Healthcare Management Medical Sciences Diagnostics Information Technology Surgical Speciality

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Art for Global Health Medical

Health’s Sake Landscape Banking
In association with
An evidence-based Healthcare A new
approach “beyond borders” stakeholder
w w w. a s i a n h h m . c o m 
 Asian Hospital & Healthcare Management ISSUE-15 2008

Patient-Centred Healthcare
Moving beyond ailment
An involved patient is a blessing for healthcare organisations.
H
ealthcare providers—in Asia and the rest
of the world—are yet to come to terms
with the paradigm shift that is taking
place in the provision of healthcare. A re-look at
planning, delivery and evaluation of care is the
order of the day. The healthcare processes need to
be aligned to ensure that the patient is treated as
a consumer.
Though this may seem like a minor change in
perspective, the implications for healthcare provid-
ers are anything but small. The patient will move
beyond being a mere recipient of service, and
become a source of crucial feedback to the provid-
ers of healthcare. Indeed, if a process is to revolve
around the patient, it’s only fair that hospitals seek
their active participation in defining it.
An involved patient is a blessing for healthcare
organisations, provided they are able to facilitate
comprehensive communication between the staff,
physicians and the patient. To enable this, provid-
ers would need to put in place an appropriate chan-
nel of communication. Unless healthcare estab-
lishments take it upon themselves to introduce
a patient-centred approach organisation-wide, a
change of this proportion can never be positive in
the long run.
In the cover story, we present insights from
industry experts on how the patient can be an
active participant in creating processes that are
meant to serve them best. It features three inter-
views and two articles. In the interviews, indus-
try leaders who have been at the forefront of this
change, share their opinions on the various aspects
of providing patient-centred care.
Foreword
The first article, ‘Listen to the Patient’ talks
about improving the doctor-patient communica-
tion at every stage of healthcare provision. The
feedback can prove to be crucial in improving the
quality of life for the patient.
The next article, ‘Patient-centric modalities’,
talks about the factors—tangible and intangi-
ble—that need to be considered during the design
and implementation of patient-centric processes
in healthcare. The article lays emphasis on making
hospital stay as short as possible while providing
the patient the best quality care.
The two key facilitators of this trend are Inter-
net and Information Technology. The Internet has
proved to be a blessing for patients seeking infor-
mation about diseases and cure. Today, patients
are better informed in their interface with provid-
ers. With the right systems in place, hospitals can
leverage this knowledge to their advantage.
Developments in healthcare information
technology have helped create data management
systems that enable storage, analysis and retrieval
of even the smallest bits of data. With so much
information on call, the onus will be on hospitals
to provide focussed care. How a hospital uses this
opportunity could also affect its competitiveness.
The one entity that stands to gain most from this
movement, though, is the patient.
Akhil Tandulwadikar
Editor
w w w. a s i a n h h m . c o m 
 The Big Shift 48
Stephen C Schoenbaum
Executive Vice President
The Commonwealth Fund
USA

Meeting Diverse Needs 50

Amy Wilson-Stronks
Project Director, Division of Standards and
Survey Methods, The Joint Commission
USA

The New Challenge 52

Gary Kaplan
Chairman and CEO
Virginia Mason Medical Center
USA

53 Listen to the Patient

Assuring quality care
WF Bower, Assistant Professor
CSK Cheung, Research Associate
CA Van Hasselt, Professor
MJ Underwood, Professor
Department of Surgery, The Chinese University of
Hong Kong, Hong Kong SAR

57 Patient-Centric
Modalities
Strategies for
better implementation
Julio A Reategui, RA / QA and
Compliance Asia Pacific
MEDRAD, Inc., USA

HEALTHCARE MANAGEMENT Chronic Diseases 10

Prevention is better than cure
Anna Coote, Commissioner for Health
Sustainable Development Commission, UK
Global Health 6
Landscape
Healthcare Vision Care 15
“beyond borders” The next step in comprehensive
disease management
Ori Karev, CEO
Cheryl Johnson, Vice President
UnitedHealth International, USA
Health Care Services, VSP Vision Care, USA

 Asian Hospital & Healthcare Management ISSUE-15 2008

 Contents
Six Sigma in 20 38
Healthcare Safety in
Effective use of the Tool Box
Maria H Foschi, Assistant Vice President, Anaesthesia
Virtua Health, USA Promoting sustainable
Adrienne Elberfeld, Six Sigma Champion, change for the future
Virtua Health, USA Alan F Merry
Professor and Head of Department,
Anaesthesiology
24 University of Auckland, New Zealand

Lean and Six Sigma

Transforming healthcare Telemonitoring in Cardiac Device Therapy 42
Enabling optimal management of patients
Jason Lebsack, Manager Auricchio Angelo, Professor,
Six Sigma, Nebraska Medical Center, USA Division of Cardiology, University Hospital, Germany

SURGICAL SPECIALITY

MEDICAL SCIENCES Patient Safety in Surgery 60

Current ‘key’ issues
Philip F Stahel, Department of Orthopaedic Surgery
The Changing Face of Cancer 27 Wade R Smith, Department of Orthopaedic Surgery
Implications for Anaesthesia Philip S Mehler, Department of Medicine
Thomas W Feeley, Helen Shafer Fly Distinguished Professor Denver Health Medical Center, University of Colorado School of Medicine, USA
Anesthesiology and Head, Division of Anesthesiology & Critical Care
The University of Texas M.D. Anderson Cancer Center, USA
DIAGNOSTICS
Multidisciplinary Collaboration 30
in the ICU
Promoting effective care 63
Ruth M Kleinpell, Professor Advanced CT Imaging
Rush University College of Nursing, USA Effective diagnosis
of coronary disease
Michael Chun-Leng Lim, Medical Director
Targeting 32 Singapore Heart Stroke and
Cancer Centre Singapore
the Stress
of Diabetes
Preserving vascular
longevity
67
Kenneth Maiese, Professor
Departments of Neurology and PACS in
Anatomy & Cell Biology Barbara Ann
Karmanos Cancer Institute Indian Hospitals
Center for Molecular Medicine and Catching up
Genetics Institute of Environmental
Health Sciences Deepak Kumar, Chief Technology Officer
Wayne State University School of Srishti Software, India
Medicine, USA

Embolic Protection During 35

Technology, Equipment & Devices
Carotid Stenting
Using FiberNet device Devices Containing Membranes 69
Jennifer Franke, CardioVascular Center Frankfurt, Germany Better membrane, improved outcomes
Horst Sievert, CardioVascular Center Frankfurt, Germany and Nicholas Hoenich, Clinical Scientist
Washington Hospital Center, USA Medical School Newcastle University, UK

w w w. a s i a n h h m . c o m 
C o ntents

Issue 15 2008

Facilities & Operations Management Editor : Akhil Tandulwadikar

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Healthcare Editorial Team : Prasanthi Potluri
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Health’s Sake

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An evidence-based
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 Asian Hospital & Healthcare Management ISSUE-15 2008
H ealthca r e M anagement

Global Health
Landscape
Healthcare
“beyond borders”
At a time when the global citizen
is transforming how healthcare is
delivered worldwide, there’s a need
for a vision for delivering coordinated,
high-quality and affordable care
“beyond borders.”

Ori Karev
CEO
UnitedHealth International, USA

T
he rise of a global health-
care marketplace is underway.
Thanks to a new global citizen,
whose work and life transcends borders,
the delivery of healthcare worldwide
is being transformed. Simultaneously,
other economic and social realities are
fuelling what will be a major shift from
national to global approaches in health-
care delivery. Innovations in medical
technology, strong economic pressures
on individual countries to reinvent their
healthcare systems, and a transparent,
collaborative approach to prevention
and treatment, all contribute to an
expanding global landscape that cannot
be ignored.
We are already making strides towards
a border-neutral healthcare system that
freely shares knowledge and technol-
ogy. This foundation will bring about
an interconnected network of medical
professionals, facilities and global best
practice standards that will help drive
seamless access to quality healthcare,
regardless of where care is provided.
Stakeholders—both payers and
consumers—want healthcare solutions
that serve the new global citizen. We
must understand, embrace and lead the
global healthcare market’s evolution.
Healthcare payers will continue to inno-
vate methods to serve healthcare needs
through competition, risk pooling,
mandatory insurance, wellness incen-
tives and public sector funding.
The old healthcare paradigm is
increasingly becoming outdated. In
the past 15 years, per capita healthcare
expenditures have risen dramatically, yet
healthcare systems have not succeeded
in delivering care to all citizens.

 Asian Hospital & Healthcare Management ISSUE-15 2008


US healthcare spending, as a percent-
age of GDP, is the highest in the world,
yet many US citizens have limited or
no access to health insurance. Mean-
while, the European Union countries
are striving to effectively manage costs
while facing the challenge of providing
timely access to care.
Global citizen-driven healthcare
The mechanisms for delivering global
healthcare must be established in a
systematic way, not as ad hoc solu-
tions—some promoted by providers
and others by consumers. Individual
consumers around the world have access
to an enormous pool of knowledge.
They are researching their conditions
and making decisions on what treat-
ments are needed and, more impor-
tantly, where they will be provided.
Individuals are searching outside their
present healthcare systems for better
answers, and are willing to travel and
pay for them.
The elements shaping a new para-
digm for global citizen-driven health-
care include:
• Consumer mobility: In today’s global
economy, many people no longer
live exclusively in their country of
origin. Workers are often expatri-
ates or third country nationals who
live and work outside their country
of citizenship. This trend will likely
increase, with the largest markets in
Western Europe, the Middle East,
North America and East Asia. As
people become increasingly mobile
for both temporary and permanent
work assignments, they will need a
healthcare system that can support
their needs.
• Medical travel: While medical tour-
ism in the past was associated with
spa treatment and cosmetic surgery,
today more than 100 hospitals
worldwide are Joint Commission
International (JCI) accredited, and
others are building a massive pres-
ence in low-cost high-quality envi-
ronments. It is worth noting that the
H ealthca r e M anagement
Making it work
In order to drive the international coordination of high-quality healthcare
for consumers at an affordable cost, there needs to be a greater degree of
integration between global healthcare participants.
Specifically, most countries in the Asia Pacific region lack sufficient
clinical data and the ability to analyse it. As these countries’ healthcare
systems grow, and as demand grows, they will require healthcare intelligence
to make good decisions about care delivery, resource allocation and
treatment of chronic conditions. Robust analysis of clinical data translates
into positive health outcomes. Clinical data analysis can prevent mega
illnesses, improve preventive care, predict with a high level of accuracy which
treatment has higher likelihood of success, reduce mortality rates and create
a healthcare environment that is based on data, outcomes and best practices
employed in other countries. As citizens of the global economy, we have
a keen interest in making clinical data tools and analysis readily available
where they are not today, to ensure the development of rational, efficient,
high-quality healthcare systems in these countries.
JCI accreditation programme is not and government are reviewing the
unique in its activities of accredit- viability of employer health bene-
ing. However, it is the JCI accredi- fits programmes. Governments are
tation which transcends borders and experiencing increasing costs and as
contributes effectively to the neces- a result, they are shifting healthcare
sary element of accreditation in the delivery and management to private
globalisation of healthcare. Accord- providers. We are experiencing a
ingly, both providers and payers can major shift in funding, both from
gear up to meet an increased demand a public policy and an individual
in global healthcare. perspective.
• Language and culture: To facilitate Clinical analysis, predictive model-
the rapid exchange of innovation, ling and evidence-based medicine are
English is increasingly becoming all manifestations of the rising need to
the lingua franca of medicine. At the manage healthcare from an economic
same time, an increase in migration perspective. This is not to say “to
to Europe and the US from Latin reduce the cost of healthcare,” but only
America, Asia and Africa is causing to reallocate resources in the proper
policy makers and healthcare provid- direction. Simply put, a key element in
ers to incorporate the diverse view- the fulfilment of the globalisation trend
points of medical and technological in healthcare stems from our collective
professionals who have trained and ability to generate and analyse useable
gained practical knowledge outside clinical data
their countries. During our lifetimes, each of us
• Healthcare financing: Traditional experiences medical challenges arising
funding methods for healthcare are from current health conditions, well-
being challenged. Globally, out of ness activities, our gene pool and our
pocket spending is straining the surrounding environment. Assuming
healthcare consumer’s personal we are able to categorise and cata-
budget regardless of whether their logue such information or data from
country has nationalised health- the outset, we would then be able to
care coverage. In the US, employers develop a personal clinical profile.
w w w. a s i a n h h m . c o m 
H ealthca r e M anagement

Armed with that data, we can now
begin to track various medical proce-
dures and treatments and the effect of
each on our overall health.
In short, by leveraging statistical
analysis and measurement tools to eval-
uate efficiency (the equation of resource
applied and the results obtained) we
can predict outcomes, which helps us
select the most appropriate treatment
modalities for each individual.
Why is the issue so relevant in the
Asia-Pacific region? First, most Asia
Pacific countries neither rigorously
adhere to clinical data generation and
utilisation principles nor do they apply
clinical data outcomes to their popula-
tions. In the meantime, Southeast Asian
residents are earning higher incomes
and demanding a say in the goods and
services they purchase. Concurrently,
they expect their countries to actively
participate in processes that increase
their well-being. As their healthcare
systems mature, these countries now
have the opportunity to improve care
for their citizens
In addition, as active participants
in global healthcare, there must be
common data platforms and effec-
tive linkages amongst data collecting
entities. There is an inherent chal-
lenge in transporting critical clinical
data—patient history, diagnosis of the
presenting concern, prescription drug
use etc.—between countries. From a
data infrastructure viewpoint, clini-
cal data must be readily transportable
(HIPPA implications not withstand-
ing) so that the patient, the treating
physician, the examining physician,
and the payer all have access. What is
sometimes forgotten is that care coor-
dinators and payers must also be able
to access this information to coordi-
nate care and pay the bills when the
A global legal framework
Another major challenge to the trend of
globalisation of healthcare is the lack of
an integrated, international legal frame-
work. The healthcare market in the US
has liability legislation and a massive
body of common law that clearly estab-
lishes the patients’ right to sue if they
feel they have been wrongfully treated.
It is this specific right (or perhaps even
a sense of entitlement) which may be
one of the key factors giving rise to the
need for US medical providers to over-
test, over-prescribe and practise defen-
sive medicine. The fear of one’s medical
decisions being challenged down the
road, with the benefit of hindsight and
a good legal counsel, drives US provid-
ers to seek extraordinary treatments,
procedures and advice. This approach
costs money. Accordingly, a portion of
the high costs of US healthcare is the
cost of protecting against litigation.
Those who participate in shap-
ing global healthcare must take into
account fundamental cultural and
legal differences in the expectations of
global healthcare consumers. Univer-
sally accepted solutions must be negoti-
ated. An example of global negotiation
would be ongoing worldwide efforts to
develop common intellectual property
protection, offering owners of intellec-
tual property the assurance of marketing
their products in other countries with-
out placing their products or services at
risk of duplication.
Lastly, the trend of globalisation
of healthcare must go hand in hand
with a robust solution for country-
of-origin support systems. At some
point, most patients who participate in
global healthcare, may return home
with ongoing health needs relative
A uthor
to their recovery that require clinical
support. Outside of the legal considera-
tions, the fundamental issue is ensuring
that returning patients have access to the
clinical support they need to continue
their recovery. It is too early to tell
whether clinicians accepting foreign-
treated patients will be fully supportive
of their patients who have received treat-
ment overseas, but let’s assume that this is
the case. Even the best intentioned, fully
supportive providers will have a need for
data, assessments and support to provide
for appropriate continuity of care.
Trends in the globalisation of health-
care present us with a number of ques-
tions: What role will any specific health-
care industry assume during this period
of transition? And, will the new para-
digm of global healthcare simply emerge
organically from these trends, or, will
it be shaped thoughtfully, optimising
healthcare for all of the world’s citizens?
I advocate for the latter.
Leadership for the transition to a
truly global healthcare system is resident
in the private industry that has insured,
managed and administered healthcare
for over a century. The industry has the
knowledge, the technology, the scope,
and the ability to drive efficiency and
ensure quality outcomes. However, it
is the public-private partnerships that
will serve as the catalyst in transform-
ing the healthcare industry into a truly
global industry. Our challenge as future
contributors or beneficiaries of the
trend is to anticipate rapidly changing
consumer requirements and be fully
prepared to deliver the products and
services that meet these needs. This is an
exciting opportunity—an opportunity
to improve a critical aspect of people’s
lives on an unprecedented scale.

patient returns to his country of origin.
Personalised and transportable elec-
tronic health records are also critical
to understanding costs and determin-
ing future insurance premiums, both
locally and globally.
Ori Karev is the CEO of UnitedHealth International, a UnitedHealth
Group company. He drives UnitedHealth International’s growth, ad-
vancing its position as the leading global health and well-being com-
pany. Under Ori’s leadership, the company actively pursues its local
and global potential in its various market segments: global health
insurance, third-party administration, healthcare management con-
sulting and global health solutions for leading benefit plan sponsors.

 Asian Hospital & Healthcare Management ISSUE-15 2008

w w w. a s i a n h h m . c o m 
H ealthca r e M anagement
Chronic Diseases
Prevention is better than cure
Regular physical exercise, healthier food and greater contact with the environment
reduce the risks of chronic diseases and promote sustainable development.
Anna Coote
Commissioner for Health
Sustainable Development Commission, UK
S
ustainable development is a long-
term, whole-systems approach
that gives equal weight to five
principles: living within environmen-
tal limits; a strong, healthy and just
society; a sustainable economy; good
governance, and using sound science
responsibly. By promoting sustain-
able development we help to prevent
chronic disease. By preventing disease
we help to promote low carbon living
and prevent damage to the environ-
ment.
The policies we need to safeguard
human life on the planet are the same
or very similar to those we need to
prevent human illness in general and
chronic disease in particular. Global
warming presents enormous new chal-
lenges to the way different countries
treat each others’ citizens and to the
way welfare systems across the world
deal with risk and disadvantage. So,
we need to transform social policy—at
local, national and global levels, to
meet the needs of the modern world.
Chronic disease is a global prob-
lem. The World Health Organization
(WHO) says 66 per cent of all prema-
ture deaths are due to chronic diseases.
In the next decade, it is estimated that
nearly 400 million people will die of a
chronic condition.
10 Asian Hospital & Healthcare Management
In the developed world, there are
three factors that greatly exacerbate the
problem and point to higher rates and
greater costs in future:
1. One is the rising epidemic of obes-
ity—bringing with it grave risks of
heart disease, cancer and diabetes.
In England, one in four is affected
and the rates are rising rapidly. This
currently costs US$ 7.4 billion (£3.7
billion) every year.
2. The second factor is the rising levels
of mental ill-health. The WHO has
predicted that by 2020, depression
will be the second greatest contributor
to the burden of disease for all ages and
both sexes. We are learning that above
a certain level, higher income does not
make people happy any more. People
in richer countries suffer from high
levels of stress, anxiety and depres-
sion. These mental illnesses often lead
to physical disorders. A recent report
in The Lancet found that depression
is more dangereous to health than
the four major chronic conditions:
angina, arthritis, asthma and diabetes.
Projected global distribution of chronic disease deaths
Low income
countries 35%
37%
Lower middle income countries
ISSUE-15 2008
In England alone, one in 6 is affected
by mental health problems and it
costs the country US$ 152 billion
(£76 billion) a year—in health and
social care services, lost economic
output, and associated costs.
3. The third factor is the ageing
population. In the last two decades
in England, life expectancy for men
increased by just over 5 years, but
healthy life expectancy increased
by less than three years. So, more
people are old and ill—suffering, in
the main, from chronic mental and
physical illness.
Furthermore, both poverty and
insecurity result in chronic disease.
So, what can be done to prevent
chronic disease? According to the
WHO, the causes are known, the risks
are largely preventable and the key is to
focus on risk factors that link across the
major killer diseases.
The three overlapping risk
factors are: exercise, diet, and human
contact with natural environment. It is
with these ‘upstream’ determinants of
High income
20%
countries
8%
Upper middle
income countries
Graph 1
w w w . a s i a n h h m . c o m 11
H ealthca r e M anagement
health that we find the greatest synergy
between sustainable development and
health.
Exercise
There is strong evidence that physical
inactivity is related to ill health. As a
factor that contributes to heart disease,
lack of exercise can be looked upon as
serious as smoking.
In England, as in many other coun-
tries, very few people take exercise. Two
in three men and three in four women
fail to take the recommended mini-
mum of 30 minutes’ moderate activity
five times a week. This is partly because
of the vast increase in the use of private
car for transportation and also due to
the road traffic conditions.
Reduction in motorised road traf-
fic—and the resultant reduction of air
pollution—combined with an increase
in physical activity through walking and
cycling would have multiple benefits
like: reductions in lung disease, asthma,
obesity, diabetes, cardiovascular disease,
osteoporosis and certain cancers;
improvements in mental health. This
can also significantly reduce CO2 emis-
sions and other environmental damages
that in turn present threats to the cohab-
itant's health and well-being.
It’s a virtuous cycle. Public policies
that promote sustainable and active
travel—for everyone, not just the
middle-classes, can reduce the risks of
chronic disease, combat global warming
and help us all live with the resources of
one planet instead of three.
Diet
A poor diet made up of processed foods
that are heavy in fat sugar and certain
artificial additives is harmful for physi-
cal and mental health. It is an acknowl-
edged cause of obesity and depression.
Processed foods are energy-inten-
sive. Food items which are transported
over long distances have a larger carbon
footprint. Conversely, food bought
locally helps to stimulate local econo-
mies, create jobs, reduce poverty and
12 Asian Hospital & Healthcare Management
give people greater control over their
own lives—all important determinants
of health.
Public procurement, planning, regu-
lation and transport policies are all levers
for government to promote sustain-
able food production and help people,
regardless of their income, to maintain
a good diet. This approach is now being
actively applied by a group of hospitals
in Cornwall, south-west England. They
buy food from local suppliers, improving
the diet of patients and staff and help-
ing to bring new jobs into the area—all
as a way of improving health and using
resources more efficiently over time.
This suggests another virtuous cycle.
Fresh, affordable, locally produced food
is good for health and better for the
environment.
Contact with natural environments
There is sound evidence that people
who have contact with natural environ-
ments have better physical and mental
health. They take more exercise, feel
better about themselves and reduce
their risks of getting ill. A Dutch study
has shown that the more green space
people have access to, the better their
general health would be—and the rela-
tionship is the strongest for lower socio-
economic groups. Research in Chicago,
USA, compared groups of people living
in buildings with and without trees
and grass nearby. Those without trees
and grass had a less positive attitude
to life, while those with trees and grass
around, used public space more often
and made more social contacts, which
is also known to have positive effects on
health. Another study of patients recov-
ering from gall bladder surgery found
that those who looked out on greenery
recovered faster than those who looked
out on a brick wall.
Accessible, usable, natural green
space encourages physical activity. Exer-
cising in pleasant, natural surroundings
improves people’s self-esteem and mood
(hence the growing popularity of green
gyms).
ISSUE-15 2008
Protecting green spaces—everything
from wilderness and open countryside
to parks, tree-lined streets and gardens—
can help to protect the environment
and—on the right scale—combat global
warming.
The Royal Commission on Envi-
ronmental Pollution remarked in 2007.
“The evidence is sufficiently strong (for
planners) to recognise the health benefits
of green space and to build green space
into new and existing developments”.
Here is another virtuous cycle. Public
policies that promote and safeguard
high quality natural environments—
and public access to them, especially
for low-income groups—can promote
better physical and mental health,
reduce the risks of chronic disease and
help to sustain the resources on which
human life depends.
Barriers to change
It is simply not sustainable to address
chronic disease as something that
just needs to be managed. But, why
do governments and health systems
continue to give higher priority to
managing rather than preventing ill
health?
We must recognise the danger of
‘producer capture’. Health profession-
als are trained, managed and rewarded
in ways that favour treatment and care,
rather than prevention. Professional
interest in treatment and care tends to
drain away the lion’s share of resources—
human energy, professional skills, politi-
cal capital or financial resources—from
the prevention agenda.
Much more money is invested in
research into the efficacy of clinical
interventions than into preventative
measures. Politicians who run health
systems want ‘quick wins’ to woo their
electorates and have little patience with
the unglamorous long-term efforts of
prevention. In some countries—includ-
ing England—health systems are still
organised and run separately from local
government and struggle to work in
partnership with those who run services
w w w . a s i a n h h m . c o m 13
H ealthca r e M anagement

that influence the wider determinants
of health—education, planning, hous-
ing, transport. Media campaigns exert a
vital influence over political behaviour
and public opinion—newspapers and
television usually find it easier to tell
stories about things that go wrong than
about things that prevent problems
occurring.
And there are alluring ‘downstream’
solutions that can fulfil a health profes-
sional’s desire to ‘win the battle against
disease’ but these solutions detract
attention from doing what it takes to
make that battle redundant. For exam-
ple, why worry about urban planning to
encourage walking and cycling and to
avoided, on reducing domestic and
global poverty and on measures that
safeguard the environment for our
children and grandchildren
In 2002, a report for the UK Treas-
ury anticipated that failure to pursue
what Derek Wanless, the author, called
a ‘fully engaged scenario’ (focussing on
preventing ill health and making better
use of current resources), would cost the
NHS up to US$ 60 billion (£30 billion)
extra every year by 2020.
Virtuous Cycle
Prevent the
preventable
to spend that US$ 192 billion (£96
billion) to promote sustainable develop-
ment—through procurement, employ-
ment, managing energy, buildings and
transport. A web-based toolkit for NHS
managers promotes this approach,
showing that sustainable development
can make good business sense and—
crucially—help to prevent illness and
improve health.
The WHO now advocates action on
climate change—to reduce the causes
and address the risks presented by
global warming, especially for vulner-
able people, with a view to improving
population health.
In summary, it is possible and neces-

Su prev
sta en
increase access to green spaces, or about sary to give higher priority to prevent-
ture

in tio
r fu

thr n
agricultural policy to increase access to ing chronic disease. Public health

ou
afe

gh
fresh local food—if you can prescribe protagonists have been arguing the case
As

Towards a
a pill such as statins and show posi- for decades, but there is a new sense of
sustainable
tive results in clinical trials (even if the social policy
urgency when it is linked with mount-
lity gh
Be se o

abi rou
intervention remains controversial)? ing concerns about climate change.
tte f r
u

tain n th
r h eso

Meanwhile, there is robust evidence The key message is that we must

eal ur

susentio
th, ce

showing that: move towards a more sustainable social

be s

v
Pre
tte

• Most chronic diseases can be policy. That means preventing what we

r

prevented
• Given the choice, people will choose
health rather than illness
• Key measures that promote sustainable
development will also help to prevent
chronic disease—and vice versa
• Tackling climate change should be
a primary responsibility for health
professionals and health systems,
because failure to live within the
natural limits of our planet is already
putting the health of millions at risk,
contributing to chronic disease world-
wide, and threatening catastrophic
effects on human health within a
matter of decades
• Failure to prevent chronic diseases
will have devastating effects on health
systems because of the vast and ever-
increasing costs of treating and caring
Manage unavoidable
disease
Figure 1
There are some encouraging signs.
The climate and health council, set
up under the auspices of the British
Medical Journal, has begun an intensive
campaign to persuade doctors that it
is their duty as guardians of health to
reduce carbon emissions and promote
sustainable practices. Another presti-
gious medical journal, The Lancet, has
embraced the agenda, running a series
on energy and health.
The National Health Service for
England and Wales has set up a unit
to promote what it calls ‘good corpo-
rate citizenship’, encouraging the NHS
A uthor
can—probably preventing three-quar-
ters of all chronic disease; pursuing the
goals of sustainable development by
preventing chronic disease; prevent-
ing disease by means of sustainable
development; and releasing resources
so that we can sustain our capacity
to manage unavoidable disease in the
longer term. If we do this, there is a
double prize to be enjoyed—better
health and quality of life, and more
efficient use of resources, which in
turn safeguards the future health and
well-being of our children and grand-
children, the long-term viability of our
health and social care services, and the
natural resources on which human life
depends.

people who have avoidable chronic Anna Coote is the Commissioner for Health on the UK Sustain-
diseases able Development Commission. She is a policy analyst and writer
• All this amounts to a huge waste specialising in health and social policy, sustainable development
and public involvement. She is a Fellow of the Royal Society of
of precious resources—that could Public Health.
be much better spent on health-
care to treat illnesses that cannot be

14 Asian Hospital & Healthcare Management ISSUE-15 2008


Vision care plays an important role in the early detection and prevention of disease.
The collaboration of evidence-based eye care with healthcare will have a positive
impact on patient care and healthcare savings.
Cheryl Johnson
Vice President, Health Care Services
VSP Vision Care, USA
I
n the US, all citizens are faced with
healthcare costs that are increasing
at alarming rates and they show
no sign of slowing. Employers dealing
with rising costs are promoting preven-
tive care as a way to encourage wellness,
and provide opportunities for early
detection of disease. Hence, children
and adults should get a comprehensive
exam at least every two years.
More and more, vision care is
becoming recognised as a key element
in overall body health. It has become an
integral part of the healthcare contin-
uum.
Vision Care
The next step in
comprehensive disease
management
Vision care is an easy, as well as effec-
tive, entry into the healthcare system.
Research from the US Census Bureau,
the National Center for Health Statis-
tics and VSP Vision Care show that
working citizens with vision coverage
get eye exams nearly four times more
frequently than physicals, 61 per cent
versus 16 per cent.
This is significant because the
eyes are the only places on the
body that provide an unobstructed,
non-invasive view of the blood vessels.
Through comprehensive eye exams,
eye doctors can diagnose serious
eye diseases including glaucoma, macu-
lar degeneration and diabetic retinopa-
thy. They can also detect symptoms
of serious systemic conditions such
as diabetes, high cholesterol and
hypertension.
H ealthca r e M anagement
Often these conditions yield no
symptoms in the early stages and
early detection offers opportunities
for disease management and preven-
tion of blindness and more serious
illness. According to the Center for
Disease Control, more than 90 million
Americans live with chronic diseases.
Treatment for these diseases account
for more than 75 per cent of the
nation’s US$ 1.4 trillion medical care
costs.
The growing awareness about the
connection between vision care and
total body health is redefining what
vision plans need to provide. It’s
more than just coverage for glasses
and contacts, but a more integrated
approach to data sharing between
practitioners health plans and disease
management companies.
w w w . a s i a n h h m . c o m 15
H ealthca r e M anagement

Overview of the six conditions collected through the Eye Health Management Program®

What is it? How many Americans are affected? How does a VSP doctor detect symptoms?
Diabetes • Disease in which the body does • 21 million • Sudden or severe loss of visual acuity
not produce or properly use insulin, • One-third are unaware they have the disease • Presence of diabetic retinopathy
which is needed to convert food into • Additional 54 million have pre-diabetes
energy

Hypertension • Elevated blood pressure • 65 million • Narrowing of blood vessels

Corneal Arcus • Ring around the cornea
(High Cholesterol) • Caused by fatty deposits
• Possible indicator of high cholesterol
• 30 per cent are unaware they have the
disease
• 34 per cent do not manage it
• Prevalence of arcus ranges from 25-30 per
cent of the US population
• High cholesterol affects 20 per cent of
Americans over the age of 20
• Fluid leaking from blood vessels
• Spots on retina
• Swelling of the macula and optic nerve
• Bleeding in the back of the eye
• White or yellow ring appears around the
cornea

Diabetic • Caused by changes in the blood
Retinopathy vessels of the retina, usually when
retinal blood vessels swell and leak
fluid, or when new blood vessels
grow on the surface of the retina
Glaucoma • Group of eye diseases that causes
pressure against the optic nerve
and compression of the eye’s blood
vessels
• Results vary from slight vision
impairment to total blindness
Macular • Leaking of fluid or bleeding in the
Degeneration macula, an area in the back of the
eye that produces the sharpest vision
• Approximately 4.1 million adults 40 years • By performing dilation and examining the
and older back of the eye
• 1 in every 12 in this age group has advanced
vision-threatening retinopathy
• Diabetic retinopathy affects up to 80 per cent
of all diabetics who have had diabetes for 15
years or more
• 2.2 million • By administering a test that measures the
• Half are unaware they have it pressure inside the eye
• 2 million • Yellow deposits appear in the macula
• Patients vision can be tested with an
Amsler grid

VSP Vision Care, the largest eye
health benefit provider in the US
with 52 million members and more
than 24,000 private-practice network
doctors, is at the forefront of a conti-
nuity of care approach.
VSP doctors, conducting compre-
hensive eye exams, can detect signs of
serious eye conditions including glau-
coma, macular degeneration, diabetic
retinopathy and cataracts. In addition,
annual eye exams can detect signs of
systemic conditions including diabetes,
high cholesterol, high blood pressure
and heart disease before serious damage
occurs.
Unique in the marketplace, their
private practice doctors give personalised
care and develop long-term relation-
ships with patients and their families.
In fact, VSP doctors know their patients
so well that they can see even minor
changes in their eyes over time. With
their best practice medical guidelines,
comprehensive eye exam standards
and coordination with primary case
physicians, all members receive quality
care.
Eye Health Management
Program®
VSP has taken quality care one step
further by developing the Eye Health
Management Program®, a complemen-
tary enhancement to all VSP plans,
with the view that eye health, disease
management, and total body health is
a collaborative effort.
In a process compliant with privacy
standards, the Eye Health Manage-
ment Program® requires VSP eye
doctors to report six disease states:
Table 1
diabetes, hypertension, high choles-
terol, diabetic retinopathy, glaucoma
and macular degeneration (Table 1).
In turn, VSP can then take this data
and share patient-specific information
with health plans and disease manage-
ment companies.
This data collection process is
unique to VSP because their private
practice model allows consistent
claim information to be submitted on
routine vision claims. Capturing and
sharing these conditions can result in
significant health and cost benefits of
early detection and treatment.
According to data from VSP, the
U.S. Census and the National Center
for Health Statistics, approximately 16
per cent of Americans see their primary
care physicians regularly for preven-
tive care, while about 61 per cent of

