A case for an Indian Bumrungrad

Bumrungrad International Hospital in the Thai capital, Bangkok is easily the world’s leading hospital for international patients. It has been a beacon for patients across the world for over two decades now. The hospital treated over 1.1 mn patients in 2018 with over half of them being foreigners from 190 countries. The hospital has a reputation for great medical care along with excellent international patient services customized to the needs of their global patients.

Indian hospitals too receive hundreds of thousands of international patients from different parts of the world every year. Max Healthcare, in New Delhi, where I happen to work received over 70000 patients from over 100 countries last year. Yet, we do not have a hospital in the country that can really be called a super-magnet for International patients. For most Indian hospitals, International patients are just a tiny sliver of the patients that they take care of. Unlike, a Bumrungrad Hospital, Indian hospitals are designed to cater to local patients and the international patients that they receive, while important, are rarely an area of great focus.

International patients travelling to India often have needs, which are very different from local patients. For many, visiting a hospital in a far-off country is a big leap of faith and they often rely on the services of healthcare facilitators (HCFs), which are intermediaries representing hospitals in different countries. The HCFs often interact with these patients before they board the flight for their medical destination. The HCFs connect them with local doctors and the hospitals, help them get a medical opinion for their afflictions, advise them and help them make appropriate choices regarding their treatment. They also help arrange tickets, often pick-up patients from the airports and make their arrangements for their stay. While the HCFs need to professionalize and become more organized, the hospitals too need to build a full suite of concierge services for international patients. Since most Indian hospitals consider International patients as just an ”add-on”, the international patient services do not get as much attention as they should.

It is time, we looked at setting up hospitals, which consider mainstreaming international patient services. This would essentially mean that the hospital should fundamentally be designed to cater to the requirements of International patients. The infrastructure would typically include plush International patient lounges, exclusive international patient registration and admission desks staffed with executives with appropriate language skills and a full services concierge desk to assist the patients for any need. that they may have. The hospital will also need signage in multiple languages, medically trained interpreters available 24×7 to assist clinicians when they wish to communicate with their patients and a maybe global choice of cuisine.

The international patient experience as distinct from the medical services being offered by the hospital has to be truly world-class. The foreign patients should be made to feel comfortable and at home right from the moment they step out of the airport. India will be able to draw a significantly larger chunk of International patients if we are able to elevate the international patient experience to the highest possible level. A business case for such a hospital can easily be made. However, apart from capital and investments, this will also require a change in the mindset of the hospital promoters and their key executives. That is perhaps the bigger challenge.

Serving International patients allows the country to earn precious foreign exchange and is considered as export of services. With relatively low costs and world-class medical outcomes, Indian hospitals have tremendous competitive advantage. They must not squander it away with what might today be called as a half-hearted effort.

It is time we built a Bumrungrad Hospital of our own!!!!

The views expressed are personal

A Case of Abuse of Social Media

The last week saw a chastened-looking Mark Zuckerberg, testifying in the US Congress about data leaks from Facebook and explaining how he himself has been a victim of the same leaks. That may be cold comfort for most people and data leaks from social media behemoths are perhaps far bigger a problem than what ordinary folks face on social media on a daily basis.

Social media has been prone to abuse in multiple ways. While this piece cites a specific example that I came across last month, the wanton abuse of social media in spreading canards, abusing people in the vilest of terms, destroying reputations by twisting facts and sharing half-truths is quite worrying. Even more worrying is the lack of recourse that the aggrieved parties have in getting redress. While they can always present their side of the story, the abusers tend to ratchet up the diatribe and the language used is not something that perfectly decent folks can match. Thus, they give up.

Here is what happened last month.

A relative of a patient who died of liver failure at Max Hospital, New Delhi put up an extremely derogatory post abusing one of the doctors on the Liver Transplant team. The posts used the filthiest of language and dragged her extended family, including her long-deceased grandfather in a matter that was purely in the domain of the clinician’s work. The doctor, a lady with an impeccable track record of academics at the finest medical institutions in India and abroad was called horrible names, her competence questioned and her family’s name dragged through the mud.

