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 52 of every previous month. Posted at Patrika Channel Sorting Office, Mumbai-400001, Posting date: 30th & 31st of every previous month
Embracing modern thinking
January 2013 • Vol 1 • Issue 4 • Rs50
An ITP Publishing India publication
Plus LESSONS IN INNOVATION FROM HARVARD BUSINESS SCHOOL DEBATE
The pros and cons of group medical practice
UPDATE
Advancements in complicated spinal surgery
EXCLUSIVE HOSPITALS ARE EMBRACING HIGH-TECH ENERGY EFFICIENT SOLUTIONS
DR TURNAROUND Dr Praneet Kumar on reviving the ailing BLK Super Speciality Hospital and strengthening NABH’s appeals and grievance committee
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Contents
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January 2013
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08 NEWS
28 Event report
42 Tech Trend
This month's important news update
HospiArch 2012, Delhi—a platform to discuss designing the modern-day hospital
The future of ECMO support therapy in India holds promise
30 Roundtable
45 consumer connect initiative
Is group medical practice really as good for a hospital as it appears?
Why Tarkett is the preferred choice for innovative and sustainable flooring solutions
Dr Praneet Kumar on the plans for his two very challenging roles
34 Viewpoint
48 product showcase
10 lessons in innovation
All that is new and updated on the market
24 In design
38 insight
50 movers & shakers
The importance of flexibility while planning hospital design
The smart measures that hospitals are adopting smart to become energy efficient
Who's moved where, who's won what award and more...
14 Technology Dr Vikas Tandon discusses strides that help perform successful spinal deformities surgeries
18 Straight Talk
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Editor's Note
january 2013 • Vol 1 • Issue 4 ITP Publishing India Pvt Ltd Notan Plaza, 3rd floor, 898 Turner Road Bandra (West), Mumbai – 400050 T +91 22 6154 6000
The change maker
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he Indian healthcare industry is blessed with a handful of dynamic healthcare professionals, who go beyond their purview of professional work towards augmenting and redefining archaic industry standards and regulations, thus giving a new thrust and momentum. The 58-year-old Dr Praneet Kumar definitely belongs to this class of change makers. Dr Kumar is one of the pioneers of the quality and accreditation movement—he played a key role in drafting NABH’s standards, was the head of the NABH technical committee and, now will be strengthening the body’s appeals and grievance committee as chairman. Read about what Dr Kumar has up his sleeves in his new role and also about his plans for BL Kapoor Super Specialty Hospital after he successfully resuscitated it. From ground-breaking efforts by an individual, we take you to the significant efforts made by hospitals to reduce their energy consumption and carbon footprint. Read about how they adopted novel technologies to achieve powerful results in our ‘Insight’ section. Novel efforts require innovative thinking and learning from the success of others, and that’s what our ‘Viewpoint’ section focuses on: it tells you about 10 lessons in innovation espoused by the prestigious Harvard Business School. While on the topic of innovation, a novel concept of group medical practice is seen an emerging trend in the industry and it holds the promise of enhanced patient care. Check out experts debating on the topic in the ‘Roundtable’ section. Also, enriching your knowledge, in this issue, we have articles on technological advancements that have enhanced spine deformity correction surgeries, the rising popularity of ECMO and the need for flexibility in hospital planning and design—a loaded issue as a start for the New Year.
Deputy managing director: S Saikumar Publishing director: Bibhor Srivastava 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
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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 and published at ITP Publishing India, Notan Plaza, 3rd floor, 898 Turner Road , Bandra (West), Mumbai – 400050 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 RNI No: MAHENG/2012/46040
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News Track Fortis to expand healthcare delivery in the GCC region
To expand and leverage its primary and day care specialty vertical in Asia, Fortis Healthcare has entered into a strategic tie-up with Majid Al Futtaim Healthcare, a division of Majid Al Futtaim
Ventures. Fortis will operate and manage Majid Al Futtaim Healthcare’s assets, starting with a day care specialty clinic to be located in Deira City Centre. The project is expected to be operational in
first half of 2013. The focus of the clinics will be towards preventive and curative care with Fortis bringing to the region its more than two decades of expertise in specialty care.
Bioresorbable vascular scaffold launched
Abbott announced the launch of the world's first drug eluting bioresorbable vascular scaffold (BVS) in India.
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Abbott’s BVS works by restoring blood flow to the heart similar to a metallic stent, but then dissolves into the body over time, leaving behind a treated vessel that may resume more natural function and movement because it is free of a permanent metallic stent. The BVS is made of polylactide, a naturally dissolvable material that is commonly used in medical implants such as dissolving sutures. The potential long-term benefits of a scaffold
that dissolves are significant. The vessel may expand and contract as needed to increase the flow of blood to the heart in response to normal activities such as exercising; treatment and diagnostic options are broadened; the need for long-term treatment with anti-clotting medications may be reduced; and future interventions would be unobstructed as it would be by a permanent implant.
This agreement is the first towards a long-term association between the two organisations in bringing advanced healthcare to this region. The broader strategy is to expand the business regionally.
Attune raises USD 6M Attune Technologies, a leading cloud-based healthcare IT product company is raising 6Million $ from Norwest Venture Partners, a global multi-stage investment firm. Attune has taken a different approach to creating its technology platform (Attune Health Kernel), which helps effectively manage patient data and workflow on the cloud. It is used in hospitals, labs, imaging centres, dialysis centres and clinics, and has logged in over 2 million patient records to date.
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HID Global and Dell Combine Technologies
Artistic impression of the new hospital in Dubai
Two new hospitals in the UAE ASTER, a division of DM Healthcare, will be opening two new multi-specialty hospitals in the UAE. To be located at Mankhool Bur Dubai in Dubai and King Faisal Street in Sharjah, the two hospitals aim to offer easy accessibility to residents across the emirates. The hospitals are slated to be completed and operational during the last quarter of 2014. Together, they will add 300 beds to the ASTER portfolio. The
hospitals will also provide superspecialty clinics. Dr Azad Moopen, chairman, DM Healthcare, said, “This opening is significant in our growth and offers the ideal culmination of our 25 years in healthcare. With our expansion, Aster now has more than 600 beds across the GCC, with highly qualified doctors and paramedics aimed at providing patient care of highest quality.”
HID Global, a worldwide leader in secure identity solutions, and Dell, have combined their technologies to meet the growing needs of the healthcare industry. HID Global has provided OMNIKEY 5321 readers for use with Dell’s Mobile Clinical Computing (MCC) solution, which offers greater security through a single authentication. The solution allows healthcare providers to have secure access to all authorised data and applications without the need to memorise different login IDs and passwords to hospital systems or external solutions. Besides the unique signature and authentication features, Dell’s Mobile Clinical Computing solution consists of two pillars—cross-platform virtualisation and mobility equipment, providing healthcare organisa-
tions more efficiency, productivity and complete data security. The purpose of the solution is to bring mobility to the hospital, save time, improve the quality of patient care, and increase hospital’s operational productivity up to 25 per cent.
Amrita tech wins award
HACC gets recognition
MYA Health Credit joins hands with TATA Capital
Amrita Technologies, a leader in healthcare informatics solutions, recently won the "CSI I-T Excellence Award 2012" by the Computer Society of India, the largest association of I-T professionals in the country. The award was in the healthcare infrastructure and solutions category. Amrita Technologies, which is based in Kolkata, won the honour for its project ‘Hospital Information Management System for Pimpri-Chinchwad Hospitals, Pune, a model of egovernance’.
Health Management and Research Institute (HMRI), an initiative of Piramal Swasthya program by the Piramal Foundation, has won the ‘Innovative Initiative in Healthcare through PPP’ category for its Health Advice Call Center (HACC) in the state of Maharashtra. The solution that is deployed in partnership with the Government of Maharashtra, leverages over 750 algorithms and disease summaries approved by the Government of Maharashtra.
Mya Health Credit, India’s first patient financing company, has collaborated with Tata Capital to facilitate low interest loans for planned medical procedures at empanelled hospitals. Reputed healthcare providers such as Hinduja Hospital, Nova Specialty Surgery, Smile Care and Global Smiles have partnered in this initiative. Mya Health Credit facilitates affordable healthcare loans for pre-planned medical procedures such as fertility treatments; orthopaedic, dental procedures, gynaecology and ophthalmology procedures; and hair transplant, urology, ENT, bariatric and plastic surgeries.
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vision 2020 The healthcare sector could generate over 40 million new jobs and US$200 billion in increased revenues by 2020
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ACQUISITIONS&PARTNERSHIPS BAXTER ACQUIRES GAMBRO MOVE HELPS STRENGTHEN FOOTING IN MAJOR MARKETS
Baxter International Inc has acquired Gambro AB, a privately held dialysis product company based in Lund, Sweden, for total consideration of approximately $4.0 billion. Gambro is a global medical technology company that develops,
manufactures and supplies dialysis products. The acquisition gives Baxter a comprehensive dialysis product portfolio that complements Baxter’s global home dialysis offerings, and positions the company to better meet the evolving needs of the growing dialysis market. The transaction opens up a number of long-term growth opportunities for Baxter around the world. It can now accelerate product sales in established markets such as Europe, where Gambro has an extensive footprint. It can also expand Gambro’s reach in high-growth regions of Latin America and Asia-Pacific, where Baxter has steadily grown its peritoneal dialysis (PD) business.
TRANSASIA ACQUIRES TWO US-BASED COMPANIES Transasia Bio-Medicals, India’s leading IVD company, as part of its global expansion plan acquired two more US based companies—Drew Scientific and JAS Diagnostics Inc from Escalon Medical. Done through Transasia’s subsidiary, Erba Diagnostics USA, this is Transasia’s fifth acquisition this year. It has acquired the entire business assets,
including plant and intellectual assets, which will become a direct wholly-owned subsidiary of Erba Diagnostics. Transasia Group’s acquisition of Drew, marks its entry in the fastgrowing of diabetes management segment worldwide by offering proprietary liquid chromatography-based Glycated haemoglobin analysers and reagents to the laboratories worldwide.
PARTNERSHIP FOR CANCER MEDICINE Eli Lilly and Company and Strides Arcolab Ltd will collaborate to expand delivery of cancer medicines in emerging markets. As per the arrangement, Lilly will in-license a portfolio of high-quality, branded generic injectable and oral cancer medicines from Agila Specialties, the specialties division of Strides Arcolab Limited. Agila will manufacture the cancer medicines and Lilly will register and market them. In addition to the initial 10 medicines included as part of the agreement, Lilly can also add more high-quality branded generic oncology products to the portfolio.
250 MILLION DIABETES AFFECTS AN ESTIMATED 250 MILLION PEOPLE WORLDWIDE WITH NEARLY 60% RESIDING IN INDIA AND CHINA ALONE
PIRAMAL SUBSIDIARY ACQUIRES ABACUS INTERNATIONAL
Piramal Enterprises’ subsidiary Decision Resources Group, one of the world’s leading research and advisory firms focusing on healthcare insights and analysis, announced its acquisition of Abacus International, a pioneer in evidence-based global market access solutions for many of the world’s leading healthcare companies. The acquisition of UK-based Abacus by Burlington, Massachusetts-based Decision Resources Group will result in a significant global expansion of Decision Resources Group’s market access capabilities. “Abacus brings to the table a unique combination of technical excellence and robust, evidencebased analysis resulting in solutions that are well-designed to address the needs of our healthcare clients,” said Jim Lang, President of the Market Access Business Unit at Decision Resources Group.
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NE W L AUNCHES First automated microbial identification system Country’s first automated microbial identification has been installed in Indraprastha Apollo Hospital, New Delhi. The device is developed by bioMerieux and is based on advanced technology for quick automated microbial identification of disease-inducing microorganisms such as fungi and bacteria to accelerate and increase the accuracy of diagnosis and treatment. Dr Raman Sardana, senior consultant (Microbiology) and additional director – medical services, said “The rapid identification of microorganisms has been shown to guide patient treatment and improve clinical outcomes. Waiting several days for a definitive identification of the pathogen provides an obstacle to the clinician seeking to target therapy with the most effective treatment. This is where technologies such as automated microbial identification are helpful with their accuracy and specificity.” With the help of automated microbial identification, the type of infection present can be determined fast, allowing doctors to more specifically target their therapies with the right antimicrobial at the right dosage. This plays an important role in preventing and slowing the emergence of resistant bacteria and fungi.
NH’s yet another first Narayana Hrudayalaya Hospital, Bengaluru, and ConvaTec recently signed an MoU to establish an advanced wound clinic and limb salvage centre at the hospital. The Narayana Hrudayalaya & ConvaTec Advanced Wound
NOVA IVI FERTILITY LAUNCHES ITS FIRST IVF CENTRE IN DELHI
Nova IVI Fertility, a division of Nova Medical Centers, India’s leading short-stay surgical company, announced the launch of New Delhi’s first of its kind IVF centre with embryoscope
facility, a technology to monitor growth of embryos with real-time videos and live updates. Representing a world-class facility and spread across 12,500 sq feet, the hospital is located in the heart of the city and accessible to all patients. Dr Nalini Mahajan, who has commendable experience and expertise in ART treatment, will serve as the clinical director of Nova IVI Fertility-Delhi. There are Nova IVI Fertility centres in Ahmedabad, Bengaluru, Kolkata and Mumbai. With five well-established fertility centres in major cities, plans are launch 20 centres in the next two years.
APOLLO LAUNCHES TELEMEDICINE SERVICE IN YANGON
Clinic and Limb Salvage Centre will provide world class support and treatment for diabetic foot ulcers, pressure ulcers and venous leg ulcers, and will have state-of-the-art diagnostic capabilities, patient treatment rooms and specialists in wound management. The centre will be the first of its kind in India, bringing together the collective experiences of a leading multinational product manufacturer of advanced wound dressings and one of India’s leading healthcare service providers.
Apollo’s children's centre for trauma Apollo Children's Hospital has dedicated a state-of-the-art trauma care centre to save little lives. Apollo Children's Centre for Trauma, equipped with hightech medical equipment and expertise (physicians and surgeons across anaesthesiology and critical care medicine, emergency medicine, neurology, neurosurgery, orthopaedics, plastic surgery and radiology), will provide 24X7 trauma care for children with severe and life-threatening injuries.
