Xiaohong Fan (Figure 1), MD, Chief Physician of Respiratory Medicine, and master tutor, is currently the vice president of Shanghai Chest Hospital.
She also serves as a member of the Medical Quality Management Committee of the Chinese Hospital Association, vice chairwoman of the Medical Quality Management Committee/Hospital Medical Insurance Management Committee of Shanghai Hospital Association, member of the board of Shanghai Women Physicians Association, and member of the Internet Health Care Committee of Shanghai Medical Association.
She has been awarded many honorable titles, including “March 8 Red Flag Bearer” of Shanghai, the President Award of Shanghai Jiao Tong University, the “Medical Tree Award” of Shanghai Women Physician Association, the Innovation Award for Medical and Health Management, the Excellent Volunteer for Charity Events by Shanghai Red Cross, and Outstanding Organizer of Charity Activities by the Shanghai Charity Foundation.
Breaking up “routine practices”
“A doctor can serve only a limited number of patients, but through effective management, a hospital’s president can help more patients.”
This is what Xiaohong Fan was told by Prof. Yun Feng, former president of Shanghai Chest Hospital, when she had just graduated with a master’s degree. After hearing this, she gave up her plans to become a respiratory physician, and instead pursued roles in hospital management in a career that, to date, has spanned 16 years (Figure 2).
Xiaohong Fan on disputes between doctors and patients
“I’m now a veteran with 16 years of experience in dealing with disputes between doctors and patients.”
Xiaohong Fan’s first job when she took office in 2003 was to deal with a medical dispute. “Generally speaking, only serious or death disputes require hospital leaders to deal with. In most cases, I am the one to settle the disputes,” she recalls.
At that time, the hospital did not have an outpatient building. The entrance gate was flanked by two old four-story buildings: the building on to the east was the emergency building, and the building to the west housed the hospital’s administrative operations. Both the office of medical dispute settlement and the division of medical affairs were located on the second floor of the administrative building.
“In the most serious scenario, a group of the patient’s family members blocked us inside the office. We had to climb out of the window down a ladder to the ground floor.” Xiaohong Fan had to escape via the window on two more occasions.
One day, a patient died because of poor prognosis after the surgery. His family members stormed into the office and demanded an explanation from the surgeon who had performed the surgery. After initial communications failed to resolve the matter, the office asked for an explanation from the head of the thoracic surgery department. The head, however, was besieged by the hysterical family members. “But we examined the whole treatment process, and confirmed that there was nothing wrong,” Xiaohong Fan stresses. In order to prevent a serious confrontation and cause safety risks, she made a prompt decision to ask the security guards to escort the head out of the office on the grounds of “emergency medical duties” while she stayed in the office to console the bereaved family members.
On another occasion, a patient fell to the ground from the inpatient building after he was transferred to the hospital due to serious complications following surgery. An experienced staff member on duty called the police and arranged an emergency rescue. After hearing of the incident, Xiaohong Fan rushed to the hospital and found there was still a shred of hope that the patient could be saved. After the patient had undergone emergency treatment, she arranged a swift transfer of the patient to another hospital with more experience of emergency rescues and better medical facilities, and sought the assistance of two doctors throughout the whole process.
She subsequently led a team to examine work records, check evening patrols, and revisit CCTV footage to find out what had happened in the build up to the incident. “Finally the patient passed away, but we did nothing wrong,” she says in an affirmative tone, “even in terms of humanistic care, we did a good job. Nevertheless, the patient’s family members were still making trouble. Our stance is clear, the dispute should be resolved through legal means.”
Under Xiaohong Fan’s leadership, the hospital has developed a stringent self-examination system in the resolution of medical disputes. “Whenever there is a medical dispute, we launch a rapid evaluation mechanism to resolve it and provide the patient’s family with an appropriate explanation and clear communication.” She stresses, “We must create an atmosphere that fact is fact. We do not shirk our responsibilities, but we also do not offer unconditional compromise.”