16 Asian Hospital & Healthcare Management ISSUE-15 2008

w w w . a s i a n h h m . c o m 17
H ealthca r e M anagement

Americans with coverage see their eye
doctors annually. Using the Eye Health
Management Program®, patient-
specific information could be shared
with health plans and disease manage-
ment companies who may have been
previously unaware of the patient’s
condition as illustrated in the State of
California Case study.
A major chronic disease focus is
diabetes. Being one of the fastest grow-
ing diseases in the US, it affects 21
million Americans, and another 54
million have pre-diabetes.
In addition to data reporting, VSP
also provides educational materials and
exam reminders to identified members
with diabetes.
Through the Eye Health Manage-
ment Program®, VSP uses data
collected by their doctor network to
determine when the member last had
an eye exam. If a diabetic patient hasn’t
returned for an eye exam after a period
of time, they’ll receive a reminder to
visit their eye doctor.
Studies show that 90 per cent of
diabetes-related blindness is prevent-
able with a regular eye exam; yet only
50 per cent of people with diabetes
receive a comprehensive eye exam.
Case study – State of California
One of VSP’s largest clients, the State
of California, announced that by
utilising the Eye Health Management
Program®, it could help avoid up to
US$ 1 million in diabetic management
costs. VSP used targeted communica-
tions to promote awareness about
Cheryl Johnson as Vice President of VSP Vision Care’s Health
Care Services division, is responsible for developing and maintain-
A uthor
the important health benefits of annual
eye exams.
When the State’s 209,000 employ-
ees and dependents had eye exams,
VSP doctors collected data on chronic
diseases, including diabetes, and shared
with the State’s health plan. So far, the
results have identified 136 members
with diabetes whose health plan was
previously unaware of their condition.
Research by Medco Health Solu-
tions, a leading prescription drug bene-
fit management organisation, illustrated
how diabetic patients can manage to
keep their disease cost at US$ 4,300 or
less annually; indicating that the long-
term health and pharmacy cost savings
for the State will be substantial.
Future impacts
To date VSP has 74 active clients and
another 24 are in the process of partici-
pating in the data exchange feature of
the Eye Health Management Program®.
Since inception, VSP doctors have
identified more than 250 members
with diabetes who are unaware of their
condition.
The programme provides members
with consistent, personalized care.
Focusing on early detection, treatment
and education management of certain
diseases, the programme mitigates
costly surgeries, complications and
hospital stays.
Additionally, the collection and
exchange of medical data for VSP
members help their clients manage their
healthcare costs, and ensures that their
members receive optimal care.
BOOK Shelf
Cardiac Resynchronization
Therapy
Editor(s) : Martin G St John Sutton
Jeroen Bax
Mariell Jessup
Josep Brugada
Martin Schalij
Year of Publication: 2007
Pages : 336
Description
Cardiac resynchronization therapy (CRT)
is one of the most exciting new advances
in the treatment of chronic severe heart
failure associated with dyssynchronous
ventricular contraction that is refractory to
medical treatment. This new text is edited by
5 experts in heart failure, electrophysiology
and non-invasive cardiac imaging and is
extensively illustrated with high quality
figures and examples of clinical cases. The
purpose of the book is to put into perspective
this novel therapy with regards to traditional
heart failure treatment and to provide
criteria for identifying patients likely to have
an optimal and sustained response to CRT
using a practical “how to” approach. This
text begins by describing the background
and evolution of the technique to the
current implementation and the impact of
complications on clinical outcome. There
are chapters describing “cutting edge”
Doppler echocardiography for assessing

dyssynchrony, reverse remodeling and

ing VSP’s network of 24,000 private practice optometrists and
triaging patients into those with greatest
ophthalmologists, and oversees functions such as doctor recruit-
ment, credentialing, quality management, utilisation management, likelihood of responding to CRT with
reimbursement, as well as VSP’s Eye Health Management® and illustrative clinical case examples.
mobile clinics programmes. Ms. Johnson joined VSP in 1993 and
has more than 20 years experience within the healthcare industry.
She attended Pacific Lutheran University and is a graduate of the For more books, visit Knowledge Bank
University of Washington.
section of www.asianhhm.com

18 Asian Hospital & Healthcare Management ISSUE-15 2008

w w w . a s i a n h h m . c o m 19
H ealthca r e M anagement
Six Sigma
in Healthcare
Effective use of the Tool Box
The integration and coordination of the healthcare
system’s process improvement tools, utilising Six
Sigma concepts, Lean, Management Engineers
and Information Services are the key to ensure that
processes are first assessed and simplified before
introducing anything new.
Maria H Foschi, Assistant Vice President, Virtua Health, USA
Adrienne Elberfeld, Six Sigma Champion, Virtua Health, USA
20 Asian Hospital & Healthcare Management ISSUE-15 2008
D
elivering outstanding patient
care in the most safe, efficient
manner through streamlined
processes is the number one priority
for Virtua Health. This is a common
goal for many healthcare organisations
but it is approached in a very differ-
ent way at Virtua Health. Rich Miller,
President and CEO of Virtua Health
explains, “we are dedicated to provid-
ing an Outstanding Patient Experience
and have harnessed advanced technolo-
gies, attracted renowned physicians,
employed the very best people in their
fields, and instituted processes and
procedures to ensure the highest levels
of quality and safety—all in the pursuit
of providing excellent service within a
caring environment.”
Serving and meeting customers’
needs, higher consumer expectations,
rising healthcare costs, an ageing popu-
lation, easy access to information, and
continual advancements in technology
are some of the challenges healthcare
faces today. Through a strategic part-
nership with GE Healthcare, which
began in 2000, Virtua has successfully
leveraged the use of the Six Sigma
Tool Kit to overcome these challenges.
From Virtua’s perspective, a prodigious
benefit of the partnership has been the
incorporation of new advanced tools
and technologies to ensure the delivery
of quality clinical service and patient
safety.
Virtua promotes innovation,
transformation and sustainment of
gains or performance in improve-
ments via the use of the Six Sigma
Tool Kit which includes the method-
ologies of Six Sigma (Define, Measure,

Analyse, Improve, Control), Design for
Six Sigma (Design, Measure, Analyse,
Design, Verify), Lean, FMEA (Failure
Modes Effects Analysis), Workout and
most importantly, Change Acceleration
Process (CAP). Tools and techniques are
continually evolving and added to the
Tool Kit. The DMAIC process and Six
Sigma methodology tools are utilised
across all of the healthcare processes
to achieve process improvements in
service, patient and family satisfaction,
clinical quality and safety and financial
performance.
Virtua Health is currently in its
seventh year of project activity, where the
use of these tools by internal resources of
Black Belts, Green Belts, Management
Engineers, Information Services, Opera-
tions and Clinical Informaticists, have
been successful in improving, stream-
lining and standardising clini-
cal and non-clinical processes
throughout the organisation.
Individuals at all levels within
the organisation participate in
Six Sigma projects and utilise the
tools not only in specific projects
but also in their day-to-day oper-
ations. Upon hire, all employees
receive training on the use of
DMAIC as the model for improve-
ment. All participants in a DMAIC,
DMADV or Kaizen team receive foun-
dational principles training for each Six
Sigma process phase. All Virtua manag-
ers are required to obtain their Yellow
Belt certification, which provides them
with a general understanding of the Six
Sigma Tool Kit, knowledge of statistical
process control and the skills to facili-
tate the utilisation of these tools. Green
Belt training is provided to key project
facilitators and is available to anyone at
any level within the organisation. All of
these training efforts contribute to driv-
ing Six Sigma into the Virtua Health
culture as the key process improvement
method.
Senior management scopes, evalu-
ates, prioritises and sponsors all proj-
ects throughout its lifecycle. All levels
of the organisation utilise these tools
and participate in these projects. Senior
leaders also participate, where titles
are “checked at the door” promoting
frank, two-way communication and
dialogue with direct staff members.
There is a quarterly session at which a
report out is provided on the projects
utilising the tools and, the results and
status are shared with Senior Manage-
ment. All Senior Leadership including
the CEO / President, Executive Vice
President of Health Services, CMO and
all Chiefs, Vice Presidents and Assistant
Vice Presidents are expected to attend.
The report outs are also a way to rein-
force empowerment and to motivate
the team members by giving staff level
employees an opportunity to “shine” by
sharing their knowledge and content
expertise with Virtua leadership.
Use of Six Sigma has resulted not only
in statistically significant and sustained
improvements but also recognition at
local levels.
The use of the Tool Kit has realised
a financial impact of more than
US$ 25 million and it continues to
grow; however, it is the quality of care
influence, that has been most impres-
sive, as the application of the meth-
odologies in project activity has been
transformational. Use of Six Sigma,
(DMAIC), in addressing Centers for
Medicare & Medicaid Services core
measures for Cardiac Medication
Administration, Pneumonia, Surgi-
cal Infection Prevention, and most
currently Normothermia (Surgical Care
Improvement Project), have resulted
not only in statistically significant
and sustained improvements but also
recognition at national and local levels
(Table 1). The application of Design For
Six Sigma and Lean concepts partnered
with Information Services has resulted
H ealthca r e M anagement
in designing a surgical registration and
scheduling system based on the voice
of the customer. This methodology was
also utilised in creating a Breast Care
Navigation Model, which supports
patients diagnosed with breast cancer
through the continuum of care.
The discipline of using the Six
Sigma Tool Kit to obtain the true voice
of the customer and rigour in improv-
ing current state processes is even more
critical as Virtua breaks ground on a
state-of-the-art acute care facility and
two ambulatory centres, expands vari-
ous clinical programmes, implements
the newest technologies and applies
for the Malcolm Baldridge Award for
quality. “It’s our ability to identify the
key processes that drive our business
and work with operations to focus on
the appropriate tools and resources to
improve these processes that
will be critical moving forward”,
says Adrienne Elberfeld,
Master Black Belt, Six Sigma
Champion, Virtua Health.
Virtua Health uses in-process
and outcome indicators to moni-
tor the control and improve-
ment of healthcare processes.
These measures are developed in
the MEASURE phase of DMAIC when
new processes are being designed or
current processes are redesigned. Data
collection and performance measures are
determined in the MEASURE phase.
Critical To Quality (CTQ) are defined
by customers as the key requirements
of a particular healthcare process is
obtained and the CTQ is translated into
a “Y” or measurable outcome. During
the MEASURE phase of DMAIC,
the “Y” data is obtained to understand
how the process is performing against
customer specifications (defect rate) and
a baseline of performance is established.
In ANALYSE, the team utilises the data
to understand the process root cause
drivers and then develops an improve-
ment plan. IMPROVEMENT strat-
egies are piloted and remeasured to
determine if the strategies demonstrate
w w w . a s i a n h h m . c o m 21
H ealthca r e M anagement
Observed improvements
Core Measure / Project Focus Project Start Date
Cardiac Medications (AMI & CHF) 10/2002
Surgical Infection Prevention (3) 8/2004
Pneumonia Core Measures (5) 4/2005
a statistically significant difference in
improving the “Y” while decreasing
process variation. In the CONTROL
phase, the defined measures are tracked
to assure statistical process control
(stable and reliable) meet the customer’s
specifications. The process is maintained
and monitored by the DMAIC process
owner. If the process becomes out of
control and / or unstable, a review of
root causes is commenced, and actions
plans are implemented to regain control
and stability. If the process owner needs
assistance to understand why the process
is not in control, resources are made
available to implement DMAIC tools.
Improvement strategies developed are
compliant with regulatory, accreditation
bodies, payers, patient and operational
requirements.
Virtua minimises overall costs,
reduces redundancy and prevents errors
and rework through improvement
processes such as Lean, Six Sigma, DFSS
and FMEA. These services and processes
are piloted to test that errors, rework,
safety and functionality requirements are
intact.
Ninfa Saunders, Executive Vice
President of Health Services, has recently
challenged the organisation to also
incorporate the Six Sigma Tool Kit in all
technology implementations. Saunders
states, “rather than just fixing a broken
process with a technology solution,
Black Belts, Green Belts, Informaticists,
Management Engineers, Information
Services, Clinicians and Operations will
work together to assess the current state
and determine which technologies could
enhance our processes to deliver the best
care to our patients.”
The biggest challenge, both
from a resource and process perspective
is the technology transformation.
22 Asian Hospital & Healthcare Management
Virtua is utilising all the tools
within the Tool Kit as they undertake
Initial Performance Current Performance
a major implementation of a fully
91% 96%
Electronic Medical Record (EMR) and
86% 98% many other clinical supporting systems.
85% 95% Key individuals including clinicians,
Table 1 physicians, nurses and corporate
The integration and coordination of staff across the enterprise are looking
the system’s process improvement tools, closely at each of the key healthcare
utilising Six Sigma concepts, Lean and processes early in the EMR planning
CAP have been the key to ensuring that and designing phases. Workflows and
current state processes are first assessed processes are designed to reduce risks
and simplified before introducing any and errors while minimising costs.
new technology. Systems are then designed and built to
The appropriate tools are utilised in support the newly designed workflows
all technology implementations both and processes.
in the clinical and non-clinical depart- Voice Of the Customer (VOC)
ments. The use of the improvement along with the use of all the Six Sigma
tools is incorporated in the technology Tool Kit is the major influence that adds
project methodology business practice value as Virtua successfully ensures that
and they result in positive changes to the delivery of patient care is safe and
the processes and workflow prior to the efficient.
technology implementation. Systems are Virtua Health has made effec-
then designed and built to accommodate tive use of the “Tool Kit” in improv-
the new improved workflow. “No longer ing processes and its innovative
can new technology be implemented partnerships with nationally known
in a silo; it’s the on-going coordination organisations evolving into an to
with Operations and using the process organisation dedicated to providing a
improvement tools that will yield the best world-class patient experience.
results”, explains Maria Foschi, Assistant
Vice President, Information Services, Virtua Health is a multi-hospital healthcare system
Virtua Health. “This is a huge cultural headquartered in Marlton, New Jersey, USA. Its mission
is to deliver a world-class patient experience through its
change and we wouldn’t be successful programmes of excellence in cancer treatment, cardiology,
if we didn’t appreciate the ‘people aspect’ orthopedics, women’s health, pediatrics, surgery, neuro-
as we change workflow, process and science and geriatrics. A non-profit organisation, Virtua
employs 7,450 clinical and administrative personnel, and
technologies.” 2,100 physicians serve as medical staff members.
Maria H Foschi is responsible for the management of information
technology financials, processes, and planning for Virtua Health.
Foschi has more than 20 years of progressive experience imple-
menting systems and managing information services in multiple
areas. Prior to this position, Foschi served as interim CIO / VP
of Information Services. She also was Assistant Vice President,
A uthor
Information Services for Customer Relations and Customer
Support at Virtua Health.
Adrienne Elberfeld is currently the Six Sigma Champion at Virtua
Health in Marlton, New Jersey. As one of the Master Change Agents
at Virtua, she also coordinated the training and development of
the CAP and WorkOut processes. Her responsibilities include
overseeing all Six Sigma Black Belts and Green Belts, co-devel-
oping curriculum for Six Sigma education, driving system-wide
projects and customising the Six Sigma methodology to best suite
Virtua’s needs. She is also a Malcolm Baldridge certified board
examiner for the New Jersey Quality.
ISSUE-15 2008
w w w . a s i a n h h m . c o m 23
E x pe r t tal k
How will the application of Lean and
Six Sigma help in improving the quality
of services?
I think it will help in a number of ways.
Our organisation looks at the benefits
in terms of what we call the ‘Three
Goods’ that can come out of a project:
improved clinical safety and outcomes
for patient, improved efficiency and
effectiveness of what you do at the
hospital operation and improved work
satisfaction among employees. Overall,
we are looking at making the jobs easier
for staff and for the physicians who
practice in the hospital.
How have Lean and Six Sigma jelled
when it comes to the healthcare sector?
I think they have jelled very well. In
our organisation, for example, we feel
like without having Lean as a part of
our whole improvement tool kit, we
would have not been able to identify
many of the improvement opportuni-
ties that we have over the last five years
within our project work. Because of
the access to data and because of the
24 Asian Hospital & Healthcare Management
Lean and
Six Sigma
Transforming
healthcare
Lean and Six Sigma are powerful tools that
help in making the leadership strong.
Jason Lebsack
Manager, Six Sigma
Nebraska Medical Center, USA
variations that exist in some process
and some complexity, a lot of time can
be saved by just using Lean thinking in
terms of looking at the flow of people,
material and information in a process.
You can find a wealth of opportunities
right there. We’ve seen from colleagues
around the country some more benefits
that ensue through the application of
Lean in combination with Six Sigma.
Do you think Six Sigma has caught on
in healthcare the way it has in other
service sector industries?
I think so. Especially in last seven years,
Six Sigma has caught on substantially
within healthcare. The wave of imple-
mentation of Six Sigma Lean, has facili-
tated by the To Err is Human report that
happened in late 90s. I think the differ-
ence that I see in the way it has caught
on in the healthcare vs. any other
industry is that their primary focus is
on Revenue, Cost reduction and other
financially-focussed kind of measures
and metrics. In healthcare, you see that
spectrum that I talked about before
ISSUE-15 2008
i.e. using it to sometimes work on
projects that have no apparent financial
benefit that can be clearly attached to
it—perhaps, improved patient safety
and patient care clinical outcomes are
the most common results. I think it has
caught up in a different way for a differ-
ent reason and continues to be used
and applied in different ways in many
projects with great success.
What about the other parts of the
world?
The other parts of the world, I am not
so sure. I think that I have a glimpse
of it from the conferences that are
being held in Europe and other places.
I know from the folks who taught us,
GE Healthcare, the consulting firm of
General Electrics Healthcare, about the
business they are doing in other parts of
the world. I’ve also come across exam-
ples in recent months of Lean being
applied in a number of hospitals across
Canada. So, saying that it is growing in
its application would be the best way
I can describe it.

It is said that Six Sigma improves any
existing business process by constantly
reviewing and retuning the process. How
easy or difficult is this in healthcare?
Well, I think that in terms of ease or diffi-
culty, one of the things I say is that it’s not
just about how you can apply the techni-
cal aspects of either Lean or Six Sigma.
I think, for us the number one issue is
the availability of data. A lot of times,
when you get into the project, there isn’t
any data colleted about what ultimately
becomes the outcome measure or many
times the input measure that you want
to look at. The time and energy it takes
for the project team to work through to
development of the measurement system
is quite considerable. Another important
point is of ownership and sponsorship;
that is, the leaders and their ability to
hold accountability for the behavioural
changes and process changes that are
going to be a part of the improvement
plan from a day-to-day and the long-term
perspective. What does not help here in
healthcare is that there isn’t necessarily
a strong heritage of having operational
measurement as a part of the leadership.
What are the areas to be covered while
implementing Six Sigma in healthcare?
There is book by Jim Collins titled Good
to Great: Why Some Companies Make the
Leap...And Others Don’t, that talks about
placing ‘Who’ before ‘What’.What he
means is that the focus has to be on the
people who are going to be doing work
and the talent that you have in the organ-
isation to get the task accomplished. In
Six Sigma programmes, we have to look
at people who are going to be dedicated
resources for leading project efforts. The
people need to have a unique combina-
tion of the ability to think about the
technical, analytical and quantitative
parts of what goes along with doing
quality improvement work and a strong
interpersonal skill set. They have to be
able to build trust with a group, build
team dynamics within the group and
build relationships. So, that’s the one
place I can say the effort must start.
How can hospitals scope and create
a project roadmap to run Six Sigma
projects?
To begin with, there is a need to get a
direction from your senior executives on
the most important areas for improve-
ment in the organisation. In other words,
where do they want their finite resources
within their quality improvement group
to focus on? If you know those areas of
focus, then it is really about using assess-
ment tools, looking at data, spending
time doing some initial investigation and
getting some requests or some calls from
the leadership to find out not just one
project that would be helpful in that area
but multiples, if any. And then to be able
to run parallel projects within a particu-
lar area—like for example in our organi-
sation it would be within our Operating
Room—along with multiple belts or
having one project getting done and the
another one starting immediately and
continuing to work in that area to get
larger scale improvement. The idea of
focussing on an area and having focussed
projects to get out the little pieces of the
problem is the key.
What could be the time frame for the
implementation?
When we were first taught about Six
Sigma from GE Healthcare, they talked
about a 4-6 months as the time frame
for a project to go from beginning and
defining phase to getting to an improve-
ment and initiating a hand-off. That is
the typical time frame we try to shoot
for a good project. At the low end, we’ve
had project where we worked on a 30-
60 days time frame. But they tend to be
very focussed efforts on a very specific
issue. We’ve had other projects at the
maximum that have gone on for 18–24
months to get a particular thing solved.
And the thing I would emphasise about
this is: it all depends on what you would
call a project. Learning from experiences
as an organisation is what adopting Six
Sigma and Lean is all about. What we
thought of as a single project today, we
probably think about as three or four or
E x pe r t T al k
five distinct projects. And so, a piece of
advice that I give to folks who are just
getting started is to really focus on scop-
ing down your projects to as narrower a
topic as you can and think about getting
improvements committed in that before
going to the next thing, rather than
trying to bite off a very huge chunk and
feeling kind of defeated because it takes a
long time to get all the things in place.
What happens after the implementa-
tion?
After you have initially implemented
something what you should hope to
have done is demonstrate your goal.
Once you can demonstrate a goal
in first one or two projects, the key is to
continue to build knowledge and skills
within the organisation and the ability
to lead projects gained by black belts
and green belts.
Another key is to build in some
steps for self-sustainability for teach-
ing and mentoring projects. So, you
will be working to develop those who
are the internal master black belts so
that you don’t have to rely upon exter-
nal consulting to keep going. The focus
then would be to continue to work all
the way down to the staff level to build
that skill set. In summary, the answer
would be, continue to get the people
to understand what it means to apply
Six Sigma, and then you just need to
continue to work on getting better at
how you do it from the stand point of
how long your projects take, how well
you scope the project and learn from
previous project work that you do—
both for the improvements to come out
of it and the way that you went about
doing the project.
Do the benefits outweigh the costs
involved in adopting Six Sigma?
You are asking the question to a biased
guy. I say, absolutely they do, if you are
committed. And this is the big If. If you
are committed to applying the tools
and principles appropriately, if you are
dedicated to the idea that you are going
w w w . a s i a n h h m . c o m 25
E x pe r t tal k
to follow a process, that you are going
to use data to drive decisions, that you
are going to involve the people who
are close to the work to come up with
solutions and recommendations for
improvements, Then you are going to
put in accountability structures to hold
people to keep up the improvement
that would be made. So, absolutely, the
benefits outweigh the cost and you have
to look at it in healthcare to be a bigger
thing than simply the financial returns
that you get.
Considering the importance of the
organisation’s leadership, could it be a
roadblock to the success of a project?
Absolutely. The way I would describe
the leadership and its importance
is that I would say it is a critical, but
not sufficient, component to making
all this kind of work successful. What
I mean by that is, if you do not have
senior executive support, if you do
26 Asian Hospital & Healthcare Management
not have them serving as the people
to be communicating the importance
of quality improvement, as the people
who are removing barriers in terms of
getting improvement projects moving
down the road and to be sponsored, if
they are not the folks providing direc-
tion in terms of focal areas for where
they would like the resources to be
deployed, if they are not playing a part
in holding people accountable, it will
not work.
But, when I say it’s not sufficient,
I say that a strong set of leadership in
the absence of having people who are
leading the project and most impor-
tantly the staff who are engaged and
motivated in recognising the rewards
of being involved in the actual prob-
lem solving. So, you need both pieces
of it. But I am yet to see an example
of an organisation who is successful in
applying either Six Sigma or Lean where
they did not have strong leadership.
ISSUE-15 2008
Could you share with us a real life
situation from your experience,
where the top management’s role was
epitomised?
There are several examples. In one of
the projects, some of the improvements
that had come out were about getting
some physical, technological changes
and enhancements to the nursing
ward. The work was queued up within
the various groups of the hospital and
wasn’t moving along. The sponsor of
the project was made aware of that
through the concerned black belt and
got directly involved in working back-
wards with the areas responsible and
initiated a continued follow-up with
them. He got the work queued up and
finished in the time frame needed.
Project sponsors in a number of
situations have had to address leader-
ship concerns in the areas involved.
In some cases this has meant making
leadership changes.

The Changing Face of Cancer
Implications for Anaesthesia
Given the unique skills of anaesthesiologists in pain management and regional anaesthesia,
the role of anaesthesiologists is increasing in the care of cancer patients.
Thomas W Feeley
Helen Shafer Fly Distinguished Professor
Anesthesiology and
Head, Division of Anesthesiology &
Critical Care
The University of Texas M.D. Anderson
Cancer Center, USA
T
he global burden of cancer is
increasing. Currently, about 11
million people develop cancer
and 6.2 million people die every year.
This represents a greater than 15 per cent
increase since 1990 in both incidence
and mortality. Worldwide, 12
per cent of deaths are due to
cancer, which is the third lead-
ing cause of death following
infections and cardiovascular
diseases. In the industrialised
world, one in four people die
from cancer. In the US, the life-
time risk of developing cancer
is an astounding 41 per cent.
Cancer incidence in the developed world
is twice that in the developing world.
This is due to the earlier onset of tobacco
epidemic, earlier exposure to occupa-
tional carcinogens and the western diet
and lifestyle. Worldwide, one-third of
new cases are preventable while another
third are amenable to early detection and
treatment. Pain and palliative care strate-
gies enhance quality of life but access to
these services is limited.
Trends in cancer cases
By 2020, the global cancer burden
is expected to rise by 50 per cent due
to increasing age of populations and
rising trends in cancer risk factors. In
the developed world, this explosion of
cancer cases is beginning to happen due
to the confluence of two trends.
The first is the fact that cancer strikes
people over the age of 50 with greater
frequency than it does youth. Both the
incidence and mortality for cancer rises
dramatically in people over the age of
50, and by age 60 that rate increases
with each additional year.
The second trend, in the US in partic-
ular, is that the population is rapidly
ageing due to the so called “baby boom
Pain management and palliative
cancer care are the areas where
anaesthesiologist can have significant
impact worldwide.
generation” which began after the World
War II. In 2008, the US population over
the age of 50 will be about 91 million
and by 2025 that number will rise to
130 million—a 42 per cent increase in
17 years or about one generation.
While mortality rates for cancer in the
developed world have begun to decline,
the increased number of cases will have
dramatic implications for healthcare
delivery systems within the first quarter
of the 21st century. Currently in the US,
cancer has surpassed cardiac disease as
the leading cause of death of individuals
under the age of 85.
medical sciences
Cancer in the developing world
By 2020, new cancer cases will grow
from 11 million to 15 million per year
and over 75 per cent of the new cases
will be in the developing world. These
countries will have only 5 per cent of
the treatment resources. While cancer
is a major problem worldwide, there
are marked geographical differences in
incidence and type. The most common
cancers worldwide are breast, colorec-
tal, prostate, cervical with the most
lethal being lung, stomach and liver.
Preventing cancer is easier, cheaper
and more effective than treating it. To
transfer medical technology “as
it is” to developing countries is
difficult and usually economi-
cally impossible.
While prevention and treat-
ment are desirable, most cases
are diagnosed late with surgical
resection being the only realistic
treatment possible. Of India’s
1 billion people, for example,
the incidence of cancer is 1 million per
year with 80 per cent deemed incurable
at the time of diagnosis.
Chemotherapy and radiation
therapy are costly and are not widely
available in most developing coun-
tries. Palliative care is a key priority but
access to those services is also restricted
since narcotic access is limited in many
developing countries to prevent misuse
of drugs. More than half of all cancer
deaths occur in developing countries.
Resources for diagnosis and treatment
of cancer in developing countries are
limited or non-existent.
w w w . a s i a n h h m . c o m 27
M edical sciences
Cancer and the anaesthesiologist
The unique skills of anaesthesiolo-
gists in pain management; regional
anaesthesia, airway management and
critical care make them important
members of the healthcare team treat-
ing cancer patients. The functions of
anaesthesiologist include management
of the patient undergoing surgical and
diagnostic procedures, management
in the Intensive Care Unit (ICU), and
management of cancer pain and deliv-
ering palliative care services.
During surgical anaesthesia, the
anaesthesiologist must always be
concerned about the airway. The high-
est prevalence of difficult airways,
known, suspected and unrecognised,
occur in cancer patients, especially
those with head and neck malignan-
cies. Additionally, chemotherapy
can adversely affect cardiac, pulmo-
nary and renal function. Radiation
therapy can also have adverse effects
on heart, lungs and the airway. The
patient’s age and history, concurrent
disease also influence the outcome.
In the ICU, the use of mechanical
ventilation for post-operative ventila-
tion is commonplace. Non-invasive
ventilatory support is commonly used
as a bridge to reintubation and intu-
bation can be avoided in up to half of
Cancer treatment disparities
Tremendous disparities exist world-
wide in the way cancer is treated. In
the developed world, modern surgery,
radiation and chemotherapy, often
in combination with personalised
and molecularly targeted approaches,
have prolonged the time taken for
cancer treatment. In the developing
world, cancer is generally detected at
a very advanced stage. As a result, the
treatment would be limited only to
palliative care to relieve suffering.
The WHO estimates over 50 per
cent of cancer patients worldwide suffer
unrelieved pain. It is estimated that
28 Asian Hospital & Healthcare Management
properly selected patients using mask
and pressure support ventilation.
Additional useful strategies in
treating cancer are to minimise inva-
sive monitoring; provide good pain
management with regional anaesthe-
sia and epidural techniques as needed.
Special attention should also be paid
to prevention of ICU acquired infec-
tions such as Catheter Related Blood
Stream Infections (CRBIS) and Venti-
lator Associated Pneumonias (VAP),
which increase length of stay and
morbidity in some patient popula-
tions. Care bundles for managing all
patients receiving ventilatory support
and requiring invasive venous access
have been shown to reduce these infec-
tions.
Pain management and palliative
cancer care are the areas where anaes-
thesiologist can have significant impact
in the care of patients worldwide. It is
estimated that 50 per cent of all cancer
patients experience pain at some point
of their illness; 70-80 per cent of all
advanced cancer patients experience
pain, 50 per cent moderate to severe
pain, and 30 per cent severe pain. Pain
management and palliative care are
closely related—hence this tremen-
dous role for anaesthesiology.
1 million people experience cancer
pain in India alone every year.
The simple implementation of
known pain and symptom control tech-
niques using narcotic analgesics could
improve the lives of many patients dying
of cancer. However, a major problem in
developing world is simply obtaining
and distributing narcotic analgesics.
For many years, the WHO has
advanced its “pain ladder” approach
to pain management in the cancer
patient. According to this approach,
if pain occurs, there should be prompt
oral administration of drugs in the
following order: nonopioids (aspirin
ISSUE-15 2008
and paracetamol); then, as necessary,
mild opioids (codeine); then strong
opioids such as morphine, until the
patient is free of pain. To calm fears
and anxiety, additional drugs—“adju-
tants”—should be used. To maintain
freedom from pain, drugs should be
given “by the clock”, that is every 3-6
hours, rather than “on demand”. This
three-step approach of administering
the right drug in the right dose at the
right time is inexpensive and felt to be
80-90 per cent effective.
Anaesthetic and surgical interven-
tion on appropriate nerves may provide
further pain relief if drugs are not wholly
effective. The use of such interventional
techniques for pain management has
been advocated by some a fourth step
on ladder. This so-called fourth step
on the ladder of interventional pain
management has been poorly stud-
ied but could be more applicable than
previously understood.
Local anaesthetics are more widely
available than opioids, especially in
some parts of the developing world
and the skills required to provide nerve
blocks are easily acquired by anaesthesi-
ologist. The most useful interventional
pain management procedures are celiac
plexus block, epidural infusions, verte-
broplasty, intra-thecal neurolytic blocks
and intrathecal pumps.
Opioid availability is a major imped-
iment to providing cancer pain relief
in the developing world. In India, the
Narcotic Drugs Act of 1985 produced
stringent rules to prevent misuse
and resulted in severe shortages of
narcotics for care.
By 2004, 8 of 25 states amended
their laws to liberalise the availability of
narcotic analgesics. However, narcotic
availability needs improvement at the
local level in all countries. Worldwide
data regarding the availability and use
of narcotics has been compiled by
researchers at the University of Wiscon-
sin and demonstrate dramatic differ-
ences in the availability of these drugs,
especially in developing nations.
 M edical sciences

A shining example of what can
be done in palliative care comes from
India. In the state of Kerala, which has
a population of 30 million, 30,000
new cancer cases are adding every year.
Kerala liberalised their narcotic access
in 2000. Cancer care is provided in
six hospitals and one Regional Cancer
Center. Cancer treatment is available
on payment. However, most patients
can afford limited treatment. The
average daily income is US$ 0.25 and
average daily cost of palliative care is
US$ 1.
The Pain and Palliative Care
Society, led by Dr M R Rajogopal,
an anaesthesiologist who is the father
of palliative care in India, developed
patients in Kerala. They provided free
service and discovered that narcotic
diversion was minimal and success-
fully brought palliative care services
to villages and people who needed
it most. More needs to be done;
Dr Rajogopal estimates that currently
less than 1 per cent of India’s 1.6 million
people suffering from cancer pain
get relief in Kerala since restrictive laws
and fears limit narcotic availability in
other states. In 2007, India’s Health
Minister, Dr Anbumani Ramadoss,
intervened with the Parliament to
increase its national cancer plan’s
budget for palliative care, thanks
A uthor
largely to the efforts of physicians like
Dr Rajogopal and others.
Conclusion
In summary, cancer is becoming an
increasing health problem worldwide
as world population ages and western
lifestyles encroach upon developing
nations with limited resources. Anaes-
thesiologists can have important roles
not only in the OR and ICU where
patients are treated, but also in pain
centres and the community where
improved palliative care and pain
management can impact the lives of
millions suffering from this disease.

a network of 33 palliative care clinics Thomas W Feeley is Division Head of Anaesthesiology & Critical
throughout Kerala. They provide outpa- Care and VP for Medical Operations at UT MD Anderson Cancer
Center. He has served in this capacity for the past ten years and
tient treatment with home support with coordinates the medical operations of the institution to ensure high
volunteer community assistance. quality and safe patient care.
In 2000, they treated 6,000 new
patients or about 25 per cent of cancer

