Asian Hospital & Healthcare Management - Issue 45 by Ochre Media Pvt. Ltd.

I S S U E 45

2019

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Nursing Building a future-ready workforce

Associate Partner

Digitalisation The future of laboratory medicine

The Science of Healthcare Delivery The symphony

Foreword NURSING

Building a future-ready workforce Sustainable primary healthcare is the key to achieve the World Health Organization’s (WHO) goal of universal health coverage. Nursing staff are a vital factor in delivering effective primary healthcare. However, there has been a crunch in the nursing workforce. A UN report published in 2016 warned that the healthcare industry could witness a shortfall of 18 million health workers to accelerate universal health coverage by 2030, with nurses accounting for almost 50 per cent. What’s alarming is not just the number of personnel leaving the profession, but their valuable experience. The industry needs experienced personnel who can deliver quality care and also train and guide the younger generation. In February 2019, the International Council of Nurses (ICN) convened the ‘2019 International Workforce Forum’, called for urgent action from governments to address global shortage of nurses.

The WHO executive board recently proposed that the year 2020 be designated as ‘Year of the Nurse and Midwife’. ICN members believe this move will positively impact recruitment and retention of nurses. In 2011, WHO passed a resolution to devise strategies aimed at enhancing capacity of nursing and midwifery workforce. The organisation achieves this by working with the member states on setting targets, developing action plans, and establishing interdisciplinary health teams. The global strategic direction 2016–2020 for WHO calls for greater collaboration with all the key stakeholders to achieve the ultimate goal of universal health coverage and sustainable development goals. These revolve around skilled and competent workforce, optimising policy development, striving to enhance capabilities and potentials of nurses, seeking political support to invest in an effective workforce development.

Representatives of various countries stressed on the need to make adequate investments in order to create new jobs in the healthcare sector in the lower middle-income countries. ICN suggests that in spite of rise in nurse staffing levels in some of the countries, the number of nursing professionals across the globe is not meeting the demand. So what’s causing such a huge shortage of nurses? Some of the factors creating this shortage are migration of workforce, undesirable working conditions, problems relating to recruitment and retention, working overtime, remuneration concerns etc. Migration of nurses to the developed countries in pursuit of better opportunities is pushing developing countries into a quandary as they are deprived of quality nursing professionals.

The cover story talks about opportunities in nursing, countries facing shortage of nurses and qualified faculty, while reviewing recruitment efforts, and retention strategies and steps to attract new talent. It outlines how shortage of resources actually encouraged organisations, educational institutions, and governments work hand-in-hand with an objective to develop quality nursing staff.

Prasanthi Sadhu

Editor

CONTENTS

NURSING RETENTION AND RECRUITMENT

The reality

Uche Nwabueze, Instructional Professor of Management

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Department of Maritime Administration, Texas A&M University

06 Neuromarketing An overview K Ganapathy, Director, Apollo Telemedicine Networking Foundation & Apollo Tele Health Services

22 Another American Revolution! Peter A Gross, Chairman, Hackensack Alliance Accountable Care Organization

30 The Science of Healthcare Delivery The symphony Gurrit Sethi, Strategic Advisor, Global Health Initiatives

MEDICAL SCIENCES 36 Acknowledging Amyloid Transthyretin (ATTR) Amyloidosis Diego H Delgado, Cardiologist, Division of Cardiology, University Health Network Associate Professor of Medicine, University of Toronto Specialised in heart failure, transplantation and cardio-oncology

COVER STORY

Bennett Di Giovanni, Research Fellow, Division of Cardiology University Health Network

DIAGNOSTICS 42 Safe Actions to Guard against Electrosmog Beverly A Jensen, President / CEO, Women's Medicine Bowl, LLC

TECHNOLOGY, EQUIPMENT & DEVICES 48 Digitalisation The future of laboratory medicine Suresh Vazirani, Chairman & Managing Director, Transasia

FACILITIES & OPERATIONS MANAGEMENT

60 INFORMATION TECHNOLOGY 60 Healthcare Digital Transformation R B Smarta, Managing Director, Interlink Marketing Consultancy Pvt. Ltd.

52 Programming Planning and Design

64 Applying the KonMari Method to Your Health Data Strategy

Angela Lee, Principal and Regional Director, Asia Pacific, HKS

Jan Herzhoff, Managing Director for Asia Pacific, Elsevier Health

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SMART STORAGE

Effective Solutions

Compactors Lockers Filing Cabinets Shelving Systems Multi-tier Racking FIFO / LIFO Racking

Record Storage Linen Storage X-Ray Film Storage Medicine Storage Tissue Trap Storage Glass Slide Storage

Advisory Board

EDITOR Prasanthi Sadhu EDITORIAL TEAM Debi Jones Grace Jones ART DIRECTOR M Abdul Hannan PRODUCT MANAGER Jeff Kenney

Pradeep Chowbey Chairman Minimal Access, Metabolic and Bariatric Surgery Centre Sir Ganga Ram Hospital, India

SENIOR PRODUCT ASSOCIATES Peter Thomas David Nelson Susanne Vincent PRODUCT ASSOCIATES Austin Paul John Milton Jessie Vincent

David A Shore Adjunct Professor, Organizational Development Business School, University of Monterrey, Mexico

CIRCULATION TEAM Naveen M Sam Smith SUBSCRIPTIONS IN-CHARGE Vijay Kumar Gaddam

Gabe Rijpma Sr. Director Health & Social Services for Asia

HEAD-OPERATIONS S V Nageswara Rao

Microsoft, New Zealand

Associate Partner

In Association with

Peter Gross Chair, Board of Managers HackensackAlliance ACO, USA

Malcom J Underwood Chief, Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong

John E Adler Professor Neurosurgery and Director Radiosurgery and Stereotactic Surgery Stanford University School of Medicine, USA

A member of Confederation of Indian Industry

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Neuromarketing An overview Advances in neurosciences are re-defining and enhancing our understanding of how we make decisions in general and how consumers make decisions from a marketing perspective. Some neuroscientists claim that identifying location of the â&#x20AC;&#x2DC;Buy Buttonâ&#x20AC;&#x2122; in the brain may be possible. This overview summarises current concepts on Neuromarketing. K Ganapathy, Director, Apollo Telemedicine Networking Foundation & Apollo Tele Health Services

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euromarketing is the branch of neuroscience research that aims to better understand the consumer through his cognitive processes and has applications in marketing, explaining consumer's preferences, motivations and expectations, predicting his/her behaviour and explaining successes or failures of advertising messages. Neuro science can help marketers by providing confirmatory evidence about the existence of a phenomenon, generating more fundamental (i.e., a neural level) conceptualisation and understanding of underlying processes, refining existing concepts of various phenomena, and providing methodologies for testing new as well as existing theories are in the offing. The term Neuromarketing was first used in a June 2002 press release by an Atlanta-based advertising firm, BrightHouse, announcing the creation of a business division using fMRI for marketing research. The annual advertising market in the USA

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alone in 2014 was US$475 billion. Traditionally marketers have watched what we do in stores or tracked how purchases rise or fall in response to promotional campaigns, changes in pricing, endless surveys and focus groups, asking us what we buy and why. In Neuromarketing one understands patterns of brain signals (electrical, blood flow, O2 and blood utilisation in specific regions) as a function of time (milliseconds) during observation of commercial advertisements, leading to information about cognitive and emotional processing of information in the brain. The neurophysiological changes in the complex neuronal network, during a simple decisional process, involved in purchase of a specific product is studied. The response to advertising (how the message is encoded) matters more than the stimulus (the ad itself ) because the response is what the ad leaves behind. Advertising productivity will increase if managers knew how advertisement stimuli (the unique selling proposition) were received and stored by the brain, and how they affect brand choices. Individuals with a high body-mass index (BMI) prefer a thin-shaped bottle, even if this drink is higher in price. Brains in obese people respond differently to nutrition labels. When given an identical milkshake, there is an increased brain activity in reward areas if the label reads ‘regular’ compared to ‘low-fat’. Neuroimaging has been used to identify structural and functional brain markers associated with racial biases, trustworthiness, moral reasoning, economic cooperation, social rejection, sexual preferences and even consumer brand attachment. While one school of thought says “Don’t just advertise. Neurotise", others believe that brain scans are only brain scams !! Basis of Traditional Marketing

The main objective of marketing is to match products with people. Guiding

Neuro-caution must be used in deploying the new neuro culture of neuromarketing, while appreciating the exciting discoveries about human behaviour using neurotechnologies.

design and product presentation to suit consumer preferences. Is it possible to examine what the brain does while making a purchasing decision? Basis of Neuromarketing

Cognition describes the way our brain thinks, reasons and solves problems. Changes that occur in the brain while we focus, concentrate, maintain or divide attention can now be qualitatively and quantitatively measured. Learning, remembering new things, planning, executing, and regulating activities, understanding and using language, assembling and grouping things together all form the basis of neuromarketing studies. Neuromarketing Tools

This is represented pictorially below. However, these studies can only be done in well-equipped neuro labs with considerable infrastructure and technical expertise. Techniques of NeuroMarketing

Eye movement tracking is a standard tool deployed for understanding interaction with both online and bricks-and-mortar environments. Eye movement (fixed and interrupted) reveals focus and attentional bias, distribution and gaze time (of the look) and pupil dilation. These are surrogate markers of the subject’s attention and cognitive processing. A longer blinking interval would correspond

to better processing of information. The ERP ANALYSIS: An EventRelated Potentials (ERPs) analysis, revealed that visuo cortical processing shows an increase in the early positive component (P1 of an ERP), at central and parietal sites, along with increase of the later negative component (N2 of the ERP), at parietal and occipital sites, related to the observation of disliked logos. Brain fingerprinting includes identification of the p300 wave in EEG and MEG and correlating this with observed responses when exposed to a marketing stimulus. Transcranial magnetic stimulation (TMS), a neuro enhancer, could even have potential for altering “Neuro responsiveness” to branding. The brain is the ultimate business frontier and technology is now letting marketing managers peek inside our heads. An EEG allows neuroscientists to track the electrical changes occurring in the brain when watching a commercial. Miniaturisation and portability of the equipment has made evaluation of potential customers easier. Illustrations of Neuro Marketing

Subjects preferred Pepsi if they did not know what they were drinking, but preferred Coke if they did. Brain scans showed different activity in different areas. When tasting blind, the ventro medial prefrontal cortex responded more actively to Pepsi. When told they were drinking Coke, there was more activity in the medial prefrontal cortex — a part of the brain dealing with higher cognitive processing and memory. Positive brand associations could almost literally be seen overriding the basic pleasure response (taste) Specific Documented Brain Changes when Seeing an Advertisement

Strong activation of the right inferior frontal cortex (Vocalisation), at 500ms, latency and in the left orbitofrontal

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Neuromarketing tools

Record metabolic activity in the brain

Recording electric activity in the brain

Steady State Topography (SST)

Positron emission tomography (PET)

Functional Magnetic Resonance Imaging (fMRI)

Without recording brain activity

Facial coding

Implicit association test

Skin conductance

Eye Tracking

Transcranial magnetic stimulation (TMS) Magnetoencephalography (MEG) Electroencephalography (EEG) Facial Electromyography

Source Sharad Agarwal IIM Ranchi

cortex (Judgement) between 600 and 1200 ms after stimulus presentation has been recorded. Active involvement of the Anteriorcingulate Cortex (ACC) and Cingulatemotor Area (CMA) have been correlated to liking or disliking particular advertising logos. Ventromedial Prefrontal Cortex (VMPC) is critical for emotion and emotional regulation, playing a pivotal role in brand preference. The prefrontal cortex discriminates cognitive processes, encoding new complex stimuli (e.g., logos, products, testimonials, payoff, etc). Amount individuals were willing to pay (a measure of decision utility) correlated with activity levels in the medial Orbitofrontal Cortex (OFC) and Prefrontal Cortex (PFC). Similar activation in the OFC was observed when subjects anticipated a pleasant taste, look at pretty faces, hear pleasant music, receive money and experience a social reward. In a study of neural responses to sips of wine, medial OFC response were higher when subjects were told that wine was $90 per bottle vs. $5

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per bottle. If an ad does not modify the brains of the intended audience, then it has not worked. This would be the way a marketing campaign is assessed Neuromarketing: A Peep into the Future

MRI scans for neuromarketing studies are at present not regulated by US Food & Drug Administration (FDA) or an Institutional Review Board (IRB). Neuro-caution must be used in deploying the new neuro culture of neuromarketing, while appreciating the exciting discoveries about human behaviour using neurotechnologies. Commercial effectiveness indicators could be measured including emotional engagement, memory retention, purchase intention, novelty, awareness and attention. We make decisions based on our emotions. Emotional engagement is secondary to the emotional excitement. What happens in the brain when consumers respond differently to an ad, brand or campaign will be understood. Cerebral changes during the Emotional Reaction

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Measuring Physiological Responses

and Cognitive Processing component of seeing an advertisement can be studied. This is correlated with remembering / forgetting the Ad, attention sustenance, like/dislike. Marketers could exploit these tools in an ad pretest. The exact location/s of the â&#x20AC;&#x153;Buy Buttonâ&#x20AC;? could be identified. Using. Principles of reverse engineering the BB could be stimulated and consumer behaviour modified. Improbable? Yes. Impossible? No.

AUTHOR BIO

K Ganapathy, Past President, Telemedicine Society of India. former Secretary and Past President of the Neurological Society of India, former Secretary of the Asian Australasian Society of Neurological Surgery , Past President of the Indian Society of Stereotactic & Functional Neurosurgery. He is a pioneer in introducing Telemedicine in India.

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COVER STORY

NURSING RETENTION AND RECRUITMENT The reality

Employment opportunities in the healthcare industry, and in particular in the nursing field, are expected to grow over the next ten years. However, it is no secret that America is experiencing a nursing shortage due to low enrolment in nursing schools and an ageing workforce. In order to bridge the gap, the healthcare industry needs to retain employees from the current workforce, while recruiting new employees. The paper will review current retention techniques and will identify those that are most effective. The subject of recruitment is of equitable importance. The research will review current recruitment techniques and identify what the healthcare industry is doing to entice new prospects to the nursing field. Finally, the paper will examine nursing programmes and the lack of qualified faculty. Uche Nwabueze, Instructional Professor of Management Department of Maritime Administration, Texas A&M University

s many corporations in this economy are downsizing, the healthcare industry continues to grow. The advancement of technology in the healthcare field sustains patients far past what was expected only a few years ago. This technology also requires more skilled personnel to operate these devices. In addition, the general public is ageing and the longevity of the human race has substantially increased. Therefore, there is an increase in the need for more healthcare employees, due to the increase in the populationâ&#x20AC;&#x2122;s healthcare needs. For instance, the nursing field alone continues to grow in size as the demand for nurses grows by 2-3 per cent a year (Rosseter, 2009).

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Currently, the healthcare industry worldwide is unable to keep up with this demand. Further compounding the shortage, the average age of a registered nurse (RN) continues to climb. It is estimated the average age of an RN is 43 years of age (Roman, 2008).This number is projected to climb due to fewer young people entering the field and even fewer students graduating with a nursing degree. This declining statistic is mainly a result of nursing schools that are unable to admit more nursing candidates due to the lack of qualified faculty. In addition, nurses are leaving the industry due to levels of moral distress and decreased job satisfaction. Therefore, employers are experiencing an increase in turnover and lack of qualified candidates from nursing schools. By the year 2025, it is projected that the nursing shortage will reach 500,000 positions (Rosseter, 2009). This topic of the nursing shortage, and ways to reinstate these positions, is of great importance to society as a whole. It will affect every person due to the ageing population, with an increased need for accessing the healthcare industry. Nurses are continuously at the bedside caring for and becoming more familiar with their particular patients. As a result, nurses have been an important factor in the prevention against potential adverse medical events. Therefore, this nursing shortage and its effects will directly impact the quality of care a patient receives. Growth of the Healthcare Industry

The healthcare industry continues to grow despite the current economic times. Advances in technology have swept the healthcare field, and in particular the field of nursing. With this technology, patients are surviving illnesses that were previously deemed fatal. This leads to more complicated health issues in patients. As a result, the idea of preventative medicine is a rising trend thus requiring more nursing positions.

