IndiaMedToday October 2017

OCTOBER 2017, VOLUME 1 ISSUE1 `200 INDIA MED TODAY

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LEADERS INAUGRAL ISSUE

GUIDING THE FLOCK ACROSS THE SKY

OCTOBER 2017

Can Activity Based Costing

How ISRO improved

Simulation in Medical education

change the fate of private hospitals

critical care medicine in India

can save lives

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OCTOBER 2017 EDITORIAL

BOARD OF ADVISORS

Editor Neelam Kachhap editorial@ indiamedtoday.com

Dr Dr Dr Dr Dr

Alexander Thomas Girdhar Gyani Prem Kumar Nair Bhabatosh Biswas Alok Roy

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IndiaMedToday expressly disclaims liability for errors and omissions in this publication. While we try to keep the information timely and accurate, we make no guarantees. The views and opinions expressed in this article do not necessarily reflect the official policy or position of IndiaMedToday or the publication. Information on IndiaMedToday should not be used as a substitute for professional healthcare advice. Readers are advised to always seek specialist advice before acting on information contained in this publication. Never disregard professional medical advice or delay in seeking it because of something you have read on IndiaMedToday. No part of this publication or any part of the contents thereof may be reproduced, stored in a retrieval system or transmitted in any form without the permission of the publishers in writing.

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STAY CONNECTED & KEEP UPDATED WELCOME TO the inaugural issue of IndiaMedToday, a national healthcare magazine published monthly from Bangalore. The magazine aims to bring together diverse ideas and interdisciplinary expertise in the growing field of healthcare delivery on a single platform.

Our vision is to do more than just publish information. We want to be a catalyst for deliberation and dialogue among different stakeholders; leading to formulation of best practice guidelines, policies and strategies which will change the way healthcare is delivered in India.

The magazine also seeks to support and foster interest of doctors in terms of voicing their concerns on medical education, working conditions, ethics and legalities of practicing in India.

We want to be a catalyst for deliberation and dialogue among different stakeholders; leading to formulation of best practice guidelines Launching a new magazine is almost impossible without collaboration. We would like to thank the members of the Advisory Board, our Consulting Editors, contributors, supporters and critics for their valuable inputs and help in bringing this magazine to life.

In the following months, contributing authors will address a variety of issues that have emerged and are continuing to emerge as concerns and accomplishments in Indian healthcare domain. Given the focus of this magazine, we anticipate that these articles will stimulate reflective commentary on partnerships as forms of and sites for healthcare leadership.

We look forward to articles and dialogue that provide us with those “high moments capable of inspiring us�.

As readers, you are invited to contribute to the dialogue by submitting opinions or comments on the web site (www.indiamedtoday.com), our social media handles or write to me at editorial@indiamedtoday.com.

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CONTENTS 13 OPINION

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DIFFICULTIES FACED BY HOSPITAL ADMINISTRATORS Does anyone raise objections when top lawyers charge Rs 10 lacs for a single appearance in court?

ACTIVITY BASED COSTING With Activity based Costing hospitals can measure, analyze, plan, implement, and control financial as well as operational efficiency in quantifiable terms

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UPFRONT 03 Editorial 05 Letters 06 News roundup 47 Events 50 Ask the expert

FEATURES 30 ICU Design of the Future

Design of critical care facilities has an impact on organizational performance, clinical outcomes, and cost of care delivery 97% of manmade radiation exposure is contributed by diagnostic radiation and the best way to reduce exposure to radiation dose is to avoid repeating investigations

HEALTHCARE LEADERS

IMPACT

Facebook

40 Radiation safety

COVER STORY

Guiding the flock across the sky Hospitals are complex organizations. The need to upgrade clinical quality and maintain costs is a priority for hospitals. How do hospital leaders do this and continuously service the growing customer demands?

Twitter

44 Health-IT INNOVATE

HEALTH QUEST

Who’s accountable for a Security Breach?

90% of organizations have suffered at least one data breach in the past two years

Story of an endeavour to incorporate the best quality practices of ISRO in emergency medicine and critical care medicine

17 PULSE

SIMULATION TRAINING Can Simulation Help You Save lives in a healthcare setting

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LETTERS

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n behalf of the Association of Healthcare Providers of India (AHPI), I am delighted to announce the launch of the inaugural issue of IndiaMedToday.

The Indian healthcare industry is evolving at a rapid pace. There is a need for a credible, quality source of information which provides insightful and unbiased coverage of the various developments in the healthcare sector from across the country. IndiaMedToday, a monthly B2B print and online magazine for the Indian healthcare community, highlights the collaborations between healthcare providers in redefining and redesigning healthcare delivery in the country, with the goal to enhance the value of care, improve quality and reduce costs.

Conceptualized and implemented by senior healthcare journalist Ms M Neelam Kachhap, this magazine had taken nearly a year in the making, and is a natural outgrowth of the expansion of the efforts of AHPI in advocating issues with the Government, regulatory bodies and other stakeholders. AHPI is happy to be associated with IndiaMedToday to create a platform for the communication of these issues, which have a bearing on AHPI’s mandate to deliver affordable and quality healthcare services to the community at large.

I would like to congratulate the team of IndiaMedToday who have brought the magazine from its inception to its present form, and wish them success in their endeavor.

Dr Alexander Thomas President- AHPI

Healthcare delivery in India is extremely fragmented and the organized sector accounts for less than 10 per cent of the beds. Healthcare news magazines like IndiaMedToday provide valuable information to healthcare providers to help them navigate this vast and challenging field.

Viren Shetty Senior VP - Strategy & Planning Narayana Hrudayalaya Hospital

Congratulations! I am glad that you are launching IndiaMedToday.

I feel, India today is at cross roads in healthcare. Private enterprise has played a major role for decades and nearly managing over 75 per cent of the healthcare in the country which has resulted in providing quality healthcare to large section of the population. Private healthcare has brought in value medicine to this country.

But, the recent amendments from the Government are of some concerns, like price control, leverage on private hospitals for lack of government infrastructure which has

to be addressed properly in the first place. We need a committee representing healthcare and the authorities have to understand on how the healthcare is working in India and based on that systems have to be put in place for betterment of the patients.

This intern will have positive effect on the entire healthcare providers including the Government.

Dr B S Ajaikumar Chairman & CEO HealthCare Global Enterprises Limited

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NEWS ROUNDUP ASIA’S FIRST UPPERARM DOUBLE HANDTRANSPLANT DONE AT AMRITA HOSPITAL

is currently undergoing a regime of movements for her fingers, wrists and shoulders.

The elbow movements are planned to be started in a couple of weeks. We expect that she will regain 85% of hand function in the next one-and-a-half years,” said Dr Mohit Sharma, who, along with Dr. Ravishankaran, played lead roles in the surgery.

FIRST OF ITS KIND SCLERAL LENS FACILITY AT L V PRASAD EYE INSTITUTE The Amrita Institute of Medical Sciences (Amrita Hospital) at Kochi has conducted India’s – and Asia’s – first upper-arm double hand-transplant on Shreya Siddanagowda, a 19-year-old chemical engineering student who lost both her hands in a road mishap last year. The donor was 20-year-old Sachin, who was declared brain-dead after suffering fatal head injury in a motorcycle accident.

His parents readily agreed to donate his hands and other organs for transplant.

Dr. Subramania Iyer, HOD, Plastic & Reconstructive Surgery, Amrita Hospital, led a team of 20 surgeons and a 16-member anesthetic team in a surgery that lasted 13 hours.

He said: “Upper arm transplants are much more challenging than those at the wrist or forearm level due to the complexity involved in accurately identifying and connecting various nerves, muscles, tendons and arteries. Rehabilitation is also much more difficult because the patient bears the weight of the transplanted hands at the upper arm. In Shreya’s case, both transplants were done at the middle of the upper arm. This is the first time that an upper arm transplant has been done in India or even Asia. Only nine such transplants have been conducted in the world till now.”

Shreya’s body has accepted the transplanted hands and is showing good signs of recovery. She has been discharged from the hospital and put on an intensive physiotherapy and rehabilitation program. “Shreya

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L V Prasad Eye Institute (LVPEI) has been at the forefront in setting up state of the art eye care services to cater to all sections of the society. The latest one for this global eye care institute is a new unit that produces special type of contact lenses (Boston Scleral lenses) that was inaugurated by Chief Guest Gene Guselli, President & CEO, BostonSight, Massachusetts. This new facility is established in collaboration with the Boston Foundation for Sight, USA, with the goal of increasing access to specialized forms of contact lenses for the treatment of corneal problems, avoiding corneal transplantation in some cases. Prof Deborah Sweeney, Pro Vice-chancellor (Research & Innovation), Western Sydney University, Australia was the Guest of Honour.

Gene Guselli, President & CEO, BostonSight, said, “This partnership creates an opportunity for our organizations to combine our collective expertise, and provide affordable access to visually impaired, underserved populations around the world. The Boston Foundation for Sight is privileged to be working with such a prestigious organization as LV Prasad Eye Institute to make this a reality.”

Speaking on this new development, Dr Gullapalli N Rao, Founder and Chair, L V Prasad Eye Institute said, “For many of the thousands of patients suffering with complex corneal disease, PROSE may be the ideal, and sometimes only treatment capable of restoring visual function and reducing

eye pain and light sensitivity. Till date, the benefit was limited in India because of the high cost. The new manufacturing facility has been created to make it available to all sections of society.”

NEW DA VINCI X SURGICAL SYSTEM TO BE LAUNCHED IN INDIA

The low-cost surgical robot da Vinci X Surgical System will be launched in India soon, a source close to the development said.

The first surgery using the new da Vinci X System was performed at Manipal Hospital, Bangalore.

There are several models of the da Vinci Surgical System. This is the first low-cost model launched by the company. The launch of the da Vinci X System underscores Intuitive’s commitment to meeting customers’ needs with a strong value-oriented portfolio and an array of financing options.

“This new system enables access to Intuitive’s leading and proven robotic-assisted surgical technology at a lower price point,” said Dr. Gary Guthart, CEO of Intuitive Surgical. “Customers around the globe have different needs from a clinical, cost and technology perspective; Intuitive’s goal is to meet those needs by providing a range of products and solutions: the da Vinci X System helps us continue to do so.”

The da Vinci X System offers surgeons and hospitals access to Intuitive’s portfolio of advanced, innovative robotic-assisted surgical technologies – and its full ecosystem of programs, support, services, and solutions – at a lower price. The System uses the same

vision cart and surgeon console that are found on the flagship product, the da Vinci Xi® System, enabling customers the option of adding advanced capabilities, and providing a pathway for upgrading should they choose to do so as their practice and needs grow.

The new robotic system received FDA clearance in May this year and CE Mark in April, 2017.

The da Vinci X System enables optimized, focused-quadrant surgery including procedures like prostatectomy, partial nephrectomy, benign hysterectomy and sacrocolpopexy, among others. The System features flexible port placement and 3D digital optics, while incorporating the same advanced instruments and accessories as Intuitive’s flagship system. The new system drives operational efficiencies through set-up technology that uses voice and laser guidance, drape design that simplifies surgery prep, and a lightweight, fully integrated endoscope.

“The da Vinci X System is a value-oriented option for hospitals that are just starting their robotic-assisted surgical program and for our existing customers who want to expand their existing robotics programs,” said Henry Charlton, Senior Vice President of U.S. Sales. “As customers’ needs grow, the da Vinci X System can grow with them. The da Vinci X System enables our customers to take immediate advantage of Intuitive’s full ecosystem of support and services,” he added.

The da Vinci X System will be available for sale in India soon. Vattikuti Technologies, which distributes da Vinci Surgical Robots, from Intuitive Surgical Inc., will make the new system available for the Indian market.

“Intuitive Surgical is continuously innovating to ensure that complex surgeries are minimally invasive. da Vinci Xi with innovations like firefly fluorescence, in-built energy source and multi quadrant access was a leap forward over da Vinci Si. These made a big difference in outcomes in cancer surgeries and naturally added to the price,” said Gopal Chakravarthy, CEO, Vattikuti Technologies. “da Vinci X, incorporating the most innovative technologies available today, is a

platform for development of future technologies just like da Vinci Xi. Intuitive Surgical has innovated on the price front as well to make it more affordable for most hospitals,” he added.

INCIDENCES OF PROSTATE CANCER RISING IN RURAL INDIA

Registry data clearly indicates rising cases of Prostate Cancer among rural populace and experts are of the view that advanced treatment, drugs and technologies need to be made available to them. “There is an urgent need to create awareness about prostate cancer threat amongst the rural populace”, expressed Prof Dr Anup Kumar, Head of Department, Urology and Renal Transplant, Vardhman Mahavir Medical College and Safdarjung Hospital. Majority of the metastatic CA prostate cases are coming from rural areas.

The Registry at Safdarjung Hospital, where registered cases of patients in OPD exceeds 1 lac every month, reveals that out of 1 lac, 20% are prostate cancer patients, 40% are clinically localized, 30% are locally advanced and 30% are metastatic prostate cancer. The Registry reveals that PCa incident is increasing in India. Earlier, 80% cases were metastatic and rests were only 20% and most of the metastatic CA prostate cases are from rural areas.

The data shows that almost all regions of India are equally affected by this cancer. The incidence rates of this cancer are constantly and rapidly increasing in all the Population Based Cancer Registries (PBRCs). The cancer projection data shows that the number of cases will become doubled by 2020. Delhi Cancer registry shows prostate cancer is the second most frequently diagnosed cancer among men in Delhi accounting for about 6.78% of all malignancies.

Prof Dr P N Dogra, Head of Urology, AIIMS says, “This disease has become a major health problem globally during the last few decades. Prostate cancer is the second most common cause of cancer and the sixth leading cause of cancer death among men world-

wide. No doubt, the proportion has changed in the metro cities but there is still a limited access to rural areas in India. Most of the metastatic CA prostate cases are from rural areas. Therefore, it’s a challenge to government and doctors to decrease the risk factors and take causation of prostate cancer in the rural areas very seriously.”

Prof Dr Anup Kumar, Head of Department, Urology and Renal Transplant, Vardhman Mahavir Medical College (VMMC) and Safdarjung Hospital expresses that “There is a need to upgrade more government hospitals and treatment, surgery available, drugs and the cost i.e. 3-4 lac should be reduced to affordable levels. With targeted prostate-specific antigen screening, better access to health care facilities and with advance technology like 3D laparoscopy and robotics, better cancer drugs, survival can be improved and quality of life is expected to be improved for the patients in rural areas. There is a high need to provide this access to rural population and to make them aware of this disease and treatment technologies.”

UNIQUE CASE: KNIFE SPLITS SPINAL CORD, PATIENT SURVIVES AFTER SURGERY

A 43-yr-old male arrived in emergency medicine of Columbia Asia Hospital, Hebbal with knife stuck to the nape of the neck.

The surgery was challenging as the doctors had to operate in the position the patient arrived, without any upper body movements and neck manipulations due to spinal cord injury. Usually, anesthesia is administered

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NEWS ROUNDUP in the supine position, however in this case it was administered in the same position as the patient arrived. After a 3-hour operation, the patient was shifted to the ICU for further observation and is now recovering at the hospital.

