Stefan Larsson: What doctors can learn from each other

Prevodilac: Stefan Zrnović Lektor: Mile Živković

Five years ago, I was on a sabbatical,

Pre 5 godina bio sam na plaćenom odsustvu

and I returned to the medical university

i vratio sam se na Medicinski fakultet

where I studied.

gde sam studirao.

I saw real patients and I wore the white coat

Video sam prave pacijente i nosio sam beli mantil

for the first time in 17 years,

po prvi put u 17 godina,

in fact since I became a management consultant.

zapravo od kada sam postao konsultant upravljanja.

There were two things that surprised me

Postojale su 2 stvari koje su me iznenadile

during the month I spent.

tokom mesec dana mog boravka tamo.

The first one was that the common theme

Prva stvar je bila je to što su zajedničke teme

of the discussions we had were hospital budgets

diskusija koje smo imali, bili bolnički budžeti

and cost-cutting,

i smanjenje troškova,

and the second thing, which really bothered me,

a druga stvar, koja me je stvarno brinula,

actually, was that several of the colleagues I met,

zapravo bila je to što nekoliko kolega koje sam sreo,

former friends from medical school,

kolege iz srednje medicinske škole,

who I knew to be some of the smartest,

za koje sam znao da su među najpametnijim,

most motivated, engaged and passionate people

najmotivisanijim, najangažovanijim i najstrastvenijim ljudima

I'd ever met,

koje sam ikada sreo,

many of them had turned cynical, disengaged,

mnogi od njih su postali cinični i odvojeni

or had distanced themselves from hospital management.

ili su se distancirali od bolničkog upravljanja.

So with this focus on cost-cutting,

Sa fokusom na smanjenje troškova,

I asked myself, are we forgetting the patient?

pitao sam se, da li zaboravljamo na pacijenta?

Many countries that you represent

Mnoge zemlje koje predstavljate

and where I come from

i odakle ja dolazim

struggle with the cost of healthcare.

se bore sa troškovima zdravstvenih usluga.

It's a big part of the national budgets.

To je veliki deo nacionalnog budžeta.

And many different reforms aim at holding back this growth.

Mnoge različite reforme pokušavaju da uspore ovaj rast.

In some countries, we have long waiting times

U nekim zemljama pacijenti dugo čekaju

for patients for surgery.

na operaciju.

In other countries, new drugs are not being reimbursed,

U drugim zemljama, novi lekovi se ne refundiraiju

and therefore don't reach patients.

i stoga ne dolaze do pacijenata.

In several countries, doctors and nurses

U nekoliko zemalja, doktori i medicinske sestre

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

su u neku ruku mete za vlade.

After all, the costly decisions in health care

Uostalom, skupocene odluke u zdravstvenoj nezi

are taken by doctors and nurses.

donose doktori i medicinske sestre.

You choose an expensive lab test,

Izaberete skupocen laboratorijski test,

you choose to operate on an old and frail patient.

izaberete da operišete starog i bolešljivog pacijenta.

So, by limiting the degrees of freedom of physicians,

Ograničavajući stepen slobode lekara,

this is a way to hold costs down.

ovo je način da se troškovi smanje.

And ultimately, some physicians will say today

Na kraju, neki doktori će danas reći

that they don't have the full liberty

da nemaju potpunu slobodu

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

da naprave izbore za koje misle da su pravi za njihove pacijente.

So no wonder that some of my old colleagues

Nije ni čudo onda da su neki od mojih starih kolega

are frustrated.

isfrustrirani.

At BCG, we looked at this,

Na Bostonskoj grupi za konsultacije, pogledali smo ovo

and we asked ourselves,

i zapitali smo se,

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

ovo ne može da bude pravi način vođenja zdravstva.

And so we took a step back and we said,

Stoga smo se vratili korak unazad i rekli:

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

"Šta je to što želimo da postignemo?"

Ultimately, in the healthcare system,

U suštini, u sistemu zdravstvene nege,

we're aiming at improving health for the patients,

težimo da poboljšamo zdravlje naših pacijenata,

and we need to do so at a limited,

i treba to da uradimo sa ograničenim

or affordable, cost.

ili pristupačnim troškovima.