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The Apollo Group of Hospitals has announced the launch of its telemedicine service in Yangon. With this facility, people of Myanmar can now consult worldrenowned Indian doctors and get access to quality treatment and latest medical technology without physically visiting Apollo Hospitals. At the inaugural function, live tele-consultation was
demonstrated between doctors of KC Healthcare, Yangon and Apollo Hospitals, Delhi. Sailesh Thangal, deputy chief of mission, Embassy of India, Yangon, Myanmar, inaugurated the facility services at the Keen Cie Co Ltd along with Dr Prathap C Reddy, chairman, Apollo Hospitals Group, who was joined by tele-link.
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DIGITAL BREAST TOMOSYNTHESIS IN DELHI Rajiv Gandhi Cancer Institute & Research Centre has installed digital breast tomosynthesis, a state-of-theart technology for breast imaging. Tomosynthesis provides 3D imaging of the breast in which the breast is virtually sliced into multiple images. In this imaging method, the machine moves in an arc to obtain and process 30 – 40 remarkably sharp images of a breast at high speed with the help of a computer. It produces digital breast images into a stack of thin one millimetre layers, where only a small fraction of the tissue is visible and can be examined. The high-end technology, which is similar to a CT scan but with fewer images, takes just a few seconds to capture detailed scans. It enables detecting cancer that may go undetected by conventional methods of screening.
CLEAN INDIA SHOW 2012 The 9th edition of Clean India Show, held in the city of Bengaluru, was inaugurated by CS Kedar, additional chief secretary, Government of Karnataka and chairman of KUIDFC along with Dr Janardhan Reddy, Commissioner & Director of Municipal Administration, Andhra Pradesh. This year’s show had exhibitors like Sealed Air India (Diversey India), Karcher Cleaning Systems, Eureka Forbes, Pest Control of India, 3M, TSM and InventaCleantec. The inauguration was followed by a seminar on hospital hygiene. Speaking on the need for cleanliness and hygiene practices in a hospital and systems, Dr A Mohan, professor, Department of Urology and Head Quality Control Department, St John’s Medical College Hospital, said that community involvement in hospitals was required to maintain hygiene. “Modern engineering treatments and renewal of old fixtures and furniture should be done in the context for better hospital maintenance,” he said. Dr BN Gokul, senior infection control officer at the Fortis Hospital-Bengaluru, said there is need for proper waste management in hospitals through segregation at source as 10 – 15 per cent of bio medical waste is hazardous and therefore should not be allowed to mix with other refuse.
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Technology
Strides in spinal surgery Dr Vikas Tandon discusses the advancements that have enabled surgeons to perform challenging spinal deformity surgeries with great success
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orrection of deformity dates back to the days of Lord Krishna, who corrected a woman’s (Kubja, evil king Kansa’s maid) kyphotic deformity by simply putting his feet on her back and straightening her chin. His divine touch was enough to cure the lady. Unfortunately, for today’s spine surgeons, managing spinal deformities poses a great challenge. All deformities are in the coronal plane (known as scoliosis) or in the saggital plane (known as kyphosis). However, usually, they present as combinations in different planes, more in one than the other, making a deformity three dimensional.
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The various parts of the spine balance each other well to keep the person upright. Any deviation from their normal ranges is considered a deformity. When these deformities cross a certain degree, they require surgical intervention to provide cosmesis (surgical correction of a disfiguring defect), prevent damage to internal organs or correct neurological issues.
The backbone Surgical correction of deformed spines requires great planning, which comes with experience. It is a result of years of work that surgeons across the world have put in. A greater understanding
of the patho-anatomy of spinal deformity in itself can be considered a major advancement in management of deformed spines as it provides for improved results. There cannot be a substitute to a surgeon’s understanding of the deformity and his skills to perform these challenging surgeries—they are the backbone of this procedures.
The tools Advancements in imaging, neuro-monitoring, implants, bone graft substitutes and blood salvage techniques further assists a surgeon to carry out these challenging surgeries, safely and optimally. Blood salvage techniques: Advancements
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Technology
in the field of anaesthesia to keep mean blood pressure low, autologous blood transfusions and cell-saver machines have all worked for the betterment of patients. They help to keep a check on blood loss during surgery and make these lengthy surgeries safe. All these techniques of blood salvage have revolutionised the surgical management, eliminating the need for large amount of blood transfusions. OTs: Modern operation theatres provide an aseptic environment, considerably bringing down the possibility of infections—a surgeon’s nightmare. Implants: Innovations in implants pertaining to their design and metallurgy have all improved the final results. Surgeons have moved on from using hooks and laminar wires to placing pedicle screws in the spine. The pedicle screws provide better stability as they engage all three columns of the spine and can be better manipulated to achieve correction of deformity. Furthermore, improvisation leading to vertebral column manipulator and direct vertebral rotation devices have also improved the final results as now surgeons are even able to correct rotation of the deformed spine, which was not possible earlier. There have been improvements in implants for surgery in children as well, which have further improved the final outcome as they allow the spine to grow and also correct the deformity. Growing rods, vertical expandable prosthetic titanium rib (VEPTR), and convex apical vertebral body staples are some such improved implants. High-tech gadgets: Today, we have certain imaging and neuro-monitoring gadgets that have changed the outlook of a spine surgery, making them absolutely safe. Also, navigation techniques that guide a surgeon during surgery for safe placement of instruments are a boon. Gadgets like O-ARM are highly accurate and provide a real time image, thus promoting safety to the delicate spinal cord. They provide a 360-degree view of the spinal column and assist a surgeon to correctly place pedicle screws in a deformed spine, which would otherwise be a major challenge with a great margin for error. Neuro-monitoring: There is a high risk of injury to the spinal cord during corrective surgery. However, neuro-monitoring has become an inseparable part of these procedures. It enables real-time monitoring of cord function and makes the life of a surgeon comfort-
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thoracoscopic/ laparoscopic anterior releases render a stiff curve more flexible in the most minimally invasive way, without opening the chest or the abdomen able, reducing errors to negligible. Monitoring is of different kinds—while Somato sensory evoked potentials (SSEPs) monitor the sensory or posterior pathways of the spinal cord, motor evoked potentials (MEPs) monitor the motor or anterior pathways. Combined together, they provide an accurate status of the cord function pre-operatively. This was earlier not possible to ascertain in an anaesthetised patient. Surgeons today can perform these complex surgeries with confidence of not injuring cord at any step. Bone graft substitutes: The advent of bone graft substitutes has changed the outlook of spine surgeries that require a lot of bone graft, which had to be harvested from the patient or from bone banks. Donor site morbidity and the need to use bone grafts in high quantity has lead to the invention of the substitutes, which now are being used routinely in sur-
geries. A notable component available these days is the bone morphogenic protein (BMP), which is a good osteo-inductive protein that helps in bone fusion, because ultimately a good fusion is mandatory for a good result. In the end, our understanding of spine pathology and biomechanics is improving and so are the gadgets, making spine surgeries today totally safe. And as our understanding of the spine evolved, the zest to achieve beyond the optimal also grew. Over the years, surgeons throughout the world have been inventing newer techniques to correct these deformities. They involve thoracoscopic/laparoscopic anterior releases to render a stiff curve more flexible in the most minimally invasive way, without the need of opening the chest or the abdomen. Vertebral Column Resection (VCR) is another technique wherein a whole vertebra is restructured, all through posterior approach. This is highly effective for correction of severe and stiff deformities. Similarly, over these years many other osteotomies have emerged as methods of correction of deformities. They all are instrumental in helping us become better spine surgeons.
Dr Vikas Tandon is a consultant spine surgeon with the Indian Spinal Injuries Centre, New Delhi.
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Dr
Fix it Congratulations for taking over as chairman of NABH’s appeals and grievance committee. What does this role signify? Currently, 154 hospitals and 16 small healthcare organisations are NABH accredited. Applications for re-accreditations are on the rise with many organisations completing the three year validity period for renewal. Furthermore, there are hospitals that are not granted accreditation (at present three) and those that are refused re-accreditation (at present nine). Thus, NABH feels it is important to strengthen its appeals and grievance committee. Based on appeals from hospitals and small organisations and complaints about non-conformance with quality standards and other issues, either from the industry or patients, this committee will review the appeals and complaints and suggest remedial measures. These could include withdrawal or suspension of accreditation, if needed. We will be fair and transparent in dispensing justice. How do you look back at your contribution as chairman of technical committee of NABH? I have been associated with NABH even before it was formally instituted—I was a part of the healthcare committee at CII that prepared the initial draft for NABH’s constitution. After the body was formed, initially, I was a member of the accreditation body and then I chaired the technical committee from August 2010 to July 2012, when I was also an ex-officio member of the accreditation committee. During my tenure, I made it a point to remove all ambiguity related to the accreditation standards and measurable elements of each individual standard. We reviewed all the standards, but our larger focus
Dr Praneet Kumar speaks to Rita Dutta on his role in reviving the struggling BLK Super Speciality Hospital and strengthening NABH’s appeals and grievance committee as its chairman
was on patient education to include family education, infection control, responsibility of the management and facility management. We modified and clarified the standards to ensure that healthcare facilities undergoing the journey have clarity for implementation. We also merged the guidebook with standards to rule out chance of ambiguity and misinterpretation. We organised workshops to help hospitals get a better understanding of all sections of the standards. We also conducted refresher courses for assessors to prepare them better for the assessment process. Is not the new role less taxing than heading the technical committee, after all, how many complaints would there be? No, my role is far more challenging and daunting now. Attending to appeals, complaints and grievances is a thankless job. When you deliver the verdict, it is going to be in favour of one or the other — complainant or the other party.
I am chosen for this role because of my reputation for being forthright and my non-tolerance to non-compliance”
This aggrieves the losing side. Giving hospitals the bad news about suspension or withdrawal of their accreditation or to the complainant that the complaint does not hold merit needs courage and I think I have been chosen for this role because of my reputation for being forthright and my non-tolerance towards noncompliance. Also, NABH’s technical committee has been present since its inception and is strong enough as we have reviewed the standards and adopted best practices from accreditation bodies of other countries. In contrast, the grievance committee needs strengthening due to the increasing number of stakeholders and growing public awareness about it. So, we needed to make it more proactive and responsive. Currently, we are in the process of reviewing the existing policies, procedures and SOPs of the appeals and grievance committee to make them more robust and transparent so we can conduct free and fair review. We will be reviewing the need to conduct personal meetings with the hospital against which we received complaint and also review code of conduct for assessors. We will also be studying the standards of other countries for reference. So, are you working on some complaints now? Yes, two or three complex ones. It would be nightmarish addressing the issues. As the number of accredited hospitals and SHCOs has increased, I am definitely expecting more complaints to come in. Has any NABH withdrawn any accreditation? Withdrawal of accreditation is considered and reviewed by the accreditation committee and
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Straight talk
The BLK Super Speciality Hospital has undergone remarkable transformation not just with regards to its looks but also in terms of its functioning
its recommendations are then put up to the NABH board for approval. With the increase in appeals/complaints considered by the appeals and grievance committee, the number of such recommendations is likely to go up too. Has NABH received complaint against assessors? Yes. We did receive two complaints, where the hospital accused the assessor of being rude and unfair. NABH takes a strong view on such feedbacks. We also received complaints from assessors about some hospitals being violent with them once the hospital authorities realised that the assessors pointed out many instances of nonconformance. These would have definitely resulted in that facility not procuring the minimum score required to be considered for accreditation. Now, such complaints would see speedy justice. Do you see NABH accreditation becoming more popular outside India than it is today? It’s with exactly that objective that we constituted NABH International (NABH-I). Today, we are present in Philippines. Furthermore, NABH-I has now been officially accepted by Health Regulation Department, Dubai Health Authority as an approved accrediting agency for hospitals in Dubai. In the immediate future, India and Asia will remain our focus, rather than Europe and America. In addition, NABH-I has conducted awareness workshops and final assessments of four centres of Belo Medical
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Radiant growth Which are the other projects of Radiant? In January 2012, Radiant signed an agreement with Delhi Sikh Gurdwara Management Committee for developing and managing the Guru Harkishan Hospital & Medical Research Institute, Ashram in South Delhi, for a period of 30 years. The super structure of the hospital is already there. We will develop the project to build a 700-bed super-specialty tertiary healthcare facility, spread over one million square feet. We will build, equip and operate the project. In the second phase, we will build 300 to 400 beds with a medical college within the same premises. We are waiting for clearance to start the project, and once started, we will complete it in 18 months. We are also looking at building, equipping and managing a 130 to 150-bed hospital project in Maharashtra. This should be ready by December 2013. Are you looking only at an asset-light model? We are looking at all kinds: greenfield, acquisition, brownfield, JV and management contracts. Any projects that fit into our scheme of things will interest us. People who say that they are only keen on asset-light models are dressing up their balance sheets. This is only possible if all the facilities are under management contracts, something similar to hotel industry.