September 14th was like just another day for 43-year-old Rage Venkata Ram Prasad of Ananthapur. Little did he know that he will never be able to forget that fateful day ever in his life. At around 1 p.m. in the afternoon when Prasad was returning from court, near the coca cola godown, he was suddenly attacked by someone with a knife.

The attacker who himself was on a twowheeler, attacked Prasad who was riding his motorbike on his way back home. The sharp knife hit Prasad’s nape, damaging the spinal cord with a splurge of blood. Till the time police reached at the crime scene, Prasad laid unconscious on the road covered in a pool of blood.

Police immediately rushed him to a nearby hospital, and later shifted him to Columbia Asia Hospital, Hebbal for multi-specialty care, where he underwent emergency surgery on the same night of the incident.

No neurosurgeon would have witnessed such a case where knife has entered to spinal cord spliting it into two in the neck.

“The patient was brought to the hospital with knife intact in his neck. The CT scan revealed that the knife had pierced into the spinal cord in the neck. In this situation, administrating anesthesia was difficult as patient had to be turned on to the supine position. We decided and went ahead giving anesthesia in the position which he arrived.” explained Dr. Prasanna, Consultant – anesthesiologist, Columbia Asia Hospital, Hebbal.

“Once the anesthesia was given, the next challenge was to position him for surgery, which needs manipulation of patient and his neck. We made sure that the complete surgery was done without any movements of the neck, and was done in the same position the patient arrived, without any upper body movements and neck manipulations due to spinal cord injury. He had also suffered left hand paralyses due to the injury,” said Dr.

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Avinash K M, Consultant – Neurosurgery, Columbia Asia Hospital, Hebbal.

“Patient is a miraculous man to have survived and able to walk with the nature of spinal cord injury,” added Dr Avinash KM “Usual prognosis in such cases is not good.

Most of the time patient will be paralytic. In this case because he underwent both anaesthesia and surgery without any manipulation of the neck he has recovered well and able to move his limbs,” he added.

“Patient is doing fine. He is extubated and breathing and talking well. He is moving hands and legs well.He is able to walk now.

Prognosis is good,” said Dr Prasanna.

THE FEDERATION OF HEALTHCARE ASSOCIATIONS – KARNATAKA LAUNCHED AT BENGALURU

Honourable Chief Minister of Karnataka

The Federation of Healthcare Associations – Karnataka (FHA-K) was inaugurated by the Honourable Chief Minister of Karnataka Siddaramaiah at the first National Healthcare Summit involving the representatives of Government Policy Makers, Government and Private Healthcare Organisations and Healthcare Associations, Legal Experts, Media Members, NGOs, Public, and Practicing Doctors here today at Jnana Jyothi Auditorium, Bengaluru. This ‘National Health Summit 2017’ was jointly organized by the Private Hospitals & Nursing Homes Association – Karnataka (PHANA), Federation of Healthcare Associations – Karnataka (FHA-K) and

Indian Medical Association (IMA-KSB), Karnataka with an intention to debate, deliberate and recommend various policies required for the betterment of healthcare in the state and the country.

FHA-K is a think-tank, comprising of various Healthcare Associations to assist and recommend various policies for betterment of Healthcare both to policymakers and private organisations.

Addressing the gathering, the Honourable Chief Minister of Karnataka, Sri Siddaramaiah said, “It is heartening to see that all the medical stakeholders have come together to debate, discuss and to improve the Healthcare scenario in our state and in our country. The prime focus of private sector and the government medical sector should be to cohesively be beneficial to the Community as a whole. Everyone should work towards serving the Community Ethically and Compassionately keeping the interests of the Common Man in mind. Healthy individuals lead to Healthy Community, in turn contributing to a Healthier Nation. Private Sector is a major partner in providing healthcare to the society, and the Government always supports the good works. On behalf of the Government of Karnataka, I congratulate and appreciate PHANA, FHA-K and IMA to have taken this initiative in bringing in all the stakeholders and started the step of getting the collective views of various people into consideration. I wish them all the best in their future endeavours.”

MEDICA SUPERSPECIALTY HOSPITAL ORGANISED WORKSHOP ON ULTRASOUND GUIDED REGIONAL ANAESTHESIA Of late, the field of Anaesthesiology, has seen a spurt in the use of ultrasound for many procedures. Most notably, Anaesthesiologists are using this technology for peripheral nerve blocks wherein the nerves supplying a particular area are visualised by the ultra-

sound and various medications are given to block the nerve transmission. This results in complete anaesthesia of the area/limb supplied by the nerve. At the same time, the patient remains awake and the risks associated with general anaesthesia can be avoided.

Medica Superspecialty Hospital, Kolkata in association with Daradia Pain Foundation, an institute for management of chronic pain, organised a one- day workshop on “Ultrasound Guided Regional Anaesthesia” on September 17, 2017 in the hospital premises.

The aim was to familiarise budding Anaesthesiologists and practitioners with the use of ultrasound and how to perform the various procedures.

According to Dr. Amiya Kumar Mishra, the head of the Department of Anaesthesiology and organising secretary of the workshop, Medica Superspecialty Hospital is one of the few hospitals in Eastern India practising this modality of Anaesthesia. “We plan to familiarise budding anaesthesiologists and practitioners with the use of ultrasound and how to perform the various procedures,” said Dr. Mishra.

Dr. Alok Roy, Chairman, Medica Group of Hospitals said that going forward, the aim of Medica is to make this technology popular so that other hospitals start using it too. “Seeing the response of the delegates, we plan to organise more such workshops in the near future, explaining more advanced procedures in this arena”, he said

RETROFIT PATIENT TRANSFER SYSTEM WINS INTERNATIONAL PRIZE

James Dyson Foundation announced the first ever Indian winner of the James Dyson Award- Asish Mohandas, product design student of IIT, Kanpur for his innovative product, MAATTAM, retrofit patient transfer system.

Asish Mohandas witnessed the plight and pain of an old lady while being shifted from one stretcher to another by lifting. Upon researching further and speaking to more than 50 people including doctors, nurses, ward boys etc., it became evident that there is no existing patient transfer mechanism that can efficiently transfer patients without causing any pain to the patients. With the aim to solve this problem, and to eliminate involvement of manual labour in shifting patient, Asish designed MAATTAM retrofit patient transfer system as a part of his final year degree project. MAATTAM, Retrofit Patient Transfer System has been selected as this year’s winner for India James Dyson Award 2017 and will now be running for the International Winner Award and prize money of £30000.

This product is of particular importance to India as Healthcare has become one of India’s largest sectors – both in terms of revenue and employment. Healthcare in India is also cost competitive compared to its peers in Asia and Western countries. The cost of surgery in India is about one-tenth of that in the US or Western Europe making it a hotbed for medical tourism. Even though Indian hospitals are cater to such large numbers of patients from India and abroad, they are still following the old mechanism for patient handling often causing inconvenience and pain to the patients. The product has huge potential in other global markets as well as Healthcare is amongst the biggest sectors for every economy.

“I resolved to design MAATTAM as I surveyed amongst doctors, nurses, ward boys to conclude that the majority of hospitals and clinics in India does not have efficient stretcher that transfers patient without any pain. I wanted to design a simple, affordable and retrofit solution which would most appropriately solve the problem of patient transfer in hospitals and create a better ex-

perience, every time the patient is getting transferred. It will also ensure evading the problem of spine disorders while shifting. I strongly felt that creating medical equipment like this would impact and help the needy at large.” said Asish Mohandas.

The mechanism works similar to a treadmill having a moving platform with a wide conveyor fabric belt and rollers on either ends. MAATTAM being a retrofit can be put on top of any wheeled stretcher with flat top surface and height adjustment facility, converting it into a transfer stretcher. To check the functionality a 1:2 scale prototype was fabricated and was tested by transferring a mannequin and was later tested with a human body, by transferring the child from a rest unit to the stretcher.

MAATTAM, Retrofit Patient Transfer System will receive £2,000 along with James Dyson Award Certificate from the James Dyson Foundation, and progress to the international stage of the award. Asish aims to commercialise this product and is in process of developing the full-scale model of the retrofit stretcher which would be able to transfer an adult of height up to 180 cm and weight of maximum 95 kg. He is also planning to further tweak the model to be used for transferring accident victims on the road.

There is a large occurrence of worsening the condition of accident victims due to mishandling of victims from road to hospitals due to ineffective patient handling mechanisms.

The James Dyson Award runs in 23 countries. The contest is open to university level students (and recent graduates) studying product design, industrial design and engineering.

SURGICAL CANCER CENTRES INVEST HEAVILY IN UNPROVEN TECHNOLOGIES TO ATTRACT PATIENTS FINDS STUDY For the first time an analysis of the impact of

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NEWS ROUNDUP NHS patient choice and competition on the reorganisation of surgical cancer services and investment in high cost medical technologies published in The Lancet Oncology has revealed that retaining competitive edge through new technology investment, rather than quality improvement, appears to be a powerful driver in the reconfiguration of surgical cancer centres in England.

Of the 16 prostate cancer surgical centres that closed between 2010 and 2017, none had done so because of explicit evidence of poor quality care. Instead, patients often travelled to alternative centres that provided robotic surgery, leaving other centres that couldn’t attract the same level of patients faced with the threat of closure.

Between 2010 and 2017, the number of robotic centres has more than tripled – increasing from 1 in 5 (12/65) centres providing the technology in 2010 to over three quarters (42/49) in 2017. This has occurred despite a lack of evidence of improved outcomes in terms of survival and side effects for robotic surgery compared to open surgery.

The authors say that better regulation is needed to assess technology delivery in the NHS, and that quality indicators should be made available to inform patient choice.

The study, led by the London School of Hygiene & Tropical Medicine and King’s College London (UK), included data from 19256 men in England who were diagnosed with prostate cancer and underwent radical prostatectomy between 2010 and 2014. It is the first analysis of the impact of patient choice and competition on the reorganisation of surgical cancer services in England.

“NHS choice and competition policy is based on the principle that patients will travel to centres they think will provide the best service. Closures were never intended to result from this, but the large number of patients deciding to receive treatment elsewhere meant some centres faced the risk of closures as they were no longer performing a sufficient number of procedures to sustain their service,” explains Dr Ajay Aggarwal, London School of Hygiene & Tropical Medicine, UK. “However, since there are no publicly

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available indicators to help patients judge the quality of prostate cancer surgery, patients have to make their choices based on other factors. In this case, it appears that patients use the availability of robotic prostatectomy as an indicator of high quality care, despite a lack of evidence of its superiority compared with open surgery. NHS hospitals are subsequently investing millions of pounds into new and sometimes unproven technologies which has a direct impact on the type of care patients receive, but also the configuration of services as a whole,” he adds.

Previous research found that 1 in 3 men with prostate cancer who had a radical prostatectomy in the NHS between 2010 and 2014 travelled beyond their nearest prostate cancer treatment centre. Younger, fitter and more affluent men were more likely to travel, highlighting the risk of further increasing inequalities in access to care. Men were most attracted to centres offering robotic prostatectomy or who employed surgeons with a national reputation.

During the time of the study, 23 of the initial 65 prostatectomy centres gained patients, with some centres doing an additional 400-500 procedures as a result of people travelling to that centre. By comparison, 37 of the 65 centres lost patients, with some doing 200 fewer operations than expected based on where patients lived.

Centres that gained patients were eight times more likely to offer robotic surgery, compared to centres that lost patients (10/23 [43.5%], compared to 2/37 [5.4%]).

Over this period, 16 (25%) of the initial 65 centres closed, none of which had introduced robotic prostatectomy.

“Even within publicly-funded systems like the NHS, competition policies have stimulated a form of centralisation through ‘natural selection’, as centres invest in unproven new technologies to protect their status, instead of services being regionally planned and coordinated. Similar patterns have been observed in other health-care markets such as the United States. Rapid adoption of high technology therapies is not unique to prostate cancer, and further research should look

at other types of cancer where new types of treatment are increasingly available as well,” says Dr Aggarwal.

COMBINED DIAGNOSTIC EXPERTISE OF FIVE LEADING LABS NEUBERG DIAGNOSTICS, LAUNCHED

In a first-of-its kind step in consolidating the fragmented diagnostic sector of the country, four nations joined hands to form first global Pathology Laboratory Consortium- Neuberg Diagnostics- launched today in Bangalore.

Founded by the renowned healthcare entrepreneur, Dr GSK Velu, the international alliance brings together leading laboratories from India, Sri Lanka, South Africa and UAE under one umbrella, positioning it among the top laboratory chains of the country from the day of its inception, both in footprints and revenue.

Neuberg Diagnostics (Neuberg literally translates to New City or New Neighbourhood apart from also being the namesake in honor of the Father of Modern Biochemistry, Carl Neuberg), was conceived with the goal to erase geographical borders and make the world of healthcare one, bringing advanced diagnostics affordable to people across the globe. The conglomerate, which has a combined diagnostic expertise of over two centuries, is an alliance of top laboratories like Anand Diagnostic Laboratory, Supratech Micropath, Ehrlich lab, Global labs and Minerva Labs, which have already made their presence in their respective countries and states such as Karnataka, Gujarat, Tamil Nadu, South Africa & UAE. Neuberg will have 3 world class global reference laboratories located in Bangalore, Ahmedabad, and Durban (South Africa) car-

rying out advanced range of testing using new generation In vitro diagnostics techniques along with total lab automation & big data analytics tools supported by robust world-class laboratory information system.

These laboratories will have collective annual revenue of INR 400 crs with the formation of the new entity. Neuberg Diagnostics will operate under one corporate team headed by Dr GSK Velu as the Chairman, Anand K, as the Chief Executive Officer. Dr Sujay Prasad will hold the mantle of the Medical Director and Dr Sandip Shah will be the Executive Director. The Technical Board will comprise of top pathologists like Dr Jayaram, Dr Bhagyam Nair, Dr Lorna Madurai, and Dr Bhavini Shah among others.

The global brand was launched in the presence of the esteemed guests, Ms. Anupriya Patel, Minister of State in the Ministry of Health and Family Welfare, Government of India, Dr Rajitha Senaratne, Minister of Health, Nutrition & indigenous Medicine, Sri Lanka, Dr Awatif Juma al Bahar, Medical director of Dubai Health Authority, UAE and Prof. Salim S Abdool Karim, Director of CAPRISA & Pro vice-chancellor, University of KwaZulu-Natal in Durban, South Africa along with the senior management officials of the brand.

The new generation consortium will pool in cutting-edge advanced diagnostics technology and actively perform 5000 plus variety of pathological tests, promoting prevention and early diagnosis, thereby empowering the Indian healthcare consumer. In conjunction with providing comprehensive laboratory services, covering all areas of laboratory medicine, Neuberg will combine conventional pathology testing, new generation laboratory techniques and basic Radiology & imaging techniques for enhanced patient outcomes.

Dr GSK Velu, Chairman of Neuberg Diagnostics said, “The aim of the partnership is to develop a new shared services model for the provision of pathology services in the Middle East, Africa including west and South India. Neuberg Diagnostics is built on the vision to provide modern, innovative and sustainable services that deliver world-class lab

facilities with the focus on high-end technology and services like genomics and proteomics to doctors and patients alike.”

Anand K, CEO of Neuberg Diagnostics added, “An association with the pathology experts will lead to the implementation of best practices, adoption of new technology and convert research into innovation, benefiting the medical community and ultimately improving patient care.”

