What Makes a Hospital Great

We are finally on the last day of the year and the decade too. This is usually a time for reflection and I too have been thinking about my good fortune in never having been admitted to a hospital so far. God has indeed been kind and merciful. However, while I have been able to avoid a visit to the hospital so far, I have spent most of my working life and almost all of the last 10 years roaming the corridors of hospitals all over the world. This has been a great privilege for someone who isn’t even a clinician. I have been a part of teams trying to create wonderful hospitals that patients would love to come to. This quest continues with the realization that patients do not love to go to any hospital, whatsoever. They go there under the force of circumstances and are keen to return home as soon as possible.

So, what would constitute a hospital that one wouldn’t mind going to if the situation so demanded? Here are some thoughts.

The first and foremost is the obvious. The hospital must have great clinical expertise. This essentially means that the hospital should have a great set of clinicians well trained and experienced in their areas of medicine. It should also be equipped with some of the best medical gadgetry to allow the medical wizards to treat patients safely and to the best of their ability. This is relatively easy to achieve. The really difficult part is to get the great clinicians and the nurses and everybody else who delivers care to work together in the best and abiding interest of each patient. It takes years for a team to tango together. Large, successful hospitals are busy places, filled with thousands of patients demanding attention and care round the clock. For most patients a hospital visit or a surgery is perhaps a once in a lifetime experience. For busy clinical teams, scores of patients everyday is the norm. In all this a great hospital would be one where care and attention is lavished on each patient as she is the only one under their care that day.

Apart from providing great medical care, I would truly treasure a hospital that talks to me as a partner and treats me as an equal stakeholder in my own care. Very often this is a neglected area in most of our hospitals. Rarely, clinicians take the trouble to explain to the patients the medical conditions they have been diagnosed with, the treatment plan, the prognosis and the complications that may arise. There are many reasons for this – doctors are extremely busy juggling multiple balls all the time, do not consider this conversation as very important one, believe that patients do not have adequate medical knowledge to benefit much from this discussion and some, dare I say, are just not trained to address all the queries the patient may have. In a great hospital, medical teams must spend time with each patient, explaining and answering their questions as best as they can and with candor, empathy and respect.

There is something else that as a patient I rarely get to see or know but is absolutely critical for my well-being. This is the effort and investment a hospital makes in ensuring patient safety. Hospitals are inherently dangerous places teeming with germs and instruments, which are used for jabbing, invading and cutting open patients. Of course, all this is done in a controlled and highly sanitized environment, yet chances of someone slipping somewhere, making a grave and maybe an inadvertent error is always round the corner. The trick is in trying to eliminate these errors as far as possible through technology and stringent process controls. Ultimately, patient safety is an organization wide effort to establish a culture, which looks at learning from mistakes all the time. Great hospitals are obsessive about patient safety and treat even the smallest transgressions with utmost seriousness. To them nothing is more important than ensuring that the patient comes to no harm in the hospital.

Everything else to me in a hospital is a given. I would expect the hospital to be clean, the food to be of decent quality and served on time, the air-conditioning to be working well, the nurses to be responsive and the staff pleasant. I would greatly value efficiency in a hospital and wouldn’t like to wait endlessly for things to get done. I do expect the hospital to transparently charge me for its services and make a reasonable profit for its share-holders. A great hospital is also one, which does all of this effortlessly and as a matter of course.

As the new decade begins, I would certainly hope not to land up in a hospital in the next 10 years too. Yet, if it becomes unavoidable, I would certainly want to be in a hospital, which does all of the above rather well.

Here is wishing all of you a wonderful new year, filled with good health, happiness and much joy.

The views expressed are personal

The Aggressive Patient

Why are we intimidating and beating up our doctors ever so often these days?

Every other day one see’s newspaper headlines where doctors find themselves facing angry patients and their attendants who believe that misbehaving with hospital staff and doctors is no big deal at all. That breaking furniture and maybe a few bones will get them better service or perhaps the hospital will waive off a portion of their bills. Doctors and hospitals today are quite scared of such hooligans, who create a nuisance in the hospital demanding better treatment for their patients without realizing that their behavior is putting other patients at grave risk.

Part of the reason for this I suppose is that we are becoming a more aggressive nation. The road rage that one witnesses on the roads in Delhi everyday, the ugly fights among neighbors usually for parking spots, the crazy honking even on a red light are perhaps all a manifestation of this malaise. The medical profession too I suppose cannot escape its share of problems in a society becoming louder, more aggressive and more demanding. Everyone seems to be on a short fuse.