We call this value-based healthcare.

Mi ovo nazivamo zdravstvenom negom zasnovanom na vrednosti.

On the screen behind me, you see what we mean

Na ekranu vidite šta podrazumevamo

by value:

pod vrednošću:

outcomes that matter to patients

ishodi koji se odnose na pacijente

relative to the money we spend.

u odnosu na novac koji trošimo.

This was described beautifully in a book in 2006

Ovo je prelepo opisano u knjizi iz 2006.

by Michael Porter and Elizabeth Teisberg.

Majkla Portera i Elizabet Tajzberg.

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

Na ovoj slici se nalazi moj tast

surrounded by his three beautiful daughters.

okružen sa svoje tri prelepe ćerke.

When we started doing our research at BCG,

Kada smo počeli da radimo istraživanja na BGK

we decided not to look so much at the costs,

odlučili smo da ne gledamo toliko na troškove,

but to look at the quality instead,

nego na kvalitet,

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 bile su varijacije koje smo videli.

You compare hospitals in a country,

Uporedite bolnice u zemlji,

you'll find some that are extremely good,

naći ćete neke koje su izuzetno dobre,

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

ali ćete takođe naći veliki broj onih koje rade dosta lošije.

The differences were dramatic.

Razlike su bile dramatične.

Erik, my father-in-law,

Erik, moj tast,

he suffers from prostate cancer,

pati od raka prostate,

and he probably needs surgery.

i verovatno mu treba operacija.

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

Živeći u Evropi, može da bira da ide u Nemačku

that has a well-reputed healthcare system.

koja ima sistem zdravstvene zaštite sa dobrom reputacijom.

If he goes there and goes to the average hospital,

Ukoliko ode tamo i poseti prosečnu bolnicu,

he will have the risk of becoming incontinent

imaće rizik od dobijanja inkontinencije

by about 50 percent,

za oko 50 procenata,

so he would have to start wearing diapers again.

pa bi morao ponovo da počne da nosi pelene.

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

Bacate novčić. 50% rizika. To je prilično mnogo.

If he instead would go to Hamburg,

Da je umesto toga otišao u Hamburg,

and to a clinic called the Martini-Klinik,

u kliniku po imenu Martini-Klinik,

the risk would be only one in 20.

rizik bi bio jedan u 20.

Either you a flip a coin,

Ili bacate novčić

or you have a one in 20 risk.

ili imate rizik jedan u 20.

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

To je velika, sedmostruka razlika.

When we look at many hospitals

Kada pogledamo mnoge bolnice

for many different diseases,

za mnoge različite bolesti,

we see these huge differences.

vidimo te 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.

A podaci često zapravo ne postoje.

Nobody knows.

Niko ne zna.

So going the hospital is a lottery.

Odlazak u bolnicu je lutrija.

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

To ne mora da bude tako. Postoji nada.

In the late '70s, there were a group

Kasnih '70-ih, postojala je grupa

of Swedish orthopedic surgeons

švedskih ortopedskih hirurga

who met at their annual meeting,

koji su se sreli na svom godišnjem sastanku,

and they were discussing the different procedures

i počeli su da diskutuju o različitim procedurama

they used to operate hip surgery.

koje su koristili za operaciju kuka.

To the left of this slide, you see a variety

Na levoj strani ovog slajda, vidite razne

of metal pieces, artificial hips that you would use

metalne delove, veštačke kukove koje biste koristili

for somebody who needs a new hip.

za nekoga kome je potreban novi kuk.

They all realized they had their individual way of operating.

Svi oni su shvatili da imaju sopstveni način operisanja.

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

Svi su tvrdili: "Moja tehnika je najbolja,"

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

ali nijedan od njih zapravo nije to znao i to su i priznali.

So they said, "We probably need to measure quality

Stoga su rekli: "Verovatno treba da merimo kvalitet

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

da bismo znali i mogli da naučimo od najboljeg."

