Registered with Registrar of Newspapers under RNI No. MAHENG/2012/46040, Postal Registration No. MH/MR/N/242/MBI/12-14, Published on 27th Total number of pages 48 of every previous month. Posted at Patrika Channel Sorting Office, Mumbai-400001, Posting date: 30th & 31st of every previous month
Embracing modern thinking
April 2013 • Vol 1 • Issue 7 • Rs50
Published by ITP Publishing India
REMOTE CONTROL
CUTTING EDGE
TUBA VERSUS OTHER BREAST AUGMENTATION TECHNIQUES
WIRELESS AND REMOTE PATIENT MONITORING IS REVOLUTIONISING CRITICAL CARE
>>> IMPORTANT LESSONS IN PATIENT COMMUNICATION
SPOTLIGHT
THE MANY OPTIONS OF MECHANISED FLOOR CLEANING
OPINION
MIXED REACTIONS TO UNION BUDGET 2013
INNOVATION
COST-SAVING IDEAS FROM NH, MYSORE
FOCUS
SEVEN CHALLENGES TO ACCREDITATION
DR VIKRAM SHAH OF SHALBY HOSPITALS ON BUILDING A STRONG HEALTHCARE EMPIRE
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Contents
18
09 NEWS
24 TECHNOLOGY
38 PATIENT RELATIONS
This month’s important news updates
Wireless remote patient monitoring in critical care
How hospital staff behaves with patients matters
13 PROJECT SPOTLIGHT
28 INNNOVATION
40 EVENT REPORT
The upcoming Dr Jayharan Hospital in Nagercoil
How Narayana Hrudayalaya Hospital Mysore reduced cost of project and operations
HospiArch, Chandigarh
14 BUDGET ANALYSIS Industry veterans rate the new Union Budget
42 QUALITY CONTROL 30 OPINION
Seven challenges of accreditation
A call for donating blood stem cells to the needy
17 PREVIEW Healthcare Radius' very own conference
44 CONSUMER CONNECT INITIATIVE 32 BEST PRACTICES
Carestream’s e-Radiograph
The latest in hygienic floor cleaning practices
18 STRAIGHT TALK CMD of Shalby Hospitals Dr Vikram Shah talks about the group’s rapid growth
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45 MOVERS AND SHAKERS 36 CUTTING EDGE Benefits of trans-umbilical breast augmentation
Rakesh Singh joins as Manipal COO, Dr Devi Shetty felicitated by IMC and much more
Healthcare Radius April 2013
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Editor's Note
APRIL 2013 • VOL 1 • ISSUE 7 ITP PUBLISHING INDIA PVT LTD Notan Plaza, 3rd floor, 898 Turner Road Bandra (West), Mumbai – 400050 T +91 22 6154 6000
Deputy managing director: S Saikumar Publishing director: Bibhor Srivastava
To the torchbearers
W
ith the Indian healthcare industry evolving faster than the speed of light, it is difficult to find a single trend that could hold our undivided attention for long. But one facet that continues to enthral us, over the years, is the inspiring sagas of doctors turned into mega entrepreneurs. From first such icon, the legendary Dr Prathap Reddy, a cardiologist who founded Apollo Hospitals, today, the industry boasts of hundreds of successful medical entrepreneurs, who have created state-of-the-art institutes and pioneered cutting-edge technology, bringing quality healthcare to a larger populace. Though many of the pathfinders have had fascinating tales to share about their struggle to becoming much-sought after practitioners, their true journey started, or shall I say, that their true character was revealed, only when they decided to don the hat of an entrepreneur. For most, who started in the ’80s and ’90s, the journey was an ordeal by fire, scrambling for funds for a business that is capital intensive and has a long lock-in period. It did not help either that the banks levied an exorbitant rate of interest and that one had to constantly take on the Government for its archaic rules. It was sheer conviction in their dreams and their unswerving grit and determination that helped these individuals achieve their vision. Reflecting this die-hard spirit of entrepreneurship is our cover person, the CMD of Shalby Hospitals, Dr Vikram Shah, who belongs to the heartland of India’s entrepreneurship — Gujarat. Read about his exciting journey that started in a small rented apartment in 1990s. From a single orthopaedic set-up, his enterprise has flourished into a multi speciality network of hospitals, spanning Gujarat and Goa. Despite such Herculean efforts and strides by the private healthcare sector, it’s a pity that the Union Budget has failed to provide any worthy incentive to it. But, incentive or no incentive, the sun in the Indian healthcare industry continues to shine, powered by its many visionaries.
Group editor: Shafquat Ali
EDITORIAL Consulting editor: Rita Dutta T +91 9980 588199 rita.dutta@itp.com Managing editor: Shiv Joshi T +91 22 6154 6034 shiv.joshi@itp.com
ADVERTISING National business head— Manoj Sawalani T +91 9821 76965 manoj.sawalani@itp.com Business head— Douglas Menezes T +91 9821 580403 douglas.menezes@itp.com Regional sales manager — South: Sanjay Bhan T +91 9845 722377 sanjay.bhan@itp.com
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The publishers regret that they cannot accept liability for error or omissions contained in this publication, however caused. The opinions and views contained in this publication are not necessarily those of the publishers. Readers are advised to seek specialist advice before acting on information contained in this publication, which is provided for general use and may not be appropriate for the readers’ particular circumstances. The ownership of trademarks is acknowledged. No part of this publication or any part of the contents thereof may be reproduced, stored in a retrieval system or transmitted in any form without the permission of the publishers in writing. An exemption is hereby granted for extracts used for the purpose of fair review.
Printed and Published by Sai Kumar Shanmugam, Flat no 903, Building 47, NRI Colony, Phase – 2, Part -1, Sector 54, 56, 58, Nerul, Navi Mumbai 400706, on behalf of ITP Publishing India Private Limited, printed at Repro India Limited, Marathe Udyog Bhavan, 2nd Floor, Appasaheb Marathe Marg, Prabhadevi, Mumbai 400 025, India
Rita Dutta
and published at ITP Publishing India, Notan Plaza, 3rd floor, 898 Turner Road , Bandra
Consulting editor rita.dutta@itp.com
Editor: Rita Dutta
WRITE TO THE EDITOR Please address your letters to: The Editor, Healthcare Radius, Notan Plaza Third Floor, 898 Turner Road, Bandra West, Mumbai - 400050 or email rita.dutta@itp.com. Please provide your full name and address, stating clearly if you do not wish us to print them. The opinions expressed in this section are of particular individuals and are in no way a reflection of the publisher’s views.
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Published by and © 2013 ITP Publishing India Pvt Ltd Title verification no. RNI No: MAHENG/2012/46040
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Embracing modern thinking
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Publishing Director Bibhor Srivastava Tel: +91 22 6154 6046 GSM: +91 9323 252340 e-mail: bibhor@itp.com
National Business Head Manoj Sawalani Tel: +91 22 6154 6026 Mobile: 09820176965 e-mail: manoj.sawalani@itp.com
Executive Editor Rita Dutta GSM: 09980588199 e-mail: rita.dutta@itp.com Group Editor Shafquat Ali Tel: +91 22 6154 6038 GSM: +91 9769 203153 e-mail: shafquat.ali@itp.com
A DV I S O R Y B OA R D OUR EDITORIAL BOARD HOLDS UP A MIRROR TO THE HEALTHCARE INDUSTRY, HELPING US UNDERSCORE THE KEY TRENDS AND DEVELOPMENTS OF THE INDUSTRY
DR NAROTTAM PURI (HONY) BRIGADIER DR ALOK ROY Chairman, NABH and DR ARVIND LAL Chairman, Medica advisor, Fortis Healthcare Chairman and managing Synergie director, Dr Lal PathLabs
DR PRANEET KUMAR CEO, BLK Super Speciality Hospital and chairman, NABH appeals and grievance committee
DR GIRDHAR J GYANI Director general, Association of Healthcare Providers
DR RAVINDRA KARANJEKAR CEO, Global Hospital and chairman, NABH accreditation committee
DR G BAKTHAVATHSALAM DR MK KHANDUJA
Chairman, KG Hospital & Post Graduate Medical Institute
Chairman, BSR Healthcare
DR GUSTAD B DAVER Director, professional service, PD Hinduja Hospital
BRIGADIER JOE CURIAN CEO, SevenHills Hospital
DR DURU SHAH Eminent gynaecologist
DR NC BORAH Chairman, GNRC
SANDEEP SINHA Director, South Asia and Middle East, Healthcare & Life Sciences, Frost & Sullivan
DR SANJEEV SINGH Medical superintendent, Amrita Institute of Medical Science and chairman, research committee, NABH
M O N T H LY M A I L Registered with Registrar of Newspapers under RNI No. MAHENG/2012/46040, Postal Registration No. MH/MR/N/242/MBI/12-14, Published on 27th of every previous month. Posted at Patrika Channel Sorting Office, Mumbai-400001, Posting date: 30th & 31st of every previous month
Embracing modern thinking
Total number of pages 48
March 2013
Vol 1 • Issue 6 • Rs50
An ITP Publishing India publication
IN FOCUS PPP: SOLUTION TO INDIA’S HEALTHCARE WOES? HOW BAPS YOGIJI MAHARAJ HOSPITAL INCREASED EFFICIENCY DEBATE: DOCTORS VERSUS SUPPORT STAFF
MEDICALL 2013 A LOW-DOWN
CASE STUDY MAKEOVER OF PARAS HMRI
DR BS AJAI KUMAR, CHAIRMAN, HEALTHCARE GLOBAL ENTERPRISE, ON MAKING CANCER CARE PROFITABLE
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Good work I have been reading this magazine on a regular basis for sometime now, and I just wanted to appreciate the team for the initiative, inputs and information provided in each issue. The recent one featuring an interview with Dr BS Ajaikumar was impressive. It is indeed true that it takes tremendous grit, courage and drive to build an organisation such as HCG. I complement Dr Ajaikumar for this outstanding achievement and wish him all the success in the years to come.
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Healthcare in India needs a big thrust and I hope this decade really stands up to what has been predicted as the ‘decade for healthcare’. We saw tremendous success in IT, and then it was telecom. I am really hoping that healthcare becomes even more successful not just in treating people in major cities but also in treating every other individual, who lives in the remotest corner of our country. Ashwin Benegal President, India and SAARC Merit Medical Systems India Pvt Limited, Mumbai
What a feat! I liked reading the article ‘Small measures, big benefits’ article about BAPS Yogiji Maharaj Hospital in Ahmedabad. It’s encouraging to see their results. I wish to congratulate the team of the hospital for their feat. Dr Reshma Ansari Manager Quality & Patient Safety Breach Candy Hospital, Mumbai
Impressive I really liked reading the March issue of Healthcare Radius.
I am a regular reader of Healthcare Radius and find the magazine impressive.
Dr Aashish Contractor HOD, Preventive Cardiology Asian Heart Institute, Mumbai
Sudhaker Jadhav Associate vice-president Yashoda Hospitals, Hyderabad
Healthcare Radius April 2013
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NEWS TRACK
NEWS TRACK LVPEI’S NEW CENTRE AT BELLARY
LV Prasad Eye Institute (LVPEI) inaugurated a secondary care satellite service centre, the Y Mahabaleswarappa Memorial Eye Centre, at Talur Road in Bellary. It is LVPEI’s 11th satellite secondary care service centre, and the institute’s first in Karnataka. The centre is constructed on a 3.5-acre of land, with 20,000 square feet built up area in phase one of its
development. It will undertake preventive eye care programmes, provide community-based rehabilitation services, serve as a site for epidemiological studies and be an eye donation centre. It will provide high quality eye care services to a population 1.0 million in and around Bellary district, catering to both paying and non-paying patients, wherein
BGS GLOBAL INTRODUCES FFF
patients who can afford to pay will be charged according to their ability to pay. The three tier fee structure cross subsidises the cost of care for patients, who cannot afford to pay, while ensuring equitable quality of services to all. From the third year onwards, the centre is expected to cater to over 20,000 out-patients and perform 3,000 surgeries annually.
NH: EMPOWERING WOMEN
MATERNAL AND CHILD HEALTH ALLIANCE
There is a dearth of women staff in healthcare. Thus, on the occasion of World Women’s Day, Narayana Hrudayalaya announced being one of the largest employers of women in the healthcare industry. The Narayana Hrudayalaya, Bengaluru, has around 3,000 women on its staff, including doctors, nurses, paramedics and administrators. In the supporting services staff too, it has employed large number of women employ-
The US Agency for International Development (USAID), the Kiawah Trust of UK, and Dasra, an Indian philanthropy foundation launched a $14 million partnership to address the healthcare needs of adolescent girls, mothers, newborns, and children in India. The alliance will enable greater engagement and committed resources through a multi-stakeholder approach focused on fostering innovation, improving health outcomes, and scaling high impact interventions.
ees: nine ambulance and buggy drivers, 70 security and lift operators, 400 house-keeping staff and 20 cafeteria staff.
BGS Global Hospitals, Bengaluru, has announced the launch of the innovative Flattening Filter Free Mode (FFF). This is possible through the advanced TrueBeam STx machine installed at the hospital. The FFF not just helps reduce radiation exposure to just a few minutes per session, but also enables treatment of complex and hitherto untreatable cancers with better outcomes. The technology delivers a high dose radiation to the target tumour, which is generally critically located, precisely and accurately without damaging neighbouring tissues/organs. The FFF beam has high dose rate 2 to 4 times more than the regular beam, hence treatment time is drastically reduced.
67,000 THE NUMBER OF MOTHERS WHO DIE EACH YEAR FROM COMPLICATIONS DURING PREGNANCY AND CHILDBIRTH
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NEWS TRACK
NICU UNIT AT DWARKA Fortis La Femme has launched an advanced, level III NICU at Bhagat Chandra Hospital in Dwarka. A level III NICU offers advanced care, including assisted ventilation and CPAP to very sick newborns and pre-term babies. With the launch of level III NICU, Bhagat Chandra Hospital now gets access to the super-specialised care and services of the NICU of Fortis La Femme. The NICU will be serviced by trained neonatologist, round-the-clock neonatal resident doctors, NICU trained nurses, paediatric cardiologist — neonatal ECHO, paediatric surgeon and paediatric ophthalmologist for screening of retinopathy of prematurity and treatment and developmental clinic for long-term follow-up of premature babies. Said Dr Raghuram Mallaiah, head of neonatology, Fortis La Femme, “There has been an increasing trend towards having premature babies and hence it is important to have a well-equipped NICU to not only save their lives but also to improve the long-term outcome for these very precious babies.”
