The clinic of tomorrow is already here today

On February 10, 2015, Russian Prime Minister Dmitry Medvedev signed Government Decree No 184-r, integrating the multifunctional clinical centre, which had been split off from the Pirogov National Medical and Surgical Centre, into St Petersburg University. The centre now 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, and also information on the Russian Government website).

We wanted to have a first-hand look at the University’s new acquisition.

The Advantages of “Small Fish”

“The time of whales, sharks and other giant monsters of the deep is long gone; the large and slow-moving fish have demonstrated their sluggishness and inefficiency. Today is the time of small, mobile fish. They are much more active, they swim faster, they “catch” more in less time and, as a result, they are the winners!” These are the words of Yury Fedotov, a Doctor of Medical Science, the Director of the St Petersburg Multifunctional Clinical Centre, and an Honoured Doctor of Russia. “The achievements of our clinic have repeatedly proved this during the last 15 years. If you compare our clinic with large medical centres in Russia, you will see that the capabilities of a smaller, independent economic entity are much higher.”

Yury Fedotov knows what he is talking about. During the 14 years that he has run the clinic, it has changed its status four times at the behest of the Ministry of Health. And Dr Fedotov is glad that now, after joining St Petersburg University, the multifunctional clinical centre has not only retained its independence but has also gained great opportunities for further development.

What Are the Advantages of This Clinic?

First of all, a highly effective 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 effectiveness of the medical staff. During the last year, 10,500 operations have been performed at the clinic — this is more than 50 per day. And it has just 170 beds for surgery patients.

As an example, the clinic’s Trauma Care Department has 39 beds, but its staff performed 2,261 operations in 2014. This translates into more than 9 operations per day! The average number of bed days per surgery patient is a mere 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 this become possible?

Dr Fedotov invited me to recall a traditional Russian hospital, which all of us have had to experience at some point — either while being treated or visiting sick friends and relatives. The patient checks into the hospital before an operation and has to undergo all the tests they have already been given once 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 to a VIP-ward or their treatment is not covered by medical insurance but by the person themselves. Only after that is a decision about an operation made. After being operated on, the patient waits for three or four days before they are transferred from the intensive-care unit to an ordinary ward, and then they spend another week in hospital under the constant supervision of the doctors … And we are all used to this! It turns out, however, that things can be very different.

“At our clinic, the doctor makes a decision about an operation beforehand — a week and sometimes a month in advance, when they establish a diagnosis and inform the patient about the need for surgery. On the morning of the operation, the patient is admitted to the clinic and at noon they are already operated on (or it can be 2pm, 3pm, or 5pm — depending on the schedule); by the evening, the patient is transferred to a ward and in two or three days they are discharged from the clinic,” Dr Fedotov explained. “For instance, after a hip or knee endoprosthetic replacement, our patients get back on their feet and start walking the day after the operation! At traditional hospitals, it takes them two or three days… So, though we have fewer beds, our treatment is more effective and reliable, and the so-called “bed turnover” at our clinic is higher, owing to more effective, up-to-date management”.

Another advantage is that the clinic performs complex operations and provides secondary and high-tech healthcare. The clinical centre has around 20 departments, encompassing about 40 medical specialties and services, from ophthalmology and radiology to IVF (in vitro fertilisation). The newest department is cardiovascular surgery, which was opened in 2014.

“We created the Department of Cardiovascular Surgery from scratch in just two and a half months, and we have already performed over 90 open-heart operations,” Dr Fedotov said. “We made the decision in June 2014, and by the middle of November we had already performed the first operation… Our Endocrinology Department is number one in Russia in terms of the number of operations and medical care administration, while it is in third or fourth place in Europe.”

A third advantage is the consummate professionalism of the medical staff. The clinic employs over 600 medical workers, including 244 doctors, among whom there are 20 doctors of medical science, 57 candidates of medical science and 8 honoured doctors of Russia. In the last three years, doctors working at the clinic have successfully defended five candidate’s theses and five doctoral theses. All of these people are practicing doctors, who perform the 50 operations per day mentioned above.

They have amassed a wealth of clinical experience and a vast body of research data, which needs to be analysed, summarised and disseminated. Every year, they perform an average of 1,500 joint replacement operations, around 400 arthroplasties, 2,400 thyroid and parathyroid operations, 600 endoscopic operations for urolithiasis, 400 unique female pelvic floor reconstructive operations, etc. In the last three years, one out of three doctors at the clinic has participated in training programmes abroad and received a grounding in the latest treatment methods. They read contemporary medical literature, and they have learned many new methods through their own “work experience”.  

A fourth advantage is the commitment to innovation. Government Decree No 184-r, which integrated the multifunctional clinical centre into St Petersburg University, directly states one of the main goals of the medical centre: “…the investigation, consolidation, and dissemination of the experience gained by medical organisations in the field of surgery and related medical fields, along with the implementation of innovations in the field of medicine and related scientific and practical fields, including the introduction of new medical technologies” (see Government Decree No 184-r).

