RS ONKOLOGI SURABAYA(BOUTIQUE HOSPITAL CONCEPT)

An Alternative Model for Secondary CareArio Djatmiko

RS ONKOLOGI SURABAYA

Medicine is the art of dealing with uncertainty

Moskowitz,1988

quality lies in detail

USA (SOC of North America, 1994):

Woman, 29 years old complained thickness sensation in the left breast.Doctor: Nothing wrong with your breast (PE).3 months after, she got married and after 6 month pregnancy, she felt her left breast was getting bigger and harder.Hospital: Breast cancer in advanced stage.She died a month after having a baby.Litigation: The doctor had been sentenced. Medical problem: misdiagnosed.

Opinion Based Decision Making

Breast cancer is one of the most complicated diseases (USA)

§ High risk management§ High diagnostic pitfalls§ Irreversible error§ The error is always late detected§ No tool can be used to convince no cancer Misdiagnosis of breast cancer is the secondmost medico legal allegation and the mostexpensive overall condition to litigate in US

Kenneth A. Kern.MD.FACS(SOC of North America 1994)

I Mitra (Tata Memorial Hospital) 1994:Good bye solo player…..opinion based

decision making is actually personal prejudice ….it will be extremely dangerous

in cancer world.

Indonesia (Surabaya, April 1991)

Miss An, 23 years old with advanced breast cancer (local advanced + milliar metastase to the lung).

History:She had been operated 8 months before. Surgeon at municipal Hospital no serious thing, only small benign tumor without sending the specimen to a pathologist.She died 3 months after she came to our clinic.

Opinion Based Decision Making

March 2000Mrs T, 45 years old came with breast cancer T4N1M0 in the left breast.11 month before she felt a small lump in the left breast. GP sent her to get USG and FNA, the result was Mastitis.

She got medicine for a month, but there was no improvement, FNA was repeated with the result was still mastitis. The tumor was getting bigger and bigger. After 9 months she came to RSOS. Triple Dx: Malignant.The patient did not believe it à open biopsy was done: Malignant.Problem:The Authority of GP? The reliability of FNA?11 months delay, late stadium.

FRAGMENTED APPROACH à No System

Fragmented approach(Opinion Based Decision Making)

Decision making is decided by the clinician (surgeon)90% error is in diagnostic procedure

Patient Doctor/Surgeon?

Other doctor (consultation)

Radiologist

Cytopathologist

Laboratory

OBDM – Opinion Based Decision Making

EBDM – Evidence-Based Decision Making

Increasing Pressure

The “Driven” of Decision Making

Increasing Quality

HARM

GOOD

Category of Delivered Service

NEW MIND SET

System approach(Evidence based and Team management)

Decision making is controlled by Tumor Board

PatientMedical Team

FacilitiesGUIDELINE

Medical Record

June 2002 45 years old woman, with multiple lump in both breasts

Mammography: C 3 multiple benign mass in both breast, no sign of

malignancy. USG: Ca in the left breast among

Fibroadenomas

Evidence Based Decision Making(System Approach)

July 2003Woman 54 years old has been followingbreast screening program for 6 years. The last Mammogram, no sign of malignancy BIRADS C3USG: 1 solid intra-cystic lesion among other simple cystics peri-areolar Left Breast.Open Biopsy:Intra cystic Papillary Ca 8 mm.Non palpable BC Detected by USG àEVIDENCE BASED DECISION MAKING

(SYSTEM APPROACH)

SYSTEM FRAGMENTEDDECISION MAKING EVIDENCE BASED OPINION BASED

COMMUNICATION Optimal Minimal

COORDINATION + -

GUIDELINE + -

MEDICAL RECORD good poor

EVALUATION + -

FEED BACK + -

SUPERVISE + -RISK MANAGEMENT + -

RESEARCH + -

INNOVATION + -

QUALITY & PRICE CONTROLED

+ -

DELIVERY CONTROLED

+ -

The Uniqueness of Cancer

• Undeterred and urgent • No tolerance for mistake •The biggest chance to cure is at the first treatment• Need multidisciplinary interdisciplinary approach• Need specific knowledge, skill and technology• (The most) expensive disease• Long life evaluation• Highly needs “human touch”