PIRAMAL FOUNDATION’S NEW PROJECTS Piramal Foundation’s Swasthya project and Health Management and Research Institute (HMRI) has signed an Agreement of Service with the Government of Karnataka that aims to provide health information help line services in the state through 104 BSNL telephone number. This service has been named ‘Arogya Vani’. As a part of the agreement, ‘Arogya Vani’ will assist people living in rural areas of the state, who face difficulty in accessing a qualified doctor. The help line will ensure that these people get basic information on their health conditions and the available medical facilities through a process, which is easy and accessible, through the year.
PHILIPS CONTRIBUTES TO SLEEP DISORDERS AWARENESS On the eve of World Sleep Day 2013, celebrated on March 15, Philips Healthcare India reiterated its commitment to increasing awareness on common sleep disorders that affect an overwhelming 93 per cent Indians. As part of its awareness drive, Philips Home Healthcare division organised over 150 sleep-focused events in 2012 and intends to increase this to 250 in 2013. Also identifying the need for trained sleep specialists across the country, Philips has already trained over 200 technicians and 500 physicians, and will continue to grow this number over the next few years. In addition to this, Philips will continue to help assist hospitals in setting up more sleep labs across the country.
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7 MILLION
Indians live with different types of sleep disorders, with obstructive sleep apnea being the most common
JASLOK HOSPITAL PRESENTS BREAKTHROUGH IN DEEP BRAIN STIMULATION Jaslok Hospital & Research Centre, the pioneer in introducing deep brain stimulation (DBS) therapy in India, demonstrated its experience in corroborating and supporting the breakthrough research on the therapy for early stages of Parkinson’s Disease, published recently in The New England Journal of Medicine. DBS therapy has been conventionally used after 11 - 13 years of disease, when the quality of life and social status of the patient are considerably damaged, which even a successful DBS surgery cannot fully restore. However, if performed in early stages, it gives patients of Parkinson Disease, a new lease of life. Explained Dr Paresh Doshi, consultant neurosurgeon in-charge, Jaslok Hospital, “Our experience at Jaslok Hospital has been confirmed by the research, which states that neuro-stimulation was superior to medical therapy alone at a relatively early stage of Parkinson’s disease, before the appearance of severe disabling motor complications. Neuro-stimulation may be a therapeutic option for patients at an earlier stage than current recommendations suggest.”
Healthcare Radius April 2013
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NEWS TRACK
VASAN EYE IMPLANTS CALL FOR COLLECTIVE LENSE IN AN INFANT CANCER RESEARCH
In first of its kind in south India, the Anna Nagar branch of Chennai’s Vasan Eye Care Hospital has implanted a onemonth-old baby with Intraocular Lens (IOL). The baby had cataract in both the eyes. When the baby was brought to Vasan Eye, its eyes were closed and it was not responding to visual stimuli. Before the surgery, other coexistent abnormalities including glaucoma, small corneas, very small eye balls and presence of active infections were ruled out. According to Dr Manjula Jayakumar, paediatric ophthalmologist, Vasan Eye Care Hospital, “In children born with cataract, their immature nervous system will not receive visual stimulation that needs to develop the visual pathways in the brain. This even leads to permanent vision loss. Therefore, paediatric cataract surgery and visual stimulation needs to be addressed as early as possible to avoid complications such as lazy eye and squint.” Added Dr J Arun Kumar, who is a cataract, cornea and refractive surgeon at the hospital, “Most tertiary referral centres implant IOL only at two years of age. However, we took it as a challenge and performed the surgery on a month-old baby.” The infant's eyesight was restored after the surgery.
The three-day Afro-Asian Conference of Transitional Research in Oncology (ACTRO) brought together oncologists from Asia and Africa to Bengaluru. It discussed the need for a repository of cancerbased research in the country. Said Dr BS Ajaikumar, president, ATRO, “India as a country has immense potential to be one of the leaders in oncology research with its burgeoning cancer population and comprehensive cancer care centres. Due to dearth of research in India, we have been depending on the western population data and guidelines, to manage the problem.” Said Dr Prahlad Ram, medical oncologist, MD Anderson Cancer Center, USA, “One of the emerging challenges in oncology is the utilisation of patient-specific genomic information to develop personalised and targeted therapeutic options based on molecular aberrations in the tumour. A second challenge facing cancer medicine is the identification of pharmacological options to overcome resistance and the repurposing of currently approved drugs for cancer therapy.” Said Dr Samuel JK Abraham, surgical oncologist, Yamanashi Universityfaculty of Medicine, Japan, “In the human immune surveillance system, a combination of adaptive and innate pathways work together to tackle cancer. When functioning optimally, they destroy any aberrant cell, which might evolve into a cancer. The dysfunction of the immune system by itself or a relative dysfunction against an overwhelmingly strong cancer causative factor culminates in cancer development. One of the aims of the therapy is to empower the autologous immune cells to treat an already diagnosed cancer and also to prevent a cancer development as well its recurrence.”
IMS TO DEVELOP LOCAL PARTNERSHIPS
TRIVITRON HEALTHCARE WINS AWARD
The IMS Institute for Healthcare Informatics has announced a new initiative to develop local partnerships with leading universities, research institutions, development agencies and the government to reinforce the value of information and analytics in decision making across a range of healthcare issues in India. The India Branch of the IMS Institute for Healthcare Informatics, with the support of IMS Health India, will leverage relationships in the public and private sectors to deliver objective, relevant insights and research to advance the country’s health agenda. The institute will focus on advancing health services research, capacitybuilding, professional training and analytics-based performance improvement. “The transformation of healthcare systems to better serve the needs of patients worldwide can be energised through a tighter linkage between information and decisions,” said Murray Aitken, head, IMS Institute for Healthcare Informatics.
Trivitron Healthcare was conferred with the Global HR Excellence Award for Innovative HR Practices by the World HRD Congress. Trivitron is India’s first medical technology company winning this award in healthcare. “We are glad to receive this award in a category, which is a challenge in HR practices worldwide. In diverse business segments and industries, especially in healthcare, one of the fastest growing competitive and quality focused industry sectors, this award motivates us to take this initiative a step ahead,” Chandra Ganjoo, general manager, human resources, Trivitron Group of Companies.
Healthcare Radius April 2013
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News Track
at a gl ance Alacurity allies with Bensups Hospital Alacurity, a provider of organised services in the healthcare segment, has now extended its reach by forming an alliance with Cygnus Bensups Hospital in Dwarka, New Delhi. The association aims at providing pre and post hospitalisation services like nurses, ac-
commodation, translators, medical equipments, transport, etc to the patients of the hospital group. At the same time, it will also promote various services of the Hospital group. Alacurity’s team plans to be present onsite at the hospital to help the patients.
Temasek Holdings invests in HCG Temasek Holdings, a Singaporebased investment company, has invested in HealthCare Global Enterprises Limited (HCG). Temasek joins existing investors, Premji Invest, and Milestone Religare in a primary equity issuance by HCG. Evolvence India Life Sciences Fund, which has been an investor in HCG since 2007, will be moving
out of the investment in HCG. “Temasek’s global perspective and long-term interest in healthcare makes them a valuable partner. We also welcome Dr Jennifer Lee to our board and look forward to benefiting from her vast experiences in health management and policy,” said Dr BS Ajaikumar, chairman, HCG.
APOLLO GLENEAGLES' world record Apollo Gleneagles Hospitals, Kolkata, became the first hospital in the world to enter the prestigious Guinness Book of World Records for performing 755 free cervical cancer screenings in a single day. The screening programme was a part of the Apollo-YOUWECAN
Hiranandani Hospital inaugurates HBOT unit
A Hyperbaric Oxygen Therapy (HBOT) and wound care facility has recently started at Mumbai’s Dr LH Hiranandani Hospital - IHS Centre for Advanced Wound Care and Hyperbaric Oxygen Therapy. The facility has two new and latest hyberbaric chambers. HBOT is effective in non-healing wounds, acute thermal burns, traumatic brain injury, refractory osteomyelitis, radiation damage to tissues, crush injury, compromised skin grafts and flaps, acute sensorineural hearing loss and several other conditions. The treatment is non-invasive and the patient just needs to lie down in the transparent pressurised hyperbaric chamber and breathe. Each session lasts 60 or 90 minutes and the patient can watch television or DVD movie as the sound comes inside the chamber even though the television is outside.
Fortis launches kidney support group
initiative. Apollo-YOUWECAN has been formed by Apollo Gleneagles Hospitals in association with YOUWECAN Foundation founded by eminent cricketer Yuvraj Singh for organising mass cancer screening programmes across various locations in the state of West Bengal. Art by kidney patients.
DM Healthcare signs Hospital in Qatar DM Healthcare has announced strengthening its operations in Qatar through its first ASTER Hospital project in the country to be commissioned by 2015. The hospital will provide tertiary care services and will cater to
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multi-speciality departments with super-specialty clinics. The focus will be on offering excellence in care delivery with clinical offerings to ensure faster recovery and a minimal length of stay for ultimate patient satisfaction.
On world kidney day, March 14, Fortis Hospital, Mulund, launched the Fortis Kidney Support Group to enable those suffering from kidney ailments to share their treatment and lifestyle experiences, and learn from them. Kidney experts (from Fortis Hospital) will provide guidance to the group, helping them manage their conditions and lead a healthy lifestyle. On the same occasion, an exhibition of 30 paintings made by kidney patients was held at the hospital premises as part of the ‘Kidney Mela’. The paintings narrated the real-life aspirations of patients currently undergoing kidney-related treatments. The fair had several stalls on kidney-related information.
Healthcare Radius April 2013
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PROJECT SPOTLIGHT
COMPREHENSIVE CARE IN KANYAKUMARI
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Name: Dr Jayharan Hospital Location: Nagercoil, Kanyakumari Type: Tertiary care hospital Project: Greenfield Bed strength: First phase 230, when fully commissioned, 500 Promoters: Dr Sunil Jayharan, a leading medical practitioner, and his wife Dr Sashya, a leading gynaecologist Focus: Along with cardiac and orthopaedics as super specialities, the hospital would have other specialities as well. The hospital will be well equipped with operation theatres and ICU facilities, private and general ward along with other services. Commissioning by: 2014 Status: Planning done, drawing in approval phase Design: Hospaccx India Systems Land: 86,865 square feet In-built area: 1,30,780 square feet Project cost: Over Rs90 crore, inclusive of land, construction and equipment Funding: Mix of debt and equity Catchment: Nagercoil and its vicinity. Design highlight: Due to the intolerable heat in Nagercoil during summers, the building is designed such that, inside temperature will be colder in summers as compared to outside temperature. Since the hospital makes maximum utilisation of natural light and ventilation, this will not directly cut the operational cost. However, it will certainly offer more comfort to those inside the building and thus aid recovery of patients.
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Budget analysis
Mixed bag Industry veterans are divided in their opinion on Union budget presented by Finance Minister P Chidambaram AMEERA SHAH | MANAGING DIRECTOR AND CEO | METROPOLIS HEALTHCARE RATING: Although the increase in allocation for healthcare is a positive move, it is certainly not enough. For the sector to make significant strides, a minimum allocation of 4 to 5 per cent of GDP is necessary. Although an increase in spending has been promised, a more sound allocation of resources is crucial for India to enjoy its benefits. A lot of importance is accorded to treatment, but the basic question is — can one prescribe a drug without diagnosing the disease? Despite diagnostics being the first step towards effective treatment, none of our vertical programmes have given adequate importance to it. The Union Budget also fell short of this. The diagnostic industry did not get any relief in tax exemptions for life-saving reagents on pathology tests. Such taxes get transferred to patients and this is important for the 1.2 billion Indian healthcare consumers who pay for healthcare, particularly for diagnostics, out of their pocket. However, 24 per cent increase over the
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allocation to National Health Mission is certainly a positive note for the sector. There is a lot of hope from the National Urban Health Mission, and one could contemplate that diseases, which were out of focus hitherto, would garner more attention. Chronic diseases and mental illnesses should gather pace with the National Urban Health Mission. The allocation for geriatric care too is a step towards preparing India to face the burden of healthcare costs of the ageing population. Allocation of Rs4,727 crore and making six more AIIMS like institutions functional this year should increase the medical capacity, but is too small to affect the doctor : population ratio significantly. Incentivising doctors and paramedics is the only promising way to ensure an equitable distribution of medical capacity. Apart from direct allocation, healthcare would benefit from other sector allocations. Prominent among such allocations is the mid-day meal programme and Integrated Child Development Programme (ICDS). Since these do not fall under the ambit of healthcare, measuring their impact on reducing child-malnutrition is difficult. The budget’s focus on women is a strong enabler towards making them financially independent, which improves their access to healthcare services.
DR E SANEESH | RESEARCH ANALYST
BUSINESS AND FINANCIAL SERVICES | FROST & SULLIVAN RATING: The mention of ‘Health for all as Priority’ by the Finance Minister in the budget speech has clearly implied the Government’s interest to boost public spending on healthcare. As compared to last year, public spending on healthcare has been increased with higher allocation of funds to the Ministry of Health and Family Welfare. Increasing the scope of Rashtriya Swasthya Bima Yojana and proposal for a comprehensive social security package for unorganised sector emphasises the Government’s approach towards Universal Health Coverage. The increasing need for healthcare for the elderly has been addressed by the proposal to create regional geriatric centres. This budget has also focused on strengthening the alternative medicines and central medical institutions. Two big industry expectations such as granting ‘infrastructure status’ for healthcare and lowering the duty of medical equipment have not been considered.
Healthcare Radius April 2013
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Budget analysis
DR BS AJAIKUMAR | CHAIRMAN
DR RR PULGOANKAR | CEO | JALSOK
GIRISH MEHTA | CEO | BEAMS
HEALTHCARE GLOBAL RATING:
HOSPITAL & RESEARCH CENTRE RATING:
RATING:
The percentage of GDP on healthcare allocated is starting from a low base and is still insufficient, but it is good to see an increase. The government should focus on more PPPs in healthcare, which is the only successful model. There are many states that are not able to carry forward the healthcare programmes due to insufficient funds; more funds should be allocated to these states. The tax increase on tobacco products is a good move. Health problems from tobacco usage are on the rise in the country, particularly cancer and cardio vascular diseases. The money generated from this tax should be used appropriately on health and not any other purpose.
