Hospital Accreditation in India - Standardising healthcare

"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."

Girdhar J Gyani, CEO, National Accreditation,Board for Hospitals & Healthcare Providers

India

The Indian healthcare delivery system consists of varied health institutions and mixed ownership patterns. Private and/or public-private partnerships dominate the tertiary care, while secondary healthcare is a lopsided mix of both, private and public and government health systems cater mostly to primary care. It is estimated that there are more than 15,000 hospitals operating in the country, of which 30 per cent are in public sector. However, number of beds in the public sector is almost four times that in the private sector. While 80 per cent of hospitals in the private sector have less than 30 beds, about 10 per cent of hospitals are with beds in the range of 30-100. Only six to seven per cent of the hospitals are with more than 100 beds.

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.

The call for quality

Until a few years ago, most people in healthcare were convinced that higher quality meant higher costs. If people wanted better healthcare, they would have to be willing to spend more. Better quality meant new technologies, new medicines and more staff. While all this was evidently being worked upon, paucities in access, affordability, efficiency, quality and effectiveness of health services have remained the same. There have been numerous instances of poor care, inadequate facilities, unnecessary interventions and insufficient information that has called for a closer look at our healthcare delivery system. Concerns on quality of health facilities have been generated lately because of increasing awareness among the consumers. 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 demand for appropriate health services.

In such settings healthcare quality requires regulation & accreditation. Barring few a states, regulation in healthcare is almost non-existent. Regulation is mandated by Government and is based on minimum standards, inspection, enforcement & public accountability. Government is working on introducing regulation in all segments of healthcare delivery. Accreditation on other hand is voluntary. Accreditation is based on optimum standards, professional accountability and encourages healthcare organisations to pursue continual excellence. In most developed economies there are very strong financial incentives to seek accreditation. Governments acknowledge that independent assessment programme by way of accreditation should be encouraged with incentives, more so for secondary/tertiary level of hospitals to bring in the best in terms of patient safety and quality of care.

Indian national accreditation structure

The attempts to evolve a voluntary accreditation system began in late 1980s with the Bureau of Indian Standards putting down standards for 30, 100 and 250 bed hospitals. The National Institute of Health and Family Welfare had also specified rules for more than 50-bed hospitals. Since health is a State subject, there have been attempts in some States to incorporate standards for hospitals. Such compartmentalised initiatives have led to further fragmentation of an already segmented industry. The lacuna lies in not having a united and single system to monitor the functioning of hospitals in India and the stringency of compliance to established standards.

Accreditation is one of the mechanisms identified in WTO agreement as means to promote universal acceptance of conformity assessment results. Realising the need for establishing a national accreditation structure, that was

suitable to the Indian conditions and credible in the eyes of international markets, an inter-ministerial task force was set-up up in 1991. The report of the task force was brought out in January 1993. As an outcome of its recommendations, Quality Council of India (QCI) was established in 1997 as an autonomous body. The mandate given to QCI was to establish and operate the national accreditation structure and obtain international recognition for its accreditation schemes.

National Accreditation Board for Hospitals and Healthcare Providers (NABH) has been set-up under the national accreditation structure to establish and operate accreditation programme for healthcare organisations. NABH is an institutional member of International Society for Quality in Health Care (ISQua). The Board has representation from all stakeholders including government, consumers and healthcare industry. The structure incorporates Accreditation Committee, Technical Committee, Appeal Committee, Secretariat and a panel of over 100 assessors/surveyors selected among clinicians, hospital administrators and nursing supervisors. They have been empanelled after having qualified through a five days training programme.

Accreditation standards

NABH’s accreditation focuses on learning, self development, improved performance and reducing risk. Its assessment relies on establishing technical competence of healthcare organisation in terms of accreditation standards in delivering services with respect to its scope. It goes beyond compliance and calls for excellence on continued basis. It is this feature, which makes it market driven involving all stakeholders; be it consumers, empanelling agencies, regulators and other third parties.

NABH accreditation is based on optimum standards, professional accountability and encourages healthcare organisations to pursue continual excellence. Cardinal principles of accreditation evaluation are as follows:

Hospital operations are based on sound principles of system-based organisation, which are transparent and objective

Accreditation standards are implemented and institutionalised into hospital functioning

Patient safety and quality of care, as core values are established and owned by management and staff in all functions and at all levels

There is a structured quality improvement programme based on continuous monitoring including feedback on patient care services

The evaluation process incorporates interview with patients, residents and staff. It calls for on-site visit to patient care areas and to departments addressing issues related to physical assessment of infrastructure, medical equipment, security, infection control, etc. as required in the accreditation standards. In short, the accreditation involves a is comprehensive review of not only facility but also of clinical competence of hospital to deliver services within its scope.

NABH’s roadmap

As of today, the accreditation programme for hospitals is fully functional. Out of 30 applicant hospitals, two have already been granted accreditation and rest are undergoing different stages of evaluation. NABH will soon be launching accreditation for blood banks, diagnostics centres (imaging services), dental hospitals/ clinics and ayurveda hospitals. A rough estimate shows that about 250 hospitals in secondary/tertiary level will be able to comply with the NABH accreditation standards (edition 2005) in next two years. The next in line are about 300 medical colleges, as the hospitals attached to these colleges are expected to operate at the highest level in terms of patient safety and quality of care ¾the cardinal points in accreditation standards. There have been concerns that many of these hospitals, operate below par and there is a need to drive these hospitals to seek accreditation. The fact that these hospitals are nurseries for our budding doctors, it is all the more necessary that we set high standards in terms of clinical processes in these hospitals. Putting the two figures together will mean 550 hospitals are potential hospitals to make up for Indian accredited healthcare hub in what we call first phase. These would be taken as referral centres for patient safety and quality of care. On one hand, these will motivate other hospitals to raise bar and prepare for accreditation and on the other hand, they will be our showcase for the medical tourism.

Considering that there are more than 15,000 hospitals in the country, debate has begun on what would be the status of remaining hospitals and nursing homes. This includes about 600 district level hospitals, which cater to masses. The standard for such hospitals will comparatively have lower yardsticks for management related issues, yet maintaining same level of patient safety. NABH is working on developing a separate set of standards to address these issues. These standards are expected to be announced in Jan 2007 and made operational by April 2007.

Widening Horizons for NABH

To cater to its growing demand, NABH would soon roll out a slew of initiatives to strengthen its functioning, says Rita Dutta

Seeing the reams of files awaiting inspection at NABH's office in Delhi, who would believe that the quality and accreditation wave in healthcare started in India only a few years back! With 52 hospitals already NABH accredited, 132 under process and over 400 applications awaiting response, there’s no denying that NABH accreditation has become a rage.

The swelling demand for an accreditation that comes under the purview of the quasi-Government body?Quality Council of India?is quite an interesting phenomenon. And to think that most of the board members are veteran administrators from private and public sectors doing honorary work and the assessors also don’t get major monetary benefit! But the most interesting development in recent times has been change of the old guard and constitution of a new board.

At the helm of the reconstituted NABH board is Dr Narottam Puri, President-Medical Strategy and Quality, Fortis Healthcare Limited, as the Chairman, NABH Committee, who has taken on the baton from Dr PK Dave, Chairman, Rockland Hospital, New Delhi. Dr Praneet Kumar, CEO of Integrated Health & Healthcare Services India, has taken on the mantle of Chairmanship of NABH Technical Committee from Brig Pawan Kapoor, Head of Hospital Administration, AFMC. Mumbai-based Dr Ravindra Karanjekar, Group Medical Director, Global Hospital has taken on the reins of Chairmanship of Accreditation Committee from Dr Nandakumar Jairam, Chairman, Columbia Asia, Bangaluru. Additionally, an Appeals Committee has also been newly constituted with Dr Uma Nambiar from Fortis SL Raheja Hospital, Dr K Verma from Malabar Institute of Medical Sciences, Kozhikode and Dr Anita Arora from Escorts, Delhi.

New Guard, New Roadmap

The dynamic new board members have already convened several meetings to roll out a few initiatives that outline its agenda for the next two years. The initiatives are:

ISQUA Compliance: After making NABH standards ISQUA (the International Society for Quality in Health Care) compliant in 2008, the technical committee is working on attaining accreditation of NABH from ISQUA. “This would ensure that NABH's systems and processes are compliant with an international organisation, thus guaranteeing better documentation and process orientation,” says Dr Praneet Kumar, Chairman, Technical Committee, NABH. It is expected that an ISQUA-accredited NABH would give a boost to medical value travel, especially from the US and the UK. “It would bring in more transparency and clarity in processes involved for medical value travel,” says Dr Kumar. So far, hospital standards of only 11 countries are accredited by ISQUA.

Building robust IT: Most Government-led initiatives are plagued by slow processes and lack of transparency. NABH wants to address these challenges by more effective use of IT. Explains Dr Narottam Puri, Chairman, NABH Committee, “Though the status of NABH registration can be viewed online, hospitals can neither apply nor get queries answered online. We also have a space crunch to stack all this paper in the office. Right now, the use of IT is very rudimentary. Going forward, we need a robust IT system.”

NABH is exploring the option of having dedicated software tailor-made for its accreditation, so that the entire process is documented and updating data is faster. It has already shortlisted a few vendors for this. Later, it may go in for analytical software and an MIS.

IT would also empower the accredited hospitals. It is planning to make a daily update of data on some key parameters mandatory for the hospital. “For instance, if updating an accredited hospital's score on HAI is made mandatory, then all hospitals would be made more accountable and responsible towards quality compliance. This would help hospitals get a snapshot of where they stand and enable them to

learn from each other. It would also empower patients to choose the hospitals they want to seek treatment from by noting comparative scores on key parameters,” says Dr Kumar.

International Venture: The demand for NABH accreditation has gone beyond Indian shores. It has recently launched its international arm—NABHI or NABH International, similar to JCI of JCAHO. It has already signed an agreement with the Philippines Government to launch NABHI in Philippines. NABHI has also been approached by countries like Bangladesh, Pakistan and the UAE. About the rationale of launching its international arm, Dr Puri says, “These countries respect the clinical acumen of Indian doctors. We also get a regular stream of patients from these countries. So, we are tapping a business opportunity here.” Would the standards be the same for all the countries? “Depending on the country we are working in, we would tweak our standards,” says Dr Puri.

