Service Design Prescriptions for Indraprastha Apollo Hospitals

A couple of weeks back I had written about my experiences at the Indraprastha Apollo Hospitals. Following the publication of that post, I received a call from the hospital. I must say I was very surprised. The caller was a lady who said she looked after service quality and was calling to learn more about my experiences at the hospital. While apologising for what we had to go through the hospital, she wanted more details and appeared keen to fix the problem. Subsequently I also received a call from my former colleague Usha Bannerjee, who presently heads nursing at the hospital. She too admitted that they have been having ’service’ issues and they are trying their best to rectify these.

I would like to believe that Apollo’s problems are those typical of enterprises, who have more customers that they can possibly handle. To compound matters, they are stuck with poorly trained people and processes, which make matters infinitely worse. That they are committed to better services is great. However, the problems will not go away in a hurry.

The problem of plenty in a hospital is just as bad as the problem of having very few patients. Apollo Hospitals attracts patients from across the country and pretty much from the whole world. ( I literally live in the hospital’s shadow and keep running into enrobed Arabs, staying in rented digs in Sarita Vihar, where many an enterprising landlords have converted their flats into makeshift guest houses). The sheer numbers mean that the hospital staff is unable to give enough time and attention to each patient and there is always a rush at hospital counters. Thus, the service folks at the hospital are not interested in looking after individual patients, all that they do is ensure that the patient is lobbed in another direction, away from the counter they man. This is all too common in service establishments where there are a surfeit of customers (bus and railway stations, government hospitals, etc.)

Apollo gets away with this because it is a healthcare establishment, which has some of the best known doctors working for it. The patients flock to the doctors looking for succor and inevitably get sucked into the Apollo system. The other thing that works in Apollo’s favour is the simple fact that most Indians still consider doctors and medical establishments as demi Gods and rarely challenge small service failures, lest they offend their doctors who they believe hold the power of life and death over them. I am sure if Apollo was a hotel, its customers would be a lot more demanding and a lot less forgiving of its follies.

How can Apollo improve its services. Here are a few suggestions.

The management team at Apollo Hospitals should be clear in its customer experience goals. They must set the agenda for service excellence and establish clear and measurable goals. They must also demonstrate their willingness to bring about serious change and the ability to stay the course.

Apollo needs a complete makeover in terms of service processes and their flow. While the hospital has embraced the JCI processes, they seem to be more from the perspective of getting a certificate rather than genuinely improving customer experiences. Each process needs to be carefully studied and calibrated in terms of the delivery of the right customer experience.

The hospital needs to look at its people dispassionately and put them in a matrix based on their ’service’ orientation.  Any other consideration such as the number of years they have spent working in the hospital should not matter (there is no such thing as loyalty). Only those who demonstrate adequate customer orientation, empathy for patients and the willingness to go the extra mile to ensure patient satisfaction must be retained.  Others, who have the potential and need training should be taken through a structured training program focussed on delivering the right customer experience.  This process would lead to the elimination of a lot of employees, particularly those who have been with the hospital for long.  This should be viewed as an opportunity to induct fresh talent, young and bright people more in tune with the needs of the present-day customers.

The change towards a better customer focus, will also entail a new cultural orientation. The hospital should aim to embrace a more open, customer friendly culture, which rewards team members going out of their way in delivering great customer experiences. The new culture should be transparent, encourage team play and the senior management should lead by example.

I know these prescriptions are easy to suggest. However, the real challenge lies in implementing these and managing the transition. Great customer service must be driven with great force and alignment of every individual including medical folks is a must.

For Apollo Hospitals, I reckon it is really high time they began.

Dr. Naresh Trehan at the HT Leadership Summit

I had the privilege of listening to Dr. Naresh Trehan at the HT Leadership Summit organised by the Hindustan Times in New Delhi on Oct 30th and 31st 2009. The Leadership Summit has over the years become the marquee event in the city’s calendar and leaders like the Prime Minister, the Finance Minister and a former US President (George W Bush) addressed the gathering, which was composed of the who’s who of the Delhi elite. Dr. Trehan, who is widely regarded as one of the most accomplished cardiac surgeons in the country, was invited to speak on the challenges that the healthcare industry faces and how he saw things working out by 2020.

Dr. Trehan spoke with great passion and expressed anguish at the huge gap that exists in the supply of healthcare to the haves and ‘have nots’  in our country. “While Delhi draws thousands of patients from across the globe, 50 kms outside the city, one would struggle to find a qualified physician. India has some of the finest healthcare facilities, comparable to the very best anywhere in the world, which offer services at a fraction of the cost in the west, yet most Indians can hardly access these. The real challenge is how do we bridge this huge divide”, pointed out Dr. Trehan.

