Need of Change to Run the Business

Time For Change

ways to implement change
Possible challenges faced by the management that limit the ability to run the business better. Knowing where or what to change is only the first and simple step in the exercise. Just an analysis of the situation would be of no use. There is always a need to move towards making this change.

To quote Karl Marx -

"The philosophers have interpreted the world in several ways; the point though is to change it."

Facts
Before pondering upon several options that can be taken care, it is important to understand a few facts:

1. A majority of those among the management believe that problems are attributable to people in an organisation. The fact though is that over 90 per cent of all problems are due to the processes. Only 10 per cent is attributable to the people.

2. The person owning the process has the authority to change it, usually top management in an organisation.

3. It therefore obviates the necessity to work actively on processes and not people. Changing processes requires one to have a thorough understanding of its impact. It is also necessary to be responsible and accountable for it.

4. Changing a process requires every person responsible to be taken into confidence. This is probably the most difficult part of the process.

5. Keep in mind that about 10 per cent of the problem is attributable to people - it may, however, have a far greater impact on processes to be ignored. The fact therefore is that change management sometimes does require you to "change the management".

6. Making a change in your organisation is not a magic bullet. At no stage can one allow the current systems to stop working without an alternative one being put in place. In a hospital environment, therefore, change needs to be initiated without disrupting the present system. This requires one to follow a method of evolution or making one change at a time, and waiting for it to stabilise before making another. Any attempt at drastic change can only be doomed to failure. It must therefore, be evolutionary in nature.
There are essentially four questions we must ask before bringing about the change contemplated. Why is it necessary to change and what needs to be changed? And if change has to be implemented, what should it be changed to? Finally, how would one go about doing this?

Methodology
Way back in the early 1950s, a physicist and statistician, W Edwards Deming evolved a methodology for business process improvement that came to be known as the the Deming Cycle. His method was one of the continuous improvement process. This is also known as the PDSA cycle - plan, do, study and act. It seems quite simple and obvious until we look at the elements that go into each of these components.

Using the Deming Cycle
The components of the Deming cycle indicate the steps required to be taken in the process of making the change. Though it is not simple math, it is no rocket science either. The following paragraphs outline the steps involved in the PDSA cycle:

Plan - The first stage requires establishing objectives and processes that are required to deliver the desired end result; the focus of the entire plan. All specifications, policies, practices, procedures and other aspects that may need change must be formally listed. An exhaustive list and accuracy of detail should be a part of the plan.

Do - The second stage requires one to carry out changes taking small steps at a time to examine its impact on the results. Every aspect of the process will have to undergo change in line with the overall plan, and not be limited to individual functions, departments or activities. The correlation between each part of the plan and its implementation is extremely crucial to its success.

Study - The third stage requires one to formally study the impact this change would bring. Often, whenever change is put in place, there could be some volatile fluctuations in its results. Such impact of any change that one makes to the system is not abnormal. One of the most dangerous things to do when one observes such fluctuations is either to revert to the older system, or try to take immediate corrective action. But, it should be kept in mind that the results now seen are based on a small sample. Trying to correct a system at such a nascent stage often leads to changes that are even more abnormal than what one started with.
Therefore one should ensure that the process has stabilised before reviewing it or studying its impact. Depending on the magnitude, carry out the study every day, or over a one-year period. For instance, if the change is to impact patients' waiting time in a queue, it is best assessed every day. If, it is to impact the capital structure of the organisation, it is better to review it only after a significant time has elapsed; say six months to a year. It is also important to study the impact not merely as visible numbers of the results, but to try assess the non-measurable, qualitative changes that have resulted from the processes.

Act - In the final stage, one needs to understand with clarity the impact that should be made by using the new standard. It is worth taking a relook at the plan, the method by which it was acted upon, and the end results as seen by stakeholders. One may also need to guage the success and failure involved in the process.

Warning Signs and Mirages

The most important aspect that the management often misinterprets is in involving people in the change process. It is often understood to mean that they communicate with everyone through slogans, posters and notices. This is probably the worst form of communication. They seldom serve any purpose and often have no, or at best negligible impact, on the results in a coprporate setting. It is better to communicate the changes formally through short daily meetings, highlighting the achievements and progress.