The facts of the case as gleaned from the hospital records are quite straightforward. The patient had first been seen at Max Hospital, New Delhi in the last week of November 2017 when he had presented with symptoms quite clearly suggestive of liver cirrhosis. The patient was admitted to the hospital, investigations were conducted to confirm the provisional diagnosis and he was managed on medicines. He improved symptomatically and was discharged from the hospital 3 days later.

The patient again showed up at the hospital in early February 2018 and was advised admission. The patient’s family chose to disregard this advice and took the patient home. The patient was subsequently brought to the hospital in an emergency situation by the end of the month. He was admitted to the hospital ICU and was managed with medications. The patient’s family, however, decided to leave the hospital against the medical advice (LAMA).

The patient returned to the hospital the very next day. He was admitted and advised a Liver Transplant Surgery. The patient was managed and was provided all supportive therapy and the hospital waited for the patient’s family to take the decision on the liver transplant and arrange a suitable family member who can be the donor. The family once again discharged the patient LAMA and moved him to another hospital.

Incredibly, three days later the patient once again arrived in an emergency situation. The patient had deteriorated significantly. He was admitted to the hospital, needing an urgent liver transplant. The family now consented to the transplant. His wife agreed to be the donor and she was worked up for the surgery. Unfortunately, she was not found fit to donate and the patient in the meanwhile kept deteriorating. Sadly, the patient passed away without receiving the transplant. These are facts recorded in the EMR’s of the hospital.

While going through the hospital records, it was quite evident that the patient hardly followed the medical advice provided to them, they remained undecided about the transplant, till it was too late.

To blame a particular doctor in the transplant team for their travails is clearly unfair. The doctor advised them well, did her duty even when the family kept vacillating. To abuse her in the vilest of terms on a social media platform and to declare a ”war” against her and the hospital, vilify her family, which had nothing to do with any of this was most unfortunate.

The clinician chose not to respond to this calumny and decided to sue them for defamation. Taking on such elements on social media itself would clearly have been futile.

In an environment, where there exists a huge trust deficit between doctors and patients is there anything else that she could have done???

The views expressed are personal










The Destruction of Trust – A Media Trial and a Witch-Hunt

The last couple of weeks have been a difficult time for the healthcare services providers in the NCR of Delhi. The media have been busy reporting about how Fortis and Max Healthcare ill-treat their patients and how the only thing they care about is profits. Having worked in both the hospitals, I can only say that this is completely wrong. The media-houses in their zeal to sensationalise and chase TRP’s are doing a great dis-service to these hospitals and the the medical profession in the country. The reporting is biased, short on facts and the conclusions drawn are completely unwarranted even bordering on fantasy.

The stories pertain to two cases, one at Fortis Hospital, Gurgaon where a 7-year-old child died of complications related to Dengue and the hospital is accused of over-charging and being callous. The other pertains to Max Healthcare, which is charged with negligence as one of the twins born at 23 weeks gestation was wrongly declared dead at Max Hospital, Shalimar Bagh, Delhi. The false narrative being spun is that the hospital chains are negligent, money- making machines and do not care for their patients. The outrage is completely manufactured and the stories falsely amplified and one-sided.

To make matters infinitely worse the politicians too have jumped in. They clearly want to be seen as championing the poor masses, who mostly cannot afford the services of these hospitals. The hospitals are being subject to multiple enquiries and the police has been called in to investigate the ‘murders’. The hospitals are being threatened with the cancellation of their licenses. (Strangely, a few months ago when scores of children died at a government owned hospital in Gorakhpur because the hospital ran out of oxygen supplies, no one thought of cancelling the license of that hospital)

Lest, we forget, both these hospital chains are amongst the top 5 private healthcare services providers in India. Between them they run more than 40 hospitals, treating thousands of patients every day. They are amongst the most well equipped hospitals in the country, boasting of the highest levels of technology, processes and systems and have patient outcomes comparable to the best in the world. They employ the finest of clinical talent available in the country and provide them an environment to excel. The hospitals attract thousands of patients from all over the world, who travel from across the globe seeking treatment for the most complex of diseases. Having worked in both the organisations, I can confidently say, that while there are many differences between the two institutions, both are thoroughly committed to the highest standards of patient care.