Speaking about the new venture, Anupriya Patel, Minister of State for Health and Family Welfare, India said, “Indian healthcare delivery is growing by leaps and bounds. A global consortium is therefore set to be a major platform to introduce new generation pathology services to the sector, thereby increasing the quality and affordability of the country’s healthcare services.”

Dr Hemantha Beneragama, Ministry of Health, Nutrition and Indigenous Medicine – Sri Lanka added, “This global alliance with the top pathology laboratories will help in strengthening our relationships with the neighboring nations. Leveraging the expertise of world-class pathology brands, we look forward to leveling the existing gaps in our healthcare system.”

We first reported on this development last month on www.indiamedtoday.com

the course also focused on infectious diseases like Tuberculosis, HIV, Pneumonia, Hepatitis A to E, etc. and panel discussions with interactive sessions led by experts on topics ranging from ICU Infections, Infection Control, Adult Immunization and more.

Dr. Rajeev Soman, Consultant Infectious Disease Physician, P. D. Hinduja Hospital said, “A multidisciplinary approach is needed to understand the requirements for infectious diseases control at a community level.

P.D. Hinduja Hospital & MRC’s IDCC is designed to train post-graduate students in the principles and practice of infectious diseases & microbiology, including anti-microbial resistance and update them on the latest developments in the area of infection control.”

Dr. Camilla Rodrigues, Consultant Microbiologist & Chairperson Infection Control Committee, P. D. Hinduja Hospital said, “Infectious diseases (ID) remain one of the leading causes of morbidity and mortality in India and across the world. The objective of our annual IDCC course is to provide comprehensive knowledge on basic microbiology, disease transmission process, principles of epidemiology, current evidence-based infection control principles & practices and enhance skills of post-graduates in both medical and microbiology.”

P.D. HINDUJA HOSPITAL & MRC ORGANIZED 14TH INFECTIOUS DISEASE CERTIFICATE COURSE

MANUAL ON MEDICAL ETHICS AND PROFESSIONALISM RELEASED AT NATIONAL HEALTH SUMMIT 2017

P.D. Hinduja Hospital & MRC organized its 14th Infectious Disease Certificate Course (IDCC) from September 11 – 16, 2017. The Infectious Disease Certificate Course helps budding and established medical professionals analyze the latest information and developments associated with the diagnosis and management of various infectious diseases.

The course began with basic programs, growing into more advanced programs and sessions, all within a span of 6 days.

Along with a focus on Diagnosis, Management & Prevention of Infectious Diseases,

The Principal Secretary, Health & Family

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NEWS ROUNDUP welfare, Government of Karnataka Dr Shalini Rajneesh, released manual on ‘Medical Ethics and Professionalism’ at ‘National Health Summit 2017’. The summit was jointly organized by the Private Hospitals & Nursing Homes Association – Karnataka (PHANA), Federation of Healthcare Associations – Karnataka (FHA-K) and Indian Medical Association (IMA-KSB), Karnataka with an intention to debate, deliberate and recommend various policies required for the betterment of healthcare in the state and the country.

Releasing the Manual Dr Shalini Rajneesh said, “There should be no place for fear or apprehension in anyone’s mind on the government policies of Private Healthcare.

The Government aims to bring the Happiness Index of Karnataka up by several notches and we cannot do it without the support of Private Healthcare Providers. All Private and Government Healthcare stakeholders should be an ardent part of this noble venture, and ensure that there is no fear or apprehension or unhappiness in anyone’s mind.” This manual will serve as general guidelines to the entire healthcare fraternity.

The Secretary to the Government, Department of Health and Family Welfare, Legal Experts, Media Members, Eminent Personalities, Independent Thinkers, Policy Makers, National Leaders of IMA, IIM-A, KPMG, National Health Mission, Suvarna Arogya Trust, NGOs, Owners of small, mid, and large sized Hospitals, Office bearer of South Indian Hospital Association, Members of various speciality Associations, and many practicing Doctors participated in this Summit. These personalities deliberated and brainstormed during Panel Discussions on Healthcare Ethics & Governance, the challenges in Financing and Costing in healthcare organisations and the Future of Healthcare in our country.

“The conclusions arrived at during the panel discussions was shared as the ‘Bengaluru Declaration’ and will be submitted to the appropriate agencies. This Summit will henceforth be organized annually and move

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towards being a major policy recommending body.” Expressed Dr. C Jayanna, Convenor of National Health Summit 2017.

The Summit also witnessed felicitation of various Doctor MLAs for their contribution in their respective fields. Dr. Sharan Prakash Patil, Honourable Minister for Medical Education, Government of Karnataka; Dr. CN Ashwath Narayan, MLA Malleshwaram; and Dr. Ajay Kumar Singh, MLA Jevargi were felicitated.

CAHOTECH 2017 CONFERENCE ON ADAPTABLE FUTURE TECHNOLOGIES FOR INDIAN HOSPITALS HELD AT B’LOR The Consortium of Accredited Healthcare Organizations (CAHO) organised an international conference on health technology CAHOTECH -2017 on September 23, at National Institute of Advanced Studies, IIS campus, Bangalore. The event was organised with the vision to introduce newer and better technology solutions for hospitals.

The conference was attended by around 200 delegates and had speakers from Sweden, US and India. Dr Nagendra Swamy S C, Sr. President, Group Medical DirectorManipal Health Enterprises & ChairmanQuality Council and Dr Narendranath V, Chief Administrator, Ramaiah Medical College Hospital were the Organizing Chairman and Secretary respectively.

The event was inaugurated by Dr. Nanda Kumar Jairam, CEO, Chairman and Group Medical Director, Columbia Asia Hospitals, India and Chairman of the NABH in the presence of Dr Vijay Agarwal, President CAHO, Dr Alexander Thomas, Immediate Past President, CAHO, Dr CM Bhagat, Secretary General, CAHO, DR Girdhar Gyani, Director General, AHPI, Dr Nagendra Swamy S C (Sr. President, Group Medical Director- Manipal

Health Enterprises and other dignitaries.

“Technology has been and will play a huge role in healthcare delivery in the coming years. In fact, last year at the economic forum at Davos it was observed that The Third industrial revolution used electronics and information technology to automate production. Now a Fourth Industrial Revolution is building on the Third and the digital revolution that has been occurring since the middle of the last century. It is characterized by a fusion of technologies that is blurring the lines between the physical, digital, and biological spheres,” said Dr Agarwal. “This will impact our lives in ways that we cannot even imagine. It was observed that maximum impact will be on healthcare and paradoxically the medical professionals are the ones least prepared to embrace and make use of it,” he added.

Dr Ambuj Chaturvedi, Chairman, Medtronics and Dr Ajay Bakshi, MD & CEO, Manipal Health Enterprises delivered the keynote address.

Hakan Jideus, CEO, Predicare AB, Sweden and Todd Kalynik, VP, Open Technology, IBM US presented compelling arguments for the use of technology in healthcare.

Dr Lulu Sherif, Father Muller Hospital, Mangalore gave an interesting insight on the use of simulation in training healthcare workers. Dr Somashekhar SP, Chairman & HOD Surgical Oncology, Manipal Health Enterprise gave a very interesting talk on next gen robotics for surgery. Dr Mahesh Kappanayil, Pediatric Cardiologist, Department of Pediatric Cardiology, Amrita Institute of Medical Sciences, Kochi, talked about 3D-printing and its impact on surgical decision-making.

CAHOTECH 2017 was a great success.

This event was well attended by senior representatives of hospitals, start-ups and technology companies alike. Accompanying trade exhibition displayed latest technologies from start-ups and medical technology companies. Some of the participants were Stasis lab, Medblaze and Maxlife India.

OPINION

PRIVATE HOSPITAL ADMINISTRATOR HAS A DIFFICULT PILL TO SWALLOW Should the government dial back its recent policies on healthcare delivery? How can the burden on hospital administration be eased without compromising the patients?

Dr Ashish Banerji

THE INDIAN private healthcare sector is undergoing momentous changes, and the pace of change is accelerating. Nearly 80 % of healthcare is delivered through private providers in India. Out of these only 5% hospital beds are managed by the corporate hospitals rest are managed by small hospitals or nursing homes. But today private healthcare has become synonymous with corporate healthcare delivery, which in the collective consciousness of the Indian people, is equivalent to profiteering hospitals. This is not entirely true. One needs to look at the larger picture and the truth is that it is very difficult to have a private practice in healthcare in India.

Roadblocks Galore Hardly a day goes by without some news about a case against a hospital, or some violence against a doctor or hospital. In the past occupational health hazard for healthcare providers was limited to cross-infections, stress, NCD or

depression. And all of them still exist. But now doctors and nurses are also afraid of violence and humiliation at the hands of some antisocial elements. Besides these the government, both the Central as well as State government, has taken steps which are not pro doctors, and hinder the delivery of healthcare in some ways.

In addition axillary government bodies like The National Pharmaceutical Pricing Authority (NPPA) have now focused their time and effort to control healthcare delivery either by capping prices of stents used in cardiology, orthopedic implant prices, and the prices of various drugs.

This is all for the benefit of patients. The interventions by government (Central and States) and by courts, have had major impacts on pricing of healthcare delivery and have impacted administrators and clinical consultants equally.

What does all this mean for the patient at large? To ascertain the effects of these two sweeping changes, I scanned media reports for relevant stories and spoke to leading hospital administrators all over India, encompassing the four major regions: North, South, East and

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OPINION “The top management cannot absolve themselves in case of medical negligence”

West. While some of the inputs were similar, others were widely divergent.

Noted Incidents Two incidents, which shook up the entire private hospital industry in India, need mention.

The first one took place on 27 February 2017, when a patient called Sanjay Roy died soon after he was shifted from Kolkata’s most prestigious hospital (Apollo Gleneagles) to a Government hospital called SSKM. His wife

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cleared bills over Rs Seven lacs at Apollo, but SSKM hospital doctors said that no surgery had been done at Apollo to arrest his intra-abdominal bleeding.

An FIR was lodged against the hospital for extortion. Just a few days before this, the CM of West Bengal Mamata Banerjee had lashed out at leading private hospitals where the press was present. She also stated that West Bengal Clinical Establishment Act has to be modified and lent more teeth. “The West Bengal Health Regu-

latory Commission will have representatives of private hospitals, health department, consumer affairs department, doctors and police representatives,” said the Chief Minister.

A few days later Dr. Rupali Basu, Vice President and CEO (East) of Apollo Hospitals, resigned. A few weeks later, Dr. Pratap Reddy’s daughter, Ms. Preetha Reddy, came to Kolkata, met the CM of West Bengal, and told the press: “We need to be more caring so far as emergency is concerned. When it comes to treatment of patients we need to improve the quality of care.”

The second incident culminated on 05 June 2017 when 6 doctors of Artemis hospital Gurgaon were booked for medical negligence, because Mrs. Rajni Makkar (48) who had been operated on twice, died in August 2016, after being on a ventilator for 45 days. The list included the three treating doctors, the CEO, Medical Director and Medical Superintendent of the hospital. The police had sent the medical documents to Haryana’s most well-known medical institute: PGIMS Rohtak. A case was filed in nearest police station under 304 A of IPC (causing death by negligence), based on the recommendation of PGIMS doctors.

What stands out about both these incidents is that the top medical and administrative authorities were not spared when it came to death of patients and allegations are made pertaining to negligence or lack of appropriate treatment.

The top management cannot absolve themselves by saying that consultants are left to treat patients in the way that they deem fit, or that the consultants are not on the payroll of the hospital.

Reality Check It may be noted that most private hospitals have contracts with consultants on a “fee for services” basis, wherein the Consultant only gets paid for services rendered. These include seeing patients in OPD, ward visits made, and payment for surgeries or procedures. The Consultant is not on the payroll of the hospital. To make matters more complicated, some hospitals do not have laid down charges for surgeries or procedures, and Consultants have the “freedom”to charge what they can, often after talking to patients/relatives. While all hospitals discourage this, the system exists, due to the dependence of hospitals on Consultants to “bring cases”. However, even when these “Visiting Consultants” get involved in medical negligence cases, the top management of the hospital is held responsible, and may be indicted, or even placed in custody.

There is a dangerous tendency to avoid admitting and treating extremely critical cases like bad

road traffic injuries with a component of head injury, due to fears of violence, litigation etc.

This makes the whole field of hospital administration very risky and stressful, and youngsters do not opt for a career in hospital administration.

They prefer to go for “softer options” like joining one of the “Big Four” companies: Deloitte & Touche, PwC, Ernst & Young, and KPMG. Price Cap All administrators agree that patients are eriving huge benefits by the new prices, which are 70- 80 per cent lower than the earlier prices and the transparency rules (like displaying stent prices) are welcome. While some hospitals have passed on the full benefit to the patients, others have not. Some hospitals have tried to compensate by increasing other charges like Cath lab charges and fees of cardiologist in order to recoup the major losses.

The Cath Lab story Many administrators pointed out that unning a Cath Lab is extremely expensive, and the annual maintenance contract (AMC) of a Cath lab is above Rs 35 lacs per annum. alaries of staff such as Cath Lab technicians and specially trained nursing staff have to be paid at par. A large inventory of drugs, uide wires, balloons and stents has to be maintained.

Besides many large hospitals have “full timers” in Cardiology, and their “minimum assured amount” is always in excess of Rs 5-6 lacs per month. While patients should (and often do) get the full benefit of the reduced stent prices, hospitals also need to make the two ends meet and avoid losses. In this scenario, the availability of centers that can run a Cath Lab service will reduce drastically and the service will not be as easily accessible as it is today.

“There is a dangerous tendency to avoid admitting and treating extremely critical cases like bad road traffic injuries with a component of head injury, due to fears of violence, litigation etc.” www.indiamedtoday.com

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OPINION On-the-other hand There are daily news reports about certain high-end stents being withdrawn from the Indian market, due to the capping of prices, and this is a major cause of concern. Stents come in a wide variety of shapes and sizes, and there is no “one size fits all” concept. Hospitals and patients need a wide range of stents to meet the needs of different blockages. If the best stents are no longer available in Indian hospitals, patients will be forced to go abroad for Angioplasty. While this may solve the problem for those who can afford it, it does not address the issue of Primary Angioplasty in Myocardial Infarction (PAMI). If a patient reaches on time, emergency Angioplasty (PAMI) is done within 90 minutes of onset of heart attack, and the blood supply is restored before the heart muscle (myocardium) dies. Many hospitals offer this facility, with teams being available 24/7, but the withdrawal of best stents will obviously impact this treatment modality.

A few days ago, media reports stated: “Due to low commercial sales, Abbott will stop selling the first-generation Absorb Bioresorbable Vascular Scaffold.” On 13 September, an article in Economic Times stated: “the US firm (Abbott) has also moved an application to NPPA to withdraw its metallic drug-eluting stent ‘XIENCE Alpine’ from India…” All agree that this will result in more stent companies withdrawing their best stents from India. Is this fair to the public? Are there any restrictions on other very high priced items like cars, watches, jewelry, etc.?

The Ministry of Health needs to find ways to ensure that the highest quality stents are available in India.

Capping the price of procedures There are discussions going on about capping prices of hospital procedures, and insurance companies have been leading the way.

