Healthcare project management

HEALTHCARE PROJECT CONSTRUCTION MANAGEMENT “A STRUCTURED APPROACH” DESIGN DISSERTATION SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE DEGREE OF MASTERS OF ARCHITECTURE IN PROJECT MANAGEMENT

BY

AR. ROHIT A. DIGRA UNDER THE GUIDANCE OF ARCHITECT KALYANI SALVI MA'AM

DR. BALIRAM HIRAY COLLEGE OF ARCHITECTURE (L.B.H.S.S.T) BANDRA, MUMBAI UNIVERSITY OF MUMBAI

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DR. BALIRAM HIRAY COLLEGE OF ARCHITECTURE (L.B.H.S.S.T) BANDRA, MUMBAI UNIVERSITY OF MUMBAI

CERTIFICATE

This is to certify that ARCHITECT ROHIT A. DIGRA has satisfactorily carried out and completed

the

Project

entitled

HEALTHCARE

PROJECT

CONSTRUCTION

MANAGEMENT “A STRUCTURED APPROACH” This work is being submitted for the award of degree of Master of Architecture. It is submitted in the partial fulfilment of the prescribed syllabus of University of Mumbai for the academic year 2017-2018.

………………………………

Ar. Nupur Lal | Mrs. Darshana Vyas (Course Co-Ordinator)

……………………………………

………………………………

Ar. Kalyani Salvi (Thesis- Guide)

………………………………

Ar.Sunil Magdum (Principal |Study Centre Head)

(External Jury)

Date: 24th April 2018 Place: Mumbai

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Declaration

I hereby declare that these Thesis Report Titled Healthcare Project Construction Management “A Structured Approach” submitted by me in partial fulfilment of the requirement for the degree of Masters of Architecture in Project Management course of Dr. Baliram Hiray College of Architecture (L.B.H.S.S.T). India is a record of my own work. The matter embodied in this report has not been submitted for the award of any other degree or diploma.

Name of student: Ar. Rohit A. Digra Project Guide: Ar. Kalyani Salvi Ma’am Year: 2017 -2018

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DEDICATION

This Thesis report is dedicated to my loving “FAMILY” Whose blessing and prayers strengthen up, to do my project successfully.

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Acknowledgement I would like to dedicate this dissertation to all the patients across the world, for whom attaining medical care is a far-fetched dream due to the non-availability of healthcare facilities in India alone, the disparity between demand and supply of healthcare facilities is a difficult fathom. The government is making efforts to overcome this difference, but the process is time consuming. Through this dissertation, I have tried to offer a solution to make this process more efficient and effective The result that is here today would not have been possible without my guide Ar. Kalyani Salvi., I would also like to Thank You Ar. Sunil Magdum Sir - Principal, Ar. Pranav Bhatt Sir - Head of Department, and Mr. Anil Parab Sir - Office Superintendent of Dr. Baliram Hiray College of Architecture (L.B.H.S.S.T.) for giving opportunity to take this course. I would like to thank my college staff, both teaching and non-teaching for being patient with me through the last seven years of our association. They were always ready with solution whenever we were stuck.

The entire venture right from beginning has been learning experience has brought into light the finer aspects of the healthcare industry and the efforts that goes into setting up a such a facility to serve mankind, I take this opportunity to congratulate the healthcare project team right from sponsor to the labourer for their hard work so as to make these facilities available.

Place: Mumbai Date: 24th April 2018

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LIST OF CONTENTS

PAGE NO

Research Proposal

08 - 12

The Healthcare Industry: An Overview

13 - 48

Working Definition

49 - 61

The Project Teams

62 - 67

Healthcare Project Management

68 - 79

Healthcare Project Lifecycle

80 - 91

Case Study: Asian Heart Institute and Research Centre

92 - 103

Case Study: Wockhardt Hospital, Mira Road

104 – 110

Implementation

111 - 115

Recommendations

116 - 117

References

118 - 119

List of Figures

120

List of Tables

121

Abbreviation

122 - 123

Appendix

124 - 132

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ABSTRACT Health care organizations need project and change management support in order to achieve successful transformations. A project management helps support the organizations through their transformations along with increasing their capabilities in project and change management. The aim of the present study was to to formulate a framework of guidelines to regulate the healthcare projects management, in order to achieve optimization of results.

This study is a descriptive case study physical approach and interview with the directors and mangers of HOSMAC which conducted from October to December 2017 Participants suggested a number of elements including carefully selecting the members of the HOSMAC, having a clear mandate for the healthcare project management, having a method and a discipline at the same time as allowing openness and flexibility, clearly prioritizing projects, optimizing collaboration, planning for everything the Project management will need, not overlooking organizational culture, and retaining the existing support model. This study presents a number of factors ensuring the sustainability of changes.

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RESEARCH PROPOSAL

1. Research Proposal 1.1] Background of Study Healthcare today, is no longer restricted to the sphere of medicine alone.it is one of the largest business prospects in the developing world due to the vast disparity that exist between the healthcare needs and the existing facilities. This potential has been sought to be exploited by many international corporates. thus, management of such projects has a great scope in developing countries like ours.

An efficient healthcare facility consists of coordinated efforts of Promoters, Hospital Management Consultant, Facility Planners, Architects, Consultants, Engineers (Structural, MEP, HVAC, Biomedical, etc.) Project Managers, Contractors, Labourers, Equipment Vendors, Commissioning Consultants etc. to mention few. The roles of these specialist differ, at various points of the project lifecycle. coordinating this individual expertise and aligning them with the project objectives requires integration by the management process of Planning, Organizing, Directing and Controlling.

1.2] Need and Importance Project management and architecture have come a long way from the civilizations of the past to the modern world today. Contemporary professionals implement project management technique for the effective completion of the project at hand. This has helped project management to evolve and advance as a science experience has been the key to establish the norms of project management as a disciplinary Health care project management is an emerging filed today. This has led many firms internationally to offer expert services in this filed yet, there are only few institutes offering specialized courses on this subject. Since there is very little literature available most of strategies and techniques are acquired by experience on site. This makes it a vague ‘science’ and would imply that to ‘learn from your mistakes’ one would actually have to make a blunder and that too at the risk of the project objectives. Thus, such an approach has innumerable stumbling blocks This thesis intends to create awareness towards the deficit knowledge pool in this challenging area of expertise

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RESEARCH PROPOSAL

1.3] Hypothesis Healthcare project management is primarily based on experience on site, the documentation of which is essential to develop a structured approach in order to optimize the healthcare projects

1.4] Aim To formulate a framework of guidelines to regulate the healthcare projects management, in order to achieve optimization of results

1.5] Objectives of Research The objectives of research are as under: 1. to understand how project management is required to have a specialised approach with respect to healthcare projects.

2. to study the typical projects life cycle of health care projects 3. to understand the roles and responsibilities of the different teams involved in typical healthcare projects 4. to study the present approach towards healthcare project management 5. to study typical green field projects 6. to critically analyse project management strategies and techniques in green filed project through case studies with respect to healthcare project management.

1.6] Scope and Limitation The scope of study is manly directed towards documentation of the present-day approach towards healthcare project management and giving recommendations for healthcare projects based on study .it includes the investigation of the different factors influencing healthcare project management.it studies the project team of various professionals with their different knowledge pools, their roles and responsibilities and their integration to achieve the desired objectives.

Healthcare project management is a nascent filed resulting in limited literary references. The main sources of information will be the experience. The main source of information will be the experience of health care project managers and their project teams. Healthcare projects that are excited and those that are at the different phases of the project life cycle will be studied separately for the green filed and brown field projects to extract the different aspects of the proposed study. The scope of the study is directed towards investigating the evolution of healthcare project management, understanding the present-day scenario. The projects will be studied for green filed projects.

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RESEARCH PROPOSAL

1.7] Operational definitions 1.7a] Healthcare The preventions, treatment and management of illness and the preservation of mental and physical well-being through the services offered by the medical and allied health professions (The American Heritage Medical Directory by Houghton Miffin Company) 1.7b] Health Care Industry The complex preventive, remedial and therapeutic services provided by hospitals and other institutions, nurses, doctors, dentists medical admirations, government agencies, voluntary agencies, on institutional care facilities, pharmaceutical and medical equipment manufacturers and health insurance company (Mosby’s Medical Dicitionary,8th Edition) 1.7c] Healthcare Projects A healthcare project is something that is new, has a beginning and an end, and uses limits organizations resources with respect to the healthcare industry (Project management for Healthcare by David Shirley) 1.7d] Greenfield Projects A project development which is totally new and not associated with any existing infrastructure (http://s.pangonilo .com/index.php) 1.7e] Healthcare Project Management The body of knowledge concerned with principles, techniques and tools used in planning, control, monitoring and review of healthcare projects (www.bussinessdictionary.com) 1.7f] Project Life Cycle A project lifecycle is series of events a project undergoes from beginning to end.

(Project management for Healthcare by David Shirley)

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RESEARCH PROPOSAL

1.8] Research Methodology 1.8a] Healthcare project manager An employee who plans and organise the resources necessary to complete to healthcare project 1.8b] Project team The project team consists of the full time and part time resources assigned to work on the deliverables of the project all of who will help achieve the project objectives. The project team can consist of human resources within one functional organisation of it can consist of members from many different functional organisation 1.9] Data Collection The proposed study shall be carries out in following steps 1. Study the different phases of the project life cycle for green filed and brown filed projects 2. Study the roles and responsibilities of the members of the project team 3. Perform case studies of green filed and brown filed projects in different phases of project lifecycle and compare critically analyse the strategies and techniques used

1.10] Chapter Plan 1.10a] Sources of Data 1.diffrenet stake holder on healthcare projects 2.case studies of different healthcare projects 3.various books and research papers of experts in related filed 1.10b] Data Gathering Tools 1. Primary Data Collection a) interviewing the different stake holders b) studying projects in different phases of the project lifecycle c) interviewing the different members of the project team 2. Secondary Data Collection a) reading books and research paper on healthcare project management and related fields b) studying documents of already executed projects c) opinion of experts in related field

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RESEARCH PROPOSAL

The Chapter Plan for The Proposed Study Shall Be as Under • Introduction-A Overview of The Healthcare Industry • Working Definitions-Terms and Terminology • Healthcare Project Management • Project Team - Roles and Responsibilities • The Healthcare Project Life Cycle ▪ Green Fields Project ▪ Intro ▪ Case study ▪ Case study • recommendation • references

1.10c] SUMMARY This dissertation is divided into six chapters, with appendixes, a glossary and references.

Chapter One contains the RESEARCH PROPOSAL introduction, which discusses the purpose, focus and objectives for this study. Following the introduction, a review of the literature is presented Chapter Two, THE HEALTHCARE INDUSTRY: AN OVERVIEW Theoretical Framework, discusses basic concepts of organization, the design parameters, IT-enabled design variables and measures of organization structure.

Chapter Three, WORKING DEFINITION Research Objectives and Methodology, presents the statement of research objectives, research methodology and project selection criteria.

Chapter Four, HEALTHCARE PROJECT MANAGEMENT Research Analyses, presents the case study projects and cross-case analyses of conjectures, measures, and the IT documentary information questionnaire.

Chapter Five the Project Teams, it is all about the healthcare management team and professional involved in health care project management Chapter Six Healthcare Project Lifecycle Chapter Seven discusses the findings, references, list of figures, abbreviations, appendix, conclusions and recommendations for future research. presents a step-by-step methodology, using the extended framework that construction management professionals can use, as another tool for construction project organizational structuring

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The Healthcare Industry: An Overview

2. The Healthcare Industry: An Overview 2.1] Introduction The health care industry is a sector within the economic system which provides products and services like diagnosis, treatment and prevention of diseases, illness and injury. Health care is delivered by practitioners from the fields of medicine, nursing, psychiatry, dentistry and others. Allopathic healthcare 8, Ayurveda are the two main forms of healthcare practiced in India. Homeopathy is also practiced but in comparatively lesser amounts.

Ayurveda. the oldest most comprehensive scientific discipline is known as the knowledge of life and longevity. It has been preached and practiced since the ancient times. Ayurvedic medicines have ways to totally rejuvenate the body and mind. All ayurvedic medicines are botanical preparations and it's a holistic approach to well-being of an individual.

Homeopathy on the other hand is a science developed by a German physician. Rd. Samuel Hahnemann. It is based on a principle life cures like-. It means that any substance which produces symptoms in a healthy person can cure similar symptoms in a sick person.

Healthcare can be through products or services and can be provided privately or publicly.

Healthcare sector is said to be the sector which will largely influence the economic growth of the country bang with IT and Education sector. ibis sector will generate 40 million new jobs and 200 billion in revenue by 2020.

Private healthcare, with hospital chains exploring the markets in tier H cities and metros is an emerging part of the healthcare sector. Also. the PPP model helps in improving the healthcare provision of India through development and delivery of low cost basic health care services.

Since the healthcare industry is highly fragmented, the industry is divided among many different companies. Price levels cannot be influenced by one player as no single Finn has large enough market share to influence price.

The primary demand drivers of the industry are advances in medical care and technology. increasing life expectancy, patients demanding more services and breakthroughs & population growth rate. The drivers of profitability are effective management of patient demand, obtaining grants and funds & referring patients to the most cost-effective providers.

Access to health care varies in different countries owing to the influence by the social, economic and judicial influence. As in, the health care industry is distributed among market participants in some places while its controlled by the Government at many. Anyhow, according to the WHO (World Health Organization), for the smooth functioning of the health care industry in any country, there has to be a robust backing on the financial grout.

International standard industrial classification Health care forms the pillars of the national economy. Health care is one of the world's largest and fastest growing industries. Our main focus for this project is Allopathic care in India 2.2] History India — A country of rich culture and heritage. Where there was man, there was need for medicine. Medicine today is a cumulative knowledge gathered for centuries. India, due to her ancient knowledge and practice initiated the system of healthcare not just through the physical ailment of the patient but also the environment and other elements.

Unlike modern medicine during those times, medicines were dealt with plants, minerals, stars. spirits and voodoo. Treatment was done mainly by pries., herbalists, sorcerers and magicians.

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The Healthcare Industry: An Overview

2.2a] Ayurveda Ayurveda has its origin in the Vedas, particularly the Atharva Veda It is connected to the Hindu religion. Ayurveda originated from the 114 hymns of the Atharva Veda. It possibly dates back to 2000 BC. This system of medicine was received by Dhanavantari- the God of medicine from Brahma. The present knowledge of Ayurveda is by the texts of Charka.

Suthruta and Vaghbata Homeopathy Homeopathy was founded by Samuel Hahnemann. a German physician in 1790. It was based on the law of sunhats. The law of similar was utilized by many cultures like the Chinese.

Greek Mayan. Native American Indians and Asian Indians. But it was Hahnemann who developed a systematic medical science out of it. The first Homeopathic school was founded by his students in the US during late 1800s. Homeopathy gained recognition because it succeeded in treating disease epidemics like cholera, scarlet fever, yellow fever and typhoid.

2.2b] Allopathy In the 1600s, under the reign of the Emperor Akbar, allopathy found its way in India.

However, after 300 years, recognition of allopathy, as a form of medicine came under the Indian Medical Decree in 1960.

In between the 50s and the 80s, healthcare facilities increased substantially, but the number of licensed practitioners per 10.000 individuals decreased due to fast population growth.

In the early 70s, vaccinations against diseases like polio and small pox became prevalent. By the end of the 70s, small pox was declared to have been eradicated from the country.

The end of 80s saw the industry moving towards diagnosis before treatment. Medical education increased and industry began to grow. This was the time the incidents of cancer increased and posed problems to the medical community all over the world and the country.

There Were 128 medical colleges by the end of the 80. we struggled with a mortality rate of over 80. in India. 90s saw a rise in health care. During this decade. Indian healthcare grew at a CAGR of 16%. In 1991. India had 27.400 dispensaries 22.400 PHC's and 11.200 hospitals. The primary health centers relied mostly on trained paramedics. Also. in 1991 there was uneven distribution of medical facilities in the country. India, most populated sta. UP (over 139 minion) had 735 hospitals whereas Kerala (29 million) had 2053 hospitals. In 19. there were 7.300 hospitals, out of which 4.000 were owned and managed by the Go. Another 2.000 owned and managed by charitable trusts when the other 1.300 were private sector hospitals and in turn, very small facilities. The major hospitals were a pan of the Govt. medical colleges. Lack of sophisticated medical facilities was common in private hospitals, but the pace of development was very quick. Today, it is the largest service sector in India.

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The Healthcare Industry: An Overview

2.3] Healthcare Industry Analysis The healthcare industry comprises of both products and services. the products are in the form of drugs, health care equipment and health insurance. our study focuses on the service segment of the healthcare industry. services in the healthcare industry can be diagnostic services, small scale clinics & full-fledged hospitals.

The Indian healthcare industry is projected to grow 23 % per annum. There would be increase in number of public and private healthcare facilities accounting for another 56.7 billion. This industry will touch .8.76 bn by 2020.

The expenses of this industry comprise 5.25% of the GDP of the country. In a few years it is projected to reach 6.2% within the next few years.

Growing population. cheaper treatment costs, creasing lifestyle related health issues thrust in medical tourism. improving health insurance penetration. government initiatives. increasing disposable income and focus on PPP are &lying fetors for the growth of healthcare sector in India.

Research says that only 12% of the industry potential has been tapped in our country which tens us that the scope for is very large.

The healthcare industry shows high opportunity for economic of scale. Narayana hrudayalaya is the ideal example as to how economics of scale can be achieved in this industry. Through low cost measures and continuous innovation, he has made it a big success There is no target customer for this industry. The entire human population is their target.

There are hospitals at every income level targeting people accordingly. The sad, is that the specialty service., are out of reach for a large amount of our population. Even basic health services are rural population. The government is. taking initiatives but for a country like India it’s not enough Till few years ago. healthcare was the responsibility of private practitioners and doctor owned hospitals. Large hospitals were run mostly by the government.

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The Healthcare Industry: An Overview

2.4] The Healthcare Industry in India The Healthcare sector, in India, has become one of India's largest sectors - both in terms of revenue and employment. The industry comprises hospitals, medical devices, Pharmaceuticals, clinical trials, outsourcing, telemedicine, medical tourism, health insurance and medical equipment. The Indian healthcare industry is growing at a tremendous pace due to its strengthening coverage, services and increasing expenditure by public as well private players.

The Indian healthcare delivery system is categorized into two major components – public and private. The Government i.e. public healthcare system comprises limited secondary and tertiary care institutions in key cities and focuses on providing basic healthcare facilities in the form of primary healthcare centres (PHCs) in rural areas. The private sector provides majority of secondary, tertiary and quaternary care institutions with a major concentration in metros, tier I and tier II cities.

The Indian healthcare industry is projected to continue its rapid expansion, with an estimated market value of USD 280 billion by 2020, fuelled by increased population growth in India's low-income communities. Large investments by private sector players are likely to contribute significantly to the development of India's hospital industry and the sector is poised to grow to USD 280 billion by 2020.

Rising incomes, greater health awareness, lifestyle diseases, and increasing insurance penetration will contribute to growth. Healthcare spending in India accounts for over 4.2 per cent of the country's GDP, of which the public spending is around 1 per cent of GDP. The presence of public health care is not only weak but also under-utilized and inefficient.

Healthcare delivery and pharmaceuticals account for nearly 75% of the total healthcare market. India has only 0.7 beds per 1,000 people, far below the global average of 2.6. India needs to add 2 million beds to the existing 1.1 million by 2027 and requires immediate investments of USD. 2.5] Healthcare Industry in India and GDP In India, healthcare sector suffers from underfunding and bad governance. Yes, India has made huge improvements since independence. But majority (70%) of the effort has been private sector led. Still India accounts for 21% of the world’s burden of disease.

In fact, India has increased spending over the years. Also, the government plans to increase it even further nearly by 2.5% of the GDP in the 12th five-year plan. The amount of public fund that India invests in health care is very small compared to other emerging economies.

With 6% of GDP expenditure on Healthcare, India ranks among the bottom five countries with the lowest public health spending globally.

Krishna Giri (MD) Health & Public Services, Accenture India said “Our report identifies the importance of shifting from ‘infrastructure focus’ to ‘productivity focus’ to generate corresponding improvements in India’s healthcare access. This can only be achieved if larger fund allocation for healthcare is accompanied by effective and innovative interventions to improve the existing healthcare ecosystem in order to achieve global standards” The report points three major challenges hampering the growth of the healthcare sector and therefore the delivery of healthcare services: 2.6] Substantial Gaps in Healthcare Infrastructure Hospital bed density in India has stagnated at 0.9 per 1000 population since 2005 and falls significantly short of WHO laid guidelines of 3.511 per 1000 patients’ population. Moreover, there is a huge inequity in utilization of facilities at the village, district and state levels with state level facilities remaining the most strained.

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The Healthcare Industry: An Overview

2.7] Low Healthcare Insurance Service Coverage This leads to high levels of out of pocket spending: Nearly 80% of spend in India is out of pocket, primarily due to with extremely limited insurance coverage, both personal and government funded. Research has shown that the proportion of medical and healthcare expenditure in overall personal consumption has risen considerably over the years.

2.8] Medical Manpower Remains Inadequate India is currently known to have approximately 600,000 doctors and 1.6 Mn nurses. This translates into one doctor for every 1,800 people. The recommended WHO guidelines suggest that there should be 1 doctor for every 600 people. This translates into a resource gap of approximately 1.4 Mn doctors and 2.8 Mn nurses. There is also a clear disparity in the man power present in the rural and urban areas.

Krishna Giri also added, “Comprehensive adoption of Information Technology and digitization of systems to improve access to these services is central to the success of these projects”.

The report proposes five key measures that Accenture believes will have the most significant impact on improving healthcare access in India: • Implementing (HIS) Hospital Information Systems and record-digitization to improve delivery of healthcare services to the public.

• Automating supply chain management is the cornerstone of all successful healthcare systems.

• Empowering Citizens through Information Dissemination.

• Collecting data via handheld mobile devices, given the limitations of providing hard IT infrastructure in the vast reaches of rural India.

• Analytics-enabled real time disease surveillance, with real time surveillance costs, and ‘time-to-reaction’ are significantly lowered, leading to not only economic savings, but a much more efficient outbreak intervention mechanism as well.

These recommendations can address several inefficiencies in the healthcare value chain in India, and provide increased healthcare access to citizens, without significantly increasing the spending on the same.

2.9] The Growth Story • A sudden in paradigm shift in the last five years. This shift has become visible only in the last two years.

• A shift from an unorganized to an organized structure.

• It was earlier seen only as a social sector but now there is a move towards corporatization.

• Apollo pioneered the trend of corporate hospitals in India.

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The Healthcare Industry: An Overview

2.10] Factors for The Healthcare Boom in India 2.10a] Strong Indian Economy The Indian healthcare sector is expected to increase from US$ 110 billion in 2016 to US$ 372 billion in 2022. Rising income level, greater health awareness, increased precedence of lifestyle diseases and improved access to insurance would be the key contributors to growth.

58,000 job opportunities are expected to be generated in the healthcare sector by the year 2025.

The hospital industry in India stood at Rs 4 trillion (US$ 61.79 billion) in 2017 and is expected to reach Rs 8.6 trillion (US$ 132.84 billion) by 2023.

The private sector has emerged as a vibrant force in India's healthcare industry, lending it both national and international repute. It accounts for almost 74 per cent of the country’s total healthcare expenditure. Telemedicine is a fast-emerging trend in India; major hospitals (Apollo, AIIMS, Narayana Hrudayalaya) have adopted telemedicine services and entered into a number of public-private partnerships (PPP). Further, presence of world-class hospitals and skilled medical professionals has strengthened India’s position as a preferred destination for medical tourism.

In December 2017, the Government of India provided grant-in-aid under the National AYUSH Mission (NAM), to set up AYUSH educational institutions in States and Union Territories where such institutions are not available in the government sector.

The Government of India aims to develop India as a global healthcare hub. It has created the Intensified Mission Indradhanush (IMI) for improving coverage of immunisation in the country and reach every child under two years of age and all the pregnant women who have not been part of the routine immunisation programme. As of January 2018, Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA), a programme launched in 2016 to ensure comprehensive and quality antenatal check-ups to pregnant women across India, has crossed the 10 million marks.

2.10b] Increasing options for Healthcare Financing • Health services financed broadly through private expenditure or public expenditure or external aid • Public expenditure includes all expenditure on health services by • central and local government funds spent by state owned and parastatal enterprises as well as government and social insurance contributions • where services are paid for by taxes, or compulsory health insurance contributions either by employers or insured persons or both this count as public expenditure.

• Voluntary payments by individuals or employers are private expenditure.

• External sources refer to the external aid which comes through bilateral aid programmed or international non-governmental organizations • The ownership of the facilities used whether government by government, social insurance agencies, nonprofit organizations private companies or individuals is not relevant 2.10c] Increasing Opportunities in Healthcare delivery • The current healthcare infrastructure in India is inadequate • The overall number of beds, physicians and nurses is low compared to other developing countries and international averages. The situation is worse in the case of tertiary beds and specialist physicians.

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The Healthcare Industry: An Overview

• The quality of provision too is poor due to the dominance of unqualified practitioners and sub- optimal size of facilities.

• Higher Investment in Training required.

• Meeting the expected demand in 2012 will require and investment of US$25 billion • An additional 750,000 beds will be required (from 1.5 million today to 2.25 million in 2012), of which 150,000 beds need to be tertiary beds.

• The number of doctors and nurses enrolled in medical colleges and nursing schools will have to triple over the next 10 years. Additional 520,000 student’s physicians will be required by 2012.

