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Subtitles and Transcript 0:11 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. 0:29 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? 1:08 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. 2:11 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. 2:53 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. 4:15 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. 4:26 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. 6:06 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. 6:22 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. 7:14 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. 7:54 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. 8:15 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. 9:24 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? 10:59 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." 12:13 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. 12:43 Thank you. 12:46 (Applause)
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Transcript Translated by Senzos Osijek Reviewed by Ivan Stamenkovic 0:11 Prije pet godina, bio sam na dopustu, i vratio sam se na medicinski fakultet gdje sam studirao Vidio sam prave pacijente i nosio sam bijelu kutu prvi put u 17 godina, zapravo otkako sam postao upravni konzultant. 0:29 Dvije su me stvari iznenadile tijekom mjeseca koji sam tamo proveo. Prva je da su česta tema razgovora koje smo vodili bili bolnički budžeti i smanjivanje troškova, druga stvar koja me jako smetala, je zapravo da sam susreo nekoliko kolega, nekadašnjih prijatelja s medicinskog fakulteta, koje sam znao kao neke od najpametnijih, najmotiviranijih, najangažiranijh i najstrastvenijih ljudi koje sam ikada upoznao, mnogi od njih su postali cinični, neangažirani, ili su se distancirali od bolničke uprave. S ovim fokusom na smanjivanje troškova, Zapitao sam se, zaboravljamo li pacijenta? 1:08 Mnoge od zemalja koje vi predstavljate, i ona iz koje sam ja došao, bore se s troškovima zdravstvene skrbi. To je velik dio državnih proračuna. I mnoge se reforme trude da se taj rast zaustavi. U nekim zemljama, imamo duge liste čekanja pacijenata na operacije. U drugim se zemljama ne nabavljaju novi lijekovi, te tako nisu dostupni pacijentima. U nekim zemljama, lječnici i medicinske sestre su u nekoj mjeri mete vladama. Na posljetku, skupe odluke u zdravstvenoj skrbi donose liječnici i sestre. Vi birate skupu laboratorijsku pretragu, birate operirati starog i slabog pacijenta. Tako da je ograničavanje slobode liječnika način za snižavanje troškova. Na kraju, neki liječnici danas kažu kako nemaju punu slobodu donijeti odluke za koje mislie da su najbolje za njihove pacijente. Nije čudo da su neki od mojih starih kolega frustrirani. 2:11 Na BCG-u smo ovo razmatrali, i zaključili smo, da to ne može biti ispravan način upravljanja zdravstvenom skrbi. Odmakli smo se korak unazad i zapitali, „Što to pokušavamo postići?“ Konačno, u sustavu zdravstvene skrbi, želimo poboljšati zdravlje pacijenta, i to trebamo napraviti uz ograničen, ili prihvatljiv trošak. Zovemo to zdravstveni sustav usmjeren na vrijednost. Na zaslonu iza mene, vidite što mislimo kada kažemo vrijednost: ishodi koji su važni pacijentima u odnosu na novac koji potrošimo. Ovo je prekrasno opisano u knjizi iz 2006. koju su napisali Michael Porter i Elizabeth Teisberg. 