BACKGROUND§ Indonesia is a big country with 230 million

population§ There are many problems, economic,

geographic, infrastructure, technology gap, transportation, education etc § Cancer treatment in Indonesia is not well

organized à “no access ~ no system”

§ Systematic (quality) assessment is never been done, standardization?§ The incidence rate of (breast) cancer is

increasing significantly§ Cancer is not a health priority program in

Indonesia

The basic idea of RSOS :

§ Centralization is not the right answer for health care in Indonesia§ A big hospital is not always needed for breast

cancer services (thyroid, colon, skin, soft tissue, cervix etc)§ Small clinic will be more efficient, economist,

and controllable (quality and finance)§ Flexible in size and quantity§ Adaptive in structure and MIS§ Accessible, practice and easier for patient

To achieve the highest value of treatment

Efficient Referral System

Bekasi Tebet RSOS

Primary Care (GP, Family Physician, Puskesmas)

Secondary care

Tertiary Care

RS Dharmais

Strategy àto set up strong and efficient Referral System

Efficient Referral System:• Vision : To provide the highest value of treatment (Best QPD)• Clear measurement and transparent • Good communication ~ intra & inter level of care• Each level must do their role optimally based on guidelines • Primary, secondary & tertiary care are working as a team,

Concert ~ Harmony

OPTIMIZING THE ROLE OF EACH LEVEL

TERTIARY HEALTH CARETERTIARY HEALTH CARE

§§ Teaching Hospital Teaching Hospital §§ Doing more research and innovation.Doing more research and innovation.§§ Top Referral Hospital Top Referral Hospital àà for for extraordinary diseases extraordinary diseases -- extra big surgery: extra big surgery:

liver and bone marrow transplant, pancreatic surgery, etcliver and bone marrow transplant, pancreatic surgery, etc§§ Trend setterTrend setter§§ Benchmarking, training and supervising the Secondary HCBenchmarking, training and supervising the Secondary HC§§ Leading in technology: high tech and heavy equipment (PET scan,Leading in technology: high tech and heavy equipment (PET scan,

gamma knife, advance radiology equipment etc) gamma knife, advance radiology equipment etc) §§ Testing and analyzing (cost benefit analysis) for new technologies Testing and analyzing (cost benefit analysis) for new technologies §§ Government think tank: to set up public policiesGovernment think tank: to set up public policies§§ Global networking in science and technology Global networking in science and technology §§ Need more super specialist doctorsNeed more super specialist doctors

Secondary Care (RSOS)Secondary Care (RSOS)§§ Focuses on health services Focuses on health services àà plays the biggest curative plays the biggest curative

role in the population role in the population §§ An equitable distribution of health servicesAn equitable distribution of health services§§ Geographic, cultural and financial accessibleGeographic, cultural and financial accessible§§ Proper Tech Proper Tech àà Should not follow technology competitionShould not follow technology competition§§ Specialist level Specialist level àà high standard treatment and reliablehigh standard treatment and reliable§§ Selector to higher referral Selector to higher referral §§ (Epidemiology) research (Epidemiology) research

Strengthening the Secondary HC will be the answer of curative problems in the population

Effective and efficientNote: Secondary Care is the back bone of curative sector in most countries in the world

April1995 – April 20064 beds, 1 operating theatres

April 2006 –28 beds, 3 operating theatres

Klinik Onkologi Surabaya Rumah Sakit Onkologi Surabaya

INNOVATIONS:1. Boutique Hospital Concept (System Approach) 2. The first non-palpable breast cancer management in Indonesia (1991)3. Overnight stay for breast cancer surgery (1995)4. Diagnosis Related Group (DRG) payment system (1995) 5. Introducing immediate breast reconstruction post mastectomy (1985)6. Sentinel node, tracing with blue dye (ongoing study)

International Scientific Papers : 14National Scientific Papers : 8

Adila Soewarmo Makarim Wibisono

Prof J Oldhoff Dr Peterse

Prof Emille Roetgers PhD Prof Dr Hoekstra PhD

Dr Marie Rickard Dr Mahdi Rezai

(AZG) (AVL)

(AZG)(AVL)

(BSC, Sidney) (Breast Centre Dusseldorf)