BOOK Shelf

Cancer Pain Description

Management
Editor(s) : Michael Fisch
Allen Burton
Year of Publication: 2006
Pages : 544
For more books, visit
Knowledge Bank section
of www.asianhhm.com
Introducing the first definitive guide to pain management in the cancer patient
This pioneering book is the first to provide in-depth coverage of all the interventional and medical strategies
needed for effective cancer pain management. Logically organized, this immensely practical guide
starts with general principles in cancer pain management, followed by management of specific cancer
pain syndromes, unique issues, interventional techniques, and other specialized approaches. Reflecting
an approach to pain management developed at the prestigious M. D. Anderson Cancer Center, Cancer
Pain Management addresses the full spectrum of cancer pain syndromes and reviews the selection and
administration of various treatment options.
Cancer Pain Management features:
• Discussions of the psychosocial aspects of pain and how to resume and retain function for specific
pain- or disease-affected areas, such as in muscle tissue and bowels
• An incisive examination of all cancer pain syndromes
• Evidence-based pain management algorithms for each pain syndrome (included in each chapter) and
synoptic tips for ensuring optimal patient care and pain relief
• Special issues in cancer pain management, such as ethical issues; dealing with regulatory concerns
related to the prescription of opioids; chronic pain in the cured cancer patient; complementary and
alternative approaches to cancer pain; intervention, spiritual, family and cultural issues; wound care; and
procedural pain management
• Coverage of advanced technical protocols involved in interventional pain management
• Chapter-ending summary bullets and references that provide important opportunities for further study
• Helpful, practical appendices
• And more

w w w . a s i a n h h m . c o m 29
M edical sciences
Multidisciplinary Collaboration
in the ICU
Promoting effective care
Collaboration and communication among all the team members of the
Intensive Care Unit (ICU), where patient activity is high, goes a long way in
promoting effective care of critically ill patients.
Ruth M Kleinpell
Professor
Rush University College of Nursing, USA
C
ollaboration between physi-
cians and nurses is an impor-
tant component of effective
care in the hospital setting. When
working together toward common
goals, collaboration has been identified
as a way of improving care for the criti-
cally ill patients as it enables input from
the multidisciplinary team members in
promoting decision-making based on
more useful information. Patient care
depends on the interactions of various
providers, especially in the Intensive
Care Unit (ICU), where patient acuity
levels are high and critical illness states
often result in sudden changes, some
of which are life-threatening. As a
result, collaboration is vital in ensur-
ing appropriate care and treatment of
the critically ill patient.
The importance of collaboration
and communication and its impact
on patient outcomes in the ICU is
well recognised by many national
and international organisations. The
Joint Commission, the American
Association of Critical Care Nurses,
the Society for Critical Care Medi-
cine and the National Institutes of
30 Asian Hospital & Healthcare Management
Health have previously advocated for
interdisciplinary communication and
collaboration for patient care in the
ICU. Recent recommendations from
the American College of Chest Physi-
cians and the American Association
of Critical Care Nurses also focus on
the importance of skilled communica-
tion and true collaboration as essential
elements for transforming work envi-
ronments. The Society of Critical Care
Medicine’s clinical practice guidelines
for patient-centered care in the ICU
advocate for communication and
shared decision-making to enhance
care for the critically ill patient. Most
recently, the results of a critical care
consensus initiative identified that
improving communication among
providers and formal training on the
interdisciplinary team model are advo-
cated to improve the management of
ICU services. As communication and
collaboration are essential to patient-
focussed care, open communication
and interdisciplinary collaboration are
key components in achieving patient-
centred care and meeting patient care
goals.
Clinical practice guidelines for
patient-centered care highlight that
collaboration, good communica-
tion skills and conflict management
skills are needed for the shared deci-
sion making model to be effec-
tive in the ICU. Characteristics of
ISSUE-15 2008
collaboration include collegiality,
communication, cooperation, mutual
trust, respect and shared decision-
making (Table 1). Research has demon-
strated associations between increased
nurse-physician collaboration and
lower risk of negative patient outcomes
including lower risk of re-admis-
sion to the ICU and risk-adjusted
mortality. In a series of prospective
multisite studies, Shortell, Knaus,
and Zimmerman and colleagues
Qualities Essential for
Building Collaboration
• Cooperation
• Shared decision-making
• Communication
• Dependability
• Willingness to listen
• Accessibility
• Reliability
• Open dialogue
• Teachable
Willingness to listen & learn new things
• Intelligence
Ability to work independently
• Modest
Not afraid to ask questions if something
wasn’t known or understood
• Team player
Table 1
 M edical sciences

demonstrated that organisational char-
acteristics including communication
and collaboration influenced patient
outcomes. In examining characteristics
of effective care in the ICU in 17,440
patients across 42 ICUs, Shortell and
colleagues found that caregiver interac-
tion including leadership, coordination
and communication was significantly
associated with lower risk of adjusted
length of stay (beta=.34), lower nurse
turnover (beta=-.36), higher evaluated
technical quality of care (beta=.81) and
greater evaluated ability to meet family
members needs (beta=.74). In a sample
of 3,672 ICU admissions involv-
ing 316 nurses and 202 physicians,
Zimmerman and colleagues demon-
strated that superior organisational
practices among ICUs with increased
risk-adjusted survival were related to a
patient-centered culture, strong medi-
cal and nursing leadership, effective
communication and coordination and
open, collaborative approaches to solv-
ing problems and managing conflict.
Additional studies have found
significant associations between the
use of effective multidisciplinary
rounds and collaboration. In a study
assessing the impact of an interven-
tion focussed on improving commu-
nication and collaboration in the ICU
which included daily multidisciplinary
rounds, the addition of a nurse prac-
titioner and the appointment of a
hospitalist medical director to oversee
patient care, increased collaboration.
This is attributed to the interactions
of the nurse practitioner with medical
and nursing staff along with multidis-
ciplinary rounds. The use of a daily
goal sheet in rounds can be a useful
adjunct to promote awareness of the
patient care goals as well as to promote
changes, consultations, family commu-
nication and other aspects of care can
be discussed among the team to clarify
the focus of patient care for the day.
Use of the daily goal sheet promotes
collaboration among the ICU team
members as it establishes priority areas
of patient care and promotes further
discussion throughout the day with
updates for team members. In work-
ing to achieve the patient goals identi-
fied in the daily goal sheet, ICU team
members further collaborate to meet
those goals.
Opportunities for improving
collaboration
A number of opportunities have been
identified for improving collaboration
in the ICU including participation of
the multidisciplinary team in grand
rounds, research and quality improve-
ment initiatives (Table 2). Rapid
response teams are one specific exam-
ple of an institution-wide initiative that
promotes collaboration among the ICU
team members who serve as respond-
ers. Forming multidisciplinary teams
to address clinical issues, formulating
new protocols, or implementing best
practices help to promote collaboration
among the ICU team members. Specific
examples of initiatives include form-
ing a committee or task force to focus
on sepsis identification, management,
and implementation of the Surving
Sepsis Campaign Guidelines, targeting
hypoglycemia prevention for patients
on intravenous insulin protocols, or
promoting palliative care consultations
in the ICU. Conducting research in
Ruth M Kleinpell is currently the Director for Clinical Research and
Scholarship at Rush University Medical Center and a Professor at
A uthor
Opportunities for
Collaboration in the ICU
• Patient care
• Daily rounds
• Institutional recognition i.e. Grand rounds
• Quality improvement projects
i.e. implementation of the surviving
sepsis campaign guidelines; targeting
hypoglycemia prevention for patients on
intensive insulin therapy
• Specific initiatives i.e. rapid response
teams
• Scholarly writing projects
• Professional presentations
• Community projects
• Research
Table 2
the ICU offers additional experiences
to promote collaboration among the
ICU team. Other opportunities includ-
ing publications and presentations of
ICU team initiatives at local, regional
and national forums, also promote
collaboration among the ICU team
members.
Summary
Multidisciplinary collaboration in the
ICU is vital in ensuring appropriate
care and treatment of the critically ill
patients as well as an important compo-
nent of establishing and meeting patient
care goals. Collaboration should be
encouraged and promotedon the ICU
team as it is an essential component of
high performance and helps to promote
best patient outcomes.

improved communication and collabo-
ration in the ICU. In using a goal sheet
on daily rounds, the patient care goals
for the day can be discussed and areas
that need addressing can be easily iden-
tified. For example, ventilator weaning
goals, nutritional goals, medication
Rush University College of Nursing. She maintains active practice
as a Nurse Practitioner at Our Lady of the Resurrection Medi-
cal Center in Chicago, Illinois. She is an experienced researcher
and clinician, an active member of several critical care organisa-
tions, and a member of the editorial boards of several journals.
She is also a fellow of the American Academy of Nursing, the
American Academy of Nurse Practitioners, the Institute of Medicine
of Chicago and the American College of Critical Care Medicine.

w w w . a s i a n h h m . c o m 31
M edical sciences

Targeting
the Stress
of Diabetes
Preserving
vascular longevity

Diabetes Mellitus
occurs in more than
165 million individuals
worldwide and leads to
both acute and long-
term cardiovascular
complications that
can be tied to cellular
oxidative stress. Three
exciting novel therapeutic
strategies offer significant
promise to extend
vascular longevity.

B
y the year 2030, it is predicted
that more than 360 million
individuals will be affected
by the complications of Diabetes
Mellitus (DM). Type 1 DM, also
known as insulin dependent DM,
affects approximately 10 per cent of
diabetics while type 2 DM, non-insu-
lin dependent DM, is found in the
remaining majority of diabetic indi-
Kenneth Maiese
Professor
Departments of Neurology and
Anatomy & Cell Biology Barbara Ann
Karmanos Cancer Institute
Center for Molecular Medicine and
Genetics, Institute of Environmental
Health Sciences
Wayne State University School of
Medicine, USA
viduals. Furthermore, the significance
of DM and its complications in the
vascular system should not be under-
estimated, since it is believed that the
incidence of undiagnosed DM in the
population worldwide is increasing.
Individuals with impaired glucose toler-
ance have a risk of developing diabetic
complications two times greater than
those with normal glucose tolerance.

32 Asian Hospital & Healthcare Management ISSUE-15 2008


Both type 1 and type 2 DM can lead to
complications in the cardiac and vascular
systems, such as impairment of vascular
integrity and alter cardiac output that
may ultimately affect brain cognitive
function. DM can increase the risk of
vascular dementia in elderly subjects
and can potentially alter the course
of Alzheimer’s disease. Some studies
suggest a modest adjusted relative risk
of Alzheimer’s disease in patients with
DM compared to those without diabe-
tes to be 1.3. Costs to care for cogni-
tive impairments resulting from DM
that can mimic Alzheimer’s disease can
approach US$ 100 billion per year.
Diabetes Mellitus and
oxidative cell damage
Although a number of path-
ways in the body can lead to
DM most of its complementory
arise due to cellular oxidative
stress. During oxidative stress,
the release of Reactive Oxygen
Species (ROS) occurs, that is associated
with mitochondrial DNA mutations.
These processes together can lead to
apoptotic cellular injury.
Apoptosis, also known as
programmed cell death, can contribute
to several disease states such as DM,
dementia, stroke, and trauma. At the
cellular level, apoptosis has an early
occurrence that leads to the exposure
of Phosphatidylserine (PS) residues,
which can attract immune system
cells for the phagocytosis of injured
cells and a later event that involves the
cleavage of genomic DNA into frag-
ments. Mitochondrial membrane
transition pore permeability is also
increased during oxidative stress that
results in a significant loss of mito-
chondrial NAD+ stores and the further
generation of ROS.
In disorders such as DM, elevated
levels of ceruloplasmin have been
suggested to represent increased ROS
and acute glucose fluctuations have
been described as a potential source of
oxidative stress. Elevated serum glucose
also has been shown to lead to increased
production of rROS in endothelial
cells. However, prolonged duration of
hyperglycemia does not necessarily lead
to oxidative stress injury, since even
short periods of hyperglycemia can
generate ROS in vascular cells. Recent
clinical research correlates support these
experimental studies to show that acute
glucose swings in addition to chronic
hyperglycemia can trigger oxidative
stress mechanisms in DM. The main-
tenance of cellular energy reserves and
mitochondrial integrity also becomes a
significant factor in DM, since insulin
resistance in the elderly also has been
Both type 1 and type 2 DM can
lead to complications in the cardiac
and vascular systems.
associated with reduction in mitochon-
drial oxidative and phosphorylation
activity.
Identifying novel strategies to tackle
vascular injury
A precursor for the coenzyme ß-nicotinamide
adenine dinucleotide (NAD+)
One potential pathway to consider for
the maintenance of cellular metabo-
lism in DM is nicotinamide, a precur-
sor of the coenzyme ß-nicotinamide
adenine dinucleotide (NAD+). Oral
nicotinamide protects ß-cell function
and prevents clinical disease in islet-cell
antibody-positive first-degree relatives
of type 1 DM. Furthermore, treatment
with nicotinamide in patients with recent
onset type 1 DM, combined with inten-
sive insulin therapy for up to two years
after diagnosis, can significantly reduce
HbA1c levels. In addition, nicotina-
mide has been shown to reduce intesti-
nal absorption of phosphate and prevent
the development of hyperphosphatemia
and progressive renal dysfunction,
which would be of significant medical
M edical sciences
assistance to diabetics with renal compro-
mise. During periods of oxidative stress,
nicotinamide can improve glucose
utilisation and prevent excessive lactate
production in ischemic animal models.
Nicotinamide is believed to be respon-
sible for the preservation of endothelial
cell integrity during periods of oxida-
tive stress and it assists left ventricular
cardiac function. Nicotinamide also
employs the modulation of unique tran-
scription factor pathways, such as with
the forkhead family member Foxo3a, to
promote cellular protection. The NAD+
precursor may derive its protective capac-
ity through two separate mechanisms of
post-translational modification
of Foxo3a. Nicotinamide can
not only maintain phosphoryla-
tion of Foxo3a and inhibit its
activity, but also can preserve the
integrity of the Foxo3a protein
to block Foxo3a proteolysis
that can yield pro-apoptotic
amino-terminal fragments.
Cysteine-rich glycosylated Wnt proteins
Wnt proteins, derived from the
Drosophila Wingless (Wg) and the
mouse Int-1 genes, are secreted cysteine-
rich glycosylated proteins that can
control cell proliferation, differentia-
tion, survival and death. Abnormalities
in the Wnt signaling pathways, such as
with transcription factor 7-like 2 gene,
may yield an increased risk for DM in
some populations and have increased
association with obesity. Other studies
demonstrate an increased expression of
Wnt family members in adipose tissue,
the pancreas, and the liver in diabetic
patients, illustrating a potential regula-
tion of adipose cell function by Wnt.
Impaired Wnt function has also been
observed in patients with the combined
metabolic syndrome of hypertension,
hyperlipidemia and DM.
Interestingly, Wnt may offer
glucose tolerance and increased insu-
lin sensitivity and also protect kidney
cells from elevated glucose injury and
apoptosis. New work shows that Wnt is
sufficient for cellular protection during
w w w . a s i a n h h m . c o m 33
M edical sciences

elevated glucose exposure and is a vital
component for vascular protection
provided by growth factors such as
erythropoietin (EPO). Wnt prevents
apoptosis through the inhibition
of glycogen synthase kinase-3ß
(GSK-3ß) and ß-catenin. Inactivation
of GSK-3ß by small molecule inhibi-
tors or RNA interference, prevents
toxicity from high concentrations of
glucose to suggest a possible targeting
of GSK-3ß during DM. Clinical appli-
cations for GSK-3ß that are tied to
EPO are also worthy of consideration.
The benefits of EPO to improve cardi-
ovascular function in diabetic patients
and the positive effects of exercise to
improve glycemic control during DM
appear to rely upon the inhibition of
GSK-3ß activity. EPO can prevent
GSK-3ß activity and combined with
exercise may offer synergistic benefits,
since physical exercise also has been
shown to phosphorylate and inhibit
GSK-3ß activity.
A growth factor and cytokine
EPO is a 30.4 kDa glycoprotein
with approximately 50 per cent of
its molecular weight derived from
carbohydrates. As a growth factor and
cytokine, EPO is considered to be
ubiquitous in the body, since it can
be detected in the breath of healthy
individuals. Although EPO is currently
approved for the treatment of anemia,
the role of EPO is far-reaching beyond
the need for erythropoiesis. Plasma
EPO is often low in diabetic patients
whether or not anemia is present and
is believed to have limited response to
progressive anemia onset in diabetics.
However, EPO secretion is regulated in
diabetic pregnancies that may suggest
the body’s effort to protect against
the complications of DM. Treatment
with EPO has been shown in diabetic
glucose upon vascular cells, EPO is
protective and prevents early apop-
totic membrane PS exposure and late
DNA degradation in vascular cells
at concentrations that are clinically
relevant.
Vascular protection by EPO is
closely tied to the maintenance of
mitochondrial membrane potential
to prevent cell injury and the subse-
quent blockade of apoptotic cascades.
Yet, similar to nicotinamide, EPO
may require the forkhead transcrip-
tion factor Foxo3a to prevent vascular
injury during DM. Foxo3a is involved
in pathways responsible for cell metab-
olism, DM onset, and diabetic compli-
cations. Administration of a high-fat
diet in animals induced with hyperin-
sulinemic insulin-resistant obesity was
associated with an increased expression
of Foxo3a.
Additional studies have linked
diabetic nephropathy to Foxo3a, by
demonstrating that phosphorylation
of Foxo3a increases in rat and mouse
kidney cells, after the induction of
diabetes by streptozotocin. Interest-
ingly, prevention of Foxo3a activation
by EPO during oxidative stress, also
protects against vascular cell injury.
Considerations for the future
Although application of novel agents
and pathways may offer great prom-
ise to extend vascular longevity during
conditions such as DM, nicotinamide,
Wnt and EPO can raise potential
concerns similar to the consideration
of any new therapeutic strategy. For
example, in some reports nicotinamide
has resulted in impaired ß-cell function.
Although nicotinamide can protect cells
Kenneth Maiese is a physician-scientist. At present, he is the Chief
A uthor
against oxidative stress in millimole
concentrations, lower concentrations
of nicotinamide can inhibit sirtuin
function that may be beneficial and
that has been tied to increased lifespan
in yeast and metazoans. In addition,
both Wnt and EPO, under certain
conditions, have been associated with
malignancy. For example, EPO may
sometimes enhance tumour progres-
sion by assisting with tumour angio-
genesis. EPO has also been associated
with increased incidence of thrombotic
vascular effects, progression of cardiac
insufficiency, potential vascular steno-
sis, elevation in mean arterial pressure,
and increased metabolic rate and blood
viscosity. It is, therefore, evident that
for novel therapeutic strategies to effec-
tively and safely extend vascular cell
longevity, future studies that involve
basic and clinical research must care-
fully and systematically address both
the potential benefits and disadvantages
of new therapies. As a result, enthusi-
asm for developing new therapeutic
agents to preserve vascular longevity
during debilitating conditions such
as DM will continue to grow at an
exponential pace and avoid clinical
complications to offer patients the best
available care.
Acknowledgments
This work was supported by the follow-
ing grants (KM): American Diabetes
Association, American Heart Association
(National), Bugher Foundation Award,
Janssen Neuroscience Award, LEARN
Foundation Award, MI Life Sciences
Challenge Award, Nelson Foundation
Award, NIH NIEHS (P30 ES06639),
and NIH NINDS/NIA.

of the Division of Cellular and Molecular Cerebral Ischemia and is

patients with severe, resistant conges-
tive heart failure to improve vitality,
increase cardiac output, and remark-
ably decrease the number of required
days in the hospital. In studies that
examine the toxic effects of elevated
Professor in Neurology, Anatomy & Cell Biology, Barbara Ann Kar-
manos Cancer Institute, Molecular Medicine, and the Institute of
Environmental Health Sciences at Wayne State University School
of Medicine. His investigations are designed to translate basic sci-
ence into successful therapeutic treatments for conditions such
as metabolic disorders, cancer, cardiovascular disease, diabetes,
stroke, and Alzheimer’s disease.

34 Asian Hospital & Healthcare Management ISSUE-15 2008


Embolic Protection
During Carotid Stenting
Using FiberNet device
The FiberNet device is the first embolic protection device, which combines features of a filter,
and an occlusion device in one system to overcome the complications of carotid angioplasty
like distal embolisation of debris.
Jennifer Franke
CardioVascular Center Frankfurt, Germany
Horst Sievert
CardioVascular Center Frankfurt, Germany
and Washington Hospital Center, USA
A
fter having performed angio-
plasty in coronary and peripheral
vascular disease with excellent
results, carotid angioplasty was thought
to be an opportunity to simplify the
treatment of carotid stenosis. Until
then, there was no apparent reason to
protect patients against distal embolisa-
tion. With the development of carotid
angioplasty and stenting, prevention
of distal embolisation of arterioscle-
rotic debris and thrombus became a
main focus of the intervention. There
has been rapid development in new
techniques and equipment for carotid
artery stenting, including embolic
protection devices as adjunctive devices
to trap potentially harmful debris that
is dislodged during the procedure.
Several physicians have reviewed the
results for carotid artery stenting with
and without embolic protection devices
and have shown superior results utilis-
ing embolic protection devices during
percutaneous interventional proce-
dures. The use of embolic protection
devices as an adjunctive device during
carotid artery stenting procedure has
now become a standard of care. There
has been little interest in conducting
randomised trials to examine carotid
stenting both with and without embolic
protection. Most physicians believe that
debris that can be seen in the filters is
evidence enough. Another explanation
is that the complication rate of carotid
interventions without embolic protec-
tion devices is already low (<5 per cent),
which means a large number of proce-
dures would be necessary to prove the
benefit of these devices. Currently, there
are three types of embolic protection
devices for carotid arteries: Distal filter
devices, distal occlusion systems and
proximal occlusion systems.
• Distal filter devices generally capture
only up to a certain size of the particle
while allowing continuous blood flow
throughout the procedure. Most of
these devices have a pore size of 100
microns or larger. Potential disadvan-
tages with filter devices include prob-
lematic tracking of the device to the
proper location for deployment, the
inability to capture small particles,
and poor apposition in eccentric or
severely diseased vessels.
• Distal occlusion devices interrupt
flow to the lesion. The debris from the
interventional procedure is aspirated
prior to deflating the device. These
devices have a low-crossing profile
and allow the potential capture of
particles less than 100 microns that
M edical sciences
are dislodged during the procedure.
The disadvantage of occlusion devices
is the temporary restriction of blood
flow in the artery, which may not be
well tolerated by patients.
• Proximal occlusion devices interrupt
blood flow from the common carotid
artery to the lesion along with block-
ing flow in the external carotid artery.
The debris from the interventional
procedure is aspirated prior to deflat-
ing the device. These devices allow for
the potential capture of particles less
than 100 microns that are produced
from the procedure. Proximal occlu-
sion devices do not require a device
to cross the lesion prior to protec-
tion. The disadvantage of proximal
occlusion devices is, as with the distal
occlusion devices, the temporary
restriction of blood flow in the artery,
which may not be well tolerated by
the patient. These devices also require
a large introducer sheath and are quite
bulky compared to the other available
protection devices.
First-in-man trial
The first-in-man trial was reported by
M. Henry et al. in June 2007. Since
then, 35 high-grade lesions of the inter-
nal carotid artery have been treated
in 34 patients by stent implantation
under embolic protection with the new
FiberNet device. Mean patient age was
71.4 ± 8.8 years (range 50-85 years).
w w w . a s i a n h h m . c o m 35
M edical sciences

FiberNet - The technology

FiberNet device - Closed The FiberNet device developed by Lumen Biomedical

is the very first embolic protection device, which incor-
porates the advantages of both occlusion, and filter
distal protection devices. The proprietary filter design
promotes conformability to asymmetrical vessels,
minimising openings through which emboli can pass.
The unique 3D filter design has the goal of providing
continuous blood flow and efficient capture of emboli
as small as 40 Microns (µm). In addition, the Fiber-
Net has a low-crossing profile (1.7–2.9 French). All
Figure 1
of these features could lead to possible advantages of
the FiberNet device and meeting unique needs over
the other commercially available embolic protection
FiberNet device - Expanded
devices.
Device specifications
The FiberNet Embolic Protection System is a filter
system mounted on a 0.014 high-performance guide
wire. It is designed to be placed distal to the vessel
lesion. The system consists of an expandable, three-
dimensional Polyethylene Terephthalate (PET) fiber-
based filter mounted onto a 190 cm long wire, an
aspiration catheter and retrieval catheter. The Fiber-
Figure 2 Net device has radiopaque markers for visualisation
of the device under fluoroscopic imaging. The Fiber-
Retrieval Catheter Net device is shown in Figure 1 (closed) and Figure
2 (expanded). When deployed, the filter device is
designed to capture and recover emboli that may be
produced during the interventional procedure while
allowing antegrade blood flow to continue. Upon
completion of the procedure, the retrieval catheter
is advanced over the wire and positioned just proxi-
mal to the expanded filter. The retrieval catheter
is shown in Figure 3. A syringe is used to provide
suction through the retrieval catheter while the filter
is collapsed and drawn into the catheter. The entire
Figure 3
system is then removed and discarded.

67.6 per cent were male. 29.4 per cent
of the lesions were symptomatic.
The procedure was technically
successful in 34 / 35 (97 per cent)
interventions. There was no stroke
or death within 30 days. Two perma-
nent amaurosis and one amaurosis
fugax occurred. Visible debris was
captured in all cases. No changes were
noted in CT/MRI during 30 days
post-procedure. The mean surface area
of debris caught was 63.8 mm² (range
37.7-107.5mm²).
EPIC European Study
Evaluating the use of the FiberNet Embolic
Protection Device in Carotid Artery Stenting
Recently, enrolment in the
European multi-centre EPIC study
(FiberNet™ Emboli Protection Device
in Carotid Artery Stenting Study) has
been completed. Data presentation
is pending. Patients with sympto-
matic, atherosclerotic stenosis ≥50 per
cent or asymptomatic atherosclerotic
stenosis ≥70 per cent of the internal
carotid artery according to NASCET
(North American Symptomatic
Carotid Endarterectomy Trial) Criteria
were included.

36 Asian Hospital & Healthcare Management ISSUE-15 2008


NASCET Criteria: Degree of
stenosis is calculated from the ratio
of the linear luminal diameter of the
narrowest segment of the diseased
portion of the artery to the diameter
of the artery beyond any post-stenotic
dilation.
Primary endpoint for this study was
defined as all death and stroke within
30 days post-procedure. Secondary end
points included:
• Death due to any cause, all stroke,
including major, minor, ischemic
and non-ischemic and myocardial
infarction
• Non-stroke neurological events,
such as visual / speech disturbances,
amaurosis fugax, confusion, seizure,
weakness, and TIA
• Technical success (Successful place-
ment, deployment, and retrieval of
the FiberNet device)
• Procedural success (Device success
with the absence of any stroke, death,
or MI during the hospitalisation)
• Access site complications requiring
transfusion or surgical intervention
(AV fistula, dissection, hematoma,
hemorrhage, pseudoaneurysm,
puncture site infection)
Plaque debris analysis
In addition to the feasibility study,
plaque debris was collected during
randomly selected carotid stenting
procedures in which the FiberNet device
and other CE marked embolic protec-
tion devices were used. Visible debris
was captured in all cases. The debris
was classified for quantity, analysed
Common Clinical Dilemmas in
Percutaneous Coronary Interventions
BOOK Shelf
Editor(s) : Eulogio Martinez
Pedro A Lemos
Andrew T L Ong
Patrick W Serruys
Year of Publication: 2007
Pages : 352
M edical sciences
histologically and differentiated into may have one or two SVG grafts to be
atheromatous plaque, cholesterol crystals treated and each SVG may have more
or macrophage foam cells. Data evalua- than one lesion. The primary objec-
tion is still pending. But, our experi- tive of the study is to evaluate the
ence shows that the average mean debris safety and performance of the Fiber-
surface area captured with use of the Net Embolic Protection System during
FiberNet device or with proximal occlu- SVG interventions. The primary
sion devices was larger than with the use endpoint is Major Adverse Cardiac
of existing competitive filter devices. Events (MACE) rate during 30 days
post-procedure. The secondary study
RETRIEVE Feasibility Study objectives are endpoints related to
Evaluating the Use of the FiberNet Embolic the use of the FiberNet system and
Protection System in Saphenous Vein Grafts additional safety endpoints.
This is a multi-center prospec-
tive study designed to demonstrate Conclusion
the performance and safety of the Embolic protection with the FiberNet
FiberNet Embolic Protection System device is an interesting new concept to
when used as an adjunctive device during prevent peri-procedural stroke in patients
Saphenous Vein Graft (SVG) inter- with carotid stenosis. Debris may be kept
vention. This study will enroll up to back more efficiently than with other
30 participants in up to 10 centres embolic protection devices. To substan-
in the United States and Europe. tiate this theory a larger number of
The lesion must be located within the patients treated with competitive filters
SVG and must be ≥50 per cent and and proximal protection devices should
<100 per cent stenosed. The patient be analysed.
Jennifer Franke is a fellow in cardiology, angiology and inten-
sive care medicine at the Sankt Katharinen Hospital in Frankfurt,
Germany. She has been the study coordinator of over 20 clinical
trials at the Cardiovascular Center Frankfurt under the direction of
A uthor
Horst Sievert, the scientific secretary of the International Course on
Carotid Angioplasty (ICCA).
Horst Sievert is the Director of the CardioVascular Center
Frankfurt, Sankt Katharinen, and the Department of Internal
Medicine, Cardiology and Vascular Medicine of the Sankt
Katharinen Hospital in Frankfurt, Germany and Director of the
Catheterization Lab for Peripheral Vascular Laboratory / Struc-
tural Heart Defects. He is also an Associate Professor of Internal
Medicine/Cardiology at the University of Frankfurt.
Description
Coronary stenting is the most commonly used method of myocardial revascularisation,
with approximately 2 million stents implanted in 2004 throughout the world. The
development of drug eluting stents has resulted in very low rates of repeat intervention
and will further increase the scope for percutaneous coronary intervention. The evidence
from large randomized trials is generally accepted to be the gold standard source of
information for patient care in interventional cardiology. However, it is well recognised
that information from these trials is frequently insufficient to guide the wide-ranging
clinical situations found in routine practice. In this context, decision-making is often
based on a composite of information from multiple clinical studies, pathophysiological
considerations and importantly, personal experience or ‘gut-feeling’.
For more books, visit Knowledge Bank section of www.asianhhm.com
w w w . a s i a n h h m . c o m 37
M edical sciences
Safety in
Anaesthesia
Promoting sustainable
change for the future
The future of safety in anaesthesia
lies partly in technological advances
in countries that can afford them.
The priority, however, is to address
the unacceptable deficiencies in
anaesthesia services globally.
38 Asian Hospital & Healthcare Management ISSUE-15 2008
Alan F Merry
Professor and
Head of Department, Anaesthesiology
University of Auckland, New Zealand
I
t is widely claimed that anaesthe-
sia today is very safe. As a teacher,
I often ask trainee anaesthetists two
questions: “What is the risk of dying
from an anaesthetic today?” and “What
risk would be acceptable?” The answer
to the second question is really the start-
ing point for thinking about safety in
anaesthesia.
The answer depends on context. If a
surgical procedure could be done under
local anaesthetic, and / or is not really
essential to preserve life or limb, then the
risk of dying from the anaesthetic has to
be very low indeed. If, on the other hand
a surgical procedure has the potential to
save life, a higher risk would be accept-
able; if the odds faced by the patient
(perhaps expressed in quality-adjusted
life years or QALYs) are better with the
procedure and anaesthetic than without,
it would make sense to proceed.
What then is the answer to the first
question? The astonishing fact is that we
don’t really know.