I welcome the 22 per cent increase in budget allocation for the healthcare sector, up from Rs30,702 crore in the current fiscal to Rs37,330 crore in the next fiscal (2013-14). Out of this, 56 per cent is allocated for primary healthcare. There is a special focus on completion of six institutions in 2014 that are similar to AIMS and allocation of Rs4,724 crore for medical education. This will help meet the growing manpower demand of doctors, nurses and paramedics. Increasing expenditure on healthcare and healthcare infrastructure will give a boost to the industry.
VISHAL BALI | GROUP CEO | FORTIS
DR NC BORAH | CHAIRMAN
HEALTHCARE RATING:
GNRC RATING:
The budget reflects the urgent need to stimulate growth in the economy. A single healthcare agenda for the country under the national health mission with an outlay of Rs27,200 crore provides an increase of 27 per cent but is still negligible as a per cent of GDP for a country of 1.2 billion people. The budget disappoints the healthcare sector once again since it does not provide any fundamental impetus to accelerate the growth of the sector. The only positive move is an outlay of Rs4,727 crore for medical education, a good directional change to improve the medical talent pipeline for the country. Lowering of fiscal deficit from 5.2 per cent to 4.8 per cent will be a challenge to meet.
Health is one of the sectors that the union budget of 2013 has focussed on. More than 24 percent increase in funding for the NRHM will benefit large number of people in the rural areas and also poor people in the urban areas. Of all things, the allocation of more than Rs4,000 crore for human resource development in the healthcare sector is a step in the right direction. This will help address the inadequate numbers of doctors, nurses and technicians that impairs the healthcare industry
The current budget did not offer anything in specific for healthcare, neither in terms of positive measures nor in terms of new road blocks.
DR GSK VELU | FOUNDER AND MD TRIVITRON HEALTHCARE RATING: Yet another year in which the Government has ignored the healthcare sector. We wanted a status similar to infrastructure, incentives for local innovation and manufacturing in the medical technology industry and higher tax exemption for annual health checkups to achieve the ‘Health For All’ by 2020 objective. There is just marginal increase in Government spending on healthcare. Overall, a disappointing budget for the sector.
Despite diagnostics being the first step towards effective treatment, none of our vertical programmes have given adequate importance to it" — AMEERA SHAH, MANAGING DIRECTOR AND CEO, METROPOLIS HEALTHCARE
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Budget analysis
RAJEN PADUKONE | MD AND CEO | MANIPAL HEALTH ENTERPRISES RATING: The positives are the increase in focus by the Government to cover a larger portion of the economically weaker segments of our population and lower income groups with health cover through the RSBY and other schemes. This is an indirect acknowledgement by the Government to move towards taking on the role of a payer than a provider. Also, given that healthcare sector is capital intensive, an investment allowance for capital expenditure of over Rs100 crore is a welcome move. Additionally, the focus on increasing employable skills and skill building through the
NSDC and allocation of Rs1,000 crore towards this is encouraging. The disappointments are several. The incremental allocation of expenditure over the previous year is only about Rs7,000 crore of Rs37,330 crore. Government health expenditure is still at one per cent of the GDP out of a total public and private spend of around 5 per cent of GDP.
DR NANDKUMAR JAIRAM | GROUP
DR SANJEEV CHAUDHRY | MD
MEDICAL DIRECTOR AND CHAIRMAN COLUMBIA ASIA HOSPITALS, INDIA RATING:
SRL DIAGNOSTICS RATING:
The budget has failed to provide an impetus to healthcare finance, which is a vital need as it is the only way to energise the private healthcare delivery sector that accounts for 80 per cent of the healthcare market and will continue to grow. It is unfortunate that the budget has not provided for adequate incentives towards mandating or permeating health insurance, the only viable alternative to the ever increasing healthcare costs in our country.
DR AM ARUN | CHAIRMAN VASAN HEALTHCARE GROUP RATING: The finance minister has rightly accorded top priority to the health of the citizens with an increase of over 24 per cent to the NHM. He has also realised the need to augment supply of medical professionals and has increased the contribution to the newly started six AIIMS-like institutions as also increased the allocation to medical education and research. I welcome the investment allowance of 15 per cent intended to spur asset creation.
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Considering that private sector serves 75 per cent of the healthcare diagnostics responsibility for the country, the Union budget has yet again missed the opportunity to recognise the stellar role of the private sector both in terms of providing high quality affordable services and geographic reach. The long-standing industry demands of providing fiscal relief for consumables and tax incentives for accreditation have been left unmet, yet again. Industry really hopes the debate on Finance Bill brings these important issues to the table to enable private sector to provide high quality affordable diagnostics to more and more people.
DR A VELUMANI | FOUNDER | THYROCARE RATING: The Government is thinking in the right direction by increasing attention to healthcare. Though late and very little, it is still appreciated. If adequate attention is given to preventive care, it will help the overall healthcare business and improve quality of life for citizens as well.
DR RAMAKANTA PANDA | VICECHAIRMAN | ASIAN HEART INSTITUTE RATING:
The deadline of 2014 and an amount of Rs1,650 crore for setting up six institutions modelled on the AIIMS will go a long way in strengthening the country’s medical education infrastructure. The additional Rs4,727 crore allocated for medical education, training and research will help promote innovation. The Indian systems of medicine have age-old acceptance in several communities and, in most places, they form the first line of treatment in case of common ailments. Hence, I welcome mainstreaming of AYUSH so that some form of medical treatment is available across rural and semi-urban India as well.
DR GIRDHAR GYANI | CEO ASSOCIATION OF HEALTHCARE PROVIDERS (INDIA) RATING: I welcome the 24 per cent increase in the allocation to NHM, the allocation for six AIIMSlike institutes and the allocation for skill development, education and research. However, the budget is silent on any kind of support to the private sector. The Government should have seriously considered giving concessions like abolition of import duty on medical equipment. The Association of Healthcare Providers (India) had submitted to the Finance Ministry a detailed account of how the Government would lose only Rs224 crore if it abolishes the import duty, but the benefit to population will be huge. Similarly, we had submitted a proposal to create a Road Accident Fund, so that victims of road accidents could be provided with timely care in the nearest hospital. But I see none of that mentioned in the budget. Healthcare in this country still has not become an election agenda and therefore does not get the kind of priority, given in countries like the US.
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Preview
Smart Healthcare India Summit The two-day event will be a meeting place for the best minds in healthcare
C
onstruction of healthcare facilities and the renovation of existing ones have created a spurt in the demand for skilled services, be it in hospital planning and design, engineering and IT requirements, medical equipment, etc. Healthcare Radius, a publication of the ITP Publishing India, is pleased to announce the ‘Smart Healthcare India Summit’ on May 23 and May 24, 2013 at the ITC Gardenia, Bengaluru. Spread over two days, the event will be content-driven and invaluable for those in the management and execution of hospitals, where key decision-makers within the healthcare industry will address the strategies and approaches, which help increase efficiencies and drive costs low, leading to improved quality of care for patients. The platform offers hospital managers the opportunity to learn specific tools and techniques to do their jobs better, in an environment of quality learning and networking with peers. Key to this process is the staging of howto, skills-related sessions, run only by experienced professionals and industry experts.
With exclusive C-level roundtable discussions, this is an event that you can’t afford to miss!
KEY TOPICS
SPEAKER PANEL
• Government regulations & policies
• Rajen Padukone, CEO, Manipal Health Enterprises Pvt. Ltd., Bengaluru • Dr Umapathy Panyala, CEO, Apollo Hospitals– Karnataka Region, Bengaluru • VP Kamath, COO, Wockhardt Hospitals Limited, Mumbai • Dr Ravindra Karanjekar, CEO, Global Hospitals, Mumbai • Dr RR Pulgaonkar, CEO, Jaslok Hospital & Research Center, Mumbai • Dr Sameer Khan, CEO, Rockland Hospitals Group, New Delhi Anupam Verma, Group CEO, DM Healthcare, • Mumbai • Dr Mudit Saxena, COO, Healthcare Global Enterprises, Bengaluru • Brig Joe Curian, CEO, Seven Hills Hospital, Mumbai • Udayan Lahiry, President & CEO, Medica Synergie Pvt. Ltd., Kolkata • Dr Raja Sekhar Gujju, Medical Director, Global Hospitals & Health City, Chennai
• Financing hospital setup • Facility management • Maintaining hospital equipment • Supply chain management • Medical waste management • IT innovations and Data security • Bedside Terminal Technologies.
• Dr Chandy Abraham, Group Head For Quality, NH Hospitals, Bengaluru We are expecting over 150+ delegates from hospitals, nursing homes and clinics pan India. The conference is also an ideal forum to interact with technology providers who offer turnkey and cost effective solutions that will help in efficient hospital operations. For registration, contact: Anjali Shetty, sales manager, conferences, ITP Email: anjali.shetty@itp.com Cell: +91 96194 53737 Direct: +91 22 6154 6010
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We put Gujarat on the medical tourism map by performing over 40,000 joint replacements, the largest by a single centre in the world� 18
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Straight talk
The healing touch
Shalby Hospitals has managed to resuscitate the recently acquired ailing Krishna Heart Institute in just three months. CMD Dr Vikram Shah reveals the secret behind the turnaround and the group’s rapid growth INTERVIEWED BY RITA DUTTA
Know Dr Vikram Shah Dr Vikram Shah did his MBBS and MS, Orthopaedics from BJ Medical College, Ahmedabad. He worked in Ormskirk and Wrightion Hospital, England for two and a half years and later in Shelby Baptist Medical Centre, Burmingham, US, Beth Israel North Hospital, Manhattan New York and Darmstadt Hospital, Darmstadt, Germany.
Various media reports placed the cost of acquiring majority stake at Krishna Heart at Rs75 to Rs80 crore, but insiders say that it was much less… I will refrain from commenting on the amount we paid as the founders, the Chokshi brothers (Dr Atul and Dr Animesh Chokshi), would not like the details to be divulged. It was their dream project and even though we are 86 per cent stakeholders of Yogeswhar Healthcare Limited, which runs Krishna Heart, the brothers continue to be associated with the project. Dr Atul, who was the chairman, still takes part in camps, seminars and conducts free angioplasties at Krishna Heart, now known as Krishna Shalby Hospital. The former founders’ connect with the hospital will not be severed in the years to come.
How were you associated with Krishna Heart? From 2001 to 2007, I worked there as a consultant joint replacement surgeon. During that period, I performed over 3,000 joint replacement surgeries. What made you zero in on the project, which was in the red? It is also remotely located. With our flagship hospital on SG Highway running to full capacity, we have been ramping up our bed strength in Ahmedabad by building two more hospitals. As the other two upcoming hospitals that are greenfield would take time, we acquired Krishna Heart, which was a ready facility with a bed strength of around 100. After the acquisition, we have become the largest private healthcare player in Ahmedabad with 450 beds. As for the location, which is Ghuma, I was not
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Straight talk
a 250 bed hospital. We are investing around Rs20 crore to install latest CT scans, X –ray machines, cath labs, and creating two ERs and two OTs. After six months, the hospital will start a liver transplant unit.
Dr Shah turned around Krishna Heart Institute in just three months and now plans to scale it up to a 250-bed hospital. concerned about it as we have a steady inflow of patients to be sent to the Krishna Shalby from the main hospital, where we face perennial bed shortage.
TODAY, THE QUALITY OF IMPLANTS REQUIRED IN JOINT REPLACEMENT HAS IMPROVED, ENSURING 20-YEAR SURVIVAL IN 90 PER CENT CASES
Shalby had to carry forward a debt of Rs45 crore from Krishna Heart… That’s true. But that didn’t bother us. In fact, we made the hospital cash positive in less than three months of taking over. How did you turn it around? By keeping the cost of operations low, sharing clinical resources with the main hospital and allowing doctors to only focus on clinical work. Patient footfall at Krishna Shalby is good as medical tourism patients and patients we cannot accommodate at the main hospital are diverted there.
SHALBY GROWTH JOURNEY 45000
20
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35000
30000
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18197 20000
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10296 10000
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What are your plans to strengthen the unit? After three months, the hospital will be transformed from a cardiac unit into a 150-bed multi speciality hospital. At a later stage, it will become
42500
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In Lacs
Do you think that the remote management of the hospital from the US impacted the functioning of the hospital, which had state-of-theart infrastructure at one point of time? That did have a negative impact. Also, the unit lacked good doctors, and the doctors already present were burdened with mundane administrative work, which affected their clinical output. It’s the doctors that patients queue up for, and when the doctors are busy doing other things, clinical work takes a backseat.
How has Shalby grown over the years? We invested our savings, took small loans and family’s help to start a medical centre at Vijay Cross Road in 1994. The centre had six beds, one operation theatre and five staff. The centre, housed in a low-rise building with our residence upstairs, offered only joint replacement, while my dental surgeon wife Dr Darshini practiced highend dentistry with oral implantology. In 2006, our 200-bed flagship hospital, which is a greenfield project, was commissioned. Today, we have a combined bed strength of over 700 beds with multi speciality hospitals across Ahmedabad, Vapi and Goa, and 16 OPD clinics including a patient counselling centre at Nairobi, Kenya. We have grown 10 times in the last five years and 100 times in the last 10 years. Our turnover last year was around Rs168 crore and EBIDTA was 28 per cent. The EBIDTA fluctuates between 29 to 30 per cent for the flagship hospital. The expected turnover this year is Rs250 crore. Here, on an annual basis, we make Rs1.6 crore per patient per bed or Rs50,000 per bed per day. Our breakeven time for a greenfield project is 18 months, which is faster than the standard two to three years.