• The bulk of the investment will need to be made by private providers • Total Healthcare Market in India could increase from US$35 billion today to US$60 billion by 2012.

• Preventive Healthcare market is for over 160 million people largely funded by corporate / government sector 2.10d] Better Profitability (15-20%) Profitability and cost management is an imperative for healthcare insurance providers. This is being driven by both regulatory requirements and competitive pressures. Effectively addressing the challenges of profitability and cost management involves mastering a methodology, understanding the business drivers, changing business processes, and introducing a system that supports an efficient process. The impact of profitability and cost management ripples through to all management processes and is a key component of an overall enterprise performance management system.

2.10e] Earlier Break Even (2-3 years) Break-even analysis is the use of a simple mathematical formula to determine the sales level at which the business is neither incurring a loss nor making a profit. In other words, when the firm’s total expenses equal its net sales revenue that is the break-even point for the operation.

1The break-even point (BEP) is, in general, the point at which the gains equal the losses. A BEP defines when an investment will generate a positive return or also the point where total costs equal total revenues. There is no profit made or loss incurred at the break-even point.

This is important for anyone who manages a business, since the BEP is the lower limit of profit when prices are set and margins are determined. Break-even analysis, sometimes called cost-volume-profit analysis, is an important analytical technique used to study relations among costs, revenues and profits. Both graphic and algebraic methods are employed. For simple problems, simple graphic methods work best. In more complex situations, analytic methods, possibly involving spreadsheet software programs are preferable. Defining the break-even point in mathematical terms is simply the point where: Total expenses = Net sales revenue The amount of sales revenue should be readily available on income as ‘Net Sales’. Net sales revenue is all sales revenue (often called gross revenue) less any sales returns and allowances or sales discounts. The break-even point represents the level of revenue that equals the total of the variable and fixed costs for a given volume of output service at a particular capacity use rate. Other things being equal, the lower the break-even point, the higher the surplus and the less the operating risk. The BEP also provides non-profit managers with insights into surplus/deficit planning.

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The Healthcare Industry: An Overview

2.11] Medical Tourism Medical Tourism means the process of leaving home and going abroad or a different place for medical care.

Medical tourism has become one of India's major sources of income it the past few years. India with its well educated. English speaking medical staff, diagnostic conveniences, state of the art private hospitals and comparatively low cast healthcare services, has emerged as a destination for medical tourism. the fields in which India hospital excel are cardiology, joint replacement, hip replacement, gastroenterology, ophthalmology, cosmetology, orthopedics and urology.

Medical Tourism is growing at the rate of 30%. It will be a $200 billion industry by 2015.

6.00.000 patients travelled to India last year for medical treatment. Corporate hospitals are commenting that the figure is going up every year.

A Mckinsey Report says that only 9% of travelers seek lower costs as their prim, consideration. 15% seeks faster medical services. 32% seek better healthcare. and 40% seek advanced technology.

India offers medical services at 1/10th the cost of an American or British hospital. A Business world report says that a heart bypass surgery costs $144,000 in united states, $25,000 in costa rica, $20,000 in Mexico, $24,000 in Thailand, $13,500 in Singapore and $8,500 in India along with the cost factor, the quality Indian hospital provide is excellent.

Hospitals are not the only ones affected by medical tourism, hospitality, pharmaceutical and medical equipment industry are greatly affected Medical tourism Ayurveda has attracted thousands of tourists to our country. authentic and monitored ayurvedic programme are sought to heal, cleanse, relax and rejuvenate. the most common place for ayurvedic treatment in India is kerla. the benefits of Ayurveda are being enjoyed by medical tourist coming from countries like the US. south America, UK, Germany, France, Sweden, Canada, Netherlands & Europe. many other wellness seekers are also coming from countries like Oman, Jordan, Egypt, Australia, New Zealand, Saudi Arabia, Kuwait, UAE, Malaysia, Singapore, Korea, japan etc.

Combination of Ayurveda, yoga and meditation is the most common package available to medical tourist’s package also takes the tourist through the beauty of the country as Ayurveda, yoga and meditation centre are present mostly in the holiday destinations of the country.

2.12] Increasing demand from within the county • The manpower demand of the healthcare industry would double up in the next 7 years. For example, the current Marketing & Sales manpower in the healthcare and pharmaceutical segment is 200,000 plus, which is expected to double up in the next 7 years. In clinical research the current shortage is 10,000 personnel, which is going to increase to 50,000 personnel by 2012.

• At present there is huge shortage of trained healthcare & pharmaceutical marketing and sales executives, medical representatives and managers.

• There is a major shortage of quality professionals for hospital services; service professionals for bio medical equipment, diagnostics, pharma R&D professionals.

2.13] Indian healthcare review • Conducive demographics: While the population growth rate for India has steadily gone down, it is still at over 1.3 percent and is not expected to go below one percent in the near future. Also, it is interesting to note that our population aged above 60 years is projected to grow to around 193 million, compared with over 96 million in 2010. This change in the

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population pyramid is expected to fuel the demand for healthcare in general, particularly lifestyle diseases.

• Rising affordability: In the past decade, India has witnessed a rapid increase in levels of wealth and disposable incomes. Coupled with a better standard of living and health awareness, this has led to an increase in spending on healthcare and wellness.

• Increase in lifestyle diseases: Lifestyle-related diseases comprised 13 percent of total ailments in India, according to a 2008 data, and this number is expected to increase to 20 percent by 2018. This is expected to trigger an additional demand for specialized treatment, which in turn, will lead to increased margins for hospitals since these diseases lie at the high margin end of the spectrum.

• Health insurance and medical tourism: While out-of-pocket spending remains the mainstay of healthcare expenditure, health insurance is gaining momentum in India. The increasing penetration of health insurance is expected to significantly increase the affordability of healthcare services, driving up the demand for preventive healthcare and curative services.

Medical tourism is also driving the healthcare market in India.

2.14] Morbidity and hospitalization rates The decade from 2004 to 2014 saw the Indian economy grow at an impressive rate. This was also the time when the government brought sweeping policy initiatives into the healthcare sector. New health schemes were introduced at the national level as well as state levels. After a decade of experimentation, India is still faced with national and international criticism for its low investments in healthcare and for overall poor health outcomes. This study aims to systematically analyse health and morbidity in India during this time period. The NSSO data from round 60 (2004) and round 71 (2014) make it possible for us to compare healthcare in India over the 10 years. In particular, we analyse changes in health-seeking behaviour of Indian households, changes in their out-of-pocket health expenditures and changes in their major sources of healthcare financing, over time. We are able to map some of the major healthcare initiatives of the government to these changes in outcomes of health-seeking, outof-pocket expenditure and health financing.

The years from 2004 to 2014 have witnessed many significant policy changes in the healthcare sector of India. One of the overarching initiatives was the National Rural Health Mission (NHRM)which later expanded into the National Health Mission. The main investments in NRHM were for reproductive, maternal, new born, child and adolescent health. It was also a timely response to the Millennium Development Goals with a special focus on reducing maternal and infant mortality in India. The other significant policy intervention was the launch of several publicly funded health insurance schemes in India.

While the central government rolled out the Rastriya Swasthya Bima Yojna, a national health insurance scheme for people living below the poverty line in 2008, proactive states like Andhra Pradesh launched the popular Aarogyasri insurance scheme a year earlier in 2007.

Several other states also followed with their own government funded health insurance schemes. Besides large schemes the government also launched several National Disease Control Programmes. New commitments were made to address water and sanitation problems. The government also emphasised the need to have regular scientific evaluations of different health interventions in the country.

In this study, we use National Sample Survey (NSS) data from surveys conducted by the Government of India. These are recall-based household surveys on multiple topics, including healthcare and consumer expenditure. More specifically, we use the 60 th and 71 st rounds of the NSS which included a questionnaire focused on healthcare, with questions on morbidity and the consumption of healthcare for all individuals within the surveyed households. Over the 10 years, the similarity of information collected in the two rounds of the surveys, gives us

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an opportunity to make scientific comparisons to understand the big changes in health and morbidity outcomes for Indian households.

Our main results for health-seeking behaviour show that households still overwhelmingly depend on private providers for healthcare services. While as much as 75 per cent of outpatient care is exclusively private, 55 per cent of in-patient care is from private hospitals in India. This dependence, however, is declining and more significantly so for in-patient care.

Indian households’ dependence on public care has risen by 6 per cent for out-patient care and by 7 per cent for in-patient care. Most of these increases are driven by rural women seeking more public healthcare, over last 10 years. More precisely, our analysis of the data shows that the Janani Suraksha Yojana incentives led to a significant increase of 15 per cent in institutional childbirth in India with a commensurate decline in deliveries at home. The disaggregated data also shows that there was a large increase of 22 per cent in deliveries in government hospitals, which was mirrored by an 8 per cent decline in childbirth at private hospitals and a 16 per cent decline in childbirth at home. Given that the fundamental objective of the JSY was to raise institutional deliveries, the NSSO data shows that the scheme performed well over the 10 years. At the same time, it is important to note that our analysis points to the increase in public hospitalisation being incentive driven, which does not allow us to draw an inference about either the quality of services provided or the sustainability of the increase.

The results also point to a significant association of health insurance coverage and hospitalisation in India. We note that having insurance coverage is highly correlated with being hospitalised. In particular, being insured is associated with a 17 per cent increase in probability of being hospitalised in a government hospital and an 8 per cent increase in probability of being hospitalised in a private hospital.

In terms of the out-of-pocket (OOP) health expenditure, a common measure of health burden, we note that the overall OOP spending has risen significantly, and mostly from a rise in inpatient spending and not from out-patient spending of households. The results show that there was a significant increase in a household’s real total OOP expenditure of Rs.750, over 10 years. This amounts to an increase of approximately 20 per cent in households’ total OOP over 10 years. Disaggregating the data further, we note that the increase in total OOP expenditure was essentially from significant rise in in-patient, and not from out-patient spending. At the household level, in-patient expenses rose by Rs.563 over the 10 years, while out-patient expense did not see any significant change in this time period.

There are serious disparities across rural and urban households when we disaggregate total OOP for an in-patient case into different components such as doctors’ fees, expenditure on medicines and costs of diagnostics. Compared to a rural household, an urban household spends five times more on diagnostics, 2.6 times more on medicines and 2.4 times more on doctors’ fees. It is also important to note that the rural-urban differences were very small in 2004 with absolutely no difference in the average expenditures on medicine per in-patient case. This has changed remarkably in the 10 years, with urban households paying 57 per cent more for medicines per in-patient case than rural households. The biggest difference between rural and urban areas has arisen from the increase in average expenditure on diagnostics per in-patient case, where urban households pay more than 73 per cent of what rural households pay.

Over time, we find that households with catastrophic health expenditures have risen significantly for all three threshold levels (15 per cent, 25 per cent and 40 per cent), and across both rural and urban India. Once again, this increase was much larger for urban households than for rural households. In terms of impoverishment caused due to poor health, we estimate that overall the percentage of Indian households that fell below the poverty line

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due to OOP health expenditures has remained unchanged at approximately 7 per cent of the population, over the 10 years.

In terms of sources of financing for healthcare expenditures, the data shows that households are increasingly relying on their own income and drawing down their own savings to finance their healthcare expenses. Reliance on borrowing, contributions from friends and relatives and all other major sources have come down steadily over the 10-year period. This holds for both rural and urban households in India.

From the healthcare financing perspective, it is important to understand the role of health insurance, and in particular, the role of recent public health insurance programmes in reducing health burden of Indian households. First and foremost, the data for insurance coverage shows that while private health insurance is largely limited to the richer urban households, in contrast, public insurance coverage is evenly distributed across all quintile groups. Overall, the different regression analysis shows that having public health insurance coverage in India has not been associated with lower health burden as measured by total OOP expenditure, probability of catastrophic health expenditures or impoverishment caused by health expenditures. However, we do find an increase in use of services associated with insurance, and in particular a significant increase in hospitalisation. This could mean that people suffering from ailments are more likely to be treated if they are covered by insurance. So, on the whole, it appears that the public health insurance programmes have been ineffective in lowering health expenditures of Indian households but have improved access to IPD care on average.

The rest of the paper is organised as follows – section 2 describes the policy background and context within which we must interpret health and morbidity changes in India over 10 years, section 3 looks at health-seeking behaviour of Indian households and includes descriptive statistics and hypothesis testing of specific interventions. Section 4 outlines the analysis for changes in out-of-pocket health expenditures and includes the descriptive statistics, in-patientout-patient disaggregated analysis, changes in expenditures per case, catastrophic health expenditures and impoverishment due to poor health. Section 5 outlines the analysis for changes in health financing in India, and looks at the role of health insurance, particularly public health insurance. Section 6 provides a brief analysis of inter-state variations in OOP expenditures, government spending, insurance coverage and catastrophic expenditures at the individual state level. Section 7 concludes the paper.

2.14a] Morbidity and Hospitalisation • About 9% of rural population and 12% of urban population reported ailment during a 15day reference period.

• Proportion (no. per 1000) of ailing person (PAP) was highest for the age group of 60 & above (276 in rural, 362 in urban) followed by that among children (103 in rural, 114 in urban).

• Around 96% of rural and 97% of urban ailing persons were administered some treatment.

• Treatment without any medical advice was primarily attributed to financial constraints’ (57% in rural, 68% in urban).

• More than 70% (72% in rural and 79% in urban) spells of ailment were treated in the private sector (consisting of private doctors, nursing homes, private hospitals, charitable institutions, etc.).

• Relatively high percentage of treatment at public hospital was reported in the rural areas of Assam (84%), followed by Odisha (76%), Rajasthan (44%) and Tamil Nadu (42%), and in the urban areas it was Odisha (54%), followed by Assam (44%) and Kerala (31%).

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• Higher preference towards allopathy treatment was prevalent (around 90%) in both the sectors.

• A bout 4.4% of the urban population was hospitalized (excluding childbirth) • any time during a reference period of 365 days. The proportion of persons • hospitalised in the rural areas was lower (3.5%).

2.14b] Highlights • Both in rural and urban areas highest proportion (around 25%) for hospitalisation (excluding childbirth) were reported for ‘Infection’ (inclusive of all types of fever, jaundice, tuberculosis, tetanus, diarrhoeas/dysentery and other infection).

• In treating the in-patients, private institutions dominated both the rural (58%) and urban areas (68%).

• Higher amount was spent for non-hospitalised treatment of an ailment by the urban population (`639) than the rural population (`509).

• Out of the total medical expenditure, around 72% in rural and 68% in urban areas was made for purchasing ‘medicine’ for non-hospitalised treatment.

• The rural population spent, on an average, Rs.5636 for a hospitalised treatment in a publicsector hospital and Rs.21726 for that in a private sector hospital.

• A s high as 86% of rural population and 82% of urban population were not covered under any scheme of health expenditure support.

• Rural households primarily depended on their ‘household income/savings’ (68%) and on ‘borrowings’ (25%), the urban households relied much more on their ‘income/saving’ (75%) for financing expenditure on hospitalisation, than on ‘borrowings’ (only 18%).

2.15] Economic profile of consumers 2.15a] Hospitalization Stay 1

in 5 urban families forced to borrow to fund hospital stay

HIGHLIGHTS • In rural India 65.6% of the poorest and 68% of the richest depend on household income or savings to meet hospitalisation costs • Average cost per hospitalization case in rural areas was Rs. 35,500 in Gujrat, over four times that in UP

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About a quarter of all rural households and one in five urban families in India are forced into debt or sale of assets to meet hospitalization costs. This is true across income levels, revealed the National Health Profile 2017 published recently by the central bureau of health intelligence in rural India, about two-thirds - ranging from 65.6% in the poorest to 68% for the richest depend on the household income or savings, while 27% of the poorest household and 23% of the richest households depend on borrowings for hospitalization costs. In urban India, 68% of the poorest and about 80% of the most well-off households depend on their own income and savings.

As they get richer, their reliance on borrowings goes down from 22% among the poorest to 14% among the richest. In rural India, about 1% whether rich or poor meet hospitalization

costs through sale of assets. This is negligible among urban households. Roughly 5% of rural and urban households are helped out by friends and relatives to meet the cost.

The data on hospitalization was from the health expenditure survey conducted by the National Sample Survey Organisation from January 2013 to June 2014. The data also shows that getting hospitalized was most expensive in Gujarat for rural households and in Assam for those who lived in towns and cities.

The average cost per hospitalization case in rural areas was Rs. 32,500 in Gujarat, over four times as expensive as in Uttar Pradesh. Similarly, each hospitalization in urban Assam cost on an average about Rs. 52,368, nearly seven times as much as in urban Delhi. Next to Assam, the urban areas of Goa and Himachal Pradesh were the most expensive places to get in-patient treatment, costing over Rs 37,000 and Rs 35,200 per hospitalization case. Interestingly, in states with very high total per capita spending on health, such as Himachal Pradesh, Uttarakhand, Kerala and Jammu and Kashmir, the average expenditure on each hospitalization was not among the highest. This could be due to higher spending on outpatient costs. In many of these states, the presence of a robust public hospital network could also be the reason for lower expenditure on hospitalisation as several of them also have the highest government spending per capita on health.

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2.15b] Infrastructure and technology The infrastructure sector has become a focus area of the Government of India. Under Union Budget 2017-18, US$ 61.92 billion was allocated to the sector.

Increased impetus to develop infrastructure in the country is attracting both domestic and international players. Private sector is emerging as a key player across various infrastructure segments, ranging from roads and communications to power and airports. In order to boost the construction of buildings in the country, the Government of India has decided to come up with a single window clearance facility to accord speedy approval of construction projects.

Significant allocation to the infrastructure sector in the 12th Five-Year Plan, and investment requirement of US$ 1 trillion is expected to create huge demand for construction equipment in India. The country needs around 55 new airports by 2030 with an investment of US$ 36-45 billion. In the road’s sector, the government’s policy to increase private sector participation has proved to be a boon for the infrastructure industry with a large number of private players entering the business through the public-private partnership (PPP) model. During the next five years, investment through PPP is expected to be US$ 31 billion. India has a requirement of investment worth Rs 50 trillion (US$ 777.73 billion) in infrastructure by 2022 to have sustainable development in the country.

Sectors like power transmission, roads & highways and renewable energy will drive the investments in the coming years. In October 2017, road projects worth Rs 6.92 trillion (US$ 107.64 billion) were approved to build an 83,677 km road network in the country. In August 2017, a new Metro Rail Policy was announced to boost private investment in the sector. In January 2018, the National Investment and Infrastructure Fund (NIIF) partnered with UAEbased DP World to create a platform that mobilise investments worth US$ 3 billion into ports, terminals, transportation, and logistics businesses in India. The Government is also working on improving energy infrastructure in the country and investment opportunities worth US$ 300 billion will be available in the sector in the coming 10 years.

2.16] Utilization pattern of hospitals This chapter presents survey findings on utilization of hospitals in India. The utilization can be measured in two ways: in the global context one can examine what proportion of morbid population in a State are using hospital services; and at the facility level one can assess how well the hospitals are utilized in different regions. The former gives an idea about the intensity of use of hospital services in different States and the latter measure indicates how efficiently hospital facilities are utilized. The chapter shows both the measures of utilization. In the context of utilisation of hospitals, availability of medical personnel and their productivity are also discussed in the chapter.

The concepts/measures used to assess the utilization are: Bed Days Utilized (BDU); the Patient Turnover Rate (PTR); the Average Length of Stay (ALS); and the Bed Occupancy Rate (BOR). The BDU per bed shows the days for which any given bed is occupied in a year.

Normally a bed can yield up to 365 BDU in a year11. The PTR indicates on an average the number of patients using any given bed during a year. By dividing the BDU per bed with the PTR (or total BDU with the total in-patients admitted in a year) one can get the ALS. The ALS indicates on an average the number of days a patient stays in the hospital. The BOR, which is considered as a summary facility level measure of utilization, is the ratio of the BDU and the bed days available (beds multiplied by 365) expressed in percentage terms. Usually, the BOR should be less than 100 but in the event of extreme congestion, when the BDU per bed exceed 365, it can exceed 100.

As one can see, all these four measures are interring related and the knowledge of any two of them will permit computation of the remaining two. Further, one can also notice that, the value of BOR is not invariant of the ALS. For any given number of in-patient admissions, the

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BOR increases as the ALS increases. Thus, the ALS plays a crucial role in determining the value of BOR and hence one should analyse the BOR taking into account the ALS. The ALS, which is an important indicator of hospital efficiency, depends on a number of factors. Case-mix, case severity, and the prevailing treatment practices determined by the medical technology are considered as primary factors determining the ALS. For example, communities with a high proportion of infectious diseases tend to have shorter ALS and chronic and severe episodes of illness require longer hospital stays. Thus, a hospital has little control on the primary factors. Besides these, certain secondary factors also influence the ALS. These are scheduling of diagnostic and surgical procedures; hospital cost reimbursement procedures; recovery environment in the post hospital care; institutional structure for taking care of certain chronic illnesses which require long term but low intensity medical care; and permitting hospital physicians to do private practice. If the secondary factors cause an increase in the ALS, it will be considered as a sign of inefficiency.

Among the secondary factors influencing the ALS listed above, hospitals have control on two factors: the scheduling of procedures in the hospital and the physician behaviour. The remaining factors fall in the realm of health care policy and any individual hospital can do little about them. For instance, in societies where the in-patient hospital costs are reimbursed on per-diem basis, the ALS tends to be longer as hospitals gain by keeping patients for longer duration. This happens because the intensity of medical care falls with the length of stay; the marginal cost of treating an in-patient also falls commensurately. On the contrary, if the reimbursement is made as a fixed fee for each diagnostic related group, hospitals tend to reduce the ALS and strive to increase the PTR, for that would maximise their net revenues.

Similarly, if low cost institutions are created to take care of chronic diseases that require long term low intensity medical care, the ALS for the tertiary and secondary hospitals tend to fall.

For these reasons, the ALS varies considerably across countries. In Indonesia the ALS varies between 5.9 to 9.4 days with an average of 6.6 days12. Zimbabwe too has a comparable ALS, varying between 6.1 to 7.8 with an average of 7.1 days13. In contrast, the ALS in China is extremely long, varying between 13.7 to 26.1 days with an average of 19.1 days14. While one should expect China to have a higher ALS compared to other developing countries due to its low fertility rates and lower incidence of infectious diseases, very long duration of stay is attributed to the reimbursement mechanism based on per-diem cost.

2.17] Mode of payment The government needs to allocate more funds for public health. The mismatch between the declared objective of universal healthcare through the public health system and the actual level of expenditure remains serious.

One of the three most important planks on which Barack Obama won the U.S. presidential election was the country’s healthcare system, which he promised to fix. Indeed, the most important legislative measure initiated by Mr. Obama so far is the health reform legislation, titled the Patient Protection and Affordable Care Act. It was reported that the U.S. pharmaceutical lobby has spent an average of $600,000 a day over the last six months lobbying against the Bill, mostly seeking to curry favour with Congressmen and Senators.

The main reason for healthcare in the U.S. receiving so much attention is its political and economic costs. The new U.S. legislation involves nearly $1 trillion over a 10-year period.

In India, meanwhile, problems related to the financing of healthcare continue to be politically insignificant and publicly invisible. Healthcare has not been an important election campaign issue except in 2004 when the United Progressive Alliance promised to raise expenditure on healthcare to 2 to 3 per cent of the Gross Domestic Product. According to recently released National Health Accounts (NHA) statistics, public health expenditure as a share of GDP increased from 0.96 per cent in 2004-05 to just 1.01 per cent in 2008-09.

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Broadly, there are three patterns of healthcare financing across the world. The National Health Service (NHS) of the U.K. is a stark example of a state-run and publicly-funded system. As in the case of the Scandinavian countries, the U.K. uses tax finances to pay for 80 per cent of its healthcare spending. Elsewhere in Europe, social insurance schemes bear most of the financial burden. The U.S. relies on private insurance, paid for mostly by employers: almost half of the supersized health spending (16 per cent of GDP) is financed by tax money for the care of the old and the very poor.

The NHS is relatively inexpensive, accounting for 8 per cent of GDP, even below the OECD (Organisation for Economic Co-operation and Development) average of 9 per cent. The U.K. and other OECD countries have better health indicators than the U.S., although they spend less on it. The contrast between the health indicators of Cuba vis-À-vis the U.S. health expenditure is even more striking. Cuba, with a per capita income that is less than a fifth of that of the U.S., has a publicly funded system that yields better health outcomes than the U.S. The William Beveridge Committee report (1944) formed the basis of the NHS. Beveridge designed the NHS when Winston Churchill was in power, and there was little hope in hell of his government ever implementing a National Health Service fully funded by tax money. But after the War, the Labour Party headed by Clement Attlee came to power, and one of the first major welfare schemes his government took up was the NHS. In the 1980s, the Conservative government of Margaret Thatcher stripped the NHS of much of the funds and manpower. The ‘New Labour’ government of Tony Blair, however, restored the finances and infused new life into it. The NHS today remains one of the world’s best healthcare models.

Parallel to the developments in the U.K., India had the Joseph Bhore Committee report which came up with somewhat similar recommendations. The Government of India’s acceptance of its major recommendations resulted in a nationwide healthcare machinery with reasonable norms in terms of coverage, availability of personnel and institutional linkages. The Indian public health system never reached NHS standards in terms of universality and access. But following the Alma Ata Declaration and the first National Health Policy in the 1980s, an attempt was made to strengthen it. This enthusiasm, however, was short-lived. Since the start of the economic reforms in the early-1990s, systematic efforts have been made to weaken India’s public healthcare system.

