常這種資料並不存在 沒人知道差別 所以去醫院等於是抽籤
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.
我們不見得命該如此 還是有希望的 在1970年代晚期 有一群瑞典骨科醫生 在1970年代晚期 有一群瑞典骨科醫生 在醫學年會上相遇 會中他們探討應用在 髖關節手術的種種不同程序 會中他們探討應用在 髖關節手術的種種不同程序 圖左有多種 金屬物件,那是人工髖關節 用於需要置換髖關節的人 醫生們都知道各自的程序不同 他們都聲稱「我的技術最好」 但他們也承認沒人能確定 所以他們表示,我們可能需要衡量品質 這樣才能向最佳醫生學習 於是他們花了兩年時間辯論 髖關節手術品質的評估標準是什麼 噢,該測量這個 不,該測量那個 他們最後達成協議 一旦大家同意,他們開始測量 並且開始分享數據 他們很快發現,如果先把膠結材料 填入病人的骨頭 然後再置入金屬關節 其實會大大提高耐用度 大多數病人不再需要 日後重做手術 他們發表了結果 並且改變了全國的手術程序 大家都認為這很明智 從此以後,他們每年發表 每年公佈一次成績單 誰領先,誰殿後 他們互相參訪學習 不斷地循環改進 有很多年,瑞典的髖關節醫生 手術的結果全世界最佳 至少參與測量的醫生如此 很多醫生並未參與
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.
我認為這個原則真的令人興奮 醫生聚集起來 訂出一個品質的標準 開始測量,並分享數據 找出最佳醫生,然後向其學習 不斷改進
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.
這不是唯一值得興奮的部分 雖然已經很令人興奮了 但是如果再把成本 加入考量 我們發現注重品質的醫生 其醫療成本也最低 雖然成本一開始不是考量 我們再以髖關節手術為例 幾年前有研究 比較美國和瑞典 檢視有多少病人需要 在首次手術七年後再動手術 美國的數目 是瑞典的三倍 太多可以避免的手術 太多可以避免的痛苦 必需再動手術的病人 在七年間可避免的痛苦 想想看,避免重做手術 將替社會省下多少錢
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.
我們研究OECD的資料 (OECD為經濟合作開發組織之簡稱 ) OECD經常檢視保健的品質 OECD經常檢視保健的品質 只要他們能獲取成員國的資料 在美國,許多疾病 其實醫療品質 低於OECD的平均值 如果美國的保健體系 能夠更加著重於衡量品質 並把品質提高至OECD的平均水準 將替美國人 每年省5000億美元 那是預算的兩成 全國保健的預算
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.
你可能會說,這些數字 太棒了,而且言之成理 但實際可行嗎 保健需要典範轉移 我主張不但做得到 而且必須做到 改革的推手是醫生和護士 他們身處保健體系
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.
我以顧問的身份 每年大概會遇到上百位 醫生和護士,以及其他 醫院職員或保健工作人員 這些人的共同點是 他們非常在意自己的成就 治病品質方面的成就 醫生,就像大多數在場者 非常好勝 他們總是名列前茅 我們總是名列前茅 如果有人能證實 他們治病的成效 沒比別人好 他們會竭盡所能去改進 但多數不知道互相的成績 但是醫生還有一個特性 同儕的認可會讓他們進步 如果心臟病科醫生打電話給 另一家競爭醫院的同行 討論對方的醫院為什麼 成效好那麼多,他們會分享 他們會分享如何改善的資訊 所以藉由衡量品質與公開資訊 就能夠促使改進不斷地循環發生 就是這個圖顯示的
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?
或許你會說這是好主意 但這不只一個主意 這個主意正在實現 我們正在創立一個全球社群 大型的全球社群 我們在其中可以衡量比較 大家的成績 兩家學術機構 哈佛商學院的波特教授 以及瑞典的卡洛林斯卡(Karolinska)學院 和BCG共同成立了ICHOM 你或許以為那是打噴嚏 但那是一個縮寫 全名是「國際衡量健康成效聯盟」 全名是「國際衡量健康成效聯盟」 我們聚集了頂尖的醫師 還有病人,逐一討論各種疾病 品質到底是什麼 該如何衡量 並且制定全球的標準 目前四個工作小組 在過去一年已有成果 白內障,背痛 冠狀動脈疾病 就是心臟病這類的疾病 攝護腺癌 這四個小組的研究數據 將在今年11月發表 這將是我們首次 用同一標準比較,不只是國內互比 也是國際之間互比 明年我們計劃比較八種疾病 後年16種疾病 三年之內,我們計劃涵蓋 四成病人所患的疾病 拿蘋果和蘋果比,看看誰較佳 為什麼較佳
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 我在北歐最大的教學醫院 主持了一個研討會 我在北歐最大的教學醫院 主持了一個研討會 新院長表示她的願景是 對於這個大型機構的管理 我要更加注重病人關心的品質和成效 對於這個大型機構的管理 我要更加注重病人關心的品質和成效 那天我們在研討會上 和醫生、護士,及其他工作人員 討論兒童白血病 我們討論到 現在是如何衡量品質 衡量方法能改進嗎 我們討論治療兒童的方法 有什麼要項仍待改進 我們討論到這些病人的花費 治療是否能夠更有效率 全場活力十足 充滿了主意,充滿了熱情 會議結束時 該部門的主任起立 看著與會成員,說道 我忘了,他是先舉手 他舉手,握著拳頭 然後跟大家說:謝謝 謝謝,我們今天討論醫院的方式 終於走對路了
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.
藉由衡量保健的價值 不僅考量費用 也包括病人關心的成效 會使得醫院的職員 和保健體系其他工作人員 不再是問題,反而是解決方案的重點 我相信衡量保健的價值 會引發變革 我相信現代醫學之父 古希臘的希波克拉底 他總是以病人為中心 將會含笑九泉
Thank you.
謝謝
(Applause)
(掌聲)