So they in fact spent two years debating,

Oni su zapravo proveli dve godine u raspravi:

"So what is quality in hip surgery?"

"Kakav je kvalitet operacije kuka?"

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

"Trebalo bi da merimo ovo." "Ne, trebalo bi da merimo ono."

And they finally agreed.

I konačno su se dogovorili.

And once they had agreed, they started measuring,

Kada su se jednom dogovorili, počeli su da mere

and started sharing the data.

i da razmenjuju podatke.

Very quickly, they found that if you put cement

Veoma brzo, otkrili su da ukoliko stavite cement

in the bone of the patient

u kost pacijenta

before you put the metal shaft in,

pre nego što unutra stavite metalnu cev,

it actually lasted a lot longer,

to je trajalo mnogo duže,

and most patients would never have to be

i većini pacijenata više nije bila potrebna

re-operated on in their lifetime.

ponovna operacija za života.

They published the data,

Objavili su podatke

and it actually transformed clinical practice in the country.

i to je zapravo preobrazilo kliničku praksu u zemlji.

Everybody saw this makes a lot of sense.

Svako je primetio da ovo ima dosta smisla.

Since then, they publish every year.

Od tada, objavljuju radove svake godine.

Once a year, they publish the league table:

Jednom godišnje, objavljuju tabelu saveza:

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

ko je najbolji, ko je na dnu?

And they visit each other to try to learn,

Sreću se međusobno kako bi pokušali da uče

so a continuous cycle of improvement.

i nastave stalni krug poboljšanja.

For many years, Swedish hip surgeons

Godinama, švedski hirurzi za kuk

had the best results in the world,

su imali najbolje rezultate na svetu,

at least for those who actually were measuring,

barem za one koji su zapravo merili,

and many were not.

a mnogi nisu.

Now I found this principle really exciting.

Smatram ovaj princip izuzetno uzbudljivim.

So the physicians get together,

Doktori se okupe,

they agree on what quality is,

dogovore se šta je kvalitetno,

they start measuring, they share the data,

počnu da mere, razmenjuju podatke,

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

otkriju ko je najbolji i uče iz toga.

Continuous improvement.

Stalno poboljšanje.

Now, that's not the only exciting part.

Međutim, to nije jedino zanimljivo.

That's exciting in itself.

To je zanimljivo samo po sebi.

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

Ali ako se vratimo na deo jednačine s troškovima

and look at that,

i pogledate to,

it turns out, those who have focused on quality,

ispostavlja se da su oni koji su se fokusirali na kvalitet

they actually also have the lowest costs,

zapravo imali i najniže troškove,

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

iako to nije bila prvobitna svrha.

So if you look at the hip surgery story again,

Ako ponovo pogledate priču o operaciji kuka,

there was a study done a couple years ago

urađeno je istraživanje pre nekoliko godina

where they compared the U.S. and Sweden.

gde su poređene SAD i Švedska.

They looked at how many patients have needed

Videli su kom broju pacijenata je bila potrebna

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

ponovna operacija nakon 7 godina od prve.

In the United States, the number was three times

U SAD broj je bio tri puta

higher than in Sweden.

veći nego u Švedskoj.

So many unnecessary surgeries,

To je mnogo nepotrebnih operacija

and so much unnecessary suffering

i mnogo nepotrebne patnje

for all the patients who were operated on

za sve pacijente koji su bili operisani

in that seven year period.

u periodu od sedam godina.

Now, you can imagine how much savings

Možete zamisliti kolika bi to ušteda

there would be for society.

bila za društvo.

We did a study where we looked at OECD data.

Napravili smo istraživanje sa podacima organizacije za ekonomsku saradnju i razvoj.

OECD does, every so often,

Ova organizacija veoma često

look at quality of care

posmatra kvalitet nege

where they can find the data across the member countries.

gde mogu naći podatke o zemljama članicama.

The United States has, for many diseases,

Za mnoge bolesti SAD zapravo imaju

actually a quality which is below the average

kvalitet koji je ispod prosečnog

in OECD.

u OEES.