NURSING SHORTAGE

Many researchers today discuss the current nursing shortage as grave and in crisis. In 2008, it was reported that the current vacancy rate for nursing was 8.1 per cent (Rosseter, 2009). This equates to each staff nurse today carrying an extra 10 per cent patient load. Despite these losses, the nursing profession is projected to grow in need over the next 10 years, thus creating an even greater shortage. In addition, the care a nurse provides today is further complicated by technology and higher acuity patients due to complex medical conditions. Therefore, the workload a nurse carries today is drastically different than it was only a few years ago, thus creating even more vacancies. Buerhaus stated, in RN magazine in 2008, that “the full impact of the nursing shortage would not be felt until between 2015 and 2020” (as cited in Roman, 2008). This is, in part, due to the fact that the average age of nurses continues to climb. In 2006, it was reported that 55 per cent of nurses planned to retire between 2011 and 2020 (Rosseter, 2009). This delayed impact is also a result of the fact that nursing schools are unable to accept all of the eligible nursing candidates due to the shortage in qualified nursing faculty. Technology continues to advance and be implemented in various aspects of the healthcare field. Patients today receive more radiologic tests, laboratory tests, and surgical interventions than ever before. It is typically the bedside nurse that coordinates and performs these interventions for the patient. As a result of these advanced technologies, tasks that were straightforward only a few years ago have become complex endeavours (Rosenkoetter, Bowcutt, Khasanshina, Chernacky, & Wall, 2008). For example, when a nurse administered an antibiotic fifteen years ago, the bedside nurse would first get the medicines from the patient’s bin, add tubing, and then hang the medicine and count the drips to determine the correct rate. Today, the nurse has to log into a computerised vending machine to obtain the correct medicine. The nurse then logs onto the computer system to verify the medication against the patient’s electronic medication record. Then, the nurse logs into another vending machine to obtain the tubing. Finally, she or he enters the room, scans the patient’s identification band, and then places the medication on a pump. In addition, the pumps now require

a nurse to enter the patient’s personal data, select the correct medication to be administered, and verify the correct rate. Meanwhile, she or he might have received three phone calls and two pages from other locations or patients within the hospital that require immediate attention. As a result of these new technological advances, patients are facing new health issues. Patients are now surviving illnesses that were labeled terminal only a few years ago. This results in new health concerns and conditions for these patients. For example, children who were born with certain congenital heart defects a few years ago were treated with palliative care or kept comfortable until they passed away. Today, the defects are being surgically repaired in these children after only a few days of life. As a result, these children are successfully growing into adulthood. Most of these patients continue to be followed by paediatric cardiologists due to the fact the adult cardiologists have little to no experience with these conditions. Therefore when these patients become ill, either they report to a paediatric hospital, where they will be out of place due to age, or an adult hospital, where

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the staff may not be experienced with their condition. The healthcare industry has to learn how to treat these patients long term. In addition, more patients are living longer with multiple chronic illnesses. For instance, these paediatric cardiac patients in adulthood are beginning to experience problems with their respiratory systems due to the demand on their impaired hearts. Therefore, as

society continues to age, the demands on the entire healthcare industry will continue to escalate to care for this medically complex aged population. As technology advances and preventative medicine extends the longevity of those in the community, the population will continue to mature. The healthcare industry will face patients with more complex medical conditions. Therefore, the nursing staff

MANAGING THE NURSING SHORTAGE

The numbers of those who are active in the nursing field continues to fall. The fast growth of the healthcare industry, ageing workforce, lack of new nurses entering the field, and the ageing population has perpetuated the nursing shortage. Some employers and nursing associations are looking to the government and the nursing boards for solutions to this shortage. The legislative body can rule on decisions and make guidelines for the healthcare industry. Also, the government can allocate more funds for nursing education to faculty and schools. Thus far, this has been inconsistent. On April 22, 2009, a bill was

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introduced to the 111th congressional session by US Congresswoman Nita Lowey from New York. This bill, coined the Nurses Education, Expansion, and Development Act of 2009, addresses the current faculty shortage in the nursing schools (2009).This legislation, also known as H.R. 2043, amends the Public Service Act by allowing for more generous grants for nursing schools per nursing student enrolled (2009). This would help with nursing school funding to offset the cost of education and the acquisition of the latest technology. In addition, this would benefit the nursing schools to allow more qualified applicants to attend. This bill is currently sitting in committee. However, the government is not ultimately responsible for this shortage in the nursing field. Thus, the nursing boards could make changes in the requirements for nursing students and faculty. On the other hand, they should not compromise the profession by speeding up the education process or require less of students to expedite graduation. The high expectations of a nursing student should remain the same. One modification that can be made is in regard to the faculty requirements.

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will have an increased patient load and more technology with which to master and perform their basic duties. The healthcare field is also moving more in the direction of preventative medicine and health promotion. If one can prevent the illness from ever occurring or prevent the spread of disease, there would be less crowding in the hospitals. Healthy People 2010 was a governmental funded campaign

In order to be an educator for any collegiate program, the nursing instructor must hold a degree higher than the degree in which the students seek (Texas Administrative Code, 2008). For example, in order to teach in the baccalaureate program, the instructor must be a master’s prepared nurse and for a master’s degree programme the instructor must have a doctoral degree. Requirements could be changed to allow for master’s degree candidates to hold education positions in the baccalaureate degree programmes. This would support the current supply of available nursing faculty. In addition, some master’s degree students, who are currently unemployed due to school requirements, could fund their education with nursing faculty salaries. This, in turn, could financially encourage more candidates to enter into the master’s degree programmes, thus advancing their careers. The previously mentioned bill, H.R. 2043, would increase funding to schools, which in turn could increase faculty salaries. A typical nursing school faculty member earns roughly US$53,000 per year, in comparison to a new graduate nurse who would earn roughly US$47,000 per year, and an advanced practice nurse who would earn roughly US$73,000 per year (Mee, 2005). Therefore, a new graduate nurse will essentially receive the equivalent salary to that of the master’s prepared nursing instructor. In addition, this nursing faculty salary is also lower

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started to reach a goal of a healthier society by the year 2010 (Martin, 2005). This campaign focused on health promotion and prevention. It targeted a close relationship between the patient and the primary healthcare provider. Therefore, preventative medicine began taking hold within community offices and facilities. Immunisation campaigns for children have continued, despite the

in comparison to other faculty in non-nursing fields (Rother & Lavizzo-Mourey, 2009). Therefore, what is the incentive for a nurse with a graduate degree to become an instructor at a nursing school versus practicing in the clinical arena where she or he can make US$20,000 more a year? Nursing boards and societies can influence and lobby the governing body for an increase in funds for nursing school, such as in H.R. 2043. In addition, they can change the requirements for nursing faculty. This would recruit more nursing faculty which would allow for more qualified candidates to be able to attend and graduate nursing school, thus effectively decreasing the nursing shortage. However, the healthcare industry needs to take some of the responsibility with regards to this issue. First, the facility needs to examine its own practices and policies with regards to their current employees. What are they doing to keep the nurses they currently have? And, what are they doing to market their facility to the external environment and hire new staff? Changes in current management behaviour, with regards to established employees, to aid in retention and alternative recruiting methods are the answer to the nursing shortage.

autism versus vaccination debate. In addition, there is a push toward re-immunising adults. This is due to decreased immunity with certain diseases, such as pertussis (Casey &Pichichero, 2005). Other common health campaigns are smoking cessation, asthma education, diabetes education, general health promotion and nutrition, and cardiovascular disease. With these initiatives, there are a lot of additional education and wellness screenings being performed in the communities. Nurses play a vital role in the education and health screening of patients. Many times these clinic visits are to a nurse practitioner or just a simple nurse visit, without physician participation. Therefore, nurses are a key player in the preventive medicine and the health promotion movement. With all of these new initiatives, the average age of the population continues to climb, which in turn requires more nursing care. It is estimated by 2016, the nursing field will create 587,000 new positions which would be amid the highest for any profession (Bureau of Labor Statistics, 2007). This would, in fact, be an increase of 23 percent from those currently in today’s workforce.

this lack of quality time with the patient (Roman, 2008).This leads to a decrease in the quality of care a patient can and will receive. As a result, this issue of the current nursing shortage will eventually affect everyone in our society. Moral Distress

Moral distress can be defined as an act of not pursuing what is right due to certain obstacles which make it impossible to do so (Zieber et al., 2008). Moral distress affects a nurse’s interpersonal relationship, mind, and body, which will eventually affect the nurse’s bedside duties and demeanour. When nurses are not able to perform as a nurse patient advocate, they become frustrated and disappointed. This behaviour can slowly increase and eventually cause nursing burnout, especially if there is a lack of administrative or managerial support (Zieber et al.). A staff nurse’s morale is already experiencing the negative effects of the nursing shortage (Ellenbecker, Samia, Cushman, & Porell, 2007).This can be exhibited by a staff nurse caring for a terminal patient. The nurse wants to

Impact on the Patients

The nursing shortage and increase in workload on the nursing staff directly affects the way in which nurses are able to deliver patient care (Rosseter, 2009). If there are fewer nurses with a higher workload, the quality of care a nurse can deliver will ultimately suffer. The physicians have already become far removed from bedside care, due to their increased patient loads and external demands. For that reason, a patient is dependent on the nurse and the quality and quantity of time that a nurse can spend with them to care for their basic needs and monitor their progress. Yet, the nursing shortage has greatly reduced this bedside time. Their capability to detect complications early has been significantly hindered due to

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spend time with the patient and their family to prepare them for what is to come. She or he wants to educate them on the feelings and emotions they may experience and the physical symptoms that might occur. The nurse wants to help them with the grieving process and dealing with their loss, all the while continuing to administer the patient medications and therapies. However, one of the other nurse’s patients needs her or him to travel to Diagnostic Imaging (DI) for a test. Meanwhile, the nurse is needed to discharge another patient home, which includes arranging for transportation, making follow up appointments, explaining prescriptions, and verifying their understanding of the discharge instructions. But before all of this occurs, she or he has to admit a new patient coming from the emergency room. This entails orientating the patient and family to the unit, verifying the admission orders, and completing a full head to toe assessment including past medical history. Furthermore, the nurse has to set up services for the new patient such as meals and therapies in addition to ordering supplies and medications. Moral distress arises when the nurse has to prioritise patient care. The patient requiring the test and the new admission are going to take precedence over educating the terminal patient and their family on what they can expect to occur. Unfortunately, there are only so many hours in a shift with which to complete these tasks. Therefore, the education might not get accomplished. This can cause moral distress in the nurse. She or he knows the right thing to do would be to educate and spend more time with the terminal patient and their family preparing for their loss. However, due to the lack of assistance from other nursing staff, secondary to the shortage, the nurse is unable to do what she or he feels is right. This moral distress will ultimately lead to job dissatisfaction.

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Job Dissatisfaction

There are multiple factors that contribute to an employee’s job satisfaction. Most of these are individualistic, yet some are universal. The work environment plays a large role in an employee’s contentment. In particular, the internal work environment of the healthcare industry is pivotal to employee satisfaction. This environment must protect the safety of both the patient and the nurse (Ellenbecker et al., 2007). In the previous example of moral distress, the nurse might feel the assignment is unsafe. Maybe the patient who needs the procedure in DI has altered mental status and might be trying to climb out of bed. If the nurse is with her or his other patients, the nurse might not be able to protect the patient’s safety. What if the nurse was pregnant? Maybe she would feel uncomfortable traveling to DI due to risk factors regarding the pregnancy, such as radiation. Or maybe the nurse

has multiple medications due for her or his other patients while the nurse will be away in DI. Therefore, they will not be administered on time, consequently making it an unsafe assignment. Meanwhile, the terminal patient and their family are still awaiting the education. In addition, the last patient is complaining, because they have not been discharged home. This nurse will be dissatisfied with the assignment, due to the inability to complete the basic nursing tasks. If someone is not satisfied in their current position, what is going to keep them from leaving? Financial Impact

This turnover and loss of nursing staff is costly to institutions. The financial burden of replacing an experienced nurse is anywhere from 50 to 200 per cent of the nurse’s base salary (Ross, 2009).Staff salaries tend to account for the majority of an institution’s budget. With the current economic times and budgets being unyielding, there is little

NURSING RETENTION According to Ross, retention is the key (2009): “Our efforts to eliminate the nursing shortage will only be successful when we improve the working environment for nurses and, in turn, improve retention” (p.22). An experienced employee’s knowledge base benefits the novice employee by training beginner nursing staff with evidenced base practices. The experienced nurse also enhances patient care by her or his ability to detect adverse patient conditions more quickly. Retention of experienced nurses is essential to retaining the expertise and knowledge that only hands-on experience can provide (Ross).In order to effectively enhance retention, first the employer must understand what is causing the nurses to leave their organisation or the profession itself.

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The nursing shortage has compounded the stress and demand on the current nursing staff. Therefore, due to moral distress and job dissatisfaction, more and more nurses are leaving the profession altogether. In the 2005 survey by Buerhaus, 93 per cent of nurses stated that the nursing shortage and its affect on the work environment would lead them to leaving the profession (as cited in Rosseter, 2009). The current lack of qualified staff increases the workload for each individual nurse. This increased workload is physically and emotionally draining for these nurses. It causes moral distress and job dissatisfaction among the nursing field which generates turnover and burnout, therefore perpetuating the nursing shortage.

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opportunity for the high cost of training new employees. It has been shown that having experienced nurses on staff improves the quality of care that a patient receives and their presence directly affects patient satisfaction (Westendorf, 2007). Patient satisfaction can be transmitted to customers via public access or word of mouth. It is one of the main driving forces of consumers in choosing their healthcare facility. With financial reimbursements tied to performance outcomes and quality of care, it is essential that organisations preserve their experienced staff (Roman, 2008). These institutions need to devise a plan to increase the retention in their facility. Retention Solutions

Nurses are stressed due to the lack of qualified staff which causes them to leave the organisation or profession. This intensifies the nursing shortage for the facility and creates more stress among the nursing staff remaining. In turn, they decide to leave. It is a cyclical event that needs to be broken. There are various tactics being introduced throughout the country to increase retention rates. Residency programmes Organisations need to start retention endeavours from the very beginning of employment. It is estimated that one half of

A SI A N H O S P I T A L & H EA LT HCA R E M A N AGE M E N T

graduate nurses will leave their first employer in less than one year (Delegates to ANA, 2008).Some facilities are utilising mentorship programmes where graduate nurses and new hires are assigned to veteran nurses who assist them with learning the intricacies of the workplace. Other facilities are implementing a nurse residency program. These are hands on learning experiences for graduate nurses within the workplace. These typically work in conjunction with a mentorship program. Both of these programmes are relatively inexpensive and cost effective. A positive relationship between retention and nursing residency programmes has been previously demonstrated (Wishall, 2008). Ericksen (2009) states the first year turnover rates with these programmes is nearly one sixth of those without these programmes. Positive working conditions, which include an acknowledgement of work life balance, are crucial to nursing retention. This includes flexible work schedules, which allow the individual to plan their work around various activities and situations that arise in their personal life. Independence in scheduling has proven to be a key determinant in job satisfaction ratings (Ellenbecker et al., 2007). This positive working environment also includes professional growth. Some organisations offer financial reimburse-

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ment or incentives for seeking advancement in education. Higher education allows for professional advancement which can heighten oneâ&#x20AC;&#x2122;s self-esteem. With a heightened self-esteem due to career advancement, job satisfaction tends to follow. Many organisations are utilising financial incentives to assist with retention such as increased salaries, retention bonuses, and educational incentives. Individual units often give advantages to tenured employees, such as fewer holidays, scheduling perks, and freedom from being pulled to another unit (Ellenbecker et al., 2007).With the current economy, these incentives still play an important part in job satisfaction and retention. However, these tactics are typically short term and are utilised by many institutions. Therefore, they present no clear advantage over other facilities. Autonomy is the ability to determine your actions or make your own decisions (Ellenbaker et al., 2007). Nurses do not want to just follow physician orders. Nursing is its own profession. Nursing has its own set of diagnoses and therapeutic measures. Nurses are important members of the healthcare team. Autonomy has been reported as a key factor in job satisfaction, therefore potentially increasing retention rates. This independence needs to be supported by upper leadership. A large determining factor in job satisfaction is the environment in which one works. Internal environments can be moulded by the current practices and philosophies of the management (Pierce & Gardner, 2002).Most healthcare facilities are regulated by certain governing bodies to ensure safety and security. However, there are more factors in the environment equation than the physical structure. In addition, a manager must be in tune with their employees by listening to their concerns and letting the members know they have a voice. Employees who feel their ideas are being heard and considered are more

HEALTHCARE MANAGEMENT

likely to stay with the organisation (Gaddis & Cates, 2009). Many changes in policies and procedures have come directly from nurses at the bedside. These modifications were possible as a result of receptive management. Overall, an employee wants to be a valued asset to the organisation. They want to be rewarded, either formally or informally, for good performance. Employees perform better when they are motivated by managers who display the attitude or behaviour which they are seeking (Gaddis & Cates).Employees who feel they are valued have better job satisfaction and therefore better retention rates. Many of these tactics are utilised by hospitals to obtain Magnet status. Magnet is a voluntary surveying organisation for nursing in hospitals. Westendorf (2007) reviews that Magnet hospitals must exhibit the eight essentials of magnetism: support for education, working with competent coworkers, positive nurse-physician relationship, nursing autonomy, a working culture that places emphasis on the patient, control over nursing practice, adequate staffing, and administrative support. In order to achieve Magnet status, a hospital must undergo an evaluation by the organisation in which the hospital is visited. The nursing staff is interviewed and their current policies and procedures are reviewed. There has been a direct correlation with Magnet status and increased retention rates (Wishall, 2008). The title of Magnet status can also be beneficial when recruiting new nurses. It speaks to what kind of nursing organisation is present within the institution. Barriers

First of all, society still has the stereotypical image of nursing as a subservient role. Nurses are still portrayed in the media as behind the scene servants and minor characters in the healthcare industry. In order to recruit the younger generations, this image needs to be addressed. In 2002,

RECRUITMENT

With the current movement towards high-involvement management, or management with more participation from all positions, companies are realising the organisational members are their most valuable resource (Pierce & Gardner, 2002). Recruiting new employees adds diversity with new ideas and perspectives from the outside world. However, the healthcare industry faces many barriers with regards to recruitment.

Johnson and Johnson launched the Campaign for Nursingâ&#x20AC;&#x2122;s Future. Its sole purpose is to improve the image of the nursing field (Rosseter, 2009). They utilised television and magazine ads, brochures, and launched an interactive website1. These images and personal testimonies display the various career choices a nurse has and the everyday rewards of being a nurse. This campaign is geared toward young adults, typically high school to college age. They have continued to run this campaign and plan to continue it throughout the current nursing shortage. In addition, the healthcare industry is not well versed in the strategies of recruitment. A study showed that 75 per cent of the surveyed hospitals did not respond appropriately to qualified applicants (Westendorf, 2007). Materials requested from these applicants were not delivered and when there was follow-up, there was a lack of personalisation. Also, technology was not utilised in the recruitment process. Snail mail was utilised as the primary method of communication. However, the applicants from the younger generations primarily use e-mail, Twitter, facebook, and texting (Westendorf ).The industry needs to learn from its corporate fellows the fundamentals of good recruitment techniques. 1 www.discovernursing.com

Many incentives are currently used to recruit new hires such as sign-on bonuses, free housing, relocation support, international recruitment, liberal shift differentials, and benefits for part-time employees which are equivalent to those of full-time employees (Westendorf, 2007). However, the organisation needs to tread lightly in this arena with regards to their tenured staff. These recruitment methods may cause animosity amongst the long-term hospital employees (Westendorf 2007). The organisation should offer these same benefits for retention purposes. Therefore, exhibiting equality and not alienating the existing employees. In addition, temporary sign-on bonuses tend to encourage the job hopping phenomena (Ericksen, 2009). The nursing shortage is further compromised by the lack of qualified faculty in the nursing schools (Roman, 2008). Nurses seeking higher education are going into clinical roles as opposed to the education system. Faculty pay and benefits cannot compete with those of the larger healthcare organisations. Therefore, the schools are only able to accept a limited number of applicants. This reduces the amount of available candidates for these new positions. Due to the current state of our economy, there are many people that might be looking for a career change

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A SI A N H O S P I T A L & H EA LT HCA R E M A N AGE M E N T

(Erickson, 2009). Mentorship is also a great way to unify the staff by partnering the established staff with the new hires. This programme, like the residency programme, contributes to higher retention rates. The existing staff can also benefit from the use of recruitment strategies. Some organisations offer finder’s fees and tour bonuses to employees for recruitment of staff (Westendorf, 2007). In addition, participating in an interview panel or becoming a mentor are excellent opportunities to get the current staff involved and motivated for the recruitment process.