The second aspect is not to go by visible figures alone as the basis of evaluating any change. It is often the invisible part of change that is far more important than the visible component.
The third aspect is never to reward or punish people based on short-term results. There have been numerous cases of people working their way around the system rather than working for the system. The biggest reward for individuals in such cases are rarely monetary. These are usually best offered in the nature of being duly recognised as a leader of the group, or appointment to a job suited to the person's aspirations. It could even be a small memento declaring the good work carried out.

And Finally we can conclude...

The journey of change has begun. As the clichéd proverb goes - the only constant is change. While embarking upon this journey, it is often not the destination, but the journey which is important. If you do things even reasonably right, it will lead you to your destination eventually. But, what you might find on this journey is that somewhere the gradient gets too steep or you are running into uncharted territory, and at this stage you may find it difficult to proceed.
I recollect a famous quote often used in rural India, which roughly translates as - "The first time is always a big issue, every subsequent time it is monkey business!" It is therefore necessary to look for help, the first time, but for that expert who has been through this several times before, it is monkey business. Would you be able to make it to the next stage of the journey? There are three facets to it - a Yes, a No and a Maybe. Yes, because failure may not be the only option and help is always available. No, because it is not a question of getting there eventually, but within a timeframe. Time and competition will not wait for you to catch up.
And the Maybe quotient; because you may be already far too deep in the water than you imagined. Getting out of the current mess may be far more difficult than thought. There may be a way out but the "cost" may be far too much to swallow. Henceforth, we should empower ourselves to l address the question of "What to do? When?"