The prescription that he had for the malaise was simple enough.

Dr. Trehan, suggested a healthcare model based on Preventive, Primary, Secondary and Tertiary Healthcare centres connected with each other through a hub and spokes system. Indian villages are filthy, people do not have any sense of public hygiene and children, who are most vulnerable die of infections, which can easily be prevented if only one could improve sanitary conditions in our villages. Dr. Trehan demonstrated, how by just improving village sanitation and building a proper school in a village in North India, he and his team has been able to cut down disease and infection in the village. This he said was accomplished with financial support from a few large business houses who generously donated for this cause. One would reckon that this can just as easily be done with funds from the government. After all this is an investment in healthcare and education of the future citizens of the country and is bound to pay healthy (no pun intended) dividends.

Dr. Trehan acknowledged that no self-respecting doctor wishes to practice medicine in the hinterlands of the country. The quality of life that he expects for himself and for his family, just does not exist in Indian villages as yet. Thus, it makes no sense to have Primary Healthcare Centres in every village simply because it would be impossible to have qualified doctors functioning at these centres. Dr. Trehan instead suggested mobile clinics located in district headquarters and small towns, which can visit nearby villages on fixed schedules and offer Primary Health Care services in remote villages.

The government has a fairly vast healthcare infrastructure at the district level. The district hospitals can easily serve as good secondary care hospitals, provided they are managed efficiently and are held accountable for the quality of care they deliver. Dr. Trehan mooted a model based on a Private Public Partnership (PPP), which would allow efficient utilization of these resources and also generate a decent profit, which can be used to further strengthen these hospitals.

As far as the Tertiary Healthcare is concerned Dr. Trehan indicated access and pricing as the big issues. He felt that low-cost universal health insurance as a possible answer. Dr. Trehan also believes that tertiary healthcare costs can be significantly brought down if a hospital has a high throughput of patients. Thus, a tertiary hospital can amortize its fixed costs over a large number of patients, bringing the overall costs down. In this context he mentioned his own efforts at establishing ‘Medanta – The Medicity’ a large 1200 bed facility that he has built in Gurgaon.

Medanta, set to commence operations in a few months is a large tertiary care facility located hopes to attract patients not only from big cities but also from smaller towns and cities.  Dr. Trehan believes that more such large institutes will help bring the costs down and will allow more Indians to access world-class healthcare.

Dr. Trehan also mooted setting up a National Task Force, consisting of healthcare experts and government officials to try and put together a national level plan to rejuvenate Indian healthcare. “I had met the Prime Minister of India in the early 1990’s, with ideas on revamping our healthcare system. He agreed with most of what I had to say and promised that in a few months, things will move. Twenty years hence I am still waiting for a cohesive healthcare policy” lamented Dr. Trehan.

One hopes that with Dr. Manmohan Singh, the Prime Minister of India, talking about huge investments in healthcare to drive ‘inclusive growth’, things are finally set to move.

My experiences at the Indraprastha Apollo Hospitals

The other day I landed at the Indraprastha Apollo Hospitals, a stone’s throw away from my residence in New Delhi.  My wife needed a test and our doctor at Max Healthcare asked us to get it done at Apollo as the equipment at Max was out of order. The moment I walked in I felt as if I was on a railway platform.  The hospital was full of patients as everybody appeared to be in a mad rush. In the OPD area, the ladies at the reception were busy, chatting amongst themselves, while patients and their caregivers waited for their attention. They wore no uniforms and for some strange reason, they were also collecting cash from the patients (apparently for the doctor’s consulting charges) and handing out receipts scribbled on small chits, which did not even have the hospital’s name on it.

Strangely, I was than directed to a cash counter to pay for the tests.

Since my wife needed some injections we were asked to go to the pharmacy and buy them, bring them back to the treatment room in the OPD area, where a nurse would help us with the shots. As we wound our way back to the Pharmacy we discovered that buying medicines is a huge chore. We submitted our prescription at a counter in the pharmacy and were handed over tokens and asked to wait. There was no place where one could even stand, without being pushed around. After being jostled around for 30 mins, we managed to buy the medicines, only to discover that we also needed to buy the disposable syringes, which the doctor had forgotten to mention on the prescription. So lo and behold the charade of the tokens was repeated.

