PHMI Blog - Blog from Partners Harvard Medical International

We know that increasing numbers of patients around the world are traveling outside their own country for health care, whether they’re looking for better quality, affordability, or both. An entire industry is growing out of the need to connect patients with faraway providers, manage travel and logisitics, and ensure that patients’ experiences abroad are satisfactory. One of the big questions raised by skeptics of “medical tourism” is this: how is one to assess the quality of hospitals abroad?

In recent years, accreditation by Joint Commission International has served as a kind of stamp of approval that patients look for when considering foreign providers. But JCI accreditation — like accreditation by the Joint Commission (formerly JCAHO) — isn’t really a measure of clinical quality. What it is, says PHMI Senior Consultant Dr. John Helfrick, is an indication that a hospital has the systems and processes in place to support high-quality, safe patient care:

“Accreditation” is generally not well understood. It is a process, not an event. There is a “validation” survey but it’s the maintenance of good processes and the improvement of deficient ones that occurs between surveys that really constitutes accreditation. Most “accreditationists” believe that health care outcomes are dependent on the quality of the structures and processes in place in a health care organization. The accreditation process is designed to assist organizations in implementing and then improving their structures and processes. The effectiveness of this process is borne out by the measurement of and, hopefully, the improvement in the outcomes of care.

In recent years PHMI has worked with several health care organizations who have used the JCI accreditation process as a guide for instituting a culture of quality. The process provides a roadmap that helps the provider to develop the kinds of structures they need to produce good outcomes. And while the distinction of earning JCI accreditation can be used as a marketing tool for as long as it is viewed as an indicator of attention to quality care, most clients believe that the process of earning accreditation is most important. From Dr. Helfrick:

Some hospitals pursue accreditation to give themselves a marketing advantage; others do it for the right reason. Interestingly, it’s this latter group that has the most effective marketing approach: commit to high-quality, safe care, and the patients will come. Hospitals that go through the triennial cycle once and then drop out have most likely become accredited for the wrong reason. 

Read what else Dr. Helfrick has to say about hospital quality improvement in the July-August issue of PHMI WORLD.

Back in the September/October 2007 issue of PHMI WORLD, we reported that then-Harvard Medical International was advising the Springfield Land Corporation on the development of a new health care and education project in Springfield, a suburb of Brisbane, Australia:

The Springfield Land Corporation (SLC) has tapped HMI to assist with the strategic planning of an integrated health, wellness, and education campus that will be part of a community expansion in the state of Queensland . . .  

. . . HMI’s role thus far has been to facilitate collaboration between the key stakeholders, including not only SLC and provider groups in the health care community, but also the Queensland government and its Department of Health. HMI is also helping SLC explore how education programs will be integrated into the campus. Dowton and other HMI team members have conducted a series of site visits aimed at synthesizing the perspectives of the groups involved and advising SLC on its long-term strategic plan.

Now the Springfield group has unveiled the blueprint for the Springfield Health City, which “will be a revolution in the approach to health care and wellness in Australia, and provide all the necessary services for the rapidly growing population of Greater Springfield and its surrounds,” according to City chairman Professor John Hay. Hay said the plan for the Health City was based on research conducted by HMI, which recommended a Health City concept with a private/public partnership incorporating all forms of health care including primary care, acute care, alternative care, integrated residential including aged care, retirement living and hotels, education, research and E-health, underpinned by a strong focus on training future health workers.”

Complete release from Greater Springfield

In the wake of the Institute of Medicine’s call for more geriatric medicine training, the Wall Street Journal’s Health Blog highlights how Hebrew SeniorLife, an organization that operates two nursing homes in Boston, is providing opportunities for students at Harvard Medical School and other Boston-area institutions to learn how to address the health care needs of our rapidly growing elderly population.

HMI WORLD correspondent Natalie Engler wrote about this topic in a 2006 Forum article. Read “Meeting the health care needs of an aging population.” An excerpt:

What’s the solution? Simply churning out thousands of geriatricians clearly won’t solve the problem, even if such a thing were possible. If geriatric training was required in every medical school today it would take more than 40 years for all practicing physicians to be replaced by those with geriatric training, says Greg O’Neill, PhD, director of the National Academy on an Aging Society. He adds that new geriatricians, like people in other medical specialties, tend to cluster, leaving an oversupply in some areas while others remain underserved.