The share of health expenditure in total public expenditure peaked in the Indian States in 1987, but it has been more or less secularly declining thereafter. According to the constitutional division of expenditure responsibilities, the principal burden of health expenditure has to be borne by the States. In recent years, the Centre has stepped up healthcare expenditure through various schemes. Nevertheless, the States’ share in health expenditure remains above 70 per cent.

The Central theme of the Eleventh Five-Year Plan is to deepen the role of the market in healthcare. The principal instrument suggested is Public-Private Partnership (PPP). Though the professed objective of the National Rural Health Mission (NRHM) is to strengthen primary healthcare infrastructure, in practice it has been pandering to the private sector.

Reviews of the NRHM indicate that its intended objectives are not being achieved.

An admired aspect of the U.K.’s NHS and European healthcare models is the presence of the General Practitioner (GP), who acts as a gatekeeper for more expensive hospital treatment.

Though one of the main recommendations of Bhore Committee was the creation of a ‘Basic Doctor’, Indian policy-planners did not carry it forward. The basic weakness of the Indian system is the absence of an accessible basic doctor. Even today, 70 per cent of primary healthcare is provided by unqualified practitioners.

Over 80 per cent of the health expenditure in India is in the private sector, while in most developed societies more than 80 per cent of health expenditure is borne by the exchequer.

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Our public-sector share is around one per cent of GDP: in this respect India’s peers are Burundi, Myanmar and Sudan. Among the countries of the South Asian Association for Regional Cooperation (SAARC), all except Pakistan have a higher proportion of health expenditure in the public domain. India does not shine among its neighbours in terms of health outcomes. India’s infant mortality rate at 56 per 1,000 live births in 2005 is better than that of only Pakistan. It is a far cry from 12 in Sri Lanka. Similarly, life expectancy at birth of 64 years in India compares favourably only with that of 63 in Nepal. Again, it is a far cry from Sri Lanka’s 75.

One of the reasons for cost escalation in the U.S. system is the nexus between private health insurance companies and healthcare providers. The performance incentives in the private sector boosts the expenditure in a commercialised context. Invariably expensive drugs and procedures are prescribed. Insurance companies provide health cover to the young, the employed and the rich, and avoid those who are elderly, unemployed and poor. There is a cosy relationship between the insured, the insurance company and the healthcare provider.

In India, the share of healthcare expenditure borne by insurance companies is now less than 3 per cent. But there is a build-up for a significant expansion of the health insurance business.

Those think-tanks and economists who support this, forget certain facts. Most important, insurance covers only the cost of hospitalisation and not expenditure on outpatient care. NHA statistics show that close to 70 per cent of the out-of-pocket expenditure of the household is for outpatient care, which will not be covered by insurance. Secondly, even in the U.S. about 50 million persons (over 15 per cent of the population) do not have any health insurance cover as they do not have employers to pay their premium. In the Indian situation where a majority of the people are self-employed, universal coverage will remain a mirage. Thirdly, many villages in India do not have a hospital worth the name within accessible distance. What use would insurance cover be for people living there?

For the same reason, even the publicly funded Rastriya Swasthya Bima Yojana (RSBY) meant for the poor is unlikely to serve its purpose. Further, the present level of funding is sufficient to provide insurance to only a small proportion of those who need it.

After 60 years of planned development, there is a serious mismatch in India between the declared objective of universal healthcare through the public health system on the one hand, and the actual level of public health expenditure on the other. This mismatch between objectives and resources is at the heart of the inadequacies and inequities of the health system.

2.18] Hospital beds tariff rates In some Indian hospitals, when a wealthy patient calls in sick, it isn't enough to plop him on a king-size bed and get a bevy of your good doctors to fuss over him. Medical care in the country is going extreme. Starting with room tariffs that can put the best luxury hotels to shame, private hospitals are adopting the best practices in hospitality to satisfy the whims of the truly demanding. For instance, some hospitals provide pick up and drop patients in luxury cars. Others whip up gourmet fare for those who are fussy about their meals. Some even take a huge leap of faith and play the Gayathri mantra in the labour room while a baby is being born.

And there is a veritable technology arms race, with Wi-Fi enabled suites, extra-large LED TV sets and ultramodern gadgets all vying for the attention of an unwell CEO, a minister, or just someone with a packed wallet who would want to run his office from the superlative comfort of his hospital room. The Apollo Hospitals Group, for instance, has a few Rs 30,000-a-night suites that can house the patient and his entourage in luxury with interpreters, personal attendants, a well-stocked pantry and the works.

Similarly, a suite in Fortis La Femme in South Delhi will set one back by around Rs 37,000 for one night. At that price, one can stay at The Oberoi, New Delhi, for two nights. A

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presidential suite in Mumbai's Hiranandani Hospital costs Rs 30,000. Seven Hills Hospital, where Bollywood actor Aishwarya Rai Bachchan gave birth to her child, charges Rs 20,000 for a suite. And the tariffs don't include medical charges. A two-day all-inclusive childbirth package at Fortis La Femme can go up to Rs 4-5 lakh.

Says Dr Anupam Sibal, group medical director of The Apollo Hospitals Group, "Look at it this way. We cater to patients from different parts of the world and they would have very unique tastes. We can't be serving South Indian food to somebody from Moscow or for that matter Mozambique. Similarly, for a Mongolian patient, we have to arrange an interpreter. It's a different matter that getting interpreters who speak Mongolian is very challenging."

The challenge doesn't end there. Apart from helping outstation patients book hotels for relatives, some hospitals also go out of their way to take care of their diverse religious needs.

"Healing and faith go hand in hand," says Sibal. "If a patient wants to pray in a Russian orthodox church or in a synagogue, we try to get that arranged as well."

Contrary to the elite image of these hospitals, it is actually the low cost of treatments here that is helping them rake in foreign patients. "A liver transplant in the US costs Rs 2 crore. We do it for Rs 30 lakh and that includes airfare," says Sibal. According to him, the number of foreign patients opting for organ transplants in Apollo is increasing at the rate of 20% every year.

"It's not like 10-15 years ago when you had to go to a hospital and wait for the doctor.

Expectations of people have changed. Some facilities that we offer are best in the world," says Dr Dilpreet Brar, regional director of Fortis Memorial Research Institute in Gurgaon. "Now, it's also imperative for us to take care of the needs of the patient's family." Read: movie theatres, food courts, spas, gyms and even a glitzy shopping arcade.

However, experts say that luxury medical services in India are in a nascent stage when compared to the US or the Middle East where one comes across 5-star hospitals or complete floors dedicated to luxury treatments. "Medical practices are getting globally standardized and India is adopting these at a quick pace," says Amit Mookim, head of healthcare at market research firm KPMG in India. "However, it's a small market and price points are big impediments for it to percolate down to the masses."

In hindsight, if one has the dough, it would seem that falling sick these days could make for memorable dinner table conversations.

2.19] Cost of manpower category wise perspective Indian healthcare delivery system comprises of 152,326 sub-centres (SCs), 25020 primary health centres (PHCs), 5363 community health centres (CHCs), 1024 sub-district hospitals and 755 district hospitals. The sub-centres being the most peripheral units of health care delivery caters mainly to preventive and promotive care with some curative services for minor ailments such as fever, acute respiratory illnesses, diarrhoea etc being provided by auxiliary nurse midwives (ANM) and community health workers (CHW). PHCs are referral centres for sub-centres and are first contact point between community and the qualified medical doctors in India. As per Indian Public Health Standards (IPHS), a PHC caters to a population of around 20,000 in hilly, tribal and desert areas while 30,000 in better accessible plain areas. It consists of medical officers, staff nurses, health supervisors like lady health workers, head staff nurse and supporting staff to provide outpatient and inpatient care Patients who require further specialist care are referred to next higher level of heath service delivery called CHCs which cater to a population of around 80,000–100,000. These are designed to be equipped with at least four specialists in the areas of medicine, surgery, paediatrics and gynaecology along with the complementary medical and para medical staff with facilities for 30 indoor beds; operation theatre, labour room, X-ray machine, pathological laboratory etc

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The extent of utilization of primary health care centres for antenatal care services among the public health facilities in India is 22%. Nine percent of total institutional deliveries, i.e. using a health facility with all the essential lifesaving amenities for giving birth to a child under the supervision of competent health personnel and skilled birth attendant, happens at the level of PHCs and 7% at CHCs. In terms of total public-sector spending for healthcare in India, 41% is spent on primary health care and 15% on secondary healthcare. While some primary care is also provided by the secondary and tertiary care institutions, however, the extent of primary care provision in these two categories is relatively less. Moreover, nearly one-fifth (18.25%) of all health care cost is constituted by the outpatient care provided through PHCs, dispensaries i.e. health care facilities for the out-patient care where medical care and medicines are dispensed and sub-centres. These facts suggest that there is a significant volume of service provision at the level of PHCs & CHCs Moreover, at national level, there has been an increase of 6300 sub-centres, 1784 PHCs and 2017 CHCs in 2014 as compared to those existing in year 2005, implying a 7.7% and 60.3% increase in the number of PHCs (from 23236 to 25020) and CHCs (from 3346 to 5363) respectively since the introduction of National Rural Health Mission (NRHM) in the country.

There has also been a significant increase in the number of manpower positioned in these health facilities in the last decade with an increase of 63%, 35% and 15% in the numbers of ANMs, allopathic doctors at PHCs and specialist doctors at CHCs respectively. These facts highlight that considerable amount of resources are spent at the level of PHCs and CHCs. Now, with the advent of National Urban Health Mission, health care delivery structure similar on the lines of rural areas is being developed in urban India. So, there is a need for evidence generation for the effective planning and allocation of resources for a large scale up Also, there is limited availability of literature on costs spent per service delivery at level of primary and community health centres and the present literature is more than a decade old which limits its application. Most of the health costing studies in India highlight the cost of delivering particular services like paediatric care, referral transport, new-born care in district hospitals, specific diseases like respiratory diseases or typhoid and service provider like at primary health centre or district hospital With the commitment of Government to provide each of its citizen with universal health care, it is important from the perspective of planners and policy makers as to how much cost is being levied by the government per unit service delivered. This can also be used in terms of equity research, i.e. benefit incidence analysis, and determining allocative efficiency of Government health care services. In this paper, we reported the overall annual cost for delivering the gamut of services at PHC and CHC level in public sector. Secondly, we assessed unit cost of specific services delivered at PHCs and CHCs 2.20] Deficiencies in healthcare: Regional perspective India accounts for a substantial part of the global burden of disease, with 18% of global deaths and 20% disability-adjusted life-years (DALYs).1 While the growing burden of chronic disease accounts for 53% of deaths (44% of DALYs), 36% of deaths (42% of DALYs) are attributable to communicable diseases, maternal and perinatal conditions, and nutritional deficiencies suggesting a protracted epidemiological transition. 2 One-fifth of maternal deaths and one-quarter of child deaths in the world occur in India. 3,4 Life expectancy at birth is 63 years for males and 66 for females, and the under-5 mortality rate of 69 per 1000 births in India falls behind the South-East Asia regional average.5

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The above statistics, however, mask the marked variation in the distribution of health within India.

While health outcomes have improved over time, they continue to be strongly patterned along dimensions such as gender, caste (Side Panel 1), wealth, education, and geography.6–8 For example, the infant mortality rate among the poorest and richest wealth quintiles was 82 and 34 per 1000 births in 2005–6, respectively (Figure 1).9 Similarly, the under-5 mortality rate among mothers with no education compared to those with secondary or higher education was 106 and 49 per 1000 births, respectively. As shown in Figure 2, typically the state variation in under-five mortality tends to be largely patterned along the level of state economic development. Substantial geographic inequalities in health outcomes in India, with life expectancy ranging between 56 years in Madhya Pradesh to 74 years in Kerala; a difference of 18 years, which is higher than the provincial differences in life expectancy in China,10 or the inter-state differences in the United States.

Many of these health inequalities result from a broad set of social, economic, and political conditions which influence the level and distribution of health within a population.

Addressing these structural factors which constitute the social determinants of health (Box 1), is important as some of these health inequalities may represent health inequities that result from the unjust distribution of primary social goods, power and resources. Redressing any inequities in health can be considered a primary goal of public policies, with health systems having a specific and special role in achieving equity, alongside efficiency, in the distribution of health in a population and the exposure and vulnerability to ill-health.14–16 Equity in health and equity in health care have been a longstanding guiding principle, with commitment to the serving the needs of the poor and underprivileged being central to health policy documents. The ‘Health Survey and Development Committee Report ‘of 1946 led by Sir Joseph Bhore set out a detailed vision and plan for providing universal coverage to the population through a government-led health service.17 Since then, health policies and priorities have been outlined in the “Five Year Plans”, developed as a part of India’s centralized planning and development strategy. The first official National Health Policy, put forward in

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1983, reiterated the need for universal comprehensive care. 18 Influenced by the Alma Ata declaration, the policy emphasized the primary health care approach, in addition to recommending decentralization of the health system, improved community participation, and expansion of the private sector to reduce the burden on the public sector. While the next National Health Policy of 2002 continued to champion India’s vision, this was to be carried out on the “basis of realistic considerations of capacity”. 19 More recently, in 2009, the Government of India drafted a National Health Bill proposing the legal framework to recognize the ‘right to health and ‘right to health care’ with a stated recognition to address the underlying social determinants of health. 20 However, implementing policy commitments to equity in health care remains a challenge given India’s institutional and implementation capabilities,21even though this is a challenge facing the global health community, and not unique to India.22 In this review, we begin by describing the inequalities in access to health care. Using a supply-demand framework, we discuss the key challenges facing the health system in its pursuit of equity in service delivery and equity in health financing and financial risk. We conclude by arguing for the need to explicitly incorporate and implement an equity perspective in the development of a health care system in India and propose a set of principles are necessary to ensure more equitable health care for India’s population.

Summary Healthcare Industry of India . is a project aimed at analyzing the Healthcare Industry of India and its Future prospects? Healthcare can be Allopathic. Ayurvedic. Homeopathy. Unani.

Naturopathy etc. Our project focuses on Allopathy as that is a mainstream medicine in India.

Healthcare contributes to 5.25% of GDP expenditure. There is a very large market potential in India. Only. 20% of this industry potential is tapped. The government cannot afford to spend the necessary amount and hence it opens up a large area for private investors. The factors for the boom of this industry are more options in healthcare financing. growing economy. saturation of other sectors like IT and retail and the the different models of healthcare delivery.

The key players of t. industry (on basis of number of beds) are Apollo, Fortis, Manipal, aarving eye clinic care, max hospitals etc. The regulators of this industry are government of India directory of heath and family welfare, ministry of health and family welfare, Indian council of medical research, central drug standard control organization. Porter's Five Forces Analysis, SWOT Analysis and PESTLE were done. In than environment provides a very good opportunity for private players in healthcare. The growing population with a much deeper pockets and low government participation has led to higher demands where Noble are willing to pay high costs for proper medical care. India's unmet demand for healthcare facilities. rapidly changing demographics. increasing private spending on healthcare. and a readily available intellectual pool are Melling the growth of the healthcare industry and making it highly attractive for investors 2.21] Interpretations and suggestions 2.21a] Solution to Indian Healthcare Problems • Improve Budget: Indian budget is very low it is not even above the average budget of world in health care and when it comes to public spending it is less than 1%. But just spending high is not solution but we definitely need to improve current scenario.

By improving budget, we can immediately resolve some of the problems which makes doctor reluctant to go and work in rural area like giving 24/7 water and electricity and also providing pain killers and some lifesaving drugs.

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• Public-Private Partnership: This model can bring some of the tremendous changes. We have many models working in different states which we can study and use them for national purpose.

• Improve Healthcare Workforce: India has very few public seats for MBBS and especially for MS. And also, number of courses for healthcare jobs should be increased because workforce of healthcare is quite different from other. We need a specialize dedicated team to train new workforce.

• Education: By educating we indirectly improve some healthcare problems like maternal mortality rate and also educating rural health workers to assist rural in emergency times.

There is a health train which runs in India which performs surgery and also educate people about healthcare.

• Insurance Scheme: This is very important as this shows the concern of individual towards healthcare and also helps a government sector to properly organize some health centre according to data collected. Government both state and central are running many such schemes and they can be game changer.

• Rashtiya Swasthiya Bima Yojana (RSBY) RSBY (Rastriya Swasthiya Bima Yojana) has been launched by Ministry of Labour and Employment, Government of India to provide health insurance coverage for Below Poverty Line (BPL) families. Beneficiaries under RSBY are entitled to hospitalization coverage up to Rs. 30,000/- for most of the diseases that require hospitalization. Beneficiaries need to pay only Rs. 30/- as registration fee while Central and State Government pays the premium to the insurer selected by the State Government on the basis of a competitive bidding.

• Yeshasvini Yeshasvini is the world's cheapest comprehensive health insurance scheme, at Rs. 10 (20 cents) per month, designed by Shetty and the Government of Karnataka for the poor farmers of the state. It is very well-used in Karnataka with 4 million people covered • Conclusion This analysis concludes on the note that Indian Healthcare Industry is an ideal place for private players to invest in.

Its contribution to GDP is forecasted to increase to 6.2. within next few years. There is 80% market potential left to tapped.

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Sustenance in this industry is not very difficult as the potential is so large that for a long time now there will be no internal rivalry. Player's survival will be easy if they approach the right business model. There are various models available in the market like PPP, small clinics, super specialty hospitals etc. The only criteria for success are the human resource involved.

Qualified Human Resource is available in plenty in India. There is an emerging threat from substitutes like Ayurveda and Homeopathy but in our country these forms of medicine are always taken as a last resort. Trends are changing but it will take time for them to become perfect substitutes.

The weakness of this industry is basically the high delivery cost and hence the unavailability of good specialized healthcare for the people low on the income scale. T. is the major factor which counter reacts to the numerous strengths of the industry.

The government is encouraging investment in Healthcare which makes it easier for the companies as the process will be comparatively hassle free. Every force is in favor of investors.

These healthcare procedures save lives and improve quality of life. Millions of test operations. and other healthcare services will happen regardless of world even., economic, political, or otherwise. When people are sick, they'll do anything in their power to get better.

And it doesn't matter one bit what else is happening on the planet. It's one of the reasons investors should love the healthcare sector. The population is aging and you don't need a doctorate in demographics to know that older people consume more healthcare as they age.

If asked, we would say that investment in this industry is the right thing to do in the current scenario. It is a sector not affected by economic cycles, where demand is much higher than supply and a necessity for our country.

Investing in this industry will not only give enormous returns to the investor. It will also be a great help towards improving the healthcare situation in our country.

Investment opportunities • According to the Rural Health Survey report 2009, the rural sector has added 15,000 health sub centers and 28.000 nurses and midwives in the past 5years. Primary Health Centers has increased by 84. increasing the number to 20.107.

• From $2.7 billion in 2008. Indian medical technology is expected to reach $14 billion by 2020.

• Frontier Mandeville, the country's first healthcare SEZ is being set up by Frontier Lifeline Hospital at Elavoor, near Chennai.

• The substantial demand for specialty healthcare is driving players such as Apollo and Fortis to tier II and tier III cities.

• Big groups are targeting new segments such as primary care and diagnostics • The preventive healthcare segment in India is being driven by demographics, health awareness and increasing capacity to spend.

• Organizations like Narayana Hrudalaya and the Mazumdar Shaw Cancer Center are entering into computer —based bio surveillance projects. These generate data about diseases and create healthcare databases in rural areas.

• Medical Tourism is booming in the country with over 6,00,000 patients travelling to India for health care.

• Narayana Hrudayalaya plans to expand its presence in the next 3 yrs. to 7 more cities which will take the number of hospitals to 14

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• An Australian medical devices company called Cochlear Ltd plans to set up its wholly owned subsidiary in India Cochlear will provide better patient and product support. S15 million is the investment planned.

• The drugs and pharmaceuticals sector has attracted FDI worth S1.70 billion between 2000 to 2010.

Hospitals and Diagnostic centers have received FDI worth 5786.14 • Wockhardt plans to invest up to $158.32 million and Fortis Healthcare plans to invest $146.81 million •

GE Healthcare plans to invest US $ 50 mn to set up more facilities for developing diagnostic services.

• Manipal Hospitals plans to invest US $ 45.23 million in the next three years to take its capacity up to 8000 beds.

2.22] Investment policy updates Foreign Direct Investment The economic reforms launched by the Government of India since 1991 have resulted in substantial economic growth and the integration of India into the global economy. The pace of reforms has gained momentum due to political stability and strong industrial growth.

Foreign investment into India is governed by the Foreign Exchange Management Act, 1999 (“FEMA”), the rules and regulations made by the Reserve Bank of India (“RBI”), and the Industrial Policy and Procedures issued by the Ministry of Commerce and Industry through the Secretariat for Industrial Assistance, DIPP. The provisions pertaining to FDI are laid down in Schedule I of FEMA (Transfer or Issue of Security by a Person Resident outside India) Regulations, 2000.

While the DIPP issues policy guidelines and press notes/releases from time to time regarding foreign investment into India, it also issues a consolidated policy on an annual basis (“Consolidated FDI Policy”). Currently, foreign investment is regulated by the Consolidated FDI Policy of 2015.

100 percent FDI is permitted in most sectors under the automatic route, i.e., where prior approval of the Foreign Investment Promotion Board (“FIPB”) is not required. Currently, FDI is permitted up to 100 percent under the automatic route in the hospital sector and in the manufacture of medical devices.9 In the pharmaceutical sector, FDI is permitted up to 100 % in Greenfield projects and 74% in Brownfield projects under the automatic route and FDI beyond 74% in Brownfield projects requires FIPB approval.10 Green field projects are new projects that are coming up in India while Brownfield projects are existing projects in India.

The cap on FDI in the insurance sector has been increased from 26 percent to 49 percent (under the Automatic Route subject to approval/verification by the Insurance Regulatory and Development Authority of India (“IRDA”)) with the directive that the ownership of the insurance company be retained in Indian hands. This should lead to a growth in the insurance sector.

2.23] Foreign Venture Capital Investment Another vital means of investment into the healthcare, as well as medical and surgical appliances sectors is through venture capital investment by entities registered with the Securities Exchange Board of India (“SEBI”) as foreign venture capital investors. While it is not mandatory for a private equity investor to register as a Foreign Venture Capital Investor (“FVCI”) under the FVCI regulations 11, there are some significant advantages to be gained by registering as an FVCI. An FVCI is exempt from compliance with the pricing guidelines under the Consolidated FDI Policy for the acquisition of securities at the time of entry as well

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as for the transfer/sale of securities at the time of exit. Secondly, in cases where the promoters of the company intend to buy-back the securities from an FVCI, they are exempted from making an open offer under the Takeover Code.12 It should be noted that SEBI has been granting approvals to FVCIs only for investments in certain identified sectors, amongst them being research and development of new chemical entities in the pharmaceutical sector, and units of SEBI registered Venture Capital Funds (“VCFs”). Further, the Reserve Bank of India (“RBI”) has made recent amendments to the foreign exchange control regulations to permit FVCIs to invest in SEBI registered Alternate Investment Funds (“AIFs”) 2.24] Some of the benefits available to FVCIs are: 1. Free pricing Registered FVCIs benefit from free entry and exit pricing and are not bound by the pricing restrictions applicable to the FDI investment route. The exemption from pricing guidelines is a very significant benefit from a FVCIs’ point of view, especially with respect to exits from unlisted companies through strategic sales or through buy-back arrangements with the promoters and the company.

2. Exemption under the Takeover Code SEBI has also exempted promoters of a listed company from the public offer provisions in connection with any transfer of shares of a listed company, from FVCIs to the promoters, under the Takeover Code.

3. Status of QIB in IPOs FVCIs registered with SEBI have been accorded Qualified Institutional Buyer (“QIB”) status and are eligible to subscribe to securities in the IPO through the book-building route.

4. QIP route FVCIs (as well as VCFs and AIFs) by virtue of being QIBs, are eligible to subscribe to the securities of Indian listed companies under the Qualified Institutional Placement (“QIP”) route as prescribed under the SEBI (Issue of Capital and Disclosure Requirements) Regulations, 2009 (“ICDR Regulations”). Under this route, there is no lock-in on the securities allotted (as long as they are traded on the stock exchange).

5. Lock In Under the ICDR Regulations, the entire pre-issue share capital (other than certain promoter contributions which are locked in for a longer period) of a company conducting an IPO is locked for a period of one-year from the date of allotment in the public issue. However,} an exemption from this requirement has been granted to VCFs and FVCIs, provided the shares have been held by them for a period of at least one year as of the date of filing the draft prospectus with the SEBI. This exemption permits the FVCI to exit from its investments, post-listing.

2.25] PESTLE ANALYSIS • Political Lower Pub. Expenditure Public expenditure on health is lower than in other developing countries as a rash, the healthcare industry is highly dominated by the private sector. The Government facilitates the functioning of the industry and helps attract foreign invest= through investor-friendly policies and tax incentives. Government hopes to provide innovative drugs, expand facilities of healthcare insurance, and provide modem medical equipment and better services. By implementing Telemedicine in India. one of the biggest healthcare projects in the world, it

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wants to revolutionize the delivery of healthcare services using information technology and communication.

Private Investment The Government is also encouraging public-private partnership. It is promoting medical tourism. Indian government is working toward delivering effective and affordable healthcare services to the vulnerable sections of population residing in rural areas through its National Rural Health Mission. The government plays a critical role in prioritizing the healthcare industry in the development agenda of a country.

The country's recognition of product patent for pharmaceuticals is expected to lure more foreign investors into using the outsourcing opportunities in the country. The initiative taken by the government to set up additional hospital schemes will create further opportunities for the industry. Hence, India's healthcare industry is anticipated to grow tremendously in the next five to ten years.