Hospitals in Pune are in a cold war with GIPSA companies since 01 April 2017, and people with Insurance policies of GIPSA companies are facing huge problems. Hospitals state that the rates being quoted are far too low, and the GIPSA companies are refusing to relent. This stale mate has lasted for almost six months, and no resolution is in sight.

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Concerns of Specialists Is there any capping on prices charged by professionals like Chartered Accounts, Lawyers, Architects etc.? Super-specialist doctors have to go through a minimum of 11-12 years of rigorous academic training. This includes 5.5 years of MBBS + Internship, 3 years for basic degree specialty, and 3 more years of super-specialty training. At each level, the student/doctor must pass through very tough competitive exams. Even after these years, which include sleepless nights of duties combined with studies, a super-specialist doctor keeps learning new techniques, keeps abreast of latest developments in his field through journals, and attends conferences (often abroad).  Do any of the other non-medical professionals go through all this?  Does anyone attack a lawyer if he loses a case in court?  Does anyone raise objections when top lawyers charge Rs 10 lacs for a single appearance in court?

The changing medical scenario in India, coupled with the Government’s tough stance on regulation, is discouraging many youngsters from entering the medical field, as a career option. To make matters worse, doctors are also actively discouraging their children from following in their

All administrators I spoke to stated that they are releasing dead bodies without insisting on clearance of bills. Now should the hospitals insist on pre-payment for the patients, because patients and relatives are abusing the rules to stop making payments if the patient becomes very critical?

This non-payment of bills affects hospitals very adversely, because the bills are used for payment to vendors who supply medicines (like expensive antibiotics), consultants (who may be visiting and not on payroll), apart from salaries of nurses, technicians etc, and utilities. This is a significant loss for the hospital, because the amounts are always in excess of a few lacs. As the word spreads, people may resort to this tactic more and more often.

Is this fair? Can hotels or airlines be asked to not take payment of bills if the passenger or traveller does not want to pay? It is unthinkable!

While all hospitals have systems in place to collect interim bill payments, relatives are always informed about outstanding bills. Yet they refuse to pay, knowing that the courts will support them.

Should the hospitals then stop taking in critically ill patients?

In conclusion, all progressive and patient friendly measures are welcome, and are an important component of development for any country. However, for healthcare delivery two of the

“Does anyone raise objections when top lawyers charge Rs 10 lacs for a single appearance in court? ” footsteps. This will only lead to shortage of doctors in a country that is already plagued by low doctor patient ratio.

Another concern The last issue is about court rulings on discharging patients who don’t clear their bills, and allowing relatives to take dead bodies from hospitals without paying the bills. Although it would seem “inhuman” and “cruel”, (language used by the Courts) to insist on payment of bills before discharging a patient who has availed of treatment, or releasing a body, one needs to look at the other side of the story.

stake-holders are the hospitals and the doctors, and their inputs seems to be drowned by votebank policies. The Indian Medical Association (IMA) was on the streets of Kolkata and Bangalore, in response to such regulation and government policies. It is my considered opinion (based on interactions with administrators, doctors and students) that the entire field of medicine and health administration is gradually becoming more and more unpopular as a career option.

For any country, this is sad, but for a country like India, it is all the more so. We need to look for a solution.

INNOVATE

HOW ISRO IMPROVED CRITICAL CARE MEDICINE IN INDIA Story of an endeavour to incorporate the best quality practices of ISRO in emergency medicine and critical care medicine M Neelam Kachhap

WHAT HAS Indian Space Research Organisation (ISRO) got to do with healthcare delivery in India? And we are not talking about Telemedicine. Every time ISRO successfully puts up a satellite in space there is all round jubilation.

But one forgets that this success is a cumulative effect of various departments who do not leave any room for error.

In the same way, a successful healthcare delivery system should have no room for error, but this is not always the case. The effectiveness of the healthcare delivery system depends on complex and varying interplay of several factors, making it vulnerable to a high incidence of errors. Data from developed countries show that nine out of every 100 patients who are hospitalized encounter medical error related events.

Association of Healthcare Providers is working towards minimising such errors.

“Studies show that 5.2 million medical errors are happening in India annually,” said Dr Alexander Thomas, President, (AHPI). “Maintaining quality and developing protocols for error free healthcare delivery is one way of solving this problem,” He added.

With this aim in mind Dr Thomas met Dr K Kasturirangan, former Chairman- ISRO and this chance

meeting led to the novel idea of adopting some of the appropriate best practices of ISRO in healthcare.

ISRO and healthcare ISRO is one of the largest and most successful space organizations in the world, with an immaculate performance record, evidenced by its aim to consistently deliver zero-defect systems.

Under GRAMSAT (rural satellite) programme ISRO has already undertaken telemedicine projects, through Indian Satellites linking remote/ rural areas like Jammu, Kashmir and Ladhak in north near Himalayas, Offshore Islands of Andaman and Lakshadweep, North Eastern States

& some of the remote and tribal districts in the main land States across the country.

Brainstorming The next step for Dr Thomas was to get the likeminded people under one roof to discuss how ISRO best practices could be matched with healthcare delivery. “We debated and decided that focus should be on two areas with highmortality rate; the emergency medicine and critical care medicine. These departments cater to a high number of critical patients and it was mutually agreed that adapting best quality practices here would significantly bring down mortality and morbidity,” informed Dr Thomas.

“I am glad that the Indian medical fraternity is very keen on adopting some of the best quality practices of ISRO into the areas of emergency care and critical care departments. Our organisation stands by our vision to harness space technology for national development ” – AS kiran Kumar, ISRO Chairman

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INNOVATE

Stakeholders at ISRO meeting

Under the leadership of A.S Kiran Kumar, Chairman, ISRO and the Association of Health Care Providers India a meeting was organised in Jan 2017, which was attended by prominent members of both organisations along with stakeholders from Consortium of Accredited

Healthcare Organizations (CAHO), Planet Aerospace, NABH, Society for Emergency Medicine, India (SEMI) and the Indian Society for Critical Care Me Dr Alexander Thomas, President, (AHPI) Dr Alexander Thomas, President, (AHPI) dicine (ISCCM).

“ISRO has earned a unique place of pride in the arena of space technology through its world acclaimed best practices.

Adopting these best practices into the emergency and intensive care unit set-up through standardised protocols is certainly bound to reduce human error” – Devi Shetty, Founder & Chairman, Narayan Health Group

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Subsequently the stakeholders met multiple times to shape up the Indian guidelines in these two very important areas of healthcare delivery.

“I am glad that the Indian medical fraternity is very keen on adopting some of the best quality practices of ISRO into the areas of emergency care and critical care departments. Our organisation stands by our vision to harness space technology for national development,” said Kiran Kumar.

The core focus areas, as suggested and agreed by domain experts, were discussed at length at ISRO headquarters, Bengaluru.

The best quality practices of ISRO, were incorporated into these areas and the resulting document underwent several reviews. Finally, under Kiran Kumar’s exemplary leadership and farsightedness, the joint efforts between all these organizations resulted in a document

happen is in the emergency and intensive care set-up of any healthcare center. Statistics across the world show that the human errors in these two settings are quite significant. ISRO has earned a unique place of pride in the arena of space technology through its world acclaimed best practices. Adopting these best practices into the emergency and intensive care unit set-up through standardised protocols is certainly bound to reduce human error,” said Dr Shetty.

Way forward The objective is to circulate the document through the network hospitals associated with AHPI, SEMI and ISCCM. If the rate of medical errors is reduced by even 1-2% because of this endeavour in the initial stages, it will still create a significant, positive impact on the effectiveness of patient care and safety in the country. “I believe that these guidelines can be easily adopted by any healthcare institution in India, both in the private and public sector without any significant cost implications, infrastructure or human resource addition. It is my ardent hope that Health QUEST will bring about a huge change in the way that emergency and critical care medicine is delivered in our country,” Dr Thomas said.

“These guidelines can be easily adopted by any healthcare institution in India, both in the private and public sector without any significant cost implications, infrastructure or human resource addition ” – Alexander Thomas, President, (AHPI) With the idea of reinforcing the concept of quality through incorporating ISRO process into emergency and ICU set-up, SEMI and ISCCM are conducting a study to document and assess the benefits of using these guidelines.

Ten hospitals across India are involved in this study, designed by ISRO and carried out by respective associations. AHPI is the focal point coordinating the study.

called Health QUEST (Quality Upgradation Enabled by Space Technology). This unique collaboration between a space organization and the field of medicine is the first of its kind in the country.

Welcome effort The first edition of Health QUEST was launched at the National Health Conclave in New Delhi on August 10th, 2017, by Dr Devi Shetty, Founder & Chairman, Narayan Health Group; Dr. Soumya Swaminathan, Secretary- Department of Health Research, and Director General-ICMR; Prof. R. Venkata Rao, Vice Chancellor, National Law School of India University (NLSIU); Dr. Alexander Thomas, President, AHPI, and senior officials from ISRO. The document was well received by the medical community. “The nerve center of activity where human errors are most likely to

Launch of Health Quest at New Delhi

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COVER STORY

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HEALTHCARE

LEADERS GUIDING THE FLOCK ACROSS THE SKY M Neelam Kachhap

How do hospital leaders adapt to change while leading their people and institutes forward

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COVER STORY

HOSPITAL LEADERS present a remarkable portrait of courage, taking difficult decisions while managing diverse set of functions and people. One thing central to hospital leadership is ambiguity, complexity and anxiety related to changing environment that the leaders have to deal with often. “Hospitals are complex organizations in terms of the services and functions they need to offer. The need for continuously service the growing customer demands while maintaining/ upgrading clinical quality and maintaining costs is a priority for hospitals today,” says Suresh Ramu, CEO & Co-Founder, Cytecare Hospitals, Bengaluru. In fact, it is the critical interaction between diverse realms that forms the core of a leader’s value preposition and drives success. Indeed, running a private healthcare set-up in today’s changing environment is challenging. And yet, hospitals across India are able to navigate through these tuff times. All thanks to the leadership at the helm of these set-ups, who never lose sight of their goals and continue to lead their institutes to greater heights. But what are the challenges they face while leading their pack?

What keeps the CEO up all night?

Most CEOs would agree that the healthcare delivery dynamics is unique to the industry and therefore the challenges they face are different from other industries. “Hospitals are in their own an open and dynamic ecosystem that has numerous people engaging in various functions and roles, the changing environment puts an additional burden of embracing the new and evolving themselves all the time to ensure that they and their organizations are able to deliver and achieve the best,” says Dr Dharminder Nagar, Managing Director, Paras Healthcare.

“Manpower shortage and challenges, changing financial landscapes, evolving statutory compliances and a strong and dynamic digital environment are some of the common challenges that the hospital leadership is experiencing. While each challenge is also an opportunity, it puts the top management in a constant struggle of change management and updating,” he adds.

In fact managing the talent pool is one of the most challenging aspects of any CEOs job profile.“In the last few years, it has been noticed that there is an evident shortfall in specialist in India. Adequate doctors, nurses and other

We are seeing increased participatory leadership where key stakeholders like clinicians and nursing are involved in management thinking and decision making Suresh Ramu, CEO & Co Founder, Cytecare Hospitals

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Today, there is a need of involving patient and their families with the decision making process along with the healthcare provider Madhur Varma, CEO, Sahyadri Hospitals, Pune

health cadres are missing from hospitals which need them the most. This further deteriorates the quality of care which is today majorly palpable in government run hospitals,” says Madhur Varma, CEO, Sahyadri Hospitals, Pune.

Agreeing to this Dr Rajendra Patankar, CEO, Nanavati Super Speciality Hospital, Mumbai says, “ A major challenge still faced by the healthcare industry is the availability of quality skill sets as there are many who are eligible to secure jobs based on their certificates but very few display the right set of quality, intent and value system. This leads to inefficiency guiding the flock through the sky while delivering healthcare which has a direct relation to patient outcomes.”

Another reason why managing people in a healthcare set-up is difficult, is because of the diversity of the people. “Handling diversity is the key challenge. There are diverse group of people - specialized doctors, nurses, hospital administration, customer care, finance, IT, HR and so on. Given the space is highly technical and knowledge based, leading a groups of technical and non-technical can be a leadership challenge,” opines Om Prakash Manchanda CEO, Dr Lal PathLabs, New Delhi.

“The second challenge is managing patients and their support system. While the mandate for the institution is to care and cure and yet differential payer status may pose a challenge,” he adds.

Improved performance leads to better patient care Healthcare leaders today, understand that the healthcare landscape will become more competitive due to consolidation and there will be little room for non-performers. But then does improved performance of the hospital translate to better patient care?

“I think so,” says Manchanda. “Any improvement in any institution performance creates a virtuous cycle thereby impacting all param-

eters favorably including better patient care in this case,” he says.

Adding to this Dr Patankar says, “Improved performance has a direct relationship with patient care. In fact patient outcomes have become the new benchmarks for healthcare industry where numbers will follow only if you are seen to be achieving better patient outcomes. An important element in this process of performance achievement is the capability of the team to be a differentiator with respect to service standards.”

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COVER STORY

Indeed, if the patients, the end users are satisfied, the hospital is bound to do well. “The improved revenue performance may or may not highlight the same. However a growth may suggest that new patients did get added due to excellent clinical performance of the hospital.

This context of improvement for a hospital should always hence be for clinical parameters, patient outcomes and service delivery. Quality care, benchmarked standards, efficient clinical systems and operational flows, all can ensure that the best is being delivered to the patients,” explains Dr Nagar.

Patients should always be at the center of healthcare delivery in any setting. Increasingly, healthcare leaders around the world have recognized the importance of patient centric care and have reformed systems, strategies and policies to suite this need. “Over the years, healthcare reforms have become patientcentric in order to fit patients’ needs in the best way. Hospitals in India have increasingly focused patient-doctor relationship offering

An analytical mind with a strong inclination towards teamwork, learning and conflict resolution is the best for healthcare delivery in India” Dr Dharminder Nagar, Managing Director, Paras Healthcare

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Any improvement in any institution performance creates a virtuous cycle thereby impacting all parameters favorably including better patient care Om Prakash Manchanda, CEO, Dr Lal PathLabs, New Delhi

quality services to patients. Patient care is not just about giving people whatever they want or providing information. Today, there is a need of involving patient and their families with the decision making process along with the healthcare provider. A seamless information flow between these two parties and a true partnership is what will drive the best outcomes both clinically, emotionally and financially,” says Verma.

Managing Conflict Conflicts are essential in all learning and growing organizations. “Managing conflicts is therefore, key to creating a healthy organization that is able to confront issues and yet work cohesively,” says Dr Ramu.

Conflict, while often avoided is not necessarily always bad. In fact, conflict can be good for organizations because it encourages openmindedness and helps avoid the tendency toward sycophancy that many organizations fall prey to. The key is learning how to manage conflict effectively so that it can serve as a catalyst, rather than a hindrance, to organizational improvement.

“When there is no conflict, nothing changes.

There is no need to question or challenge the status quo. Conflict represents an opportunity to reconsider, which can lead to breakthrough thinking,” opines Dr Patankar. He further says that there is no other profession with such high tension and conflict as healthcare. The health

care professional’s typical day involves a frantic race to coordinate resources, provide patient care, perform procedures, gather data, integrate information, respond to emergencies, solve problems and interact with diverse groups of people. Regardless of the role of the professional; physician, nurse, administrator, manager, social worker or technician, as a group, health care professionals face more conflict and greater complexity than any other profession.

