ICHA Is An Accreditation System That India Can Identify With’

Today, Indian healthcare organisations are waking up to international accreditation. The

Indraprastha Apollo Hospital in New Delhi and Wockhardt Hospital in Mumbai, last year
secured Joint Commission International Accreditation (JCI) and now Asian Heart Institute in
Mumbai too is gearing up for it. In the country, associations like CII-IHCF and QCI are
working towards forming National Accreditation Board for Hospitals and Healthcare Providers
Dr Akhil (NABH). Parallel to this initiative, is the formation of Indian Confederation for Healthcare
K Sangal Accreditation (ICHA), a national accreditation body.
Dr Akhil K Sangal is the CEO of ICHA , a management adviser and an accredited management
teacher in General Management, in addition to being a practicing medical doctor. Over the last 30 years,
he has acquired in-depth experience in all healthcare systems and sectors, both in India and abroad. In an
interview with Falaknaaz Syed, Dr Sangal discusses ICHA’s objectives, its operational plans and
emphasises its importance.

Please brief me about ICHA.

ICHA is an association of national associations / institutions of all stakeholders in healthcare. The basic
objective of ICHA is to create a mechanism to establish validated excellence in healthcare through a
comprehensive healthcare accreditation system.

It was envisaged that a widely held, consensus-based organisation be developed with synergy of all
concerned with healthcare. It is a non-political organisation driven by professionals with actual healthcare
providers at the core to take the lead. The organisation is an autonomous, not-for-profit, but self-sustaining
institution that encourages volunteering. The initial funds have to come from various sources.

When did you start work towards creating ICHA?

Appreciating the current realities and situation, coupled with the learn’t experience from the world over of
development and establishment of Healthcare Accreditation Systems, a participative approach was chosen. It
was decided through a series of progressive interactive meetings beginning August 2002, that an
autonomous body of all stakeholders be formed.

The National Associations of Physicians (API), Surgeons (ASI), Anaesthetists (ISA), Ophthalmologists
(AIOS), Pharmacists (IPA), Hospital administrators (AHA), Hospital Pharmacists (IHPA) were the initial
members of ICHA, however, as of now all the major associations of all stakeholders have either joined in, or
decided to join.

The ICHA register may be seen on the ICHA web page- www.indmedica.com / icha for updated details of
associations and institutions / individuals / organisations.

While the national associations are the voting members, individual organisations are enrolled as affiliates.
This structure not only ensures credibility but also encourages apolitical contributions by all stakeholders.

How many members does ICHA have so far on board?

As on date we have 23 National Associations (of across the board stakeholders) as members, 4 affiliate
associations, 12 Individual organisational affiliates and 179 individual affiliates. We have also “Friends of
ICHA” who contribute as donation.

By when will ICHA be operational?

ICHA is already operational. We are focusing on the plan of action in three phases. Phase I will strengthen
the organisation by enrolling all stakeholders, awareness campaigns, fund raising and building databases.
Phase II will focus on content building, which includes training, guidelines and standards development.
Phase III will entail accreditation implementation. The major work so far has been on Phase I. The work on
Phase II is also underway.

Quality improvement is the primary agenda. This requires convinced and committed participation by all.
Also given the nature of healthcare and diverse stakeholders, it takes much longer to bring people on board.
Even the ‘good’ hospitals in the developed world take two and a half to three years to get ready for
accreditation. The major part of this time is invested in bringing people on board and also recording the
current situation.

How will you ensure transparency in ICHA?

 The structure of ICHA has been so built that it ensures transparency.  In fact, that is what takes the longest.
However, given the current situation in India as below, the greatest need is to create awareness and build
trust.

 Review of literature and experience of Indian situation points to: -

 All pervasive felt need for improving healthcare delivery in all its dimensions.
  General lack of awareness about the above worldview of accreditation, with perceptions bordering
on the negative.
  India with its vast reservoir of expert resources has a unique advantage.
  There are areas of excellence, which need sharing and evolving a consensus.
  Mistrust is rife.

The key issues that need to be addressed thus are: -

 Widespread awareness, creation to establish trust

 Finalisation of consensus based guidelines for successful implementation. This would also ensure
committed participation to the maximum possibility.

What should be the government’s role? 

The government can facilitate by providing resources, having appropriate infrastructure, providing
corrective mechanisms and so on. By virtue of its power and authority, it can promulgate acts and
regulations. However, acts and regulations can only ensure the minimum (if at all, and only when the acts
and regulations are wisely written and implemented properly). But is the minimum sufficient? The simple
answer is – we all want more than minimum; we all want quality care. Thus, the government’s role is both
crucial and “necessary”. But it is neither “sufficient” nor “enough”.

There are several bodies already working towards developing a national accreditation system.
Besides, several hospitals prefer ISO and a few corporate hospitals are waking up to international
accreditation. Is ICHA really required? 

In all countries there have been a multiplicity of systems. Perhaps it is a matter of choice or an evolutionary
process. There are also different agendas. For instance ISO had its origins in the manufacturing sector to
streamline and standardise the production process. Even the automotive sector, evolved its own system
which was later adopted and incorporated by ISO. Similarly, NABL in India was established for all
laboratories - Clinical laboratories being a small subset of the whole range. Similarly many of the initiatives
are piecemeal or local. The all-inclusive ICHA model envisages to integrate t hese and hope as greater
realisation dawns, they would join in.  

Some corporate hospitals have sought and received international accreditation for several reasons - one
being absence of a credible system in India. They have gone in for this despite high costs - out of reach and
not cost effective for Indian hospitals. Another driving force has been “Medical Tourism” now rechristened
as “Medical value travel”. However, international accreditation does not guarantee patients coming in e.g.
JCI accreditation does not assure that HMOs will send American insurance beneficiaries to India.

Yes, ICHA is required very much so for the long-term evolution of the Indian Healthcare delivery and
ultimately the health status of Indian society. We need to collect and collate data to build evidence of proven
innovative practices in India, which are not recognised presently due to lack of evidence. Most of the Indian
systems have suffered immensely due to the lack of evidence based data and hence are presumed to be
conjectural.

So, how different is ICHA from other accreditation bodies being developed?

ICHA model is of a comprehensive accreditation system on lines of worldwide accreditation systems with
global acceptance. The primary agenda is excellence in care and patient safety as is evident from ICHA logo
and mission statement. The accreditation award is an outcome or by-product of this content based
excellence. We all need to work to achieve the objective of patient centred healthcare leading to lasting
improvements in the health status of the nation and also get integrated with the world. Everybody can
participate in and contribute to ICHA as an Individual or Organisational affiliate or “Friend of ICHA”.

Don’t you think a collaborative effort by all these agencies is required to build one accrediting system
for the country rather than having so many accrediting systems and rating agencies?

Yes, I agree a collaborative effort would be ideal and that is what is envisaged in ICHA. The structure of
ICHA reinforces this vision. I am sure progressively most would realise this and start contributing to ICHA
objectives. Let me reiterate that many of the efforts at present are towards licensing and badging or
certification.

When these are called accreditation it only tends to bring bad name to accreditation and is to be a “Stick to
beat with”. Let us all understand that accreditation derives its strength from credibility, which comes from
content and that depends on competence for which capability is necessary; available in plenty and our
greatest strength. Let us capitalise on it. True accreditation is the process of third-party validation that
indicates that healthcare delivery systems accredited conduct their activities with integrity, deliver outcomes
that justify public confidence and demonstrate accountability for the effective use of public and private
funds and achieve set standards in the process.

Accreditation of Hospitals

Worldwide, the Standardization of Healthcare Delivery System has become the focus. In India health care
delivery system has remained largely fragmented and uncontrolled. The focus of accreditation is on
continuous improvement in the organizational and clinical performance of health services, not just the
achievement of a certificate or award or merely assuring compliance with minimum acceptable standards.

Definition
 “A self-assessment and external peer assessment process used by health care organizations to
accurately assess their level of performance in relation to established standard and then to implement
ways to continuously improve it”.
 

”Market forces, such as medical tourism, insurance and corporate sector have accelerated the
demand for quality in healthcare services. As a result, there is a growing demand from consumers for
better healthcare as the lack of quality assurance mechanisms limits their access to appropriate health
services" - Mr. Girdhar J Gyani, CEO, National Accreditation Board for Hospitals & Healthcare
Providers India.

Why Accreditation?

Ensures a Quality Index for Health Consumers.

A growing number of hospitals in India are turning to accreditation agencies worldwide to both standardize
their protocols and project their international quality of health care delivery. 
It is a Public Recognition of the achievement of accreditation standards by a healthcare organization,
demonstrated through an independent external peer assessment of that organization's level of performance in
relation to the standards.

Attract foreign patients

The process of accreditation is envisaged to result in a process of fundamental change in the technical
procedures of service delivery, in the appropriate use of available technologies, in the integration of relevant
knowledge, in the way the resources are used, and in the efforts to ensure social participation. Quality
Assurance helps improve effectiveness, efficiency and in cost containment, and accountability and the need
to reduce errors and increase safety in the system.

Advantages of Accreditation:

Accreditation benefits all Stake Holders.

Patients are the biggest beneficiaries. Accreditation results in high quality of care and patient safety. The
patients get services by credential medical staff. Rights of patients are respected and protected. Patient
satisfaction is regularly evaluated. 
Accreditation to a Hospital stimulates continuous improvement. It enables hospital in demonstrating
commitment to quality care. It raises community confidence in the services provided by the hospital. It also
provides opportunity to healthcare unit to benchmark with the best. 
The Staff in an accredited hospital are satisfied lot as it provides for continuous learning, good working
environment, leadership and above all ownership of clinical processes. It improves overall professional
development of Clinicians and Paramedical staff and provides leadership for quality improvement within
medicine and nursing. 
Accreditation provides an objective system of empanelment by insurance and other Third Parties .
Accreditation provides access to reliable and certified information on facilities, infrastructure and level of
care.

1. Joint Commission International (JCI)

Joint Commission International (JCI) is a division of Joint Commission Resources (JCR), the subsidiary of
The Joint Commission working since more than 50 years from now. 
The Largest accreditor of health care organizations in the United States.
 It surveys nearly 20,000 health care programs through a voluntary accreditation process.

The Joint Commission and its subsidiary are both not-for-profit corporations.

Accreditation by JCI in various Countries

 

Joint Commission International (JCI), the leading healthcare accreditation agency in the United States has
accredited eight hospitals in India till date. The JCI accreditation is likely to be limited to only to bigger
players owning to its high cost.

India: JCI Accreditation Hospitals

1. Apollo Hospital, Chennai

2. Apollo Hospital, Hyderabad
3. Asian Heart Institute, Mumbai
4. Fortis Hospital, Mohali
5. Indraprastha Apollo Hospital
6. Satguru Partap Singh Apollo Hospital, Punjab
7. Shroff Eye Hospital, Mumbai
8. Wockhardt Hospital, Mumbai

2. Internationally Acclaimed? Healthcare Accreditation Organization

 The Joint Commission on Accreditation of Health Care Organizations

 (JCAHO),USA.

 The Canadian Council on Health Service Accreditation (CCHSA), Canada.

 The Australian Council on Healthcare Standards (ACHS), Australia.

 Health Quality Services (HQS). The King's Fund Centre, England.

 Council on Health Services Accreditation? for South Africa (COHSASA).

 The Malcolm Baldrige National Quality Award, USA. (Including the Swedish and European versions and
the version modified for health care evaluation, USA).
Accreditation by various National health agencies in their respective Countries

Accreditation Body in India

National Accreditation Board for Hospitals & Healthcare Providers (NABH)

National Accreditation Board for Hospitals & Healthcare Providers (NABH) comes under the purview of
board of Quality Council of India, set up to establish and operate accreditation programme for healthcare
organizations. The board is structured to cater to much desired needs of the consumers and to set
benchmarks for progress of health industry. The board is functionally autonomous in its operation. Currently
it accredits Hospitals & Nursing homes, and is expected to accredit ate Blood Banks, Diagnostic Centers
(Imaging), Dental Centers and Ayurvedic Hospitals/ Clinics in future.

NABH Accreditation Hospitals

1. B.M. Birla Heart Research Centre, Kolkata

2. MIMS Hospital (MIMS Ltd.), Calicut
3. Kerala Institute of Medical Science, Thiruvananthapuram
4. Max Super Speciality Hospital, New Delhi
5. Max Devki Devi Heart & Vascular Institute, New Delhi
6. Moolchand Hospital, New Delhi
7. Narayana Hrudayalaya, Bangalore
8. Dr. L. H. Hiranandani Hospital, Mumbai
9. Fortis Hospital, Noida
10. Sagar Apollo Hospital, Bangalore
11. Columbia Asia Medical Centre – Hebbal, Bangalore

And as per latest figure, 45 hospitals have further applied for NABH Certification.

Assessment Process in general

 
Accreditation is a voluntary process. Its standards are usually regarded as optimal and achievable. It
provides a visible commitment by an organization to improve the quality of patient care, to ensure a safe
environment and to continually work to reduce risks to patients and staff. Accreditation has gained
worldwide attention as an effective quality evaluation and management tool.

Benefits of Accreditation:
• Greater Efficiency
• More Accountability & Responsible governance in hospitals
• Overcome quality of care deficiencies in their practices
• Prevents negligence

Personalised Medicine: A Revolution In Healthcare

Neesha Patel
Personalised medicine is the understanding of mechanisms and pathways of disease together with the unique
characteristics of the individual to accelerate the prevention, detection and cure of disease. It is the re-
definition of diseases on a molecular level so that diagnostics and therapeutics can be targeted to specific
patient populations, thereby offering the right treatment, to the right patient. Personalised medicine
represents a significant advance from most current diagnostic methods and therapies, which were developed
to detect and treat the symptoms and/or apparent causes of disease broadly across all patients.

Conventional drug development approaches do not take into account that due to genetic variations, a disease
may manifest itself slightly differently in different types of patients. For instance, while some people are
prone to strokes or heart disease and others are to cancer in more aggressive way. Personalised medicine
deals with the genetic basis underlying variable drug response in individual patients and enables researchers
to better identify drug targets and the mechanisms of action of investigational new drug candidates.
Advances in genomics-related technology facilitates the elimination of unfavorable products at earlier stages
of development than is currently possible. Such technology relies on the deep understanding of the human
genome and epidemiology to focus on developing diagnostic and therapeutic products that target the
underlying elements of disease and the molecular profiles of specific patient populations.

The shift to genetically-tailored drugs is expected to bring massive changes to the pharmaceutical industry’s
‘blockbuster’ model. Current concepts in drug therapy often attempt to treat large patient populations,
irrespective of the potential for individual, genetically-based differences in drug response. Examples of
differential drug response include Prozac, which only works on 40 per cent of the population, possibly due
to variations in the cytochrome P450 gene family. Such variations also contribute to adverse reactions in
people taking the drug Seldane, which is why it was withdrawn from the market. A study carried out by the
Institute of Medicine (IOM) concluded that in the US, more people die in a given year as a result of medical
error than from motor vehicle accidents, breast cancer or AIDS.

In contrast, personalised medicine may help focus effective therapy on smaller patient sub-populations
which although demonstrating the same disease phenotype are characterised by distinct genetic profiles.
Genomic Messaging Systems link archives of digital patient records to enable analysis by a variety of bio-
informatic tools, while universal medical records could help doctors create individualised prescriptions and
treatment regimens. However, despite such technological advances, numerous genes play a role in drug
response and toxicity, introducing a daunting level of complexity into the search for candidate genes.
Although it is expected to take another decade for personalised medicine to be an accepted and integral part
of mainstream healthcare, the high speed and specificity associated with newly emerging genomic
technologies enable the search for relevant genes and their variants to include the entire genome.

Assessing Genetic Basis Of Drug Response & Toxicity

With the advent of the 20th century, came a broad arsenal of therapies against all major diseases, from
cardiovascular to mental disorders. However, drug therapy often fails to be curative and may in fact cause
substantial adverse effects. Today, nearly three million prescriptions out of the three and a half billion
written annually are wrong; that is, patients are treated with incorrect or ineffective drugs. Moreover,
worldwide use of these drugs has revealed substantial inter-individual differences in therapeutic response.
Any given drug can be therapeutic in some individuals but ineffective in others, causing some to experience
adverse drug effects whereas others remain unaffected. In one measure, there are high responders, who
demonstrate high drug efficacy; poor responders, who demonstrate incomplete drug efficacy; and non-
responders, who demonstrate no drug response.

The observations of highly variable drug response, which began in the early 1950s, led to the birth of a new
scientific discipline arising from the confluence of genetics, biochemistry, and pharmacology called
pharmacogenetics, which focuses on drug response as a function of genetic differences among individuals.
Medicine today, still targets therapy to the broadest patient population that might possibly benefit from it
and relies on statistical analysis of this population’s response for predicting therapeutic outcome in
individual patients. Therapists of necessity make decisions about the choice of drug and appropriate dosage
based on information derived from population averages. By broadening the search for genetic factors
affecting drug response, personalised medicine is beginning to supersede the candidate gene approach
typical of earlier studies. Determining an individual’s unique genetic profile with respect to disease risk and
drug response will have a profound impact on understanding the pathogenesis of disease, ensuring that
therapies are safer and more effective.

The “one drug fits all” approach, with the fruits of pharmacogenomic research, could evolve into an
individualised approach to therapy where optimally effective drugs are matched to a patient’s unique genetic
profile. This involves classifying patients with the same phenotypic disease profile into smaller
subpopulations, defined by genetic variations associated with disease, drug response, or both. The
assumption underlying this approach is that drug therapy in genetically defined subpopulations can be more
efficacious and less toxic than in a broad population.

Impact On Treatment

Though sometimes described as a phenomenon of the future, personalised medicine is already having an
impact on patient treatments. New diagnostic and prognostic tools will increase our ability to predict the
likely outcomes of drug therapy, while the expanded use of “biomarkers”, biological molecules that are
associated with a particular disease state, could result in more focused and targeted drug development.
Molecular testing is being used to identify cancer (colon and breast) patients likely to benefit from new
treatments and test newly diagnosed patients for the likelihood of recurrence. In addition, genetic tests for
patients with an inherited cardiac condition can help physicians determine which course of hypertension
treatment to prescribe in order to maximise benefit and minimise serious side effects.

In few cases, genetic tests (specifically association studies and candidate gene mapping) are beginning to
find their way into clinical practice, making a proactive approach to personalised medicine possible. In
association studies, a high density map of the human genome is prepared and studies correlate the disease
and drug response with specific polymorphisms. In candidate gene mapping, high probability genes are
chosen; those that are known to be involved in a particular drug reaction. Researchers then identify all the
polymorphisms (variations) of the gene and correlate them back to specific drug responses.

In cancer chemotherapy of acute lymphocytic leukemia, administration of drugs such as 6-mercaptopurine ,

6-thioguanine, and azathioprine can cause severe hematologic toxicity or even death in patients possessing
nonfunctional (“null”) variants of thiopurine methyltransferase (TPMT). Functional assays of TPMT in red
blood cells, or alternatively genotyping, can identify those patients (approximately 1 in 300) who are
homozygous for alleles encoding non-functional enzyme, and therefore unable to metabolize the drugs to
their inactive methylated forms. These patients can be safely treated with doses 10 to 15 times less than
commonly prescribed. Therefore, genotyping, or functional enzyme analysis, has become standard practice
in major cancer treatment centers such as the Mayo Clinic (Rochester, MN) and St Jude’s Children Research
Hospital (Memphis, TN).

The Herceptin case offers multifold lessons for personalised medicine. Herceptin is based on a marker
protein that is present on the surface of malignant cells. Called neu when it was first discovered by Robert
Weinberg’s group at MIT in 1982, and more popularly known as Her-2 following its independent isolation
in 1985 by Genentech scientist Axel Ullrich, the molecule ‘listens’ for cell growth and multiplication
signals. Large numbers of these receptor molecules turn out to be present in certain aggressive breast
cancers because the gene for the receptor is over-expressed. Originally approved for patients with the Her-2
marker who had developed metastatic breast cancer and had failed to respond to all other forms of
chemotherapy, Herceptin is being tested as supplementary therapy following surgery for breast cancer and in
cases of ovarian and lung cancer in which Her-2 is over-expressed.

Promise of Personalised Medicine

On the whole, personalised medicine promises many medical innovations and has the potential to change the
way treatments are discovered and utilised. At the same time, it is important to remember that personalised
medicine is based on probabilities and interpretations of data. The presence of a single gene or combination
of genes makes it likely that a person will develop or avoid a particular disease, but the outcome is almost
never certain.

DNA, RNA, proteins, and chemical signals among cells all play a role in diseases, as do higher-level
structures such as the human immune system. Subsequently, as personalised medicine becomes more
pervasive, a number of policy issues arise. A new healthcare paradigm with far reaching implications,
personalised medicine requires us to examine our current approaches to clinical trials, intellectual property
rights, reimbursement policies, patient privacy and confidentiality. The way such issues are managed will
affect the evolution of personalised medicine and shape its ability to prevent, diagnose and manage disease.

Marketing Of Hospitals In The Modern Era

Vivek Shukla

India is witnessing an era where new hospitals are being built at a pace like never before. There are exciting
challenges that these hospitals are facing while they are being commissioned. One daunting task that every
hospital, new or old, small or big, is facing today is the task of marketing itself.

