New Healthcare Management Approach. Digital Health Interviews: Alfred Angerer

Greetings, ladies, and gentlemen! Welcome to the Digital Health Interviews, where we continue to bring you insightful conversations with notable figures from the ever-evolving world of healthcare and technology. Today, we are in the picturesque country of Switzerland, and we have the pleasure of introducing our esteemed guest — Alfred Angerer.

Introduction:
Alfred Angerer: Professor of Healthcare Management, Speaker, Consultant, and Podcaster. His research primarily revolves around two key areas: process optimization in healthcare organizations, specifically focusing on Lean Healthcare, and examining the impact of digital health on healthcare management. Collaborating with hospitals, insurance companies, and Pharma/MedTech organizations, the professor has undertaken numerous projects in conjunction with the Zurich University of Applied Sciences (ZHAW). These projects aim to develop both analog and digital strategies that enhance the quality and efficiency of healthcare delivery. To foster an interdisciplinary approach to the field of Digital Health, the professor, along with colleagues from diverse institutes, has established the “ZHAW Digital Health Lab.” Furthermore, the professor is also an accomplished author, having penned the book “Management im Gesundheitswesen: Die Schweiz.” He hosts a podcast on healthcare management.

So how did Alfred become interested in healthcare management and its improvement? “I was working for the Nestlé food corporation, then I spent a couple of years with the McKinsey consultancy company, so there was nothing related to healthcare but always about process optimization: how can I ensure a better quality with less money with higher efficiency? I’ve been here in diversity for the last 15 years, and one day my boss came to me and said: “I’m teaching operation management processes to a couple of doctors, and nurses, so I just took my slides from the industry, and they hated it. I need to develop a new course but to be very honest I don’t want to do it. So, Alfred, why don’t you take over it?”. I started thinking about healthcare: what kind of problems do they have in the sense of process optimization, in the digital world? And I noticed: it has a purpose to lag. Okay, let’s go for healthcare!”.

Let’s immerse ourselves a little in the atmosphere of the healthcare system in Switzerland. Here are its characteristics in general: “To understand the Swiss Healthcare System, you need to know it’s obligatory to refer to insurance companies, but you can always choose the kind of insurance you want. So it’s always a mixture of forcing you to have health insurance but giving you an opportunity to choose from which side. Yes, it’s rather expensive. The Swiss Healthcare System is expensive overall because we are the third most expensive country in the world with about 11 or 12% of our GDP given to healthcare. The thing is everyone can afford it: if you are too poor to have insurance then the state will come in and help you; no one is left on the street without insurance, and that’s not the case here.”

The citizens have both private and public institutions, and they can choose which one they prefer: “Everyone gets high-quality service here in Switzerland. We still have a lot of money that we put in our system, so the waiting times are much shorter than in other countries. But if you ask my colleagues here and the other professors doing health economics, to be very honest, we don't have that much data on the real quality, especially in the continuity of care. We know that one hospital is excellent, but if you leave it a year later and you have any problems after that, we cannot connect both issues. We don’t know if the continuum of care works as well as we perceive.”

Alfred thinks many things can be improved in their system: “I think we have become a little bit slow because of the money we have not had enough pressure lately, and it’s working for scarcity. Every country is complaining about that. We were attracting people from all different countries, so if you go to a hospital in Switzerland, here in Zurich, for example, 30% of the people will be from abroad. We were very good at it, not so good at developing some training for our people, but the worst problem we have at this moment is how to manage the digital transformation. We’re lacking behind, we’re not good at that. Usually, if you look at the rankings about who is the most innovative country on the planet, we are in first place according to the UN for the 12th time. But if you want to learn about digital health, maybe, you should look somewhere else.”

Angerer mentioned that they’ve attracted lots of doctors from abroad. The obvious reason is a combination of higher salaries and quite good conditions which always helps: “If you look at how many nurses we have per bed, and how many doctors we have per patient, there are pretty good ratios. So the horror stories I hear from many neighbors from France, Germany, and Italy that one person is responsible for the whole world during the night shift are not yet the case here. We are also in a shortage after COVID, so we have to look at this for sure.”