Despite her many dangerous encounters with patients’ family members, she says that she has never been verbally or physically attacked. “Perhaps because I’m a woman, and I’m also a daughter, a wife, and a mother, so I can give more consideration to their feelings.” In her opinion, it’s not bad for women to show their weaknesses. She still remembers meeting a patient’s family when she was seven months pregnant, their startled reaction, and their request to negotiate with another member of staff. She responded by insisting nobody else was available and that she was the only member of staff who could deal with the issue. As a result, the agitated family calmed down and held amicable conversations with her.
As patients develop a better awareness of how legal means can be used to protect their rights and interests, they are increasingly using audio and video recordings to preserve evidence. However, Xiaohong Fan discovered that doctors still have insufficient legal awareness, “Sometimes our doctors try to comfort the patients and tell them it’s just a small surgery and not to worry”. These casual talks, however, could cause big problems.
A chest hospital mainly treats heart and chest diseases, and third and fourth-level surgeries account for 90.47% of total surgeries. From a doctor’s perspective, “a small surgery” may mean that it is not a difficult or complicated surgery and is among the third and four-level surgeries. Patients, however, might think that “a small surgery” should carry less risk than surgeries like appendectomy.
“Patients and doctors may have totally different interpretations of the same word. Once the surgery is not going as well as it should, patients’ misunderstandings can be exaggerated, and a dispute becomes inevitable.” A string of practical experiences have reinforced her determination to teach doctors how to use “plain language” and to enhance their communication and legal awareness.
In 2015, the hospital and Xuhui District’s Mediation Committee for medical disputes launched a joint initiative to send the hospital’s doctors to work for a week at the committee before they are promoted to become associate chief physicians. The hospital made a mandatory requirement for doctors’ promotions: before clinicians are promoted to the position of associate chief physician, they must transfer to positions at medical management departments (medical department and outpatient offices) and work for one month, including one week handling medical disputes.
In addition, clinicians are also required to hold job rotations at the emergency department and ICU. “Four months at the emergency department and one month at the ICU. This arrangement aims to enhance doctors’ communication with patients and their awareness of legitimate practice and to improve their ability to deal with medical emergencies. Through direct communication with patients’ family members, doctors can show sympathy and compassion and strengthen the reputation of their occupation”, she says.
In the past, the general outpatient services were provided by outpatient doctors; under the watch of Xiaohong Fan, the hospital now requires the residents and senior doctors in the department of surgery to see a certain number of outpatient patients every year, and they must meet stringent performance evaluation standards. The outpatient services are a helpful means of improving doctors’ logical thinking and ability to handle emergencies, so that the whole hospital can provide better medical services.
Xiaohong Fan on management
“The respiratory department is in no need of a doctor like me.”
When she was appointed as assistant to the hospital’s president, Xiaohong Fan thought the new role would not affect her job as a doctor. However, she soon came to realize that she had to make a choice, because she had neither the time nor energy to balance the two roles.
“Actually, I’m not very enthusiastic about administrative management. But I thought that there are many doctors in the respiratory department, and I would not be able to make a big difference as a doctor. However, for the entire hospital there is only one assistant to the president, one director of the medical department, and one vice president of medical affairs. I have to do a good job for myself, because no one else can replace me,” she explains. Based on this, she decided to give up clinical jobs and devote more of her time to hospital management.
Xiaohong Fan had spent more than five years as an attending doctor at the Sir Run Run Shaw Hospital under the Zhejiang University of Medicine before she was admitted for postgraduate study at Shanghai Chest Hospital. “The hospital admitted only one postgraduate student in the first batch, and two in the second batch, and I was one of the two,” she recalls. In the early 2000s, the hospital was at a critical stage of introducing new talents. President Yun Feng hoped to build a young and well-educated management team and picked Xiaohong Fan for targeted cultivation.