In developed countries, estimates
of avoidable anaesthetic mortality vary
from as low as 1:2,00,000 to as high as
~1:10,000. Australia probably provides
the best data in the world about anaes-
thesia mortality, but even there it is diffi-
cult to determine a true rate with confi-
dence. A rate of 1 in 79,509 was cited
in the “Review of Anaesthesia Related
Mortality” published by the Australian
and New Zealand College of Anaesthet-
ists for triennium 1997-1999. However,
the rate for the next triennium (2000-
2002) was 1 in 56,000. Does this mean
that anaesthesia was becoming more
dangerous over time? No! In fact, the
apparent increase in risk in the second
report is attributable to improved collec-
tion of denominator data. Of course,
this implies that the rate in the first
report is wrong, which raises the ques-
tion as to whether further refinements in
data collection will show that the current
rate is not reliable either. In reality, there
has been a wide variation in reported
rates from many countries over the last
30 years. Difficulties in data collection
certainly contribute to this variation,
but a more significant factor is the lack
of an agreed international definition of
anaesthetic mortality.
What the numbers say
Most current estimates of anaesthetic
mortality pertain to the first 24 or 48
hours after an anaesthetic (with perhaps
a few extra deaths after that), but there is
no particular reason to choose either of
these time periods. In developed coun-
tries, it is quite unusual for a patient
to die on the operating table, and rela-
tively few die within 24 hours of an
anaesthetic. On the other hand, fami-
lies are probably interested in having
their loved ones leave hospital and come
home in good health and the rates for
in-hospital death or 30-day mortality
have not been widely evaluated.
The risk of death attributable to
anaesthesia also depends on the condi-
tion of the patient. For a fit young
patient undergoing minor surgery
in countries like Australia, this risk
is obviously very low (although not
zero). However, the risk to patients at
the extremes of life, with co-morbidi-
ties, and undergoing major surgery is
much higher. As I have said, this may
be acceptable from a pragmatic stand-
point, but it is not ideal. Anaesthesia is
not in itself therapeutic, and it should
not add to the risks faced by patients,
even if they are unwell in the first place.
There is, therefore, considerable room
for improvement.
Regional disparities
In developing countries, the situation
is much worse. The risk of avoidable
mortality associated with anaesthesia
in some rural areas of the world may
be as much as 1,000 times higher than
in cities that can afford to invest in
well-trained anaesthetists, expensive
drugs and modern technology. Illus-
trative estimates vary from 1:3,000 in
Zimbabwe to 1:150 in Togo. This
high risk reflects a failure to invest in
anaesthesia as part of the provision of
surgical services. Surgery without safe
anaesthesia cannot be safe, but it can
be marketable. Countries may claim
to provide “essential surgical services”
when, in fact, the net effect of these
services may be to the detriment of
public health, because of inadequate
infrastructure including the necessities
for safe anaesthesia (trained anaesthet-
ists being the foremost requirement,
but oxygen, equipment and drugs are
also essential).
In the developed world, the level
of training for anaesthesia providers is
comparable similar to that provided to
surgeons. In the UK, Australia and New
Zealand, anaesthetists (called anaesthe-
siologists in the US) must be medi-
cally qualified and require seven years
of training after qualifying as a doctor.
In the US, Scandanavia and certain
other countries, many anaesthetics are
provided by nurses, but these providers
must satisfy high standards of training
and examination, and typically work
M edical sciences
in teams that include medically quali-
fied anaesthesiologists. In some coun-
tries, on the other hand, anaesthetics
are given by people with no medical or
nursing background, and with little if
any specific training: in fact, it is not
uncommon for the surgeon to take
responsibility for the anaesthetic as well
as the surgery. This might possibly be
workable if the surgeon were also an
adequately trained anaesthetist, but
that is often not the case. Under these
circumstances, poor anaesthesia tech-
nique, lack of monitoring and lack of
expertise have been identified as factors
contributing to the high death rate. In
addition to lack of training and exper-
tise, anaesthesia providers in these
circumstances usually face a shortage
of the most basic facilities, equipment
and drugs, particularly in rural areas. A
recent study from Uganda, where there
are few medically qualified anaesthe-
sia providers (13 anaesthesiologists for
27 million vs. 12,000 for 64 million
in the UK), identified deficiencies
in running water, electricity and the
availability of oxygen for example. Even
sterile gloves were in short supply.
Do no harm
The goal of the American Society of
Anaesthesiologists is “no harm from
anaesthesia”. Even in developed coun-
tries we are a long way from achieving
this. The most obvious problems today
involve avoidable errors, particularly in
the assessment of patients before admin-
istering their anaesthetics, and in the
processes of administering anaesthetics.
For example, it has been shown that a
wrong drug is given once every 150
anaesthetics. Often, this is without seri-
ous consequence, but occasionally the
results are catastrophic. For countries
that can afford it, technological advances
will build on the gains already made and
lead to continued if gradual improve-
ments in safety. These will include the
use of bar coding (or other technologies,
such as radio frequency identification
devices or RFIDs) to improve the safety
w w w . a s i a n h h m . c o m 39
M edical sciences
of drug administration, computerised
systems for facilitating the pre-opera-
tive assessment of patients, and further
improvements in the drugs available for
anaesthesia. Adjunctive agents designed
to mitigate the cardiac and renal effects
of anaesthesia and surgery will be as
important as anaesthetic agents, and
research will increase our understanding
of how to mitigate the stress response
of the human body to the assault of
surgery. Improvements in surgery (the
greater use of endoscopic “keyhole”
techniques) and lesser need for major
radical and mutilating procedures will
also help. The holy grail of a synthetic,
effective and safe substitute for blood
will be another important advance if it
is ever achieved.
The high standards of training in
anaesthesia will need to be maintained,
and in fact, extended. Increased exper-
tise in diagnostic imaging (notably
echocardiography) will enable anaes-
thetists to improve their pre-operative
assessment and their intra-operative
management of patients. In addition,
there is considerable evidence of over
treatment in relation to a number of
surgical procedures. An important part
of reducing the risk of anaesthesia is to
limit surgery to those operations that
are truly indicated and genuinely likely
to improve the quality of the patient’s
life. It seems likely that this insight will
gain traction over the next few decades
and anaesthetists, as perioperative physi-
cians, will have a greater role in ensur-
ing the appropriateness of surgery.
Promoting sustainable change
To improve the safety of anaesthesia
globally, the greatest gains will come
from addressing the completely unac-
ceptable risks of anaesthesia in much
of the developing world. The World
Federation of Societies of Anaesthesi-
ologists (WFSA), many of its member
societies and the World Health
Organisation (WHO) recognise this fact
and are investing in projects to promote
the safety of anaesthesia globally. The
40 Asian Hospital & Healthcare Management
The way ahead
The future of safety in anaesthesia lies in a world in which all patients can
enjoy essential surgical services with a standard of anaesthesia that I (as a
trained anaesthetist) would be willing to accept for my family. For essential
surgical procedures, this does not imply everything that can be done to
increase safety, but it does imply well trained anaesthetists, minimal standards
of monitoring (including the presence of the anaesthetist and a pulse
oximeter), and an adequate infrastructure with running water, electricity
and supplemental oxygen. Other than in an extreme emergency, there is
certainly no excuse for accepting a lower standard for anyone, anywhere.
Global Oximetry (“GO”) initiative is an the WHO has recognised that surgery is
excellent example of a practical contri- a major issue for public health. Surgical
bution being made by these organisa- operations today are twice as common
tions. It involves the WFSA, and the as births, and substantially more danger-
Association of Anaesthetists of Great ous. Much of the risk lies with anaesthe-
Britain and Ireland and GE Healthcare. sia, and in simple avoidable errors (such
Regional support has been forthcoming as operating on the wrong patient or
from local societies, notably the New with unsterile instruments). The aim of
Zealand Society of Anaesthetists. Pulse the challenge is to introduce a checklist
oximetry is mandatory in all developed for use in every surgical procedure, and
countries, because it has been recognised ensure safe anaesthesia as per the check-
as a major aid to safety by their anaes- list. A key objective is the promotion
thesia organisations. The GO initiative of teamwork. The whole team (anaes-
involves a package of education and aid thetists, nurses and support staff as well
to kick-start the use of this increasingly as surgeons) should be well trained
inexpensive technology in regions that and empowered to contribute to the
do not have it. The aim is to promote a overall management of the risk in the
sustainable change in practice, with the operating room, only then could we
engagement of both local government achieve real gains in the health of the
and local anaesthesia providers. A key population.
insight is that limited resources should All of this will cost money, and
be directed to those things which concerns are sometimes raised that
really will make a difference (oximetry the real problem is that of access to
and training being the two examples essential surgical services. Yes, access
promoted in this project). to life-saving surgery is a priority, but,
The WHO’s Second Global Patient in fact, many operations that are not
Safety Challenge, Safe Surgery Saves essential are carried out everywhere.
Lives (under the leadership of Atul Moreover, the lack of access is not
Gawande), is another key example of an constructively addressed by providing
initiative to address the risks of surgery services with a death rate of 1 in 150
worldwide. It is highly significant that anaesthetics.
A uthor
Alan F Merry is Professor of Anaesthesiology, University of
Auckland, a Councillor of ANZCA, and Chair of its Quality and
Safety Committee. He is co-author of Errors, Medicine and the Law
(CUP, 2001), Essential Perioperative Transoesophageal Echocar-
diography (Butterworth Heinemann 2003), Safety and Ethics in
Healthcare (Ashgate, 2007) and various peer-reviewed papers.
ISSUE-15 2008
w w w . a s i a n h h m . c o m 41
M edical sciences
Telemonitoring in
Cardiac Device Therapy
Enabling optimal management
of patients
The vastly increased complexity of cardiac rhythm therapy over the past several years,
demands commensurate improvements in overall device monitoring and telecommunication
technology.
Auricchio Angelo
Professor, Division of Cardiology
University Hospital, Germany
I
n stark opposition to the undeni-
able demographic changes and
medical advancements taking
place throughout the world, health-
care payers are increasingly pressuris-
ing the treating physicians to reduce
their costs. Because of the inherent
chronicity of cardiac disease, the costs
for managing these patients have
risen notably in recent years, while
the technological options for the best
possible care of the patients have made
astounding leaps forward.
Demographics drive the increased
prevalence of cardiac device
usage
Parallel to these demographic and
health related changes come significant
technological and medical advances in
cardiac rhythm therapy. Because of the
improvements in device functional-
ity and impressive medical innovation
in cardiovascular medicine, the total
number of cardiac device patients is
rising rapidly. Depending on one’s
cardiac situation, a patient may receive
a standard pacemaker, an implantable
42 Asian Hospital & Healthcare Management
cardioverter defibrillator, a device for
heart failure-related dyssynchronies or
a combination of devices all built into
one small implanted device. In addi-
tion to the implanted device, the physi-
cian must also implant one or more
electrical leads, which conduct large
and small electrical signals between the
microchip device and the heart’s cham-
bers virtually each time the heart beats.
While most cardiac lead implants are
considered permanent hardware in the
body, the longevity of the implanted
device varies by the patient’s cardiac
condition and other programmed
device functions. Notable improve-
ments in battery technology and
more energy-efficient device function,
however, have greatly extended the
longevity of most devices to several
years, at which point the device can
typically be safely removed from the
patient in the hospital and replaced
with a new implanted device during a
brief surgical procedure.
Advent of remote telemonitoring
For years, a very simple patient-
driven telemetry has been available
for cardiac device patients. With this
decades-old system of data transmis-
sion from home, the patient places
a magnetised wand over the cardiac
device and the stored data are extracted
ISSUE-15 2008
from the device, processed in a small
home-based receiver, then transmit-
ted via standard telephone line to the
physician’s office for appropriate inter-
pretation. However, with the increas-
ing complexity of today’s devices and
their multiple functions, this rather
rudimentary approach to collect-
ing limited device data is losing its
appeal. Furthermore, this form of data
transmission costs valuable time of
physician and clinic staff. It also
requires a certain degree of patient
involvement, which is typically not
preferred when one considers today’s
complexity of functions and the aver-
age age of patient. Clearly, the vastly
increased complexity of cardiac rhythm
therapy over the past several years,
demands commensurate improve-
ments in overall device monitoring and
telecommunication technology. Indus-
try has kept pace with these demands
for more robust monitoring and data
processing. Arguably, the implantable
cardiac device manufacturers are at the
forefront of highly advanced biomoni-
toring and implantable sensor technol-
ogy. Moreover, both Heart Rhythm
Society and European Heart Rhythm
Association have recently recommended
that cardiac rhythm management
device manufacturers should develop
and utilise wireless and remote
 M edical sciences

monitoring technologies to identify are functioning as anticipated, the Even the best monitoring systems
abnormal device behavior as early as physician does not require a special in the world are not foolproof
possible. To reduce under reporting report. When appropriate, the physi- Despite the incredible advances we
of device malfunctions, its functional cian can safely rely on a home moni- have witnessed in implantable cardiac
status has to be determined more toring-based follow-up routine for device function and reliability over
frequently and more accurately. ICD-patients to significantly reduce the past several years, it is important
the follow-up burden in their clin- to note that even the best function-
Fully automated monitoring picks ics. An abbreviated mode of patient ing cardiac device systems can develop
up asymptomatic events follow-up was recently confirmed by structural defects after days, months or
An ‘intelligent’ automated telemoni- Brugata, whereby the predictive value years of use.
toring system that communicates of a remote-based device follow-up Unfortunately, these product fail-
bidirectionally back and forth, routine (with one annual follow-up ures are very difficult to anticipate
preferably daily with the implanted visit) was considered clinically equiv- and can occur at any given point in
device, is required for recognising alent to standard quarterly patient the devices’ life. Furthermore, the
errant device behaviour, as well as follow-ups. The total office follow- most advanced device system has to be
the patient’s immediate physiological up burden for defibrillator devices able to adapt immediately to the vari-
response to the multitude of program- in this study was reduced by nearly ances that can arise at any moment
mable therapies these devices now one-half. within the dynamic human heart.
With continuous automatic home
Completely automated telemonitoring systems monitoring, virtually every imaginable
system disturbance can be measured
In today’s advanced telemonitoring systems, the patient’s device and physiologic and quickly communicated to the
parameters are collected daily throughout the life of the device and are treating physician if the severity of
automatically channelled into a series of easy-to-use reports for the physician the problem is deemed to be highly
to review. Standard nightly data transmissions are sent from the implanted relevant clinically.
cardiac device to a small tabletop receiver, which then sends the encrypted
patient and device data via standard telephone line to a central server for The physician is in control of the
immediate processing. Depending on the device manufacturer, individualised data reporting
patient data are posted in a comprehensive report format with informative Today’s implanted devices have the
trends, charts, parameters, high definition IEGMs and graphs. One device potential to monitor many dozens
manufacturer also offers a fully mobile, worldwide patient monitoring system of device parameters and automati-
via cellular phone network (Biotronik GmbH & Co. KG, Berlin (Germany). cally give the physician important
early detection information on heart
rhythm disturbances, advanced therapy
offer. Additionally, device patients In past, physicians would first learn delivery, medication effects and device
frequently experience asymptomatic about many critical device malfunc- status via fax, text messaging or a secure
cardiac-related events, the knowledge tions and physiolgical changes when website from the doctor’s own laptop.
of which may be of clinical relevance the patient returned to the clinic for Access to the report data is secure,
in appropriate patient care. Some of a regularly scheduled follow-up and and physicians have large control
today’s more refined home monitoring manual device interrogation, which over many aspects of early detection
systems have the capacity to monitor would only take place two to four reporting and the data management
whether the patient has experienced times per year, depending on patient process. Physicians control how,
short periods of tachycardia, atrial status. In one study by Lazarus, the when and where the alerts are sent,
fibrillation, inadequate pacing stimuli author suggests that widespread so that office staff could also view the
or a declining heart failure status. Since cardiac telemonitoring offers infor- reports, if the physician permits such
patients may experience such events mation that could allow for the early access. By delivering comprehen-
completely without pain or in their detection of adverse events two to five sive data comparable to a standard
sleep, a fully-automated system should months sooner, respectively, than what in-office visit, there is a reduced need
monitor, review and deliver occasional is currently feasible by using the stan- for patients to come into the clinic for
special reports to the treating physician, dard in-office follow-up model, which frequent routine follow-ups, which
so that he or she can respond quickly often tracks device patients quarterly in turn reduces scheduling strain on
to problem. If device and patient or biannually. the clinic and staff.

w w w . a s i a n h h m . c o m 43
M edical sciences
The world’s first fully automated
CRM home monitoring system was
developed for commercial application
in 2001. Currently, approximately
200,000 device patients are being
managed via home monitoring systems
worldwide, and this patient popula-
tion is expected to grow significantly
in the coming years with the increased
adoption of the technology.
Special alerts will quickly notify
physician of device, patient
problems
Today’s telemonitoring is unique in
that standard data transmissions can
also be supplemented with special
alert messages if the patient or device
experiences some clinically urgent
functional change. In the event of silent
arrhythmias, asymptomatic device
and lead changes and delivered shock
therapies trigger the telemonitoring to
deliver additional special alert messages
to the physician via internet, fax or text
messaging. Because the triggering and
reporting requires no action on the
part of the patient or physician, these
unique systems are able to recognise
and deliver critical messages within a
very short time of their actual occur-
ance, as opposed to the old system of
standard in-clinic devices follow-up
at pre-set quarterly or semi-annual
intervals. Although current bidirec-
tional home monitoring systems do
not provide for the remote reprogram-
ming of implanted devices, this feature
may become reality in the near future.
Early detection of serious lead
failures
In recent months, there have been a
number of published clinical reports
regarding post-implant reliability and
malfunction of certain types of defi-
brillator leads. Current telemonitoring
systems make daily painless imped-
ance checks of pacing and shock coils
and continually monitor significant
changes in these values. Today’s device
monitoring should be able to quickly
44 Asian Hospital & Healthcare Management
Device lead alert report
Impédances de stimulation
Imp. stim. ventriculaire [ohms]
Evénem
Evénem
ImpV
ImpV
Ventricular impedance
>3000 An episode alert was
3000 generated because
of highly abnormal
2600
Imp. stim. [ohms]
lead function
2200
1800
1400
1000
600
200
<200
BIOTRONIK Suivi Suivi
23/06/07
25/06/07
27/06/07
29/06/07
01/07/07
03/07/07
05/07/07
07/07/07
09/07/07
11/07/07
13/07/07
15/07/07
17/07/07
19/07/07
21/07/07
23/07/07
Temps (jours)
Rapid, clinically-significant changes in cardiac lead impedance measurements
caused by a short circuit in the patient’s lead; two days after the first monitored
episode, the impedance abruptly increased (shock lead was replaced on October
23rd). Patient was a 49 years old French male who had received an implanted,
prophylactic cardioverter defibrillator device for a genetic anomaly called Brugada
Syndrome, which can cause sudden cardiac death.
Figure 1
and reliably recognise faulty lead lead failure. Fortunately, the defective
performance, providing the highest lead was quickly identified and imme-
degree of patient safety and security. diately replaced within two days once
Figure 1 is an example of a device the alert report was automatically sent
lead alert report generated with one directly to the treating physician.
manufacturer’s telemonitoring system Another example of the value of
as soon as a defective shock lead was automated home monitoring is the
detected in a middle-aged male. very early detection of atrial fibrilla-
The real-life situation shown in tion, a frequent symptom-free precur-
figure 1 is an example of very early sor to debilitating embolic strokes and
detection of a potentially life-threat- also a common co-morbidity in cardiac
ening cardiac lead failure. Without an device patients. If atrial fibrillation can
intelligent telemonitoring system, this be recognised early in its course, appro-
patient would have retained his defec- priate medical care—antithrombotic
tive lead up until the next standard drugs or cardiac ablation—can be initi-
in-clinic follow-up, which could have ated to greatly reduce the risk of future
been months from the date of actual strokes. The following Intra-cardiac
ISSUE-15 2008
w w w . a s i a n h h m . c o m 45
M edical sciences

Electrogram (IEGM) was generated

the very day a patient developed atrial Intra-cardiac Electrogram (IEGM)
fibrillation for a pre-specified duration
of time (Figure 2).

What does the future hold for

remote cardiac device monitoring?
For one thing, the automatic monitor-
ing outside the hospital provides clear
clinical benefits for the patients, physi-
cians and healthcare providers. Poten-
tial medically-relevant problems can be
recognised and addressed proactively,
avoiding unnecessary hospitalisation
costs. The clinical value of such home
monitoring systems for cardiac device
patients is already well. It appreciated,
as is the improved Quality of Life for
the patients who are monitored at
home daily. This probably is no more
apparent than in the management of This patient had just experienced new-onset atrial fibrillation. Since this event
heart failure patients. qualifies for alert report generation, a high-definition Intra-cardiac Electrogram
Secondly, the robust incorporation (IEGM) was automatically sent to the physician’s laptop in a pdf file. The treating
of (cardiac) telemonitoring into a given physician was then able to rapidly respond to this change in patient’s cardiac
clinic’s work routine will likely require function with appropriate adjunctive therapy.
a commitment to redirect certain
Figure 2
internal resources and work processes
in order to reap the full benefits of a
telemetric patient monitoring. Unlike developed by industry and are becom- clinics and physicians are greeting
many medical innovations, the true ing more prevalent in daily practice cardiac telemonitoring with vary-
benefits of cardiac telemonitoring will across the globe. ing degrees of comfort and eagerness.
be spread over many of those involved Though the clinical advantages of Another structural hurdle is the current
in the patient care cycle. continuous telemonitoring are quite lack of reimbursement to the physi-
Finally, a growing number of apparent, major ongoing trials are soon cian or clinic for adopting a system of
hospitals and pacemaker clinics have expected to more specifically quantify cardiac telemonitoring.
already recognised the inherent value the economic benefits of using this excit- In countries where healthcare
of adopting this new technology to ing technology. Also, new sensor tech- reimbursement for remote monitoring
improve work efficiency, deliver more nology research suggests that numerous has been instituted, the uptake of this
timely urgent medical responses when physiologic functions might be included valuable technology has become much
cardiac events occur, and to use this in future cardiac monitoring systems, more attractive.
monitoring tool for establishing a thus widening their applicability. The US may soon become
more productive professional interface Because the use of novel technolo- the model and leader for widespread
with a given patient’s non-specialist gies also requires a willingness to drop telemonitoring of cardiac device
physicians and caregivers. old processes and adopt new ones, patients.

What are the future prospects

A uthor

for widespread cardiac device
telemonitoring?
Essentially, cardiac telemonitoring has
very positive near-term growth aspects
for a variety of reasons. User-friendly
Auricchio Angelo is Director since 2006, Heart Failure and
Electrophysiology program, Fondazione Cardiocentro Ticino,
Lugano, Switzerland. Since 2007 he is Co-chair (EHRA), HRS-
EHRA Task Force on Implantable Cardiac Device Monitoring
and he is also the Chairman, Scientific Documents Committee,
European Heart Rhythm Association (EHRA).

monitoring systems have now been

46 Asian Hospital & Healthcare Management ISSUE-15 2008

The concept of patient-centred care is taking root in healthcare.
For hospitals, this is a paradigm shift. Processes hitherto
designed around the disease or physicians, are now being
redesigned keeping the patient in mind. This also means that
the patient will be more involved with the care providers.

w w w . a s i a n h h m . c o m 47
 Stephen C Schoenbaum
Executive Vice President
The Commonwealth Fund, USA

Healthcare processes are mostly disease-

centred. How big a shift is it then for
hospitals to create processes that are
patient-centred?
I do not believe that the main issue
is shifting from disease-centred to
patient-centred care. It is shifting
from physician-centred or provider-
centred to patient-centred, and that
is a very big shift. It is a big change
because in order to accomplish it one
has to re-think every aspect of the
patient’s journey from the patient’s
perspective. Patients wish to under-
stand the medical treatment offered
to them and how it would affect them
immediately and in the longer run.
In early 1990s, Picker Institute, an
organisation that promotes patient-
centred care, where I am a board
member, convened groups of patients
in order to define the attributes of
care that patients felt were essential.
This process led to a set of eight
dimensions of ’patient-centred care’
including:
• respecting the patient’s values, pref-
erences and expressed needs
• Informing and educating the
patients about their treatment
• Patient’s access to care
• Emotional support to relieve fear
and anxiety
• Involvement of family and friends
• Continuous and secure transition
between health care settings
• Physical comfort
• Coordination of care

48 Asian Hospital & Healthcare Management ISSUE-15 2008

 How important a role does technology

The Big Shift

play in this scenario? Is there enough
technology available to push for a
patient-centred care model?
Health information technology makes
Shifting to patient-centred care implies a it easier to coordinate care. Having the
re-think of every aspect of the patient’s electronic medical records available to
journey through an episode of care from the all care providers, with accurate labora-
tory results, information on allergies,
patient’s perspective. medications etc. makes it easier to ‘pass
the baton’ and eliminate waste and
duplication.

What role does the leadership play

I would add that simplicity is a very What systems need to be put in in bringing about a patient-centred
important attribute of patient-centred place in order to provide care approach throughout the organisation?
care. Patients must be told what is neces- that best suits the patient’s needs Patient-centred care can occur even in a
sary and the care they receive must be (i.e. patient-centred care)? single clinical encounter. However, it is
explained to them in the terms that are Most importantly, one needs to have a important that it happens throughout a
comprehensible to them. The shorter the system that can obtain and assess the patient’s stay in the health care set up. For
patient’s stay is in the hospital, the better patient’s experience. It is only through that, leadership is absolutely essential.
it is. the patient’s feedback you know if When one looks at health care organ-
I cannot overstress the importance you are patient-centred or not. isations that are patient-centred, first
of co-ordination of care and smooth Some aspects of patient-centred thing one discovers is that the patient-
transitions in a healthcare set up. care can be facilitated by ’systems’. For centred care is highly valued by leader-
A patient’s stay in the hospital is like a example, engaging the patient in the ship and it has worked hard to establish
complex relay race wherein the patient process of shared-decision making is those values within the organisation.
and information about the patient, are an important aspect of patient-centred
the baton. The baton must be passed on care. There are information tools Any other comments that you would
securely from one provider to the next. If such as DVDs that can help patients like to make?
the baton is dropped, there is waste and a learn about common procedures or Yes. I’d like to make a couple of
poorer outcome. Unfortunately, we know situations—choice of treatment comments:
from surveys that about one-third of the for breast cancer or prostate cancer 1. Measuring of patient’s experience
time, patients think that their care has been or back pain, and make it easier is just beginning to become a stand-
poorly coordinated, and the transitions, to engage the patient in shared ard in hospitals in the US. For the first
poorly managed. decisio-making. time in March 2008, results for almost
all hospitals using the standardised H-
CAHPS instrument were made public.
They showed tremendous variation in
performance and large opportunities for
most hospitals to improve some aspect of
When one looks at healthcare organisations the patient-centred care they delivered.
2. Do not think about patient-
that are patient-centred, first thing one centred care as an ‘add-on’ or a ‘frill’.
discovers is that the patient-centred care It is absolutely essential to achieve
is highly valued by leadership and it has excellent care. Patient-centred care is
one of the six aims of the high-quality
worked hard to establish those values care that the US Institute of Medicine
within the organisation. delineated in its report ‘Crossing the
Quality Chasm’. It is intimately related
to the other five: safety, effectiveness,
efficiency, timeliness and equity.

w w w . a s i a n h h m . c o m 49
 Amy Wilson-Stronks
Project Director
Division of Standards and Survey Methods
The Joint Commission, USA

Healthcare processes are mostly disease-

centred. How big a shift is it then for
hospitals to create processes that are
patient-centred?
I have been fortunate to serve as the
Principal Investigator of a study (Hospi-
tals, Language and Culture: A Snapshot
of the Nation) that investigated how
hospitals across the US are meeting the
diverse cultural and linguistic needs of
the patients they serve. A key principle
of patient-centred care is, sensitivity and
responsiveness to the patients’ cultural
health beliefs and communication
needs. Our study found that hospitals
in the US are challenged to meet these
needs. Despite the challenges, some
hospitals have implemented promising
systems and practices to better meet
diverse needs. Our most recent research
report, One Size Does Not Fit All: Meet-
ing the Health Care Needs of Diverse
Populations found that hospitals need
to consider several things in order to
become more patient-centred:
• They need to consider how the focus
on culturally competent, patient-
centred care is reflected in their poli-
cies, procedures, mission, vision and
values
• They need to collect and use data and
information to improve their systems
to meet patient’s needs
• They must determine the specific
needs of their patient populations
and consider how they may need to
make adjustments to their service
systems to accommodate the needs of
specific populations and

50 Asian Hospital & Healthcare Management ISSUE-15 2008


Meeting
Diverse Needs
Patient-centred care means sensitivity and
responsiveness to the cultural health beliefs
and communication needs of patients.
• They must engage in collaborative
relationships, both internally and
externally
These ‘themes’ represent a systematic
approach that results in action, tailored to
the specific needs of the patient. Through
our work, we observed that “one size fits
all” approach does not exist and hospi-
tals must be willing to continually assess,
monitor and evaluate how they meet the
patients’ needs. Since demographics and
needs change, this is a continuous proc-
ess. It becomes a difficult concept for
hospitals to grasp since they are driven
by metrics and patient-centred care is
difficult to measure. It is often consid-
ered to be ‘soft’ and of a lesser merit than
other safety imperatives.
What systems need to be put in place
in order to provide care that best suits
the patient’s needs (i.e. patient-centred
care)?    patient-centred care is entirely depend-
As I mentioned above, we have identi-
fied four main areas or ‘themes’ that
should be present in a hospital in order
to provide care that suits best to patient’s
needs. These are rather broad-based
themes, which allow a hospital to focus
their approach towards resources and
needs. There is a growing appreciation
of the need for patient-centred care
among providers, hospitals and patients.
Healthcare systems that can provide
appropriate monitoring and evalua-
tion of patient-centred approach needs
to be improved. While many promis-
ing practices have been identified for
providing patient-centred care, many
remain untested for their effectiveness.
Better mechanisms to monitor the needs
and effectiveness of systems to respond
to those needs must be in place, so that
there is a greater evidence base of quality
and safety. But individual hospitals can
look at these systems through their qual-
ity improvement initiatives. Integrating
patient-centred and culturally competent
care principles into quality improvement
effort was one amongst the 32 recom-
mendations that were made in our first
research report, Exploring Cultural and
Linguistic Services in the Nation’s Hospi-
tals: A Report of Findings.
How important a role does technology
play in this scenario? Is there enough
technology available to push for a
patient-centred care model?    quality is achieved.
I think technology can support patient-
centred care, but I don’t believe that
ent upon it. I believe that technology
can facilitate systems for information
sharing that can improve the way needs
are met. But, there must be an organi-
sational commitment to providing
culturally competent, patient-centred
care. As a part of our research, we inter-
viewed administrators and clinical staff
at 60 hospitals in the US. In some cases,
responses to our interviews indicated a
desire for better technology to address
the issues. However, patient-centredness
is not simply information management,
nor is a specific practice or procedure.
It is the provision of the type of care
that is able to adapt to changing needs,
is sensitive to different beliefs and can
accommodate and assist patients as they
navigate a complex system. As I reflect on
some of the hospitals I visited that were
particularly adept at providing culturally
competent patient-centred care, I recall
that I was impressed not with the tech-
nology, but with the human element that
was present within the hospital’s systems.
These were also hospitals that made use
of information technology to assist in the
collection and use of data; and invested
in systems such as remote video interpret-
ing and telephone interpreting systems
to compliment human resources to meet
the language needs. So, there is a need
for technology, but it is secondary to the
need for organisational commitment.
What role does the leadership play
in bringing about a patient-centred
approach throughout the organisation?
Leadership support and organisational
commitment is essential. Without this
commitment, patient-centred care can
not be achieved at an organisational
level. Leadership brings attention to the
issues allowing discussion and collabora-
tion to occur and bring about proposed
solutions. It also provides the necessary
financial and human resources to make
certain that in the domain of healthcare,
Any other comments that you would
like to make?  
I think it is important that we define
patient-centred care. To define, it should
include attention to the myriad of health
care needs that individual and popula-
tions of patients wish to be fulfilled. These
needs may include issues like cultural,
educational, physical and environmen-
tal constructs that may impact how care
is interpreted by the patient. It is also
important for hospitals to consider how
their processes, systems and environment
can influence the way care is provided.
For more information, please visit http://
www.jointcommission.org/PatientSafety/
HLC/
w w w . a s i a n h h m . c o m 51
CoverStory
The New
Challenge
The challenges presented by this
shift in focus can be overcome with
strong leadership, clarity of purpose
Gary Kaplan
Chairman and CEO
Virginia Mason Medical Center, USA
Healthcare processes are mostly disease-
centred. How big a shift is it then for
hospitals to create processes that are
patient-centred?
Most care providers are drawn to
healthcare, in large part, because they
want to make a difference in people’s
lives, but that healthcare processes can
make delivery of patient-centred care
challenging. At Virginia Mason, we
recognise that we would not exist with-
out our patients. Everything we do is
ultimately to improve their health and
well-being. Otherwise we wouldn’t
be here. That’s why our patients are at
the top of our strategic plan. This clear
and unequivocal focus on the patient
helps remind us, in everything we do,
to place the patient’s requirements on
top priority. This focus is somewhat of a
shift and presents challenges that can be
overcome with strong leadership, clarity
of purpose and a shared vision of what
patient-centred care can mean in terms
of an optimal patient experience.
52 Asian Hospital & Healthcare Management
What systems need to be put in place
in order to provide care that best suits
the patient’s needs (i.e. patient-centred
care)?    for our patients and does not merely
Systems that provide opportunities
for active participation of patients
and family members in policy and
programme development, to enhance
clinical care and improve outcomes,
need to be put in place. We have been
fortunate at Virginia Mason to be able
to involve patients and families in our
improvement work; from evaluating
patient education to assisting with
major programme redesign like in our
Cancer Institute. When the focus is on
patient centredness all processes and
systems can be modified to ensure that
they truly add value for our patients.
How important a role does technology
play in this scenario? Is there enough
technology available to push for a
patient-centred care model?
Technology is playing an ever-increas-
ISSUE-15 2008
ing role in healthcare; however, the
emphasis must be on using technol-
ogy in a way that makes a difference
automate longstanding inefficient
processes that are not designed to be
patient-centred. We, therefore, work
hard to re-design and re-engineer our
processes using our Virginia Mason
Production System methods prior to
automating with innovations such
as CPOE.
What role does the leadership play
in bringing about a patient-centred
approach throughout the organisa-
tion?
Leadership’s role is critical in articu-
lating the vision, helping connect
the dots between the vision and
the work people do every day and
helping remove barriers to patient-
centred care. Virginia Mason’s strate-
gic plan, helps us to put the patient’s
requirements first.
Listen
to the Patient
Assuring quality care
In striving for excellence in patient
care via scientific means, clinicians
may be omitting a potent source of
relevant information—the patients
themselves.
WF Bower, Assistant Professor
CSK Cheung, Research Associate
CA Van Hasselt, Professor
MJ Underwood, Professor
Department of Surgery
The Chinese University of Hong Kong
Hong Kong SAR
A
s noted in a previous disser-
tation of this publication,
embracing healthcare quality
assurance in Asian healthcare requires
the commitment of all parties involved
in the patient’s hospital journey
(Underwood 2006). It is incumbent
upon the institutions to provide appro-
priate frameworks to facilitate data
collection and analysis, and to support
a culture of response to findings and
continuous change toward improved
safety and high quality outcomes. To
this end, discipline-specific data regis-
ters can be established that include inde-
pendent risk factors and summated risk
scoring systems. Mortality along with
the spectrum of secondary outcomes,
will be incorporated and with relative
ease it becomes possible to translate
practice into quantified end points. This
is crucial in providing transparency and
 Quality Assurance Programmes for Surgery – How and
why in Asia? Published in Issue 12 (March ‘07) of Asian
Hospital & Healthcare Management.
accountability to patients, professionals
and administrators and is the hallmark
of excellence.
What is often missing in this evalu-
ation of quality of care is the patient’s
voice. Throughout the hospital journey,
opportunities exist to incorporate the
patient as a source of report, informa-
tion and opinion, and to include their
preferences in decision-making. In some
units, evaluating outcomes routinely
includes patient-completed measures,
so that functional and quality of life
aspects can be incorporated into over-
all outcome analysis. In Asia, we have
been slow to appreciate the benefits that
accrue from patient feedback in aspects
of care and assessment of efficacy.
Symptoms scores
Possibilities of input exist for the patient,
right from admittance till discharge
from hospital. Validated symptoms
scores are the first level of patient input
and summarise the reality of living with
a particular set of problems. Informa-
tion gained from patients about their
symptoms can influence how doctors
manage and prioritise their care. It can
also affect a patient’s compliance with
medical recommendations and their
satisfaction with treatment. The process
of “being heard” may alter the path to
recovery.
Quality of life measures
Until recently, the paradigm “Quality
of life” (QoL) has been associated more
with individuals facing life-threaten-
ing diseases than those with organic
or treatable disorders (Gerharz 2003).
QoL has now come to denote a general
and holistic measure of well-being and
disease impact (Wallander 2001). It is
a validated way of measuring a patient’s
perspective of their life situation both
before and after intervention (Donovan
2002). In adult patients such measures
are obtained via self-completion of a
psychometrically robust questionnaire.
w w w . a s i a n h h m . c o m 53
CoverStory
QoL tools can be used as a potent
summary of disease impact on an indi-
vidual’s well-being. Scores also serve
as an outcome measure of symptom
control following interventions, and
may discriminate between treatment
approaches. QoL results assist clinical
decision-making by serving as surro-
gate end points in chronic disease when
there may be only a small difference in
symptom severity following treatment.
In fact, QoL measures can detect greater
change in patient status than the subjec-
tive report (Osoba 2003). Lastly, QoL
data is commonly scrutinised in the
substantiation of service provision or
resource allocation.
Patient-reported outcomes
Once hospitalised and undergo-
ing treatment, the patient becomes a
reliable source of clinically useful infor-
mation that can facilitate doctor-patient
communication. Including the patient
enquiry “What matters” can augment
the overriding clinical process driven
by questions about symptoms. A recent
study reported that one-half of cancer
patients preferred to have a collabora-
tive relationship with their doctor rather
than play a passive role (Wilson 2000).
For a variety of reasons, face-to-
face encounters between doctors and
patients regularly fail to unmask the
entirety of the patients’ concerns. There
may be discordance between how
the patients and physicians view the
presence and effect of individual
symptoms (Wilson 2000). Consulta-
tion times are often short and patients
experience stress during the course of
disease. They feel reluctant to bother a
doctor with apparently unrelated prob-
lems and present a positive effect in grat-
itude for treatment, and even respond to
questions in ways they feel would most
please the clinician. Patients expect and
need clinicians to make decisions about
their disease and both parties may resist
diversion of attention to apparently
non-medical issues. Aspects of care,
such as QoL, threatening side effects
54 Asian Hospital & Healthcare Management
of treatment or depressive or adjust- experience, knowledge and expectations
ment problems that are unrecognised and may not be readily appreciated by
and thus untreated, may compromise doctors or fully explored in available
adherence to therapy (Fallowfield metrics. However, since satisfied patients
2001). Alternatively, improvement in are more likely to follow planned care
patients managed with explicit inclu- and make better use of health services
sion of their own reported outcomes institutions must find a way to
i.e., collaborative care, is likely to be understand the tenants underpinning
clinically meaningful (Velikova 2004). satisfaction within their population
Clinical care that comprehensively (Fitzpatrick 1990).
addresses both medical and key areas
of the patient’s well-being is associated Cultural appropriateness of
with higher levels of patient satisfaction available measurement tools
(Jackson 2005). Patients may be offered Having decided to include the patient’s
a disease-specific “happiness today” voice in the evaluation of care outcomes,
questionnaire on tablet or touch screen the next step is to identify valid and reli-
computers, where the results are avail- able measurement tools. Scrutiny of elec-
able to doctors prior to reviewing the tronic databases reveals ever increasing
patient. Graphical representation facili- number of patient-completed metrics,
tates single-occasion or longitudinal however, they are commonly reported
interpretation. in English and developed in Western
Including the patient’s voice
Including the patient’s voice as an integral part of health service evaluation is logical and time-efficient.
Deriving data from the combination of patient and doctor’s knowledge and experience broadens the
pool of available feedback. What we do with this information is critical. In a transparent environment
the issues are offered for discussion and mediative measures proposed. This forms the basis of an
audit exercise, where changes are made to processes or practices and the original measure then
re-applied to evaluate efficacy. This reactive response to quality concerns raised by patients extends
from voicing of bothersome symptoms right across the board to major issues with service provision.
If, however, patients are not seen as valuable sources of relevant information, the individual clinician,
doctor, nurse or administrator will miss a potent opportunity to tailor their input to meet the true needs
of the patient.
Patient satisfaction countries. Concerns arise as to whether
Patient’s evaluation of medical care it is appropriate to use these tools within
reflects performance of the system as an Asian context and assume findings to
whole, as well as specific aspects of be representative. One example of diver-
advice and intervention (Hall 1988). gence in the same tool administered in
It has been argued that satisfaction either Chinese or English is reported
is a desirable outcome of healthcare by Cheung and colleagues (2004) who
in its own right (Donabedian 1988) explored equivalence in cancer-specific,
and allowing “feedback” becomes an health-related quality-of-life question-
integral part of quality assurance and naires. Chinese translation of the question
accountability (Redfern 1990). “I have a lack of energy” produced results
Satisfaction is also an indicator of that differed from the results generated
patient acceptability of new forms of by the original English version.
care or intervention and is frequently The adaptation of existing measures
used as an outcome variable in trials involves stages. Translation is the first step
(Koh 1994; Thompson 1990). and necessitates a forward-backward proce-
Aspects of in-hospital care that dure, independently carried out by two
are important to patients are derived native-speakers of the target language or a
by them from their own values, professional translator (Kholler 2007).
ISSUE-15 2008
 QoL measures available in Asian languages
Instrument Version Reference
Brief Fatigue Inventory (BFI-C) Chinese version Wang XS 2004