To put it all in perspective, Dr Fedotov compared how, for instance, a femur fracture was treated only 10-15 years ago and how it is treated now: “After a highly complex operation, as it was regarded at that time, the patient would spend a whole month in hospital undergoing skeletal traction therapy. Then they would be discharged from hospital but still had to spend three months (!) in a plaster cast — from their waist to their toes. This means that the patient could not even take a shower (including in the summertime in 30C° heat). Today we discharge such patients in three days, and they can walk on their own! The pain experienced by a patient with herniated intervertebral discs disappears right on the operating table. And they are discharged from the clinic the next day!”

At a meeting of the Academic Council of the St Petersburg Multifunctional Clinical Centre, held on March 11, 2015, Yury Fedotov presented a report entitled “The Current Work and Prospects for the Development of the St Petersburg University Clinic of the Future”, in which he demonstrated the advantages of his clinic operating as part of the University.

On the Road Towards Unity – Part 1

The University and the Clinical Centre had been moving towards each other for many years. Joining the multifunctional clinical centre to St Petersburg University 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, clause 2.3). The University clinic (one of the projects included in the St Petersburg University Development Programme) is first of all a contemporary 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 a basis for the development of new medical technologies.

The University administration is trying to meet this challenge in different ways (see the following documents on the St Petersburg University website: Minutes of the Rector’s Meeting held on 05 December 2011, clause 3; Minutes of the Rector’s Meeting held on 09 April 2012, clause 6; Minutes of the Rector’s Meeting held on 16 September 2013, clause 1). An up-to-date university should, of course, have an up-to-date medical clinic, which, similar to the 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 will strive to solve the most pressing problems: ensuring human health and a healthy lifestyle, along with improving social and environmental conditions. The Rector of St Petersburg University, Nikolay Kropachev, has repeatedly stressed that human health is what should, and certainly will, become the main incentive for the development of science at the University.

Yury Fedotov recalled that the order which made the North-Western Regional Medical Centre (this is what the clinic was called back then) a clinical site for training St Petersburg University medical students had been signed back in 2006. The clinic has changed names several times (from the Chudnovsky Hospital of the Central Baltic Watershed District to the North-Western Regional Medical Centre of the Federal Agency for Healthcare and Social Development, and then to the St Petersburg Clinical Centre of the Pirogov National Medical and Surgical Centre under the Ministry of Health) and has gone through different levels of independence, but it has never stopped developing.

In the spring of 2014, the Rector of St Petersburg University received a letter from the Pirogov National Medical and Surgical Centre in which the administration of the centre offered to hand over the multifunctional clinical centre, which included two in-patient clinics, one at 13-15 Kadetskaya Line and the other at 154 Fontanka Embankment, to the University. As stated in the letter, the administration of the centre had obtained approval for this proposal from Veronika Skvortsova, the Minister of Health and Social Development. And in accordance with Government Decree No 184-f of 10 February 2015, the St Petersburg Multifunctional Clinical Centre was to be separated from the Pirogov National Medical and Surgical Centre and integrated into St Petersburg University.

To See Everything and to Know Everything or … Seven Steps to Success

Dmitry Shkarupa Assistant Director of Healthcare Administration, 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. How then, I wondered, are the advantages of the clinic that the director described to me borne out in practice? Is it possible to see how this clinic stands out from other healthcare providers in the city?

What I discovered is the following: they have removed all of the imaginary “obstacles” between the patient and the clinic here, and they have reached out to their patients — this, it would seem, is the reason for their success.

Step One

Let us recollect what usually happens in other hospitals. A patient needs to undergo an operation — but there are no openings in the schedule for the endocrinology (or gynaecology) operating room... In this clinic, they have united all ten operating rooms into one consolidated pool. Dr Shkarupa explains: “Today, for instance, in one and the same Operating Room Number 3, we first perform a urological operation, then two surgical operations one after another, and following 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 around the clock, and the nurses participate in different operations, gaining more experience. Specialised operating rooms have remained only for orthopaedic and cardiac surgery, where special equipment is required.

Step Two

Let us look at another patient who needs to have an operation: this time there are no vacant beds in, for example, the Trauma Care Department, and they have to wait... But this clinic has a unified hospital bed stock. Patients with urological problems and those recovering from traumas or a 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 caters only to orthopaedic patients.

Step Three

But someone needs to know where a particular operation is performed and where particular patients are accommodated. How can you manage such a complex, constantly changing system? It turns out that the mystery lies in the depths of the computer. “The entire work of the clinic can be monitored through our electronic information system,” and Dr Shkarupa showed me how it works. “There are 700 workplaces in the clinic,” he pointed out. “Every doctor has a computer, and there is a computer at every nurse’s station, in the admissions room, and in every executive office.”  On the screen, we can see the information for every ward, for every operating room — and everything is online. The clinic has its own IT-department, and they have developed their own proprietary information system called “Econbol” (a portmanteau word joining together “economics” and “hospital” (“bol’nitsa” in Russian)), and it is already in its third version. The clinic also has its own Wi-Fi network, so there is a good connection between the users.

