The St. Petersburg Multidisciplinary Clinical Centre, separated from the Pirogov National Medical & Surgical Centre, is now part of St. Petersburg University. Let us have a better look at the University medical centre — the future centre of multidisciplinary medical research.
On February 10, the Chairman of the Government of the Russian Federation Dmitry Medvedev signed Government Decree No 184-r on integrating the multidisciplinary clinical centre, separated from the Pirogov National Medical & Surgical Centre, into St. Petersburg State University. Now the centre includes an outpatient facility that can accommodate up to 120,000 patient visits per year and an in-patient clinic with 345 beds. The government decision will help to improve the quality and accessibility of secondary care (including high-technology medical care) in St. Petersburg (see Minutes of the Rector’s Meeting held on 16 February 2015, clause 1; information on the Russian Government website).
We wanted have a first-hand look at the new acquisition of the University.
Advantages of a “small fish”
“The time of whales, sharks and other giant monsters is long gone; the large and slow-moving fish has demonstrated its sluggishness and inefficiency. Today is the time if small mobile fish. They are much more active, they swim faster, they “catch” more in shorter time and, as a result, they are the winners!” These are the words of Yuri Fedotov, doctor of medical science, Director of the St. Petersburg Multidisciplinary Clinical Centre, and the Honoured Doctor of Russia. “The achievements of our clinic have repeatedly proved this during the last 15 years. Comparing our clinic with large medical centres of Russia, you will see that the capabilities of a smaller independent economic entity are much higher.”
Yuri Fedotov knows what he is talking about. During the 14 years that he has been heading the clinic, it has changed its shape four times by the decision of the Health Ministry. And Dr Fedotov is glad that now, after joining SPbU, the multidisciplinary clinical centre has not only retained its independence but has also has gained great opportunities for further development.
What are the advantages of this clinic?
First: A highly efficient medical centre has been created here. The “performance” and capacity of an inpatient facility in Russia is traditionally measured in the number of beds. But beds do not provide treatment! Dr Fedotov is sure that the most important factor is the efficiency of the medical personnel. During the last year, 10,500 operations were performed in the clinic — this is more than 50 per day. And the clinic has just 170 beds for surgery patients.
For instance, the clinic’s trauma care department has 39 beds, but its personnel performed 2,261 operations in 2014. This translates into more than 9 operations per day! The average number of bed days per one surgery patient here is only 5.2. The figure for the department of endocrinology is even lower — 3.2 bed days per person (the department has 29 beds, while the number of operations performed here in 2014 was 2,442, i.e. about 10 operations per day). How did it become possible?
Dr Fedotov invited me to reminisce about a traditional Russian hospital, which all of us had to experience at some point — either being treated there or visiting sick friends and relatives. The patient checks into the hospital before the operation and has to undergo all the tests again, sometimes one or two tests per day. Several days pass in this way, or maybe a week — especially if the patient has been admitted into a VIP-ward or to a “commercial” bed (i.e. a pay bed). Only after that, the decision about the operation is made. After being operated on, the patient waits for three or four days before he/she is transferred from the intensive-care unit to an ordinary ward, and then spends another week in hospital under constant supervision of the doctors … And we are all used to it! It turns out, however, that things can be very different.
“In our clinic, the doctor makes a decision about the operation beforehand — a week and sometimes a month before, when he/she establishes the diagnosis and informs the patient about the need for an operation. On the morning of the operation, the patient is admitted into the clinic and at noon he/she is already operated on (or it can be 2pm, 3pm, or 5pm — depending on the schedule); by the evening the patient is transferred to the ward and in two three days he/she gets released from the hospital,” Dr Fedotov explained. “For instance, after hip or knee endoprosthetic replacement, patients in our clinic get back to their feet and start walking the next day after the operation! In other hospitals it takes them two or three days… Therefore, we have fewer beds, but our treatment is more efficient and reliable. As a result, the so called “bed turnover” in our clinic is higher owing to a more efficient, modern workplace management”.
A second advantage: The clinic performs complex operations and provides secondary high-tech care. The clinical centre has about 20 departments, encompassing about 40 disciplines and services from ophthalmology and radiology to IVF (in vitro fertilisation). The most recent department is cardiovascular surgery, which was opened last year.
“The department of cardiovascular surgery we created from scratch, in just two and a half months. And we have already performed over 90 open-heart surgeries,” Dr Fedotov said. “In June 2014, we made the decision and at the end of November we already performed the first surgery… Our endocrinology department is number one in Russia in terms of the number of operations and medical care administration, while Europe-wide it is in third or fourth place.”