Group under SHCO and signed an MOU with Razi Resalat Accreditation Company, Teheran, Iran in July 2012. What would drive NABH’s popularity are our stringent standards and our cost effectiveness. Our standards, after several reviews, have been simplified, but they are the most rigorous standards—superior than any other international body. I have been associated with various international accreditation bodies, and from my experience, I can state that other international standards may appear complex, but are less stringent than NABH. In terms of cost, we are far more cost effective than even JCI. While a 250-bed hospital spends around Rs50 lakh to Rs60 lakh on getting JCI accreditation, it will have to spend a maximum of Rs10 lakh to Rs12 lakh on NABH accreditation, including charges for the process and consultants, among others. So, as in India, soon in Asia too, NABH will be more sought-after than JCI. You surprised the industry by joining Dr BL Kapur Hospital. What made a veteran like you take up a project that was struggling? I joined Radiant Lifecare Private Limited as its CEO and as its first project was Dr BL Kapur Hospital, I became the CEO of the hospital. Yes, when I took over the reins of the hospital in July 2010, the market perception about the hospital was extremely negative. Though it was functioning in the new building for over a year, there were strong rumours in the market that
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it was a dead project and likely to shut down. Joining the hospital was considered a professional hara-kiri. No good doctor or professional wanted to join us then. Obviously, people questioned my sanity in joining a struggling hospital after 15 years of taking up a variety of senior positions with an established player like Fortis Healthcare. But I was determined to take up the challenge of making this hospital work. I had rolled out several hospital projects from the scratch including from planning stage, turned around sick hospitals, re-engineered and developed newer programmes in existing hospitals, which had tasted success but were on decline, so I was confident of my skills and ability. It was a personal challenge to see whether I could turn the struggling hospital into a profitable one. Had I failed, I was ready to take it in my stride as I knew that no one can take away my professional achievements away from me. With that thought, I plunged headlong into the project. What reactions did you elicit from the staff when you joined? During my interactions with Radiant, I never visited the hospital once. However, interestingly, when I joined everyone thought that the hospital had been acquired by Fortis. That was because Fortis was on an acquiring spree then, and I was a recognised face with Fortis. But once they knew the truth, their faith in the project was re-instated as at least in this part of the country, I am recognised for being a skilled leader. What were the issues with the hospital when you joined? After the redevelopment of the hospital, it offered excellent infrastructure and state-ofthe-art equipment. We already had pneumatic chute system and a pathological lab that was unmatched by any in NCR, in terms of infrastructure, design and equipment. Similarly, the operation theatres were modular, ICUs had fantastic infrastructure and all patients’ rooms had adequate natural light coming in to provide comfort to the patient and the family. However, what was pulling the hospital down was a lack of vision and poor management. Since the commencement of the project, the manpower hired and equipment installed were for occupancy of approximately 200 – 250 beds. However, even after a year of commissioning, only around 45 beds were being filled up. Staff optimisation was low and with the high cost of operation and low returns, the project was bleeding. When I joined, the nursing and paramedical
staff was still temporary and many were not paid increments and other arrears. Naturally, they were a disgruntled lot. What aggravated the problem was that there was no well-laid out strategy to get more patient footfalls. A delayed start, low patient turnout and demotivated staff dissuaded doctors from joining. But why did the redevelopment take so long? The 60-year-old hospital had a chequered history. The project, owned by Lahore Hospital Society Trust, was started way back in 1959 as a maternal and child hospital. It was inaugurated by Pandit Jawaharlal Nehru and was a successful and popular hospital. With the passage of time, it kept on adding specialities to become a multi-speciality hospital in ’90s. But the old infrastructure was not conducive for responding to the changing needs of modern healthcare. In 1999, the trustees decided to redevelop the hospital to meet the requirements of the
People who say that they are only keen on asset-light models are dressing up their balance sheets”
contemporary times. It needed investment for technology and redevelopment, but the trust failed to get sufficient funding till 2004, when they approached Integrated Health and Healthcare Services India Pvt Ltd (IHHS) based in Middle East for redevelopment, operations and management contract for a period of 45 years. However, the redevelopment got delayed in design finalisation and then in getting the necessary approvals. Then around 2006, when the government allowed FAR to be increased from one to two for hospitals, the management wanted to take advantage of this new rule and thus once again, the project went to the drawing board. The re-developed project building was ready by 2007, but then the Government fire safety norms got modified and that caused further delay. Also, the government made it mandatory for hospitals to get all clearances and not merely occupancy certificate before commencing operations. That took another 18 months, and thus finally, the redeveloped hospital was finally commissioned in April 2009. Once again, there was a change of management. How did that impact the project? Halcyon Finance and Capital Advisors Pvt Ltd acquired IHHS in 2010 via their Singaporebased wholly-owned subsidiary Infrahealth Pvt Ltd, around the time I joined IHHS. The ownership change has not affected our day-today functioning as Infrahealth agreed to take over IHHS, only when they were sure that I was
The hospital had state-of-the art equipment, yet no doctor was willing to join it two years back
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Straight talk
Though there was excess staff for a hospital that had occupancy of only 45 beds, we were determined not to boot out anyone”
stepping into the project. The name of the company was changed to Radiant Life Care later to reflect the focus for future. What were the first few things that you set out to correct after joining? First, I chalked out a vision, which was to make the hospital a multi-super speciality hospital. We developed the concept of centres of excellence, which I call tower specialities. I put together a team of some of the best professionals in the industry. As we already had the necessary equipment installed and trained manpower to man these equipment, we just needed to focus on specialities that would help us differentiate. Since central Delhi did not have a full-fledged private oncology centre, we decided to have oncology as one of our first tower specialities, now known as BLK Cancer Centre. Then, we worked on strengthening the bone marrow transplant unit, which was struggling due to lack of management support. Thereafter, GI, neuro sciences, renal sciences and cardiac were strengthened as our other centres of excellence. Before chalking out the strategic direction and improving the day-to-day functioning of the hospital, I sent out communication to the doctors, sending some 20-odd questions that sought their suggestions and ideas to improve the working of the hospital. I shared with all, a 100-day plan, a short-term plan (of around nine months coinciding with remaining part of financial year 2010-11), a medium-term plan for next two years and a long-term plan beyond that period. The discussions focused on getting a consensus for the road map to attain the goals as a unit followed by each department’s individual goals. These were not business goals, but goals about the road ahead. It made sense taking suggestions
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from them as they had worked in the system and were well-versed with the strengths and weaknesses. In that communication, I also stated my shortcomings—I am quite impatient and have no tolerance for lies and non-performance. Did you really mention your shortcomings? Yes, I did. I wanted the exercise to be a free, fair and a transparent one, where we come to realise our strength and weakness and then lay the path for a common goal. How did the exercise go with the doctors? We held meetings with all department heads first to chalk out a vision for the hospital and then for individual departments, and also to invite their suggestions. After understanding their viewpoints, we implemented some changes. We also showed no tolerance to one department that came unprepared for the meeting. How did you handle the disgruntled staff? My most pressing task was resolution of all pending issues of the staff, which included regularisation, increments and other small issues. Though there was excess staff for a hospital that had occupancy of only 45 beds, we were determined not to boot out anyone. Had I done that, the image of the hospital would have further nosedived. The industry would have come to know about the job loss and the damage to the reputation of the hospital would have been instant, making it difficult to rope in good clinical acumen. It was worthwhile retaining the staff and thus, we worked towards training and preparing them for the future. You also re-christened the hospital… Yes, in 2011, we launched a major re-positioning and rebranding exercise for the hospital. We renamed it as BLK Super Speciality Hospital and also unveiled a new logo. How did you go about getting good doctors? There was an urgent need to get good doctors on board, which was a challenging task given the rumours in the market. Doctors, who I thought would be willing to join seeing the infrastructure, refused. So, I first set out taking help from the doctors already with us. Then, I waited for the right market opportunity to get doctors from outside. In the beginning of 2011, when there was a cloud of uncertainty at Artemis as a result of their CEO leaving, we got a team of six senior oncologists and three technicians and nurses from there
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full-fledged neuro interventional team and neurology consultant to the existing pool of doctors and brought in a full team for liver transplant. How have the centres of excellence shaped up? The bone marrow transplant unit offers both allogenic and autologous transplants for various benign and malignant disorders. I am proud to state that we have done over 100 bone marrow transplants in around two years and our success rate is almost 100 per cent. Our renal sciences department, started doing kidney transplant and soon, our liver transplant unit would start functioning. In oncology, our department of radiotherapy has the latest generation Trilogy Tx Linear Accelerator, offering state of art IGRT, IMRT, 3DCRT, Stereotactic RT and High dose rate Brachytherapy. In September 2012, we pumped in Rs 20 crore for introducing the latest version of Cyberknife.
and that helped us strengthen our cancer centre. For almost a year, I wooed GI specialist Dr JC Vij working at PSRI to strengthen the BLK Centre for Liver & Digestive Diseases. Meanwhile, we had been successful in getting Dr Yogesh Batra of Batra Hospital for the liver transplant department. Dr Deep Goel had already joined us from Artemis and strengthened our Minimal Invasive Surgery & Bariatric Surgery Programme. What was the turning point? It was the dengue outbreak during September - November, 2010 that made patients flock to us in large numbers. From 45 – 50 in-patients in July, we had 150 - 190 in-patients a day by October - November. And this happened over a period of almost two weeks. We were the only transfusion medicine centre in Delhi with a large capacity for blood component separation and thus were able to cater to the wide demand of platelets for dengue, not just for our patients but for even other hospitals. As the dengue strain was severe with hemorrhagic type being dominant, other hospitals started referring cases to us. We became popular almost overnight. So, was it a smooth journey after that? Far from it; while we were dealing with the sudden surge of patients, I realised that though the hospital was made operational for 250 beds, permission was taken for only 74. We immediately applied for permission for registering 150 beds to cater to the demand. The authorities,
THE DR BL KAPUR HOSPITAL PROJECT WAS STARTED IN 1959 AS A MATERNAL AND CHILD HOSPITAL, AND WAS INAUGURATED BY PANDIT JAWAHARLAL NEHRU
Have you initiated any research? No hospital can excel unless it relies on the tripod of clinical care, academics and research. In December 2010, we started the department of academic affairs, research and continuing education, popularly called AARCE. We applied for DNB for four disciplines and got permission for all. This year, we have applied for four additional specialities for DNB. In addition, we now offer a diploma course and fellowship programme in association with the Indian Society of Critical Medicine. We also have two courses certified by FOGSI. As far as research is concerned, we have tied up with companies for multi-centre clinical trials and are part of four trials.
however, rather than appreciating our effort in containing the dengue outbreak, threatened to penalise us for allowing excess patients without prior permission. We were not deterred. When we pointed out that we were only complying with the government diktat, which stated that hospitals should not turn away dengue patients, the authorities had to ignore the threat. Actually, as we were already touching 180 -190 occupancy, we filed an additional application for registration of 300 beds even as we were waiting for the formalities of our previous application to be completed.
What are your plans for further developing the hospital? We are currently a 300-bed facility. The building was made for 500 beds. With re-modelling and modification of existing infrastructure, the hospital would have the installed capacity increased from 500 to around 650 beds by the middle of next year. Also, I am focusing on optimum utilisation of space as most of the rooms and wards are highly expansive. The same space can be used for adding more departments and facilities. In terms of technology, we will soon be installing PET-CT.
So, did your efforts help the bottom line? Yes, from monthly revenue of Rs3 - 4 crore per month two years back, now we are clocking Rs18 crore a month. However, much of goes back in enhancing our existing programmes and adding newer ones—for instance we added a
How do you see the project a few years down the line? By the next financial year, we would have monthly revenue of no less than Rs22 to Rs23 crore. And by the end of two years, we would be utilising all of 650 beds.
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In design
Factor in flexibility It is a good idea to leave scope for future modifications when designing hospital spaces, writes Tarun Katiyar
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ospital infrastructure is typically designed to last beyond 30 years. During this time, the demands on it change significantly and unpredictably. A good value-for-money hospital infrastructure, therefore, needs to be flexible in design to allow effective adaptation to changing circumstances.
Challenges to overcome It’s not easy to plan a flexible design and it’s 100 per cent application is almost impossible without going overboard with building specification. For instance, one needs extremely strict vibration and load bearing criteria for imaging radiotherapy departments. However, we can still plan hospital buildings with some design aspects that will allow, with minimum disruption and time and cost, to alter a department or a building's layout to suit future needs. This can be done by keeping a high ceiling, providing for extra space to add clinical and support services, additional engineering plant space, and extra duct capacity for envisaged services requirements. Ease of installing and dismantling internal partitions, ceilings and re-configurable signage are other things that can be factored in.
Requirements The advancement in medical science and hospital design has led to the development of new diagnostic and treatment procedures for clinical administration. The replacement of bigger, bulkier and inefficient energy-hungry machines with smaller ones that are more efficient and environment friendly has reduced the product life cycle for medical equipment, which is good for clinicians and patients alike. But this change also means that the current design, layout and service provision of hospitals and within them departments, such as OTs, surgeries, OPDs and imaging and radiotherapy, need to be re-designed. The speed of redesign is directly proportionate to the speed of research and development going on around the world, which explains the need for flexibility.
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Benefits of flexibility Efficient and effective use of space is the main objective of the planning and design process. Incorporating flexibility when planning hospital space has the following benefits: • Change in programmes being provided by the organisation. • Change in how service is being delivered. • Changes related to operations, such as the re-organisation of services, new methods in workflow, and re-organisation of staff roles and responsibilities. • Changes in future workload (increase or decrease). • Optimal utilisation of current/available space. • Use of an expensive resource in a sustainable manner in the hospital facility.
Acquiring flexibility The establishment of the basic building block must be considered carefully. Most obviously, the establishment of the structural grid or column layout is important to the planning of the spaces. A grid too small will limit the ability to accommodate large rooms. A grid too large will tax the building’s capital budget. Some hospitals have used the concept of interstitial space to accommodate a super grid or large column-free space with limited structural limitations on the planning and changes to the floor plates. The increased capital cost associated with interstitial space must be justified to provide an organisation with this type of flexibility.
Space for access and expandability of building systems is particularly useful above highly technical and heavily serviced areas such as operating rooms and diagnostic imaging. In such cases, full height interstitial spaces may be considered. Vertical expansion must be considered early to ensure that future needs can be accommodated. It requires specific plans to get accomplished and is not limited to simply ensuring that the foundations and columns are capable of supporting the loads. A system is required that allows ongoing operation of the occupied floors below the expansion to protect the occupants during construction. Once again, the concept of interstitial space can assist in this regard by separating the construction activity from the occupied space. In an ideal scenario, there is a perfect balance between functionality of the space and the generic parameters that afford its flexibility. In the real world, this point of balance may seem elusive at times, but team work, attention to detail, and open communications throughout the planning and design process help us close in on our target.
Tarun Katiyar is principal consultant with Hospaccx India Systems.
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Consumer Connect Initiative
Growth agent
pOWERED BY
The 3rd International Hospital Build & Infrastructure India 2012 served as the perfect stage for the industry to network and expand business
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or those associated with the healthcare industry, 14 - 16 December 2012 were very significant days as the 3rd edition of India’s premier and only dedicated B2B event on Hospital Infrastructure, Planning, Supplies & Healthcare Development was underway at Bombay Exhibition Centre in Mumbai.
A runway success Packed with informative conference sessions, matchmaking service, industry-specific conference tracks, product demonstrations and seminars, the event was a smashing hit with over 3000 trade visitors coming in to see the explicit display of latest Hospital Infrastructure products & technologies. Visitors comprised CEOs, medical directors, hospital administrators, medical superintendants, bio medical consultants, healthcare architects, project management consultants, developers, PE firms, and many senior decision makers and healthcare professionals.
The exhibitors included hospital consultants, healthcare architects, planners, developers, medical equipment suppliers, Hospital Furniture & Interiors, flooring, roofing, lighting, clean room partitions, hospital paints, modular OTs, bedhead panels amongst many more. Around 100 exhibitors from India and abroad, showcased the entire gamut of hospital infrastructure products, medical equipments/technology, and hospital solutions all under one roof.
