Stefan Larsson: What doctors can learn from each other

Prevoditelj: Senzos Osijek Recezent: Ivan Stamenković

Five years ago, I was on a sabbatical,

Prije pet godina, bio sam na dopustu,

and I returned to the medical university

i vratio sam se na medicinski fakultet

where I studied.

gdje sam studirao

I saw real patients and I wore the white coat

Vidio sam prave pacijente i nosio sam bijelu kutu

for the first time in 17 years,

prvi put u 17 godina,

in fact since I became a management consultant.

zapravo otkako sam postao upravni konzultant.

There were two things that surprised me

Dvije su me stvari iznenadile

during the month I spent.

tijekom mjeseca koji sam tamo proveo.

The first one was that the common theme

Prva je da su česta tema

of the discussions we had were hospital budgets

razgovora koje smo vodili bili bolnički budžeti

and cost-cutting,

i smanjivanje troškova,

and the second thing, which really bothered me,

druga stvar koja me jako smetala,

actually, was that several of the colleagues I met,

je zapravo da sam susreo nekoliko kolega,

former friends from medical school,

nekadašnjih prijatelja s medicinskog fakulteta,

who I knew to be some of the smartest,

koje sam znao kao neke od najpametnijih,

most motivated, engaged and passionate people

najmotiviranijih, najangažiranijh i najstrastvenijih ljudi

I'd ever met,

koje sam ikada upoznao,

many of them had turned cynical, disengaged,

mnogi od njih su postali cinični, neangažirani,

or had distanced themselves from hospital management.

ili su se distancirali od bolničke uprave.

So with this focus on cost-cutting,

S ovim fokusom na smanjivanje troškova,

I asked myself, are we forgetting the patient?

Zapitao sam se, zaboravljamo li pacijenta?

Many countries that you represent

Mnoge od zemalja koje vi predstavljate,

and where I come from

i ona iz koje sam ja došao,

struggle with the cost of healthcare.

bore se s troškovima zdravstvene skrbi.

It's a big part of the national budgets.

To je velik dio državnih proračuna.

And many different reforms aim at holding back this growth.

I mnoge se reforme trude da se taj rast zaustavi.

In some countries, we have long waiting times

U nekim zemljama, imamo duge liste čekanja

for patients for surgery.

pacijenata na operacije.

In other countries, new drugs are not being reimbursed,

U drugim se zemljama ne nabavljaju novi lijekovi,

and therefore don't reach patients.

te tako nisu dostupni pacijentima.

In several countries, doctors and nurses

U nekim zemljama, lječnici i medicinske sestre

are the targets, to some extent, for the governments.

su u nekoj mjeri mete vladama.

After all, the costly decisions in health care

Na posljetku, skupe odluke u zdravstvenoj skrbi

are taken by doctors and nurses.

donose liječnici i sestre.

You choose an expensive lab test,

Vi birate skupu laboratorijsku pretragu,

you choose to operate on an old and frail patient.

birate operirati starog i slabog pacijenta.

So, by limiting the degrees of freedom of physicians,

Tako da je ograničavanje slobode liječnika

this is a way to hold costs down.

način za snižavanje troškova.

And ultimately, some physicians will say today

Na kraju, neki liječnici danas kažu

that they don't have the full liberty

kako nemaju punu slobodu

to make the choices they think are right for their patients.

donijeti odluke za koje mislie da su najbolje za njihove pacijente.

So no wonder that some of my old colleagues

Nije čudo da su neki od mojih starih kolega

are frustrated.

frustrirani.

At BCG, we looked at this,

Na BCG-u smo ovo razmatrali,

and we asked ourselves,

i zaključili smo,

this can't be the right way of managing healthcare.

da to ne može biti ispravan način upravljanja zdravstvenom skrbi.

And so we took a step back and we said,

Odmakli smo se korak unazad i zapitali,

"What is it that we are trying to achieve?"

„Što to pokušavamo postići?“

Ultimately, in the healthcare system,

Konačno, u sustavu zdravstvene skrbi,

we're aiming at improving health for the patients,

želimo poboljšati zdravlje pacijenta,

and we need to do so at a limited,

i to trebamo napraviti uz ograničen,

or affordable, cost.

ili prihvatljiv trošak.

We call this value-based healthcare.

Zovemo to zdravstveni sustav usmjeren na vrijednost.