I have spoken to countless doctors, who own hospitals, about their marketing strategies. It is rather
unfortunate that almost all these doctors had a dismal marketing strategy, if indeed they had one. For the
most part, they were not even aware that a marketing strategy needs to be crafted. What pains me is the fact
that millions are spent upon creating a product called a hospital and so little is done to promote them in a
professional manner. The people who offer this product are are very well trained in their profession. But
what is pitiable is the way this product called ‘hospital’ is packaged and
marketed. For those of you who are not clear as to how the hospitals are
It is a well known fact that
marketed, here is a glimpse:
if we retain our existing
customers and make sure
Referrals
they buy from us again and
again we can increase our
There is an attempt from hospitals to generate referrals from the Registered
business by 10 to 30 per
Medical Practitioners (RMPs). The hospitals appoint Public Relation
cent. Also it is cheaper to
Officers (PROs) for the purpose. The job of the PRO is to visit these RMPs
retain exisiting customers
every day and ‘lure’ them into referring patients. I wonder, who was the first
than to find new ones.
person to come out with this shoddy idea of luring people with money or
Loyal customer will
other freebies for sending patients.
recommend you to others
This is a bad marketing strategy. The simple reason being that once a
hospital starts indulging in what is called ‘cut practice’, its competitors will
not be far behind to follow suit. They want to lure the RMP with more money. The RMP becomes a pursued
commodity who has to be won over at any cost. Commissions, free gifts, dinner and liquor in the name of
CMEs and others are offered on a platter to the RMP sitting in a shady clinic in the outskirts of the city or in
the villages.

Yes, we all know that it is not legal to offer commissions for soliciting patients. But let’s face it, the cut
practice is still rampant.

Coming back to the RMP, all of a sudden, he is made to feel very important. He has discovered a way to
make a quick buck. All he has to do is coax a patient to get surgery done (even if it is not required). Once the
patient consents, the RMP rushes to the town to bargain for the ‘best price’ for his newly acquired
scapegoat.

Now, looking at the strategic business implications of this strategy of alluring RMPs, the hospitals have dug
a grave for themselves. All of them are dependent on outsourcing patients. The source that they depend upon
is greedy and has no loyalty. Whatever anyone might say, hospitals have ended up on the losing side of the
bargain and the RMPs have pulled the tide in their favour. The profit margins are going down even as I am
writing this article. The naïve hospital owners have shot themselves in the foot.

Lowering Prices

This is another amateur business strategy. The logic goes- ‘We are both physicians with same skills and if I
offer my services at a lower price, I will get more clients.’ Why do not the multi nationals learn from these
new-found strategists? Why does not Pepsi reduce the price of its bottle by Rs 2 and spell doomsday for
Coke? Going by the same logic, Sony can overthrow Samsung in a month.

Thinking the other way round, why does Pepsi not lower its prices? It is because if Pepsi starts this trend, the
competitor will follow suit. Do you think Coke will stay silent if Pepsi reduces the price of its 300 ml bottle
by Rs 2? Of course, not. The result will be that both the players will have shrunken profit margins. This may
further result in compromising the quality of both the products.

It does make sense if Apollo hospital charges more for a normal delivery than a small town clinic where
only one MBBS doctor sits. That is justifiable. But two similar competitors indulging in a price war and
shrinking each others’ margins is sheer foolhardy. This brings us to the million rupee question called how to
market a hospital in a professional and ethical way?

To answer this question in a very brief way, here are some tips:

Be Unique

Ever heard of the phrase ‘Differentiation’ or USP [Unique Selling Proposition]? Be original, be genuine and
be different. Do not imitate what the others are doing. Anyways, who will buy a cheap imitation when the
original is already available? There are a lot of creative ways to be different. You could be the most
experienced. You could have the best technology. You could also be the most reliable. You could be doing
the same procedures differently.

Whatever your differentiation stance, it will work as long as it is authentic and well communicated to the
target market. Communicating your marketing stance is yet another big topic. For the lack of space, I am not
discussing it here. May be some other time, I will throw some light on that. But I can not resist stressing that
don’t copy someone else’s uniqueness or don’t cut your fee to be different.

CRM

This is the thing for tomorrow. CRM or Customer Relationship Management as it called is a very important
tool to retain your customers and to make sure that the word of mouth publicity is ensured for the long term.

It is a well known fact that if we retain our existing customers and make sure they buy from us again and
again we can increase our business by 10 to 30 per cent.

Also it is cheaper to retain exisiting customers than to find new ones. Loyal customer will recommend you
to others. You may find their friends, neighbours and relatives coming to you over a period of time. Perhaps
you should appoint a PSO [Patient Service Officer] rather than a PRO.

Essentially, a CRM would include systems of staying in regular touch with your customers. You may need
to regularly send them cards, gifts, etc.It will also include inducing the past patients to participate in
activities being carried out by your hospital for social causes. Having feedback forms filled during the
discharge hour of the patient is one useful CRM exercise. Suggestion boxes and patient satisfaction surveys
can also be used.

Focus
Last word of advice from me is- Don’t try to be many things for many people. I will go to the extent of
saying that don’t be many things for the same set of people. If you are a famous orthopaedic hospital, just
stay with that. Don’t fall into the trap of adding gynaecology or skin specialty. Yes you can become better
and better in orthopaedics. No harm in that. But please don’t play with your brand image by making it too
confusing for your target market to understand.

Ever noticed, why MacDonald’s is not selling potato parathas? They can try to sell pizzas, but who will eat a
pizza at MacDonald’s when Pizza hut is specialist Pizza chain?

Strategy is a long term proposition. So don’t expect to get instant results. It will take time and perseverance.
But remember what the old and wise say. They say- ‘Good happen to those with patience.’

I personally feel that marketing and business strategies are more or less absent from this burgeoning
healthcare industry. The sooner the light dawns on this critical aspect of business, the better it will be for the
healthcare industry.

Global Healthcare In A Local Framework

Back from her trip to participate in UK’s Group Study Exchange Programme, Sheenu Jhawar shares her
experience.

Rotary Group Study Exchange is a wonderful platform for observing one’s vocation as it is practiced in
other countries. It also gives an opportunity to observe culture of a country reflected through the finer
nuances of ‘vocation’.

It is oft repeated, western culture does not care for its elderly. Excuse me one time, does it not? And we do?
We have a large percentage of senior citizens, not all of them dependent but progressing towards that stage,
when strong hands might become feeble, and ‘CARE’, if not help, will be required. What are we doing
about them? Do we have any national / state plan? Is making an old age home a cultured answer to this
question? It is oft repeated that western culture does not really care for its infants. Pardon me, yet again.

Indian Scenario

Unacceptable practices exist in India- whether among the rural areas, or even unfortunately in some urban
areas, where working is not just an option, but a necessity for mothers, and in the wake of nuclear families-
whether out of choice or compulsion, care of the young, is seriously neglected. Are we planning anything on
that front?

Indian healthcare functions to a great balance between: public- private partnership. It is an opportunity for
both to wake up to some ground realities. Yes, we do have state of art tertiary care centres— a very large
percentage of which comes from the private sector as we have a new mission is in the form of National
Rural Health Mission (NRHM). But is healthcare in our country really equitable?
 At the launch of state-of-the- art pathology
lab Acute Penine NHS Trust Hospital, UK,
seen from left to right: Steven Price, Chief
Executive, Sheenu Jhawar, Lesley Holland,
Communications Manager- Lesley Holland
and Dr Reeta Burman, consultant-
pahologist

GSE Experience

‘Care of the elderly’, ‘care of the young’ and ‘equitable healthcare provision’ were three parameters that I
got a good insight into, during my Group Study Exchange (GSE) visit to the UK. I was fortunate to be
included as a team member of the GSE Programme, and sent to GSE dist 1280- Manchester, UK. This
constituted a four-week-long stay during which I was to study my vocation, and participate in culture
exchange between the two districts (ours and theirs).

My vocation being healthcare management, I was able to see and appreciate various aspects of this and felt
compelled to compare the healthcare structures of the two countries as reflected by the district under study.
Healthcare, termed as the ‘National Health Service’ (NHS) is provided by the government of the UK.

The Difference

Unlike India, where around 60 per cent share of healthcare provision comes from the private sector,
healthcare in the UK is primarily from the government and is a major political issue. General Taxation
(almost akin to social insurance) provides the resources for the provision of healthcare.

In India, not only can social insurance not work because only 10 per cent of the labour is in the organised
sector, but sadly private insurance advertises and caters only to those people, who might not need it. Rural
India has never heard of this concept and as research has proved, more often than not, after dowry-
healthcare is the next major burden and can lead to further poverty.

In the UK, the ‘Department of Health’ regulates the spending and provision. There are some other agencies
too, like ‘National Institute of Clinical Excellence’- which sets clinical standards for providing treatment,
and the ‘Healthcare Commission’, which inspects the NHS trust hospitals against the various standards.

The service provision is set in various tiers. About 28 ‘Strategic Health Authorities’ all over the country
have some ‘Primary Health Care Trusts’, and some, ‘Trust Hospitals’ working within their area. The
interesting thing is that rather than these being accountable to the Government, the Government is
accountable to the public through service provision by these units.
Of the hospitals, some are district hospitals, some are large teaching hospitals, some are specialty hospitals
and some are dedicated to ‘mental health’ among other specialties.

The Primary Health Care Trusts have a two-fold activity. They commission services from the hospital for
their individual catch-ment area (the community) to provide community healthcare. The second key role is
to improve the health of the general population through each Trust’s own customised public health initiative.
(Some areas might be rural, with worrisome healthcare statistics/ prone to patterns of particular diseases
etc.)

The prices of all kinds of hospital activity are set on a national weighted average scheme. Then as per the
different range of activities done by a particular organisation, funding is provided by the Government.
Various charitable trusts help support their local NHS Trusts too.

Healthcare is free at the point of delivery, and therefore is equitable. This is a brilliant concept since it does
not differentiate upon the paying capacity of people to render care.

However, the dynamics have changed over time. Litigation and risk management issues have caused
immense paper work, owing to pending waiting lists. Although service provision needs to be reviewed over
time, but here is a classic case of constant review, constant changes and growing personnel requirements,
amounting to a very management heavy NHS- another resource crunch on the patient money, (although it is
reported that overall management costs are lower than in most private companies).

The staff, whether they are doctors, nurses, or other allied professionals like the physiotherapists,
occupational therapists, ambulance, paramedical staff members, have the privilege of working on their own
initiatives- given that the targets come from the top management. It is rare to find the drudgery of routine.
Creativity exists in most areas, and most people work as team-players.

Little wonder that decentralisation is successful, and every little department of a hospital as big as 2000 beds
is able to work on its own initiative. The targets of-course come from top-down, but brainstorming to
achieve them and implement the job profile, lies to great extent with the staff.

The actual technique of treatment between doctors of the two countries is very similar. Indian doctors are
working with pathbreaking technologies, and providing state-of-the-art treatment and this can be comparable
to any of the high-tech hospitals of dist 1280.

However, a major difference in the two scenarios is the professional status of the nursing community. In
UK, they hold a very important role in healthcare, and work tremendously for achieving better patient care.
Freedom of work is a mega booster. The doctors and nurses work in tandem to achieve patient goals. The
patient is never just a medical record number. He is treated in entirety. The piecemeal approach of Indian
healthcare towards its patients can learn something from the holistic and personal approach of NHS.

Elderly care is on the priority list of NHS. The latest approach is to treat the elderly in their own home-
environment. The reasons are two fold- entry to the hospital entails various problems- higher chances of
cross infection since this is a susceptible population, the burden of transport for the elderly, lack / shortage
of care takers.

The second reason is more administrative in nature. There is a dearth of hospital beds and if a patient can be
treated at his own home, not only are the chances of patient attitude towards his healthcare better, but it can
also save the hospital bed for an emergency admission.

There is a range of professionally competent elderly healthcare staff supervised by the district nurses, and
chaired by elderly care consultants to cater to the needs of this population. The patient care activities involve
taking care of the preventive and curative aspects, and include, among other things, home environment
assessment, state grants / provisions for relevant helpful equipment for home care and even social care
needs.
Lessons for India

The UK government has a national mandate on ‘elderly care’ and takes it as its personal responsibility. It is
a lesson which India can learn. The question is not whether it is right or wrong for the family members to
leave their responsibility on external factors, but the fact that this situation exists and something needs to be
done about it.

Another thing, we need to learn is bettering our child care support system. Government provides partial
funding support for childcare organisations. Various perks exist for working mothers, like flexible working
system, wherein the working hours maybe adopted at the convenience of the employee. Funded ‘after school
care’ exists for bigger children.

Unfortunately in our country, a big chunk of possible GDP is being allowed to go waste because willing
workforce cannot function. Private agencies in urban settings, and/or the government in rural India need to
come forward and step into the ‘care taker’ shoes.

It is a mere window to another system. However, every glimpse has something to teach, provided we are
willing to learn and practice.

Charity Begins In The Hospital

With the report on free medical treatment in charitable hospitals expected in April 2006, Shardul Nautiyal
gives you a ringside view of the squabbling going on between charitable hospitals and healthcare activists
regarding free treatment

The committee set up to formulate a scheme for providing free medical

treatment to the masses at various trust hospitals in Maharashtra will submit
its report by April 5, 2006 to the High Court. The scheme is the outcome of
an interim order passed on October 14, 2005 by the High Court. (See box on
page 16 for salient features of the Interim Order)

The committee has representations from the Association of Hospitals (AoH),

Charity Commissioner’s office, Government representatives from the
finance, legal and medical departments, representation from the Director
General of Health Services (DGHS), government hospitals and all the concerned stakeholders. The
committee is discussing various options within the framework of the terms of reference given by the court.

The interim order bears significance in the light of the dharna staged by the NGO Citizen’s Rights Group
outside two charitable hospitals in the city, HN Hospital and Bombay Hospital, against the State
Government’s inefficiency in providing healthcare facilities to the masses. The dharna once again brought to
the fore the wrangling going on between activists and managements of trust hospitals regarding free and
concessional treatment given to the common man.

Genesis Of The case

Sanjiv G Punalekar, a Mumbai-based lawyer filed an application in the High Court in December 2004 based
on the refusal of charity for treatment to his father in the State Aided Charitable Hospitals, which get several
concessions under the Bombay Public Trust Act, 1950. The hospitals maintained that neither Punalekar nor
his father came anywhere near ‘poor’ or ‘weaker section’. However, the High Court, hearing the
complainant and the respondent’s views converted the application into a PIL.

Punalekar had sought High Court’s order for formulating a scheme of centralised admissions to provide free
treatment to patients up to a statutory quota in view of the concessions availed by them. This was opposed
by the charitable hospitals saying that there should be no centralised admission and that admission of
patients would be at their own discretion. The charitable hospitals had also expressed their inability to
provide completely free treatment and raised objections over the definition of free treatment. They
contended that free medicines would not be provided to the patients. The interim order states that the
medicinal cost of Rs 3,000 per week should be borne by the hospitals till the Court finally decides the
definition of free treatment.

Punalekar had pointed out that a number of leading hospitals such as Jaslok Hospital and Lilavati Hospital
are running on land allotted to them at the rate of one rupee. The long term lease deed granted to these
hospitals as also the benefit of extra FSI made available to hospitals such as Breach Candy Hospital,
Harkisondas Hospital and Bombay Hospital brings them under the purview of Bombay Public Trust Act,
1950. This makes aided public trust charitable hospitals liable to reserve 10 per cent of the operational beds
and 10 percent of the capacity for treatment of the poor free of charge, and 10 per cent of the capacity for
economically weaker sections at concessional rate. (See box for details of concessions)

Concessions Given To Charitable

Hospitals

a) Tax/ Octroi/custom duty exemption and

Full Octroi Refund
b) Concessional electricity/water
c) Concessional land.
d) Income tax exemption
e) Receiving donations easily as the donor
gets tax concessions
f) Concessional / Additional FSI

The Big Fight

"Hospital alone AoH, an umbrella organisation for over 45 private charitable hospitals in
cannot control cost.the city, has condemned staging protest outside private charitable
Stakeholders and hospitals. Brig Joe Curian, Chief Spokesperson, AoH argues, “Since the
government hospitalsGovernment has miserably failed in providing healthcare facilities to the
have to pitch in to common man, the Citizens’ Rights Group should rightly observe dharna
control the cost" outside the government offices and not private hospitals. As regards the
obligations of the private hospitals based on State aid received, the court
- Joe Curian, has already appointed a committee to look into the provisions of Section
Chief Spokesperson, AoH 41AA of the Bombay Public Trust Act, 1950 in its entirety.”
Speaking on the Citizen’s Rights Group plea on reducing the cost of the
treatment, Curian, says that the cost of the treatment is the sum total of many cost inputs like high end
equipment, drugs, land, building, personnel, technology, the rate of
"Charitable hospitals
obsolescence, electricity and other hospital charges. “Hospital alone
have so far been
cannot control cost. Stakeholders, including government hospitals have
spared from penal
to pitch in to control the cost. If hospitals are making exorbitant profits,
action only due to the
they can be considered as the Billian of the piece in this, which they
inefficiency of
certainly are not.
government
machinery in fixing
To which Punalekar argues that misdeeds of trustees of private bodies
accountability on them"
are not committed in person but through paid employees, who are made
to violate laws for saving their jobs.
- Sanjiv Punalekar,
Petitoner
“They are under a shell of privacy. Hence, there is a need to make their
affairs more transparent. This is possible only through centralised
admissions. It is strange that everyone including the industrial giants desire to do charity only in Mumbai
and that too on plots at Peddar Road and Cumballa Hill,” says Punalekar. As regards the government, he
says, “The lacunae in government reflect on all of us and we ought to fight against it through a democratic
process.”

AoH believes such action would deter potential investors including foreign Salient Features of the
investors who may be considering investing in healthcare in India. “Instead Interim Order
of hospitals they will divert their funds to other profitable ventures or
industries leaving the common man deprived of healthcare facilities,”  The Committee at all
Curian opines. times while making
recommendations
Punalekar refuses to buy the argument and states that, with regard to will keep the purpose
discouraging private investment in healthcare, the issue is being messed up. of Section 41AA in
“Nobody can oppose a private investment. But then they should not take mind
government patronage and at the same time refuse to be accountable to the  Definition of ‘free’
people,” he says. and ‘weaker section’
“State Aided” for
Punalekar feels that charitable hospitals have so far been spared from penal medical facilities will
action only due to the inefficiency of government machinery in fixing be deliberated upon
accountability on them. “The huge aid from the coffers of Maharashtra,  Inclusions and
which is on the verge of bankruptcy, was used to subsidise the treatment of exclusions are to be
the rich people. Today, they are expressing apprehensions about efficiency considered
of government and about likelihood of corruption. This very same  Viability of hospitals
government was efficient, when these people got lands allotted to them,” he concerned must be
adds. kept in mind at all
times
Dr Ketan Parekh, former President, Association of Medical Consultants
(AMC) feels, “The action of the Citizen’s Rights Group in targeting private
hospitals is not justified as the onus of identifying people for free or
concessional treatment lies with the Government, which has miserably failed. The quality of care which any
hospital offers can be maintained only when the economics of running a hospital is properly understood. The
government and the healthcare rights activists should realise this aspect in the interest of the common man.”
Medico-legal consultants are also not in favour of attacking the private healthcare institutions. Says Dr Lalit
Kapoor, Chairman, Medico-legal Cell, AMC, “The agitation of the Citizen’s Rights Group would make
sense only if they make the Government realise that it should monitor the infrastructure and the healthcare
facilities delivered in a proper manner.”

Experts claim that delivery of healthcare at out patient department (OPD), in-patient department, critical
care and emergency is becoming more critical with technological advancement. Speaking on the delivery of
healthcare in public charitable hospitals, Dr ME Yeolekar, Dean, LTMG Hospital, Mumbai says: “Much of
the care has tended to become diagnostic based, requiring several investigations. This has its own financial
implications, therefore healthcare providers/organisations have their own set of personnel and financial
problems. If these are addressed too, many of the grievances or perceived grievances can be redressed.

An appellate board of non-judicial nature should therefore be formed for redressal of grievances of the
patient. ”

Emerging Trends In Planning And Designing In Indian Hospitals

Dr K B Sood

Hospital is the most visible face of the healthcare industry. It handles the dynamics of life and
death situations during the process of rendering healthcare. Peter Drucker, the management
Guru has said, “Hospitals are the most complex human organisation ever devised”. Today,
hospital buildings are considered the most complex building forms. Integration of developing
technologies into healthcare delivery is making hospital buildings more complex. Therefore,
planners and designers of hospitals must be conversant with emerging trends in the fields of
technological developments, which shall be deployed in foreseeable future. They must understand the
complexity of integrating these technologies with the building systems and forms, to create hospitals where
the healthcare provider can utilise these comfortably to deliver most appropriate healthcare.

This process had started by middle of 19th century when new emerging technologies like X-ray machines,
new drugs and better instrumentation was integrated into the healthcare delivery. The pace of integration of
technology was slow and deliberated at length. But encouraged by the results, healthcare providers started
adopting new technologies at a faster pace, so much so, that in middle of 20th century, it was said that the
hospital building has become obsolete by the time they are built.

It was at this time that hospital planners evaluated the emerging trend in technological developments in
various fields like Space Technology, Information Technology, Aviation Technology, etc, and made a
forecast for the emerging trends, which may soon be seen in hospitals. These technologies were integrated
with existing healthcare delivery models and the new healthcare delivery models that emerged were tested
and if found useful, were made part of hospitals. This required that all hospital planning consultants keep a
track of all emerging trends in various developing technologies. As and when the trends start finding an
application in healthcare delivery, the hospital buildings are ready to adapt to them without many structural
changes.

Let us look at these emerging trends as they are available to us for planning and designing Indian hospitals
in the next three to five years. We shall group these trends into three categories.

 Technology trends which directly affect delivery of healthcare.

 Technology trends which affect hospital engineering and support services and thereby indirectly
affect the delivery of healthcare.
 Non-technology trends which directly affect delivery of healthcare.

In this article, we will discuss the Technology Trends Directly Affecting Healthcare Delivery.