Hospital with (L) Dr Rajeev Boudhankar, Kohinoor h & Family Dr R Chandrashekhar, Minister of Healt Welfare
Key players Among the notable companies that participated in the event was Knauf Middle East that was present along with business partners Aquapanel, Heradesign and AMF. Knauf had showcased its wide range of products and systems, from Safeboards to Aquapanel and Partition System among others. Knauf witnessed a good response from the visitors who come to its stand like prominent people from hospitals, construction companies and Ministry of Health which made the participation worthwhile.
ital (A Fortis (L) Manpreet Sohal, SL Raheja Hosp ma Exhibitions Asociate) with Nicky Mason, Infor
ition The Godrej Interio stall at the exhib
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Building the Future Knauf is one of the world’s leading production and construction material company with over 220 facilities and 22,000 employees present in over 60 countries. Knauf is a family-owned business, headquartered in Iphofen-Bavaria, Germany. The 80-year-old company specializing in gypsum products has an astonishing range of over 30,000 products, and that tally is growing all the time. The company’s Dubai headquarter services the entire region, and represents its first foray into the Middle East. In addition, it has a manufacturing facility in Ras Al Khaimah, and with a production capacity of 30 million square meters of gypsum board a year. This production is exported throughout the GCC, East Africa and India, which constitute Knauf’s main growth markets at present.
Ras Al Khaimah, UAE
The Crown Prince of Ras Al Khaimah, His Highness Sheikh Mohammad Bin Saud Al Qasimi with Knauf’s Managing Director and Shareholders, RAK, UAE
KNAUF LLC PO Box 112871 Dubai, UAE Tel: +971 4 337 7170 Fax: +971 4 334 9659
KNAUF RAK PO Box 50006 Ras Al Khaimah, UAE Tel: +971 7 221 5300 Fax: +971 7 221 5301
KNAUF Qatar PO Box 27111 Doha, State of Qatar Tel: +974 4452 8191 Fax: +974 4452 8181
KNAUF KSA Branch PO Box 3051 Jeddah 21471 KSA Tel: +966 2 606 7364 Fax: +966 2 606 7251
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Consumer Connect Initiative
Knauf makes a positive impression on the Indian healthcare market at the 3rd International Hospital Build & Infrastructure India 2012 Knauf's vast range of products
Being one of the world's leading productions and construction material company with over 220 facilities, Knauf has a wide variety of products. Knauf recognises that each part of a new hospital holds unique challenges, such as mixtures of acoustic, fire ratings and impact performances. It has solutions for special requirements such as X-Ray protection (new technologies), interior and exterior design, and Access Panels options for operation theatres.
“Knauf Middle East experience at HBII 2012 was outstanding, looking at the feedback and the quality of visitors. The exhibition brought together the decision makers and providers for the region. We are looking forward to participate again at HBII 2013.� KNAUF MIDDLE EAST
One of the major highlights of this edition was the announcement of the first Hospital Build & Infrastructure Awards that felicitated the best efforts in the Healthcare Facility and recognised leaders in the Healthcare industry who have devoted their efforts to building hospitals that help improve healthcare services and raise the bar in providing world-class patient care. The HBI Awards, India, is in line with the International Series of Hospital Build & Infrastructure Awards which is organized by its other portfolio of events like Hospital Build Middle East, Dubai. The event also included technical conferences that focused on the burgeoning opportunities and technological advancements in the Indian hospital infrastructure sector. Packed with so many notable features, the event served a true platform for all the stakeholders of the industry to connect, learn, stay updated, source and grow.
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Event report
Designs on hospitals HospiArch 2012, Delhi, was a great platform for the industry to discuss various aspects related to designing the modern-day hospital
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ospiArch, a conference series on ‘hospital architecture’, was held on 24 and 25 November in Delhi. Jointly organised by AMEN & HOSPACCX India Systems, the event was attended by over 150 delegates. Healthcare Radius was one of the media partners for the event. Among the speakers was Dr Chandrashekhar R, chief architect, Ministry of Health, who spoke on ‘Architectural challenges involved in building a new hospital’. He discussed various models available in brownfield projects, known as the ‘retrofit’ model of expansion. It optimises on all available resources in existing hospitals and yet helps a hospital create its own brand identity. He also discussed technological advancements like modular pre-engineered solutions, plug-andplay concepts with minimum gestation time, while retaining the utility and primary circulation horizontal and vertical infrastructure in the process. Bringing forth the importance of master planning strategies, designing to include zones for future growth, Dr Chandrashekhar took the audience through minute details needed for
micro zoning and environmental comfort (HEPA MD, HVAC, VAV). Awadesh Verma, distinguished fellow, Institute of Hospital Engineering, Delhi, spoke on ‘Architectural planning of green hospitals as a high-performance healing environment’. He discussed concepts like eco-friendly materials, energy optimisation, patient comfort without hurting the balance-sheet. Sadanand Reddy, MD Gold Star Healthcare, New Delhi, spoke on ‘Material Management and equipment planning for a new hospital’. He said that the objectives of inventory control are to reduce financial investment in inventories, to provide good customer services and holding inventories costs to the organisation as holding cost. Speaking on medical equipment procurement, he said, “The medical equipment piece of the puzzle is often overlooked or grossly underestimated. The end result is unexpected expense and the potential for costly redesign.” According to him, the points to focus on before procurement are: latest technology, availability of maintenance and repair facility, minimum down time, post warranty repair at reasonable cost, up-
gradeability, manufacturer reputation, availability of consumables, low operating costs, reagent contracts, installation and proper installation as per guidelines. On the topic of re-location planning, he said, “Relocation of existing equipment requires meticulous scheduling and coordination with vendors, department managers, movers, and the hospital administration. Precise sequencing of existing equipment relocation is critical to ensuring timely deliveries and proper installation of new equipment.” Dr Arvind Lal, chairman and MD, Dr Lal PathLabs, Delhi, shared his expertise on planning and designing laboratories and other diagnostic areas of the hospital. He gave an overview of the present Indian pathology market, estimated at 1.5 billion USD and expected to grow at a CAGR of 20 per cent over last five years. Dr Lal also spoke on various aspects that go into an ideal design of a lab, planning key areas, facilitating lab services, taking into account quality concepts of lean design. He discussed ‘future driver- molecular diagnostics’ as the fastest growing segment of IVD market and state-of-the-art PCR lab and biosafety measures, when it comes to handling
(L – R) Dr Kul Bhushan Sood, Dr Manjushri Sharma, Rang Emai, Tarun Katiyar and Dr Param Hans Mishra
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highly infective specimens (such as TB and swine flu) or radioactive substances. Naresh Duble, DGM-business development, Armstrong World Industries, Mumbai, discussed the concept of vinyl floorings and ceilings meeting the challenges of long-term durability, cost effectiveness and infection-free environment and minimum maintenance costs. And how today’s floorings are also required to be aesthetic in addition to be able meet the needs of different departments in a healthcare setup. Anil Maini, executive director, Moolchand Medcity, stated that the Indian healthcare sector is emerging as one of the largest service sectors in India in terms of revenue and employment. It has posted growth of 9.3 per cent over the last decade, comparable to other emerging economies (Brazil, Mexico and China). “Factors such as rise in insured population and widening demand-supply gap of healthcare expertise and infrastructure are likely to push the growth rate of healthcare industry further up this decade. As differentiation is the key to competitive advantage and where healthcare has already taken its lessons on global quality upgradation, now needs to evolve as a marketing strategist.” He emphasised that strategising for this sector becomes all the more essential in India
with the advent of tertiary care, cutting-edge technology, internationally renowned clinicians, competitive cost, economical medication, skilled management and international quality protocols (like JCI, NABH and NABL). To cash in on medical travel and health travel, making effective use of web tools like Twitter, Google, Internet and Facebook is required. Tarun Katiyar, principal consultant, HOSPACCX, New Delhi, spoke about considerations before planning and designing a hospital. These include quality norms for various approvals and accreditation, future expansion, budget and flexibility. Green concept for patient-centric design, demographic impact, cost-effectiveness and value-added services that would also contribute to increase in revenue generation also need to be factored in while designing a hospital. He also discussed the various government schemes— such as EPCG scheme for hospitality and healthcare sectors—which help reduce the cost of the project. He said that re-planning and redesigning existing hospitals in an integrated attempt to sustain, could, at times, add to the cost vis-a-vis a new setup. He cited case studies from across the country to illustrate his point. Dr Pradeep Bharadwaj, CEO and executive director, Six Sigma Star Healthcare, New
Delhi, spoke on ‘Manpower Planning for a New Hospital’. He also spoke on India as the skill capital of the world as it produces the largest number of healthcare professionals including medicos, paramedics and IT professionals. “The real problem with such huge numbers is with the quality of patient care and ultimately achieving the growth of the organisation and the sector as a whole,” he said. Anuradha Desai, manager, Getinge Academy, Mumbai, took the audience through various General CSSD & TSSU design concepts to minimise risk of cross infection by staff and the guidelines to be followed as per the flow of sterilisation, storage and reuse of sterilised goods to optimise capacity in terms of turnaround times and increased customer value. CK Babu, CEO, dWise Healthcare IT solutions, Bangaluru, highlighted the new formats developed for diagnosis and treatment in healthcare such as the IT- EHR-driven healthcare information systems. According to him this tool helps sets standards of patient management and creates an online interface between patients and doctors. It enables accessing medical records about the patient across different departments whenever needed.
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Roundtable
Group benefits Several hospitals have been exploring the concept of group medical practice. However, the emerging business practice is not without its risks. We engage industry leaders to debate on how savvy a model it is
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ospitals are exploring the concept of group medical practice, whereby a group of doctors rather than an individual doctor, mans entire departments. Often, these are preestablished groups with the team of doctors having worked with each other for several years. Together, they serve one or more hospitals. In some cases, doctors, after working with a hospital for some time, leave and team up to serve the same hospital as a group.
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While the hospital benefits due to collective decisions as two minds at work are better than one, doctors in the group also see it as a win-win. The practice, which was earlier more common in anaesthesia and cardiology, today can also be witnessed in pulmonology, critical care, urology, sleep medicine, ophthalmology and ENT. Most hospitals pay the groups as per volume. Consultants dictate financial arrangements with hospitals having no say in the matter. Normally, the professional earnings are pooled
and divided among consultants. While some hospitals insist that the group only work them, others have no problem with the group working for other hospitals. However, the model is not without risks— revenue-generating departments of hospitals become non-functional if a successful group walks out, like in the case of Manipal Heart Foundation that floundered for sometime after Dr Devi Shetty and his team quit. Sir Ganga Ram Hospital’s transplant department too suffered a similar fate after Dr AS Soin and
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Roundtable
his group moved to Medanta, Gurgaon. Does it make sense then for hospitals to rely on groups for revenue? We got together experts to discuss the pros and cons. Lending the perspective of doctors in a group medical practice is Dr Bhaskar Shah, an interventional cardiologist with Western Heart Clinic, a group of medical practitioners that runs the cardiology departments of Fortis Hospital, Vashi and Jupiter Hospital, Thane. To understand what’s propelling hospitals to go for this emerging concept, we engaged Dr Narottam Puri, advisor – medical, Fortis Healthcare; Dr Anupam Sibal, group medical director, Apollo Hospitals Group; and Dr Nagendra Swamy, president, Manipal Health Enterprises. All these institutes are exploring group medical practice, either in all or some of their facilities and departments. With Global Hospital involving group medical practitioners also as founder investors, we spoke with Dr Ravindra Karanjekar, group director - medical services, Global Hospitals.
FINANCIAL ARRANGEMENTS Dr Sibal: We allow group practice in specialities where we have fee-for-service consultants and it has several advantages over individual practice, both for the institution as well as for the consultants. Doctors in the same speciality can practice together and share their income among themselves as they deem fit. In fact, now, we are promoting group practice as the preferred model. Dr Karanjekar: We follow a unique model, wherein the group medical practitioners are also founder investors with stakes in our hospital in Mumbai. They are in urology, gastroenterology and nephrology departments.
In group practice
doctors utilise collective skills and experience to handle complex cases. It also enhances patient confidence”
Dr Swamy: We have been encouraging group practice at Manipal Hospitals in Bengaluru, since many years. It started in our department of nephrology more than 15 years back, and today, we are encouraging it in all departments and also across units. We have a ‘non-compete’ clause, which forbids groups to practice in certain hospitals. These issues are discussed and the terms finalised right at the time we are enrolling the group. Exceptions, if any, are documented. Our arrangement with consultants is ‘fee for service’ — their takehome depends on their direct professional earnings. In a start-up hospital, we may give certain amount as retainer. Dr Shah: From 1996 to 2008, I have worked as an individual practitioner and from 2008 onwards, I became a part of Western Heart Clinic. We are a group of five cardiologists—two cardiac surgeons and three interventional cardiologists. We are paid as per the volume by the hospitals. Between us, we pool our resources and divide earnings as per the contribution of the member.
Dr Narottam Puri
Dr Anupam Sibal
BENEFITS GALORE Dr Sibal: A group practice gives patients the opportunity of a second opinion and mutual consultation as a group. Doctors utilise collective skills and experience to handle difficult and complex cases. It also enhances patient confidence. At the individual level, scheduling improves for each of the members through call and vacation coverage, thereby improving quality of life. It also provides experts time to attend conferences and upgrade their skills, while at the same time, giving them the opportunity to enhance their geographical reach by travelling to other locations. We have 450 post graduates in the group and more than 200 research initiatives and group practice helps support academics and research. It also provides an opportunity for undertaking super specialisation. Dr Karanjekar: Our hospital has benefitted immensely as these established groups have ensured good patient footfall from day one for a greenfield project like ours which will, without a doubt, translate into better revenues. Furthermore, we need not chase individual doctors as the responsibility of making doctors available lies with the group. It also ensures getting
Dr Bhaskar Dr Ranjan Shah Pai
Dr Nagendra Swamy
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Dr Ravindra Karanjekar
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good clinical talent within sub specialities as we empower the group to hire all other doctors to complete the speciality. Doctors have more bargaining power when they approach as groups, while patients are benefitted as their care is not dependent on one doctor—the clinical team is available to treat them round the clock. Dr Swamy: Group medical practice offers enhanced quality and continuity of patient care. The collective decision making and participation of other peers, who provide input to the primary admitting doctor, leads to better patient outcomes, and availability of consultants on all days of the year. For consultants, it means improved quality of life since the workload is shared.