A third advantage: High professional qualification of the medical personnel. The clinic employs over 600 medical workers, including 244 doctors, with 20 doctors of medical science and 57 candidates of medical science as well as 8 honoured doctors of Russia among them. In the last three years, the doctors working in the clinic successfully defended 5 candidate’s thesis and 5 doctoral theses. All these people are practicing doctors, who perform the mentioned above 50 operations per day.
They possess enormous clinical experience and a vast body of research data, which needs to be investigated, summarised and disseminated. Every year, they perform an average of 1,500 joint replacement operations, about 400 arthroplasties, 2,400 thyroid and parathyroid surgeries, 600 endoscopic surgeries in connection with urolithiasis, 400 unique female pelvic floor reconstructive surgeries, etc. In the last three years, one out of three doctors of the clinic participated in training programmes abroad and received training in modern medical methods. They read contemporary medical literature, and they have learned many new methods through “work experience”.
A fourth advantage: Commitment to innovations. Government Decree No 184-r on integrating the multidisciplinary clinical centre, separated from the Pirogov National Medical & Surgical Centre, into St. Petersburg State University, issued on 10 February 2015, directly states one of the main goals of the medical centre: “…the investigation, consolidation, and dissemination of the experience gained by medical organizations in the field of surgery and related medical fields as well as implementation of innovations in the field of medicine and related scientific and practical fields, including implementation of new medical technologies” (see Government Decree No 184-r).
To put it all in perspective, Dr Fedotov suggested comparing how a femur fracture was treated say about 10-15 year ago and how it is treated now: “After a highly complex operation, as it was regarded in the past, the patient spent a whole month in hospital getting skeletal traction therapy. Then the patient was discharged from hospital but still had to spend three months (!) in a plaster cast — from the waist to the heels. This means, that the patient could not even take a shower (including summertime and +30C° heat…). Today we discharge such patients in three days and they can walk independently! The pain experienced by a patient with herniated intervertebral discs disappears right on the operating table. And he/she is discharged from hospital the next day!”
At the meeting of the Academic Council of the St. Petersburg Multi-Disciplinary Clinical Centre held on March 11, Yuri Fedotov presented a report on “The current work and prospects for the development of the future SPbU University clinic”, where he demonstrated the advantages of his clinic operating as part of the University.
On the road towards each other
The University and the Clinical Centre have been coming towards each other for many years. Joining the multidisciplinary clinical centre to SPbU is just one stage in the process of establishing the University medical clinic as a centre of interdisciplinary research (see Minutes of the Rector’s Meeting held on 27 January 2014, paragraph 2.3). The University clinic (one of the projects included in the SPbU Development Programme) is first of all a modern scientific and educational centre, not just a medical clinic. It will conduct cutting-edge research in various scientific and academic fields (chemistry, physics, mathematics, management, psychology, etc.), which will form the basis for the development of new medical technologies.
The University administration uses various ways for solving this task (see the following documents on the SPbU website: Rector’s Meeting held on 05 December 2011, clause 3; Rector’s Meeting held n 09 April 2012, clause 6; Rector’s Meeting held on 16 September 2013, clause 1). A modern University should, of course, have a modern medical clinic, which, similar to human heart, will unite all parts of the University’s body — biologists, chemists, physicists, mathematicians, psychologists, lawyers, geographers, sociologists, etc. — into one team of researchers who strive to solve the most pressing problems: ensuring human health and a healthy lifestyle, improving social and environmental conditions. The Rector of SPbU N. Kropachev has repeatedly stressed that human health is what should become and certainly will become the most essential motivation for the development of science in SPbU.
Yuri Fedotov reminded me that the order about making the North-Western Regional Medical Centre (this is what the clinic was called then) a clinical site for training SPbU medical students had been signed in 2006. The clinic has changed names several times (the Chudnovsky Hospital of the Central Baltic Watershed District, the North-Western Regional Medical Centre of the Federal Agency for Healthcare and Social Development, the St. Petersburg Clinical Centre of the Pirogov National Medical & Surgical Centre under the Ministry of Healthcare); it has changed the level of its independence but never stopped developing.