In hospitals, where life and death situations are routine, people are perhaps a lot more stressed and express their frustrations by mishandling the folks right in front of them. These are mostly doctors and nurses, who bear the brunt of their anger. Little do they realize that beating up the doctor won’t help them get better care. And that beating-up anyone is no solution to any problem.

The other reason that I find for all this anger in the hospital is a lack of communication between doctors and the patient’s attendants. Usually, the clinicians are very busy folks who have very little time for patient’s attendants. They believe that their primary duty is to look after the patients, without realizing that in today’s world they also have an equal duty towards addressing the attendant’s fears and concerns regarding the patients. Hospitals spectacularly fail in impressing on the clinicians that they must meet the attendants regularly and address all their queries as honestly and as transparently as possible. This must be a part of a process and not a random meeting in a corridor or when a patient’s attendant catches hold of a doctor fortuitously. Better communication will help reduce these unsavory episodes far more than more security guards manning the hospital doors.

I also look upon these incidents as reflective of a loss of respect and trust between patients and doctors. With the media awash with stories of profiteering hospitals and grasping clinicians engaged in dubious practices, no wonder that the relationship between patients and doctors have almost broken down. The noble profession has been reduced to no more than a transaction. There is no longer the old world courtesy and respect that clinicians commanded not so long ago. No longer are they the Gods of their realms. This is rather sad. The relationship between a doctor and a patient and their care givers has to be a a bond of great trust. The patient willingly allows the doctor to treat and operate upon him believing that he will do so to the very best of his skills and ability. The doctor on the other hand accepts this as a huge and crushing responsibility and does his best to ensure that the patient comes to no harm, while under his care. This is the covenant that has always existed between doctors and patients. This sacred bond is now stretched almost to the breaking point.

What is it that we can do to get back from the brink??

As hospitals and clinicians we have to understand that the patients are increasingly getting impatient and we must learn to deliver all that we commit. We must find more time to address their concerns and not just fob them off with some sarcastic remark about their limited understanding of medical matters. We must engage with them more, learn to treat them as equals and partner them in their treatment. A dialogue is essential.

As patients and their attendants we must understand the tremendous pressure and responsibilities each clinician carries. We must also have an unshakable faith in their good intent, skills and abilities. This has to be a given. We must also have the wisdom to realize that in medicine an adverse outcome is not necessarily the fault of the doctor or the hospital. Actually, at times it is no one’s fault. We must treat our doctors and nurses as fallible humans, just like ourselves.

Finally, there will always be those who believe that creating a ruckus helps get things done in the hospital. In my view the hospital must deal with them firmly and take whatever action is required to ensure orderly conduct.

Violence can not be justified, whatever the reason or the grievance. Beating up ones doctor is almost the most stupid thing imaginable that one can do.

The views expressed are personal

 

 

 

The Doctors who Communicate Better, are Better Doctors.

Communication with patients is perhaps the most important component in the overall patient experience at the hospital, yet it is a rare hospital that gets it right. The communication with patients largely involves the clinicians. The nurses, front-office executives, the house-keeping staff and even the security guard manning the elevator too can help deliver a wonderful experience by reaching out with kind words. However, it is really the doctors, whose words make the biggest difference in a patient’s life.

A few years ago, a friend’s husband needed a kidney surgery. The patient was to be wheeled into the surgery at around 10 am in the morning and the surgery was to finish in 4 hours. He was wheeled in for surgery from the hospital room at around 0930 in the morning. When I met the friend’s family a couple of hours later the attendants sat huddled together in the cafeteria, anxious and hopeful in equal measures. The time went by rather lethargically and their anxiety kept mounting. When 6 hours had gone by, the frantic family members approached the doctor’s secretary, who assured them with great panache that the surgery has gone without any hitch and they will soon be able to see the patient. Much relieved, the family members decided to have a celebratory coffee as they waited to see the patient in the recovery.

While they waited to hear from their surgeon, a couple of hours went by. The helpful doctor’s secretary by now had finished work and gone home. The surgeon was no-where to be found and there was just no one who could give them any information about the patient. Again frantic with worry the friend reached out to me to get some information about the patient’s well being and also when can they possibly see him and their surgeon.

