and I returned to the medical university

五年前我放了一段給薪假

where I studied.

回到醫學院

I saw real patients and I wore the white coat

我的母校

for the first time in 17 years,

實際看到病人，而且我還穿著白袍

in fact since I became a management consultant.

已經17年沒有這種經驗

There were two things that surprised me

我成為管理顧問以後就停止了

during the month I spent.

在醫學院的那個月

The first one was that the common theme

有兩件事令我訝異

of the discussions we had were hospital budgets

第一件是我們討論的主題

and cost-cutting,

常常圍繞著醫院預算

and the second thing, which really bothered me,

和削減成本

actually, was that several of the colleagues I met,

第二件事真的令我不安

former friends from medical school,

有關我遇到的幾位同儕

who I knew to be some of the smartest,

我讀醫學院時交的朋友

most motivated, engaged and passionate people

我知道他們是我所認識的人中最聰明

I'd ever met,

最積極、最投入

many of them had turned cynical, disengaged,

也最有熱誠的人

or had distanced themselves from hospital management.

但其中許多人變得悲觀、消極

So with this focus on cost-cutting,

或者不願與醫院管理沾上邊

I asked myself, are we forgetting the patient?

所以強調削減成本

Many countries that you represent

我捫心自問：我們是否忽略了病人

and where I come from

很多你們所代表的國家

struggle with the cost of healthcare.

以及我的國家

It's a big part of the national budgets.

都忙於應付保健的成本

And many different reforms aim at holding back this growth.

該成本佔了國家大量的預算

In some countries, we have long waiting times

許多改革專注於控制成本增長

for patients for surgery.

在許多國家，得等上很長一段時間

In other countries, new drugs are not being reimbursed,

病人才能動手術

and therefore don't reach patients.

其他國家，病人須自費買新藥

In several countries, doctors and nurses

因此無法使用新藥

are the targets, to some extent, for the governments.

有些國家的醫生和護士

After all, the costly decisions in health care

或多或少成了政府的標靶

are taken by doctors and nurses.

畢竟保健的重大花費

You choose an expensive lab test,

掌握在醫生和護士的手中

you choose to operate on an old and frail patient.

他們選擇昂貴的檢測

So, by limiting the degrees of freedom of physicians,

他們選擇為體弱的老人動手術

this is a way to hold costs down.

因此，限制醫生選擇的自由

And ultimately, some physicians will say today

是壓低成本的一種方式

that they don't have the full liberty

終於有些醫生如今表示

to make the choices they think are right for their patients.

他們不能完全自由地

So no wonder that some of my old colleagues

替病人的福利把關

are frustrated.

難怪我的一些舊同僚會感到挫敗

At BCG, we looked at this,

難怪我的一些舊同僚會感到挫敗

and we asked ourselves,

我們在BCG（波士頓顧問公司）探討了該現象

this can't be the right way of managing healthcare.

我們捫心自問

And so we took a step back and we said,

這種保健管理是行不通的

"What is it that we are trying to achieve?"

所以我們退一步思考

Ultimately, in the healthcare system,

那我們的目標是什麼

we're aiming at improving health for the patients,

保健體系終究是

and we need to do so at a limited,

為了改善病人的健康

or affordable, cost.

並且在此目標下還須節制成本

We call this value-based healthcare.

至少要能夠負擔得起

On the screen behind me, you see what we mean

我們稱之為「價值為主的保健」

by value:

螢幕上是我們所定義的價值

outcomes that matter to patients

螢幕上是我們所定義的價值

relative to the money we spend.

病人關心的成效

This was described beautifully in a book in 2006

相對於花費

by Michael Porter and Elizabeth Teisberg.

2006年一本書對此有極佳的描述

On this picture, you have my father-in-law

作者是波特與泰斯伯格 （Michael Porter and Elizabeth Teisberg）

surrounded by his three beautiful daughters.