During all this I counted 18 people inside the pharmacy store and the two guys who handed me the medicines and accepted my cash kept chatting with each other in a south Indian tongue, without bothering to pay any attention to me whatsoever.

We returned to the OPD and were directed to room no. 15 for the shots. This room was locked and we were than directed to a paediatric immunisation room full of anxious parents and bawling kids. This is where my wife managed to get the shots she needed. We wasted more than an hour in all this and ran around the hospital OPD trying to get some very basic services. The staff was uniformly disinterested in us, poorly trained and too busy to attend to us. Fortunately, the test my wife needed was routine and she is in good health. I can just about imagine the plight of  patients and their care givers flocking to this hospital and being shunted around by a callous system, which barely works.

And now here is what happened when I came to collect her reports two days later.

I called up the hospital to check if the reports were ready. On being informed that I could collect these by 8 PM, I agreed to stop by to pick these up. As I walked in at about quarter to 8 in the evening I discovered a security guard merrily locking up the report collection area. He directed me to take another door into the radiology reception and 5 minutes later, when I walked in I found the lights switched off, the guard had also disappeared and there was not a soul to be found. Perplexed, I walked into another adjacent room and found someone busy on the phone.

As I explained my predicament, this gentleman informed that I was late and that the staff usually left 15-20 minutes earlier than closing time! Amazed and incensed at all this I asked to be directed to someone, whom I could lodge a complaint with. Much to my disbelief I was told to approach the Emergency Medical Officer in the Emergency!

At the reception in the Emergency, I found myself explaining my situation to a young man, who was simultaneously trying to answer questions from an anxious gentleman, whose father had just been brought in with severe chest pain!!! The emergency medical officer, who was supposed to record my complaint was predictably busy with a patient and I was asked to wait. After about 30 minutes of watching the bedlam of a busy Emergency room with no one paying me the slightest attention, I raised my voice (and in the process added to the chaos)  and demanded to see the highest ranking hospital official to record my complaint.

I was than informed that the Night Duty Manager will now attend to me soon. Another wait of about 15 minutes followed and yet no one showed up. I again screamed at someone and in another 10 mins a nurse walked out looking for me. She understood my problem, asked me to wait and went to fetch my reports. She returned in a while with my reports and gently admonished me for being so late and irresponsible in collecting my documents.

This is a true story of Delhi’s only JCI accredited hospital. God help us all!!!

The Future of Medical Education in India – The Way to Go

The Union Health Minister Ghulam Nabi Azad appears to be busy shooting the breeze by announcing vague policy changes involving setting up of Medical Colleges through private capital and in collaboration with government run district hospitals. The minister who is well known for putting his foot in the mouth, recently announced at a FICCI conference that the government is considering relaxing the norms for setting up medical colleges by the private sector. He also announced that these colleges can be affiliated with the government owned district hospitals, thus doing away with the requirement of a teaching hospital to be attached with the medical college.

The minister is seeking private equity participation in rural, backward and far-flung areas of the country. He believes that the private players can be attracted to set up medical colleges in these parts of the country by offering concessions such as access to district hospitals.

Doesn’t this sound completely hare brained?

Why would a private entity invest money in backward and far flung areas? The minister must know that what passes for District Hospitals is a sham. The hospitals are poorly equipped, have limited resources and are dens of corruption. Many are old and decrepit, some even falling apart with peeling plaster and leaking roofs. How will these private medical colleges attract students when they will be offering their students medical training in these hospitals? Will these students learn cutting edge medicine in hospitals, where high tech might mean an X-Ray machine? Why would they pay hefty fees to go to attend these medical colleges, knowing fully well what lies in store for them in the future? And if the students don’t find this proposition attractive, how will the medical colleges make money and generate a return for their investors?

India needs more doctors. According to the current planning commission estimates India needs 600000 doctors, a million nurses and more than 200000 dentists. The only way this shortage can be met is by investing in medical education. The government must find the resources to set up more medical colleges and teaching hospitals across the country. The bulk of the investment must come from the government. After all, this is an investment in the future of the health of the citizens.

The private sector can be roped in to partner in this effort, where in some of these colleges can be set up in collaboration with private players. The government can facilitate these investments by offering tax breaks, land at concessional rates,  soft loans, duty concessions on buying high tech equipment, and by developing allied infrastructure like power, roads and telecom in these areas. The teaching hospitals established along with the medical school can than serve as regional/district level referral centres for far flung Primary Health Centres. The teaching hospitals can also run outreach programs, touching lives of people in remote areas through regular camps and mobile hospitals.