Cancer Fatigue Scale Taiwanese version Shun SC 2006

Chinese WHOQOL-BREF Hong Kong version Leung KF 2005

EORTC QLQ-BR23 Taiwanese version Chie WC 2003

EORTC QLQ H&N35 Taiwanese version; Japanese version Chie WC 2003; Toth G 2005

Functional Living Index – Cancer (Quick-FLIC) Singapore version Cheung YB 2004; Cheung YB 2005

Functional Assessment of Cancer-G Therapy General (FACT-G) Hong Kong version Yu CL 2000

Gastrointestinal Quality of Life Index (CGQLI) Hong Kong version; Taiwanese version Yeung SM 2006; Lien HH 2007

Hospital Anxiety and Depression (HAD) Hong Kong version; Chinese version Lam CL 1995; Wang W 2006

Impact of Event Scale-Chinese Version (IES-C) Taiwanese version Chen SC 2005

Impact of Event Scale-Revised (CIES-R) Hong Kong version Wu KK 2003

Inflammatory Bowel Disease Questionnaire Hong Kong version; Chinese version Leong RW 2003; Ren WH 2007

Irritable Bowel Syndrome (IBS-QOL) Chinese version Huang WW 2007

McGill Quality of Life Questionnaire Hong Kong version; Taiwanese Version Lo RS 2001; Hu WY 2003

Minnesota Living With Heart Failure Questionnaire (MLHFQ) Taiwanese version Ho CC 2007

Myocardial Infarction Dimensional Assessment Scale (MIDAS) Chinese version Wang W 2006

Quality of Life in Constipation Patients Hong Kong version Chan AO 2005

SF-36 Chinese version; Hong Kong version Li L 2003;

Lam CL 2005; Wei YY 2006
St. George Respiratory Questionnaire (SGRQ-HK) Hong Kong version Chan SL 2002

Voice Outcome Survey (VOS) Taiwanese version Fang TJ 2007

Worry Scale (WS) Hong Kong version Shiu AT 2004

Table 1
Discrepancies are arbitrated by a third consultant
and solutions are reached by consensus. Translated WF Bower is an Assistant Professor and Surgical Audit
questionnaires then undergo a pilot-testing for concep- Team Leader, Department of Surgery Chinese Univer-
tual appropriateness and wording acceptability. At this sity of HK. Executive Board member of the Interna-
tional Continence Society and past executive of The
stage, ambiguities and cultural nuances are identified International Children’s Continence Society.
and corrected. Common problems include: lack of
expressions for specific symptoms in various languages,
the use of old-fashioned language, and different priori- CSK Cheung is a Research Associate, Department of
Surgery, joined Department of Surgery, The Chinese
ties of social issues between cultures (Kholler 2007). University of Hong Kong as Research Associate,
A uthor

Table 1 summarises QoL measures in Asian languages. participating and contributing work involving patient
If the measurement tool has already been reported satisfaction initiatives across public hospitals and car-
diac surgery registry.
extensively, it may not be necessary to re-examine its
face validity and inter- and intra-reliability. However, CA Van Hasselt is a Professor of Surgery and Chair-
within a new cultural context, it is mandatory to man, Department of Surgery Chinese University of
Hong Kong, Prince of Wales Hospital, Professor of
establish content validity. This process involves ques-
ENT Surgery.
tionnaire completion by at least 200 local subjects,
with a caregiver available to clarify individual difficul-
ties. Complex statistical analysis follows to identify
MJ Underwood is a Professor and Chief, Division of
items that do not generate useful information within Cardiothoracic Surgery, Chinese University of Hong
the local population. Problematic items within the Kong, previously Consultant Cardiac Surgeon and
original measurement tool are then either removed Audit Lead in Cardiac Surgery, Bristol Royal Infirmary,
United Kingdom.
or modified before the tool can be used as a valid
population-specific research or outcome measure.

w w w . a s i a n h h m . c o m 55
56 Asian Hospital & Healthcare Management ISSUE-15 2008
Patient-Centric
Modalities
Strategies for better
implementation
Care providers must
consider some key factors
they need to balance for
effective implementation of
patient-centric modalities.
Julio A Reategui
RA / QA and Compliance, Asia Pacific
MEDRAD, Inc., USA
I
n recent times there has been a trend
towards adoption of patient-centric
modalities as a cost-effective way.
These modalities address the needs of
various groups of the population, includ-
ing the ageing population segment, a
large percentage of which are affected
by chronic conditions that are the
leading causes of illness, disability and
death. Patient-centric modalities aim
for effective integration of technologies,
information and tools to address patient
care needs and to enable comprehensive
treatment, and close physician guid-
ance and coordination. Ideally, in this
environment, physicians will be able to
make critical decisions for their patients
with complete and relevant informa-
tion, real-time input from online clinical
decision tools and access to electronic
health records.
The current health system and
technology and / or disease-centric
approaches to the design of medical
devices and therapies offer, in most cases,
fragmented care that is inconsistent with
the scope of needs described above. These
needs can only be addressed effectively
by a patient-centric view of medicine,
technology and regulations.
How it all plays together
The typical factors that we must balance
for effective implementation of patient
modalities are: patient / profile, disease,
healthcare factors, choice of treatments,
available technologies and special-
ised tools, patient data, regulations
& reimbursement and environment
(Figure 1).
Intangible factors
The factors listed above plus other intan-
gibles such as the quality of the relation-
ship between the patient and the health-
care provider are closely linked and
must be balanced to ensure a successful
outcome.
Positive relationship
A positive relationship between the care
provider and the patient can lead to full
understanding of the patient profile. The
patient profile involves looking at a vari-
ety of factors that provide the full picture
of the patient. They include elements
such as gender, age, weight, height, over-
all health, dietary preferences, genetics,
background and ethnic characteristics,
lifestyle, personality, religious beliefs,
psychological profile and mental health.
The understanding of the patient profile
together with the patient’s views and
priorities is the first step in developing a
successful patient-centric modality.
Understanding the disease
The second set of factors requires an
understanding of the stage of the disease
or diseases, for instance, is it an acute
or a chronic condition? Is it a single
or multiple conditions? Do we under-
stand the trade-offs of therapies, moni-
toring and sample requirements, e.g.
type, frequency, quantity and how these
parameters affect the patient and the
selection of any available treatments.
This can be accomplished through a
systematic series of examinations and
gathering of data and correlation with
the medical history of patient. One
opportunity in this area is the education
of the patient about the disease. The level
w w w . a s i a n h h m . c o m 57
CoverStory
of education that the patient has about
his or her condition and the awareness
of the progress and constraints faced by
the provider will enhance the chances of
a successful outcome.
Healthcare factors
The third set of factors is designated
as the healthcare factor. The elements
connected to healthcare are mainly
driven by the care provider and the
provider preferences, level of care, avail-
ability and affordability of treatment,
quality of provider services, socialised
medicine or for profit model, provider
policies and insurance coverage.
The three set of factors above can
help narrow down the treatment plan or
choice of treatments, including deciding
among traditional, non-traditional and
holistic medicine. Also, there is an array
of alternatives available depending upon
the condition being treated. In recent
times, there has been an increased atten-
tion to therapies combined with dietary
practices.
Along with the above, we have a
choice of technologies and tools that
allow deeper investigation, going from
laboratory testing to imaging to genom-
ics. The promise of genomics is that we
would evolve into a truly personalised
medicine by including the patient’s geno-
type and levels of gene expression. This
allows precise tailoring of the treatment
to the individual. In the area of medical
devices, we are already observing a shift
towards providing the physician with the
tools to personalise treatments. Many
companies are using this as a way to differ-
entiate their products. Figure 2 illustrates
a contrast injector used to enhance imag-
ing procedures. This device allows enter-
ing a patient’s physiologic parameters
to recommend personalised settings for
delivering a customised contrast proto-
col (volume and flow rate) to a specific
patient.
The resulting patient data offers
challenges of its own. The collection,
storage, retrieval and analysis of the data
coupled with the logistics of managing
the information itself has opened up a
58 Asian Hospital & Healthcare Management
Factors influencing patient-centric modalities
Figure 1
series of opportunities for a new technical which would include the type of therapy
discipline, Healthcare IT. Other factors and testing, observation, periodic assess-
include ensuring portability, data accu- ment and rationale for plan updates and
racy and integrity, plus data security and possibly referral and follow-up. Table 1
privacy issues. illustrates the aggregate of elements that
Additional considerations include come into play. We can see that the analy-
the regulatory and reimbursement envi- sis and integration of factors can become a
ronment. In an ideal world, these two complex decision requiring formal tools to
factors would be considered non-issues. ensure an effective patient-centric therapy.
However, depending on the conditions
being treated and the type of therapy being Opportunities and challenges
pursued, they may pose major constraints Opportunities to facilitate the evolu-
on the patient and the provider. tion towards patient-centric modalities
Last but not least, the environment include a strategic and behavioural shift
around the patient plays a crucial role, from the pharmaceutical industry since
for instance the hospital versus home care they currently develop and commer-
setting; and urban versus rural setting. cialise drugs that are targeted to broad
The quality of patient’s life, occupation, segments of the population as opposed
living conditions, support networks, all to targeting designated sub-popula-
influence the outcome of the treatment. tions. The medical device industry also
Once all the above mentioned are needs to increase its efforts in developing
considered, one is ready to narrow down diagnostic tests that would enhance the
the development of a treatment plan, definition of those sub-populations.
Medical device manufacturers are increasingly providing
computerised tools that allow personalised protocols
In this picture we show MEDRAD’s Stellant, an injector of intravenous contrast
media for enhancing images in diagnostic studies in Computerised Tomography
applications. A new feature of this device computes a personalised patient
protocol for cardiac studies (P3T CardiacFlow). P3T CardiacFlow takes into
consideration several variables including patient weight, cardiac output, and
scan duration. P3T will then recommend a customised injection protocol
specific to that patient’s condition, leading to more reproducible and consistent
results, which are vital to the evaluation of progressive disease(s).
Figure 2
ISSUE-15 2008
 Elements to be considered in establishing an effective Patient-Centric Modality
1. Patient Profile
- Age / Weight / Height
- Overall Health & Dietary habits
- Gender & Genetics
- Ethnic Background
- Personality / Lifestyle / Religion
- Mental Health/Psychological
4. Choice of Treatments
- Traditional vs. Non-Traditional vs. Holistic Medicine
- Detoxification / Dialysis
- Therapy vs. Surgery
- Radiology vs. Drugs
- Chemotherapy vs. Radiotherapy vs.TK Inhibitors
- Experimental Treatment
- Psychiatric
7. Regulations & Reimbursement
- Approvals of Devices & Therapies
- In-country Regulations
- Reimbursement
- Payer / Payee models
- Intellectual Property concerns
Also, the regulatory environment in
most countries fosters above practices by
requiring expensive and lengthy clinical
trials that add to drug development costs.
A concept being proposed in recent times
is to allow for expedited approvals of drugs
that have demonstrated effectiveness to
a smaller sub-set of the population, e.g.
by targeting a population segment with
a common genetic characteristic and
require testing for that characteristic prior
to administering the drug.
Another opportunity is related to
the current training of physicians and
what is expected from them is acceptable
behaviour when it comes to treating
a disease. Traditional methods can be
compared with trial and error-repair
strategies, as opposed to a carefully
crafted treatment plan.
On the healthcare system side,
we are challenged with systems that
establish providers’ compensation plans
that are largely focussed on completing
procedures and prescribing medications
as opposed to early disease detection and
prevention.
In terms of patient data, some of the
upcoming challenges in this area require
adopting a different paradigm. Tradi-
tional patient records, even in electronic
format, organise the patient history from
2. Disease(s) 3. Healthcare Factors
- Disease and Disease stage - Care Provider & Provider Preferences
- Multiple Conditions - Level of care
- Chronic vs. Acute conditions - Availability & Affordability of treatment
- Therapy/Monitoring/ - Quality of Provider Services
- Sample Requirements - Socialized Medicine vs. for profit
- Provider policies & Insurance coverage
5. Technologies / Tools 6. Patient Data
- Imaging - Data Entry / Sharing / Paper vs. Electronic records / Portability.
- Physiologic Monitoring - Distributed vs. Centralized information
- Pharma-biotech / Molecular Diagnostics - Record Accessibility and Location
- Laboratory Testing - Data Accuracy / Interpretation capability
- Genomics / Proteomics - Data Transmission / Storage / Retrieval / Analysis /
- Patient Education/Learning
- Data integrity / Security / Privacy concerns
8. Environment 9. Analysis and Integration of Factors
- Hospital vs. Specialist vs. Home Setting - Translating Requirements
- Demographics & Socio-economic factors - Decision Making Models
- Urban vs. rural Setting - Integration of ptatient care needs, Technologies, therapies,
- Quality of life / Living Conditions / Occupation Information, Regulations and Environment.
- Work Environment / Support Networks Table 1
the provider’s perspective in a chronologi- requirements, regulatory constraints and
cal sequence of events. However, they do environmental factors.
not support physician-patient interac-
tion or ease communication with the Conclusion
patient. For the next generation of data Patient-centric modalities improve
systems to be fully supportive of patient- the effectiveness of our healthcare
centred modalities, they are expected to systems thereby benefiting patients.
look at presenting the data in a way that While the extent of changes required at
the patient can get the full educational industry, governance legislation,
benefit from his / her own health assess- provider and consumer levels are
ment and affect to his or her behaviour. numerous and profound, the shift
Further, this data can also be combined towards patient-centric modalities
in a way to facilitate decision-making and has already begun and is expected to
help narrow down choices of treatments. accelerate in the coming years.
Additional opportunities exist in the Acknowledgements
use of systems engineering techniques for Many thanks to Larry Kopyta, Tito Aldape, Anthony
translating individual patient and situ- Emerick and Linda Rachul-Rymniak from MEDRAD
Inc. that reviewed the draft and provided valuable inputs
ation requirements into actual therapy to this manuscript. Many thanks also to Al DiRienzo,
or modality and implementation maps. Susan Alpert, Javad Seyedzadeh and Tom Taylor, for
their valuable comments and insight during the forum
To establish objective decision-making, discussion on Patient-Centric Modalities. “Translating
these models optimise the integration Requirements and Integrating Technology” at Frost &
of patient care needs, technology and Sullivan’s Medical Device Conference in March 2006.
These early discussions helped establish the groundwork
tools, therapy alternatives, information for this article.
A uthor
Julio A Reategui is Director of RA / QA and Compliance,
Asia-Pacific, at MEDRAD, Inc. He has over 25 years of experience
developing and commercialising clinical, laboratory and field instru-
mentation and disposable devices for the medical industry, life and
analytical sciences, and environmental monitoring applications,
worldwide. He has also authored / co-authored seven patents and
over 15 technical publications.
w w w . a s i a n h h m . c o m 59
S u r gical S pecialit y
Patient Safety in Surgery
Current ‘key’ issues
Increased vigilance for key patient safety issues will impact quality assurance in the future
and help to reduce the incidence of iatrogenic morbidity and mortality after surgery.
Philip F Stahel, Department of Orthopaedic Surgery
Wade R Smith, Department of Orthopaedic Surgery
Philip S Mehler, Department of Medicine
Denver Health Medical Center, University of Colorado School of Medicine, USA
C
omplications due to individual
surgeons’ errors and system
failures are inherent in surgi-
cal practice and represent important
preventable causes of morbidity and
mortality. In spite of the increasing public
attention to medical errors in general, a
new level of transparency for consum-
ers, and the current trend to process
preventable adverse events systemati-
cally, surgical complications appear to
represent a persistent taboo throughout
different countries and institutions. One
would assume that a patient scheduled
for a surgical procedure would expect
to be better off after the intervention
than before. However, while physicians
strive to achieve excellent results and
favourable patient outcomes in daily
practice, this noble task has failed more
often than one expects.
Perioperative communication
breakdown
A recent analysis of the American
College of Surgeons’ closed claims
study revealed that most events leading
to iatrogenic patient injuries involved
a delay in diagnosis, a failure to diag-
nose. Thus, patient safety in surgery
appears to be challenged more by the
mistakes and failures that occur before
and after surgical procedures than by
60 Asian Hospital & Healthcare Management
Malpractice Insurers Medical Error
Prevention Study recently provided
information related to trainee involve-
ment in medical errors. Teamwork
breakdowns in the form of (1) a lack
of adequate supervision and (2) “hand-
off” problems were causative in 70 per
the operative intervention itself. Inter- cent of all errors leading to malprac-
estingly, technical intra-operative errors tice claims (Source: Archives of Internal
resulting in surgical complications Medicine 2007).
represent less than half of all events A written form of communica-
leading to a claim. Indeed, about 25 tion appears to protect from erroneous
per cent of all medico-legal surgical reporting, since written communica-
claims related to errors leading to an tion breakdowns occur in only about
adverse patient outcome are attrib- 4 per cent of all cases. An alarming
uted to a perioperative breakdown in aspect is the finding of 81 instances
communication. Thus, the surgical (14 per cent) of communication break-
patient appears to be more at risk of downs which involved a miscount
Three “key” issues related to patient safety in surgery
(1) perioperative communication breakdown; (2) the concept of a surgical “time-out” and
(3) the reporting of medical errors and complications in surgery. These topics should provide
the foundation for development of institutional quality assurance protocols and thereby
reduce the incidence of system errors, which potentially jeopardise the safety of patients
undergoing surgical procedures.
sustaining an adverse outcome from of instruments or sponges in the
hidden system errors than from an operating room (Journal of the American
individual surgeon’s human failure. A College of Surgeons 2007). According to
detailed analysis of communication the National Quality Forum (NQF)
breakdown patterns revealed an equal consensus report, the unintended reten-
distribution of occurrence during the tion of a sponge or other foreign body
pre-, intra-, and postoperative phases after surgery is defined as one of the five
of surgery. More than 90 per cent of “serious adverse surgical events” (Table
communication breakdowns appeared 1). These are informally termed “never-
to occur verbally. Of these, information events”, since they should never happen
was either transmitted in an inaccurate and they can never be defended success-
fashion (about 40 per cent of cases) or fully on a medico-legal basis.
it was never transmitted at all (about An adequate approach for improv-
50 per cent of cases). Similarly, the ing “communication safety” in the
ISSUE-15 2008

operating room should include the
implementation of standardised “read-
backs” of received information, and the
unambiguous assignment and transfer
of responsibilities. These strategies have
long been implemented in other high-
risk domains, such as nuclear reactor
control rooms, submarine services and
commercial aviation safety protocols.
In clinical practice, clear-cut algorithms
should define triggers which mandate
the communication with an attend-
ing surgeon (Journal of Patient Safety
& Quality 2007). Furthermore, stan-
dardised protocols for patient handoffs
and transfers should be defined at the
institutional level. Written orders and
checklists should support inter-indi-
vidual verbal communication, includ-
ing the count of lap sponges and surgi-
cal instruments, in order to reduce the
incidence of adverse events related to
communication breakdowns in surgery.
Currently, the development of specific
communication skills is underempha-
sised in residency programmes and may
contribute to the missing system factors,
which beget poor results of patient care.
The concept of a surgical
“time-out”
Any intervention involving a wrong
site (wrong side / wrong level / wrong
anatomic structure), a wrong procedure,
or a wrong patient, represents an unac-
ceptable surgical complication “never-
events” (Table 1). A lesson learned from
aviation safety is that a “culture of blame”
approach for dealing with individual
surgical errors is not helpful in improv-
ing patient safety or reducing the inci-
dence of severe complications. On the
contrary, wrong site surgery represents
a “classical” system error rather than
pure human failure by an individual
surgeon. Ten years ago, this notion led
to the implementation of a standardised
surgical “time-out” in North America
as an improved method of verifying
patient identity, correct procedure and
intended-site operations. Since then,
the concept of a surgical time-out has
Serious reportable surgical events (“never-events”), as defined by
the National Quality Forum (NQF consensus report, update 2006)
Surgical “never-events”
1. Surgery performed on the wrong body part
2. Surgery performed on the wrong patient
3. Wrong surgical procedure performed on a patient
4. Unintended retention of a foreign object in a patient after surgery or other procedure
5. Intra-operative or immediate postoperative death in an ASA class I patient
been widely implemented in operating
rooms throughout the US and repre-
sents a standard recommendation by the
Joint Commission on Accreditation of
Healthcare Organizations. A culture of
zero tolerance for “never events” is a key
to keeping patients safe. From a patient
safety perspective, the fact that this surgi-
cal time-out paradigm has not yet been
implemented as a standard of care in
most parts of the world appears incom-
prehensible and ethically unacceptable.
Of note, the time-out concept can
never be 100 per cent protective from
wrong site interventions. Potential
loopholes in this system include relegat-
ing the time-out to a robotic hackneyed
type ritual or the continuing “dilution”
of the time-out by expanding to second-
ary safety issues, such as antibiotic and
venous thromboembolism prophy-
laxis, as implemented in the so-called
“expanded surgical time-out” or “univer-
sal protocol”. The (ab)use of the formal
time-out as a quality control tool for
secondary parameters may deflect from
its original purpose of ensuring correct
site, correct procedure and correct
patient surgery. Another risk factor for
wrong site surgery is represented by
the situation of multiple simultaneous
procedures performed during the same
surgical session. This is exemplified by
the case of a patient undergoing multi-
ple surgical interventions for different
injuries, thereby obscuring the focus of
the time-out on a particular operation.
In addition, some specific anatomic
locations may represent “black boxes”
during the time-out, and thus represent
  www.jointcommission.org
S u r gical S pecialit y
Table 1
a particular risk for wrong site interven-
tions. These include orthopedic proce-
dures at the torso (spine, pelvis), dental
surgeries, neurosurgical interventions,
and intra-abdominal or intra-thoracic
operations. For example, an orthopae-
dic surgeon may perform a sacroiliac
screw fixation on the wrong side or fuse
a wrong intervertebral segment of the
spine.
An example of a wrong site compli-
cation in general surgery is the erroneous
clipping of the common bile duct, instead
of the cystic duct, during laparoscopic
cholecystectomy. Furthermore, inter-
ventional radiology procedures pose a
similar risk for wrong site surgery, e.g.
by the erroneous coiling of a wrong
artery. Finally, neurosurgical interven-
tions on the wrong part of the brain
are reported on a scarily frequent basis.
Unlike symmetric external body parts,
such as extremities, eyes and ears, these
“hidden” surgical sites may not be easily
identified, confirmed and marked prior
to surgery. Thus, these particular circum-
stances may mandate an accurate intra-
operative localisation under fluoroscopy,
in conjunction with a careful evaluation
of the surgical site by additional pre-
operative diagnostics, such as CT, MR,
angiography, or cholangiography.
Recently published studies indi-
cate that wrong-site / wrong-procedure
/ wrong-patient surgeries surprisingly
continue to occur in North America.
For example, adverse event data from
the state of Florida, US, reported 178
wrong site, 82 wrong procedure and
34 wrong patient cases for the years
2000-2003 (Archives of Surgery 2006). A
detailed analysis of an extensive database
w w w . a s i a n h h m . c o m 61
S u r gical S pecialit y
at the Colorado Physician Insurance
Company (COPIC) on 20,775 physi-
cian self-reported complications, we
detected 99 cases of wrong-site surgery
and 20 cases of wrong-patient proce-
dure in the years 2002-2007 (Stahel
et al., unpublished results).
The persistent occurrence of these
“never-events” in the era of a surgical
time-out may be explained by individual
surgeons’ non-compliance and by numer-
ous pitfalls related to accurate surgical
site determination, as outlined above.
Also, the time-out should not absolve
the individual surgeon from taking full
responsibility in ensuring by all avail-
able means that the correct procedure
is performed at the correct site on the
correct patient. All institutions have to
now consider adapting a formal time-out
concept as a standardised quality assur-
ance tool. Patients must be educated to
inquire their surgeons whether a formal
time-out procedure will occur in the
elective surgical suite.
Reporting of medical errors in
surgery
Systematic medical errors represent an
essential “information problem”. While
the intellectual argument for reporting
medical errors in surgery is compel-
ling beyond a doubt, surgeons remain
inherently reluctant to disclose surgical
failures and complications in public.
The main barriers for reporting surgical
errors are based on the fear of medico-
legal lawsuits, potential loss of profes-
sional prestige among peers, and the
well-engrained tenet of non-admission
of guilt and fallibility among surgeons
(“blame and shame culture”). In this
regard, the major ethical concern is
that the suppression of data on surgi-
cal errors will deprive other surgeons of
adequate scientific knowledge, which
may help prevent identical errors in the
future. In contrast to aviation safety,
where the implementation of system-
atic error reduction policies has led
to an irrefutable, impressive drop in
fatal accident rates in the past decades,
62 Asian Hospital & Healthcare Management
surgeons remain reluctant to recognise, for critical discussion of surgical errors
analyse, and officially report their own and lower the threshold for reporting
errors. The “human factor” which may adverse events in all fields of surgery. As
help explain the discrepancy between a result, the long-term goal of increas-
the situations in aviation versus surgery ing safety and quality of care for patients
is based on the fact that a pilot is usually undergoing surgical procedures will be
killed with a crashed plane, whereas a effectuated.
surgeon suffers no personal physical
harm from a patient’s complication. Conclusion
Thorough reporting and peer-review In summary, surgeons who wish to
of surgical errors creates a new dilemma decrease errors in their practice should
for the surgeon in practice: an increased consider implementing the following
quality of reporting leads to an increased three-standard procedures:
official number of complications and 1. Standardised pre- and post-opera-
adverse events, thus affecting the indi- tive communication handoffs between
vidual surgeon’s professional track record medical consultants, surgeons, anesthe-
and the respective institution’s ranking sia, and nursing staff, and formal “read-
among peers. Until legislation provides backs” supported by written checklists
legal protection for medical error disclo- and protocols.
sure and analysis, we continue to rely 2. Standardised surgical time-out for
on the inadequate reporting of errors all cases.
and complications in the peer-reviewed 3. Systematic error reporting and
biomedical literature. A recently launched real-time (weekly) peer-reviewed
open-access online journal, Patient Safety analysis of all complications,
in Surgery, was designed to complement “near-misses”, and “no harm” events.
traditional journals in surgery by filling
this essential void, through providing a Acknowledgments
forum for discussion, review, and “root We thank Drs Ted Clarke, Mike
cause” analysis of failures in the manage- Victoroff, Dennis Boyle, Alan Lembitz,
ment of surgical patients. This scien- and Jeff Varnell for providing access to
tific forum should create a focal point the comprehensive, physician self-reported
adverse events database at COPIC,
  www.pssjournal.com Denver, Colorado.
Philip F Stahel is an Attending Surgeon, Department of Orthopae-
dic Surgery, Associate Professor, University of Colorado School of
Medicine, Denver Health Medical Center. He has also involved in
many research activities. He has been honoured Yearly Award for
Experimental Surgery by The Swiss Surgical Society.
A uthor
Wade R Smith is a Surgeon, Department of Orthopaedic Surgery,
Denver Health Medical Center, University of Colorado School of
Medicine, USA. He is DH Executive, Patient Safety Committee
since 2006. He is also an External Fixation Working Group Mem-
ber, AO Foundation Technical Committee (AOTK) since 2005.
Philip S Mehler has been at Denver Health since training there as
a resident in the early 1980s. Philip Mehler is also a Professor of
Medicine at the CU Medical School where he holds the Glassman
Endowed Chair of Medicine. He has been honoured by 5280 Maga-
zine numerous times as the Top Internist in Denver, Best Doctors in
America for the last twelve years is listed in Who’s Who in American.
ISSUE-15 2008
 DIAGNOSTICS

Advanced
CT Imaging
Effective diagnosis
of coronary disease
Michael Chun-Leng Lim
Medical Director
Singapore Heart Stroke and Cancer Centre, Singapore

The advent of 256 and 320-slice CT scanners will eliminate many of the technical
difficulties that affect the temporal resolution of coronary CT angiogram. As technology
advances, MDCT imaging of the coronary arteries will become the diagnostic tool of
choice for the detection of coronary artery disease.