• Economic Environment Growing incomes Much of India's healthcare expenditure comes from private patients, primarily the higherincome households. The proportion of households in the low -income group has deemed significantly. Rising incomes are leading to a rise in the rich and middle-income groups, and they are expected to form 49 % of total households in financial year 2010, as compared with 33 % in financial year 2004, thus driving growth. A survey conducted by NCAER, an independent economics research agency, suggests that per-capita expenditure on healthcare rise with higher education levels Significant investment opportunities are present for the private sector Limited government investment provides significant opportunities for private healthcare service providers as large investments are required to scale up the In.'s healthcare infrastructure. Our healthcare infrastructure needs substantial investment. The government is likely to meet only 1520 % investment in hospital beds. Assuming 10-15 % commitment from international donors, there would be a shortfall of 70 %, which can be funded by private companies. Presently, the majority of healthcare services in India are provided by the private sector. Public spending on healthcare will continue to rise, but chances of large and sustained increases are low.

• Sociocultural Environment Increase in the life expectancy and ageing population In the domestic market, health spending will be sustained by two demographic trends namely increased life expectancy and an ageing population. In India, the proportion of the population aged 65 years and over is also on the rise. Although the rate of ageing in India is slower than the developed country., the large size of our population makes any increase significant in terms of numbers. and hence also in terms of market potential.

A shift to lifestyle-related diseases will be the driver for higher healthcare spends The shift in disease profiles from infectious diseases to lifestyle related diseases is expected to raise expenditures for treatment. On the basis of demographic trends and disease profiles lifestyle diseases - cardiovascular disease, cancer and asthma have become the most important segments. and in-patient expenditure is expected to represent nearly 50% of total healthcare expenditure.

Higher Population and Literacy India has the 2nd largest population in the world. It is estimated that by 2050 we will be having the largest population in world. This factor displays a huge opportunity for the health

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sector in terms of sheer volume. Also, there is huge urban shift in India the private hospitals are mainly located in the urban areas and there is rural to urban shift of 26% which greatly increases the size of the target market for the private players. Rising literacy in India is improving health awareness., about lifestyle-related diseases— which tend to be costlier to treat than infections.

• Global & Technological Environment Health infrastructure in the West.

The healthcare systems in Europe and the United States are under severe pressure. The National Health Service (NHS) in the UK has along .t of patients waiting for over a year for surgery. In the US the issues are different. Around 50 million citizens are uninsured. The shortage of paramedical professionals such as nurses has aggravated the situation. Patients from the US are now regularly coming to India Quality Service and low cost of Healthcare India offers highly cost-competitive medical statement and technological advances in areas such as cardiology. cosmetic. orthopedic surgery. eye care. dentistry. and preventive health checkups. India offers world class cardiac bypass surgery. organ transplant. hip replacements. cosmetic. dental surgery and vision correction. The associated costs of surgery are also low.

This brings down the overall cost of treatment. In I. A. diagnostic checkups are comparatively inexpensive. India also has the potential to emerge as a hub for preventive health screening. At a private clinic in London a health check-up for men that includes blood tests lung tests. electrocardiogram tests. chest X-Rays and abdominal ultrasound costs around 350 British Pounds. In comparison. a comparable check-up at a clinic operated by Delhi-based healthcare company Max Healthcare costs USS 84. A Magnetic Resonance Imaging (MRI) scan casts USS 60 at the Escorts Hospital in Delhi as compared to USS 700 in New York.

2.26] Potters five force analysis Demand is exceeding supply India's demographics are changing, economy is growing, there is a shift in the disease patterns & awareness of health and fitness is increasing by the day. The demand for healthcare services has indicated a CAGR of 16%. India still falls short on various key health indicators for e.g. our hospital be. per 1000 stands at 0.7 whereas the world average is 3.96. There is a big mismatch between demand and supply of healthcare infrastructure and services in India India needs to add over a million beds to increase its ratio to 1.7.

Medical Tourism The increase in medical tourism in India has led to reduction on the dependence of Indian hospitals on local customer.

Equipment Players: The competition in the equipment market is on a high. Consumables and disposable equipment are made locally whereas high value equipment’s are made by international companies. The companies have expanded their operations to the Indian market and established assembly centers. The government is encouraging the growth of this market.

High competition is turning out to be beneficial for the hospitals.

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Rivalry among Competitors Increasing Competition The drugs and pharmaceuticals sector has attracted FDI worth $1.66 billion. Hospitals and diagnostic centers have received FDI worth 5761.18 million. Presently the market is fragmented but the market is changing. The sector is organizing into distinct sectors which are one more reason the competition is increasing. Investments are increasing by the day as the potential in this market in India is very high. Only 20% of the market Ls tapped.

Low Competition from Public Sector The share of private sector in India is 78% which is mostly out of reach for the rural and poor population of the country. An estimate is made that out of the 525.7 billion required to increase the number of be., the government is contributing only 15,0% of the amount which is a large opportunity for private playas.

Threat of New Entrant Encouraging Government Recons The government does not have the financial strength for large scale investments in the healthcare sector. government is encouraging FDI in the country.

Barrier for Foreign Fi mu Even thus, government is encouraging FDI in the country. there are very few FDI hospitals in India. Other forms of fun.ng are more prevalent. The reason for this can be long gestation period of investments and relatively low ram of return.

Threat of Substitutes Alternative medicines Alternative medicine includes Homeopathy. Ayurveda. Unani etc. They are safer and have lesser side effects as compared to al allopathy. The society is moving towards alternative medicine mainly due to the advantage of painless procedures. lesser side effects. organic medicines etc.

Medical Tourism has seen the shift of people towards Ayurveda. The age-old practice is gaining popularity all over the world. There has been a rise in the amount of people who come to India to undergo Ayurvedic treatment.

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2.27] SWOT Analysis Strength • Good quality services are available at a low cost • India has a large supply of qualified doctors • India has a strong reverence in good quality and advanced healthcare. We also have a high success rate in operation • Doctors reputation on the international front is very high • Medical tourism Weakness • Delivering healthcare in India is costly.

• We have a limited access to life saving medicines • A normal middle-class family cannot afford the specialty healthcare Opportunities • Healthcare industry has good support from the government • Major pharmaceutical companies to choose India as the preferred hub for their global R&D and manufacturing operations • The growth of middle class in the country has resulted in fast changing lifestyles in urban and to some extent rural centres. this opens a huge market for lifestyle-oriented drugs, which has very low contribution in the Indian markets.

Threats • Primary health infrastructure is the responsibility of the government • Cost of discovering new drugs is very high

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2.28] Stake holders in healthcare There are five key stakeholders in any healthcare service system as shown below. Implementing a healthcare PPP will have an impact on all these stakeholders and the PPP itself can be structured along any of the roles where private sector participation is applicable.

Stakeholder Roles Public vs. Private In the roles of provider, payer and the area of IT infrastructure, there are significant advantages as well of areas of concern between the public and private sector as discussed below

The policy goal of PPP in healthcare would be to bring out the synergies in key stakeholder interests between the public and private sector and at the same time have a strong regulatory mechanism of maintaining quality along with equity in service. Any model of healthcare PPP that is implanted and the framework used in evaluating it will need to accommodate for the key concerns raised in the above discussion. PPP models will vary in design and implementation based on structural, regional and goal differences. Yet a framework for evaluating such models will try to ensure that the PPPs are setup for success rather than failure 2.28a] Managing Stakeholder Interests The key to success in PPP initiatives lies in effective management of the public sector and private player interests across different stakeholder roles. PPP experience from different sectors indicate some key implementation aspects of PPP which need upfront clarity and have to be kept in mind by concerned parties before initiating PPP projects in healthcare Defining and differentiating scope of free services at PPP hospitals – Free service implies access to healthcare to the beneficiary free of charges. However, there is a cost to the service provider which has to be met either through a global budget or through cross subsidy out of revenue from paying patients. While the qualitative aspect of the core service of the patient’s medical care must be equitable irrespective of the socio-economic background of the beneficiary, there could be difference in catering to the patient’s personal conveniences for those who are able to and willing to pay for such services. The quantitative aspect of free 11 service can be determined on the basis of the built-up facilities with maximum capacity utilization, or alternatively on the basis of the actual service provided. In order to establish clarity of objectives upfront in any PPP project, it is recommended that the MoUs or SLAs define the complete scope of “Free Services” and include the following:

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• Determination of “Free Services” to be provided at the PPP Hospital • Definition of the scope of “Free Services” to be provided at the PPP Hospital • Definition of the eligibility of patients to avail the “Free Services” • The Quality charter of “Free Services” • Differentiation of facility’s infrastructure for “Free” & “Paid” Services

2.28b] Tariff Determination It is essential that pricing strategies and service tariffs of the ‘free services’ are determined on mutually agreeable platforms. The government is the third-party payer covering the cost of services for the private sector service provider, on all ‘free services’. But the government generally does not have a mechanism to administer financing and provision of care through preauthorization of rendered services as is the case of insurance or employee benefits. Hence it is invariably a matter of conflict to estimate and compensate the quantitative aspect of care.

Therefore, in most successful PPP models, tariff determination actually works top downwards from a global budget based on built up capacity and capacity utilization. Global budget on utilization is also auditable and therefore fits into the public accountability. Based on mutual understanding this global budget figure can be determined, based on the cost of reimbursement or on a cost-plus basis should there be an incentive provided in the PPP model. It can also lower than cost of operation if cross subsidy is part of agreement. The value of assets provided by the government could be considered as contribution in which the government can expect certain returns in the form of return on capital employed or dividend on equity.

In general, the service tariffs should be determined on the basis of the following criterion while entering into the partnership agreement between government and private sector: • Inflation (current & projected) • Project Operational Expense • Project Capital Expense • Project Profitability • Public Sector partner’s obligation • Periodicity of tariff change • Agreeability by both partners

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• Role of advisors to the PPP In most PPP initiatives, the public-sector partner identifies the management and financial consultants to advice on the projects. It is important that the appointed advisors should develop the contractual clauses after discussion and in mutual agreement of both the public and private sector interests. This would enable a better business projection and incentivize the bottom-line objectives of the project.

• Regulatory Role in a PPP setup PPPs are looked upon as bringing the best of both public and private sector world practices and benefits together to provide better healthcare. At the same time, a strong control mechanism is also needed to ensure that the public and private players operate within their defined roles and do not transgress boundaries that may undermine that larger industry context. While selfregulatory mechanisms are an option for enforcing quality controls through professional associations, such a mechanism might still need some time to evolve in India. An independent regulatory watchdog is needed in dealing with dispute resolution to maintain the business viability of the PPP as much as it is needed to ensure equitable access to all sections of the population. Some of the areas where the regulator could contribute are: • Consumer Rights Protection – Ensuring that the poor are not worse off if PPPs are set up to serve remote areas of India. A clear policy on rights of consumers in a PPP-type of arrangement, and patient rights in case of a PPP failure are genuine concerns that need to be addressed in any policy framework and have to be employed by the regulator to manage PPPs. Litigation issues - Litigation has been a source of concern to the private sector. One of the key instruments used by governments to encourage PPPs is subsidizing inputs (mainly land), and the common property element of such inputs makes them vulnerable to public scrutiny and litigation, which can be detrimental. While there is clearly a case for opening such decisions to public litigation, governments need to identify correct procedures and the regulator needs to ensure some amount of protection to the private partners so that they can be assured of the continuation of PPPs unhindered by the constant threat of litigation. Keeping these in mind, it is necessary that even at a contractual stage, a “Scope of Protection” of both the partners is clearly documented in the MoU of the PPP. The “Scope of Protection” of the partners’ and partnership’s interests (both financial and brand image) need to be clearly specified in the agreement. Moreover, litigations arising out of public outcry need to be fundamentally cleared at inception to avoid any debate in the future.

Specifically, the Scope of Protection should cover the following: • Operational issues • Manpower Planning in terms of issues like • Local employment generation, • Outsourcing requirements, and • Specialist requirements Ensure timely decisions – In some of the cases the delays in decision making from the side of the government has been a significant challenge in the successful execution of the PPP model.

The regulatory body which looks into the PPP aspects should be well empowered to take decisions and act as a speedy channel to address the various issues.

Exit options for private providers - In deciding on a PPP, private providers not only look for attractive economic returns but also look for a hassle-free exit strategy in case a partnership goes wrong. There is little evidence on what kinds of exit clauses have been included in PPP

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contracts in India so far. Penalties and compensation issues must be clearly outlined in the MoU whether the public sector or the private party wants to exit the contract. MoUs must clearly and objectively define the necessary exit options that can be exercised by the partner along with the rights of the partner at the time of exercising such rights. The MoU should clearly provide for necessary exit clauses and exit events which can be exercised by the partners any time after the expiry of the stipulated lock-in period. The exit clause should also clearly define the necessary conditions which will deem and affect the expiry of an existing partnership. The MoU should also provide scope, in case of any financial fallouts, the rights of the partners, to seek regulatory intervention and to appoint an “arbitrator” towards resolution of issues and concerns before seeking legal recourse. In such cases, the role of a regulator becomes critical to ensure that the process is fair to both state and private sector, while the interests of the beneficiaries is not compromised

To summarize, the role of the regulator is seen as a neutral operator between the public and private sectors whose primary interest is the benefit of the general public benefiting from the system but is also aware and active in mitigating potential sources of conflict within PPP arrangements.

2.29] Healthcare financing 1.Definition of health care financing • mobilization of funds for health care • allocation of funds to the regions and population groups and for specific types of health care 2.Health service financing source • Health services financed broadly through private expenditure or public expenditure or external aid • Public expenditure includes all expenditure on health services by • central and local government funds spent by state owned and parastatal enterprises as well as government and social insurance contributions

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• where services are paid for by taxes, or compulsory health insurance contributions either by employers or insured persons or both this count as public expenditure.

3.Voluntary payments by individuals or employers are private expenditure.

• External sources refer to the external aid which comes through bilateral aid programmed or international non-governmental organizations • The ownership of the facilities used whether government by government, social insurance agencies, nonprofit organizations private companies or individuals is not relevant 4.Mechanisms of Health Financing •

general revenue or earmarked taxes

•

social insurance contributions

•

private insurance premiums

•

community financing

•

direct out of pocket payments

•

Each method

•

distributes the financial burdens and benefits differently

•

each method affects who will have access to health care

•

financial protection

•

Accreditation of healthcare facilities

5.Why accreditation?

• Ensure a quality index for health consumer. A growing number of hospital in India are turning to accreditation agencies worldwide to both standardize their protocol and project their international quality of health care delivery.

• Attract foreign patients.

• Quality Assurance helps improve effectiveness, efficiency and in cost containment, and accountability and the need to reduce error and increase safety in the system.

• The process of accreditation is envisaged to result in a process of fundamental change in technical procedures of service delivery, in the appropriate use of available technologies, in the integration of relevant knowledge, in the recourses are used and, in the efforts, to ensure social participation.

6.Benefits of accreditation • Improve public trust that the organization is concerned for patient safety and quality of care.

• Provide a safe and efficient work environment that contributes to worker satisfaction.

• Listen to patient and their families, respect their rights, and involving them in the care process as partners.

• Create a culture that is open to learning from the timely reporting of adverse events and safety concerned.

• Established collaborative leadership that sets priorities for and continues leadership for quality and patient safety levels.

• Identify systemic break-down and close gaps or loopholes

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• Provide ways to detect and correct error and problems • Ensure conformance to and effectiveness of documented processes • Focus on patient and provider needs and expectation • Streamline work flow and maximize resource utilization • Maximize customer satisfaction 7.Accreditation authority in India NABH (national accreditation board for hospitals & healthcare provider) QCI (quality council of India)

8.The future The Indian health sector is growing at a brisk pace while providing investors with plenty of opportunities. Although there’s a great scope for the sector to flourish more in the future, the health sector remains the most neglected GDP. There are many factors that have contributed to the success of the industry and opened the doors of opportunities for small and medium businesses in India. In recent years and across multiple regions the sector has become consolidated and corporate.

Some of the factors that are driving the growth of the health industry are •

The economic growth

•

Increasing income

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Increasing population

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Increasing working class group – 65% by 2020

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Advancement of medical treatments and technologies

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9.A good rate of employment generation With an increase in the old population and rising disease, the need for healthcare services is anticipated to become stronger. While it’s an opportunity for the industry to grow and create job opportunities, it’s also a big challenge for them to meet this demand. To meet this huge demand, the industry will need a great number of healthcare experts and skilled labour.

10.Productivity will be increased Healthcare investment can be a constructive step for various areas of the country’s economy.

Many big and small firms are now investing in employee insurance to ensure the health of their employees. The labour productivity can only be enhanced by helping them improve their physical and mental abilities, such as strength and cognitive functioning. Therefore, health Therefore, health has far-reaching effects on productivity.

11.Forex will be increased India is an emerging power and it is investing wisely in its health industry. We are emerging out to be one of the fastest evolving leading destinations for international patients. India is advancing technologically, enhancing its quality of care imparted, skilled medical staff, and cost. All this has invigorated the influx of foreign exchange which is eventually strengthening our position in the international market.

12.Innovation and entrepreneurship Entrepreneurship can have a major effect on the economy’s growth. With the arrival of pioneering healthcare models, such as fitness centres, diagnostic chains, diabetes clinic, the entrepreneurial spirit has definitely increased. Eventually, this will create direct or indirect employment opportunities, increase productivity and the potential.

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3.Working definitions in healthcare industry 3.1] Regulatory in health care industry Indian society is going through a catharsis. In an increasingly interactive but ever more disintegrated world, Indians are finally finding both the confidence and the desire to transform their own society. A country of 1.3 billion people is no longer prepared to accept being an “also ran”. In this process of churning, undeniably, there will be much pain but from this one hopes, will emerge an India – confident, strong, and sure.

There is a lot wrong with contemporary Indian society – it’s thinking, it’s structure, it’s systems but we still have a chance. Each one of us alive today will not be here in say just less than 100 years’ time. Almost every single house in the country will become inhabitable in not too distant a future, and our cities will almost completely have to be rebuilt. We just need to ensure that the “new” that replaces the “old” is robust and before you know India would be transformed. I sincerely believe that with appropriate corrective action, we can resurrect almost every aspect of the Indian society – yes, it’s thinking, the structures, and even the systems.

This corrective action, however, will only become possible if we come out of our current situation where failure has led to arrogance rather than introspection. We will have to start by admitting freely and openly what is wrong with our society and then engage in a collective discourse to fix it. We need to raise both the level and the intellectual quality of our public discussion and move forward slowly – a step at a time – but decisively.

Any detailed analysis of the current state of Indian healthcare can be confusing. The decades of under-investment and lack of systematic planning has resulted in widespread chaos, degeneration of values, skewed distribution of resources, and a sense of helplessness on the part of both the state and the population. The task at hand is enormous.

3.2] Human Resources Healthcare industry is heavily dependent upon human resources. You can’t look after patient without doctors, nurses, technicians, etc. and yet little thinking has gone into ensuring an adequate work-force for the future that we can retain to work in the country. The current situation is that we are creating doctors and nurses but without the adequate hospitals and clinics for them to work in. The government keeps saying doctors and nurses don’t want to work in rural India but without understanding that doctors and nurses need adequate facilities, diagnostics, and other supporting services to deliver healthcare. Doctors and nurses need decent houses, schools for their children and facilities for a productive and entertaining social life. Given the fact that this is unlikely to change anytime soon in rural India, we will need to provide incentives for people to work in the villages – the same sort of thing that can force a doctor or a nurse to go and work in a small town in Saudi Arabia can also take them to a village in their own country. Our planners simply need to wake up to this reality. If a doctor or a nurse sees that he’ll save for four years by working for a year in a village, he is likely to drag himself there and also ensure he works hard to keep his patients and employers happy.

The current situation where nobody wants the job in the first place does not leave the government with any levers when those in it don’t perform or simply don’t turn up! Adequate salary and tax incentives can go a long way in helping retain our homegrown talent and will ultimately pay back for itself by ensuring a healthier society. Health, after all it used to be said, is wealth.

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3.3] The Role of the Government In modern societies, we have left it to the governments to set the appropriate structures upon which we can all build our individual lives. If the structure is robust, our lives can indeed be very fulfilling but if it is not, the whole system can degenerate into chaos. The policy has failed Indian healthcare at every step and exploited by the very people entrusted to protect and develop it. Doctors continue to be educated and trained in a system that rarely keeps pace with the changing needs of the patients and the scientific developments. Underfunded medical colleges continue to treat the impoverished in shabbiest of the conditions and produce little in the name of research and scientific output. They struggle to recruit world-class faculty while those who take up these jobs find they can neither deliver world-class care nor engage in academics or research because of the lack of funding and bureaucratic controls. Our corporates happily donate millions of dollars to foreign institutes as they have well-established mechanisms for publicity that our institutions have failed to establish. And while our educational institutions and hospitals are crumbling due to lack of resources, our temples are one of the wealthiest in the world. There is much for us all to reflect over in the contemporary Indian society.

3.4] The Profession At the same time, it cannot be denied that healthcare is fundamentally the doctors’ responsibility in any society. If any of the other stakeholders are falling short, it is up to us to make noise and ensure we can deliver quality healthcare to the people. However, Indian healthcare is remarkably short in this area too. A large number of doctors, let down by the system, have become so cynical that greed and self-aggrandisement have taken over empathy and ethics. The profession has got infested with one corrupt practice after the other and the doctors have simply chosen to look the other way. Yet, they complained bitterly when medical services were brought under the purview of the consumer courts. I agree that involving courts was not the right thing to do but what options did the doctors leave for the patients when the regulator, the Medical Council of India (comprising entirely of doctors), does not have an effective patient complaint cell or even a register of all qualified doctors. It is true that the desire of the medical profession in India to protect each other is much stronger than their will to protect patients. And while the rot was setting in, the so-called leaders of the profession were building their own hospitals and nursing home. Isn’t it amazing that not a single leader from the profession has spoken against the widespread lack of healthcare provision in the country for the poor or the ethical abyss that the profession has sunk into? It is sadly true that doctors have systematically attempted to benefit from the failure of the policy and the regulation rather than seeking to correct it and their leaders have been busy protecting their own positions and interests rather than that of the patients they are meant to serve. If you don’t believe me, just think how many of hundreds of medical societies in the country come out with anything useful for the people. Where is the desire to develop the local evidence base to guide local care? Where are the local guidelines for common clinical conditions that can be used by doctors and nurses working in remote towns and villages?

Despite this, hundreds of conferences are organised annually at considerable expense and much fanfare where the emphasis is on reciprocating lectures and chairmanship rather than any real scientific data sharing. There will no doubt be islands of excellence in this vast sea of greed and corruption but I hope I have been able to give you a general idea of the state of the affairs. Many of these problems are not simply confined to India either.

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3.5] The Private Sector The private sector rose to fill in the vacuum left by the state and it is a fact that without private healthcare, large sections of our communities will have nowhere to go. But once again, the private sector has been allowed to mushroom without any attempt to match demand to supply. This has led to a situation where they are killing and pulling each other down into a moral quagmire with over competition in urban areas while vast sections of rural parts of the country are left un-served. Private nursing homes, diagnostic facilities, and hospitals are functioning without a regulatory overseeing mechanism and poor patients have no alternative, as the state hospitals are not fit for human treatment.

Though the situation seems impossible, there is still hope. A series of determined initiatives can fix the problem. We need reform across the board. We need to reform our state primary health care provisions, our medical colleges and how we fund them, medical education and postgraduate training, continued medical education, regulation of the profession and the hospitals, mechanisms for patients to voice complaints, planning to distribute provisions evenly, and systems for accountability from all. And even if we did all this, there will be yet more left to do.

3.6] Decision making tools 3.6a] Decision support systems as a potential tool to enhance the uptake of evidence Many problems facing health care systems today are not caused by lack of knowledge but by the gap between what we know and what we do in the face of staff shortages, economic pressures and rising public demand [1]. Systematic reviews or randomised-controlled trials of new health technologies published in prestigious journals are a linchpin of evidence-based medicine and help to establish the effectiveness of drugs or procedures but are rarely enough to ensure that the technology is actually used.

The process from innovation to routine clinical use is complex. For example, in cardiovascular disease prevention, despite the systematic reviews, evidence-based guidelines and decision tools (e.g. the Joint British Charts), there is continuing evidence to suggest that these approaches have not yet changed actual clinical practice[2, 3]. The Leeds Acute Abdominal Pain system [4], which estimates patient-specific diagnostic probabilities and underwent extensive development and testing over decades, is scarcely used today. Many factors appear to influence the uptake of these systems, and the guidelines on which they are based[5]. For example, some health professionals are unaware of, or simply forget, guideline recommendations, while others fail to follow them because of patient choice or peer pressure.

Hundreds of computerised decision support systems (DSS) and other aids have been developed to assist patient management. In Garg et all’s systematic review of controlled trials of DSSs, about two thirds of these are effective at narrowing knowledge gaps, improving decisions, clinical practice or patient outcomes [6], but many are not (e.g. computer-based guidelines on the management of angina and asthma[7]) Why did one third of the computerised DSSs that were sufficiently mature to be exposed to a randomised trial fail to influence clinical actions in Garg et all’s systematic review [6]? Reasons why this might have happened include: 1. Failure of clinicians to use the DSS e.g. because they did not understand what it was for, the prevailing clinical culture was against it, their patients or peer group objected to it, it was too slow, or was not linked to the electronic patient record (EPR).

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2. The DSS did not produce an effective output in time to influence their decision: e.g. the output was not available in time; they could not understand the output.

