The Importance of the Culture of Caring

Last year my father was diagnosed with cancer. The doctors devised a treatment plan, which included chemotherapy and radiation therapy. As a caregiver, I had to take my father to the hospital for his radiation sessions. I opted for an early morning slot, which would have us in the hospital at around 7 every morning. I would drive up to the porch of the hospital, find a wheel-chair, get him on the chair, leave him for a while to go and park my car and would wheel him over to the radiation department for his sessions to commence. While, the hospital employed General Duty Assistants (GDA’s), who would normally wheel patients around the hospital, their duty hours began from 8 in the morning. My routine lasted only a couple of days as I soon discovered helpful hospital security staff, who would happily wheel my father as I went to park my car.

This simple act of caring and kindness spoke eloquently about this hospital’s shared culture. Here, even the security guard at the hospital’s door exhibited behaviour, which showed that he and the hospital cared. Thus to me, he repeatedly demonstrated that in the life of the hospital, it is not only the medical folks, the doctors, the nurses and the paramedics that deliver care, it can almost be anyone.

I believe for a hospital to be successful, it is imperative it has a culture of ”caring” ingrained in its very DNA. A hospital apart from being a repository of cutting edge technology, monumental medical knowledge and expertise must essentially be a caring institution. It is true that one goes to a hospital only when laid low by a debilitating illness, that one often needs the high-end diagnostics and surgical technology that modern hospitals are crammed with, the fact remains that more than anything else, one craves for great care during this period of uncertainty.

This is largely because most patients do not understand the intricacies of their scans or the technical difficulties of their surgeries, what they do understand are simple gestures of caring and support at a difficult time in their lives.

Healthcare organisations must aim to build a distinct culture of caring. This is far easier said than done. A culture of caring must flow from the top. Every individual in the organisation must understand that aside from whatever role they have in the hospital, the biggest role that they all have is to care for the patients in the hospital. The medical folks of course grasp this naturally, they are trained to care for their patients and they are also at the forefront of the delivery of care in the hospitals. However, it is not all that easy for others. The senior management team of the hospital, must ensure that there is clear communication down the line to everyone that they have a role to play in patient care.

The hospital leadership team should also step up and demonstrate their roles in patient care. The hospital policies formulated by the leadership team should have patient care policies right at its core. The patient care initiatives should be highlighted and communicated often, and those who go the extra mile in caring for the patients should be recognized and rewarded without hesitation.

Everyone who works in the hospital should fully understand what is expected of them vis-a-vis patient care. The folks at the front office should know that they must speak with the patients politely, demonstrate caring by helping and guiding patients to various part of the hospital. The F&B service should understand that they can demonstrate care by ensuring that the food served is piping hot, tastefully presented, delivered on time and served with a smile. An extra portion of desert for a patient with a sweet tooth (and of course no Diabetes!) will also help demonstrate patient care. The house-keeping detail too can underline care by keeping the room spick and span and by dusting the corners and those hard to reach places, that hide many unseen specs of dirt.

The most important element in building a culture of caring in the hospital is by communicating. Nothing showcases the culture of caring better than a little chat, whether it is the doctor stopping by for one after her rounds, or a nurse delivering a message of hope as she goes about her work. A GDA can demonstrate care by engaging with the patient as he wheels him around the hospital, a billing clerk can do so by explaining the components of the bill and listening to patients, who believe they have been over-charged and even a valet parking service attendant can demonstrate caring by bringing over a shiny car, when the one he received from the patient was caked with dirt.

A culture of caring is also rooted in a culture of empowerment. As far as patient care goes, every individual in the hospital should be empowered to act and help deliver great care. There should be no ifs and buts here and those so empowered must clearly know, without an iota of doubt that as long as their actions  result in better patient care, they will only be appreciated.

All good hospitals know that their success and even their profits are derived from the care that they deliver. A culture of caring and empathy must be a  hospitals most cherished and enduring asset. Unlike everything else, it can not be bought, it has to be built, brick by brick, over a long period of time and then it has to be zealously guarded from complacency, which often is, ironically a by-product of the hospital’s success.