The Sir Run Run Shaw Hospital was funded by the well-reputed industrialist Sir Run Run Shaw and built with assistance of professionals from Loma Linda University Medical Center, USA. Since 1978, the hospital has been the only large public hospital in China funded by a Hong Kong businessman and managed by foreigners, and it has adopted advanced modern models for hospital management. Xiaohong Fan explains, “I have worked at the hospital after completing undergraduate study, and I have been deeply impressed and impacted by the hospital’s advanced healthcare concept and modern management models.” She recalls, “the hospital opened for business on May 2, 1994, and I came to work at the hospital on August 8, when there were only two wards in the Department of Internal Medicine.”
When she started working at Shanghai Chest Hospital, she bore witness to the conflicting approaches to hospital management between China’s traditional and modern hospitals. She remembers, “In the early years I was just a resident doctor, but I have kept the experience in mind. When I have the ability, I use it to make a difference.”
At that time, postgraduate students were appointed as resident doctors. A team leader asked Xiaohong Fan to use penicillin to treat infections. She continued the practice as she did at the Sir Run Run Shaw Hospital: 800,000 units of penicillin sodium for six hours of intravenous infusion per day. However, another doctor told her that a colleague was making “bad remarks” about her, claiming her handwriting was not good and that she did not know how to prescribe penicillin.
She quickly admitted that her handwriting was indeed not good, but she could not agree that her prescription of penicillin was wrong. “The head nurse asked me to modify the prescription, saying other doctors prescribe 9.6 million units of penicillin a day. I told her that they were all wrong. Penicillin is time-dependent, and according to the drug instructions, it should be administered two to four times a day.”
Since the early 1990s, the Sir Run Run Shaw Hospital has implemented stringent regulations on antibacterial drugs—medical prescriptions are written out on three copies of paper, no venous transfusion service is offered in the outpatient department, and special prescription sheets are designed for antimicrobials. Rigorous training has rooted the drug specifications deep in her mind, “but for a long time, the conventional practices have also been deeply entrenched”.
Are traditional practices always right? Xiaohong Fan’s experiences have made her determined to push for standardized use of antibacterial drugs. But a hasty and one-size-fits-all approach to reverse traditional practices would only make the changes meaningless.
Electronic medical records were an important part of her progressive push. In 2018, Shanghai Chest Hospital introduced electronic medical records for all patients. Thanks to the now well-established information system, the medical advice doctors give must be consistent with existing standards.
“Many hospitals are adopting electronic medical records, but a truly paperless process involves no paper at all.”
In most hospitals, when doctors use computer to provide medical advice, they have to print a copy and sign their names. Xiaohong Fan explains, “When you print advice, it means that doctors can revise prescriptions on paper, but the revisions are not reflected in the electronic records.” Such revisions are unhelpful for quality control of medical services and impede large data-based clinical trials.
In the past, after performing surgeries, doctors had to make several copies about surgery records and discharge summaries. With the use of electronic medical records, they can substantially reduce the amount of paperwork. More importantly, after scrapping paper-based medical advice, the hospital has realized a real-time and efficient form of information management which improves the safety of medical services and drug administration. “I have to keep my promises. If the prescription is unreasonable, it will not be made”, Xiaohong Fan states.
Introducing paperless medical records is not as simple as introducing an information management system. Xiaohong Fan has to resolve two problems: the legal effect and historic paper documents. In order to ensure the electronic records have the same legal effect as paper records, the hospital has introduced CA-certified handwritten signatures for all medical staff. A certificate authority or certification authority (CA) is an entity that issues and manages digital certificates. As a trustworthy third-party institution, it examines the legitimacy and validity of the electronic signatures.
In addition, the hospital has arranged for staff to input all historic paper records into the information system to reduce its dependence on paper records. As the first paperless information management system in China, the system was based on mobile electronic signatures. In 2017, it received an award for excellence in health information inter-connectivity, and in 2018, due to its role in improving patient experience and service quality, was recognized as an example of smart healthcare (Figures 3,4).
Bed management is another problem Xiaohong Fan hopes to address. For a long time, hospital beds have been separately managed by different departments, and she is determined to change this “consensus”.