In-spite of all this, the hospitals are not infallible. No hospital in the world is. They can only aspire to do better, keep improving themselves and always try to do the best they can.We need to ponder, how these centre of clinical excellence have suddenly become pariahs overnight basis two cases, where there have been lapses. Like in any other profession or sphere of human endeavour, errors are inevitable. Tight processes, technology support and intent to weed these errors out is far more important than the errors themselves. On these, I can say without any hesitation that the hospitals compare favourably  with the very best that we have in the country.

The line between genuine errors and negligence is very thin. Doctors, while racing to save lives are required to make split second decisions, which may mean the difference between life and death to their patients. Sometimes not taking a particular decision may prove fatal and at others taking a particular decision may lead to complications. We have to trust our doctors to take the right decisions based on their experience and judgement. We also have to accept the fact that their decisions might turn out to be wrong and that these decisions can have horrendous consequences. This is just the nature of medicine. An adverse outcome doesn’t mean that the surgeon or the hospital messed up. It mostly means that they tried their best and yet didn’t succeed.

This is something very fundamental to healthcare. As patients or care-givers, we must support the doctors as best as we can. We can question, we can ask but let us not blame, at least, not every time something goes wrong. If we believe that there is a case of genuine negligence, as consumers we do have options. We can lodge a complaint with the Indian Medical Council, approach the consumer courts or go to the police. We must use these options judiciously.

Getting back to the baby, who was born at 23 weeks of gestation at Max Hospital, Shalimar Bagh. It has now been established that the decision, not to resuscitate the child was medically correct as he had a very slim chance of survival. The prognosis in case of survival too was also very poor. The decision to declare the child lifeless, without fully ascertaining the fact of death was wrong. Failure to properly communicate this tragedy to the parents too was an error. Was this negligence? Was their any malafide intent of causing harm to the child or undue pain to his parents? In my view this certainly wasn’t the case. I am not an expert in these matters and various eminent clinicians are conducting an enquiry about what happened. My view as a layman is that someone made a mistake, it was a bad mistake to make, hopefully some lessons too would have been learned and this would never be repeated again.

Does this mean that the hospital, the doctors and the administrators be called vultures, cheats and murderers and have rampaging mobs running amok in the hospitals baying for their blood?

The views expressed are personal.

Medical Outcomes and Customer Experiences

My father was diagnosed with an oral cancer last March. He had been staying with me in Delhi and fortunately, we had plenty of choice in selecting a hospital, where we could possibly have him treated. After carefully evaluating these choices, we zeroed in on two possible facilities –  Medanta Medicity, the new hospital in Gurgaon and Max Hospital in Saket. At Medanta the leaders of the Oncology team were my colleagues during my stint at Artemis Hospital in Gurgaon, and I enjoyed a great relationship with both Dr. Ashok Vaid and Dr. Teji Kataria, the medical and the radiation oncologists respectively. At Max Hospitals I did not know the doctors personally, they did not have a cancer facility when I worked there, but I had plenty of other close friends who ran the hospital and vouched for the caliber of their team of Dr. AK Anand and Dr. Anupama Hooda. Ultimately, with all things equal we chose Max, simply because it is closer to our home and the logistics prevailed.

This was in March and my father had since undergone Targeted Chemotherapy and Radiation Therapy on an IGRT machine. Post the treatment, he is doing as well as can be expected and I am extremely grateful to the oncologists at Max Hospital. In these past 6 months, I have been visiting the facility often and have become familiar with the customer handling processes at the hospital, which unfortunately still leaves a lot to be desired. While, the medical outcome of the treatment we have received at the hospital has been good, purely as a customer, my experience with the hospital services can hardly be termed satisfactory.

Here are some suggestions as to what can be done to improve the overall hospital experience.