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The Healthcare Marketer’s Life

Yesterday evening while I was returning from work a friend called. He has recently taken over as the Head of Marketing Communications at an upcoming hospital. I had met him a few weeks ago to congratulate him on his new assignment and he seemed quite kicked about his new role. He had grand plans of changing the way the hospital communicated with its patients and other stakeholders, he wanted to run customer facing programs, drive relationships with patients through effective engagement and deliver uniformly great experiences to those who touched the hospital.

Yesterday over the phone Ajay felt he had made a big mistake by joining the hospital. I was quite flummoxed by this turn-around. Further inquiries revealed a familiar story. The hospital has a brand new CEO, someone who has worked for many years in hospital operations but have no knowledge or appreciation of communication. However, like most folks he too believes that marketing communications is hardly something to be left to experts. In fact the CEO believes that he knows exactly how a piece of advertising or a brochure should look like. Download the text from the web, adapt it by rewriting some of it, slap a few images downloaded from the net and include the mandatory images of some if the hospital doctors, run it past a few senior hospital bigwigs and, voila the ad or the brochure is ready. As far as hospital signage are concerned, the CEO feels that they really are meant to provide legible directions to the patients and fussing over them, their aesthetics and design is a gross waste of time, energy and money. Well I might be exaggerating a little here but this is really the long and short of what Ajay felt his CEO was doing and no wonder he had started feeling frustrated in the set up.

Marketing folks in hospitals always grapple with the problem of every one who is anyone coming up and advising them on how to create a piece of communication. Some doctors love to see their pictures in the ads and some other feel great if gory images of them operating heroically could be included in the communication. The CEO’s love to mutilate the advertising copy, insist on correcting perfectly well written text, increasing or decreasing the font and of course having the logo bigger, bolder and always 2mm to the right! Many a times the marketing communication executive has to sweat many hours trying to accommodate the conflicting wishes  of the CEO, the star surgeon and his favourite flunky. All in a day’s work for the intrepid marketing guy, who can be forgiven for wondering if he is the only one who knows nothing about marketing communications.

Those who have worked in hospitals long enough know how to maintain a fine balance. They will wait till the last-minute, before asking a doctor to go through the text and approve the ad, they will sneak it past a doctor who they know is not too interested in the brochure’s finer details, they will get the mailer made and when a livid doctor would approach them on their failure to show it to him, they will deftly show an e-mail sent a few days ago knowing fully well that the doctor rarely checked the mail. Tricks of the trade, which one learns on the job.

Well, while all this may sound hilarious, the fact is that a hospital marketer’s life is not easy. If the hospital is doing well, his budgets are the first to be cut (why do we need to spend money on advertising, we have hardly a bed to spare!) and God forbid, if the hospital is not doing too well, the marketer knows that the hospital can hardly spare cash to blow its own trumpet. The doctors and particularly who head various departments are always after his life to see their ads in the newspapers, whether the marketer has the budget for such advertising is of course none of their concern. The CEO is always looking to pinch a few more pennies from a meager budget and he insists on stretching the money to impossible levels.

Such is than the life of a healthcare marketer.

Usually, in all this the silver lining is a boss, who understands the inner dynamics of the hospital, who knows how to work with medical folks without unnecessary confrontations, who lets the marketing guy go about his job without much hindrance and steps in to resolve conflict as it arises. He is the one who understands the aspirations of a good marketer as well as the concerns of the medical folks in the hospital and strives to achieve a balance.

At the end of the day, and in like most other things in life, a fine balance is the key.

 

 

 

The Perils of Standardized Health Care

Can healthcare delivery be standardised? This is the question, which has been bothering me this week.

The thought itself was triggered by a report in ‘Mint’ earlier this week titled ‘Government plans common healthcare standards’. (http://www.livemint.com/2010/08/24233218/Govt-plans-common-healthcare-s.html)

While the report portrays the benefits of standardization of care with millions of patients receiving standard care prescribed by the government thus saving them from being shortchanged by unscrupulous doctors and mercenary hospitals, there is also a flip (and a more real) side of the argument that we must understand.

While the government pushes through the Healthcare Standardization agenda, one wonders how can the delivery of healthcare be standardized across all medical facilities in the country? Every individual is different, reacts differently to treatments, the doctors are required to take decisions based on their experience and training and not on the basis of a set of guidelines decided upon by the government. If I was to fall sick, I would want my doctor to treat me based on his knowledge and experience and do what he feels is the best for me rather than stick to a standard set of guidelines mandated by the government. All doctors and medical establishment should have one guiding principle – the interest of the patient must be supreme and if there is a situation of uncertainty, I would want my doctor/hospital to always err on the side of caution.