On the screen behind me, you see what we mean

Na zaslonu iza mene, vidite što mislimo

by value:

kada kažemo vrijednost:

outcomes that matter to patients

ishodi koji su važni pacijentima

relative to the money we spend.

u odnosu na novac koji potrošimo.

This was described beautifully in a book in 2006

Ovo je prekrasno opisano u knjizi iz 2006.

by Michael Porter and Elizabeth Teisberg.

koju su napisali Michael Porter i Elizabeth Teisberg.

On this picture, you have my father-in-law

Na ovoj slici, imate mog zeta

surrounded by his three beautiful daughters.

okruženog s njegove prekrasne tri kćeri.

When we started doing our research at BCG,

Kada smo započeli s našim istraživanjem na BCG-u,

we decided not to look so much at the costs,

odlučili smo se ne posvetiti toliko troškovima,

but to look at the quality instead,

nego kvaliteti,

and in the research, one of the things

i u istraživanju, jedna od stvari

that fascinated us was the variation we saw.

koja nas je fascinirala bila je raznolikost koju smo vidjeli.

You compare hospitals in a country,

Ako usporedite bolnice u jednoj zemlji,

you'll find some that are extremely good,

naći ćete neke izrazito dobre,

but you'll find a large number that are vastly much worse.

ali naći ćete i velik broj onih koje su značajno lošije.

The differences were dramatic.

Razlike su bile dramatične.

Erik, my father-in-law,

Erik, moj punac,

he suffers from prostate cancer,

pati od raka prostate,

and he probably needs surgery.

i vjerojatno treba operaciju.

Now living in Europe, he can choose to go to Germany

Kako živi u Europi, može izabrati otići u Njemačku

that has a well-reputed healthcare system.

čiji je zdravstveni sustav na dobrom glasu.

If he goes there and goes to the average hospital,

Ako ondje ode u prosječnu bolnicu,

he will have the risk of becoming incontinent

imat će rizik da postane inkontinentan

by about 50 percent,

od oko 50 posto,

so he would have to start wearing diapers again.

znači da opet mora početi nositi pelene.

You flip a coin. Fifty percent risk. That's quite a lot.

To je kao bacanje novčića. Rizik od 50 posto je prilično velik.

If he instead would go to Hamburg,

Ako bi umjesto toga išao u Hamburg,

and to a clinic called the Martini-Klinik,

u kliniku koja se zove Martini-Klinik

the risk would be only one in 20.

rizik bi ondje bio jedan od 20.

Either you a flip a coin,

Tako da ili bacate novčić,

or you have a one in 20 risk.

ili imate rizik 1 prema 20.

That's a huge difference, a seven-fold difference.

To je ogromna razlika, sedmerostruka razlika.

When we look at many hospitals

Ako gledamo puno bolnica

for many different diseases,

i puno bolesti,

we see these huge differences.

vidimo ogromne razlike.

But you and I don't know. We don't have the data.

Ali vi i ja ne znamo. Nemamo podatke.

And often, the data actually doesn't exist.

Često, podaci zapravo ni ne postoje.

Nobody knows.

Nitko ne zna.

So going the hospital is a lottery.

Tako da je odlazak u bolnicu lutrija.

Now, it doesn't have to be that way. There is hope.

Ne mora biti tako. Postoji nada.

In the late '70s, there were a group

U kasnim '70-im bila je grupa

of Swedish orthopedic surgeons

švedskih ortopeda

who met at their annual meeting,

koji su imali godišnji sastanak,

and they were discussing the different procedures

razgovarali su o različitim postupcima

they used to operate hip surgery.

koje su koristili u operaciji kuka.

To the left of this slide, you see a variety

Na lijevoj strani vidite mnoštvo

of metal pieces, artificial hips that you would use

metalnih komada, umjetnih kukova koji se koriste

for somebody who needs a new hip.

kada osobi treba novi kuk.

They all realized they had their individual way of operating.

Shvatili su da svatko od njih ima svoj individualni način operiranja.

They all argued that, "My technique is the best,"

Svi su govorili kako je njihova tehnika najbolja,

but none of them actually knew, and they admitted that.

ali nitko od njih nije zapravo znao, priznali su to.