By the year 2025, it is projected that the nursing shortage will reach 500,000 positions (Rosseter, 2009).

Conclusion

The nursing shortage is here and is expected to worsen over the next few years. The shortage affects everyone from fellow nurses, to physicians, to patients and society as a whole. If organisations and educational facilities do not respond quickly, matters are only going to get worse. Organisations need to realise that employees are their most valu-

able resource. Therefore, organisations should first put forth the effort to retain these existing staff members. In addition, recruitment of new employees should begin in the school system, starting as early as school-age students all the way to those graduating from nursing school. The healthcare organisations need to welcome these new hires with mentorship or nurse residency programmes to solidify the employee’s place within their institution. Where these efforts fail, management needs to step forth and analyse the current work environment. They need to make efforts to reduce the moral distress and workload, therefore increasing job satisfaction (Ellenbecker et al., 2007). In addition, these organisations should consider obtaining Magnet status. This status helps the organisation address recruitment and retention issues by analysing their current practices. Nevertheless, there is a positive side to all of this. The shortage has revealed the importance of the role the nurse plays in the healthcare field to both lay people and fellow healthcare providers (Roman, 2008).Nursing is a great profession with the ability for autonomy and a work life balance. Nurses are the frontline members of the healthcare industry. They are with the patients, caring for them at the bedside around the clock. Nurses are the first ones to detect complications and prevent adverse patient outcomes. As Johnson and Johnson states in their Discover Nursing campaign (http://discovernursing.com), “There has never been a better time to be a nurse”. References are available at www.asianhhm.com

AUTHOR BIO

into the healthcare industry due to job security and numerous employment opportunities. These might be second career candidates or high school graduates. As previously stated, nursing residency programmes are successful in both recruitment and retention of new graduates (Westendorf, 2007). Organisations need to go to schools and actively recruit these potential employees. Most schools offer on-sight job fairs that the organisations can have their human resources attend. In addition, the organisation can partner with the schools by offering student job opportunities and guest lecture series. Some organisations are utilising their nurse leaders as instructors for associated courses. The students attend lectures given by these leaders then rotate through the various units of the hospital (Ericksen, 2009). This familiarises the student with the facility and already fosters a working relationship. Westendorf (2007) suggests we need to foster these relationships earlier on. She suggests visiting school-aged children in the classroom to open their eyes to the nursing profession. These school-aged children will be entering the workforce in 15 to 20 years when the shortage is supposed to be at its peak. Gearing them towards the nursing profession at this early age influences them before they determine what is or is not a desirable career (Westendorf, 2007). Recruitment of experienced staff is geared more toward incentives. However, as stated before, these incentives must be available for the long-term staff. Tuition reimbursement, clinical ladders, and vacation packages are examples of incentives that can be offered to both new recruits and existing employees (Westendorf, 2007). The mentorship program for experienced nurses, like the nurse residency program for new graduates, fosters a welcoming environment and encourages staff to join the organisation

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Uche Nwabueze is an Instructional Professor of Management in the Department of Maritime Administration at Texas A&M University.

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Advertorial www.asianhhm.com

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ANOTHER AMERICAN REVOLUTION! Fee-for-service is on its last legs in the United States. More important is rewarding healthcare providers for the quality of care, efficiency of services provided, and degree of coordination of care. The healthcare system in the United States is outrageously expenses. Dramatic steps have to be taken to correct the situation. Peter A Gross, Chairman, Hackensack Alliance Accountable Care Organization

revolution is taking place in healthcare in the United States. The current fee-for-service approach to paying for provider services is too expensive and at the root of abuse. The Center for Medicare and Medicaid Services (CMS) is leading the charge for change. The new view of how to pay for healthcare is in evolution. CMS is testing many different approaches to paying for healthcare services. The common factor among them is the offer of financial incentives to the providers when they present evidence of improve quality of care and a reduction in the costs in that care. These changes were initiated in 2012.

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The quality measures selected are typically based on Don Berwick’s Triple Aim: better care, better health, and at a lower cost. Better care refers to the patient’s experience of care from their healthcare provider. Better health has to do with compliance with several preventive practices such as colonoscopy, haemoglobin A1c less than 9, use of statins, and control of hypertension to name a few. Cost of care can be lowered by attacking the low hanging fruit, namely reduced hospital admission, emergency room visits, and readmissions. In addition, there are many other opportunities to reduce costs such as admissions to and length of stay in skilled nursing facilities (SNFs).

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The most common payment approaches used by CMS are the: • Accountable Care Organizations (ACOs)through the Medicare Shared Savings Program (MSSP) • Bundled Payment for Care Improvement (BPCI) and Advanced BPCI • The most common applied program is based on MACRA legislation (Medicare Access and CHIP [Children’s Health Insurance Program] Reauthorisation Act of 2015). MACRA created the quality improvement program known as Merit-based Incentive Payment System (MIPS). So much for the acronyms, now let’s get on with what it all means.

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The idea for ACOs was actually initiated in the George W. Bush Republican administration and later added to the Obama Democratic creation of the Patient Protection and Affordable healthcare for America (PPACA or simply ACA, also known as Obama Care). Currently, in the United States, there are approximately 500 Medicare ACOs and an equal number of commercial ACOs. It is a huge programme that is not widely recognised yet. You ask, how are they doing? It depends on how you calculate success. Medicare uses as its benchmark for individual ACOs, how that individual

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ACO performed in the previous three years versus the current year. If the ACO performed better than its three year average benchmark, then they saved money. CMS will split the savings 50-50 with the ACO tempered by the ACO’s performance on the quality measures. CMS estimated that the MSSP programmes saved US$954 million in the first few years. Approximately 25 per cent of the ACOs saved enough money to warrant sharing of the savings. Far fewer ACOs saved money in every year of the program. Dobson, Pal, Hartzman, Arzaluz, Rhodes, and DaVanzo took a different analytic approach than CMS. They compared the ACOs expenditures versus expenditures by practice groups

who were not ACOs during the same time period. Their benchmark for the ACOs was the expenditures by the non-ACO practices. For the years, 2013-2015, they found that ACOs saved US$1.84 billion which is nearly twice the above CMS savings estimated. Using their method of calculating savings, it is possible that more ACOs would be credited with sufficient savings to raise the percentage of ACOs sharing savings. McWilliams and Chernew’s group published several studies showing more detail. They highlighted which years and practice groups did well or did not do well. The Office of the Inspector General (OIG) in a separate survey of ACOs, listed likely success factors. So, the method of analysis

determined the degree of savings, that’s no surprise. Another payment method being studied is the bundled payment initiative. It is well underway. Success has been identified for Comprehensive Care for Joint Replacement (CCJR or CJR).The procedures are hip and knee replacements. It has been extensively tested throughout the USA. Quality is assessed by examining complications from surgery, patient experience, and reporting of these first two measures. If the actual cost per case is less than a predetermined benchmark, the savings is shared between Medicare and the orthopaedic surgeons, similar to the approach used for the ACOs. Other bundled payment programmes are available for oncology, end-stage

APPENDIX A: COMPARISON OF BASIC TRACK AND ENHANCED TRACK CHARACTERISTICS BASIC Track’s Glide Path

Shared Savings (once MSR met or exceeded)

Shared Losses (once MLR met or exceeded)

Advanced APM status under the Quality Payment Program?

Level A & Level B (one-sided model)

Level C (risk/reward)

Level D (risk/reward)

Level E (risk/reward)

ENHANCED Track (Track 3) (risk/reward)

1st dollar savings at a rate up to 40% based on quality performance; not to exceed 10% of updated benchmark

1st dollar savings at a rate of up to 50% based on quality performance, not to exceed 10% of updated benchmark

No change. 1st dollar savings at a rate of up to 75% based on quality performance, not to exceed 20% of updated benchmark

1st dollar losses at a rate of 30%, not to exceed 2% of ACO participant revenue capped at 1% of updated benchmark

1st dollar losses at a rate of 30%, not to exceed 4% of ACO participant revenue capped at 2% of updated benchmark

1st dollar losses at a rate of 30%, not to exceed the percentage of revenue specified in the revenue-based nominal amount standard under the Quality Payment Program capped at 1 percentage point higher than the benchmark nominal risk amount (e.g., 8% of ACO participant revenue in 2019 – 2020, capped at 4% of updated benchmark)

Yes

N/A

No change. 1st dollar losses at a rate of 1 minus final sharing rate, with minimum shared loss rate of 40% and maximum of 75%, not to exceed 15% of updated benchmark No; highest level of risk/ reward under Shared Savings Program

Yes

For more information, please visit: https://www.federalregister.gov/public-inspection/and https://www.cms.gov/newsroom/press-releases/cms-finalizes-pathways-success-overhaulmedicares-national-aco-program

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HEALTHCARE MANAGEMENT

renal disease, and a host of diseases and procedures. The last alternative payment model (APM) considered is MIPS. It applies to all physicians who are not in an Advanced APM. Advanced implies that the organisation is taking “downside risk.”In other words, the organisaiton is totally or at least partially responsible for reimbursing CMS for losses or cost overruns beyond the pre-determined benchmark. The four areas of the MIPS’ Quality Payment Program represent a consolidation of most of CMS’s earlier individual quality programmes. MIPS requires that the following four components be assessed: • Quality by the medical or surgical specialty • Improvement Activities • Promoting interoperability • Cost Looking at overall healthcare expenditures for these three payments methods and others, Glickman, DiMagno, and Emanuel pointed out that since 2011, healthcare expenditures have actually decreased significantly. Consequently, the above three alternative payment systems should continue to be studied and assessed. If this trend continues, it looks like the revolution will begin to have a successful outcome. To paraphrase Winston Churchill, this is not the beginning of the revolution nor the end. It is the end of the beginning. Financial incentives work in some programmes and only partially in other programmes. To try to insure success in their cost reduction programmes, CMS is upping the physicians' responsibilities to insist they take downside risk. Namely, if they spend more than a benchmark for their patients, the provider will be responsible for some or all of the loss. The new programme is called ‘Pathways to Success.’ It applies to the Medicare Shared Savings Program (MSSP) which is the payment program

Cost of care can be lowered by attacking the low hanging fruit, namely reduced hospital admission, emergency room visits, and readmissions.

for CMS’s ACOs. It goes something like this. As shown in the figure below, an ACO, under the new rules, can have upside gain only for 1 ½ to 2 ½ years at the most, then they have to move into a program that has downside risk. In summary, Basic Level A and B one-sided means upside gain only. In other words, if the ACO has gains above a certain level (i.e., the minimum savings rate or MSR), that ACO can share in the savings. The exact amount is determined by their degree of quality measure compliance. ‘“Risk/reward”’ means the ACO also has downside risk, not just upside gain potential. So, they are liable for part of the losses when that loss exceeds a certain amount (i.e., the minimum loss rate or MLR). Advanced APM status applies to Basic Track Level E and Enhanced Track only. These two are exempt from MIPS. Basic Track Levels A through D need to complete the MIPS Quality Payment Program components, which is a significant burden. Other options offered in Pathways to Success are: • Increasing use of telehealth • Choosing beneficiary assignment as either prospective or retrospective • Giving the provider the option to offer beneficiaries a financial incentive to cooperate with the program better, thereby earning not only the incentive, but better health!

• Increasing access to a Skilled Nursing Facility (SNF) without having to be admitted to a hospital first for 3 days. Pathways to Success is a brand new program. It will begin on July 1, 2019 for current ACOs accepted into the program. For others, the newbies, it will begin January 1, 2020. Now you can see how a healthcare system that hasn’t been able to control its costs is trying to reign in those costs. The initial effort was to offer providers financial incentives to reduce the costs. Surprisingly, not many providers took up CMS on its offer to do that and share the savings at the same time. This result debunks the popular notion that providers are motivated primarily by financial gains. The second and current approach is to put providers at risk for losses and make them liable for excess expenses when their expenses exceed a predetermined benchmark. As this is a new approach, the jury is still out on whether this approach will succeed. A lot will depend on whether commercial payors also insist on forcing providers to assume downside risk. If there are too many escape clauses, this effort will have a limited effect. So, those of you outside the United States, wish us good luck. We can’t match your numbers for providing good care at a lower cost, but we are trying. References are available at www.asianhhm.com

AUTHOR BIO

Peter A Gross is the Chairman of Hackensack Alliance Accountable Care Organization.

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DUBAI HEALTH INVESTMENT GUIDE 2019 Focusing the future

Dr. Ibtesam AlBastaki, Director of the Investments & PPPs Department, DHA

1. The Dubai Health Investment Guide comes very handy for potential investors. The gap analysis with the facilities is very helpful too, but to maintain uniformity among the investors how the DHA is going to market this program across the various private facility providers (to fill-in the gap)? Do you have facility specific promotion programs? Thank you, DHA is working continuously to inform investors on the gaps and health system needs for Dubai through the Health Investment Guide 2019, and we are currently developing a Certificate of Needs Guidelines for Dubai, the purpose of which is to channel investments in priority areas to meet the needs of our community.

The initiative is aimed at:

• Supporting and guiding investments of the “right” caliber to deliver high - quality services as per best-in-class international standards • Limiting overcapacity of specialized services and protecting investments into these services

• Ensuring stability and sustainability of quality of care by service providers through supporting enhanced reimbursement (where necessary), empanelment with insurance cos. and other commercial incentives

2. Can you throw some light on the new health facility guidelines that are laid down by Health regulation sector? What has changed in the newer version? The new Health Facilities Guidelines have been revised and updated and these have been benchmarked to best practices in other parts of the world. The Guidelines are more comprehensive in scope, patient focused, and have been developed after considerable research to ensure that we have modern and efficient planning principles on administrative provisions, efficient design, access/ mobility THE GATEWAY and safety for both new public and private • An open economy and a strategic location, betwe facilities. More information on this initiative and Asia world class transport services and infrastructur is available in the• ADubai Health Investment trade and business Guide 2019 and on the DHA portal.

DUBAI HEALTH INVESTMEN

THE DUBAI ADVANTAGE THE CITY

EALTH INVESTMENT GUIDE 2019 • A young and fast growing population estimated to reach between 4.6 and 5.5 million in 2030

• An alluring destination for tourists with landmark destinations and attractions • A well diversiﬁed economy with low dependence on the oil & gas sector

3. Could you explain in short the licensing process for a new healthcare facility THE GATEWAY THE HUB in Dubai? een • An open economy and a strategic location, between Europe, Africa • An investor-friendly destination, Setting up a health facility in Dubai is leading an the region Asia investment, technology and innovation By Outp Landmark projects and A growingand population with greater easy and smooth process, optimised By 2030, it and attractions • A world class transport services and infrastructure for tourism, • Globally recognised quality of lifeby and ability to reta infrastructure need for health services trade and business digital procedures. Investors wishing to Rooms will b as sector • One of the fastest growing populations in the world • Dubai Expo 2020 is set to host est. 25 million visitors facility in the Emirate of open a health Preliminary gaps in no. of a • Approximately 8% UAE Nationals aged +60 y.o. by 2030 • Major touristic and leisure attractions and upcoming residential OP rooms, Dubai and/or one of its free zones will base case communities in South Dubai and other catchments 2020 20 a different journey, based on the 2025 A high prevalence of chronic and • Dubai Int. Airport welcoming 90follow million passengers per year and Al 2,1 Maktoum Int. Airport has capacity to handle 26.5 million passengers nature of their project (new constructions non-communicable THE HUB diseases vs. refurbishments/ expansions). 447 urope, Africa • An investor-friendly destination, leading the region in sustainable • The UAE is amongst the countries with the highest prevalence coverage sustaining the By Outpatient Health Visit Rooms other Key Landmark projects and diabetes, investment, technology Detail process maps are By available in Planning rates for obesity, cardiovascular diseases and and innovation smoking development the healthcare sector By 2030, it is forecasted that around 2,106of additional Outpatient (OP) Visit r infrastructure tourism, • Globally recognised quality of life and ability to retain talent compared to OECD countries the Dubai Health Investment Guide Rooms will be required in Dubai*, mainly in sectors #5, #1 and #2. Operating Theatres • Cardiovascular diseases and cancer are the main causes of • Over 98% of Dubai’s population2019, beneﬁts for fromhealth health insurance 1,161 facilities and hospitals/ o 2020 is set to hostmortality est. 25 million visitors in Dubai and are seeing a rising prevalencePreliminary and gaps in no. ofcoverage additional Gaps in no. of additional OP rooms, per specialty, base case growing burden of disease for both new construction and ristic and leisure attractions and upcoming residential OP rooms, base case • In 2017, est. 60% Allied Primary ofCare the health clinics, expenditure ofhealth est. AED 17.5 billion

DRIVERS FOR HEALTH INVESTMENT

HEALTH INV

NT GUIDE 2019

ies in South Dubai and other catchments

HEALTH INVESTMENT NEEDS AND OPPORTUNITIES

2020

2025

An increasing utilisation Airport welcoming 90 million passengers per year and Al STMENT NEEDS AND OPPORTUNITIES Int. Airport has capacity to handle millionhealthcare passengers of 26.5 private

726 was reimbursement 501 2030covered by health 198 insurance 120 2,106

194

262

Respiratory Medicine Paediatrics Embracing digital revolution 209 228 145 100 76 and innovation 26 coverage A SI A N H O Ssustaining P I T A L & H EA LTthe HCA R E M A N AGE M E N T IS S UE - 45,447 2019 Health • Utilization of healthcare services in Dubai increased at est. 6-7% 60 ent Visit Rooms By other Key Planning Units 2012 andOutpatient 2017 • Innovative applications and robotic surgery for Endocrinologysuch as 3D printingNeurology development of the healthcare sector ecasted that aroundbetween 2,106 additional (OP) Visit

2020

26 By Acut

By 2030, it 2025 Beds will be

Emergency Departm Preliminary gaps in no. of a IP beds, base case 2020

2025

THE DUBAI ADVANTAGE THE CITY

THE GATEWAY

• An alluring destination for tourists with landmark destinations and attractions