And now let’s speak about what a smart hospital should look like: “We started a big research project called Shift. If you go there to our website, you will see we have a consortium of 20 hospitals, 24 industrial partners, and 5 different universities. We are trying to find the answer to the question: what is a smart hospital? It is a combination of the right technology, the right organization, and the right focus on people. If you think about smart hospitals you would start with the technology and we are doing it as well. For example, one of the sub-research projects is about what kind of sensors we should have on our patients to monitor them all the time, what data we want to collect, and what we can do with it soon. That’s one part of the smart hospital: it gave us data from everywhere. But another important part that makes the hospital not only smart but also liquid means we can take this technology and break the walls of the hospitals. It doesn’t matter if you’re at home, at your appointment with your doctor, or in the hospital. We have a continuous collection of all this data. Organizational staff is always important. For example, many hospitals are not that smart at the moment and have a lot of issues with resource assignments: which person should attend to which patient, which bed, and in which location. This is a very complex problem that is wasting a lot of people's time and a lot of resources. What we try there is artificial intelligence to solve this problem. The last thing is about persons and people. The best hospital with the best technology and the best medicine will fail if you don’t have the right cultural attitude of your staff members. For example, in our hospitals in Switzerland, we think a lot in little compartments. So I care about my unit and don’t care at all if other units are doing well or not. We are trying to break this mental barrier of the thinking system. You have to think not only about you and your little team but about the whole hospital and the whole system by developing a serious scheme. We teach people the value of collaboration and thinking bigger not in your next budget and your little team. So that’s what we do and all these things together can make a smart hospital.”

Alfred has mentioned that Switzerland is a bit slow in adopting new technologies, but it has all the components for innovations and their adoption. So who should be the driver? “In Switzerland, we have a strong aversion to centralizing things. We try to make the central government and its role as small as possible. We have been talking for the last 14 years about introducing electronic health records so that you can take your data everywhere and it doesn’t matter which doctor you’re talking to. 0.1% of Swiss people have electronic health records. One of the reasons is that we don’t have one system with one standard: the government decided every region can have its own, so we have from 20 to 30 different systems competing against each other. To try to make the government in the driving seat is not working here, so I would say it’s the place for individual organizations. What we have here is either startups or healthcare providers who are trying new things out. This is like the source of innovations. This sounds for people coming abroad sometimes a little strange. Our insurance companies are there to link service providers, insurance, and patients, and they manage the money but they want to be more than just the money managers: they are also very open to innovations in how to improve processes and how to help patients better.”

Then we decided to speak about the regional startup scene. What keeps and motivates digital health startupers? “We have a very healthy startup scene here. I don’t have numbers compared per capita, but I know many young people who are really driving forward the whole thing. In the hospital, it came out that the typical doctor spends 20% of their time at the bedside talking with patients, and 80% doing other stuff like a lot of documentation. Nurses spend only 30% of their time with patients. For example, the founders of a startup — a doctor and a nurse — I just talked to told me: “Why can’t we make it more efficient, especially this documenting part? Why do I have to spend 30-40% of my day writing down what I have done? Why can't technology help me?”. This is just one little example but it really shows how we have really strong drivers here from individuals who try to improve their work processes and their lives.”

So is the number of large Pharma companies one of the reasons why there are lots of startups? “They are trying to collaborate with Pharma. The Pharma companies I’ve been talking to there are more likely to be not in the driver’s seat, but maybe lying down on the back of their cars observing the scene. And if they see a good opportunity, they will take it. So I think pharmaceutical companies have been a little bit slow with adaptation to all this digital health stuff. I don’t think they’re the main drivers. Once you want to conquer the worldwide market, you have to start thinking big. I think the most innovative things come from the bottom, from the individuals. You need to take a risk to become independent to create your startup. Most of our people are not afraid of being unemployed or not having enough money to pay their rent, so maybe this also facilitates things.”

Alfred Angerer is a great specialist on the topic of lean healthcare and the impact of digital health on healthcare management: “It’s a management philosophy: it comes from the car industry, basically — from Toyota, and it’s already 50-60 years old. The most important thing is to explain it with a “why”: “Why should I adopt this philosophy?”. If you are passionate about your job in healthcare, you want to focus on helping people and our organizations are not very good at supporting those individuals to do what they are looking forward to. Lean comes here as a philosophy that has some principles and a lot of tools and helps you to focus on whatever you think is the core of your work. These are triple wins: it’s a win for the staff because they can do what they think is the most important. It’s also a win for the organization: if I have doctors I don’t want them to spend 40% of their time writing things down. They’re expensive, and they should treat patients, that’s how I earn money. And the third win is about patients. If I’m there in the hospital and I notice the doctor, they have exactly two minutes for me then they’re running to the next patient, so I won’t be happy. Lean helps to mitigate all of that.”

