CEMS INTERNSHIP REPORT

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Company Overview
During July and August 2017, I was given the outstanding opportunity of working at Americas Medical City, in Rio de Janeiro, Brazil. The medical complex is composed of two high quality hospitals – Hospital Samaritano and Hospital Vitoria - with a total of 494 beds, 16 surgery rooms and 11 Day-Hospital beds. Both hospitals are fully equipped with state-of-the-art technology, enjoy a complete and multidisciplinary team of medical professionals and luxurious facilities. Additionally, there is an outpatient center with 252 spaces dived into medical offices, clinics and convenience stores.
Americas Medical City initiated its operations in 2015 and it has been growing impressively ever since. A training center designed for minimally invasive and robotic surgeries was recently inaugurated. Furthermore, by the end of 2017 the “city’s” pediatric services are expected to move to a different, better equipped space. This will allow this service’s expansion and an improved capacity of answering to patients’ needs and address the overwhelming demand that the group has been facing as of late. 	Comment by joaomariadfrato@gmail.com: 
Americas Medical City (AMC) is part of Americas Serviços Médicos network, composed of 22 hospitals. Their commitment is to offer the best in health care, focusing on high performance and process innovation, seeking the best experience for their clients and contributing to the development of the Brazilian medical-hospital sector.	Comment by joaomariadfrato@gmail.com: Pois, isto é que devia tar antes percebes? Uma pessoa que não conheça fica a pensar porque é que estás a falar da amil e da United até ler este paragrafo
Americas Serviços Médicos belongs to UnitedHealth Group. UHG is healthcare company headquartered in the United States and a leader worldwide in improving the healthcare system and helping people live healthier lives. UHG offers a wide range of products and services through two business platforms: UnitedHealthcare, which provides coverage and healthcare services, and Optum, which offers integrated health and wellness solutions based on data and technology. In 2012 UHG acquired a majority ownership in Amil Participações S.A., Brazil’s largest health care company.	Comment by joaomariadfrato@gmail.com: O Unitedhealth group cai aqui “do nada”... Porque não começar com “The City is a parto f Americas Serviços Médicos, an entity that belongs to UnitedHealth Group, a healthcare company headquartered in the US.....”?
In 2016 UnitedHealth Group Brazil was established and it is divided in to three main pillars:
Americas Serviços Médicos – hospitals and specialty centers;
Amil – Health and dental plans;
Optum – Technology applied to healthcare.
Narrative
My first week was spent doing a recognition of the complex and the different departments such as Finance, Billing and Quality, amongst others. This period was very important to further my knowledge of healthcare management and to experience the differences between the Portuguese and Brazilian systems. My previous experience in the healthcare industry, an internship in CUF Descobertas Hospital (José de Mello Saúde Group) in Lisbon, Portugal shed a more interesting light on my first week in AMC.
One of the major differences between Portugal and Brazil’s healthcare system is the billing methodology. In Portugal, insurance companies pay a fixed amount based on the patient’s Diagnosis Related Group (DRG). However, in Brazil, the method in play is fee for service, that is, each item of the procedure is paid separately, meaning that payment is dependent on quantity rather than on quality. 
Additionally, during my first week, I learned about how to properly evaluate a business with tools such as Net Promoter Score (NPS), which measures the customer experience and predicts business growth.
Specialty Centers Project
In my second week, I was assigned a challenging yet deeply interesting project, which was to develop a model that could measure the performance of specialty centers, using as a pilot the trauma center. Specialty centers consist of teams of highly skilled experts that deliver the best outcomes for their patients and are often involved in research and innovation to advance the field. 
In both Vitória and Samaritano Hospitals there has been a lot of effort put into structuring these centers and their implementation started as of late. Therefore, there was a need for a well-thought model that measured and compared results.	Comment by joaomariadfrato@gmail.com: Mudei só um bocadinho
The first phase of the model development was research. I studied the new paths of healthcare management such as value-based medicine and outcome measurement. My research led me to the conclusion that is extremely important to take the first steps towards value-based medicine, as it is important to develop an operations chain that places the well-being of clients at its center. Therefore, I decided that the model I was going to create should have a great focus on outcome assessment.	Comment by joaomariadfrato@gmail.com: Ou não? Não estudaste técnicas cirúrgicas e tal ou estudaste?