Despite the challenges of balancing competing interests, philosophies, training backgrounds, the endless quest for adequate resources, and the emotional quality of the work that they do, very few health care professionals have had the opportunity to learn the skills and processes necessary for negotiating their environments.

There is little formal training available to them in this area and role models for collaboration and good negotiation are far and few. As a result, the clinical environment is one of competition, quick fixes, hot tempers, avoidance tactics and at times, hopelessness.

So how does one address conflicts in a healthcare set-up? “Transparency is the best way to manage conflict,” says Manchanda. “Discuss the difficult issues openly and be decisive.

There are times when a leader may find himself in a situation when there is no consensus. So be it, as long as leadership commands respect everyone can openly express divergent views,” he says.

In some situations, conflict can become something much more complicated and unmanageable if one doesnot know the limitations and boundaries of their conflict resolution.

“Rather than imposing influence, hierarchy or rank respect the unique differences in people and learn to see things from differing points of view to understand how to avoid conflict in the future,” advises Dr Patankar. “Conflict resolution is rarely black and white. In fact, there are more and more grey areas these days as the workplace becomes more generationally and culturally diverse than ever before,” he adds.

“Discussion and dialogue is the best way to resolve issues and conflicts,” opines Dr Nagar. “It is also important to know that conflicts happen due to difference in opinion; however it is this difference of opinion that can lead to creativity and a revolution. Debating or working out the details can help people patch up their difference and work out a middle path that would benefit the organization greatly.

Please note since hospitals and operations are so dynamic, we as hospital administrators need to acknowledge and appreciate this aspect that not all shoes fit the same size. There can be different systems and processes put in place to resolve conflicts,” he explains.

According to some industry veterans managing conflicts also needs special skills. “Managing conflict requires training, a leadership style that is participative and consensus-driven

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COVER STORY

as well as focused on a single goal - in our case, better patient outcomes. With a clear goal, we are able to manage many of the conflicts as we can help stakeholders involved to prioritize and plan activities such that we balance the interests of various stakeholders, with the primary objective of improving patient outcomes,” shares Dr Ramu.

Adapting effective leadership Today’s healthcare leaders need to be skilled in adapting effective leadership approaches in different situations. “Healthcare delivery leadership has seen changes worldwide and India is no exception. We are seeing increased participatory leadership where key stakeholders like clinicians and nursing are involved in management thinking and decision making. We believe that this would make hospitals great places to work where all staff can have the satisfaction of having contributed to improving patient and their families’ lives,” shares Dr Ramu.

So what kind of a leader would succeed in the healthcare industry? Dr Nagar answers this question saying, “An analytical mind with a strong inclination towards teamwork, learning and conflict resolution is the best for healthcare

delivery in India. You need people who work along with the workforce and inspire others with their dedication and hard work, after all respect cannot be demanded, it can only be earned. Being active and enthusiastic is one part; however the enthuse needs to be complimented with analytics to know where to go and what to do. You need to be a smart worker instead of being a hard worker too!”

Providing a different perspective to the same discussion Verma says, “In India, the healthcare industry has witnessed consolidation at various levels which includes, pharmaceuticals, diagnostics space, multispecialty hospitals which are often backed with private equity firms. In order to promote a strong healthcare system with the best deliverables, our healthcare system should work towards a

chain of transparent practices. A leadership team which is responsive, approachable and amicable towards its staff and patients can successfully run a hospital in India.”

Concluding the discussion Dr Patankar says, “Leadership is less about your needs, and more about the needs of the people and the organization you are leading. Daniel Goleman, who popularised the notion of ‘Emotional Intelligence,’ describes six different styles of leadership viz; Visionary, Coaching, Affiliative, Democratic, Pacesetting, Commanding,” he shares.

“The most effective leaders can move among these styles, adopting the one that meets the needs of the moment. There can never be a perfect leadership style suiting an organization leave alone a country like India,” he concludes.

Leadership is not a popularity contest; it is a serious responsibility that primarily involves developing and guiding the full potential in people, teams and the organization at-large Dr Rajendra Patankar, CEO, Nanavati Super Speciality Hospital, Mumbai

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October 2017

PULSE

CAN SIMULATION HELP YOU SAVE LIVES IN A HEALTHCARE SETTING

Dr Lulu Sherif, Simulation Instructor Masterclass (U.K), Associate Professor In Anaesthesiology, Fmmc; Academic Incharge Of Fmssc

CRITICAL THINKING is a crucial outcome of healthcare educational programs.

It is defined in a number of ways but perhaps it’s easiest to comprehend when you understand that it includes identifying a problem, determining the best solution and choosing the most effective method of reaching that solution. Effective caregivers should be knowledgeable about varied patient situations, confident in their skills and be competent to handle such stressful situations. One teaching strategy recently adopted by educators to develop critical thinking, confidence and competence is simulation. Simulation is a well-established tool for training personnel in aviation, the military, and industry, so why not in healthcare training. It has the potential to revolutionize health care and address the patient safety issues if appropriately utilized and integrated into the educational and organizational improvement process.

What is simulation? Arrays of dummies with palpable pulses, who can talk, breathe and cough, which we can kill and bring alive again?

Well, not exactly. Simulation can take various forms, from a simple role play model to use of high-tech simulators. The point to emphasize here is that simulation is a teaching technique and not a specific technology. It can

be effective with low- or no-tech options. Alone or in combination with manikins, human actors or virtual computer programs, a simulation can provide the hands on experience that connects theory to practice. The Virginia State Simulation Alliance in 2008 has defined “a clinical simulation experience as an active event in which learners are immersed into a realistic clinical environment or situation. During this authentic clinical experience learners are required to integrate and synthesize core concepts and knowledge and apply appropriate interpersonal and psychomotor skills. They must incorporate critical thinking and decision making skills involving assessment, diagnosis, planning, implementation or intervention and evaluation”.

The purpose of a simulation experience in education is to use an innovative teaching method to create a shift from teacher-centered to student-centered learning. Unlike the traditional classroom setting, where instruction is teachercentered, simulation is student-centered, with the teacher in the role of facilitator in the student’s learning process. Simulation encourages the student to develop psychomotor, cognitive, and affective skills prior to entering the real-world clinical setting. The facilitator has the opportunity to

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PULSE

assess and evaluate the student’s skill level and ability to meet learning outcomes. Remediation of the learner can occur almost immediately, potentially leading to decreased errors in the real world. Hence, as a healthcare training approach, simulation offers an opportunity to teach and engage learners in a manner far superior to traditional methods of lecture and demonstration and the highlight of this teaching methodology is that the simulation activities are designed to provide learners with opportunities to learn in a safe, non-threatening and controlled environment. It is safe to allow students to actually make an error in order to reflect and learn to recognize their own errors.

Simulation technology is used not only to improve individual performance but also team performance through interdisciplinary team training in the non-technical skills like communication, situational awareness, leadership and mutual support.

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“Ultimately, by far the greatest benefit to patient safety will be achieved by increasing the skills and the knowledge of the many rather than penalising the very few.”

– Don Berwick A critical element of simulation is fidelity.

This is the degree to which a key element of a situation, action, or object resembles real-life. In simulation, we can manipulate realism. Learners should think of simulation as real from Day one.

The degree of fidelity required is determined by the type of learner, the complexity of what they

need to know and how best to achieve learning outcomes. Careful scenario construction and planning will prevent the technology from becoming the focus of the simulation. Depending on the type of simulation, the learner receives the scenario ahead of time to review and prepare for the simulation. The scenario will consist of

a brief synopsis of the patient’s condition along with the learning objectives. The simulator and the environment will complement the scenario, thus requiring the learner to reflect on the patient holistically and not just focus on the diagnosis.

The framework for simulation methodology includes briefing of the scenario prior to the session, orientation to the simulator & environment, followed by the short simulation experience and the final debriefing session where the actual guided reflective learning takes place. To be successful, each learner must be self-motivated and self-directed to learn during the simulation.

Even though simulation is arguably the most prominent innovation in medical education over the past 15 years, we have to bear in mind that the simulation training program does not replace clinical training and does not guarantee clinical competency. It serves to enhance the performance of the learner in a safe and supervised realistic setting, thereby improving clinical outcomes. Events such as the creation of an interna-

tional academic society dedicated to simulation and proliferation of simulation-based literature and research have all heralded the promise of simulation as a keystone of healthcare education and patient safety.

We are definitely privileged, proud & thankful to the management of our institute for setting up a comprehensive simulation centre in the campus. The Father Muller Simulation and

in India has a dedicated team of multidisciplinary faculty who has been providing healthcare training to the non-healthcare community, clinical undergraduates, postgraduates and qualified professionals from the fields of medicine, nursing and other allied sciences. The centre is also the first medical college in Mangalore to be accredited by the American Heart Association as an authorized training centre for

“Create a shift from teacher-centered to student-centered learning�

Skills Centre (FMSSC), a unit of Father Muller Charitable Institutions, is a state of the art, multi-professional training facility equipped with the most advanced medical simulators and skills trainers,. The centre, one of its kind

CPR & ECC courses. Established in November 2015 as the first functioning advanced simulation centre in Mangalore, FMSSC is committed to inculcate evidence based simulation competence into the healthcare curriculum.

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FEATURE

APPROACH

ICU DESIGN OF THE FUTURE: ICU PLANNING AND DESIGNING Planning and designing guidelines for Intensive Care Unit Design for future as per Indian prospective

DESIGNING AN intensive care unit (ICU) to handle the needs of critically ill patients in the future requires both an ability to predict which of today’s healthcare trends will still be influential 20 years from now and the flexibility to adapt to these trends.

Tarun katiyar, Co-founder - Hospaccx Healthcare business consultancy

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October 2017

Two current trends that are likely to remain current are: using resources efficiently and meeting the expectations and needs of patients’ families.

ICU is highly specified and sophisticated area of a hospital which is specifically designed,

staffed, located, furnished and equipped, dedicated to management of critically sick patient, injuries or complications. It is a department with dedicated medical, nursing and allied staff. It operates with defined policies; protocols and procedures should have its own quality control, education, training and research programs. It is emerging as a separate specialty and can no longer be regarded purely as part of anaesthesia, Medicine, surgery or any other specialty. It has to have its own separate team in terms of doctors, nursing personnel and other staff who are tuned to the requirement of the specialty

Why Build a New ICU or Renovate an Old One? Hospitals undertake ICU construction for many reasons: to adapt to changing patient demographics or disease patterns; to upgrade or add services; and to accommodate changes in the ow of information, materials, or patients.

New construction may become cost effective when an older ICU requires expensive repairs or upkeep to remain viable, or simply ceases to function well.

Changes in performance standards and new issues in reimbursement and risk management may suggest alterations. Designing for

“It is recommended that total bed strength in ICU should be between 8 to 12� infection control by separating patients, adding isolation facilities, adding hand hygiene stations, upgrading mechanical ventilation and ltration, re- vising provisions for disposal of human waste, or introduction of antimicrobial materials can lower infection rates and therefore morbidity and mortality, cost per case, and length of stay.

How many ICUS and Beds are needed?

Before going for planning and designing of ICU we need to understand first how many ICU units are required with how many beds each unit. How many ICU beds are needed and how many ICUs should be made which may include Advanced ICU, HDU, PICU and Specialty re-

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FEATURE

APPROACH the desired probability of having an ICU bed immediately available for a new admission.

Therefore, it is recommended that total bed strength in ICU should be between 8 to 12 and not <6 or not >14 in any case.

Location ICU in Hospital with entry and exit points ICU should be Safe, easy, fast transport of a critically sick patient should be priority in planning its location, therefore, ICU should be located in close proximity of ER, Operating rooms, trauma ward. hospital Corridors, lifts & ramps should be spacious enough to provide easy movement of bed/ trolley of a critically sick patient. Close/easy proximity is also desirable to diagnostic facilities, blood bank, pharmacy etc. There should be single entry/ exit point to ICU, which should be manned.

However, it is required to have emergency exit points in case of emergencies and disasters.

lated ICU like Neuro-intensive care, Cardiac Intensive Care and Trauma.

The number of Intensive Care beds will depend on the data available from the hospital and current/future requirements of the hospital.

Some ICUs particularly in Private set ups in India may be main specialty in the hospital and they should be very careful in deciding about the number of beds and budgetary provisions and viability issues are very important in such cases.

Numbers of ICU Beds recommended in a hospital are usually 1 to 4 per 100 hospital beds ICUs having <6 beds are not cost effective and also, they may not provide enough clinical experience and exposure to skilled HR of the ICU. At the same ICU with bed strength of >24 are difficult to manage and major problems may be encountered in management and outcome.

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Recommendations suggest that efficiency may be compromised once total number of beds crosses 12 in ICU. The Canadian Department of National Health and Welfare has developed a formula for calculating the number of ICU beds required based on the average census in the existing unit and

“A usual problem observed in ICU is getting access to the head of the bed in times of emergency”

ICU Bed Designing and Space required Space per bed has been recommended from 125 to 150 sq ft area per bed in the patient care area or the room of the patient. Some recommendation has placed it even higher up to 250 sq ft per bed. In addition, there should be 100 to 150% extra space to accommodate nursing station, storage, patient movement area, equipment area, doctors and nurse’s rooms and toilet.

ICUs in India it may be satisfactory to suggest an area of 100 to 125 sq ft be provided in patient care area for comfortable working with a critically sick patient where all the paraphernalia including monitoring systems, Ventilators & other machines like bedside X-ray will have to be placed around the patient. Bedside procedures like Central lines, Intubation, Tracheostomy, ICD insertion and RRT are common. It may be prudent to make one or two bigger rooms or area which may be utilized for patients who may undergo big bedside procedures like ECMO, RRT etc. and has large number Gadgets attached to them.10 % (one to two) rooms may be designated isolation rooms where immuno- compromised patients may be kept, these rooms may have 20% extra space than other rooms.

We should be thinking of introducing newer technologies in their ICU like ECMO, Nitric Oxide and Xenon clearance etc. Do they need Laminarllar flow for specific patient population in their ICUs? This will be highly specific for High end up ICUs and is not recommended in routine Provisions may be kept open for such options in future.

Partition between two room and maintaining privacy of patients It is recommended that there should be a partition/separation between rooms when patient privacy is desired which is not unusual. Standard curtains soften the look and can be placed between two patients which is very common in most Indian ICUs, however they are displaced and become unclean easily and patientâ&#x20AC;&#x2122;s privacy is disturbed Therefore, two rooms may be separated by unbreakable fixed or removable partisans, which may be aluminum, wood or fiber. However permanent partitions take away the flexibility of increasing floor space temporarily (In Special circumstances) for a particular patient even when the adjoining bed/ room may not be in use. There are also electronic windows which are transparent when the switch is off and are opaque when the switch is on, although expensive now, the cost of this option may come down over time.

MEP design Constrain: Pendant vs Head End Panel One of the most important decisions is to how to plan bedside design Two approaches are usually practiced

1. 1 Head wall Panel 2. 2 Free standing systems (power columns) usually from the ceiling Each can be fixed or 3. moveable and flexible can be on one or both sides of the patient.