REASONS FOR ITS POPULARITY Dr Sibal: With the increasing complexity of medicine, consultants as well as hospitals realise that collective opinions are important in treating complex patients. Equally important is the need for updating oneself through academic activities, conferences and research. Time for all these can be made only through group practice. With the globalisation of health, consultants increasingly need to travel to international locations to see patients. Again, they need to be in group practices to be
able to leave their base locations for a while. Dr Shah: Hospitals are opening up to the concept as it leads to assured good service as the full team is looking after the patients. It instils confidence in the hospital, leading to greater volumes of patients and thus improving the bottom line. Dr Puri: Often, a particular doctor may be interested in a sub-speciality and wants the other to look at the other sub-specialities. However, I am not so sure they are that popular in India—certainly not as much as in the US. Group medical practice is of two types—organised groups and those that come together after working separately for some time and then forming a group. The business model depends on location, size, type and volume of practice. It also depends on who is responsible for equipment purchase, upgrade and maintenance. Dr Shah: I have been drawn it to it because it ensures shared workload and responsibility and a strong support from team members. Now, I can at least think of taking a vacation. Dr Karanjekar: Hospitals are tempted to go for group practice as, besides ensuring good clinical outcome, it rules out competition between individual doctors since the group manages the department. For instance, if an adult cardiologist wants to treat paediatric
patients or paediatric cardiologist wants to see adult patients, this would lead to a clash and would require us to intervene. However, there would be no conflicts when it is with group medical practice as the financial arrangement is settled within the doctors, right from the beginning. Dr Swamy: Doctors find group medical practice attractive as it is leads to better patient care and better quality of life for consultants. Among peers, it fosters understanding, and helps them move away from a competitive mindset to a complimentary mindset and manage challenging cases collectively. Doctors can plan a holiday or stay at home if unwell, without the fear of losing their practice.
SELECTION CRITERIA Dr Puri: In pre-selected ones, more thought has to be given to consultants as regards the business of the practice, investments made and expected returns. In post-selected ones, convenience is a major factor—especially for doctors, who no longer wish to be on call 24/7. Dr Swamy: Normally, these groups are formed after the doctors have worked with each other for years. It is essential that they share common vision and understanding to succeed in group medical practice. Transparency and open discussions make the group stronger. We have a strong credentialing and privileging policy, which is the foundation for selection of a consultant. Even though doctors come as a group, each individual has to fulfil the criteria stipulated by credentialing and privileging policy of the institution. Dr Shah: The doctors need to work together at some point to understand each one’s strength and weaknesses. You need to be a cohesive team. Just good revenue cannot keep them together; there should be perfect understanding between the doctors to stand for each other. Dr Karanjekar: You need to ensure that all doctors in the group are competent and that they do ethical practice. Dr Sibal: We prefer that all consultants working for a speciality in a hospital be in group practice. However, if the number of consultants is more than 10 in a particular speciality, we accommodate more groups.
CHALLENGES TO OVERCOME
It is important that patients understand the arrangement of group practice and consent to it
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Dr Sibal: The challenges are the same as with any financial arrangement, where temperamental and financial disagreements
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can occur occasionally. Any change is a challenge, even if it is for the better. Breaking the status-quo needs time. But the advantages are far too compelling. Several consultants, who have been in individual practices at Apollo, are now organising themselves into groups. Examples of successful group practices will help overcome the challenges. Dr Shah: It is important to understand the valuation of a team member and decide his percentage of the revenue accordingly. However, when the group is new, you will often come across obstacles over a period of time and this may led to disintegration of the group, if not tackled with tact. Like, you may realise that the output of a member is not in sync with the percentage of revenue that he is taking home or he doesn't have the same fire in the belly to make the group a success. So, it’s important to have a periodic evaluation of the members to assess who is contributing how much and decide on the revenue sharing. Flexibility should be built in from before, else it will not take long for the group to fall apart. Also, it is difficult to change your methods of practice after working as an individual for many years. It is easier to comply with the group’s methods and practices, when you are younger. For doctors keen on group practice, I would suggest that they enter into it from early days of their practice. Dr Karanjekar: Hiring a well-established group is an expensive proposition, and thus for a new hospital it may turn out to be financially non-viable and may even make it bleed. Also, when the group walks out, the functioning of the entire department is affected. So, it is
The institution may face hardships if one group entirely moves out and alternate arrangement has to be done on short notice”
It helps to periodically evaluate the performance of the group to determine individual contribution
advisable that the hospital has some control on the groups. Hospital needs to have a plan B for such eventualities. However, when you have the group as investors, like in our model, there is no such risk. Dr Swamy: One important aspect is to educate the patient regarding this arrangement and obtain a proper ‘consent’ in place. The institution may face hardships if one group entirely moves out and alternate arrangement has to be done on short notice. It is better to have two groups or combination of groups with availability of individual consultants to protect from this risk.
THE ROAD AHEAD Dr Sibal: In the years to come, group practices will become dominant. The need for super specialisation will propel the growth for such teams. For example in neurosurgery, it would be ideal to have a team of neurosurgeons, each one doing skull back surgery, epilepsy surgery, deep brain stimulation, paediatric neurosurgery and aneurysm surgery. Dr Puri: Development of group medical practice is still being tried out in India and maturity will be needed at both the payer and provider level. Hospitals and medicos need to work in tandem if everyone is to benefit. Most
of all, it has to be something that benefits the consumer. Only time will tell, if the model will become more popular. Since we tend to emulate what the USA does, group medical practice is here to stay and is likely to grow. Dr Shah: In the coming years, it will become more popular in cities, where the distance between hospitals is not that much. When the distance is less, doctors get to treat a larger volume of patients, without wasting too much time commuting. For instance, in a city like Ahmedbad, group practice is more prevalent with hospitals located close by. The average patient volume for angiograms and angioplasties in a hospital in Ahmedabad is 500 to 600 per month, which is a good number for group practitioners comprising, say four members. However, in a hospital in Mumbai, we would get only around 200 cases per month, forcing us to associate with multiple hospitals. However, the distance between hospitals in Mumbai becomes a deterrent, making group medical practice a little challenging here. Dr Karanjekar: It would become more popular as the benefits are too compelling. However, it would be witnessed more in tier-1 cities than in tier-2 cities, as in the latter, it’s still about individual practice.
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Lessons in innovation Ritesh Dogra lists 10 things that Harvard Business School taught him about innovation in healthcare
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hile attending the Executive Education Programme on ‘Driving Innovation’ by Harvard Business School, I had the opportunity to be a part of a discussion on how some world-renowned companies have successfully championed innovation. Here I attempt to encapsulate my learning and its likely implication on healthcare, particularly in the Indian context. As per the Wall Street Journal (May 23, 2012), over 250 books have been published in 90 days with the word ‘innovation’ in the title. While it has become a ‘way of life’ to a large extent for many industries, in healthcare, innovation has been confined to affordability and technology. To us, serendipity is not innovation. Innovation needs a much more structured and disciplined approach. However, organisations fail to realise the importance of innovation and recipes to innovate. To make matters worse, the healthcare industry, in particular, also suffers from insularity and fails to appreciate the need and opportunity to learn from other industries.
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The ten commandments Think simple ‘Simplicity is the ultimate sophistication’ is a line we have heard many times. However, there cannot be a better example than Apple. Instead of focusing on too many product lines, Apple has proven time and again how just ‘one’ product, be it iPod, iPhone or iPad, can not only change the fortunes of a company, but also redefine the industry. Apple, like many others, also does not believe in ‘adding’ features. On the contrary, it mercilessly strips its products of irrelevant frills. Most of the healthcare delivery models, however, have multiple service offerings. Their inward-looking mindset had led to an increasingly complex set of processes and layers of bureaucracy. The way the entire discharge process continues to be handled in a typical hospital illustrates the point. It not only takes endless hours, but also makes ‘leaving’ the hospital such an ‘I-wish-I-could-forget’ kind of an incident for the patients. There is no reason why simplicity, technology and strong customer orientation can’t help arrive at the right solu-
tion. For some projects in the past, we have tried to streamline this process with technology tools and have achieved commendable results creating a strong differentiator for the hospital.
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Question the status quo Whenever we have a great product or service, we focus on communicating the same to the external world. However, often, it is the internal team that is resistant to the concept. Aqualisa, a company that specialises in showers, had introduced a new range of showers with digital temperature controls instead of manual mixing that required lesser installation time. The sales team was quite averse to selling the new range, citing that ‘plumbing has not changed since time immemorial’ and that the innovation was ‘good for elderly’. At the same time, plumbers, who were paid per hour, resisted it as lesser installation time meant reduced payments. Aqualisa was faced with a classic problem,
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It's been observed that some of the most innovative solutions have come from people outside the industry
where the company had a revolutionary product without a marketing strategy. It decided to reach directly to the customers with a well-defined marketing plan, bypassing the sales force and plumbers. In December 2001, when the company was facing the problem, the sales were 600 units per month. Exactly one year later, the sales shot up to 2,000 units per month. In healthcare too, we come across ‘plumbers’—people who are resistant to change. These include management, sales force and others. We need to find them, and, at the same time, engage the customers directly whenever we introduce an innovative model. As a consulting firm focusing on innovation, the number of times we hear, ‘this is not possible, it can’t be done’, or ‘it has never been done before’, or even worse ‘healthcare cannot be marketed’ is no surprise to us.
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Change with time Starting off with a customer-centric approach will ensure quick gains, but not sustaining it could have adverse effects. CISCO, a large routers and networking solutions multinational company, offered customised solutions to customers in the initial stages. It gave an immense advantage since the customers did not know what they wanted. With more entrants in the space, the
market matured and the firm lost personal touch. At the same time, the industry too became price sensitive. A crisis prompted culture change in the organisation, leading to subsequent erosion of profits. To regain the market share, the firm launched a host of consumerfocused initiatives, while creating different market segments. The entire approach again seemed too confusing for customers. So often, we come across senior physicians or nursing homes, which simply lose touch with the changing times when they scale up or reach high volumes.
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Think like an outsider “No matter who you are, most of the smartest people work for someone else” – Bill Joy, co-founder, Sun Microsystems. There are numerous times when we hear ‘healthcare is different’. When asked why it is so, people cite endless examples to prove their point. Large companies have often benefitted from ‘open innovation’, a concept that is gaining increasing popularity. Some of the most innovative solutions have come from people outside the industry. After the 1989 Exxon Valdez oil spill in Alaska, Oil Spill Recovery Institute (OSRI) was formed and was chartered
with developing recovery techniques. Even the brightest minds in the industry could not solve the problem of separating frozen oil from water. In 2007, OSRI got a game-changing solution for $20,000 from a chemist, who suggested a technique used in the concrete industry for keeping cement fluid during large pours. There are immense opportunities for healthcare to learn from others only if it were willing to think like an outsider. For instance, airlines can help in redefining discharge process, hotels can teach the softer aspects and from banks, we can learn how to maintain confidentiality of records. Unfortunately, in healthcare, we always come across more ‘explanations’ than ‘solutions’ to problems. Not ‘thinking as an outsider’ is certainly a deterrent to innovation in healthcare.
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Create a culture Many ask us a simple question: ‘why innovate’, ‘what if the innovation does not work’. Apart from citing reasons such as creating a differentiated model, we have always believed that innovation is pertinent to creating a culture, which takes time to create. While some innovations fail others take time. Still they make a larger case within the organisation. M&M, one of the largest Indian automo-
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a much higher capacity utilisation and revenue per bed than something that caters to everyone. Even models that start off with a vision to provide services to a particular segment, end up addressing all segments, tempted by the ‘perceived possibility’ of a faster breakeven.
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bile company, worked on a concept to create a vehicle that would meet farming as well as transportation needs in villages. The concept was not an immediate success, but that did not bother M&M. Instead, it created a culture of innovation that eventually led to the creation of many successful products. In healthcare, for long, we have been ‘sacrificing’ innovations to maintain ‘status quo’. What most healthcare organisations need is to take the lead and create such a culture, and innovation will, of course, follow.
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Focus on your core segment One of the key tenets that we believe in is ‘doing something for someone’. Unfortunately, today, the larger target segments we address, the larger the numbers. Callaway Golf Company, manufacturers of golf equipment, focused on new golfers and the entire product line was customised for
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Although the market forms an important aspect of innovation, sometimes keen observation too helps in figuring out what the customers actually need the target segment. The brand slowly got into the ‘professional golfers’ category leading to a decrease in profitability. Often, in healthcare, we find people creating delivery models that target ‘every section’ of society. The models, as such, have a number of inherent problems. A model providing services to a specific target segment has the potential for
Observe, don’t just see Human-centred design is now at the forefront of innovation and designbased thinking is the future. Although market forms an important aspect of innovation, sometimes keen observation helps in figuring out what customers actually need. Large firms attach significant importance to this approach. IDEO is a classic example of a firm that helps create solutions based on the designthinking approach. The firm focuses on learning from the field followed by a quick prototyping culture: rough, rapid and right. Learning from failures is equally central to the innovation process. Redesigning the mammography experience for GE was one such project undertaken by the firm. The project uncovered nine key insights about the mammography experience, each of which led to design opportunities that addressed women’s basic needs for support, information, and inclusion during a mammography. Needless to say, it led to a wider acceptance of the cancer screening campaign. Observational studies, especially in a healthcare delivery setting, could help understand inherent problems and resolve them. In one of our studies in a hospital, a simple observation about the transport staff and the stretcher created an altogether different experience for the patients. In creating innovative healthcare delivery models, for instance, specialty hospitals, promoters can never do justice unless they understand all specificities associated with the particular discipline for the entire patient cycle.
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Get customers to participate We often come across the word ‘cocreation’. In reality, co-creation is nothing but encouraging customers to innovate along with the organisation. This requires empowering the customers and presenting them with tools that could help them run experiments. It also helps customers know that the firm is in a process of continuous innovation. It is equally important to select the right customers. Bush Boake Allen, a leading firm in the business of supplying specialty flavours to customers, had a tightly integrated network involving customers, marketing de-
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partment, flavourists and quality control. The firm could command profits only from flavours that were selected and only 5-10 per cent of all flavours made it to the market. At the same time, innovation capacity was limited by internal resources. Customer needs were subtle and frequently changed. The solution envisaged was to help customers innovate by deploying machines, which could make alterations to the base flavour. In healthcare, co-creation is a powerful tool for medical equipment manufacturers. In one of our projects for a leading medical equipment MNC, the brief was to design a product based on customer needs. Different stakeholders were interviewed and changes were suggested for the product purely based on needs. A surprising fact that emerged was that the stakeholders needed only 20 - 30 per cent of the features present in the current equipment. Closely explaining the model to end users with live demonstration of imaging features helped the firm create one of the best imaging solutions for tier-2 and tier-3 cities.