THE ADVISORY BOARD OF RSOS

Number of RSOS Patients ( 2006 – 2008)

The level of patient increment from 2007 to 2008 was 12%. New patient increased 12% from 2007 to 2008.While follow up patient increased 22% from 2007 to 2008

Trend of patient visitation increases every year:

2.7483.779 4.215

11.571

15.210

18.598

-2.0004.0006.0008.000

10.000

12.00014.00016.00018.00020.000

Year 2006 Year 2007 Year 2008

new patientfollow up patient

0500

1000

15002000

25003000

35004000

45005000

2003 2004 2005 2006 2007 2008

mammo

us g

fna

Supportive diagnostic activities

What is a Quality Standard ?

§ What have to be measured ?§ How can we measure it ?§ Who is the assessor (qualification) ?§ What is the methodology used ?§ How can we improve or maintain the quality

of the services ?

Standard quality is dynamic measurement, Standard quality is dynamic measurement, which have to be continually evaluated.which have to be continually evaluated.

RSOS, validity test every 6 monthsRSOS, validity test every 6 months

THE KEY POINT

The technology, (man, method, material) must be validated first, and there

must be regular internal and external quality control and

quality assurance procedures

Sensitivity & Specificity USG

88.890.5

94.9

90

94.694.393.8

92.8

88

89.2

97.9 97.8

93.7

97.5 96.7

100 99.5 10098.63 99.07

828486889092949698

100102

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

sensitivity

spesificity

Sensitivity & Specificity Mammography

83.388

90.7 91

90.4 91.0496.36

9199.2

89.795.1

100 100 99.2 100

0

20

40

60

80

100

120

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

sensitivityspesificity

Sensitivity & Specificity FNA(palpable breast tumor)

100 100 100 100 100 100

0

20

40

60

80

100

120

2003 2004 2005 2006 2007 2008

sensitivityspecifisityspecificity

Breast cancer new patients trend in RSOS

331357

301

201

251

0

50

100

150

200

250

300

350

400

Thn. 2004 Thn. 2005 Thn. 2006 Thn. 2007 Thn. 2008

Age distribution of Breast Cancer at RSOS 2008

0,3% 0,0%1,2%

7,9%

11,8%

17,6%

13,8%

16,2%

9,7% 9,7%

11,8%

0,0

2,0

4,0

6,0

8,0

10,0

12,0

14,0

16,0

18,0

1 2 3 4 5 6 7 8 9 10 11

Age group :

1 = • 20 years old

2 = 21 - 25 years

3 = 26 - 30 years

4 = 31 - 35 years

5 = 36 - 40 years

6 = 41 - 45 years

7 = 46 - 50 years

8 = 51 - 55 years

9 = 56 - 60 years

10 = 61 – 65 years

11 = > 65 years

Stadium distribution Breast Cancer at RSOS, 2008

2,5%

10,1%

16,5%13,8%

31,0%

6,2%

16,4%

3,4%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

0 I IIA IIB IIIA IIIB IIIC IV

RESPONSE TIME, 2008:The measurement of how many visits to obtain definite diagnosis

57%32%

11%

2nd VISIT

1s t VISIT

3rd VISIT

Number of Surgical Procedures at RSOS ( 2006 - 2008)

589

731

828

-

100

200

300

400

500

600

700

800

900

Year 2006 Year 2007 Year 2008

surgery

72%

3%

12%

13%

MR MB C TMR M + L D F L APMR M + TR AM

2006 – 2008: 584 Breast Cancer Surgery

Mastectomy & direct reconstruction with TRAMP Flap

Mastectomy & direct reconstruction with TRAMP Flap

Mastectomy

Mastectomy + TRAM

BCT + LD Flap

BCT + LD Flap

Surgeon performance at RSOS

Performa MRMBCT / LD

FLAPMRM + TRAM

MRM + TISSUE

Exp

Duration 100 – 120 min 150-180 min 240 - 300 min 120-140 min

Bleeding < 200 cc < 200 cc <300 cc < 200 cc

Length of stay

< 24 hours < 24 hours < 3 x 24 hours

< 24 hours

Infection 0 0 0 0

Suture off 10-14 days 10-14 days 14 days 10-14 days

Drain off 10-14 days 7-10 days 7-10 days 10-14 days

0

100

200

300

400

500

600

700

800

th 2006 th 2007 th 2008

B reas t C anc er

Non B reas tC ancer

CHEMOTHERAPY ACTIVITIES

Boutique is a small company that offers highly specialized services or products

MULTI DISCIPLANARY APPROACH WHICH FOCUS ON High QualityEfficiency

Specific touch

BOUTIQUE HOSPITAL concept

§ Meet the specific (consumer) need§ Proper Tech§ Slim organization, more efficient & cost-effective.§ Optimal communication àTQM automatically and