Strengthening Manpower: Besides some key devoted Government officials, NABH is mostly managed by people doing honorary work. To cater to the increasing workload, the board has decided to strengthen its manpower. NABH is looking for a full-time Director and an executive for him/her. “In the long run, we are also looking at a CEO,” says Dr Puri. As of now, Dr Giridhar Gyani, Secretary General, QCI, is officiating as the CEO for NABH. However, with QCI being a quasi-Government body, it has been a challenge to get good manpower at a Government salary.

Training Conclave: Learning is a continuous process and it is time for a refresher course for the 450-strong team of NABH assessors. “Out of 450 assessors, not more than 70 would be regular assessors and it is time that all of them undergo a refresher course, so as to keep them abreast of the latest NABH guidelines,” says Dr Puri. NABH is organising a training conclave to impart a refresher course, which would occur over three to five days, to its existing assessors. “The idea is to utilise the experience gathered over the last three to four years to further improve the competencies and skill set of assessors for an improved survey process,” says Dr Kumar.

It is planning to have two conclaves, most probably in cities like Delhi and Bengaluru. Would the course be mandatory for the assessors? “All assessors would be expected to attend the conclave. It is purely voluntary, however, those who attend will definitely have an advantage,” says Dr Kumar. This course is different from the NABH assessor qualifying programme, which occurs over a phase where the applicant progresses from being an assessor to observer to surveyor. “As of now, we are not proposing changes in the NABH assessor test. That continues to be as rigorous as before,” says Dr Kumar. Also, there are no immediate plans to hike the fees for assessors. “NABH assessment is a non-commercial exercise and hiking charges for assessment would be a travesty,” says Dr Puri.

Quality Journal: On the anvil is a periodical journal on quality, authored by experts in quality. “We need to collect data on quality and publish it. In India, there is a severe shortage of published data,” says Dr Puri. The periodicity of the journal is not yet decided. The budget for this journal has already been allocated by QCI.

Checklist: In the pipeline is a checklist for assessors. The checklist would be for various aspects like pre-assessment, final survey, surveillance, etc. “Though NABH guidelines are very detailed, we need to rule out chances of individual interpretation by assessors. For instance, one surveyor may be OK with one lapse, while another one may not be, and this often results in one institution getting accreditation and another not getting it. We need to devise a more standardised way of assessing the hospitals, which is above individual interpretation,” says Dr Kumar.

Self-Sustainable: Efforts are also on to make NABH a self-sustaining body. As of now, despite the rising popularity and workload for NABH, it is being fully financially supported by QCI. Already a directive has been issued to make every arm of QCI self-sustainable with a separate profit and loss account. “In the next two years, hopefully, we will able to achieve that,” says Dr Puri.

Other Standards: The present board is also working on standards for dental and wellness centres. The latter would cover gymnasiums, spas, skincare centres, cosmetic care centres, fitness centres, immunisation centres, executive health check-up centres with associated advice etc. These standards are slated to be launched by this financial year. Its newly launched standard for radiology centres has been well accepted. It has received applications from seven centres and a batch of 23 people has received training for the assessor course for radiology centres.

With a well chalked out strategy and a determination to take the quality movement forward, NABH would surely set new benchmarks on how committed people from both private and public sectors can come forward to make a difference.

AIMS Launches Health Scheme for Rural Populace

Carrying forward its social, public health and welfare agenda, Asian Institute of Medical Sciences (AIMS) recently announced the 'Grameen Swasthya Pariyojna'. AIMS launched this major initiative and joined hands with the local village ‘sarpanches’ to ensure the benefits of good health and modern medicine penetrates the remotest of villages and districts and is accessible to the marginalised and rural sections of the population.

Speaking about the Grameen Swasthya Pariyojna, Dr NK Pandey, Chairman & MD, AIMS, said, “The Grameen Swasthya Pariyojna launched has been conceptualised to ensure that the best available healthcare services reaches the rural and underprivileged sections of the population. Under this scheme, we have empowered the village sarpanch, who leads the panchayat in different villages and districts. They will be issued health cards for the people of their areas and districts.” The card will offer treatment in all specialities at AIMS at subsidised rates.

“Ever since it’s inception, The Asian Institute of Medical Sciences has been hosting free health check-up camps in backward areas with its team of doctors. Through more of these camps in remote areas under the Grameen Swathya Pariyojna we will also garner more data on trend of diseases afflicting people in villages. This will also aid our efforts in spreading awareness among them on various diseases, its causes and educate them about the benefits of preventive healthcare. Usually the rural population suffers from lot of age related eye-ailments, heart ailments and other diseases,” added Dr Pandey.

He appealed to the sarpanches of the villages and gram panchayats to include in their calendar of events, days dedicated to hosting free medical camps. The expert team of doctors from AIMS would then diagnose, treat and educate the marginalised sections of society about the onset and causes of diseases and will also impart benefits of preventive healthcare check-ups in through these free health check-ups camps.

MCI Allows Pharma Companies to Sponsor Speakers to Conferences’

Experts engage and brainstorm on MCI guidelines on doctor-pharma interactions

There are ample reports of expensive gifts offered and holidays sponsored by pharma companies to woo doctors to prescribe medicine from their companies. There have been several incidents of doctors found enjoying international jaunts in the guise of attending sponsored conferences or doctors' holidays being sponspored by pharma companies.

Such ethical violations by pharma companies and doctors, which ultimately affect patients, made the Medical Council of India (MCI) come up with detailed guidelines on doctor-pharma interactions. However, these guidelines have stirred up a controversy, with many dubbing them as ‘impractical’. These diktats have also given rise to ambiguity on what is allowed and what is not. To bring clarity to these guidelines, Express Healthcare and Express Pharma along with Wiley India organised a panel discussion on 24th September at Hyatt Regency in Mumbai. More than 100 delegates from pharma, hospital, diagnostic (radiology and pathology) companies attended and participated in the event.

The welcome note for the discussion was delivered by Rita Dutta, Senior Associate Editor, Express Healthcare. The discussion was moderated by Vikas Gupta, MD, Wiley India. Before the discussion started, Eric Rozario, Director, Corporate Sales, Wiley-Blackwell Asia Pacific gave a presentation on ethics in publishing.

The panel discussion was kick started by Dr Gustad Daver, Director, Professional Services, PD Hinduja Hospital. “It is the duty of the physician to understand what is ethical and follow that. Since some doctors were found not following it, MCI had to come out with these guidelines,” said Dr Daver. According to him, “It’s not fair to only crucify doctors and dub them as corrupt. Greed and violations run across all profession, so why single out doctors? On the contrary, doctors do the maximum amount of charity.”

Said Dr R K Sanghavi, Head- Medical Subcommittee, IDMA, “I don’t understand why would a doctor change his prescription after taking favours from a pharma company.” He questioned why there should be another rule for doctors, who are already saddled with multiple rules and regulations. According to him, small gifts of less than Rs 1,000 from pharma companies should be allowed. He also made it clear as per the MCI guidelines, for conferences, speaker’s travel can be sponsored by pharma companies, but not that of delegates.

Said Dr Ajit Dangi, President & CEO, Danssen Consulting and Former Director General OPPI, “There exists symbiotic relations between doctor and pharma companies since ages.” He pointed out that OPPI was the first body to come out with a code of conduct for pharma companies on this matter. He informed that countries like the UK, the US and Switzerland have well-defined guidelines pertaining to this subject.

While speaking on violations, he stated it was unethical for doctors and medical associations to endorse commercial products. He referred to a toothpaste ad which was endorsed by IDA. What was ethical, according to him, is pharma companies participating in clinical research. “Books and printed material should not constitute as gift items,” he said. He summed up saying that a voluntary code of conduct has little value. “All cases of violations to these guidelines should be reported to the MCI which must take punitive action after proper investigation,” said he.

Said Maj General Vijay Krishna, CEO, Breach Candy Hospital and VP, Association of Hospitals, “Ethics come from the heart. It cannot be taught.” Expressing his helplessness as an administrator, he said, “If I found that that our doctors have taken gratifications from pharma companies, as an administrator what am I supposed to do? It’s between the pharma companies and the doctors. Why should I interfere in their interactions? Is it possible for me to monitor my 1,000 doctors’ interaction with pharma companies? What power do I have to do something to correct them?” He suggested that hospitals should sponsor trips of doctors to conferences than allow pharma companies to do it. He urged his fellow hospital hospital administrators not to take a rigid stance on this matter. “Whenever there is ambiguity, read between the lines and act,” he said.

Dr Arun Bal, Chairman, MCI’s Ethics Committee, informed that the current MCI guidelines are being modified to address many ambiguities. “Now, doctors have to sign a declaration when they renew their registration that they have read the MCI guidelines.” He also stressed upon the importance of the guidelines to curb practices like doctors going missing from foreign junket conferences. “In a conference of 5,000 doctors, one would hardly find 500 doctors in the conference hall,” he said, adding, “Both MCI and the health ministry have been receiving constant complaints about various erroneous practices of doctors and thus we had to come up with these stringent guidelines.” Asked about whether violators of these guidelines could have face some punitive action in the future, he said, “We are at a stage where these guidelines are still emerging.” He informed that people could send on-line feedback and suggestions to MCI on these guidelines.

The panelists concurred that as much as travel of speakers to be conferences could be sponsored by pharma companies, they also agreed upon the fact books and printed material should not constitute as gift items. The discussion ended with the hope that the upcoming MC guidelines would be more well-defined and demystify the doubts surrounding the current guidelines. The conference ended with vote of thanks delivered by David Fischer from Wiley-Blackwell.

HR Innovation

Meenakshi Mission Hospital and Research Centre was facing challenges in getting skilled manpower and retaining them. However, a well-thought out strategy in employee engagement and retention has worked wonders. Express Healthcare provides an insight

It is a paradox that the Indian healthcare industry known for its people-driven approach is today plagued by high attrition and lack of trained manpower. You can blame it on the growth and the increasing options available to its people and lack of training institutes to dole out sufficient number of skilled manpower. Layers of staff requirement and the depleting ratio is not just restricted to clinicians anymore. And the rising demand for trained managers and paramedics has only increased. Getting trained personnel who understands healthcare finance, HR and materials is a mammoth task. Besides management and administrative staff, it is always a challenge to get technicians for pump, cathlab, nuclear medicine etc as the demand is more than the supply.

Madurai-based 650-bed multi-speciality hospital, Meenakshi Mission Hospital and Research Centre (MMHRC) was facing similar challenges in getting skilled manpower and retaining them. However, the shift in the attitude and innova tion within few crucial areas played the trick. Today, the hospital with the total employee strength of 2,223, is reaping the benefits of it’s ‘out of the box' thinking.

