healthcare radius magazine march 2013

Embracing modern thinking Vol 1 • Issue 6 • Rs50An ITP Publishing India publication

Registered with Registrar of Newspapers under RNI No. MAHENG/2012/46040, Postal Registration No. MH/MR/N/242/MBI/12-14, Published on 27th of every previous month. Posted at Patrika Channel Sorting Office, Mumbai-400001, Posting date: 30th & 31st of every previous month

MEDICALL 2013A LOW-DOWN

PPP: SOLUTION TO INDIA’S HEALTHCARE WOES?

HOW BAPS YOGIJI MAHARAJ HOSPITAL INCREASED EFFICIENCY

DEBATE: DOCTORS VERSUS SUPPORT STAFF

March 2013Total number of pages 48

AGAINST ALL ODDSDR BS AJAI KUMAR, CHAIRMAN, HEALTHCARE GLOBAL ENTERPRISE, ON MAKING CANCER CARE PROFITABLE

IN FOCUS

CASE STUDY MAKEOVER OF PARAS HMRI

01_HCR_Mar13_Cover.indd 1 21-02-2013 15:39:32

25

Knauf participated as a platinum sponsor in the National Conference onSafe & Sustainable Hospital (SASH 2013) held at the NCUI Convention Centre, New Delhi, on February 9, 2013. Hospitals and healthcare units are respon-

sible for a wide range of functions from clinical care to complicated surgeries to basicservices. SASH 2013 aimed to provide insights into the seamlessmanagement of building a safe and sustainable hospital.

The event's theme was an interactive hospital environment andtechnology, and it offered a preview of numerous hospital products,services and technologies that contributes to hospitals of the future.The objective of the conference was to showcase current research,educational and professional development, and contribute to makinghospitals safer in a sustainable manner.

Knauf had put up a stand at the venue, which was visited by numerous architects,consultants, superintendents of known hospitals, scholars, teachers andstudents attending the event.

Knowing KnaufKnauf Middle East is one of the world's leading productions and construc-tion material company with over 220 facilities and 22,000 employees pres-ent in over 80 countries. Knauf is a family owned business headquartered in Ipfohen-Bavaria, Germany. The 80-year-old company specializing in gypsum products has an astonishing range of over 30,000 products, and that tally is growing all the time.

The company's Dubai headquarter services the entire region, and represents its first foray into Middle-East. In addition, it has a manufac-turing facility in Ras Al Khaimah, and with a production capacity of 30 million square meters of gypsum board a year. This production is exported throughout the GCC, East Africa and India, which constitues Knauf's main growth markets at present.

Partners in growthKnauf Middle East was the platinum sponsor of

SASH 2013, the National Conference on

Safe & Sustainable Hospital

KNAUF LLCPO Box 112871Dubai, UAETel: +971 4 337 7170Fax: +971 4 334 9659

KNAUF QatarPO Box 27111Doha, State of QatarTel: +974 4452 8191Fax: +974 4452 8181

KNAUF KSA BranchPO Box 3051Jeddah, 21471 KSATel: +966 2 606 7364Fax: +966 2 606 7251

KNAUF RAKPO Box 50006Ras Al Khaimah, UAETel: +971 7 221 5300Fax: +971 7 221 5301

Website: www.knauf.ae | E-Mail: [email protected]

00_HCR_Mar13_KANAUF_Consumer Connect initiative.indd 25 22-02-2013 14:30:31

Healthcare Radius March 2013 3

06 NEWS This month’s important news updates

12 SPOTLIGHTThe IACTS 2013 was an ideal platform for learning about new techniques and procedures

16 STRAIGHT TALKDr BS Ajai Kumar, chairman, on the challenges he faced in building a cancer care business

22 PROFILEThe recently commissioned 100-bed BAPS Shastriji Maharaj Hospital at Vadodara

24 ROUND TABLEAre doctors the only heroes?

28 CASE STUDYParas HMRI Hospital's design challenge

32 ANALYSISPPP: The answer to India's healthcare woes? 34 INNOVATIONBAPS Yogiji Maharaj Hospital's unique solutions

36 EVENT REPORTHospiArch in Vijaywada

Contents16

38

22

28

38 INFRASTRUCTUREMore and more hospitals are going for drywalls

42 VIEWPOINTThe value of health technology assessment

43 MEDICALL 2013What attracted the industry to the event

03_HCR_Mar13_Contents.indd 3 21-02-2013 17:45:30

Editor's Note

Healthcare Radius March 20134

Dispelling myths

Sometime back, we were all appalled to learn that Apple Inc’s co-founder Steve Jobs, who was diagnosed with a rare kind of cancer in the pancreas, chose alternative treatments like juice therpay, acupuncture and dietary supplements over surgery, at least in the initial phase after diagnosis. When he finally went

for surgery, it was too late! If people like Jobs resist cancer treatment, what about lesser mortals?