Guide to NABH Accrediation

A brief guide for healthcare providers who wish to go for NABH accreditation.
Having gone through the rigorous assessors training for National Accreditation Board for Hospitals & Healthcare Providers (NABH), I understand how demanding the standards are. Moreover, as NABH is very recent, doubts persist over explanation and application of various objectives of the NABH standards. Here I am trying to elaborate few NABH standards.
.2.
Patient and family rights, support individual beliefs, values and involve the patient and family in decision making processes.
Objective Elements
2. A. Patient and family rights include respect for personal dignity and privacy during examination, procedures and treatment.
Explanation: To ensure that inappropriate (revealing/short/broken buttons etc) patient gowns are not in circulation. Right size of gown to be given to the patients. Dignity for the patient to be observed even when the patient is semi/unconscious, while shifting the patient, etc.
2. G. Patient and family rights include information on how to voice a complaint.
Explanation: There should be a mechanism for receiving verbal complaints from the patients/their relatives. Methods could include feedback forms, suggestion boxes etc.
2. H. Patient and family rights include information on the expected cost of the treatment.
Explanation: There should be evidence by way of patients'/admitting relatives' signature that he/she has understood the encumbrances and possible increase in costs depending on further care requirements of patient.
COP.2
Emergency services are guided by policies, procedures, applicable laws and regulations.
Objective Elements
COP.2 B. Policies also address handling of medico-legal cases.
Explanation: Local laws and guidelines also have to be considered while handling medico-legal cases. Medico-legal cases should be intimated to the local police station immediately.
COP.3
Ambulance services are commensurate with the scope of the services provided by the organisation.
Objective Elements
COP.3 A. There is adequate access and space for the ambulance(s).
Explanation: Easy turnaround of vehicle is a must, and ramp must not be steep to cause inconvenience.
COP.3 C. Ambulance(s) is manned by trained personnel.
Explanation: Only well-trained staff (nurses and technicians, etc.) should man the ambulance. And proper training record of the same should be maintained as evidence.
COP.3 G. The ambulance(s) has a proper communication system.
Explanation: A working method of communicating with the base to be made available. Mobile phones accepted as compliance.
COP.7
Policies and procedures guide the care of vulnerable patients (elderly, physically and/or mentally challenged and children).
Objective Elements
COP.7 A. Policies and procedures are documented and are in accordance with the prevailing laws and the national and international guidelines.
Explanation: Lunacy Act 1912 (now replaced by the Mental Health Act 1987) to be referred to for details.
COP.7 C. The organisation provides for a safe and secure environment for this vulnerable group.
Explanation: Hospital to ensure provision of railing, skid free tiles, easy access to wheel chair, nearness to call bell, easy to open doors, prevention for abduction of babies, baby swap, etc.
MOM.2
There is a hospital formulary.
Objective Elements
MOM.2 A list of medication appropriate for the patients and organisation's resources is developed.
Explanation: All medicines for all available and advertised specialities to be available. For instance, narcotics under NDPS Act to be available for pain elevation clinic etc. To ensure availability of all essential drugs, daily and common use drugs, etc.
MOM.2 C. There is a defined process for acquisition of these medications.
Explanation: To include vendor selection method/policy, lead time, cold chain concerns etc.
MOM.2 D. There is a process to obtain medications not listed in the formulary.
Explanation: Short purchase policy, policies for outside purchase, allowing patient to purchase, et., but in consonance to the above point MOM 2-A.
MOM.4 Policies and procedures guide the prescription of medications.
Objective Elements
MOM.4 B. The organisation determines who can write orders.
Explanation: Keeping in mind statuary requirements, the organisation has to outline who shall write orders apart from the treating consultants. This point is of importance in instances when the treating physician may not be available and the orders may be given by him on the phone etc to the nurse/RMO. Also refer point MOM 4 E below.
MOM.4 E. Policy on verbal orders is documented and implemented.
Explanation: The organisation needs to make a policy on accepting verbal orders, especially keeping in mind the potential communication errors which may lead to a wrong medication. A policy may be in place to not to accept verbal orders (preferably) or to get it doubly checked by a senior staff member or a senior resident etc. Apart from that, verbal orders have to be countersigned by the prescribing consultant within 24 hours.
MOM.5 Policies and procedures guide the safe dispensing of medications.
Objective Elements
MOM.5 B. The policies include a procedure for medication recall.
Explanation: Policies have to be in place to recall a particular batch or a lot of medicines/consumables. This is essential in case of identified defective batch or notice from Government regarding the same. The same should also be done when an instance of wrong prescription or wrong administration of medication is identified, to ensure that the same mistake is/was not duplicated for other patients.
