RS ONKOLOGI SURABAYA

(BOUTIQUE HOSPITAL CONCEPT)

An Alternative Model for Secondary Care
Ario Djatmiko
RS ONKOLOGI SURABAYA
Medicine is the art of dealing with
uncertainty
Moskowitz,1988

quality lies in detail

 USA (SOC of North America, 1994):

Woman, 29 years old complained thickness

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

Opinion Based Decision Making

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

§ High risk management

§ High diagnostic pitfalls
§ Irreversible error
§ The error is always late detected
§ No tool can be used to convince no cancer
Misdiagnosis of breast cancer is the second
most medico legal allegation and the most
expensive overall condition to litigate in US
Kenneth A. Kern.MD.FACS
(SOC of North America 1994)
I Mitra (Tata Memorial Hospital) 1994:
Good bye solo player…..opinion based
decision making is actually personal
prejudice ….it will be extremely dangerous
in cancer world.
 Indonesia (Surabaya, April 1991)
Miss An, 23 years old with advanced
breast cancer (local advanced +
milliar metastase to the lung).
History:
She had been operated 8 months
before.
Surgeon at municipal Hospital
no serious thing, only small benign
tumor without sending the specimen
to a pathologist.
She died 3 months after she came to
our clinic.

Opinion Based Decision Making

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

She got medicine for a month, but there was no improvement,

FNA was repeated with the result was still mastitis. The tumor
was getting bigger and bigger. After 9 months she came to
RSOS. Triple Dx: Malignant.
The patient did not believe it à open biopsy was done: Malignant.
Problem:
The Authority of GP? The reliability of FNA?
11 months delay, late stadium.
FRAGMENTED APPROACH à No System
 Fragmented approach
(Opinion Based Decision Making)

Other doctor
(consultation)

Patient Doctor/ Cytopathologist

Surgeon?
Radiologist

Laboratory

Decision making is decided by the clinician (surgeon)

90% error is in diagnostic procedure
 NEW MIND SET
The “Driven” of Decision Making Category of Delivered Service
OBDM – Opinion Based HARM
Decision Making

EBDM – Evidence-Based GOOD

Decision Making
Increasing Pressure Increasing Quality
 System approach
(Evidence based and Team management)

Medical Team
Patient Facilities
GUIDELINE
Medical Record

Decision making is controlled by Tumor Board

June 2002 45 years old woman, with
multiple lump in both breasts
Mammography: C 3 multiple benign
mass in both breast, no sign of
malignancy.
USG: Ca in the left breast among
Fibroadenomas

Evidence Based Decision Making

(System Approach)
 July 2003
Woman 54 years old has been following
breast screening program for 6 years.
The last Mammogram, no sign of
malignancy BIRADS C3
USG: 1 solid intra-cystic lesion among
other simple cystics peri-areolar Left
Breast.
Open Biopsy:
Intra cystic Papillary Ca 8 mm.
Non palpable BC Detected by USG à
EVIDENCE BASED DECISION MAKING
(SYSTEM APPROACH)
 SYSTEM FRAGMENTED
DECISION MAKING EVIDENCE BASED OPINION BASED
COMMUNICATION Optimal Minimal
COORDINATION + -
GUIDELINE + -
MEDICAL RECORD good poor
EVALUATION + -
FEED BACK + -
SUPERVISE + -
RISK MANAGEMENT + -
RESEARCH + -
INNOVATION + -
QUALITY & PRICE + -
CONTROLED
DELIVERY + -
CONTROLED
 The Uniqueness of Cancer

• Undeterred and urgent

• No tolerance for mistake
•The biggest chance to cure is at the first treatment
• Need multidisciplinary interdisciplinary approach
• Need specific knowledge, skill and technology
• (The most) expensive disease
• Long life evaluation
• Highly needs “human touch”
 BACKGROUND
§ Indonesia is a big country with 230 million
population
§ There are many problems, economic,
geographic, infrastructure, technology gap,
transportation, education etc
§ Cancer treatment in Indonesia is not well
organized à “no access ~ no system”
§ Systematic (quality) assessment is never
been done, standardization?
§ The incidence rate of (breast) cancer is
increasing significantly
§ Cancer is not a health priority program in
Indonesia
 The basic idea of RSOS :
§ Centralization is not the right answer for
health care in Indonesia
§ A big hospital is not always needed for breast
cancer services (thyroid, colon, skin, soft
tissue, cervix etc)
§ Small clinic will be more efficient, economist,
and controllable (quality and finance)
§ Flexible in size and quantity
§ Adaptive in structure and MIS
§ Accessible, practice and easier for patient
 To achieve the highest value of treatment

Efficient Referral System

RS
Dharmais

Tertiary Care

Bekasi Tebet RSOS

Secondary care

Primary Care (GP, Family Physician, Puskesmas)

 Strategy àto set up strong and efficient Referral
System

OPTIMIZING THE ROLE OF EACH LEVEL

Efficient Referral System:

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

Concert ~ Harmony
 TERTIARY HEALTH CARE

§ Teaching Hospital
§ Doing more research and innovation.
§ Top Referral Hospital à for extraordinary diseases - extra big surgery:
liver and bone marrow transplant, pancreatic surgery, etc
§ Trend setter
§ Benchmarking, training and supervising the Secondary HC
§ Leading in technology: high tech and heavy equipment (PET scan,
gamma knife, advance radiology equipment etc)
§ Testing and analyzing (cost benefit analysis) for new technologies
§ Government think tank: to set up public policies
§ Global networking in science and technology
§ Need more super specialist doctors
 Secondary Care (RSOS)
§ Focuses on health services à plays the biggest curative
role in the population
§ An equitable distribution of health services
§ Geographic, cultural and financial accessible
§ Proper Tech à Should not follow technology competition
§ Specialist level à high standard treatment and reliable
§ Selector to higher referral
§ (Epidemiology) research

Strengthening the Secondary HC will be the

answer of curative problems in the population
Effective and efficient
Note:
Secondary Care is the back bone of curative sector in most countries in the world
Klinik Onkologi Surabaya Rumah Sakit Onkologi Surabaya

April1995 – April 2006 April 2006 –

4 beds, 1 operating theatres 28 beds, 3 operating theatres

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

International Scientific Papers : 14

National Scientific Papers : 8
 THE ADVISORY BOARD OF RSOS

Adila Soewarmo Makarim Wibisono

Prof J Oldhoff Dr Peterse

(AZG) (AVL)

Prof Emille Roetgers PhD Prof Dr Hoekstra PhD

(AVL) (AZG)

Dr Marie Rickard Dr Mahdi Rezai

(BSC, Sidney) (Breast Centre Dusseldorf)
Number of RSOS Patients ( 2006 – 2008)

20.000 18.598
18.000
16.000 15.210

14.000
11.571
12.000
new patient
10.000
follow up patient
8.000
6.000 4.215
3.779
4.000 2.748
2.000
-
Year 2006 Year 2007 Year 2008

Trend of patient visitation increases every year:

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

5000
4500
4000
3500
3000 mammo
2500
us g
2000
fna
1500
1000
500
0
2003 2004 2005 2006 2007 2008
 What is a Quality Standard ?
§ What have to be measured ? THE KEY POINT

§ How can we measure it ?

§ Who is the assessor (qualification) ?
§ What is the methodology used ?
§ How can we improve or maintain the quality
of the services ?
The technology, (man,
method, material) must be
validated first, and there
must be regular internal and
external quality control and
quality assurance procedures

Standard quality is dynamic measurement,

which have to be continually evaluated.
RSOS, validity test every 6 months
 Sensitivity & Specificity USG

102 100
100 99.5
100 98.63 99.07
97.9 97.8 96.7
98 97.5
96 94.3 94.6 94.9
93.8
94
93.7 sens itivity
92 92.8 90
89.2 90.5 spesificity
90
88.8
88
86 88

84
82
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
 Sensitivity & Specificity Mammography

120

95.1
100 100 99.2 100
100 89.7 91 91
90.7
99.2
96.36
88 90.4 91.04 83.3
80

sensitivity
60
spesificity

40

20

0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
 Sensitivity & Specificity FNA
(palpable breast tumor)

120

100 100 100 100 100 100 100

80
sensitivity
60
specificity
specifisity
40

20

0
2003 2004 2005 2006 2007 2008
Breast cancer new patients trend in RSOS

400

350 357
331
300
301
250 251
200
201
150

100

50

0
Thn. 2004 Thn. 2005 Thn. 2006 Thn. 2007 Thn. 2008
Age distribution of Breast Cancer at RSOS 2008

17,6%
18,0 16,2% Age group :

16,0 1 = • 20 years old

13,8%
2 = 21 - 25 years
14,0 11,8%
11,8%
3 = 26 - 30 years
12,0
9,7% 9,7% 4 = 31 - 35 years
10,0 7,9%
5 = 36 - 40 years
8,0
6 = 41 - 45 years
6,0
7 = 46 - 50 years
4,0 8 = 51 - 55 years
1,2%
2,0 0,3% 0,0% 9 = 56 - 60 years
0,0 10 = 61 – 65 years
1 2 3 4 5 6 7 8 9 10 11
11 = > 65 years
Stadium distribution Breast Cancer at RSOS, 2008

35.0 31,0%

30.0

25.0

20.0 16,5% 16,4%

13,8%
15.0
10,1%
10.0 6,2%
3,4%
5.0 2,5%

0.0
0 I IIA IIB IIIA IIIB IIIC IV
RESPONSE TIME, 2008:
The measurement of how many visits to obtain definite diagnosis

11%

2nd VISIT
1s t VISIT
3rd VISIT 32% 57%
Number of Surgical Procedures at RSOS ( 2006 - 2008)