So they said, "We probably need to measure quality

Rekli su: „Trebamo odrediti kvalitetu

so we know and can learn from what's best."

tako da znamo i možemo učiti od najboljega.“

So they in fact spent two years debating,

Proveli su dvije godine u raspravi,

"So what is quality in hip surgery?"

„Što zapravo znači kvaliteta u operaciji kuka?“

"Oh, we should measure this." "No, we should measure that."

„Trebali bismo mjeriti ovo.“ „Ne, trebali bi mjeriti ono.“

And they finally agreed.

I konačno su se složili.

And once they had agreed, they started measuring,

Jednom kada su se složili, krenuli su mjeriti,

and started sharing the data.

i dijeliti svoje podatke.

Very quickly, they found that if you put cement

Vrlo su brzo shvatili da ako stave cement

in the bone of the patient

u pacijentovu kost

before you put the metal shaft in,

prije nego što stave metalnu osovinu,

it actually lasted a lot longer,

trajat će duže,

and most patients would never have to be

i većina pacijenata neće morati biti

re-operated on in their lifetime.

ponovo operirana do kraja života.

They published the data,

Objavili su podatke,

and it actually transformed clinical practice in the country.

i promijenili kliničku praksu u zemlji.

Everybody saw this makes a lot of sense.

Svi su vidjeli da to ima smisla.

Since then, they publish every year.

Od tada, svake godine objavljuju.

Once a year, they publish the league table:

Jednom godišnje objave ljestvicu:

who's best, who's at the bottom?

tko je najbolji, tko je na dnu?

And they visit each other to try to learn,

Posjećuju jedni druge pokušavajući učiti,

so a continuous cycle of improvement.

tako nastaje neprekidan krug pobojšanja.

For many years, Swedish hip surgeons

Već mnogo godina, švedski ortopedi

had the best results in the world,

imaju najbolje rezultate na svijetu,

at least for those who actually were measuring,

barem među onima koji su ih mjerili,

and many were not.

a mnogi nisu.

Now I found this principle really exciting.

Smatram ovu ideju vrlo uzbudljivom.

So the physicians get together,

Liječnici se okupe,

they agree on what quality is,

slože se oko toga što znači kvaliteta,

they start measuring, they share the data,

počnu mjeriti, podijele podatke,

they find who's best, and they learn from it.

otkriju tko je najbolji, i uče od njega.

Continuous improvement.

Stalni napredak.

Now, that's not the only exciting part.

To nije jedini uzbudljivi dio.

That's exciting in itself.

To je uzbudljivo samo po sebi.

But if you bring back the cost side of the equation,

Ako se sjetimo novčane strane jednadžbe,

and look at that,

i pogledamo ju,

it turns out, those who have focused on quality,

ispadne da oni koji su se usredotočili na kvalitetu,

they actually also have the lowest costs,

imaju najniže troškove,

although that's not been the purpose in the first place.

iako im to nije bila prvotna svrha.

So if you look at the hip surgery story again,

Ako se vratimo na priču o operaciji kuka,

there was a study done a couple years ago

prije nekoliko godina je rađena studija

where they compared the U.S. and Sweden.

gdje su uspoređeni SAD i Švedska.

They looked at how many patients have needed

Razmatralo se koliko je pacijenata trebalo

to be re-operated on seven years after the first surgery.

reoperaciju unutar sedam godina nakon prve operacije.

In the United States, the number was three times

U SAD-u je broj bio tri puta

higher than in Sweden.

veći nego u Švedskoj.

So many unnecessary surgeries,

Toliko nepotrebnih operacija,

and so much unnecessary suffering

toliko nepotrebne patnje

for all the patients who were operated on

za sve pacijente koji su bili ponovo operirani

in that seven year period.

u tom sedmogodišnjem periodu.

Now, you can imagine how much savings

Možete zamisliti koliko bi tu uštede

there would be for society.

bilo za društvo.

We did a study where we looked at OECD data.

Napravili smo studiju u kojoj smo gledali podatke OECD-a.

OECD does, every so often,

OECD povremeno

look at quality of care

uspoređuje kvalitetu njege

where they can find the data across the member countries.

u zemljama članicama u kojima mogu naći podatke.

The United States has, for many diseases,

SAD ima, za mnoge bolesti

actually a quality which is below the average

kvalitetu koja je ispod prosjeka

in OECD.

OECD-a.