MOM.7 Patients and family members are educated about safe medication and food-drug interactions.
Objective Elements
MOM.7 A. Patient and family are educated about safe and effective use of medication.
Explanation: The patient and family members should be explained clearly and in detail about the medication, specially in the OPD and at the time of discharge. This should be done to avoid incidences of over dosage, allergic reaction, etc.
MOM.7 B. Patient and family are educated about food-drug interactions.
Explanation: There is a need to educate the patients and their family members about the adverse reaction of certain food items on some drugs, and the necessity to avoid such food items during the medication period. Example, alcohol contradicted with metranidazole etc.
MOM.11 Policies and procedures govern usage of radioactive or investigational drugs.
Objective Elements
MOM.11 C. The policies and procedures include the safe storage, preparation, handling, distribution and disposal of radioactive and investigational drugs.
Explanation: There was a concern that some junk dealers may sell the nuclear portion/source for making a crude bomb. BARC can be notified to dispose this nuclear source prior to disposal. BARC disposes of the same in safe controlled methods.
HIC.7 There are documented procedures for sterilisation activities in the hospital.
Objective Elements
MOM.7 C. There is an established recall procedure when breakdown in the sterilisation system is identified.
Explanation: Example: Recall of entire CSSD load for a wet item found in the dry pack.
CQI.3
The organisation identifies key indicators to monitor the managerial structures, processes and outcomes.
Objective Elements
CQI.3 D. Monitoring includes utilisation of facilities.
Explanation: Monitoring of bed occupancy, average length of stay (ALOS), ICU utilisation etc. This indicates whether we are optimally utilising our resources and can also pinpoint a deviation in the quality of care if an ALOS varies from estimated for a particular case.
CQI.3 G. Monitoring includes adverse events.
Explanation: There should be a system in place to monitor and also minimise adverse events like bed falls, accidents, drug allergy, wrong drug, etc.
CQI.6 Sentinel events are intensively analysed. Monitoring of these events are essential as occurrence of these will only reflect poor processes and lack of training of staff, both reflecting poor patient care.
Objective Elements
CQI.6 A. The organisation has defined sentinel events. Sentinele even may include neonatal abduction, rape, murder, fall from staircase, electric shock, sparks, birds in AC ducts, bed falls, bed sore after admission, fall from window/balcony, suicide, discharge against medical advice.
ROM.5
Leaders ensure that patient safety aspects and risk management issues are an integral part of patient care and hospital management.
Objective Elements
ROM.5 D. Management provides resources for proactive risk assessment and risk reduction activities.
Explanation: Similar to preventive and corrective action of ISO 9001:2000. Confusion surrounds between the difference of preventive and corrective actions. A preventive action is one where an incidence has yet not occurred, but there is a potential hazard, while a corrective action is one when an incidence has occurred and necessary corrections are put in place for immediate reprieve and further prevention.
Examples of preventive action are naked electrical wires and a check on it to prevent any electric shock and; observing that there is lack of pest control and carrying an immediate pest control activity before infestation of insects and rodents, etc.
While example of corrective action is an electric shock has occurred due to a naked wire and now the naked wires are repaired to prevent such an incident from occurring again.
FMS.1
The organisation is aware of and complies with the relevant rules and regulations, laws and byelaws and requisite facility inspection requirements.
Objective Elements
FMS.1 D. There is a mechanism to regularly update licenses/ registrations/ certifications.
Explanation: SOP may be made with instructions as to how, when and where the licenses will be renewed and from which nodal agency. A list of licenses, consisting of renewal dates (including software package renewals) and trigger date for each, and responsible authority for renewal is a good practice.
HRM.6
The organisation has a well-documented disciplinary procedure.
Objective Elements
HRM.6 B. The disciplinary policy and procedure are based on the principles of natural justice.
Explanation: Both employee and employer shall be given enough opportunity to defend the case. Complainant cannot be the judge.
IMS.5
Policies and procedures are in place for maintaining confidentiality, integrity and security of information.
Explanation: To ensure that there is access only by authorised personnel and that processes exist to safeguard against unauthorised access, physical as well as digital, by way of lock and key, password protection etc. Protocols should be in place to disseminate the right information to the right person/patient and at the right time. Care also has to be taken while sharing data with external agencies where some tests are outsourced as the confidentiality of patients always needs to be maintained.