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Look beyond the next quarter We have often asked one single question to our partners – ‘Are you willing to innovate?’ Since the same requires a lot of conviction, it elicits a mixed response. Many of them have believed that any innovative model is synonymous to shorter gestation period. P&L statements, on the other hand, could be a major deterrent to innovation. It is simple to project numbers on an Excel sheet and even simpler to justify cost-benefit analysis, but for a firm focused on innovation, projecting numbers does not make sense. In fact, relentless focus on operational efficiency can drive innovation out. Cutting innovation budgets can improve short-term financial results which, in reality, is a ‘waste’. Let’s take example of a firm like 3M. There was a time when leadership at 3M implemented Six Sigma, trained thousands of black belts
expert view
and slashed spending. On the contrary, what the firm really needed was a thousand for one successful business. When GE started the Business Innovation initiative, it recruited 5,000 engineers, 2,000 marketing experts, invested in growth leader skills, and defined five traits of next generation leaders. The organic growth objective was raised from 4 per cent to 8 per cent. There were five imagination breakthrough (IB) proposals costing $100 million in three years. All of these initiatives are accompanied with discipline, accountability and flexibility. And these initiatives have made GE as one of the most successful organisations in the world.
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Empower, not manage Promoters of new healthcare start-ups, often get into micromanaging the entire project. Doctors starting their own ventures often believe that they can manage the entire show, right from planning the building to marketing and service quality. Building a team early is crucial for an organisation to innovate. For instance, right from the early days, Nestlé’s historic success is built on deep agricultural supply chains, strong local market teams and strategic acquisitions. Although it employed over 2,75,000 people and sold products in 130 countries, the organisation was decentralised and is relatively flat. Country managers had a fairly large degree of autonomy in matters dealing directly with customers. The company felt that the local managers were in
According to Regina E Herzlinger, the Nancy R. McPherson Professor of Business Administration at the Harvard Business School, three kinds of innovation can make healthcare better and cheaper: One changes the way in which consumers buy and use health care, another taps into technology, and the third generates new business models. But the system erects barriers to each, which can be overcome by managing the six forces that impact healthcare innovation: Players—the friends and foes who can bolster or destroy; funding—the revenuegeneration and capital-acquisition processes; policy—the regulations that pervade the industry; technology—the foundation for innovations that can make healthcare delivery more efficient and convenient; customers—the empowered and engaged consumers of health care; and accountability—the demand from consumers, payers, and regulators that innovations be safe, effective, and cost effective.
a better position to understand the knowledge about customers and transform it into products tailored to meet their needs leading to longterm customer relationships. Compared to some of the developed countries, which have gotten into a mess, having done too many things and spent endless sums of monies, we have the luxury of making an almost clean start rather than get to a situation, where things would need to get re-done. A culture to innovate can be the most crucial approach to reach our goals in healthcare and create ‘breakthrough’ products or services. We do have a few champions even in healthcare, be it Aravind Eye or Narayana Hrudayalaya, who have demonstrated how innovation can help scale unimaginable heights. As per a Business Week survey, long development times, lack of coordination, a risk-averse culture, limited customer insights, poor idea selection and inadequate measurement tools are some of the major obstacles to innovation. We certainly know what not to do. It’s high time, we stopped doing it.
Ritesh Dogra is engagement manager with Hyderabad-based Medium Healthcare Consulting.
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The energy efficiency meter Rita Dutta gives you an overview of the technological advancements that help hospitals get energy smart
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ospitals are considered the highest energy guzzlers of all the commercial buildings: they use two and a half times more energy than office buildings. Because of operating roundthe-clock, use of high-tech imaging and other medical equipment, and requirement for sanitised air, the per square foot energy consumption of hospitals is much higher than that of several other types of buildings.
Benefits galore With the demand for energy going up, the need to reduce carbon footprint and escalating electricity prices, hospitals are seen adopting smart tools and technologies for energy conservation. The primary benefit of which is reduction in energy spend. Experts feel that adopting energy conservation measures can help Indian hospitals reduce up to 30 to 40 per cent cost on energy. Some hospitals have already taken the requisite steps and are reaping the benefits. For instance, Mumbai’s Kohinoor Hospital, which is India’s first LEED-certified, platinum-rated hospital, uses measures like variable frequency drives, variable air volume, heat recovery wheels and solar panels. This has lead to 30 40 per cent reduction over AHSRAE 90.1 ,62.2. Same is the case with Mumbai’s PD Hinduja Hospital, which installed economisers in boilers for waste heat recovery from flue gases, BMS for specific areas, condensate heat recovery systems for service water heating and VVVF lifts.
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Says Maj. Gen. Naresh Vij, director, projects & engineering, PD Hinduja Hospital, “We are saving more than 15 per cent in our energy bills, thanks to the energy efficiency measures.” Also, Fortis Hospital, Mulund, winner of the National Energy Conservation Awards – 2012 saved 8.20 lakh units a year by using technologies like VFDs and screw chillers. Besides reduced electricity bill, energy conservation also helps curb equipment maintenance costs, which extends the lifespan of equipment. There are some indirect benefits as well. For instance, achieving energy efficiency requires proper maintenance of HVAC systems, which improves indoor air circulation. This, in turn, eliminates the risks of air-borne infections. Research shows that facilities that implement energy conservation measures outperform their competitors by as much as 10 per cent in net operating income. Dr Satish Kumar, vice president- energy
Watch out for Stratified chilled water storage systems Under floor air distribution Solar thermal air conditioning Chilled beam Smart grids Demand response Passive solar building design Use of nano-fluids in heat transfer.
management solutions, Schneider Electric India, says, “Energy saving measures also imply lower operating costs and lower capex for replacement of existing equipment. On one hand, using energy management systems helps facilities identify energy wastage, maintain power factor and improve uptime through inbuilt alarms, which alert maintenance staff on performing preventative maintenance. On the other hand, they help in benchmarking energy use at the facilities and systems level.”
HVAC tools With HVAC contributing to approximately 50 - 60 per cent of total electricity consumption, efforts are primarily focused on energy conservation for HVAC. Some significant tools are: Heat pumps: This is a device used for extracting heat from a source and delivering it elsewhere at a much higher temperature. Heat pumps are the most cost-effective form of heating using electricity and most good quality systems achieve an average COP (Coefficient of Performance) figures of four or more. Now, the market offers geo-thermal heat pump comfort system, which has a 400 per cent efficiency rating. Heat pumps are particularly suited for hospitals as they have a high demand for space heating and sanitary hot water production, extensive work-in times and a simultaneous need for cooling. Fortis Hospital at Bannerghatta Road in Bengaluru claims that it is the first hospital in the country to install air source water heating
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pumps, which resulted in a 50 per cent reduction in the power consumed for hot water generation. According to P Davison, AVP of the hospital, “The system also gives us 20TR per hour of air-conditioning as a by product, which is ducted into our corridors, thereby reducing the chiller load and energy consumption.” Installed in 2011, the system has reduced the monthly power consumption for hot water generation by 50 per cent from 40,000 KWH to 20,000KWH. Power factor improvement: The power factor of an AC electrical power system is defined as the ratio of the real power flowing to the load to the apparent power in the circuit and is a dimensionless number between 0 and 1. The advantages of power factor are reduction in Kilo Volt Amps (KVA), distribution losses and electricity bill and allowing better voltage of motor terminal. Kohinoor Hospital has maintained the power factor around 0.99 to 1.00. Says Dr Rajeev Boudhankar, vice president, Kohinoor Hospital, “If power factor is maintained between 0.99 to1.0, there is a benefit of 5 – 7 per cent incentive on the total bill amount.” Mumbai’s Asian Heart Institute states that it has improved its power factor from 0.87 to 0.99 in the last one year andFortis Hospital, Mulund, states that it has maintained its power factor between 0.98 to 0.99 in the last six months. Demand control ventilation: Kohinoor Hospital has been using demand control ventilation to reduce the energy conservation, reduce wear and tear losses of the equipment and confirmed/documented indoor air quality. Carbon Dioxide (CO2) sensors are the only currently accepted method of demand control ventilation. Condensate heat recovery systems: Condensate recovery systems help reduce the tangible costs of producing steam, fuel/energy costs and boiler water make-up and sewage treatment. Hospitals like Hinduja and Asian Heart have been using condensate heat recovery systems for service water heating. Variable frequency drives: A variable frequency drive (VFD) is an electrical device used to control the speed of a standard three-phase AC induction motor, which leads to reduced energy consumption. Hospitals have been using VFD in air handling units, cooling towers and to reduce power in off-peak conditions. Asian Heart has been using VFDs in its AHUs, primary pumps and secondary pumps since the last five years. “We spent Rs10 lakh on installing VFDs and got returns from it in 18 months. Our power saving due to this tool was around 7
Who’s doing what Hinduja Hospital • Solar Panel for water heating • Condensate heat recovery systems for service water heating • Installation of economizers in boilers for waste heat recovery from flue gases • Installation of Variable Frequency Drives in air handling units and cooling towers • Installation of BMS for specific areas • Installation of energy efficient ballast in lighting system • Power factor improvement • Replacement of less efficient electrical motors by energy efficient motors • Installation of VVVF lifts • Running of boilers on Natural Gas instead of LDO • Running of autoclave on centralised steam supply. Kohinoor Hospital • VFDs in AHUs and cooling towers • Variable air volume in supply grill • Heat recovery system • Demand control ventilation • Timers and sensors • High COP screw chillers • Low water loss cooling towers • Use of heat recovery wheels in OT AHUs • Use of STP recycled water for cooling tower make up • Solar panels. Asian Heart • VFDs • Condensate heat recovery systems • Screw chillers • Carrying out non-core work, like laundry, during night as the energy saving is Rs3 per unit • Building management system.
to 8 per cent,” says Dr Ramakanta Panda, vice chairman & MD, Asian Heart Institute. The monthly energy consumption of the hospital is 4 lakh KWH . Variable air volume: Variable air volume (VAV) is a type of HVAC system that provides the right quantity of cool air required for a specific building zone, while at the same time supplying different volumes to different zones. Kohinoor Hospital uses VAV. CHP: Combined Heat and Power (CHP) is not a single technology but rather a suite of technologies that can be mixed and matched in many ways to provide high-efficiency, low-emissions source of heat and power from a single process. In the context of hospitals, the heat is usually
used to provide hot water, reducing the need to operate less efficient boilers. For example, instead of allowing excess heat generated from electricity usage to escape from the facility, some hospitals harness that heat to warm their water tanks and thus create more efficient boilers. Timers and sensors: Kohinoor Hospital has benefitted from installing timers at its air handling units by reducing the energy consumption in air conditioning. The helps as the system automatically shuts off when the desired temperature is reached and when the area is empty of people. High COP screw chillers: In air conditioning systems, chilled water is typically distributed to heat exchangers, or coils, in air handling units
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LEDs are replacing CFLs in many hospitals
or other type of terminal devices, which cool the air in its respective space(s), and then the water is re-circulated to the chiller to be cooled again. These cooling coils transfer sensible heat and latent heat from the air to the chilled water, thus cooling and usually dehumidifying the air stream. Asian Heart has recently replaced its VAM chillers with screw chillers. Fortis Hospital, Mulund, also uses three screw chillers, each having a capacity of 250 TR. High efficiency motors: Energy-efficient motors use less energy to perform the same amount of work as standard motors. They also reduce operating expenses through lower failure rates and longer service life. Solar panel for water heating: Solar water heating system, now used by many hospitals, has helped HCG, Bengaluru, reduce up to 80 per cent unit consumption per annum and saved over Rs6 lakh spent on electricity.
Measures in lighting LED lighting: Many hospitals such as Fortis Hospital, Bannerghatta Road, have already replaced or are in the process of replacing CFL with LED lighting as the latter uses one-third less energy and also last longer than the conventional ones. Says vice president of the hospital PK Davison, “This initiative reduced our energy consumption in lighting by 50 per cent and provided us savings in air conditioning due to lower temperature emissions.” While Kohinoor Hospital has been using
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LED lighting in OTs to reduce heat on surgical field for increased patient safety and improve surgical team comfort, Asian Heart has used only LED lights for all areas of its newly added 70,000 additional square feet. As and when the existing CFL lamps phase out, the hospital installs LED lights. Timer switches: This helps controlling external lighting. The switches are programmable, and work without the use of light sensor. “Programming is stored in the timer to switch on and switch off the external lighting automatically. This saves substantial amount of electricity and increases the life of lamps,” explains Dr Boudhankar. HCG claims that using timers on AHUs saves approximately save 70,000 units/annum or about Rs4 lakh/annum. However, Fortis Hospital Mulund, which installed the timers in OPD area reveals that it had faced some challenges. “When the timers would switch off the lights, patients complained that the OPD area was not well-lit. We also did not get any energy saving benefits from timers,” explains Dr Anil Jadhav, Headoperations, Fortis, Mulund. Now, the hospital is exploring the possibility of using timers in places where the patient footfall is low. Motion sensor: Kohinoor Hospital uses them in the common washroom and corridors as they help save the lighting energy. Other lighting features: Hospitals are using other features like tinted or reflecting windows and relying on daylight to light their facility.
Energy efficiency approach in existing buildings Hospitals are going for benchmarking, energy audit, BAS and remote management systems. BAS: Building Automation System (BAS), which includes the comprehensive and co-co-
We spent Rs10 lakh on installing VFDs and got returns from it in 18 months” – Dr Ramakanta Panda, vice chairman & MD Asian Heart Institute
ordinated control of one or more major system functions required in a facility, is considered a powerful tool for energy conservation. Many Indian hospitals are using it in specific areas. Energy audits: Many hospitals are going for either internal or external energy audit to improve on energy conservation. For instance, Healthcare Global conducted an energy audit that indicated that if a hospital focuses on some priority areas like HVAC, or makes small changes like lightening options, they can contribute substantially. Says Dr Samir Singh, manager-operation, HCG, “We used simple innovative options like special wall paints that help maintain the room temperature effectively, reducing the burden on room air-conditioning.” He added that installing split ACs instead of conventional ones, central air-conditioning only at required areas that too with temperature control regulators; and designing a well lit and ventilated basement or ground floor to allow usage of just regular fans, are some of the other measure adopted by the hospital after the audit. Unless the equipment installed has special temperature needs, some simple, yet effective HVAC load-saving principles have worked well in a climate like Bengaluru. Remote Energy Management (REM): This solution measures, monitors and manages the energy consumption of WAGES (water, air, gas, energy and steam) and can complement the requirements of healthcare facilities effectively. Energy consumption data can either be captured directly from communicable meters or retrieved through an existing BMS for analysis. “Remote energy management can help in identifying opportunities, which can result in incremental savings on a year on year basis. This can have a large impact in terms of energy savings without incurring significant costs,” informs Dr Satish. Since IT hardware is taken out of the equation by hosting the data on the cloud in a REM solution, a lot of issues related to computer malfunction, unintentional shutdown, renewal of software licenses and service of software is automatically eliminated. “A good and functional REM can not only help identify worst performers from a portfolio of buildings as they come with advanced normalisation routines, but it can also help reduce the energy audit cost as a lot of effort spent in data collection is reduced,” informs Dr Satish.