Digitisation of Hospital Equipment & Processes

Imaging services, especially radiology, has now been fully digitised. Physiology monitors have been
digitised. as well as clinical laboratory. The patient file is being digitised. This has also enabled hospitals to
archive full patient files on hospital servers to be shared between various healthcare providers.

After digitisation, virtual doctors shall become a reality. There shall be centralised control rooms to monitor
clinical and administrative data. Digitisation will enable hospitals to become paperless and film-less. Patient
files shall be issued as smart cards. The doctors, on ward rounds, shall carry a laptop and accessories on a
trolley and review patient data online. The doctor orders shall be transformed into hospital vide activities on
real times basis. Even the prescribed treatments can be evaluated for incompatibility, patient’s allergy
history, past history, etc.

This will provide maximum benefit to the patient being evacuated to a hospital because the digitisation will
enable patient monitoring and possibly, provisioning of critical care from the start point. When standardised,
it shall be most useful for cases of heart attack where “Time is Muscle”. By the time patient reaches the
hospital, the latter shall be geared to provide all needed services immediately.

This will impact the way cross consultations are carried out because after digitisation, geographical
distances shall lose their meaning. It shall also enable vertical integration across healthcare providers in
primary care, secondary care and tertiary care as well as across healthcare providers in rural centres and in
specialised centres located anywhere in India.

Hospitals have to gear up to meet the challenge of digitisation of patient data in terms of digitised
equipment, interpretation, staff skills and training. Essentially, it shall require deployment of optical fibre
networks within the various departments of the hospital for very fast transfer of data. It shall also require
broad band connectivity across majority of healthcare providers in India to realise the full potential of
digitisation. This shall specially require evaluation of interference across various cable and data transfers.

It shall also require deployment of ambulances, which shall provide critical care while moving and will need
proper communication links on the move. We feel, if this happens, some staging stations shall need to be
created whenever the patient is being evacuated long distance say over 100 Km.

To make future hospitals compatible with older machines or less digitised hospitals, some additional
equipment like film scanners, film printers shall also be installed all across the chain of hospitals and other
facilities in a hospital group or at state level or national level.

We believe that this trend is going to affect all hospitals, small or big in the next three to five years because
digitisation also has been reducing the costs and all kinds of hospitals shall gradually upgrade to digitised
equipment for up-linking themselves to various networks for various purposes like insurance, cross
consultations, tele-medicine, etc.

Optical Coherent Reflectometery

Optical Coherent Reflectometery is the integration of infra red or lasers with guide wires to visualise as well
as treat obscure lesions when conducting any intervention procedure on any organ using various systems of
minimally invasive procedures or surgeries. This will enable superior management of 100 per cent coronary
blocks as well as other vascular accidents and prevention of vascular accidents on table during procedures.
This requires integration of an additional monitor in cath labs, vascular labs and operating rooms to beam
the images as generated by the addition of electromagnetic rays. At times, it shall involve placing the
standard monitor rails, if the pendants are not deployed.

Hospitals have to gear up by providing adequate interstitial area over false ceiling, which can take extra rail
mounts. This requires proper planning at structural design stage to plan the structural beams in a manner that
it causes least interference with other accessories in the room. This is a trend that will have its maximum
impact on tertiary care hospitals.

Computer Assisted Surgical Planning & Robotics

This involves deploying the computers to support precision surgical techniques for all complex procedures
like hip implant or coronary by-pass surgery thereby reducing the operating time & better outcomes. In fact,
it shall become possible for the Surgeon to practice the proposed surgery – by deploying on-screen surgery,
plan the rational activities for problem areas, determine activities for support team including a robot, if
available, and improve the results of surgical intervention.

It shall require integration of an additional robotic control room in surgical operating rooms. At a later date
when stem cell therapy has been approved, another room for a bio-reactor may be needed along with the
robotic room for transferring the scaffoldings to the patient from the Bio-reactor. Adequate considerations
for nosocomial infections due to presence of robots in the operating room need special mention here. The
operating room planning must be simulated to check activity traffic, robot movement and placement of
trolleys for providing a well laid out work area for the surgeons. This is a trend that will have its maximum
impact on tertiary care hospitals.

Image Guided Surgery

Image Guided Surgery is integration of Diagnostic – Monitoring – Operative Technologies. The operating
room shall have combined operating table with a CT Scanner workstation or a Vascular Intervention
workstation. It shall provide intra operative use of these workstations thereby reducing trauma, enhance
surgical precision and improve surgical access to literally every cell in the human body. The process of
treatment planning shall be monitored by a computer and based on artificial intelligence models for online
evaluation of treatment modalities – may be across the world in multiple centres. The concept is not very
new as Operating Room have been using mobile X-ray machines or ultrasound for making diagnostic or
therapeutic studies while surgery is being performed. But the new modalities, which are being used, require
much more technical back up.

This shall totally change the planning of Surgical Suites and Vascular Laboratories. In addition to addressing
the concerns of nosocomial infections, it shall have to meet the installation requirements for scanners or flat
panel vascular Laboratory in the Operating Room. The Operating Room shall have to interface with control
rooms and panel rooms and meet the scatter radiation safety norms. The surgical techniques shall also be
realigned to work with radiation safety screens. This is a trend that will have its maximum impact on tertiary
care Hospitals.

Virtual ICUs and Deployment of Robots in ICUs

Digitisation of Physiological Monitors, Cameras, Pumps, Ventilators and other accessories have made it
possible to deploy robots to assist the ICU nurse to render intensive care more effectively.

First step in this direction is creation of Virtual ICU where a control room is created. In Virtual ICU, a
Critical Care Internist monitors a large number of patients with the help of computers and monitors. The
patient data and live images from various ICUs in a given hospital or across a number of Hospitals are
constantly monitored and evaluated for variation from set benchmarks. These are generally missed out by
the staff on duty due to human factors of stress and fatigue. The Critical Care Internist, with the help of two-
way audio-video communications, helps the staff deployed in ICU to monitor the patients and effects of
therapy in more intensive manner.

Once the protocols of Virtual ICU have been standardised, a walking robot can be deployed to assist ICU
staff to carry out many of the repetitive activities in an efficient manner. This shall not only reduce the cost
of care because the expensive Critical Care Internist resource is shared across a larger number of beds, it
improves the outcome of intensive therapies by reacting faster to various alarms and by providing adequate
instant support to ICU staff.

Hospitals have to gear up by providing adequate number of data ports, audio-video communication ports and
plan the ICU layout in such a manner that unobstructed view of the patient at all times is possible.

We believe that this trend is going to affect hospitals, which have provided ICUs, small or big in the next
three to five years because virtual ICUs provide for a far superior care at a reduced cost.

Integration of Various Diagnostic Modalities Into A Single Machine

The CT Scanner has integrated Gamma camera and the MRI Scanner has integrated PET scanner. This is
being done to reduce the diagnostic time of the patient. Hospital laboratory already has such machines,
which perform tests across various organ systems from same sample of blood.

Easy & Functional Mobility of Patient & Critical Care Equipment

One of major problems in rendering critical care is managing the critical care equipment that is used to
provide infusions, ventilator support, monitors, etc. When patient is moved from the ambulance to triage
station to ward or operating room, these present a major problem for provisioning of continuous care.
Though it is being managed with success, the modalities involve deploying additional staff and lot of special
care during transits.

Development of Satellite Care Systems coupled with Standard Docking Stations provides for provisioning
of standardised equipment at all places. The critical care equipment moves with the patient attached to
trolley or bed with its captive power and gas supply and in ICU, triage station or operating room, it is
docked on to special pendants which provide total connectivity at the turn of a knob. The docking station
provides for changeover from cylinders or battery power as available in Satellite Care Systems to centralised
services at the turn of a knob. Simultaneously, the battery in Satellite Care Systems is put on charging mode.
A single attendant can move the patient over a reasonable distance without any fear of any mishap.

This trend is going to become the universal standard for movement of critical patients., affecting all
hospitals, small or big in the next three to five years. Hospitals need to plan for a comprehensive set of piped
medical gases, electrical services and data cable provisioning at all docking stations for satellite care
systems. It must also consider sanitation requirements when the satellite care systems are moved into clean
or sterile zones.

Practising Medical Tourism: A Resounding Success

EHM News Bureau - Mumbai

It was a meeting ground of intellectuals debating and deliberating on trends, potential, roadblocks and the
future of Medical Tourism in India.

‘Practising Medical Tourism’, organised by Express Healthcare Management of The Indian Express Group,
was a stupendous success. Everyone of the over 80 delegates sat glued to their seats, absorbing every word
and information, questioning constantly and getting their doubts answered. They thanked us profusely for
organising such a unique conference.

The speakers were the best from the industry. Dr Bhaskar Shah, Director, Asian Heart Institute. Anil
Kamath, Senior Vice-President and Business Head, Wockhardt Hospitals, Anil Maini, President, Corporate
Development, Apollo Hospitals Group (Delhi ) and Dr Premhar Shah, Medical Director and CEO of The
Medical Tourist Company. A separate session on dental tourism had Dr A Kumarswamy, Clinical Director,
The Chicago Centre for Advanced Dentistry and Dr Ajay Kakar, Director, Sanjeevani Dental Clinic. All the
brain-storming sessions were moderated by the suave Anupam Verma, Honorary Secretary of Maharashtra
Medical Tourism Council.

The Sessions

The sessions started with the key note address by Anupam Verma, who informed the audience about the
initiatives taken by Maharashtra Medical Tourism Council and set the ball rolling by introducing the
speakers.

How An Institute Should Prepare Itself For MT

Speaking on the subject “How an institute should prepare itself for medical tourism” Dr Bhaskar Shah, said,
“The scope and concept of Medical Tourism (MT) has today transgressed and evolved from healing by
mineral and hot spring in the Neolithic and Bronze Age to today’s health farms. India is hoping to expand its
tourist industry to include visitors with heart conditions and cataracts. Indeed, MT where foreigners travel
abroad in search of low cost, world-class medical treatment is gaining popularity in countries like India.

The concept is likely to have broad consumer appeal, if people can overcome their prejudices about
healthcare in developing countries. More and more tourists are choosing India as their medical treatment
destination because it has a rich cultural heritage and innumerable tourist destinations. The other advantages
are that most of metros have good infrastructure, majority of population speak English and Indian surgeons
have world class skills and surgical exposure, he added.

India should provide the best of Eastern and Westerm healthcare systems. Ayurveda, Yoga and Siddha can
be India’s gift to the world. “Ayurveda is recognised as an official healthcare system in Hungary. Doctors in
the West are increasingly prescribing Indian Systems of Medicine. More than 70 per cent of the American
population prefer a natural approach to health,” he added. Americans are said to spend around USD 25 bn on
non-traditional medical therapies and products.
Low-cost cardiac surgery in India costs USD 4,000 – 9,000 and in the US as high as USD 30,000 – 50,000
and orthopaedic surgery costs as low as USD 4,500 with a corresponding surgery in the US with USD
18,000. Besides this, the cost Comprehensive Health Check-up for US patient in India is USD 80, which
costs USD 600 in the US. The MT business has gained more strength in the context of National Health
Policy declaring treating of foreign patients an ‘export’ and therefore eligible for fiscal incentives on export
earnings. Further deregulation makes it easier to import most modern medical equipment.

“Some of the challenges in MT which need to be addressed are the perceived lack of regulation in the
healthcare industries, perceived lack of controls and loopholes in the regulation of medical professionals and
perceived widespread of unethical professional behaviour and lack of infrastructure facilities,” concluded Dr
Shah.

Hospital Economics In MT

Speaking on the subject of “Hospital Economics in Medical Tourism”, Anil Kamath, pointed out that good
news about India is that medical tourism is growing at a rate of 7.5 per cent to 8.0 per cent with healthcare
growing at a rate of 20 per cent. MT has also received a boost with corporatisation of the hospitals sector
and interest of international players with reference to investment and foreign direct investment.

The medical tourism market is estimated to grow by USD 2.2 bn with a corresponding increase in the
healthcare market by USD 60 bn by 2012. The growing international competition is another attribute with
India facing a stiff competition with the East Europe having approximately half of US tariffs, Thailand
having approximately 1/8th of US tariffs and India having 1/10th US tariffs. The comparative cost analysis
of the commonest surgical procedures in the US, Thailand and India reveals that the cost of Bone Marrow
Transplant (BMT) is Rs three lakh USD in the US, 62, 500 USD in Thailand and Rs 30,000 USD in India.
Besides this, heart surgeries in the US costs USD 30,000 in Thailand costing USD 14,500 USD and in India
having as low as USD 5,000. Hip replacement costs USD 20,000 in the US, USD 7,000 in Thailand and
USD 4,500 in India, he added. He asked the audience: Is MT a new hype in the healthcare sector. “No, It can
be the next boom in India with over one million visitor coming to India last year.” To give a fillip to MT,
India needs to have better roads, airports, transportation, flight schedules, connectivity, trained hospitality at
all points and response networking, he added.

MT: Challenges And the Road Ahead

Speaking on the subject of “Medical Tourism: Challenges and the Road Ahead”, Anil Maini, said, “MT has
gained prominence with the advent of cuttind edge technologies in India in specialties like cardiology,
oncology, neurology, molecular and receptor imaging, which have improved sensitivity and specificity,
early diagnosis, accurate and precise staging in oncology, significant input in decision making, evaluation of
treatment outcome and improved morbidity and mortality.”

Hospitals have also aggressively started taking up accreditation in order to ensure the flow of medical
tourists in the country. Apollo Indraprastha Hospitals, New Delhi after getting Joint Commission
International (JCI) accreditation gets 40 to 60 patients per week from abroad. “We generate an income of Rs
30 crore per annum from MT. We have set a target of Rs 40 crore in the next four years,” informed Maini.
Apollo Hospitals is the largest corporate healthcare group in Asia having its branches in 38 locations across
the country.

Facilitating Flow Of Medical Tourists In India

Speaking on the subject of “Facilitating flow of medical tourists in India,” Dr Premhar Shah started by
thanking the Indian Express Group for thinking ahead of its times by organising such a conference. The
traits that a prospective medical tourists look for are quality of work and hospitals, affordability, easy access,
easy mode of payment and follow-up answers to their queries. The benefits offered by India to western
patients are significant savings compared to their domestic private healthcare, no waiting time, access to
state of the art facilities and technology, choice of luxury air-conditioned room and round-the-clock service.
The main deterrents to MT are poor airports and infrastructure, non-medical people getting into the business,
unnecessary investigation and treatment, no replies to follow-ups and Indian doctors not providing sufficient
information to patients. The threats to India are the practice of Indian hospitals raising their prices every now
and then, while treatment in Eastern European countries like Poland and Hungary are good and cheap, with
France being just around 25 per cent costlier.

Tooth, Tourism And Trade - Destination India

Speaking on the subject of “Tooth, Tourism and Trade- Destination India”, Dr Ajay Kakar and Dr A
Kumarswamy said dental tourism has got a boost with dental treatment having comparable expertise, high
technology and high value for treatment costs. Dental tourism in the country got a boost due to factors like
Indians with foreign postings, NRI’s and foreign nationals of Indian origin, foreign nationals working in
India, casual tourists, dental tourists coming to India for treatment, said Dr Kakar. “For a population of one
billion, there are currently over 60,000 dentists with 15,000 dentists in metros and 5,000 dental specialists,
which include orthodontists, peridontists, endodontists, prosthodontists, dental surgeons and pedodontists,
said Dr Kumarswamy.

Right To Mental Health And The Barriers

Kamayani Bali Mahabal

Mental, physical and social health are vital strands of life that are closely interwoven and interdependent.
Mental health is crucial to the overall well-being of individuals, societies and countries. Mental health
includes subjective well-being, perceived self-efficacy, autonomy, competence, intergenerational
dependence, and self-actualisation of one’s intellectual and emotional potential.

Health behaviour can affect physiology, while physiological functioning can influence health behaviour,
resulting in a comprehensive model of physical and mental health, in which the various components are
related and mutually influential over time. The health behaviour of an individual is highly dependent on
mental health, individual psychological factors are also related to the development of mental disorders.
Social factors such as uncontrolled urbanisation, poverty and rapid technological changes are also important.
The relationship between mental health and poverty is particularly important: the poor and the deprived have
a higher prevalence of disorders, including substance abuse.
Isolation, separation and
discrimination of patients
The World Health Organisation (WHO) reports that 450 million people
lead to worsening of health
worldwide are affected by mental, neurological or behavioural problems at
from a mental health
any time. They are also universal, affecting people of all countries and
perspective. This is the first
societies, individuals at all ages, women and men, the rich and the poor,
principle which was truly
from urban and rural environments. They have an economic impact on
applied in the reform in Italy.
societies and on the quality of life of individuals and families. Around 20
Italy, the Nordic countries,
per cent of all patients seen by primary healthcare professionals have one or
Australia and Brazil were
more mental disorders. One in every four families is likely to have at least
among the leading reformers
one member with a mental disorder. Furthermore, according to the WHO,
in the area of mental health
most middle and low-income countries devote less than 1 per cent of their
health expenditure to mental health.

In India, we do not have a separate mental health budget, but details are available for the state of Gujarat.
The State’s total allocation towards mental health works out to Rs 82 million out of a total health budget of
Rs 8,562 million. Of this Rs 82 million, Rs 37 million is spent on mental hospitals, Rs 34 million on medical
colleges (presumably departments of psychiatry in medical colleges) and Rs five million on district hospitals
(Mission Report, 2003). It appears that Rs 2.15 million under ‘central sponsored schemes’ is the only outlay
on a community programme. About 67 per cent of the total expenditure is on salaries and 20 per cent on
medicines and supplies.
The paradox is that although treatment is available and are relatively cheap, the problem continues to mount.
A combination of relatively cheap medicines and family support can effectively handle the problem. The
gap between the treated and untreated, between those reached and those not reached, is enormous.

This gap exists because there are barriers to implementation of the available knowledge. The first barrier is
the stigma and the discrimination attached to those suffering from mental disorders. This prevents those
affected from being properly treated because the family hides the patient from the health services. People
believe that this happens only in developing countries. It is not so. Insurance schemes are not recognising
the parity between physical and mental illnesses and they reimburse expenses on physical ailments but not
mental ailments. This practice is prevalent in many countries.

The second barrier is the wrong public health choice in the matter of allocating money for mental health. In
many countries, 80-90 per cent of the financial resources go for maintaining large, inhuman and outdated
mental health institutions. There was a episode in Ervadi of an institution where basic human rights were
violated by chaining mentally ill patients.

Money is being allocated to such institutions even when we know that the most effective interventions are
community-based ones. Sometimes, this also explains why people do not seek treatment. If the only option
is a psychiatric hospital, one that is poorly maintained, people will have no option but turn to quacks.

The third barrier is that we do not have enough specialists to deal with the problems of mental illness. There
is also a need to mainstream the skills and knowledge of mental disorders, particularly in recognising and
treating them. This means training primary health care doctors, nurses and social workers-people who are
working in the community. We must use the few psychiatrists as multipliers so that mental illnesses are
treated effectively in the communities.

To address the barriers, we need more awareness among politicians and policymakers that investing in
mental health is better than non-treatment. Non-treatment is much costlier than treatment because the
consequences of non-treatment are huge.

The public perception is that a mentally ill patient is a dangerous person and is best locked up. Ironically,
doctors themselves strengthen this perception. They are delighted to remain in their offices instead of
visiting communities where the disease is prevalent. They find the option of staying back in their hospitals
more prestigious.

As a result, we tend to invest too much in hospitalisation, neglecting long-term care at the community level.
Human rights and the full enjoyment of citizenship are the preconditions for any talk on mental disabilities.

Being a citizen is the best treatment for mental health problems. Isolation, separation and discrimination of
patients lead to worsening of health from a mental health perspective. This is the first principle which was
truly applied in the reform in Italy. Italy, the Nordic countries, Australia and Brazil were among the leading
reformers in the area of mental health.

We need to combine civil passion, which recognises the rights of the patients, with the intellectual passion
for science. Civil passion without science will be a disaster; and science without social commitment is a
disaster as well. These two ingredients need to balanced to make a difference to mental health and well-
being.

Healthcare Systems World Over In The Balance: Need To Find Global Solutions

EHM News Bureau

Healthcare systems across the world are facing problems of spiraling costs, diminished resources and
escalating demands and there is growing evidence that the current health systems of nations around the
world will be unsustainable if unchanged over the next 15 years. These startling facts came to the light with
unveiling of PricewaterhouseCoopers (PWC) report titled ‘Healthcast 2020: Creating a Sustainable Future’.
The report warns that many of the health systems will be unsustainable within 15 years unless fundamental
change occurs.

The report is based on research, which included a survey of more than 580 executives of hospitals and
hospital systems, physician groups, payers, governments, medical supply companies and employers from
around the world in 27 countries. In addition, PWC conducted in-depth interviews with more than 120
healthcare thought leaders in 16 countries. They included policy makers, employee benefit managers and top
executives of health organisations in Australia, Canada, Europe, India, the Middle East, Japan, Singapore,
South Africa, the United Kingdom and the United States.

Globally, the report says, healthcare is threatened by a confluence of powerful trends — increasing demand,
rising costs, uneven quality, misaligned incentives. If ignored, they will overwhelm health systems, creating
massive financial burdens for individual countries and devastating health problems for the individuals who
live in them.

According to Jim Henry, Global Leader for healthcare, PWC, one can gauge from the responses of the
people in all the countries that their current health system was not built to last. "Most countries have some
aspects of their health system that are working, but no one country has the magic bullet. We need to learn
the lessons of other countries and sectors, and build on the best ideas. It will be up to governments, working
together with private industry and consumers who not only have a bigger financial stake but also a greater
responsibility in their healthcare," he added. An interesting point highlighted in the report is about finding
healthcare solutions by going beyond boundaries. Because they are often viewed as a local industry,
healthcare organisations haven't exchanged ideas globally as much as other industries such as manufacturing
and services, it says. While each country faces unique hurdles - regulatory, economic, cultural — the
challenges they face are remarkably similar. In their responses, common themes are emerging.