In the spring of 2014, the Rector of SPbU received a letter from the Pirogov National Medical & Surgical Centre. The administration of the Pirogov Centre suggested that they transfer to SPbU the multidisciplinary clinical centre which included two in-patient clinics, one at 13-15 Kadetskaya Line and one at 154 Fontanka Embankment. According to this letter, the administration of the centre had obtained approval for the proposal from the Minister of Healthcare and Social Development V. Skvortsova. And now, in accordance with Government Decree No 184-f of 10 February 2015, the St. Petersburg Multidisciplinary Clinical Centre will be separated from the Pirogov National Medical & Surgical Centre and joined to SPbU.
To see everything, to know everything, or … Seven steps towards success
The assistant director responsible for medical care administration Dmitry Shkarupa showed me around the clinic. I must say, however, that I did not notice anything out of the ordinary: the usual wards, the usual patients, the usual doctors and nurses — at least it seemed so at first glance. Then how are the advantages of the clinic that the director described to me implemented in practice? Is it possible to see the difference between this clinic and other medical institutions of the city?
This is what I have found out: here they have removed all imaginary “obstacles” between the patient and the clinic; they have reached out to their patients — this is most probably the reason for their success.
Let us remember how thing usually happen in other hospitals. It is time to check in for the operation — but there are not spots in the endocrinology (or gynaecology) operating room... Here they have created a unified bank of operating rooms, which unites all 10 operating rooms of the clinic. D. Shkarupa explains: “Today, for instance, in one and the same operating room No 3, we first perform an urological operation, then two surgical operations one after another, and after that a gynaecological operation...” As a result, the capacities of the operating table are used more efficiently, the equipment (which is the same for different operations) is used to the full, almost for 24 hours per day; the nurses participate in different operations and gain more experience. Specialized operating rooms have only remained for orthopaedic and cardiac surgery, where special equipment is required.
Let us return to the patient. It is time for him/her to check in for the operation; however, there are no vacant beds in the trauma care department, and the patient has to wait... But this clinic has a unified hospital bed stock. Patients with urological problems and those with injuries or recovering after thyroidectomy are all accommodated in the same ward. The beds are suitable for any patients. The only exception is the orthopaedic department, which has special beds and accommodates only orthopaedic patients.
But someone needs to know where a particular operation is performed and where particular patients are accommodated. How is this complex, constantly changing system controlled? It turns out that the mystery lies in the depths of the computer. “The entire work of the clinic can be monitored though the electronic information system,” D. Shkarupa explained. “There are 700 workplaces in the clinic: every doctor has a computer, there is a computer at every nurse’s station, in the admissions room, in every executive office.” On the screen we can see the information for every ward, for every operating room — and all that is online. The clinic has its own IT-department; they have developed their own proprietary information system called “Econbol” (a portmanteau word joining together “economics” and “hospital” (“bol’nitsa” in Russian), the third version already); the clinic has its own Wi-Fi network; therefore, there is good connection between the users.
Dr Shkarupa demonstrates the advantages of this system: as an illustration, he clicks on a patient’s name and shows to me that the patient’s entire movement through the system can be easily traced, starting from the initial examination by the trauma surgeon and up to the patient’s discharge from the hospital. The results of all the tests are also there — the doctor is able, without leaving the computer workplace, to look through X-ray images, the results of the ultrasound scan, computer tomography, cardiogram, blood and urine tests, etc. The date and time of the operation are registered as well (three days ago, knee endoprosthesis, performed by doctor such-and-such). The patient has been transferred to ward No 18 (located at the urological department, by the way); there is data on postoperative supervision. The patient is getting released from hospital today; there are recommendations for rehabilitation therapy and rehabilitation exercises — to be provided in the other building of the clinic, at 13-15 Kadetskaya Line of Vasilyevsky Island. Similar information is available for every single one of the 270 patients accommodated in the clinic today and for 1,400 patients who are to enter the clinic during the next month, strictly according to schedule. There are even archives for the last 10 years with the data on over 1,000,000 patients.
The general electronic information system is useful for both doctors and patients. Thanks to this system, hospital beds can be booked several months in advance. For example, the computer shows that in three weeks the operating rooms will be about 70% occupied, but there are still some “empty cells”. Every doctor, when making a decision on a particular operation, chooses the time when he or she can perform it. The doctor then discussed the date with the patient and reserves a spot in the operating room, putting the patient on the “waiting list” for a particular date.
But every patient needs to be examined, talked to, diagnosed, and then the decision has to be made about the necessary treatment. How can the doctors do it thoroughly and efficiently within a short space of time allocated? Every doctor here has assistants who carry out initial examinations, listen to patients’ complaints, interview the patients about their medical history, prescribe the necessary tests, keep case records, and maintain contact with the patients. They lessen the workload of highly qualified doctors by performing the necessary routine duties, so the doctors can work more efficiently − determining a precise diagnosis and, if necessary, making the decision to perform an operation.