Obtain and Retain

MMHRC has started the initiative of mass interviewing the non-clinical candidates. This step has turned out to be an immensely time saving and practical way of recruiting the staff in this category. Through mass interviewing, the soft skill deficiency of the person is analysed. “We evaluate leadership skills, communication skills, body language, presentation skills, drive etc,” says Dr N Sethuraman, Founder Chairman, MMHRC. The hospital has been recruiting most of its doctors, managers, technicians during conferences and through word-of-mouth publicity. The forum, known as Federation of Hospital Administrators (where Dr Sethuraman is the founder Chairman), makes a good platform to recruit through various resources.

While attracting good people is half job done, motivating them to higher goals and retaining them is an uphill task. MMHRC has devised strategies to motivate and retain staff that includes a right mix of training initiatives and employee welfare schemes.

Appraisal and Training: The hospital started preparing a ‘training need chart’ based on the 360 degrees performance appraisal of each staff. “We conduct 360 degree performance appraisal of all the staff once in a year and undertake re-skilling of staff from one department to other. We make the staff realise where they stand and how they can modify their roles,” Besides, the regular training programmes in technical as well as soft skills has been emphasised upon and almost three per cent of turnover is spent on the same. The hospital has started involving the employees in the decision-making process. The suggestion schemes have been floated in the hospital, whereby employees can give their suggestions about different functional issues. The hospital has identified key performance areas (KPAs), key result areas (KRAs), managing points (MP) and core functional teams (CFT).

Addressing aspirations: “We develop our staff to do things differently- what others don’t do. We try to balance individual aspiration with the organisation goals so as to prevent loss of employee confidence, talent and opportunity. For this we communicate effectively with our staff,” says Dr S Gurushankar, Vice Chairman, MMHRC.

Dr Sethuraman points out that MMHRC is trying to build an atmosphere where people will be treated not just as resources but as capital of the institution. “We strongly believe that rules, regulations, restrictions will not work in today’s modern employee management. All staff is empowered so as to decide on their own. We inculcate high performance and high caring culture as core values among our staff. This only brings innovation in our institution,” he adds.

The hospital has been diligently following a model where compensation is based on an employee’s experience, skills and above that, their output and not reflect biases. “We promote and embrace mentoring in both individual and organisational levels,” shares Dr Sethuraman.

Employee welfare schemes: MMHRC initiated employee welfare schemes which cover welfare benefits apart from superannuation and statutory benefits, like the festival bonus, educational allowance for their children etc. “We take care of the entire family with initiatives like appointment of spouse and educational allowance. This year we have sponsored the entire expenses for employee’s children admission in the medical college,” he adds.

It also organises summer camps for the staff children in the hospital premises. “This initiative motivates our staff and gives exposure to their children about our hospital. This has developed a strong bond with the staff,” adds Dr Gurushankar.

Addressing grievances: Often people leave for flimsy grievances and for lack of mechanism to address them. Thus, a CFT has been established, which keeps a watch on the grievances of key performers, and in case of any issues, they are settled either then and there or by a methodical approach.

Permission to fail: According to Dr Sethuraman, the best way to learn is by failing and this is also important while retaining talent. “We permit them to fail as we feel that failure is the best trainer for future success. Giving them the ‘permission to fail’ and learn from their mistakes is as important as empowering them to take crucial decision,” says Dr Sethuraman.

Train the Leaders: 'Do you work for the organisation or for your boss' is often a debated topic. “We strongly believe that employees are not leaving the institution, but they are leaving their boss. We periodically motivate, train, teach the team leaders about the importance of affection towards their staff,” says Dr Gurushankar.

Initiatives for employees

Family Medical benefits:Free medical treatment to all employees and 50 per cent concession to their dependents. Free medicines worth Rs 500 (maximum) is given to an eligible employee who is admitted as an in-patient in the hospital.

Education Allowance:Maximum of Rs 3,000 per child/per year.

Crèche:The hospital runs a crèche for the employee’s kids on free of cost.

Employee’s Welfare fund:It caters to urgent needs of the employees who have completed one year of service.

Funeral benefits:It extends to the spouse of the employee in case of death.

Statutory benefits: PF, ESI and gratuity benefits are offered.

Other benefits:Hospital gives loyalty bonus and various types of incentives to eligible employees.

Humour at work: In Dr Sethuraman’s words, earlier HR meant horror, but now in MMHRC it means humour at work. “Humor also helps reduce the day-to-day stress of office life. It helps people cope with frustrations, tiring schedules, irate clients, etc, resulting in reduction in stress,” he shares. Firms that have a light hearted working environment are better places to work in. People feel unafraid to express their thoughts or ideas, which brings in vitality to the organisation. Employees work with constant energy and motivation that produces better output for the firm. Also, it results in an increase in productivity. When people work in a vibrant office environment, they work with a lot of motivation. This happens as they work not only for a living, but also because they derive a lot of joy from the job.

Boredom at work is one of the main reasons why people quit jobs. The high attrition rate adds to the organisational costs of hiring and training new people. A pleasant atmosphere at work is a breeding ground for creativity and innovation, as it allows employees to think creatively, which can bring great results for a company.

Such well-thought strategies have helped the hospital to retain talent. “Almost 70 per cent of our staff and almost 40 per cent of our doctors are with us for more than 10 years. We have developed a sense of belongingness among them,” he says. Thus, in spite of industry-wide high attrition in the nursing staff, the hospital claims to have successfully retained 45 per cent of its nurses.

Strengthen Measles Vaccination Programme

The recent death of four children due to measles vaccination during an immunisation drive at a health centre in Uttar Pradesh has once again raised concerns about the shoddy manner in which measles vaccination drives are conducted. The health authorities have washed their hands off by dubbing them as 'rare' deaths due to adverse effects, and as a remedy the Government immediately stopped the vaccination drive. However, this is not the single episode of measles vaccination-related death, this year. In March, four infants died in Madhya Pradesh and 15 were taken ill, after being administered with tetanus and measles vaccines. In April, last year, four infants died out of 20,000 who received the measles vaccine in Tamil Nadu, as they developed severe allergic reaction to the vaccine.

How can a preventive strategy become so deadly? When between April 2009 and March 2010, eight innocent lives were lost in an attempt to save them from a deadly virus (that is one of the leading causes of death among young children), something is grossly wrong. However, this is not to doubt the effectiveness of measles vaccination programme, which India badly needs as the country accounts for an alarming two-thirds of global measles deaths in infants and children. Estimates state that in India everyday 500 children die because of measles. According to the WHO, measles vaccination resulted in a 78 per cent drop in measles deaths between 2000 and 2008 worldwide.

The side effects of the measles vaccine are well-documented: there is a chance of severe allergic reaction in two to four babies out of 1 lakh vaccinated, 10 per cent of children develop fever, and a rash

5–21 days after the first vaccination and five per cent may develop temporary joint pain. Measles vaccine is known to be very sensitive and effective, but when inappropriately manufactured, stored or handled, it’s a potential killer. The MMR (Measles, Mumps and Rubella) vaccine has been in the eye of controversy before when a 1998 paper reported a study of 12 children who had bowel symptoms along with autism and other disorders, soon after administration of MMR vaccine. However, several subsequent peer-reviewed studies and bodies have rubbished the link between the vaccine and autism. Such controversies often dent immunisation coverage and thus lead to spurt of measles-related deaths.

The WHO has selected measles vaccination coverage as an indicator of progress towards achieving its ‘fourth Millennium Development Goal’ that aims at reducing the under-five mortality rate by two-third between 1990 and 2015. In association with the Indian Association of Paediatrics, the Government needs to pro-actively devise strategies to strengthen the measles immunisation programme, whose average coverage is only 66 per cent and even below 50 per cent in some states. While the Government’s recent decision to introduce a second dose of measles vaccine to make the programme more effective is a step in the right direction, there is a lot more that needs to be done. First, there should be strict guidelines to ensure that no outside infectious pathogen creeps in due to faulty preparation of solution, the cold chain is not compromised, storage is proper and health staff is adequately trained to handle and administer the vaccination. One way to check such measles-vaccine related deaths would also be to make it mandatory for the vaccine to be administered in the presence of a doctor who is adequately trained to deal with reactions caused by the vaccination. Besides encouraging research on reducing complications associated with the vaccine, the Government needs to screen clinics/centres administering MMR vaccines and take strict action against them when untoward incidents happen.

India has to think of innovative ways to reduce the vaccine-related complications. Perhaps, the ‘inhalable’ measles vaccine developed by the University of Colorado and undergoing clinical trial in Pune, could be a better choice as it does away with the hassles associated with cold chain, storage and needle injuries associated with the current injectable MMR vaccine. If the results of the trials encourage Government to adopt it in its national immunisation programme, then it is expected to reduce the unfortunate deaths

Reasons to Smile

The dental care services market in India, which is estimated to be $600 million, is witnessing a boom with a slew organised players entering the space. Sonal Shukla analyses the trend

It’s not just hospitals which are coming up in large numbers, now it is time for chain of dental clinics to show their prowess. Dental clinic chains, like Dentistree, Axiss Dental, Apollo Dental Centres, Swiss Smile India, and healthcare groups like Narayana Hrudayalaya, are chalking out massive expansion plans in dental care. Analysts say that India has one of the fastest growing dental markets, growing at a rate of about 10 per cent, annually. In view of these rapid developments, the dental care services market seems to be finally coming of age.

From Nowhere to Everywhere

In India, 98 per cent of the dental care services segment is still ‘dentist-entrepreneur-driven’. However, the situation is changing rapidly with dental specialty undergoing the same transformation which the medical specialty underwent 20 years ago. “Two decades ago, nursing homes and small branded hospitals were occupying the healthcare space in tier I cities. However, with the increased awareness among patients and their expectations in terms of quality, accountability and dependence on medical technology to deliver high end care, the corporate hospitals with the onus on quality and accountability have become the order of the day. Similar changes are being observed in terms of patient expectations of dental care,” reasons out Dr Nitish Shetty, Managing Director, Narayana Hrudayalaya Dental Clinic (NHDC). While the smaller unorganised players display a limited ability to scale up, there are very few organised players operating in this segment at present. This marks the vast opportunity existing for them to tap this segment. The growth potential is enormous, especially in creating a brand value that is to be identified with the best dental services that can be provided nationally. Dr V Vijayakumar, CEO, VV Dentistree India Private Limited, says, “There is a good opportunity for dental chains as there is a good demand for organised dental centres, growing number of chains is a proof of this.”