828
900
731
800
589
700
600
500
surgery
400
300
200
100
-
Year 2006 Year 2007 Year 2008
2006 – 2008: 584 Breast Cancer Surgery

MR M
BC T
MR M + L D F L AP
MR M + TR A M
13%

12%

3%

72%
Mastectomy & direct reconstruction with
TRAMP Flap
 Mastectomy BCT + LD Flap

Mastectomy + TRAM BCT + LD Flap

 Surgeon performance at RSOS
MRM +
BCT / LD
Performa MRM MRM + TRAM TISSUE
FLAP
Exp
Duration 100 – 120 min 150-180 min 240 - 300 min 120-140 min
Bleeding < 200 cc < 200 cc <300 cc < 200 cc
Length of < 24 hours < 24 hours < 3 x 24 < 24 hours
stay hours
Infection 0 0 0 0
Suture off 10-14 days 10-14 days 14 days 10-14 days
Drain off 10-14 days 7-10 days 7-10 days 10-14 days
CHEMOTHERAPY ACTIVITIES

800
700
600
500
B reas t C anc er
400
300 Non B reas t
C ancer
200
100
0
th 2006 th 2007 th 2008
Boutique is a small company that offers highly
specialized services or products

MULTI DISCIPLANARY APPROACH WHICH FOCUS ON

High Quality
Efficiency
Specific touch
 BOUTIQUE HOSPITAL concept
§ Meet the specific (consumer) need
§ Proper Tech
§ Slim organization, more efficient & cost-effective.
§ Optimal communication àTQM automatically and
optimally done
§ Transparent & accountable (moral & ethic) à
certainty
§ Create more personal relationship and personal
touch
§ Continues improvement of skill & knowledge (feed
back) of the medical team
§ Adaptive & flexible in size
§ Simpler management information system
 ONE ROOF CONCEPT
(Carve out Organization)

§ Comprehensive :
All procedures are carried out in one control
system (RSOS) except radiotherapy
§ Multidisciplinary approach :
the team involves since the beginning, “sit
together” to make a decision
§ Integrated care :
The delivery system is based on “patient
focus care”
 Integrated care Pathway
the course of events in the care of patient with a particular condition, within a
set time-scale. To facilitate the introduce of an evidence – based approach
into routine clinical practice and guideline for multidisciplinary work:

SCREENING SCREENING

CANCER (-
(-)

PHYSICAL IMAGING LOCALIZATION PATHOLOGY

SYMPTOM EXAMINATION USG + FNA / VC / PA
PROCEDURE
MAMMOGRAPHY

CANCER +

TREATMENT
Medical Team
Facility
Guideline FOLLOW UP
Medical Record
Zero defect program RSOS
Evidence Based Decision Making

PE RD LAB FNA

COLLECTING
DATA
TUMOR BOARD ~ Internal Auditor
ASSESSMENT
Tuesday and Friday Coffee Morning:
a. Cases discussion.
PLANNING b. Evidence Based Decision Making
FINAL DIAGNOSTIC TRIPPLE DIAGNOSTIC
(Biopsy & Localisasi
Procedure)
TREATMENT (tailoring)

FOLLOW UP
Keterangan:
PE : Phisycal examination
RD : Radiodiagnostik
FNA : Fine needle Aspiration
Localization Procedure: biopsy guided by hook wire

The key of the treatment lies in the accurate diagnose

Tumor Board RSOS:
dr Iskandar, dr Wiwin, dr Heny, dr Lies, dr Sindra, Dr. Ami, dr Ario Djatmiko
 GUIDELINE
Guidelines for the treatment of cancer in clinical practice are intended to give
physician around the world to provide the right care, at the right time, for the right
person, in the right way. Emma Mason

Guidelines ~ decision tree

• To ration treatments
• To ensure all patients are treated
equally
• Clear for the patient
• To be regularly updated
• Clear for the third party payer, cost

St. Gallen, Swiss

 Without vision, people perish

Mission
Why we exist
John F. Kennedy
Values
What we believe in and how we will behave

Vision
What we want to be
The BASIC ELEMENTS
Strategy of a strategic statement:
What our competitive game plan will be
OBJECTIVE = Ends
SCOPE = Domain
ADVANTAGE= Means
Our Value

Hospital is a “Noble business”

Morally & ethically, we have to be on

the patient’s side by:
• enhancing the quality services
• cost containment ~ efficiency
• humanity in services

Best outcome + Best service + lowest cost = Best value

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

QUALITY

RSOS

ACCESSIBLE AFFORDABLE
 Conclusion
§ Strong and efficient referral system is a must
§ New Mind Set: Opinion Based Decision Making à
Evidence Based Decision Making
§ Multidisciplinary approach (Team Work)
§ Boutique Hospital Concept is an alternative model for
Secondary Care

People need us…

we (RSOS) can not do it alone.