Concerned, I made inquiries with the team in the OR and learned that the patient’s surgery had been delayed by a few hours as the previous surgery in the same OT had lasted longer than planned. The surgeon had been busy operating his scheduled cases and did not have the time to step out and explain the delay to the anxious patient’s relatives. The surgeon’s secretary had not heard anything untoward from the OT either and just assumed that everything would have gone as planned.

The patient’s surgery was uneventful and he made a full recovery. However, for the patient’s attendants, this was a harrowing experience. This is a true incident, and we know that something like this happens every day in our hospitals.

I have often pondered over the stark difference in the situation between the surgeon and the patient. Consider this for a minute. For a surgeon, a surgery is something that he does every day (maybe multiple times every day!!!), for a patient it is a frightening and hopefully once a lifetime experience. The surgeon, while operating in his theatre, surrounded by a team that he has perhaps worked with for years is usually confident of his skills and the ability to help the patient. The patient and his family are on the other hand in an alien environment. No one likes to be in a hospital and surgery is scary. The outcome in the patient’s mind is always uncertain. Given a choice, he would be anywhere but the hospital. Such is the power imbalance and asymmetry in the equation between the doctor and the patient, that it is imperative that we use clear communication to keep things on as even a keel as possible.

Patients will always see doctors who communicate well as better clinicians. Patients and their families like their doctors if they step down from their pedestals and treat them as friends. They will readily narrate stories about their interaction with their doctors and tell all their family and friends on how approachable and wonderfully transparent their doctor was. They will readily recommend the doctor to their family and friends and ultimately restore the doctor back on the pedestal!!!

It is very hard for the hospital administrators to mandate processes that define when and how should the clinicians meet their patients. Afterall, this is really a matter between a doctor and his patient and the hospital management isn’t usually welcome as a participant in this relationship.

However, hospitals must encourage their doctors to spend more time with patients and their families and not just fob them off with brusque briefings in the corridors. They must provide infrastructure, where patients and their families can meet their doctors and spend time together.

Doctors who communicate well with their patients can easily transform the hospital experience for a vast majority of patients.  Hospitals will do well to remember that.

The views expressed are personal

 

 

The Winds of Change

With the trust levels between clinicians in private practice and their patients plummeting to what many would call an all-time low, many clinicians have been wondering what they need to do to regain the lost trust.

In a recent interaction with some senior clinicians, I found that many are reflecting deeply on things that they perhaps need to do differently and maybe unlearn some of what they learned early on in their careers. The new skills they felt they needed to acquire lie not in the domain of medicine but in the areas of patient communication, documentation and even bed-side manners.

The clinicians are increasingly realizing that treating patients and saving lives is much more than just wielding the knife or taking life and death decisions based on their clinical acumen and skills. The clinicians feel that they need to engage with their patients in multiple ways to earn the patient’s trust once again.

The good news is that they are more than willing to do so.

The new age clinicians are learning lessons in patient communication (pun intended) as they deal with Google strengthened patients, who have dozens of questions on their differential diagnosis, tests needed, treatment plans and even backup plans if things go wrong.  The patients are asking questions on drug reactions, likely side-effects and how would one cope with them if God forbid, they occur. They want to know why a particular implant is being recommended, what are the chances of an allergic reaction from the metal used in the implant and what can be done about it!!! From the clinician’s point of view, this is many worlds’ away from the time when they were treated like demigods and their pronouncements considered to be almost divine.

The clinicians are getting used to the new reality and many are keen to be trained in being able to address these questions adequately and in a manner that the patients understand. The clinicians are trying hard to learn the language of their patients. Many do not shy away from passing on patient literature developed by hospitals, especially for this purpose. Many are equipped with videos of past patients, which they happily handout to their new patients. Some, direct the patients to check out authoritative resources on the web and satisfy their thirst for knowledge. Clinicians are writing blogs and creating web content for patients to read and understand their conditions better before they decide on surgery.

In India, very few clinicians are as digital media savvy as say their colleagues in management. I reckon this is primarily because many senior clinicians are still from a generation when they never had social media when they were growing up or training in medical schools. They became professionally busy well before the advent of the smartphone and the 24×7 assault of the Facebooks, the Linked-Ins, and Twitters of the world. Thus, they hardly had time to get used to the tremendous power these digital tools wield in engaging with consumers today.  This too is now changing. Many clinicians are now harnessing the power of these social media platforms to engage with their patients. That the mediums allow for a continuous engagement, which is way beyond the episodic nature of a surgery or hospitalization is an added advantage. Many clinicians in a sincere effort to shed the old world aura of being  Gods are also sharing snippets of their personal lives, hobbies, family pictures and vacations to connect better with their patients.