T
he main trigger for the onset
of Acute Coronary Syndromes
(ACS) following a prolonged
period of coronary atherosclerosis is the
rupture of an atherosclerotic coronary
plaque followed by localised coronary
thrombosis and / or spasm. The major
factors that predispose to rupture of a
vulnerable plaque are a relatively large
lipid core, a thin cap, and an accumu-
lated macrophage content. None of
these determinants of plaque rupture
are related to each other or to the
severity of luminal stenosis.
Plaque rupture typically occurs at
milder stenoses with 40 to 60 per cent
diameter narrowing or less. These mild
stenoses generally do not give rise to
symptoms or ischemia on treadmill
testing.
The degree of stenosis in focal
plaque segments on coronary
angiograms does not correlate with
the risk of plaque rupture. Plaques
which have developed more recently
are lipid laden, cause minor lumi-
nal narrowing and are more likely to
rupture than older, hardened plaques
with more severe luminal narrowing.
It is therefore, not surprising that 65
per cent of stenoses associated with
subsequent myocardial infarction have
<50 per cent luminal diameter narrow-
ing, and 85 per cent have <70 per cent
diameter narrowing.
Conventionally, non-invasive
methods for detection of coronary
disease using stress treadmill testing,
stress echocardiography and myocar-
dial perfusion scan provide indirect
means of diagnosing significant coro-
nary disease where the coronary lumi-
nal diameter narrowing is more than
70 per cent. But they are unable to
detect the vulnerable plaques that do
not cause any significant functional
stenoses, though they account for the
large number of patients who eventu-
ally develop ACS. Coronary CT Angi-
ography (CCTA) is one of the new
modalities of coronary artery imaging.
It is playing an important role in the
assessment of coronary artery disease.
CCTA is performed by imag-
ing the coronary arteries with a
Multi-Detector CT scan (MDCT).
Multiple sub-millimeter detector
elements mounted on a gantry with
a sub-second gantry rotation time,
allow high-resolution axial images of
the coronary arteries to be recorded
while the patient holds his breath. A
16 channel MDCT scanner will have
a lower volume coverage than a 64
channel MDCT scanner. Hence,
the breath holding duration for

w w w . a s i a n h h m . c o m 63
DIAGNOSTICS
a 16 MDCT CCTA is between 20 to
25 seconds, whereas for a 64 MDCT
CCTA, it is 7 to 10 seconds. With
newer 256 and 320-slice CT scanners
which will become commercially avail-
able next year, the scanning time will
be about 1 to 2 seconds.
Accuracy of Coronary
CT Angiography
With such a wide choice of non-inva-
sive cardiac imaging modalities, it is
important to assess each new modal-
ity on its own merits. Compared to
current modalities, CCTA must be
able to demonstrate accuracy of infe-
rior quality for it to be used routinely.
Conventional non-invasive modal-
ities for coronary artery assessment are
performed to detect the likelihood of
significant flow-limiting lesions but
provide no information as to the pres-
ence of vulnerable plaques. They are
also unable to detect the presence of
sub-clinical atherosclerosis, which may
predispose the patient to future cardiac
events. Gender, cardiac rhythm,
inability to exercise and the number
of vessels involved may influence the
results of these tests.
The sensitivities, specificities and
accuracy of treadmill tests, stress echo-
cardiography and myocardial perfusion
scan are mentioned in Table 1.
Many centres, including our centre,
have demonstrated that compared to
invasive coronary angiography, CCTA
has a high sensitivity and specific-
ity for detection of coronary artery
disease. At our centre, we were able
to demonstrate a sensitivity of 99
per cent, specificity of 98 per cent,
Positive Predictive Value (PPV) of 94
per cent and Negative Predictive Value
Sensitivities, specificities and accuracy of non-invasive cardiac imaging modalities
Treadmill
Testing
Sensitivities 68
Specificities 85
Accuracy 89
64 Asian Hospital & Healthcare Management
(NPV) of 99 per cent for the detection
of significant coronary artery steno-
ses. This compares very favourably
with the other conventional modali-
ties of non-invasive cardiac imaging.
Hence, amongst the non-invasive tests,
CCTA has the highest specificity and
sensitivity for detection of coronary
artery disease.
It is also consistent in most of the
published papers that CCTA has a high
NPV. The PPV of CCTA varies from
centre to centre as different protocols
and different post-processing methods
are used. There is a tendency towards
over-diagnosis initially, as there is a
learning curve for CCTA. However,
with proper patient preparation, expe-
rience, optimal protocols and appro-
priate post-processing techniques, a
high PPV is achievable.
Comparison with invasive
coronary angiography
Increasingly, CCTA is being compared
with Invasive Coronary Angiography
(ICA). Unlike CCTA, which is able to
provide a three-dimensional image of
the coronary vessel including the vessel
wall and the presence of plaque, ICA is
a “lumenography” demonstrating only
the lumen of the coronary artery with-
out visualisation of the vessel wall or
plaque. The presence of a plaque in a
coronary artery segment is inferred from
the narrowing of that segment relative
to a wider adjacent segment. Hence,
plaques which are not visible by ICA
are visible by CCTA. A “normal” angio-
gram by ICA assessment may be abnor-
mal on CCTA as some of the plaques
may not cause an obvious reduction in
the lumen size; this is usually seen in
bifurcation plaques or diffuse plaques.
Stress Myocardial Perfusion
Echocardiography Scan
77 73
84 87
80 89
Table 1
ISSUE-15 2008
The limitation of ICA as a
lumenography is particularly appar-
ent in diffuse coronary artery disease.
Intra-vascular ultrasound (IVUS) has
been able to demonstrate the pres-
ence of diffuse, extensive coronary
atherosclerosis in the absence of vessel
stenoses on angiography. Compared
to IVUS of the coronary arteries, the
sensitivity of ICA to the diagnosis of
diffuse coronary artery disease ranges
from 7-43 per cent, with a specificity
of 95 per cent.
In addition, the diagnostic errors in
visually interpreted coronary arterio-
grams, where vessel diameter narrow-
ing is visually estimated, are well
documented. Even for cardiologists
with extensive experience in coronary
angiography, the severity of diameter
narrowing is commonly overestimated
by 30-60 per cent.
Hence, visual assessments of coro-
nary angiograms severely underesti-
mate mild or diffuse coronary artery
disease and overestimate the severity
of plaques which have >50 per cent
diameter stenosis. Therefore, ICA as
the “gold standard” for coronary artery
disease has several limitations.
CCTA holds much potential as
a highly accurate modality for assess-
ment of coronary artery disease. Unlike
ICA, which provides two-dimensional
imaging and is essentially a lumenog-
raphy, CCTA provides three-dimen-
sional imaging and is able to visualise
the coronary plaques and other cardiac
structures. In addition, CCTA also has
the advantages of being non-invasive,
is less costly and is an outpatient proce-
dure. In contrast to the known stroke
and myocardial infarction risks of ICA,
in the first 4000 CCTAs performed
in our centre, there were no myocar-
dial infarctions, no strokes and no
mortality risks.
However, CCTA has certain inter-
pretative pitfalls resulting from arti-
facts. The artifacts may be due to
respiratory (poor breath holding) or
cardiac motion (sinus tachycardia,

irregular rhythm), beam harden-
ing effects (caused by the presence of
severe calcification, metallic stents,
pacing wires), contrast related arti-
facts (produced by filling of adjacent
chambers and coronary venous vessels)
and post-processing artifacts (common
cause of overestimation of luminal
stenosis is due to “partial volume
effect” during post-processing).
In experienced centres, using the
64-slice MDCT, CCTA may be
comparable to ICA in sensitivity and
specificity for the detection of signifi-
cant coronary artery disease for the
majority of patients. So it increasingly
being used as the non-invasive tool of
choice.
In the CARDIAC study (CT
Angiogram as Replacement Diagnostic
Investigation for Angioplasty of
Coronary arteries—submit-
ted for publication), a total
of 121 consecutive patients
in our centre, who were listed
for PTCA solely based on the
results of coronary CT angio-
each new modality on its own merits.
gram were picked up for the
study. We assessed the diag-
nostic accuracy of coronary
CT angiography on a per patient
basis. Peri-procedural complications
such as Major Adverse Cardiac Events
(MACE), stroke and emergency bypass
graft surgery were evaluated. MACE
including death from any cause, Q-
wave myocardial infarction, and
target vessel revascularisation during
the next 30 days, were analysed. At
the catherisation laboratory, follow-
ing the pre-PTCA invasive diagnostic
angiograms, 118 respondent (97.5
per cent) proceeded with coronary
artery stenting. There were no peri-
procedural complications. Durng
the 30 days, there was no episode of
death from any of the causes: Q-wave
myocardial infarction or target vessel
revascularisation. Hence, in addition to
providing an alternative to ICA, CCTA
may allow better pre-planning of PTCA
and hence, low complication rates.
Safety of CCTA
The main risks associated with CCTA
are the use of iodine-based contrast
agents potential risks arising from radi-
ation exposure during the scan.
Contrast risks are low. Post market-
ing surveillance of one particular
contrast agent, Ultravist (data from
Schering), showed that there were 14
serious adverse drug reactions in 75,000
patients (<0.02 per cent) Contrast
risks are minimal and comparable for
both CCTA and ICA for native coro-
nary angiography. In the case of ICA
of bypass grafts, the contrast load will
be significantly higher as compared
to CCTA of bypass grafts. With the
64 slice MDCT, Coronary CTA can
be performed with as low as 50cc
of iodinated contrast. The precau-
With a wide choice of non-invasive
cardiac imaging modalities,
it is important to assess
tions to be taken for those with renal
insufficiency are the same as in any
examination, which require contrast
agents. Most adverse contrast reac-
tions present with rash and in rare
cases, anaphylaxis can occur. From our
centre’s experience, for the first 4000
Coronary CTA examinations, we only
had one case where adrenaline had to
be given as a result of anaphylaxis. The
patient did not go into shock and did
not require hospitalisation.
The other main risk associated with
CCTA is the radiation risk. In under-
standing the potential risks of radia-
tion, it is important to understand
the terminology. The term “radiation
exposure,” which quantifies the ioni-
sation in the air produced by X-ray
photons does not equate with the term
“radiation dose”, which quantifies the
amount of radiation absorbed by the
DIAGNOSTICS
patient’s body as a result of exposure
to X-rays.
Radiation dose assessment is
important for decisions on the risk-
benefit value of the CT examina-
tion and to assess the effectiveness of
measures for minimisation of radia-
tion during CCTA. The fundamen-
tal radiation dose parameter in CT
is the Computed Tomography Dose
Index (CTDI), which is a measured
parameter. The Effective Dose (ED)
is the main parameter, which is used
to compare the potential biologi-
cal risk of X-ray examinations. It is
commonly used to compare the
different absorbed radiation dose
and radiation risks of different X-ray
examinations.
Unlike the CTDI, which is a
measured parameter, the ED
is derived from the CTDI.
The SI unit for measurement
of ED is the sievert (Sv) or
millisievert (mSv). The ED is
calculated from the relative
weight radiation risks of each
specific organ.
Reduction in radiation dose
during CCTA has been made
possible by two different methods.
The first method utilises the fact that
due to the elliptical axial section of the
human body, the attenuation of the X-
ray is less if the X-ray beam traverses in
an anterior-posterior (AP) direction as
compared to a lateral direction. Hence,
less X-ray energy is required to produce
a comparable image in an AP direction
when compared to X-ray source in a
lateral direction. The second method
involves the optimisation of radia-
tion exposure by ECG-controlled tube
current modulation during periods of
the cardiac cycle where cardiac motion
artifact is minimised (ventricular dias-
tole). Reduction of the tube current
output in systole, when the likelihood
of cardiac motion artifact is higher,
can result in dose reductions of 45-48
per cent, depending on the patient’s
heart rate.
w w w . a s i a n h h m . c o m 65
DIAGNOSTICS

Many studies have been performed
to study the radiation dose of CCTA.
Some of the earlier studies had
shown that the radiation dose from
MDCT was approximately 4–7 mSv
and was comparable to that from
uncomplicated conventional coro-
nary angiography. In a study where
the ICA was performed by different
cardiologists, the average dose varied
from 3.1 mSv to 8.6 mSv. In a more
recent study, continuous scanning
with the newer 64-slice CT scanner
without using ECG-controlled tube
current modulation resulted in an
ED of 13.4 mSv for males and 18.9
mSv for women. With dose modula-
tion, the ED was reduced to 7.45 to 8
mSv for men and 10.25 to 11.3 mSv
for women. This study assumed an
effective mAs of 880. At our centre,
when using the 64-slice CT scan-
ner, the tube current for CCTA stud-
ies is routinely set between 500 to
600 mAs.
The increased radiation risk of
CCTA is offset by the increased
morbidity and mortality risks of ICA.
In one prospective study, which inves-
tigated the risk of stroke embolisation
following ICA, asymptomatic new
cerebral infarction detected using MRI
following left cardiac catheterisation
occurred in 15 per cent of patients.
Hence, invasive cardiac catheterisation
carries a significant risk of embolic
stroke­—mainly “silent strokes”.
ICA carries a non-radiogenic risk
of mortality of 0.11 per cent, a major
complication risk (excluding contrast
reaction) of 1.3 per cent, radiogenic
risk of mortality of 0.02 per cent
and an overall mortality risk of 0.13
per cent (nearly two times that of
CCTA) and major complication risk
of 1.3 per cent. These risks do not
Hence, with proper optimisation
of the protocols and settings, the radia-
tion risk of CCTA can be minimised
and the overall mortality and morbid-
ity risks of CCTA as compared to
ICA can be made favourably weighted
towards CCTA. The main risk of
CCTA is radiation risk. So protect-
ing the patients from radiation is
necessary. This means the justifica-
tion for the radiological procedure is
based on the premise that the poten-
tial benefit for the patient outweighs
the potential risk of radiation. It also
means that the ED for each procedure
is calculated to assess the risk-benefit
value of the CT examination and
the effectiveness of the protocols
and the settings in minimising
radiation risks.
The development of the new CT
scanners means that radiation doses will
continue to decrease. Using prospec-
tive ECG gating protocols and new
imaging sequences, radiation doses in
64-slices CCTA have been reduced to
doses comparable to invasive coronary
angiography.
Conclusions
CCTA can provide three dimensional
view of the coronary vessel wall struc-
ture, heart muscle, valves, pericardium
and even ventricular contractility
function. It has a higher sensitivity
and specificity for the detection of
coronary artery disease compared with
conventional non-invasive tests. Its
main disadvantage is its potential radi-
ation risk.
This is, however, balanced by it
being the only non-invasive cardiac
imaging modality with the ability to
A uthor
detect sub-clinical plaques, which
may predispose to myocardial infarc-
tion and its ability to provide plaque
characterisation. Hence, it can poten-
tially play a role in risk stratification
of patients with cardiovascular risk
factors and provide physicians with
added information on treatment
decisions.
In contrast to ICA, which only
visualises the lumen of coronary
arteries, CCTA holds the potential
for a comprehensive examination of
the heart using one single examina-
tion technique. In addition, it can
provide information on plaque distri-
bution and characteristics which
cannot be obtained on ICA. The
examination is easily reproducible,
objective and has a very high nega-
tive predictive value. In high-volume
experienced centres, a high PPV is also
attainable.
CCTA may potentially provide
patients an alternative to ICA. In our
centre, CCTA has replaced ICA as the
diagnostic tool of choice for patients
who are suspected to have coronary
artery disease.
However, in some patients, the
presence of severe calcification can
present significant diagnostic chal-
lenges. The advent of 256 and 320
slices CT scanners will eliminate many
of the technical difficulties that affect
the temporal resolution of coronary
CT angiogram.
As technology advances, MDCT
imaging of the coronary arteries will
be increasingly used and will grow
in importance as a diagnostic tool
for the management of coronary
artery disease.

Michael Chun-Leng Lim is an internationally renowned Cardiologist

include contrast reactions and silent
strokes. In comparison, CCTA carries
no non-radiogenic risk of mortality
and no major complication risk. It
carries a radiogenic risk of mortality of
0.07 per cent.
and is the Medical Director of Singapore Heart, Stroke & Cancer
Centre. He is currently the Dean of the College of the Asian Pacific
Society of Cardiology (CAPSC), Chairman, Board of Trustees
(CAPSC), Scientific Advisory Board, World Heart Federation
and Immediate Past President of the Asian Pacific Society of
Cardiology (APSC).

66 Asian Hospital & Healthcare Management ISSUE-15 2008


How has the response to PACS been?
PACS in India, the response has been
very good so far. In fact, there are quite
a few hospitals that are fully using the
PACS software. The hospitals that we
have been targeting have shown very
keen interest in PACS. We feel that
market is getting mature and is set
to boom.
How is the technology likely to evolve
in the coming years?
PACS technology has been changing
quite rapidly. Initially it was newer
and more sophisticated equipment,
like good quality CT, MRI, PET/
CT etc. These have already allowed
clinicians to diagnose with much
better accuracy. In future we
anticipate that with more develop-
ment in algorithms and comput-
ing power, Computer Assisted
Diagnosis based on radiology data
will evolve as a feasible technology
and will enhance quality of diagnosis
to unprecedented level.
DIAGNOSTICS
PACS in
Indian Hospitals
Catching up
More and more physicians and
radiologists have started preferring
the PACS systems to hard copies.
Deepak Kumar
Chief Technology Officer
Srishti Software, India
What are the basic requirements • A good quality network to connect
to implement a PACS across an equipments, PACS server and
organisation? DICOM workstations
Assuming that a hospital already has a • Storage and backup infrastructure for
radio diagnosis facility with equipments reliably storing the studies
and radiologists, the following would be
additional requirements: How have physicians and hospitals
• Equipments must be DICOM responded to the technology, since
compliant. Some of non-compliant they have been used to hard copies of
equipments may still be used with X-ray reports for so long now?
additional DICOMisers That’s quite interesting. In fact, we
• A PACS server that will receive stud- are finding that more and more physi-
ies from equipments, store those, cians and radiologists have started
allow queries & retrieval, archive, and preferring the PACS systems to
allow automated routing hard copies. Turn around time for
• DICOM workstations that would modalities connected with PACS
be used by Radiologists for viewing, is much faster in comparison to
processing, analysing, and reporting traditional films. Further there is no
the studies easy way to keep hard copies of 64-slice
Are hospitals in India self-sufficient as far as using this technology is concerned?
Yes, to a great extent. In fact, Indian hospitals are well equipped with the PACS technology.
There is good quality support available from various vendors. Additionally number of
radiologists, who are comfortable in using sophisticated PACS workstations, is growing
and hence pushing the utilisation of PACS infrastructure in hospitals.
w w w . a s i a n h h m . c o m 67
DIAGNOSTICS

India are treating IT as a strategic area

How do you view the market for PACS in India? and willing to invest.
Quite good. In fact, the market is getting very exciting. Most of the top league hospitals
are already using PACS while most other progressive are exploring PACS. Earlier From your experience in implement-
significant high cost of ownership, due to high license fee and hardware & storage costs. ing PACS in India, what are issues you
However the crashing prices of hardware & storage, combined with reasonably priced came across as a service provider?
solutions from some of the vendors has removed that barrier. Today hospitals of In few occasions, hospital may not be
any size can acquire highest quality PACS server and specialist workstation at a
clear on human resource needed from
price affordable to them.
their side to maintain and use their
PACS environment. For example, to
CT, PET / CT, 4D / 5D etcetera and These need to be understood and effectively use PACS Radiologists,
keeping these digitally remain the only handled by hospitals that implement Clinicians, Operators and PACS admin-
viable option. PACS. Hospitals needs to additionally istrators must get trained properly.
understand the security issues and risks These need to be properly planned and
What are the benefits of PACS when involved when PACS is used to enable executed; otherwise all benefits from
you look at it from the point of view of tele-radiology to allow access of study PACS might not be realised. Another
the entire healthcare continuum? outside hospital premises. set of issues comes when hospital does
IT applications that a hospital uses not have clarity about the duration
can be categorized as PAS [Patient Does PACS help in providing tele- for which they want to retain studies,
Administration System], CAS medicine? making estimation of storage compli-
[Clinical Administration System], Most of PACS solutions, when imple- cated.
EMR [Electronic Medial Records] mented properly, will allow out of the
and ERP [Enterprise Resource Plan- box tele-radiology. Enabling stud- Any other comments?
ning]. In order to get complete ies to be reported by remote radiolo- Indian healthcare is fast moving to
view of a patient’s EMR, one gists. However there may be additional a stage where hospitals will need to
needs complete radiology stud- application required to allow handling compete more for the same set of
ies as well, which is maintained in of transfer of clinical data, appoint- patients and in order to do so improve
PACS. This makes PACS an inte- ments, tele-conferencing, billing etc. quality while keeping the costs in
grated part of full patient care control. In this regard, many hospitals
applications and workflows. Do you think Indian hospitals are have started looking or otherwise should
interested enough in Healthcare IT? look in to way to improve their quality
Does it raise the issue of security of All the hospitals we have been inter- and controlling costs. IT can be a strate-
data? acting are considering IT as their way gic enabler, however hospitals should be
In any form of Medical records, we to improve quality, processes and bring careful and engage with a vendor only
get privacy and data protection issues. cost down. So we feel that in hospitals with proper due-diligence.

Industry Report
Advances in PACS Technologies
Today, PACSs are being widely implemented in radiology departments for routine clinical diagnosis. Though there are
several hundreds of first-generation PACSs currently used by many hospitals to support direct radiological softcopy
readings they are not capable of integrating other related text-based information. But the subsequent development
of second-generation PACSs, which is now known as hospital integrated PACSs (HI-PACSs) or enterprise PACSs,
meets this criteria, which is integration of PACSs with heterogeneous information systems such as HIS and RIS,
transition to an open client / server system architecture, and the implementation of recognized imaging standards
such as DICOM and HL7.
Sangeetha Prabhakar
Research Analyst, Technical Insights (Healthcare), Frost & Sullivan, Singapore

For the full report, visit Knowledge Bank section of www.asianhhm.com

68 Asian Hospital & Healthcare Management ISSUE-15 2008

 T echn o l o g y , e q uipment & devices

Devices Containing Membranes

Better membrane, improved
outcomes

Devices containing artificial membranes for the treatment of kidney disease lack the ability
to replace or augment metabolic and endocrine functions, which are non-selective and
biologically reactive.

Nicholas Hoenich
Clinical Scientist, Medical School
Newcastle University, UK
membrane. Variations of this concept are
the newer modalities of treatment, which
introduce an element of convection to
the process. Such approaches, however,
retain their reliance on a membrane, but
tend to utilise membranes with a high
application. By the early 1940s, cellu-
lose was manufactured using the
viscose process replacing collodion.
With the availability of a reliable
method of vascular access in the 1960s,
treatment of renal failure became more

T
he ability to separate molecu-
lar species in a solute using a
membrane was first described
by Thomas Graham in 1861, and today
the process is widely used in a variety of
industrial and clinical applications. In
the latter, commonly used applications
are: plasma separation, oxygenation
and the augmentation of renal function
(Haemodialysis).
In plasma separation, 2-3 litres of
plasma is removed from the patient
during treatment and replaced. The
frequency of the treatment and the
volumes exchanged depends onthe
disease being treated and the patient’s
hydraulic permeability (Table 1).
Currently used membranes and
demography of their use
Early experimental dialysis treatments
used membranes based on cellulose,
namely, collodion formed from the
mixture of cotton, sulphuric and nitric
acid redissolved in alcohol. This material
is difficult to produce, sterilise, is subject
to leakage and has a lack of consist-
ency with respect to the pore size. All
of this contributes to its limited clinical
DIAPES®
­AN69® AN69ST
Synthetic
widespread and retained its reliance
on membranes manufactured from
cellulose. Widely used membrane
variant being Cuprophan, used prima-
rily in a flat sheet or tubular form. By the
late 1960s, technology became available
to produce such membranes in a hollow
fibre format, which is used almost univer-
sally in the treatment of renal failure.
Concerns began to arise in the 1970s
regarding the poor biocompatibility of
cellulose-based membranes as well as the
narrow range of molecules that could be
>20 ml/h/mmHg
PEPA®

Polyamix® Frsenius Polysulfone®

UFC

response to the treatment. Membrane Toraysulfone® PAN

oxygenation is used during cardiac a Polysulfone Arylane®
Rexeed® PMMA
procedures or also over extensive peri- CTA
ods to provide support for patients with
DIAPES®
10-20 ml/h/mmHg
modified cellulose

pulmonary distress. The most widely used PEPA®

Sythetically

application is haemodialysis, a treatment EVAL® Fresenius Polysulfone®

UFO

that is generally performed three or more PAL Polysulfone®

Cellulose-diacetate PMMA Arylane®
times a week to sustain life. In haemo- Cellulose-triacetate Polymax® Toraysulfone®
dialysis, the membrane ontained within
a haemodialyser, or artificial kidney, acts HEMOPHAN®
< 10 ml/h/mmHg

SMC®
Un modified

as a selective barrier between two phases,

Cellulose

Cellulose-diacetate DIAPES®
UFO

regulating the transport of substances, CUPROPHAN® Cellulose-triacetate ­Polyamix®

which occur as a consequence of SCR Excebrane® Fresenius Polysulfone®
Cuprammonium Rayon PEG-RC a Polysulfone
concentration difference across the
Table 1

w w w . a s i a n h h m . c o m 69
T echn o l o g y , e q uipment & devices
removed by such membranes. This led
to extensive studies on the biocompat-
ibility or blood contacting behaviour of
membranes used in clinical procedures
as well as the development of more
open-pored synthetic membranes and
new treatment techniques.
The poor biocompatibility of cellu-
lose-based membranes was found to be
due to the presence of OH or hydroxyl
chemical groups on the membrane
surface and modifications either by
chemical replacement of groups, or
by the grafting of polyethylene glycol
chains onto the membrane ensued. The
structural modifications used may be
tertiary amino groups such as Di-Ethyl-
Amino-Ethyl (DEAE) or acetate groups
as used in the production of cellulose
acetate or cellulose triacetate with
the magnitude of the hydroxyl
group substitution varying
between 1 and 100 per cent.
Synthetic membranes are
produced by the chemical trans-
formation of polymers, which
may be either hydrocarbon
or heterochain. One, two or
more polymers may be mixed
to produce the membranes,
which can be symmetric, whereby both
sides of the membrane are identical
in structure, or asymmetric. In asym-
metric membranes, a thin dense inner
layer normally in contact with the blood
overlies a porous substructure. As the
base materials used in the production
of synthetic membranes tend to be
hydrophobic, the manufacturing process
involves their blending with a hydrophilic
material, generally, polyvinylpyrrolidine
(PVP). Such membranes due to their
different surface structure compared to
cellulose-based membranes, are gener-
ally more biocompatible, but currently
no membrane is available for clinical use,
which is inert.
Grassmann and colleagues, analysing
global trends in the treatment of renal
failure by dialysis showed in 2000 that
when 1.297 million patients underwent
treatment, 46 per cent of dialysers used
70 Asian Hospital & Healthcare Management
were high-flux and 50 per cent contained
synthetic membranes. Their later survey
in 2005 indicated that 62 per cent of all
dialysers sold were high-flux and 73 per
cent contained synthetic membranes.
To curtail costs, haemodialysers
were historically reused on the same
patient. Whilst this continues, globally,
the number of patients treated with
reused dialysers decreased steadily from
around 34 per cent in 2000 to 26 per
cent in 2005, a development that was
driven primarily by the abandonment of
reuse in many clinics in the USA and in
Eastern European countries.
It has been estimated that the global
growth rate of haemodialysis is around
6 per cent per annum, with trends
observed to date dominated by econom-
The manufacture of membranes has
been optimised to produce
materials with a tightly modulated
pore size distribution.
ically well-developed countries, such as
the USA, Japan and Germany. Based on
the status as of 2005 and the observed
growth rates, the emerging picture of
dialysis treatment in the year 2010 is
one with a global population approach-
ing two million patients, furthermore
it is estimated that by this time around
800,000 of the patients receiving
treatment will be living in countries
that are presently defined as low- or
middle-income countries.
Limitations of current membranes
Membranes, whether they are manu-
factured from cellulose or synthetic
materials, are subject to limitations in
their solute transport characteristics.
Membranes may be considered as porous
structures that act as non-selective
molecular sieves i.e. molecules of a
specific molecular weight, the membranes
ISSUE-15 2008
cut-off weight (~25kD) traverse the
membrane irrespective of whether
they are implicated in uraemia or not.
The rate of solute transport across the
membrane is inversely proportional to
the square root of the molecular weight
of the chemical species. This means that
a molecule such as B2 microglobulin,
a compound with a molecular weight
of 15kD implicated in the evolution
of long-term problems associated with
regular dialysis therapy, diffuses approxi-
mately at 7 per cent of that for urea
(60 daltons) and clearly highlights the
limitations of membranes in removing
larger molecules. In both cellulose and
synthetic membranes there is a distribu-
tion of pore sizes. Increasing this distri-
bution means that whilst there may be
an improvement of middle-size
molecules, there will also be loss
of proteins such as albumin,
unless the pore size distribu-
tion is tightly controlled. The
issue of protein leakage in high
flux membranes has long been
recognised. Today, protein-leak-
ing membranes are available
and have been used in a small
number of clinical trials in which
improvement in anemia, decreased
plasma total homocysteine and reduced
plasma concentrations of glycosylated
and oxidised proteins was demonstrated.
It remains unclear if routine use of such
membranes is warranted.
Today, manufacture of membranes
has been optimised to produce mate-
rials with a tightly modulated pore
size distribution, thereby improving
the removal of specific compounds.
However, such manufacturing altera-
tions cannot be leveraged further to
generate improvements in selectivity. An
alternate approach to improving solute
transport is to move away from the
circular or elliptical pores to a
rectangular slit, an approach that offers
considerable advantages in terms of
solute transport.
In membranes used in the treatment of
chronic kidney disease, the primary focus
w w w . a s i a n h h m . c o m 71
T echn o l o g y , e q uipment & devices

has been to improve removal of metabo-
lites from blood. However, in a haemodia-
lyser, the blood side of the circuit is sterile,
but the dialysis fluid side is not. Unless the
water distribution system is cleaned on a
regular basis, a potential for the develop-
ment of a biofilm within the water distri-
bution network, as well as the hydraulic
circuit of the dialysis machine, leading to
the release of endotoxin fragments and
bacteria exists. Bacteria, due to their size,
cannot cross the membrane but endo-
toxin fragments are able to do so. And
this has raised concerns that membranes
with a large pore size may confer a risk to
the patient of exposure to cytokine-induc-
ing bacterial substances in the dialysate,
thereby contributing to the micro-
inflammatory state of patients undergo-
ing regular dialysis. A number of studies
Future approaches
Membranes used in the treatment of
chronic renal disease are manufac-
tured in large quantities and their
production has been optimised.
However, currently used membranes
are at their limit with respect to
transport characteristics, although
some improvements are possible with
the use of slit shaped geometries,
rather than the currently used cylin-
drical pore configuration or by the
development of membrane absorb-
ers. Alternately, the surface grafting
of macromolecules to capture solutes
of interest may also offer solute
transport enhancement.
A uthor
With respect to biocompatibility,
current approaches aim to minimise or
suppress the patho-physiological mecha-
nisms by the shielding or manipulation
of the hydrophobic and hydrophilic
domains in the polymer blend. Whereas
this approach yields positive results,
totally inert membranes are not yet
available.
Finally, it should be stressed that
all currently used membranes lack the
ability to provide replacement or
augmentation of the human kidneys,
metabolic and endocrine functions. This
issue is now being addressed as polymeric
membranes offer a considerable potential
as supports or anchors for cells.

Nicholas Hoenich is a scientist University of Newcastle upon Tyne.

have demonstrated that such transport
across the membrane is dependent not
just on the size of the pores, but also the
membrane material, due to the ability of
synthetic membrane materials to absorb
cytokine-inducing bacterial substances.
He serves on the Editorial Boards of several bioengineering jour-
nals, is a member of the Research Committee, British Renal Soci-
ety, and expert advisor to the Medicines and Healthcare Products
Regulatory Agency for the UK. He is the author of over 100 peer
group reviewed publications and has contributed to several text-
books dealing with the treatment of renal failure.

