Managing IJN

Prime Minister Dato Sri Najib risks becoming unpopular if he succumbs to the idea of IJN reverting to a single structure like pre 2005. Suddenly the 13 head of departments and the 33 senior doctors found out they can't have absolute control over many matters most notably finances. We don't have problems with doctors wanting to go up the ladder in life provided they do it with a creature they owned. They can't do this with an institution owned by the government and the people. The management model which they are proposing will in effect take IJN private into their hands. Our main objection is that such a management model cannot sustain IJN as a center of excellence.

THE MANAGEMENT AND GOVERNANCE MODEL WHICH THE 33 ARE SUPPORTING IS NEITHER COMPATIBLE NOR ADEQUATE WITH THE AGENDA OF MAKING A MAYO OUT OF IJN. It's more suitable for a small GP's clinic with some locums. Accordingly the PM assumes the risks of IJN deteriorating in many aspects just because he has agreed to the doctor's presentation recently. Like many others, I am asking the PM to exercise prudence over this delicate matter.

I was ready to lay off the discussion on IJN. Then I read Rocky Bru mentioning something about it. I regard Rocky as the Godfather of Blogging who is responsible for making blogging an avenue for the voice of common people. His mention, suggests that this issue is still alive.

Let's be clear in this issue. The people involved in this issue, doctors and non doctors in IJN are proposing constructing models of management and governance. Doctors are proposing a single structure similar to that of pre 2005. In 2005, the doctors together with administrative officers, not happy with the single structure submitted a management structure and governance to EPU. The government through EPU agreed with the submission. We must inquire and probe why the management and governance model agreed upon by staffers at IJN is now disowned and in its place, the very one they sought to replace is revived?

The issue here is which is the contending model more suitable/amenable to the vision of making IJN a first class hospital or whatever grander name we care to give it. My principal contention is, a single structure isn't adequate for this purpose. If we want to become like Mayo, we must replicate as many of the substantive elements that made Mayo or Cleveland into such venerable institutions.

Many people I think are concern about this issue of how to keep IJN as an institution. In order to do that it must be supported by a management and governance model that allows it to be so. Such a model is the one accepted after the pre 2005 model was replaced. The current one isn't by all means perfect. Indeed the management at IJN took the very rational step of inviting a business consulting group to evaluate a suitable governance and management model. The consulting group brought in by the IJN people is not a lightweight in this very cerebral industry. IJN brought in the Boston Consulting Group which re affirmed that in order to become an institution like Mayo and Cleveland, IJN Must have a governance model as the present one.

Of course the findings of the BCG destroy the management and governance model promoted by the doctors. But instead of building a better mousetrap, they took the unprecedented and unscientific step of rejecting the findings of the BSG but not before IJN paying them RM3 million.

In my previous article, there were some responses from Dr Azlan who we found out, is a cardiologist at IJN. He has countered many of my points in my previous 4 essays. In doing so, I assume that Dr Azlan serves as spokesperson for IJN.

It will take some effort on my part to response to his rebuttals. The one I am interested is his mention about management lessons from Mayo Clinic. He stresses that an institution like IJN has to be led by a physician. He quotes an act of parliament to support his assertion. I have no quarrel over this position he is taking. I am prepared to give it a qualified consent.

In my mind, that act is relevant to private hospitals and clinics and is of relevance only when IJN is taken private. But everyone says, IJN isn't going to be privatized, meaning, Dr Azlan's quote of the act is superfluous, no? Doesn't matter- at first impression, a hospital is about doctors and so doctors must lead them.

For the moment though, I would like to explain something about how Mayo is managed since Dr Azlan has made reference to that matter. We can Google about this or read a book on this.

Very early on, the founders of Mayo Clinic, the two Mayo brothers who were doctors did something which is opposite to what the doctors at IJN are doing. They created the Mayo Properties Association which later evolved into Mayo Foundation. They later surrendered all future earnings and assets to MPA. They became in effect, salaried workers to the Mayo Properties Association. What was the intention? The intention was to create an institution that could survive beyond the lifetimes of the Mayos themselves and place the whole institution upon trust.