Pros and Cons

Pros:

Enormous need gap. Availability of manpower. (over 250 dental colleges

churn out about 23,000 dental graduates every year) Various government incentives like reduced excise

duty on dental furniture. 100 per cent FDI being allowed in healthcare sector. Dental tourists. Changing mindset of people to approach organised

providers.

Cons:

Skewed geographical distribution of dentists (42 dental colleges are in Karnataka whereas there are only two dental colleges in Orissa)

Only 30 per cent dentists have specialists degrees. Dental treatment not covered by insurance.

Changing Paradigm

Since dental health is of critical importance, going by its impact on cardiac diseases and diabetes, there is a need to expand dedicated facilities in the country. In the past, dental care had often been relegated to the back end. However, changing lifestyle, especially dietary habits leading to various dental problems, rising incomes and standard of living as well as aging population, increasing patient awareness driving more regular dental checkups; are some major factors responsible for the growth of dental clinic chains. “The present generation understands the value of good quality dental care and how important oral health is and how often it is a window to your overall health. The awareness has cropped in recent times in the mindset of the population, and hence, we are now observing the growth trend in this segment,” shares Dr Sathya Kallur, CEO and Director of Clinical Operations, Swiss Smile India.

Increasing Competition

A spate of organised players in the market are rapidly opening dental clinics all across major tier I cities. Axiss Dental, a brain child of two dentists, Dr Amit Sachdeva and Dr Sandeep Sharma, has so far established 17 multi-speciality dental clinics all over India and has plans to open four new clinics--one in Bangaluru, two in Pune, and one in Kolkata this year. The company plans to fund the expansion through internal accruals. Dr Sandeep Sharma, Director, Axiss Dental, says that they are eyeing locations where there is a demand for speciality dentistry.

Dentistree, a Chennai-based chain of dental clinics started in 2000, has one hospital and five satellite centres in Chennai and is planning to expand its reach into three southern metroes, with six clinics in Hyderabad, six in Bangaluru and three clinics in Kochi. The group is investing another 70 million for this in its first phase. “We are looking for a possible venture to join hands with leading hospitals,” shares Dr Vijayakumar. Apollo Dental Centres has seven clinics situated in Bangaluru, Chennai and Hyderabad. With increased scale of operations, NHDC is on its way to become the largest player in the dental care services industry in India. Started in 2008, NHDC has expanded to seven dental clinics- six in Bangaluru and one in Kolkata, which are in various stages of operation. Current expansion plans of the group include establishing up to 300 clinics by 2013 across India and abroad with an investment of around Rs 150 crore. The funds will be raised through debt and internal accruals. “Initial expansion plan is to roll out 30 clinics in Bangaluru and Kolkata in the next six months,” shares Dr Shetty.

Besides organsied domestic players, dentistry is also luring international chains. One such example is of Europe's leading dentistry brand, Swiss Smile, which has chosen India for its foreign foray. The brand is operational in India as Swiss Smile India which is a 50:50 venture between Swiss Smile Holdings and local investment firm Global Tech Park. Swiss Smile India plans to open 10 clinics at the initial phase. The group is to invest $25-30 million in India in the next three years with targeted growth phase in multi tiers covering major cities nationally. “Our Bangaluru centre, a facility which is more than 5,000 square feet, is the maiden launch and we aim to be the largest end to end dental centre in India. In the first phase we will be targeting the major metros,” shares Dr Khullar.

The Spectators

When organised players are investing big bucks in establishing dental clinics, hospitals are still not ready to venture out in this segment as they still do not see dentistry as a core expertise. As Dr Vijayakumar points out, dental treatment as such is 95 per cent related to out-patient facility, and this is a major factor for hospitals to outsource dental treatments. Agrees Dr Shetty, according to whom hospitals work on ‘pull factor’ and dentistry does not generate that kind of money as other specialties do. Most of the private hospitals are not convinced about the right model for the dental business, however, once somebody gets it right, the herd mentality will prevail. “Most of the leading players like Artemis, Medanta outsource dental departments. However, some of the players like Narayana Hrudayalaya are showing interest in dentistry as stand-alone profit centres,” says Arockiasamy.

Moulding it Right

The presence of many corporate players and their increasing investments in this segment plans to bring in more sophistication and professional approach. Dr Shetty avers, “Dental practice depends on accessibility as patients do not travel beyond a point for dental treatment.” According to him, the major differentiating factor between the single doctor driven dental clinic and a chain of clinics established by organised brands is the convenience and an array of services offered. A dentist owning a clinic will call the patient according to his convenience, whereas in the corporatised dental clinics, the patient has an option of taking the appointments at his/her convenience. With Narayana Hrudayalaya brand, NHDC plans to remove such gaps in dental care and establish the concept of neighborhood clinics at various location points to make them more accessible.

Likewise, the major players are experimenting with different models to make the most of this opportunity. There are chains only providing basic and specialised treatment and not the highly specialised treatment. Dentistree has adopted the hub and spoke model, where the basic and specialised treatments are covered by the group’s satellite centres, whereas the hospital covers high end treatment in addition to basic and specialised treatment. The Dentistree clinics cater to low end treatments such as scaling, to high end such as CAD CAM, crowns and bridges, guided surgeries for dental implants, smile designs, laser assisted surgeries and in patient facility. Groups are investing in aspects like environment in the clinic, maintaining the data and regulating the processes. They are also targeting the overall oral health factor. Swiss Smile India is providing comprehensive dental programme which includes screening for oral cancer, sleep apnea and TMD.

Business Benefits

Opening such dental clinic chains is helping hospitals like Narayana Hrudayalaya create a brand name in diverse territories. Dr Shetty points out that since Narayana Hrudayalaya is expanding nationally as well as internationally, a dental chain with its capability to role out much faster then hospitals chain will be in position to create a brand visibility in newer areas and areas where hospital operation is not possible. Groups like Dentistree and Axiss Dental are also looking at corporarte tie-ups to enhance their scale and scope of operations. Establishing tie-ups with hospitals is facilitating the dental tourism objectives of Axiss Dental, which is working closely with groups like Fortis Healthcare, Columbia Asia and Artemis. As foreign patients do not tend to come only for dental treatments and prefer to have it as a part of the full medical tourism package, having the clinic set up within the hospital is helping the group cater to more patients.

India and Dentistry

According to market reports, global dental care industry is estimated to be around $ 18 billion and the dental equipment is pegged at $ 15 billion with a CAGR of five per cent and 4.5 per cent respectively. In India, the dental care services market is estimated to be $ 600 million with a CAGR of 10 per cent since 2000 and its equipment sector valued around $ 90 million. The key growth driver in dental medicine is the growing awareness and interest towards need for healthy teeth and dental cosmetics. India produces more than 18,000 dentists annually from 283 dental colleges. The country has around 1,500 oral and maxillofacial surgeons. Dental tourism forms 10 per cent of the total medical tourism industry in the country, which is projected to grow at 30 per cent a year, into a Rs 9,500 crore industry by 2015.

The general dentist concentration is one dentist for every 30,000 persons. While urban concentration indicates one dentist for every 10,000 persons for the rural areas it is one dentist for every 2,50,000 persons. The oral disease prevalence in the country indicates that over 80 per cent of children and 60 per cent of adults suffer from dental caries. More than 90 per cent of adults in the age-group of 30 years suffer from periodontal diseases.

Dental surgeons in India perform a number of Cranio Maxillo-Facial surgeries primarily because of the high incidence of congenital abnormalities affecting around 35,000 babies. Around 35 per cent of children suffer from misaligned teeth and jaws. Further, Decayed Missing Filled Teeth (DFMT1) score for teenagers is 2.4 and for 35-40 age-group is 5.4. In addition, over 17 per cent of the aged population is edentulous, the remaining 78.3 per cent have some teeth missing.

Bridging the Gaps

It is a general perception that dental treatments at such corporate chains are highly priced. Dr Vijayakumar agrees that the treatments cost at least 15 per cent more than what a dentist with private practice might charge. “In corporate centres, all the treatments are carried out by the specialists and super specialists are present to give the best verdict for the patient’s dental treatments. High end technologies like digital OPG, CAD CAM are available to bring in accuracy and precision. These aspects increase the cost to a certain extent,” he says. According to Dr Sharma, it is the overall treatment experience that matters to today’s patient and he/she is willing to spend for the same. Though the cost seems to be higher because of the cost of implants and the lab costs, it is still only a fraction of the costs in Western countries. There is a lot of scope for volume based modules, which will bring costs down across the chain. “There is a lot of scope for innovative disruptive models that will cater to the different market segments. Backward and forward integration needs to happen to bring the costs down, further,” feels Anitha Arockiasamy, Consultant-Healthcare, Technopak. There is also a need for more full-fledged hub and spoke model which will cater not only the primary dental care, but also the complex tertiary cases. The penetration of organised players in tier II and III cities is also relatively low, which stresses the opportunity that exists in these geographies.

Expansion-The Community Way

Columbia Asia Hospitals Private Limited is rolling out 11 community hospitals across India, says Rita Dutta

The Indian arm of Malaysia-based Columbia Asia Hospitals Private Limited, which has built an empire of six hospitals and one clinic across India over the span of last five years, is ready to roll out 11 more multi-speciality community hospitals in its second phase. The expansion is a part of the group’s strategy to strengthen its market in Asia, which includes adding 1,000 beds and 17 new hospitals in India, Malaysia and Vietnam to the existing fleet of 16 facilities in operation at the mentioned countries and Indonesia.

From Ghaziabad to T'puram

Spread across the North, South and West of the country, the 11 new hospitals are strategically located-in Ghaziabad, Meerut, Chandigarh, Jalandhar, Dehradun, Ahmedabad, Thiruvanathapuram, Pune and two in Bangaluru. In Pune, the hospital is coming up at Pune Khardi, while in Bangaluru the hospitals are coming up at the Western and Southern parts of the city.