72 Asian Hospital & Healthcare Management ISSUE-15 2008


Art for Health's Sake
An evidence-based
approach
The human mind and body are so intrinsically linked that “feeling” better is a huge step
towards “being” better. This makes the role of art very critical in today’s healthcare.
T
hey say a picture is worth
a thousand words. In a
museum, we can stand and
ponder on what these thousand words
may be. We can look at a picture,
wonder, and let our thoughts wander.
But, what about art in a hospital?
In a hospital, patients, visitors and
staff are all under constant pressure and
in a state of stress and anxiety. Patients
T echn o l o g y , e q uipment & devices
want to feel better and care givers want
to make patients feel better. Good
doctors, good infrastructure, good
medication and a clean, safe environ-
ment is all that should be needed to
achieve this objective. And yet, there
is a growing movement away from the
cold, sterile, pearl-white and disinfect-
ant-smelling environments of yore to
more humane environments that are
Upali Nanda
Vice President, Director of Research
American Art Resources, USA
less frightening to the patient and less
stressful to the staff. The key is in percep-
tions—the human mind and body are so
intrinsically linked that “feeling” better
is a huge step towards “being” better.
And this is where the role of art becomes
so critical.
Today, nearly 50 per cent of all
hospitals in the US have art programmes.
In 2003, the Society for the Art in
w w w . a s i a n h h m . c o m 73
facilities & o pe r ati o ns management

Healthcare (SAH) and the National to prove otherwise. Studies have now and care givers. This implies that art
Endowment for the Art (NEA) under- linked the effect of Art to measurable interventions must not only base deci-
took an analysis of Joint Commission health outcomes, such as reduction in sions on the best available research find-
on Accreditation of Healthcare Organi- stress, pain perception and anxiety and ings, but also commit to the process of
zations (JCAHO)-affiliated hospitals increase in satisfaction and restora- generating new evidence base on these
to determine the current level and tion. These studies form the evidence interventions. According to Ulrich and
characteristics of art activities in base for a more responsible and Gilpin (2003), within the healthcare
healthcare (Wikoff, 2004). Two thou- ethically driven aesthetic of what is environment, the important outcomes
sand hospitals responded that they had being termed as “Evidence-based Art.” relevant to art / health research are the
art programmes in place—73 per cent health outcomes, which include:
of those reported permanent displays The evidence base on healthcare 1. Clinical indicators: Observable
of visual art in the hospital; 32 per visual art: A quick overview signs and symptoms related to patients
cent reported having rotating exhibits, In Florence Nightingale’s Notes for conditions such as length of hospi-
typical art by local or regional artists. Nursing ([1860], 1969), she describes tal stay, intake of pain medication
The study found that 96 per cent of the patients’ “need” for beauty and argues or biological markers such as blood
hospital art programmes were intended that the effect of beauty is not only on pressure and heart rate
to “serve patients directly.” The primary the mind, but on the body as well. Since 2. Patient / Staff / Family-based
reason given for having art programmes that first emphasis more than a century outcomes, such as patient ratings of
was “benefit to patients” (78.8 per ago, art has continued to have a presence perceived pain, satisfaction with health-
cent), noting them “specifically to be in the healthcare environment. During care services, staff-reported satisfaction
a part of their mental and emotional the Depression, artists were put to work etc and
recovery (72.8 per cent).” The study on painting murals in US hospitals. In 3. Economic outcomes such as cost
also found that 25 per cent of hospitals the 1970s and 1980s, hospitals in the US of patient care or cost related to nursing
with art programmes allow patients began to “decorate” with art—but with- turnover etc.
an opportunity to choose their own out particular consideration to the “ther- Focussing on the above outcomes
art. In the US$ 41 billion healthcare apeutic benefit” art might have had. The allows the development of an evidence
construction industry in the US, by a early 1990s saw a new interest in thera- base that can guide best practices for
conservative estimate, US$ 2 billion peutic environments, which emphasised creating therapeutic art programmes. In
will be spent on art for new hospital art that was intended to contribute more the medical community, Art interven-
constructions this year. Yet, despite the than decorative value to the hospital tions are often used as “positive distrac-
obvious support for art in the health- environment. Today, there is yet another tions” for patients. For example, adult
care setting, finding resources for shift to more rigorous evidence-based patients in a procedure room reported
information on how to create a success- design, which is both the process and better pain control when exposed to a
ful and empathetic art programme product of scientific analysis of health- nature scene with nature sound in the
is difficult. The popular notion is to care environments (Hamilton, 2003). ceiling (Diette, Lechtzin, Haponik,
consider Visual Art as nothing more In the context of art, this refers to the Devrotes, & Rubin, 2003). Murals (as
than pictures that can entertain, but not process and product of scientific distraction) resulted in a significant
heal. Over the past decade or so, there analysis of the impact of art on decrease in reported pain intensity, pain
has been a growing body of evidence healthcare environments; on patients quality and anxiety by burn patients
(Miller, Hickman, & Lemasters, 1992).
Breast cancer patients reported reduced
In addition to appropriate image content, three aspects of art need to be taken into anxiety, fatigue and distress during
consideration for creating healing environments (Hathorn, 1998)
chemotherapy when exposed to virtual
1 Location of artwork - The exact location of the artwork so as to enhance the physical environment
reality intervention displaying underwa-
and also develop a healing atmosphere. For example, when patients undergo mammography, the
screening happens one breast at a time. This positioning creates limitations in terms of the lines of ter and art museum scenes (Schneider,
view, which must be taken into consideration. If possible it is recommended pictures, one for each Ellis, Coombs, Shonkwiler, & Folsom,
line of view. For MRI and CT scans, where patients have to lie on their backs, placing art on the 2003). A similar finding was made when
ceiling, or using artwork that is large enough to fill the patients view, is advisable (Hathorn, 1998).
patients were asked to enter a virtual
2 The needs of the special patient populations - Evaluating the unique needs of the kind of patients environment by playing video games or
who will view the artwork. For example art for pediatrics may differ from art for palliative care.
wearing a headset (Hoffman, Patterson,
3 Role of demographics in the healing environment - Understanding the ethnic, gender and age Carrougher, & Sharar, 2001). In a 2002
make-up of the location of artwork and choosing art accordingly. study researchers found that with the

74 Asian Hospital & Healthcare Management ISSUE-15 2008

w w w . a s i a n h h m . c o m 75
facilities & o pe r ati o ns management
Treatment Room at Mays Clinic
use of soundless nature video there was a
significant increase in pain threshold and
pain tolerance.
Art has also been seen to have ‘stress
reducing’ effects. Evidence from heart-
rate recordings and questionnaires
showed that stress in a dental clinic was
appreciably lower on days when a large
mural was hung at the back of a waiting
room (Heerwagen, 1990). In another
study, ceiling mounted pictures shown
to highly stressed pre-surgical patients
on gurneys, resulted in lower blood pres-
sure when the images were of serene
nature scenes (Ross, 1990). While it has
become increasingly common to use art
interventions to distract patients from
their pain or stress, the body of work on
the appropriate image content used for
such interventions remains small.
Research by Ulrich and Gilpin
(2003, p.123) suggests that nature art
(or art with views or representations of
nature) will promote restoration if “it
contains the following features: calm or
76 Asian Hospital & Healthcare Management
slowly moving water, verdant foliage,
flowers, foreground spatial openness,
park-like or Savannah like properties
(scattered trees, grassy undershot) and
birds or other unthreatening wildlife,”
Ulrich and Gilpin (2003) also suggest
that in addition to nature art, humans
are genetically predisposed to notice,
and be positively affected by smiling or
sympathetic human faces.
In a landmark study conducted in
1984 in Pennsylvania, Ulrich found
that post-operative gall-bladder surgery
patients whose rooms had windows with
views of a park had better outcomes than
those patients whose rooms had windows
with views of a brick wall. Patients
complained less to staff, needed analge-
sic pain medication of lesser strength,
and were discharged earlier (Ulrich,
1984). In a study with post-opera-
tive heart patients in Sweden (Ulrich,
Lunden and Eltinge, 1993), it was found
that exposing heart surgery patients in
intensive care units to pictures of nature
improved outcomes. On the other hand
patients reacted strongly in a negative
manner to abstract art. This is one of the
few studies that highlights not only the
positive impact of appropriate art, but
the potentially harmful effect of inap-
propriate art. The study shows that it
is risky to place art in a hospital that is
ambiguous, subject to interpretation, or
that has obvious negative connotations.
Because, when viewers are stressed or in
a negative emotional state, which they
often are in a healthcare setting, they are
likely to respond in a negative manner
to art that they cannot understand or
that contains negative images or icons.
Ulrich and Gilpin (2003) suggest that
the explanation for the appropriateness
of nature images, and inappropriate-
ness of abstract or ambiguous images,
lies in the two basic theories: Evolution-
ary Theory and Emotional Congruence
Theory. Evolutionary Theory holds that
man’s evolutionary survival skills in a
natural world have hardwired humans
to find nature calming and restorative.
Emotional congruence suggests a person
ISSUE-15 2008
perceives his or her emotional state in
a manner congruent with their current
emotional state. In a hospital environ-
ment, it is likely that the high stress that
patients and staff are under colours their
responses to the art.
In fact, the usual yardstick for art
evaluation may be quite inadequate and
inappropriate in healthcare settings.
Nanda and Hathorn (2006) conducted
an art preference study with inpatients at
St.Lukes Episcopal Hospital in Houston,
and found that patients preferred nature
scenes and representative images over-
stylised or abstract art, even when the
latter were rated as “best-sellers” by
different online art vendors. The study
is yet another indicator that high qual-
ity art, or even popular art, is not always
appropriate art for healthcare settings.
In fact, there were many pictures,
which the patients said they would like
to put in their homes, but not in their
hospital rooms. This shows the distinction
patients make between their emotional
state at home and in the hospital.
An area where more investigation
is warranted in an increasingly global
healthcare market is the role of ethnicity
on Art Preferences. In a small prelimi-
nary survey conducted in a large urban
midwestern hospital Hathorn and Ulrich
(2001) found that Caucasians’ and
African-Americans’ responses to figu-
rative art depicting caring faces and
positive body language were the same.
Results also showed that both groups
preferred representational paintings of
nature landscapes and rural areas show-
ing spatially open settings in clear, sunny
weather, with water features and verdant
vegetation. Paintings of gardens with
flowers were also rated as appropriate.
Implementing evidence-based art:
Mays Clinic, M.D. Anderson Cancer
Center, Houston, Texas, USA
In 2002, the University of Texas M. D.
Anderson Cancer Center made a deci-
sion to change the fundamentals of its
art programme from an art-for-art’s
sake to a evidence-based approach; one
 facilities & o pe r ati o ns management

that used previous research to determine
appropriate art content for patients and
staff in the hospital. The approach was
also committed to evaluating the results
of any art intervention, and collecting
evidence on the effectiveness of the art-
intervention that was implemented.
An art programme based on guide-
lines developed from previous research
was developed to address the following
goals:
• Create a healing and hopeful envi-
ronment
• Relieve stresses associated with a
healthcare environment
• Reflect and enhance images developed
through design and architecture
• Address a culturally and regionally
diverse population
• Accommodate needs of special
patient populations
• Reflect overall standard of excellence
The art selection criteria were as
follows:
• Landscapes: Regional, generic or
seasonal
• Positive fall and winter landscapes
• Waterscapes: Regional, generic, or
seasonal
• Floral: Familiar flowers, garden /
bouquet style
• Flowers in vases (used sparingly for
variety)
• Figurative: Observational rather than
Interpersonal, people in positive
relaxed nature surroundings
• Still lifes (used sparingly for variety)
In February 2007, a Post-Occupancy
Public Corridor at Mays Clinic
Evaluation (POE) of the Art programme
implemented at the Mays Clinic, M.D.
Anderson was undertaken to understand
the effectiveness of the applied guide-
lines, and the need to change based on
user feedback. Five units were identified
to conduct the surveys with the patients
and visitors: Radiation / Oncology,
Breast Imaging, CT Imaging, MRI and
Outpatient and Diagnostics. Each of
these clinics hosted artwork that adhered
to one or more of the art criteria. An on-
site questionnaire was administered to
210 patients and visitors, and an online
questionnaire was administered to 240
staff members. Eighty-four per cent of
Patients / Visitors thought the artwork in
the Mays Clinic, overall, made them feel
much better (15 per cent) or better (68.5
per cent). When asked about the role of
art, patients / visitors mentioned that art
served as a distraction, made the hospital
de-institutionalised, gave comfort, was
cheering and uplifting, helped get rid of
anxiety and contributed to the percep-
tion of the overall quality of care. The
staff of M.D. Anderson were also asked
about how appropriate they thought the
artwork in the Mays Clinic was for the
patients. Ninty-seven per cent of the staff
thought the art was highly appropriate
(56 per cent) or moderately appropriate
(41 per cent).
Overall, both the quality of the
artwork and the emotional / healing
effect of the art were rated positive. Also,
the rate of response was indicative of an
involvement in art by all the users, which
is significant. Finally, it is important to
note certain themes that were emergent
from the qualitative data in the POE
about the role of art:
• Healing: Making patients and staff
“feel” better
A uthor
• Positive Distraction: Allowing patients
and visitors to focus on something
other than their (and the people
around them) condition
• Branding: Improving the perception
of care at the hospital, and serving as
an element that users identify with
• De-institutionalisation: Making the
hospital less intimidating
• De-stressor: Both patients / visitors
and staff use favourite pieces of art
to de-stress This is particularly true
for the staff
• Way finding: Prominent pieces of art
serve as landmarks for patients
The M.D. Anderson case study is
an example of basing design decisions
on best available evidence, and then
evaluating the success of the imple-
mented design decisions. While the
tools used (on-site and on-line surveys)
are basic, they form the foundation for
an ethical approach to healthcare art,
one that goes beyond mere aesthetic
considerations.
If a picture is worth a thousand
words, then these words must be care-
fully chosen, and clearly spoken, via the
medium of art, to convey the message
to patients and care-givers alike that
every aspect of their environment is
aimed at making them feel better and
get better.
About American Art Resources:
American Art Resources is USA’s leading
evidence-based art consulting firm. Their
expertise is in producing award winning
art programmes, unique to each client,
that are based on patient specific needs,
community resources, and produced
within defined budget / time constraints,
targeted exclusively at the healthcare
industry.

Upali Nanda, has a Bachelor of Architecture from School of Plan-

ning and Architecture, New Delhi, a Master of Arts from National
University of Singapore, and a PhD from Texas A&M University.
She is the Vice President and Director of Research at American
Art Resources, where she conducts research on Visual Images for
Healthcare Environments.

w w w . a s i a n h h m . c o m 77
facilities & o pe r ati o ns management

Healthcare
Facilities Design
A global perspective
The battle to deliver high-quality care
at affordable costs will only be won
through refinement of process flows and
a thorough understanding of long-term
operational costs as well as initial
capital costs.

Judith D Mitchell
Director of Planning
Harvard Medical International, USA

T
oday, we are seeing an unprec-
edented global boom in health-
care facilities development
fuelled by a wide variety of economic
and social factors:
• The Private Finance Initiative that is
spawning significant new develop-
ment in the UK
• The creation of free zones giving rise
to entire healthcare “cities” in the
Middle East
• China’s transformation from a
monolithic public system to a hybrid
public / private model of care deliv-
ery, which is necessitating a complete
rethinking of their healthcare infra-
structure
• Privately held companies leading
the way in building new hospitals in
India
• Public outcry in Australia forcing
policy makers and developers to
work together to provide improved
quality and access to care
• The realisation that massive rebuild-
ing of decaying infrastructure will
be essential to the future of Eastern
Europe’s healthcare system
Simultaneously, a multitude of
forces—a shift in the burden of disease
towards chronic illness, rising costs
coupled with heightened demands
on the part of more educated health
consumers, and a global shortage of
healthcare professionals—are giving rise
to new thinking about how to design
integrated care environments that serve
patients’ needs while allowing health-
care organisations to attract and retain
quality healthcare professionals.
The healthcare building boom across
Asia and the Middle East provides a
clean slate for facility designers and a
unique opportunity to forge new models
without the constraints that often limit
existing medical centres in North Amer-
ica and Europe. Most significantly,
these greenfield developments create
the potential to break down traditional
barriers in support of multi-discipli-
nary practice. Service lines may now be
Acibadem (Bursa and Kozyatagi Facilities)
Architect: Ertum Artunga Architecture, Instanbul.  
Photos courtesy: Harvard Medical International
rethought and organised around disease
rather than in traditional departments,
thereby creating a more patient-friendly
experience where clinicians have the
ability to engage in cross-speciality
consultation for more efficient and effec-
tive patient care. Advancements in infor-
mation systems are enabling a complete
rethinking of radiology and a movement
towards more dispersed models where
imaging capability is decentralised and
spread throughout the medical and surgi-
cal specialities. Ultrasound, CT scanners
and MRIs are conveniently located in
proximity to the patient populations
they serve and radiologists now have the
option to leverage their time by support-
ing multiple practices from remote

78 Asian Hospital & Healthcare Management ISSUE-15 2008

 facilities & o pe r ati o ns management

Mohammed Bin Rashid Al Maktoum Academic Medical Center’s

University Hospital Architect: Ellerbe Becket, Minneapolis.
Artist’s Renderings provided courtesy of Ellerbe Becket

w w w . a s i a n h h m . c o m 79
facilities & o pe r ati o ns management
locations. While the shift from inpatient
to outpatient care has been occurring
gradually over the last 25 years in North
America, it has lagged far behind in Asia
and the Middle East. However, the new
developments in these regions present
an opportunity to leap ahead with facil-
ities designed to accommodate high-
volume intake of ambulatory patients
in welcoming environ-
ments that do not compro-
mise patient privacy or
dignity. Development of
modular approaches to the
planning of both inpatient
and outpatient units prom-
ise increased flexibility to
accommodate shifts in patient
volumes as well as medical
advances we cannot predict today.
Pioneering new models
Today’s healthcare leaders have tremen-
dous opportunities to change the health-
care scenario, and their challenge will be
to craft financially sustainable models
uniquely tailored to the communities
they serve. Healthcare facilities plan-
ning, like healthcare itself, is increasing
80 Asian Hospital & Healthcare Management
Acibadem (Bursa and Kozyatagi Facilities)
Architect: Ertum Artunga Architecture, Instanbul.  
Photos courtesy: Harvard Medical Internation
in complexity at a rapid pace. Hospital
design is perhaps the most demanding of
all building types, requiring designers to
stretch across all scales of design address-
ing issues related to urban planning and
campus site development, coordination
of complex building systems as well as
detailed room and furniture design.
Poor design can have long-term impacts
resulting in increased staffing and opera-
tional inefficiencies, which unnecessar-
ily burden an organisation and may not
be immediately visible to a healthcare
administrator. The introduction of high
tech equipment and the proliferation
of computers necessitates sophisticated
mechanical systems which today may
account for as much as 45 per cent to 50
Hospital design is perhaps the most
demanding of all building types,
requiring designers to stretch across
all scales of design.
per cent of a total construction budget.
So, making the right decisions regarding
systems has become increasingly impor-
tant. In the United States, healthcare
facility design has long been an area of
specialisation for architects and engi-
neers; however, in many parts of the
world, design teams are yet to develop
the expertise necessary to successfully
accomplish these complex building
ISSUE-15 2008
projects. Finding a qualified design team
is central to the success of any significant
healthcare project and poses a special
challenge for developers in many parts
of Asia and the Middle East.
Many institutions, investors and
developers have a tendency to focus
on high tech equipment as a tangible
evidence of progress. It is important
to recognise, however, that planning a
state-of-the-art hospital involves much
more than creating a wrapper for high
tech equipment. A successful hospital
design must reflect local circumstances
and, in a competitive marketplace,
the battle to deliver high-quality care
at affordable costs will only be won
through refinement of process flows and
a thorough understanding of
long-term operational costs
as well as initial capital costs.
The design of support spaces
is critical for attaining opera-
tional efficiency and central to
a top-quality infection control
programme. Thus, the planning
of a successful hospital encom-
passes far more than the accom-
modation of equipment. It intertwines
building design with the design of care,
with the clinical programme serving as
the first critical blueprint in the devel-
opment of any physical structure. Clin-
ical programming must drive hospital
design and the planned functions of the
facility must be addressed in its form.
At Harvard Medical International
(HMI), we have participated in a
 facilities & o pe r ati o ns management

Xiamen University/Fupond International Hospital

Architect: AKS, Beijing and Xiamen Faculty Architects, Xiamen.  
Rendering provided courtesy of AKS and Xiamen Faculty Architects.

new models, which local government

officials may then use to demonstrate
the effectiveness of proposed regula-
tory changes. It’s a win-win situation
for all involved, and can produce a
powerful ripple effect throughout the
broader healthcare community.

Global examples indicate the way

wide range of facilities design and
development projects, in a wide variety
of social, environmental and regulatory
contexts. Our core objective of creat-
ing sustainable models for delivery of
high-quality care, is reflected in our
approach. We use the design process
to foster dialogue about local practices
and explore applicability of models
being used elsewhere around the world.
Through these discussions, we seek
to initiate operational advancements,
explore new approaches to staffing, and
identify training needs. In attempting
to meet this objective, we have tried to
adhere to a singular guiding philosophy
during the planning process: to consist-
ently strive to make decisions and create
solutions that result in a patient-centred
environment, where patients want to go
for care and where top healthcare profes-
sionals want to practice and teach utilis-
ing the latest healthcare technologies.
In the healthcare facilities planning
process, this is accomplished by making
the design process a collaborative effort
involving every member of the care
team. Healthcare planners work in close
collaboration with doctors, nurses,
quality experts and administrative
leaders, all of whom bring a unique
perspective on healthcare. We use tools
Addressing regulatory obstacles
The local regulatory environment is
another key factor which healthcare
developers and institutional leaders
must consider in developing a sound
development strategy. Often, health-
care regulations lag far behind current
medical practice and present obstacles
to forward-looking planning. This is
particularly true in the developing
economies where healthcare facili-
ties have long been neglected and a
rapidly expanding economy is now
propelling rapid advancement in the
state of care. Often, executive lead-
ers fail to understand or consider
the negative impact these regulations
may have on the long-term success of
their institution. In other instances
they simply do not feel empowered
to challenge the regulations that are
out of step with advances in health-
care. We have learned that develop-
ers and institutions can influence
public policy—for the betterment of
healthcare delivery—through their
own projects. By proactively engag-
ing regulators early in the design
process, it is often possible to iden-
tify issues of mutual concern and a
strategy for addressing them. Often,
projects may be used as pilots for
Judith D Mitchell is Director of Planning at Harvard Medical Interna-
A uthor
forward
Not very long ago, the US academic
medical centres stood alone as
examples of state-of-the-art facility
design. Today, innovations in healthcare
facilities are taking place in all corners
of the globe. In response to the
catastrophic SARS outbreak of 2003,
Chinese architects and engineers
are creating new models for control
of airborne infection. In Australia,
design teams are assisting government
officials in responding to a massive
public outcry for improved quality
of care. Lower population densities
in that part of the world are driving
providers to more distributed,
community-based models of care that
in turn will rely on highly advanced
IT systems. In the UK, design firms
are exploring modular prefabricated
systems in an effort to build ambulatory
clinics quickly and cost-effectively
to meet demand for greater access to
quality care. These are just a few
examples of the kinds of innova-
tion that will define healthcare
environments of the future. Healthcare
facilities must continue to be designed
to respond to local context and needs,
but increasingly, healthcare leaders
will look to all corners of the globe for
inspiration.

tional. She has served as a consultant to Harvard Medical Interna-

such as computer-generated proto- tional since 1996 and joined HMI on a full time basis in 2000. She
typical designs to simulate and study consults with HMI’s partners in the early stages of planning on real
workflows within the hospital, and estate development strategies, master planning and regulatory is-
sues. She is a member of the American Institute of Architects and
instigate discussions aimed at discover- currently serves on the National Advisory Board to the American
ing how best to create effective models Institute of Architects Committee on International Practice.
of delivery that meet their needs.

w w w . a s i a n h h m . c o m 81
facilities & o pe r ati o ns management

Lean Process Program Planning

Guidelines for optimum operations
and design

Lessons learnt from the appropriate incorporation of “Lean” considerations during the
functional and space programming phases and then the conceptual and preliminary design
phases, can positively impact immediate, short-term and long-range operational expenses.

George Pressler
President
Planning Decision Resources, Inc., USA

O
ver the past several decades,
healthcare planning and
design have developed into a
multi-speciality arena beyond most of
any other building type. This has been
mandated as a result of the increas-
ing complexity of factors like: inter-
twining codes, regulations, technolo-
gies, reimbursement and insurance
impacts, medical systems, informat-
ics, equipment, staffing patient care
ratios, patient confidentiality, safety,
risk management and quality of care
guidelines. Increasing attention has
been given to rising operational costs
and capital costs for new construction
and renovation.
A myriad of new trends have flooded Figure 1
the industry with solutions to improve
select foci, either service line or depart-
ment-based. These have included: Terminology has expanded beyond developed in the early 1990s. Like
Centres of Excellence, Patient-Focussed high tech / high-touch to include: no other industry, healthcare has
Care, Family-Centred Care, Focussed Single-Care, Same-Handed, Flexibil- attempted to learn from other success-
Hospitals and Healing Environments. ity, Adaptability, and Modularity. ful enterprises. These approaches,
Healthcare leadership has been intro- many geared toward marketing, busi-
duced to various approaches, such as And now, LEAN… ness development and patient satisfac-
Six Sigma, Evidence-Based Design, The origin of Lean and the Lean tion improvement, have explored the
Sustainability and Green Build- Production System is certainly hospitality and resort industry. Lessons
ings towards planning and design. credited to Toyota manufacturing learned from these settings explored

82 Asian Hospital & Healthcare Management ISSUE-15 2008


support services such as food service,
materials management and logistics
as well.
Lean Process Program Planning
(LPPP) has successfully demonstrated
an incredible potential for improve-
ment in operational efficiency while
incorporating a multitude of goals
and objectives of many of the trends
and philosophies identified above. In
addition, Lean process improvement
extends well beyond the planning and
design process into construction and
engineering and transition planning.
It was observed that constructions and
project costs have been reduced due to
lean process improvements.
It appears that further explora-
tion of the intent and lessons from
Lean thinking may result in a winning
solution for all stakeholders—
Patient, Family, Physician, Staff and
Leadership.
As the Lean process was developed
around production, significant thought
has been given to application towards
healthcare, resulting in multitudes of
statistics and promises for amazing
improvement in operations and cycle
times. New vocabularies have evolved
and are now commonplace.
Caution! Beware!
If healthcare leadership—the “C-Suite”
(offices of CEO, COO, CFO, CIO
and CNO)—becomes interested in
the Lean process, merely because of the
enticement of the metrics, the process
will ultimately fail. Promises of 25 per
cent reduction in operational costs, 50
per cent reduction in errors, and 7 per
cent gains in annual revenue, 55 per
cent reduction in response times, 43
per cent reduction in required FTEs
per adjusted patient discharge, and
40 per cent reduction of area—are all
very enticing lures. These promises are
enticing especially to those individu-
als who formulate budgets and form
Board financial expectations in a highly
competitive industry. This must be
emphasised to encourage and educate
facilities & o pe r ati o ns management
COST Vs EFFICIENCY
Volum
e
opera Capacity
tional
Efficie
ncy
Figure 2
leadership on the true, more global
values of the Lean process. While gains
will be achieved in most of the areas
outlined above, the actual figures may
vary from one institution to another.
The variables include new or extensive
remodelling of facilities, the existing
or proposed integration of advanced
informatics systems, the plan and
budget for acquisition of new technol-
ogies and medical equipment, and new
organising tools for all administrative
functions. Other significant variables
relate to logistics, material supply and
distribution systems.
A key consideration is the
willingness for change, and the
executive team’s willingness to devote
the support and financial resources
for the investment of time and dollars
on the long-term basis. A basic
principle of Lean is the investment in
the future and the understanding that
this approach is not a static solution, but
one that requires continuous improve-
ment with the goal of zero defects and
zero waste of time and resources.
From significant experience
with Lean approaches as applied to
programme, planning, and design,
lessons have been learnt as to the
appropriate level of detail to attain
significant benefit. The principle is
to remove waste in the form of time,
number of steps in a process, distance
travelled for each step, the number
of individuals required per step in a
Opera
tio
Cons nal Cost
tr uctio
Space nC
SqMt ost
.
process, and resources that may be
redundant or unnecessary in the proc-
ess. Examples and actual experience
has shown that the majority of waste
can indeed be greatly reduced or
eliminated. This allows for awesome
change in clear thinking of what can
be achieved if these applications are
incorporated throughout the facility—
or as in Lean thinking—the entire
enterprise.
Principle concepts include elimi-
nation of “departmental” thinking to
adopt a systems approach. Standardi-
sation of spaces, resources, equipment
and supplies, as well as actual processes
to the degree possible are all primary
considerations. It is very important to
accept that quality in all aspects must
be maintained to highest potential
possible. This includes elimination
of risk, and promotion of safety and
security as applicable in all areas.
Flexibility in the utilisation of
spaces and other resources has proven
to be of significant value in multiple
ways. As with decrease of through-
put times, these concepts can, on one
hand, decrease the quantity of spaces
that must be constructed—decreas-
ing construction costs, or on the other
hand, increase volume capacity which
can increase return on investment
by allowing for future growth while
reducing operational costs.
Each facility, as well as each appli-
cation of Lean Thinking, must be
w w w . a s i a n h h m . c o m 83
facilities & o pe r ati o ns management

customised to the needs of specific
owner. The development and imple-
mentation of Lean can be applied
to specific functional areas, entire
service or product-lines, throughout
the facility or throughout the health-
care system. Of primary importance
is the acceptance and support of lead-
ership for the right reasons. Planning
Decision Resources (PDR) has devel-
oped a simple tool to be utilise as a test for
decision-making called the “PDR Lean
Statement of Rights”.
Collapsing barriers, separating
healthcare operational departments is
not restricted to the physical barriers
of walls and corridors. The barriers are
more often in the mind—preparing to
accept change—for the overall good
of the enterprise. Patient and family
satisfaction as well as Healthcare Givers’
satisfaction are the true goals of a long-
range solution. These are the factors
that can ultimately benefit and impact
the bottom line.
From a facility planning and design
perspective, Lean Thinking is not to
simply reduce construction costs. It is
for operational improvement, which in
turn reduces operational costs, thereby
improving capacity for greater return
on investment. This in turn results
in decreasing cost of construction.
In the past too, often from unsuc-
cessful approaches to cost mainte-
nance, costs were cut simply through
Value Engineering. Although this
short-term approach fulfilled
immediate needs, if failed in the event
of unforeseen circumstances. The
Lean process certainly considers the
immediate need of responsible project
cost maintenance, but in the realm of
the larger long-term picture.
Continual improvement seeking
emergencies or unscheduled events, but
the process encourages Lean Thinking to
consider and plan for how these emer-
gency needs can be met in other ways.
It considers the ways, that do not force
“our” enterprise to pay the cost for exces-
sive inventories, costs for space to house
the excessive stock, personnel to clean,
maintain, and inventory the excess,
and then transport the inventory when
needed to where needed. This is just one
example of stretching the standard
thinking into totally new approaches.
Opportunities abound within
this new approach for programming
more functional spaces that utilise less
space and provide greater capacity for
increased volumes. Programming net
PDR lean statement of rights
1. Right Staff 7. Right Size
2. Right Place 8. Right Distance
3. Right Quality 9. Right Information
4. Right Time 10. Right Care
5. Right location 11. Right Reason
6. Right Supplies
usable spaces with much tighter gross-
ing factors for decreased wasted space
for circulation is achievable. Relocating
non-essential spaces outside of expen-
sively constructed hospital or acute
patient care zones, and placing these
services in less expensive structures can
be considered. An alternative approach
is to outsource many of these functions
to other vendors. This reduces cost for
construction as well as the staff required
to operate these functional zones.
George Pressler is the Founder and President of Planning Deci-
sion Resources, Inc. (PDR). He provides planning, programming,
A uthor
Focus on the bottom line is not
incorrect, and in fact is a necessity. Focus
on the construction costs and bottom
line, without considering greater long-
term costs may be a risky proposition.
Although long-term solutions impact
operational costs, they prolong the life
of the building.
The side benefits of the Lean
Process Program Planning approach
include exemplary team building and
streamlined communications through
simplified organisational and report-
ing structures. Focus on the “whole”
while not ignoring the detail, has long-
term benefit. The continual improve-
ment and simplification of each step
and process, with incorporation of
improved technologies and informatics,
is virtually unlimited in scope. These
constant changes emphasise the need
for flexibility and adaptability in space
and facility planning and design. Engi-
neering participation very early in the
conceptual programming and planning
stage is a necessity. New approaches in
structural, electrical and mechanical
systems play a significant role in accom-
plishing the ultimate potential of lean
thinking.
Where, in the past, new emerging
concepts and trends-of-the-moment
had fleeting moments of excitement
in the healthcare industry. The Lean
approach, however, shows greater, more
significant opportunity for complete
integration of the broader range of
ideas, encompassing the positive bene-
fits both operationally and related to
capital expenditure.

and design services throughout the world to healthcare systems,

ways to reduce, or even totally elimi- facilities, architects, and consultants. He maintains a leader-
ship role with the AHA/Health Forum, AIA, The Healthcare Facili-
nate inventory is an incredible thought. ties Symposium, Health Care Executives of Southern California,
This creates the necessity of total reli- and the Hospital Association of Southern California. He contin-
ance and trust in persons or outside ues as faculty, as he has been for the past fourteen years, with
California State University Northridge, Graduate Program in Health
organisations, to meet the scheduled Administration as well as UCLA School of Public Health, and USC
needs without fail. Certainly some Graduate Program in Health Administration.
degree of backup is required to consider

84 Asian Hospital & Healthcare Management ISSUE-15 2008


Generative Space
Creating sustainable improvements
The Leading by Design research project is working with 11 case studies in three countries to
operationalise ‘generative space’ as a means to use the environment to make
systemic and sustainable improvements in healthcare.
Wayne Ruga
Founder and President
The CARITAS Project, USA
Annette Ridenour
President, Aesthetics, USA
T
he CARITAS Project was
launched in 1999 by Dr Wayne
Ruga, who had also founded
the annual Symposium on Healthcare
Design and The Center for Health
Design. The purpose of The CARITAS
Project is to pioneer the development
of the next generation of resources to
systemically and sustainably improve
health and healthcare delivery with
design of the environment.
The Leading by Design research
project is the third project that The
CARITAS Project has initiated. Now
on the verge of beginning its fifth year,
Leading by Design is actively working
with 11 individuals in three countries
to demonstrate the tangible benefits
that ‘generative space’ (see definition
below) can offer to improve healthcare
as a whole.
Each one of these 11 Leading by
Design individual participants repre-
sents a different set of stakeholders
within the healthcare industry. All the
Leading by Design participants represent
non-competing stakeholder organisa-
tions. They holds a senior-level executive
positions within their respective organi-
sations, and several of these organisations
are large multi national companies.
facilities & o pe r ati o ns management
Research context Practical application
Leading by Design is an applied Leading by Design is a learning
research project that is based on process that supports each participant
an action research methodology in actively exercising ‘health design
with an integral reflexive prac- leadership’. It is through this exer-
tice. It uses a case study format and cise that participants develop
conventional qualitative research increasing mastery at cultivating
methods to produce its evidence. ‘generative space’.
he methods include: personal The purpose of the 22 themes in
interviews diary writing and focus the learning process is to enable deep
group meetings. personal learning in the ability to
Leading by Design is based upon cultivate ‘generative space’, which can
original research that was conducted be measured and documented as a
by Dr Ruga as a four-year pilot performance- effectiveness improve-
study, funded by the UK government. ment strategy to make sustained
The second stage of this research, improvements in health and healthcare
currently in progress, involves the with design of the environment.
on going field-testing of these The individual participant works
initial findings across a much larger closely with Dr Ruga to learn this
industry-wide stakeholder group and process and then applies it to the
geographical area. contextual situations that are unique
‘Generative Space’­ - A working definition
‘Generative space’ is a place—both physical and social—where the experience of the
participants fulfills not only the functional requirements but also materially improves the health,
healthcare and / or quality of life for those participating in that experience in a manner that they
can each articulate it in their own terms.
Additionally, and by its very nature, a ‘generative space’ is a place that progressively and tangibly
improves over time.
The purpose of cultivating ‘generative space’ is to improve performance effectiveness. Depending
upon the interests of the particular individual, the organisation, or the community—the
measurements of effectiveness will vary. However, in all cases, whatever these measures
are—they will be used to encourage, support and reinforce increasing performance effectiveness
in health, healthcare, and / or quality of life.
The goal of understanding how to cultivate ‘generative space’ is to be able to produce it
consistently, reliably and predictably across the full range of life’s contextual situations including:
1. Our personal lives
2. Our professional and organisational work and
3. The vast spectrum of our community engagements
w w w . a s i a n h h m . c o m 85
facilities & o pe r ati o ns management

to his / her own respective situation.
This practical personal approach, linked
with the action research methodol-
ogy and the reflexive practice, provides
the real-world opportunity for the
participants to practice the cultivation of
‘generative space’ in situations that
can make sustainable improvements in
health and healthcare.
Case Study: Annette Ridenour,
President, Aesthetics
At Aesthetics, Inc., the company
I founded in 1980, our 35-person
interdisciplinary team leads interior
architectural design programmes,
creates way finding systems, assists
with regional arts programmes, co-
designs healing gardens, and provides
a number of other arts-related services
to healthcare institutions.
I attended the first CARITAS
Leadership Summit, convened by
Dr Wayne Ruga, I arrived with many
questions and left with even more. What
makes a healing environment? What is
required to permit us to work harmo-
niously and with genuine collaboration
across design disciplines and through-
out the construction process? What
will sustain a positive, healing vision for
healthcare design in general and for my
company in particular? The answers to
those and many other questions lay in
Dr Ruga’s profound concept of genera-
tive space, I was sure. In 2003, I agreed
to join Leading by Design and to make
my life and practice an action-learn-
ing research project on how to create
generative space.
I decided that if I was going to help
others create generative space, I ought
to start in my own backyard. I carried
out a survey in my company, Aesthetics
As a result, we are now a much
more aligned staff, focussing on learn-
ing how to deliver generative space to
our clients. We have made exciting
progress on several major projects, one
of which, at the Atlantic City campus of
AtlantiCare Regional Medical Center,
I will briefly describe here.
AtlantiCare’s hundred-year-old
campus was tired and in need of an
upgrade. The administration wanted the
best of evidence-based patient-centric
care, it wanted a technologically sophis-
ticated medical centre, and it wanted
to reinvigorate its relationship with the
diverse community around it.
Asked to be involved from the
beginning, we began our work of culti-
vating generative space throughout the
institution by our guiding collaborative
visioning sessions to capture everyone’s
aspirations. To keep those aspirations
as focal points of the redesign work, a
Partnership Agreement was created,
expressing not only the key goals but
also a set of communication guidelines
to honour a commitment to hear and
respect all members of the team.
We helped institute a process
through which community members,
using guidelines jointly created with
AtlantiCare staff, selected and acquired
all of the more than 500 original works
by local artists that are displayed at
the facility. A 400-foot display was
installed to communicate the organisa-
tion’s values, which also were reflected
in the wayfinding design and in the
building and pavilion names: Harmony,
Wayne Ruga founded The CARITAS Project in 1999 for the purpose
of ‘pioneering the next generation of resources to improve health
and healthcare with design of the environment’. He is a US regis-
A uthor
Heritage, Wellness, Friendship and
Community.
A particular example of how an
open-minded administration used
design to engage with the commu-
nity in a generative and sustainably
lasting way occurred when leaders
from all the area’s faith communi-
ties were invited to oversee the design
of the medical center’s chapel. The
physical outcome of that involvement
is a beautiful, functional chapel design
that serves all religions with respect.
The larger outcomes for AtlantiCare
have included a greater understand-
ing of faith-based perspectives on
healing and a deeper relationship with
an influential group of community
leaders to whom AtlantiCare can turn
for advice on a wide range of topics.
Conclusion
Sustainability only occurs when you
bring along people who have similar
philosophies, train them, provide them
with resources, and trust them to do the
right thing—that is, when you empower
them. This requires balancing feelings of
vulnerability with the enormous value
that comes from growing people and
giving away power responsibly.
Leading by Design is a bold experi-
ment. Now, almost eight years into
its development, it is beginning to
provide documentation of sustained
improvements that reflect the robust
character of the 22 thematic
findings that are embedded in its
unique learning process.

tered architect and a Loeb Fellow at Harvard University.

and was surprised to note that my staff
were not nearly as satisfied as I thought
they would be. With guidance from
Dr Ruga, I turned over the resolution
of many of the issues raised by staff
to a task force led by an executive
who was very vocal about the
incongruence at Aesthetics.
Annette Ridenou is founder and president of Aesthetics, Inc., a
multidisciplinary design firm creating healing environments since
1980. Annette is an internationally recognised specialist in interior
design, wayfinding, arts and music for healthcare, and is a highly
sought after consultant and lecturer. She is currently authoring
books on wayfinding and evidence-based arts programs.