As the old Chinese proverb goes, when you face a problem, you should take progressive actions to find a satisfactory solution. She decided to launch a pilot plan at three special wards on the 13th, 14th, and 15th floors of the hospital’s No.2 Building. In the past, these three floors separately accommodated patients of the oncology, thoracic surgery, and respiratory medicine departments, but all of them were underused. She started from performance evaluation. “For instance, for the nursing department, whether a bed is used once or three times a month, the workload is totally different,” she says.
Under the support of the president, she optimized performance evaluation standards for these wards. According to her plan, these wards are not evaluated as a part of a department; rather, the nursing units are separately evaluated based on the beds’ overall utilization rate. Overcrowded wards are encouraged to borrow beds so that nursing staff can take care of more inpatients and receive higher remunerations. Surgeons and physicians can also get additional rewards after they perform more surgeries and discharge more patients than expected. These three special wards have provided a public platform for Xiaohong Fan to realize her dream of optimal ward management.
Afterwards, the hospital introduced performance evaluation standards for bed management across individual medical teams. “All beds of the Department of Thoracic Surgery were divided into sub-specialties and then medical teams,” Xiaohong Fan explains. Independent bed management by medical teams is helpful for unified management of patients. “However, the beds are the hospital’s resources, and the teams only have the right to use the beds”, she stresses. Based on the annual average number of surgeries performed by each medical team, and taking into account the surgeries’ complexity, the hospital calculated the standardized average length of hospitalization of surgical patients and distributed bed resources accordingly. “We make calculations and adjustments once a year, and build a new management model for these wards,” she says.
Xiaohong Fan is the youngest leader at her hospital. After she became the head of the Division of Medical Affairs in 2006, she could stay in the same meeting room as other department heads. “Only two directors of medical laboratories were younger than me, others were much older and could be my teachers.” However, thanks to the support and confidence of the president, she continued to push ahead with the reform measures. As she recalls, “Conflicts were inevitable, but I was fearless, because what I was doing was in the interest of the hospital; besides, we had good strategies and figured out transitional plans to get them to know that the changes were also beneficial to their departments. When they realized the changes were good for them, they gradually accepted and supported them.”
Despite busy schedule in administrative management, Xiaohong Fan has continued to spend two half-day outpatient services every week. In the consultation room, she returned to the role of doctor and personally experienced the electronic outpatient procedures to find potential problems. She says, “When we hold meetings about the health information system, I feedback these problems to relevant staff, and ask them to work out appropriate solutions. Sometimes I find the problems before they do.”
Xiaohong Fan on herself
“I’m a traditional woman.”
As a “young female leader”, age and gender are immovable labels, but Xiaohong Fan has never placed any label on herself. “No matter on work and life, I have never sought special treatment or protection because I’m a woman,” she says.
When she entered the medical trade, she realized that being a doctor was a special occupation. She explains, “American doctors at the Sir Run Run Shaw Hospital asked us to carry out thorough physical examinations of the patients, including their genitals.” That was apparently an awkward requirement for young doctors like her, but her tutor’s words have remained fresh in her memory: “he said that when you wear the white uniform, there is no gender difference. Your only role is a doctor.”
“From other perspectives, I’m also not so ‘feminine’. I don’t like to spend a lot of time or money on makeups or shopping.” she smiles, “I grew up in the countryside and had a tough childhood. I have led medical teams to serve people living on 4,500-meter-high plateaus.”
During the years, she has led medical teams to travel to high-altitude western regions, including Kashi, Qapqal, Naqu, Shigatse, Zunyi, Dali, Baoshan, and Xishuangbanna, where congenital heart diseases are more prevalent. Since 2007, the hospital has sent medical teams to screen congenital heart diseases in these areas.
It is in these areas she has a greater sense of her value as a doctor.