3. The output was not convincing enough to persuade the users to change their practice: e.g. the output showed poor accuracy, was badly worded, users had never before heard of this drug and required more details.

4. The output was available and was convincing enough to influence user decisions, but the user was unable to change their practice: e.g. the drug was too expensive to prescribe, there was adverse peer or patient pressure, the user was missing some vital information, equipment or skill that they needed before being able to enact their decision.

5. The performance of the clinicians was already optimal, given the circumstances and patient case mix.

Each of these potential reasons for failure needs to be considered carefully by DSS developers before they start work. This means that DSS developers need to start with the steps necessary to bring about the intended user actions or behaviour, not with the improvement of the quality of user decisions or the accuracy of the DSS itself. Those wishing to improve clinical practice and patient outcomes need to analyse the steps necessary to bring about the intended change and accept that, quite often, a DSS will not be the solution, as the long list of issues above demonstrates. We are thus advocating that the development of decision support systems need to shift from being technology led to problem led, and that a new mindset is needed to encourage this.

3.7] Scope statement in healthcare industry With the concept of healthcare going beyond hospitals, the health care industry in India has witnessed remarkable growth in the past few years. According to India Brand Equity Foundation (IBEF,) the Indian health care sector, which consists of hospitals, medical devices and equipment and health insurance, is expected to reach U.S. $160 billion by 2017. Major factors driving this growth could be increasing demand of superior health care facilities, rising health awareness and health policies.

The biggest challenge to make these figures come to reality is to create a skilled workforce which is equipped to deal with the issues pertaining to the healthcare industry. Besides doctors, nurses and other paramedical staff, the industry also requires qualified health care management professionals. This creates the need for specialized management course in health care. A Master of Business Administration (MBA) in Health Care can be the answer to this need.

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3.8] Requirement and expectation 1. Rural Versus Urban Divide While the opportunity to enter the market is very ripe, India still spends only around 4.2% of its national GDP towards healthcare goods and services (compared to 18% by the US) [2].

Additionally, there are wide gaps between the rural and urban populations in its healthcare system which worsen the problem. A staggering 70% of the population still lives in rural areas and has no or limited access to hospitals and clinics [3]. Consequently, the rural population mostly relies on alternative medicine and government programmes in rural health clinics. One such government programme is the National Urban Health Mission which pays individuals for healthcare premiums, in partnership with various local private partners, which have proven ineffective to date.

In contrast, the urban centres have numerous private hospitals and clinics which provide quality healthcare. These centres have better doctors, access to preventive medicine, and quality clinics which are a result of better profitability for investors compared to the not-soprofitable rural areas.

2. Need for Effective Payment Mechanisms Besides the rural-urban divide, another key driver of India’s healthcare landscape is the high out-of-pocket expenditure (roughly 70%). This means that most Indian patients pay for their hospital visits and doctors’ appointments with straight up cash after care with no payment arrangements. According to the World Bank and National Commission's report on Macroeconomics, only 5% of Indians are covered by health insurance policies [3]. Such a low figure has resulted in a nascent health insurance market which is only available for the urban, middle and high-income populations. The good news is that the penetration of the health insurance market has been increasing over the years; it has been one of the fastest-growing segments of business in India.

Coming to the regulatory side, the Indian government plays an important role in running several safety net health insurance programmes for the high-risk population and actively regulates the private insurance markets. Currently there are a handful of such programmes including the Community Health Insurance programme for the population below poverty line (like Medicaid in the US) and Life Insurance Company (LIC) policy for senior citizens (like Medicare in the US). All these plans are monitored and controlled by the government-run General Insurance Corporation, which is designed for people to pay upfront cash and then get reimbursed by filing a claim. There are additional plans offered to government employees, and a handful of private companies sell private health insurance to the public [3].

3. Demand for Basic Primary Healthcare and Infrastructure India faces a growing need to fix its basic health concerns in the areas of HIV, malaria, tuberculosis, and diarrhoea. Additionally, children under five are born underweight and roughly 7% (compared to 0.8% in the US) of them die before their fifth birthday. [4] [5].

Sadly, only a small percentage of the population has access to quality sanitation, which further exacerbates some key concerns above.

For primary healthcare, the Indian government spends only about 30% of the country’s total healthcare budget [6]. This is just a fraction of what the US and the UK spend every year. One way to solve this problem is to address the infrastructure issue… by standardising diagnostic

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procedures, building rural clinics, and developing streamlined health IT systems, and improving efficiency. The need for skilled medical graduates continues to grow, especially in rural areas which fail to attract new graduates because of financial reasons. A sizeable percentage of the graduates also go abroad to pursue higher studies and employment.

4.Growing Pharmaceutical Sector: According to the Indian Brand Equity Foundation (IBEF), India is the third-largest exporter of pharmaceutical products in terms of volume. Around 80% of the market is composed of generic low-cost drugs which seem to be the major driver of this industry.

The increase in the ageing population, rising incomes of the middle class, and the development of primary care facilities are expected to shape the pharmaceutical industry in future. The government has already taken some liberal measures by allowing foreign direct investment in this area which has been a key driving force behind the growth of Indian pharma.

5.Underdeveloped Medical Devices Sector: The medical devices sector is the smallest piece of India’s healthcare pie. However, it is one of the fastest-growing sectors in the country like the health insurance marketplace. Till date, the industry has faced a number of regulatory challenges which has prevented its growth and development.

Recently, the government has been positive on clearing regulatory hurdles related to the import-export of medical devices and has set a few standards around clinical trials. According to The Economic Times, the medical devices sector is seen as the most promising area for future development by foreign and regional investors; they are highly profitable and always in demand in other countries.

3.9] Managing project cost in healthcare industry 3.9a] The healthcare industry The healthcare industry faces many of the same challenges as other industries, with some very particular stress points. Efficient processes are vital, not just to decrease costs and increase revenues and gain a competitive edge, but to offer the highest quality care. They also face much more scrutiny from various stakeholders, such as government and private agencies, health insurance companies, and of course, patients. These demands mean, that healthcare organizations need to make an effort to run more efficiently to be able to manage the increasing patient numbers - and their increasing demands.

3.9b] The state of healthcare Healthcare is changing. Americans spend more than ever on healthcare, e.g. more doctors’ offices visits and more spending money on brand-name drugs, and healthcare costs are expected to increase even more. While this leads to a higher demand for healthcare professionals, it does not translate into a productivity increase as, compared to other industries, healthcare has the slowest productivity rate across time.

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3.9c] Project management in healthcare Healthcare projects are unique and you won’t find a lot of these types of projects in any other industry, e.g. projects to implement new approval processes for helicopter landing or a project to reduce errors in the operating room. More so than in other industries, the success or failure of healthcare projects can mean the difference between life and death. Which is why applying project management to healthcare processes and structures is so important because it enable hospitals to run more efficiently and as a direct result offer more affordable and higher quality care to patients and ensures safety in the hospital.

3.10] Project management can help healthcare providers improve: 3.10a] Processes Hospitals can use methods such as Lean, Six Sigma or the 5S to identify and eliminate wasteful processes, and as a result save valuable time. Emergencies need acute medical care and timely treatment, in many of such cases delays can be fatal. Which is why healthcare providers need to make sure that the process from admittance to the hospital to getting the patient to the operating room is as quick as possible. These types of processes can be standardized and optimized and enable hospitals to offer better care for patients.

3.10b] Planning Planning is key – in project management and healthcare. Planning tasks and scheduling is challenging in the healthcare industry, particularly in hospitals. Each department has different activities, and each employee has a specific role and tasks they need to complete. Most tasks also face various external and internal constraints, and often also depend on one another. For example, before an operation nurses have to prepare the patient for it, then the anaesthesiologist has to anesthetize them before the operation can begin. So, if one tasks hasn’t finished, the next one can’t start. Having a complete project plan enables hospital employees to understand their own role and responsibilities, so they know exactly what they need to do, when they need to do it, and where they need to be.

3.10c] Budgeting The healthcare industry has experienced incredible growth due to medical and technological advancements. While this helped developing more efficient and effective treatments, it also came with high costs. In order to keep costs low, healthcare providers need to control the costs by choosing the right projects to implement, i.e. those that create the most value to the organization, and by planning these projects carefully and avoiding costly scope creeps and project failures. Project management tools enable hospital leaders to create more accurate budgets and gives them the ability to control these budgets.

3.10d] Communication Healthcare teams need to work extremely close together, not just within a department, but also across departments or even across hospitals. Depending on a patient’s medical condition, they will be treated by several different physicians at the same time. These physicians need to coordinate their efforts, such as making sure that they prescribe the right drugs to the patients, and also that these drugs are compatible with each other. So effective communication is essential – for the healthcare organization as well as the patient. Defining clear communication processes and channels, make sure that everyone has immediate access to important information.

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3.10e] Stakeholder Relations All of the above-mentioned improvements ultimately lead to better stakeholder relations.

Healthcare providers deal with a multitude of stakeholders, who each have different expectations and requirements: e.g. the government wants to ensure that laws are being followed, insurers want to know exactly for what they’re paying, and patients who want affordable care at low costs. Implementing project management tools and methodologies enables healthcare providers to meet the requirements of the various stakeholders by improving processes, budgeting and communication and overall project planning.

3.11] Why Healthcare Needs Project Management At the dawn of the 20th century, Wilbur and Orville Wright developed the first airplane capable of sustained heavier-than-air human flight. Working from their bicycle shop, the Flyer was built of spruce, linen, and wire, and fitted with a crude engine of their own manufacture. It flew successfully on the Kill Devil Hills of Kitty Hawk, North Carolina on December 17, 1903.

But what if Orville had crashed on that first flight? Most likely, he would have been treated by a local physician, working from an office in his home, to whom Orville would have paid cash at the time of service.

Fast forward one-hundred years. Aircraft are now built in plants that resemble cities, with components and raw materials assembled from around the world. Yet air travel, even in the age of global terrorism, is still one of the safest activities in which a human being can engage, despite the myriad opportunities for a small glitch, whether in design or manufacture, to cause the plane to fall in flames from the sky.

So, what about the healthcare industry—how has it handled the process of maturing, as private practices have been swallowed by giant healthcare corporations? Indicators are that it has not done as well. A 2012 report by the National Institute of Health and the Medicare Inspector General states that as many as 440,000 deaths per year result from hospital errors…

It is estimated that as many as one in three patients is affected by hospital errors and complications…” Since the initial NIH report of 1999 (“To Err is Human”), hospitals have risen from the sixth place to third place among the leading causes of death in the Unites States. Hospital costs and death rates have been doubling every decade.

These statistics are appalling. Consider the public outcry if 440,000 people died each year because of preventable errors in the aircraft industry. As the NIH report observes, the 2012 mortality rate from preventable hospital deaths was “equivalent to two daily Jumbo Jet Crashes.” When a single plane crashes, the FAA examines every possible cause to prevent further carnage. So, what can healthcare learn from the aerospace industry?

Let’s look at the years between the Wright Brothers and the Dreamliner—between the country doctor and the HMO—to find out. In both aerospace and healthcare, advances in research and technology exploded in the 20th century, spawning phenomenal growth within, and the birth of new industries to support them. But rapid deployment of new technologies came with a price tag, both in squandered money and in lost life.

While some of the blunders and tragedies can be attributed to and the growing pains of these new industries, significant blame can be traced to the preventable human errors that came from a lack of proven, systematic processes, administered by trained professionals, to shepherd projects from inception to completion. Absent this overarching administration,

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projects that were not well defined to begin would receive more money thrown at them, often amid a cloud of miscommunication and resentment. When the money ran out, these projects would be judged as failures, or, worse yet, they would be deployed with their flaws in place, resulting in crashed planes, or in the case for healthcare, dead patients.

So, what changed in the aircraft industry that the healthcare industry might learn from?

Someplace around WWII, the aerospace industry, building on methodologies that date back to the construction of the pyramids, began compiling data and practical evidence on what caused projects to succeed and fail. This grew over the years into a body of knowledge that now guides those trained in its ways through the process of initiating a project, managing its scope, risk, duration, cost, and stakeholders, and succeeding with a quality deliverable.

Using these techniques resulted in • • • • • • • •

Better control of financial, physical, and human resources, Improved client and stakeholder relations, Shorter development times, Lower costs, Higher quality and increased reliability Improved productivity, Better internal coordination, and Higher worker morale and reduced stress.

But hold on—human beings aren’t airplanes, and all the aerospace engineers on the planet couldn’t create anything so elegant or complicated as a toddler’s left foot. Perhaps not, but much of the business of healthcare doesn’t involve medicine. Healthcare will continue its astronomical growth, and provide some of the highest paying jobs, each of which plays a critical role in delivering quality, affordable patient care. But the reality is that these jobs are frequently project driven, and the success of these projects can quite literally mean the difference between life and death.

3.11a] Consider just a few scenarios • Information Technology, including data management, records, and artificial intelligence

systems, where wrong information can kill patients and intelligent mining of data can identify lifesaving patterns on which to develop new research.

• Facilities upgrades, where development of new standards and specializations in operating theatres, clean rooms, ICUs, and in the wards can abate the spread of resistant bacteria.

• Process improvement projects, targeted at each critical procedure, to reduce errors and cut cost, including nursing procedures, nutrition, drug administration.

These are clearly within the domain of project manager, and the application of good project management practices may be part of the overall solution of how to make hospitals safer.

Much of the research currently being developed in this field is from the USC Schaeffer Centre for Health Policy and Economics, led by Professor Joel W. Hay. Indeed, as the healthcare industry continues to grow, it is being pushed towards upping its project management game. In a report co-sponsored by Georgetown University and the National Institute of Health, it is predicted that the healthcare industry will create 5.6 million new jobs by 2020. Americans spent $2.6 trillion on healthcare in 2010, which is ten times more than in 1980, and the demand for healthcare continues to grow at a rate twice that of the national economy. Rising costs are increasing scrutiny of how healthcare providers run their

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businesses. An example of this can be found in a provision of the Affordable Care Act that holds providers to higher standards for their major IT functions.

While the government’s desire to reduce overall cost of care serves as an external pressure to improve processes from admittance through discharge, internal pressure is also mounting.

Healthcare organizations are realizing that, to remain competitive, they must develop skills to effectively select and manage the projects they undertake. They also realize that many of the concepts of project management will help them as they execute projects in such diverse areas as Information Technology, Facilities Management and Process Improvement. In addition to project management, healthcare organizations are embracing program and portfolio management as a means to address enterprise-level needs and to balance conflicting needs and priorities among stakeholders.

What is clear is that healthcare will need to hire or train employees to serve in project management roles. These jobs will require higher levels of education, along with continuous certification. UC Irvine Extension’s Project Management Certificate Program focuses on the specific areas of project management that are necessary in the healthcare delivery environment.

3.12] Estimating cost 3.12a] Introduction This paper attempts to do a comparative analysis of cost efficiency of health care services provided in government facilities, in particular the community health centres (CHC's). The objective is met by developing and then applying separate framework for analysis of aggregate budgeted cost and unit recurrent financial cost and assessing time allocation by doctors and ANMs to their duties. It also recommends possible interventions in government costing procedures to improve on unit cost information for financial efficiency.

3.12b] Why Unit Cost Analysis Because Money talks; health, planners must listen to what it says. Cost efficiency and cost containment are a critical requirement of efficient financial management of health care. Yet it finds no place in the health sector research agenda in the country. Available studies concentrate on expenditure analysis. Financial management of government health care facilities come up against two options.

Either, mobilise enough financial resources to finance all health care activities without constraints or bottlenecks or alternatively utilise the limited available financial resources efficiently, that is maximise health outcomes from the limited resources. Keeping in view that government budgets have seldom been adequate to finance health care but at the same time government cannot withdraw from health sector by 'opening it up' to private sector, government has to be persuaded to exercise the second option fruitfully. Cost efficiency information is a core part of efficient utilisation of finances. Its role is not reduced even if some mechanism of cost-recovery is used to manage the limited finances since the cost information (unit cost or aggregate cost) is a likely benchmark to fix the cost recovery rates such as user charge. Cost efficiency does not necessarily mean that provider (the government) hits the least cost point. Other factors, e.g. quality of care, are also required. But cost efficiency is indispensable since in the last analysis we do need to know what we can afford to provide within the available resources. Just how much of this could be accomplished would emerge from unit cost information.

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3.12c] Cost categories Costing started with the estimation of the operational cost of the operating theatres of our study hospitals. Operational costs include both direct and overhead costs. Direct cost was calculated as the sum of the labour, capital and materials cost. Labour cost comprises the salaries and fringe benefits of all staff involved in the operating theatres (regular and contract).

Comprehensive information about the surgeons, anaesthetists, nurses and the ground level support staff involved in each operating theatre of the study hospitals was taken from the hospital payroll and confirmed by the hospital administrators. For operating theatre staff who also served other divisions, such as the outpatient or inpatient departments, labour costs were apportioned based on the working time in each division as reported by the operating theatre in-charge. Capital costs of the operating theatre include the annualised discounted depreciation cost of the building (area under the operating theatre), furniture, vehicle, equipment and instruments used in the operating theatres and the opportunity cost of the land.

Recent government contracts for purchasing equipment, instruments and furniture were used to get the price information of capital items. Based on the government of India income tax depreciation rule, we calculated the useful life of the building, equipment and furniture.

The useful life of buildings and structures was considered to be 10 years (this is under the category of buildings other than those used mainly for residential purposes); the useful life of furniture and fittings was assumed to be 10 years and that of machinery and plant, 7 years.

However, for some lifesaving medical equipment such as the heart lung machine, colour Doppler, ventilator, etc, the useful life was considered to be 2.5 years. A 3% discount rate was used to calculate the cost of depreciable assets and the interest rate on the 1-year government bank fixed deposit rate was used to calculate the opportunity cost of land. The materials cost covers drugs, medical supplies, office supplies and utilities (water, telephone, electricity and Internet charges).

It includes the actual usage of materials by the operating theatres during the study period.

Utilities costs were distributed based on the allocation criteria. For example, the electricity cost of the operating theatre was calculated based on the floor area of the operating theatre, and the telephone cost was distributed based on the number of personnel in the operating theatre.

To assign the other overhead costs, such as administration, nursing administration, laundry, kitchen, maintenance, transport, blood bank and store, we devised allocation criteria that would be appropriate for our study hospitals based on either the literature or our knowledge about the particular hospital. For example, laundry charges, meal charges, maintenance, transport and sterilisation costs were the actual spending of the operating theatres, administration/nursing service; office expenses were distributed based on the full-time equivalent; water, cleaning services and sanitation charges were distributed based on the floor area.

The simultaneous equation method was used for overhead cost distribution. In this method, we made full adjustment for the interaction of overhead departments and solved a set of simultaneous linear equations to make the allocations to the operating theatres. Hence, the operational cost of the operating theatres includes not only direct costs but also the distributed overhead costs, known as indirect costs.

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3.13] Methods of communicating A multidisciplinary approach is recommended in the management of most medical ailments.

Communication between doctors, paramedical staff, and importantly, between the medical team and the patient and relatives has been discussed in the medical literature. Patients have different psycho-social needs and tailoring the communication to the patients’ requirements is highly valued. Communicating the key points during each step of the patient’s journey is now considered to be an essential criterion for good medical practice and improves the job satisfaction of doctors. The benefits of communicating appropriately have been investigated in the setting of clinical oncology and studies have reported improved treatment adherence and better psychological performance by our patients. Studies have also looked at cultural and gender differences in the motivation of blood donors, making it important to develop individualized communication strategies. Communication skills are not routinely taught in many Indian medical undergraduate or postgraduate courses, and there is a feeling that in a busy outpatient department, such skills may not be optimally applied. The article highlights some of the benefits of using appropriate communication skills and suggests a framework to train medical personnel.

The term communication is one of the most important and significant terms of the English language. It has its root in the Latin word communicate, which means to share, and this sharing is of information, knowledge and thoughts. Communication touches every sphere of our lives. Everything done throughout the day involves some or the other kind of communication – at work or at home, in politics, commerce, sport, entertainment, the financial world, education, and more specifically, medical education. With the advent of new and more sophisticated technologies, our world is fast shrinking into a global village.

Therefore, the ability to communicate effectively, not only through verbal means but also non-verbally, has become very essential. While students feel the need to communicate successfully through oral and written media for their academic tasks, professionals face numerous challenges of communicating effectively and efficiently in their workplace. Lack of communication and the inability of people to communicate effectively causes a large amount of stress, frustration, anger, resentment, misunderstanding and disappointment.

Education is all about communication - not only of hard facts but also of thoughts and ideas and proposals on which to base discussion and debate. However, there is one thing lacking in almost all education systems around the world and that is, teaching students how to communicate their thoughts to others. This results in producing professionals who may have good domain knowledge but are unprepared for what the world needs. This is particularly true in the field of medical education.

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3.14] Communication management plan healthcare industry The healthcare industry is one of the largest and fastest growth industry worldwide. US is spending close to $3 trillion, by 2018 it will consume nearly 18% of US economy . China healthcare industry will touch $1 trillion by 2020. In India, it is growing at CAGR of 16.5 % and expected to become $280 billion by 2020.

Despite the huge opportunity, the healthcare industry is still very conventional in adopting to new communication technology. According to the Joint Commission, an independent organization that certifies U.S. healthcare organizations, it was found that ineffective communications were the primary cause of more than 70 percent of treatment delays and unexpected deaths or injuries.

3.15] Communication solution for Healthcare & its impact Ozonate is providing communication solution to many organizations in healthcare sector, irrespective of their services. Few of our customers are Cloud Nine, Dr Lal Path Lab, Prato, Med Life, Health kart etc. Our contact centre solution and cloud telephony platform are highly flexible and can be customized to meet the needs of all organizations. Salient feature of our solution isCall recording - Record and track all incoming, outgoing and missed calls, helps to track all customer conversation.

CTI Integration - All incoming and outgoing customer can be handled via CRM or HMS, get customer info for all calls, get advanced call control features etc.

Manage distributed centre - Manage and monitor customer calls of all branches from you headquarter Multichannel communication - Omni-channel communication platform, communicate via all channels using a single platform Dialler integration - Increase outbound calling efficiency Open Platform - Develop your own customize communication application Monitoring and controlling risk Project risk control and risk monitoring is where you keep track of about how your risk responses are performing against the plan as well as the place where new risks to the project are managed.

You must remember that risks can have negative and positive impacts. Positive risk is a risk taken by the project because its potential benefits outweigh the traditional approach and a negative risk is one that could negatively influence the cost of the project or its schedule.

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The purpose of project risk control is to • Identify the events that can have a direct effect in the project deliverables • Assign qualitative and quantitative weight—the probability and consequences of those events that might affect the project deliverables • Produce alternate paths of execution for events that are out of your control or cannot be mitigated • Implement a continuous process for identifying, qualifying, quantifying, and responding to new risks The main goals to risk monitoring and control: • To confirm risk responses are implemented as planned • To determine if risk responses are effective or if new responses are needed • To determine the validity of the project assumptions • To determine if risk exposure has changed, evolved, or declined due to trends in the project progression • To confirm policies and procedures happen as planned • To monitor the project for new risks • To monitor risk triggers Risk triggers are those events that will cause the threat of a risk to become a reality. For example, you have identified the fact that you only have one pump set available and the replacement takes six weeks to arrive. In the middle of your irrigation and recycling process tests, you discover that water pressure tends to fluctuate beyond pump tolerance levels. If you do not find a way to solve this problem, your risk will become a reality.

Make sure that for each identified risk, you must provide a response plan. It is not much help to you if the risk becomes a reality or issue and you do not have an alternate execution path or some other emergency procurement plan.

Main inputs to to effectively monitor and control risks • Risk management plan • Risk Register / Risk Tracker • Risk response plan • Project communications • New risk identification • Scope changes Outputs of Risk Monitoring and Risk Control: • Workaround plans • Corrective / Preventive actions • Change requests • Risk response plan updates • Risk database • Checklist updates

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4.The Project Teams 4.1] Project team in healthcare project management Project management has emerged as one of the most prominent business skills of our time because its use can help control costs, reduce risk, and improve outcomes. Used across disciplines, project management is the process of systematically planning, organizing, and then executing a pre-determined set of steps in order to maximize resource use and achieve specific objectives. According to a U.S. News and World report, project management is one of the top skill sets sought by employers.

Why? The Project Management Institute (PMI), an organization created in 1969 to promote the discipline of project management, credits the process with helping businesses save time and money, improve ROI, and reduce risk. It also cites many benefits to staff members including improved collaboration and decreased stress.

As healthcare in the United States continues to evolve under mounting cost and quality pressures, the need for project management becomes ever more apparent. Understanding and applying the foundations of project management can significantly improve outcomes across health care delivery settings.

This article will give an overview of project management, provide some practical tips on how to incorporate its principles into your work, and explore why a more formal approach to project management is needed in health care.

4.2] History of motivation Motivation is an intrinsic phenomenon that is affected by four factors: Situation (environment and external stimulus), Temperament (state and organism internal state), Goal (purpose of behaviour and attitude) and Tool (tools to reach the target). People are motivated for achieving to the goals, necessities and instincts. Academic achievement has a special importance for seekers of science and students. With this motivation, people are motivated enough for successful completion of a task, gaining to a goal or access to a certain degree from competence in their job until they gain enough success in learning and academic achievement (13: p66). Hence, can be said motivation shows reasons for their behaviours and indicate why they act in a certain way. Motivated behaviour is an energetic, oriented and continued behaviour (15: p45). From educational point of view, motivation is a polyhedral structure which is associated with learning and academic achievement (13: p67). There are several interpretations and differences from motivation. In the field of education, motivation is three-dimensional phenomenon that include beliefs about one's ability to perform the desired activity, reasons or purpose for doing that activity and emotional reactions associated with the activity 4.3] Historical process of concept of motivation The concept of motivation can be traced from ancient Greeks, Socrates, Plato and Aristotle ages. Plato believed in a hierarchy organized such as dietary component, the emotional and the rational. Aristotle, for more than twenty years continued to affirm the hierarchy spiritual.