As it is, despite advancements in cancer care, treatment doesn’t reach out to all—a clear indication that still a lot needs to be done. Quite aptly, World Cancer Day on February 4, this year was focused on debunking myths and misconceptions about cancer. Hospitals across the world did their bit to create awareness about the disease, raise funds and introduce advanced technologies to the general public. Such efforts are laudable, but not enough. To cater to the growing burden of cancer patients, we need treatments that have less side effects and are more holistic and integrated in approach. We also need more cancer centres equipped with advanced technologies.

And the good news is there is one person, who has been making a valiant attempt to change the bleak scenario — Dr Ajai Kumar, chairman, Health-Care Global. Despite many challenges he went on to create the largest net-work of cancer centres in South Asia opposing various myths, the primary one being that oncology care is a loss-making business. His interview will give you an idea of how his group is successfully running a business that has a high capex and long gestation period. More importantly, how it is building cancer centres in remote areas and attempting to make a differ-ence in the lives of many.

Rita DuttaConsulting [email protected]

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MARCH 2013 • VOL 1 • ISSUE 6

(Statement about ownership and other particulars about the newspaper/magazine HEALTHCARE RADIUS to be published in the first issue every year after the last day of February)Name of the Publication: HEALTHCARE RADIUSPeriodicity of the publication/ Language: Monthly/EnglishPrinter’s Name: Saikumar ShanmugamNationality: Indian(i) Whether Citizen of India: Yes(ii) If a foreigner, country of origin Not applicableAddress: Notan Plaza, 3rd Floor, 898, Turner Road, Bandra (w), Mumbai- 400 050, MaharashtraPublisher’s Name: Saikumar ShanmugamNationality: Indian(i) Whether Citizen of India: Yes(ii) If a foreigner, country of origin: Not applicable

Address: Notan Plaza, 3rd Floor, 898, Turner Road, Bandra (w), Mumbai- 400 050, Maharashtra.Editor’s Name: Rita DuttaNationality: Indian(i) Whether Citizen of India: Yes(ii) If a foreigner, country of origin: Not applicable Address : Notan Plaza, 3rd Floor, 898, Turner Road, Bandra (W), Mumbai- 400 050, Maharashtra.Name and address of the individuals who own the newspaper/magazine and partners or shareholders holding more than one percent of the total capital.ITP Publishing India Pvt.Ltd. ITP Holdings Inc, PO Box 500024, Dubai, U.A.E.

I, Saikumar Shanmugam, hereby declare that the particulars given above are true to the best of my knowledge and belief.

Date: February 28, 2013 Saikumar ShanmugamSignature of the publisher

FORM IV

04_HCR_March13_Ed letter.indd 4 21-02-2013 15:43:35


ADV ISORY BOARD

DR NAROTTAM PURIchairman, NABH and advisor, Fortis Healthcare

DR PRANEET KUMARCEO, BLK Super Speciality Hospital and chairman, NABH appeals and grievance committee

(HONY) BRIGADIER DR ARVIND LALchairman and managing director, Dr Lal PathLabs Pvt Ltd

DR GIRDHAR J GYANIdirector general, Association of Healthcare Providers

DR ALOK ROYchairman, Medica Synergie

DR G BAKTHAVATHSALAMchairman, KG Hospital & Post Graduate Medical Institute

DR RAVINDRA KARANJEKARCEO, Global Hospital and chairman, NABH accreditation committee

DR MK KHANDUJAchairman, BSR Healthcare

SANDEEP SINHAdirector, South Asia and Middle East, Healthcare & Life Sciences, Frost & Sullivan