The doctors are also trying to be nicer to their patients and are even considering sartorial changes to make them look smarter and more approachable. It is now quite usual to see smartly attired,  doctors welcoming patients in their OPD chambers. Some are even spending time in the gym, making them look fitter and healthier. They are certainly willing to spend more time with the patients and their attendants. The clinicians are also realizing that patients admitted to the hospital under their care look forward to seeing and hearing from them at least once a day. Many now hold conversations with their patients on their medical rounds, which are far more reassuring than in the past. Some clinicians are also sharing their phone numbers so that patients can WhatsApp if they need to reach out for anything.

These are all welcome developments.

However, the biggest change, which appears to be happening is in the area of documentation. Unfortunately, medical education and training in India, which is still largely in government-run institutions does not equip doctors with the meticulous documentation needed, while working in large corporate hospitals. The clinicians need to learn to work on HIS systems of various degrees of complexity, put in orders in the system, prescription have to be recorded in electronic formats and the smallest of thing needs to be properly documented. The days of the clinician’s iconic scrawl are well and truly over. Verbal orders barked to nurses no longer suffice. The culture of documentation and the use of technology allows for significant reduction in medication and other errors. It leads to far greater patient safety and protects everyone from doctors to nurses to hospitals from disputes and legal action.

These are welcome changes. That the clinicians are thinking about ushering in these changes to help reach out to their patients better is indeed reassuring. I am sure these will go a long way in bridging the gulf that now divides patients and their doctors.

The Demonizing of Private Healthcare in India

The demonizing of private healthcare services providers in India seems to have reached a fever pitch. Everyday the social media is agog with how private hospitals, mostly in the quest of unhealthy profits are compromising with patient safety, recklessly using expensive medicines, over-charging and generally not treating patients well.

This is rather sad and generally a very one-sided view.

Private Hospitals in India invest heavily in hospital infrastructure. The cost in building the infrastructure, installing cutting edge medical equipment, hiring experienced and statured clinicians and managing the enterprise is high. The patients who prefer private healthcare providers also demand world-class services. There is nothing wrong in this. However, this also means that the healthcare costs are going up. Most patients do recognize the fact that a private hospital is a for-profit enterprise and the investors do need a return on their investment.

Thus, the quest for profits by the investors is legitimate. However, this must not deteriorate into blatant profiteering. This is clearly understood by most of the corporate hospitals. Even a casual glance will indicate that the EBITDA margins of most of the large healthcare chains in India are below 15%. At these levels the hospitals can hardly be accused of profiteering, particularly when the up-front investments are high and the profits emerge usually after 5-7 years of operations.

It is also a fact of life in India today that most people who can afford to pay prefer to go to private hospitals.  The subsidized government hospitals are over-crowded, filthy and callous. The accountability of the care being provided is very limited, the clinicians are over-worked and under-paid. Industrial disputes with the government are rampant and often some or the other section of the employees are on strike. The private corporate hospitals in sharp contrast to the government hospitals provide high quality care in state of the art hospitals. The clinicians are paid much better, they are also held accountable for the quality of care being provided, peer reviews are regularly done and hospitals are run on processes and systems that rival the best in the world.

Now, with this being our reality, it is rather unfair to blame private hospitals for ‘over-charging’, which is often confused with being expensive. That the hospitals use expensive branded drugs can hardly be held against them. If we expect great patient outcomes, the hospitals have to use the most appropriate and efficacious drugs and these are expensive. In India, where there are more than 30000 drug manufacturing units, some of them manufacturing spurious or barely efficacious drugs, the clinicians will tend to use drugs manufactured by large well-known drug companies and one will have to defer to their judgement. After-all, they are squarely accountable for the clinical outcomes and we can hardly ask them to produce great outcomes, while working with their hands tied behind their backs.

Pretty much the same applies for everything else that happens in a hospital. Infection control, IT system led processes to reduce medical errors, high-end diagnostic equipment and world-class OT’s all cost a lot of money.

The problem seems to be that, while the patient expectations in terms of care and outcomes has significantly gone up, they are just not reconciled to pay for these services as much as they cost to deliver.