Also, the healthcare delivery model in the country is hugely diversified. In its current form with poor regulation and monitoring it just does not lend itself to any standardization of care.The government-run tertiary care hospitals in large cities are filthy and over-crowded with patients and over-worked and under-paid doctors. The government run district hospitals as well as Primary Health Centres are even worse off with out dated equipment, poorly trained doctors, who often do not even show up for work. The private healthcare is dominated by secondary care establishments (usually called nursing homes), which have 10-50 beds and are usually owned by a doctor or a group of doctors. These are mostly mom and pop establishments, where owner doctors reign supreme and are answerable to none. Quality of care in these establishment is of dubious standard and these are neither properly regulated nor monitored vis-a-vis outcomes or treatment protocols. Christian missionaries and other charitable institution also run a large number of hospitals and now we have a nascent category of corporate style hospitals coming up in large cities offering cutting edge care. My point-all these hospitals are differently equipped, have differing goals  (for profit, non-profit, govt. owned etc.), have vastly different resources at their disposal, have different cultures and widely varying medical expertise available to each of them. How on earth can they all provide standardised, similar quality care to their patients?

Last December my father underwent a prostate surgery in a hospital in Delhi. Elderly men usually require this surgery at some point in time in their lives. Now, while I researched the treatment options for him and took surgeon’s opinions I discovered that we had several options. Our surgeon felt that the best and the safest alternative for him would be a laser surgery involving a cutting edge holmium laser. Now, this option is not available at most of the hospitals even in a city like Delhi, thus it can safely be ruled out from the ‘standardised treatment guidelines’ that are being framed by the government. In a situation like this, will it mean that patients like my father will be denied this option and he will have to endure the conventional surgery with its attendant risks of infection, excessive bleeding and a much longer hospital stay?

Let us now also look at the genesis of all this.

The health insurance companies (mostly state-owned)  want treatment protocols for some common diseases to be standardised so that they can fix a rate for these procedures, irrespective of the hospital and the doctor one chooses to go to. For the insurance companies this will lead to a state of nirvana, as they would be required to pay a fixed lump sum to the hospitals irrespective of the bill a patient runs up. They can then squeeze the hospitals further and make greater profits. Now, I am not against profits, however the problems that I see in this arrangement is that the patient will suffer, the quality of care will go down as hospitals will try to manage the delivery of care with in the financial limits set by the insurance companies (after-all they also need to be profitable). This is clearly hazardous.

One buys a health insurance cover  to ensure that in the time of need, financial constraints do not come in the way of accessing the optimum quality healthcare. The operative words here are ‘optimum quality’ and not ‘standard quality’ as mandated by the government. To equate these two will be a great folly. If the insurance companies believe certain hospitals are taking advantage of the situation by excessive billing (which I submit happens), they must put in place strict monitoring mechanisms including peer group reviews of treatment provided by the hospital. A healthcare regulator needs to be set up by the government to arbitrate between insurance companies and the hospitals. The regulator can possibly frame broad treatment  guidelines, which can serve as references in case a dispute arises between a patient, the hospital and the insurer.

Standardizing treatment protocols in a healthcare environment as complicated and as unregulated as ours is a dangerous and mostly an impractical idea. We need to first standardize our healthcare delivery systems before even thinking about standardizing treatment protocols. Paying hospitals based on these standardized treatment protocols because it makes health insurance companies profitable is inviting hospitals to cut corners. Once this happens, it will lead to serious erosion in the quality of care and even more  importantly a big trust deficit between patients and hospitals will emerge.

That would really be the ultimate irony, for if a patient does not trust his doctor or hospital, he really would have nowhere to go.

The Necessity of Sunday OPDs

The other day a colleague called on a Sunday morning. He was hoping to meet a doctor in a hospital OPD and was seeking directions to the hospital. The colleague, whom I will call Sanjay here, had recently joined work and was for some reason feeling a little under the weather. Nothing serious, but the usual stresses, which are so familiar to sales people in the month of March. When he shared his symptoms with me, I advised him to see a doctor and on this Sunday morning he was headed to the hospital.