However, he used different reforms which were different from his original belief. He believed in those dietary and emotional components are relevant to body and part of concept of motivation. They can prepare some sensors like growth, physical comfort (food) and some sensory experiences such as pain and pleasure (emotional). These two parts together were basis of irrational motivation force. The logic section was including all rational aspect of soul such as intellectual concept and some voluntary features. The ancient Greeks presumed three

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component, the body's desires, pleasures and pains (senses and efforts of will and spirit) in a hierarchical arrangement for the first theoretical justification of the motivational activities. In the modern era after the Renaissance, René Descartes distinguished between inactive and active aspects of motivation. Descartes believed in that body is inactive factor of motivation, while will is active factor of motivation. Body has a physical and mechanical nature with nutrition desires that answer to those desires by senses and physiological reflects to external environment. (If you wanted to understand physical motivations, physiological analysis must be used). The mind has mental, moral and intellectual nature which has purposefulness will.

(If you wanted to understand targeted motivations, will analysis must be used). Therefore, will always is force of motivation, Descartes devoted motivation exclusively to the will of man for a first time. He provided the first great theory of motivation for philosophers 4.4] Definitions of Motivation The term of motivation derives from the Latin root which means Stimulate. Motivation is behaviour; it isn’t a thing or special event that can be observed directly. It is a compound which describes specific behaviours. Two aspects of the behaviour described by the concept of motivation which consists justify the behaviour or purpose of a behaviour and appropriate consuming energy. In the other word, when behaviour is motivated to get a particular purpose, or when severity and incidence level of energy is different from previous situation.

Thus, the term of motivation refers to two different problems. First, what does make a man activate? Then, what does dominate a form of some activities to the others? Sometimes we meet some people who say: “there is no motivation!” or “I am not motivating enough to do anything!” Term of motive is known as a force within individuals that lead them to a target.

"Motivation" refers to a process or a circulation which help us for motivating others. So, there is a potential motivation inside of men which others have raised it 4.5] What motivates you Effective project management requires that the people involved in a project contribute through distinct roles, each with their own set of responsibilities: • The project manager is responsible for planning, managing, and executing the project by engaging team members.

• The project sponsor is a senior leader who provides guidance and makes key decisions.

• The project team consists of anyone who contributes to the execution of the project.

• A project stakeholder is anyone who is impacted by the project’s outcome or provides resources.

According to many project management guidelines, projects consist of four phases. In each phase, key activities must be accomplished and key deliverables must be produced. Below is a description of each phase along with practical tips you can use to implement project management in your own work.

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4.6] Planning for the team Phase 1: Initiate the Project At their onset, projects must be defined and approved. During this phase, background information, market research, and other pertinent data should be reviewed. The project manager should be selected. Project goals should be determined and aligned with those of the organization. If goals do not align, the project will likely not be approved.

Key activity: Do your homework. Talk to colleagues who have undertaken similar efforts and conduct background research. Learn about the cost (in terms of financial and human resources) and amount of time the effort would require.

Key considerations: Think critically about the need driving this project. How will a successful outcome improve your work, organization, and field? Is that outcome worth the effort and cost? Think realistically about the resources the project requires and whether they justify the end result. Consider who would carry out the work at each stage.

Key deliverable: Create a concise but powerful overview of the project’s expected outcomes, costs, and benefits. This should include both a description of and a justification for the project. Present your overview to an organizational leader who has the authority to approve the project.

Phase 2: Plan the Project Once the project has been approved, the next step is creating a step-by-step plan of how it will be executed. The project plan should contain a schedule detailing all project-related activities, a budget, a list of everyone who will contribute and what they will do, and a description of how progress and results will be measured.

Key activity: Develop the project plan as stated above, including a budget, schedule, list of team members, and progress indicators.

Key considerations: Think carefully about everyone involved in the project, including the project team, any stakeholders, or any other colleagues or leaders who may want to have a say – or provide valuable advice – about the project plan. It’s easy to make changes while in the planning stages but very difficult to make any changes after execution is under way.

Key deliverable: The key deliverable is the project plan. Once it is finalized, it should be presented for approval. Once it’s approved, a kick-off meeting with the project team should be held to review all components.

Phase 3: Execute the Project The third phase is carrying out the project plan. Measuring progress and monitoring any changes from the plan are important steps in this phase. Peter Drucker, a notable Austrian management expert, famously said, “If you cannot measure it, you cannot manage it.” This statement underscores the importance of measuring one’s progress against pre-determined criteria for success.

Key activities: As you begin to execute the project, be sure to communicate key deadlines and activities with the project team. Keep a close eye on your schedule and budget. Track and communicate your progress and results with the project team and the project sponsor.

Key considerations: When executing your project, one or many tasks or results will inevitably diverge from the project plan. This is normal. The important thing is to adjust future steps to minimize any negative effects. Your project sponsor can provide guidance around how to reallocate resources in order to get your project back on track.

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Key deliverables: Keep a detailed list of any delays, failed steps, additional costs, or other unforeseen changes. Make any necessary adjustments to future project steps to ensure that your project stays on time and on budget – and communicate all changes with your team.

Continually update the schedule and budget as steps are completed.

Phase 4: Close the Project At the very end of the project management process, there are several key deliverables: documentation from each step, any products or deliverables the project yielded, reviews for each team member, and lessons learned. An updated budget and an updated timeline should reflect the total cost and number of hours spent as compared to the budgeted amount.

4.7] Leadership and power Healthcare delivery is one of the world’s largest industries, and it is growing and changing rapidly. The Henry J. Kaiser Family Foundation reports that there are nearly 5 million practicing physicians and nurses in the nation – and these figures do not include the many other types of healthcare professionals. A report on the future of healthcare co-written by Georgetown University’s Health Policy Institute and the National Institutes of Health predicts that 5.6 million new healthcare jobs will be created by 2020.

Much of this growth is driven by the rising number of Americans who have health insurance, or “covered lives.” Since the passing of the Affordable Care Act, the U.S. government reports that the uninsured rate fell to a record-breaking 9.2 percent and experts predict that an additional 34 million Americans will enrol for coverage over the next 10 years. While this shift is generally viewed as favourable, it has drawn more attention to the need for efficiency and effectiveness in how healthcare services are delivered.

Another major issue is cost. Americans spent $3.0 trillion on healthcare in 2014 and spending is expected to grow, according to projections published in the journal Health Affairs. In a 2009 Institute for Healthcare Improvement white paper, Martin et al. stated, “Until recently, the rationale for health care providers to undertake quality improvement initiatives rested largely on ‘doing the right thing.’ Any financial benefit…was an attractive side effect.”

Today, this statement couldn’t be farther from the truth as decreasing reimbursements have forced healthcare organizations to explore ways to lower costs.

These issues, coupled with new electronic health records systems, regulations, and technologies have drastically enhanced the need for project management in healthcare.

Organizations are taking on projects to incorporate new elements into their workflows, improve processes at every stage of the continuum of care, and enhance their facilities while improving outcomes and decreasing costs. According to the Massachusetts Hospital Association, the benefit of using project management in healthcare is “to be one step ahead of any potential risk” as they complete this vast array of projects.

Additional complexities, such as regulatory limitations and varied stakeholders, increase the need for project management in healthcare. Project managers must be mindful of countless processes and regulations around patient safety, quality, and privacy. All industries have their own rules, but healthcare is notably complex, with the government and private agencies, such as the Joint Commission, watching closely. These increased restrictions place all the more importance on project planning and execution.

Further, healthcare lacks a simple “buyer” and “seller” relationship. Rather, there are many parties involved. If the product is care, patients are the recipients and doctors and nurses are the providers, however health insurance payers and the government are the buyers. The number of stakeholders increases complexity. Similarly, healthcare project teams may be larger and more diverse due to the inherently cross-functional nature of patient care, requiring a project manager who is flexible and willing to take all views into consideration. Projects in

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health care may require more approvers or more buy-in; it’s important that all parties be identified in the planning stage to avoid delays in the execution stage.

All in all, more project managers, and project management, are needed in healthcare. In an industry that is changing and growing at an astounding pace, project management can offer structure and discipline. Using this proven methodology will help the field accomplish more in less time, save resources, and foster collaboration.

Project management team ▪ Project manager

▪ Office assistant

▪ Asst Interior designer

▪ Asst Project manager

▪ Site management team

▪ MEP engineer

▪ Project coordinator

▪ Healthcare consultants

▪ Structural consultant

▪ Project engineer planning

▪ Clinical planner

▪ Plumbing consultant

▪ Project engineer MEP

▪ Equipment planner

▪ Firefighting consultant

▪ Project engineer quality and safety

▪ Design team

▪ Electrical MGPS, dg set consultants

▪ Project engineer civil and finishes

▪ Project architect

▪ Hvac consultants

▪ Site engineer

▪ Architect

▪ Municipal architect

▪ Site supervisor

▪ Architectural assistant

▪ Contractors

▪ Store/purchase/accounts

▪ Interior designer

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5.Healthcare Project Management Introduction It was just a few decades ago, in the 1950s, that modern project management was first seen as an individual subject within the area of economic sciences. Centuries back, so-called “projects” were finished successfully, e.g. the building of the aqueducts in Roman times or the construction of the Great Wall in China, but these projects were managed more on an adhoc basis mostly using informal techniques and tools.

Project management nowadays is regarded as a very high priority as all companies or organisations, whether small or large, are at one time or another involved in implementing new undertakings, innovations and changes etc. – projects! These projects may be individually diverse, however over time, some tools, management techniques and problemsolving approaches have proven themselves to be more rewarding than others in bringing projects to a successful end. The development of project management has always been in parallel to the development of general trends in worldwide economics. The 1990's were all about globalisation; the 2000's are about velocity and close to the edge of a new decade in which the world maybe has to face an economic recession. Nowadays, almost more than ever, everybody asks for “projects” to return the world economy to its former speed. This also underlines the importance of continuous learning and development of project management capabilities in organisations to allow corporate teams in a fast-changing world to work collaboratively in defining plans and managing complex projects by synchronising teamoriented tasks, schedules, and resource allocations.

However, gaining and sharing project information is not the only key to success. Today’s information technologies allow project managers to practise and work with their teams in a real-time environment. As a consequence of this potential, project team members are able to concurrently view, act and react to the same updated information immediately. Additionally, to external challenges, project teams are forced on a macro level to deliver satisfying results for internal or external customers and stay within the restrictions of budget, time and resources (quality and quantity). In parallel to these deliverables, executives are also asking the project management on a micro level to ensure the use of modern management tools, such as (1) customising the project organisation to fit the operational style of the project teams and respective team members, (2) informing the executive management about the project's progress on a real-time basis, (3) ensuring that critical task deadlines are met and (4) ensuring that project team members know about and monitor project risk and share accurate, meaningful and timely project documents. As a result, the thrilling and demanding position of a project manager not only requires a particular set of skills - how to communicate, to control and to motivate people, but also the specific knowledge about tools and techniques required to run a project successfully.

Project selection In our experience at Hosmac, clients usually (almost always) come to us with the map of a piece of land and the desire to build a healthcare facility. Many times, we find the shape and size of the piece of land to be unsuitable for the healthcare facility desired. In urban areas in India the price of land is very high, especially so in Mumbai, where we are based. If only the client would come to us with the desire to build a hospital and a budget for the land, we could then evaluate various potential sites with regard to location, size, shape and orientation, in short, evaluate their suitability to house the proposed facility. In fact, our second client, a

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cardiac surgeon, consulted us before buying the land and the project is till date our most outstanding success. Among the above four factors, location, size, shape and orientation, for a proposed healthcare facility the most important is location. Whether it is in an urban area or not, the location of the facility will be an important determinant in its financial success.

Corporate healthcare providers even study which city to base their facilities in based on various demographic conditions. I have had the opportunity to be an onlooker of one such analysis, but the details of how to go about it are beyond the scope of this book. Proximity to transportation hubs, good access roads, visibility, the location of competitor’s hospitals with regard to the proposed facility all contribute to the suitability of the site. The size of the piece of land is linked to its price and also to the Floor Space Index (FSI) of the site. This, taken along with the various statutory requirements of the piece of land determines how much builtup area the site will sustain. The FSI (similar to the Floor Area Ratio or FAR) is the ratio between the site area and how much area in square feet can be built upon it. Healthcare facilities command an increase in FSI over other usages even on adjacent or nearby plots, and with the right kinds of authorities being approached many times this FSI can be increased, which will substantially enhance the value of the plot. It is best if this is determined before purchasing the plot. Hospitals in India can possibly get an FSI of 2.0 all the way up to 5.0. A note of caution here; the size (area) of the plot and the FSI will not be the only determinants of how much area can be built. Other municipal regulations such as the open spaces to be left around the building (which are often related to its height) and the Ground Coverage, which is the percentage of the site the footprint of the proposed building can cover, will sometimes prevent you from using the full FSI. Thus, you see that a careful analysis of the plot will go a long way to determine the efficiency and thus the cost-benefit advantages of its proposed usage. There may be a high tension electrical line running through the plot. It should be ascertained whether these can be shifted or how much it will disrupt planning if not. Many such pitfalls await the unwary. While the municipal regulations that come hand in hand with every plot of land will permit the desired usage are a very important site attribute, they differ considerably from city to city, and even with in cities from site to site, and a detailed discussion on them is beyond the scope of this book. The National Building Code of India, however, specifies that the maximum height a hospital building can go up to is 30.00. This height is usually measured from the centreline of the access road to the site, i.e. the widest, major road. We come to the third attribute, the shape of the site. This is usually a matter of common sense. As a thumb rule, we have found that given the area as a constant, for the smaller sites, a ratio of 1:1.5 between the two sides of a rectangle (approximately) works best.

Usually you will find there is only one access road on the short side of the site. If it is on the long side you are luckier. I there are roads on two or more sides of the site you are even luckier and it has access roads on all four sides you are indeed blessed. Small sites with odd, jagged shapes are obviously unsuitable, large sites are a pleasure to work with, despite a few zigs and zags. By orientation of a site I mean the orientation of the building(s) it will permit.

In the smaller urban sites, we have been discussing before, it is unlikely you will have any choice in the matter. As large parts of these hospitals are likely to be artificially lit and ventilated, the orientation is important as to the heat gain from sunlight. Techniques exist to calculate and minimize this with various building features and materials. On larger semiurban and rural sites, the opportunity exists to orient the buildings to make most use of natural light and ventilation. This is the subject matter of a science called Climatology and a detailed discussion is beyond the scope of this book. A lot of reading and reference material is available on this subject in this age of green architecture. I would suggest to future clients that an inherited site or a site bought on the attractiveness of the asking price is not the most cost-

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beneficial way of going about planning a healthcare facility. Attention to the selection factors outlined above would go a long way to contributing to the success of the project.

• Understanding the Scale of the Building(s) In this age of AutoCAD one of the greatest problems I have found with young architects who have grown up working largely on this software is their inability to conceptualize scale, both of drawings and buildings. Model making skills too seem to have suffered and there is a reluctance to build a lot of quick and dirty study models because of the time taken and the easiness with which the building views can be prepared in 3-D. The views are so much more seductive than our little dirty models of Styrofoam of yesteryear that I too stand guilty of being seduced by them, not to speak of the ultimate authority, the client. I leave it to you to decide which road is better. In our youth we had to baptize these models with drops of blood from accidentally cut fingers. As Bob Dylan sings (albeit nasally) …’the times they are a-changing’… We move on to the conceptualization of the scale of buildings while designing on paper. I taught design in an architectural school briefly once, and the thing that most amazed me was that given a design assignment with the same site and the same brief the size of the buildings put down on paper by these students varied greatly! On probing a bit more I found there was no idea in their heads at this initial first cut of design of how big these buildings were. The way I approach the issue is to take the total footprint area of the building, punch it into my calculator and hit the square root button.

Then you draw a square with that dimension to scale. After drawing this square, you can very quickly be using your eye alone modulate this square into various basic building forms of the same area. This gives you a very quick idea about various footprints in plan. To get the thirddimension scale I suggest axonometric pulled up from these building shapes to the appropriate level with the floor heights to scale (in today’s world I feel the need to mention this!) and the buildings will bulk out of the paper. More amazing is that they will stay the same size with respect to your body and you can see the whole site (and its surroundings!) all the time, unlike zooming in and out on the computer (which sometimes makes me dizzy...) It is very important to understand the scale of your designs; simplistically put, you could say it is what architectural space is all about.

• Zoning Zoning of a site is a concept every architect is familiar with, so I will just give a brief description for the benefit of my healthcare professional readers. On a site that has multiple usages by which I mean buildings housing differing kinds of functions it is useful at the onset of design to block out appropriate areas that each usage will occupy. This is done by considering the following factors: • The functional and spatial relationships between the various buildings/usages.

• The topography of the site.

• The vehicular and pedestrian circulation connections between the buildings.

• Any special site features such as trees, existing buildings, water bodies, HT lines etc.

• Orientation of the buildings with respect to sunlight and prevailing winds.

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Decision making tools The whole purpose of indulging in the decision-making process is to make a rational decision.

Rational decision making means a tendency that is suitable to the already existing goals within the given conditions and constraints. Project Management thrives on the rationality of decisions and here is where it is important for the Project manager to have a process which enables him and his team decide rationally about different aspects of the project.

Let us take a look at what really helps to make decisions Facts If you want to make a decision, the basic requirement for the same is gathering relevant information. Appropriate use of this information will be helpful in deciding about ways to reach to the goal or an objective.

Values Decisions are primarily based on situations. An action to a particular situation is determined by values.

Means It is the way you reach your objective based on already devised values and significances Ends These are the intermediate goals which add up to a final objective. Here, you can see that decision making is an iterative process.

In simple words, there are four steps in the process of decision making pertaining to the above points • • • •

Identify the problem, gather relevant information Look out for the constraints and limitations Find, analyse all the alternatives and select the best of them Implement the same and establish a control and valuation system.

Here are some of the most commonly used decision-making models in Project Management SWOT Analysis This is a very common decision-making model specifically used during feasibility study of the project.

SWOT analysis brings unsorted issue to a conclusion when the project is gauges based on Strength, Weakness, Opportunity and Threat.

The steps for SWOT analysis are the same as mentioned above, but there is one caution which needs to be followed which is the emphasis on deep analysis of strength and weaknesses similarly, opportunities and threats.

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Maslow’s Pyramid Maslow’s Pyramid of hierarchical need has been very well spoken and discussed in the HR industry which is an integral part of Project Management. Deduced in 1943, by Abraham Maslow, this decision model speaks volumes about basic human needs and their effect on human behaviour. While working on the projects the most inconsistent variable which a project manager faces is a human resource.

Understanding Maslow’s pyramid helps project manager to identify problems related to human resources.

Maslow typically says that there are five levels of human needs and it is through their accomplishment one by one that the human can reach self-actualization.

The pyramid consists of physiological needs, security requirements, social relationships, recognition and self- actualization.

This theory of understood properly can help a project manager a great deal while working with human resources.

Pareto Principle This is also called as 80-20 rule wherein you prioritize your problems and then find out solutions. In order to understand the concept, this 80-20 rule can be described as an example of problems in organization created by people. We can say that the 80% of the problems are created by 20% of the people in any organization.

Let us say you have a BPO and 5 of the problems in your organization are due to lack of promptness, 3 problems are due to poor linguistic ability and 2 problems are due to poor organization skills. So, you can say that major problem here is caused by the lack of training and development because if you impart training to your employees automatically promptness and linguistics will be taken care.

Monte Carlo Simulation Now here is a cache, Monte Carlo simulation is a model which essentially focusses on the numerous simulations over random sampling yielding results which are approximate. It just tells us that even models can be random and have very less reality attached to it. This Monte

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Carlo simulation model is interesting because of the random sampling and use of probability and statistics to determine the result. In project management Monte Carlo simulation method is used for quantitative risk analysis wherein you will be able to identify quantitative impact of a risk on project’s objective.

Decision Tree Analysis This decision model is used while performing procurement analysis. The question of whether to build or buy is answered using this decision tree analysis. You can give each of the possibility a chance of yes and no in percentages and calculate the amount invested against the amount received. Based on the profits you can decide whether to build or buy for a particular project.

There are many more decision-making models and those can be effectively used in professional as well as personal life. These tools are sometimes regarded highly in the sphere of project management as their capacity of backing up decisions taken by project manager is enormous. A good project manager can understand the need of these effective tools which can be used all through the life cycle of project management.

Goals and objectives Stay on Budget One important objective of the project should be to stay on budget. Every project should have a specific budget assigned. The project manager must keep track of project costs and make adjustments as necessary to avoid going over budget. Typical costs include resources such as team members, supplies, materials and equipment, depending on the nature of the project.

Additional costs might include travel and other administrative expenses.

Finish On-Time Another objective should be to bring the project to completion on time. In order to manage time, many project managers use Gantt charts to track tasks, dependencies and milestones.

Whether a Gantt chart or other tracking model is used, the critical path must be identified.

Critical tasks are those that will delay the project if they are not completed on time. Project managers should identify these tasks, determine how long each will take, and gauge their dependence on other tasks. He should also stay abreast of when critical path tasks are completed so he can gauge the progress toward the objective of on-time project completion.

Stay In-Scope A third objective for a project manager is to keep the project in scope. The project's scope defines its boundaries. If the project represents an engineering design, for example, the scope will identify the features and functionality that must be included. Over time, stakeholders can influence the scope, such as when they try to add new features and functionality that were not originally discussed. In-scope items are typically defined in a work breakdown structure, or WBS. The WBS should be monitored to identify and prevent anything that can impact the project's scope.

Triple Constraints Model If any of the above objectives is threatened, the project manager should see where adjustments can be made in the other objectives to compensate. For example, if the project timeline is being threatened by the late completion of critical path tasks, he must decide if the scope needs to be adjusted to reduce the project's requirements, or if the budget should be increased to expedite completion of other tasks. Similarly, if stakeholders demand making an addition to the project scope, the project manager should determine if the timeline should

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extended or the budget increased. Finally, if the budget is threatened, he must determine if the scope be reduced, or the timeline extended into a new budget period.

Create Quality Building quality into the project management process is another potential objective.

Measuring quality can be based on maintaining the balance of budget, time and scope, in addition to reviewing customer or stakeholder satisfaction indicators. Stakeholders will be satisfied if the project meets all of its key objectives or provides added value by improving the efficiency of the overall process. Additional value can be provided if the project comes in under budget or early, or if the team can meet both of those original objectives while also delivering out-of-scope items that had been identified as “want-to-have” but not “need-tohave” items by stakeholders.

Project sponsor The Project Sponsor is the individual (often a manager or executive) with overall accountability for the project.

The Project Sponsor is primarily concerned with ensuring that the project delivers the agreed business benefits.

The Project Sponsor acts as the representative of the organisation, and plays a vital leadership role through: • providing 'championship' for the project, selling and marketing the project throughout the • • • •

organisation providing business expertise and guidance to the Project Manager acting as the link between the project, the business community and perhaps most importantly, management decision making groups acting as an arbitrator and making decisions that may be beyond the authority of the Project Manager acting as chairperson of the Steering Committee.

Project players In a matrix environment, key players have critical roles in every project’s success. Working in a matrix environment requires that the project manager deal with the styles, interests, and demands of more people who have some degree of control over his project’s resources, goals, and objectives than in a functional or projectized structure.

Critical roles in a matrix environment are • Project manager • Project team members: • Functional managers • Upper management Work breakdown structure The work breakdown structure (WBS) defines the work that is required in order to produce the product or deliverables. It is represented as a hierarchical subdivision of a project into work areas with the lowest generally being a work package or sometimes even an activity.

The lowest level of the WBS should be consistent and agreed at the outset of the creation of the WBS. The WBS provides the foundation for all project management work, including

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planning, cost Creating a WBS: ▪ ▪ ▪ ▪ ▪ ▪

and

effort

estimation,

resource

allocation,

and

scheduling.

enables the definition of the total scope of work provides the ability to assign work to people responsible for carrying out the work establishes a control baseline measures accomplishments objectively when the work is done defines, collects and reports information at the appropriate level required defines the relationships between work, organisation and cost.

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Managing time and project cost Although cost may not always be at the forefront of an active project manager’s mind, ineffective cost management is often the very reason that projects fail. Managing cost is essential to completing a venture and should be considered an important subset of project management.

How to manage cost in project management is often about taking a calibrated approach to your portfolio and understanding the various facets of costs that can arise during a project.

The following are a few tips and pieces of advice for managing project cost: Estimate and Budget Planning is the first step to ensuring a project manager is aligned with the project management budget. This is done by meeting with your team and compiling a realistic estimate of costs. Consider all the project phases, tasks, activities and that it contains sufficient contingency. All people, material, hardware and software should be accounted for and the estimate should be used to achieve a baseline budget.

Once the estimate has been approved and the funds have been released, the project manager will have a baseline budget to work with and use against other project management cost. The monthly budget can now be worked out by dividing the estimated project length with your baseline budget. This will give a project manager an idea of exactly what they can spend in a month to stay on track.

Establish Cost Controls Clear cost controls should be established (including sign-off responsibilities) for every expenditure. Part of maintaining a smart project management budget is planning early on who oversees what monies. Who will be approving and signing off on timesheets? Invoices?