The Issues with Group Practice

The radiation team at Max Hospital follows a group practice system and is led by Dr. AK Anand, who comes across as an extremely competent and experienced physician. He has a fairly large team of physicians, who support him in the OPD. Now, these are mostly young physicians earning their spurs under Dr. Anand’s supervision. Since, the team works on a group practice system, a patient gets seen by any of these physicians in the OPD. Thus, more often than not it so happens that one meets a new physician whenever one visits the hospital. From a patient’s point of view, it is very disconcerting to interact with a new physician and start the entire conversation right from the beginning every time one visits the hospital OPD. Also, the entire team is not of the same pedigree, many doctors are younger, less experienced and seem to be apprenticed with Dr. Anand. They often do not come across as confident and as sure as Dr. Anand, a very important factor, when the disease involved is a cancer.

The entire system revolves around a physical file, where all the doctors jot down their noting on loose sheaf of paper, which is than filed away. Each OPD visit means that the physician assigned to see the patient goes through the file, figure out what had happened in the previous visit and issues fresh instructions on the file. I submit it is quite impossible for a physician to study this file in the time that he is spending with the patient and fully understand what has happened thus far. The chances of human error are high. Max Hospital is bristling with posters on the notice boards about a state of the art e-initiative which is supposed to take care of all medical records electronically. While one goes through the tall claims about this new system, one finds it hard to reconcile it with the archaic processes in the Max Cancer Centre.

The system seems to have been designed around the physicians, one feels it should be, in this age and time around the customers. It should assign a particular doctor to a patient and he should see the patient through. If there are junior doctors involved, they should see patients along with the seniors, till they themselves feel comfortable in handling patients on their own. The physical files are ridiculous and can be done away with completely. Like in any other modern hospital, the information should flow seamlessly on a well-connected network. Reports, instructions etc. can and should be as far as possible e-mailed to patients.

The Appointment System

Strange as it may sound the appointments given to the patients have little value. Almost all patients are required to wait for a minimum of 30-40 minutes, whether they have a confirmed appointment with their physicians or not. Because of the prevalent group practice system, it is also quite immaterial whether you have an appointment with Dr. A or Dr. B.,  you can be ushered into the office of any  doctor on the team and he will see you irrespective of the fact that you have an appointment with a particular doctor. Thus, I have not really understood, why are appointments given for any particular doctor. In this system, it would make greater sense if one was to just walk in and gets seen by which ever doctor who is free at that point in time!!!

The Files

The files are the most important element in this entire process. Sometimes I have wondered what would happen if it would be misplaced. Actually it happened with us once, when the file had been requisitioned by the medical oncologist, and it took two hours, some very heated words and a few very flustered employees to find it. In the absence of the file, I would reckon the doctors too would be quite helpless. I have been assured that the paper file does have an electronic back-up, which honestly I doubt. I shudder to think that in this age and time, at Max Hospital, we might be at the mercy of a file, which changes hands every time a doctor sees us and God forbid, if somehow it is lost in the hospital.

While all this may sound strange and terribly dated, I must say that the system somehow works. We have no complaints on the medical outcome, which is the primary reason we have been visiting the hospital. As a patient and a care-giver I do not have much to complain about. However, as a modern-day paying consumer, wouldn’t I want my hospital experience to be far superior and fool-proof than what it is.

Hospitals must understand that in this age of customer experiences, it isn’t the medical outcome alone that counts. Max should know this better than anyone else.

The Afghans at Max Healthcare

I have been in and out of the Max Hospital in Saket the last week, mainly on account of my grandmother who is admitted in the hospital’s medical ICU, trying to beat a tough infection and the kidney failure it has brought on. My grandmother is over a 100 years old and is a fighter to the core. At her age, we know her prognosis is grim, however she is not giving in-not just yet at any rate.

As I spent time in the hospital, I could not help but notice the Afghans flooding the hospital. The tall and strapping Afghans, many in their traditional dresses are easily recognisable.  Seeing so many of them using the hospital now, sent me back 5 years down the memory lane, when we had first looked at Afghanistan as a possible business opportunity.