However, much to his dismay I informed him that hospital OPD’s are generally closed on Sunday mornings and he might as well head back or he was really unwell he could visit the emergency services. ‘Listen, I really do not think I need to go to the ER, can you help me find a hospital, where in a physician can examine me, check my BP and hopefully start me on some medication that can take care of my niggling symptoms?’ hollered Sanjay over the phone.

Here is why I believe Sunday OPD’s are a great idea.

Most people like Sanjay, who lead busy overworked lives find it difficult to take time off from work and visit their physicians, particularly for small niggles except on Sundays. A lingering cough, a bad cold, a running nose, a painful joint, a niggling back ache are pretty much part of the power packed 9 to 9 week. Most people ignore these or try self medication to keep going till the weekend. (I know they shouldn’t, but they do). If things haven’t taken a turn for the better by then, Sunday mornings are the time to see the doctor. Thus, for a hospital running Sunday OPD’s, would mean offering a great convenience to its customers.

Saturdays are generally the busiest in a hospital. The simple reason is that in many work places, Saturday is a holiday and customers get an opportunity to visit the hospital to see their doctors, get the pending diagnostic tests done, get the physiotherapy they need and attend to their own and their families healthcare needs.  For the same reason, Sundays can be even busier.

While I worked at Artemis Health Institute in Gurgaon, we had started doing a “Public Forum’, on Sunday mornings. This involved inviting our customers and pretty much the public in general to come to the hospital and listen to doctors discuss common medical conditions in layman’s terms. Post the presentations we had an interactive session, where the doctors took questions from the audience. The sessions ended with brunch, which afforded opportunity for people to interact with the doctors one on one. When the idea was first mooted, I must confess, I was not sure of the kind of public response to expect. My fears evaporated on the morning of the first day that we held the forum. We had a house-full with people standing in the aisles of the 270 seater auditorium we had in the hospital. We not only generated a full-house, we also generated lots of goodwill from the local community.

Thus Sunday OPD’s are not only a revenue opportunity, they also are a wonderful opportunity to generate the goodwill of the local community. It is also an opportunity for the hospital to communicate that it cares.

With all this going for a Sunday OPD, why do hospitals are still chary of having a full-fledged Sunday OPD?

The answer is that they can not get the doctors to come out and work on Sundays. Most doctors love their Sunday mornings as much as you and I do and hate to work (just like you and me, I guess!) Sundays. Hospitals have tried cajoling and even forcing them to attend to Sunday OPD’s but have met with no success. They have offered other weekdays as holidays in lieu of Sundays, which too hasn’t worked.

The only way to convince the doctors to do a Sunday OPD is to convince them of its immense value both from a business as well as a customer need point of view. The hospitals must also make it worth the while for the doctors by handsomely rewarding them for attending OPD’s on Sundays. Last but not the least the hospitals must spend big bucks in marketing the Sunday OPD’s. Once the patients start trickling in, the doctors too will not mind spending their Sunday mornings in the hospital.

Hospital Pricing Must be More Transparent

Most people in India are scared of hospitals, more for the unpredictable financial implications that hospitalisation engenders than anything else. While most folks stoically accept the medical outcome, many find accepting the hospital bill far more difficult. This should not be the case.

Hospital pricing in India continues to be shrouded in mystery and one pays pretty much whatever the hospital asks. Most people do not even have elementary knowledge about how the hospital charges. At the time of admission, the hospitals proffer an estimate of expenses for what they assume would be an uneventful stay in the hospital. The patients expect that the hospital bill would be around the indicated estimate and plan accordingly. They do not realise that a hospital estimate has a large number of  variables, which can often lead to a higher bill and what the hospital is indicating is the best case scenario and what they need to be prepared for is perhaps the worst case scenario.

While there are often legitimate instances where one can understand the initial estimate going haywire, sadly their are also cases where the hospitals deliberately mislead the patient to make a fast buck. When my mother underwent a bypass surgery, she also contracted a serious chest infection and we had a very difficult time. The hospital did its best to see her through and the expenses mounted. However, in this instance since I was aware of the risk of infection, and had decided to go ahead with the surgery, paying more did not bother me and I certainly never felt that the hospital had cheated us.

