RS Onkologi Surabaya (Boutique Hospital Concept), An Alternative Model for Secondary Care
-
Upload
indonesian-journal-of-cancer -
Category
Documents
-
view
908 -
download
1
description
Transcript of RS Onkologi Surabaya (Boutique Hospital Concept), An Alternative Model for Secondary Care
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.