DR NC BORAHchairman, GNRC

BRIGADIER JOE CURIANCEO, SevenHills Hospital

DR GUSTAD B DAVERdirector, professional service, PD Hinduja Hospital

DR DURU SHAHeminent gynaecologist

DR SANJEEV SINGHmedical superintendent, Amrita Institute of Medical Scienceand chairman, research committee, NABH

OUR EDITORIAL BOARD HOLDS UP A MIRROR TO THE HEALTHCARE INDUSTRY, HELPING US UNDERSCORE THE KEY TRENDS AND DEVELOPMENTS OF THE INDUSTRY

MONT HLY M A IL

Great insightsI liked reading the interview of Dr Praneet Kumar, CEO, Dr BLK Hospital. I also immensely enjoyed the interview of Brig Joe Curian, CEO, SevenHills Hospital — he tackled the controversies dogging the hospital with admirable candour. Healthcare Radius gives me wonderful insights into the industry.

Micah Joseph

Director, administration

Nanavati Hospital, Mumbai

Two of a kindI liked reading the interview of Brig Joe Curian in your magazine. It is true that there are very few people, in fact perhaps only Joe and I, who continue to bat as CEOs of multi speciality super speciality corporate hospitals in their 70s. The only difference between him and me is that Joe has changed jobs frequently whereas I have continued to remain at the helm of Mallya Hospital, hopefully without gathering any moss.

Commodore Indru Wadhwani

President & CEO

Mallya Hospital, Bengaluru

More pleaseI liked the article on troubleshooters by Sandip Chaudhuri. I found the writer’s style tongue-in-cheek and appealing. I would like to read more articles by him in the forthcoming issues.

Dr Aniruddha Malpani

Malpani Infertility Clinic, Mumbai

Close to the heartI personally liked the article about Dr.Mukesh Hariawala, not only because he is a consultant at Jaslok Hospital, but because it spreads awareness about newer technologies like Triple Heart Therapy. Another article I liked was the interview of Brig Joe Curian.

Krishnakant Dasyam

Marketing head,

Jaslok Hospital, Mumbai

I found the February issue of Healthcare Radius informative.Dr Vikas Tandon

Consultant spine surgeon

Indian Spinal Injuries Centre, New Delhi

Embracing modern thinking February 2013 • Vol 1 • Issue 5 • Rs50An ITP Publishing India publication

HEART HEART

BRIG. JOE CURIAN ONTHE SEVENHILLS CONTROVERSY

Total number of pages 52Registered with Registrar of Newspapers under RNI No. MAHENG/2012/46040, Postal Registration No. MH/MR/N/242/MBI/12-14, Published on 27th of every previous month. Posted at Patrika Channel Sorting Office, Mumbai-400001, Posting date: 30th & 31st of every previous month

REPORTIRIA 2013:CAPTURED

ON CAMERA

BALANCE SCORE CARD IN A HEALTHCARE

SETTING

ILEAL TRANSPOSITION WITH SLEEVE

GASTRECTOMY

TROUBLESHOOTERSIN SMALL HOSPITALS

FOCUS

ABMH’S EXCITING JOURNEY TO JCI ACCREDITATION

CASE STUDY

DR MUKESH HARIAWALASPEAKS OUT ON HIS

PIONEERING TRIPLE HEART THERAPY

01_HCR_Feb13_Cover Final.indd 1 23-01-2013 10:36:22

Namesake The headline of an article in the February issue mentions Aditya Birla Memorial Hosiptal as AMBH instead of ABMH. We regret the error.

5_HCR_Feb13_Advisory Board.indd 5 21-02-2013 15:45:26


MANIPAL PLANS MORE HOSPITALS IN BENGALURU

Fortifying its position in Benga-luru, Manipal Health Enterprises (MHE) has plans to roll out as many as four hospitals in the IT capital of India. The group already has three hospitals in the city that add up to 800 beds.

Said Rajen Padukone, MD & CEO, MHE, “The steady annual

Fortis Healthcare Limited recently launched Mamma Mia, a comprehensive and distinctive bouquet of fitness, wellness and in-formation solutions for maternity and child care.

Anika Puri, COO, Mamma Mia, said, “Mamma Mia is a unique offering of medical facilities com-plemented by holistic services for pregnancy and baby care, inside a protected hospital environment.