7454 209
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1936
4877
0 2002 -03 2003 -04 2004 -05 2005 -06 2006 -07 2007 -08 2008 -09 2009 -10 2010 -11 2011 -12 2012 -13 2013 -14 2014 -15
Revenue
EBIDTA
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Straight talk
surgery is eight to ten minutes and the patient starts walking a few hours after the surgery. But there will be more advancements.. I believe that 1995 to 2005 belonged to the era of cardiology, while the 2000 onwards belongs to joint replacement. Today, the quality of implants required in joint replacement has improved, ensuring 20-year survival in 90 per cent cases. The design of the implant has changed significantly to achieve high flexion, which is a must for functionality. Over the last decade, the age of patients undergoing joint replacement has reduced. As against the earlier age group of 60 to 65, today, 50 - 55 year olds are going for joint replacement, which calls for implants with high flexion. What’s the secret behind the large number of joint replacements at Shalby? In our first year, we could perform only 15 operations. This grew to 600 around 2007 and today, we are able to conduct 5,500 joint replacements annually. This has been posThe group’s flagship hospital at SG Road in Ahmedabad conducts the largest number of joint sible only due to ‘zero technique’ that, besides replacements by a single centre. significantly reducing the surgery time, has ensured minimal incision and painless surgery. How do you assess the group’s contribution It has also reduced hospital stay, blood loss and SHALBY HOSPITAL, SG ROAD, to healthcare in Gujarat? medication. It gives good flexion of the knee as AHMEDABAD: We put Gujarat on the medical tourism map by it uses superior quality implants. The infection 200 BEDS performing over 40,000 joint replacerate has also improved from 1-2 per cent in ments, the largest by a single centre 1994 to 0.03-0.04 per cent today. The in the world. Presently, we perform ‘OS’ needle, which I invented, also KRISHNA SHALBY SHALBY, VIJAY HOSPITAL, GHUMA, CROSS ROADS, in excess of 500 primary joint helps cut through both bones and AHMEDABAD: AHMEDABAD: replacement and seven to eight resoft tissue and saves time during 150 BEDS 25 BEDS surgery. vision joint replacement surgeries every month. Shalby Hospitals pioneered Total Knee Replacement (TKR) So, how do you manage to balance surgery in Ahmedabad. Using my method, the time between surgery and administrative pioneering zero technique, we can perform a work? joint replacement surgery in just eight to ten I do zero administrative work. Every day, from minutes. 9 am to 7 pm, I am busy only with clinical work. Among other things, we were the first On any day, I do over 30 to 35 knee replaceUSHA SHALBY, VRUNDAVAN Indian hospital with a Class 100 OT that ments. There is no better job satisfaction than SHALBY, VAPI: ensures safe and successful knee replaceGOA: 140 BEDS to see the patients, who were suffering from ment surgeries. Also, our main hospital has excruciating pain in the joints, walk back to 140 BEDS initiated cardiac stem cell transplant, ozone pain-free life after the surgery. therapy for non-invasive and painless uterine I have appointed a team to give wings to my fibroid embolism and Kyphoplasty to treat painvision. It’s only once or twice a week that I meet ful, progressive vertebral compression fractures the CEO of the hospital and that is also not a (VCFs) in the Western region. We are also the structured meeting. I don’t ask for updates like joint replacement was hardly known in India. first hospital in Gujarat to procure fractional patient turnout or revenue. Usually, it’s held to At that time, TKRs surgery took more than two laser for high-end cosmetic treatments. know regular administrative work. hours to perform and the patient had to stay in hospital for 15-20 days, post surgery. In 2007, How do you assess the advancements in joint Do tell us about your upcoming projects. the hospital stay was reduced to five days and replacement over the years? We are coming up with two 250-bed multi surgical time became 30 minutes. Today, thanks In the 90s, when we started Shalby Hospitals, speciality hospitals, one in Indore and another to the ‘zero’ technique, the duration of the
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Straight talk
one in Surat. Both are greenfield hospitals that would be commissioned after two years. Another multi speciality hospital of around 200 beds is coming up in Jaipur. In Ahmedabad, we have two more projects coming up at Naroda (200 beds) and Bopal (400 beds). In Goa, where we already have three units that add up to 140 beds, we are planning to add another 150 bed multi speciality hospital in Panjim. Our investment per bed is Rs50 lakh for new hospitals. This is lower than the market rate of Rs80 lakh to Rs one crore per bed. And existing units? Our 120-bed project in Vapi would be scaled up to 250 beds. In both Goa and Vapi units, we are adding high-end cath lab, CT Scan and MRI. Why are most of your hospitals 250 beds? I believe that a hospital with 200 to 250 beds has the highest efficiency and gives the highest profitability. Any institute above it, is too large to manage and anything below that is too small. What’s the secret behind the high profitability of the group? We keep our cost of operations low right from
the inception of the projects, and emphasise on proper planning before executing the projects. To save electricity, we use fire bricks, dual reflective vacuum spaced glasses, lot of natural light and cool compressed air. Such small measures lead to high profitability. Shalby is perceived as a doctor-driven organisation… No, we are not doctor-driven. We are process driven. People may have perceived us as doctor-focused as doctors here are satisfied with their work. The proof of my statement lies in the fact that we have zero attrition rate among doctors. Otherwise, we have clear demarcation between administrative and clinical work. Doctors are not allowed to interfere in the dayto-day administrative matters of the hospital and have limited say in it. While the head of our administrative wing is the CEO, the clinical wing is represented by the medical superintendent and the medical director. Both the administrative and clinical wings report directly to me. Each wing has no say in the other and thus there is no conflict between the two. The administrative work in the clinical wing is headed by the medical superintendent, who is not allowed to practice medicine. This is because we don’t to mix power with clinical work. Mixing the two can prove to be a dangerous combination for patients.
GUJARATIS AND MARWARIS CAN TRAVEL ANY DISTANCE IN THE PURSUIT OF TWO OBJECTIVES: PILGRIMAGE AND A GOOD DOCTOR
Shalby’s upcoming hospital at SP Ring Road in Bopal area of Ahmedabad.
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So, what’s trick to having happy doctors? In any hospital, as long as doctors are allowed to do clinical work, they feel happy and the hospital does well. On the other hand, if the clinicians are bogged down by administrative work, it spells doom for the institute. Also, doctors should be allowed to take part in conference, training, research projects and camps. If you manage to keep a happy force of doctors, you need not worry about patient footfalls and revenue.
Shalby’s training programme Shalby provides fellowship training to orthopaedic surgeons from across the globe in joint replacement as well as spine surgery. Many surgeons from India, China, Vietnam, Bangladesh, Kenya, UK, North America have visited Shalby, ranging for training spanning over one week to one year. It’s the only accredited hospital for DNB programme in orthopaedic surgery in Gujarat which is recognised by the Diplomate of National Board for providing post graduate training to four students every year. It is also affiliated with many paramedical training collages for clinical training and internship programmes for their students. It is also associated with IIM-Ahmedabad for conducting healthcare-related projects for their management students.
Do you see Shalby as a pan India player? Definitely. We will be a pan India player in the next two to three years, but we don’t intend to foray into the Delhi-NCR region. We are keen on exploring Punjab, Haryana, western India and even south India. Right now, we are looking for a project in Hyderabad, which would be our first southern project. How do you foresee the group a few years from now? In the next two and a half years, we will have 1,500 beds and in the next five years, we will have 6,000 beds. How do you see healthcare in Gujarat changing over the years? Gujarat has always been on the forefront of medical care, be it in technology, clinical workforce or infrastructure of hospitals. Our clinical outcomes and facilities are on par with those in Mumbai or Delhi. Most of the hospitals in Gujarat are headed by doctors. Do you see this changing in future? No, doctors will continue to remain in the spotlight and even head hospitals. Professional management has already come in hospitals in Gujarat, but I don’t think it will impact the popularity of a good doctor. Let’s face it: It’s doctors that attract patients. Gujaratis and Marwaris can travel any distance in the pursuit of two objectives: pilgrimage and a good doctor.
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Embracing modern thinking
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Technology
Courtesy: Philips
Dr N Ramakrishnan, sitting at an eICU command centre located in Chennai, monitoring an ICU setup in a remote location.
Remote possibilities Remote and wireless patient monitoring has enhanced critical care by reducing hospitalisation and ALOS, improving medication compliance and quality of life BY RITA DUTTA
E
ven a year ago, the family of a critically-ill patient in a place like Dehradun had to brave potentially harmful hospital transfers to rush the patient to Delhi, more than 250 kilometres away, to avail of world class medical treatment. Today, patients in Dehradun and even Raipur, which is 4,000 kilometres away from Delhi, can receive real-time monitoring from intensivists at Fortis Escorts Hospital, Delhi. This has been possible through Critinext, an eICU, whereby timely treatment and monitoring of patients is provided in collaboration with local physicians over audio/video. Critinext has been launched by GE Healthcare in collaboration with Fortis Healthcare. The project kick started in September 2011 at the Raipur unit of Fortis which has 18 ICU beds
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but lacks 24X7 critical care specialists. For the pilot, four ICU beds at the unit were supported with Critinext, with the command centre at Escorts. After a three-month pilot study, and a pre- and post-stat analysis to prove evidencebased outcomes, the Raipur unit went live with Critinext from April 2012 onwards. Through remote monitoring, continuous and live data (from monitors, ventilators and other patient-bedside equipment from the satellite centre) is transmitted to the intensivist who is remotely situated at the command centre and can access this data 24 X 7. Smart alerts built into centricity can flag trends in patient’s condition like picking up a spike in a white blood cell count, the start of a low grade fever, and a drop in urine output. When the intensivists at the command centre
put all those together, they are able to conclude if a serious infection is setting in. With the help of state-of-the-art rules-based engine, clinical parameters are tracked and used to generate clinical notifications, which can be overseen in a paper-based workflow. Thus, the intensivist at the hub offers proactive and reactive solutions to provide the right care at the right time. As per data available till June 2012, eICU at Escorts has enabled 40 per cent reduction in severity-adjusted mortality across seven academic intensive care units, 58 per cent reduction in severity-adjusted mortality over 2.5 years, 63 per cent reduction of ICU mortality comparing pre- and post-data over a three-year period and 32 per cent reduction in severityadjusted ICU mortality and hospital mortality by 18.9 per cent.
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Technology
THE EVOLUTION Remote patient monitoring (RPM) has witnessed huge advancements in recent times, since the days when RPM and disease management guideline programmes heavily depended on daily paper logs of vital signs like weight, BP, pulse rate and glucose readings entered by the patient or care provider at home. Explains Navin Govind, CEO, Aventyn, which offers three core products in the RPM segment, “In earlier times, the paper logs were reviewed by the clinician after 30 day or 45 days during a personal visit to assess the patient’s response to guidelines. However, the paper method was quite obviously inefficient and expensive. It did not engage the patient regularly, and considered information in silos and was non interoperable.” Subsequently, the Interactive Voice Response (IVR) systems and web-based approaches complemented the paper-based RPM programmes with better success in automating patient – clinician
GE Healthcare CEO John Dineen at the Escorts Raipur Hospital during the inauguration of Critinext at Fortis Escorts Hospital, Delhi.
responses. In the last few years, mobile and cloud technology has played a significant role in engaging patients to respond to care guidelines with the smart phone and tablet replacing paper/IVR/Web apps. “Also, wirelessly enabled, wearable vital sign monitoring devices have improved vital sign measurement of patients non-intrusively un-tethered to bedside console. Monitoring clinicians are also now un-tethered to consoles at hospitals by successfully using tablets and ultrabooks to monitor patients remotely anytime and anyplace securely,” says Govind.
Technological advancement has allowed doctors to be in touch with the patients 24X7 even when they are travelling” — JV BALAKRISHNAN,SENIOR VP, SCHILLER INDIA
THE DIRE NEED
tated brand building in tier-II and tier-III cities. While well-equipped ICUs, qualified intensivists Explains Dr N Ramakrishnan, managing and their 24/7 availability are considered the key director, Chennai Critical Care Consultants, who determinants of successful critical care outprovides eICU service to ICUs located in the comes, India has only 6,000 intensivists/anaesUS and India, “With the increase in the average thetists and only 70,000 well-equipped ICU lifespan of a person on one hand and the disease beds as against an estimated demand of 4,00,000 burden growing on the other, the need for critiICU beds to provide critical care for about five cal care is rising by the day. million ICU cases per year. eICU addresses this Besides most elderly people requiring ICU shortage. Says Dr Amit Varma, executive direchospitalisation, today we have a lot of young tor, Critinext, Fortis Group of Hospitals, “eICU is people admitted to ICU because of trauma and a solution to bridge this huge gap of ICU beds by adverse effects of lifestyle diseases like diabetes providing specialist care at the point, where it is and hypertension. In the years to come, the numneeded in a cost-effective way.” As ber of young and elderly patient we treat in the many as 1,000 ICU beds can be ICU will only multiply. We do not have enough manned by only 20 intensivmanpower to manage the situation and have ists through eICU. It also to look at innovative solutions.” provides successful According to him, remote evidence-based outmonitoring offers a good comes, helping standsolution to the many ardise critical care for challenges we are patients irrespective of facing at a global where they live. level as well as According to Varma, in India. He has eICU has helped standselected InTeleICU ardise critical care SOPs services, powered by across Fortis Group, Philips Technology, to enabled data capture reach out to critically ill and retrieval, allowed patients anywhere, anytime. more critical patients “We already have several hospitals in to be treated at periphremote locations which are availing of this eral units, ensured quality facility with good results,” says Dr similar to the hub and facili- Vitalbeat app from Aventyn Ramakrishnan.
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Technology
A nurse is using InTeleICU services from Philips to take instructions from a doctor sitting miles away from the patient.
THE BENEFITS eICU helps in providing pro-active care to save the patient’s life. The eICU solution also reportedly reduces the length of hospital stay for patients as they receive the highest level of managed critical care. While the ICU care at a local hospital allows patients get better support from family as well as help reduce costs by shortening the stay in ICU, the eICU helps to addresses the shortage of critical care staff in remote areas and enables physicians in remote units to manage ICUs more efficiently. Remote ICU monitoring technology combined with expert set of eyes can help reduce medical errors and infection within ICUs leading to reduction in patient mortality by up to 60 per cent. The unique advancements in mobile medical technology have improved patient engagement and medication compliance. They have reduced hospitalisations and re-admissions, reducing the cost of care with efficient care delivery and improving the quality of life of patients. “Now, the market has several aspects of wearable physiological vital sign sensors and mobile medical devices continue to evolve with Bluetooth low energy, NFC and cloud based monitoring services for specific monitoring of disease conditions,” says Navin Govind, CEO, Aventyn. Today, Remote patient monitoring (RPM) technologies are not only capable of monitoring patients but of sorting data and automatically updating patient records. “It allows the health staff to provide care more efficiently and also monitor patients in off-site locations. Technological advancement allows doctors to be in touch with the patients 24X7 even when they are travelling or outside the hospital,” says V Balakrishnan, Sr
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Vice President, Schiller India. For instance, the IntelliVue Charting solutions from Philips Healthcare ensure that there are no errors in reporting of patient vital signs and the nurses or technicians follow the doctors instructions completely and on-time. In this segment, Philips Healthcare has a few key solutions like IntelliVue, IntelleICU, Philips Information Centres and IntelliVue charting systems. There has also been a significant growth in the usage of wireless networks in patient monitoring, enabling hospitals to carry around patient monitors anywhere in the hospital and allowing patients to stay connected to be able to go to various departments or have a walk. Hospitals are installing wireless networks as they are much easier to install and require no infrastructural changes in the hospital building for installation.
