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Sakmongkol ak 47

Wednesday 4 November 2009

IJN- What’s up Docs?

Doctors are the kindest people on earth. I cannot imagine any other reason for any person wanting to become a doctor other than having the wish and obsession to help out the sick. They are also smart people. They can be smart and still help people. They can do and achieve this under the proper environment. So when an eminent lady doctor asked in a meeting- as if setting the tone for that meeting, what do we want to become, we can only give one answer. That IJN becomes the centre of excellence.

How will it achieve  this? By organizing itself as an entity with a vast support system, not found in a family like business structure. In business the family owned business structure has given way to the professionally run business organizations by people who are neither the owners nor founders of the business. These outsider professionals run the business while preserving the core values of the owners as best as possible.

If they chose to go back to an organizational structure based on a command centre kind, the move will surely be a retrograde one. Imagine now, the pioneer doctors who started with the founding of IJN as owners and founders. 15 years ago, a simplified structure with one command centre was sufficient to carry out work. One person and a close circle were able to function the hospital. He assumes ultimate responsibility, hire and fire, procurement (where the money was). On the flip side, one person can also screw the system and people up. But the organization thugs along.

Today, as new patient demands emerge, as new challenges emerge, that simplified structure cannot sustain IJN's quest to become a centre of excellence. The only way, I can think of for IJN to remain on its course to becoming a centre of excellence, is to duplicate or replicate the templates of such esteemed health institutions as Mayo and Cleveland. That is, you must have the right organizational structure. That right structure isn't the one promoted by some doctors at IJN presently. They are proposing to go back to pre 2005 of one command centre organization. You can't run an institution on the work ethics of a single general practitioner's clinic. That doctor in particular may be good and even outstanding, but his clinic isn't an institution. You need a support system.

The only interest is for the government to insist that IJN remains as a premier institution of medical excellence. It can only achieve this aim, if IJN remains as an entity that supports and promotes excellence. Further, that can only be achieved if IJN re-structures along the proposal made in 2005. That is, it organizes itself, in substance to the lines on which Mayo and Cleveland Clinics are organized. Basically these institutions are organized along a business structure that allows professionals do their best in their chosen vacations- doctors and clinicians concentrate on medicine while support staff creates the environment in which doctors thrive and prosper.

In 2007, for example, Mayo Clinic had some 2700 doctors and medical scientists. But it had almost 36,000 administrative and allied staff and some 3000 residents, fellows and students. To me, what makes Mayo great isn't because it privatizes but because it has the organizational structure that allows doctors and medical scientist blossom and proper financially and professionally. It's the support system that consists of 36,000 non medical people. With that Mayo made USD622 million profit.

I am not at all belittling the intellectual capacity of a single doctor or a small group of doctors , but surely a single command center system can't provide the supporting environment established along the lines of a Mayo.

There's even a more fundamental reason to reject a proposal to go back to a command centre kind of arrangement. It's to avoid concentration of power and tyranny. The basic principle to avoid tyranny (used in the widest sense possible) is to champion a dispersal of power. Milton Friedman the Nobel Prize winning economist wrote, if power is to be exercised, better in the county than the district, better in the district than in the state and better in the state than in Washington. What he meant was, we had better avoid concentration of powers in one person or one small group.

That principle finds expression in a more contemporary form in management theory – that of concentrating on the clock and not the clock builder. The institution is exceedingly more important that the personalities involved in building the clock.

Here's the deal. When Sime Darby wanted to take over IJN ( the clock), the idea was resisted on many fronts. Although, many different people resisted the idea, through representations, though joining forces ( soliciting the support of our eminence grise Tun M for example), through our writings- we were actually united for a purpose- that of preserving the barely 20 year old IJN as an institution. It was also directed at the attempt to concentrate power in a small group.

Hence this idea (being mooted by some eminent physicians at IJN) is doing exactly the reverse. First, they are attempting to concentrate power in a cartel like club whose membership perhaps number 12 or 13. Imagine the possible effects. One, it will have the immediate effect of closing membership of the physician's cartel. The club of 13 has absolute discretion and powers to limit entry into the cartel and it will determine who, how and when any other physicians not currently belonging to the club, can become a member. This will stifle the advancement of those physicians outside the club and will definitely reduce morale. Second and more important to me, the members of the physician's cartel alone have the power to decide on the application of the RM411 million cash or near cash which IJN has. Or maybe RM100 million or so if one takes into account the seed capital given by the Government and other capex outlay. What's to stop one decision maker( the boss of the company) deciding how to spend the RM 100 million or so. Divide RM 100 million among 13 people for example.

This idea is inherently flawed and contain within it, the seeds for the future destruction of IJN as an institution. What's the emotive of the doctors? Why do the doctors who agreed to a 2005 organizational structure, abandoned this management idea which can turn IJN into a centre of excellence agree to revert to a management organization which was abandoned in the first place? Why must IJN go back to the pre 2005 to turn IJN into effectively, a general one person general practitioner's clinic? Its back to the Yahya Awang days with a management system, the doctors themselves disapproved. What's up docs?

If the PM agrees to this idea, he is ill advised.


Anonymous,  4 November 2009 at 12:27  

It was reported that the government have to subsidise RM20M to IJN and the implication was a burden to the treasury.

I say if the RM100M commission paid in the defense deal given to IJN, for the next 5 years this is non-issue and not a burden which benefit more rakyat. But the commission benefited whom??????

You ponder.

Anonymous,  4 November 2009 at 18:37  

Hear, hear,... too many years of fiscal imprudence and financial mismanagement. Subsidies, procurements,contracts, projects privatisations, concessions, benefiting the same group of elites, while in the end, rakyat have to bear and pay the costs via higher Govt debt, bailouts, taxes, extra spending on basic needs like education and health, poor quality of life...