• A world class transport services trade and business

• A young and fast growing population estimated to reach between 4.6 and 5.5 million in 2030

• An open economy and a strateg and Asia

• A well diversiﬁed economy with low dependence on the oil & gas sector

DRIVERS FOR HEALTH INVESTMENT A growing population with greater need for health services • One of the fastest growing populations in the world • Approximately 8% UAE Nationals aged +60 y.o. by 2030

A high prevalence of chronic and non-communicable diseases • The UAE is amongst the countries with the highest prevalence rates for obesity, diabetes, cardiovascular diseases and smoking compared to OECD countries • Cardiovascular diseases and cancer are the main causes of mortality in Dubai and are seeing a rising prevalence and growing burden of disease

An increasing utilisation of private healthcare • Utilization of healthcare services in Dubai increased at est. 6-7% between 2012 and 2017 • Private sector treated 79% of outpatients and 74% of inpatients in Dubai in 2017 • Number of licensed health facilities and healthcare professionals has grown of +3.9% p.a. and +8.1% p.a. between 2014 and 2017, and 10 new hospitals have come between 2010 and 2017 in the private sector

A leading position as a health tourism hub • 500,000 health tourists are expected in Dubai by 2020, growing from est. 326,000 health tourists in 2016 • Health tourists can choose from more than 600 packages supported by healthcare visas issued within 48 hours

HEA Landmark projects and infrastructure

• Dubai Expo 2020 is set to host est. 25 million visitors

Prelimin OP room

• Major touristic and leisure attractions and upcoming residential communities in South Dubai and other catchments

2020

• Dubai Int. Airport welcoming 90 million passengers per year and Al Maktoum Int. Airport has capacity to handle 26.5 million passengers

Health coverage sustaining the development of the healthcare sector • Over 98% of Dubai’s population beneﬁts from health insurance coverage

1,161

• In 2017, est. 60% of the health expenditure of est. AED 17.5 billion was covered by health insurance reimbursement

Embracing digital revolution and innovation

Prelimin IP beds

• Innovative applications such as 3D printing and robotic surgery for complex procedures are adopted at leading hospitals

2020

• Ranked #1 in the MENA region as per the Global Innovation Index • Licensing of telehealth and homecare providers in place with supporting initiatives by Dubai Accelerator Program

A positive investment climate

654

* As per t Plan 2018 planned b (861 beds and 2030) probabilis supply to

• Dedicated free-zones for healthcare and life sciences allow for 100% ownership and repatriation of proﬁts

• 7th most globally competitive country, home to 196 regional ofﬁces of Fortune 500 companies • Proposed 10 year visa for investors and doctors

Source: Pr Clinical Se

ENABLERS: DUBAI SUPPORTS The growth we see is supported by a rise in popularefurbishment HOW / expansion projects. In any PRIVATE case, on INVESTMENT?

tion, rising utilization of health services specifically in the new hospitals in planning stages it is advised to first get in REGULATIONS AND HEALTH INSURANCE THE INVESTMENTS & private sector, the implementation of mandatory health touch with DHA Investment and PPPs Department, which • Health insurance spending has LICENSING PPP’S DEPARTMENT insurance has seen approximately 98% of Dubai’s will be able to provide guidance and advice throughout risen from AED 4which billion in 2012 • AI enabled Sheryan system to ease licensing • Promotes investment in priority areas to est. 10.5 billion in 2017 covered by health insurance (as of 3 resident population the process. of health facilities and professionals • Engages government stakeholders and • Plans to ensure price stability September 2018), and an increase ininvestors healthcare spend• Key initiatives to improve quality: health on priority investments improve through facility guidelines, KPI insurance framework toframework report due efﬁciency to growing confidence in the health system and 4. With the mandatory health in place, anding • Facilitates planning and insights to the introduction of the DRG’s for quality and etc. investors through in ‘Dubai improved services theHealth how do you think it efﬁciency boosts outcomes, the healthcare ecosystem in inpatient servicesaccess to specialized health Services Navigator’ Emirate of Dubai. Dubai, does it presents any hurdles for the prospective Increase in demand for quality health services due to investors? Dubai’s rapid urban development, population growth and Dubai’s health sector has seen tremendous growth over influx of medical tourists is one of biggest opportunities for the last few years, with number of licensed health facilities private sector providers and investors in the health sector. growing to 3,100 by April 2018 from approximately 2,800 Many of world’s largest hospitals and specialized centres facilities in 2014 with an approximate year-over-year growth have invested in Dubai’s healthcare sector after realizof four per cent. This increase includes private hospitals, ing the city’s unique investment climate, which provides specialised health centres, pharmacies, diagnostic centres a number of investment incentives in the healthcare and dental centres. Contd.... www.asianhhm.com

sector. Investors and providers would need to study and better understand the different segments of population covered by different types of insurance packages. There are differences to the limits on health spending, coverage of services and access to a network of providers that is linked to the type of insurance coverage plan, which is often customized to the needs of the population segments and the employers.

ENABLERS: HOW DUBAI SUPPORTS PRIVATE INVESTMENT?

5. What is Dubai Healthcare City and how does it fit itself in the Dubai health investment program? Dubai Healthcare City Authority is a free zone home to clinical partners including hospitals, outpatient medical centres and diagnostic laboratories across 160 specialities with licensed professionals, strengthening the free zone’s medical tourism portfolio. Dubai Healthcare City Authority has numerous advantages for investors in healthcare, such as 100% ownership for both expatriates and UAE Nationals. More information on Dubai Healthcare City Authority is available in the Dubai Health Investment Guide 2019. 6. What is Dubai science park and what will be its role in health investment program? Dubai Science Park (DSP) fosters an environment that supports scientific research, creativity and innovation for the life sciences and health sector. Since its inception, the community has grown to more than 350 companies, employing over 3,600 professionals in the sciences, energy and environmental sectors. DSP has numerous advantages for investors in life sciences and healthcare related sectors, such as: • 100% foreign ownership and repatriation of profits and capital • Exemption from customs duty for goods and services • No trade barriers or quotas • Strong regulatory framework • More information on Dubai Healthcare City Authority is available in the Dubai Health Investment Guide 2019. 7. How the government has aligned its various policies to attract positive health program investments from desired regions? At DHA engage with stakeholders across Government and the Private Sector to support a positive and thriving investment climate that fosters private sector investment and participation. Through Government investment promotion agencies such as Dubai FDI and other DHA led efforts at events regionally, we engage with investors and stakeholders on health system needs and opportunities, and through our upcoming Certificate of Needs Guidelines and other initiatives we will continue to support, facilitate and promote strategic investments in healthcare for Dubai. H.H. Sheikh Maktoum bin Mohammed bin Rashid, Deputy Ruler of Dubai has emphasized and laid the foundations

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for investment and growth in the health sector – “Our aim is to attract investments that benefit the emirate and the community via an investment strategy in the health sector in line with the emirate’s aspirations to provide a healthy

global model that also meets with the objectives of the Dubai Plan 2021” The Dubai Health Investment Guide, a key initiative of the Dubai Health Investment Strategy 2017-21, aimed at providing investors and private sector health facilities with information on investment priorities and gaps as well as mapping of the investor journey for health investments, key developments in the health sector and to highlight the drivers that underpin investment and growth in the health sector in Dubai. The drive to establish advanced medical capabilities and modern infrastructure and facilities in the city make Dubai an attractive destination for private sector investment which also supports Dubai’s ambition to grow in profile as the leading medical tourism destination in the Middle East.

disease management, developing Centers of Excellence for Cardiology, Oncology, Diabetes and other specialties, to enhance and improve access to long term care, physical rehabilitation and home based care particularly to support the needs of the elderly and others with special needs in our Emirate, and to enhance and improve access to mental health services In the long term, we want to focus much more on population health management, value based care supported by better clinical outcomes and efficiency for the health system, improvements and adoption of genetic medicine and precision medicine, and beyond the pill initiatives. We are very focused on supporting the emergence of urgent care clinics, ambulatory care, specialized centers for different diseases and specialties and the use of telehealth in primary care and remote patient monitoring.

8. What are the aims of the Dubai Health Investment Guide and what is the rationale behind this initiative? The over arching aim of the Dubai Health Investment Guide is to provide investors with real time, reliable and robust information on demand for health services, supply and capacity gaps, and to enable investments in strategic opportunities and specialized health services. This benefits Dubai’s economy and the health sector, as it helps optimize and balance the supply of health services, informing investors clearly about areas of overcapacity, and quantifying the gaps where investment is needed. The Dubai Health Investment Guide is broken up into different segments and it – • Details the drivers underpinning the growth of healthcare demand in the Emirate of Dubai which includes the growing population, strong and diversified economy, stable and attractive investment climate, rising burden of disease and prevalence of chronic diseases, rise in health tourism among others • Provides an overview of health regulations and the health insurance system which includes upcoming changes and initiatives relevant to investors • Maps the investment journey for different types of facilities • Highlights the investment needs and priorities for outpatient care units, acute inpatient beds and specialized services including long term care and critical care beds for 2020, 2025 and 2030 based on the Dubai Clinical Services Capacity Plan 2018-2030 • Provides details on free zones in Dubai focused on supporting healthcare and life sciences

DHA’s investment focus for the next 2 to 3 years

9. What are the opportunities in the healthcare ecosystem in Dubai that are identified by the Dubai Health Investment Guide? In the short term, 3-4 years have needs along the continuum of care – to develop and enhance services for chronic

• Innovations in primary care • Ambulatory care • Urgent care clinics • Mental Health • Chronic Disease Management • Tertiary Care for diabetes, cardiology and oncology • Diagnostic Health and Remote Monitoring • Rehabilitation and Physical Therapy • Home-based care • Long-term and extended care

DHA’s investment focus for the next 3 to 5 years • Prevention and Pharmacy beyond-the-pill • Precision Medicine and Genetics • Population Health Management • Nursing Homes and Palliative Care

Dr. Ibtesam Al Bastaki is the Director of Health Investments & PPP’s Dept. in DHA. In career spanning over 21 years in healthcare in the UAE, Dr. Ibtesam has held senior leadership positions in Dubai Health Authority, Prime Minister’s Office and VPS Healthcare focusing on strategy planning and implementation, investment planning and facilitation, driving innovation, health system reform, public – private partnerships and private sector business development and medical tourism, spearheading the set up and expansion of health facilities and services in both public and private sector

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HEALTHCARE MANAGEMENT

THE SCIENCE OF HEALTHCARE DELIVERY The symphony

Communication and Information (C&I) forms the base of care delivery, and, many times the outcomes of situations. This is true for any healthcare service organisation. The patient communicates problems and medical history to the doctor, the doctor communicates the condition and treatment plan to the patient and communicates orders to the nurses / RMOs, the orders for medication / investigation are communicated further, the results and effects are communicated back to the doctor, and to complete the loop, the patient condition is tracked. This loop continues till the patient is well again. What if this loop breaks or becomes a Chinese Whisper…? Gurrit Sethi, Strategic Advisor, Global Health Initiatives

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he construct of healthcare delivery is a complex maze and an interesting one — this science involves various industries come together, like the tunes of many instruments in an orchestra —-to name a few the pharmacy, the IT, the hotel experience — all come together with medical services to create one hospital! When not in harmony the beautiful tunes turn into a cacophony of sounds. The same happens in healthcare service delivery as well when these different parts do not function in harmony. And worse when the wrong cords are pulled.

HEALTHCARE MANAGEMENT

Picking up again on the construct of healthcare organisations (refer last article in Issue 44), like all structures, a good plumbing system is critical to the flow — of information and communication. In the last issue we looked at the Patient / Family experience. Now let’s examine the scene behind the scenes. The physician and the support that is critical to the medical delivery of outcomes expected. Imagine this situation: The family stood at the admissions counter. It was almost thirty minutes. The receptionist sat at her desk trying to punch in furiously. The system, read – Hospital Information System (HIS), was running slow. The receptionist was too involved in getting the computer to respond to make the family comfortable and offer them a seat since it was taking time. The nurse rushes across the nursing station in the morning to fetch the patients’ file as the surgeon walks across to meet the patient on his morning round. The reports of the investigations ordered the evening before have not arrived. The patient and family eagerly await to be told of the patients’ progress and prognosis. The doctor ordered medications scribbled across the sheet. The nurse sent the request to the pharmacy. The pharmacy did not have the medication. An alternative was suggested, cross checked for doctors’ approval and ordered. The dosage got delayed. The doctor had ordered a medication which was not part of the formulary. The surgery was scheduled. The patient was prepared. The Nurse refused to shift the patient. The surgery consent form was missing / incomplete. The family needed to be explained the risks and agree to those. The patient was to be wheeled into the operation theatre at 9 AM. The first case got delayed. The patient was rescheduled for surgery at 2pm. The nurse got into action to keep the patient hydrated via IV while the

A proper flow of communication and information helps build a bridge of trust between care givers and care takers.

patient demanded water and food… she felt bad for the patient but this has to be… Recent policy changes made by the government on consumable pricing and chargeability had the respective companies pull back certain products. Many patients who preferred and could afford these supposedly better products could not use the discretion to avail the opportunity for better care. The expensive consumables required by the surgeon were not procured and this delayed the surgery causing inconvenience to the patient and the staff. The internet connection was out and the indents for the items could not be received in time therefore the timely purchase was not possible. The patient was on the table in the Cathlab. The doctors were all scrubbed and huddled around him about to begin the procedure. The patient then wanted to pass urine. However, the general duty attendant was missing. Also no one could find the urine pan. The doctor had to de-scrub and catheterise the patient and then continue with the procedure. Three patients were lost in an OT post the surgery while weaning off the patients from anaesthesia. The scientific team much later realised that

this happened because of the exchange in gas pipelines of oxygen and nitrous oxide. The patient went into a shock. The nurse was given a verbal order for 14 units of insulin, the nurse interpreted it as 40. The sound alike drug and dosage orders need to be interpreted correctly and should be written. The doctor meant x units of IM to be administered but transcribed as IV. The nurse administered as IV and the patient went into an anaphylaxis shock. The patient was allergic to nuts and was a diabetic. He was served a sweet dish with nuts. The Endocrinologist reconciled the insulin dose as per the blood sugar of an operative patient. The RMO missed transcribing this to the drug chart. The nurse administered the continued dosage and the patient went into hypoglycaemic coma. The patient was in the hospital for over ten days and waited eagerly for the doctor to come. The senior consultant however remained busy in the OPD and then went to the OT. The patient was verbally advised for discharge by senior doctor, the junior doctor / nursing forgets to mention the same in the progress sheet and the patient stays in the hospital wondering why is he made to stay back. Such are the results if communications go haywire in hospitals. Thus the lengthy documentation procedures that teams have to follow. And the strong need for everything to be ‘protocolised’. This ‘protocolisation’ helps manifold. It helps work as a reminder for various pathways to follow by way of forms to be filled out. It supports reliability, repeatability and replicability – in the way care is delivered, the outcomes and the way of work. This predictability oils the system in a way that various different moving parts come together at the right time in the right way to do the right thing.

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but the delivery itself is through the nursing teams largely supported by other para-medical teams as well as non-medical teams. The attendants, and or the family, also plays a vital role in the delivery and the decision making. So educating these key stakeholders also become an important part of the care delivery system. For other stakeholders this provides an opportunity to build a predictable business steeped in a common goal of proving good patient care. A proper flow of communication and information helps build a bridge of trust between care givers and care takers (patients and family). When things go haywire, which many times they will, as after all doctors are not Gods, it is this trust that will save the day and the SYMPHONY. For the general masses who question the costs of healthcare, it is what does not meet the eye that largely accounts for quality of outcomes, and which is what we pay for. The process of hygiene, infection control, treatment protocol, along with and over and above the communication & information, calls for intensive training of care delivery teams across the spectrum. The intensive training requirement is not limited only to medical and paramedical teams. Rather for the required support from the Food & Beverage teams, the house keeping teams and others, the training needs extend across. Availability of medicines and consumables while maintaining the temperature and storage requirements through the supply chain, ensuring the right food is prepared for the patients and provided timely, the hygiene care for the patients keeping them tidy and infection free and ensuring the same for the environment, encompasses and defines the medical care environment and the outcomes of it.

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For care givers, these misses on symptoms through a proper history taking, misses on investigations for various reasons and more specifically misses in treatment protocols and documentation land many in trouble along with the institutions. The protocols are meant to aid in care and serve as tools to support good care and outcomes. These go a long way to also support the physicians in case of legal consequences should they arise. Care giving itself is a very complex process. While largely the two key players are the patient and the doctor AUTHOR BIO Gurrit K Sethi, Hospital Chief Operating Officer, Care Hospitals; Strategic Advisor for Global Health Services, Global Strategic Analysis, contributes to healthcare by helping providers build and better business efficiencies and concept development, also strives to contribute socially through the Swiss Foundation, Global Challenges Forum as Strategic Advisor, through conception of sustainable health initiatives. She started her career from the shop floor working her way up to lead and set up different healthcare businesses.

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Swiss WorldCargo

Shipping to destinations worldwide Susanne Wellauer, Senior Manager, Healthcare & Pharmaceuticals Vertical Industry

You've been in the industry for several decades, could you please highlight some of the noteworthy changes that the industry has undergone? What were the game changers for the industry players? We’ve definitely noted industry-wide changes in recent years. Digitalization has become more than just a buzzword; technological developments are now occurring throughout the freight industry. Shifts to eAWBs as well as continued investment into developing the right solutions, such as APIs and web services, show that we are increasingly living in a digital world and that the air cargo industry is part of this. The cargo and freight industry is always racing against time, how crucial is this when it comes to Pharma/Healthcare logistics and fulfillment? Time-critical shipments are an important and core part of pharma logistics. Pharmaceuticals often require quick shipping and rapid logistics throughout the world. Medicines, vaccines or clinical trials all count on speedy and agile shipping times and methods to ensure that these goods arrive in time. And this translates into results. Often, an on-time arrival can mean saving lives. For Swiss WorldCargo, this means that we must continue to invest in the right products and technologies that ensure

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that we can meet the critical needs and quick deadlines our customers require. How, over the years, has Swiss WorldCargo grown to fulfil client’s expectations which are categorically time bound? Investment in the right products and technologies is key for fulfilling our customers’expectations. Swiss WorldCargo continuesto do this, as we strive to findthe right innovations that can meet demanding and even challenging needs within a time-critical supply chain. Our company has specialized itself as a niche charrier, which has allowed us to differentiate ourselves from the competition. A big part of this is our temperature-sensitive product portfolio. Swiss WorldCargo currently has several solutions for demanding shipments: • SWISS Celsius Active: For transport of active temperaturecontrolled temperatures in ranges of -20 °C to+20 °C • SWISS Celsius Passive: Offers a choice between the four official IATA temperature ranges: controlled frozen (FRO -20 °C), controlled cool (COL + 2 °C to +8 °C), controlled room temperature (CRT +15 °C to 25 °C) and controlled extended room temperature

A330-300 we can reach a variety of destinations including New York, Miami, Boston, Chicago, Montreal, Bombay, Delhi, Tokyo, Johannesburg, and many others. Through a partnership with our sister airline Edelweiss, Swiss WorldCargo is also responsible for handling freight to a variety of intercontinental destinations. Finally, Road Feeder Services (RFS) complement our network and allow us to truck to destinations that may not be served by a direct flight.