Now, if the American healthcare system

Ukoliko bi se američki sistem zdravstvene nege

would focus a lot more on measuring quality,

fokusirao više na merenje kvaliteta,

and raise quality just to the level of average OECD,

i podigao kvalitet na nivo prosečnog u OEES,

it would save the American people

to bi američkom narodu uštedelo

500 billion U.S. dollars a year.

500 milijardi dolara godišnje.

That's 20 percent of the budget,

To je 20% budžeta,

of the healthcare budget of the country.

budžeta za zdravstvenu negu zemlje.

Now you may say that these numbers

Možda ćete reći da su ovi brojevi

are fantastic, and it's all logical,

fantastični i to je sve logično

but is it possible?

ali da li je moguće?

This would be a paradigm shift in healthcare,

Ovo bi bila promena paradigme u zdravstvenoj nezi,

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

i ustanovio bih da to ne samo da može da se uradi,

but it has to be done.

već i mora da se uradi.

The agents of change are the doctors and nurses

Agenti promene su doktori i medicinske sestre

in the healthcare system.

u sistemu zdravstvene nege.

In my practice as a consultant,

U svojoj praksi kao konsultant,

I meet probably a hundred or more than a hundred

srećem verovatno stotinu ili više od stotine

doctors and nurses and other hospital

doktora i medicinskih sestara i ostalog bolničkog

or healthcare staff every year.

i zdravstvenog osoblja svake godine.

The one thing they have in common is

Jedna stvar koja im je zajednička

they really care about what they achieve

je da oni zaista paze na to šta postižu

in terms of quality for their patients.

u smislu kvaliteta za svoje pacijente.

Physicians are, like most of you in the audience,

Doktori su, poput mnogih vas u publici

very competitive.

veoma takmičarski nastrojeni.

They were always best in class.

Uvek su bili najbolji u generaciji.

We were always best in class.

Bili smo najbolji u grupi.

And if somebody can show them that the result

Ako neko može da im pokaže da rezultat

they perform for their patients

koji pokazuju za svoje pacijente

is no better than what others do,

nije bolji od onog koji postižu drugi,

they will do whatever it takes to improve.

uradiće bilo šta što je potrebno za poboljšanje.

But most of them don't know.

Ali većina njih ne zna.

But physicians have another characteristic.

Ali doktori imaju drugu karatkeristiku.

They actually thrive from peer recognition.

Oni zapravo napreduju kroz prepoznavanje uspeha od strane kolega.

If a cardiologist calls another cardiologist

Ako kardiolog zove drugog kardiologa

in a competing hospital

u suparničkoj bolnici

and discusses why that other hospital

i razmatra zašto ta druga bolnica

has so much better results, they will share.

ima toliko bolje rezultate, oni će to podeliti.

They will share the information on how to improve.

Deliće informacije o tome kako se poboljšati.

So it is, by measuring and creating transparency,

Dakle, kroz merenje i stvaranje transparentnosti

you get a cycle of continuous improvement,

dobijate ciklus stalnog usavršavanja,

which is what this slide shows.

što je ono što vam ovaj slajd pokazuje.

Now, you may say this is a nice idea,

Možete reći da je ovo dobra ideja,

but this isn't only an idea.

ali ovo nije samo ideja.

This is happening in reality.

Ovo se dešava 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

gde ćemo biti u mogućnosti da merimo i poredimo

what we achieve.

ono što smo postigli.

Together with two academic institutions,

Zajedno sa dve akademske institucije,

Michael Porter at Harvard Business School,

Majkl Porter na Harvardskoj poslovnoj školi,

and the Karolinska Institute in Sweden,

i institutu Karolinska iz Švedske

BCG has formed something we call ICHOM.

BGK je formirala nešto što zovemo IKMZI.

You may think that's a sneeze,

Možda ćete pomisliti da je to kijavica,

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

ali nije, to je skraćenica.

It stands for the International Consortium

To je skraćenica za Internacionalni konzorcijum

for Health Outcome Measurement.

za merenje zdravsvenih ishoda.