"India represents an interesting case study in the global healthcare market as we are stuck with some issues
which HealthCast 2020 refers to as fundamental," said Rajarshi Sengupta, Executive Director and Leader of
PWC' healthcare practice in India. "On the one hand a public health delivery mechanism and a public health
infrastructure that can be enhanced; a divide between urban and rural India where the former is increasingly
having to deal with lifestyle-related diseases and the latter is still in urgent need for even the most basic
public health services; lack of customised and focused healthcare financing mechanisms; absence of quality
of care and safety standardisation; and misaligned incentives structures are making our healthcare scenario
seem bleak," he added. On the other hand, a large pool of best-trained medical practitioners, healthcare
specialists and scientists; world class hospitals and R&D facilities in the public and private sectors;
renowned R&D facilities; exports of trained and skilled technicians, care providers and knowledge workers;
increasing, albeit at a slow rate.

Sustainable Systems Demonstrate Some Or All The 7

Features

 A vision and strategy is needed to balance public

versus private interests in sharing risks and
responsibilities, building an infrastructure, sharing an
information platform, and in providing basic health
benefits within the context of societal priorities.
 Better use of technology and interoperable electronic
networks accelerate integration, standardisation, and
knowledge transfer of administrative and clinical
information.
 Incentive Realignment: Incentive systems ensure and
manage access to care while supporting
accountability and responsibility for healthcare
 decisions.
 Quality and Safety Standardisation: Defined and
enforced clinical standards establish mechanisms for
accountability, enhance transparency, and build trust.
 Strategic Resource Deployment: Resource allocation
appropriately satisfies competing demands on
systems to control costs while providing sufficient
access to care for the most people.
 Climate of Innovation: Innovation, technology and
process changes are a means to continuously
improve treatment, efficiency and outcomes.
 Adaptable Delivery Roles and Structures: Flexible
care settings and jobs provide avenues for care that is
centered on the needs of the patient.

Knowledge Management In Managed Healthcare

With the emergence of corporate hospital entities and complex core and non-core operations in healthcare
sector, the role of knowledge management is bound to make a headway, say Prof B B Tandon, Dr Anil
Kumar Angrish and Shiv Kumar Anand

For a knowledge-based society, knowledge-based economy, knowledge-based corporate entity and for a
managed healthcare entity, knowledge management is indispensable. Corporate entities are building
Knowledge Management (KM) systems and employing professionals in their knowledge centres, which are
being managed by knowledge executives. A few companies even boast of appointing a Chief Knowledge
Officer to manage knowledge in their concerns. It is visible that significance is being given to KM. With the
emergence of corporate hospital entities and complex core and non-core operations in healthcare sector, the
role of KM is bound to make headway.

Recently, Dr Anbumani Ramadoss, Union Minister for Health and Family Welfare, asked for revision of the
curricula of medical colleges to make it more modern, besides holding examinations for medical
practitioners after every five years for re-registration as is the case in many developed nations. Basically, it
requires doctors to update their knowledge.

For all medical practitioners, a vast knowledge is available about their domain. More than 10,000 different
diseases and syndromes, 3,000 medications, 1,100 laboratory tests are in use. Moreover, plenty of articles
are added each year to the biomedical literature. In this way, it is quite difficult for a doctor to keep himself
abreast of new knowledge in his field and at the same time perform his routine tasks.

This is not an end in itself. A number of studies have been conducted on medical errors. The Institute of
Medicine, USA in the year 1999, in its repot titled 'To Err is Human', stated that more than 98,000 deaths
each year are attributable to medical errors in the US. In India, we find various cases in routine such as
patients having adverse reactions to drugs while under medical care, out of which, some reactions are life
threatening. The underlying reason is inappropriate drug prescriptions. Not difficult to find are instances
where common laboratory tests ordered by physicians are clinically unnecessary and prescriptions
inappropriate.

A shocking statistical evidence is cited in a report released by the Nutritional Institute of America (NIA) in
October 2003. The results of seven years of research reviewing thousands of studies conducted by the NIA
show that medical errors (iatrogenic errors) are the number one cause of death and injury in the US.
According to NIA's report, over 7,84,000 people die annually due to medical mistakes. And over 2.2 million
people are injured every year by prescription drugs alone and over 20 million unnecessary prescriptions for
antibiotics are prescribed annually for viral infections.

If such alarming situation is of a country like the US, where regulations regarding healthcare are most
stringent in the world, the condition of a developing country like India can only be imagined, where the
pharma covigilance system in not even in the nascent stage.

The reasons attributed to such mistakes are many. A significant reason is that, clinicians are not able to track
such massive amounts of complex information. So, knowledge workers cannot keep up with the knowledge
being generated. Even though the failure to keep up may not result in deaths, but definitely it leads to lower
chances of success in projects and products and wastage of resources.

In the last decade, the focus of KM was to establish employee networks and communities of practice,
building of knowledge repositories in organisation and sharing of information. Still, the focus is to embed
the knowledge into knowledge work and technology, which is used by knowledge workers to perform their
jobs. However, this is time consuming and an expensive exercise, but still worth implementing.

Apply Information Technology

It is desirable for a hospital to link massive amounts of constantly-updated clinical knowledge to IT systems
that support doctors' work processes. It will improve the quality of physicians' decision-making and hence
improve the quality of patient care. However, what poses a major problem is, hospitals are not able to codify
millions of facts and data points, which are used by doctors to make complex decisions about treatments. So,
as a starting point, choose a narrow area; for example, target an essential work process such as physician
order entry and a problem that was well documented, errors in drug prescriptions and lab-test ordering.

Drug interactions are relatively straightforward and easy to programme. This is central point as when
doctors order tests, medications, or other forms of treatment, they are actually translating their judgements
into actions. At this moment, outside knowledge is most valuable. And it is here that without the system,
doctors would have no easy way to access others' knowledge in real time.

Order entry system increases efficiency and safeguards against errors due to poorly-written orders. It allows
physicians easy access to massive amounts of up-to-date medical knowledge (even though they are doing
their daily work). Finally, it forces physicians to engage with queries or recommendations (even though they
can override the system's recommendations).

In this way, order entry is a key work process. Further, the approach should be built on a set of integrated
information systems which physicians can use to manage patient care. These all draw from a single database
of clinical information and use a common logic engine that runs physicians' orders through a series of
checks and decision rules.

For Instance: A patient has a serious infection and the doctor decides to treat it with some drug, say
cefazoline. After logging on to the computer to order the drug, the system checks patient' medical records
and if it finds that patient has a history of immediate type of hypersensitivity reaction with penicillin then it
will immediately alert the doctor about the possible side effects. This is similar to the pop-up message
shown by a computer while downloading files from the net — this file may harm your system would you
like to continue — though the ultimate decision is left in the hands of the decision-maker. If positive effects
from the prescription overweigh negative effects, the physician goes on with his decision after 'risk-benefit
analysis' (remember the case with glucocorticoids that has major side effects but even then, are prescribed
due to their indispensable ability to save life of patients in extreme emergencies).

Similarly, when doctors order test for a patient, the system may tell that such a test is useful or not in
addressing the symptoms identified or it has already been performed on patient for a number of times and a
retest will not serve any purpose. This may be useful during review of patient medical records as well as
follow-up appointment.

The key success factor of knowledge-based order entry, referral, computerised medical record and event
detection systems is its real time application. Moreover, physicians can consult other experts in real time
through teleconferencing and other technologies. Even through video conference screens, doctors can
observe a patients' speech and moves and review scan results, the likelihood of effective treatment will go
way up. Few months ago, PGIMER, Chandigarh has announced the telemedicine project that would be
linking civil hospitals of Ajnala, Patiala and Dassua to the PGIMER. So, the patients from these far-flung
areas, not having access to specialty medical facilities can now have an expert advice from PGI doctors
without actually visiting the place. Indirectly, doctors can seek advice from experts in their domain in real
time.

This means that advice about patient's diagnosis and treatment can be given by reviewing test reports, all
diagnostic tests, X-rays, CT scans, pathology slides et al, can be transmitted to PGI for consultation. This
initiative will indeed reduce the patient load from the doctors and will allow doctors devote more time for
high-level research, for which these kind of high-level institutes like AIIMS, PGI etc have been established.

Knowledge Repositories

There are other knowledge resources which are not otherwise accessible in real time even though they are
valuable. Knowledge repository in hospitals should include online journals and databases, care protocols or
guidelines for particular diseases, interpretive digests prepared by physicians, formularies of approved drugs
and details on their use, and even online textbooks. An integrated intranet portal can make these resources
accessible. Practitioners can share this set of resources on mutually-agreed terms.

Benefits Of Knowledge Repositories

 Recommendation of cheaper and more effective drugs.

 Helps prevent longer hospital stays.
 Prevents repeat tests that result from adverse drug events.
 Lowers malpractice reserves (phenomenon prevalent in developed countries) on account of fewer
drug-related claims.

Critical Aspects

They are either technical or non-technical.

Technical Aspects: Development of such a system is not easy from either a technical or a managerial
standpoint. Systems allowing individuals and organisations to embed their own knowledge are not available.
Hospital entities have to develop most of its systems from scratch, which includes modules such as an
integrated patient-record system, a clinical decision support system, an event management system, an
intranet portal and several other system capabilities.

Non-technical Aspects: This includes managerial and few other aspects. The harder task is to convince
knowledge workers about the utility of the system. It is because their willingness to support the system and
new way of working that can make or mar all other efforts. Up-to-date clinical database is another pre-
requisite. Else, it would put patients as well as hospitals at high risk. To address this issue, different
committees can be formed and empowered to identify, refine and update knowledge used in each domain.
Overall, a step-by-step approach is required. KM initiatives should be undertaken for truly critical
knowledge work processes because of cost and difficulty involved. At the same time, preference should be
given to develop systems in fields, which have low levels of ambiguity, a well-established external
knowledge base and a relatively low number of possible choices facing the decision-makers.
Besides, it is easier to embed knowledge into the work of less-skilled workers; the higher you go, the harder
it gets. Middle-level knowledge workers such as programmers, engineers, designers depend increasingly on
knowledge repositories built into the technology they use to do their jobs. For high-end knowledge workers,
ie doctors/physicians, the spirit behind integrated systems is that the physicians should combine their own
knowledge with that of the system. Both are supportive and not alternative to each other. Following are
certain unique features of these high-end knowledge workers which are clear pointers in this direction:

(i) They are generally paid more and receive more intensive training.

(ii) They make decisions based largely on intuition and years of experience.

(iii) They have historically enjoyed high levels of autonomy.

(iv) They are sufficiently powerful that the organisations they work for are reluctant to tinker with their
work processes.

(v) They do most of their work away from a computer screen.

To put it straight, doctors/physicians are high-end knowledge workers, so it would be a mistake to remove
them from the decision-making process. Otherwise physicians/doctors might end up resenting or rejecting
the system altogether if it challenges their role. If the system generates conflict warnings then orders should
be cancelled as per warning; and if the hospital's event-detection system generates a given number of alerts
during a given period then treatments should be changed as per requirements. It will indicate that hybrid
human-computer knowledge system is working as it is expected.

Another non-technical aspect that has significant bearing on overall KM initiatives is a measurement-
oriented culture. It lays emphasis on output of a given system to justify the time and money spent on an
embedded knowledge system. The tracking mechanisms help in detecting whether physicians/doctors use
the knowledge and also show change in treatment decisions, if any. This ensures that the system is working
effectively. Parameters for measurement can be fixed beforehand and then progress-reporting tools are used
to improve existing processes.

Then there is interaction and co-ordination of 'back office' and 'front end'. The reason is that technology
itself does not ensure success. Persons working behind it have to work with staff which is skilled in
information management, besides doctors who are high-end knowledge workers. In healthcare sector, the
task is entrusted to people skilled in information management and discipline is called medical informatics. It
can have other medical informatics departments such as clinical and quality analysis, medical imaging,
telemedicine and clinical information systems R&D.

To put it in perspective, with the growing complexity in the human living patterns, the nature and number of
diseases are increasing significantly, while the drug discovery and development is not able to keep pace in
providing a cure for them. Also is increasing the complexity of information regarding these diseases and
their management.

In order to safeguard the interest of patient and provide the best of healthcare, need is to design and adopt a
system, which can streamline available information and assist high-end knowledge workers for continuously
upgrading the practice of medicine and provide the best and the safest medical care to patients.

Simplicity, Cost-effectiveness & Ease Of Implementation Will Make NIAHO Popular’

Spurred by emphasis on standards, quality and medical tourism, health accreditation is

gaining popularity in Indian hospitals. And to cater to the surge in demand are a basket of
accrediting bodies-JCI, JCAHO, NIAHO and ISO 9001 to choose from. US-based TUVHS is
an accreditation firm engaged in accreditation of hospitals under NIAHO-ISO standards.
Recently, its officials had come down to Mumbai to do a gap-analysis for Asian Heart
Rebe Ashit
cca J Dalal
Wise
Institute (AHI), which will soon apply for JCI. TUVHS's CEO Rebecca J Wise and Senior Project Manager
Ashit Dalal told Rita Dutta about the demand for various accrediting bodies and why some are more
popular

How different are JCI, JCAHO, NIAHO and ISO 9001 from each other? Please give a brief
background of each of these accreditations.

Rebecca: JCI and JCAHO are very similar, as Joint Commission in the US has developed these standards.
While JCAHO is typically applicable in the US, JCI is an international version of JCAHO (toned down
version) and can be applied to any country.

NIAHO is again an international standard developed by TUVHS in the US and is based on ISO 9001:2000
framework, which is the generic standard for Quality Management System (QMS), developed by
International Organisation for Standardization, Geneva. It is by far the most popular QMS standard in the
world with about 7,00,000 certifications worldwide. NIAHO is the actual standard for healthcare developed
by healthcare professionals with several decades of relevant experience. Since it has ISO 9001:2000 as its
key framework, it integrates System and Process (Plan-Do-Check-Act) based approach of ISO with clinical
and medical processes that one sees typically in any healthcare and hospital environment. In short, it brings
together the best of both the worlds.

Which is the most popular accreditation system and why? Is popularity country-specific?

Rebecca: It is a tricky question and depends from what perspective you are looking. From the US
perspective, JCAHO is the most popular as the Center for Medicaid and Medicare Services (CMS) makes it
mandatory for US hospitals to get accredited by JCAHO (Joint Commission). JCI being an international arm
of the Joint Commission is getting popularity outside the US and especially in India. However, outside the
U, especially in Japan and EU, ISO 9001:2000 is still being commonly applied as Healthcare Quality
Management System Standard. NIAHO is relatively new, but due to its simplicity, cost-effectiveness, ease
of implementation and close interdependence with ISO 9001:2000, it is gaining popularity in the US. In the
years to come, it will also become popular in India and other countries too.

Do you think that the Indian hospitals are ready for international accreditations, which are
expensive? After all, only Apollo Hospitals, Delhi and Chennai Wockhardt Hospitals have acquired
JCI and AHI is going through pre-assessment analysis for it.

Ashit: Yes, absolutely. India for whatever reason never had a formalised quality system framework, unlike
the US, till recently. However, with the medical tourism growing at rapid pace, international accreditations
like ISO-NIAHO and JCI have become the need of the hour. Expensive is a relative term again. When one
sees the tremendous benefits and value-add that these accreditations bring onto the table, the cost of
implementation and accreditation will be far outweighed by the benefits (such as enhanced patient
satisfaction, lower infection control, improved patient safety, reduction in medication errors etc). In addition,
tapping the medical tourism boom in itself will demand sine-quo-nun need for accreditation.

NIAHO is relatively new, awaiting US government's approval. Do you think that it is going to pick up
fast? If yes, why?

Rebecca: Yes. CMS is close to approving NIAHO and is expected to accord final approval by the last week
of June 2006. As such there are already about 25 hospitals accredited in the US in the last three to four
months. Once CMS approval comes in June this year, the number of accreditations is expected to grow to
more than 500 in next 12-18 months in the US alone. Even in India, there has been a lot of interest from
large hospitals to acquire ISO-NIAHO certification.

With so many accreditation systems, how should a hospital shop for the best for them?
Ashit: Hospital has become an industry, which has very complex clinical and other support processes (like
EHS, Facility Management, IT etc.) Patient safety and infection control are two key areas that one can
improve with properly implemented Quality System Standard, be it JCI or ISO-NIAHO. Selection of the
appropriate accreditation is contingent on the overall value and objectives, cost and internal requirements of
the healthcare organisation.

Should a hospital go for a basket of accreditations, rather than only one? How will that help?

Ashit : It is dependent on what a hospital is overall looking for and what its business and internal
requirements are. I feel starting with one set of accreditation (based on overall cost-benefit) system is the
most cost-effective approach. For instance, a hospital can surely go for ISO-NIAHO based system to begin
with. And once they get accredited, they can go for more expensive JCI type accreditation since with ISO-
NIAHO in place, it is very easy and cost-effective to implement JCI, if required. In addition, hospitals that
already have either ISO 9001: 2000 (like AHI) or JCI (like Wockhardt Hospital), it is very easy to
implement NIAHO at marginal cost.

It is a known fact that most hospitals prepare themselves for getting accreditation, but once they
achieve it, they are negligent towards maintaining the quality standards. How do we address such
issues?

Ashit: It is the question of commitment of the hospital senior management and staff towards providing
quality healthcare to their patients. That commitment and philosophy will drive the entire initiative and not
just having a certificate on the wall. AHI is one such brilliant example of this kind of unparallel
commitment, which we can see right from CEO to the lower most level. Being an Indian, I am very proud to
say that hospital like AHI has one of the best patient safety and infection control standards in the world. This
cannot just come from accreditation to ISO or JCI or NIAHO, but also requires an exemplary commitment
of the senior management and the entire staff to achieve this kind of success.

A lot of people believe that ISO 9001 is the stepping stone to JCI. Please comment.

Ashit: As I have mentioned, ISO 9001:2000 is the generic standard that can be applied to any organisation
including healthcare. Using that as the foundation, one can build any other system like JCI or NIAHO.
However, I want to further add that it is easier to get accredited to NIAHO than JCI if the hospital already
has ISO 9001:2000 accreditation. As a matter of fact, to get NIAHO accreditation, ISO 9001:2000
accreditation is mandatory, while there are no such requirements if you are just seeking JCI accreditation.

In India, JCI is picking up because of emphasis on medical tourism. Do you see other international
accreditation systems also gaining equal popularity in India?

Ashit: Your observation is partly true. Till recently, JCI (based on JCAHO) has been the only known
healthcare-specific standard internationally apart from generic ISO 9001:2000. However, with the advent of
NIAHO, which is getting a lot of attention and popularity in the US, scenario shall change soon and you will
see (especially those already accredited to ISO or are in the process of acquiring ISO) may soon start
adopting NIAHO.

In the face of international accreditation systems coming to India, do you think that indigenous
accreditation formed by QCI and CII-IHCF will stand a chance?

Ashit: QCI is the governing body for accrediting registrars that provide ISO accreditation services; JCI and
NIAHO are healthcare industry-specific international standards from different organisations and are not
governed by QCI accreditation.

A lot of auditors in healthcare accreditation don't have experience in healthcare. So, what is the ideal
qualification for an auditor of accreditation in healthcare?
Rebecca: We are going to accept only those people as the auditors who are doctors or with MHA degrees
and relevant healthcare background. Non-medical professionals without proper healthcare background will
not be able to qualify to audit or certify hospitals. In addition, to become a NIAHO auditor, the healthcare
professional must have completed recognised (IRCA or RABQSA) Lead Auditor Course in ISO 9001:2000
and also completed requisite training in NIAHO, which we shall start offering soon in India.

Please tell me about TUVHS and your plans for Indian operations.

Ashit: TUVHS is the part of Global TUV Group. TUV is a reputed accreditation body and registrar with
excellent operations and large number of clientele in India. We shall work closely with their Indian
operations in providing these services to Indian healthcare industry. However, overall programmes of ISO-
NIAHO accreditation will be managed by TUVHS, US.

Unique Way To Cut Down On Capital Cost In Building Hospitals

G D Kunders

By one reckoning, the broad range of total costs of building a hospital facility are found to be 78
– 81 per cent for construction which includes built-in equipment, 12 – 15 per cent for
depreciable and non-depreciable equipment and six to eight per cent for fees. The last item
includes legal fees as well as fees paid to architects, consultants and other professionals.
Depending on the kind of hospital and how advanced and hi-tech it is, the cost of depreciable
equipment in today’s hospitals may be more than 12 to 15 per cent of the total cost.

The typical units of cost of a hospital facility may be divided into two parts. In the first part, they are for the
acquisition of site, land development, off-site improvements, legal fees and expenses, preliminary survey or
feasibility study, setting up of a permanent organisation and community and public relations exercise and
fund raising.

In the second part, costs relate to site survey and soil investigation, work covered by construction contracts
(as specified in the drawings and specifications which include fixed equipment, contingencies for minor
alterations, extra work etc), supervision and inspection at site, depreciable and non-depreciable equipment,
professional fees and payment to statutory bodies.

The major costs in building a hospital relate to land, construction and equipment. And within the facility, the
per square foot cost varies greatly – from the cost of storage space, which is the cheapest, to such areas as
surgical suite and radiology which are the most expensive. Cost of construction in its turn depends on the
total square footage required for the hospital. The number of beds, the extent of primary, secondary, tertiary
care and other specialised services, the number and types of specialties, the degree of sophistication and use
of cutting edge equipment and technology determine the total cost of the hospital building.