Anonymous,  4 November 2009 at 21:18  

When Columbus first step his foot on America, he declared the 'terra nullius' as the property of Spain.

It seems the fervent disapproval by the practitioners have triggered an awakening. And, so somebody must have experiencing the sensation that they are being pulled inside the vacuum - a property that belongs to nobody.

The reality is that if a property belongs to the people, it has no actual owners.

They just have to stake their claim or so they thought.


Anonymous,  5 November 2009 at 11:57  

You said:

"If the PM agrees to this idea, he is ill advised."

The doctors led by the eminent lady doctor made a presentation to the Economic Council on the 27th Nov presenting the single structure as the "way-forward".

The PM, chairman of that meeting, bought the idea sold by eminent lady doctor hook, line and sinker.

Therefore, the PM, has indeed agreed in that 27th Nov meeting, on the single structure, thus reverting to the pre-2005 structure.

Now, surely the PM must be aware of the short and long term effect of such a reversal.

umar,  5 November 2009 at 22:24  

Every predator has superior master plan for IJN. Simply because it has 400M cash and sitting on goldmine: the market value of its land. That is why you too seem promoting this ' centre of excellence' idea.
If IJN is in the red , would Sime Darby or anybody come forward?
It goes without saying that all this crap about creating business synergies is hollow . At the end of the day, they would need the government to bailout IJN minus the huge pile of cash.
Why not set up your own hospital, support services, medical college with your own capital ? Then you can claim to be successful business model. Don't simply blow hot air about instituitions in USA. Malaysia has too many private hospitals ; Pusat Rawatan Islam , Pantai, KPJ. They are all business units that charge you a thousand for simple circumcision! Why not start their own hospital 'Centre of excellence' for cancer or Liver etc. Why should any entity takeover what was built with public funds be that PROTON ,KTM.
Please tell all these giant corporates to excell in their core business like plantation,construction,education etc.

Donplaypuks® 6 November 2009 at 01:01  

What's up, docs?

Why, isn't it obvious? It's PM Najib's "2nd wave of privatisation" that's poking its head out from the nether regions.

They smell easy money, low transparency & accountability, willing PM & EPU and a sucker public. Just the right ingredients for anothe PKFZ, Tanjung Agas or dell computers at a whacking $40K each when you can get them at $2.5K each on the net!!

Watch them sell 10% of Sime Darby and bankrupt Maybank!

The sharks smell blood and are circling the waters!

We are all of 1 race, the Human Race

Anonymous,  7 November 2009 at 09:21  

Sang Mongkol,

Thank you for your interest in my institution. I am an electrophysiologist from IJN and appreciate the space I hope you will accord me to correct your perceptions and misconceptions on my institution.

As your blog entry on IJN are 3 entries long and for the sake of brevity, I will frame my factual responses based on the summarized common threads running thorough your three entries namely :

a) That a group of doctors in IJN are in the process of taking over and privatizing the institution

b)) That the institution be run like a corporation with corporate people running the business side of IJN and cross holdings within IJN.

c)) That IJN neither have the tradition nor volume to evolve into Mayo or Cleveland standing

1)(a) Institut Jantung Negara is an entity governed by the Private Healthcare Facilities and Services Act 1998(PHFS 1998) which became was fully enforced in 2006.

Section 32(1) of the PHFS Act 1998 clearly state that the person in total charge of this entity must be a physician of certain defined standing.

Therefore, your assertion on IJN being taken over by doctors do not arise as doctors are required by PHFS to manage IJN. Any non physician who manage any part of IJN has to be SUBSERVIENT to the physician as only the physicians are recognized by PHFS to be the person in charge.

1) (b) Be that as it may, the doctors in IJN are well aware of their limitations and has in fact, proposed that a professionally qualified Chief Operating Officer(COO) who will report to the CEO(who fulfils the definitions spelled out in the PHFS Act) be created to manage non medical/cooperate matters.

1(c)Concerning privatization, I refer you to the article which appeared in Malay Mail bylined 23rd October 2009 which quoted our shareholders MOH and MOF.
Minister Nor Mohammed Yaakop said "IJN will never be privatized" while Deputy Health Minister were quoted as saying that her ministry (MOH) "will never let IJN be privatized "

Therefore your reservations/ideation that IJN are in the process of being taken over by some "eminent physicians" can be safely laid to rest.

2) Our proposal to have a professional COO reporting to a medically trained CEO to run IJN are consistent with the practices of Mayo and Cleveland Clinics.
We proposed this to our shareholders as we strongly felt that all decisions taken at any levels of operations has to put the interest of patients above all other interests. .
It is only by having this safeguard mechanism that we can continue to excel at what we do.

A good background reading on the culture of putting the patients' interest first will be "Management Lessons from Mayo Clinic : Inside One of the World's Most Admired Service Organizations " ( Leonard L. Berry, Kent D. Seltman,2008, McGraw Hill publ)

3)(a) Though I do agree with you that we do not have as a century long tradition as compared to that of Mayo’s or Cleveland’s , we certainly do have the volume and the skills to evolve to be just like them, clinical productivity wise.

For example, we benchmarked our 2006 and 2007 clinical performances against Cleveland Clinic output in 2006.Though Cleveland Clinic Cardiac Services has approximately 20% more bed capacity than us, our cardiac procedure rates, surgical rates and mortality rates almost matched theirs and and/or even exceed them on some accounts.

3(b) With this new information, perhaps the better statement will be DESPITE having such a short tradition of less than 15 years, the volume performed and the quality achieved showed that IJN has indeed evolved into Mayo- like or Cleveland- like.

Azlan Hussin

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