Ceci n’est pas un hôpital

UZ Brussels is one of the seven Belgian University Hospitals, which implies – by law – the triple assignment of care, teaching and research. In order to facilitate the latter two missions, and to make them independent or ‘free’ from the particularly financed care-function (I’ll come back to that), University Hospitals have to meet some specific legal constraints. For instance, (at least 70% of) doctors have to be salaried, and the Hospital has to obey to the officially agreed tariffs of invoicing. In exchange, the Hospital receives an additional budget from the Ministry of Social Affairs, meant to compensate for the loss of income (agreed tariffs, opportunity cost of teaching and research,…) and the surplus of expenditure (employer contributions, social security expenditures, …) for the hospital. Belgian and international studies have shown that the surplus expenditure needed for a University Hospital to organize and facilitate a comprehensive academic portfolio varies between 15 and 20% of the total annual budget. In Belgium, this surplus budget approximates only 7 to 8 %, implying that the rest of this necessary budget has to be found elsewhere. In Belgium, this means – for the greater part – ‘indirect’ financing of the academic functions of the university hospital by the ‘normal’ financing mechanisms of other, non-academic hospitals. That is through the social security funding channel of national insurance honoraries for doctor’s intellectual and technical activities. Indeed, Belgium is one of the last countries where the principle of ‘fee-for-service’ financing still weighs enormously in healthcare expenditure. And this is a huge paradox to be solved by Hospital Management: how to ‘liberate’ doctors from their clinical care tasks, and allow them to spend time on teaching and research, whereas at the same time the hospital looses money (because when teaching or researching, they do not generate clinical income) which is insufficiently compensated by surplus academic funding.

Looking at this from a helicopter viewpoint and a more global perspective, things become even trickier and more paradoxical. Global Healthcare Expenditure has followed national GDP-growth rates, and – during the last decades – even at increasing rates (OESO average 4 % marginal increase per annum). Discarding the exceptional and dramatically distorded situation of the USA, most Western countries spend around 9 % of their GDP on Healthcare. Belgium has chosen for a Healthcare system based on an extremely high service level (objectively # 1 in the world – Oeso statistics and Eurobarometer) which of course is highly appreciated by the population (objectively # 2 in the world). However, this is only possible through the heavy built-in financial incentive of fee-for-service financing for doctors (and thus hospitals – even university hospitals!). This choice has two consequences: first, this is a very expensive way of organizing healthcare (free choices of general practicioners, free choices of specialists and hospitals, very high redundancy in technical medical services in order to avoid waiting lists, etc), reaching 10.3 % of GDP and making Belgium the third most ‘expensive’ country in Europe and the fifth most expensive in the world. Secondly, this system has very few built-in incentives for increasing cost-efficiency or increasing quality outcome. Indeed, Belgian Healthcare performs only moderately well on average (ranking around 15th place in EU-27) despite its very high expenditure.

Facing the global economical crisis and budget constraints on national healthcare expenditure, most countries however are currently issuing plans to control expenditure and at the same time increase clinical outcome. In fact, this should not be too difficult because healthcare as a service industry is notoriously poor in terms of cost-efficiency: up to 45 % of patients do not receive evidence-based healthcare, up to 30 % of all tests, procedures and treatments are redundant, up to 50 % of total expenditure can be questioned in terms of utility and efficacy, and even up to 20 % of patients experience some form of harm after healthcare delivery (which again costs 30 cents per dollar or euro to fix!). This is because most doctors who are today’s leaders and medical opinion makers have been trained as soloist domain experts, with a huge degree of ‘personal engagement, accountability and responsibility’ with regard to patients.  Doctors are not trained to ‘see’ clinical medicine in terms of teamwork, organizations or processes, but rather as a highly individual effort to do the utmost to diagnose and treat the individual patient. Paradoxically, even if it has been abundantly shown that a more process-oriented, ‘intelligently standardized’ teamwork approach leads to better quality and safety outcomes, ànd is less expensive (and thus dramatically more cost-effective). Against a background of considerable expenditure ‘drivers’, such as globalization, increasing chronic diseases and elderly populations, personalized medicine, technical developments etc, it is time to act. 

UZ Brussel can by itself not change the Belgian healthcare system, but has chosen a threefold answer.

A threefold answer

First, on a strategic level, the organization has to be ‘redesigned’ into a more flexible, dynamic system, where strategic endpoints can be adapted more easily to the rapidly changing environment. This is possible by introducing adaptivity and readiness-to-change at every level. This is communicated through public speeches by the CEO for all, early morning breakfast sessions for all with the CEO, and through numerous carriers (intranet, leaflets, etc), and everybody is invited to adapt or change their own fields and activities. On the management level, investments, desinvestments, strategic choices are now questionable and debatable. There are no dogmas or taboos. 

Second, on an operational level, major efforts are made to increase cost-efectiveness and quality, even if this goes – at first glance - against the payment system which paradoxically mainly rewards volumes. Every large medical and supportive project is now managed through a hospital-wide, standardized project management system (‘NEXUS’). Medical and supportive processes are carefully scrutinized, and redesigned using standard tools such as ISO, lean, balanced scorecards and care pathways. KPI’s also have to include quality parameters. Our very performant hospital-built ICT system supports these endeavours. A critical success factor here is communication: convincing doctors that their job, indeed probably the most beautiful and rewarding in the world, is also possible when performed in another, more process-oriented way.  It is not a shame to be ‘part of a team’.  It is good to think and practice in terms of quality outcomes and cost-efficiency. Moreover, patient reward will not decrease, on the contrary! All of this implies a huge and continuous effort. Not only towards doctors, but also – and probably even more – towards patients, hence society. This also means explaining to the public and policy makers that, for instance, making doctors wash their hands after every patient visit, is about a hundred times more cost-effective than – let’s say – introducing million dollar surgical robots in every hospital. It means explaining that it is not useful having a total-body scan for ‘prevention’, but quitting smoking or controlling your diet ìs. And we need to prove to the public that paying huge supplements for having elective surgery done the next day is not a guarantee for better outcome. 

Third, searching for alternative financing is now no longer taboo. This includes introduction of a professional fundraising system, valorization of innovative developments (patenting, spinnofs, contracting with private business partners, introduction of high-level temporal professoral chairs, and internationalization: for instance, UZ Brussel recently and successfully started a joint-venture fertility clinic in the state of Kuwait).

I know, all of this is not very sexy. But it’s a necessary effort. Not only for individual doctors or our hospital, but for society as a whole.

Hence, the need for objective information.

Hence, this article.