These state of the art medical colleges and teaching hospitals will than be able to attract bright students and dedicated faculty. Many of them will come hopefully, not from far off places but also from local areas and will be happy to serve their own communities. Thus, they will form the backbone of a medical network that will extend its reach into the farthest nooks and corners of our country, making it possible for our citizens to access high quality healthcare nearer to their homes.

The minister must find a way to make a clean break from the past, think afresh and find the resources to get this going. More importantly he needs clear thinking and resolute will to bring about the change in the way healthcare is delivered in our country.

Pic courtesy http://www.flickr.com/photos/orissa/1296855022/

The Fall of the Noble Peace Prize

Had Alfred Noble been alive today, he would indeed be a very sad man. The wise men who decide the winner of the peace prize named in his memory have done a great disservice to him by honouring Barack Obama. Strange as it may sound they have also done great injustice to Mr. Obama by bestowing upon him a prize that he does not truly deserve, certainly not as yet.

Like most people across the world, I have the greatest respect for the Nobles. They are the highest recognition for excellence, for real achievement untainted by parochial considerations of nationality, race, gender and politics. The Noble Peace Prize, is meant to promote peace amongst nations, communities and people and recognises efforts by individuals and organisations in that direction. Barack Obama without doubt is a great man. However, his achievements however lofty they may be today, still do not qualify him for the award of the Noble Peace Prize.

Mr. Obama is the president of the world’s most powerful nation. He is the supreme commander of the mightiest army on Earth, with a nuclear arsenal that can destroy the world several times over. He has also inherited an army, which is largely seen as an occupying force in Iraq and is in active combat in Afghanistan.

Mr. Obama has been in office less than a year. He  is yet to resolve an international conflict, stop the proliferation of nuclear weapons in Iran and North Korea, ensure justice to the Palestinians, the Kurds and the Chechans. He is yet to engage with the world as a champion of peace, a harbinger of a different, more equitable world order. To be fair to him, what with the domestic economic turmoil and the healthcare reforms that he has been championing, he has had very little time to make a significant contribution to world peace. He is busy setting his own house in order, the world can wait for a while. One can hardly fault him for his priorities.

Mr. Obama has however spoken of peaceful co-existance amongst nations, about reducing and withdrawing American troops from the world’s trouble spots and of encouraging nations to resolve their differences amicably. He has talked about stopping human rights abuse and has ordered the shutting down of the Guantanamo Bay detention facility holding alleged Al Qaida terrorists without a fair trial.

I submit that Mr. Obama does not be deserve the Noble Peace Prize, for declaring his intent of promoting peace in the world. He has to do a lot more to reduce conflict in the world, promote harmony and peace amongst nations and peoples, before he can rightfully claim the prize.

Ironically, had the Noble committee waited a few years, Mr. Obama might have earned the prize on merit and he would have been saved the acute embarrassment of  being the recipient of this great honour, which he knows he does not truly deserve.

 

The Apathy of Delhi Hospitals Towards the Poor

The Delhi High Court has been after private hospitals in Delhi to honour their commitments regarding the treatment of the poor, but sadly to no avail. The hospitals are just not willing to treat poor for free, a condition that they agreed to while accepting land from the government at hugely subsidised rates. In-spite of the Delhi high court directing the hospitals time and again to fill up the beds for the poor, the hospitals are dragging their feet by hiding behind every legal loophole that they can find.

For the uninitiated here is the story. As many as 38 private hospitals in the city managed to get land at subsidised rates from the government under the condition that they will treat certain number of poor patients free of cost. The list of these hospitals today read the whose who of the hospitals in the city. However, once these hospitals commenced operations, they never honoured their part of the bargain. Thus the poor continue to be unwelcome in these hospitals, while beds reserved for them either remain empty or are filled up with full paying patients. This needless to say is criminal.

The reasons for this, however are not too difficult to fathom.  The business of healthcare is a capital intensive business and the cost of real estate in Delhi is a prohibitively high expense.  Thus, getting land from the government at very cheap rates against a commitment of treating the poor once the hospital starts, seems to be a good way of grabbing land. I seriously doubt that any of these private hospitals had any intention of treating the poor to begin with. This was just a ploy to grab land to build the hospital.