While a few good, well established hospitals do not try to ‘reel in’ patients by indicating a lower than expected expense at the time the patient is making up his mind about the hospital, many unfortunately deliberately mislead the patient. This is a pernicious practice and actually amounts to taking undue advantage of the patient. Some hospitals also quote a higher price if a patient has an insurance cover and a much lower one if they are paying on their own. This is unfortunate and self defeating as insurance companies will soon start tightening the screws and once they have sufficient strength, they will drive a very hard bargain, which will have the hospitals cutting corners and the hapless patients paying the price literally and figuratively.

In the mad scramble for patients, hospitals have also started bargaining. As the patient walks in the hospital, the executives will discuss the likely expenses and if they find that the patient is likely to go ‘shopping’ to other hospitals, will make an instant offer much lower than quoted initially. This is largely to entice the patient to choose their hospital. It works well as the patient is spared the hassle of going to other hospitals and he believes he has got a bargain. What he does not know is that at that price the hospital is likely to compromise on consumables like implants, which may later on have serious medical consequences. I remember a few years ago we had a patient at Artemis Hospital from Bangladesh for a cardiac valve replacement surgery, for which the hospital had quoted an estimate and explained to the patient in detail the implants it proposed to use and all the other associated costs. The patient went shopping and landed at another hospital in Delhi, where he was quoted a price roughly 50% of what we had quoted. He had no idea of the quality of the implant proposed by this hospital but felt he could trust the doctor and the hospital (in that order). He went ahead with the surgery not knowing that he would probably require corrective surgery in a few years, which would be a lot more expensive and riskier.

The answer to all this madness lies in a better educated customer and more hospitals with a conscience. Hospitals must spend in educating customers about the likely costs, the risk factors, which can push the costs up and explain the possible consequences of choosing a cheaper, though a sub optimal treatment option. Transparency and honest intent are the key to winning a patient’s confidence. And of course they should be driven by a motive, which is more than profits at all costs.

Pic courtesy http://content.bored.com/comics/snap01636.gif

The Silly Question of RoI in Healthcare Marketing

The other day I was with Dr. Jadhav who heads the Marketing function at the well known Narayan Hrudayalaya in Bangalore. Dr. Jadhav was keen to use radio for his hospital’s communication needs and I was hoping to persuade him to advertise with Fever 104, the radio station owned by The Hindustan Times, my current employers. Narayan Hrudayalaya, which is a well-known cardiac hospital thanks to the famous Dr. Devi Shetty and his pioneering initiatives, has recently started a Cancer Centre as well as a Multi Speciality hospital and wanted to promote these. The aim of the communication was to tell the citizens of Bangalore about these services available at Narayan Hrudayalaya and to drive ‘footfalls’.

While I discussed the plans with Dr. Jadhav, I could not help but notice his concern about the RoI on his marketing spends. Dr. Jadhav was very clear that if he spent Rs. 100, he needed 3 times the  sum in revenue, which could be directly attributed to this activity. I could easily relate to this because this is exactly the kind of  expectations the management teams had of me, when I headed the Marketing function at Max Healthcare and Artemis Health Institute.

I wish calculating RoI on healthcare spends was this easy. While there are many websites, which help one calculate RoI on marketing spends using complex formulae and spreadsheets involving the lifetime value of a customer, the cost of capital and what have you, I believe quite often the best way forward is a subjective gut feel and patience.

Measuring the success of a healthcare marketing campaign by merely counting the number of queries/walk ins generated in the hospital OPD is a great folly. The hospital business is unlike any other business and one must remember that exciting marketing communication alone will not lead to people walking in to check out the services of the hospital. This can happen for a new restaurant or a movie theatre,  but for someone to visit a hospital he must have a pressing need.

Tactical communication involving discounts, freebies and the like should be handled with care. I am not sure I would prefer to go to hospital for cardiac surgery because there is a discount being offered on the surgery, or I would like to go under the knife at a particular time just because the hospital is offering a deal. Come to think of it, I would be downright suspicious of the hospital if it tries to hustle me into a medical procedure by making a commercial offer.