In his New Healthcare Management approach, Alfred proposed seven management concepts to make a major contribution to the further development of the healthcare system: positive leadership, value-based healthcare, design thinking, Lean & Kaizen, self-organization, agility, and digital health. Are they of equal value or is one of these characteristics of greater value? “It’s like asking which of your children you like most. The first message is what the management systems of the future are. I think we all agree that the traditional hospital like how it was structured and used for the last 100-150 years is not the right place and it’s not the right organization form to run to go forward. So we started thinking about collecting all the different approaches on how to solve that. So we came up with this list. I think all of them make sense, and the interesting thing is there are connections between them, they rely heavily on each other. By the way, it’s not only focused on hospitals: you can also think about insurance, pharmaceutical companies, and so on. Those management concepts help you to find the true purpose and to have an organization that supports you in finding one. Maybe it’s the first step. The second step is if we want to survive in a market we need high quality and efficiency. If technology is changing all the time, you should start thinking about being agile. With Lean, you also help to engage your community, and your staff to come up with new ways of working: that’s also part of the Kaisen way of thinking. Digital health helps you obviously to optimize things, and so there’s a natural order and link between all these different concepts. I think you cannot start doing all seven, you have to prioritize, but I think sooner or later every company in healthcare will have to start thinking about when and how fast they should implement those management concepts.”

To help the healthcare providers to implement it faster, Alfred and his team are working very closely with many hospitals and healthcare professionals; their main problem at the moment is time. “You’re drowning now in the sea of work but you don’t have time to learn how to swim. If you’re here on a management road you need to give your staff members a certain time when they can really start innovating their processes and the ways they work with each other. The sad news — I’m a businessman myself so I know that you don’t like to hear this — is that you need to invest money. You have to pay your staff for not treating patients but being in a workshop developing new technologies, and experimenting around. The biggest help would be to give some space to the workers so they can start thinking about what would be a smarter way of organizing themselves.”

Let’s look a little further into the future. What could the future of healthcare look like? “I think we have been making a lot of progress, so if this continues, that’s a bright future in front of us. I know there are some issues but overall I’m very positive. We studied a lot about the impact of digital health on our society, and I think three major parts would change shortly. The first one is about the empowerment of individuals: for the first time in history, together with a smartphone or some software, I’m able to answer medical questions that I would not be able to answer as a non-nurse and non-doctor. We are giving this knowledge to everyone basically through technology. The second way is if you look at how patients with chronic diseases run through our systems, it’s fragmented. They go to one doctor to do something, they go to the next one and do the same things again, so they just hop from one doctor to the other one. With the help of digital health solutions, we can streamline those networks, those flows, and those patient journeys. You could take all the data, you could avoid so much pain in unnecessary treatments, so that’s going to be a real game-changer. And the third thing that the media usually focuses on is the processes that are happening within a hospital with a doctor talking to a patient and treating them. There you come with your robots and AI diagnostics. When I talk to Swiss doctors and nurses, they’re not so excited about AI helping them to be better doctors, and to find the right cause of illnesses faster. They want to have some technology that helps them to avoid all this administrative stuff I was talking about. So the healthcare of the future is where the doctor can be a doctor and not a secretary.”

Since our main audience is startup founders in digital healthcare and Alfred works closely with hospitals, here are some recommendations for startup founders in order to make the collaboration between a startup and a hospital better and more productive: “Unfortunately, there are no magic bullets. You have just to find the right person out there, you need someone in the hospital that believes in whatever you’re doing. Our doctors in Switzerland have two budgets: one is for running the system, and the other one is for doing some research, it’s something like play money. Once you understand that, you should go there and suggest to them how you can use the play money to fund or make a clinical trial. Many doctors in Switzerland are very eager to publish, so maybe you can join a university to make a nice publication and increase your authenticity out there. You have to understand what the motivation of the doctors is. Some of them will be research-focused, and other doctors will be more like: “I have 80 doctors and nurses under me, how can I do it more efficiently? Because my director is pushing me every year to save five percent of the cost.” And Those doctors won’t react at all to the research approach: they will react to the software to save time and have more patients. So my biggest advice is to put yourself in the shoes of the doctors.”

Our previous episode was with Philippe Gerwill: Healthcare in the Metaverse