Knowing all of this is crucial to controlling the costs of a project.

Increase your business agility with Clarizen’s project management software Record Costs and Calculate Metrics To ensure you are staying within budget, you should be making cost comparisons between your estimated baseline and the actual amount of money being spent. If the numbers are far apart, a project manager will not be meeting the budget at the end of the project unless they do something. The metrics ought to be calculated at the end of each reporting period and the total amount spent should be compared to what you were expecting to spend.

Update Forecasts If any numbers are off, you need to update your forecasts to have a better understanding of how you will be using future funds more efficiently. You never want to let it get to the point where you are surprised about budget losses and need to ask stakeholders for more. Revisiting these numbers on a monthly basis will allow you to initiate any changes that need to take place and adjust the budget accordingly.

When asking how to manage cost in project management, it is all about planning and continuous updates. Understanding who is responsible for what costs is also helpful for a project manager to stay on task with the budget. Creating a monthly expected budget and frequently matching your forecasts to these numbers will ensure you are aligning tasks as close to the budget as possible. And when the budget is on point, then the project is generally successful.

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Risk What is a risk?

This easy question already shows that risk can be rather difficult to define as expectations are focused on the future and therefore a lot of uncertainties could come into play. Additionally, these uncertainties could result in an outcome that is either more positive or more negative than expected. So, it might be better to start with a definition of uncertainties: Uncertainties = Threats + Opportunities - Threats are events that have a negative impact on any result.

- Opportunities are events that have a positive impact on results; and - Uncertainty encompasses the complete range of positive and negative impacts Risk management Risk management is a procedure to minimize the adverse effect of a possible financial loss by: (1) Identifying potential sources of loss; (2) Measuring the financial consequences of a loss occurring and (3) Using controls to minimize actual losses or their financial consequences.

The purpose of monitoring all project risks is to increase the value of each single activity within the project. The potential benefits and threats of all factors connected with these activities have to be ordered and documented. If the project team is aware of the importance of the risk management process, the probability of success will be increased while at the same time failure will become unlikely.

Risk identification is not solely done by the project manager. All relevant stakeholders are involved in keeping an eye on all risks that matter. Generally, the risk identification sessions should include as many as the following participants: - Project team - Risk management team - Subject matter experts from other parts of the company - Customers and end-user - Other project managers and stakeholders - Outside experts Risk Identification Risk identification is the first and most important step because it builds the basis for all subsequent steps. The risk identification step is very similar to a transformation process. In the beginning you have inputs and, in the end, you have a result or simply an output. In the middle step there are tools and techniques to fulfil the transformation process For the first input for risk, external and internal factors of the project environment have to be considered. External factors could be described as attributes of the environment whereas internal factors are attributes of the (project) organisation itself. Typical examples for external factors are:

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- Economic conditions - Social, legal or regulatory trends - Political climate - Competition – international or domestic - Fluctuation in demand - Criminal or terroristic activities Typical examples of internal factors are: - Internal culture - Staff capabilities/ numbers - Capacity - Systems and technology - Procedures and processes - Communication effectiveness - Leadership effectiveness - Risk appetite Within the Tools & Techniques step you start with the documentation review to analyse information that already exists in a written form. In project management it is the project plan and the planning documents: - Project charter - Project scope - Work breakdown structure (WBS) - Project schedule - Cost estimates - Resource plan - Procurement plan - Assumptions list - Constraints list Risk Analysis The basis of risk analysis is the above explained risk identification. Risk analysis covers a complete and continuous evaluation which should be realized quantitatively as well as qualitatively for all identified risks. The goal is to detect possible interrelationships and enable the project manager to identify a kind of importance order, also called prioritizing.

Furthermore, the consequences for the project itself and the organizational goals can be identified. The evaluation of the risks should meet the following demands: - Objectivity: The reference to the special market should be taken into consideration to make the objectivity practicable. For internal risks a subject evaluation is often necessary.

- Comparability: The evaluation of risks should lead to comparable results.

Therefore, the organisation should use consistent and standardized methods and data.

- Quantification: By means of quantification the organisation is able to detect deviation from the targeted goal.

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Project closeout Project Closeout Phase The Project Closeout Phase is the last phase in the project lifecycle. Closeout begins when the user accepts the project deliverables and the project oversight authority concludes that the project has meet the goals established. The major focus of project closeout is administrative closure and logistics.

Project closeout includes the following key elements: • Turnover of project deliverables to operations • Redistributing resources—staff, facilities, equipment, and automated systems • Closing out financial accounts • Completing, collecting, and archiving project records • Documenting the successes of the project • Documenting lessons learned • Planning for Post Implementation Review

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6.Healthcare project life cycle Introduction The PMO’s involvement at the project level will be framed around the project lifecycle. The major categories usually inherent in a lifecycle include the initiation phase, planning, executing and controlling and, finally, the closing phase. Depending on the ambitions of your organization, it may also make sense to add in an opportunity identification phase.

Once you have set up the project chronology and timeline through a lifecycle, it is essential to define the activities, deliverables, and decisions that occur at each phase. These activities will build your process while the deliverables will be the tools that support the activities.

Initiation phase – The essential tool at this stage of the project is the project charter. The charter should define the project at a high level and include the following components: • Problem statement • Project objectives • Project goals • Team leads and members • Expected benefits • Constraints • Dependencies Planning phase – Planning is more than just listing out the tasks of a project. It is critical that the project manager answers the following questions when planning the project.

• What is the expected project outcome?

• How will the work be done?

• What do you expect of the project team members?

• Who reports to whom?

• When will the work be performed?

• Are there any costs associated with the work?

• Who will be affected by the change?

• When will the team meet?

• Who is required to attend the meetings? How will minutes be recorded?

The work plan is the primary tool that the project manager should use during this phase. The “perfect” work plan will include all project related tasks and key milestones with specific timeframes. In addition, the work plan will list the individuals or teams responsible for each task. Another important tool is the risk register. Mitigating risks is an important responsibility of the project manager and the whole team should support it by pointing out possible barriers to the project.

Execution phase – plans remain merely good intentions unless they rapidly translate into hard work. The execution phase is when the project team begins to realize the initiatives and tasks set out in the work plan. Clear communication and coordination are essential. At this stage, the PMO is responsible for getting the project moving and tracking implementation. This phase has many parallels with the monitoring stage and involves keeping a close eye on all issues and risks.

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To accomplish this in an efficient manner, the project manager and PMO will set up regular meetings, usually every fortnight, to review the work plan throughout the duration of the project. Issues which cannot be resolved during this meeting will be elevated to a senior level committee. The main tools used during this phase are issue logs and meeting minutes.

Monitoring and controlling phase – during execution of the project, it is critical to monitor the Key Performance Indicators (KPIs). Each KPI should have a target established and be measured on a weekly basis. KPIs are typically managed through dashboards which help visa Alize project progress and keep track of goals, budget, and schedule. Dashboards can be developed using business intelligence software or through Microsoft Excel.

Closing phase – a project is complete when it starts working for you, rather than you working for it. Once a project is closed there are a number of activities that can be considered. The first activity should be to review project performance and discuss lessons learned. In addition, the project manager should consider archiving project files in a centralized database so that materials can be easily accessed for future projects. Finally, the team itself should receive recognition and celebrate its achievements!

Preconstruction In the pre-construction phase, we work to determine what type of medical building construction project you need. Our goal is to fully understand what you are trying to accomplish so that we can recommend what might work best for your situation—medical building new construction, upfit, or medical renovation. After establishing the type of project that will work best for you, we generally follow this plan: Establish a budget. One of the most important parts of a medical building construction or medical renovation project is creating and adhering to a budget that you are comfortable with and that allows us to give you the end result you want. We will always provide the most costeffective solutions for your healthcare project.

Find an appropriate site. For new medical building construction, if needed, we will assist you with site selection and will help you find a real estate broker to handle the transaction.

Determine the staff and office space needs for your building. We will talk with you extensively about your vision for your medical office and collect information regarding your staff size, office space needs, and other details about your healthcare business that will help us with your medical building construction or medical renovation project.

Design your project. Our architect has worked alongside the Cunningham-Waters team to create many outstanding medical buildings. We will use his services to create a project perfect for you. And, with our computer-assisted design process, we will work with you on interior selections, from trim work to windows. This process also helps determine if any adjustments need to be made to the healthcare construction budget to accommodate any changes.

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Avoid unexpected surprises. Our goal is for you to be completely satisfied with your medical building construction or medical renovation. We strive to remain within your budget, avoid any unexpected surprises, and meet our agreed upon completion date with a quality healthcare construction project that exceeds your expectations.

Feasibility study A feasibility study in healthcare is part of a strategic plan designed to address a medical, acute, or long-term care, in or outpatient service expansion or new development. The healthcare feasibility study and strategic planning process encompasses several components.

First, the market study identifying where the customers are and how they get connected to your service. Second, a financial feasibility analysis, typically encompassing three to five years of pro forma financial statements. The final step in the completion of the healthcare strategic planning process are the business plan components specifying the execution plan for making the project a reality.

Financial analysis Financial feasibility analyses demonstrate the ability to reach the desired level of return The second component of a feasibility study, the financial feasibility analysis, focuses on the development of detailed operating pro forma financial statements. These statements should outline in detail, both revenue and expense items for your project. Since these are pro forma statements, it is important to specify the myriad of assumptions that were utilized in identifying the revenue and expense items in the pro forma. These pro forma statements can project income/loss at the net operating line or can even take into consideration asset related expenses and thus, project down to the net income line.

We tend to recommend that the financial feasibility analysis account for the financial performance of the proposed project from the time of opening until 12 consecutive months of stabilized operations. Doing so allows the analysis to cover the full start up period (which in turn identifies the amount of working capital required to sustain the operations through the period of financial loss) and also identifies the amount of profit at the time of operational maturity.

Detailed project report As the identification and intention for the implementation of the project grow, the depth of the study for the probable project increases. Further analyses of the details relevant to such a project become imperative.

We know that the feasibility report contains sufficient detailed information. It is from the study of the pre-feasibility or feasibility report that approval is made by the project owner (an individual or a project director/manager or the management of a company) for the investment on the project or for a request to prepare the DPR. Preparation of DPR is a costly and time-taking job (which may even extend to one year) when reports of specialists from different streams like market research, engineering (civil, mechanical, metallurgical, electrical, electronics), finance etc.—as relevant to the project itself—are considered in the DPR.

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Example of a space programme for emergency care service

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Example of functional plan for ambulatory care services

▪ Room Data Sheets The room data sheets are an extension of the space program. Usually confined to an A3 sheet, it can contain a plan of the room, minimum dimension of the space, a list major items of medical or other equipment to be housed within that space, and any unique temperature, humidity, lighting etc. conditions.

Without the plan, the same information can be given in an Excel sheet, and the plan can be added after schematic design is done to complete the sheet. At this stage the room data sheets could only be generic to help the non-healthcare architect plan the furniture, fixture and equipment plan (FFE). For the room data sheets to be of optimal use, they would need to be prepared after the FFE is in place.

• Stack Plan A “stack” plan as the name suggests is not an architectural plan but an Excel spreadsheet which has the departments from your space program listed on the Y axis and the floors as in basement, ground, first etc. listed on the X axis. The idea is to distribute the areas of the

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departments on the various floors to get a handle on how much area each floor template is holding, and which departments too. Now for this exercise to be productive and realistic, the designer needs to have conceived some sort of basic building form derived either from site restrictions along with height constraints, or maybe from a preliminary working of what kind of inpatient tower he/she has conceived of, in conjunction with then either a straight tower, a tower plus podium building form or any of the other various kinds of building forms possible.

It could also be based on some formal conception of the building, which, however, would take a lot of experience and confidence.

At times the healthcare facility may comprise of several buildings on a healthcare campus.

You could then replace the floor list with building numbers and prepare a so-called “stack plan” for various buildings on the campus instead of floors. Of course, you would then need to prepare the regular stack plan for each building. The designer may be tempted to hold all this information in his/her head, as they are usually notoriously shy of paperwork and in a rush, as I have mentioned before, to start the design process. A word of caution here, healthcare facility design is always much more complex than design of other building types that you might come across, and these documents will help you steer your way through the time-consuming and thus expensive pitfalls that you will face. By using an Excel spreadsheet, it is easy and quick to examine various alternatives and fine tune the area distribution.

Tendering /Types of Tendering Healthcare Projects What is Tender?

Definition Tendering is the process of choosing the best and cheapest company to supply goods and services by asking several companies to make offers for supplying the goods and services.

Tender is an offer which incorporates the sum of money, time and other conditions required to carry out the contract obligations in order to complete a project or a part of it consisting of specified works.

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3. Types of Tendering The majority builders still obtain much of their work by system of tendering. There are three principle method of choosing a contractor. They are, 1. Open Tendering 2. Selective Tendering 3. Negotiated Tendering 4. Open Tendering This usually takes the form of an advertisements in a national or local newspaper inviting contractors to apply for tendering competition for carrying out the work. The main characteristic of which are given usually the deposit is required in order to discourage frivolous applications. The deposit is returnable on submission of a tender. In this method allows any contractor to submit a tender to an advertised project.

Process • Client advertises openly in the press or the trade publications inviting contractors to apply for the project • Contractor that is able to undertake the project would request a tender document • After receiving the tender from the architect, the contractor may be required to give a deposit and to ensure a bona fide tender. This is done to filter out the contractors who are not interested in submitting a tender.

Advantages • Keep competition from large number of applicant.

• Possibility to get competitive price.

• No chance for favours.

• Provide opportunities to new comers, unknown contractors to enter to the market.

Disadvantages • Time and cost taken to review the large number of applicant.

• The cost of tendering accumulated to the industry and general cost to the industry is high.

• Difficult to evaluate and select best one from wide range of applicant.

2. Selective Tendering Contractor apply to be included on an approved list maintain by an employing body often an architectural practice, local authority or statutory body. These organizations have extensive knowledge and experience of individual contractors and regularly review contractor performs and approval list from such list. There are able to select contractors most suited to the contract the number invited will according to the value of the contract.

• Note • Compile a list of preferred builders for the project.

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Healthcare project life cycle

• Based on builders established skill. Reliability and proven competence for the type of work given.

• Each contractor is bend ask to provide a tender.

Advantages • Cost of tendering is reduced.

• Time consuming for the tender evaluation is reduced.

• Allow only capable and approved firms are to be tender.

• Provide limited competition and easy to screen and select.

Disadvantages • Let’s competition forces high tender sum.

• Opportunities for collusion among competitors and mislead the time.

• Mis opportunities. (new comers) • Industry complain those who have not short listed.

3. Negotiated Tendering In this process only well, reputed contractors are being negotiated by inviting them to submit their tenders. Client can contractors determine the perimeters for negotiation before commencement of the project. The maintenance of positive relationship during the negotiation process in essential.

Why client went to negotiate?

• Business relationship • Contractor, finance project (client find difficult to finance then negotiate with the builders who is willing to finance the project) • Continuation of contract • Special circumstances (only one contractor available to work) • Special expertise of equipment • Wish to take advantages of the builder’s specialized knowledge at the design stage.

• To have quick start Advantages • Expected quality and functions can be achieve more.

• Speed up the entire project.

• The project objective and definition may be managed. (builders involvement of the design stage) Disadvantages

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Healthcare project life cycle

• Non-competition forces for high tender sum.

• Less formality make course more contract administration inquiries.

• Lack accountability.

Flowchart of tendering process

Tendering Process Tendering process can be divided in to six stages. These stages are shown in below Stage 1: Preparation • Final completion of drawings, specification, measurement / take-off process.

• Choose conditions of contract.

• Parties involved: architect, engineers, QS, client, project manager Stage 2: Approval to tender • Discussion and decision on type of tender to be used.

• Selection of tender: • Open • Selective • Negotiate • Parties involved: client, consultant, project manager.

Stage 3: Tender Documentation • Letter of invitation to tender • Letter of acceptance • Bills of quantities • Relevant drawings • Schedule of rates

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Healthcare project life cycle

Stage 4: Invitation • Based on selection of tendering methods • Open / competitive / bid tender – produce tender notice • Selective – shot listed contractors will be invited to tender if they wish • Negotiated – only one contractor is approached- direct entry to project Stage 5: Processing • Received tender submitted by contractor • Tender assessment / evaluation • Completed tenders are received • Arithmetical check • Reasonable tender sum • Reasonable completion time • Capabilities of tenderers under considerations • Tender recommendation / report – tender board Stage 6: Award contract • Pre-award meeting with contractors – validation of lowest complying bid • Validate lowest bid - Pre-contract meeting with contractor for contract signing • Approval by tender board / treasury (tender exceeds RM10 mill.) – an acceptance of tender form is issued to tenderer, signed by the authorized officer

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Healthcare project life cycle

Flowchart showing construction work of the typical projects & Flowchart showing commissioning of hospital

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Healthcare project life cycle

Flowchart showing handing over project

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Case Study

Case study Name: Asian Heart Institute and Research Centre Location: Bandra Kurla Complex, Mumbai Type: Super Speciality Size: 250 beds BUA: 450000 No of floors: 2B+G+10 Duration: 48 Months Preconstruction: 22 Months Construction: 22 Months Post Construction: 4 Months Date of Commencement: April 1998 Date of Completion: April 2002

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Case Study

Project phasing The hospital will be developed in three phases are proposed for activity purpose. The phase will cover construction of two basements in full and part ground floor, second floor, third floor, service floor and two patient floors (4th and 5th floor) however only part of the area on these floors will be finished and furnished for immediate occupation in the phase 1 The phase 2 will be for finishing the balance area constructed under phase 1 but left unfinished /unfurnished The phase 3 will be the total development of the project Floor Total Area

Phase 1 Construction

Phase 2

Finished

Phase 3

Finished

Construction

Finished

Basement 2 (7245)

7245

NA

NA

--

NA

Basement 1 (5835)

5835

NA

NA

--

NA

Ground (3640)

3360

3270

90

280

280

First (2953)

2811

2518

293

142

142

Second (3332)

3190

1704

1486

142

142

Third (3571)

3429

3022

407

142

142

Service (3571)

3429

--

--

142

--

Fourth (2586)

2207

2207

--

379

379

Fifth (2586)

2207

1697

--

379

379

Sixth (2586)

--

--

--

2586

2586

Seventh (2586)

--

--

--

2586

2586

Eight (2586)

2586

2586

Ninth (2586)

2586

2586

Tenth (2586)

2586

2586

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Case Study

Space programme

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Case Study

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Case Study

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Case Study

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Case Study

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Case Study

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Case Study

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Case Study

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Case Study

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Case Study

Name: Wockhardt Hospital Location: Mira Road (East), Thane, Maharashtra Type: super speciality Size: 350 beds Total BUA: 1,64,038 sq. Ft No of floors: G+14 Duration: 48 months Date of commencement; February 2007 Date of completion: November 2010

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Case Study

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Case Study

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Case Study

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Case Study

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Case Study

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Case Study

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Implementation

Implemetation The healthcare project construction management has a good scope in country like India. The majority of hospital in India in todays time also get delayed in construction due to no availability of project management in healthcare. Most of project management in India are done by foreign players like architects, interior designer, project management, construction project management etc. India has large scope in healthcare sector, currently HOSMAC is the only firm in healthcare which is engaged in healthcare project management.

India has growing and largest population and need the better healthcare facility thus need healthcare construction and project management for proper facility in construction of hospitals and better construction. There are currently 3 million healthcare professionals in India in which only 0.9 million are registered doctors. Thus, we are in need of healthcare facilities currently we need 6 million healthcare professionals for healthcare The frame work of guidelines is setup as follows

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Implementation

The 3 method in management of healthcare projects which we follow was

The majority of project delayed the reasons are SR.NO FINANCE 1 FLUCTUATION OF PRICES

DELAY IN PROJECTS LITIGATION GOVERNMENT INTERFERENCE

TECHNICAL ERROR DURING CONSTRUCTION

2

SHORTAGE OF MATERIAL

GOVERNMNET POLICIES

IMPROPER PLANNING

3

DELAYS IN PAYMENT TO CONTRACTORS

ACT OF GOD

DESIGN CHANGES

4

FUNDING PROBLEMS

POOR UNDERSTANDING OF PROJECT

SKILL LABOUR SHORTAGE

5

MONEY RELATED PROBLEMS

CONTRACTUAL CLAIMS

REWORK DUE TO ERROR

6

INACCURATE COST ESTIMATION

ACCIDENTS

OLD TECHNOLOGY

CONFLICTS AMONG THE INVOLVED

LATE DELIVERY OF MATERIALS

7 8

MULTIPLE PROJECTS BY CONTRACTORS

The majority of healthcare project delayed in india thus we find the solution for it

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Implementation

Comparision of case studies COMPARISON OF CASE STUDIES APPOLO BSR,BHILAI

ASIAN HEART

WOCKHARDT

Construction Time completion is within 4 years

Construction Time completion was 5 year

Construction Time completion was 4 year

Area 4,80,000 Sq.ft

Area 4,50,000 Sq.ft

Area 1,64,038 Sq.ft

Correct use of PM tools and techniques: should improve efficiency of process

Traditional approach on civils contracts little contractor involvement in design or constructability though contractors could offer alternative designs risk analysis used throughout project.

There were no tools and techniques were used of project management were used

Project culture team-based partnership approach improves likelihood of project success

Projects managed through Project Director/Project Managers and large project team became inflexible and adversarial.

Project was managed by local contaractors, and small team of professional along with the directors of the project

Using of modern construction equipment’s and other tools and techniques for fast construction

During construction no modern tools were used even in some cases there were manual feeling in construction of RCC

During construction the local contract were appointed for construction no use of modern tools and techniques

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Implementation

Project schedule comparison

SR NO

1 2 3 4 5 6 7 8 9 10 11 12 13 14 26

PROJECT SCHEDULE MASTER SCHEDULE OF THE PROJECT TASK NAME APPOLO ASIAN WOCKHARDT BSR HEART HOSPITAL ,BHILAI HOSPITAL DURATION DURATION DURATION (DAYS) (DAYS) (DAYS) TOTAL DAYS 1460 1460 1825 DRAWING PHASE 315 423 511 ARCHITECTURAL DRAWING 80 105 123 STRUCTURAL DRAWING 45 47 60 ELECTRICAL DRAWING 35 39 47 PLUMBING DRAWING 35 42 58 WORKING DRAWINGS 40 54 65 SERVICES DRAWING 30 48 57 LANDSCAPE DRAWING 35 60 68 ELEVATORS DRAWINGS 15 28 33 CONSTRUCTION PHASE 1095 1095 1314 RCC WORKS 544 623 733 FOUNDATION & RETAINING WALL 150 163 176 GROUND FLOOR TO TERRACE FLOOR 300 255 373 MASONARY BASMENT TO TERRACE 219 137 216 FLOOR

38 WATERPROFING BASEMENT TO TERRACE FLOOR

650

555

623

44 SERIVCES WORKS

197 90 120 90 120 60 60 134 100 60 30 60 70 50 120 120

215 80 132 100 165 79 75 155 169 79 45 75 89 79 149 135

232 105 123 111 230 99 75 189 222 98 65 88 109 111 191 165

45 46 47 48 49 50 51 52 53 54 55 56 57 58 59

PLUMBING WORK ELECTRICAL WORK HVAC WORKS ELEVATORS FIRE FIGHTING WORK FIRE DETECTION SYSTEM INTERIOR WORK DOOR AND WINDOW STAIRCASE RAILING LANDSCAPE FALSECEILING PAINTING & POLISHING POP WORKS EQUIPMENTS FURNITURE

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Implementation

Process for implementation Mostly the healthcare project delayed are due to three conditions 1.FINANCE 2.LITIGATION 3.TECHNICAL Finance To solve the financial issues we have tied up with NBFC bank so the cash flow should be there in entire project while construction. The majority of project halts and stops due to financial need in projects. Well with NBFC banks we get opportunity to open ESCROW account and thus we solved the financial issues in project by help of NBFC banks.

Litigation Litigation is another issue which we face in every construction project either it technical or government or local people harassment the entire project could stop in legal terms and conditions. To carry on with smooth construction with out halting or disturbing the project we have applied the CAVEAT from high court and get renewed every 90 days from high court to carry on smoothly construction without any disturbance and hesitation.

Technical The technical issues are mostly get project delayed due to using of old technology materials thus healthcare project delayed to solve the delay process we have used PPCP (Polypropylene Co-Polymer) shuttering which help to reduce time consumption as well cost, with this material entire project completed very fast and we have achieved the optimization results PPCP Benefits • • • • • • • • • • •

Good fatigue resistance Good heat resistance Strong & Durable.

100% recyclable & Non toxic Water resistance, will not rot & mould Excellent acid and chemical resistance Very low moisture absorption Impervious to moisture, insects & salts, Wide variety of application, Virtually maintenance free Higher scratch resistance

Concrete process In most of construction project the DE shuttering is done in 7 days but with advance concrete we can reduce the number of days by achieving the same strength thus there are some chemical compound to get mixed in the process Mostly these are calcium compounds such as calcium chloride, calcium nitrate, calcium formate. With this chemical we may reduce the no of days and can be done DE shuttering within 5 days than 7 days thus we are saving the cost and days also.

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Conclusion

Inferences On performing the case studies to evaluate the present data scenario, I was observed that healthcare project management is primarily based on experience at site.in the projects that were implemented in the beginning of the 21st century, the documentation of the projects falters during many phases. Due to this, limited information is available on the life cycle of these projects, with time, the importance of documentation of projects is being realized as there is improvement in the approach towards documentation in projects like Asian heart institute, which are currently being executed It was also found that in most cases, the different phases of the project lifecycle were considered in isolation. The approach to the project has always been more task oriented than project oriented. The project team is more focused on completing the milestones than the completing the project. This outlook has led to poor co-ordination and thus delays in the project.