• SWISS Celsius Passive Solutions: Temperature ranges between -60 °C and+25 °C according to the customer’s needs In addition to this, a focus on quality is central to Swiss WorldCargo’s service offering. We continue to look at ways we can offer quality services while helping to meet complex global shipping needs, including pursuing accreditations and certifications that promote our capabilities as a market leader. Swiss WorldCargo was awarded IATA’s CEIV certification – do you see it as a milestone for future business growth and market penetration? Does such certification SWC's brand? Receiving this CEIV certification was certainly a big milestone for us! It was an honor to receive this designation, as it states that we have remained committed to pursuing the highest quality in global pharma shipments. Swiss WorldCargo is known for being a reliable, quality-driven and focused brand. This certification is a strong reinforcement of this, and states clearly that we will continue to be able to play an important role in healthcare logistics worldwide, and that we will remain a key provider for carrying out sensitive global shipments.

How different are Pharma cargo requirements from other forms of logistics? What kind of product mix and service spectrum has Swiss cargo developed to cater to a wide customer base? Pharma shipments are some of the most care-intensive. They frequently require speed and temperature control, as well as flawless communication across the supply chain. As a result, Swiss WorldCargo has developed a pharma product portfolio that meets the needs of our customers in providing the right solutions. Additionally, our Swiss xPresso product covers the element of speed – with this we can ensure that our products benefit from industry-leading transit times, including an option for 60 minute transit times at our hub in Zurich.

Susanne Wellauer, Senior Manager of Vertical Industry Pharmaceutical and Healthcare at Swiss WorldCargo, began her career at Swissair in 1996 as Cargo Expert in Basel. Since then, she has held several sales and marketing positions at Swisscargo and Swiss WorldCargo, based in Switzerland. Before being appointed to her current role in 2014, Susanne was the Cargo Manager for the Basel region. Now, she monitors the industry needs and trends on a global scale and liaises closely with cold chain experts at freight forwarding companies, as well as at major pharma and healthcare companies. Email: susanne.wellauer@swiss.com

What regional markets is Swiss WorldCargo presently focused on? How do you see the Healthcare Where does it aspires to go from here? We focus onall global markets. Swiss WorldCargo operates a wide-ranging network of over 130 destinations, to destinations in Asia, North and South America, Africa and within Europe. With our Boeing 777-300ER, we are well-positioned service long-haul routes to important international business centers, including Singapore, Los Angeles, San Francisco, Hong Kong and Sao Paulo. With our Airbus A340-300 and Advertorial www.asianhhm.com

MEDICAL SCIENCES

ACKNOWLEDGING AMYLOID TRANSTHYRETIN (ATTR) AMYLOIDOSIS Amyloid transthyretin (ATTR) cardiac amyloidosis is increasingly recognised as a cause of heart failure with preserved ejection fraction (HFpEF). Physician awareness of this condition and the necessary investigations will allow for quicker diagnosis and treatment, which benefits both patient and healthcare systems worldwide. Diego H Delgado, Cardiologist, Division of Cardiology, University Health Network Associate Professor of Medicine, University of Toronto Specialised in heart failure, transplantation and cardio-oncology Bennett Di Giovanni, Research Fellow, Division of Cardiology University Health Network

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he ever-growing population of heart failure patients has put increased pressure on the healthcare systems of countries worldwide to accurately diagnose and provide holistic care. There are numerous pathologies which contribute to the development of heart failure and it is essential for physicians to be aware of all possible etiologies. Optimisation of care requires physicians to know the

MEDICAL SCIENCES

underlying disease process and the treatment options available. One such example which has been increasingly recognised as a cause of heart failure with preserved ejection fraction (HFpEF) is amyloid transthyretin (ATTR) cardiac amyloidosis. Definitively diagnosing this condition can help physicians improve quality of life for patients and work to limit the economic strain hospitals experiencewhen managing heart failure. Amyloidosis is a disease produced by abnormal proteins, amyloid, which deposit in tissues and cause organ dysfunction. Cardiac amyloidosis is therefore the impairment of cardiac function because of amyloid build-up in the heart itself. Patients are left with a thickened heart and continued amyloid accumulation over time willworsen restrictive cardiomyopathy and HFpEF. Amyloidosis can be caused by several misfolded proteins, with over thirty different precursor proteins currently identified. One such protein is transthyretin (TTR), a protein which is mainly found in blood and responsible for transportation of thyroxine and retinol. In some individuals, this protein becomes misfolded and forms ATTR. All types of amyloidshare characteristics in terms of structure and insolubility which explains why continuous amyloid deposition in tissue canbecome extremely problematic. ATTR can be produced in direct relation to a genetic mutation in the TTR gene that affects protein stability, which is referred to as hereditaryor variant amyloid (ATTRv). There is also a large cohort of individuals which possess no identifiable mutation and are described as having wild-type amyloid (ATTRwt). ATTRv amyloidosis was previously referred to as familial, because it has been identified in several countries and can often be tracked to specific lineages. The most common mutation worldwide is a point mutation, Val50Met (V50M,

previously V30M), with a significant cohort in the Japanese population. ATTRwt amyloidosis was previously referred to as senile because of its higher prevalence with increased age. Epidemiology

Though ATTR amyloidosis has traditionally been considered a rare disease, there is substantial evidence implicating this condition in HFpEF. Advances in diagnostic techniques including non-invasive options have played a large role in increased identification of cardiac amyloidosis. There is increased accessibility to these investigations and healthcare professionals are more capable of reaching a definitive diagnosis at an earlier stage of the disease. The prevalence of ATTR cardiac amyloidosis has been supported by autopsies demonstrating ATTR deposits in cardiac biopsies in a substantial proportion of elderly individuals with HFpEF. Many of these individuals did not have a pre-existing diagnosis, which helps emphasise that epidemiology of this disease is currently underestimated. ATTR amyloidosis has been typically associated with elderly males, but is likely under-diagnosed in all groups, especially females. Awareness of this condition, appropriate referrals, and improved diagnostics has contributed to the detection of increased prevalence of this condition.Furthermore, earlier identification will open new opportunities to tailor treatments to combat

the disease process before extensive amyloid deposition can occur. Presentation

Awareness of the condition is paramount because there is minimal information that can be discerned from a physical examination to identify ATTR amyloidosis. Therefore, physicians must consider the clinical picture, patient demographics and family history before proceeding with a more extensive amyloidosis work-up. There should be suspicion for ATTR cardiac amyloidosis in patients who are in their sixth decade of life or older, particularly if they have carpal tunnel syndrome or investigations showcasing hypertrophic or restrictive changes in the heart. Carpal tunnel syndrome can be one of the earliest signs of ATTRvandATTRwt amyloidosis, therefore it is essential for physicians to consider neuropathic symptoms or previous release surgeries when formulating their differential. Circulating amyloid can result in deposition in a multitude of organs and often depends on the genetic variant that a patient has. ATTRv amyloidosis patients fall on a spectrum of symptoms which range from exclusively neuropathic to exclusively cardiac depending on their specific variant. This contrasts with ATTRwt amyloidosis which tends to produce mainly cardiac involvement and symptoms in most patients.

Figure 1: Gross pathology of the heart from an individual with cardiac amyloidosis, demonstrating universally thickened myocardium (A), with some predilection for the interventricular septum (B).

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MEDICAL SCIENCES

Investigations

Identification of ATTR cardiac amyloidosis is not a simple task and requires a series of investigations to help differentiate from other serious pathologies. If a physician is considering cardiac amyloidosis as a possible cause of HFpEF, they should begin with a standard clinical examination to determine the status of the patient and if immediate interventions are required. The initial work-up should involve standard cardiac investigations which include echocardiography (echo), and electrocardiogram (ECG), followed by cardiac magnetic resonance imaging (CMR) for additional information. Echo is valuable for characterising and monitoring heart failure, providing ejection fraction which is often preserved in patients with ATTR cardiac amyloidosis. Furthermore, physicians can visualise structural changes including thickening of tissues in the heart, overall heart mass and any resulting impairment of heart function. ECG can be helpful in combination with echo because it also gives an indication of the degree of amyloid infiltration if there are conduction abnormalities or low voltages; however, there are no pathognomonic tracings. It is important to note that basic laboratory work is recommended alongside initial investigations and despite uncertainty in the interpretation of cardiac biomarkers (troponins, brain natriuretic peptide) they should still be monitored to evaluate differentials. CMR should be done in all suitable patients as it provides greater insight into structural changes of the heart which may indicate amyloidosis. CMR involves a gadolinium contrast agent which is helpful at identifying amyloid fibril deposition. Amyloid deposits result in increased extracellular volume and the accumulation of contrast around these sites produces late gadolinium enhancement (LGE) which allows for visualisation of amyloidosis. The tendency for amyloidosis patients

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Patients with ATTR cardiac amyloidosis should be treated for HFpEF, with caution or avoidance of calcium channel blocks and digoxin which have demonstrated interaction and increase toxicity with amyloid fibrils.

to present with advanced age creates a challenge in utilising CMR because of the limitations on contrast in a setting of poor renal function. Research efforts into CMR data analysis are continuing to look for improved ways to identify and characterise amyloidosis. While none of the mentioned investigations are definitive, a CMR showcasing LGE is highly suggestive of cardiac amyloidosisand can help guide suspicions in cases with cardiac infiltration. Technetium pyrophosphate (PYP) scintigraphy has been extremely valuable in making non-invasive diagnosis of ATTR cardiac amyloidosis a reality. This bone scan was found to be useful in showcasing the extent of cardiac amyloidosis related to ATTR and has become a mainstay in investigations. A positive pyrophosphate scan has been shown to be highly specific and sensitive for ATTR cardiac amyloidosis, and physicians are often able to bypass the need for a cardiac biopsy because of this. Endomyocardial biopsy (EMB) is the gold standard for achieving a definitive diagnosis of cardiac amyloidosis. This is because taking a direct heart tissue sample provides the ability to analyse it with stains and various specialised

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techniques to determine not only the presence of amyloid, but the subtype. Amyloid fibrils will stain with Congo red and display the characteristic applegreen birefringence under polarised light. Mass spectrometry is then performed to identify the subtype of amyloid. If a patient presents symptoms of amyloidosis in an extra-cardiac site, a physician may consider a biopsy of this tissue for analysis. Presence of ATTR in an extra-cardiac site is suggestive of systemic amyloidosis and can therefore imply cardiac involvement in symptomatic patients. A common site for extra-cardiac biopsy is the abdominal fat pad, which should be used to rule out other forms of amyloidosis rather than identifypresence of ATTR. Biopsies are invasive, specialised and expensive procedures, which is why there has been an emphasis on non-invasive diagnosis. Before proceeding to biopsy, patients should be evaluated for a proliferative blood disorder to rule out amyloid lightchain (AL) amyloidosis. This can be accomplished with a blood test, serum immunofixation electrophoresis, which if abnormal or unclear can be escalated to bone marrow biopsy. If a proliferative blood disorder is present, it will require treatment before proceeding with additional investigations for ATTR amyloidosis. When ATTR amyloidosis is confirmed through any diagnostic method, a patient should undergo genetic testing to determine if there is a mutation in the TTR gene. Categorising patients into ATTRv or ATTRwt amyloidosis is inherently helpful to guide management and selectfrom available treatments. Genetic testing should be offered to all first-degree relatives of an individual diagnosed with a pathogenic TTR gene mutation asvariants are inherited. Treatment

ATTR amyloidos is is an insidious process that can greatly affect quality of life and patient outcomes. In AL

MEDICAL SCIENCES

Figure 2: Endomyocardial biopsy of individual with ATTR cardiac amyloidosis displaying characteristic Congo red staining (A) which exhibits apple-green birefringence under polarized light (B).

for HFpEF, with caution or avoidance of calcium channel blocks and digoxin which have demonstrated interaction and increase toxicity with amyloid fibrils. There are several ATTR-specific treatment options currently available which have been proven to be effective in their ability to treat neuropathic or cardiac symptoms anddisease progression. These medications fall into three general categories based on mechanism of actionand are referred to as stabilisers, silencers and degraders. Stabilisers are drugs which bind to the TTR protein to prevent unfolding into components which can form amyloid. Diflunisal is a non-steroidal anti-inflammatory (NSAID) drug which was found to stabilise TTR and has shown success after being repurposed for treatment of neuropathic symptoms in ATTR amyloidosis. The only drug available for treatment of

AUTHOR BIO

amyloidosis, there is an identifiable blood disorder which is the source of all amyloid being produced. Therefore, treatments such as chemotherapy and autologous stem cell transplantation are utilised to stop amyloid production. ATTR amyloidosis is a slower process, given its presentation with advanced age, but similarly would benefit from earlier diagnosis and treatment. Previously treatment options for ATTR amyloidosis were limited to transplantation of affected organs for those who were suitable candidates. The main focus was liver transplantation for individuals with ATTRv amyloidosis because majority of the TTR protein is produced by this organ. An orthotopic liver transplantation from an individual with a normal TTR gene would eliminate production of abnormal protein and subsequent amyloid. Additionally, this treatment allowed for domino liver transplantation, whereby the patientâ&#x20AC;&#x2122;s affected liver which is functionally normal aside from its production of TTR, could be given to someone in dire need. In some cases of cardiac amyloidosis, isolated heart transplants or combined heartliver transplants have been done with varying degrees of success in managing the condition. There is increased interest in developing treatments for ATTR amyloidosis because of the evidence suggesting the disease may not be as rare as previously thought. Patients with ATTR cardiac amyloidosis should be treated

polyneuropathy and cardiomyopathy is a stabiliser, tafamidis, which through multiple trials has been proven to halt disease progression and help maintain quality of life.Silencers are drugs which target a mechanism in the production of the TTR protein which eliminates any possibility of amyloid formation. Patisiran is a small-interfering RNA (siRNA)that prevents the translation of TTR mRNA, whereas inotersen directly targetsTTR mRNA to form a complex which is degraded. Both patisiran and inotersen have been shown to halt progression of neuropathic symptoms and improve quality of life when given to individuals with ATTRv amyloidosis with polyneuropathy. Degraders are a group of drugs which are still being investigated but are meant to address disease burden by removing amyloid deposits in tissue. Conclusion

Advances in diagnostic techniques and continued awareness of ATTR amyloidosis in relation to HFpEF will lead to greater understanding of this condition. Suspicion of amyloidosis will allow earlier identification and therefore earlier treatment for patients in order to improve quality of life and survival. It is likely that ongoing research and evaluation of ATTR amyloidosis will lead to newdiagnostic techniques and drugs in the years to come.

Diego H Delgado is a cardiologist at the Peter Munk Cardiac Centre at the Toronto General Hospital, University Health Network in Toronto, Canada and associate professor of medicine for the University of Toronto. He has specialised training in heart failure, transplantation and carido-oncology.

Bennett Di Giovanni is a research fellow with the University of Toronto, working for the Division of Cardiology at the University Health Network in Toronto, Canada. He has an interest in cardiac amyloidosis and aims to provide insight into diagnosis and management of this condition.

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USE SAFETY PRODUCTS

Fight against needlestick injuries

One of the most effective ways to protect yourself against needlestick injuries (NSI) is to use safety products in your everyday work. In this area, Greiner Bio-One can offer you a comprehensive portfolio for a variety of requirements.

of these products. Unfortunately, potential hazards are often not noticed or taken seriously and those affected attribute too little or sometimes even no significance to injuries caused by a contaminated needle.

Employees in the healthcare sector handle a wide range of tasks and are exposed to many different risks. Particularly when working with sharp and/or pointed objects such as cannulas, workers face an increased risk of injury and infection with transmissible pathogens.

The cause of a needlestick injury can include a mechanical failure of the safety mechanism, incomplete activation or improper use by the user. However, there are varying degrees of technical development of the safety products to avoid these sort of malfunctions.1 It is particularly important that the correct handling is practised and to always be careful when dealing with contaminated objects.

Pay more attention to the risks It is a key concern of ours to inform you about the risk of injury you are exposed to as an employee in the healthcare sector when handling and disposing 40

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1 Tosini, William, et al. 2010. Needlestick injury rates according to different types of safetyengineered devices: results of a French multicentre study. In: Infection Control and Hospital Epidemiology, Vol. 31, No. 4.

The best safety level possible thanks to products from Greiner Bio-One Greiner Bio-One carries a wide range of safety products to give you the best protection possible from bloodborne diseases caused by an NSI. • VACUETTE® Safety Blood Collection Sets have a safety mechanism which is activated after blood has been collected and the needle is still in the vein, thus protecting against needlestick injuries • The VACUETTE® CLIX Safety Hypodermic Needle has a built-in safety shield which irreversibly encloses the needle after it is activated. Successful activation is indicated by a clearly audible ‘click’ • The VACUETTE® QUICKSHIELD Safety Tube Holder is equipped with a mechanism which keeps the needle safe after venipuncture and thus protects against needlestick injuries. In addition to their high degree of safety, the products distinguish themselves with their optimised ergonomic design. For further information on our products, please visit our brand-new website www.power4safety.com.