4. Flexibility is usually desirable, 5. Panels on head wall systems allow for free movements 6. Adaptable power columns can move side to side or rotate, 7. Mounts on power columns are also usually adjustable, 8. Flexible systems are expensive and counterproductive if the staff never move or adjust them, 9. Head wall systems can be oriented to one side of the patient or to both sides, some

10.

11.

12.

13.

units use two power columns, one on each side of the patient, Other units use a power column on one side in combination with some fixed side wall options on the opposite side, Ceiling mounted moveable rotary systems may reduce clutter on the floor and make a lot of working space available, However, this may not be possible if the weight cannot be structurally supported Power columns may not be possible in smaller rooms or units.

Each room should be designed to accommodate portable bedside x-ray, Ultrasound and other equipment such as ventilators and IA Balloon pumps; in addition, the patientâ&#x20AC;&#x2122;s window view (If available) to the outside should be preserved.

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FEATURE

APPROACH Height of Monitoring System Excessive height may be a drawback to the way monitoring screens are typically well above eye level and display more parameters. Doctors and nurses may have chronic head tilting leading to cervical neck discomfort and disorders, Therefore, the levels of monitors should be at comfortable height for doctors and nurses.

Keep Bed 2 ft. away from Head Wall A usual problem observed in ICU is getting access to the head of the bed in times of emergency and weaving through various tangled lines.

And at the same time patient also should not feel enclosed and surrounded by equipment and induced uncalled for fear About 6 inches high and 2 ft. deep step (Made of wood) usually temporary/removable (which would otherwise would stay there only) is placed between the headwall and the bed lt will keep the bed away from the wall and automatically gives caregivers a place to stand in emergencies without too much of problems. Lines may be routed through a fixed band of lines tied together.

Provision for RRT Two beds should be specially designated for RRT (HD/CRRT) where outlets should be available for RO/de-iodinated water supply for HD machines. Self-contained HD machines are also available (Cost may be high) Isolation Rooms 10% of beds (1 or 2) rooms may be used exclusively as isolation cases like for burns, serious contagious infected patients.

Alarms. music. phone etc.

Each group should decide if they want to provide the patient access to music (audio), telephone etc. However, an alarm bell which has both indicators by sound and light must be provided to each patient and he be taught about it, how to use it when needed STORAGE It is important to decide what is to be stored by the bedside

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October 2017

At the Nursing station Nursing stores  Remote central store Those supplies used repeatedly and in emergencies should be readily available and easy to find, storing a large inventory can be costly, but so is wasting personnel time, Making supplies more available may increase their use. Some over cautious or clever staff may decide to hoard or hide them. Cost effective and efficient designs are needed.

Staff nurses can always give useful ideas about improvement of systems, which they develop while working with patients. Their opinion can be invaluable.  

When medications are kept at the bedside, JCAHO currently requires that the storage be lockable, these stores can store medicines, disposables, records, injections, tabs etc. Bedside supply carts that are stocked for different subsets of patients can make storage in the room more efficient, for example, surgical, medical, trauma patients, cardiac patients where needs are different. Staff nurses may be specifically trained for such care and work Determining what supplies are placed near but not at the bedside is based on the size of the unit, the grouping of patients and the pat-

terns of practice, although many units organize supplies by the department that restocks them (central services, nutrition, pharmacy, respiratory therapy, etc.,) it is worth considering grouping supply by activity, like Chest tray, Central line tray, skin care tray, catheterization tray, Intracranial pressure tray etc. They may be labelled by name or color code.

Heating, Ventilation and Air-conditioning (HVAC) system of ICU The ICU should be fully air-conditioned which allows control of temperature, humidity and air change. If this not be possible then one should have windows which can be opened (‘Tilt and turn’ windows are a useful design.).

Suitable and safe air quality must be maintained always. Air movement should always be from clean to dirty areas. It is recommended to have a minimum of six total air changes per room per hour, with two air changes per hour composed of outside air. Where air-conditioning is not universal, cubicles should have fifteen air changes per hour and other patient areas at least three per hour.

The dirty utility, sluice and laboratory need five changes per hour, but two per hour are sufficient for other staff areas.

Central air-conditioning systems and re-circulated air must pass through appropriate filters.

It is recommended that all air should be filtered to 99% efficiency down to 5 microns. Smoking should not be allowed in the ICU complex.

Heating should be provided with an emphasis on the comfort of the patients and the ICU personnel.

For critical care units having enclosed patient modules, the temperature should be adjustable within each module to allow a choice of temperatures from 16 to 25 degrees Celsius.

A few cubicles may have a choice of positive or negative operating pressures (relative to the open area). Cubicles usually act as isolation facilities, and their lobby areas must be appropriately ventilated in line with the function of an isolation area (i.e. pressure must lie between that in the multi-bed area and the side ward).

Power back up in ICU is a serious issue. The ICU should have its own power back, which should start automatically in the event of a

“It is recommended that all air should be filtered to 99% efficiency down to 5 microns” power failure. This power should be sufficient to maintain temperature and run the ICU equipment (even though most of the essential ICU equipment has a battery backup). Voltage stabilization is also mandatory. An Uninterrupted Power Supply (UPS) system is preferred for the ICU Negative pressure isolation rooms (Isolation of patients infected/suspected to be Infected with organisms spread via airborne droplet nuclei <5 μm in diameter) In these rooms the windows do not open. They have greater exhaust than supply air volume. Pressure differential of 2.5 Pa. Clean to dirty airflow

i.e. direction of the air flow is from the outside adjacent space (i.e. corridor, anteroom) into the room. Air from room preferably exhausted to the outside, but may be re-circulated provided is through HEPA filter NB: re-circulating air taken from areas intended to isolate a patient with TB is a risk not worth taking and is not recommended Positive pressure isolation rooms (To provide protective environment for patients at Highest risk of infection e.g. Neutropenia, post-transplant) These rooms should have greater supply than exhaust air. Pressure differential of 2.5 – 8 Pa, preferably 8 Pa. Positive air flow relative to the corridor (i.e. air flows from the room to the outside adjacent space). HEPA filtration is required if air is returned.

CONCLUSION Design of critical care facilities has an impact on organizational performance, clinical outcomes, and cost of care delivery. Organizations involved in design and construction projects are advised to engage experienced consultants who will collaborate with the users and make key design decisions on the basis of best current evidence.

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IMPACT

HOW ACTIVITY BASED COSTING CAN CHANGE THE FATE OF HOSPITALS With Activity based Costing hospitals can measure, analyze, plan, implement, and control financial as well as operational efficiency in quantifiable terms.

INDIAN HEALTHCARE industry is undergoing a reforming era. Innovative solutions and tools are needed to achieve the goal of quality and affordable healthcare to all. By introduction of new tools with efficient management, we can look at transforming the healthcare sector and providing quality medical service at affordable cost.

Latesh Sen, Head- Costing & Business Analysis, BLK Super Speciality Hospital, New Delhi

Price capping With the arrival of universal health coverage many healthcare providers are anxious about the rates which the insurance provider will fix for certain treatment options. There is also a lot of discussion on price capping of treatment and devices by the government. Many providers want to know how the government is pricing the treatment modalities. In this scenario, it is of the utmost importance to know the actual

cost of treatment provided to the patient.

Costing based pricing is not the norm in healthcare in India. If you ask a provider they may not have any clue to Procedure wise costing. The government may look at value based pricing but even to articulate that one needs to know the costing.

Costing solution Activity based Costing (ABC) is one of new management tools that gives 360-degree control to the provider to measure, analyze, plan, implement, and control financial as well as operational efficiency in quantifiable terms.

What this means is that a hospital will be able to make an informed decision on planning its finances when they know in detail the cost and spending on treatment modalities.

For example: It doesn’t matter if the hospital

“Costing based pricing is not the norm in healthcare in India” 36

October 2017

is a charitable hospital or a non-profit hospital, they will not be able to sustain operation by going into losses. If they know what is the cost of a procedure they will be able to give proper discounts and still be able to serve a large population base.

Quality and affordable healthcare can only be possible if India’s healthcare sector can maintain a balance between cost of services, it’s delivery and price at which these services are provided to the patients.

Actual cost of procedure The need to know the actual cost of procedures is not only limited to fixing appropriate pricing.

It helps the hospital provider greatly to reduce

their overheads. Cost-cutting is a reality in all industries. More so in healthcare because a hospital cannot cut costs to reduce quality of the service provided. They need to look for incremental costs that pile up along with the medical costs of procedures and reduce those.

This leads to efficient cost strategies.

The future of sustainability lays in efficient cost control strategies. For better results every department in a hospital set-up needs 100% implementation of Activity Based Costing.

With the help of Activity Based Costing and its application in a hospital, the targets of operational efficiency and cost reduction can be achieved in a short span of time. Accurate costing procedures and services leads to affordable

“The need to know the actual cost of procedures is not only limited to fixing appropriate pricing”

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IMPACT pricing, which provides quality healthcare services to the patients.

in healthcare sector we have just started to talk about uniform pricing. Mostly in organizations, cost reduction is done on a pro- rata basis, which however is not an accurate cost control strategy. Actual cost strategy can by attained

vice delivery is much higher, it becomes critical to adopt new and innovative tools to optimize resources for cost effective services.

For example, private hospitals today are the black sheep of the healthcare industry. We

Affordable quality services With a fifth of the worldâ&#x20AC;&#x2122;s disease burden, a growing incidence of non-communicable diseases such as diabetes, hypertension and poor financial arrangements to pay for care, India lags behind among the BRICS countries in health sector performance. Moreover, to address these challenges, the health management system needs to be strengthened. The pricing of services needs to be done on the basis of costing. Only then hospitals, be it public or private domain can provide the most competitive price or affordable quality services to patients as well as maintain financial sustainability.

â&#x20AC;&#x153;The future of hospital sustainability lays in efficient cost control strategiesâ&#x20AC;?

Uniform pricing for cost reduction Various sectors like PSUs and insurance sector today are struggling to establish uniform pricing on the basis of actual cost incurred, whereas

Affordability It is widely admitted that affordability can only be achieved with efficient cost management.

For private sector, where cost of healthcare ser-

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October 2017

by rationalization of over and underutilized resources, which at present we follow at BLK Super Speciality Hospital.

provide 80% of the healthcare in India but are still singled out as the villain. Private providers are at the receiving end of much criticism for the price they charge, which again is not uniform across the industry. But if you look at the cost incurred on one day bed you would be in a better position to judge the pricing. One has to take under consideration the personnel cost,

salary of nurses, resident doctors, consultants who work in shifts. So an ICU bed requires 1:1 nursing 24X7, which means 3 shifts of nurses and 3 salaries of nurses spent on one day bed. Add to that cost of electricity, housekeeping, maintenance, these are actual costs incurred by hospitals. The costing on one hospital bed may be complex and should not be looked at in silos.

Financial Sustainability Balancing cost and price in private hospitals or Super Speciality hospitals is a big task and costing plays a very critical role for financial sustainability. In the National Capital BLK Super Speciality Hospital has successfully implemented ABC Cloud. The Hospital is certainly a case in point here to emphasize, how cost management can influence the outcome of services both in terms of quality and affordability. Recently the hospital received a National Award for excellence in cost management by Institute of Cost Accountants of India.

Set Targets ABC Cloud comes as great support to provide affordable health services to the masses without compromising on quality as it results in efficient cost control. Though there are many challenges in front of the hospital management, first of all, we need to set targets. For example targets can include maintaining financial health of the hospital; stable pricing of services or it can be providing affordable services to patients. All the targets can be intertwined to get the best results. The new tool guides us to keep control on wastage and underutilized resources. As the adage goes â&#x20AC;&#x2DC;What cannot be measured cannot be controlledâ&#x20AC;&#x2122;; so It becomes essential to calculate the cost of each and every services, resource and then make a mechanism to control it. It is easier to adopt this in manufacturing industries but due to the complexities of services in healthcare, it is very difficult to get accurate data in real time in a hospital set up.

To plug holes and leakages, it is also necessary that a hospital should implement ABC Costing in all departments fully. By doing this hospitals

can achieve operational efficiency and cost reduction. Hence, it becomes easy to achieve all the set targets. The best thing about this costing tool is that it can be integrated with the Quality tool - Six Sigma which seeks to improve the quality of the output of a process by identifying and removing the causes of defects and minimizing variability in business processes. Six Sigma uses a set of quality management methods, mainly empirical, statistical methods, and creates a special infrastructure of people within the organization who are experts in these methods.

Traditionally, hospitals focused more on managing revenue rather than the cost to ensure profitability. Now due to competition, focus on continuum of care and changing scenario of Healthcare ecosystem, financial health of organization is largely dependent on efficient cost management. The resources are limited so the optimum utilization of resources is the only way to sustain in long term.

Strategic planning Accurate costing of procedures and services leads to affordable pricing, which provides quality healthcare services to the patients. Instead of market comparative pricing, standard costing

for major surgeries and packages should be developed with calculation of cost and margin.

Instead of allocating the burden of additional cost on all service centers, the price revision can be done strategically. The cost centers where revenue and cost ratio are balanced, there would certainly be no need to hike prices.

If implemented meticulously, hospital can witness a radical change in cost management within a year. It would not be surprising to note that due to the effective cost control measures and accurate budgeting, the price revisions are being done rationally or it is at its lower end.

ABC tool can also absorb the inflationary pressure which forces the management to go for 7-8% increase in the prices of services annually.

Recommendation It is recommended that the pricing of services must be done on the basis of ABC. Only then hospitals whether it is public or private domain can provide the most competitive price to patients as well as maintain financial sustainability. For patients, accurate costing of procedures and services leads to competitive pricing which will make high-end and quality healthcare services affordable to the masses.

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FEATURE

RADIOLOGY

RADIATION SAFETY TOWARDS QUALITY HEALTH CARE Principles of radiation protection for hospitals

Dr Libert Anil Gomes and Dr G M Vinay, Associate Professor Department of Hospital Administration, JSS Medical College & Hospital, JSS University Mysuru

IMAGING OF internal organs of the human body was literally unheard a few decades back. With the advent of Computerisd Tomography (CT), Magnetic Resonance and Imaging (MRI) and Single Photon Emission Computed Tomography (SPECT),the scenario has completely changed. It goes without saying the importance of radiation safety in the hospital is of utmost importance where ionising radiation is used for both diagnostic and therapeutic uses round the clock. The safety of the patients, the staff working, visiting public and the environment becomes the prime responsibility of the hospital administration. It is therefore very important for the hospital to comply with the guidelines and regulations issued by the regulatory bodies.

Radiation Safety The Indian radiation regulatory board Atomic Energy Regulatory Board (AERB) was constituted on November 15, 1983 by the President of India by exercising the powers conferred by Section 27 of the Atomic Energy Act, 1962 (33 of 1962) to carry out certain regulatory and safety functions under the Act. The mission of the Board is to ensure that the use of ionizing radiation and nuclear energy in India does not cause undue risk to health and environment.

Quality in health care is patient focussed and

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emphasises on the patient needs, expectations and safety. Quality is not obtained by chance and efforts should be made continuously at various stages of healthcare delivery system so as to deliver safe investigations and treatment without harming the patient, working staff and the visiting public.