Effective Management of Medical Records is in our own interest

Effective Management of Medical Records is in our own interest In-patient as well as out-patient medical records generated in the hospital, in its own interest as well as for the patient are required to be stored for stipulated time depending on the relevance of the record. There is a lot of significance of good practices required in managing medical records.
Are medical records so important?
Medical records constitute a range of medical care documents, which include patient’s history, diagnostic investigations, consent documents, operative notes, nurses’ daily notes, intake / output sheet, treatment sheets, etc. Managing these records systematically is really important, as these records are the only way for the doctor to prove that the treatment was carried out properly. These records become the sole and critical evidence for the treating doctors to defend themselves from any claim of negligence and also for further treatment of patient whenever needed.
How Are Medical Records Stored?
Today in most hospitals, medical records are paper based and are stored manually in designated areas in the hospitals – some have a dedicated medical records room and officers looking after them. However, with increasing volumes of patients over the years, the physical records occupy more space and its more time consuming and difficult to retrieve the patient record. The paper based records are also prone to damage by weather, rodents, dust, etc. along with occupying hell lot of space and also the retrival becomes difficult and lengthy process.
Classification of Medical Records
There are two ways in which medical records can be relevantly classified: the extent to which they can be shared and the contents of the records.
The Extent to Which Records can be Shared
Must be given to the patient- certain records, viz. discharge summary, referral notes, etc., have to be shared with all patients including those who are discharged against medical advice irrespective if the bill payment has been made.
Can be given to the patient after formal application- records such as, indoor papers, operative notes, investigations, etc., requires a formal application from the patient. The copies of these records given to the patient are generally attested as true copies by the hospital.
Given only with direction of the court - some OPD and IPD records, especially those of medico-legal cases cannot be given to the patient without the direction of the Court.
On the other hand, medical records can be distinguished as per the constituent documents and each of them have its own significance, for example – discharge notes, are considered as a critical proof with respect to the in-hospital treatment provided to the patient, irrespective of the fact that the patient has been discharged with / against the advice of the doctor.
Preservation Period, Legal Aspect
There has been ambiguity with respect to clear regulations on how long a medical record must be preserved. Most hospitals follow their own set of policies in retaining records as per the relevance. The limitation period for filing a case paper is up to three years under the Limitation Act 1963 (two years under the Consumer Protection Act 1986). Nonetheless, the limitation period starts only after the patient becomes aware of the effect of the alleged negligence by the doctor.
The Maharashtra Government has issued a resolution (ref GR No. JJH-29 66/ 49733) which says that OPD paper should be kept for three years, indoor case papers for a period of five years and in case of a medico-legal case, 30 years. Usually medical records are summoned in a court of law in:
• Medico legal cases: where often the medical records are referred to establish medical history / treatment given, especially important in road traffic accidents, medical negligence, etc.
• Insurance cases: where the insurance company wants to review the medical records verify the claim
• Workmen’s compensation cases: In cases where an injury occurs to a workman out of and in the course of employment.
• Criminal cases – to prove the nature, timing and gravity of injuries.
MCI Guidelines
The Medical Council of India, has issued the (Professional Conduct, Etiquette and Ethics) Regulations, 2002, which mentions the following on Maintenance of Medical Records (Section 1.3)
• Every physician shall maintain the medical records pertaining to his / her indoor patients for a period of three years from the date of commencement of the treatment in a standard proforma laid down by the Medical Council of India (Section 1.3.1 and Appendix 3).
• If any request is made for medical records either by the patients / authorised attendant or legal authorities involved, the same may be duly acknowledged and documents shall be issued within the period of 72 hours (Section 1.3.2)
• A registered medical practitioner shall maintain a Register of Medical Certificates giving full details of certificates issued. When issuing a medical certificate he / she shall always enter the identification marks of the patient and keep a copy of the certificate. He / She shall not omit to record the signature and/or thumb mark, address and at least one identification mark of the patient on the medical certificates or report. The medical certificate shall be prepared as in Appendix 2. (Section 1.3.3 and Appendix 2).
• Efforts shall be made to computerise medical records for quick retrieval. (Section 1.3.4)
Role of Virtual Record Room (VRR) in Maintaining Medical Records
In my last article in June 2011 of Express Healthcare, I had introduced the concept of VRR. This time, I have outlined a practical case study of VRR implementation.
Quick recap; a VRR is like an online vault of patient records just like the MRD room – a secure online library containing Electronic Medical Records (EMR) of the patients – available for view / access to the authorised personnel as per their preferences. It’s a centralised repository of all patient records at one place, which can be securely accessed 24x7 from anywhere.
A VRR is not something that is important only for tax authorities or municipal corporations as we think of in India, but it is extremely important, critical and legally required in the context of medical care provided to patients. Following is the case study of BSES MG Hospital, Mumbai.
Example BSES MG Hospital, Mumbai
Since the time BSES MG Hospital has implemented the virtual record room; it has been empowered with 24x7 secure retrieval, enabling the admin to process queries regarding medical records substantially faster. Apart from the most evident improvement in time efficiencies, the EMR solution has made BSES MG Hospital’s medical record keeping more systematic. Each physical file has been scanned and fed in the software application. All scanned images can be easily identified intuitively. Ready reference information on the patient demographics (identification, emergency contact, doctor details, etc.) is instantly available from the patient profiles created.
BSES MG Hospital receives end-to-end service (from scanning till patient profiling) to achieve this in addition to the EMR application. The hospital staff doesn’t have to worry of records getting damaged or being misplaced. By using secure login, the authorised personnel can know at all times how many / which records belong to which patient; especially useful in medico-legal cases such as accidents, domestic violence, etc. The software also facilitates them with audit trails, telling them when and by whom the application was accessed.
Implementation of the EMR solution was a fairly simple affair for BSES MG Hospital. They outsourced the entire piece – including software, hardware and manpower. All they had to do is provide a small space for the scanning to happen and an internet connection for data transfer. In fact, they were also able to export all the patient registration details from their existing Hospital Information System (HIS) to the new application – rendering a high degree of accuracy of data entry of patient details. This made the EHR solution complimentary to the existing HIS.