Now with the hospital up and running they had to find excuses to wriggle out of the commitment made.  Here is a sample of what the hospitals have been saying. A large 600 bed hospital sitting on prime land in south Delhi and part of the largest hospital chain in the country claims that they are unable to treat the poor because they can not find them! As per them the government needs to refer poor patients to the hospital, and since there has hardly been any government referrals, they can not fill up the beds reserved for the poor. They further claim that ‘free’ to them means a free bed and the patient has to pay for all other expenses, thus making the hospital out of reach of the poor. (Mercifully, this claim has now been thrown out of the window by the high court). Other hospitals too advance similar claims. Strangely many do not offer any reason for not filling up these beds.

A recent report in The Times of India indicates that 16 of these 38 hospitals have not even bothered to submit details of the status of their free beds to the government. Hospitals like Dharmshila Cancer Hospital and the Jaipur Golden Hospital have submitted that all their free beds are empty. The Times of India report also alludes to a nexus between the health officials of the government and these hospitals. The health officials refer their kith and kin or their political masters to these hospitals and they are treated free against the beds meant for the poor.

While all this has been going on for many years, some public spirited Non Governmental Organisations have moved the courts. The high court has made all the right noises but justice is yet to be done. While the cases against these hospitals meander in our courts, the poor, as always continue to suffer silently.

Pic courtesy http://www.flickr.com/photos/9019392@N08/552358084/

So much for my ‘Indian Hospital Experience’

While trawling the net I came across a blog (http://www.travelblog.org/Asia/India/National-Capital-Territory/Delhi/blog-440604.html) about the travails of an American, getting treated for a mole/wart/skin cancer in New Delhi. The experience narrated in this post is exactly the kind of stuff we do not want. I am amazed at some of the narration and the stereotyping this does of the Indian doctors and medical system.

The blog has a semi mad sardarji (sikh) as a doctor who speaks and understands no English, laughs at his own jokes in Hindi and does not understand the difference between a mole and a pimple. The doctor has never heard of the United States and knows America, a country whose citizens are rich and ripe for fleecing. The doctor prescribes lotions and creams for treating the mole, which are not available at his own pharmacy and the patient (the author) walks out, having parted with Rs. 500 and nothing to show for it. Astoundingly, this gentleman returns to the clinic of the mad sardarji, encounters a ‘wildeyed’ patient on a wheelchair, and asks the doctor to burn off the offending mole in the emergency room next door.  

Chasing Immortality

Immortality seems to be staring the human race in the face. If one was to believe the ‘futurist’ (never knew what this meant till recently) Mr. Ray Kurzweil, mankind will find a permanent solution to the scourge of dying and that too, not in too distant a future. Mr. Kurzweil believes that by 2029, that is in just 20 more years, man will conquer the final frontier in medicine and will be able to continue to live forever.

Ray Kurzweil has been a thinker, author and entrepreneur.  He has done pioneering work in developing optical character reading technology as well as developed a text to speech synthesizer way back in the 1960’s and 1970’s. Of late he has been researching and writing on Artificial Intelligence and how life as we know it is on the verge of extinction, thanks to what Kurzweil calls ‘The Law of Accelerating Returns’. Kurzweil believes that we are on the verge of a technology explosion, which will grow human knowledge exponentially by a billion times in the next 25 years or so.  

The Need of Customer Experience Managers in Hospitals

I believe the time has come for hospitals to seriously look at taking on people tasked with managing the customer experience, while interacting with the hospital at its various touchpoints. The Customer Experience Manager must be an individual, who can integrate the plethora of experiences that one is likely to have in a hospital in one unique experience, even a memorable one, (which is difficult, considering one is talking about a hospital).

A Customer Experience Manager should be empowered to act on behalf of the patients in the hospital, have overriding powers and must be guided by just one consideration, which is, if I was the patient, would I expect this from my hospital. An affirmative answer to this question is what should guide the Customer Experience Manager.  

If Only They Could Talk-Reading James Herriot

These days I am enjoying James Herriot’s omnibus collection ‘All Creatures Great and Small’. I must confess I am great fan of James Herriot’s writing and have read most of his books including the other omnibus collections ‘All Things Bright and Beautiful’ and ‘All things Wise and Wonderful’. A few years ago, I also came across the authorised biography of James Herriot (by his son Jim Wight), in a London bookstore and without much ado picked it up.

I recall I first encountered James Herriot, almost 20 years ago when in school. The CBSE English Core Curriculla, that we were taught had a wonderful James Herriot story titled ‘God is Near’.  Even after almost two decades I remember the old lady and her brood of aging dogs and how James Herriot, country vet practising the Yorkshire Dales took care of the dogs and the old woman, who wanted to know from the young and kindly vet, if animals had souls and will she be reunited with her beloved dogs in hereafter.