How much space is required for a hospital? In the earlier times, a simple method – a rule of thumb as it were
– was used to estimate the space requirement: Space required for one bed multiplied by the number of beds
the hospital is going to have. The minimum space occupied by one bed itself and access is approximately
100 square feet. It is seen that the total hospital area is eight to ten times that for the beds. For example, the
total space required for a hospital of 200 beds on this basis is 100 sq feet x 8 to 10 x 200 = 1,60,000 to
2,00,000 sq feet.

Regardless of how carefully one has studied and taken into account all factors in the planning phase, total
space requirements will to a certain extent represent some guesswork. It is impossible to predict accurately
the degree to which new services will develop and used and what other factors will appear in the overall
picture. It should also be remembered that the actual space required for a hospital could be estimated only
when the programmes, activities and services that the hospital is going to offer and the space required for
these programmes and services are known.
There is one unique way of computing and actually cutting down the required space in the hospital thereby
significantly cutting down on the cost of building the facility without compromising on the quality and
efficiency that very few hospitals in this country, if at all, may have tried. This is based on the premise that
the solution to meeting space needs does not always lie with acquiring more space. The method that we are
talking about is a careful study of available time and occupancy time in certain departments, and maximising
use of space and equipment by extending hours and days of service.

When considering space requirements for a department, the planners should carefully look to the hours and
days of operation as another alternative to acquiring more space simply because space, equipment and
furnishings represent a costly investment. Once acquired, they are available 24 hours a day and seven days a
week, which means a total of 168 hours per week. Given that our hospitals by and large work six days a
week and 8 hours a day, services in most areas of the hospitals are offered 48 hours a week. This means that
the costly investment, which is at the disposal of departments for 168 hours a week, is utilised for less than
30 per cent of the total available time.

A study done in three large US naval hospitals showing the several components of occupancy time of their
physical therapy department, such as attended time, preparation and clean-up time, and non-attended
treatment time, for an extended list of physical therapy activities threw up some interesting facts.
Noteworthy was the time when the facility remained idle. The lesson learnt from this exercise could be put
to good use in space planning in hospitals.

Experts say hospitals of the future wanting to maximise their utilisation potential and reduce construction
and equipment costs, must give serious consideration to extending periods of service. For instance, areas like
the operating rooms, outpatient and physical therapy departments can extend their utilisation by working 12
hours or more a day by staggering staff working hours and lunch break, and working in two shifts. It is
beneficial to patients too. Most physical therapy patients, for example, are outpatients. As working people,
they would want to utilise the services of outpatient and physical therapy departments outside their normal
working hours and so would welcome extended hours. Visiting and part time medical consultants who
practise in more than one hospital would also welcome the move as they will have greater freedom of choice
of hours of work.

Many hospitals in the West have responded to these demands and are offering extended hours and days of
service. Some of the innovative staffing arrangements are staggered hours of work, compensatory time off
for staff working on weekends (Western hospitals work for five days a week), the 10-hour, five-day-week
concept, and use of part-time and visiting staff in the evenings and on Saturdays and Sundays. This can be
more easily accomplished in large and medium-sized hospitals in cities where staffing is not such a problem
as it is in smaller and rural hospitals. For the hospitals, it is doubly rewarding. On the one hand, they save on
their investment on space and equipment. On the other, they have the satisfaction of meeting the special
needs of their patients. This can also be used as a strategy for marketing the hospital and for building a
strong brand image and brand loyalty. Besides, it is incongruous, they say, to think that a patient hospitalised
for physical therapy should go without these services on weekends. Times are changing in our country too.
Many hospitals now keep their outpatient departments open till late in the evenings. But that is not done for
the purpose we are talking about. This practice would have started long after their investment on
construction was made.

Considerations of the available time and space become all the more significant when one realises that in
designing a modern hospital, the space required for corridors, circulation, mechanical equipment,
architectural requirements and access to various functional areas takes priority over others things. That
reduces the space that could be allotted to departments. The constraints imposed by construction costs,
which can be formidable, take a heavy toll of the ultimate amount of space that is apportioned to various
departments of the hospital.

Although space requirements vary from the small one-storey rural hospital to the sophisticated and high-tech
urban medical centre, these differences are diminishing. For one thing, standards are becoming more and
more common in our country and are bound to pervade all hospitals in the long run. More importantly,
today’s rural middle class population with a fair amount of disposable cash is becoming so health conscious
that it demands the same high quality healthcare services and facilities that are available to its counterparts
in larger cities.

Medical Tourism: Positive Publicity Is The Need Of The Hour

Dr Saji Salam

What prompted me to write this piece is a news item in a financial daily which quoted ‘experts’ stating the
medical tourism industry in India would bring in revenues worth USD 25 billion by 2020.

A Look At The Numbers

Let’s look at some numbers to put this in perspective. The idea here is to not be precise but to give a sense of
what numbers we are talking here and what it takes to the numbers projected. One of the best-managed
healthcare groups in India with about 6,000 beds, has revenue of about USD 125 million. I do not have the
break-up of what percentage of these beds is owned vs managed. However, going with these numbers, my
assumption based on crude mathematical projection is that, it would require about 60,000 beds, to reach
USD 1.25 billion revenue and 12,00,000 beds to obtain a revenue of USD 25 billion exclusively from
healthcare services.

Let us look at some of the actual numbers from the tourism industry as well. The numbers may be a little
dated but this is what it looks like. In 2003, about 2,726,000 tourists visited India and the revenue from the
same was USD 3.5 billion. Well, if that many relatives of patients (about 3 million) travel to India, we could
manage another USD 3.5 billion from tourism services. Barring inflated projections like these, it remains a
fact that medical tourism in India is a growing trend.

Segmentation Of The Patient Population

Currently, the bulk of the patients come to India from neighbouring countries such as Bangladesh, Pakistan,
other Asian countries, Africa and the Middle East. In many cases, the driver for cross border care is a
question of quality of care than cost itself. The quality of care that we provide in India is simply not
available in some of the neighbouring countries.

The second segment is the segment of patients sponsored by the governments in their respective countries
such as Middle East and Africa. For those governments, India is relatively a cost-effective option compared
to Europe or the US. Private patients (not sponsored) from these countries look at India as value for money
option vis a vis Europe and US. Moreover, post 9/11 there has been a dramatic drop in patients from Middle
East to the US.

The market segment that the healthcare industry is targeting is the patient population from Europe and the
US. There are several patients of Indian origin residing in UK and US, who are already using the services of
hospitals in India, when they are on vacation etc. Apart from this we have the widely-publicised cases of
patients from the US and Australia.

True, these countries do have an increasing population and the healthcare systems are on the verge of
collapse. Even though it is economically viable for some of these governments to officially bless shipping of
patients abroad, it is the political viability of such a decision that may need to be worked on. Would a
political party in power in Europe/US would want to face the next election as the pioneer of shipping
patients to ‘third world countries’?

We may want to recognise that a strategy which works for attracting patients from Bangladesh may not
work for patients from Britain, since the expectations and drivers are different. The industry think tank may
want to recognise the diversity in the medical tourism patient population and devise niche strategies to tap
into each of the segments.
Competition

What is a good reason for an average senior citizen in the US to fly 18-20 hours to get his hip replaced? Can
he even travel with hips in such bad shape? Obviously if he is not covered by insurance and cannot afford
the same in US he has to look at options. What if this can be done in Mexico or Costa Rica at comparable
rate and a shorter flight?

I am not an expert of the patient flow patterns to competitor locations such as Hong Kong, Singapore, South
Africa, Costa Rica, Mexico, the Caribbean and emerging destinations such as Dubai. Per Becca
Hutchinson’s article on a University of Delaware publication looks like this is what is going on in
competitor markets.

South Africa draws many cosmetic surgery patients, especially from Europe, and many South African
clinics offer packages that include personal assistants, visits with trained therapists, trips to top beauty
salons, post-operative care in luxury hotels and safaris or other vacation incentives. Because the South
African rand has such a long-standing low rate on the foreign exchange market, medical tourism packages
there tend to be perpetual bargains as well. Bangkok Phuket Hospital is the premier place to go for sex
change surgery. In fact, that is one of the top 10 procedures for which patients visit Thailand.

Argentina ranks high for plastic surgery, and Hungary draws large numbers of patients from Western Europe
and the US for high-quality cosmetic and dental procedures that cost half of what they would in Germany
and America. Duba is scheduled to open the Dubai Healthcare City by 2010. Situated on the Red Sea, this
clinic will be the largest international medical centre between Europe and South East Asia.

The Indian healthcare industry needs to examine the factors that have made these medical tourism
destinations popular.

Challenges

There are definitely areas for improvement as the Indian healthcare industry starts marketing services to
newer patient segments. A key difference in healthcare services in India, unlike the IT sector is the critical
role the government has to play to utilise medical tourism opportunity to its best. Some of the areas for
improvement, to make India a global healthcare destination are:

Image Makeover

Despite the success of India in the IT market, perception of India in the eyes of the target audience has to
change dramatically. The predominant image of India the average senior citizen in Europe (who is a target
customer) has in his mind is picture of pre-independent India. To transform those images and present an
image of India where he can trust Indian surgeons with his heart, his face and hips is a challenge
(outsourcing your heart surgery is a lot different from outsourcing a software code!). To the average senior
citizen in the US, it is more of a challenge, since to many, India is still a land of snake charmers and cows in
traffic, a land far far away.

Perception Of Quality Of Care

Though one may argue against this, an average patient half a world away perceives the quality of care based
on the perception of the country’s image as a whole. The patients may have a hard time comprehending that
the quality of care in India can be comparable to the US. One way to get over this is for hospitals to follow
international healthcare accreditation standards. Would a patient be willing to trust his heart, kidneys, hips
and face if there is an iota of doubt regarding the quality of care? (This segment of high yielding procedures
is where the Indian medical tourism market is looking forward to for better profits). In fact, there have been
cases of plastic surgery gone bad, particularly from Mexican clinics in the days before anyone figured out
what a gold mine cheap, high-quality care could be for the developing countries.
Scalability Of Healthcare Infrastructure

The first question that comes to my mind is whether India can scale up to address the increasing patient
mass. Do we have enough specialists and super specialists? We may have enough and more of entry-level
physicians, but how are we placed with regard to doctors with postgraduate qualifications? What is the
reality on the group with regard to paramedical staff? How is the attrition among nurses due to demand
abroad?

I am sure these questions are being asked. The other question is the sheer number of beds and physical
healthcare infrastructure required. On a different note, from a social perspective, would there be enough
doctors and infrastructure left to treat the not so ‘profitable’ Indian patient?

Role Of IT Standards

Finally, adopting and adapting of IT systems and standards that are in vogue in the developed world would
be required to ease the administrative processes involved in cross-border care and integration with the
medical records in the country of origin.

How Can The Government Facilitate?

The role of the government is critical in various areas if we need to scale the existing model. Some of the
areas where government can and should act are:

Medical Education

It is high time that the government really looked hard at the demand supply situation of human resources in
the healthcare sector and recalibrated the supply of specialists and paramedicals in the country. This would
mean changes to policies on post- graduate medical education, nursing education etc.

Infrastructure

Quality of healthcare service can be limited by traffic and hartals. The last thing the fledgling medical
tourism industry in India wants is bad press on a couple of foreign patients in ambulances that were stuck in
traffic for several hours due to a political party’s rally. From airports, and high ways, and hassle free
environments for patients’ relatives, there is quite a bit where improvements can be made on the
infrastructure side.

Law And Order

Law and order and general sense of security are definitely areas for improvement. For all the gold in the
world, I might want to get my hip replaced in nearby countries, which are infested with and mines and
missiles waiting to take off.

Legal Infrastructure & Ethics

What is the mechanism for international patients who seek legal redressal for service gone bad? How long
would it take for resolving the same in India? Is our legal infrastructure geared up to handle healthcare
specific issues in a speedy manner?

Privacy Of Patient Information

One area that is understated in discussions around healthcare services in India is confidentiality of patient
data and regulations related to privacy and security of patient data in India. A good start would be to adopt
HIPAA standards in India.
Emerging Trends In Planning And Designing In Indian Hospitals

Dr K B Sood

Hospital is the most visible face of the healthcare industry. It handles the dynamics of life and
death situations during the process of rendering healthcare. Peter Drucker, the management
Guru has said, “Hospitals are the most complex human organisation ever devised”. Today,
hospital buildings are considered the most complex building forms. Integration of developing
technologies into healthcare delivery is making hospital buildings more complex. Therefore,
planners and designers of hospitals must be conversant with emerging trends in the fields of
technological developments, which shall be deployed in foreseeable future. They must
understand the complexity of integrating these technologies with the building systems and
forms, to create hospitals where the healthcare provider can utilise these comfortably to deliver most
appropriate healthcare.

This process had started by middle of 19th century when new emerging technologies like X-ray machines,
new drugs and better instrumentation was integrated into the healthcare delivery. The pace of integration of
technology was slow and deliberated at length. But encouraged by the results, healthcare providers started
adopting new technologies at a faster pace, so much so, that in middle of 20th century, it was said that the
hospital building has become obsolete by the time they are built.

It was at this time that hospital planners evaluated the emerging trend in technological developments in
various fields like Space Technology, Information Technology, Aviation Technology, etc, and made a
forecast for the emerging trends, which may soon be seen in hospitals. These technologies were integrated
with existing healthcare delivery models and the new healthcare delivery models that emerged were tested
and if found useful, were made part of hospitals. This required that all hospital planning consultants keep a
track of all emerging trends in various developing technologies. As and when the trends start finding an
application in healthcare delivery, the hospital buildings are ready to adapt to them without many structural
changes.

Let us look at these emerging trends as they are available to us for planning and designing Indian hospitals
in the next three to five years. We shall group these trends into three categories.

 Technology trends which directly affect delivery of healthcare.

 Technology trends which affect hospital engineering and support services and thereby indirectly
affect the delivery of healthcare.
 Non-technology trends which directly affect delivery of healthcare.

In this article, we will discuss the Technology Trends Directly Affecting Healthcare Delivery.

Digitisation of Hospital Equipment & Processes

Imaging services, especially radiology, has now been fully digitised. Physiology monitors have been
digitised. as well as clinical laboratory. The patient file is being digitised. This has also enabled hospitals to
archive full patient files on hospital servers to be shared between various healthcare providers.

After digitisation, virtual doctors shall become a reality. There shall be centralised control rooms to monitor
clinical and administrative data. Digitisation will enable hospitals to become paperless and film-less. Patient
files shall be issued as smart cards. The doctors, on ward rounds, shall carry a laptop and accessories on a
trolley and review patient data online. The doctor orders shall be transformed into hospital vide activities on
real times basis. Even the prescribed treatments can be evaluated for incompatibility, patient’s allergy
history, past history, etc.

This will provide maximum benefit to the patient being evacuated to a hospital because the digitisation will
enable patient monitoring and possibly, provisioning of critical care from the start point. When standardised,
it shall be most useful for cases of heart attack where “Time is Muscle”. By the time patient reaches the
hospital, the latter shall be geared to provide all needed services immediately.

This will impact the way cross consultations are carried out because after digitisation, geographical
distances shall lose their meaning. It shall also enable vertical integration across healthcare providers in
primary care, secondary care and tertiary care as well as across healthcare providers in rural centres and in
specialised centres located anywhere in India.

Hospitals have to gear up to meet the challenge of digitisation of patient data in terms of digitised
equipment, interpretation, staff skills and training. Essentially, it shall require deployment of optical fibre
networks within the various departments of the hospital for very fast transfer of data. It shall also require
broad band connectivity across majority of healthcare providers in India to realise the full potential of
digitisation. This shall specially require evaluation of interference across various cable and data transfers.

It shall also require deployment of ambulances, which shall provide critical care while moving and will need
proper communication links on the move. We feel, if this happens, some staging stations shall need to be
created whenever the patient is being evacuated long distance say over 100 Km.

To make future hospitals compatible with older machines or less digitised hospitals, some additional
equipment like film scanners, film printers shall also be installed all across the chain of hospitals and other
facilities in a hospital group or at state level or national level.

We believe that this trend is going to affect all hospitals, small or big in the next three to five years because
digitisation also has been reducing the costs and all kinds of hospitals shall gradually upgrade to digitised
equipment for up-linking themselves to various networks for various purposes like insurance, cross
consultations, tele-medicine, etc.

Optical Coherent Reflectometery

Optical Coherent Reflectometery is the integration of infra red or lasers with guide wires to visualise as well
as treat obscure lesions when conducting any intervention procedure on any organ using various systems of
minimally invasive procedures or surgeries. This will enable superior management of 100 per cent coronary
blocks as well as other vascular accidents and prevention of vascular accidents on table during procedures.
This requires integration of an additional monitor in cath labs, vascular labs and operating rooms to beam
the images as generated by the addition of electromagnetic rays. At times, it shall involve placing the
standard monitor rails, if the pendants are not deployed.

Hospitals have to gear up by providing adequate interstitial area over false ceiling, which can take extra rail
mounts. This requires proper planning at structural design stage to plan the structural beams in a manner that
it causes least interference with other accessories in the room. This is a trend that will have its maximum
impact on tertiary care hospitals.

Computer Assisted Surgical Planning & Robotics

This involves deploying the computers to support precision surgical techniques for all complex procedures
like hip implant or coronary by-pass surgery thereby reducing the operating time & better outcomes. In fact,
it shall become possible for the Surgeon to practice the proposed surgery – by deploying on-screen surgery,
plan the rational activities for problem areas, determine activities for support team including a robot, if
available, and improve the results of surgical intervention.

It shall require integration of an additional robotic control room in surgical operating rooms. At a later date
when stem cell therapy has been approved, another room for a bio-reactor may be needed along with the
robotic room for transferring the scaffoldings to the patient from the Bio-reactor. Adequate considerations
for nosocomial infections due to presence of robots in the operating room need special mention here. The
operating room planning must be simulated to check activity traffic, robot movement and placement of
trolleys for providing a well laid out work area for the surgeons. This is a trend that will have its maximum
impact on tertiary care hospitals.

Image Guided Surgery

Image Guided Surgery is integration of Diagnostic – Monitoring – Operative Technologies. The operating
room shall have combined operating table with a CT Scanner workstation or a Vascular Intervention
workstation. It shall provide intra operative use of these workstations thereby reducing trauma, enhance
surgical precision and improve surgical access to literally every cell in the human body. The process of
treatment planning shall be monitored by a computer and based on artificial intelligence models for online
evaluation of treatment modalities – may be across the world in multiple centres. The concept is not very
new as Operating Room have been using mobile X-ray machines or ultrasound for making diagnostic or
therapeutic studies while surgery is being performed. But the new modalities, which are being used, require
much more technical back up.

This shall totally change the planning of Surgical Suites and Vascular Laboratories. In addition to addressing
the concerns of nosocomial infections, it shall have to meet the installation requirements for scanners or flat
panel vascular Laboratory in the Operating Room. The Operating Room shall have to interface with control
rooms and panel rooms and meet the scatter radiation safety norms. The surgical techniques shall also be
realigned to work with radiation safety screens. This is a trend that will have its maximum impact on tertiary
care Hospitals.

Virtual ICUs and Deployment of Robots in ICUs

Digitisation of Physiological Monitors, Cameras, Pumps, Ventilators and other accessories have made it
possible to deploy robots to assist the ICU nurse to render intensive care more effectively.

First step in this direction is creation of Virtual ICU where a control room is created. In Virtual ICU, a
Critical Care Internist monitors a large number of patients with the help of computers and monitors. The
patient data and live images from various ICUs in a given hospital or across a number of Hospitals are
constantly monitored and evaluated for variation from set benchmarks. These are generally missed out by
the staff on duty due to human factors of stress and fatigue. The Critical Care Internist, with the help of two-
way audio-video communications, helps the staff deployed in ICU to monitor the patients and effects of
therapy in more intensive manner.

Once the protocols of Virtual ICU have been standardised, a walking robot can be deployed to assist ICU
staff to carry out many of the repetitive activities in an efficient manner. This shall not only reduce the cost
of care because the expensive Critical Care Internist resource is shared across a larger number of beds, it
improves the outcome of intensive therapies by reacting faster to various alarms and by providing adequate
instant support to ICU staff.

Hospitals have to gear up by providing adequate number of data ports, audio-video communication ports and
plan the ICU layout in such a manner that unobstructed view of the patient at all times is possible.

We believe that this trend is going to affect hospitals, which have provided ICUs, small or big in the next
three to five years because virtual ICUs provide for a far superior care at a reduced cost.

Integration of Various Diagnostic Modalities Into A Single Machine

The CT Scanner has integrated Gamma camera and the MRI Scanner has integrated PET scanner. This is
being done to reduce the diagnostic time of the patient. Hospital laboratory already has such machines,
which perform tests across various organ systems from same sample of blood.

Easy & Functional Mobility of Patient & Critical Care Equipment

One of major problems in rendering critical care is managing the critical care equipment that is used to
provide infusions, ventilator support, monitors, etc. When patient is moved from the ambulance to triage
station to ward or operating room, these present a major problem for provisioning of continuous care.
Though it is being managed with success, the modalities involve deploying additional staff and lot of special
care during transits.

Development of Satellite Care Systems coupled with Standard Docking Stations provides for provisioning
of standardised equipment at all places. The critical care equipment moves with the patient attached to
trolley or bed with its captive power and gas supply and in ICU, triage station or operating room, it is
docked on to special pendants which provide total connectivity at the turn of a knob. The docking station
provides for changeover from cylinders or battery power as available in Satellite Care Systems to centralised
services at the turn of a knob. Simultaneously, the battery in Satellite Care Systems is put on charging mode.
A single attendant can move the patient over a reasonable distance without any fear of any mishap.