The model is divided in two main segments. First, the overall results related to target volumes and revenues for inpatient, outpatient and emergency services. Secondly clinical, financial and process KPIs are analyzed. The KPI list employed in this project is described below:
CLINICAL
% of patients with adverse effects
Mortality rate within 30days of surgery
Re-operation rate within 30 days of surgery
% of patients that are happy with the results
Staff to patient ratio
FINANCIAL
Average cost per patient
Average cost per surgery
Average revenue per patient
Operating Margin
% Glosas (Specific to Brazil’s healthcare system) [1: Glosas: the term refers to the non-payment by health plans of care, medication, materials or fees charged by companies providing services (hospitals, clinics, laboratories, among others). Medical glosas can have damaging effects on the companies’ financials.]
PROCESS
% new patients
Average number of visits per patient
% cancelled surgeries 
%cancelled appointments
Nº of surgeons
Nº of beds dedicated to the center
Average waiting time for surgeries
Additionally, I suggested segmenting the patients by age and insurance company as to better understand the market and to be able to understand demand and structure the service and marketing.
In the picture above it is possible to observe part of the dashboard, the output of the model, that displays the information regarding a specific center of excellence analyzed.
Weekly Meetings Project
Every Wednesday the key leadership of AMC gets together to discuss and evaluate the performance of the hospital’s main sectors. Currently, the meeting’s focus is mainly on numbers and their weekly evolution which, after a while, can become rather repetitive and even tedious. Consequently, I was asked to suggest some changes as to revamp the meetings, encouraging debate and strategic planning.
Firstly, I thought that I should involve the participants in the changes so I designed a questionnaire and asked everyone that attended the meeting to fill it. Subsequently, I gathered the resulted and analyze them as to take into account the attendees’ thoughts and ideas. 
On the left it can be seen the questionnaire and below the main results.
Secondly, I decided to use the Surgical Center as a pilot and to re-structure the excel model behind the meetings. Currently, each unit works on a different excel file per week, which accounts to 52 separate files a year. Ten years from now, or even three, it will be somewhat highly inefficient to have that many files. Hence, one of my suggestions was to completely modify the structure of the model used and compile the information in one single excel file that performs the analysis by day, week, month and year. 
Furthermore, I linked the excel information to the PPT presentation so that the process would becomemore effective and automatized. Also, I furthered some analysis with the aim of forming a more strategical path. Some of these changes and results I worked on can be observed in Annex 1.
One other important characteristic of these meetings is the visual feature of the presentations. Not only there are different designs and layouts spread out across the several units and their corresponding slides, but also the latter are very polluted, making the presentation grim and considerably hard to read. For that reason, I completely reshaped the presentation and proposed a transversal format for all the units with cleaner slides resulting in an overall more appealing presentation. 
Moreover, I tried to lead the meetings towards a more strategic oriented debate with result interpretation, weekly feedback, and interaction amongst every co-worker. Hence, I designed the presentation as to include in the beginning a summary of the week with the highs and lows and a short description of what lies ahead, the main challenges to come. Likewise, in the end of each segment presentation, the leader should specify the goal for the next week and the steps his team will take to achieve it. The point is to share the successes and the failures so that the group as a whole can improve its care delivering services and skyrocket the hospital’s performance and clients’ satisfaction.
Part of my suggestions can be seen in Annex 2.
Finally, I also made some practical suggestions such as having the presenters use a microphone as well as giving the audience time for Q&A.
In conclusion, these were the two main projects I was responsible for in my time here. Also, I had the outstanding opportunity of getting to know and working with an extremely experienced and caring team and to attend meetings and conferences. The most important thing I take from this experience is the in-depth knowledge of hospital management practices that will be very useful as it is my ambition to work in this area.
Evaluation
It has been an overwhelming experience and highly rewarding one. Throughout these couple of months, I had to deal with the many challenges of working in a much larger country with an organizational culture completely different from Portugal. Also, I worked in a medical complex of envious dimension and structure, with advanced technology and, most importantly, in a company going through an interesting adaptation period.
I learned a great deal from experiencing first hand business meetings, presentations and great professionals at work. Nonetheless what I found the most valuable take-away from this experience was the people. At Americas Medical City, everyone is treated the same and there are no inappropriate questions nor does the will to teach ever cease. I learned something new from the entire team, from the CEO and medical director, from doctors, nurses and technicians to administrative staff. Each one of them contributed to the wonderful time I spent in Brazil.
Conclusion
In conclusion, I had a fantastic experience. I feel extremely fortunate to have had the opportunity of doing my internship at Americas Medical City in Rio de Janeiro, Brazil.
I return home with a lot more baggage regarding hospital management, work ethics and people skills. My learning process was incredibly and I believe it will prove itself extremely helpful in my future endeavors. 
Annex 1
Annex 2
 CURRENT FORMAT 				 MY SUGGESTION