這張照片是我的岳父

When we started doing our research at BCG,

和圍繞他的三個女兒

we decided not to look so much at the costs,

我們在BCG開始研究時

but to look at the quality instead,

決定不要著重於成本

and in the research, one of the things

而是要重視品質

that fascinated us was the variation we saw.

研究當中有一件事讓我們相當感興趣

You compare hospitals in a country,

那就是各家醫院素質的參差不齊

you'll find some that are extremely good,

比較同一國家的醫院

but you'll find a large number that are vastly much worse.

會發現有部分表現極佳

The differences were dramatic.

但還是有很大一部份的醫院素質差許多

Erik, my father-in-law,

優劣之間的差距驚人

he suffers from prostate cancer,

我的岳父艾瑞克

and he probably needs surgery.

罹患了攝護腺癌

Now living in Europe, he can choose to go to Germany

可能需要動手術

that has a well-reputed healthcare system.

他現居歐洲，可以選擇去德國就醫

If he goes there and goes to the average hospital,

德國的保健體系聲譽卓著

he will have the risk of becoming incontinent

他如果去德國一家普通的醫院

by about 50 percent,

手術後尿失禁的風險

so he would have to start wearing diapers again.

大約是百分之五十的可能性

You flip a coin. Fifty percent risk. That's quite a lot.

不幸的話，他就必須再度穿尿褲

If he instead would go to Hamburg,

一半的風險，等於擲硬幣，機率相當大

and to a clinic called the Martini-Klinik,

如果他去德國漢堡就醫

the risk would be only one in 20.

去當地的馬丁尼診所（Martini-Klinik）

Either you a flip a coin,

風險只有二十分之一

or you have a one in 20 risk.

看你是要擲硬幣

That's a huge difference, a seven-fold difference.

還是要冒那二十分之一的風險

When we look at many hospitals

二者差距之大，是十倍之差

for many different diseases,

我們檢視了許多醫院

we see these huge differences.

觀察許多不同疾病

But you and I don't know. We don't have the data.

我們看到這種極大的差異

And often, the data actually doesn't exist.

但是一般人不會知道 因為我們沒有這些資料

Nobody knows.

而且通常這種資料並不存在

So going the hospital is a lottery.

沒人知道差別

Now, it doesn't have to be that way. There is hope.

所以去醫院等於是抽籤

In the late '70s, there were a group

我們不見得命該如此 還是有希望的

of Swedish orthopedic surgeons

在1970年代晚期 有一群瑞典骨科醫生

who met at their annual meeting,

在1970年代晚期 有一群瑞典骨科醫生

and they were discussing the different procedures

在醫學年會上相遇

they used to operate hip surgery.

會中他們探討應用在 髖關節手術的種種不同程序

To the left of this slide, you see a variety

會中他們探討應用在 髖關節手術的種種不同程序

of metal pieces, artificial hips that you would use

圖左有多種

for somebody who needs a new hip.

金屬物件，那是人工髖關節

They all realized they had their individual way of operating.

用於需要置換髖關節的人

They all argued that, "My technique is the best,"

醫生們都知道各自的程序不同

but none of them actually knew, and they admitted that.

他們都聲稱「我的技術最好」

So they said, "We probably need to measure quality

但他們也承認沒人能確定

so we know and can learn from what's best."

所以他們表示，我們可能需要衡量品質

So they in fact spent two years debating,

這樣才能向最佳醫生學習

"So what is quality in hip surgery?"

於是他們花了兩年時間辯論

"Oh, we should measure this." "No, we should measure that."

髖關節手術品質的評估標準是什麼

And they finally agreed.

噢，該測量這個 不，該測量那個

And once they had agreed, they started measuring,

他們最後達成協議

and started sharing the data.

一旦大家同意，他們開始測量

Very quickly, they found that if you put cement

並且開始分享數據

in the bone of the patient

他們很快發現，如果先把膠結材料

before you put the metal shaft in,

填入病人的骨頭

it actually lasted a lot longer,

然後再置入金屬關節

and most patients would never have to be

其實會大大提高耐用度

re-operated on in their lifetime.