The Role of the Media

The sad truth about media in India today is that in search of TRP’s, they have lost objectivity and even probity in what they report. The media is no more interested in facts or for that matter the truth. Most viewers want to see an individual patient, maybe a grieving father, take on the big hospital, which “killed” his daughter. This is clearly high drama and the media just loves it. The images are just too compelling and it is so easy to paint the big hospital as the ogre. The TRP’s are there to be had.

This kind of vilification and sensationalism, with very little care for truth or fairness is unfortunate but in today’s times, inevitable. While, a sustained onslaught is mounted for a few days, the hospitals run for cover, it is great spectacle for the mass viewer. And then a new story comes along and we all move on.

Sadly, while the media moves on, this kind of reporting causes long term loss of trust between patients and hospitals. This is a catastrophic and an insidious loss as trust between a doctor/hospital and their patients is usually the bedrock of  the relationship itself. In the absence of trust, things between clinicians and patients start going wrong right from the beginning.

The media must realize this and play a more non-partisan and balanced role in this dialogue. It should certainly highlight the shortcomings of the hospitals, however it should do so in a balanced and judicious manner.

The Role of Social Media

Social media has empowered patients and customers. It has given a voice to the ordinary man, who can at the push of a few buttons air his grievances to many and watch others join in, sharing in the anguish or narrating their own past woes.

However, here too rampant abuse is visible. It has become fashionable to troll service companies be it an airline or a hospital. Yes, sometimes front line service staffers may behave rudely, particularly when provoked, but is that a reflection of the organisation’s culture and ethos?

In cases involving hospitals and death, which unfortunately cannot be avoided in hospitals, it is common for the grieving relatives to take to social media airing all kinds of issues related to the quality of service and billing deficiencies. Most of these issues emerge only with hind-sight. Many of them, sadly are a matter of perception but are always aired as indisputable facts. The doctors working hard to save a life suddenly become merchants of death. While the patient is in the hospital, the usual demand is “do whatever to save my baby”, suddenly the hospital starts being accused of callous behaviour, ill-treatment and criminal negligence. In a recent case, I even heard an argument that the hospital charged so much, yet they couldn’t save the child. If only, we could buy a precious life, by spending money….

To make matters worse, we than see the proverbial mob arrive. Everyone here has a past tale to narrate about the horrors they suffered at the same or even other private hospitals. This becomes the pre-dominant narrative, and if the hospital tries to respond with facts, they are showered with the choicest and the nastiest abuse. The hospital decides to usually cop it and wait for this to blow-over.

Sadly, this too causes a serious erosion of trust between doctors and patients. It simply helps no one.

So What needs to be done

The hospitals need to acknowledge that there might be some bad eggs among their fraternity. These need to be weeded out. They also need to acknowledge that patient communication is not their strongest suite and they need to work on it more diligently. They also need to show greater empathy and take care of the “small things” that can so easily be fixed yet cause serious consternation among the patient community. They also must set up Patient Grievance Committees to help patients reach out and complain if they are not satisfied with any aspect of care or have an issue with billing.

The patients have to realize that private healthcare in India is becoming more and more expensive (while it still remains the cheapest in the world). This is only natural as Indian hospitals aim to deliver better quality healthcare across the board. If they choose to go to private hospitals in the hope of receiving world-class care, it is bound to be expensive. As responsible citizens they must have health insurance to protect themselves in medical emergencies. Running down hospitals and doctors on social media does not help in any manner. On the contrary it does immense damage. Patients and their care-givers must also realize that hospitals cannot guarantee a particular outcome, they can only try. By being dismissive of their desperate and perhaps ”expensive” efforts later on, they are only encouraging doctors and hospitals to hold their horses in their battle against disease. Let us not do this.

As far as media is concerned, they must stop playing to the galleries. Individual lapses must not be generalized to vilify hospitals and clinicians in general. While one understands their love for the TRP’s (after-all everyone needs to make a living!!!), they must carefully ponder the kind of damage they are doing to the sacred relationship between doctors and patients. Do highlight lapses as human errors, negligence as failure of an individual or a system but do not call everyone crooked and corrupt. The majority and by far the majority of clinicians try their best to cure without causing any harm.

Sadly, in the polarized, binary world that we increasingly inhabit, this is perhaps too much to ask.

The views expressed here are personal.