This trend is going to become the universal standard for movement of critical patients., affecting all
hospitals, small or big in the next three to five years. Hospitals need to plan for a comprehensive set of piped
medical gases, electrical services and data cable provisioning at all docking stations for satellite care
systems. It must also consider sanitation requirements when the satellite care systems are moved into clean
or sterile zones.

Emerging Trends In Planning And Designing In Indian Hospitals - Part II

Dr K B Sood

Trends Affecting Hospital Engineering & Support Services

This process had started with Florence Nightingale when she studied in detail the way healthcare
providers are delivering healthcare and methods of improving the outcome. She mainly focussed
on the healing environments. Today, it is possible to control all environmental parameters to not
only promote healing, but also to provide all kinds of support to the healthcare provider.

Web-enabled Hospitals

Deployment of new tools of IT shall create web-enabled hospitals, which will have seamless integration
across all healthcare providers for managing patient data and administrative data. This shall especially
benefit hospital chains to manage performance tracking, human resource, financial and purchasing
functions. At the same time, the same technology shall enable the hospitals to provide a web-based audio-
video communication between the patient and his family. The same technology will enable doctors to
monitor their patients at their place of practice or rest within the hospital or at their residence, as appropriate.

The hospitals need to have a definite IT department to manage this capability. The department shall be
tasked to manage tele-medicine, links for various virtual control rooms, access to third party payment plans
online, patient interaction vide web and other such activities. An independent system administrator for this
department will be responsible to maintain confidentiality of the information, its proper use, prevention of
misuse and upgradation of the data at regular intervals. This trend is going to influence all hospitals, small or
big in the next three to five years. Depending upon the resources available to hospitals, it will be
implemented in a limited way in hospitals, while big hospitals will see implementation of full web abilities.

Wireless Monitoring Systems

Though wearable computers are still not available outside the defence research laboratory, its derivatives in
the form of wireless monitors for such patients who do not need intensive care but still need close
monitoring of their physiology are now freely available. This will enable such patients to regain their
confidence immediately after an episode of critical illness. They are allowed to move within the confines of
the hospital wearing such devices. So, they gain the confidence of being active and independent under close
scrutiny.

The hospitals deploying such devices have to be planned and constructed by avoiding use of wire mesh as
much as possible to allow free transmission of radio waves. The requirements are opposite of interference
shielding that we generally provide in selected areas of hospitals now. This is a very specific application
requirement that must be evaluated at an early stage of hospital planning to be really effective. When
upgrading an existing hospital, this requires number of transmitters and boosters, which is not a very
aesthetic solution. This trend will have its maximum impact on tertiary care hospitals.

Pre-engineered Workspaces

Pre-engineered workspaces are being deployed in most of the clean room areas of the hospital as well as in
laboratory, blood bank, offices etc. These are modular units, which are pre-engineered and are built in
factories to pre-defined specifications. They perform definitive functions and provide a defined controllable
environment. The user has a choice for selecting some, out of a large number of modules, to meet the
specific work conditions. On site, these are assembled quickly to provide defined workspaces. The modules
by themselves provide partitions, walls ceilings, HVAC ducts, AHUs and other utility devices. The modules
are generally steel-lined panels with built-in elements of piped medical gases, electrical distribution, data
cables, X-ray viewers, automatic doors, HVAC fans etc.

They have proved to be highly reliable, have performed consistently well over years with minimal
maintenance. First created for aero-bridges, they are very useful for making operating rooms, PCR
laboratory, ICUs, recovery wards etc. Their main advantage is their ability to adapt to new technologies,
new equipment systems and new work routines by changing some of the constituent modules. They have
proved their usefulness in clean room and sterile room applications in pharmaceutical industry. Extensively
used in last two decades in European hospitals, they shall be the new trend in designing the surgical suites in
India in the coming decade. This is a trend that will have its maximum impact on tertiary care hospitals.

Bio-medical Waste Handling

It is now mandatory for hospitals to handle bio-medical waste in a defined manner. This warrants
sterilisation of some wastes at the point of origin to make it safe for refuse handlers. So far, the existing
hospitals found it difficult to meet this requirement for various reasons primarily because the planning had
not catered for this. So, no definite spaces were provided for sterilisers or autoclaves to be placed
strategically. The emerging trend in hospitals is to cater for the required spaces and areas for autoclaves,
trolley sterilisers etc as appropriate. This is a trend that will have its maximum impact on secondary care and
tertiary care hospitals.

Automatic Bedpan Washers

Today hospitals have few bedpan washers. Generally, the normal toilet is used. Over the years, it has
conclusively been proved that bedpans and urine bottles played a major role in nosocomial infections and
cross infections in hospitals. Deployment of automatic bedpan washers which clean and sterilise bedpans
and urine bottles are most cost-effective and environment-friendly solution to contain this menace of cross
infection.

The emerging trend in Indian hospitals is to provide one automatic bedpan washer per floor. However, I
believe it shall soon be same as the NBC requirement for toilets, ie one automatic bedpan washer for every
five to eight patients who shall need it regularly. It is not needed for patients who are ambulatory. The
hospitals shall need to plan well in advance to make extensive use of automatic bedpan washer, as their
deployment needs same services as a toilet.

Non-technology Trends Directly Affecting Healthcare Delivery

The changing socio-economical parameters of Indian society in this millennium are also impacting the
planning and designing of Indian hospitals. Some of these trends, which have already started to influence the
planning and designing of Indian hospitals are as under:

The Nuclear Family

Earlier, when somebody fell sick, the whole family used to come to hospital and test the hospital resources
in terms of its ability to provide comforts to patient’s visitors. The concept of nucleus family, especially in
metros and in most of the urbane cities, coupled with the fact that both husband and wife are working have
started impacting the number of hospital visitors and the manner in which they visit the patient in the
hospital.

Earlier, they came and cared for the patient, including performing some of the nursing jobs. Now, they come
for limited time and expect the hospital to perform all its duties well. Only if the patient happens to be a
child, or if the patient is very critical, the whole family is there. Earlier the whole family meant three to nine
members, now it is generally two to three persons.

This requires that hospitals must have well-planned patient relations services so that patient information, and
if possible, online communication ability is put on hospital server for the relatives to access this facility
anytime. This has also reinforced the emerging trend of day care surgery, annual check ups and scheduled
appointments. This trend will affect all medium size hospitals that provide secondary level care.

Third Party Payment For Healthcare

The emerging trend of non-price competition is the direct result of third party payment for healthcare. Since
third party payment provisions are based on diagnosis, the hospitals compete to attract patients by providing
better patient-comfort facilities. This trend has lead to provisions of well appointed rooms, better catering
service, and like airlines, upgrading the accommodation entitlement without charge etc.

The hospitals have to gear up by making provisions for this ability to offer better accommodation, more
comforts, matching the life style of the community it serves. It shall affect all hospitals, small or big in next
three to five years.

The Ageing Population

The ageing population utilises the hospital services more than any other segment. This warrants that
hospitals must be planned and designed to be user-friendly to this segment. Hospitals need to have floors
distinctly marked with contrasting colour bands to indicate where it ends. Similarly, the stairs also need to
be suitably designed to indicate where the steps end to facilitate visually handicapped to use them. Hospitals
have to make an informed choice about the type of seat that future hospitals shall have, because the
European type of seat is more comfortable to elderly patients. This trend is going to affect all medium size
hospitals that provide secondary level care.

The Educated Patient

The educated patients have brought in another interesting trend of discussing in detail — the diagnosis, the
treatment plan, the choice of healthcare provider, the prognosis and the outcome of the treatment. This
warrants that hospitals must provide adequate number of well-appointed rooms for this personal discussion
in most of its departments. It shall especially be seen in all secondary care and tertiary care hospitals.

Leland Kaiser, American healthcare futurist, has said: “The hospital is a human invention and as such can be
reinvented at any time.” Over the centuries, they have proved to be best at absorbing all changes, adapting to
all applied technologies, and hospitals do it with great wisdom. It must be said that if one hospital embraces
any new technology, others are very quick to take a call on this change.
 As hospital consultants, we must keep track of the emerging trends applicable for foreseeable future or
distant future. When planning any hospital, we must evaluate and make a forecast of what is going to come
in the next 5-10 years and plan the hospital to be able to adapt to the changes when required. This is the key
to prevent obsolescence in hospital planning and designing.

Today's patients have more healthcare information as well as more choices than ever when it comes to
choosing and using health care resources, and they are increasingly taking on the role of active and involved
consumers. In the present scenario, providers need to offer innovative services and products that are geared
toward health care consumerism - encouraging patients to become better educated about their care and
coverage and helping employers offer better choices

Today's patients have more healthcare information as well as more choices than ever when it comes to
choosing and using health care resources, and they are increasingly taking on the role of active and involved
consumers. In the present scenario, providers need to offer innovative services and products that are geared
toward health care consumerism - encouraging patients to become better educated about their care and
coverage and helping employers offer better choices. This is affecting the sector as a whole, though effects
seem to be quite vague as of now which is most probably going to gain momentum in years to come as per
the opinions of sector experts.

 A problem-solving approach.
 A top- down approach.
 Emphasizes radical redesign of business process to achieve dramatic improvements in critical
contemporary measures of performance such as cost, quality, service and speed.
 The elements of BPR are to be constrained by total service experience and also should focus on
seamless service to patients across various functional areas in hospital.

Technology is playing a major role in creating awareness. They are becoming more and more aware about
new technologies, and the rising income of consumers is contributing to their affordability. Dissatisfaction is
creating a climate for change.

Business Process Re-engineering (BPR) is any radical change in the way in which an organization
performs its business activities. BPR involves a fundamental re-think of the business processes followed
by a redesign of business activities to enhance all or most of its critical measures - costs, quality of service,
staff dynamics, etc.

DEFINITION

“Reengineering is the fundamental rethinking and radical redesign of business processes to achieve
dramatic improvements in critical, contemporary measures of performance, such as cost, quality, service,
and speed.”
Extensive research has been carried out and numerous methodologies churned out.

Hammer and Champy (1993), a well known BPR theorist defines BPR as...
"... 'the fundamental rethinking and radical redesign of business processes to achieve dramatic
improvements in critical contemporary measures of performance, such as cost, quality, service, and
speed."

Thomas H. Davenport (1993), another well-known BPR theorist, uses the term process innovation,
which he says...
"encompasses the envisioning of new work strategies, the actual process design activity, and the
implementation of the change in all its complex technological, human, and organizational dimensions”.

Fundamental
Understanding the fundamental operations of business is the first step prior to reengineering. Business
people must ask the most basic questions about their companies and how they operate: Why do we do what
we do? And why do we do it the way we do? Asking these basic questions lead people to understand the
fundamental operations and to think why the old rules and assumptions exist. Often, these rules and
assumptions are inappropriate and obsolete.

Radical
Radical redesign means disregarding all existing structures and procedures, and inventing completely new
ways of accomplishing work. Reengineering is about business reinvention, begins with no assumptions and
takes nothing for granted.

Dramatic
Reengineering is not about making marginal improvements or modification but about achieving dramatic
improvements in performance. There are three kinds of companies that undertake reengineering in general.
First are companies that find themselves in deep trouble. They have no choice. Second are companies that
foresee themselves in trouble because of changing economic environment. Third are companies that are in
the peak conditions. They see reengineering as a chance to further their lead over their competitors.

Processes
Process is the most important concept in reengineering. In classic business structure, organizations are
divided into departments, and process is separated into simplest tasks distributing across the departments.
The preceding order-fulfillment example shows that the fragmented tasks - receiving the order form, picking
the goods from the warehouses and so forth - are delayed by the artificial departmental boundaries. This type
of task-based thinking needs to shift to process-based thinking in order to gain efficiency. The following
example is taken from Hammer and Champy to illustrate the characteristics of reengineering - fundamental,
radical, dramatic, and especially process.

SALIENT FEATURES
10 principles to make BPR a success
1. Start BPR by setting up one task force to select and structure all processes, to conduct the first high level
process review and to eliminate structural inefficiencies

2. Each process has to cover the entire sequence of activities from source to customer and produce
measurable results which are relevant to the customer.

3. Set the objectives from the customer’s viewpoints and measure results as relevant to them; always
measure costs, response time, quality and variance.

4. Measure the result of existing processes first before setting targets and compare them with competition
and customer’s feedback. Set the baseline for improvement.

5. Appoint one person to be responsible for the re-engineering process and implementation management and
success tracking of one complete process.

6. Develop the “should be” process from the customer backwards and never forwards from resource level.
“Engineer from scratch” rather than “re-engineer”.

7. Choose a “top down” approach to process mapping and avoid overly detailing... but take great care in
measuring and defining the output. Use maps of existing processes primarily for “as is” vs. “should be”
comparison and implementation action planning. Do not use detailed process mapping for upwards
elimination of steps.
8. Involve every function which takes part in the whole process. Train, motivate and support the teams in
every possible way. Recognize and reward success. Cascade experience down the organization.

9. Set performance measures for each participating function. This enables tracing performance deviations
back to the originator and prevents failures being blamed on other links in the process chain. Avoid double
counting of successes.

10. Set up one decision making team for each whole process and another for the whole programme. Manage
conflicts though teams.

THE APPROACH
These fundamental questions that need to be addressed first:

What are the underlying costs for the implementation of the radical change?
People need intensive training for their new skills and their styles - the ways in which they think and behave
- and their attitudes - what they believe is important about their work.

What are the implications of the radical change to the organisation, especially the human issues?
Organisations are communities of people and cannot treat as machines. People may resist the change and
fear losing their jobs. Inspirations and cultures may therefore destroy during reengineering. Furthermore,
reengineering requires people to take more responsibilities and to learn and change constantly. These may
contradict the majority people who seek for stability for their lives.

Even company provides intensive training, can people change their styles?
People who are used to think the purpose of their work is to perform the same task over and over again, may
feel uncomfortable to change the new styles that first concern is creating value for the customer and taking
responsibility for the performance of an entire process. They just cannot work in this way.
THE PROCESS
APPLICATIONS

 Discover best processes for performing work and thereby reengineering those processes to increase
productivity.
 Reducing Operating Costs.
 Bringing Down operating costs to a level where it remains Competitive.
 Streamlining Service Delivery Processes
 Improve Financial Performance by cost cutting.
 Reduction of Service Processing time.
 Improving Service Quality.
 Adopt Experiences of International Healthcare bodies.
LIMITATIONS

 Fears and apprehensions of employees

 Resistance to change
 Lack of co-operation from staff.
 Cannot be implemented without support from the top management.
 Selection and training of the team is time consuming.
 Since it’s implementation of a new process, so new employees as well as old ones take time to
understand things. As a result, employee turnover may increase.

Criticism brought forward against the BPR concept includes:

 Lack of management support for the initiative and thus poor acceptance in the organization.
 Exaggerated expectations regarding the potential benefits from a BPR initiative and consequently
failure to achieve the expected results.
 Underestimation of the resistance to change within the organization.
 Implementation of generic so-called best-practice processes that do not fit specific company needs.
 Over trust in technology solutions.
 Performing BPR as a one-off project with limited strategy alignment and long-term perspective.
Poor project management.

Systems-engineering tools have been used in a wide variety of applications to achieve major improvements
in the quality, efficiency, safety, and/or customer-centeredness of processes, products, and services in a wide
range of manufacturing and services industries. The health care sector as a whole has been very slow to
embrace them, however, even though they have been shown to yield valuable returns to the small but
growing number of health care organizations and clinicians that have applied them

CASE STUDY

1. In Sweden, rising costs and a weakened economy in 1990s were forcing the government to reassess and
reduce health care expenditures. A hospital reorganized its work around patient flow by creating a new
position of "nurse coordinator" in most departments. By redesigning operating procedures and staffing
patterns, Karolinska was able to cut the time required for preoperative testing from months to days, close 2
of 15 operating rooms and still increase the number of operations per day by 30 percent.

2. This case study was designed to reveal the application of Business Process Reengineering (BPR) and BPR
concepts to the restructuring of Raymond W. Bliss Army Community Hospital. The hospital is restructuring
from an inpatient hospital to an ambulatory care center or super clinic. The reengineering project developed
a series of deliverable results during the case study. The reengineering has developed a Combined
Ambulatory Nursing Unit (CANU) prototype, which is expected to provide nursing care for urgent care,
ambulatory procedure pre and post-operative care, and medical observation. A reengineering cost impact
model was developed to help the facility assess the impact of changes on the cost of delivering health care.
This model uses standard expense data pulled from the facility's expense accounting system. Using the
model, the projected savings from the project range from between $860,000 to $2,640,000. The case study
has shown that Business Process Reengineering concepts were useful in the restructuring of Raymond W.
Bliss Army Community Hospital. They provided a good framework for the restructuring and have generated
a series of useful deliverable products that are expected to guide the implementation of the conversion of the
facility from a hospital to an ambulatory care center.

Third Party Administrators or TPAs are intermediaries that coordinate between Insurance companies and
hospitals. From here emerged the concept of cashless hospitalization. While the insured is benefited by
better service, insurers are benefited by reduction in their administrative costs, by outsourcing their
management administrative activities, including settlement of claims at a certain cost. They come under the
purview of Insurance Regulatory and Development Authority (IRDA), India. There are at present 27 TPAs
registered under IRDA (as on 31st August 2007).

TPAs maintain proper records, documents, evidence and books of all transactions carried out by it on behalf
of an insurance company in terms of its agreement. These books and records are maintained in accordance
with accepted professional standards of record keeping and for a period of not less than three years which
are made available to the insurance company and the Authority.

Below is an overview of the activities of TPA :

1. All the records of medical insurance policies of an insurer will be transferred to the TPA.

2. TPA issues identity cards to all the policyholders, which they have to show to the hospital authorities
before availing any hospitalisation services.

3. In case of a claim, policyholder has to inform TPA on 24 hr toll free line provided by the TPA.

4. On informing the TPA, policy holder will be directed to a hospital where the TPA has a tied up
arrangement. However policyholder will have the option to join any other hospital of his choice, but in such
case payment shall be on reimbursement basis.

5. TPA issues an authorisation letter to the hospital, for the treatment wherein the TPA will pay for the
treatment.

6. TPA will be tracking the case of the insured at the hospital and at the point of discharge, all the bills will
be sent to TPA.

7. TPA makes the payment to the hospital.

8. TPA sends all the documents necessary for consideration of claims, along with bills to the insurer.
9. Insurer reimburses the TPA.

The Six Sigma Approach - 'doing things right, first time and every time'

Six Sigma is a set of practices originally developed by Motorola to systematically improve processes by
eliminating defects. A defect is defined as nonconformity of a product or service to its specifications. The
Six Sigma quality certification was established by the International Quality Federation in 1986, to judge the
quality standards of an organization. While the particulars of the methodology were originally formulated by
Bill Smith at Motorola in 1986, Six Sigma was heavily inspired by six preceding decades of quality
improvement methodologies such as quality control, TQM, and Zero Defects.
The term "Six Sigma" refers to the ability of highly capable processes to produce output within
specification. In particular, processes that operate with six sigma quality produce at defect levels below 3.4
defects per (one) million opportunities. Six Sigma's implicit goal is to improve all processes to that level of
quality or better.

The term and process evolved over the past two decades. “Six Sigma” can be defined in three ways-
Literally, Conceptually and Practically.
Is has three levels

 As a metric – Scale for levels of quality: 3.4 defects per one million opportunities.
 As a Methodology- DMAIC & DMADV
 As a Management System

Six Sigma simply means a measure of quality that strives for perfection. It is disciplined, has a data-driven
approach and methodology for eliminating defect in any process. Six Sigma provides a methodology to
continue our improvement in everything we do.

Methodology
2 basic methodologies:
I. DMAIC – approach for existing facility

  Define - Identification of the process for improvement, the key customers & elements which are
critical to quality. Then development of a team, define goal, project scope, identify team roles and a
process map.
  Measure the current process and collect relevant data for future comparison.
  Analyze – to find the critical factors that are statistically most significant contributors to the
variance.
  Improve - A previously unknown or known factor that was found to be significant is translated into
a new process and improved performance.
  Control by ongoing performance monitoring can focus on those critical areas, thereby improving
overall efficiency. This ensures that any variances are corrected before they result in defects. Set up
pilot runs to establish process capability, transition to production and thereafter continuously
measure the process and institute control mechanisms.
II. DMADV – approach for new facility

  Define the goals of the design activity that are consistent with customer demands and enterprise
strategy.?
  Measure and identify CTQs (critical to qualities), product capabilities, production process
capability, and risk assessments.
  Analyze to develop and design alternatives, create high-level design and evaluate design capability
to select the best design.
  Design details, optimize the design, and plan for design verification. This phase may require
simulations.
 Verify the design, set up pilot runs, implement production process and handover to process owners.

The Six Sigma Philosophy

The Goal: Support/serve customer requirements through transformation of knowledge–enable capabilities

and sustain continuous improvement of performance, processes, products, service, people and profit.

The Vision: Drive organizations to design and offer products/services at increasing sigma levels of quality.

The Strategy: Provide a data-driven structured approach that addresses causes for defects; thereby,
improving business processes that meet customer needs.

The Tools: Use process/product exploration and data analysis to solve the equation
Y = f(X) and translate this solution to practical applications.