The project management consultancy has been appointed during the pre-construction phase in all cases. This approach towards healthcare project management opposes the basic concept of project management.as on today, there are two schools of thought with regards to the role of project management .in theory project management consultants assist the client through entire process from project inception to closure.in practise, however, the project management consultancy overlooks only the tendering aspect of pre-construction phase while the construction and post construction phase are seen in totality Recommendations Based on the study, it was observed that there is disparity between the theoretical and practical approach towards healthcare project management.an attempt must be made to bridge this gap to ensure the smooth movement of the project from beginning to closure The following points should be kept in mind while carrying out healthcare projects

:

I. It is essential that the project manager be an independent authority who is not associated with any of the stake holders of the projects so that he is neutral is judgement is unbiased II. The project manager should be a part of the decision-making process of the project from the inception to the commissioning. He should be an advisor while forming the project team III. The different members of the project team should have a formal induction into the project, to clarify the goals, objectives, requirement and expectations of the project. Team building activities should be conducted for breaking the ice between the individuals and giving them time to bond. Many may look at these programs as time consuming but they help in ensuring the smooth flow of the project and ensure that the individuals are aligned with the team and project goods and objectives IV. A document management plan should be made at the very benignities document should define how the documentation of the project should be carried out during the different phases.

V. A project charter should be compiled at the beginning stating the mission, vison, goals, objectives, etc of the project. The project organogram, roles and responsibilities, reporting structure, communication guidelines etc. Should also be defined in this document

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Conclusion

VI. A master plan of the project should be made in the beginning to identify the approximate time frame required to complete the project and the resources required during the life cycle VII. It is essential that this schedule be updated at specific intervals to track the project VIII. Incase of delay in any activity, the reason for delay shall be mentioned as a note and its effect on other activities should be noted and adequate measures should be taken IX. Periodic review meetings should be conducted to track the progress of the project. The duration of these meeting should be pre-determined along with the intervals between meetings.an agenda should be circulated well before the meeting so that the members are prepared beforehand. The minutes of the meeting should be prepared and circulated within the team at the earliest and action plan shall be outlined X. The signoff of the client should be sought at every milestone to ensure that the project is progressing as per their requirement and expectations.

XI. Any small or major incident or even should be recorded in a project log book. Any minor or major decision taken and he reason for it should also be recorded XII. In case of accidents, accident reports should be prepared stating the cause and extent of damage XIII. A quality manual and quality assurance plan should be prepared at the beginning of the project. Audits should be conducted at periodic intervals to ensure that the project is progressing as per the quality standards required.

XIV. In case of changes, a change register shall be prepared listing the time and reason for change.it should be ensured that the aspect of change is circulated to everyone within the project team.

XV. Lessons learned register should be maintained stating the different issues that arose during the project and the action plan adopted along with its impact on the issue. This will help for making decisions in the future XVI. The project team should be kept motivated throughout the project and periodic formal and informal team building activities should be planned to keep the morale high XVII. At the end of the project, a project closure report shall be prepared indicating the lifecycle of the project, the mile stone and important events.it should also contain the documents required by the clients for future use like the as built drawings, approvals and licenses, list of equipment and their details along with the vendor and maintenance details. A brief of the cash flow and resources involved may also be indicated along with the project team.

XVIII. An adjourning meeting or celebration should be planned to mark the completion of the project and adjourn the project team. This is an expression of acknowledgement to the hard work put in during the lifecycle of the project and serves as a platform to give the appropriate credits to the project team These recommendations along with the activities mentioned in the earlier chapters of this dissertation will ensure that complex healthcare projects are dealt in the best possible way to ensure the smooth flow of the project in the most efficient and effective manner.

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References

References Health Care Industry an Overview Economy watch: world industry directory: healthcare industry International Standard Industrial Classification Rev4 Code Q Economy Watch: Indian Industries: Health Care Industry in India HOSMAC foundation Consolidated FDI policy, DIPP www.expresshealthcare.in Working Definition Project Management for Healthcare-David Shirley www.bussinessdirecory.com www.medicaldirectory.com Health Care Project Management Project Management for Healthcare-David Shirley The Project Team Project Management for Healthcare-David Shirley manuals of different organizations contract documents of different projects job description various websites The Healthcare Project Lifecycle Interview of Mr.J.C. Pariera, Consultant at HOSMAC India Pvt Ltd Interview of Ar. Satish Bhalerao, GM HOSMAC Projects, HOSMAC India Pvt Ltd Dr. Abhishek Pawar, Management Consultant at HOSMAC India Pvt Ltd Mr Kunal Vaidya, Interior Designer, HOSMAC India Pvt Ltd Case Studies Project Document by the PMC

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Bibliography

Bibliography Internet www.wikipedia.com www.slideshare.com www.scribd.com www.google.co.in www.expresshealthcare.in www.bussinessdirecory.com www.medicaldirectory.com Books Project Management for Healthcare - David Shirley Manuals of Different Organizations Contract Documents of Different Projects Economy Watch: Indian Industries: Health Care Industry in India Miller, Richard L. and Swenson, Earl S., New Directions in Hospital and Healthcare Facility Design. New York: McGraw-Hill, Inc., 1995.

Cox, Anthony and Groves, Philip, Hospitals and Health-Care Facilities: A Design and Development Guide: London: Butterworth Architecture, 1990.

Cynthia Hayward, SpaceMed Guide: A Space Planning Guide for Healthcare Facilities: HA Ventures and Hayward & Associates, LLC, Ann Arbor, Michigan.

Wilbur H. Tusler, SMP, San Francisco, California, with Frank Zilm James T. Hannon, and Mary Ann Newman, Programming: The Third Dimension.

Library IES College of Architecture Rachna Sanad College of Architecture (Academy of Architecture) Dr. Baliram Hiray College of Architecture

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List of Figures

List of Figures 1. News Paper Cut-out

25

2. Average Cost Per Hospitalization

25

3. Public Vs Private Participation ICT In Healthcare

47

4. NABH

60

5. Key Communication Challenges

61

6. Key Stakeholders

61

7. SWOT Analysis

71

8. Maslow Pyramid

72

9. Pareto Principal

72

10. Construction of house

75

11. Risk Management Process

77

12. Project Management knowledge areas

78

13. Tender

85

14. Tender Process

88

15. Flowchart Showing construction work of typical projects and

90

flow chart showing commissioning of hospital 16. Flowchart showing handing over project

91

17. Asian heart building photos

92

18. Plan 1st to 5th floor

95-100

19. Wockhardt hospital photos

101-103

20. Plan 1st to 14th floor

105-110

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List of Tables

List of Tables 1. Healthcare industry analysis

15

2. Infant mortality rate

32

3. Census of India, central statics organization of India

32

4. PPP model public private partnership

34

5. Porters five forces analysis

39

6. SWOT analysis

41

7. Stake holder healthcare PPP

42

8. Public vs private providers in healthcare

43

9. Public vs private financing in healthcare

45

10. Public vs private participation ICT in healthcare

45

11. Project management team

67

12. Lifecycle and recurring activities

81

13. Example of space programming for emergency care services

84

14. Project phasing

93

15. Space programming

94

16. Space programming

110

17. Appendix registration and licenced required

120-122

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List of Abbreviations

List of Abbreviations ACHS - Australian Council of Healthcare Standards AHIRC - Asian Heart Institute and Research Centre AIIMS - All India Institute of Medical Sciences ALOS - Average Length of Hospital Stay ANDA - Abbreviated New Drug Application

DPR - Detailed Project Report EBITA - Earnings Before Interest, Tax and Amortisation EMR - Electronic Medical Record EPS - Earning Per Share EPS - Engineered Performance Standards EVM - Earned Value Management F-Finnish

AYUSH - Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy

FDA - Food and Drug Administration

BEP - Break Even Point

FF - Finnish To Finish

BOQ - Bill of Quantities

FS – finish To Start

BPL - Below Poverty Line

GDP – Gross Domestic Product

CAGR - Compound Annual Growth Rate

GE - General Electric

CAT/CT - Computerised Axial Tomography

HCL - Hindustan Computer Ltd

CCHSA - Canadian Council on Health Service Accederation

FDI - Foreign Direct Investment

HIPAA - Health Insurance Portability and Accountability Act HP - Hewlett Packard

CEO - Chief Executive Officer

HQS - Health Quality Services

CER - Cost Estimation Relationship

HR - Human Resources

CFO - Chief Fire Officer

HAS - Health Savings Account

CGHS - Central Govt Health Schemes

HVAC- Heating, Ventilation, And Air Conditioning

COHSASA - Council of Health Service Accederation For South Africa COTW - Cards on The Wall

IDFC - Infrastructure Development Fiancé Company

DBR - Design Basis Report

IIMA - Institute of Innovative Management Approach

DFID - Department for International Development

IMA - Infant Mortality Rate

DG - Diesel Generator

INR-Indian Rupees Rate

DIPP - Department of Industrial Policy and Promotion

IPS - In Patient Department

DMLT - Diploma in Medical Laboratory Technique

IRDA-Insurance Regulatory and Development Authority

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List of Abbreviations

ISIC - Industrial Standard Industrial Classification

NHS-National Health Service NRHM - National Rural Health Ministry

ISQUA - International Society for Quality in Healthcare

NRI - Non-Resident Indian

IT - Information Technology

NUHC - National Union Healthcare Workers

JCAHO - Joint Commission on Accederation Of Health Care Organisations JCI - Joint Commission International JCR - Joint Commission Resources JV - Joint Venture LEED -Leadership in Energy & Environmental Design

O&M - Operations & Management OR - Operating Room PACS - Picture Achieving Communication Systems PAKH - Prince Aly Khan Hospital PDM - Precedence Diagramming Method PEST - Political

M&A - Mergers and Actuation

PMC - Project Management Consultancy

MBBS -Bachelor of Medicine, Bachelor of Surgery

PPP - Public Private Partnership

MD – Doctor of medicine MEP – Mechanical, Electrical & Plumbing MGPS - Medical Gas Piping Systems

QA - Quality Assurance QC - Quality Control R&D – Research & Development RDS - Room Data Sheet

MIMS - Malabar Institute of Medical Science

S - Start

MRI - magnetic

SIEU - Service Employees International Union

MS – Master of Surgery NABH -National Accreditation Board for Hospitals & Healthcare Providers NASA - The National Aeronautics and Space Administration

SF - Start Finish SOAP - Subjective Objective Assement Plan SOW - Statement of Works

NCAER -National Council of Applied Economic Research

SPV - Special Purpose Vehicle

NCMC - Northwood Medical Care Centre

SS - Start to Start

NGO-Non-Government Organization

TEV - Techno Economic Viability

SS -Scope Statement

TPA - Third Party Administration VAC - Volts Alternating Current VP - Vice President WBS - Work Breakdown Structure

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Appendix

Appendix 1 Registration and Licences Required REGISTRATION AND LICENCES REQUIRED REGISTRATION REQUIREMENTS TIME TO SR.NO PROCEDURE COMPLETE 1 145 Days Obtain Construction Drawing Plan Approval 2 30 Days Obtain Approval of Construction from The Area Development Authorities 3 Notify the Municipal Corporation of The 7 Days Construction Foundation 4 Receive an On-Site Inspection by The 1 Day Chief Engineer of The Municipal Corporation 5 Receive an Inspection by The Assigned 1 Day Sub Engineer of The Municipal Corporation 6 Receive an On-Site Inspection Midway 1 Day Throughout Construction by The Assigned Sub Engineer of The Municipal Corporation 7 8 9

10 11 12 13 14 15 16 17

18

COST TO COMPLETE INR 37,729 No Charge No Charge No Charge No Charge No Charge

Receive an Inspection Midway Through Construction by The Fire Department Apply for An Occupancy Permit at The Municipal Corporation

1 Day

No Charge

1 Day

No Charge

Receive Final Inspection of The Construction by The Municipal Corporation Apply for Approval of Completed Construction from The Fire Department Receive Inspection of The Completed Construction by The Fire Department Apply for Permeant Water and Sewage Connections Receive an Onsite Inspection and Water Connection by The Utility Provider Receive an Onsite Inspection and Water Connection by The Utility Provider Obtain Permanent Water and Sewage Connection Apply for Permeant Power Connection Receive an Onsite Inspection and Electricity Connections by The Utility Provider Apply for Telephone Connection

1 Day

No Charge

1 Day

INR 70,000

1 Day

No Charge

1 Day

INR 50,000

1 Day

No Charge

1 Day

No Charge

62 Days

No Charge

1 Day 39 Days

INR 25,000 No Charge

1 Day

No Charge

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Appendix

19

20

Receive an On-Site Inspection and Telephone Connection by The Utility Provider Obtain an Occupancy Permit

13 Days

No Charge

30 Days

INR 10,000

LIST OF LICENCES, REGISTRATION AND APPROVALS SR.NO LIST OF ITEMS AGENCY 1 Nursing Home/Health License (Form B) Local Ward Office MCGM 2 Drug License-Form-12 (Permission to Central Government Import) 3 Storage of Spirit Municipal Authority 4 Storage of Acids, Alcohol, Acetone, X- Excise Department, Old Custom House Ray Films, O2 Cylinders Cylinders (Kitchen) 5 License for Spirit - Denatured Spirit -Iv Excise Department, Old Custom House 6 LICENESE FOR ALCOHOL Excise Department, Old Custom House RECTIFIED SPIRIT II 7 FOOD INSPECTOR LICENSE (FOR Municipal Authority, Public Health EATING HOUSE & STORAGE OF Department KITCHEN ITEMS) 8 LICENCE FOR NEON LIGHT/SIGN Local Ward Office MCGM BOARD 9 LICENSE FOR BLOOD BANK District Drug Controller & FDA 10 LICENSE FOR PHARMACY District Drug Controller & FDA 11 FOR DRUG STORE - FORM D&B

Local Ward Office MCGM Under as Shops and Establishment Act REGISTRATION 12 Reg Under Shops & Commercial ESTB Act Local Ward Office MCGM 13 Hospital (Esp, Conducting Mtp) Public Health Department, Municipal Authority South 14 Reg With Dept Of Health Govt Of Maharashtra 15 16 17 18 19 20 21 22 23

Reg Sales Tax for Pharmacy Provident Fund No ESIS Exception Ref of Vehicles(Ambulance), Taxes Etc 35AC For Research Centre Building, Equipment, Land & Vehicles USG AS PER PNDT ACT 1994 Local Road Tax for Vehicles Occupancy Certificate

Govt Of Maharashtra PF Commission PF Commission RTO Income Tax Insurance Local Ward Office MCGM Municipal Authority Municipal Authority

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APPROVAL Setup of Imaging Dept (X-Ray, MRI, Ct, BARC-Central Government Mamo, Cath) Ga Cam.Ria Electrical Installation PWD -Municipality Authority

26

Lifts

27

Fire Fighting (Appendix D)

28 29 30 31

Liquid Oxygen Plant (Usually Done by Vendor) Incinerator & The Chimney STP Boiler (If Above A Certain Standard)

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Authorization for Waster Generation

Pollution Control Board

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Tie Up for Waste Disposal

MCGM

24

Electrical Inspectorate-Municipal Authority Chief Fire Officer, Mumbai Fire Brigade With MCGM Chief Controller of Explosives Pollution Control Board Pollution Control Board Pollution Control Board

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Appendix

APPENDIX 2 HEATHCARE CONSULTANCY PROCESS PROJECT • Facility Mix The facility mix is a list of the various components of the proposed hospital and is derived from the Detailed Project Report. It will give the number and types of inpatient rooms and wards, thrust areas for the proposed hospital i.e. the departments or modalities that will form the cutting edge of the various services the hospital will offer, and a list of other departments and support services necessary. This facility list forms the input for the functional and space program, discussed next.

• Functional & Space Programs Once you have agreement on a capital investment strategy and a facility mix (derived from the detailed project report), it is time to undertake programming. The detailed project report (DPR) may have been done for a long-range planning strategy, a short-term need or maybe both. The functional program and the space program is to be prepared for the short-term project or for phases of a longer-term project for which planning has already been done in totality, like a teaching hospital. It serves as a common policy document which outlines the parameters and vision of the project for all the members of the planning and design team. It should also contain all the necessary information for the architectural design team to commence conceptual and schematic design.

Architects and the designers among them in general are eager to put pencil to paper and are impatient with reading through long briefs. Many times, in my experience I have received plans (or maybe even semi-constructed buildings) where the architect has “jumped the gun” so to speak and then paid a heavy price for that impatience. It is very difficult to extricate the project from this mess if it is semi-constructed, and it invariably results in a compromised design. The method in which the functional and space programs are produced is very important to the healthcare facility design process. This is because in larger projects the initial capital costs very often exceed the long term operational of the facility in four to five years in India and in two to three years in the West. Quality thought being given to the initial planning will go a long way towards decreasing long term operational costs. Care should be taken to develop realistic workload projections in the DPR and distinguishing between actual area requirements and the “wish lists” of departmental heads occupied in building their own subkingdoms. Many times, this kind of empire building will result in the provision of extra, unnecessary space with which nothing can be done later. Traditionally, the space program (or area program as it is also referred to in India) was the only programming document prepared before the start of the design process. As of today, the functional program in combination with the space program is the way to go. The components of the functional and space program for each department of the proposed

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Appendix

APPENDIX 3 Medical Equipment Planning in Healthcare Medical equipment is highly complex and its technology is ever evolving. It demands a high level of knowledge of the precise installation measures, design standards and environmental conditions for proper functioning. These requirements present numerous design challenges while also considering the intricate logistics and lowering overall costs.

From renovations to new builds, our experienced specialists work directly with clinical staff and hospital consultants to understand their needs and ensure the equipment is integrated in a way that optimises the best patient care possible, efficient healthcare delivery and facility performance. With comprehensive understanding of medical equipment specifications, their complex systems and the latest technologies, our experts bridge the gap between the hospital stakeholders and the contractors.

Understanding system requirements System coordination is an important aspect of hospital design, even more so as digitalization evolves. Lighting, alarms and ventilation are some examples of systems that must all be synchronized. The operations themselves, the sophisticated apparatus and the surgical instruments require precise environmental condition depending on their application; our specialists ensure factors such as humidity and temperature are optimal, and that the systems also support infection control, essential for the safe treatment of patients.

We understand the requirements to supply this power-hungry equipment while ensuring backup systems provide 100 percent power redundancy and efficient energy sources.

Challenging medical equipment proximity Equipment locations relative to each other are key to proper functioning and to avoid interference. For example, hybrid operating rooms are equipped with large imaging systems that must work seamlessly next to each other, allowing physicians to care for patients in one place. In Sahlgrenska’s Imaging & Intervention Centre, the unusual proximity of the operating rooms is made possible thanks to lead lined glass and copper or lead cladded walls that shield any interfering radiation.

Ensuring structures are robust and flexible Only 10% of technical installations are visible. Theatres are surrounded by unseen technical rooms, dropped ceiling space and radiation proofed walls. The supporting structures, such as the floors and ceilings, are reinforced due to the weight of the equipment and to reduce vibration. For example, the cyclotron at Sahlgrenska’s Imaging & Intervention centre weighs over 20 tonnes.

Managing complex logistics Implementing new technologies involves a great deal of planning. From pre-design to construction, we support the stakeholders in the realisation of a wide range of projects from proton beam therapy centres to hybrid operating rooms. We have developed and refined our use of specialist computer programmes for the collaborative design of buildings with colleagues such as the architects and contractors, as well as of tracking equipment specification, progress reporting and cost estimations. As specialists in project management we consolidate the complex demands and logistics of delivering an efficient installation process.

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APPENDIX 4 DOCUMENT MANAGEMENT Healthcare files, patient notes, charts, billing records, and other paper and electronic documents are managed in a secure, electronic healthcare records management system where files are searchable and instantly retrievable in Document Locator. The system provides healthcare professionals with an easy-to-use platform for managing healthcare documents electronically and in compliance with regulations like HIPAA. Electronic medical records Convert and manage paper files at the point of arrival and throughout the entire medical records, insurance, billing, and operational areas of the healthcare office. Digitized paper healthcare documents become full-text searchable and are managed together with electronic documents in a unified system. Files can be categorized and organized using any criteria of medical coding, patient record number, or other metadata values.

Accelerate patient and insurance billing with healthcare document management From the arrival of new patients to final patient and insurance billing, electronic healthcare records speed access to information and help avoid delays in the billing process. Paper-based, manual steps are slow and inefficient. Paper is easily lost, delayed in transit, and difficult to find. Electronic healthcare records are available instantly at the search of a keyboard.

Security controls who has access Document security restricts access to healthcare records so that compliance with HIPAA and other healthcare regulations is maintained. A log records all document activity, making it easy to view and audit a history of all document actions.

Benefits of electronic healthcare records • Scan patient insurance cards, identification, and consent forms at the point of arrival to

manage these files electronically • Capture and convert doctor's consultation notes, transfer records, and charts • Profile documents according to patient record numbers, medical coding, insurance coding,

and more • Manage EOBs (explanation of benefits) electronically to speed billing and customer

service

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Appendix

APEENDIX 5 CONTRACT ADMINISTARION Functions of Contract Administration Many of the functions of contract administration involve the planning and development of contracts. These functions include an understanding of all the major components of the contract. The components can include delivery dates, disbursement dates and amounts and terms to accept or dissolve the agreement. Contract administrators often will include the means by which to measure the performance of both parties to determine if they are meeting their obligations, as well as procedures to monitor the performance of both parties.

Examples of Contract Administration When a company prepares to bid out a new project, the company's contract administrator may send out a request for proposal to potential vendors. The RFP invites vendors to send the company a bid on the project. When the company selects a vendor from the various RFPs, the contract administrator works on the language in the contract between the vendor and the company. Both parties review the contract and submit any revisions to the contract administrator.

APPENDIX 6 QUALITY CONTROL IN HEALTHCARE Importance of establishing quality control in health care system was given in this paper. It is necessary to standardize the protocols in any kind of medical treatment. Only main protocols and guidelines allow us to compare its usefulness in everyday practice doctors, medical teams and medical institutions. First, it is necessary to calculate life expectancy tables for population to whom health care system is established. Then, collecting of the data should be systematically performed by health care providers. So, if we use guidelines and standardized protocols in everyday practice we could compare medical work and with other countries which are in our interest.

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APPENDIX 7 SITE MANAGEMENT The Hospital Management and its consultants handle, for several years, the entire chain of project management, dedicated to the specific health sector. Therefore, our professionals are able to: · assist own customers starting from hospital “Concept”, through the design activities until their complete enforceability, coordinate all completion procedure activities and authorizations from the relevant Authorities follow the supervision of the overall fulfilment, ensuring that what was initially conceived and designed can be built in the best possible way, in compliance with agreed deadlines and the forecasting budget.

We count over the years, a variety of highly specialized activities , from planning to realization of operating theatres, transfusion centres, intensive care, cardiology and cardiac surgery, diagnostic (Pet, MRI , CT scans, angiography devices, Mammography devices), oncology ( linear accelerators ) and nuclear medicine (Pet, Gamma Camera, Cyclotron , etc .) units, developed according to the highest global standards and using the most advanced technologies, from both a clinical and a biomedical point of view. Over the years, then, we can include the expertise and experience gained in the integral design of hospitals and complete supplying by a biomedical engineering standpoint. For all of the above, the Hospital Management becomes a candidate as highly specialized” partner” both for the Swiss market and for the global one, providing uncommon and highly professional quality expertise and know-how.

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APPENDIX 8 • CHECKLISTS FOR CONSTRUCTION • CHECKLIST FOR SHUTTERING • CHECKLIST FOR PRECONCRETING • CHECKLIST FOR REINFORCEMENT STEEL • CHECKLIST FOR CONCRETING • CHECKLIST AFTER CONCRETEING • CHECKLIST FOR CONCRETEING COLOUMNS & FOUNDATION • CHECKLIST FOR TERMITE TREATMENT • CHECKLIST FOR ROOF SLAB CONCRETING

• CHECKLIST FOR COMPRESSED AIR INSTALLATION • CHECKLIST FOR AIR CONDITIONING WORK • CHECKLIST FOR COMPLETION PHASE – SUB STATION YARDS • CHECKLIST FOR COMPLETION PHASE – DISTRIBUTION BOARDS • CHECKLIST FOR CONSTRUCTING PHASE – WIRING • CHECKLIST FOR COMPLETION WORK – GENERAL • CHECKLIST FOR ELECTRICAL WORK

• CHECKLIST FOR BOULDER SOLING

• CHECKLIST FOR SAFETY, HEALTH WELFARE ON CONSTRUCTION SITE

• CHECKLIST FOR BLOCK/BRICKWORK

• CHECKLIST FOR FINAL CHECK AND HANDOVER

• CHECKLIST FOR PLASTERING INTERNAL/EXTERNAL

• CHECKLIST FOR SERVICE FACILITY

• CHECKLIST FOR PAINTING WORK

• CHECKLIST FOR EOT / HOT

• CHECKLIST FOR FLOORING/TILING WORK

• CHECKLIST FOR MECHNICAL WORKS

• CHECKLIST FOR FINISHING WORK • CHECKLIST FOR STRUCTURAL STEEL FABRICATION • CHECKLIST FOR LAYOUT/ROADWORK • CHECKLIST FOR WATER SUPPLY/SANITARY • CHECKLIST FOR CONSTRUCTION PAHSE EXTERNAL WORKS • CHECKLIST FOR COMPLETION PHASE

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