Mamma Mia complements the existing Fortis La Femme brand,

Zeal Medical, manufacturers of neonatal /paediatric intensive care equipment, based at Mumbai, bagged an order for supply and in-stallation of medical equipments for strengthening neonatal care services in government hospitals from Andhra Pradesh Medical Services & Infrastructure Devel-opment Corporation (APMSIDC), a government of Andhra Pradesh enterprise, based in Hyderabad.

The supply consisted of 2,609 radiant warmers, 507 CFL pho-

totherapy stands, 1,619 resuscita-tors of 500ml. Zeal executed the entire order in a record-breaking five months. Installations were successfully performed at various existing SCNUs, new SCNUs, tribal SCNUs, NBSUs and NBCCs —1,786 locations, in all.

Based on its performance, the company has received a fresh order for 2,287 infant care trolleys and 3,790 oxygen hoods from the same authority. The order is now being executed.

growth rate of eight to ten per cent of the city’s population has cre-ated the need for more hospitals. The city needs at least eight more hospitals and we are ready to cater to that need.”

Three of the group’s hospitals are being planned in Whitefield, CBD Area (central Bengaluru) and

near Hebbal (north Bengaluru). “We are yet to finalise our fourth project,” informed Padukone. The group’s existing three hospitals in Bengaluru are located at Airport Road, Malleswaram and Jayanagar.

The new hospitals, around 250 beds each, will add 1,000 more beds to the group. “The hospitals,

FORTIS LAUNCHES ‘MAMMA MIA’ ZEAL COMPLETES ORDER IN RECORD TIMEdedicated to healthcare require-ments of women. Mamma Mia educates, prepares and empowers women to cope with the bodily changes and fitness challenges that accompany the birthing process. Internationally certified child birth educators, yoga and fit-ness teachers, Lamaze instructors, child birth professionals, doulas and lactation counsellors form the specialised team of qualified birth professionals at Mamma Mia that assist expectant mothers.

having a built-up area of around two lakh plus square feet, will be a mix of high-end tertiary and multi speciality tertiary. While the hospital at Whitefield will be a high-end secondary care hospital with a focussed attention on woman and child care, the other two will be multi-super speciality ones,” informed Padukone.

Though all the three announced projects are greenfield, the group has selected an asset-light model, investing only in interiors and equipment. “Total investment for all the projects put together would be Rs150 to Rs200 crore, inclusive of interiors, equipment and initial es-tablishment costs. And the nature of the funding would be a mix of debt and equity,” added Padukone.

The hospital in Whitefield will be the first one to be commissioned, slated for January 2014. The other two, to be built ground up, would be completed after two years.

RACKEWSN T

Vidhana Soudha in Bengaluru

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NEWS TRACK

Indrapastha Apollo Hospital has set up a PET Suite, which is first of its kind in South Asia. This unique concept of PET SUITE consists of PET-CT and PET-MR with advanced imaging technologies (427slice/second ultra HD). Also, by providing PET and CT & MR facilities under one roof, it significantly reduces not just the cost of diagnosis but also patient discomfort of the diagnoses done separately.

The two-day 9th Annual STEM 2013 conference, organised by SRMTE (Society for Regenerative Medicine & Tissue Engineering), was held in Bengaluru. The conference focused on the latest trends in stem cell research and application, cell-based therapy, trials involving stem cells, regenerative medicine and tissue engineering. STEM 2013 provided a platform to all those interested in learning the intricacies of stem cells to come together at this conference and share their knowledge and experience in this subject. Speakers included scientists, researchers, in-dustry professionals from biotechnological companies, pharmaceutical companies, doctors and academic faculties, IPR and Investment/Fund Managers/Bankers.

INDRAPASTHA APOLLO HOSPITALS GETS PET SUITE

9TH ANNUAL STEM 2013 IN BENGALURU

Kokilaben Dhirubhai Am-bani Hospital in Mumbai has launched a state-of-the-art comprehensive centre for liver transplant. The hospital will be offering both living donor and cadaver donor liver transplants for adults as well as children with end-stage liver disease. The unit also offers emergency liver

transplants for patients with acute fulminant liver failure.Said Dr Vinay Kumaran, head, HPB and Liver Transplant Surgery, “While around 25,000 liver transplants need to be done every year in India, only about 1,100 transplants have been per-formed that too mostly in Delhi and south India.”