Scope of Sigma in Hospitals

 Increase the quality of patient care

 Reducing the average length of stay
  Reducing Treatment Cost as well as Overhead costs
 Reducing Variance in :

Medication administration
Site-marking for surgical or other procedures
Emergency Department triage
Case management
Patient falls
Patient restraints
Assignment of patient caregivers

Difference between Traditional Systems of Quality Improvement and Six Sigma, in Healthcare:

Six Sigma is complementary to the traditional systems of Quality Improvements such as “Plan-Do-Check-
Act (PDCA)”, “Total Quality Management (TQM)”, “Continuous Quality Management (CQM)” etc. But
certain things make it different such as:

1. Initiatives in Six Sigma are identified on the basis on Customer CTQs or Critical to Quality Elements
unlike traditional systems where these are figured out internally.
2. During implantation of six sigma it becomes an integral part of the whole business strategy rather than
just a side bar activity.
3. This involves cross functional / inter departmental activities rather than just an departmental activity.
4. Focus is on eliminating variation

Organizational Issues Traditional Approach Six Sigma Approach

Problem Resolution Fixing (Symptoms) Preventing (Causes)
Behavior Reactive Proactive
Decision-Making Experience-Based Data-Based
Process Adjustment Tweaking Controlling
Supplier Selection Cost (Piece Price) Capability
Planning Short-Term Long-Term
Design Performance Producibility
Employee Training If Time Permits Mandated
Chain-of-Command Hierarchy Empowered Teams
Direction Seat-of-Pants Benchmarking and Metrics
Manpower Cost Asset

A case study:

Six Sigma is good for Health

As an early adopter of Six Sigma, one leading Wisconsin Hospital has reduced
• Turn around time for intensive care unit lab results from 53 to 22 minutes
• Time elapsed between diagnosis of a heart attack and patient arrival at the hospital for treatment by 60%
• Intravenous medication errors
• Error rates for using patient controlled pumps for administering pain medication
• Frequency and severity of hypoglycemia in the surgical intensive care unit
(Source: Motorola University, http://www.motorola.com/content.jsp?globalObjectId=3069-5787#)

Indian Healthcare: The Growth Story

The Healthcare Industry is witnessing a sudden paradigm shift in last five year. Though this change was
inevitable and the Industry has been working towards it for a decade now, this has been visible only in last
two years.

All sectors in India are undergoing a change from unorganized to an organized structure and so is also seen
in healthcare. Till few years ago healthcare delivery was sole responsibility of Private practitioners and
Doctor owned and run hospitals. Since it was also considered only as a social sector so almost all the large
hospitals were either Government or charitable hospitals.

A US$ 36 billion industry today and growing at 15% CAGR, the Indian healthcare industry will be a US$
280 billion by 2022.

Apollo Hospital started the trend of corporate hospital,

others followed. There has been a large gap after first
corporate hospital and the trend of corporatisation in
healthcare delivery in India. Today industry is moving
rapidly towards organized sector and more so towards
corporatisation of healthcare delivery.

Corporate hospitals: list and number of hospitals and their spread.

Annual Revenue
Number of Number of Number
Hospital Groups Coverage (2005-06 (In Rs.
Locations Hospitals of Beds
Crore)
Apollo Hospital
11 11 3000 All Metros 779
Enterprise Ltd
Wockhardt Bangalore, Mumbai
8 10 1400 210
Hospitals and West India
Fortis
5 13 1855 North India 100
Healthcare
Max Healthcare 1 6 765 Delhi & NCR 137
South India (Mainly
Manipal Health
9 11 3000 Karnataka) and -
Systems
Sikkim
South and West
Care Hospital 11 14 2000 -
India

Last 2 year have been years of dramatic changes. Most of the existing players announced their huge
expansion plans and many of large companies with no or very little existence in healthcare delivery declared
that they will be putting in huge investments in Healthcare Delivery. The growth and sudden interest in the
healthcare business can be attributed to many factor, one of the most strong of which is the strong Indian
economy.

Factors for the “Healthcare Boom” in India

 Strong Indian Economy

 Increasing options for Healthcare Financing
  Increasing Opportunities in Healthcare delivery
o Better Profitability (15-20% EBIDTA)
o Earlier Break Even (2-3 years)
o Medical Tourism
o Increasing demand from within the county
 Saturation of other sectors like IT, retail

Strong Indian Economy

India is predicted to cross United States by 2050. Indian Economy experienced a GDP growth of 9.0 percent
during 2005-06 to 9.4 percent during 2006-07. By 2025 the India's economy is projected to be about 60 per
cent the size of the US economy. The transformation into a tri-polar economy will be complete by 2035,
with the Indian economy only a little smaller than the US economy but larger than that of Western Europe.
By 2035, India is likely to be a larger growth driver than the six largest countries in the EU, though its
impact will be a little over half that of the US.

India, which is now the fourth largest economy in terms of purchasing power parity, will overtake Japan and
become third major economic power within 10 years.

Increased options for healthcare Financing

The reach of Insurance have been increasing. The premiums collected from Health Insurance are predicted
to increase by around 50% from last year. Two exclusive Health insurance companies have already started
selling policies.

  In Rupees Crore  
Half Year Ended Septembet Half Year Ended Septembet %
Insurance Companies
2006 2007 Growth
Royal Sundaram 42 54 28%
TATA-AIG 19 35 83%
Reliance 32 148 365%
IFFCO Tokio 32 45 41%
ICICI Lombard 296 425 43%
Bajaj Allianz 74 125 69%
HDFC Chubb 4 21 415%
Cholamandalam 16 56 255%
New India 348 483 39%
National 182 313 72%
United India 206 276 34%
Oriental 210 262 25%
Star Health & Allied
2 45 2152%
Insurance
Total Premium 1462 2287 56%

Source: IRDA Journal, Dec 07.

Better Profitability

Healthcare is a highest capital intensive service industry and profitability has never been as good to match
others. It is all changing very fast. The best of the systems of world are still struggling to achieve a good
profitability level for healthcare. Healthcare in United States had a profitability of just above 5% in last
financial year. India on the other hand, if we leave the charitable and government hospitals aside, is
witnessing a15% to 25% profitability.This increased profitability can be attributed to many factors:

 Increased flow of patients

 Higher Margins

Earlier Break Even

The break even for hospitals has been 5-7 years till last decade. The things started changing as the structure
of hospitals moved from unorganized to the organized one.

 Hospitals are now able to manage their funds in a better way

 Though costs have increased still they are able to maintain good profit margins on all their services.

Medical Tourism

Medical Value travel is one of the emerging global sectors grossing US$ 22 billion. In 2006, more than 2
million medical tourists availed services in South-east Asia from all corners of the world. With revenues
close to US$ 450 million, India has a 2% share of the global health tourism.The potential for India to
become the hub for medical value travel is huge. All the existing Healthcare Delivery providers as well as
the new entrants are in some or the other way eyeing that market.

The potential for India to become the hub for medical value travel is huge. All the existing Healthcare
Delivery providers as well as the new entrants are in some or the other way eyeing that market.
Increasing Demand from Within the Country

The demand for quality healthcare has increased within the domestic healthcare consumers. Today’s patients
have more choices than ever when it comes to choosing and using health care resources, and they are
increasingly taking on the role of active and involved consumers. In the present scenario, providers need to
offer innovative services and products that are geared toward health care consumerism — encouraging
patients to become better educated about their care and coverage and helping employers offer better
choices.So this has put up additional pressure on the healthcare provider to improve their existing services
and bring upon better and world class facilities.

The disease profile of country as a whole is changing. One can

see that the lifestyle diseases are now taking the limelight from
the traditional infectious diseases.Improvements in
socioeconomic conditions in the last five decades in doubling
longevity from 32 to 64 yrs, steep fall of IMR, elimination of
leprosy & yaws, eradication of small pox, & poliomyelitis being
on verge of eradication, credits to the success stories post
independence. However, the challenge we face with the on-going
changes in disease burden that is producing a major health
transition. Demographic transition reflects quantitative and
qualitative changes in the population profile and the country is
facing a double burden of communicable & non-communicable
diseases.Communicable diseases are still persisting as major
health problems but the Non- communicable diseases are
doubling its incidence & prevalence. Coronary Artery Disease,
Diabetes, Renal failures, Stroke, Cancer are on a rise as a result
of Hypertension, metabolic syndrome & stress.
 Indian Healthcare Systems

India is a country of striking

contrasts, with more than a billion
population; it has one of the fastest
economic growth rates in the
world since the 1980s.

Facts & Figures

Population: 1027million in 2001
Population growth (1991-2001):
21.34
Annual Population Growth
(percent): 1.6
Population Density (per sq.km):
324 as of 2001
Sex Ratio (females per 1,000
males): 933
Literacy (Total): 65.38 -- Males
75.85; Females 54.16
Increase in literacy: 13.75 in 1991 - 2001

Healthcare Spend in India

Facility Distribution

Facilities Latest available Data?

Number of hospital beds 683545
Hospital beds per 10,000 population 9
Number of health centres: Sub Centre 137371
Primary Health Centres 22842
Community Health Centres 3043
Human resources ?
Physicians per 10,000 population 7
 Nurses per 10,000 population: 7.85
Professional nurses

Bed Distribution

According to NSSO 60th Round Morbidity and Healthcare Survey, the household healthcare seeking
behavior is shifting from the public towards the private sector. The vast majority of people (around
80%) use the private sector for outpatient curative services as a first line of treatment in both urban
and rural areas. Around 60% of the population today actually prefers to undergo hospitalization at
private hospitals.

 
PUBLIC
Public Healthcare Infrastructure in India
The Health care system consists of:

• The primary, secondary and tertiary care institutions, manned by medical and paramedical personnel;
• Medical colleges and paraprofessional training institutions to train the needed manpower and give the
required academic input;
• Programme managers managing ongoing programmes at central, state and district levels; and
• Health management information system consisting of a two-way system of data collection, collation,
analysis and response.
 
PRIVATE
The sector has shown remarkable growth in the last two decades endowing India one of the largest private
healthcare delivery systems in the world.

It is estimated that over 90% of the private healthcare is being serviced by the unorganized sector. This
preponderance of the unorganized sector in healthcare is not because of a preferred choice for such health
practitioners, but by more functional imperatives, namely the absence of affordable, convenient and quality
healthcare delivery systems.

Charitable Apollo More New

& Trust Hospitals: Privates:Wockhardt, Entrants:
Hospitals the 1st Fortis, Max, Artemis,
Corporate Lilavati, Hinduja Columbia
Group Asia,
Global,
Narayan
Hrudalaya
1950-80 1980-1990 1990-2000 2000
onwards

Corporate Private Players?

Apollo Hospitals
 40 hospitals with 6,000 beds
Fortis Healthcare
12 hospitals with 1,900 beds
Wockhardt Hospitals
 10 hospitals with 1,500 beds
Max Healthcare
 7 hospitals with 800 beds

The entry of corporate players changed the way healthcare is delivered in India. Today, hospitals in India
provide the best in terms of quality and service delivery at a fraction of the cost in the west. A growing
number of hospitals have now received international accreditations.

The growth curve of the organized healthcare has been principally limited to tier 1 cities. Technopak’s India
Healthcare Trends ‘08 estimates that 46% of the patients travel over 100 kms. from small towns to these
facilities. There is a latent demand for quality healthcare in the tier 2 & 3 towns which already attract a large
proportion of rural population. But, still the growth is not gaining the momentum much needed.

Sidne. Options. Compliment.You are a very skilled surgeon. Now who wouldn't want to work with a voice-
activated system like that! This morning I got all scrubbed up and checked out the first of three newly
renovated operating rooms in St. Mary's Hospital's OR. All eleven OR rooms are scheduled to be renovated
in the coming months.

ss put on at the YMCA last night, I had no idea what to expect. I have never even considered trying
smoking; now I have more than enough reasons why.

According to the American Heart Association, an estimated 25.1 million men and 20.9 million women are
smokers in the United States. Smoking is now blamed for more diseases and conditions than I can name,
including cancer, heart attack, stroke, emphysema and more.

But it wasn?t always considered a bad thing.

There were three participants in the Yes class, which is put on through the Macon County Health
Department and led by Wole Adeoye, owner of Victory Pharmacy. Two of the participants are older than 75
and recall that when they started the habit, it was the thing to do.

When I was in high school, everyone smoked, said one. During the War, my husband was in the Navy, and
they actually gave (cigarettes) to them. We didn't know back then that it was harmful.

Wole spent the classtime openly discussing the financial burden of smoking, the participants reasons for
wanting to quit, the harmful health effects and facts about the habit.

For instance, I wasn't aware that cigarettes are stimulants. So why do people claim that smoking calms them
when they are nervous or stressed out?

Because when you smoke, you are taking nice, big, deep breaths, he pointed out. It's not the tobacco. How
can something that is stimulating your brain make you relax?

Wole also outlined the ingredients contained in cigarettes. More than 4,000 chemical compounds are created
by burning a cigarette, many of which are toxic or carcinogenic (cancer-causing). Carbon monoxide,
nitrogen oxides, hydrogen cyanide and ammonia are all present in cigarette smoke.

Would you eat a cake if I told you it was laced with cyanide? he asked the class, getting the obvious
response of No. from each person. But why do they smoke cyanide?

It's habit.

In a few weeks, I'm going to check back in with this class of three to see how they are doing with their
decision to quit. Some of them expressed concern at their full commitment, noting they actually like
smoking, but also admitted they know they need to stop. Wole encouraged them in their endeavors.

There are so many advantages you need to focus on - those advantages and improvements in the quality of
life that you will enjoy for the rest of your life, he said.

Posted by: latha

Pvt doctors oppose Clinical Establishment Act.....

The Clinical Establishment (Registration and Regulation) Act 2010, which will be implemented soon in the
state, is likely to make life difficult for private practitioners here as the state has already given ascent for its
implementation. However, private practitioners alleged that Act had been framed keeping in mind corporate
hospitals and health insurance schemes at the cost of poor patients and doctors doing private practice.

Medical practitioners alleged that the Act prescribed minimum standards for up to 10 bed clinics and
hospitals. If the minimum standards for buildings, equipments and trained manpower as prescribed in the
Act were implemented, the cost of running 10 bed hospitals would go up to about Rs 3.5 lakh

 Source :The Tribune

Information Technology (IT) has positively impacted every industry, and healthcare is no exception.
Healthcare is possibly the world's most complex and multifaceted industry, with a huge number of intricate
rules and policies. Health information technology (Health IT) allows comprehensive management of
medical information and its secure exchange between health care consumers and providers.

The Internet has made healthcare more accessible, interactive, and highly useful. Telemedicine, picture
archiving and communication systems (PACS), and healthcare information systems (HIS) are a few of the
many IT applications in healthcare.

The usage of IT in healthcare had not taken off in India despite a strong healthcare market (about
$34billion). Lack of regulations and standardization and the lack of professionalism in this sector have been
the major hurdles in the path of IT adoption. The fragmented nature of the Indian healthcare delivery
system, characterized by small nursing homes and general practitioners, has also slowed down this process.
But the Indian healthcare landscape is changing and IT is poised to revolutionize healthcare in India. There
is a change in the mindset among Indian hospitals, which, earlier, was of the perception that IT only
automates the medical process and does not lead to either cost reductions or increase the return on
investments (ROI). With the onset of health insurance in the country and the changing regulatory
framework, healthcare providers today truly see value in the adoption of IT.

Health IT has many advantages:

• Improve health care quality;

• Prevent medical errors;
• Reduce health care costs;
• Increase administrative efficiencies;
• Decrease paperwork;
• Expand access to affordable care.

According to Technopak a major healthcare consultancy market opportunity stands at around US$3billion
for the new healthcare IT infrastructure required in the country. It is expected that it will grow at a 40%
growth rate annually.
Indian market opportunities (source: Technopak advisors ltd.)

The provider of healthcare IT solutions can be divided as:

• Complete end to end solution for hospital
• Automation of hospital operation –customized to departments
• Enterprise management solutions
• Payer solutions

Providing complete end to end solutions:

Most of the hospitals having more than 100 beds may need a complete solution to their hospitals processes.
IT companies provide complete end to end solutions but it may vary with kind of hospitals. These solutions
can be customized to requirement of hospitals and like wise modules can be developed.

Automation of hospital operation:

Hospital operation departments like Labs, Outpatient department, Emergency, Medical records are
independent of their own functionality but for total service delivery they are integrated with each other.
Customized IT solutions for these departments are developed by IT companies depending on requirement of
hospital.

Enterprise management solutions:

IT Solutions companies provide Enterprise management solutions in hospital to areas like human resource,
finance, data management and other administrative departments.

Payer solutions:

Health IT companies provides Payer solutions to Hospitals, TPAs Insurance companies for smooth
transactions between payers and providers

Companies Product name, cost, year

Solutions/Services Presence Contacts
(India) of launch
Hospital information
management, Claims
management, Disease
Player, Providers, mgmt, operations mgmt,
Satyam Global ?
Enterprise EMR, hospital messaging
services, lab information
system,HL7,DIOCOM
solution
Wipro HIS Main-for large
Managed IT Hospitals.-Rs35-45 Lacs. 6th Floor, Laxmi Building,
Wipro
services, IT Released in 2002 SP road, Begumpet,
Healthcare Global
infrastructure, Wipro HIS Lite-for Mid Secundrabad-500003,AP
IT
consulting, Sized Hospitals-Rs5-8 Tel:040-39187929
Lacs
India,
IBA e HIS IBA health
Automation with South east
IBA health Version 5.2 released -2005 73-D, Electronic city,
around 35 modules Asia,
Price-INR 2 Crores Bangalore.
Africa
Companies Product name, cost, year
Solutions/Services Presence Contacts
(India) of launch
 Automation and
Enterprise
Trakhealth Trakcare Global anand.iyer@trakhealth.com
management
Solutions
Patient India,
Sobha Renaissance IT
Sobha Administration & Middle
RCare Magnum 3.0. Pvt.LTD
Renaissance care, Clinical East,
Released on 2006 SRIT House,#113/1B,ITPL
IT Pvt. LTD. support, Revenue Southeast
Main Road,Bangalor
cycle. Asia.

Conferences:

S.No. Company Event Venue Dates

24th to
1 Health Forum Leadership Summit 2008 Manchester Grand Hyatt
26th July
24th to
Himss 08 Annual Conference
2 Himss Orlando,FL 28th Feb
and Exhibition
2008
Association of British 14th to
Dusseldorf Trade Fair
3 Healthcare Industries Medica 17th Nov
Centre. Dusseldor
Limited 2007
First European Research
Glasgow Caledonian Conference on Continuous 10th March
4 ?
University Improvement and Lean Six 2008
Sigma
26th to
World Health World Congress of Health Perth Convention
5 29th March
Congress Professions Exhibition Centre
2008
28th to
7th International Conference on NewcastleGateshead,
6 Newcastle University 31st Oct
Priorities in Health Care United Kingdom
2008
Access to quality healthcare in the private sector till now is limited by the high cost for the vast majority of
India’s population. However, this is changing dramatically with the advent of health financing as a preferred
tool to cover for most healthcare expenditures.

Health financing essentially involves arranging for payment of a health service that has been arranged for
under the financing contract.

Health insurance forms a major part of financing. It is growing exponentially with large and diverse players
having entered the fray and enticing consumers with an ever-growing array of schemes. This is proved by
the fact that healthcare insurance premium collected in 2005-06 registered a growth of 35% over year 2004-
05.

The entry of pure Health Insurance companies into the marketplace in 2007 promises a plethora of
innovative products. Swiss Re estimates a potential of US$ 7,700 million in health insurance premium by
2015.

Foreign Direct Investment (FDI) limit in health insurance has rose from 26% to 49%, which would result in
surge of international players & even more customized offerings targeting all sections of society. In the
event of the minimum capital requirement of US$ 25 million being reduced to US$ 12 million, a number of
stand-alone players like Atar Health, Apollo DKV have come into being, as is the trend across the world for
health insurance.

Less than 10% of India’s population today has some or the other form of health insurance covers: either
voluntary or as a part of the Employees State Insurance, Central Government Health Scheme or Community
Insurance.

The existing models of health financing are:

Government Funded

In theory, this system is a universal pooling arrangement that involves the entire population. It provides
access to publicly provided services financed through general revenues. In practice, it usually coexists with
one or more of the other risk pooling arrangements.

State-funded systems are suitable for most countries having the capacity to raise taxes, establish an efficient
network of providers, and need to target the poor.

It is a simple mode of governance and a potential for administrative efficiency and cost control. It provides:

A comprehensive coverage to the population, and

A large scope for raising resources

Government supported

Social health insurance

Social health insurance system is established in approximately 60 countries.

It can be easily differentiated from general systems by independent or quasi independent insurance funds, a
compulsory earmarked payroll contribution, and a clear link between the contributions and defined rights for
the insured population.

The main features of social health insurance are

Financing mainly through employee and employer payroll contributions.

The efficient management by nonprofit insurance funds.

The existence of a benefits package.

This provides

More resources for the health care system.

Less dependence on budget negotiations than state-funded systems.

High redistributive dimension.; and

A strong support by the population.

Community based health insurance

Community-based health insurance schemes are also referred to as health insurance for the informal sector,
mutual health organizations, or micro-insurance schemes. This was the basis for the creation of social health
insurance systems in countries such as Germany, Japan, and Korea and the overall health financing strategy
in a number of countries.

Today in low-income countries, community-based health insurance plays an increasing role in providing
medical coverage to populations without access to other forms of formal medical protection. These schemes
are also slowly penetrating the rural market.

It provides better access to health care for low-income people and has also been proved as useful as a
component of a health financing system involving other instruments.

Micro financing

Private

Voluntary health insurance

“Voluntary” or “Private” health insurance is a health financing model that is predominantly prevalent in
high-income countries as a complement to the publicly financed systems.

In practice, voluntary or private health insurance arrangements cover a wide spectrum of voluntary financing
mechanisms and share diverse relationships with public and private health sector inputs.

It provides:

An affordable financial protection (compared with out-of-pocket expenditure)

An enhanced access to health services

For an increased service capacity and promotes innovation, and

Towards financing health care services not covered publicly, as in the case of supplementary private health
insurance.

Healthcare systems can function effectively and efficiently under the ambit of structured & organized
financing mechanism. In terms of expenditure on health, the private and public investment is roughly in the
ratio of 80:20 respectively. With regards to healthcare and services spending, 62 per cent is self-sponsored.
The Government contributes 24 per cent, employer provides for 9 per cent and only 5 per cent comes
through insurance. This is dismal, when we discover that only Rs 250 crore is being collected for health
insurance, whereas life insurance gets Rs 25,000 crores and even non-life items get Rs 9,000 crores towards
insurance.