Marketing spends in a hospital must be looked upon as an investment in the hospital brand and the values it stands for. The customers should be informed about the services of the hospital, the experience and training of its doctors, the robustness of its systems and processes and above all the promise of the experience the hospital hopes to deliver to its customers. It can highlight its ease of access, competitive pricing vis-a-vis other hospitals and superior services.  The hospital must showcase medical excellence, send out stories of success against great odds and constantly remind its customers what it truly stands for. It needs to communicate all or some of these over time before it should even attempt to measure the RoI.

A hospital’s brand equity is built over many years and much as hospital marketers would like to hurry this up, there are just no shortcuts. A hospital must set aside a small sum of money (7% of sales in the first years tapering to 2-3% in later years) year on year to spend on connecting with its patients and the local communities it hopes to serve. It should diligently spend this money informing, educating and reinforcing its brand values.

A few years later, the hospital will find itself buzzing with patients and no one would really be interested in the RoI on marketing spends.

Indian Healthcare 2010

Here is a list of 10 things one would like to see happen in healthcare services arena in India in the New Year.

1. Healthcare Service providers should move faster towards recognising the patient as a customer and focusing on delivering ‘Total Patient Care’. This would include better medical care as well as much superior levels of hospital services. Hospitals need to invest heavily in people and process improvements to achieve the goal of ‘Total Patient Care’.

2. Investment in the hospital brand. Most hospitals in India are chary of investing in the brand and whatever little marketing communication that happens is purely tactical, meant to drive traffic or communicate the commencement of a new service or the addition of another doctor. This must change. Hospitals must find a credible and differentiated positioning in the consumer’s mind and move quickly to occupy it.

3. Develop an information resource pool that allows patients and caregivers to check out the hospital services, compare doctor’s qualifications, training, specialisation and years of experience.

4. Focus on wellness rather than illnesses. Indian hospitals are mostly about sickness and ordinary folks dread visiting hospitals. It would be a lot better if our hospitals also incorporated wellness services and promoted them aggressively. Prevention and community medicine should become critical areas of focus.

5. Develop sustainable and high quality outreach programs by seeking local community participation. I live next doors to Indraprastha Apollo Hospitals in New Delhi and I often wonder, wouldn’t it be great if this hospital ran a community health program in our area. The local community can offer space for the hospital to run and manage a small clinic with a round the clock nursing coverage and doctors (family physicians and specialists) visiting for a couple of hours everyday. Imagine, all major hospitals running maybe 5 such clinics in areas abutting them. The hospitals will not only get more patients, they will earn tremendous goodwill of the local community.

6. Use social media to create patient communities and facilitate constant exchange of thoughts and ideas. Let medical experts join in to provide guidance and keep the community interactions at an even keel. We had tried something like this at Artemis Health Institute in Gurgaon. Unfortunately it fizzled out once I moved on. More hospitals need to remain connected with their patients in a meaningful manner, even when they do not need the hospital. It is an investment in a relationship, which will pay dividends in the long term.

7. Improve Emergency services. I recall calling Apollo Hospitals once to rush an ambulance to my residence to pick up my wife who had accidently hurt herself and was bleeding profusely. I explained that I was at work and was on my way as well. I reached home before the ambulance and brought my wife to the Emergency in my car. The ambulance never reached my place because the Emergency services at the hospital kept calling my wife at our home landline phone to confirm whether she was really hurt!!!

8. Government run hospitals treating the poor are models of sloth, inefficiency and corruption. It would be great if private enterprise forges some kind of a win-win partnership with these hospitals and improves services. I am sure the savings from reducing crippling systemic inefficiencies will itself ensure decent profits for the private healthcare enterprises. The government must take initiatives in inviting a few carefully selected private healthcare organisations to participate in this experiment.

9. Health Insurance must penetrate deeper and wider. The claims processing should become less cumbersome. In this age of instant communication, hospitals and insurance companies manually fax documents, seek patient histories and look for loop holes to wriggle out of paying claims. This must end. Insurance companies and hospitals must connect with each other seamlessly and exchange information that helps patients get better service.

10. Rural and semi urban India must get its due share in the development of healthcare infrastructure. The government must encourage investments in primary and secondary care  in these areas. Unless we have more and more people accessing reasonably good quality healthcare services close to where they live, the India growth story will remain a big sham.

Here is wishing everyone a happy and healthy 2010.

Pic courtesy http://www.muhealth.org