In a medically rare case, 44 fibroids were surgically removed from a young lady. The surgery was conducted by gynaecologist Dr Kiran Coelho at Mumbai’s Hinduja Healthcare Surgicals on an NRI patient from the UK.

“The patient diagnosed to have multiple uterine fibroids was asked to undergo a hysterec-tomy by doctors in the UK. Not wanting to lose her uterus at a young age, she came to India for a second opinion. Her uterus was

entirely filled with fibroids, with hardly any uterus muscle left” informed Dr Coelho.

The patient underwent laparo-scopic myomectomy. “There are global records of up to 80 fibroids being removed through open abdominal surgery. There's no record of laparoscopic removal of 44 large fibroids with preserva-tion of uterus, by suturing and restructuring the uterus through minilap incision are found,” informed Dr Coelho.

The Association of Healthcare Providers (India) or or AHPI

organised a seminar on ‘Impact of quality on patient safety and business development’ at Mum-bai’s Global Hospital. Dr Girdhar J Gyani, Director General, AHPI, spoke on the present status of healthcare regulation and the role of AHPI in building capac-ity in health systems. K Dinesh,

Co-Founder, Infosys spoke on ‘Quality as strategic tool’, while Dr Manoj Jain, Faculty at Rollins School of Public Health, Emory University, USA spoke on ‘ Hospital quality journey: Where are you now and where you want to be, way forward?’. The concluding remarks were made by Dr Ravindra Karanjekar, CEO Global Hospital, Mumbai.

MUMBAI GETS NEW LIVER TRANSPLANT CENTRE

A NEW GLOBAL RECORD?

QUALITY SEMINAR IN MUMBAI

DELHI TO INTRODUCE NANOKNIFE New Delhi’s Rajiv Gandhi Cancer Institute and Research Centre is set to introduce NanoKnife, a minimally invasive cancer treatment that uses irreversible ‘electropora-tion technology’ to precisely target and kill hard-to-reach tumours at the cellular level.

Said Dr Shivendra Singh, senior consult-ant and chief of GI Onco Surgery & Liver Transplant Services, RGCI&RC, “The Nanoknife is able to target especially small tumours, typically less than five centime-tres in size and difficult tumours, which can’t be removed because of their critical location, or those that have not responded to conventional treatment.” Developed by AngioDynamics, USA, the device costs about Rs15 crore.

2,00,000The number of Indians dying of liver failure every year

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NEWS TRACK

HEALTHCARE GLOBAL ENTERPRISES LTD

COMBATING CANCER

It introduced the first app by a hospital on breast cancer in India. This will help dispel myths and misconceptions among peo-ple about cancer.

The app explains various self

breast examination techniques for women, facts and FAQs on breast cancer. It can be down-loaded on Android phones from Google Play Store and iphones from istore, free of cost.

DR LH HIRANANDANI HOSPITAL

Hospitals around the country commemorated World Cancer Day on February 4. A look at the different initiatives undertaken by the industry

Dr A P J Abdul Kalam, former President of India, inaugurated ‘CARE outpatient centre’, India’s largest integrated out-

patient centre, in Hyderabad. This is the 13th facility from CARE.

CARE out-patient centre is well-equipped to perform different surgeries of ophthalmol-ogy, orthopaedics, obstetrics and gynaecology, cosmetology, vascular and ENT. Procedures

like urogenital surgery, chronic pain treatment by specialist and various other general surger-ies can also be performed without the need for an overnight stay at the centre. The advanced technologies at the integrated out-patient centre will allow CARE Hospitals to improve patient experience, building the ability to handle larger volumes and drive faster turn-around times.

It launched a unique oncological robotic surgery initiative, aimed at creating awareness about the advantages of robotic surgery as a better treatment for various cancers as it is more precise, mini-mally invasive, heals faster and has the best clinical outcomes.

It conducted ‘The Pink Meet, 2013’, a comprehensive two-day breast cancer care conference. The agenda of the conference was to discuss the diagnostic and therapeutic modalities in breast cancer. Leading cancer specialists including Dr Rajendra Badwe, Dr Suresh Advani, Dr Arun Chitale, Dr PSR K Sastry, Dr Shripad Banavali and Dr Girish Muzumdar shared their research and insights on the practices in diagnoses, treat-ment and preventive measures and the evolving treatment modalities in breast cancer.