Now, if the American healthcare system

Kada bi se američki sustav zdravstvene skrbi

would focus a lot more on measuring quality,

više usredotočio na mjerenje kvalitete,

and raise quality just to the level of average OECD,

i podigao kvalitetu samo na razinu prosjeka OECD-a,

it would save the American people

to bi uštedjelo Amerikancima

500 billion U.S. dollars a year.

500 milijardi dolara godišnje.

That's 20 percent of the budget,

To je 20 posto proračuna,

of the healthcare budget of the country.

proračuna za zdravstvo u državi.

Now you may say that these numbers

Možda ćete reći da su svi ti brojevi

are fantastic, and it's all logical,

fantastični, i da je sve logično,

but is it possible?

no je li moguće?

This would be a paradigm shift in healthcare,

To bi bila promjena paradigme u zdravstvenom sustavu,

and I would argue that not only can it be done,

i ja smatram da to ne samo može biti napravljeno,

but it has to be done.

nego to mora biti napravljeno.

The agents of change are the doctors and nurses

Pokretači promjene su liječnici i medicinske sestre

in the healthcare system.

u zdravstvenom sustavu.

In my practice as a consultant,

Dok sam radio kao konzultant,

I meet probably a hundred or more than a hundred

upoznao sam vjerojatno stotinu ili više

doctors and nurses and other hospital

liječnika i medicinskih sestara i drugog bolničkog

or healthcare staff every year.

ili zdrastvenog osoblja svake godine.

The one thing they have in common is

Jedna osobina koja im je svima zajednička

they really care about what they achieve

je to da zbilja brinu o tome što će postići

in terms of quality for their patients.

u vidu kvalitete za svoje pacijente.

Physicians are, like most of you in the audience,

Liječnici su, kao većina vas u publici,

very competitive.

vrlo kompetitivni.

They were always best in class.

Uvijek su bili najbolji u razredu.

We were always best in class.

Mi smo uvijek bili najbolji u razredu.

And if somebody can show them that the result

Ako im netko pokaže da rezultat

they perform for their patients

rada koji obave za pacijente

is no better than what others do,

nije ništa bolji od onoga što drugi rade,

they will do whatever it takes to improve.

napravit će što god treba da to poprave.

But most of them don't know.

Ali mnogi od njih ne znaju.

But physicians have another characteristic.

Liječnici imaju još jednu osobinu.

They actually thrive from peer recognition.

Vrlo su sretni kada dobiju priznanje drugih liječnika za svoj rad.

If a cardiologist calls another cardiologist

Ako kardiolog pozove drugog kardiologa

in a competing hospital

u konkurentsku bolnicu

and discusses why that other hospital

da rasprave zašto ta druga bolnica

has so much better results, they will share.

ima toliko bolje rezultate, oni će dijeliti.

They will share the information on how to improve.

Oni će dijeliti informacije o tome kako napredovati.

So it is, by measuring and creating transparency,

Tako da, mjerenjem i stvaranjem transparentnosti

you get a cycle of continuous improvement,

dobijete ciklus stalnog napredovanja,

which is what this slide shows.

što je upravo ovdje prikazano.

Now, you may say this is a nice idea,

Možda ćete reći da je ovo zgodna ideja,

but this isn't only an idea.

ali to nije samo ideja.

This is happening in reality.

To se događa u stvarnosti.

We're creating a global community,

Stvaramo globalnu zajednicu,

and a large global community,

veliku globalnu zajednicu,

where we'll be able to measure and compare

gdje ćemo biti sposobni izmjeriti i usporediti

what we achieve.

naša postignuća.

Together with two academic institutions,

Zajedno s dvije akademske institucije,

Michael Porter at Harvard Business School,

Michael Porter u Harvard Business School,

and the Karolinska Institute in Sweden,

i Karolinska Institutom u Švedskoj,

BCG has formed something we call ICHOM.

BCG je stvorio nešto što zovemo ICHOM.

You may think that's a sneeze,

Možda mislite da to zvuči kao kihanje,

but it's not a sneeze, it's an acronym.

ali to nije kihanje, nego akronim.

It stands for the International Consortium

Stoji za Internacionalni Konzorcij

for Health Outcome Measurement.

za Mjerenje Zdravstvenih Ishoda.

We're bringing together leading physicians

Okupljamo vodeće liječnike

and patients to discuss, disease by disease,

i pacijente kako bismo raspravili, bolest po bolest,

what is really quality,

što je zapravo kvaliteta,

what should we measure,

što bi trebali mjeriti,

and to make those standards global.

kako bismo izradili globalne standarde.