Energy conservation for new projects Many projects are going for energy saving right
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Insight
at the design stage. For instance, during the construction phase of HCG’s greenfield projects, it has avoided façade designing that increases the load on air-conditioning. “The use of materials like glass to enhance the façade value is sensibly done away with, and green designing measures like building shape and orientation, passive solar design (locating OT away from peak sun hours), and the use of natural lighting, are incorporated during designing phase of the project,” says Dr Singh. The building material used to construct OT again is of types that maintain internal temperature. Easily available material like conductive flooring, non- heating lights and heat reflecting paints have helped to prevent rise in temperature. This is especially helpful for HCG centres in geographies, where the temperature reaches +40 degree Celsius during summers.
Energy saving in equipment A few other techniques that help save energy with equipment handling are: Automatic cut off: Using equipments that have the facility of automatic cut off from mains supply once the batteries in the system are fully charged. Brightness adjustment: Many equipment come with display units that have the feature of brightness adjustment as display units are one of the major factors that require high amount of electricity. LED Strips in X-ray view box: Some hospitals, like Kohinoor, use LED strips instead of the conventional tubes for X-ray film viewing panels. There are almost 50 of them installed in the hospital in various departments. Standby mode: Using equipment with
We are saving more than 15 per cent in our energy bills, thanks to the energy efficiency measures” – Maj. Gen. Naresh Vij, director, projects & engineering, PD Hinduja Hospital
a standby mode where the processing and display units shut the intake of power and still remain on helps reduce energy consumption. Pneumatically driven respiratory support systems: In some hospitals like Kohinoor, respiratory support systems like ventilators and BiPAP machines are driven on central gas supply along with electricity, thus consuming lesser energy than the systems which involve only compressor driven unit. Maintenance: Regular preventive maintenance of all equipment is necessary.
Challenges to implementation While the market is flooded with cutting edge tools and technologies, are hospitals actively adopting them? According to a 2011 report ‘Energy Efficient Hospitals – visiting the realities’ brought out by CII Western Region Healthcare Sub-Committee along with SL Raheja Hospital and Schneider Electric, more than 60 per cent
hospitals and healthcare facilities failed to meet the minimum EPI criteria leading to a huge potential of energy performance improvement. The biggest challenge to energy conservation is the perception that energy conservation measures are costly and have long-term payback horizons. Many existing hospitals are also facing challenges to implement new techniques due to the old structure. For instance, Hindu Hospital finds it difficult to implement technologies like absorption chillers and heat pumps as the structure is 30 years old. Asian Heart too finds installing variable air volume daunting as the building is a decade old. Others point out that it’s difficult to implement energy saving measures in a hospital as different kinds of rooms have different specification for air pressure. Other roadblocks include zero price regulation, high taxes, hidden charges like cross subsidy when a hospital tries to source power from vendors like Indian Energy Exchange and wind farms. Lack of domain expertise is yet another hindrance. “A single domain expert, for example, on green construction, will have limited insight into operational protocols of operating rooms,” points out Dr Singh. Cost savings can only be fully realised when they are incorporated at the project's conceptual design phase with the assistance of an integrated team of professionals. This approach ensures that the building is designed as one system rather than a collection of stand-alone systems.
Towards non-polluting energy Despite the roadblocks, in the coming years, more hospitals are expected to actively pursue energy conservation, mainly driven by the rise in energy costs. Many hospitals, like Fortis and HCG, are exploring the possibility of going for non-polluting and renewable energy including solar, wind, geothermal, low-impact hydro, biomass and bio-gas strategies for meeting electrical demand. Also, larger penetration of technology will lead to increased complexity that can be simplified by greater level of energy management, automation and control systems. “Regulations like Energy Conservation Building Code will facilitate a greater level of technology penetration and acceptance and implementation of energy conservation measures. We also see a scenario, where large retrofit decisions will be made based on measured data versus established rules of thumb,” concludes Dr Satish.
Heat pumps are particularly suited for hospitals
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Tech trend
A positive outlook Although ECMO therapy had limited application in India, thanks to the increasing awareness and evolving technology, the future for the treatment looks bright, writes Sagar S Haval
E
xtracorporeal Membrane Oxygenation or ECMO is required in intensive care (adult/children/infants and neonates), cardiac surgery, cardiology and emergency departments of a hospital. Tertiary care hospitals with cardiac surgical facility are currently treating patients suffering from severe refractory cardiac and/or respiratory failure with ECMO therapy. As per Extracorporeal Life Support Organization (ELSO) registry data, over 70 per cent of the ECMO cases reported till date, globally, are related to respiratory failure. However in India, over 70 per cent of the cases are related to cardiac failure.
as a result of an accident. Till date, over 47,000 cases have been reported by an ELSO registry. Globally, therapy applications rose due to the 2009 H1N1 influenza (swine flu) outbreak and even India had started suffering the effects of this epidemic. Various conventional therapies were tried on patients with swine flu, but with a bad success rate. In fact, many patients succumbed to severe Acute Respiratory Distress Syndrome (ARDS), i.e. severe respiratory failure, in which the lungs failed to function normally. ECMO Therapy enables the lungs to rest by taking over the function, enhancing the chances of recovery.
Solutions Veno- Arterial ECMO Support: In this the blood is driven from any larger vein (mostly superficial) to the ECMO system and back into another large artery (mostly superficial). It is oxygenated and the CO2 removed. It has greater pressures and flows, hence assisting the systemic blood circulation (i.e. blood pressures); and protecting the organs of the body. This support type is usually used for patients with life threatening cardiac and or respiratory failure—patients with mortality chances of over 80 per cent. Veno-Venous ECMO Support: In this type, the blood is driven from any larger vein (mostly superficial) far away from the heart to the ECMO system and back into patient’s body through a ECMO Therapy is of two types:
Market trend There has been a 200 per cent rise in ECMO cases in India, of late. It is said that about 200 to 250 ECMO cases are being done in India every year and it is estimated that in the coming year, they may increase by over 400 per cent. In the near future, ECMO therapy will be instituted at peripheral locations and the patients transported to the ECMO reference center, as it is in the West.
Experience ECMO was successfully performed for the first time in the US by Dr Donald Hill in 1971. The patient, an adult, was suffering from an injured lung
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larger vein (mostly superficial) near the heart. It is oxygenated and the CO2 removed. It has greater flows, which assists the lungs. This support type is used for patients with life-threatening respiratory failure—patients with mortality chances of over 80 per cent.
Technological advancements The ECMO technology has changed widely in the past few years. The initial ECMO systems consisted of occlusive type pumps called roller pumps to drive the blood circulation and silicone rubber membrane oxygenators. Then, the pumps changed to non-occlusive type pumps called centrifugal pumps, which reduced the blood cell damage and also aided in longer life of the systems from days to weeks. In recent times, the systems have changed to low profile oxygenators and centrifugal pumps, with special treatments helping in better outcome of the therapy. The newer generation systems have helped in improving outcomes of the patients on ECMO therapy by reducing system-related complications to the patient. Moreover, the systems are now miniaturised and portable, aiding in faster application and transfer of patients on ECMO support, needing support at peripheral locations. The advanced complete ECMO systems are designed to be working for longer term, minimising the mechanical related complications during the therapy and providing the maximum benefit to the patient.
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Tech trend
therapy outcomes 1. Neonatal Diagnosis
Survival rate
Respiratory distress syndrome
84%
Meconium aspiration syndrome
94%
Persistent foetal circulation/ Persistent Pulmonary Hypertension
78%
Congenital diaphragmatic hernia
51%
Refractory cardiogenic shock/ Failure to wean from cardiopulmonary bypass after cardiac surgery
39%
Decompensated Cardiomyopathy
62%
Sepsis
75%
Pneumonia
57%
Refractory Cardiac Arrest
22%
Myocarditis
50%
Severe Air Leak Syndrome
74%
(Based on Data from ECLS registry Report, International Summary, ELSO, January 2011)
2. Paediatric Diagnosis
Survival rate
Pneumonia
• • • •
Viral Bacterial Pneumocystis Aspiration
Acute Respiratory Distress Syndrome
• Post. OP/ Trauma • No. Post. OP/ Trauma
63% 57% 50% 66% 60% 53%
charges and ICU charges. It has been noticed that the many hospitals use indigenous systems to save the cost of therapy and some even use it to make more profit. However, this leads to chances of higher morbidity and mortality to the patients. To make the therapy more affordable, insurance companies, government and charitable organisations should come together. Let me give me an analogy here. Cardiac surgery, which was once unaffordable to the middle class and lower middle class, became affordable with the advent of many cardiac surgical centres and large volumes. So, the affordability of ECMO will improve over the years. Today, a patient undergoing a Coronary Stenting Procedure (PTCA) with a single medicated stent pays the same or higher as compared to the disposable used per patient for the whole ECMO procedure. It’s the mindset, which needs to change to make this therapy accessible and affordable.
Acute Respiratory Failure
Non ARDS Type
51%
The road ahead
Refractory Cardiac Arrest
• 31 Days to 1 year • 1 year to 16 years
46% 41%
Cardiogenic Shock/ Unable to wean from CPB after Cardiac Surgery
• 31 Days to 1 year • 1 year to 16 years
35% 49%
Severe Myocarditis
• 31 Days to 1 year • 1 year to 16 years
73% 67%
Decompensated Cardiomyopathy
• 31 Days to 1 year • 1 year to 16 years
58% 60%
The ECMO systems of the future will be more portable with lot of functionality packed in it, leading to lesser user intervention and more of automatic functions. The therapy applications will be more on peripheral on site ECMOs than just in-hospital ECMOs. More therapy reference centres will be available across India to serve the needy patients by inter-hospital transports in special air-ambulances and road ambulances. Therapy will be more affordable as various insurance companies and organisations will finance ECMO programmes. Overall, the future looks brighter for ECMO therapy in terms of technological advancements, applications and affordability. The way ahead is to make the therapy more approachable by launching more numbers of quality ECMO units acting as reference centres in every region of India. These reference centres should be able to cover at least the whole of regional locations for all types of patients needing ECMO support. Frequent awareness programmes would be required to increase understanding of the therapy to the general public.
(Based on Data from ECLS registry Report, International Summary, ELSO, January 2011)
3. Adult Diagnosis
Survival rate
Pneumonia
• Viral • Bacterial • Aspiration
65% 59% 61%
Acute Respiratory Distress Syndrome
• Post. OP/ Trauma • No. Post. OP/ Trauma
52% 48%
Non ARDS Type
55%
Acute Respiratory Failure Refractory Cardiac Arrest
27%
Cardiogenic Shock/ Unable to wean from CPB after Cardiac Surgery
39%
Severe Myocarditis
69%
Decompensated Cardiomyopathy
45%
(Based on Data from ECLS registry Report, International Summary, ELSO, January 2011)
Indian potential As discussed before, globally, over 70 per cent patients on ECMO reported were suffering from severe respiratory failures from intensive care, whereas in India around 70 per cent of ECMO patients reported are cardiac failure patients from cardiac surgery. This means that there is still a vacuum in the applications on every indication of the therapy. It can be estimated that overall, every year, over 10,000 patients are
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best suited for ECMO therapy support in India, which includes the respiratory as well as cardiac failure patients. However, not all get the treatment due to inadequate ECMO units and lack of information on the therapy.
Money matters The therapy costs include the cost of ECMO system, blood investigations, blood products, medications, personnel service charges, intervention
Sagar S Haval is manager, clinical applications-South Asia, Maquet Medical India.
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Consumer Connect Initiative
Flooring Indian healthcare Thomas Schneider, general manager, Tarkett Western Asia, speaks about what makes Tarkett the preferred choice for innovative and sustainable flooring solutions in healthcare settings How have flooring solutions for healthcare institutions changed over the years? Both, the needs of healthcare institutions and flooring production technologies have changed over the past years. Since flooring solutions can be adapted to various needs and uses, flooring producers such as Tarkett customise products for specific requirements. In the old days, hospitals used hard tiles (ceramics and natural stone) everywhere. Now, not a single hospital in North America, Europe or even China, uses hard tiles anymore, except perhaps in the lobby. Resilient floorings such as PVC (vinyl) have replaced hard tiles in most areas such as the corridors, rooms, OTs and ICUs.