Suggested Topics For Doing Summer Training/Writing Thesis

1.waiting time and consultation time of old and new patient in a particular opd and find out the contributing factors and it's effect on patient's satisfaction

2.Manpower Utilization(Medicos & Para Medicos) , Space Utilization & Patient's Flow and Positioning of various service points.

3.Equipment utilization of each big equipment in OPD (specially in ENT, Dental, Chest and Urology they have many equipments)

4.Time motion study for patients and staff.

5.Diagnostic Referral trends with comparison to previous months.

6.Inter departmental referral trends.

7.Individual potential analysis (for any clarification email us at ranjanranjan@gmail.com)

8.Feasibility study to start organ transplant or any other facility not available (like CT Scan, MRI , Photo Therapy etc)

9.Waiting time and consultation time of Old & New Patients in a particular OPD & find out the contributing factors and its effect on patients satisfaction.

10.We can also do study about the patients retention measures taken by the hospital.

11. A study of credit collection unit with a view to access the feasibility of outsourcing the collection function.

12. Criticality Analysis of Pharmacy Inventory.

Health Care Business Model

Corporate Hospital which came after Apollo Hosptial like Max, Fortis, Wockhardt In less than ten years of time , Wockhardt, Fortis and Max have added close to 5,000 beds, something that took Apollo 20 years. (It is of course another matter that projections show that India needs an additional 80,000 hospital beds each year.) Their revenues have also grown briskly — about 30 per cent annualised for the past five years for each.
While their respective strategies are responsible for their success, it is also true that they timed their entry well. India has a long history of privately run and owned hospitals. By the 1960s, once it became clear that there weren’t enough government hospitals to meet the country’s needs or that they weren’t just good enough, the middle classes swiftly changed allegiance to privately run hospitals. These were of two types. A majority were trusts, set up by big business houses (Escorts in Delhi, Birla Hospital in Kolkata, etc.), while a sprinkling were for profit institutions though these were usually nursing homes and not full blown hospitals, often built by doctors.
So, the notion of a ‘for-profit’ hospital is new. And while many did crop up in the 1980s (a few even tapped the capital markets), Apollo’s is considered to be the first national success story. Till f Max, Fortis and Wockhardt jumped into the ring..
The Strategies
There aren’t any precise estimates of how big the hospital industry is. Apollo’s hospitals group has a turnover of Rs 719 crore over 8,000 beds. That translates into revenues of Rs 2,460 per bed per day. According to some approximations, there are around 875,000 hospital beds in India. So that translates into an industry worth Rs 78,630 crore. However, that would perhaps be on the higher side as majority of the beds wouldn’t fetch Apollo rates. According to a CII McKinsey report, the entire healthcare industry is worth $18.7 billion, with the private sector controlling 65 per cent of it. But this figure includes the pharma industry as well as other healthcare related businesses like pharmaceuticals, diagnostics, etc.
Indeed, hospital industry executives believe it is futile looking for over arching figures. What is more relevant is whether the drivers of the business are in place. And they are.


Firstly, the healthcare market in India is under priced, not only compared to the developed world, but also compared to other Asian countries. If a heart surgery costs $14,250 in Thailand, $20,000 in Singapore and $30,000 in the US, it costs $5,000-7,000 in India. This, despite the fact that Indian doctors (and nurses) are considered to be one of the best in the world.
Secondly , rising income levels and greater awareness has ensured that people are more conscious of the service level of hospitals and don’t mind paying slightly more if what they get in return is substantially higher.
Three, India’s cheaper healthcare has stoked the flames of healthcare tourism — patients come here from all over the world to be treated. along with the intrinsically lower costs, has ensured that hospitals are uniformly full and don’t have lean patches .Also, traditionally healthcare is a recession-proof industry.
This means hospitals can flourish pretty much, as long as they get two things right — managing doctors and understanding the psyche of Indian patients. A quick insight: unlike in the west, where people go to GPs for everyday illnesses, Indians tend to go to specialists. Max Healthcare tried changing this, but failed. Indeed, Max bore the brunt of public scrutiny far more than any other given that it came up in Delhi, and was the first private player of any significance after Apollo.
The original Max plan was simple. Have local primary care centres, which would feed into secondary care centres, which would converge at a tertiary care centre. This model is established abroad, but was being tried for the first time here. It did not worked here in India.
Doctors and patients differed. The former felt that the primary clinics were mpeting with their private practice and, therefore, were reluctant to join up. The absence of a full fledged hospital within Max was another disincentive for doctors who were usually attached to big hospitals for tertiary care treatment which is the big ticket spend. Primary care is like a filter. The absence of a tertiary care hospital also meant that Max’s clinics were used as referral centres to other hospitals.