REVOLUTIONISING CARE Indeed, remote and wireless monitoring is revolutionalising critical care. Says Jitesh Mathur, Sr Director, Patient Care and Clinical Informatics, Philips Healthcare, “Remote monitoring has completely transformed the level of patient care. Today, a physician can take virtual ICU rounds of his ICU, while being anywhere in the world using a standard tablet PC or any handheld devices.” “RPM has opened a huge window of opportunity for advancements in quality of medical care. Current technologies allow providers to monitor a patient’s health status by remotely and continuously measuring various vital signs. The ability to accurately detect abnormalities in vital signs allows intervention and prevention of problems before clinical signs are even present. The challenge of early detection of the onset of
We do expect more players in this segment, especially given the high need for improving healthcare accessibility” — JITESH MATHUR SR DIRECTOR, PATIENT CARE AND CLINICAL INFORMATICS PHILIPS HEALTHCARE
Wirelessly enabled, wearable vital sign monitoring devices have improved vital sign measurement of patients nonintrusively untethered to bedside console” — NAVIN GOVIND CEO, AVENTYN
these abnormalities is in doing so efficiently and accurately,” says Balakrishnan.
DRIVING FORCE Experts point out that nearly 10 per cent of total patient monitoring market in India is wireless and remote and the rate of growth of this market is more than 10 per cent. What’s driving this market is rising prevalence of
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Technology
APPLICATIONS IN USE Some of the popular remote and wireless applications include: • Remote ICU monitoring: One needs to have a central nursing station (CNS), which allows getting vital parameters of all the patients in the ICU on one console. When the doctor is travelling, he can access this information. • Ambulance Monitoring: When a patient is being transported from a distant location to the hospital, the basic treatment can start in the ambulance and doctor at the hospital has a facility to visualise the patient’s vital parameters and proactively decide on the treatment to be administered — an ICU on wheels of sorts. • Connect with the rural hospitals: The doctor practicing in a rural hospital can take the vital parameters of the patient and send it to the urban hospital where a super specialist can look at it and send a report back to him. • Tele monitoring: The paramedical can take the vital parameters of the patient and send it through an email to doctors sitting in other town. The doctor can looks at the vital parameters and send the report back via mail. This way the doctor saves time and can look at cases from 10 different hospitals. eICU addresses the acute shortage of intensivists and well-equipped ICUs.
We do not have enough manpower to manage the rising demand for ICU care and have to look at innovative solutions”
— DR N RAMAKRISHNAN MANAGING DIRECTOR CHENNAI CRITICAL CARE CONSULTANTS
chronic diseases like diabetes, the growing elderly population and advances in wireless and sensor technologies. “Focus of care providers on better patient care has resulted in creating demand. On the technology front, standardisation in wireless networks and adoption of wireless networks by hospitals has enabled this advancement. Wireless networks are today much more reliable, ensuring no critical alarms are lost, especially in mission critical applications,” says Mathur. Wireless communication and data transmission are playing an increasing role in critical care. Asked about the challenges in using these systems, Mathur says there are external challenges such as telecom infrastructure, slightly incremental cost and technical know-how.
A GROWING MARKET According to Govind, “The RPM market is growing globally. As per ABI Research, by 2017, the market would be growing at an average rate of 41 per cent per year, leading to 169.5 million devices being shipped in 2017. By 2017, according to ABI, 23 per cent will be home monitoring technology for seniors. Seven percent will be devices for remote patient
monitoring, with another 7 per cent for point of care healthcare use.” In the coming years, Rural health centres (RHCs) or other remote heath locations such as ships navigating in wide seas, ambulances (both air and road) carrying patients to the hospitals would become common examples of possible emergency sites with RPM, where the patient’s data can be sent to the base. This can help the doctors decide and direct the course of treatment to be started. Are more players expected in this segment? “Wireless is a critical high-end technology. While Philips is a leader in this, other companies are working to come out with reliable technologies. We do expect more players in this segment, especially given the high need for improving healthcare accessibility,” says Mathur. Fortis in collaboration with GE Healthcare has already chalked out plans to target 500 ICU beds in 20 small towns by 2014 with its Critinext. For Aventyn, whose products are being used in Bengaluru’s BMS Hospital Trust, VIVUS Heart Centre and Narayana Hruduyalaya, the growing markets are in remote home care, community care and acute-bedside care adopting their patient monitoring and chronic disease management products.
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Innovation
Low cost, high efficiency The recently commissioned Narayana Hrudayalaya Hospital in Mysore has taken several initiatives to reduce cost of project and operations BY TEAM HR
The hospital has taken several measures to reduce the costs of the project and operations.
T
he Narayana Hrudayalaya (NH) Group has recently commissioned a 200-bed multi speciality hospital in Mysore. Spread over nine acres of lush greenery, the facility is built for patients from Mysore and its surrounding districts in the 100 – 150 km radius. Since the hospital is built to cater to lower and middle income group, government schemes, corporate and PSU employees, the group has taken several measures, right from the construction stage to reduce the costs of the project and operations.
DURING CONSTRUCTION Hospital construction in India has been dictated by tall vertical structures due to constraints of space and location. The vertically developed structure has inherent cost disadvantages such as reliance on power intensive elevators, air-conditioned spaces to keep out the noise and dust associated with crowded spaces. The tall structures also present safety issues such as evacuation of patients in times of an exigency. NH’s low cost hospital is primarily built as a pre-fabricated structure with minimal RCC construction except in the OT, catheterization lab, radiology
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and diagnostic services and ICU areas. The hospital is a ground and first floor construction, thereby reducing construction costs significantly. "The construction is designed to maximise the utilisation of natural daylight and cross ventilation to minimise electrical consumption. Traditional hospitals take over two years to build, while a low cost hospital takes less than 10 months to build. This ensures early return on investment. Moving further, we believe that will be able to reduce this time span even more and bring it to as low as six to seven months," says Karthik Ramakrishnan, vice-president, general management, Narayana Hrudayalaya Hospital.
AIR CONDITIONING Contrary to popular opinion, NH believes that air conditioning in hospitals presents a grave risk to patients and increases convalescence time. An improperly designed and / or improperly maintained air conditioning system could lead to the spread of infection. Moisture and humidity, along with mixing of air from different areas, provide the right platform for infection to develop and spread. In this low cost facility, the use of air-conditioning has been restricted to essential areas such as operating rooms,
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Innovation
As a common practice, patient and patient attendant waiting areas are provided inside the hospital” — KARTHIK RAMAKRISHNAN, VP, GENERAL MANAGEMENT, NH
FAST FACTS • It’s a 200-bed hospital, which would later be scaled up to 500 beds. • The inbuilt area of the hospital is one lakh square feet. • The focus areas of the hospital are cardiology, cardiac surgery, neurology, neurosurgery, medical and surgical gastroenterology, orthopaedics, urology, nephrology, laparoscopic surgery, obstetrics and gynaecology.
• This is a greenfield project, for which the land has been taken on a longterm lease. The model is built as a pre-fabricated structure with minimal RCC construction.
• The cost of the project, inclusive of construction and equipment, is Rs48 crore.
• At a stable phase, when all the 200 beds will be operational, the number of employees will be 450.
• The hospital boasts of a 22-bed dialysis unit, six OTs with laminar airflow and the unique design of ICU wards. The state-of-the-art hospital has a comprehensive radiology department with 64 slice CT and 1.5 Tesla MRI.
ICUs, radiology and diagnostic rooms. "These areas require air conditioning for functional requirements. All other areas have been designed for maximum ventilation and natural light, which we believe, will accelerate patient’s recuperation," says Ramakrishnan. Though a low-cost project, the hospital has six OTs with laminar airflow.
OPTIMAL SPACE UTILISATION As a common practice, patient and patient attendant waiting areas are provided inside the hospital, he informed. At Mysore, NH’s designers have optimised space utilisation by clustering waiting areas and providing them outside the clinical zones. "The saving in area, thus achieved, helps reduce the initial capital expenditure on the building," says he.
COMPANION CARE MODULE
The use of air-conditioning has been restricted to essential areas such as operating rooms, ICUs, radiology and diagnostic rooms.
Continuity of care is an important factor to ensure holistic patient recovery. It is often observed that patient attendants are ill-equipped to ensure proper care, which includes basic hygiene, wound care and medicine administration. Recognising the need for this, NH has worked along with a student team from Stanford to identify gaps in attendants’ knowledge of various post-operative care requirements and equip them with the right understanding. "The patient attendants at our hospital in Mysore would be trained by skilled nurses and would be encouraged to actively involve themselves in taking care of the relative (of the patient) in the hospital under expert supervision. The objective is to ensure that expert care is not only available to the patient in the hospital but is carried forward post-discharge, at home," informs Ramakrishnan.
OUTSOURCING MODEL
Since the hospital is built to cater to lower and middle income group, the hospital has only general wards in the first phase.
This hospital will use the facilities of the main NH hospitals, such as the one in Bengaluru to outsource some of the back-end / non-critical activities and activities, which involve special skill sets. Tele-radiology is one such area where all radiology scans taken at Mysore will be interpreted by the well-equipped and specialist team at NH Bengaluru. "This will not only help prevent duplication of resources but also ensure optimal utilisation of specialists like radiologists, something which is at the core of NH’s operational philosophy," says Ramakrishnan. Similarly, activities such as claim processing and discharge summary preparation will also be outsourced to the larger NH facilities.
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Opinion
Call for a cause India needs thousands of volunteers for blood stem cell donation to unrelated patients, who need a new lease of life BY RAGHU RAJAGOPAL
S
teven Carlyle was only 18 when he gave hope of life to six-year-old Samantha, unknown to him till then. As a blood stem cell donor, Steven extended Samantha’s life span, besides sparing her from undergoing painful chemo treatments for leukaemia. And for Steven, life has been as usual—university, basket ball practice and music lessons, except for a couple of days of rest for recuperation. This is just one among thousands of instances in the US of unrelated blood stem cell donation. In India, ironically, such examples are few and far between. I say ‘ironically’, because, considering the population of our country, ideally we should have had thousands of volunteers willing to donate their blood stem cells. Especially, since the incidence of leukaemia and other blood-related critical illnesses are on the rise in the country as per research. A recent report indicated that over 55,000 children are afflicted with some form of malignancy, the most common being leukaemia.
DEARTH OF DONORS One has heard of private umbilical and menstrual cord blood banks meant only for individuals to use for themselves, when necessary. But few are aware that a concept of ‘unrelated blood stem cell donor’ even exists. There are more than 20.5 million registered donors in the world. But in India donors are not coming forward in hordes because of low awareness levels among them about the blood stem cell procedure. Few people know that blood stem cell donation is as simple as blood donation. Among those who are aware, there is a fear that they will become weak or fall ill
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after a blood stem donation procedure. Most blood stem cell donations happen among close blood relatives, provided their HLA typing matches. There are few ‘unrelated blood stem cell donor registries’ that are working towards making blood stem cell donation an accepted concept among general public.
through ‘apheresis.’ This process is to a platelet collection process and is as simple. In it, only stem cells are extracted from the blood and the remaining blood is infused back into the donor’s body. The stem cells are then delivered to the transplant centre, where the recipient is waiting.
REGISTRY BENEFITS
URGENT NEED FOR AWARENESS
Although families in India come forward to donate blood stem cells, most times, patients with life threatening blood disorders don’t find a match among their siblings. In fact, the probability of finding a sibling match is only about 25 per cent. Hence, patients have to look outside the family for a donor, called the unrelated blood stem cell donor. This is where registry of unrelated stem cell donor helps. Developed countries now boast of hundreds of such registries. There are 65 registries in the world that are recognised as members of the World Marrow Donor Association (WMDA). Datri is one of them, which improve the chance of finding a matching donor for a critically-ill patient. This is precisely an area where our country, despite its huge populace, lags behind. As the blood stem cell matching is closely related to ethnicity, there is a dire need to quickly start building such a database, as also build awareness of the concept. A registry is only a database of a donor’s HLA type; it does not physically store blood or stem cells. At Datri, we get requests for a match from the registry of the country where the patients are getting treated or from the transplant physician from the transplant centre. If the HLA typing matches with that of any of Datri’s list of donors, then the stem cell collection is done
Awareness of the need for this type of registry has to be created, so that we see a more willing public coming forward to register themselves as donors. Worldwide, several not-for-profit organisations have been working in the area and have the experience and expertise needed to handle such a registry. However, the greater challenge would be in educating the public to come forward to donate healthy blood stem cells for a cause. Firstly, not many people know that they could be the only hope for a patient’s survival and second, even fewer people know that the procedure is simple and harmless and can be over in a few hours. There are myths surrounding this medical practice and it would help if healthcare institutions get together to increase awareness of this practice through drives and education programmes aimed at enrolling young people for this noble purpose.
Raghu Rajagopal is cofounder and CEO, DATRI Blood Stem Cell Donors Registry, India’s sole public blood donor registry affiliated to the World Marrow Donor Association.