Fortis Foundation launched, ‘Chil-dren Against Tobacco’ in Mumbai, a campaign targeted at the city’s young generation. Organised in as-sociation with MET Young Explor-er, the campaign aimed at spreading awareness among parents, teachers, and decision makers on the adverse effects of tobacco consumption by children. One lakh children, from over 100 schools across Mumbai, pledged their support unanimously for the month-long drive.

Yashoda Hospital, Secunderabad, launched ‘Fight On’, an empower-ment initiative for people suffering from cancer. It will provide a plat-form to promote healing, stimulate inner resources, enhance quality of life and compliment medical care. Information will be provided on rehabilitation and coping strate-gies on different cancers and stages and build partnerships to increase awareness among partners.

DR APJ INAUGURATES ‘CARE OUTPATIENT CENTRE’

7.5 MILLION

APOLLO HOSPITALS GROUP

FORTIS HOSPITALS

YASHODA HOSPITALS

Cancer kills more than that many people a year and there are 13 million new cases of cancer every year, as per the World Health Organization (WHO)

6-11_HCR_Mar13_News.indd 10 21-02-2013 15:48:06

NEWS TRACK

Name: Kauvery HospitalLocation: Hosur, a town and a municipality in Krishnagiri district of Tamil Nadu, is located about 40 kilometres from Bengaluru. Promoted by: Kauvery Hospitals, which was earlier known as KMC Hos-pital. The Trichy-based group has 800 beds in hospitals located in Trichy and Chennai.Type of hospital: Multi super speciality Nature of the project: Greenfield project, built ground upBed strength: 100 in the first phase. It would be scaled up to 200 beds. Facilities: Will have blood bank, pharmacy, four modular OTs, out of which one would be high-end. State-of-the-art technology includes CT Scan, automated lab and pneumatic chute system. Land measurement: 1.25 acre In built area: 1,50,000 square feetCost of the project: Rs 50 crore (inclusive of land, building and equipment)Type of investment: Mix of debt and equityExpected commissioning date: After 18 months Patient catchment area: Bengaluru, Hosur and Dharmagiri. Flooring: Mix of vinyl and hard tile. Vinyl flooring in areas like OTs and ICUs.

A HEALTHCARE HAVEN IN HOSUR

6-11_HCR_Mar13_News.indd 11 21-02-2013 15:48:07

Spotlight


Know the newThe IACTS 2013, the 59th Annual Conference of Indian Association of Cardiovascular and Thoracic Surgeons, was an ideal platform for learning about new techniques and procedures REPORT BY SHIV JOSHI

For most laypeople surgeons are nothing less than Gods. But to stay on top of the game and to continue performing ‘miracles’ and save lives, they need to constantly keep

abreast of the latest in medical technologies and procedures. IACTS 2013, provided a perfect platform for the same. Held at Renaissance Con-vention Centre Hotel in Powai, Mumbai, IACTS 2013 was the largest convention of cardiovas-cular and thoracic surgeons in the country with over 1200 delegates in attendance. “2013 also marks the 50th year of open heart surgery in the country. So the theme of this year’s conference was the Indian Surgeon,” informed Dr Kaushal Pandey, senior cardiac surgeon and organising

chairman, IACTS 2013. The three-day event that kickstarted on February 14, 2013 was packed with many informative sessions. One symposium in particular drew a lot of interest as it addressed a topic that is of equal interest and apprehension for surgeons— ‘Mechanical & Extracorporeal Life Support In Acute Heart/Lung Failure’. The session featured four experts who spoke about various aspects of IABP and ECMO and also cleared the doubts of doctors in attendance.

"Maquet India has been initiating and creat-ing active platforms for building therapy in the cardiovascular domain, the lunch symposium on mechanical and extracorporeal support in heart and lung failure has been one such recent endeavour from us in the IACTS 2013," informed

Dhiman Dasgupta, business manager-South Asia, Maquet cardiovascular.