Step Four

Dr Shkarupa demonstrates the advantages of this system: as an illustration, he clicks on a patient’s name and shows me that their entire movement through the system can be easily traced, starting from the initial examination by the trauma surgeon up to their discharge from the clinic. The results of all their tests are also right there — the doctor is able, without leaving their computer workplace, to look through X-ray images, the results of an ultrasound scan, computer tomography, a cardiogram, blood and urine tests, etc. The date and time of an operation are registered as well: “Three days ago, knee endoprosthesis was performed by Doctor Such-and-Such. The patient has been transferred to Ward No 18.” (It is located in the Urology Department, by the way.). There is also data on postoperative supervision: “The patient is being discharged from the clinic today, and there are recommendations for rehabilitation therapy and rehabilitation exercises.”  (They will be provided in the clinic’s other building, at 13-15 Kadetskaya Line on Vasilyevsky Island.) Similar information is available for every single one of the 270 patients accommodated in the clinic today and for the 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.

Step Five

The general electronic information system is useful for both doctors and patients. Thanks to this system, beds at the clinic can be booked several months in advance. For example, the computer shows that in three weeks the operating rooms will be about 70 percent occupied, but there are still some “empty spaces” here and there. Every doctor, when making a decision on a particular operation, chooses the time when they can perform it. They then discuss the date with the patient and reserve a spot in an operating room, putting the patient on the “waiting list” for a particular date.

Step Six

But every patient needs to be examined, talked to and diagnosed, and then a decision has to be made about the best treatment. How can the doctors do it thoroughly and productively within the short space of time allocated? Every doctor here has assistants who carry out initial examinations, listen to patients’ complaints, interview them about their medical history, prescribe the necessary tests, keep case records, and maintain contact with the patients. They lessen the workload of the highly qualified doctors by performing all of these essential, but routine, duties, so the doctors can more effectively determine a precise diagnosis and, if necessary, make the decision to perform an operation.

Step Seven

The tests here, by the way, are performed on an outpatient, not an inpatient, basis, which helps to shorten the time that a patient needs to spend at the clinic. Besides, rehabilitation is quicker, due to the high-tech medical care, as is a discharge from the clinic. “Data from international studies have shown that the chances of contracting a so-called hospital-acquired infection increases by 10 percent with each day a patient stays at any clinic!” Dr Shkarupa explained. “This is a special bacterial flora, which is highly resistant to various types of antibiotics and is very difficult to treat! So, it is much better for patients to be discharged from the clinic 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 a hotel for a while. The risk of getting infected with hospital flora is much lower there…”

There is another advantage to the clinic, which Dmitry Shkarupa called the “cherry on top of the cake”. The electronic information system provides enormous opportunities for analysis of the work carried out at the clinic, either as a whole or broken down by departments. The work of the operating rooms (at the end of the month, the quarter, or the year) can be analysed from different angles. It is also possible to analyse the work of the call-centre, which takes at least 1,000 calls per day. And it is possible to analyse the work of any doctor, or any head of department. The clinic uses so-called performance-based contracts, which take into account the actual work of each employee during a particular month. Those who work better and do more work earn more. This means that everybody is motivated to work better and more effectively.

Director of the St Petersburg Multifunctional Clinical Centre Yury Fedotov completed the picture: he can make an executive decision from any place on Earth that has an Internet connection — in his own office, at a conference in South America, at a meeting in India, or during a vacation in Bali. He can also approve a payment transaction, sign a payroll sheet, etc.

On the Road Towards Unity – Part 2

At the end of February 2015, Rector of St Petersburg University Nikolay Kropachev and Director of the St Petersburg Clinical Centre of the Pirogov National Medical and Surgical Centre Yury Fedotov held a joint meeting with the administration of the clinic. Mr 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 doctors at the clinic and researchers at the University in connection with the decision made by the government. “It is important for us to achieve the goal of developing high-level medical science in Russia, which is impossible without the constant cooperation of practicing doctors and both 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 traditional university,” the Rector emphasised. Mr Fedotov said that a long-term research programme would be developed in the future, as University scientists and professionals from the clinic get to know each other better and their cooperation evolves.

Dmitry Shkarupa, now speaking as a urologist, gave me a good example of how much the doctors at the clinic really need the help of 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 of them being very large, even gigantic. The doctor used the screen of his smartphone to show me a photo of such a stone, which occupied almost the whole of a patient’s kidney. Dr Shkarupa is sure that “University scientists could make a detailed 3D model of such a kidney. Then we could use the model to work out various approaches to an operation. We could “scroll” the picture in all directions and look at it from all angles. Then there would be fewer surprises during the actual operation.”

Biochemists, in his opinion, could try to determine what kidney stones consist of or investigate how they are formed and what methods can be used to affect them… Similar 3D models could be created before joint surgery 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, St Petersburg University has been successfully launching projects in biomedicine, and a number of world-famous scientists have established their laboratories here, including 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 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 work on identifying the causes of thyroid cancer and adrenal cortical carcinoma. This is also consistent with the specialisation of the clinical centre, which is currently the leading medical facility in the country when it comes to the number of thyroid operations.