 

Some geriatricians—like ILC-USA’s Robert Butler, and Dr. Lewis Lipsitz, chief of gerontology at Beth Israel Deaconess Medical Center, vice president for academic medicine and co-director of the Institute for Aging Research at Hebrew SeniorLife, and professor of medicine at Harvard Medical School—advocate for geriatrics as an academic specialty.

“My approach, and that of my colleagues, is to train the trainers. We want to train the academic leaders who are training the medical students and residents, so that every emerging doctor has a basic knowledge of geriatrics—the way every medical doctor has a working knowledge of cardiology,” explains Lipsitz. “In this way, geriatricians become the researchers who generate new knowledge, as well as the teachers and consultants who disseminate it to the existing  health care workforce”—including physicians, nurses, therapists, pharmacists, and social workers.

We will again join with the University of Lausanne to gather health care leaders in Switzerland for “Mastering the New Challenges of Health Care.” This five-day executive education course is designed to equip participants with the knowledge and skills required to understand and confront complex health policy issues.  

The program will again be led by Miles Shore, MD, Harvard University professor and HMI Senior Consultant and Director; and Alberto Holly, PhD, Professor of Economics and Director of the Institute of Health Economics and Management at the University of Lausanne. They will head a multidisciplinary faculty drawn from Harvard University, the University of Lausanne, the London School of Economics, and other top institutions. For further information and to learn how to register for the program, please click here.

American Public Media’s program “Marketplace” has developed a whole series exploring the rapidly transforming Middle East – everything from the obligatory look at “indoor skiing” to stories focused on infrastructure development, new construction, and other developments that are reshaping the Middle East and creating new connections between the region and the rest of the world.

In a recent segment of the program, Marketplace focused on Harvard’s involvement in Dubai, including Dubai Healthcare City (DHCC), the University Hospital, and the Harvard Medical School Dubai Center (HMSDC) Institute for Postgraduate Education and Research. HMSDC chief academic officer Robert Thurer and DHCC CEO Muhadditha Al Hashimi talked with Marketplace about how Dubai could soon be a top health care “destination.”

Click the link to read — or listen to — the whole piece.

Today the February 2008 issue of leading academic journal Academic Medicine is online and in mailboxes. The theme of this issue is global health, and the lead article is authored by Robert K. Crone, MD, the founding president and chief executive officer of HMI.

Entitled “Flat Medicine? Exploring Trends in the Globalization of Health Care,” the article presents the context in which we at HMI collaborate with our partners around the world. Drawing on examples from our work in Dubai, Turkey, and India, the article describes a global health care landscape that is undergoing a major transformation, with ramifications for patients, providers, and governments not only outside the United States, but in our own  local communities.

From the article abstract:

Trailing nearly every other industry, health care is finally globalizing. Highly trained and experienced expatriate health care professionals are returning to their home countries from training in the West or are staying home to work in newly developed corporate health care delivery systems that can compete quite favorably with less-than-perfect providers in Europe and North America. In turn, these health care systems are attracting patients from around the world who are interested in exploring high-quality, lower-cost health care alternatives. Much of this activity is occurring in the emerging economies of the Middle East, South and Southeast Asia, and beyond. Three Harvard Medical International collaborations-in Dubai, Turkey, and India-highlight these trends and demonstrate the potential for new models of global health care, as well as potential ramifications for patients and providers in the established economies of the West, including the United States. Although globalization is not a cure-all solution to achieving universal access to health care, it is not only a significant first step for patients in these emerging economies, but may also present alternative solutions for those patients in wealthier nations who nonetheless lack adequate health care coverage. The increase in health care quality and competitiveness around the globe is important, but these improvements will need to be matched by the development of comprehensive payer solutions, to benefit as many people as possible.