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EVENT CALENDAR
HospiArch Organised by: Amen Business Solutions When: 27 April Where: Lucknow 10th Healthcare Executive Management Development Programme When: 28 April – 4 May 2013 Where: Srinagar HospiArch Organised by: Amen Business Solutions When: May 2013 Where: Jaipur XVth National Seminar on Hospital / Healthcare Management, Medico-Legal Systems and Clinical Research Organised by: Symbiosis Centre for Healthcare When: 3 – 4 May 2013 Where: Pune III Internationl congress on patient safety When: 6 – 7 September 2013 Where: Hyderabad International Convention Centre, Hyderabad
Smart Healthcare India Summit 2013 23 - 24 May, 2013, ITC Gardenia, Bengaluru Contact: Mushrif, general manager, conferences on +91 98201 53334 or sagar.mushrif@itp.com For speaking opportunities, contact Alysha Lobo, project manager on +91 9769 616685. For registrations get in touch with Anjali Shetty, sales manager, conferences on +91 22 6154 6010 Bangalore Palace, Bengaluru
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Best practices
It’s all about hygiene In healthcare institutions, cleanliness is indeed next to godliness. We track the latest hygienic floor cleaning practices
Scrubber dryers: Used for effectively washing and scrubbing the floor using rotating brushes, these dryers then dry the floors using a system of squeegees and sometimes vacuums. Single disc floor scrubbers: Most useful in narrow areas or passages, these scrubbers are also light weight and compact. Automatic floor scrubbers: Used to scrub a floor clean of light dust, oil, grease or floor marks, these can be used to scrub the floor and thereafter vacuum it with an auto scrubber squeegee. Ride-on scrubber dryers: These require the operator to ride and control the cleaning operation at the same time. They reduce the operator time and enhance the efficiency and reduce floor cleaning expenses considerably. Steam cleaners: These employ steam for cleaning purposes. High pressure cleaners: Available in cold and hot varieties, these cleaners are heavy duty. The cold water high-pressure cleaners remove stubborn dirt and are ideal for large areas. Hot water high pressure cleaners clean even better with using the same amount of pressure.
Courtesy: Sealed Air
BY TEAM HR
Mechanised means
Mechanised cleaning is being adopted in Indian hospitals too.
W
hile we may judge the cleanliness of a place by the smells and the sights, neither a visibly cleaned floor nor the smell of a disinfectant is any indication of whether the hospital floor is really clean. It is the duty of a healthcare institution to make the patient feel that the environment is clean as a hygienically cleaned floor gives patients a sense of safety. According to Debapratim Dinda, advanced engineer, building & commercial services division, 3M, in healthcare settings, cleanliness has
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to be maintained round the clock. “A hygienic atmosphere is a must for centres that deal with diseases and patients,” says Dinda.
FOR PSYCHOSOMATIC HEALING The cleaning practices a hospital follows are crucial. Says Lalit Sharma, sector head, healthcare and commercial laundry, India and SAARC Countries, Diversey, (a part of Sealed Air), “A hospital does not have to look or smell like a hospital and that’s where effective floor cleaning practices come into the picture.” He adds that cleanliness does serve as a motivator for staff and provides psychosomatic healing
for patients. Thus, cleaning takes a step ahead when it comes to cleaning in hospitals. In comparison with cleaning process in other buildings, hospital cleaning demands more scrutiny and monitoring. Hygiene becomes the primary requirement here as it concerns the health of the patients and that of the people visiting and working there. Says Raja Mukherjee, national head, training and technical services/marketing, Forbes Pro-Clean Technology Solutions, Eureka Forbes Limited, “In India, with the advent of multi specialty hospitals and private run hospitals, aesthetics have also been added to the requirements of hygiene and cleanliness.”
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Staff support
Mechanised cleaning brings in various machines that help do a good job with minimum effort. He adds that while the cleanliness standards, some years back, was considered dismal for the Government-run hospitals, today public hospitals like AIIMS, GB Pant hospital and PGI Chandigarh too have gone for outsourcing their cleaning process to facility management companies that take the lead to keep the premises spic and span.
CLEAN CHANGES The following are the key changing factors in hospital floor cleanliness.
MECHANISED CLEANING While the West has adopted mechanised cleaning at an early stage, making it as an SOP
There is no antibiotic prescription regime that can offset the impact of a dirty hospital" — LALIT SHARMA, SECTOR HEAD, HEALTHCARE AND COMMERCIAL LAUNDRY, INDIA AND SAARC COUNTRIES, SEALED AIR
in their cleaning systems, Indian hospitals have only recently taken to replacing manual cleaning with it. Mechanised cleaning has brought in various machines like scrubber dryer, vacuum cleaners, single disk floor scrubbers and polishing machines, automatic floor scrubbers (walk behind and ride on), sweepers, ride on scrubber dryers, carpet shampooing machines, high pressure cleaners (both cold and hot and cold) and steam cleaners into their cleaning processes. Mechanised cleaning has helped enhance standards, productivity and longevity of operations. “The ‘no touch’ system of mechanised cleaning has gone down well with the janitors, who have retained their interest to deliver the same diligence day in and day out. The systematic procedures have brought an accountability factor into the systems, providing monitoring options for the users,” says Mukherjee.
MICROFIBRE MOPPING From the use of conventional loop mops for wet mopping, today hospitals are switching over to a new mopping technique that involves microfibre materials to clean floors. Experts point out that to reduce the risk of cross-contamination, conventional mopping techniques demand frequently changing the cleaning solution. However with microfibre mop, the
Healthcare support workers should be acutely conscious of the critical nature of their work and should not see their work as simply a physical task unrelated to healthcare delivery. Patient care relies as much on the work of ancillary support workers as it does on doctors, nurses and technicians. “Hospital housekeeping staff must have specialised knowledge specific to a healthcare site and unit where they work. They should be required to follow complex and exacting cleaning protocols. They should be conscious of the risks involved in their work and of the grave consequences of errors on their part. Cleaning in hospitals is more demanding and complicated as patients are often present and require additional support and assistance. It is also crucial to recognise the distinct and different needs that are met in a hospital,” says Lalit Sharma of Diversey. When it comes to closing the infection control loop in a healthcare facility, the staff members of the environmental services or housekeeping department play a critical role: they can either undermine clinicians’ efforts or support the institution-wide goal of preventing the transmission of pathogens. In an acute care setting, housekeeping is second only to hand hygiene in importance in the infection control loop. “There is no surgical technique, no wound-care strategy and no antibiotic prescription regime that can offset the impact of a dirty hospital,” says Sharma.
mop head is changed after mopping every room, thus eliminating the need of wringing a conventional mop and also doing away with the need of frequent solution changes. In microfibre mopping, the split structure of the fibre makes all the difference: “The microfibre collects the parts of the dirt and leaves the surface clean and dry. On the other hand, normal fibres only push the dirt ahead, leaving the sur-
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face dirty,” says Sharma. Microfibre mopping is easier and less tiring, and thus preferred by workers. It also reduces the amount of water and chemicals used.
When it comes to floor cleaning, a majority of hospitals in the country are still stuck with old fashioned cleaning chemicals. However, the trend is slowly changing to using chemicals that are green, thus reducing environmental and health impacts. “In hospitals, emphasis on green chemicals has increased through the implementation of NAHP certification apart from the HACCP requirements. The biodegradability of product and equipment has become an important factor for their selection,” says Mukherjee. India is also waking up to a new technology in surface cleaning: Accelerated Hydrogen Peroxide technology or AHP. The AHP Technology is one of the newest disinfectant technologies to be brought to the market in the US. “The AHP technology, which is a disinfectant technology based on hydrogen peroxide, offers advantages like broad efficacy, realistic contact times, excellent surface safety, excellent worker safety, better cleaning and sustainability,” says Sharma. Many cleaners that contain AHP are ‘Green Seal’ certified.
AREAS TO BE COVERED According to Sharma, without good hygiene the chance of cross-contamination and infec-
Courtesy: Eureka Forbes
USING GREEN PRODUCTS
A ride on auto scrubber drier being used in the OPD section of the AIIMS hospital in New Delhi. tion with pathogens increases significantly. The critical hygiene requirement is to identify all risk areas and set up a well-controlled and integrated cleaning and disinfection programme. “With over 80 per cent of all hospital infections taking place in the OTs and the ICUs, the Hospital Infection Control committee, at times, can be too obsessed with implementing stringent and wholesome infection control programmes and probably undermine the importance of cleaning and hygiene in the not- so-critical areas,” says he. A washroom can as much be a potential source of acquiring infections as the OT. Or, the food that is being prepared in the kitchen can as much be a potential source of crosscontamination as would be an inappropriate hand hygiene. Only by adopting a holistic and integrated approach can such infections be reduced. So, not only using the right products but also managing all aspects of cleaning and hygiene into a workable and consistent programme is important.
MAJOR CHALLENGES Establishing an efficient mop use and mop laundry is an advanced logistical challenge.
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According to Dinda, the challenges related to hospital floor cleanliness are related to
The ‘no touch’ system of mechanised cleaning has gone down well with the janitors, who have retained their interest to deliver the same diligence day in and day out" — RAJA MUKHERJEE, NATIONAL HEAD, TRAINING AND TECHNICAL SERVICES/MARKETING FORBES PRO-CLEAN TECHNOLOGY SOLUTIONS, EUREKA FORBES LIMITED
using huge amounts of dry and wet mops and cleaning them properly. As the mops are often used in areas far from the laundry room, establishing an efficient mop use and mop laundry is an advanced logistical challenge. Also, hospitals have different flooring surfaces, different types of contaminants and different cleaning and sanitation requirements — all of which make the cleaning exercise more challenging.
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Best practices
Frequency matters The frequency of cleaning hospital floor depends on area to be cleaned. It’s important to use the highest level of cleaning and disinfection for the floor cleaning of ICUs and OTs. “The OPD, which is an area with the largest footfall in the premises, demands cleaning at regular intervals with a mix of damp and dry moping. The administrative block and the outside areas can be cleaned once or twice a day. The wards, washrooms and the special rooms should have more frequent cleaning schedules. The OTs require cleaning after every use to prevent cross contamination,” says Raja Mukherjee of Forbes Pro- Clean Technology Solutions, Eureka Forbes Limited.
THE ROAD AHEAD
Mechanised cleaning has helped enhance standards, productivity and longevity of operations.
In the coming years, experts point out that besides more hospitals going for mechanised cleaning, there would be emergence of topdown microfibre system. A top-down microfibre is a complete system, which consists of microfibre cloth, bucket with ermetic cover and trolley among other things.
“The advantages of a top-down microfibre system are it avoids the change of cloth outside the laundry or preparation room, has no risks of pollution and have higher cleaning effect due to the high capacity to pick up dust. Additionally, it comes with higher life durance of
the cloths, reduction of effective duration of work and is also easy to use,” says Sharma. Besides popularity of AHP Technology and green solutions, hospitals would be seen taking into consideration the areas outside the hospital building for cleanliness.
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Healthcare Radius April 2013
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Cutting edge
Keeping abreast The many benefits of trans-umbilical breast augmentation BY DR ABRAHAM ZACHARIAH
O
ver the years, breast augmentation techniques have undergone a wide change. The very first method of breast augmentation was developed in the 1950s by two surgeons from Texas. In this method, implants made out of liquid silicone were inserted through cuts made on the skin under the breast folds, in the so-called infra-mammary method. Though this is a simple method, the downside is that the ‘smile‘ scars are obviously visible and there is a slightly higher chance for the implants to erode the relatively thin tissues in the skin fold below the breasts. Also, there is discomfort from the support brassiere pressing on the skin cuts during the healing phase.
TOWARDS SCAR-LESS SURGERY The old adage, “necessity is the mother of invention” has turned out to be true for breast augmentation techniques. In their quest to hide the surgical scars, cosmetic surgeons then developed the “peri-areolar” technique in which the cut is made on the periphery of the areola, the pigmented circle around the nipples. The motive of the technique is to have scars that are harder to notice. However, with this technique, which takes longer, even though the chances are remote, there is a possibility of losing nipple sensation. It may also pose difficulties in breast feeding. Surgeons then developed the “transaxillary” method. Here, the surgical scars are hidden in the natural skin crease in the arm pit, which gives this method an advantage. The downside is that it is physically more
36
demanding on the surgeon, when the implants are placed in its space deep in to the pectoral muscles. Before the advent of surgical cameras and endoscopes in the field of breast cosmetic surgery, reduced visibility was a detriment in this type of technique. But today, this is a moot issue. Another disadvantage of this type of operation is the very remote possibility of injury to the sensory nerve of the nipple that traverses the tissues of the armpit on its way to the nipple. Because of the moisture from the sweat glands in the arm pit, some patients experience minor infections, which even though not serious, can produce ugly scars, which beats the very purpose of this technique.
SINGLE INCISION TECHNIQUE Then came the trans-umbilical breast
augmentation, the latest in the evolution of breast augmentation surgery. In the transumbilical method, the small skin cut is made in the umbilicus, which is the Latin word for navel. This method requires only a single cut, a very small one that is almost invisibly situated in the pit of the navel. The healing of the cut happens typically in about two weeks. The technique takes the least amount of time to perform. Most women, who choose this technique, are able to resume their full level of usual activities within a couple of weeks, or even earlier when the implants are placed right underneath the breast tissue. Because the skin cut is only a few millimetres long, only saline implants are used for this procedure. Many surgeons and patients feel more secure about saline implants as compared
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Cutting edge
Temporary tissue expander balloon is inserted and hyper-inflated to stretch open the 'pocket' for placing implant (Here, the depiction shows the pocket being created above the pectoralis major muscle. The pocket can also be created under the pectoralis major muscle). Subcutaneous 'tunnels' created by special endoscopic instruments.
Sub-cutaneous “tunnels” to introduce the implants, via the umbilicus, and the location of implant “pockets” are marked pre-operatively.
TYPES AND PLACING OF BREAST IMPLANTS • There are two different types of breast
to silicone implants. Some criticism had been raised that saline implants have a less natural feel in very skinny women, but that issue is negated with the implants placed under the pectoral muscles, which give them nice padding and hence a natural feel and appearance. Furthermore, the chance of infection of the surgical incision with this method is rare.
SOME KEY POINTS
implants. One is filled with silicone gel and other variety is filled with sterile salt water
THE TUBA METHOD
(called saline solution in medical terminology),
TUBA, the acronym for Trans-Umbilical Breast Augmentation, is the most advanced method of enlarging the size of a woman’s breasts using implants. TUBA derives its name from the Latin word umbilicus, which in English, means the navel. Cosmetic surgeons have a choice of two locations underneath the breasts where the implants can be positioned: directly deep into the breast tissue (sub-glandular location), or deep into the pectoral muscles (sub-muscular location) that are situated under the breast tissues. There is hardly any blood loss with the TUBA method. Nipple sensation is preserved and ability to breast-feed is retained. TUBA is an improvement over the earlier methods of breast augmentation and is a safe procedure that has produced pleasing and satisfying results. However, not many surgeons have been able to master this technique and the ones who have not, tend to raise unfounded criticism. TUBA procedure was invented and first described by the American cosmetic surgeon, Dr Gerald Johnson of Houston, Texas, who personally trained a handful of surgeons, in this procedure. I was fortunate to be among the group.
which is the same solution that is administered intravenously when an individual is in need of fluid for hydration. Among many surgeons, especially in North America and Canada, there are some real concerns regarding the long-term safety of silicone used to fill the silicone implants, even though the industry standards have improved over the years. They feel that saline solution used in the saline implants is physiologically safe for the body. The manufacturers seem to promote silicone implants, which costs more.