optimally done§ Transparent & accountable (moral & ethic) à

certainty§ Create more personal relationship and personal

touch§ Continues improvement of skill & knowledge (feed

back) of the medical team§ Adaptive & flexible in size§ Simpler management information system

ONE ROOF CONCEPT(Carve out Organization)

§ Comprehensive :All procedures are carried out in one control system (RSOS) except radiotherapy§ Multidisciplinary approach :

the team involves since the beginning, “sit together” to make a decision§ Integrated care :

The delivery system is based on “patient focus care”

Integrated care Pathwaythe course of events in the care of patient with a particular condition, within a set time-scale. To facilitate the introduce of an evidence – based approach

into routine clinical practice and guideline for multidisciplinary work:

SYMPTOMSYMPTOM

SCREENINGSCREENING

CANCER +CANCER +

TREATMENTTREATMENT

FOLLOW UPFOLLOW UP

CANCER (CANCER (--))

SCREENINGSCREENING

Medical TeamFacility

GuidelineMedical Record

PHYSICALPHYSICAL

EXAMINATIONEXAMINATION

IMAGINGIMAGINGUSG +USG +

MAMMOGRAPHYMAMMOGRAPHY

LOCALIZATIONLOCALIZATION

PROCEDUREPROCEDUREPATHOLOGYPATHOLOGYFNA / VC / PAFNA / VC / PA

Zero defect program RSOSEvidence Based Decision Making

COLLECTING DATA

ASSESSMENT

PLANNING

FINAL DIAGNOSTIC(Biopsy & Localisasi

Procedure)TREATMENT (tailoring)

FOLLOW UP

TUMOR BOARD ~ Internal AuditorTuesday and Friday Coffee Morning: a. Cases discussion. b. Evidence Based Decision Making

PE RD LAB FNA

Keterangan:PE : Phisycal examination RD : RadiodiagnostikFNA : Fine needle AspirationLocalization Procedure: biopsy guided by hook wire

The key of the treatment lies in the accurate diagnose

TRIPPLE DIAGNOSTIC

Tumor Board RSOS:dr Iskandar, dr Wiwin, dr Heny, dr Lies, dr Sindra, Dr. Ami, dr Ario Djatmiko

St. Gallen, Swiss

Guidelines ~ decision tree• To ration treatments• To ensure all patients are treated

equally• Clear for the patient• To be regularly updated• Clear for the third party payer, cost

GUIDELINE Guidelines for the treatment of cancer in clinical practice are intended to give

physician around the world to provide the right care, at the right time, for the right person, in the right way. Emma Mason

MissionWhy we exist

Values What we believe in and how we will behave

VisionWhat we want to be

Strategy What our competitive game plan will be

The BASIC ELEMENTS

of a strategic statement:

OBJECTIVE = Ends

SCOPE = Domain

ADVANTAGE= Means

Without vision, people perishWithout vision, people perish

John F. KennedyJohn F. Kennedy

Hospital is a “Noble business”

Morally & ethically, we have to be on the patient’s side by:• enhancing the quality services• cost containment ~ efficiency• humanity in services

Best outcome + Best service + lowest cost = Best value

Our Value

QUALITY

AFFORDABLEACCESSIBLE

RSOSRSOS

my dream…….RSOS is one of safety boats for our country

Conclusion§ Strong and efficient referral system is a must§ New Mind Set: Opinion Based Decision Making à

Evidence Based Decision Making§ Multidisciplinary approach (Team Work)§ Boutique Hospital Concept is an alternative model for

Secondary Care

People need us… we (RSOS) can not do it alone.