All these cities are virgin territories for Columbia Asia, except for Bangaluru, where the group commenced its Indian operations; the city already has two hospitals and one clinic. As of now, the group has 670 beds in community hospitals at Hebbal (90 beds) in Bangaluru, off the Ring Road at Mysore (90 beds), Palam Vihar in Delhi (100 beds), at Salt Lake in Kolkata (100 beds) and at Bhupindra Road at Patiala (90 beds). The group’s only tertiary care hospital with bed strength of 200 is located at Yashwanthpura in Bangaluru. It also runs a clinic at the Bangaluru International Airport. All these seven projects are fully owned and managed by Columbia Asia.

The Laid Out Plans

The upcoming hospitals in India would be multispecialty community hospitals with a bed strength of around 100. Centrally air conditioned, each hospital would be laid out on 1.5 acre to two acres of land with a built-up area of around one lakh square feet. As a standard, the community hospitals from the group has two storeys and include inpatient rooms on the top floor, operating rooms, emergency room and pharmacy on the ground floor and a basement for parking.

Tufan Ghosh, CEO, Columbia Asia Hospitals (India), says, “The new hospitals would offer all specialties and multispecialties, except invasive cardiology, radiation oncology and some neuro procedures.” While the construction for the hospital at Ghaziabad is over, development is in place for Lucknow, Thiruvanthapuram and Jalandhar.

According to Dr Nandakumar Jairam, Chairman, Columbia Asia Hospitals (India), the 100-bed hospital in Ghaziabad located at NH-24, Hapur Road is likely to be commissioned by September this year. The only other reputed hospital in Ghaziabed is Pushpanjali Crosslay. By next year, besides the hospital in Ghaziabad, the group’s hospitals in Chandigarh, Ahmedabad, Meerut and Bangaluru (South) are also slated to be commissioned.

All these hospitals are Greenfield ones. While groups on an expansion spree prefer acquisition, management consultancy route for faster growth, Columba Asia has been keen on Greenfield. It is to be noted that all the group's present hospitals are Greenfields, except the one in Kolkata, which is a Brownfield project. “We wanted to expand our second phase by the Greenfield model. It is more difficult to work in a JV or acquisition. However, in the future, we may explore acquisition or management,” says Ghosh.

No subsidy has been taken from the Government for the land for these upcoming hospitals. These hospitals are also not a part of the MoU that Columbia Asia inked with DLFH in 2007, whereby the latter was to construct Columbia Asia designed hospitals upon lands situated in DLFH townships in India and then lease the lands and hospital buildings to Columbia Asia. According to Ghosh, there has not been any progress on the said deal.

The cost of building each community hospital is around $14 million to $16 million (inclusive of cost of land, construction and equipment). The group has earmarked around $170 million for various expansion projects in India and around $275 million for projects in Asia. The nature of funding is a mixture of debt and equity (the ratio being 1:1). “We already have equity and are looking at more debt funding for all the projects. We are not looking at private equity, though we have been approached by many. We have roped in the State Bank of India for debt funding for our new projects,” informs Ghosh.

Strategic Decisions

As per Ghosh, the criteria for choosing a city, most of which are tier II, were inadequacy of healthcare services in these cities and presence of an affordable class ready to pay for good medical care.

But why did they choose to put two more hospitals in Bangaluru, when the city already has a clinic and two hospitals? “Our growth strategy is to consolidate our presence in a particular city where we have presence or to foray into a new city. With our Bangaluru hospitals doing well, it was just wise to strengthen our brand position by building more hospitals,” says Ghosh.

The group is clear about focusing on multi-specilaity community hospitals, only. It does not intend to scale up its community hospitals to tertiary care at a later stage. As of now, all its existing hospitals are community hospitals, except the one at Yashwanthpura, which is a 200-bed tertiary care referral hospital. The group cites multiple reasons for choosing to build only 100-bed secondary care hospitals. First, they are not many organised players in the community hospital segment. Second, building a community hospital is comparatively cheaper and thus has better economies of scale. “Community hospitals ensures focused care, are more committed to patient care and well-being and improves clinical outcomes,” says Ghosh, adding that the group’s USP has always been evidence-based medicine and excellence in patient care.

Columbia Asia’s Footprints

India BangaluruKolkata Delhi Patiala Mysore

Kuala LumpurPuchong Shah AlamSerembanTaipingBintulu Miri

VietnamSaigon Gia Dinh IndonesiaMedan

Realising market needs, the group has also modified some of its planning and design parameters of its Indian hospitals. For instance, the upcoming hospitals would have a 10-bed ICU instead of its standard five-bed ICU to cater to the burgeoning needs of trauma care. Then the system of having a nursery to keep neonates separate from their mothers has been discontinued, as most Indian mothers wanted to have their baby along with them. Also, the number of OTs have been reduced to four from five per hospital as it was realised that four OTs were enough to cater to the needs of a 100-bed hospital. From five dialysis beds, the group has decided to have around 10 beds, per unit.

The Growth

Since, the group started its first hospital in India at Hebbal in Bangaluru in 2005, it has witnessed a 30 per cent year-on-year growth. With 2,200-odd employees across various locations, it is readying itself for the big leap by doubling its headcount when these hospitals are fully functional. Each of these hospitals would have 300 to 350 employees, and 80 doctors (a mixture of both part time and full time ones). “We have 90 to 95 per cent occupancy in our hospitals at Bangaluru. Our other new hospitals are at a level much better than our expectations. We get around 600 to 800 patients in our OPDs per day, across various locations,” says Ghosh. Asked about the estimated cash breakeven time, he says, “We take around one year to 18 months to attain breakeven. Our existing hospitals in Bangaluru have attained breakeven as they are operational for more than two years.”

Slowly and steadily, this group is surely capturing a slice of the 40 billion Indian healthcare market.

National Conference on ‘Quality In Healthcare’ by CII Institute of Quality

The theme of the conference will be ‘India @75- Quality and Affordable Healthcare for All’

CII Institute of Quality is organising a national conference on quality in healthcare. The conference would be held on 24 and 25 September in Chennai. The national conference will have its theme ‘India @ 75 : Quality and affordable Healthcare for All’. The two- day conference is aimed at providing a much-needed platform for delegates to challenge debate and discuss the issues and developments with regard to quality and competitiveness of the Indian healthcare sector. The basic objective is cross learning from various sector of healthcare to evolve a more quality oriented sustainable model. To search for efficient mix of finance, technology, accreditation of processes and systems and various quality tools and technique which can aid in making healthcare delivery affordable for all. ICRA is the knowledge partner for the conference.

The conference will deliberate on topics such as:

How does a pocket of excellence in a healthcare organisation can lead to organisational excellence?

Does the standardisation and accreditation make access to healthcare expensive or affordable? How adopting new quality tools will help to ensure an effective and quality healthcare delivery

mechanism? How the technology can aid to healthcare delivery system by reducing cost at the same time

maintaining quality of delivery? nitiatives designed for addressing the need of quality healthcare services to masses and sharing

of success stories. Need for an effective and efficient healthcare financing mix where Government can work and

network with private sector to provide quality healthcare for all. eed for trained and skilled manpower for quality of delivery and steps to fill the gap

Some of the invited speakers are: Dr Girdhar Gyani, Secretary General, QCI; Dr Ashraf Ismail, Managing Director, JCI Middle east and India; Chris Lloyd, Vice President Healthcare, Simpler Consulting; B Shanthanam, Manging Director, Saint –Gobain Glass India Ltd; Shubnum Singh, Chief Medical Affairs, Max Healthcare Institute; Dr S Aravind, Administrator, Aravind Eye Hospital; Dr MI Sahadullah, Chairman and Managing Director, KIMS; Vishal Bali, CEO, Fortis Hospitals; Dr Geeta Mehta, WHO SEARO; Dr T Sundararaman, Executive Director, NHSRC; Dr Malathi Arshanapalai, Head Medical services, Clinical Compliance and Education; Harpreet Singh, Senior Advisor, Oxyent Medical; Dr Sandeep Bhalla, Programme Manager, Public Health Foundation of India.

Partnering for Better Imaging

Cutting-edge medical imaging has been made available to patients at Jabalpur's Netaji Subhash Chandra Bose Medical College and Hospital because of a PPP initiative by Wipro GE, says Rita Dutta

It's hard to believe that even three years back, Netaji Subhash Chandra Bose (NSCB) Medical College and Hospital at Jabalpur in Madhya Pradesh (MP) was not equipped with CT and MR facilities to aid diagnosis. This was despite being the second largest medical college hospital in MP, producing 100 doctors every year. In the absence of imaging facilities, doctors there were compelled to send trauma and emergency patients to private centres for CT and MR. And even private imaging centres in the ‘marble city’ of Jabalpur did not have advanced imaging facilities; they either had a very basic 0.2 Tesla MRI or single slice CT or old axial CT.

Because of the abysmal road conditions and distance of these centres from NSCB Medical College and Hospital, many critical patients succumbed either en route to these private imaging centres or on their way back to the hospital. Dr YR Yadav, HOD, Neuro Surgery Unit, NSCB Medical College and Hospital, recalls how handicapped the doctors were in absence of CT and MR. “We were so cautious and alarmed about sending these trauma patients outside that often we did not send them and preferred doing conservative treatment.” Think about it, doing a surgical procedure on a trauma patient, without an inkling of the extent of the damage! “For instance, for a road accident victim with head injury, when we needed to conduct surgery to save the patient’s life, the surgeons had to make as many as six holes to detect the clot. By the time the surgeons could detect the clot, the patient’s condition had deteriorated further,” rues Dr Yadav. In a nutshell, no surgical procedure could be planned, because of lack of CT and MR. Treatment was delayed due to lack of proper diagnosis, often leading to severe irreversible disability in patients.

A Bright Idea

What crystallised the dire need to have CT and MR at NSCB Medical College and Hospital in 2007, was MCI regulation that made CT and MR facilities sine qua non for all medical colleges offering PG in radiodiagnosis. However, installing its own CT and MRI were ruled out because of funds crunch.

It was at this juncture that Wipro GE mooted the idea of starting an imaging centre at the hospital premises via the PPP route. The then Health Minister of MP, Ajay Vishnoi realised that the PPP model would easily help the hospital tide over the crisis and thus the Government of Madhya Pradesh called for tenders for installing equipment at the hospital. Says Ashok Kakkar, Director, Government Business and PPP, Wipro GE, “We participated in this tender, offering the latest 16-slice CT and1.5T MRI equipment. Besides the hospital availing CT and MR facilities, the partnership also aimed at reducing treatment cost by a significant 30-50 per cent for disadvantaged patients.”