Private financing is gaining momentum, with about 70 % of the healthcare expenditure is out-of-pocket,
which is increasing much more higher than the per capita income growth.
 

Due to advancement in technology, improvement in infrastructure and emphasis on quality etc, the cost of
healthcare services is escalating. This is affecting the Indian middle and lower class directly. With passage
of time alternative health financing mechanisms like Healthcare Insurance come into being to streamline &
address the issue of inequitable and unaffordable healthcare delivery.

Benefits of Health Insurance:

Protection against catastrophic financial burden in case of unexpected illness or injury

Pooling of resources Limitations:

Hospitals tend to overcharge

Absence of regulatory framework for providers

Difficulty in handling fraudulent claims for insurance companies

Third Party Administrators or TPAs came into being to address these limitations. They are intermediaries
that coordinate between Insurance companies and hospitals. From here emerged the concept of cashless
hospitalization. While the insured is benefited by better service, insurers are benefited by reduction in their
administrative costs, by outsourcing their management administrative activities, including settlement of
claims at a certain cost. They come under the purview of Insurance Regulatory and Development Authority
(IRDA), India. There are at present 27 TPAs registered under IRDA (as on 31st August 2007).

Current Scenario and challenges in Health Care

New realities are placing pressures on the healthcare industry and how patient care is delivered. Rising
hospital management costs, an aging population, shortage of trained healthcare workers, challenges in
accessing services, timely availability of information, issues of safety and quality, and rising consumerism
have all added to the highly complex facts of today’s healthcare system. The dynamics between patients,
doctors and hospitals is changing and expectations of the kins of the patient have increased putting a lot of
pressure on the system. The industry has reached a point of chasm where they need to decide how services
could be delivered more effectively at reduced costs, without affecting the quality and also serving all
economic segments of society. The recent decision allowing the entry of private agencies in health insurance
is an important step taken by the government to reach out to the vast majority of people who are without any
insurance coverage. The corporate hospitals and other agencies will play an important role in the current
scenario.

Hospitals, a Socio Technical System

The critical questions facing the industry today include how can we effectively manage hospitals and
provide enhanced services without placing additional burden on a system already pushed to its limits; how
can we provide care in a cost-efficient manner at a time when healthcare spending is rising; because of
newer, costly and ever-changing equipment/technologies both in diagnostics, therapeutics and also the
expensive human resource and how do we most efficiently use other scarce resources in order to reduce
medical errors and enhance quality of care. One of the challenges is to make a trade off between optimizing
the work-force vis-à-vis introduction of automated technologies.

Why Professionally Qualified Hospital Administrator?

To address these issues, there is need for a properly trained pool of professionally qualified hospital
administrators who can design and deliver quality health services. Today the success of a hospital
administrator lies in multidisciplinary conceptual skill development and to protect medical profession and
clients from unnecessary litigation, human resource development; quality management, risk management,
environment conservation; marketing, logistics, emergency management etc. Their responsibilities are
numerous and require the assistance of the medical and supporting staff. They act as liaisons between
governing boards, medical staff & department heads & integrates the activities of all departments.

Following policies set by a governing board of trustees, administrators plan, organise and direct control &
co-ordinate medical & health services to cater to the needs of the hospital & community. The concept of
development of specialised skills and leadership in hospital administration has further emphasized the need
to rationalize the resource utilization and to maximize output in health sector. Therefore, the hospital
administrator of the future needs to be well equipped to meet the challenges and this can be effectively
performed if he possesses a PG/Master’s degree in health service administration. National Accreditation
Board for Hospitals and Health Care Providers (NABH) has laid down standards that make hospital patient
staff and environment friendly. NABH standards also states that hospital administrator should be qualified in
Hospital Management/Administration. He should have a Master’s degree in Health Service Administration.

On The Consultancy Trail

The burgeoning Rs-800-crore-strong hospital consultancy sector is making its presence felt from
Dharamsala to Delhi, penetrating even Raigarh to Rai Bareilley. Rita Dutta checks out this latest
phenomenon in healthcare industry.

In 1998, while working together on a hospital project at Surat, cardio-thoracic surgeon Dr Ramakant Panda
offered Dr Vivek Desai, MD of HOSMAC to plan and design Asian Heart Hospital. Dr Desai, who had till
then not executed any such mega project, was both shocked and surprised. “I could not believe that Dr
Panda was seeking my help for such a prolific project,” recollects Dr Desai. After seven years and 120
projects, the Rs 2-crore-firm HOSMAC is considered one of the leading hospital consultancy firms in India.

For a sector which made a very sluggish start, the success story are
many, all of which echo a similar exponential growth. So much so
that when recently a group floated tender to build a hospital in Delhi,
more than 20 groups applied for it. To think of it, even four years
back, consultancy firms had to peddle their services to hospitals.

Five years back, there were not more than five firms. Today, the
sector teems with more than 20 established firms and there are more than 50 individual consultants who
work both full-time and part-time. The consultancy market has also opened up three years back. And today,
analysts clock this sector at Rs 800 crore, set to have an annual growth rate of 15-20 per cent.
 "Only Delhi has made The firms are happy with the greenbucks they are raking in. For instance,
it compulsory to New Delhi-based NOUS Hospital Consultancy (p) Ltd has contracts
award hospital worth INR 9 crore as their fees for next five years for seven major
projects to companies projects. Says Col Dr K B Sood, Managing Director, NOUS, “This is two
which are either into per cent of the total costs of new building constructions for the projects
hospital planning & which is at Rs 450 crore. It will take almost Rs 450 crore worth of
designing or if they architects, equipment also. So the market is huge.”
they have to have an hospital "Hospital consultancy
consultant associated with them" The firms are mostly concentrated in the requires specialisation in
metropolis- mainly in Delhi, Mumbai each of the minimum 28
- Col Dr K B Sood and southern part of the country. Dr areas of hospital
Managing Director, NOUS, New Chandra Prakash Kamle, Dr Kamle’s parameters and
Delhi Prescription, Boston, US, explains the functioning, which only consultancy
trend, “Presently, small towns do not firms can do"
offer adequate business to these firms.
Small towns at the most have glorified nursing homes and mostly doctor- - Dr Chandra Prakash Kamle,
promoter with his knowledge and experience of seeing some of the Dr Kamle’s Prescription, Boston, US
hospitals in metropolis and abroad borrow the crude concept of hospital
planning.” Yet, firms located at Jaipur or Mumbai are eyeing for projects
beyond their geographical boundaries.

What Led To The Surge?

Pegged at 23 billion USD, the Indian healthcare industry is growing at an annual rate of 13 per cent, with
private spending on healthcare amounting to 60 per cent. With corporatisation of healthcare, entry of health
insurance, competition, there is a greater emphasis on quality of care and accreditation—all leveraging the
growth of hospital consultancy firms. Perhaps, the biggest factor fuelling the growth is the realisation by
stakeholders that special skill-set is required for orchestrating a hospital project from ideation to
implementation.

One Stop Shop

These firms have their fingers in every pie—from designing new hospitals, restructuring to expansion of
existing hospitals, computerisation and system management of hospitals, equipment planning, manpower
planning and training, medical informatics and telemedicine, managing operations. The practice of involving
doctors and hospital administrators for the above functions is becoming anachronistic.

While large and established firms provide a one-stop solution, new and emerging ones prefer to work on a
few specialised areas. For instance, Jaipur-based Ace Vision Health P Ltd focuses on clinic/medical audits
and clinical risk management. Says Sheenu Jhawar, Director, Ace Vision Health Consultants P Ltd, “When I
started in November, 2004, the need was very clear. The expertise was not hitherto available by other
functioning consultancies, and the northern part did not have any such consulting firms.” Small firms also
help hospitals in training, marketing and management strategies. According to Vivek Shukla, Managing
Director of Vivek Shukla and Associates, Dharamasala, “Training people in soft skills and managing their
finances constitute an important part of our services. Some hospital are willing to spend lakhs on buying
equipment, but are hesitant to spend on marketing their products. Hence we try to address such flawed
business strategies.”
"The driving principle and
ethos for each firm is
Some even work with a missionary zeal. Medicontrivers, for
different. We did not want
instance, has chosen to concentrate on semi-urban areas like
to swim in ocean of
Belgaum (KLES Hospital), Calicut (Malabar Institute of Medical
comfort. For us, it is
Sciences) and Patna (Dr Ruban Diagnostics and Dr Ruban Memorial
taking medical service to remotest
Hospital) as there is a woeful lack of medical facilities in these
corners of society"
areas. Apart from rendering consultancy services, it funds its own
projects. After transforming a sick nursing home into a clinic,
- Col A K Singh,
MD, Medicontrivers, Mumbai
Medicontrivers helped conduct the first kidney transplant in Bihar in June, 2005 and also got the first digital
X-Ray to the city. According to Col Dr A K Singh, MD, Medicontrivers, “The driving principle and ethos
for each firm is different. We did not want to swim in ocean of comfort. For us, it is taking medical service
to remotest corners of society, where big firms dread to enter.” It strives to make advanced treatment
affordable to the common man. “We have priced our bypass surgery package at KLES only at Rs 85,000 so
that more people can afford it,” says Dr Singh. His dream project is to build a 500-bed multi-specialty
hospital in Patna boasting advanced technology.

The preference scale of most firms are tilted towards planning and designing new hospitals than any other
service and why not. With around an unofficial estimate of 300 new hospitals within next two to three years,
the choice is obvious. It is said that around 50-70 per cent of project cost is spent only on constructing the
building.

Even academic institutes like IIHMR-Jaipur are trying their hand at hospital consultancy through its
consultancy division Total Health Solutions (THS). Says Santosh Kumar, Lecturer, THS, “Though THS was
formally instituted in the year July 2004, IIHMR is rendering services in hospital management consultancy
for both private and public sector since its inceptions 20 years back.”

Should large firms do multi-tasking or confine themselves to a few areas? Rendering services in multiple
areas will provide perfect co-ordination and will meet the uniformity of standards and specifications.
“Specialists from various functional areas of hospitals alone will form a true hospital consultancy firm. A
lone crusader can only be a generalist and a far cry from a hospital consultant,” reasons Dr Kamle.

Why Hire Consultancy Firms?

Recently, Jaslok Hospital had taken the help of consultancy firm Concept to train its people in soft skills. In
the words of Gurushant Phatate, GM, HRD, Jaslok Hospital, “It is always good to take external help to train
your staff as it most unbiased.” From hospitals in Rai Bareilley to Amritsar, from a meagre 20 bed to
princely 500-bed hospitals, it has become a common practice for hospitals to knock the doors of consultancy
firms. What is the need for such firms? Why cannot hospital administrators execute the same job? Hospital
administrators are generalists, say experts. “Hospital consultancy requires specialisation in each of the
minimum 28 areas of hospital parameters and functioning, which only consultancy firms can do,” explains
Dr Kamle.

Complies Dr K C Ojha, Managing Director, Hospic, “Setting-up a new hospital and running the existing
hospital professionally both are very complex. Hospital is capital-intensive, labour-intensive, high
technology-intensive and skill- intensive industry.” Add to this, the complexity of engineering requirement
of a hospital, including, AC, electricals and plumbing service, areas which doctors have very little technical
know-how.

Then, there is the economics of market. Says Dr S K Biswas, VP, Duncan Group, Kolkata, “The healthcare
market is no longer monopolyst or oligopolyst. It is attaining a perfect market competition stage, where the
same kind of service is rendered by many players. In such a scenario, one has to get the best skill set.”

A healthcare organisation goes through three stages: exponential, cost control and improve quality and stay-
afloat stage. Hospitals in the second stage have to rely on specialist’s help to survive in the business. “The
firms help the hospital attain its goal and achieve break even within the given time,” says Dr Biswas, also a
consultant to Klassi Apartments, Kolkata, which specialises in hospital construction and design consultancy.
Delays, cost over-run or even abandoning the project at a later stage can be avoided, if consultancy firm is
involved at the outset. Multiplicity of command, deviations of parameters and standards, non-coherence of
specifications and non-accountability of the final monument can also be averted if the help of a firm is
sought.
And it is not just big hospitals which seek help. “Smaller hospitals req uire more help, because they often do
not have a regular administrator. However, working for these hospitals is not very cost effective for the
firms. So, it is a catch 22 situation for the consultancy firms,” opines Jhawar.

Paradigm Shift

When did the tide turn? The winds of change started only in 90s, when hospital projects were planned and
designed by people trained for the job. This ended a regime of unplanned and haphazard planning, which
had doctors and architects brainstorming to plan and design hospitals. Explains Dr Ashish Roy, Managing
Director, Professional Health Planners, New Delhi, “Hospitals built prior to 60’s have good design and
planning as they were built by the Britishers, who employed architects having knowledge of hospital
architecture. From 60’s to 80’s, hospitals were built by general architects, with no knowledge of hospital
architecture.” The result was disastrous, with some of them building windows that could be opened, in OTs
and labour rooms. Thanks to the knowledgebase of consultancy firms, such disasters are averted now. But as
stated earlier, the boom in consultancy firm started only around three to four years back

At the Helm

The consultants are also from diverse background including doctors, architects, management experts, IT
experts, accountants, ex-administrators of hospitals, service engineers and even MCI inspectors. Apart from
a handful of full-timers, the firms often outsource specific services from outside experts on project to project
basis. Who should ideally head such firms? Responses vary from doctors to people from service industry.

Business Affairs

The burgeoning of firms is an indication of the lucrative business. Most firms ask for three to eight per cent
of the project cost. Some go for long-term revenue sharing or just on a time-bound performance contract
determined by the scope of work. While big hospitals don’t hesistate to dole out the fees, most often the
firms have to face bargaining clients from semi-urban areas.

The northern and north-eastern part of the country lies untapped for consultancy. Experts predict that the
future will see Indian firms catering to more international clients, mainly from the SAARC and ASIAN
region especially Maldives, Srilanka, Thailand, Indonesia, Nepal and Afghanistan.

Teething Trouble

Lack of Indian guidelines compel the firms to come up their own, which is often an amalgamation of various
international guidelines like JCAHO, ISO and Six Sigma. “Though the Bureau of Indian Standards is
coming out with guidelines for building a hospital of 30, 50 and 100 bed, there is none for hospitals larger
than 100,” rues Dr Roy. Lack of understanding of importance of hospital consultancy firms coupled with
ignorance about their existence also hamper business avenues.

According to Rakesh Solanki, Healthcare Projects and Marketing Consultancy Organisation (H-PAMCO),
New Delhi, “The sector is highly unorganised and needs to launch itself professionally.” The established
firms are also irked by fly-by-night operators who have “created bad odour compelling new players to
establish credentials. This is because unlike any other sector, domain knowledge is always from more than
one source in healthcare industry,” avers Dr Sood.

Future Trends

Experts predict that the current trend of turnkey hospital projects should continue only till next five years.
“Development and implementation of HMIS, performance benchmarking and quality improvement would
be the buzzworld in near future,” says S Kumar.
While the indigenous hospital consultancy sector would grow, more international firms are expected to enter
the market in future. With the increasing demand of professionals qualified in hospital planning and
mushrooming of institutes catering to training of hospital planning and design, general architects would be
completely replaced by specialists in hospital architecture, feel experts.

To maintain quality of work, however, the industry needs a statutory body which would regulate various
firms. “As architects have to be formally qualified and registered with Indian Institute of Architects, we also
need professionally qualified hospital consultants and a statutory body monitoring them,” maintains Col
Singh. To which Col Sood adds, "Only Govt of NCR Delhi has made it compulsory to award hospital
projects to companies which are either into hospital planning and designing consultants or if they are
architectural firm, they have to have a hospital consultant ssociated with them. Other states need to follow
this too.”

Once the control and statutory measures are in place, the day would not be far when large entrepreneurs and
industrial houses like Birlas and Tatas would approach a hospital consultancy firm directly for various
hospital projects, rather than first finding a consulting doctor who chooses the firm.

Some Major Hospital Consultancy Firms

Medicontrivers India Pvt Ltd, Mumbai

Started in 1993, its major projects are Ruby Hall Clinic in

Pune, KLES hospital, Belgum, Rajiv Gandhi Rural Hospital
near Belgaum and medial college in Kerala.

Ace Vision Health Consultant Pvt Ltd, Jaipur

Over an year old, they render services in clinical audits and

clinical governance. Managed by husband-wife couple of
Sachin and Sheenu Jhawar, the firm is providing
management consultation to Apex Hospitals Pvt Ltd, Jaipur,
Mahatma Gandhi Mission Trust Hospital, Aurangabad, State
Institute of Health and Family Welfare), Rajasthan. The firm
has three full-time working experts. Other are consulted on
project to project basis.

Professional Health Planners, New Delhi

It provides services in planning, concept & architectural

design, drawings, and engineering services, hospital services
planning, design and implementation, hospital systems
development & implementation and medical and non
-medical equipment management. So far, it has completed
over 35 projects.

Hospic, Mumbai

Started 12 years back, the firm has provided consultancy

services to 120 hospital projects and 9 are in the pipeline.
Their area of specialisation are market feasibility study,
medico-technical feasibility study and financial feasibility
study, and also providing criteria and coordination in
planning and designing the hospital.
Dr Kamle’s Prescription, Boston, US

This 30-year-old firm has completed over 500 projects so far

and has 10 in the pipeline. Its area of specialisation are
market research, feasibility studies, concept, design.
architecture, equipment, human resources ,management,
computerisation and other 23 parameters of hospital
functions, all of which are dealt by consortium specialist ,all
under one-roof. It has 47 specialists drawn from the areas of
architecture, finance, management, engineering and
scientific background.

Total Hospital Solutions, Jaipur

It has done 18 major hospitals related projects for various

national and national funding agencies. About 3 hospital
projects are currently under implementation.

Their areas of specialisation are hospital market research,

hospital planning, operations management, HMIS, HRD,
community financing and its innovative research for
understanding the future trends and pro- poor interventions.

Apollo Hospital Enterprise Ltd, Chennai

Their areas of specialisation are project and operations

management consultancy services from conceptualisation to
commissioning of a wide range of healthcare models.

NOUS Hospital Consultancy (P) Ltd, New Delhi

It started in 1983 as a registered firm Hospital Corporation

of India and became a corporate entity in 1993. It has a total
of 80 projects, of which 68 have been completed. It
undertakes feasibility, planning, designing, construction,
equipment planning, recruitment of departmental heads, pre
commissioning and commissioning. It has a group of 23
associate consultants.

KSA Technopak, New Delhi

Their services include strategic planning at the system,

institutational and clinical programme levels as well as
functional work in such areas as ambulat\ory care.

H-PAMCO, New Delhi

Founded in 1996, H-PAMCO specialises in technology

launches, products marketing projects, medical waste
management, lifestyle modifications courses, IT-based
solutions, and general operational audits.

‘Hospital consultancy might soon function as a BPO

 sector’
Since its inception in 1997, Hosmac has bagged
more than 120 projects in India and abroad. The
firm has designed 3 million square feet of
hospital space and handled projects of 4 billion
INR. And steering this growth single-handedly is
its Managing Director Dr Vivek Desai, who
owns 65 per cent stake in the company. Dr Desai, who
started his career as a administrative medical officer at P D
Hinduja Hospital and continues to be a visiting faculty at
leading healthcare institutes, shares his success mantra with
Rita Dutta.

How has been your journey so far?

From 1994, I started working as an individual hospital

consultant. At that time, I used to work from home and only
did departmental audits, feasibility study and market
research. HOSMAC was founded in 1997. We made a slow
start and had our own learning curve. The scenario was very
different then. We had to educate our clients about the need
of consultancy firms. Our first major break came in 2000,
when we were asked to plan and design Asian Heart
Institute. We became a fully integrated firm only in 2002,
offering one-stop solution. Today, we have expanded to
have 60 people, chosen from the field of architecture, IT,
biomedical engineering, hospital administration and
medicine. Our approach has been to add value at every stage
of product development.

Experts emphaise on the need of an association of

hospital consultants. What is your take on that?

An association should be formed only after we have around

100 consultants. An association would help in standardising
guidelines for hospital planning and design. It would also be
a source of knowledge pool, leading to research. Most
importantly, it would reduce undercutting for budding
consultants, who otherwise don’t know what they should ask
for and end up getting a meagre amount.

What are your future plans?

We want to have a pan-Indian presence. We have already

have projects in Delhi, Mumbai, Pune, Nagpur, Kerala, UP,
Bhilai, Guhawati and Siliguri. We are there in the north and
middle east for more than three years.

We want to manage more hospitals. As of now, we are

managing a hospital in Thane and Mt Abu. In the near
future, we may get into publishing, of course related to
healthcare. We want to focus more on public healthcare
projects, we are already doing work in UP, Bihar and
Uttaranchal and also want to foray into turnkey design build
concept, which is popular in the Middle East. We want to
further encourage Hosmac Foundation, a public charitable
trust, which imparts training in IT, HRD, infection control
among other things.

What hurdles does HOSMAC face?

We want to do so much, but face financial crunch for

growth. We are looking at options for venture capitals and
strategic partners to accelerate our growth.

What are your predictions for the future of this sector?

The future will witness a lot of individual consultants

getting into this business. The potential of the market is Rs
800 crore. The calculation is simple. If we require 80,000
beds per year according to estimates, and we spend Rs 20
lakh per bed with all facilities, then we spend Rs 16000
crore per year. If the firms charge five per cent, then the
market size is Rs 800 crore.

The sector might soon start funtioning as a BPO industry,

whereby international firms outsource work from us,
encouraged by our skilled but cheap labour force.