We're bringing together leading physicians

Mi spajamo vodeće doktore i pacijente

and patients to discuss, disease by disease,

da zajedno diskutuju jednu po jednu bolest

what is really quality,

šta je zapravo kvalitetno,

what should we measure,

šta bi trebalo da merimo

and to make those standards global.

i da ti standardi postanu globalni.

They've worked -- four working groups have worked

4 radne grupe je radilo

during the past year:

tokom prošle godine:

cataracts, back pain,

katarakte, bol u leđima,

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

bolest koronarnih arterija, što je, na primer, srčani udar,

and prostate cancer.

i rak prostate.

The four groups will publish their data

Četiri grupe će objaviti svoje podatke

in November of this year.

u novembru ove godine.

That's the first time we'll be comparing

To je prvi put da ćemo porediti

apples to apples, not only within a country,

babe sa babama, ne samo unutar zemlje,

but between countries.

već između zemalja.

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

Sledeće godine, planiramo da uradimo 8 bolesti,

the year after, 16.

a one tamo godine, 16.

In three years' time, we plan to have covered

U trogodišnjem periodu planiramo da pokrijemo

40 percent of the disease burden.

40% opterećenja bolesti.

Compare apples to apples. Who's better?

Poređenje baba sa babama. Ko je bolji?

Why is that?

Zašto to?

Five months ago,

Pre 5 meseci,

I led a workshop at the largest university hospital

vodio sam radionicu u najvećoj univerzitetskoj bolnici

in Northern Europe.

u severnoj Evropi.

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

Imaju novog izvršnog direktora, a ona ima viziju:

I want to manage my big institution much more

želim da svoju veliku instituciju više fokusiram

on quality, outcomes that matter to patients.

na kvalitet, ishode koji se tiču pacijenata.

This particular day, we sat in a workshop

Tog posebnog dana, sedeli smo na radionici,

together with physicians, nurses and other staff,

zajedno sa doktorima, medicinskim sestrama i ostalim osobljem,

discussing leukemia in children.

diskutujući o leukemiji kod dece.

The group discussed,

Grupa je diskutovala,

how do we measure quality today?

kako merimo kvalitet danas?

Can we measure it better than we do?

Možemo li da ga merimo bolje nego što to sad radimo?

We discussed, how do we treat these kids,

Razgovarali smo o tome kako lečimo tu decu,

what are important improvements?

koja su bitna poboljšanja?

And we discussed what are the costs for these patients,

Diskutovali smo o tome šta su troškovi tih pacijenata,

can we do treatment more efficiently?

možemo li obavljati tretman efikasnije?

There was an enormous energy in the room.

Bila je ogromna količina energije u sobi.

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.

predsedavajući odeljenja 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, zaboravio sam to -

he raised his hand, clenched his fist,

podigao je ruku, stegnuo pesnicu,

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

a zatim je rekao grupi: "Hvala vam."

Thank you. Today, we're finally discussing

Hvala vam. Danas, mi konačno diskutujemo

what this hospital does the right way."

o tome šta ova bolnica radi na pravi način."

By measuring value in healthcare,

Mereći vrednost zdravstvene nege,

that is not only costs

ne samo troškova

but outcomes that matter to patients,

već ishoda koji se tiču pacijenata,

we will make staff in hospitals

od osoblja u bolnicama

and elsewhere in the healthcare system

i svuda u sistemu zdravstvene nege

not a problem but an important part of the solution.

napravićemo ne problem, nego važan deo rešenja.

I believe measuring value in healthcare

Verujem da će merenje vrednosti u zdravstvenom sistemu

will bring about a revolution,

doneti revoluciju,

and I'm convinced that the founder

i uveren sam da bi se osnivač

of modern medicine, the Greek Hippocrates,

moderne medicine, Grk Hipokrat

who always put the patient at the center,

koji je uvek stavljao pacijenta u centar,

he would smile in his grave.

verujem da bi se osmehivao u grobu.

Thank you.

Hvala vam.

(Applause)

(Aplauz)