2:53 Na ovoj slici, imate mog zeta okruženog s njegove prekrasne tri kćeri. Kada smo započeli s našim istraživanjem na BCG-u, odlučili smo se ne posvetiti toliko troškovima, nego kvaliteti, i u istraživanju, jedna od stvari koja nas je fascinirala bila je raznolikost koju smo vidjeli. Ako usporedite bolnice u jednoj zemlji, naći ćete neke izrazito dobre, ali naći ćete i velik broj onih koje su značajno lošije. Razlike su bile dramatične. Erik, moj punac, pati od raka prostate, i vjerojatno treba operaciju. Kako živi u Europi, može izabrati otići u Njemačku čiji je zdravstveni sustav na dobrom glasu. Ako ondje ode u prosječnu bolnicu, imat će rizik da postane inkontinentan od oko 50 posto, znači da opet mora početi nositi pelene. To je kao bacanje novčića. Rizik od 50 posto je prilično velik. Ako bi umjesto toga išao u Hamburg, u kliniku koja se zove Martini-Klinik rizik bi ondje bio jedan od 20. Tako da ili bacate novčić, ili imate rizik 1 prema 20. To je ogromna razlika, sedmerostruka razlika. Ako gledamo puno bolnica i puno bolesti, vidimo ogromne razlike. 4:15 Ali vi i ja ne znamo. Nemamo podatke. Često, podaci zapravo ni ne postoje. Nitko ne zna. Tako da je odlazak u bolnicu lutrija. 4:26 Ne mora biti tako. Postoji nada. U kasnim '70-im bila je grupa švedskih ortopeda koji su imali godišnji sastanak, razgovarali su o različitim postupcima koje su koristili u operaciji kuka. Na lijevoj strani vidite mnoštvo metalnih komada, umjetnih kukova koji se koriste kada osobi treba novi kuk. Shvatili su da svatko od njih ima svoj individualni način operiranja. Svi su govorili kako je njihova tehnika najbolja, ali nitko od njih nije zapravo znao, priznali su to. Rekli su: „Trebamo odrediti kvalitetu tako da znamo i možemo učiti od najboljega.“ Proveli su dvije godine u raspravi, „Što zapravo znači kvaliteta u operaciji kuka?“ „Trebali bismo mjeriti ovo.“ „Ne, trebali bi mjeriti ono.“ I konačno su se složili. Jednom kada su se složili, krenuli su mjeriti, i dijeliti svoje podatke. Vrlo su brzo shvatili da ako stave cement u pacijentovu kost prije nego što stave metalnu osovinu, trajat će duže, i većina pacijenata neće morati biti ponovo operirana do kraja života. Objavili su podatke, i promijenili kliničku praksu u zemlji. Svi su vidjeli da to ima smisla. Od tada, svake godine objavljuju. Jednom godišnje objave ljestvicu: tko je najbolji, tko je na dnu? Posjećuju jedni druge pokušavajući učiti, tako nastaje neprekidan krug pobojšanja. Već mnogo godina, švedski ortopedi imaju najbolje rezultate na svijetu, barem među onima koji su ih mjerili, a mnogi nisu. 6:06 Smatram ovu ideju vrlo uzbudljivom. Liječnici se okupe, slože se oko toga što znači kvaliteta, počnu mjeriti, podijele podatke, otkriju tko je najbolji, i uče od njega. Stalni napredak. 6:22 To nije jedini uzbudljivi dio. To je uzbudljivo samo po sebi. Ako se sjetimo novčane strane jednadžbe, i pogledamo ju, ispadne da oni koji su se usredotočili na kvalitetu, imaju najniže troškove, iako im to nije bila prvotna svrha. Ako se vratimo na priču o operaciji kuka, prije nekoliko godina je rađena studija gdje su uspoređeni SAD i Švedska. Razmatralo se koliko je pacijenata trebalo reoperaciju unutar sedam godina nakon prve operacije. U SAD-u je broj bio tri puta veći nego u Švedskoj. Toliko nepotrebnih operacija, toliko nepotrebne patnje za sve pacijente koji su bili ponovo operirani u tom sedmogodišnjem periodu. Možete zamisliti koliko bi tu uštede bilo za društvo. 7:14 Napravili smo studiju u kojoj smo gledali podatke OECD-a. OECD povremeno uspoređuje kvalitetu njege u zemljama članicama u kojima mogu naći podatke. SAD ima, za mnoge bolesti kvalitetu koja je ispod prosjeka OECD-a. Kada bi se američki sustav zdravstvene skrbi više usredotočio na mjerenje kvalitete, i podigao kvalitetu samo na razinu prosjeka OECD-a, to bi uštedjelo Amerikancima 500 milijardi dolara godišnje. To je 20 posto proračuna, proračuna za zdravstvo u državi. 7:54 Možda ćete reći da su svi ti brojevi fantastični, i da je sve logično, no je li moguće? To bi bila promjena paradigme u zdravstvenom sustavu, i ja smatram da to ne samo može biti napravljeno, nego to mora biti napravljeno. Pokretači promjene su liječnici i medicinske sestre u zdravstvenom sustavu. 