Effects of Radiation Mechanism of effects of radiation is classified into stochastic and nonstochastic effects. Stochastic effects occur by chance and there is no threshold effects eg., Cancer breast, lung, thyroid. Nonstochastic effects are exactly opposite in nature, eg skin erythema,ulceration etc. The harmful effects of radiation can be acute and delayed. Effects occur within a short period after exposure in acute type eg., nausea and vomiting malaise and fatigue. In chronic variety there is continuous or chronic exposure and results may not be apparent for years eg., Cancer (leukaemia, bone cancer, thyroid cancer, lung cancer), Genetic defects.

Factors Determining Biological Damage Age: Children are very radiosensitive compared to adults. This is due to the rapid multiplication of the body cells in order to cope up with the growth. Old men are more susceptible to the

radiation damage because of the reduced regenerative capacity.

Site of body exposed:  Bone Marow --- Aplastic anemia, Leukemia.  Lens --- Premature Cataract.  Lungs,Kidney --- Cancer  Gonads --- Sterility.4 Stage of development of cells: Between 3rd8th week of conception, exposure can cause potential malformations of organs and between 8th-15th week can cause severe mental retardation in 1 in 2500.

Typical CT chest gives a radiation dose equivalent to 400 chest radiographs (chest tomography 8 mSv; chest radiography=0.02 mSv). CT examinations of the thoracic spine, routine chest, mediastinum, routine abdomen, liver, pancreas, kidney, lumbar spine and pelvis are associated with effective doses of > 5-15 mSv (100-300 chest X-rays if chest X-ray dose is taken as 0.05 mSv). CT fluoroscopy, CT angiography and a number of interventional procedures using CT are associated with doses

in the range of 15-25 mSv. The average radiation dose a radiologist gets in India is upto 1 mSv/year. Thus a single CT procedure implies a patient dose, equivalent to 5-25 years of work in a radiology department. In addition, superficial organs such as the breast, eyes, thyroid and testes get higher radiation doses even though they are seldom the target of diagnostic procedures.

They are needlessly irradiated during radiological procedures of the thorax, cervical spine, head, sinus and pelvis.

Ionising radiation is more commonly used for both diagnostic and therapeutic purposes.

Xray,CT, Flouroscopy, Bariumstudies, Mammography are diagnostic applications whereas Brachytherapy.(eg Iridium192,Caesium137), Teletherapy:(Cobalt60), Linear Accelerator: (High Energy X rays) are some of the therapeutic applications of the radiation.

On Ground Safety Report We conducted direct informal interviews with the radiation safety officer, radiotherapy tech-

nicians, radiation therapists and radio-diagnosis consultant to see how hospitals tackle radiation safety issue.

Radiation safety in handling of radiation generating equipment is governed by section 17 of the Atomic Energy Act, 1962, and the Radiation Protection Rules (RPR), G.S.R. - 1601, 1971 issued under the Act. Radiation safety in handling sources are governed by Sec14,16,17 of Atomic Energy Act 1962 & Radiation Protection Rules 1971. Any person who contravenes the provisions mentioned in the code are liable to be punishable under Sec 24,25,26 Atomic Energy Act1962.

Most of the radiologists, radiotherapy physicians, technologists, referring physicians are following the principles of radiation protection.

Radiation safety programme is carried out satisfactorily under the guidance of radiation safety officer and radiation specifications were complying to AERB code.

The principles of radiation protection are illustrated below.

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FEATURE

RADIOLOGY TABLE 1.

Standard practices in radiation safety can be deliberated under Regulatory Controls,Safety specifications for the equipment & sources ,layout, Radiation safety programme.

REGULATORY CONTROLS & SAFETY SPECIFICATIONS: TABLE 2: LAYOUT:

Location: Brachytherapy/ Teletherapy units, Xray units should be away from high occupancy area like paediatric, maternity wards.

Size: Size of the room should be spacious enough to permit essential operations such as installations,maintainence,patient treatment to be carried out with ease and safety.

Doors: Doors , passages should permit safe and easy transport of equipments.All the doors should have warning light and radiation signage.The treatment room should have safety interlocks at door to prevent inadvertent entry of persons during irradiation.

Sheilding: The thickness of wall and the shielding requirements are calculated after taking several factors into consideration so

that radiation outside room will be As Low As Reasonably Achievable.(ALARA).They are workload,occupancy,nature of source, energy of radiation emitted. Entrance to the treatment room should be of indirect type (Maze) incase of Brachy /Teletherapy so as to minimise shielding requirements required to be provided at the entrance door.

Role of doctors in radiation safety Ninety seven per cent of manmade radiat`ion exposure is contributed by diagnostic radiation and the best way to reduce exposure to radiation dose is to avoid repeating investigations.

Investigations for the patients can be advised only after critical evaluation where the result, whether positive or negative alters the patient management or adds confidence to the clinicianâ&#x20AC;&#x2122;s diagnosis. If the investigations do not fulfill above mentioned objectives it can lead to increase in waiting times, misuse of limited resources, lower standards and adds unnecessarily to healthcare expenditure while increasing patient irradiation.

Repeating investigation which have already

STRUCTURAL SHIELDING OF LINEAR ACCELERATOR (FIGURE1)

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been done in another hospital, outpatient department , accident & emergency should be discouraged unless direly need inorder to make better decisions in the event of changing clinical condition of the patient.

Requisitions forms for radiological investigations should be accurate ,legible . Reason for the request with sufficient clinical details should be mentioned appropriately or else wrong radiographs are taken, essential view is omitted ,no useful information will be obtained by the radiological procedure. Finally referring doctors should be honest and consult radiologist in case of ambiguity.

In the end The role and importance of radiological investigation remains undisputed in healthcare.The latest advances in technology offers better diagnostic tools to the physician and surgeon of today , while reminding of the costs and dangers of radiation.

By adhering to standard practices and guidelines issued by the regulatory authorities viz AERB radiation hazards can be minimized. The judicious use of resources and prudent application of technology will lead to quality healthcare.

STRUCTURAL SHIELDING OF BRACHY/TELETHERAPY. (FIGURE2)

JUSTIFICATION OF THE PROCEDURE

OPTIMISATION OF THE RADIATION

1

Ex: SPINE: MRI more superior to Myelography.

Optimising :-Magnitude of doses ,number of people exposed.

Use of:- High frequency three phase generator equipment.

DOSE LIMITATION

2

Ex: Benefit to risk ratio for CT: High: Cerebrovascular hemmorrhage. Low: Mammograghy

Optimising it for all social and economic strata of patients.

Use of:- High KV technique& Low mAs, (using the shortest exposure time),Beam collimation,Proper beam filtration.

3

USG and Radio-nuclide study in place of Intravenous Urography (IVU).

Administering a radiation dose which is as low as reasonably achievable (ALARA ),

Use of: X-ray table top,antiscatter grids,correct gantry angulation.

4

Evaluation of the lymph node status in the abdomen: USG in place of repeated CT.

Maximum diagnostic information with minimum discomfort to the patient.

-Reduction of exposure time. Increasing distance from source,- Shielding of patients

TABLE2 REGULATORY CONTROLS (Xray/CT/Flouruscopy/ Brachytherapy /Teletherapy).

SAFETY SPECIFICATION FOR THE EQUIPMENT&SOURCES Xray/CT/Flouruscopy/ Brachytherapy /Teletherapy).

1. Manufacturer hast to obtain design certification from AERB before the marketing of equipment.

1. BRACHYTHERAPY: Radioactive material shall not be gaseous.

Source housing should give adequate protection and prevent damage in case of fire, flood, impact. Leakage radiation(AirKerma rate measured at any location 5cm from the surface should not exceed 200µG/hr.-

2. Brachytherapy/Teletherapy units operation , shall be done in accordance with terms and conditions of license granted by AERB.

2. TELETHERAPY: Leakage radiation at any point 5cm from the surface should not exceed 200µGy/hr.Beam rotation and isocentre must be maintained within a sphere of 4mm diameter.In the event of inadvertent opening of door the beam shall be automatically turned off.

3. Xray units needs to be registered with a competent authority before use.

3.X Ray: Leakage radiation through the protective tube housing shall not exceed an Airkerma rate 1mGy in one hour at a distance of 1m from the source. Timers to terminate exposure automatically(not exceeding)5s.

4. Installation,Decommisssioning: It shall be done after obtaining approval of the AERB.

4. Flouroscopy:- General fluoroscopy :Total filtration should not be <2mm Aluminium. CVS- Should not be <2.5mm.

-Glass:100kvp-2mm thickness of lead equivalent.If >100kvp -Increase at the rate of 0.01mm/kvp.

- Timers to terminate exposure automatically(not exceeding)5min.

5. Inspection: All the units should be made available for inspection at all reasonable times by the AERB 6. Radioactive sources shall not be lended, gifted ,transferred ,sold without prior approval of AERB. 7. Certification of RSO, Service engineers before they discharge their duties.

RADIATION SAFETY OFFICER Instruct , educate , train employees about safety issues -Maintain records of personal doses and conduct surveys.-Ensure monitoring instruments are in working condition LeadAprons,Thyoidcollars, gonadal shields ,eye shields should be worn by the worker wherever necessar Obtain necessary authorisations for waste disposal from AERB. -Maintain layouts , drawings , dose mappings of the units.

- Qualification: Graduate in science with mathematics and physics,Training at BARC, One year experience of discharging relevant duties under a RSO.8

MONITORING DEVICES TLD BADGES:-Information on doses received by employees ,worn at chest level, kept in radiation free zone when not in use,changed once in 3months.

Overdose:(>100mSv):VMedical examination: Complete blood count, Differential white blood count , Chromosome aberration (CA)test.CA positive results ensures genuinity of whole body exposure.

POCKET DOSIMETER: Useful when radiation levels vary considerably and quite hazardous.Spot check on radiation doses.

AREA MONITORING:-Range of 0.2mR/hr to 5R/hr.-GM counter scintillator (Minirad, MR4500).-CONTAMNATIONMONITOR: Near sources, tools, clothing, personnel .11

PATIENT PROTECTION Females: Exposures ,limited to first 10 days of menstruation.

Pregnant women:. 1mGy in nuclear medicine. Dose to foetus shall not exceed 10mSv. -Nuclear medicine: Patient doses exceeding 500mbq shall be hospitalised.

-Protective devices: Gonadal, thyroid, eye shields should be used wherever necessary.

-DOSE LIMITS:(AED) WORKERS-50mSv/yr • PREGNANT-10mSv/yr • PUBLIC -1mSv/Yr.8

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FEATURE

HEALTH - IT

WHO’S ACCOUNTABLE FOR A SECURITY BREACH? Nilesh Jain, Country Manager - India & SAARC, Trend Micro

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FIRST THINGS first, who’s responsible for security breaches? The short answer will be everyone. Cyber security is a fundamental challenge in today’s world, as government agencies, corporations and individuals are increasingly becoming victims of cyber-attacks. It is a wellknown fact that businesses are turning more and more often to the cloud and mobile applications as to stay ahead of the competitive curve. However, cloud storage, IoT and mobile applications increase security risks for all enterprises, no matter how big or small they are in terms of size and scope.

It should be considered that cyber-attacks are not only often but frequently creative and innovative. Though many large corporations around the world consistently boasts of “security in their very DNA”, they often nose-dive to keep up pace with criminals who are always finding out newer ways to trespass your security cellar.

The point is not just about preventing breaches but also to learn from it so that it can be prevented in the future. That calls for figuring out who or what is to blame for a breach.

With the number of breaches multiplying each day and hackers taking advantage of vulnerabilities within the system, and employees bypassing security protocols and walls, thereby

exposing more and more vulnerabilities in the process, developers are struggling to create breach-immune networks and systems, which is at best, just a utopian idea.

Few ways a data breach can occur  Common human error where a user clicks on a phishing email attachment or download from an unauthorized website, thereby receiving a malware, adware, spyware or the dangerous ransomware  Data theft from an unlocked system  Stealing from unencrypted files, devices etc  Not training staff regarding simple security practices and processes  Lack of end to end data protection services and destruction services  Use of unsecured internet access services or wi-fi  Not protecting data stored, used and sent Coming to healthcare, recent studies indicate that about 90% of organizations have suffered at least one data breach in the past two years. The main cause identified in all these cases was criminal intent; unlike with most credit card data breaches, these cases were not immediately identified. The cost of all sorts of

breaches in the healthcare sector is around $6 billion per year or $2.1 million per healthcare organization annually; which is alarming.

The point arises, who is to blame when a data breach occurs or who should be accountable? Or, bear the responsibility is something that most businesses bother with, in todayâ&#x20AC;&#x2122;s time. Data breaches can occur due to a myriad of reasons such as human errors, system failures or cyber criminals looking to make quick money. Most businesses inadvertently blames the end users, IT managers, CISOs or hackers and several surveys even pointed out that companyâ&#x20AC;&#x2122;s own employees being the biggest perpetrators of data security breaches. While it is the common practice to blame the CEOs and top management, in reality everyone should be held accountable. Data security should be a collective effort, not a one-man show.

Humans are the weakest link in the security chain and hence, employees should be aware of

IT security policies and practices. That is not to discount the fact that breaches also happen due to gaps in technology. Technology is evolving fast and with it hackers are also getting more and more sophisticated and smarter. In rational terms, IT managers are to blame as it is their responsibility to keep ahead of hackers but as mentioned, no system is immune from threat but impact can be minimized to an absolute zero, if the threat is diagnosed in time.

The blame game In order to figure out the source of breach, it is important to continuously screen and log every information that is exchanged over the data carrying network. Best-of-breed security controls and data protection systems such as encryption etc, adequate access control lists and technology solutions such as threat detection system within networks are a good way for IT managers to identify the breach.

90% of healthcare organisations have suffered at least one data breach in the past two years www.indiamedtoday.com

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FEATURE

HEALTH - IT Simply put, CISOs and IT departments in organizations are responsible for data access, compliance and security through prevention, detection and response. They are also responsible for defining business policies on the use of data and breach. But in reality, things are a bit complicated. Business owners and leadership who are heading departments which transact in secure data are also accountable. They are the ones who need to guide the IT department in terms of which data should be protected on priority and which employees can be given the right to use a certain data set. They are the ones who need to devise strategies in order to prevent breaches and make security awareness and training on cyber security, a regular part of office standards.

Protection against breaches is an ongoing process and businesses need to have efficient tools and processes, like for example, passwords and firewalls to keep such untoward activities at bay. Businesses also need to put in place data usage, exchange and security policies. It is a no

Security-as-a-platform, backed by technology, automation, machine learning and the cloud, is something that will rule the roost in the coming times

alien fact the magnitude of reputation and financial loss a data breach can result to.

While large organizations can afford hi-end security systems and solutions, SMBs often do not have that luxury, though history testifies the fact that they are as much prone to data breaches as their larger counterparts are.

Once a breach occurs, we tend to say things like, the business owner should have had a vision in place and could have planned

better, developers should have programmed systems more securely, IT managers should have detected the threat faster and fingerpointing goes on. The naked truth is, there are no universal rule to understand how or why a breach happened and how to mitigate the resulting damages faster. Obviously, more capital is invested, more people are hired and more solutions are brought in and integrated thereby rendering the entire security ecosystem complicated.