Three Hands Meet

While Wipro GE became the technology provider, installing and maintaining the equipment while steering the PPP project, it roped in Delhi-based Sanya Hospitals and Diagnostic Centre as the service provider. Thus, in May 2007, a tripartite agreement was inked between the Government of MP, Wipro GE and Sanya Hospitals and Diagnostic Centre to set up an imaging centre located in a building adjacent to the medical college hospital and within the premises of the hospital campus. While the Government provided rent-free land to set up the centre, Sanya Diagnostics invested Rs seven crore to construct the building and install the equipment. GE Capital funded Sanya for procuring the equipments from Wipro GE.

The centre, spread over 3,000 square feet, was commissioned in November 2007. Named as ‘MP MRI and CT Scan Centre’, it is operational 24x7. Wipro GE has installed Signa HDx 1.5 Tesla MRI and Bright Speed Elite 16 slice CT. Justifying the selection of 1.5 Tesla MRI over 3 Tesla MRI and 16 slice over 64 slice CT, Kakkar says, “We selected these after much thought and analysis. Introducing higher end equipment would have increased the cost of diagnosis and would have made it less affordable for the patients.” The centre is manned by a posse of 20 local radiologists, radiographers and staff trained by Sanya.

The PPP Pull for GE

While most corporates shy away from PPP projects because of corruption and red tape associated with working with the Government sector, Wipro GE and Sanya braved these challenges as they had implicit faith in the untapped potential of PPP. “Technology enhances care and today leading doctors are leaving the public sector to join the private sector as the former does not offer cutting edge technology to aid diagnosis. Government hospitals have huge footfalls, which justify investment in technology

there. Even if the Government is willing, they have neither the skill set nor the funds to invest in technology. All these factors make PPP viable for the Government and the private sector,” Kakkar explains.

While Wipro GE was in talks with multiple state Governments during 2007 for starting such imaging centres in medical colleges, the MP Government was the first one to show interest and thus NSCB Medical College and Hospital become the pilot project. Why did it decide to tie-up with Sanya, which has just two private imaging clinics in Delhi and its vicinity? “Not many private players were interested in working with the Government sector and that too in a place like Jabalpur, which is neither too developed nor affluent. Sanya was interested and thus we took them along,” Kakkar clarifies.

For Sanya, this was an innovative business model. Says Hiralal Gupta, Director, Sanya Hospitals and Diagnostic Centre, “PPP ensures good patient footfall, which is what we require for an imaging centre. We knew that if this was successful, it would lead to many more such PPP projects.”

Win-win All Around

The medical college hospital is hugely relieved that the imaging centre is managed by private companies. Says Dr KD Bhagel, Dean, NSCB Medical College, “Had we been running it, maintenance would have been a continuous hassle. Maintenance of equipment often takes weeks for us, which is not the case in the private sector.” Echoes Dr S Verma, Medical Superintendent, NSCB Medical College and Hospital, “It would have been a further strain on us to run these centres 24x7, faced with dearth of manpower. Maintaining the equipment is also an uphill task. We would not have managed to get CT studies done in one hour and MR in four hours.”

Besides patients no longer having to bear the inconvenience of venturing outside the campus for imaging, CT and MR are also helping medical students in their learning. “The centre is also assisting medical students to undertake thesis research,” says Dr Bhagel.

What is of utmost importance, however, is that now more lives are being saved as doctors can clearly see diagnostic details that could only be assumed earlier. In neuro imaging and brain surgical planning, challenging vascular scans, advanced body studies and exquisite musculoskeletal exams, the 1.5 Tesla MR has turned out to be a great boon. Regarding the 16 slice CT, Dr Pushpraj Bhatele, Consultant Radiologist, MP MRI and CT Scan Centre, points out that it allows the doctor to perform clinical applications simply not possible with a single detector system while enhancing clinical workflow. “It can routinely perform minimally invasive, fast angiography and allows detailed study of arterial vascular disease, including calcified plaque and occluded or lumen reduction. With its power, speed and resolution, the CT helps with abdominal diseases through detection of small lesions, providing detailed evaluation of tumour extension and characterising lesions. Its exclusive post-processing solutions dramatically assist the doctor in diagnosis of lung pathologies like nodules, tumours and vascular lesions,” he adds.

Even the time taken for these procedures has reduced considerably. “While a single slice CT takes four to five minutes to do scan chest and abdomen, 16 slice CT takes 30 seconds to scan the whole body,” adds Dr Bhatele. Even the amount of the contrast given has reduced by 50 per cent in the advanced CT and MR, thus reducing the side effects.

Different Tariffs for Different Folks

What has made the model profitable is that besides the huge patient flow from the medical college hospital, which constitutes around 40 per cent, the rest comes from the private sector. Sanya has tied up with 10 hospitals in Jabalpur for regular referrals.

Separate tariff systems have been devised for patients (both BPL and affording) referred by the medical college hospital and patients from outside. For BPL and affording patients sent by NSCB Medical College and Hospital, the charges are reduced by 40 and 30 per cent, respectively. For BPL patients sent by the medical college, the Government reimburses the service provider.

The centre has already catered to over 20,000 patients. It receives around 800 patients per month for CT and around 400 for MR. The turnaround time for CT is one hour for non-emergency patients and immediate for emergency patients. For MR, the turnaround time is four hours for non-emergency patients and immediate for emergency patients.

Challenges to Beat

The Wipro GE PPP model is still evolving and some teething problems are still being worked upon. For instance, there has been delayed reimbursement from the Government for BPL patients due to red tape. The scheme is being worked upon to make it user-friendly to BPL patients. “Some BPL patients forget to carry their BPL status cards with them and thus we need a system to offer them hassle-free treatment,” says Dr Gupta. “Looking for the right service provider who would work according to our global mandate has also been a challenge for other PPP projects that we are looking at,” says Kakkar.

Spreading the Success

Spurred by the success of its pilot project in PPP at Jabalpur, Wipro GE wanted to replicate the model in other states. Thus, in May 2008, under the then health commissioner of Gujarat Dr Amarjeet Singh, Wipro GE sealed its second PPP agreement with the Government of Gujarat to upgrade the imaging facilities in five Government-run medical college hospitals, located in Ahmedabad, Baroda, Rajkot, Bhavnagar and Jamnagar. The PPP model was similar to the one in MP: the Government provided rent-free space for installation within the medical college campus, Sanya invested in building, equipping and manning the centre, while Wipro GE facilitated the installation of CT and MR systems. Each of these centres does 30 CTs and 20 MRs per day. As a complete service solutions provider, Wipro GE has set up a specialised, centralised teleradiology centre in Ahmedabad linking the rest of the hospitals.

Onward into AP

Andhra Pradesh (AP) was Wipro GE’s next destination. In July 2010, Wipro GE entered into an agreement with the Government of AP along with Chennai-based Medall Healthcare to provide similar imaging services in four Government-run medical college hospitals, located at Warangal, Vizag, Kakinada and Kurnool. Washington-based IFC is the advisor to the project.

“While the centres in Kakinada, Warangal and Kurnool will be started in the next eight months, the one at Vizag will take a year to start as a completely new building has to be constructed there,” says Kakkar. The Government of AP has promised a viability gap funding of Rs 2.8 crore to help build the entire project worth over Rs 20 crore. Wipro GE is currently engaged in talks with six more state Governments to set up diagnostic imaging facilities at medical college hospitals. “We believe that there is a significant opportunity since most of the large public hospitals are ill-equipped. Our estimate of market opportunity for the next five years would be around $100 million (Rs 500 crore),” Kakkar concludes.

Relevance of ‘Design Flow’ in the New ‘Patient Centric’ Hospitals

The designs are based on the space planning that is worked on during the business projection stage

In the recent years, hospitals have evolved at a fast pace from being just a spacious building to treat patients, cure diseases and look after the aged to a dynamic and integrated infrastructure that pamper and comfort patients (read guests). ‘Customised service’ is the buzzword today. Many of them house wellness, research centres, food courts, designer outlets, gift shops, etc apart from providing cutting edge treatment for specific health conditions.

Hospitals are a very complex infrastructure with a finite multiuser definition. Buildings are not designed only for the comfort of patients, but also to suit the requirements of doctors, staff and visitors besides providing for the services offered in the building premises. The designs are based on the space planning that is worked on during the business projection stage. The crucial skill of a designer is to organise the spaces to accommodate the functional requirements. After carefully considering these needs, a significant meaning is given to the building with respect to the site and surrounding environment, nature of the work and the workers who are involved in the process. Value of the investment involved should be brought out through the design through experiences of these spaces.

It is very critical for the architect to determine the degree of sophistication that should be attributed to the hospital in consideration, depending on which class of the target audience it will be catering to. An early study on the type of patients, their health profile and medical fees charged would help in understanding the health pattern of the specific target group. The overall budget which covers medical equipment, manpower, facilities and services is also related to these studies and the design is directly in co-relation to these understandings.

A poorly designed building without factoring in the ‘flow pattern’ will lead to humungous costs escalations with no provision for future expansions or considerations for users’ comforts. This will result in pilferage and security issues, besides discomfort to the patients, care-givers and visitors.Architectural designs are developed based on block diagrams, where each block would be considered a department. The development of this schematic design process answers many questions which would typically include:

Are the traffic patterns between spaces appropriate and easy to follow? Are the spaces that need to be close together for functional purposes shown close together?

A good example would be that the emergency department needs to be directly connected to the radiology department. A separate access to the operation theatre (OT) complex from the emergency would help the doctors and the support nurses in transferring the patient without entering the main lobby/public spaces. This many a time proves to be crucial for the patient.

Are Spaces Correct in Size?

Four walls built without much relevance to the equipment that goes within, the process of the function, the sterility involved, the number of people involved is a crammed space which will be a catalyst for mistakes. Experienced designers often know how to give the right sizes to give a great impact, for example the waiting area within the department.

Built-in area should provide ample provision for the equipment, process of the function, sterility procedures and the number of people that need to be accommodated. A cramped room is a catalyst for accidents and disasters. Experienced designers know how to provide the right sizes to get the correct impact, for example a waiting area within the department.

Is External Appearance of Building Appropriate?

Does the hospital look like a hospital that it is meant to be? Does the hospital convey what it is supposed to? For example, a paediatric hospital should look attractive to children. The design should make the child feel like a ‘prince’ or a ‘princess’. The kid should feel pampered and excited, forgetting his sickness, should allow him to play video games, have small parties, etc.