8:15 Dok sam radio kao konzultant, upoznao sam vjerojatno stotinu ili više liječnika i medicinskih sestara i drugog bolničkog ili zdrastvenog osoblja svake godine. Jedna osobina koja im je svima zajednička je to da zbilja brinu o tome što će postići u vidu kvalitete za svoje pacijente. Liječnici su, kao većina vas u publici, vrlo kompetitivni. Uvijek su bili najbolji u razredu. Mi smo uvijek bili najbolji u razredu. Ako im netko pokaže da rezultat rada koji obave za pacijente nije ništa bolji od onoga što drugi rade, napravit će što god treba da to poprave. Ali mnogi od njih ne znaju. Liječnici imaju još jednu osobinu. Vrlo su sretni kada dobiju priznanje drugih liječnika za svoj rad. Ako kardiolog pozove drugog kardiologa u konkurentsku bolnicu da rasprave zašto ta druga bolnica ima toliko bolje rezultate, oni će dijeliti. Oni će dijeliti informacije o tome kako napredovati. Tako da, mjerenjem i stvaranjem transparentnosti dobijete ciklus stalnog napredovanja, što je upravo ovdje prikazano. 9:24 Možda ćete reći da je ovo zgodna ideja, ali to nije samo ideja. To se događa u stvarnosti. Stvaramo globalnu zajednicu, veliku globalnu zajednicu, gdje ćemo biti sposobni izmjeriti i usporediti naša postignuća. Zajedno s dvije akademske institucije, Michael Porter u Harvard Business School, i Karolinska Institutom u Švedskoj, BCG je stvorio nešto što zovemo ICHOM. Možda mislite da to zvuči kao kihanje, ali to nije kihanje, nego akronim. Stoji za Internacionalni Konzorcij za Mjerenje Zdravstvenih Ishoda. Okupljamo vodeće liječnike i pacijente kako bismo raspravili, bolest po bolest, što je zapravo kvaliteta, što bi trebali mjeriti, kako bismo izradili globalne standarde. Radili su – četiri grupe su radile tijekom prošle godine: mrene, bolovi u leđima, bolesti koronarnih arterija, što je npr. infarkt, i rak prostate. Četiri će grupe objaviti svoje podatke u studenome ove godine. To je prvi put da ćemo uspoređivati „jabuke i jabuke“, ne samo unutar zemlje, nego i među različitim zemljama. Iduće godine, planiramo obraditi osam bolesti, godinu poslije, 16. U tri godine, planiramo pokriti 40 posto tereta bolesti. Uspoređujemo jabuke i jabuke. Tko je bolji? Zašto je to tako? 10:59 Prije pet mjeseci, vodio sam radionicu u najvećoj sveučilišnoj bolnici u sjevernoj Europi. Imaju novu glavnu izvršnu direktoricu, ona ima viziju: Želim upraviti ovu veliku instituciju više prema kvaliteti, ishodima koji su važni pacijentima. Toga smo dana sjedili na radionici zajedno sa liječnicima, sestrama i drugim osobljem, raspravljajući o leukemiji kod djece. Grupa je raspravljala, o tome kako danas mjerimo kvalitetu? Može li se mjeriti bolje nego sada? Razgovarali smo o tome kako liječimo tu djecu, koja su važna poboljšanja? I raspravljali smo o troškovima tih pacijenata, možemo li efikasnije provesti liječenje? U sobi je postojala ogromna energija. Bilo je toliko ideja, toliko entuzijazma. Na kraju sastanka, predsjednik odjela je ustao. Pogledao je grupu i rekao -- prvo je podigao ruku, to sam zaboravio -- podigao je ruku, stisnuo šaku, i obratio se grupi, „Hvala vam. Hvala vam. Danas konačno raspravljamo o onome što ova bolnica radi na pravi način.“ 12:13 Mjerenjem vrijednosti u zdravstvenoj skrbi, što nisu samo troškovi nego i ishodi bitni pacijentima, učinit ćemo osoblje u bolnicama i drugdje u zdravstvenom sustavu ne problemom, nego važnim dijelom rješenja. Vjerujem da će mjerenje vrijednosti u zdravstvenom sustavu donijeti revoluciju, i uvjeren sam da bi se osnivač moderne medicine, grčki Hipokrat, koji je uvijek stavljao pacijenta u središte, nasmiješio u svom grobu. 12:43 Hvala vam.