Flooring solutions in healthcare institutions must be seamless to prevent the growth of bacteria
While some products such as ESD floors (static control floors) find specific usage in OTs and IT rooms, other flooring products can be used in many areas. Healthcare institutions now prefer PVC floors due to their extreme resistance, easy maintenance (due to advance polyurethane surface treatments such as Tarkett IQ), fungiostatic and bacteriostatic properties. Healthcare institutions understand that infection control can be guaranteed with such products and that maintenance and replacement costs are significantly reduced. They now focus on a product’s life cycle costs rather than on investment costs. What are the challenges associated with flooring solutions for healthcare institutions? Flooring solutions in healthcare institutions must guarantee infection
control, static control in OTs and be seamless to prevent the growth of bacteria. PVC floors can be curved on to a wall so that the edges can be cleaned easily. These solutions must also be environmentally friendly and hence must emit the minimum amount of VOCs (volatile organic compounds) so that the air quality remains good. (Tarkett will never provide unhealthy products to a hospital) What type of flooring solutions are more in demand in Indian hospitals? Penetration of resilient flooring solutions such as PVC is still low in India. Most of the hospitals still use hard tiles (like ceramics and marble) unlike other countries. Resilient floors are used in critical care areas such as OTs and ICUs. Healthcare decision makers are not yet fully aware of PVC products. If the right product is chosen, it can be used in corridors and rooms
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Tarkett products have proved to be resistant in projects where traffic is high
sustaining the heavy traffic specific to India. However, the market for PVC flooring solutions is growing steadily. Tarkett products have proved to be resistant in corridors in government hospitals that have heavy traffic. When users need a resilient flooring solution because of extreme level of traffic, Tarkett IQ floors, homogeneous PVC floor coverings are usually the preferred solution in the Indian healthcare market. This is due to their effective restorable properties.
institution decides to dry buff an IQ floor made by Tarkett, it becomes brand new again for another two years. Tarkett also guarantees that neither wax nor polish is needed to maintain these products, which gives significant maintenance cost savings to our clients. Tarkett has a 40 per cent market share worldwide in single layer products, which are manufactured in our plant in Sweden. These products have an estimated lifespan of 20 years. · Heterogeneous PVC: These floors can provide unlimited design possibilities and acoustic
properties by adding a backing to the product. These products are made in our factories in France and Luxemburg. · Linoleum: This is a totally natural product made of linseed oil, wood flour and cork and is produced at our plant in Italy. · Engineered wood and laminates: These are mostly used in offices of a hospital and are made in Sweden (wood) and Germany (laminates). · Carpet tiles: With the recent acquisition of Tandus, Tarkett group can also provide such
What is the growth rate of the flooring solutions market? The global floor covering market is around 12 billion square meters and growing at 5 per cent CAGR, while the Indian floor covering market is around 500 million square meters and posts a 10 per cent growth rate. The highest selling products are ceramics and natural stone. What kind of flooring solutions does Tarkett provide for healthcare institutions? Tarkett provides multiple healthcare solutions. We, however, are the largest world producer of vinyl floors, and hence, specialise in the field. Our flooring solutions are: · Homogeneous PVC: These are single layer PVC products that are extremely resistant. Moreover, Tarkett IQ homogeneous products can be restored. A dry buffing operation can erase micro scratches from the surface. This means that after two years, if a healthcare
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Resilient floors are used in critical care areas such as OTs and ICUs
Tarkett can provide a flooring solution for every single room in a hospital
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Consumer Connect Initiative
solutions for the office section of healthcare institutions. Basically, Tarkett can provide a flooring solution for every single room in a hospital. How different are these solutions vis-a-vis your solutions for other industries? Healthcare institutions are keen on infection control, static control and resistance. Hence, the preferred solution is homogeneous PVC floors such as our IQ range (IQ Optima, IQ Granit, IQ Toro SC). Offices often look for an acoustic solution (heterogeneous PVC, carpet tiles). A retail outlet needs a design to fit with its brand image. So as you see, all segments have different needs. In fact, within the same segment too, different clients have different needs. In France, most hospitals are designed with acoustic heterogeneous floors coverings with vivid colours, whereas in Sweden, they are designed with
homogeneous floor coverings with more sober tones. Flooring solutions can differ depending on segment, culture, design and taste. The level of traffic also orientates the choice towards more or less resistant products. In India, clients prefer Tarkett homogeneous PVC products due to the high traffic and lower maintenance regime. When did Tarkett enter the healthcare segment? In how many countries, do you have a presence? Tarkett group has a rich history dating back to the late 19th century. Tarkett has been supplying flooring solutions to healthcare institutions since at least 50 years. We are present in over 100 countries with 50 sales and marketing offices and 38 plants. When and how did Tarkett enter the Indian healthcare market? How has the company
What is the nature of your clientele in India? We work with independent healthcare institutions as well as large corporate clients. We are honoured to provide floor solutions to key healthcare chains, such as Fortis, Apollo and Columbia Asia. We also provide solutions to the governmental sector such as ESIC. We are extremely proud and honoured that these companies trust our products and are repeating orders to Tarkett. This proves that our solutions are adapted to various footprints, levels of traffic and hospital sizes.
Armstrong has products to be used in different hospital zones
Tarkett provides the largest choice of flooring solutions customised to individual client needs
Tarkett has been supplying flooring solutions to healthcare institutions since at least 50 years
grown in the Indian healthcare market? Tarkett entered the Indian market with wood flooring in 1995. Our presence in India is 17 years old now. We have been providing solutions to Indian healthcare institutions since 2002 and have been growing consistently since then.
Why should consumers go for flooring solutions from Tarkett? Tarkett provides the largest choice of flooring solutions customised to individual client needs. In healthcare, we have been providing solutions to Indian hospitals for the past 12 years. In some hospitals, the floor coverings installed back then still look new. Tarkett can provide solutions on a pan-India basis, irrespective of the location. Tarkett is a transparent company with uncompromised business ethics. We produce every square meter with an environmental concern giving data about the VOC emission, amount of natural materials used and recyclable content for each of our product. Tarkett is innovative in designs and hence can propose multiple colour options to architects, consultants, contractors as well as clients. Finally, we are a global brand and a worldwide leader in floor covering production. â–
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Product showcase All that is latest on the market
JBL Professional
HARMAN’s JBL Professional, the latest portfolio of commercial series from the company, consists of loudspeakers, amplifiers and mixers. The series is cost effective and is ideal for the Indian healthcare segment. Loudspeakers: The CSS-1S/T surface-mount loudspeakers are cost-effective ceiling speakers and backcans. The speakers are compact 2-way 100V/70V/8 with a 5¼-inch low-frequency and ¾-inch high-frequency driver and a frequency response of 85 Hz--18kHz. The 10-Watt multitap transformer for 100V or 70V distributed speaker lines (10W and 5W taps, plus 2.5W at 70V only) and 60-Watt capability make the CSS-
1S/T ideal for low to medium-level background sound applications. The CSS-1S/T comes with a ball-type wall-mount bracket. Mixers: The CSM-32 and CSM-21 Commercial Series Mixers provide an entry-level, cost-effective approach to commercial audio applications. They can be configured for paging, background music, and security applications. They don't require a computer for configuration and are designed with simple analog-style controls. An included security plate can be placed over the controls to avoid uninvited changes to a commissioned system. JBL’s Commercial Series Mixers offer a diverse palette of process-
ing tools, including priority override, page ducking, source and zone EQ, LevelGuard™, AutoWarmth™ and a built-in crossover. Amplifiers: The CSA-2120 power amplifier is a two-channel amplifier that provides simple front-end amplification and a switch mode universal power supply. It provides accurate, uncoloured sound with low distortion for both audio and voice applications. An auto-standby mode allows the amplifier to save energy by disabling the amplifier pulse width modulation generator when there is no input signal. It also features thermal and low-voltage auto protection. The amplifier includes two optional accessories, a mounting kit and transformer module. The CSA-2120 has a power rating of 4 ohms/8ohms at 120 watts and weighs 2.9lbs. Email: indiaproinfo@harman.com
The new haematology analyser from Transasia Transasia Bio-Medicals Limited has launched Sysmex XN Series – a haematology analyser that uses fluorescent flow cytometry and cell counting to detect abnormal samples. Manufactured in Japan by Sysmex Corporation, the Sysmex XN Series is a next generation instrument, designed to enhance clinical values. Sysmex XN series plays an initial role in evaluation of haematological conditions and diseases, providing data in screening of anaemia and infections. On identifying abnormal samples, the analyser flags relevant information and showcases the abnormalities in the scatter grams. This helps early detection of bone marrow abnormalities and aids haematologists in determining the course of treatment. The modular integrated transportation system comprises automated haematology analyser with SP-10 slides preparation unit, thus enumerating clinically relevant parameters enhancing flexibility during diagnosis. The Sysmex XN
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series from XN 1000 to XN 9000, embraces the modular concept and scalable system lab with 50 or >500 CBC samples a day and allows combination of multiple analysers, transport system, slides preparation system and other instruments to cater to small to large workloads. Supported with innovative software, it allows laboratories to access online external quality control (QC) comparison with peer-group laboratories also from engineering perspective. Predictive failure detection and maintenance monitoring are built into the XN analysers, and can be monitored
remotely as required. The XN series increases laboratory efficiency by reducing the number of false positive flags at higher sensitivity and specificity. It provides automated reflex/re-run testing based on the results enumerated. Also, each XN module can be upgraded by additing functions or ‘apps’, RET (reticulocytes), PLT-F (fluorescent platelets) and BF (body fluids). The analyser measures NRBC with every CBC. The new XN-Series is designed for a long product life and with a consistent user interface in all models. Email: h.makasare@ transasia.co.in
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Product showcase
Prestige Elite 1.5T MRI System The Reliant Prestige Elite 16 Channel 1.5T MRI System by Reliant Imaging Diagnostic is a newly developed state-of-the-art imaging system offering advanced but practical and affordable imaging. It's features include: • RF coils that incorporate a unique feature which allows any combination of coils to be connected together; the system automatically detects the coil combination, optimises the element selection, and selects the applicable application sequences. • A newly developed multichannel spectrometer offering a 16 channel operation, incorporating the latest technology and software The system consists of these major units: 1. Superconducting magnet Actively shielded superconducting magnet system with integrated closed cycle refrigerator system: • Field strength: 1.5T • Polarity: South pole at patient end • Homogeneity (shimmed): 50cm dsv< + / –10ppm pk to pk • 45cm dsv< + / –5ppm pk to pk • 30cm dsv< + / –1ppm pk to pk • Field decay: <0.1ppm / hr. • Nominal operating current: <600A • Patient bore diameter: 60cm • Helium boil off: zero boil off • Helium volume approx. 2200 liters • Refill interval (typical) 3 to 5 years
RF coils All coils can be combined at will in any combination up to a maximum of 48 elements: • 8 Channel Head • 16 Channel Array Spine (CTL) • 6 Channel Knee • 4 Channel flexible Torso Email: sarbajitm@reliantmed.com
‘CUBE TRACK’ Patient Privacy Cubicle Tracks and Curtains
2. Patient Handling • Table height: min. 700 mm (preliminary) (27.5in) max. 980 mm (preliminary) (38.6in) • Maximum patient weight: 160 kg (350lbs) • Patient positioning: laser marker 3. Gradient subsystem Actively shield, super-compact whole body gradient coil system with integrated magnet shims • Gradient amplifier: PCI • Maximum Amplitude: 28mT/m • Max. Slew rate: 120 mT/m/ms • Duty cycle: 100% • Cooling: Water RF Subsystem • Resonant frequency: 63.88MHz • RF preamplifier integral to each coil element • Gain: 26+/–1db • Noise: <0.5db • Input frequency range: 10–200MHz • Spurious free dynamic range: >96db • RF amplifier Type: Analogic 8102 • Cooling: Air • Amplifier power: max 9kw
Cube Track by Global Healthcare solutions can be used in hospitals for privacy in ICU wards, VIP/Special rooms, semi special wards, consultation rooms, and general wards. Tracks: Made of aluminium alloys of 25 mm width with 50 - 60 microns of thick powder coating of ivory / white colour. They are free from joints up to 20 ft. The roof supporting system for tracks consists of an aluminium pipe of 12mm diameter, a fabricated wall bracket made from cold rolled carbon steel sheets. These are fixed using fasteners. Runners: The roller type runners are made of hard composite plastic material like Nylon for smooth, noise and trouble free curtain sliding. These runners are non-breakable and long lasting. Curtains: These are made of high quality imported, synthetic material. They have a nylon mesh stitched at the top for proper ventilation and nylon eye-lets for noise-free sliding. These curtains are anti-microbial, stain retardant and easy to wash. They are available in a variety of colours. Email: prabhur@globalhealthcaresolutions.in
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Movers&Shakers
A monthly round-up of high-profile appointments and accolades in healthcare
Dr Girdhar Gyani
Dr Mukesh Hariawala
Dr R Bilimagaa
Dr Girdhar Gyani joins AHPI
'India's Most Admired Surgeon'
Dr Bilimagaa becomes AROI president
After retiring as Secretary General of QCI and CEO of NABH, Dr Girdhar J Gyani has joined Association of Healthcare Providers (India) as director general. The association (AHPI) is a conglomeration of all healthcare providers (hospitals/nursing homes/clinics, diagnostic centres and supporting organisations like, pharmaceutical, medical equipment companies, and insurance providers among others) that are accountable to the community. The Association will work closely with the government and community to realise the goal of universal health coverage. “I had the privilege of contributing towards the development of the national healthcare accreditation system (NABH), which has provided effective framework for quality governance of healthcare establishments in the country. I also have been involved in the development of standards for Clinical Establishment Act-2010. And I hope to apply this experience on the vast canvas of AHPI with the singular objective of educating the common man and advocating for his wellbeing,” said Dr Gyani.
Harvard trained and internationally acclaimed cardiac surgeon Dr Mukesh Hariawala was bestowed with the prestigious ‘India's Most Admired Surgeon’ award by K Sankaranarayanan, governor of Maharashtra, at a glittering ceremony in Mumbai. This award was in recognition of the pioneering research and scientific work that Dr Hariawala has accomplished in the evolving field of angiogenesis and stem cells for the heart. This therapy taps into the passively residing micro blood vessels in the heart that have been hibernating since birth and which can be stimulated to provide a ‘natural bypass to bypass surgery’. “Stem cells are extracted from patients’ own hip bone during open heart surgery, filtered and re-injected in zones of the heart that cannot be bypassed. After this procedure, patients are unlikely to need repeat surgery and thus it will be a highly cost effective procedure saving millions of valuable healthcare resources,” says Dr Hariawala, who has been a surgical team member that performed the first bypass surgery on PM Dr Manmohan Singh in 1990.
Bengaluru-based Dr Ramesh S Bilimagaa, senior consultant and radiation oncologist with Healthcare Care Global, has been unanimously elected as president of the Association of Radiation Oncologists of India. Dr Bilimagaa had completed his MD in radiotherapy from Bangalore University in the year 1982 and received training in nuclear medicine from Bhabha Atomic Research Centre, Bombay. His special areas of interest are HDR Brachytherapy, chemo-radiation and conformal radiotherapy such as 3D CRT, IMRT, IGRT and Cyber Knife. Says Dr Bilimagaa, “It’s a great honour to be elected as the president of AROI, a body of over 20,000 radiation oncologists. With this opportunity, we would like to encourage cancer centres in India to upgrade their infrastructure to meet the requirements of cancer patients. The Government has allotted ample funds for cancer care, which is not being utilised to their full capacity. These funds would be facilitated to improve the overall standards of cancer care, so that patients suffering from the dreaded disease can avail best medical treatment.”
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