• In most western countries and in South America, surgeons prefer to place the breast implants underneath the pectoral muscles as they believe that it gives a more natural and pleasing appearance. According to them, if the implants are placed right under the breast tissues, they have a fake appearance as they are more likely to be noticed because the silhouette of the edges of the implants protruding under the skin.
• However, many other surgeons prefer to place the implants directly under the breast tissue because it is a much easier method to perform and also, patients tend to complain less about post-operative discomfort.
The permanent implant is deployed into the 'pocket' and filled to the desired size, with saline solution. (The implant can also be positioned in a sub-pectoral pocket, under the pectoralis major muscle).
Doctors/counsellors should help patients have realistic expectations from the procedure. A preliminary consultation can help the patient determine whether breast augmentation is right for her. There are not many long-term side effects to breast augmentation surgery. Most women who have breast implants believe that they feel better about themselves and more sensuous. The one single negative thing about breast implants is that some women tend to develop firmness of the breasts, over time. This condition is called “capsular contracture”. In this condition, there is increased internal scar tissue build-up around the implants. This condition is treatable. So far, the TUBA method seems to have the least problems with capsular contracture. Also, when the implant is placed sub muscularly under the pectoral muscle, there is a lower chance of capsular contracture (contraction of the tissue capsule surrounding the implant), and mammography is more reliable.
Dr Abraham Zachariah is a cosmetic surgeon with SevenHills Hospital, Mumbai.
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Patient relations
Is your staff well behaved? A hospital’s reputation depends not just on patient outcomes, but also on how its staff behaves with patients BY DR BADARI DATTA
M
r Raj comes to the reception desk of a hospital to register a consultation with Dr Krishnan. He finds the receptionist busy talking on her mobile phone on what is obviously a personal call. A few minutes later, she looks momentarily at Mr Raj, to say that the doctor will be available after two hours, and then starts reading something on her desk. When Mr Raj asks for directions to the consultation chamber, she tells him to look at a board nearby, without lifting her head. Mr Raj arrives at Dr Krishnan’s consultation chamber and awaits his turn. The two hours get over, and then another half hour, but Dr Krishnan is nowhere to be seen. Mr Raj asks the attending nurse about his appointment, and she loudly replies: “Wait outside! I’ll call you when doctor arrives.” Mr Raj goes back to his seat. Dr Krishnan arrives some time later. There is no apology from him for being late. When Mr Raj gets his turn, the doctor shoots off a few questions about Mr
38
Raj’s problem and then bluntly tells him that it’s because of his lifestyle. Mr Raj feels guilty and embarrassed. He leaves the consultation chamber and is asking the nurse for directions to the pharmacy, when he overhears Dr Krishnan mentioning his name to the next patient. The doctor is quoting Mr Raj as an example: “If you don’t change your lifestyle now, you will also become like that fat man who went out as you entered my chamber.” After his initial shock and disbelief, Mr Raj feels humiliated. He returns home depressed. How would you have felt if you were Mr Raj? If you had thought, this kind of behaviour is certainly not expected of a hospital and its staff, you would be absolutely right.
EXPECTATIONS FROM HEALTHCARE PROFESSIONALS The management of a healthcare facility as well as its patients and visitors expect a certain standard of behaviour from its healthcare professionals. These expectations can be classified into three groups:
Aspirational expectations: These expectations are what people aspire for. But they are more utopian than reality. The expectations are high and concern such behaviours of people that may not be exhibited at all or exhibited by very few – those of the highest character and integrity. These expectations are in accordance with the vision statement of a healthcare facility. For instance, a hospital’s vision statement might state that its staff will treat all patients with the love and compassion of Mother Teresa; notwithstanding the fact that very rarely indeed will a worker reach Mother Teresa’s standards. (As a rule, however, institutions set ambitious goals in the hope that the ideals they represent will have the needed motivational value.) If one achieves aspirational levels of behaviour, conflicts rarely arise and, when they do, a solution is reached without ego clashes. The fulfilment of aspirational expectations leads to the growth of love and trust. When you meet a person who displays such behaviour, you wish there were more people like them around.
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Patient relations
WHAT CONSTITUTES UNACCEPTABLE BEHAVIOUR Unacceptable behaviour refers to behaviour that is
the family gets the feeling that he is not very hopeful
even below the level of minimum expectations. It
about the success of the treatment. So, they have
is vital for a healthcare worker to know the kinds
already lost hope for Mrs Nair. At that point, the
of behaviour that are unacceptable to patients,
doctor’s friend, a Dr Chandran, enters the room with
colleagues and the administration in a hospital
his daughter’s wedding invitation cards in hand.
so that the worker may carry on with his work successfully. The responsibility of defining what unacceptable
Dr Chandran has not realised the seriousness of the atmosphere in Dr Bhaskar’s chamber and, although initially, Dr Bhaskar tries to put him off, he
behaviour is and providing guidelines for employees
soon gets sucked into the conversation. They talk
to avoid such behaviour lies with the administration
about Dr Chandran’s future plans, the bride and the
of a healthcare facility.
wedding. After a few minutes, Dr Chandran leaves. Dr Bhaskar puts on a grave face and continues the
The following is a sample list of unacceptable
conversation with Mrs Nair and her family about her
behaviour:
future treatment.
• Any behaviour of the caregiver that violates a
Learning point: If we do not empathise with
patient’s rights. • Any behaviour that causes or increases the risk of patient or employee safety.
Meanwhile, some nurses and doctors enter the
patients and their families, there is a real possibility
minor OT and see Eswaran lying there. Eswaran is
that, knowingly or unknowingly, we may hurt their
acutely embarrassed. Dr Ganesh returns after 15
feelings. Sometimes, the damage is irrevocable.
minutes and, realising that he has forgotten all about
• Any behaviour exhibited by a caregiver that does
Eswaran, is most ashamed. But he picks up from
not uphold the dignity and confidentiality of a
Points to ponder:
where he left off, as if it’s nothing, and says, “It’s OK,
patient.
• How do we make sure that we aren’t
all humans have similar organ parts, after all. You
• Any aggressive behaviour displayed towards visitors or colleagues. • Any behaviour violating the law and medical ethics of the land.
interrupted during a serious conversation with
mustn’t mind this.” But it doesn’t help Eswaran in
a patient or their family, such as when we are
the least.
breaking a bad news?
Learning point: Patient dignity should be respected
• How should Dr Bhaskar have cut short his
• Any behaviour leading to such levels of patient
conversation with Dr Chandran at the outset?
dissatisfaction that result in the patient or their
• Do you think Dr Bhaskar’s apology to Mrs Nair
relative not returning to the same doctor or
and her family, towards the end helped?
hospital.
at all costs, and no excuses. In areas like wards, clinics and OTs, we must be sensitive to the patient’s need for privacy and dignity, which can easily be compromised. Knowing the limits will help us be conscious of when we are in danger of overstepping
However, as there is often a very thin line between
Scenario 2
our bounds. This awareness is key to ethical conduct
minimum-expectations behaviour and unacceptable
Twenty five -year-old Eswaran has undergone
as a healthcare-provider and is developed by
behaviour, we shall use a scenario-based approach
circumcision surgery. He comes to the minor
continual introspection.
from real-life experience to draw the line precisely.
operation theatre for the first post-operative dressing. Dr Ganesh, the surgeon, is very friendly and nice.
Points to ponder:
Scenario 1
He asks the young man to undress and lie down on
• Although Dr Ganesh made Eswaran wait in
A 70-year-old lady, Mrs Nair, is sitting in Dr Bhaskar’s
the examination table, and removes the dressing.
an exposed position for 15 minutes on the
chamber with her anxious family. The whole family
But, just then, he gets a phone call and, apologising
examination table, would Eswaran have perceived
is depressed, disturbed and tense. Dr Bhaskar has
for the interruption, goes out to take the call. He
just told them that Mrs Nair has stage 4 cancer of
then gets busy with some other work, completely
the uterus. He explains the treatment options. But
forgetting that Eswaran is still waiting.
Reasonable expectations: Behaviour that meets reasonable expectations, although not the best, is nevertheless what most humans manifest under normal circumstances. Although conflicts do arise when such behaviour is demonstrated, they are resolved with some stress and strain. Healthcare institutions that display reasonable behaviour assure the provision of adequate levels of treatment and care and are not guilty of violating patient rights.
Minimum expectations: The minimum standards of behaviour that a patient and the administration of a healthcare facility expects from healthcare professionals. Most patients take this kind of behaviour for granted. It is routine and makes them neither happy nor angry. Human dignity and patient confidentiality are maintained. Conflicts arise frequently and are resolved with difficulty. However, basic patient rights are not violated.
it as just 15 minutes? • Can you think of situations where patient privacy and dignity can be compromised in a hospital?
Dr Badari Datta is associate professor and consultant, ENT department and head of quality department at Bangalore Baptist Hospital. Excerpted with permission from the book Communicate. Care. Cure ... A Bangalore Baptist Hospital Initiative for the Nation, which earned Bangalore Baptist Hospital the prestigious QCI-DL Shah National Quality Award 2013 for Healthcare Communication.
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Event report
Building better hospitals HospiArch, held in Chandigarh, had an eclectic mix of topics about designing truly patient-friendly hospitals
H
ospiArch, the premiere conference on hospital planning, design and architecture held in Chennai, Hyderabad, Mumbai, Bengaluru, Kochi, Delhi, and Vijayawada, was successfully conducted in Chandigarh. The event, for which, Healthcare Radius was one of the media partners, was a learning platform for hospital promoters, administrators as well as project directors. Here’s what a few key speakers spoke on.
Dr Preethi Pradhan, Dean, Chitkara School of Health Sciences Topic: Hospital planning, design and architecture Gist: The nine strategic essentials in hospital planning, design and architecture are design for flexibility and expandability, anticipating change in demand functions, building healthcare hotels, emphasising on patientfocused hospitals, focusing on energy conservation, creating a healing architecture, focusing on aesthetics, planning for green hospitals
40
and visualising the hospital of the future. Healing architecture: Patients deserve to receive treatment in a salubrious environment even if they give the highest priority to obtaining the best treatment. Aesthetics, which is the quality of the total experience of our surroundings as perceived by our senses and intellect, should be planned for all its dimensions. Green hospitals: Some of the parameters to be added for green hospitals are using passive solar energy, utilising renewable sources of energy such as solar, wind and biogas, proper waste disposal, going organic, using non-toxic and non-allergic materials in hospital building and using natural light and ventilators. The challenge is to reach a point where green architecture is indistinguishable from good architecture. The hospital of the future will successfully be reformed into organ-based centres that have a building of their own. The patients would only be moved around in the hospital in exceptional cases, when there is a need for highly specialised diagnostic equipment or treatment.
Anuj Jindal, Senior consultant, HOSPACCX India Systems Topic: Budgeting and financial planning of a new hospital Gist: Building a hospital entails several key aspects. First, it involves market research, which includes demographics, current providers, gap
analysis, availability of talent, defining target market and business model. Second, it involves financial feasibility, which includes making a revenue estimate, capex opex estimates, profitability analysis and project report. The requirements to build a hospital are land, building, interiors and furniture, medical equipment, engineering services and utilities and office equipment. The various options to fund a hospital include promoters contribution (equity or unsecured loans), debt/external funding (from banks/financial institutions generator). The project cost estimation are land (15 per cent to 18 per cent of project cost), building (25 per cent to 28 per cent), interiors & furniture (5 per cent to 7 per cent), medical equipment (30 per cent to 35 per cent), utilities and office equipment (5 per cent to 7 per cent), working capital margin (2 per cent) and pre-op expenses (3 per cent). In a 200-bed hospital, say built over two acres, the cost of the building should be Rs16 lakh, that of building Rs25 lakh, medical equipment at Rs32 lakh and rest for treatment plant,
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Event report
office equipment and working capital, among others, resulting in project cost of Rs90 lakh with a capex of Rs45 lakh per bed.
Dr Pranav Sharma, non-vascular interventional radiologist and co-founder, The TopBrass Topic: Equipment selection and optimisation Gist: Indian corporate hospitals spend about 35 per cent of their total investment to get the best equipment. The investment per bed would be about Rs50 lakh to Rs1 crore and about 30 - 40 per cent of this is often spent on equipment (including OT). The departments requiring large equipment are diagnosis area, emergency unit, radiation/ imaging unit, physiotherapy units, autopsy, central labs, central pharmacy, surgery, cathlab, cardiology, ICU/ICCU, inpatient area and OTs. The development of equipment plan involves a detailed room-by-room list of required equipment, distinguishing between new and existing equipment. The plan involves meetings with clients to develop new equipment needs, develop preliminary budget, develop alternate specifications to obtain competitive bidding on equipment, make recommendation for new equipment specifications and obtain utility requirements for all existing and new equipment. The common requirement in the development of an equipment plan is to evaluate the current equipment. Equipment audits need to be carried out to evaluate what should be kept in service (and for how long) as against what should be replaced. Existing equipment assessment services should include the following: identifying master list of existing equipment, on-site evaluation of each equipment item, evaluating condition/functionality of equipment, making recommendation for maintaining or replacing existing equipment. The medical equipment planning cycle should include planning, assessment, acquisition and disposition. Equipment planning should have a systematic approach to determine the hospital’s equipment needs. It needs a complete, accurate and up-to-date
medical equipment inventory for purchase cost, purchase date, equipment type and department name. Medical equipment planning and layout design are one of the trickiest parts within the hospital design process and should thus have a multi-discipline approach. The advisory group should have representation from clinical super speciality, medical/clinical staff — physician, doctors — finance and accounting team, purchase team, management / administration team, biomedical engineering team, building, plant and facilities team, IT and nursing ward staff.