大多數病人不再需要

They published the data,

日後重做手術

and it actually transformed clinical practice in the country.

他們發表了結果

Everybody saw this makes a lot of sense.

並且改變了全國的手術程序

Since then, they publish every year.

大家都認為這很明智

Once a year, they publish the league table:

從此以後，他們每年發表

who's best, who's at the bottom?

每年公佈一次成績單

And they visit each other to try to learn,

誰領先，誰殿後

so a continuous cycle of improvement.

他們互相參訪學習

For many years, Swedish hip surgeons

不斷地循環改進

had the best results in the world,

有很多年，瑞典的髖關節醫生

at least for those who actually were measuring,

手術的結果全世界最佳

and many were not.

至少參與測量的醫生如此

Now I found this principle really exciting.

很多醫生並未參與

So the physicians get together,

我認為這個原則真的令人興奮

they agree on what quality is,

醫生聚集起來

they start measuring, they share the data,

訂出一個品質的標準

they find who's best, and they learn from it.

開始測量，並分享數據

Continuous improvement.

找出最佳醫生，然後向其學習

Now, that's not the only exciting part.

不斷改進

That's exciting in itself.

這不是唯一值得興奮的部分

But if you bring back the cost side of the equation,

雖然已經很令人興奮了

and look at that,

但是如果再把成本

it turns out, those who have focused on quality,

加入考量

they actually also have the lowest costs,

我們發現注重品質的醫生

although that's not been the purpose in the first place.

其醫療成本也最低

So if you look at the hip surgery story again,

雖然成本一開始不是考量

there was a study done a couple years ago

我們再以髖關節手術為例

where they compared the U.S. and Sweden.

幾年前有研究

They looked at how many patients have needed

比較美國和瑞典

to be re-operated on seven years after the first surgery.

檢視有多少病人需要

In the United States, the number was three times

在首次手術七年後再動手術

higher than in Sweden.

美國的數目

So many unnecessary surgeries,

是瑞典的三倍

and so much unnecessary suffering

太多可以避免的手術

for all the patients who were operated on

太多可以避免的痛苦

in that seven year period.

必需再動手術的病人

Now, you can imagine how much savings

在七年間可避免的痛苦

there would be for society.

想想看，避免重做手術

We did a study where we looked at OECD data.

將替社會省下多少錢

OECD does, every so often,

我們研究OECD的資料 （OECD為經濟合作開發組織之簡稱 ）

look at quality of care

OECD經常檢視保健的品質

where they can find the data across the member countries.

OECD經常檢視保健的品質

The United States has, for many diseases,

只要他們能獲取成員國的資料

actually a quality which is below the average

在美國，許多疾病

in OECD.

其實醫療品質

Now, if the American healthcare system

低於OECD的平均值

would focus a lot more on measuring quality,

如果美國的保健體系

and raise quality just to the level of average OECD,

能夠更加著重於衡量品質

it would save the American people

並把品質提高至OECD的平均水準

500 billion U.S. dollars a year.

將替美國人

That's 20 percent of the budget,

每年省5000億美元

of the healthcare budget of the country.

那是預算的兩成

Now you may say that these numbers

全國保健的預算

are fantastic, and it's all logical,

你可能會說，這些數字

but is it possible?

太棒了，而且言之成理

This would be a paradigm shift in healthcare,

但實際可行嗎

and I would argue that not only can it be done,

保健需要典範轉移

but it has to be done.

我主張不但做得到

The agents of change are the doctors and nurses

而且必須做到

in the healthcare system.

改革的推手是醫生和護士

In my practice as a consultant,

他們身處保健體系

I meet probably a hundred or more than a hundred

我以顧問的身份

doctors and nurses and other hospital

每年大概會遇到上百位

or healthcare staff every year.

醫生和護士，以及其他

The one thing they have in common is

醫院職員或保健工作人員

they really care about what they achieve

這些人的共同點是

in terms of quality for their patients.