The design should help in understanding the patients thought process and the need to make them comfortable. Control of sun’s glare is very important in patient comfort and also plays a pivotal role in the development of the elevation of the building. Very large areas of glass can produce severe discomfort from the glare and can result in overheating of the building leading to extra air-conditioning resulting in extra costs.

Are Functional Aspects Included in the Design?

The major services in a hospital include electrical, HVAC, data networking, firefighting, communications, security and access control. Each of these services plays a very important role in ensuring that the experience for the patient in the hospital is fondly memorable. For example, to ensure that the hospital has enough backup power during critical moments is the task of the architects and engineers. The key is to provide easy accessibility to the service areas, and ample thought given to the level of services required.

Vertical and horizontal accesses in buildings play a crucial role in the development of the design. Wrongly placed flow systems lead to tremendous stress on the patients, costs escalations, and future modifications. For example, experienced architects would know that they need to place fire stairs at opposite ends of the building even in the early stages of design process. This emergency exit has everything to do with general working of the building than the glamorous concerns of the aesthetics.

Another important factor in ‘design flows’ is the element of hygiene in hospitals. Often hospitals are reservoirs of infections. Designing the hospital with the right concept of positive and negative air pressures, locating hand washes at ideal locations, provisions of air curtains, prove to avoid cross infections, additional sufferings and escalated hospital costs. Poorly managed waste disposal methods could prove to be the root cause of the infection spreading into the neighbourhood. Attention should be given to ensure that the waste disposal has its proper exist from the campus, without disturbing the general public and patient areas. It is now mandatory to use effluent treatment plant and sewage treatment plant for waste disposal of sewage. Isolation rooms are to be located off the main corridors

with its own ventilating system and not mixed with the general system. Ideally, there should be a buffer zone where one can change clothes and put on special clothing and shoes before entering the isolation wards. Infected linen and instruments need to be transported in special bins or in dumbwaiters to the CSSD where they are cleaned and sterilised.

Always design from ‘inside out’ and not from ‘outside in’. The process is simultaneous and directly related to each other. Design a thing by considering it in its next larger context – an OT table in the OT, OT within a cluster of OTs, cluster of OTs within the level of sterility, the total sterile area within the OT complex, OT complex with relevance to the emergency, the radiology and the entire hospital building, the hospital in an environment and the environment in the city or rural landscape.

Electrical Design in Hospitals

‘Electrical power design’ plays an important role in hospitals. In fact, for hospitals more emphasis has to be provided for electrical design as there are different requirements right from OT where power should be fail proof to common areas, general wards, X-ray, consultation room etc., where the order or priority changes. The distribution system is segregated into critical power and non critical power. The critical power is the power that feeds areas like OT, intensive care units, labour OT, X-ray units, laboratory etc., to name a few. The power supplied to these areas should always be stabilised power. Stabilised power is nothing but a constant power maintained at same voltage and is achieved by using a stabiliser. Further these powers are backed up by diesel generator and a dedicated UPS, so that at any point of time one or the other source of power is always available. The reason for providing UPS back up is that whenever the electricity board power fails, there is always a time gap before the starting of diesel generator and taking the load and critical areas like OT etc, should always have power at all times. The common areas, consultation will generally be powered by electricity board power and diesel generator and some light points on inverter to avoid complete darkness/blackout of the hospital during night times.

Hospital lighting should always be pleasant and soothing and at the same time the illumination level or the lighting level falling of the working space should always be maintained as per standards depending on the areas. A general level that has to maintained in common areas, corridors varies between 150-200 Lux, consulting areas-300 Lux, examination-500 Lux, operation theatres general 500 Lux, pharmacies-300 Lux, reception/enquiry-300 Lux, etc. The Light fittings provided should always suit the area/space for which it is used. It is generally recommended to go with direct light fittings in corridors, common areas, consultancy, examination etc., and indirect lighting for intensive care units, feeding areas/incubators areas where newly born infants are kept. Even the minutest of things like placing of switches also has to be taken care. Normally, the switches in common area, corridors should always be controlled from reception/nurse station. For general and special wards it is advisable to have two-way controlled switches in the entrance and other switches along the bedside. It is advisable to have switches to the left hand side of the patient’s bed as the human tendency is to use left hand in most cases for switching on and off the lights. A ward should always be provided with ceiling fan, wall light points above patients bed, telephone socket along the bed, TV point in front of the bed at comfortable height, and night lamp near the entrance of toilet. If the ward is provided with A/C then the location of A/C unit is always advised to be provided on the sides of the patient bed in comparison with front and above the head of the patient. It is always advisable to have one emergency light in every ward to avoid total blackout of power during night times when electricity board power fails. It is always advisable to have the wards equipped with nurse call system, so that the patient can intimate the duty nurse by pressing the bell which in turn will be connected to the nurse station provided in that floor. The nurse call system can also be extended to toilet/bath so that the patient can utilise the same in that place. As a requirement the nurse station and sometimes a small place in the corridor is always reserved for boiling/preparing hot water or heating the food that is served to the patient, so heating point is provided here to take care of the same. To minimise the cost in terms of power consumption and also to maintain eco balance, it is advisable to go with CFL lamps instead of incandescent lamps, tube lights, halogen lights etc., The CFL lamps consume less power and at the same time wattage requirement is also less in comparison with tube light wattage and the CFL instantly switches on compared to other fittings and durability (burning hours) is also high with CFL. Nowadays, the CFL is slowly being replaced by LED’s (Light Emitted Diodes) which has got lot of advantages in comparison with CFL like the wattage required is very less, power consumed is very less where as the output is high, eco friendly, durability (burning hour) is high.

Security System

Apart from power distribution, security system also plays an important role in modern hospitals. The hospital should always be provided with fire fighting system/fire detection system (as per fire

norms/guidelines).The requirement of fire fighting system is based on the area and strictly as per fire norms. However the fire detection system becomes mandatory whenever a false ceiling comes into picture. The reason is that whenever a false ceiling is provided in the hospital all the services like electrical, A/C etc., will be provided above false ceiling and incase of fire, there should be a system in place to intimate the concerned people and also the general public including patients and relatives of patients of the situation, thereby cautioning the people and avoiding damage. This is achieved by providing fire detectors above and below false ceilings and also by providing public address system by installing speakers at regular intervals.

The next step is providing CCTV (Close Circuit Television) which helps the hospital staff/management in recording the movements of people inside and outside the hospital premises thereby reducing the risks and also viewing all the areas sitting at one place. It also intimates the management of the hospital about any intruders/unauthorised personnel entering the restricted areas and in some cases helps solve thefts etc.

Doctoring Finance

The article discusses how costing can be used as a tool by hospitals to improve their financial bottom line

The fundamental framework of any profit-making organisation attempts to escalate its financial bottom line. It refers to the difference between sales and expenses. The most constructive way to increase sales is to expand the activity volume (utilisation and efficiency) of the sales department. However, this obvious approach is conceivably the most arduous of exercises in every organisation.

The elements that affect sales adhere to the universal demand and supply law. They can be notched up by way of discounts, charity, public relations, write-offs etc. There should be a defined authority to sanction, and a laid down procedure for granting such concessions, since it directly affects the bottom line. The process of sanction should be invariably difficult so as to discourage deductions from sales, which also come under the scanner of income tax authorities.

As a last resort, organisations can even consider an increase in tariff in the worst case scenario, after having exhausted all other methods of improving sales.

The Insurance Game

The revenue generated in Indian hospitals by way of insurance is only around 10 per cent of the total. However, in the near future, insurance would be a major source of income. Contrastingly, if insurance processing is not handled properly, major cash losses are probable.

Insurance companies normally favour cash-less provisions in order to attract clients, wherein they ask the provider to send invoices in batch sizes of one month. This way, the clients give a pre-dispatch credit to insurance companies before the actual credit period ticks in. Once the credit period begins, claims are processed and the payments are to be cleared within the contracted credit period, but the probability of it is low.

If there is a discrepancy/mistake in the claim, then the whole batch is sent back for correction and the money gets blocked for a longer period than contracted. This results in an interest loss, and if the invoice itself is rejected then cash is lost. Under both circumstances, the bottom line suffers. Almost 35 per cent of the hospital revenue is spent on manpower expenses including payment to doctors. In case this percentage reaches 40 per cent, corrective measures to reduce it must be called for. A positive stratagem is to optimise employee utilisation with efficiency, reallocation, multi-tasking and such other exploits. A negative approach would be to retrench or reduce salaries, though this is a very difficult process. Inversely, if the manpower is significantly remunerated and motivated, they would soon emerge as a magnanimous asset; but if handled wrongly, would become a major liability.

The Price of Consumption

Another equally important cost element is the inventory, which comprises equipments and materials supply depots. These include pharmacy, surgical store, medical store and other material store. The control should start right from the request to buy up to the ultimate consumption. Here, both the price and quantity is required to be monitored based on the needs. The best price and quality supported bargain coupled with adequate market comparison is essential, as wrong purchases would result in

cash loss. Overstocking at the main store or sub store would also block money and result in interest loss. There are other damages that may happen due to overstocking such as incurring wasteful inventory carrying cost, pilferage, expiry, breakages etc.

To avoid wastage, equipment must be bought as per the hospital's needs. Thorough negotiations must be dealt with. A complete maintenance contract for at least the first 10 years should be fixed at the time of purchase, as part of the negotiation. The required spare parts' prices should be frozen so that there are no surprises in future. IT is perhaps the most important of tools to reduce cost. Hospital operations have millions of transactions/entries, and if a good IT system is in place, performance will streamline with records. You can have less staff, more clarity and quality output. For instance, in insurance invoice processing, if the Electronic Data Interface (EDI) is available, then all transactions/reports will reach insurance companies on a real-time basis. Both the pre-dispatch credit and post-dispatch credit time is hence eliminated, and money flows in quicker, with the disallowance reduced to almost nil.

Good Electronic Medical Records (EMR) would reduce the hassle of transferring tons of papers between various departments and doctors resulting in reduced cost and better quality work with quick response. If all the modules are interfaced, single source document would deduce the final results and statements; in short, no hassle of re-entry which results in human error and additional work.

Outsource some of the services as far as possible to professionals who specialise in hospitality, engineering, maintenance field and clinical areas. This would ensure quality service with less cost since these professionals deal with a larger volume, thereby reducing the administrative burden on the hospital management.

Budget Management

Normally, budgets are made for various elements of cost, revenue, cash flow, equipment activities etc. Targeting at least a breakeven point year-on-year is a prudent approach, and if the budgeted breakeven point is lowered over the years, pressure to improve revenue efficiency or reduce the cost is imperative.