You’re probably familiar with Atul Gawande’s writing on medicine for the New Yorker magazine, but if you’re not, his most recent piece will serve as a great introduction to his work. In the December 10, 2007 issue, Gawande, who is a surgeon at Brigham & Women’s Hospital in Boston, writes about how the use of detailed checklists are enabling ICUs to provide complex care and save lives in the face of what used to be extremely long odds. In addition to providing a fascinating nuts-and-bolts analysis of an interesting element of clinical quality improvement, Gawande gets at how what is now achieveable in the hospital is pushing against traditional ideas about what makes for good doctors:

Tom Wolfe’s “The Right Stuff” tells the story of our first astronauts, and charts the demise of the maverick, Chuck Yeager test-pilot culture of the nineteen-fifties. It was a culture defined by how unbelievably dangerous the job was. Test pilots strapped themselves into machines of barely controlled power and complexity, and a quarter of them were killed on the job. The pilots had to have focus, daring, wits, and an ability to improvise—the right stuff. But as knowledge of how to control the risks of flying accumulated—as checklists and flight simulators became more prevalent and sophisticated—the danger diminished, values of safety and conscientiousness prevailed, and the rock-star status of the test pilots was gone.

Something like this is going on in medicine. We have the means to make some of the most complex and dangerous work we do—in surgery, emergency care, and I.C.U. medicine—more effective than we ever thought possible. But the prospect pushes against the traditional culture of medicine, with its central belief that in situations of high risk and complexity what you want is a kind of expert audacity—the right stuff, again. Checklists and standard operating procedures feel like exactly the opposite, and that’s what rankles many people.

It’s ludicrous, though, to suppose that checklists are going to do away with the need for courage, wits, and improvisation. The body is too intricate and individual for that: good medicine will not be able to dispense with expert audacity. Yet it should also be ready to accept the virtues of regimentation.

In the new issue of “Global Health Update” (a Partners Healthcare System publication), Dr. James Thrall, Radiologist-in-Chief at Massachusetts General Hospital, talks with the editor of HMI WORLD about his rapidly evolving field. Choice quote: “The future is going to take us to smaller dimensions. Just as scientists are very excited about nanotechnology, radiologists are very excited by our ability to image not just at the level of the whole organ, but at the level of molecules and cells.”

As scored and ranked by the U.S. News & World Report in their annual Honor Roll of American hospitals:

1. Johns Hopkins Hospital (Baltimore, MD)
2. Mayo Clinic (Rochester, MN)
3. UCLA Medical Center (Los Angeles, CA)
4. Cleveland Clinic (Cleveland, OH)
5. Massachusetts General Hospital (Boston, MA)
6. New York-Presbyterian University Hospital of Columbia and Cornell
7. Duke University Medical Center (Durham, NC)
8. University of California-San Francisco Medical Center
9. Barnes-Jewish Hospital at Washington University (St. Louis, MO)
10. Brigham & Women’s Hospital (Boston, MA)

Food for thought: of the hospitals on the list, do you know which ones are engaged in work outside the United States, in some form or fashion?

Update: Answer to the question above in bold.

National Public Radio’s “All Things Considered” began its series on global health by focusing on the rapidly developing high-quality hospitals being developed in countries like India. Now the focus is on doctors — specifically, Indian doctors who are giving up medical practices in the U.S. to return home.

NPR correspondent Richard Knox reports:

Soon India’s middle class will be as large as the entire U.S. population. For-profit hospitals like Wockhardt’s are springing up all over to serve these patients. And they’re offering signing bonuses and stock options to attract doctors from America. Often their Web sites boast of the number of American board-certified physicians on their staffs.

That has many Indian doctors in America thinking about going home.

Over a cup of coffee on the Harvard Medical Area campus in Boston, 8,000 miles from Bangalore, Dr. Manas Kaushik talks about the emigration of Indian doctors.

Kaushik is Indian himself. He has done research at the Harvard School of Public Health on the brain drain of doctors out of India. He tracked hundreds of graduates from the All-India Institute of Medical Sciences, India’s equivalent of Harvard Medical School. He looked at alumni dating back to the 1950s.

“Over this period, we roughly had 450 physicians who graduated from the All-India Institute of Medical Sciences,” Kaushik says. “And almost 50 percent of them emigrated to the U.S.”

In 50 years, Kaushik says, only one of those doctor-emigrants went back to India — and he returned to America a year later.

No other country has exported as many physicians as India. More than 40,000 practice in the United States, making up one of every 20 U.S. doctors.

But Kaushik says the tide is beginning to turn. There are no statistics, but there is a lot of anecdotal evidence that Indian doctors are buzzing about the new opportunities to practice American-style medicine in India.

“I’m a recent immigrant myself, and I’ve talked to a lot of my friends who have made tough decisions about moving to the U.S., and some of them are thinking of going back,” Kaushik says.