Ashmeena Ghei,  had just taken over as the Head of International Sales and I headed Marcom as well as domestic sales with in India. Dr. Praveen Chandra had joined the interventional cardiology team and was keen to taking a medical team to Kabul. In his earlier assignment at the Escorts Heart Institute, Dr. Chandra had successfully organised many such camps. Between him and Ashmeena, we assembled the team for Kabul. Ashmeena went earlier to set up everything, the team’s stay arrangements, local hospital tie ups, publicity for the medical camp, permissions from local authorities et al. I arranged all the publicity material-getting posters and banners in Dari was a tough ask, but we got everything organised and sent to Kabul by the Indian Airlines flight, only to discover errors in camp dates!!!. I had no way of understanding what dates have been printed in the Dari script and these were discovered when our material reached Kabul. Panic hit the Delhi team and we worked overnight to correct the mistakes and resend everything.

Dr. Chandra and his team’s visit was hugely successful. They treated scores of local people and generated tremendous goodwill for the hospital. We had them on the local Tolo TV station and the local press covered the camp. Ashmeena also roped in the general sales agent of Indian Airlines based in Kabul as the local Max Healthcare representative. His office was right opposite the Indian embassy in Nowshar area of the city and this proved hugely beneficial as patients planning to travel to India could get their visas at the embassy, walk across the road to purchase their tickets and also get information about Max Hospitals. The office was inaugurated with much fanfare with new Max signboards being put up in English and Dari. We also forged a referral tie up with the local Blossoms Hospital. This was to be used for regular referrals to Max Hospitals in Delhi.

That began a small trickle of patients from Kabul. Subsequently when Ashmeena moved on, I took over from her as the Head of International business at Max Healthcare. The traffic from Afghanistan continued to grow, we appointed a few agents in Delhi who regularly brought in their patients, hired local Afghans as translators and continued sending medical teams to Kabul frequently. My successors at Max have done a fantastic job of extending the Afghan connection so much so that in December last year when my father was hospitalised in Max for prostate surgery, I received a call from the hospital’s international desk, with someone trying to hold a conversation with me in Dari!!!. Going by our Muslim  name, the desk had simply assumed that my father must be another Afghan patient admitted in the hospital.

Sitting quietly in the hospital cafeteria I could not help but watch with pride the multi-hued, multilingual and truly international set of patients using the hospital’s services.  The preponderance of the Afghans in this mix made me wonder that the seed that was planted so many years ago has grown into a big tree.


The Hindustan Times and the Hospitals in Delhi

HT Report 1The whole of the last week The Hindustan Times carried a series of stories highlighting incidents of ‘negligence’ in high profile private hospitals in Delhi. The hospitals featured included Fortis Escorts Hospital, Max Hospitals, Apollo Hospital, Sir Gangaram Hospital and Rajiv Gandhi Cancer Hospital. Now these hospitals in Delhi are the best that we have. While, Hindustan Times has a right to expose cases of negligence in hospitals I am still not sure what purpose was served by these reports.

Here are a couple of points I would like to make about these ‘exposes’.

The cases reported highlighted horrific experiences consumers had in these hospitals. Most people featured in the story lost a loved one because the hospital failed to deliver adequate care and refused to take responsibility for what went wrong. These I am afraid were random cases picked up by intrepid journalists and made for riveting reading. However, the journalists doing these stories did not investigate the reason for these failures. The question why did these hospitals fail in their duty towards their patients remains unanswered. Was the failure a result of a doctor not discharging his duties properly, or was it a failure of the hospitals processes or both? Or was it negligence or an error of judgement on the part of a doctor? Did he deliberately mistreat a patient, was callous in discharging his duties, wilfully deviated from standard medical practices or just did not care enough?   Continue reading

Hospitals and Luxury Hotels

posh-hospsYesterday I came across a piece in The Hindustan Times, which talked about the ‘luxury’ that a hospital now offers. The piece had snaps of fancy chefs offering a choice of cuisine to patients, nurses ‘requesting’ young patients, mostly kids to have their medication and the pretty front office executive (with her ‘May I help you badge’ in place)making ‘guests’ welcome.