Health risks for healthcare workers due to NSI If a health sector employee falls ill with a bloodborne diseases, the cause is often a previous injury from a sharp, contaminated object. Direct bloodto-blood contact, such as with an NSI, is one of the recurring causes of infection. It isn’t possible to vaccinate against HIV, for instance, and the consequences of an infection remain fatal. Don’t take the dangers posed by NSI lightly: get informed and protect yourself as well as you can. Your health is important to us! Advertorial www.asianhhm.com

DIAGNOSTICS

SAFE ACTIONS TO GUARD AGAINST ELECTROSMOG The permissible level of Electromagnetic Radiation (EMR) varies between countries, but residents in urban areas everywhere are subjected to EMR. Most radiation is from personal devices. The symptoms of EMR are increasingly common as the effects are cumulative, and exposure can be reduced by changing habits. Beverly A Jensen, President/CEO, Women's Medicine Bowl, LLC

n the last three years, 726 million people have joined the online world, mainly subscribers in India and Africa. With a surge in cell phone subscribers expected globally in 2019 and the near future, it’s important for the health of all that healthcare providers become aware of the health risks of cell phone usage. The news media is rife with errors in reporting health risks of electromagnetic radiation or fields (EMR or EMF). Sometimes the ‘errors’ are blatant lies planted by the telecom industry. An article in The Guardian earlier this year reported the harm done to male sperm by men carrying their cell phones in their pants pocket. In the technologically advanced countries (and cities), some 200 studies show that sperm viability has declined by 50 per cent. The M.D. quoted in the article advised men to put their cell phone in the breast pocket of their jacket. No!

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Two major studies by the U.S. National Toxicology Program and the Ramazzini Institute in Italy reported in 2018 clear evidence for heart tumours and heart schwannomas (and tumours in the brain and adrenal glands). Men shouldn’t put cell phones in their breast pocket nor women stash it in their bra. It shouldn’t be carried anywhere on the body. Or put against the head to talk. With two independent studies finding similar tumours, the Ramazzini Institute advised the IARC to reclassify radio frequency electromagnetic fields from a potential carcinogen (Group 2B) to a ‘probable carcinogen.’ In August 2015, an article in India’s Business Standard claimed that cell towers ‘emit low frequency non-ionising radiation, which isn’t harmful.’ This has been the industry’s story line since the invention of the cell phone. Telecom has claimed that

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harm could be caused only by heating parts of the human body—the thermal effect. And regulatory standards were based upon the industry’s claims, at least in North America. In fact, while the EMF of cell phones –and all our electronics— does cause thermal effects and cancer, far more damage is done by the non-ionising radiation. Professor Martin Pall has been tracking the peer-reviewed, science research done globally on EMF for 19 years. More than 10,000 studies have been done around the world investigating the effects on humans and all living things in our ecosystem. Countries where the most extensive research has been done—Iran and Russia—have among the lowest levels of permissible radiation. In the United States, a study at the Cornell University in the 1960s showed that EMF crossed the blood

DIAGNOSTICS

brain barrier, and the telecom industry quickly shut down that line of research (and the lab). By the mid-80s, all industry-sponsored research and government-funded research on telecom devices in the US ended. US standards for EMFs were set in 1996 with the Telecommunications Act—after telecom spent US$50 million lobbying the Congress— and the standards (SAR) for thermal effects only were based upon a 6’2”220-pound male (SAM) who would be larger than 97 per cent of Americans. The ‘brain matter’ tested in SAM consisted of saline water and sugar. And SAM was only on the cell phone for six minutes! In India, two hours/ daily on the cell is common, and the average in the US is five hours daily. When engineers and scientists in the US have made discoveries in their research that didn’t support the telecom industry’s sales position to the

The scientific evidence from around the globe suggests the primary hazard of cellphone radiation is systemic cellular and mitochondrial (gut) damage, which are contributing factors to chronic diseases and any number of ailments we don’t have labels for.

regulatory agencies, they were attacked personally and professionally by the industry. Professor Om Ghandi, at the University of Utah, who is developing the SAR ratings for the indus-

try, reported that a child’s head would absorb far more radiation than an adult’s. He was viciously attacked by the industry. And did the public learn about this danger? One half of children under 10 years have cell phones in the US. Today in the US, mass media is largely owned by conglomerates, and the profit-making interests of corporations in the conglomerate can conflict with the accurate and honest reporting of journalists’ role in surveillance of the public’s environment. This spring, for example, when Brussels and cantons in Switzerland, including Geneva, said NO to 5G, saying they would not be raising radiation limits to allow this, it was not reported in The New York Times. Nor could it be found in other US mass media. The NY Times company has a large investment in rolling out 5G, so the public’s health isn’t on the agenda.

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As a result in the US, research on health consequences of electromagnetic radiation hasn’t been supported, and research from other nations hasn’t been reported in US media. With the outdated 1996 Communications Act still in effect, telecom veterans rotate through management of the federal regulatory agencies supposed to be regulating the industry. Permissible limits on EMFs in the US and Canada are more than 100x those in Russia and China, for examples. And the consequences are unfolding in the population’s health.

Children Absorb 10x More Microwave Radiation

Health Effects of Non-ionising Radiation

It has only recently been understood how non-ionising radiation causes physiological damage, although studies as early as the ‘50s and ‘60s found non-thermal cellular effects. This cellular effect is non-thermal, and it’s affecting everyone, continuously and cumulatively, whether or not we feel it—yet. If you’re humanoid and you’re living in a technologically advanced country or city, you’re impacted. And the effects are cumulative—you’re not immune at any stage from the use of the electronics. The scientific evidence from around the globe suggests the primary hazard of cellphone radiation is systemic cellular and mitochondrial (gut) damage, which are contributing factors to chronic diseases and any number of ailments we don’t have labels for. “(There’s been many studies) on various kinds of EMF exposures, each of them showing neuropsychiatric effects. What you find is that these effects have been repeated many times in these epidemiological studies. It’s the same thing that everybody’s complaining about, ‘I’m tired all the time,’ ‘I can’t sleep,’ ‘I can’t concentrate,’ ‘I’m depressed,’ ‘I’m anxious all the

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5 Year Old

10 Year Old

Adult

Slides from Dr. Om Ghandi, As cited by the World Health Organization's International Agency for the Research on Cancer Figure 1

time,’ ‘My memory doesn’t work well anymore.’” Martin Pall, Ph.D., professor emeritus at Washington State University, has been compiling scientific studies from around the world on EMF since 2001. He has degrees in physics, biochemistry, and genetics.1 VGCCs—What are they & how EMF affects them

This is our basic cell structure: aqueous cells impacted by electrical currents. Research studies show that EMFs work by activating Voltage-Gated Calcium Channels (VGCCs), the outer plasma membrane that surrounds all our cells. When they’re activated, they open up and allow calcium to flow into the cell. It’s the excess calcium in the cell, which causes most of the biological effects. We feel it as chronic disease2. Normally (with no EMF), the calcium channels admit only very low concentrations of calcium. But when 1 The Harmful Effects of Electromagnetic Fields on Health: A Special Interview with Dr. Martin Pall” by Dr. Joseph Mercola, 08/03/2017 on www.mercola.com 2 Mercola interview with Dr. M Pall, 8/03/17

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hit by the EMF, they open up and put a million ions per second into the cell causing the molecular trauma. The structure within the cell that senses the electrical current and manages the gate is the Voltage Sensor. It is extraordinarily sensitive to electrical forces, and scientists have found the forces from EMF on the Voltage Sensor are approximately 7.2 million times stronger than they are on singly charged electrical groups in the watery parts of the cell3. This means if we are to have no or minimal biological effects due to EMF, the safety standards are off by a factor of 7 million, by orders of magnitude. What are the consequences of excess calcium in the cells? One critical consequence is increased nitric oxide. There can be therapeutic effects to particular parts of the body from nitric oxide but excessive nitric oxide is destructive. The nitric oxide can react with superoxide; superoxide levels also go 3 Mercola interview with Dr. M Pall, 8/03/17

DIAGNOSTICS

up in response to increase calcium in the cells, forming peroxynitrite, which is a potent oxidant that breaks down to form reactive free radicals. Most of the damage is caused by the free radicals. It’s the excessive oxidative stress and nitrosative stress that are causes of almost every chronic disease—disease labeled by the AMA or not4! Location of the VGCCs

Nervous system The highest density of VGCCs is in the nervous system. The organs most affected through the nervous system are the brain and the heart, particularly the heart’s pacemaker. Cardiac arrhythmias, fast heartbeats (tachycardia) and slow heartbeats (bradycardia), and heart palpitations. 4 For the full discussion of this process see “The Harmful Effects of Electromagnetic Fields on Health: A Special Interview with Dr. Martin Pall” by Dr. Joseph Mercola, 08/03/2017

Young, apparently healthy athletes who have collapsed during sporting events and who survived have been found to have arrhythmias and bradycardia. The increased number of these deaths may be due to EMF. Brain impacts—neuropsychiatric effects: The voltage-gated calcium channels are responsible for the neuroendocrine hormone release and neurotransmitters, and the consequences of EMF exposure to the brain are Anxiety and depression, Autism, and Alzheimer’s. U.S. health statistics show this—incidents of Autism have exploded from 1 in 10,000 children thirty years ago to, nationally, 1 in 59. The toxic body load of chemicals, including vaccines, are surely contributing factors but recovery doesn’t happen from autism until the EMR is cleared, according to Dr. Dietrich Klinghardt who has been treating children with autism since 1990. According to a report from

the Blue Cross Blue Shield insurance company, on the state of millennials’ health, between 2013 and 2016 depression diagnoses increased by 47 per cent and a whopping 63 per cent increase in adolescents. Professor Olle Johansson of the Karolinska Institute in Sweden and editor of the Journal of Pathophysiology did a study of villages in Sweden. Looking at levels of cell phone radiation, and comparing those levels to where the highest density of Alzheimer’s disease was found. There was a direct correlation between the highest EMF exposure and highest incidence of Alzheimer’s disease. Steps to Reduce Health Hazards of EMF

Excellent resources for background information on EMF are the Environmental Health Trust, www.ehtrust.org. A series of blogs on Women’s Medicine Bowl in April are a

EMFs act via activation of voltage-gated calcium channels (VGCCs) Cytochrome mitochondrial energy metabolism, steroid hormone synthesis Microwave/ Lower Frequency EMFs

VGCC activation

[Ca2+]i

Nitric Oxide (NO)

NO signaling (cGMP)

Protein kinase G

Nrl2

Therapeutic effects

Super oxide

Calcium signaling Peroxynitrite (ONOO-)

+/- CO2 Free radieals Oxidative stress NF-kappaB Inflammation

Pathophysiological effects

Each of the EMF effects discussed earlier can be produced through the pathways shown here. Figure 2: This diagram is from a presentation to the NIH by Dr. Pall, August 2018, https://www.youtube.com/watch?v=kBsUWbUB6PE

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DIAGNOSTICS

Exposure Effects: Humans Standards Date from Firstenberg 2001

Figure 3

Use a land-line phone instead. And get rid of cordless phones (base is continuously searching for signal). Avoid all wireless devices: Baby monitors, Bluetooth speakers, head phones, and wireless keyboard or mouse. Move your WiFi Router to the least-used room in your home: This usually means getting it out of the living room! Put a timer on it so it shuts off at night or during the day if no one’s using it. If you can’t hardwire WiFi into the home, put the WiFi router in a Faraday bag to block all transmissions AUTHOR BIO

quick, easy introduction to the subject of Electrosmog and practical steps of what to do about it5. Unless you’re living close to a cell phone tower, most of the EMF you’re exposed to is within your own home and in your control. Here’s some practical steps to immediately reduce exposure to EMF, for yourself, your family, and your patients: Cell phone use: Never, ever put it against your head to talk—use an Air Tube or Speaker mode. Don’t carry a cell phone in your pants pocket, breast pocket or your bra. Carry it and use it AWAY from your body. It does cause cancer. Use texting and keep conversations short. Put the cell phone in Airplane mode at night, and remove it from the bedroom preferably. 5 http://womensmedicinebowl.com/learn-the-impact-ofelectro-smog-on-our-children-and-what-to-do-about-it/

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(or cover it with a kitchen pot!) when not in use. These are the first steps to protecting ourselves from the Electrosmog of modern life. Learning where the exposure is in workplaces and in the schools is just as important; these areas are addressed at the Environmental Health Trust website. This article is adapted from Dr. Jensen’s forthcoming book, 21st Century Wellness Rx: Health Hacks to Prevent, Treat, and Cure Chronic Disease. Her website is www.WomensMedicineBowl.com.

Beverly A Jensen works globally to promote individuals’ education and participation in their health. She is an international speaker, corporate wellness consultant, health coach, and author of 21st Century Wellness Rx (2020). Her website to promote natural health, www.WomensMedicineBowl.com, opened in 2003.

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TECHNOLOGY, EQUIPMENT & DEVICES

DIGITALISATION

THE FUTURE OF LABORATORY MEDICINE As healthcare shifts towards personalisation and digitalisation, diagnostics allow individuals to receive vital information with increased accuracy, specificity, and speed. In a bid to get closer to the end user, manufacturers are leveraging data and building intelligence into their products. This practice places prevention ahead of treatment and cure, thereby giving patients greater control over their care. Suresh Vazirani, Chairman & Managing Director Transasia-Erba Group

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he healthcare market in India is expected to reach US$372 billion by 2022, while the medical devices market is expected to cross USD 11 billion by 2022*. Rising incomes, greater health awareness, lifestyle diseases, and increasing access to insurance will contribute to this growth. Besides developing India as a global healthcare hub, the Government of India aims to increase healthcare spending to 3 per cent of the Gross Domestic Product (GDP) by 2022. With increasing urbanisation and problems related to modern-day living in urban settings, currently, about 50 per cent of spending on

TECHNOLOGY, EQUIPMENT & DEVICES

in-patient beds is for lifestyle diseases. Ageing populations and changing lifestyles are causing an increase in conditions like cancer, diabetes and heart disease, thereby leading to growth in demand for diagnostic services. This has increased the demand for specialised care. Further, the medical fraternity is educating the general population on the benefits of early diagnosis to increase the chances of a positive outcome, help improve the lives of patients and save costs of further treatment. The Importance of Laboratory Medicine

In-vitro Diagnostics (IVDs) form a crucial part of modern medicine: laboratory-based tests performed on biological samples provide vital information that is key for the prevention, treatment and management of disease. Reagents and analysers used in IVDs must ensure precise and reliable results. They can be used in a variety of areas ranging from sophisticated techniques performed in specialised clinical laboratories to userfriendly devices that are used by medical professionals, as well as simple self-tests that patients can use at home. Consolidation and Integration for a Better Business Environment

Rapid change in business models immensely impacts the medical device industry. Today, consolidation, integration and outsourcing are areas that larger players are exploring to create a better business environment. As medical research advances, newer tests are needed for accurate diagnosis. In order to ensure that the test menu remains comprehensive and updated, laboratories outsource the tests not being processed in-house. Consolidation and integration catalyse the process of smaller labs joining hands with bigger ones. This allows more comprehensive test menus, increases the reach and accessibility of services, ensures better standardisation of services and allows

greater cost benefits to be passed on to patients. The concept of core laboratory is soon catching up in India. Core laboratories collect, process, and analyse data from multi-centres through a single platform to prevent inter- and intravariability by following standardised protocols. Unified and standardised data collection with strict quality control methods facilitates easy central review by physicians and reduction in errors and meets expectations and approval of regulatory authorities. Technology Trends

Innovative developments in the IVD field are currently driven by four major trends: point-of-care testing, automation, digitalisation and the concept of personalised medicine. PoCT: Various digital technologies will improve the point-of-care testing (PoCT) options of pathology departments in the future. Just as portable diagnostic devices are making it possible to diagnose patients wherever they are, such tools enable the examination of tissues, fluids and other samples near the patientâ&#x20AC;&#x2122;s location, in the surgery or clinic at the time of consultation to facilitate prompt clinical decision making regarding patient management. Various blood glucose meters, urine test strips, pregnancy tests fall into the category of

PoCT, but their range will significantly widen in the future. Molecular diagnostics: Molecular analysis will enable more precise diagnosis in the future, and revolutionise how we define several diseases. It will also give precious information on how patients respond to treatment and what the prognosis is. The pathologist will help interpret the results and choose which molecules to be evaluated. Nex-Gen Sequencing (NGS) is another growing trend in molecular diagnostics. An analysis of the genetic information from the sample will help diagnose a disease well in advance, even before a patient actually starts presenting symptoms of a disease. It can thus be used to detect levels of TB, malaria and other diseases which all the other tests would miss. In the near future, NGS will be considered by many laboratories for routine diagnostic use. Automation: With the introduction of various government schemes, the healthcare delivery system in India is undergoing a paradigm shift. Speaking particularly of the diagnostic industry, laboratories will have to think out-ofthe-box to handle the huge workload and at the same time maintain the quality, affordability and accuracy of the tests. This is where automation can play a significant role. Over the last few years, automation is proving to be the

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TECHNOLOGY, EQUIPMENT & DEVICES

biggest growth driver for this segment. From a manual, hands-on process for a simple test menu to an instrumentcentric, high-volume set-up, automation has become indispensable to meet the increasing demand for high productivity and cost reduction. Infact, it is now a multi-billion market consisting of several manufacturers of integrated and workflow systems and components as well as software to improve the overall process efficiency. Additionally, automation is enabling healthcare companies to meet regulatory compliance and data consolidation. Most of the latest systems are equipped with reagent and sample barcode reader having HIS / LIS connectivity. Integrating the systems to the HIS/LIS interface, has drastically reduced analytical errors. Automation combined with cloudbased technology is helping laboratories streamline daily operations, troubleshooting and better management of patient information. From AI to the Cloud

New analytical technologies, extended data processing and advanced means of integration and interpretation of laboratory findings are greatly influencing the IVD industry. Business process improvement: While there has been a large focus on patient-facing aspects of digitalisation, it is also a powerful tool to reduce costs and time on the back-end, resulting in improved levels of service and increased profits from efficiency gains in R&D through supply chain management, sales and marketing. Internet of Things (IoT) has brought in a new wave of digital transformation. Manufacturers of medical devices in particular, are adopting IoT as a tool to improve operational efficiency and offer realtime insights based on patient data. Devices fitted with IoT sensors can provide information on the usage of the instrument. This is particularly relevant for a diagnostic laboratory that is faced with a major challenge of opti-