他們非常在意自己的成就

Physicians are, like most of you in the audience,

治病品質方面的成就

very competitive.

醫生，就像大多數在場者

They were always best in class.

非常好勝

We were always best in class.

他們總是名列前茅

And if somebody can show them that the result

我們總是名列前茅

they perform for their patients

如果有人能證實

is no better than what others do,

他們治病的成效

they will do whatever it takes to improve.

沒比別人好

But most of them don't know.

他們會竭盡所能去改進

But physicians have another characteristic.

但多數不知道互相的成績

They actually thrive from peer recognition.

但是醫生還有一個特性

If a cardiologist calls another cardiologist

同儕的認可會讓他們進步

in a competing hospital

如果心臟病科醫生打電話給

and discusses why that other hospital

另一家競爭醫院的同行

has so much better results, they will share.

討論對方的醫院為什麼

They will share the information on how to improve.

成效好那麼多，他們會分享

So it is, by measuring and creating transparency,

他們會分享如何改善的資訊

you get a cycle of continuous improvement,

所以藉由衡量品質與公開資訊

which is what this slide shows.

就能夠促使改進不斷地循環發生

Now, you may say this is a nice idea,

就是這個圖顯示的

but this isn't only an idea.

或許你會說這是好主意

This is happening in reality.

但這不只一個主意

We're creating a global community,

這個主意正在實現

and a large global community,

我們正在創立一個全球社群

where we'll be able to measure and compare

大型的全球社群

what we achieve.

我們在其中可以衡量比較

Together with two academic institutions,

大家的成績

Michael Porter at Harvard Business School,

兩家學術機構

and the Karolinska Institute in Sweden,

哈佛商學院的波特教授

BCG has formed something we call ICHOM.

以及瑞典的卡洛林斯卡（Karolinska）學院

You may think that's a sneeze,

和BCG共同成立了ICHOM

but it's not a sneeze, it's an acronym.

你或許以為那是打噴嚏

It stands for the International Consortium

但那是一個縮寫

for Health Outcome Measurement.

全名是「國際衡量健康成效聯盟」

We're bringing together leading physicians

全名是「國際衡量健康成效聯盟」

and patients to discuss, disease by disease,

我們聚集了頂尖的醫師

what is really quality,

還有病人，逐一討論各種疾病

what should we measure,

品質到底是什麼

and to make those standards global.

該如何衡量

They've worked -- four working groups have worked

並且制定全球的標準

during the past year:

目前四個工作小組

cataracts, back pain,

在過去一年已有成果

coronary artery disease, which is, for instance, heart attack,

白內障，背痛

and prostate cancer.

冠狀動脈疾病 就是心臟病這類的疾病

The four groups will publish their data

攝護腺癌

in November of this year.

這四個小組的研究數據

That's the first time we'll be comparing

將在今年11月發表

apples to apples, not only within a country,

這將是我們首次

but between countries.

用同一標準比較，不只是國內互比

Next year, we're planning to do eight diseases,

也是國際之間互比

the year after, 16.

明年我們計劃比較八種疾病

In three years' time, we plan to have covered

後年16種疾病

40 percent of the disease burden.

三年之內，我們計劃涵蓋

Compare apples to apples. Who's better?

四成病人所患的疾病

Why is that?

拿蘋果和蘋果比，看看誰較佳

Five months ago,

為什麼較佳

I led a workshop at the largest university hospital

五個月前

in Northern Europe.

我在北歐最大的教學醫院 主持了一個研討會

They have a new CEO, and she has a vision:

我在北歐最大的教學醫院 主持了一個研討會

I want to manage my big institution much more

新院長表示她的願景是

on quality, outcomes that matter to patients.

對於這個大型機構的管理 我要更加注重病人關心的品質和成效

This particular day, we sat in a workshop

對於這個大型機構的管理 我要更加注重病人關心的品質和成效

together with physicians, nurses and other staff,

那天我們在研討會上