They've worked -- four working groups have worked

Radili su – četiri grupe su radile

during the past year:

tijekom prošle godine:

cataracts, back pain,

mrene, bolovi u leđima,

coronary artery disease, which is, for instance, heart attack,

bolesti koronarnih arterija, što je npr. infarkt,

and prostate cancer.

i rak prostate.

The four groups will publish their data

Četiri će grupe objaviti svoje podatke

in November of this year.

u studenome ove godine.

That's the first time we'll be comparing

To je prvi put da ćemo uspoređivati

apples to apples, not only within a country,

„jabuke i jabuke“, ne samo unutar zemlje,

but between countries.

nego i među različitim zemljama.

Next year, we're planning to do eight diseases,

Iduće godine, planiramo obraditi osam bolesti,

the year after, 16.

godinu poslije, 16.

In three years' time, we plan to have covered

U tri godine, planiramo pokriti

40 percent of the disease burden.

40 posto tereta bolesti.

Compare apples to apples. Who's better?

Uspoređujemo jabuke i jabuke. Tko je bolji?

Why is that?

Zašto je to tako?

Five months ago,

Prije pet mjeseci,

I led a workshop at the largest university hospital

vodio sam radionicu u najvećoj sveučilišnoj bolnici

in Northern Europe.

u sjevernoj Europi.

They have a new CEO, and she has a vision:

Imaju novu glavnu izvršnu direktoricu, ona ima viziju:

I want to manage my big institution much more

Želim upraviti ovu veliku instituciju više prema

on quality, outcomes that matter to patients.

kvaliteti, ishodima koji su važni pacijentima.

This particular day, we sat in a workshop

Toga smo dana sjedili na radionici

together with physicians, nurses and other staff,

zajedno sa liječnicima, sestrama i drugim osobljem,

discussing leukemia in children.

raspravljajući o leukemiji kod djece.

The group discussed,

Grupa je raspravljala,

how do we measure quality today?

o tome kako danas mjerimo kvalitetu?

Can we measure it better than we do?

Može li se mjeriti bolje nego sada?

We discussed, how do we treat these kids,

Razgovarali smo o tome kako liječimo tu djecu,

what are important improvements?

koja su važna poboljšanja?

And we discussed what are the costs for these patients,

I raspravljali smo o troškovima tih pacijenata,

can we do treatment more efficiently?

možemo li efikasnije provesti liječenje?

There was an enormous energy in the room.

U sobi je postojala ogromna energija.

There were so many ideas, so much enthusiasm.

Bilo je toliko ideja, toliko entuzijazma.

At the end of the meeting,

Na kraju sastanka,

the chairman of the department, he stood up.

predsjednik odjela je ustao.

He looked over the group and he said --

Pogledao je grupu i rekao --

first he raised his hand, I forgot that --

prvo je podigao ruku, to sam zaboravio --

he raised his hand, clenched his fist,

podigao je ruku, stisnuo šaku,

and then he said to the group, "Thank you.

i obratio se grupi, „Hvala vam.

Thank you. Today, we're finally discussing

Hvala vam. Danas konačno raspravljamo

what this hospital does the right way."

o onome što ova bolnica radi na pravi način.“

By measuring value in healthcare,

Mjerenjem vrijednosti u zdravstvenoj skrbi,

that is not only costs

što nisu samo troškovi

but outcomes that matter to patients,

nego i ishodi bitni pacijentima,

we will make staff in hospitals

učinit ćemo osoblje u bolnicama

and elsewhere in the healthcare system

i drugdje u zdravstvenom sustavu

not a problem but an important part of the solution.

ne problemom, nego važnim dijelom rješenja.

I believe measuring value in healthcare

Vjerujem da će mjerenje vrijednosti u zdravstvenom sustavu

will bring about a revolution,

donijeti revoluciju,

and I'm convinced that the founder

i uvjeren sam da bi se osnivač

of modern medicine, the Greek Hippocrates,

moderne medicine, grčki Hipokrat,

who always put the patient at the center,

koji je uvijek stavljao pacijenta u središte,

he would smile in his grave.

nasmiješio u svom grobu.

Thank you.

Hvala vam.

(Applause)

(Pljesak)