Gp Capt (Dr) Sanjeev Sood, hospital and health systems administrator Topic: Quality standards applicable to hospital planning In evidence-based design (EBD), the linkage of the physical environment with safety and quality outcomes for patients is established. EBD is the process of basing decisions about the built environment on credible research to achieve the best possible outcomes. This design process leads to demonstrated improvements in the organisation’s clinical outcomes, economic performance, productivity, and clientele satisfaction. Measurable delivery outcomes aim at creating environments that are therapeutic and healing, supportive of family involvement, efficient for staff performance and restorative for workers and sustainable design. Building better healthcare buildings should come with Building information modelling (BIM) and Computational Fluid Dynamics (CFD). BIM is an intelligent modelbased process that helps service providers achieve business results by enabling more accurate, accessible, and actionable insight through a project lifecycle. CFD simulation using CFD tools can help building design teams model designs, such as operating rooms, to visualise and analyse room air flow and temperature distribution to minimise the risk from aerosol-transmitted infections. Planning a hospital for better infection control includes the following: functional
segregation of OPD, inpatients, diagnostic services and supportive services so that mixing of patient flow is avoided. Separation of critical areas like OTs, ICU from general traffic, avoidance of air movement from areas like labs and infectious disease wards towards critical areas, support concept of zoning and ventilation standards in acute care areas. The clean corridor and dirty corridor should not be adjacent and facilitate traffic flow of clean and dirty items separately.
Dr Col BP Singh, Global Healthcare Integrated Business Solutions, Chandigarh Topic: Hospital planning: An overview Gist: The guiding principles in hospital planning are patient care of high quality, effective community orientation, economic viability, orderly planning, sound architectural plan and state-of-the-art medical technology. The key planning and design aspects include hospital planning team, demographic profile, health statistics, local regulations, local cultures / practices and macro/micro planning. It also involves flexibility, convertibility and expandability – modular approach. In addition assessment of beds, wards, departments, resources/funds, landscaping and electric load, HVAC, hospital equipment interdepartmental relationships, control of hospital infections, circulation routes, utilisation of natural light /resources and eco friendly materials also need to be taken into account. The master plan includes overall site plan, section plan, department boundaries, major entry and exit points, vertical transportation – stairs, lifts, main corridors between departments and areas for future changes/expansion. The best practices in medical architecture are designing to follow function, taking a multi-disciplinary approach: scientific planning, optimum utilisation of space and making the space patient, staff and visitor friendly. The focus should be on architecture that allows seamless integration of clinical requirements with building planning, flexibility and expandability and aesthetics, functionality and easy maintainability. One must note that contemporary hospital architecture is an amalgamation of science and art.
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Quality control
Pull out these stops Considering applying for accreditation? Then, first ensure that you tackle the seven challenges that can impede your success BY DEEPAK AGARKHED
F
or a hospital, getting accredited means getting recognised for its performance standards, by a national accreditation body (NABH) or international accreditation organisation (JCI). It means that the hospital has managed to meet the stringent standards at various levels set by the body, which is an independent external peer. Accreditation is a testimony to a healthcare organisation’s commitment to improve the safety and quality of patient care, ensure a safe care environment, and continually work towards reducing risks to patients and staff. Over the years, hospitals have realised the benefits of accreditations and now have begun to see the opportunity they provide to benchmark against the best in the industry. Usually, the quality team of a hospital floats the idea of accreditation to the management, which needs to approve of it and commit to it—an important factor in getting through the accreditation. The first important decision that the hospital
42
has to take is to either rely on in-house expertise or look for an external consultant to facilitate the journey. The core team should have representation of clinicians, nursing team, quality, HR and training, and engineering. As an accreditation coordinator in one of the new multi speciality hospitals in northern India, I had the first-hand knowledge of all the processes involved. We had no external consultant and the detailed gap analysis across various departments with respect to the objective elements of accreditation standards was carried out by the core team, in tandem with functional heads. We came across the following challenges, which we managed to successfully overcome, as a team, in less than one year.
1
INCONSISTENT PROCESSES Before embarking on the journey to accreditation, most departments had no written and practiced SOPs and each department functioned based on the directions of respective
functional departmental heads. The core accreditation team had a major challenge to break the inertia and ensure that the SOPs were prepared in time by each department. Cross functional team for audits of each department were formed to check the compliance with the SOPs. Implementation of the SOPs at the ground level was a key to success and intra-departmental training was strengthened to ensure that it happened. The audit observations and its closure were linked to the key result areas of a department. The good performers in each department were recognised and rewarded. Towards the end of the accreditation journey, conducting audit had become a habit and each departmental staff ensured that there was minimum noncompliance.
2
UNSAFE ENVIRONMENT We had to work on improving the hospital infrastructure to ensure safe environment for patients and staff.
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Quality control
We found that the adherence to national
building codes on fire norms was not up to the mark. The fire sensors in some areas were partially functional, the sprinkler lines in a few areas were not charged as there was leakage of water from pipes. The fire exit passages were used as storage places and were closed. The fire exit signages were reworked in some places. There weren’t enough fire extinguishers and whatever was there weren’t even regularly serviced. The fire hydrants in some area were hardly tested and the locks to open hydrant were missing. We fixed all of that. The air changes in OT were reworked, HEPA filtration replacement standard operating procedure established, the direct access of OT to external corridor was reworked. The air-conditioning design for negative pressure in isolation room was reworked. Patient safety devices like nurse call units were tested on their functionality and hand grabs were installed in every toilet. Appropriate measures like ramps and visual signages were provided to navigate sharp bends in the building. The signages in hospital were converted into bilingual and service directory, patient rights and responsibilities were prominently displayed.
Clinical documentation is an important step towards accreditation. team. The biggest hurdle was to get employees to attend training sessions during duty hours. The challenge became intense when occupancy increased in the hospital. The constant motivation from departmental heads and the HR team helped us overcome the challenge. The mock drills on fire, community disaster, code blue and spillage of biomedical waste involved team effort. The cohesiveness in team was achieved after repeated mock tests.
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IMPROPER DOCUMENTATION There were several lapses in documentation, like unsigned treatment orders, incomplete discharge sheets and medication orders. The top management understood the sensitivity of the problem and addressed the issue. The resident medical officers played critical role to reduce these defects. The checklist was created to check patient files and a team of medical officers facilitated the activity both at ward and medical records office. Also, the weekly CMEs for clinicians laid emphasis on documentation and capturing of adverse events, near miss, and sentinel events.
UNTRAINED STAFF FOR EMERGENCY PREPAREDNESS The training department had identified both, hospital-wide and department-wide training needs. The trainers for each activity were identified and were mapped in the training calendar. Classroom training and hands-on training for emergencies like fire related training were conducted and feedback of the same were critically evaluated and presented to the core
INADEQUATE INVENTORY CONTROL MEASURES Considering the large number of stores across the hospital and drugs and consumables kept in each sub stores and patient areas, it was a major challenge to identify expired and near expiry drugs. The joint audit from central store and user department on regular basis helped reduce the error to some extent. Physical count and Hospital Information Management (HIS) count were tallied on regular basis.
LACK OF ACCEPTANCE OF DATA-DRIVEN APPROACH Accreditation pushes a hospital towards a data-driven approach as quality indicators/ metrics like surgical site infection and patient satisfaction index are captured and analysed by committees. The challenge is to capture correct information regularly, undiluted by human interference. The robust HIS comes handy in most of cases. As in many cases, the acceptance of data and arrangement to work towards betterment of metrics by functional heads was a challenge.
The top management initiative in quality improvement activities like six sigma helped the hospital to move towards the journey of continuous improvement.
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PARTIAL IMPLEMENTATION OF LAWS AND REGULATIONS The list of regulatory compliances involves obtaining and renewing pharmacy, lift and blood bank licenses before accreditation. However, before the accreditation, the hospital lacked centralised tracking of these. The legal department took the initiative to put systems in place to track every regulatory compliance. The departmental heads started sharing all documents with the legal department and management review of regulatory compliances became a priority. Overcoming these seven major challenges besides others like maintenance of facility/ equipment, medication management, and nursing care, had helped the hospital secure accreditation within a year. This was also possible because of the commitment of all stake holders—the management, the team members and the out-sourced employees.
Deepak Agarkhed is GMclinical engineering, facilities & quality, Takshasila Healthcare and Research Services Private Limited, Bengaluru. He has done Masters in six sigma black belt.
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Consumer Connect Initiative
The right platform Carestream’s e-Radiograph offers a platform for radiologists to share best practices in medical imaging Carestream Health India launched e-Radiograph, a scientific bi-yearly journal in e-book format at IRIA 2013 in Indore as part of its Radiology Education Services (CRES). The main objective of this one-of-a-kind journal is to provide the radiology community with the latest news on innovations and best practices in radiology. Prabir Chatterjee, managing director, Carestream Health India, elaborates on the purpose and strategy behind this knowledge sharing initiative. Can you briefly describe e-Radiograph to our readers? e-Radiograph is a scientific journal dedicated to radiology. It delivers in-depth technical insights and expert views in a concise, easy-to-read style. It comes in an e-book format designed to offer an informative and enjoyable read, while serving as a reference tool for practising radiologists. What is the objective behind launching eRadiograph? The objective behind launching e-Radiograph is to establish a knowledge-sharing platform, which is easily accessible for all radiologists. It is a perfect fit with our strategy, which is to always provide the radiology community with leading-edge knowledge and information that will help them in their practice. Please elaborate on how you select topics and create content for e-Radiograph? We select the topics based on feedback from practising radiologists. In every issue, we intend to cover a different topic of interest in radiology. To bring out different views and perspectives, we intend to work with eminent radiologists as guest editors for each issue. For the launch issue, Dr Anirudh Kohli, head of radiology, Breach Candy Hospital, Mumbai,
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The e-Radiograph is a first of its kind initiative
Prabir Chatterjee, MD, Carestream Health India
The objective behind launching e-Radiograph is to establish a knowledge-sharing platform, which is easily accessible for all radiologists was the guest editor. In this issue, he covered the interesting topic of bowel imaging in great detail, and we are grateful for his contribution. Where can people access e-Radiograph? e-Radiograph is available online on our website. One can simply log on to www.carestream.in/ eradiograph to subscribe to the current and subsequent issues, without any charge. The online format allows busy medical professionals
to access this comprehensive educational tool from anywhere, even while commuting. What future do you see for e-Radiograph? e-Radiograph has opened to a very positive response. Since we focus on interesting topics, collaborate with respected medical radiologists, and tap into our readers’ needs, we are confident that e-Radiograph will continue to be well-received by radiologists.
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21-03-2013 16:11:59
Movers&Shakers
A monthly round-up of high-profile appointments and accolades in healthcare
RAKESH SINGH APPOINTED MANIPAL COO Rakesh Singh has assumed charge as Chief Operating Officer (COO) for Manipal Health Enterprises, the corporate healthcare entity of Manipal Education and Medical Group (MEMG). Singh will be responsible for the entire operations and P&L of all corporate hospitals of MHE. He will also oversee MHE’s purchase, IT, sales and marketing functions. “I look forward to creating profitable business growth for the organisation with aggressive expansion of services in existing and new markets, innovative solutions and by positioning MHE’s various centres of clinical excellences strongly in different markets. I would be focused on customer-centric solutions and on ensuring that Manipal brand becomes healthcare service provider of choice across all markets that Manipal operates in,” Singh said. Singh brings with him over 24 years of business management experience from some of the best Indian and MNC organisations such as Godrej, GE Appliances, Whirlpool India, Tata Teleservices and Reliance Communications. He has holds a B Tech degree in mechanical engineering from IIT, Delhi, and PGDBM in marketing and finance from XLRI, Jamshedpur.
LALIT MISTRY JOINS KPMG Former COO of Ahmedabad-based BAPS Yogiji Maharaj Hospital, Lalit Mistry, has recently joined as associate director, strategy service group of KPMG India at Mumbai. “KPMG in India has a strong and focused healthcare team with a rich experience in the sector to provide healthcare solutions. I will build greater depth in KPMG healthcare offerings,” said Mistry. “It’s increasingly important in the recent scenario for the healthcare industry to adopt new business models and look for tools beyond healthcare industry and choose and pick the best practices and process from other industries to materialise business objectives,” he added. Mistry holds a post graduate diploma in hospital administration from KC College of Management Studies. He has also done an Internal Counsellor Programme on NABH Standards from Quality Council of India. He has worked on more than 20 healthcare projects across India, Dubai and Kenya. His areas of specialisation include: BPR, PPPs, supply chain management, process design and operating effectiveness assessment studies for streamlining systems and process.
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Movers & Shakers
DR DEVI SHETTY FELICITATED BY IMC Dr Devi Shetty, chairman, Narayana Hrudayalaya Group of Hospitals, has been awarded the 2012 IMC Juran Quality Medal by IMC’s Ramkrishna Bajaj National Quality Award Trust. The award was given by the chief guest for the ceremony, Honorable Dr Justice C S Dharmadhikari on March 13 at YB Chavan Centre, Mumbai. Viren Prasad Shetty, senior president, Narayana Hrudayalaya Group of Hospitals, accepted the award on behalf of his father Dr Devi Shetty. “Technology gives the rich what they already have and the poor something, which they could never get. We have to invest a lot in technology and this award will make us achieve our goals faster,” read Dr Shetty’s message. Dr Shetty has been the recipient of several such awards. In 2001, Dr Shetty founded Narayana Hrudayalaya, a 250-bed multi-specialty hospital on the outskirts of Bengaluru. Today, the group has hospitals across Mysore, Dharwad, Hyderabad, Jaipur, Ahmedabad, Dharwad, Raipur, Kolar and Kolkata. Dr Shetty has many firsts to his credit. He is the first heart surgeon in India to venture into neo-natal open-heart surgery and the first to conduct an open-heart surgery in the world. He also performed Asia's first dynamic cardio-myoplasty and the first to introduce the concept of assembly line heart surgery, which aims at reducing the cost of surgery and achieving zero mortality.
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DR KAMINI RAO RECEIVES SWASTH BHARAT SAMMAN Leading gynaecologist and infertility specialist Dr Kamini Rao has been awarded the Swasth Bharat Samman in the gynaecology category by minister of health and family welfare Ghulam Nabi Azad. The award was given on the occasion of international Women’s Day on March 8 at a gathering of distinguished people from different walks of life. On receiving the award, Dr Rao, who is also medical director of BACC Healthcare said, “If my work has somehow made people’s lives a little better, then I feel like it has been a huge success. I have lived my passion, which has been giving the gift of a child to those unfortunate enough not to be able to have one on their own.” She added that the inability to bear a child is regarded as a curse in India, where women still bear the brunt of social ostracism for something that often is no fault of theirs. “The joy that my team and I have brought to such couples is something that I cannot express in words,” she beamed. The Swasth Bharath Samman Award is a national award constituted to recognise and felicitate towering personalities, who have made immense contribution to healthcare sector in the country.
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