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be addressed. The future will require us to set and adjust standards in education and training programmes in order to attract the young generation of professionals with an interest in our multifaceted field of technical, analytical and medical expertise. Telepathology – How it will help

mising capacities of capital equipments. Likewise, IoT data can be used to track the usage, expiry and consumption of reagents for each test, to allow efficient management of lab inventory and utilisation. Alerts can be sent for replenishment, when there is depletion. Product service innovation: Experts estimate that 87 per cent global healthcare organisations will soon be adopting IoT. The entire ecosystem— including caregivers, patients, and manufacturers — is experiencing a new level of engagement; that arises from the need to increase operational efficiency (through predictive maintenance and remote access), to enhance patient outcomes (through predictive healthcare). Healthcare organisations are moving more towards cloud-based IT infrastructure, to better automate processes. Infact, IoT enabled medical devices can now be remotely monitored 24x7 to predict possible problems and proactively resolve them thereby improving the uptime. Besides this, data analytics is being leveraged to track the manufacturing process, allowing a more accurate and consistent output of high-quality products. Developing Skill Sets

The medical laboratory professionals will also need to reflect on future relationships with stakeholders outside the realm of the classical health care professional. Specifically, concepts like ‘the patient-oriented laboratory medicine’ and ‘the empowered patient’ will have a greatly extended meaning in the era of digitalisation and need to

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While telemedicine is currently spreading it wings to encompass all segments of healthcare, there is a special focus on telepathology, as laboratory diagnosis forms the basis of all treatment modalities. Telepathology services help in transferring superior quality imagerich pathological data for education, research, and patient diagnosis and are useful for emergency services, obtaining expert opinion on referral cases, patient diagnosis at remote locations, meetings and conferences, quality assurance, and educational purposes. The global telepathology service market was valued at US$637 million in 2018 and is expected to generate USD 1,786mn by 2027, at a CAGR of 12 per cent between 2019 and 2027**. Speaking of the Indian scenario, the telepathology market is expected to touch US$2 billion by 2020***. While North America and Europe contribute to the highest share in the global telepathology market, AsiaPacific is projected to register the highest CAGR in the near future, owing to the growing availability of healthcare facilities, rising investments for telepathology, and increasing prevalence of life-threatening diseases. The growing demand for enhanced patient management services, and government support especially in China, Japan, and India, is projected to fuel the Asia-Pacific telepathology service market in the future. The challenges India is facing today include meeting the growing healthcare demand; bringing together pathologists, biochemists, and microbiologists under one virtual umbrella; making use of technology to bridge the

TECHNOLOGY, EQUIPMENT & DEVICES

Future outlook

As a country, we are in the midst of one of the most challenging times in healthcare history, facing growing and ageing populations, the rise of chronic diseases and global resource constraints, and the transition to value-based care. These challenges demand leading healthcare players to use technology to shift from treatment and cure to prevention through integrated smart services. Digitalisation of pathology laboratories makes the specialty more efficient and the work of pathologists less cumbersome. Both physicians and AUTHOR BIO

delivery gap; and ensuring that quality and accuracy remains uncompromised. An alarming statistic; there are approximately 1 lakh diagnostic labs in the country but only 1per cent of these are accredited. For every 1 lakh people, there are just about eight diagnostic labs and 70 per cent of the industry functions by sharing the services of pathologists, biochemists or microbiologists or at times in even their absence. This obviously poses a challenge for ensuring quality services. Telepathology can play a very important role, as it allows for consultation as well as interactive peer discussions. It ensures accessibility to qualified pathologists round-the-clock, thereby ensuring real-time reporting during emergency, a boon for tier II, III and IV cities and towns. It can prove to be beneficial for smaller labs, in implementation of uniform protocols and standardisation of reports.

patients will benefit from this transformation. With better tools, medical professionals will have more chance to save lives and patients will have more chance to survive. Sources: *https://www.business-standard.com/ article/current-affairs/indian-healthcaremarket-to-hit-372-bn-by-2022-saysassocham-117120300431_1.html

**https://www.globenewswire.com/newsrelease/2019/04/05/1797517/0/en/GlobalTelepathology-Service-Market-Will-Grow-USD-1786-Million-By-2027-Zion-Market-Research.html

***http://archive.biospectrumasia.com/ Content/040112OTH1783 7.asp

As Chairman & Managing Director, Suresh Vazirani has spearheaded the Transasia - Erba group to be renowned as Indiaâ&#x20AC;&#x2122;s leading In-vitro Diagnostic Company and a fast emerging player in the global IVD arena. He decided to set up Transasia Bio-Medicals Ltd., an In-vitro Diagnostic Company focused on meeting the needs of Doctors and in-turn their patients, with quality and affordable diagnostic solutions and a strong after-sales network.

Sustainable Solutions For The Treatment and Management of solid, waste water and fluid lab Healthcare Waste www.newstergroup.com

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FACILITIES & OPERATIONS MANAGEMENT

he programming, planning and design of healthcare facilities is of prime importance to improve the patient, visitor and staff experience. The goal of architects, designers and medical planners is to envision design as good platform to innovate and create a welcoming environment for the users. What are the ways to improve the health and vitality of the communities that are served by a healthcare facility? In this article 5 key design principles in the context of healthcare facilities with case studies will be highlighted to answer this question.

1. Maximising Site Potential and Creating a Landmark for Wellness

Figure 2: Parkway Gleneagles Shanghai International Hospital

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Designing greenfield hospitals particularly in urban areas often requires a careful and sensitive approach within limited land area and stringent devel-

FACILITIES & OPERATIONS MANAGEMENT

The programming, planning and design of healthcare facilities are of prime importance to improve the patient, visitor and staff experience. In this article we will highlight 5 key design principles in the context of healthcare facilities with case studies. Angela Lee, Principal and Regional Director, Asia Pacific, HKS

PROGRAMMING PLANNING AND DESIGN Figure 1 Taikang Nanjing Hospital, China

opment controls. It is imperative to maximise the site’s full potential without sacrificing on the quality of healthcare environment. A case in point would be the Taikang Nanjing International Hospital (Figure 1), in Nanjing, China. The project is in an intensive topographical area outside of downtown Nanjing. The Gross Floor Area requirements coupled with the strict building height requirements (18 metres) required a low height building with a large footprint. The impact of a large floor plate on a sloping site had to be addressed to minimise the cut and fill of the site. This drove the project to build into the landscape working as much with the existing contours as possible. This was unique for Chinese hospital developments as they typically are built on relatively flat surfaces with

minimal grade change and posed several challenges with meeting China’s strict fire access requirements. This led to an open-air fire access path that ran the length of the building, which also doubled as a service access. In addition, it helped to reduce the volume of water runoff of the site during heavy rains. The towers straddle the service / fire lane and connect to the roof of the diagnostic areas. This move allows the patient towers to have a very low scale with landscape on both sides (natural on one and the green roof on the other). Similarly, when arriving to the main entrance on the lower level it also only feels like a three-story building since the towers are very recessed — this created the level of intimacy, fitting the building into the landscape and maintaining a human scale with them as sing. The horizontal shades on the tower emphasise the fluidity and continuity with the landscape while also providing shade to the rooms within.

2. Minimising Capital Expense while Maximising Return-On-Investment

The right vision during the planning, design, and construction of a new healthcare facility can ensure a positive return on investment and lower the overall cost basis for ongoing operations. In order to minimise capital expense and ensure operating costs yield a suitable return on investment, facilities need to implement evidence-based design to lower the cost of care without compromising on quality. In Parkway Health Gleneagles Shanghai International Hospital (Figure 2), Shanghai, capital expenses were saved by the creation of a central support services hub which was to be shared by several hospitals in the district. As a part of Shanghai’s New Hongqiao International Medical Center, the area’s shared services such as CSSD, laboratory and laundry are linked through its basement. To facilitate operational efficiency, the basement is also connected to the Imaging Center on the second floor.

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FACILITIES & OPERATIONS MANAGEMENT

The key to minimising capital costs is to envision an appropriate phasing strategy. For the hospital the right bed mix and facility planning helped in understanding the number and type of beds, operating theatres and clinics could be planned in first phase to generate maximum revenue. This helped testing out the right components and the subsequent phases were then planned in an incremental fashion. A holistic sustainability framework helped in cutting down operational costs and helped in creating a smaller carbon footprint. Some of these features do not involve additional costs — like day lighting and appropriate building orientation to minimise heat gain and maximise natural light, thus cutting long term electricity and air-conditioning costs.

3. Designing for Pandemic Outbreaks Emergency and Disaster Preparedness have become significant drivers affecting emergency and hospital design across the world. Events ranging from tsunamis, tropical storms, potential terrorist attacks and contagious outbreaks are informing hospital design and operations. Over the course of the last decade outbreaks of H1N1, SARS, and Ebola have raised concern about how to control and isolate patients with potentially highly contagious diseases. HKS was engaged by the Macau Health Bureau in the winter of 2014 to consult on the design of a new 1200 bed Macau Government Hospital Complex in Macau, SAR. As the team began to conceive the design and planning for the new hospital complex, emergency and disaster preparedness were key elements of discussion

Pandemic Pandemic Entrance Entrance

Ambulance Ambulance Entrance Entrance

Walk-in/ Walk-in/ Drop off off Drop

Ambulance Ambulance Entrance Entrance

Waiting Waiting Area Area

Pandemic Pandemic Zone Zone

Triage Triage

Emergency Emergency beds beds

Trauma Trauma Zone Zone

Normal & Flu situation: Figure 4: Normal & Flu situation: Pandemic Entrance is closed. Flu zone is Normal & Flu situation: isolated from other departments prevent Pandemic Entrance is closed. Flu zone is to divided from infection. other departments to prevent infection.

Pandemic Entrance is closed. Flu zone is divided from other departments to prevent infection.

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Triage Triage

Emergency Emergency beds beds

Infection Infection Level Level

Observation Observation Area Area

Key Design Elements • Departmental Compartmentalisation • Expandable/Convertible exterior space • Mass Casualty Decontamination Design Solutions • Dedicated Patient Transfer Elevators • Emergency Observation Unit Conversion to Pandemic Isolation Floor • Mechanical System Infrastructure (Seasonal/ Pandemic Exhaust Design).

Figure 3: Macau Island Hospital in association with EWA

Walk-in/ Walk-in/ Drop off off Drop

Flu Flu Zone Zone

during design phases. The new facility was designed with several key elements that support the hospital’s objectives for meeting emergency and disaster preparedness initiatives.

Trauma Trauma Zone Zone

Observation Observation Area Area

Pandemic Figure 5:Situation: Pandemic Pandemic Situation: entrance is open. Pandemic zone can be isolated from other

zones with lift dedicated to patients tobethe upper infection floor. Pandemic entrance is open. Pandemic zone can divided from other zones with lift dedicated to Pandemic entrance is open. Pandemic zone can be divided from other zones with lift dedicated to patients to the upper infection floor . patients to the upper infection floor .

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Emergency Department Design

The Emergency department was designed to operate under normal circumstances with 6 key zones including a Fever Clinic, multiple floors with 23-hour emergency observation, Level 1 Trauma/ resuscitation rooms, Level 2 and 3 emergency room beds, Level 4 and 5 Fast Track/ Triage area and dedicated CT and Radiology Imaging services. The final design was developed to allow for compartmentalisation into multiple zones which provide isolation and expandability during a mass casualty or pandemic outbreak. The department was designed in such a way to allow for a portion of the emergency department to be isolated for a mass casualty or contagious outbreak, while at the same time allowing for the main emergency department to remain operational. Both the interior of the emergency department as well as the exterior were designed to allow for expansion and compartmentalisation. Several design features are integral to allow for the expansion of exterior Emergency drop off area into a temporary triage area and separate decontamination area that allows for the treatment of potentially contagious or contaminated patients. While the physical design and planning of the facility were instrumental in creating pandemic zones within the facility, it was imperative that a mechanical strategy be implemented to compliment the design and provide true isolated zones within an operating hospital. This required mechanical systems which were designed to allow for the compartmentalisation and isolation of several zones during seasonal flu season or potentially pandemic events.

Figure 6: Normal and Flu situation: Pandemic entrance is closed. Flu zone is isolated from other departments to prevent infection.

Figure 7: Pandemic situation: Pandemic entrance is open. Pandemic zone can be isolated from other zones with lifts dedicated to patients to the upper infected floors

4. Creating a Responsive Environment for the Ageing Population

â&#x20AC;&#x153;Silver tsunamiâ&#x20AC;? is a term often used in the past decade to describe the rapid increase of people over the age of 60 as compared to the overall population in Western countries, but only recently has the term been heard more and more often throughout Asia.

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Figure 8: Infection floor(upper). The infection area is isolated from the staff lift and public lift. Negative pressure ensures contagious air does not_ flow outwards. Soil lift will be dedicated to pandemic patients as pandemic lift during pandemic period

Pandemic phase Interpandemic phase

Alert phase

Preparedness

Transition phase Response

Recovery

Figure 9: The continuum of pandemic phases The continuum of pandemic phases

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IS S UE - 45, 2019

Interpandemic phase

Preparedness

This trend has created a rising demand for healthcare services for the ageing population, prompting both the public and private sectors in countries across the region to massively expand healthcare and healthcare technology infrastructure. While designing Chinese University Hongkong Academic Medical Center, a non-pharmacological strategy was adopted for improving the quality of life for the elderly. Outdoor gardens provide a welcome break from sterile healthcare settings and offer elderly residents the choice of leaving the built environment for a natural setting designed to promote exercise and stimulate all the senses. Another aim of therapeutic gardens is to promote ambulation, positive reminiscences, decreased stress and stabilised sleep wake cycles. Exposure to nature has been associated with reduction in pain, improvement in attention and modulation of stress responses. In

FACILITIES & OPERATIONS MANAGEMENT

addition, some studies have reported that having free access to an outdoor area may reduce some agitated behaviours, medications and falls in dementia residents. Signage and way finding is of prime importance to ensure clarity and reduction in stressful environments for the elderly. We used yellows and reds which stimulate and are good for dining and social areas on the patient floor. As one ages, it gets harder to tell apart blues and greens than it is to tell apart reds and yellows. Regarding interior colours, unsaturated and washedout colours will be avoided in the environments for older adults, as it is difficult for them to discriminate these colours and colour confusion may result in falls. In addition, an appropriate contrast between colours of the wall and the floor, and floor surfaces at different levels emphasises the edges of spaces and help older adults distinguish features of the environment at the CUHK Hospital. A homelike environment for the design of the rooms enhanced the belief that people should be able to age in the same way they are accustomed to living. 5. Designing for Flexibility and Future-Readiness

Change is inevitable in a healthcare facility. It can be caused by a variety of factors: • Growing importance of chronic disease management • Changing consumer expectations in the delivery of care • Rapid advancement in diagnostic tools and technology demand with changing space and infrastructure requirements. Today’s world is looking for a facility that is scalable, adaptable, and modular. It needs to have the ability to expand and contract services based on changing needs, whether that be a daily peak hour or long-term growth. For the Gleneagles ChengDu Hospital we followed this approach:

Figure 10: Chinese University Hongkong Academic Medical Center

Universal rooms and modularity Universal rooms are designed to cover a wide range of care requirements so they can be used interchangeably. The design team studied all patient room requirements to design a set of rooms that can be adapted to each specialty. Rooms are sized in a modular fashion, allowing a future ‘plug and play’ approach in case of changes in patient

volumes or expectations. For example, two double rooms can easily convert into one 6-bed room, since they occupy the same space. Shell space Wherever possible, a space has been identified that can be occupied by future functions. Its location in the centre of the floor plate and adjacency to the central service corridor will allow

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Figure 11: Parkway Chengdu Project

it to either serve as future expansion area for the adjacent department or remain free-standing. Future expansion-Inside the given site boundary of certain projects, no expansion area was available to increase the building footprint. It was important to study vertical expansion with a careful study of existing and proposed structural systems. Areas needed to be cordoned off bearing in mind that hospitals need to continue functioning during the construction process and minimum disruption to existing processes would be allowed at any facility. A thorough study of the hospital’s current operations was done to propose temporary changes while the expansion process continues efficiently. A phased expansion approach is necessary where modifications can happen in an incremental fashion. Due to constraints in building size innovative ways of managing the anticipated patient volume were required. The design team was especially mindful of preparing for overflow capacity, in each area separately as well as for the department. A few strategies that were implemented to expand the current capacity are as follows: • Utilise adjacent care areas for overflow capacity. Even though all care areas are designed as independent modules, they all share one department

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corridor, allowing consult rooms to be reassigned to an adjacent module during surges in another. This strategy can be leveraged to manage seasonal events like flu season • Utilise alcoves as patient hold areas. Alcoves have been designed in a long linear fashion along corridors, allowing placement of additional recliners or beds in them as needed. These alcoves can be further enhanced by adding medical gases, power points, and curtain. This strategy can be leveraged during busy hours of the department, such as evenings • Implement low-acuity exam pods. These exam pods are gaining traction in the US and Canada to help manage the volume of low-acuity patients looking for the convenience of 24-hour access to healthcare. Designed as a one-stop shop for triage, blood draw, results waiting, and treatment, they take up significantly less space than a full consult room while still providing all required infrastructure. Patient can enjoy amenities like charging stations and wifi while they wait, not needing to visit multiple areas to complete their visit. This strategy can be leveraged to handle a permanent increase in low-acuity patient volumes. Important resources during this process included initial feasibility

IS S UE - 45, 2019

studies, future projections, and area trends, as well as any long-term growth plans the institution had in place. Other resources included the knowledge of frontline staff who can identify areas for improvement or environments where constant change is needed and difficult to achieve. Regardless of how flexibility is brought forth as a design consideration, establishing specific flexibility goals was paramount to a project’s visioning process.

AUTHOR BIO From designer, to design director, to international office leader, Angela Lee has played an integral part in the design and planning of more than 11.8 million square feet of healthcare projects worldwide, ranging in size from 15,000 to 3.5 million square feet with bed counts from 30 to 1,650

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STEP 1. Install a bedpan washer which is proven not to eradicate all sources of infection and bacterial spores.

STEP 2. The patient uses a potentially contaminated plastic bedpan caused by an ineffective wash and bacteria habouring inside scratches.

STEP 3. Repeat steps 1 and 2 increase the risk of a HCAI outbreak.