Also, Max had started its centres at upmarket Delhi localities, assuming correctly that the resident had more spending power and would be willing to afford better medical care. But this turned out to be a bit of a liability, since those patients were used to visiting marquee doctors, whom Max did not have. Though Max had consultants trained internationally, they were unknown names in Delhi.
Analjit Singh describes those days as “his struggle to understand the Indian healthcare market”. Worse was to follow. By 2003, Max’s CEO and the chief medical officer quit. Also, a tie-up with Harvard Medical International (HMI) was terminated in 2004. (Wockhardt would sign up with them later.) Many blamed Singh for his unwillingness to delegate. He took the criticism in his stride and continued to be closely involved. What he learnt has shaped the Max Healthcare of today.
It has adapted the original primary-secondary-tertiary model to a roughly secondary-tertiary model. The secondary care clinics have been upgraded to smaller hospitals (a 20-bed outfit is now a 60-100 bed outfit); simultaneously, the practice of the primary centres has moved to the secondary and main hospital and all primary centres have been closed down.
Max today has four secondary care centres — two at Panchsheel in south Delhi and one each at Noida and Pitampura (north-west Delhi). Plus, it has a general hospital (half- way between a secondary and tertiary care) in Patparganj in east Delhi. It also has as a massive tertiary care unit at Saket (south Delhi), which comprises a general hospital (Institute of Allied Medical Sciences), plus five superspecialty institutes. “Our strategy to meet the demand has been to create five institutes — cardiac, orthopedics and joint replacement, neurosciences, pediatrics and one for obstetric and gynaecology,” says Max executive director and CEO Mukesh Shivdasani. Work is on for another superspecialty hospital in Gurgaon, which will focus on transplant surgery and another one in Patparganj with oncology as the superspecialty. Analjit Singh feels he now has the critical mass to expand.But his advice to all who want to get into hospitals:

“The business is capital-intensive, it has long gestation, and the viability comes when you have played that out.”

Nephew Shivinder’s experience was different. Fortis decided to set up its first hospital at Mohali, Chandigarh, a market that didn’t have any other large, tertiary care private hospital. The idea was to attract patients from Himachal Pradesh, Haryana and Punjab. Simultaneously, it planned secondary care centres in other locations, which would be linked to the big Mohali hospital. It was a classic hub and spoke model.

Health Care Abbreviations in Govt.of India Schemes

ANM : Auxiliary Nurse Midwife
AYUSH: Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy
BEE : Block Extension Educator
BMS : Basic Minimum Services
CBR : Crude Birth Rate
CHC : Community Health Centre
FWTRC : Family Welfare Training and Research Centre
GDMO: General Duty Medical Officer
HA (F)/LHV : Health Assistant (Female)/Lady Health Visitor
HA (M) : Health Assistant (Male)
HFWTC : Health And Family Welfare Training Centre
HW (F) : Health Worker (Female)
HW (M) : Health Worker (Male)
ICDS : Integrated Child Development Schemes
IMR : Infant Mortality Rate
IPHS: Indian Public Health Standards
ISM & H : Indian System of Medicine and Homeopathy
IUD : Intrauterine Device
MMR: Maternal Mortality Ratio
MCH : Maternal and Child Health
MNP : Minimum Needs Programme
MO : Medical Officer
MOHFW : Ministry of Health & Family Welfare (GOI)
MTP : Medical Termination of Pregnancy
NHP : National Health Policy
PHC : Primary Health Centre
PRI : Panchayati Raj Institution
QPR : Quarterly Progress Report
RCH : Reproductive and Child Health