The tests here, by the way, are performed on the outpatient and not inpatient basis, which helps to shorten the time that the patient needs to spend in the hospital. Besides, rehabilitation is quicker here due to the high-tech medical care, and the discharge from hospital comes earlier. “The data from international studies has shown that a chance to contract the so called hospital-acquired infection increases by 10% with every day a patient stays in hospital!” D. Shkarupa explained. “This is special bacterial flora, which is highly resistant to various types of antibiotics and which is very difficult to treat! Therefore, it is much better for patients to get released from hospital and return home as soon as possible (unless they need constant medical supervision). As for patients from other cities and towns, it is safer for them to get discharged and stay at the hotel for a while. There the risk to get infected with hospital flora is much lower…”
There is another advantage; Dmitry Shkarupa called it “the cherry on top of the cake”. The electronic information system provides enormous opportunities for the analysis of the work carried out in the clinic, either in general or broken down by departments. The work of operating rooms (at month-end, quarter-end, or year-end) can be analysed from different angles. It is possible to analyse the work of the call-centre, which takes at least 1,000 calls per day. It is possible to analyse the work of any doctor, any head of department. The clinic uses the so-called incentive contracts, which take into account the actual work of the employee during a particular month. Those who work better and perform more work, earn more. This means that employees are motivated to work better and more efficiently.
The Director of the St. Petersburg Multidisciplinary Clinical Centre Yuri Fedotov completed the picture: he can make executive decision in any place on Earth that has Internet connection — in his own office, at a conference in South America, at a meeting in India, or during a Bali vacation. He can approve a payment transaction or sign a payroll sheet, etc.
On the road towards each other-2
At the end of February, the Rector of SPbU N. Kropachev and the Director of St. Petersburg Clinical Centre of the Pirogov National Medical & Surgical Centre Yuri Fedotov held a joint meeting with the administration of the clinic (see more on that in the SPbU News section: Meeting of the Rector of SPbU N. Kropachev and the Director of the St. Petersburg Clinical Centre of the Pirogov National Medical Centre with the administration of the clinic). N. Kropachev talked about his vision of the clinical centre and its operation as part of the University and about the opportunities that had emerged for both the doctors and the SPbU scientists in connection with the decision made by the government. “It is important for us to achieve the goal of the development of modern medical science in Russia, which is impossible without constant cooperation of practicing doctors with scientists and professionals from a variety of academic fields — from physicists to psychologists, from lawyers to economists, and this can only become a reality in the environment of a classical university”, the Rector emphasized. Yuri Fedotov said that a long-term research programme would be developed in the future, as the University scientists and professionals from the clinic got to know each other better and their cooperation evolved.
Dmitry Shkarupa, now speaking as an urologist, gave me a good example proving that the doctors of the clinic really need help from the university scientists. The clinic performs operations on patients suffering from urinary tract stones (about 600 operations per year). The stones are removed and broken up in the kidney, with some stone being very large, even gigantic. The doctor used the screen of his smartphone to show me a photo of such stone, which occupies almost the whole of the patient’s kidney. D. Shkarupa is sure that “the University scientists could make a detailed 3D model of such kidney. Then we could use the model to work out various approaches to operations strategy. We would ‘scroll’ the picture in all directions and look at it from all angles. Then there could be fewer surprises during the actual operation.”
Biochemists, in his opinion, could study the composition of kidney stones or investigate how they are formed and what methods can be used to affect them… Similar 3D models could be created before joint surgeries as well (since every joint has a highly complex morphology). And in order to treat adrenal cortical carcinoma, we need to study hormonal changes in blood… As you see, there are vast opportunities for research.
In recent years, SPbU has been successfully implementing projects in the fields of biomedicine; several world-famous scientists have established their laboratories here: Stephen J. O’Brien, Raul Gainetdinov, Pavel Pevzner, Elena Grigorenko, and others. The new form of cooperation between the University and the Clinic will make it possible to use not only the intellectual potential of the University scientists but also the technical resources of the University for the development of both clinical work and practice-oriented research. One of the first joint projects will be the work on identifying the causes of thyroid cancer and adrenal cortical carcinoma; this is also consistent with the specialization profile of the clinical centre, which is currently the leading medical facility in the country with the largest number of thyroid operations.