This made me remember my grandmother, who is all of 104 years old narrating to me her escapades in hospitals run by the British in colonial India. She had great admiration for the no nonsense English doctors, the stern nurses, who followed orders and paid little attention to patient grievances. She remembers these episodes with a mixture of nostalgia and respect for the efficiency that this system stood for. The food was always what the doctor ordered, the medicines were given like clockwork and chores like sponging were a must-the patient had little choice in the matter.   Continue reading

Pricing Healthcare Services

healthcare-pricingThe pricing of services in a hospital is perhaps one of the most complex and difficult exercise undertaken by the hospital managers. Pricing is  usually a Marketing function in most industries and the final call would usually rest with the Marketing chief. However, in hospitals this seldom happens. Pricing issues are generally discussed and debated in the executive committees and the leadership teams, views are sought from senior medical leaders and usually a consensus is arrived at. l,

Many hospitals follow a ‘market based’ pricing model, which simply means they comb through the pricing policies of their competitors, get pricing data from various labs and other diagnostic centres through their referral sales teams and establish their pricing either basis a premium or a discount from their chosen competitors.

Very few hospitals have a ‘cost plus’ pricing system. Developing an accurate costing of all medical procedures is next to impossible. This is simply because the medical consumables used vary from doctor to doctor and also depend on the complexity, age and general condition of the patient. The cost is also invariably a function of the training and competence of the concerned doctors and medical staff attending on the patient. Thus the cost of a bypass surgery may vary dramatically depending on the condition of the patient, the competence of the surgeon and his team and co-morbidities like diabetes.

The calculation of a price is usually based on a ‘surgeon’s fee’. On top of this is added the cost of anaesthetic gases, the anesthetist’s fee, an OT fee and OT consumables. The surgeon’s fee is usually checked with the hospital’s surgeons and if it is Rs. X, the fee for surgery inclusive of gases, anaesthetist’s fee and the OT charges usually adds up to Rs. 2X. 

The patient on top of this is charged room rent depending on his choice of the hospital room, the cost of medicines and room/ward consumables and all diagnostics. The hospital also charges exorbitant consultant’s visiting fee every time he/she visits a patient in the hospital. (Some hospitals like Artemis cap this to a maximum of two chargeable visits). Strangely all hospitals charge a premium on all services if a patient chooses a single or higher category rooms. This simply means that if one opts for a single room one pays higher for everything, the surgeons fee, the cost of surgery and diagnostic tests. Most people do not know this and believe that the hospitals charge a premium only on room rent. Many would consider this a pernicious practice simply because a surgeon’s skill and time, which are the determinants of his fee has nothing to do with the room category a patient is in.   Continue reading

The High Tech Story

ct-scanner1 I recently came across an intriguing piece of news on  the online WSJ about the efficacy of the 64 Slice CT  Scanner. I am familiar with this piece of high tech  gadgetry because I was tasked with marketing the  benefits of CT Angiograms, when Max Hospital had installed it at the Max Devki Devi Heart and Vascular Institute. I recall we were in a race with Apollo Hospitals, who had also bought  a similar machine and both of us wanted to claim that we were the first to offer CT Angios in the city of Delhi.

The WSJ piece titled ‘Doubts grow over High Tech CT Scans of the Heart’ refers to a study published in the Journal of American College of Cardiology and concludes that ‘in more than 50% of the subjects, CT angiography ‘detected’ coronary obstructions that simply were not there’. The study was  funded by the Dutch government and used CT scanners made by Siemens, Philips and Toshiba.   Continue reading

Marketing Maternity Programs

maternity1Fortis La Femme, a boutique hospital for women is running a promotional campaign on a local radio station for their IVF program and the venerable Moolchand Hospital has launched ‘Mother’s Nest’ a maternity services program targeting would be parents. A full page advertisement announcing the new program was carried in HT City a few days ago.

Fortis La Femme, which was known as Cradles earlier was a brain child of Ratan Jalan, the CEO of Apollo Health and Lifestyle Ltd. (AHLL) who was my boss, when I headed marketing at AHLL. The Cradles was set up as a franchised operation and was later bought over by Fortis. It was conceived by Mr. Jalan as a high end birthing centre and has now been repositioned a s a hospital for women, with Maternity Services being one of the several service lines.

Moolchand Hospital has of course been a fixture in Delhi’s firmament for decades and is undergoing a complete makeover under the guidance of Shravan and Vibhu Talwar, the present owners. Both of them are well known to me.   Continue reading