In 2016 she led a team to revisit Eryuan, where she met a boy they had treated. She remembers, “When he came into my arms, I thought that we had done the right thing.” The boy was diagnosed with Down's syndrome and had several rare congenital heart diseases including large ventricular septal defect and severe pulmonary hypertension. His parents had to stay in the village to take care of him. The entire family was forced to stay at home due to the illness.
The medical team brought the boy to Shanghai to undergo surgery, during which interruption of the aortic arch was found. Surgery for this condition carried a high risk, with a success rate of only 50%. The head of the Department of Anesthesiology called Xiaohong Fan and asked her if the surgery would go ahead. After communication with the chief of the Department of Pediatric Cardiac Surgery, she decided to take a gamble: “If the surgery is scrapped, the boy would have no more than two years of life. If the surgery is successful, he could stay alive for a long period of time. We are trying to increase the odds of making the surgery a success.”
The surgery lasted nine hours, and the boy was later sent to ICU for emergency treatment. Thanks to the concerted efforts of all medical staff, the boy was pulled out of danger one month later.
Their battle saved more than a boy’s life. By the time the team revisited the boy and his family, they had used their life savings to build a three-floor house next to their shoddy home and were living a new life.
With emotion in her voice, Xiaohong Fan recalls, “During the revisit, I had deep feelings that sickness could plunge a family into poverty, and after they got treated and recovered, the family could quickly escape poverty. You cannot have those feelings in a hospital. I’m a mother, and I’m also from a rural family. I’m well aware of the desperation and despair people feel when their sick relatives cannot get the appropriate treatment. So we have kept working on the program of screening congenital heart diseases, and we believe the program is very meaningful and that it should be further promoted.” (Figures 5,6).
Xiaohong Fan is as excellent as her male colleagues in the workplace, but she is not a “superwoman” obsessed with work. She explains, “I think I’m a traditional woman. I came to work in Shanghai because of my husband.” After years spent working at Sir Run Run Shaw Hospital, she had built solid professional foundation and developed bright career prospect. However, despite opposition from her parents, she decided to quit her promising career for the sake of her husband, and started over as a postgraduate student in Shanghai.
Three years of postgraduate study and two job appointments away from her hometown were meant to address the problem that Xiaohong Fan and her husband faced living in separate cities. “But,” she explains, “my husband works in offshore oil exploration, and he has often been sent to work abroad or at sea. Since I came to Shanghai, he has barely stayed here.” She plans to stay in the city “until my son is in the fourth grade of the elementary school.”
Once her son was old enough, she sent him to kindergarten in the morning and hired a domestic helper to look after him at home in the afternoon. She recalls, “My son was among the first to go to kindergarten, and I left after taking him there. He was very independent, and he would not cry or scream after I left.” This special family has won a number of honors including “the Most Beautiful Family in China”, “Civilized Family in Shanghai”, and “the Most Beautiful Family on the Sea”. Her family is not perfect in the conventional sense, but she believes that mutual respect and support among family members are especially important. “According to the Maslow’'s Hierarchy of Needs,” she says, “everybody hopes to realize self-fulfillment.”
“Be who you are, and do what you are supposed to do.” This principle is a self-requirement for Xiaohong Fan. Pursuing a medical career is a choice made by her parents, and shifting to hospital management is an incidental transition—they have nothing to do with her dreams or aspirations. However, she shares the good qualities of people at her generation: when you hold a position, you perform the duty associated with the position. She states, “Everybody has many roles to play. When you play a role, you act according to the duties and responsibilities associated with the role. But when you deal with other people, just be who you are.” She claims that she is outspoken and unsophisticated. These are her merits as well as her shortcomings as a leader, and she has no plans to change. This “be who you are” attitude has empowered her to break up the “routine practices” in the workplace and stay at the forefront of her profession to introduce fresh elements and replace old ones.
It is 6 p.m. before we wrap up Xiaohong Fan’s interview, and she was in a hurry to return home, “I have promised my son to make a good meal for him, so I have to go home early,” she explains.
Conflicts of Interest: The author has no conflicts of interest to declare.
(Science Editor: Siying Yan, ATM,