Poor liquidity management is the result of blockage of funds in current assets. In turn, loss of interest on the blocked funds will be faced. Most importantly, if these current assets are not liquidated within the stipulated time, then there is a fear of losing them. Particularly, long term debtors would turn into bad debt; old inventory would become obsolete or expired. Similarly, better credit facilities from suppliers must be found, but this should not result in supply at a higher prices. However, in the event of suppliers not receiving their payments on time, credibility will markedly suffer.

There are several advantages of a proper cost accounting system. Cost awareness results in cost control and cost reduction, while auto internal audits of performance and cost facilitates control all cost centers. A good accounting system also generates MIS on cost comparison and performance for various periods, aids in tariff fixation and inventory valuation, and facilitates budgeting exercise. Nevertheless, a costing exercise initiated by the management normally would be met with resistance from the staff, since it would lead to a number of revelations which would push them out from their comfort zones. These exercises may also be discounted as worthless and may be perceived as unwanted expenditure. But if the costing exercise is taken in the right spirit, it would be a boon to the hospital in improving its performance and result in cost reduction.

The staff should be taken into confidence before starting such an exercise in order to help them understand its importance along with its use in improving their individual and departmental efficiency. Such an exercise can also result in a financial turnaround and augment profitability. Another important point to be kept in mind while implementing cost accountancy is not to forego the quality, as it is of utmost importance in any healthcare system and cannot be compromised. Quality checks aid in identifying process deficiencies which when revamped may result in cost reduction by doing away with unwanted processes. Quality checks and cost controls should go hand-in-hand in hospitals to ensure orderliness.

Step By Step

Before services are price-tagged, it is necessary to study the processes involved. The next step would be to identify the process owners, whose definition of their respective processes must be amalgamated with the established best practices. This study should clearly reveal under utilisation and inefficiency, if

any, with suggestions for corrective action. As per the best practices, neither the under utilisation cost nor the inefficiency cost of the organisation should be passed on to the customer.

Therefore, it is advised to have a complete process revamp done to arrive at an accurate utilisation and productivity (efficiency) analysis, based on which aroad map for the future can be created. With the entrance of health insurance, costing of the services has become even more essential. Insurance companies demand high quality service and a low tariff structure; for which, correct systems and procedures are required to be installed, which would result in lowering the cost. If the tariff does not match the quality, the hospital may be downgraded and a lower tariff should be granted.

A nagging question that refuses to go away is that of the conventional costing systems being good enough as on today. We have moved from the old system of total cost approach (traditional) to marginal cost approach (conventional), a couple of decades back. The need of the hour is a system that would give us accurate costing, namely, the activity-based costing system.

Margins & Methods

In a hospital scenario, it is observed that the variable cost is very low i.e. around 40 per cent (direct consumable, doctors charges etc). A major portion of around 60 per cent of the cost is fixed cost (overheads). Therefore, the contribution margins in hospitals are larger and may mislead in viability decision-making process of a service. Activity-based costing reduces the contribution margin to a minimum by making majority of the cost direct. When the contribution margins are small, it puts a lot of pressure on the hospital to perform in order to get higher occupancy, thereby avoiding cash losses. This sort of pressure is good in the hospital industry, where breakeven point occupation is very high (65 to 75 per cent). Under the conventional costing method, if the hospitals do not handle computation of overheads properly for the services, it would result in wrong costing and product pricing. Due to this very reason of non-capability to apportion the overheads appropriately under the conventional costing method, it is recommended that we move towards a more refined system i.e. activity-based costing.

The benefit of implementing the activity-based costing method is that it results in accurate costing, focused approach to hospital overheads, conversion of indirect costs into direct and introduction of inter departmental billing. Further advantages of the method include equal importance to service centres like a revenue centre; activities of the service centre is monitored continuously; under utilisation and inefficiency of both revenue and service centre are highlighted; and self-discipline in both revenue and service centres. In short, each cost centre shall work like a strategic business unit, and would be seen as a profit centre, whereby reducing the burden of the hospital administrator in monitoring the day-to-day operations. Activity-based costing has thus become a priority in all hospitals for their survival and future growth.

How to Retain Your Best Employees

The cost of employee turnover adds hundreds of thousands of rupees to a company's expenses, says Dr Rashi Agarwal

Now that so much is being done by organisations to retain its employees, why is retention so important? Is it just to reduce the turnover costs? Well, the answer is a definite no. Average attrition rate in hospitals is about 15 to 25 per cent. Apart from turnover costs, there are several other reasons why the process of employee retention will benefit an organisation:

The Cost of Turnover: The cost of employee turnover adds hundreds of thousands of rupees to a company's expenses. Turnover costs include hiring costs, training costs and productivity loss. While it is difficult to get the exact estimate of turnover costs, industry experts often quote 25 per cent to 30 per cent of the average employee salary as a conservative estimate.

Interruption of Patient Care: Patients most often come to a hospital in part because of the people. Relationships are developed that encourage comfort and care for a patient. When an employee leaves, the relationships that he/she built for the hospital are severed, which could lead to potential customer loss. Also, continuity of care is severed, which causes a lot of discomfort for the patient leading to dissatisfaction.

Lost Productivity: If an employee resigns, then good amount of time is lost in hiring a new employee and then training him/her, and this goes to the loss of the hospital directly, which many a times goes unnoticed. And even after this you cannot ensure the same efficiency from the new employee.

Attrition leads to more attrition: The effect of attrition is felt throughout the organisation. Co-workers are often discouraged and the negativity affects the remaining staff and some more people may eventually leave.

Loss of Internal Information: When an employee leaves, he takes with him valuable internal information, customers, current projects and past history (sometimes to competitors). Often much time and money have been spent on the employee in expectation of a future return. When the employee leaves, the investment is not realised.

Goodwill of the Hospital: The goodwill of a hospital is maintained when the attrition rates are low. Higher retention rates motivate potential employees to join the organisation.

HR costs are about 30 per cent of the total hospital cost. Salaries increase anything from 12-14 per cent every year. With increasing demand for talent both within the country and internationally, the challenge for any human resource department is attraction and retention of staff. A major challenge for the healthcare industry would be not only to retain the workforce but also to develop an environment which would attract those abroad to return. According to a survey, nearly 70 per cent of the 110 healthcare providers surveyed had difficulty retaining workers with critical skills. According to another study conducted in healthcare industry, 63 per cent of the respondents said that the lack of availability and retention of trained manpower is their biggest challenge. In order to achieve the 1:1,000 doctor-patient ratio, as recommended by WHO, to catch up with the best world practices, India needs six lakh doctors and one million nurses right away, besides the need for other paramedical and healthcare management personnel.

The biggest and most important strategy for retention of employees is to induce the feeling of 'being looked after' by the organisation.

Work Environment

A satisfied employee clearly knows what is expected from him every day at work. There should be a specific framework that clearly gives him his job description.

The ability of the employee to speak his or her mind freely within the organisation is another key factor in employee retention.

Foster an environment of teamwork that in turn increases productivity. Communicate openly, there is nothing at more important than communication. Train your frontline, supervisors and administrators. The quality of the supervision an employee

receives is critical to employee retention. Show your employees that you value them. Respect them and appreciate them. Every human

appreciates being appreciated. Make room for fun—all work and no play makes Jack a dull boy—e.g. picnics, celebrations etc.

Make work fun! Give people the best equipment and supplies possible.

Give convenience-convenient hours, part time possibilities, services on job location etc. (Yes, his mother’s health and his son’s cricket match are important.)

Give your employees greater control on the processes and authority to take decisions in their present job. Management can assign extra responsibilities to their employees and appreciate them on the completion of these tasks. This will induce a sense of pride in the employee and will improve the relationship between the management and the employee. Infact employees feel more responsible, if they are given extra responsibilities apart from their regular job.

Career Advancements, Perks & Benefits:

Provide adequate advancement opportunities with a clear career path and develop an effective orientation and induction programme. Encourage learning through training programmes, tuition reimbursements and initiate on job training programmes. Incorporate an objective performace management system that evaluates KRAs twice a year. Recognise an employee’s achievement and reward him accordingly because bonuses and perks go a long way in employee satisfaction.

Offer fair and competitive salaries; though this is not the most important factor in employee retention and ranks lower, you cannot ignore the importance of fair compensation. Pay your best employees above average salaries. Give out bonuses on the success of both the employee and the organisation and make it limitless within company parameters (for example, pay ten percent of organisation’s profits to employees). Inculcate long term retention schemes like gratuity etc.

Retention Strategies

The practice of retention is not as easy as it seems. There are so many tactics and strategies used to enhance retention, but the basic purpose is lost which should be to increase employee satisfaction, boost employee morale and hence achieve retention. The aforementioned can be achieved by addressing small issues, for instance, by making someone accountable for retention within your HR department and conducting employee satisfaction surveys. Sometimes you will be surprised at how small issues like availability of coffee in the pantry can improve employee satisfaction and retention. Write a mission statement for each department and lay out goals for each employee. This inculcates a sense of responsibility. Let an employee use his varied skill set in multiple areas exposing to different facets of work. Hire non clinical aides to assist the clinicians. This goes a long way in retaining your clinical employees.

At most times, these strategies are not used properly or even worse, wrong strategies are used due to which the desired results are not achieved.

There are many myths related to the employee retention process. These myths prevent the employer from successfully implementing the retention strategies. Few common myths include increasing salary and incentives. Money is not the only driving factor. Job satisfaction is more important in key positions where people do not have to fight for survival. It is also a myth that taking measures to increase employee satisfaction will be expensive for the organisations. The things actually required to improve employee satisfaction like respect, career growth and development, appreciation, etc cannot be bought- they are free of cost. What really glues employees to their work and organisation is quality work, meaningful responsibilities, recognition, respect, growth opportunities and friendly supervisors. An employer or management that reacts well to the employee’s ideas and suggestions is enough for the employees to be retained. Enough emphasis cannot be laid on importance of these factors over compensation.

In a milieu where employees get a sense of achievement and belongingness from a healthy work environment, the company is benefited with stronger, reliable, and unswerving personnel harbouring bright new ideas for its growth.

We belong to the millennium workforce that needs independence, authority, flexibility, learning, fun and convenience. Your people are your biggest asset, invest in them!

Attract good people, retain the better ones, and advance the best!