Cloud can be the answer Internet has redefined the way our systems run.

Cloud technology can indeed solve the security puzzle and problems to a huge degree and that too, in a cost-effective manner. IT managers and business leadership are increasingly recognizing this fact and are starting to take a more holistic approach towards cyber security, rather than focusing on attack vectors in silos.

Security-as-a-platform, backed by technology, automation, machine learning and the cloud, is something that will rule the roost in the coming times. Not only such a system will facilitate breach alleviation but will also change the security blame game as everyone can be held responsible â&#x20AC;&#x201C; as such a system needs development, production and management. Security as a service provides access to a single point of security insight which can be leveraged to draw up a course of action. Disparate security systems working in silos can no longer address the data breaches of today and its impacts.

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EVENTS AHPI GLOBAL CONCLAVE 2018 Date: Feb 16-17, 2018 Organiser: AHPI Venue: Le Meridien City: Kochi Click: www.ahpi.in Contact: Shikhar Gupta, Assistant Director Shikhar.ahpi@gmail.com

H

ealthcare industry will play key role to make the economic growth inclusive all over the globe. On one hand it is key social sector contributing to Human Development Index of nation; on the other hand it provides employment to large segment of population per unit investment. Rightly therefore the healthcare is fast

HEALTH 2.0 INDIA 2017 Date: November 10th, 2017 Organiser: Health 2.0 and ISB City: Hyderabad, India Click: india2017.health2con.com Contact: Francis Prashanth: francis@ health2con.com

S

ince 2007, the Health 2.0 Conferences has been the leading showcase of cutting-edge innovation transforming the health care system. Not your typical stodgy conference, Health 2.0 brings a fresh approach to the space and is the leader in health care technology today. It brings together the best minds, resources and technology for compelling panels, discussions and product demonstrations. Learn the latest trends from industry experts to strengthen your strategy.

Hear from influential thought leaders as they discuss new advancements in the health technology landscape and provide solutions to challenges that impact you. Experience new technological platforms to gain insight to what’s new in the market and develop new partnerships. Watch live product demos and engage directly with companies who are looking for new business opportunities.

emerging as ‘election agenda’ in all the developing nations. Governments accordingly are working on plans to provide ‘Universal Health Coverage’. Considering that private sector is playing key role in providing healthcare in general and tertiary care in particular, the mission of ‘Health for All’ can be possible only through joint collaboration between public and private sectors including the allied healthcare industry.

Keeping above in view, AHPI has chosen the theme for its 5th Global Conclave as; “Is Quality Healthcare Sustainable? Issues, Concerns & Solutions”. The conclave will also encompass the unique blend of 4th edition of ‘AHPI Awards for Excellence in Healthcare’ which will be presented on the eve of 16th February 2018

ADVANTAGE HEALTHCARE INDIA 2017 Date: Oct 12-14, 2017 Orgaiser: FICCI Venue: BIEC City: Bangalore

T

he 3rd Edition of Advantage Healthcare India 2017 is an International Summit on Medical Value Travel which is being jointly organized by the Ministry of Commerce & Industry, Government of India, Federation of Indian Chamber of Commerce & Industry (FICCI) and Services Export promotion Council (SEPC) from Oct. 12 – 14, 2017 at Bengaluru International Exhibition Centre, Bengaluru India, with the aim of Promoting Services Exports from India.

HEALTHSCAPE SUMMIT SERIES 2017 Date: 30, Nov 2017 - 01, Dec 2017 Venue: The Lalit Ashok, Bangalore City: Bangalore

H

ealthscape Summit – India, an initiative

by IDE that offers one of a kind solution-

oriented platform to overcome the challenges faced by the healthcare industry. Healthscape Summit facilitates Face-to-Face meetings, strategically modelled networking activities and information exchange amongst the most elite assemblage of Hospital Owners, Healthcare Architects, Design Consultants, industry experts and service providers making it the most sought after business summit by the healthcare fraternity of India.

7TH INTERNATIONAL PATIENT SAFETY CONFERENCE Date: Dec 1-2, 2017 Organiser: Apollo Hospitals Venue: JW Marriot City: Mumbai

7

th International Patient Safety Conference (IPSC) is being organized by Apollo Hospitals Group at JW Marriott Mumbai Sahar, Mumbai on 1-2 December 2017, on the theme of “Exploring New Dimensions in Patient Safety”. A well-knit program with key note presentations, panel discussions, debates, paper and poster presentations, makes this a vibrant forum for exchanging ideas and knowledge, and an opportunity to think, reflect and learn the best from the best.

INDIA HOSPITAL DESIGN & BUILD SUMMIT 2017 Date: 07, Dec 2017 - 08, Dec 2017 Venue: Hotel Vivanta by Taj City: New Delhi

I

ndia Hospital Design & Build Summit 2017 is scheduled during December 07-08, 2017 at Hotel Vivanta by TAJ in New Delhi, India.

The theme for the summit is “Transforming Hospitals”. The event is being organized in association with AHPI and HIMSS India.

The aim of the summit is to Leveraging the latest innovations and best practices in Hospital Build in India to deliver cost-effective projects with effective Project management for timely completion of your hospitals.

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EVENT REPORT

THE NATIONAL HEALTH CONCLAVE 2017,

MULTI-COLLABORATIVE STEP TO ADDRESS NCD IN INDIA Stakeholders from across India come together on a single platform to deliberate on policy coherence, education, innovation and quality improvement in NCD at New Delhi.

Dr Shetty

Dr Thomas

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THE NATIONAL Health Conclave 2017, with the theme ‘Chronic Care: Innovations, Opportunities and Challenges’, focusing on NonCommunicable Diseases (NCDs) was held at New Delhi on August 10th & 11th at the NBE Auditorium. The event brought together distinguished thought leaders, policy makers and stakeholders from medical and non-medical sectors, including government, research institutions, academia, industry, community and international agencies to develop impactful healthcare solutions for the country. The conference was organized by Association of Health Providers India (AHPI), Public Health Foundation of India (PHFI) and 26 other health institutes and organisations of repute. The two-day conclave was attended by approximately 250 delegates.

India is experiencing a rapid health transition with a rising burden of NCDs. In 21 century, where India is making marked economic progress, it is confronting an ever increasing burden of NCDs while still continuing to fight against communicable diseases.

According to the World Health Organization (WHO), the burden of NCDs has increased

alarmingly all over the world and India is a major contributor to this burden. Overall, NCDs are emerging as the leading cause of deaths in India accounting for over 42% of all deaths (Registrar General of India).

Most non communicable conditions are chronic and these chronic conditions cause significant morbidity and mortality both in urban and rural population groups,with a huge loss in potentially productive years (aged 35–64 years) of life.

JP Nadda, Union Minister for Health and Family Welfare, Government of India, in his video message said, “ I am glad that various public and private sector organisations have come together to organise the National Health Conclave 2017 with a view to develop road map to address the issues related to chronic care conditions. I am sure that the conclave will be a constructive step towards a multi-sectoral collaborative approach to strengthen healthcare systems in India by bringing all stake holders on one platform to find constructive and lasting solution.”

The Inaugural Session was graced by Chief Guest Dr Soumya Swaminathan, Director General, Indian Council of Medical Research, Prof. Venkata

Rao, Vice Chancellor, National Law School of India University and Dr Devi Shetty, Chairman and Founder of Narayana Health, who delivered the presidential address.

Dr Swaminathan said that there is a huge potential for control and prevention of NCDs through early screening and we need to emphasise on understanding the social-economic and cultural contexts in countering the rising NCDs, further laying stress on social behavior change.

Dr Shetty in his presidential address laid emphasis on empowering the frontline healthcare workers like MBBS doctors, nurses so that they can perform Bellwether procedures. “Surgical conditions represent a significant proportion of the burden of disease, and surgery is an essential component of health systems. Caesarean delivery, laparotomy, and treatment of open fractures (collectively refered to as Bellwether procedures) should be standard procedures performed at small hospitals. . If these three procedures are done in every CHC level, we will have a best healthcare delivery in the world,” he said.

However, the legalities of healthcare delivery do not allow MBBS doctors to do these surgeries. “Government hospitals employ 65,697 MBBS across the country, but they are not allowed to do any of the bellweather procedures. We have created regulatory structure that a doctor cannot do a procedure without a PG. So essentially, we have disassociated the medical education from the needs of a common man. We have created a first world regulatory structure with the third world infrastructure,,” he said.

To deal with the growing burden of NCD in India the regulatory structure and medical education policy should be changed opined Dr Shetty.

“The country needs a policy on medical education, which emphasises on training doctors for

CHC and taluka hospitals, this will transform rural health in two years. Also we need to change our attitude towards medical education,” he said.

Dr Alex Thomas, Organising Chairman of the Conclave and President, AHPI, in his address said, “NCD’s are a great ‘equaliser’ affecting both sexes, rich and poor, urban and rural in almost equal proportions. We are able to bring together 26 organisations to deliberate and evolve strategies to combat the looming threat of NCDs. Our aim is to share knowledge on innovation, quality improvement, policy regulation and human resource development with regard to chronic care management.

The white paper that emerges from the deliberations of the conclave will contain useful policy advocacies and resource requirements to enable the government arrive at a more meaningful, outcome oriented resource allocation in the health sector.”

The session culminated in the launch of Health Quest, a first-of-its-kind compendium of best practices on Emergency Medicine and Critical Care jointly developed by ISRO and AHPI, NABH, CAHO and Planet Aerospace.

In addition to that Dr Thomas announced the creation of a public health think tank at the inaugural session. The main objective of the think tank is to create a database of key information relevant to the health sector. Based on this information policy related issues at both the state and central levels can be reviewed in detail. The think-tank brings together crucial stakeholders in healthcare with different experience and expertise in healthcare, on a unique platform for the formulation of policies and strategies that can be implemented realistically.

The panel of the Indian Parliamentarian and Policy Makers session was graced by the presence of Dr. Kirit Premji bhai Solanki, Honorable Member of Parliament, Lok Sabha, Chairperson, Indian Medical Parliamentarians Forum; Prof. K. Srinath

Reddy, President- Public Health Foundation of India; Mr. Dinesh C Sharma, Journalist, Author, Science and Technology Editor; Mr. Shekhawat, Member of Parliament, Lok Sabha; and Mr. R. Prasanna, Health Commissioner of Chhattisgarh.

The Valedictory session was graced by the presence of Chief Guest Shri. R.K. Singh, Hon’ble Member of Parliament (Lok Sabha) and Member, Standing Committee on Health & Family Welfare, Prof. B.N.Gangadhar, Director, National Institute of Mental Health and Neurosciences and Member of the Oversight Committee on MCI, Prof. K. Srinath Reddy, Public Health Foundation of India (PHFI); Ms. Sadhvi C. Kanth, Assistant Professor, DoR Chair, National Law School of India University (NLSIU); Dr. K K Aggarwal, President - IMA; Dr. Alex Thomas, Dr. Girdhar Gyani and Dr. Sandeep Bhalla.

The Valedictory session also featured the launch of the certificate course in health care quality (CCHQ), the first ever health quality course in India, jointly developed and implemented by PHFI, AHPI and NHSRC. The course has been specially tailored for healthcare professionals, both clinical and managerial with the objective;  To impart understanding of the fundamental management technique, which helps in improvement of quality in a healthcare setting  To provide foundation of all the core elements of healthcare quality improvement  To update the established healthcare professionals with the current tools of quality and new standard of practice The formulation of the white paper on NCD care is being done by National Law School of India University (NLSIU), along with AHPI and PHFI, and the same would be finalized in consensus with all stakeholders, and will be submitted to the Ministry of Health and Family Welfare.

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Q&A

ASK THE EXPERT

Running a private medical practice in India comes with the risk of lawsuits and property damage.

As a medical professional, you are probably well aware of the devastating effects of legal cases and security threats that await doctors who face the blunt of an angry patient. We encourage you to share your queries and concerns regarding legalities of practicing medicine in India to learn more about legal framework, legal cases and the experience of fellow doctors.

Diabetologist. CMC Vellore has a recognized DM course in Endocrinology.

Those who are MD medicine can do recognised fellowships / diploma courses to become MCI recognised diabetologist. Un- recognised diploma and fellowships have no value as per MCI norms.

Prof ( Dr ) R K Sharma, President, Indian Association of Medico-Legal Experts , New Delhi will answer questions from our readers. Please send in your queries to editor@indiamedtoday.com Q: I have a query regarding diabatology course.

Since there is no recognised post graduate qualification in Diabetology, can someone proclaim himself as a Diabetologist after doing post graduate diploma courses in diabetology from university (UGC recognised course) and also by doing Fellowship programme in Diabetology from teaching institutes like CMC vellore with having enough experience in diabetology. Please let me know.

Dr M.K.Guha.

Ans: There is a recognised post-graduate qualification in Diabetes management. You can do DM, Endocrinology or DNB, Endocrinology which is well recognised by MCI. In fact the practice of diabetes management can be done even by an MBBS doctor but he cannot call himself a

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October 2017

Q: I have a doubt regarding medical camps conducted by NGOs where no procedures are done?

Suppose a sick patient is brought to such a camp and collapses, what are the legal implications?

Dr K A Sudharshana Murthy Ans: Medical camps for screening the population only serve as place to identify sick patients, and refer them to appropriate centres if there is a need. They also serve as a medium to spread knowledge of national health programs and general healthy lifestyle g uidelines. These types of camps are mostly arranged by NGOs or Government bodies.

If a sick patient comes to camp and collapses, it does not carry any legal implications as camp was meant only for examination of patients. It is better that all sick cases should be immediately referred to the referral centre.

Q: My question is regarding use of Botox injection. I want to know if a Physical Medicine and Rehabilitation (PMR) specialist can give Botox injections to manage spasticity in stroke and cerebral palsy cases. What are the legalities for the specialist in this case?

Dr Deorishi Tripathi, New Delhi Ans: There is no law debarring PMR specialist giving Botox injection in case of stroke, as it is used for therapeutic purposes. Please understand the

honorable Court does not issue specific guidelines in each case. All standard protocols in treatment are accepted by courts. One should make sure they follow the standard treatment protocols.

Q: Many patients come to casualty with dislocation or extraction of tooth following injury on the face as a result of fight with others. In such cases the dentists may be able to put the teeth in its original position by certain techniques. Sometimes, we find that the tooth in question was mobile due to periodontal disease. Kindly let me know what kind of label (simple or grievous) should be used for the injury in such cases. Please explain in detail for the benefit of casualty doctors dealing with medico legal cases.

Dr. Prem Kumar, Safdarjung Hospital, New Delhi Ans: As per Section 320 IPC - grievous hurt has one clause which states that permanent dislocation of bone or tooth is grievous hurt.

In all cases of dental dislocation, please note whether tooth is dislocated due to old age, poor dental hygiene, disease or injury. In case of injury, the base would be swollen and congested and bleeding may be seen which may be absent in other cases. Let the dentist give opinion on whether injury is simple or grievous.

Please always note that treatment does not come into picture to decide nature of injury.

Disclaimer: This material has been prepared for informational purposes only, and is not intended to replace, and should not be conveyed or constitute legal advice. You should consult professional lawyer and legal advisors before engaging in any legal matter.