This is vastly different from what our doctors are proposing that is to create a sendirian berhad business structure. The way Mayo was structured since 1919 was that no one has control over the earnings and assets of Mayo. The Association was to be directed by a self perpetuating Board of members serving without compensation. Documents relating to the creation of the Association revealed that no part of the net income of this corporation or of its property or assets upon dissolution shall ever inure to the benefit of any of its members, or any private individual. (Management Lessons from Mayo Clinic pp 98). This simply meant that net revenues from clinical operations must benefit patients and the community rather than fat salaries or bonuses of physicians.

The basic idea is to create a sustainable model for management and governance compatible with an IJN envisaged to become a Mayo duplicate. The question before us then is: which model, the one proposed by Dr Azlan or the 2005 model that qualifies as sustainable?

In the early 1920's the Dr Mayos created a board of governors consisting of 7 physicians and a non doctor. The board was responsible for the administration and operations of the hospital. Later it also formulated policies. They then created a number of committees. These include committees dealing with clinical practice, education, research, personnel, finance and others. These committees look after the different aspects of management. The committees served as training ground for future leaders as well as functioned as a means of schooling people on the management and business dimension of the health care industry.

Under IJN's scheme, the control will be exercised by the physician CEO and his BOD. They can determine how to apply the assets and earnings and how much their remunerations are. For example, last year, doctors at IJN earned more income and bonuses than did their counterparts outside who were hit by the economic recession. IJN has proven to be a shelter from the financial storm.

Who knows what the doctors at IJN think inside? Whether they are greedy or not will not be evidenced by what they say. Dr Azlan can quote Koranic verses or even allude to higher morals, but greed or some other baser instincts are always evidenced by your deeds and actions. If Doctor Azlan and his supporters claim they are not greedy, we have to see it for ourselves. The comments from a reader asking us to come see what cars the doctors are driving suggests that they don't lead ascetic lives.

I am not going to begrudge doctors on account of them using and owning prestige marquees but it would open them up to suspicions of also being motivated by wealth seeking actions. Sama sahaja dia orang macam kita. I find it distasteful and sanctimonious on the part of Dr Azlan's supporters to suggest that doctors are not concern about wealth and in doing so, they don't behave like other wealth seeking mortals.

That these things happen and even more so when we also hear of IJN doctors enjoying all expenses paid trips and what not by Pfizer, the drug company, strongly suggests that IJN doctors are not molded in the cast of Mayo doctors or that they are motivated predominantly by altruistic motives. Translation: Doctors, like mortals like us, can also be greedy.

How can you perpetuate this kind of behavior and interests? By having an organization that's amenable to them such as creating an organization that existed before 2005. That would allow people not like Dr Azlan to pursue the baser and less than altruistic interests.

Let me quote an example. On average, non medical staffers at IJN such as nurses earn RM5000 a month. Doctors? The grunt working doctors earn RM 8000 and the specialists take away as much as RM80,000 a month. Bonus time. It was decided that non medics get 3 months bonus and doctors 2.8. The idea was vehemently opposed by the senior doctors. You do the math- doctor earning RM80k a month gets 3 months bonus and nurse with RM5k a month gets 3 months bonus.

Take another example of irrational behavior on the powers that be in IJN to limit the number of anesthetists. IJN suffers from a shortage of anesthetists. The 6 of them have to work on say 3000 patients for a specific duration. If each sleep inducer expert gets 500 patients and charges a RM1000 per patient, he gets RM500, 000. Because of the severe shortage, it was decided to get in another 5 experts in this field so that the work burden can be lightened. The proposal was rejected citing various reasons among them; the prospective candidates are not good enough despite many of them having donkey years applying anesthetics on patients.

Just consider this. Isn't it likely that by having more experts, you would have to distribute the number over more doctors and hence potentially forced to accept lower earnings?

Sure, you can say IJN is what it is now because of doctors. Good ones too. But it's also true they became prominent because IJN exists as an institution. With government money, captive market and all that.

Going back to the management structure before 2005 can lead to:-

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  Abuses of position that can lead to misallocation of resources
  
  
  
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  The pre- 2005 structure is not suitable to become a sustainable model of management in line with IJN's target of becoming a centre of excellence.
  
  
  

I am sticking to the principle that if power is to be exercised, better in the county than the district, better in the district than the state, better in the state than at the centre.