86 Asian Hospital & Healthcare Management ISSUE-15 2008


Digital Ward
Hospital of the future
Imagine a future where hospital wards have no paper case notes or files. Information on a
Patient’s medical condition is automatically captured via intelligent context-aware devices
and sent directly to the central computer systems.
Noah Tay Chin Seng
Manager
Fong Choon Khin
Group Chief Technology Officer
Grace Ng Yi Lin
IT Specialist
Yvonne Eng
Systems Specialist, InfoTech department
Singapore Health Services Pte Ltd
(SingHealth), Singapore
"The Digital Ward project was
initiated by Singapore Health Serv-
ices (SingHealth), Singapore’s largest
public healthcare group, with the objec-
tive of transforming the way healthcare
professionals capture and access clinical
information."
T
he Digital Ward project team
is made up of IT profession-
als from SingHealth’s iTAG
(Innovative Technology Application
Group). The project team works closely
with users such as clinicians, nurses
and operations colleagues of various
SingHealth institutions, to innovate
and develop systems that bring value to
the patients and improve operational
efficiency in the institutions such as:
• Creating a paper-less environment
• Reducing disruptions to patients'
rest
• Reducing time incurred in menial
tasks
• Enhancing the efficiency in the
control of infectious disease
• Improving the response time to
patient’s vital signs and abnormali-
ties
• Providing online assessment of
patient’s medical conditions
• Reducing errors in documentation
Digital ward innovations
The various wireless technologies and
devices being implemented in the
digital ward are:
Computer on Wheels (COWs)
COWs are WiFi-enabled notebooks on
ergonomically designed mobile trol-
leys, which enable clinicians to access
patients’ medical records and digital
radiology images as well as docu-
ment patients’ progress electronically
anywhere, any time in the ward.
Mobile Electronic X-Ray Computing (MERC)
MERC is a motorised WiFi-enabled
system with dual, triple or quadruple
panel display screens, which enable
patients’ electronic medical records and
digital radiology images to be displayed
across different screens. Clinicians can
access these records and images wire-
lessly at the patients’ bedside to explain
various therapies and clinical options
to them. This innovation serves to
enrich the face-to-face communication
not only with patients, but also with
their family members.
VEGA
The integrated wireless VEGA system
enables remote automated monitoring
of patients’ vital signs, such as blood
I nf o r mati o n techn o l o g y
pressure, pulse rate, electrocardio-
gram (ECG), pulse oximetry (SPO2),
temperature and respiration rate. The
system also provides proximity contact
tracing and location tracking.
The patients’ vital signs are captured
automatically via customised monitor-
ing devices (using WiFi and Active
RFID technologies) and clinicians
can view the vital signs charts online.
This reduces potential human errors
and enhances patient safety. With this
system, nurses also spend less time on
tedious menial tasks, enabling them to
devote more time in delivering qual-
ity patient care. In addition, patients
can have an undisturbed rest without
having their vital signs taken manually
by the nurses.
To enable proximity contact
tracing, specially designed wearable
tags (using both WiFi and Active RFID
technologies) are issued to the patients
and hospital staff in the ward for the
purpose of automatically and wire-
lessly recording and tracking people
with whom they have come into
contact within the ward. The contact
data captured in the tag is then auto-
matically and periodically uploaded
into the server using industry standard
WiFi access points. Hospital staff can
search, view and print records of the
contact tracing details online.
This system is especially useful in
handling infectious disease outbreaks
such as SARS and Bird Flu. It helps
to ring-fence the spread of contagious
w w w . a s i a n h h m . c o m 87
I nf o r mati o n techn o l o g y

diseases. In addition, it also has the
ability to effectively track staff and
patients’ location within the ward.
Patient Bedside Terminal (PBT)
PBT is a touch screen integrated
information system that provides
both the clinicians and patients an
efficient and convenient means to
access information within the hospital
and globally.
With PBT, clinicians can retrieve
and display patients’ medical records
and digital radiology images, as well
as discuss their medical conditions at
patients’ bedside. Through the termi-
nals, patients can speak to the nurses
on duty using a video nurse-call func-
tion, while nurses can order meals for
patients electronically instead of order-
ing manually. In addition, patients can
also access a wide variety of entertain-
ment and Internet services.
Qualitative results
COWs
•On the spot and
more eligible
documentation of
patient’s condition
Patient Safety
Mobile Clinical Assistant (MCA)
MCA is a specially designed highly
portable healthcare tablet PC, equipped
with an integrated camera for visual
clinical documentation. The built-in
barcode / RFID reader is used to verify
the patient’s identification. MCA is also
WiFi-enabled, empowering the clini-
cians with secured “anywhere, any time”
access to the hospital’s EMR systems
and other clinical information systems.
Through the integrated Bluetooth wire-
less technology, it can interface with
other medical devices (e.g. vital signs
monitors) to obtain patient data from
existing medical devices and directly
transmit captured patient data into
hospital’s clinical applications in real
time.
Such a mobile point-of-care solu-
tion helps in improving the qual-
ity of patient care and enhancing the
MERCs VEGA PBT
• On the spot and • Detection of abnormalities • Minimises loss of
more eligible within a few minutes instead critical information due
documentation of of hourly or 4 hourly reports to misplaced paper
patient’s condition records
productivity by enabling clinicians to
quickly retrieve and document patients’
information. This is especially critical in
a fast-paced environment like a hospital’s
Accident & Emergency Department.
Smart card
With the use of smart card technol-
ogy, hospital staff carries only one card
for multiple purposes. Besides door
access control, the same smart card can
be used for tracking of attendance at
staff events or trainings. Its “tap-and-
track” method makes the whole proc-
ess faster and easier. Staff immunisation
records can also be tracked by the same
smart card.
Future applications can be built
into the smart card to automate
processes and to continuously improve
the physical security, patient serv-
ices and operational efficiency of the
hospital.
Smart card MCA
• Manpower can be re- • Minimises loss of
deployed to perform Ward critical information due
Patrol & anti-crime rounds to misplaced paper
records

• Minimises loss of • Minimises loss of • Minimises contact during • On the spot and more • Enhanced patients and staff • On the spot and more
critical information critical information infectious disease outbreak eligible documentation safety. Only authorised eligible documentation
due to misplaced due to misplaced of patient’s condition personnel are allowed entry of patient’s condition
paper records X-ray films
• Continuous and automatic • Accessibility can be
recording of people-to-people restricted and controlled
contact information easily to staff and patients
• Reduces human error with real
time automatic update of data

COWs MERCs VEGA PBT Smart card MCA

• Immediate access • Immediate access • Less time spent on menial • Immediate access • Reduction in the use of pen • Immediate access
to critical patient to critical patient tasks, more time can be spent to critical patient and paper during registration to critical patient
Operational Efficiency

information information on delivering patient care information of event information

• Facilitates discussions
during ward rounds
• Reduced usage of
paper
• Facilitates • Facilitates • Avoid duplication of work • Facilitates discussions
discussions during discussions during during ward rounds
ward rounds ward rounds
• Reduced usage of • Reduced usage of • Fast and easy attendance • Reduced usage of
paper paper report generation paper
• Tool to track staff movement
and contact tracing purposes

COWs MERCs VEGA PBT Smart card MCA

Patient Services

• Improves patient- • Improves • Minimal disruption • Improves patient’s hospital stay with a • Enhanced operation and •Improves patient-
doctor discussions patient-doctor to patients’ rest variety of entertainment services safety efficiency doctor discussions
discussions
• Improves patient-doctor discussions

88 Asian Hospital & Healthcare Management ISSUE-15 2008

 I nf o r mati o n techn o l o g y

Quantitative results
COWs MERCs VEGA PBT Samrt card MCA
• Saves 10 minutes • Saves 10 minutes On average: • Saves 10 minutes • Saves about 30 per cent of • Saves 10 minutes
Time Savings (per ward)

of nurses’ time of nurses’ time • Wireless vital signs monitoring saves of nurses’ time time spent to administer & of nurses’ time
nurses time by 4 minutes per patient manage the staff cards
• Concurrent viewing • Concurrent viewing • Online location tracking saves 81 • Concurrent viewing • Saves about 1.5 hours to lock • Concurrent viewing
of patient’s record of patient’s record per cent of the time taken to track of patient’s record / unlock & checking of doors of patient’s record
manually
• Contact tracing saves 2 to 10 minutes • Saves about 4 hours for 2 staff
per nurse per shift of nurses time in register staff attendance for
events / trainings

Case study results confidential medical and financial makes continuous and concerted
Since the implementation of this Digital information efforts to work closely with the hospi-
Ward project in 2004, the team has d. Abide to policy and regulatory issues tal staff and patients in activities such
been gathering results on how the inno- in the organisation as data verification checks, surveys on
vations benefit both staff and patients. the systems, as well as to ensure that
The quantitative and qualitative results Summary the systems are functioning effectively.
are summarised in the tables below. Research has shown that the inno- Hospital staff are also trained to use the
vative use of IT not only results in a new systems and periodically briefed
Lessons learnt more efficient and effective operational on the benefits of the new changes to
The team has learnt many valuable workflow in hospitals, but also brings motivate them to adopt the changes.
lessons and acquired good experiences about enhanced personalised patient Creating such an innova-
in the process of implementing the care. tion culture is an important step
Digital Ward project. It has enabled SingHealth is one such organisation in SingHealth’s journey towards
the team to better manage subsequent that paves the way by introducing vari- embracing innovation as a strategic
projects. The lessons are categorised ous IT innovations in its institutions. priority and bringing the Digital Ward
into two main groups, the stakehold- The innovation team at SingHealth into fruition.
ers and the processes.
For stakeholders
a. Perform routine checks to ensure
that hospital staff adheres to the Noah Tay Chin Seng More than 20 years’ of working experience in
the information technology industry. He is currently a Manager with
new workflow SingHealth InfoTech department. As a team member from iTAG (In-
b. Provide sufficient staff training on novative Technology Application Group) which is part of InfoTech,
the usage of the new system he works with Clinicians, nurses and other collaborators in exploit-
ing IT innovations to reap benefits in Healthcare services.
c. Secure clinicians’ and patients’ buy-
in to ensure success of the project Fong Choon Khin is currently Group Chief Technology Officer of Sin-
d. Motivate the staff in adopting and gapore Health Services Pte Ltd (SingHealth). In this leadership role,
incubating innovations; ensure he is responsible for the SingHealth IT Vision. He also oversees the
Corporate Office Emergency Preparedness Committee, Business
A uthor

employee commitment Continuity Planning and the Information Security Office. Choon
e. Provide strong leadership in manag- Khin has more than 27 years experience in the IT industry.
ing and supporting the project
f. Solicit funding from the main Grace Ng Yi Lin is currently an IT Specialist in Singapore Health
Services Pte Ltd. As a team member of SingHealth’s Innovative
stakeholders Technology Application Group (iTAG), she works closely with cli-
For processes nicians, nurses and other collaborators in exploring, identifying,
a. Study, streamline and re-engineer building and implementing new emerging IT solutions to bring an
idea from concept to deployment.
clinical, operational and adminis-
trative processes for optimal returns Yvonne Eng is a Systems Specialist in the InfoTech department of
b. Adopt common data standards for Singapore Health Services Pte Ltd (SingHealth) and has 8 years
a seamless information flow and of experience working in the IT industry. She is part of the Innova-
tive Technology Application Group (ITAG). She has worked on pilot
shared care projects which test the concept and effectiveness of innovative pa-
c. Adopt network security stand- tient-focused solutions.
ards and policies to safeguard

w w w . a s i a n h h m . c o m 89
I nf o r mati o n techn o l o g y
Healthcare IT
Innovations for better care
Innovations will move to areas of consumer empowerment by providing greater access to
services and information including personal health applications populated with data.
Thomas M Eberle
Senior Clinical Architect
Digital Health Group
Intel Corporation, USA
T
he unique aspects of the US
healthcare system result in a
huge underinsured or unin-
sured population with income too high
to qualify for governmental healthcare.
The need to provide even minimal care
to this growing number of uninsured
Americans results in some degree of cost
shifting to those with insurance, further
adding to the cost burden of employers.
Intel Corporation Chairman and
former CEO Craig Barrett is a member
of the United States Health and Human
Services American Health Information
Community and has taken a strong affir-
mative position on the role of employ-
ers in health care reform. “The current
healthcare system is economically
unsustainable and negatively impact-
ing our nation’s ability to compete
globally”, noted Barrett at the eHealth
Initiative’s Health Information Technol-
ogy Summit. “It’s time for a systemic
transformation, and US employers must
lead,” he said.
Barrett at the eHealth Initiative’s
Health Information Technology
Summit went on to describe ways in
which the technological approaches
that companies have adopted to solve
their problems could be adapted to
healthcare. This will require overcoming
barriers to IT adoption and acceptance
90 Asian Hospital & Healthcare Management
of interoperability standards to foster
data exchange. Employers, due to their
purchasing power, should be in the fore-
front of driving system changes.
“Employers and their employ-
ees have the most to gain from creat-
ing a viable healthcare system”, said
Barrett. “Improved healthcare depends
on good information. The employer’s
role is to get this information into the
hands of their employees to make better
healthcare and lifestyle choices.”
Traditional wellness programmes
It is well established that direct links exist
between disease and lifestyle. Tobacco,
alcohol, poor diet and sedentary lifestyle
have documented connection to serious
diseases such as cancer, chronic obstruc-
tive pulmonary disease, diabetes melli-
tus, hypertension and atherosclerosis.
An analysis based on literature review
by Colditz in 1999 estimated the direct
costs of sedentary lifestyle (defined as
absence of leisure time physical activ-
ity) at US$ 2.4 billion or 2.4 per cent of
US health expenditures in 1995 dollars.
They estimated the cost of obesity (BMI
greater than 30) independent of seden-
tary lifestyle at US$ 70 billion. Together,
this comprised an estimated 9.4 per
cent of healthcare expenditure in the
US. When other potentially modifiable
causes are added to the equation, it is
clear that this is a reasonable target for
intervention.
The advent of the Internet and freely
available web-based applications resulted
in an opportunity for employers and
vendors of wellness applications. Not
ISSUE-15 2008
only could these applications provide all
types of wellness information, but also
the capability to interact with an online
tool, gave the employee the opportu-
nity to enter health data and receive a
complete health risk assessment. The
challenge has been getting employees
to use these tools, and once they have
used them, to act on the results. Various
methods have been employed to increase
uptake including direct incentives (cash,
gift cards, etc.). Similarly, employ-
ers have used incentives to modify
employees’ high-risk behaviour; though
monitoring compliance with smoking
cessation or exercise is more problem-
atic. Though health savings from these
types of programmes can be difficult to
measure and published data is sporadic,
the city of Glendale, Arizona reported
in the early 1990s that its nine-year-old
wellness programme was saving US$ 10
for every dollar spent.
Consumer-centric health and PHRs
The logical extension to the wellness
application is the concept of a Personal
Health Record (PHR). Although there is
as yet no uniformly accepted definition
of what constitutes a PHR, it is gener-
ally agreed that it contains an electronic
record of an individual’s health informa-
tion. In this context, we will consider
the PHR as a portable, life-long record
with data from a variety of sources
that remains under the control of the
consumer. The availability of personal
data allows the application to offer
health data to the consumer tailored to
his / her particular needs.

One of the major issues with PHRs
has been consumer adoption. Many
entrants in the industry have provided
applications that are totally or mainly
dependent on the consumer to enter
his / her own health data. The dynamic
nature of health data, not to mention the
arcane terminology, makes this difficult
and limits acceptance. Recently, a coali-
tion of large employers including Intel,
Wal-Mart, Pitney Bowes, AT&T, sanofi
aventis, Applied Materials, BP America
and Cardinal Health have created a
not-for-profit organisation to fund and
foster the development of a personal
health infrastructure called Dossia. This
is being developed with the assistance of
the Boston Childrens Hospital Infor-
matics Program based on their Indivo
architecture. The goal of this effort is to
create a system that will allow users who
opt in to have their health data
auto-populated to their records
from a variety of sources. These
sources will initially be insur-
ance claims databases, but it is
hoped that ultimately this data
will be superseded by actual
clinical data derived from elec-
tronic medical record systems.
Sitting atop this infrastructure
will be an ecosystem of personal health
applications that the consumer chooses
to organise, track, and display the data to
meet her particular needs, whether they
be wellness, disease management, health
finance, caretaker support or others.
Contentious issues
Ultimately, a system of this type if fully
realised could give consumers and their
care providers a common set of data
on which to collaborate. The benefits
include reduction in errors, elimination
of duplicate services, and more efficient
delivery of care utilising new paradigms
of partnership. While these goals are
doubtless worthwhile, there are many
barriers that remain to be resolved.
1. Privacy and security: Both
physicians and consumers are highly
concerned about security and privacy
of medical data. Any employer-initiated
efforts will need to assure users that there
is an arms-length relationship to the
personal health repository and that there
is no chance of this data being used to
affect employment status or insurability.
A myriad of state and federal laws need
to be considered in dealing with special
categories of data (e.g. mental health,
chemical dependency) and users (e.g.
adolescents).
2. Data availability: As of 2005,
according to a survey by the National
Ambulatory Medical Care Survey, only
a quarter of the US physicians were fully
or partially utilising an electronic medi-
cal record, and though the numbers
are steadily increasing, much medical
data is still inaccessible electronically.
Even when EMRs are used, they often
lack interoperability with other systems,
The advent of the Internet and freely
available web-based applications
resulted in an opportunity for employers
and vendors of wellness applications.
making smooth data exchange a prob-
lem. For this reason, many efforts in the
PHR area are utilising data from payer
claims databases and pharmacy benefit
managers.
3. Consumer acceptance: Adop-
tion of PHRs has been consistently low.
There are many factors that include lack
of understanding, need to self-populate
and maintain data, and lack of trust.
It is documented, however, that when
the concept is explained to consumers,
many indicate an interest in these types
A uthor
Thomas M Eberle has worked on a number of IT projects, with a
concentration on the area of database technologies. Since late
2005 he has been working in the Digital Health Group as a clinical
architect on the Personal Health Records team.
I nf o r mati o n techn o l o g y
of applications. According to consumer
research by the Markle Foundation
as part of the Connecting for Health
project, adoption is likely to be highest
among those with chronic conditions,
younger consumers comfortable with
the internet, and those who act as care-
takers for others.
4. Provider acceptance: For PHRs to
be truly meaningful to consumers, they
will need to become tools for interaction
and partnership with their care provid-
ers. For this reason, clinicians will need
to be engaged early and actively in the
discussion. Data sharing with patients
needs to be seen as mutually benefi-
cial and not a hindrance to work flow.
Furthermore, physicians who are often
distrustful of data, where the source is
not clear, must have a level of assurance
that the PHR will differentiate the data
that is patient-sourced from the
data that comes from within the
healthcare system.
Conclusion
Employers are increasingly
engaging in discussions of ways
to lower healthcare costs. Tradi-
tional wellness solutions are
evolving to include new appli-
cations that will give employees access
to more of their personal health data
and will provide tools to help them
act positively on this data. Informed
and engaged consumers, in partnership
with their care providers, can reduce
costs by improving high-risk behav-
iours, reducing errors and eliminating
redundancy. Barriers exist, but broad
consumer acceptance has the chance of
driving change that will benefit not only
employees and their employers but also
society as a whole.
w w w . a s i a n h h m . c o m 91
I nf o r mati o n techn o l o g y

Medical Banking
A new stakeholder

Healthcare Data Medical Bank Banks

Infomediary

As the management of healthcare data progressively moves to an electronic platform,

banks are realising that their technical systems, privacy and security frameworks, identity
management engines and marketing channels can be leveraged to fast forward e-Health.

F
or many years, banks have been
considered as “money changers”
that apply their trade in between
the healthcare stakeholders. The emer-
gence of privacy and security mandates
like Health Insurance Portability and
Accountability Act (HIPAA), coupled
with the growth of account-based health
plans, increasingly managed by banks,
is challenging this paradigm. Banks are
starting to throw off the mantle of back-
room payment processing agent to take
on a more active role in health data
management. This area, called “medical
banking”, may be defined as the latent
integration of banking technology, infra-
structure and credit with healthcare
administrative operations.
In healthcare, major banks are
rescoping their role from offering
funds management to becoming a
value-added data hub in between stake-
holders—a bank infomediary. This is
evolving in four key areas (See Table 1).
Administrative Processing
Using high efficiency, real time tools for
health data management.
Medical Internet
Creating the technical connective tissue for
securing, distributing and in some cases,
holding health data that is accessible only
by the customer (not even the banking staff)
and those authorised by the customer.
Health Information Broker
As consumers purchase account-based
health plans like Health Savings Accounts
(HSAs), portal solutions are expanding to
include medical research and thus the bank
is serving up health information to help
consumers make better decisions.
Community Care Platform
Creation of a robust platform to better
manage patient eligibility and collection of
funds, including charity and / or philanthropic
services.
Table 1
John Casillas
Founder
The Medical Banking Project, USA
Systemic impact of privacy
regulations
The banking industry’s response to
a global matrix of privacy and secu-
rity regulations has resulted in the
creation of cross-industry, feature-
rich, data processing platforms. Global
compliance morph has led to increas-
ing layers of security within this
platform like multi-factor authen-
tication. Bankers, ever risk-averse,
aren’t readily willing to engage new
services. Yet, even the most conserva-
tive among them will admit that the
twin impact of privacy regulations and
consumer-driven healthcare has levied
a broad impact on traditional banking.
These drivers have opened new doors
for bank and non-bank competitors,

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 I nf o r mati o n techn o l o g y

dynamic leads to a second axiom in

A medical Internet medical banking: Banks will increas-
ingly invest in healthcare IT, lead-
Another build-out of the bank infomediary is distribution of health ing to broader adoption of electronic
records to requesting online banking customers. The online banking healthcare services as banks exercise
channel is becoming increasingly securitised as banks respond to global economy of scale.
threats to a person’s online identity. Banks are locked into an identity theft As banks use their power to distrib-
arms race unparalleled by any other industry segment. ute new services, the services them-
A global consumer poll by Unisys found that banks are the most trusted selves are transforming both in terms
entity worldwide to manage digital identity. As the number of households of tighter integration with claims
using online banking is increasing, the use of this secure gateway into the processes and cost point. This will
home for eHealth is becoming a credible option. Not only can these portals tend to increase the number of physi-
present sensitive health data, but they can also provide tools that help cians using electronic claim services,
patients keep track of medication regimes, measure the benefits of expedite claims-to-payment and even
losing weight against “healthcare spend” so that there is more money at affect the very structure of health data
retirement. transactions.
The tools will be presented in an identity theft-resistant portal that is In fact, traditional healthcare
continuously and rigorously monitored. Banks understand that losing data groups are already inviting banks to
is tantamount to losing public trust, an essential cornerstone that banks sit on workgroups to learn how to
must have in order to exist. make claims processing work seam-
lessly (i.e., National Council for
Prescription Drug Programs (NCPDP),
forcing traditional banks to defend Thus, the substantive engines that Workgroup for Electronic Data
their payment franchise. Essentially, a banks own for data processing, secu- Interchange (WEDI)).
red carpet has been rolled out for banks rity systems, identity management and A major product innovation today
to enter the highly inefficient adminis- formidable marketing arsenal, are now focusses on using a bank’s computa-
trative domain in healthcare. used to streamline healthcare costs and tional and imaging capability, embed-
As banks wrestle with return on to create demand for new products ded in mail transport systems, to
investment for complying with a and services. Compliancy across indus- proactively secure payments, reconcile
global matrix of data privacy regula- tries and geographies invokes not just payments with bank accounts, catego-
tions, they have had to make hard HIPAA, Gramm Leach Bliley (GLB), rise denial and / or adjustment reason
business decisions about whether to Fair and Accurate Credit Transac- codes and present claim images within
serve or exit the existing market. These tions Act (FACTA) and other US laws a logical, computer-assisted workflow.
facts set the table for the first axiom in but the European Directive on Data Loosely configured services on a bank-
medical banking: as compliance laws Protection and other overseas laws as ing platform are becoming tightly
escalate in the digitisation of health data, well. As a result, banks have developed linked with health data partners to
banks will increasingly specialise their geographically seamless and compliant automate daily patient accounting
portfolio of healthcare services. platforms that can host new eHealth tasks. An example of this is PNC Bank,
An example of this is Bank of tools as a natural product evolution. which used a hybrid revenue platform
New York Mellon (BNY). The bank to help a national provider save US$
is implementing a pilot accredita- A unified platform 4 million in processing costs in 2006.
tion programme developed at the Developing services that link cash Concomitantly, these types of plat-
Medical Banking Project that will give management with claims clearing- forms enable insurers to ramp provid-
it a “Gold Seal” in the area of privacy houses is an area that is in full swing ers onto a digital workflow, reducing
and security. Alongside this effort, BNY today. Major banks have announced processing costs for both parties.
Mellon entered into an alliance with a new healthcare relationships. Tradi-
national claims clearinghouse, SSI Group tional stakeholders are finding highly Rationalising point of service
that provides services to over one third of capitalised banks sitting at the table, interactions
US hospitals. The organisation intends actively participating in legisla- The “hybrid revenue platform” can
to reduce transaction costs in healthcare, tive efforts and making an increas- also streamline front-end processes.
leverage marketing channels and create ing number of health information Imagine going to a kiosk at a retail
new medical banking services. technology acquisitions. This market clinic (Wal-Mart, CVS), typing in

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94 Asian Hospital & Healthcare Management ISSUE-15 2008
 I nf o r mati o n techn o l o g y

your ID just like using an ATM,
and gaining immediate access to
your HSA / HRA records, making
payments (which are automatically
reconciled and posted onto the
provider’s system), pulling down
healthcare records and forwarding
your current demographics, so you
don’t have to fill out those forms over
and over again. Variations of this
type of a product are being tested
in US markets and it’s not hard to
imagine that they will become a
global model, especially as medi-
cal tourism takes flight necessitating
on-demand access to health records
and health accounts.
Health information brokers
More consumers are turning to the
Internet for basic healthcare research.
Coupled with market demand for
digital tools, banks are increasingly
linking to health data sources. As
they do this, banks may team with
well-known brands in the academic
world, pharmaceutical manufacturers
and others. These organisations will
provide high quality, easy to under-
Medical banking holds the poten-
tial of shaping a broader understand-
ing of “human capital”. This area offers
a value-centred view of healthcare as
opposed to focussing on cost alone.
In this line of reasoning, banks will
seek to provide quality health infor-
mation to account holders for their
better lifestyle decision-making. Banks
that follow such rationale will retain
HSA assets and tend to have larger
profits. A report by Booz Allen
suggests that major banks will yield
over US$ 1 billion in net revenues in
part by meeting this key challenge.
Co-ordinating better care
Banks are scoping out a broader
platform to enable robust front end
processing for care providers. This
type of a system will be used to cate-
gorise patients that come into the
emergency room, for instance, into
an action-driven platform that better
co-ordinates care resources in the
community.
John Casillas founded the Medical Banking Project, an industry
A uthor
Sixty per cent or more of the
people treated in high-cost emergency
room settings are non-urgent cases.
The platform will address this issue
and make it easier to exchange data
and funds between stakeholders. For
a major bank that serves millions of
consumers, there is a direct correla-
tion between the health of a commu-
nity and increased deposits, a mainstay
in banking.
Conclusion
As the “health-wealth” equation
evolves, banks will increasingly be
viewed as a partner in quality living,
linking everyday banking to the
decisions we make about our lifestyle
choices. The consumer will drive the
bank infomediary and stretch it in the
ways yet to be discovered. In the mean-
time, banks are investing heavily along
this product pathway, creating increas-
ingly sophisticated processing platforms
that are well-suited to reduce transac-
tion costs in healthcare.

think tank and action group, to facilitate the convergence of bank-

stand information to bank customers. ing and healthcare systems to improve healthcare. Over 60 global
A special feature of this service will corporations, from providers, insurers, banks, IT/consultants and
even entertainment giant Disney are now involved in industry ef-
enable personalisation and automa- forts to create value with a new banking stakeholder. The Project
tion of research, “e-clipping” data that reports out its work every year at an annual Institute (April 1-3,
an online banking consumer may want 2008 in Marietta, GA).
for future reference.

Web Mobile-Based Applications for Description:

Healthcare Management Healthcare organisations are constantly designing effective systems aiming to help
achieve customer satisfaction. Web-based and mobile-based technologies are
two forms of information technologies that healthcare executives are increasingly
Editor(s) : Latif Al-hakim
looking to merge as an opportunity to develop such systems. Web Mobile-Based
BOOK Shelf

Year of Publication: 2007
Pages : 421
Applications for Healthcare Management addresses the difficult task of managing
admissions and waiting lists while ensuring a quick and convincing response to
unanticipated changes of the clinical needs. Web Mobile-Based Applications
for Healthcare Management tackles the limitations of traditional systems, and
takes into consideration the dynamic nature of clinical needs, scarce resources,
alternative strategies, and customer satisfaction in an environment that often
imposes unexpected deviation from planned activities.

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