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HEALTHCARE DIGITAL TRANSFORMATION Healthcare digital transformation is rapidly taking its hold on the industry. The primary focus is to provide patient satisfaction. With paradigm shift from paper driven industry to digitally advanced industry, primary healthcare services are more focused towards patient centric care and has evolved with contribution of smart devices, Internet of Things, Data analytics and Artificial intelligence. As per new research, Asia-pacific is showing 14 per cent-21 per cent of improvement in patient outcomes and disease prevention due to digital transformation. Digital transformation is a journey which aims to integrate elements of web, social, mobile, AI, analytics, cloud and other technologies to enhance customer experience and develop organisational competitive excellence. R B Smarta, Managing Director, Interlink Marketing Consultancy Pvt. Ltd.

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IS S UE - 45, 2019

merging technologies are moulding healthcare services in multiple ways to provide accessibility, availability at affordable costs. Thus, it is looking at how consumers access it, how and which providers deliver it and what health outcomes are achieved. Looking at spurt of digitisation across globe, the emerging technologies like connected and cognitive health devices, electroceuticals, targeted and customised medicines, robotics, 3-D printing, big data and analytics, artificial intelligence, blockchain, and robotic process automation are gaining a grip on market. It seems like in the near future, digital transformation in

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healthcare could be applied at four levels: data infrastructure, efficientsupply chain, R&D, and customised healthcare ecosystem.Fig.1

FOUR PILLARS OF FUTURE HEALTHCARE

1. Data Infrastructure:

In this process of digitisation, it is estimated that by 2020, the number of connected devices across the globe will be nearly 50 billion. Thus, the need to manage big data and further analysing it would be very critical. This data is important as it would consist of potential insights and patterns that can improve decisions. It has been claimed by healthcare providers that electronic health records (EHRs)have the ability to improve quality and safety, and improving management of health information and clinical data. It provides accurate, up-to-date and complete information about patients at the point of care, thus enabling quick access to patient records for more efficient care. These also help experts understand disease trends for better diagnosis. Also, from the patientsâ&#x20AC;&#x2122; perspective, it enables improved services and reduces redundant clinical tests. The patient data generated across various hospital departments is the most valuable raw data, that can be further used for the analysis of national health. This data can also be employed to develop the future services based on the need. This includes data like patient habits, pattern of use, frequency of drug dosages, health history, and adverse reactions. This helps to understand the tolerance and effects of drug, which in turn, helps to drill down the understanding of knowledge that can clear the way for new R&D initiatives. 2. Supply Chain:

Hospitals currently spend approximately 45 per cent of their operating budgets on supplies and materials and industry experts expect that hospitals will spend more on supply chain management than labor costs in near future. Thus, it is expected that supply chain digitisation

Data Infrastructure

Customized healthcare ecosystem

Four Pillars

Supply chain

R&D

Figure 1

will be an emerging field in healthcare. This will eventually reduce manpower, especially lower ranking medical professionals, as their job roles will be taken up by apps and wearables. Even at present, apps can signal the need of refilling the prescription medication or inform doctors of health changes or if any modification of drugs has to be done, indirectly accelerating the drug supply chain. Investing in electronic inventory tracking system will enable transfer of data on medical supplies and allow hospitals to automate the inventory replenishment process. Blockchain technology, known for its secure, wide range of database distribution, is well suited in supply chain management, serialisation, identity management, transaction processing, contract and licensing

Source: Interlink knowledge cell

management, and documentation management. This technology ensures integrity of data amongst the stakeholders in the industry. A blockchain-powered health information exchange is capable of unlocking the true value of interoperability and can directly reduce the cost of current intermediaries. Case study: BJC Healthcare, one of the nationâ&#x20AC;&#x2122;s largest non-profit healthcare organisations located in the Midwest, US, was awarded in 2015 by Gartner, a global research and advisory company, for the its efforts in supply chain digitalisation. The organisation has invested in technology that confers radio frequency identification (RFID) tags to medical devices. This enabled the automation of inventory replenishment, leading to 23 per cent reduction of

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3. RESEARCH & DEVELOPMENT There are many possible ways whereby technology can be applied in R&D. One of them is applying artificial intelligence to research. It is assessed that on average an academic researcher reads 250-270 articles per year. You can imagine how difficult it would be for a researcher to correlate, integrate, link and get insights from all this data sites. AI uses cutting-edge algorithms to interpret and structure the data. AI and machine learning speedily and efficiently enable the analysis of the sum of all scientific knowledge. By means of AI, Professor Jackie Hunter and his team were able to generate 200 hypotheses which was further brought down, using in-silico validation, to 20 novel hypotheses. Eventually, it was carved down to five hypotheses which were further tested in an academic lab. This process which usually takes months, has allowed the team to discover the latent new mechanisms for disease modification in just a few weeks.

required inventory. In fact, they also saved costs by avoiding product expiry and reduced labour costs of nurses and clinicians by decreasing time spent on inventory management. 4. Customised Healthcare Ecosystem:

Today, data from various medical devices as well as from preventive wearables is used to adjust drug and treatments precisely based on the patient requirement. AI in R&D is not only about producing new drug formulations for patients, but itâ&#x20AC;&#x2122;s also a matter of how the AI platform will access

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AI is assisting in transforming the existing drug discovery process and can acclimatise towards newer technologies. The newer technology is upgrading pharma industry to augment the work of scientist in field of R&D and enable them towards effective understanding which can direct towards smart innovations. Application of technology to reduce ever increasing cost, especially in field of clinical trials is requirement. The 3rd phase of clinical trials is very critical as the cost as well as risk of failure is too high. Thus, if technology is able to reduce the complexity of processes and manage the time of completion then nothing can be as good as that. This can be achieved by using modern data and analytics technology, to ensure faster, safer treatments for diseases. It can be used to find persons with required criteria for study, thus leading to costefficiency and saving time.

the patientâ&#x20AC;&#x2122;s medical records, genetic markers, analyse data from wearables, and how well it will predict the health conditions before they become serious. In this case, AI is enabling customised medicines to behave proactively. 3-D printers are already employed in production of drugs, and now they are looking to apply technology in printing organs. No doubt, the company that is successful in applying these technologies will enjoy competitive advantage. Aprecia Pharmaceutical has applied 3-D printing to produce pills that are easy to swallow for every age group.

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Starting from secondary research to find new links between genetic codes to robotic surgeries, AI is reinventing and reinvigorating healthcare services through modern technology that can analyse, predict, comprehend learn and act accordingly. In Germany, 54 per cent of companies have already implemented analytics. Even automation of supply chain is enabled to increase efficiency. Further, now they are looking to apply predictive analytics in production planning. Process of making digitisation: A boon for patients:

Patient-centric approach: The main idea behind this approach is to develop a patient-friendly environment whereby patients are equal partners in planning, developing, and monitoring healthcare. In the past, patients were given appointment as per the availability of healthcare service providers. Now, the whole healthcare system is running around a patientcentric approach. Digitisation has emerged one of the tools to achieve goals of excellent healthcare system. Digitisation across healthcare has provided various significant approaches to share information on quality, costs and outcomes leading to connected health. Connected health ecosystem: The connected health approach is the most crucial part of the patient flow. The objective of connected health is to connect the healthcare delivery system by means of information technology to enable access and sharing of data across healthcare providers to allow analysis as and when required by the patient or the healthcare authority. According to study done by Accenture, Consumer use of mobile and tablet health apps has tripled over the past four years, from 16 per cent in 2014 to 48 per cent today, as part of a growing digital revolution in healthcare. As per the dipstick study, which surveyed 2,301 consumers,

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Overview of usage of digitisation

10% 27%

30%

33%

AI enabled healthcare services Home based diagnostics Virtual health assistants Virtual nurses that monitor health conditions Figure 2

the recent course of the transformation, significant digitisation would be observed in the area of customised healthcare. This will ensure a patientcentric approach in which community medical services and social caregivers would also be integrated.

References: 1.Healthcare â&#x20AC;&#x201C; Where Supply Chain Digitalization is Life or Death, Healthcare Enthusiast, November 15, 2017 2.Digitization of healthcare will upend its supply chain, SUPPLYCHAINDIVE 3.Digitization in life sciences, Integrating the patient pathway into the technology ecosystem, KPMG

R B Smarta has designed management agendas for profitable growth, relevant expansion, launching new concepts, ideas and projects for National and Global clients in Pharmaceuticals, Nutraceuticals and Wellness. Being in the industry for more than 4 decades &amp; in consulting as a pioneer for 3 decades, he has a perfect blend of industry and consulting best practices. He has added value and impact on performance of wide variety of clients, inclusive of start-ups to national and multinational corporate. His firm Interlink has created valuable insights and depth of knowledge in its knowledge bank, along with its consultants and associates.

AUTHOR BIO

the percentage of consumers that are sharing the personal data willing to share with their insurance carrier personal data collected from their wearable devices has increased over the past year, from 63 per cent in 2016 to 72 per cent today. By providing to patients who are admitted or even after discharged, the hospital can take total care and provide a delightful experience. Looking at the recent developments in healthcare, such events can be bifurcated into various segments depending on their applications. The main objective of development is to improve the healthcare services and provide patient satisfaction. In reality, the hospital administrator should consider digitisation as an innovative measure that not only needs installation but also needs change of mindset with digital processes. In

Source: Interlink knowledge cell

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APPLYING THE KONMARI METHOD TO YOUR HEALTH DATA STRATEGY

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In this piece titled ‘Applying the KonMari Method to Your Health Data Strategy’, Jan Herzhoff shares some interesting parallels and lessons drawn from the popular organising consultant – Marie Kondo, whose unique way of organisation can help inspire healthcare organisations to uncover insights from the data they’ve collected and unleash the true benefits of healthcare transformation. Jan Herzhoff, Managing Director for Asia Pacific, Elsevier Health

arie Kondo – the pioneer of the Japanese art of decluttering and tidying up has been making waves globally. Her method, also known as KonMari, involves a mindful process of (re) organising belongings to live a more purpose-driven life. As I chanced upon her TV series recently with my family, I started seeing how her unique method can be reinterpreted and applied in the management of healthcare data, and in turn provide better care in patients’ lives. According to IBM, it is estimated that the average person will generate more than one million gigabytes of health-related data in his or her lifetime, doubling the amount of medical data in existence every two to five years. This astonishing growth is not only contributed by the digitisation of health records, but data collected from smart sensors and wearable devices as well. Correspondingly, research from IDC predicted that healthcare data will grow to 2,314 Exabytes by 2020 from a figure of 153 Exabytes in 2013, with an annual growth rate of 48 per cent. This poses one of the biggest challenges that healthcare providers must address: how can we organise and prepare our data in a way that achieves our ultimate purpose of raising the quality of care for patients everywhere? We all know that deep data analytics

is a pre-requisite to harness the power of Machine Learning (ML) and Artificial Intelligence (AI). Yet, healthcare providers are facing a data dilemma approximately 80 per cent of this data is unstructured, which requires further review and analysis in order to unlock their value. Therefore, while the promise of applying AI to personalise treatments and increase precision medicine is on the horizon, providers need to ensure they are capturing, sorting and uncovering actionable insights from the rich trove of data they have. This is where the Marie Kondo philosophy comes in to provide interesting parallels that we can learn from in relation to healthcare data management. Tip 1: Visualise Your Destination

When Marie Kondo first meets her clients, she would ask them to envision the life they aspire to live. Similarly, it is important for providers to take a step back and reflect on their vision in healthcare as well – whether it is the aspiration to improve the design and process of clinical trials, develop more personalised treatment options, or to establish consistent care guidelines. Having a clear vision not only puts the “why” into perspective, it also helps you to avoid investing in technologies that do not solve real-world challenges and clutter your current IT infrastructure or data pool. Bear in mind that the more data that is collected, the more vigilant we must be to guard the security and privacy of those data – less is more. Stay on track with your vision and you would be in a better position to develop a strategic framework, and decide what kind of knowledge and data systems are necessary to help you achieve those aspirations. Reach out to the right stakeholders and partners who can ask smart questions and provide a

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Tip 2: Declutter and Tidy Data by Categories

Marie Kondo also has a distinct method of decluttering and tidying things up by categories, not location. During this process, you can reflect if the items still bring you happiness before you decide if you would like to keep them. In the context of setting up a highperforming health data strategy within healthcare organisations, identifying and organising data into categories, or more generally, guiding distinctions, is key for deep data analytics and AI to take place. Providers should aim to consolidate pool of data sets according to categories, as opposed to having a large scale of data that is unstructured, heterogenous and locked up in silos where data may be available to a few clinicians but not the others. To achieve this, the first step is to establish a framework to guide the collection of data in a streamlined and integrated manner. This includes patient-generated data that shows the health status of the patient, the information on the type of care received and medication prescribed, the various test results from different labs and more. The bottom-line is to ensure the continuous flow of necessary data collected that is not restricted by time and location, and to declutter those that are non-essentials. Tools such as clinical decision support solutions can help with the proper recording and structuring of clinical data, which can be analysed later on to produce actionable insights. Next, we look at the standardisation of data format. Given that health data nowadays is collected through a multitude of sources such as electronic health records (EHRs), paper, hospital information system (HIS), and nonclinical data such as those from smart sensors, we need to ensure that the data collected can be shared easily and

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securely, in order to support workflow optimisation and system interoperability. It is only when the groundwork of data preparation and standardisation is done, can structure and categorisation be applied. Without combining data

from multiple sources and allowing data to communicate longitudinally, AI and machine learning will not be able to transform health data into actionable insights to help clinicians make more informed, personalised care decisions to improve outcomes.

TIP 3: COLLABORATE FOR THE DEMOCRATISATION OF HEALTHCARE Just like Marie Kondo’s many clients who are overwhelmed to find the best way to reorganise their homes, and seek out experts like her, managing healthcare data for the greater good is similarly a massive undertaking that is rarely achievable alone. Take the establishment of a data collection framework as an example. Since health data is generated by a plethora of sources beyond any sole provider or contributor, data interoperability can only happen if data standards are not only aligned among traditional healthcare providers such as hospitals, but among non-traditional stakeholders, such as technology companies that enable the collection and transmission of health data as well. One positive example of nontraditional stakeholders making

strides in enabling interoperability of health data is the partnership between Google and Fitbit, where Fitbit leveraged Google Cloud’s healthcare API to smoothly integrate its day-to-day users’ health metrics within patients’ Electronic Health Records (EHRs). The future of healthcare must be a collaborative effort among traditional healthcare providers and non-traditional stakeholders within the healthcare ecosystem. With a concerted approach, we can democratise healthcare in a systematic way by programming and allowing data, knowledge and insights to ‘flow’ more freely across systems. This also facilitates the development and sharing of consistent, evidence-based care practice guidelines to ultimately improve the quality of care.

A Step Closer Towards Customised Patient Care

As people around the world adopt the KonMari method to organise their households, healthcare providers can also look to it for wisdom while developing their healthcare data strategy. This includes setting a clear vision to declutter, focus and organise data in order to harness its full potential. We should also bear in mind that this strategy should not be static, as the industry and technology systems evolve, we ought to continuously evaluate and adapt accordingly to be able to “spark joy” in patients’ lives down the road. AUTHOR BIO

clear methodology on data collection and management.

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Jan Herzhoff is the Managing Director for Asia Pacific at Elsevier and is responsible for accelerating growth of the Education and Clinical Solutions business in the region. He joined Elsevier in 2012, where he was Head of Strategy for Health Solutions across Europe, Middle East, Africa and Asia, covering all five business segments in Clinical Solutions, Education, Health Analytics, Pharma and Medical Research.

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PRODUCTS & SERVICES Company............................................... Page No.

Company............................................... Page No.

HEALTHCARE MANAGEMENT

TECHNOLOGY, EQUIPMENT & DEVICES

Dubai Health Authority........................................................ 26-29

Cantel Medical........................................................................ IFC

Fotona d. d............................................................................... 09

Kompress India Pvt. Ltd........................................................... 03

Greiner Bio-One.................................................................. 40-41

IHF........................................................................................... 15

Kompress India Pvt. Ltd........................................................... 03

InterSystems...........................................................................IBC

MREPC..................................................................................... 19

ISB........................................................................................... 67

Newster Group......................................................................... 51

JET EXECUTIVE........................................................................ 33 Malaysia Healthcare Travel Council.............................. 05, 20-21 SWISS WORLDCARGO........................................................ 34-35 Turkish Cargo.........................................................................OBC

FACILITIES & OPERATIONS MANAGEMENT Cantel Medical........................................................................ IFC Greiner Bio-One.................................................................. 40-41 MREPC..................................................................................... 19 Vernacare................................................................................ 59

MEDICAL SCIENCES Cantel Medical........................................................................ IFC Greiner Bio-One.................................................................. 40-41 Kompress India Pvt. Ltd........................................................... 03 MREPC..................................................................................... 19

INFORMATION TECHNOLOGY InterSystems...........................................................................IBC ISB........................................................................................... 67 Kompress India Pvt. Ltd........................................................... 03

DIAGNOSTICS InterSystems...........................................................................IBC Mirable Health Services Pvt. Ltd............................................. 47 Vernacare................................................................................ 59

SUPPLIERS GUIDE Company............................................... Page No.

Company............................................... Page No.

Cantel Medical........................................................................ IFC

Kompress India Pvt. Ltd........................................................... 03

www.cantelmedical.com

www.kompressindia.com

Dubai Health Authority........................................................ 26-29

Malaysia Healthcare Travel Council.............................. 05, 20-21

www.dha.gov.ae

www.mhtc.org.my/insight2019

Fotona d. d............................................................................... 09

Mirable Health Services Private Limited................................. 47

www.fotona.com

www.humainhealth.com

Greiner Bio-One.................................................................. 40-41

MREPC..................................................................................... 19

www.gbo.com IHF........................................................................................... 15

www.worldhospitalcongress.org InterSystems...........................................................................IBC

www.intersystems.com/southeastasia-heathcare ISB........................................................................................... 67

www.isb.edu JET EXECUTIVE........................................................................ 33

www.jetexecutive.com

www.mrepc.com Newster Group......................................................................... 51

www.newstergroup.com SWISS WORLDCARGO........................................................ 34-35

www.swiss.com Turkish Cargo.........................................................................OBC

www.turkishcargo.com Vernacare................................................................................ 59

www.vernacare-switch.com

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