"This year we wanted to address the topic of acute and critical cases in heart and lung failure through our symposium. We were able to attract the best faculty from India and abroad to take podium space and deliberate on high risk CABG with IABP as well as experiences on ECMO, both from an Indian and international perspective. We have found a healthy acceptance of ECMO ther-apy in almost all quarters of the country in 2012. At Maquet, we believe in the staged therapy of IABP & ECMO for saving lives. We will continue to build this platform on therapy through similar scientific opportunities in the future," he added. Here’s a quick round-up of the sessions:

DR ANIL BHAN, SENIOR DIRECTOR, DEPARTMENT OF CARDIOVASCULAR SURGERY, GLOBAL HEALTH PVT LTD, MEDANTA, DELHITopic: The high risk CABG with IABP. Gist: Based on his experience and the extensive research Dr Bhan explained how opting for pre-operative IABP in high-risk patients for CABG helps. In case of prophylactic IABP, it was observed that ICU stays of patients were shorter. Planned pre-operative IABP also had better survival rates and better outcomes, though the risk and complications remain the same as no pre-operative IABP. He cited a case study of a patient with severe angina to make the benefits evident and the role ECMO played in the treatment and recovery. Quoting an impressive volume of studies to support his finding, Dr Bhan concluded that IABP is most useful before it is needed in a patient.

DR K R BALAKRISHNAN, DIRECTOR, CARDIAC SCIENCES, FORTIS MALAR, CHENNAITopic: My experience with ECMO – the Indian perspective. Gist: Dr Balakrishnan spoke about how ECMO systems have evolved over the years in terms of technology and design by comparing the large, complicated contraptions of the earlier days that occupied a better part of the room to the compact and virtually noiseless systems of today that hardly require any space. Today’s ECMO machines are not only smaller, lighter but one can also get them up and running in 6 – 7 minutes, he said. He discussed using ECMO for cardiogenic shock. He informed that the overall survival rate for the cases he has handled was 40 per cent, with overall procedural success rate being 100 per cent. He also spoke on the reasons why not everyone gets ECMO right, touching upon troubleshooting aspects such as a cannula slipping. He concluded by saying that ECMO should be considered as a part of intensive care strategy.

DR S RAO, DIRECTOR, CHILDREN’S HEART CENTRE, PEDRIATRIC & CONGENITAL HEART SURGEON, KOKILABEN DHIRUBHAI AMBANI HOSPITAL, MUMBAITopic: Our brush with ECMO-lessons learnt. Gist: Dr Rao and his team had tried their hand with ECMO on paediatric cases but encountered many challenges. According to him, it added on personal needs of the patients. But he realised that since the use of ECMO is still relatively new in India as opposed to other countries, there’s a lot to be learnt in terms of its application and maintenance. Based on his experiences, he summed up lessons learnt: ECMO requires a well-trained dedicated team comprising, surgeon, intensivist, anaesthologist and ICU nurse; surgeons should be the leader of the process; children should be put on ECMO fast. And the biggest lesson was not to get into ECMO post-operatively but before time to improve survival rates and outcomes.

PD DR D COMBONI, DEPARTMENT OF CARDIOVASCULAR SURGERY, UNIVERSITY OF REGENSBURG, GERMANYTopic: What’s new in the ECMO world? Gist: Bringing with him the experience of having provided ECMO support to many patients, Dr Comboni spoke on many aspects of ECMO including: transporting critical patients while on ECMO support; ECMO supported CPR, which has good survival benefit; outdoor cannulation of ECMO and ECMO-supported PCI or TAVI. His hospital has had extensive experience with providing ECMO support and in fact is the first point of contact for emergencies. He informed that the survival rate of ECMO for his centre was 33 per cent and that they have even put a 57 year old patient on ECMO support for 2.5 days and he survived. He said that the key to ECMO success is knowing that ECMO is not a therapy in itself but a bridge—to decision, to recovery and to transplant. It is a potentially life-saving procedure and the key to reducing complications in its proper management.

12_HCR_MAR13_Spotlight.indd 12 21-02-2013 15:48:58

EVENT CALENDAR


CRITICARE 2013Organised by: Indian Society of Critical Care MedicineWhen: 1 – 6 March 2013 Where: Science City, KolkataWebsite: emsindia.in

Hospitech India 2013When: 2 - 3 March 2013Where: Rajkot

PeopleHosp DELHIStrategic HR Management for hospitalsOrganised by: Amen Business Solutions When: 5 March 2013Where: India Habitat Centre, New Delhi

Marketing of healthcare servicesOrganised by: Aum Meditech When: 7 March 2013Where: Delhi

The DICOM 2013 international conference& seminarWhen: 14 – 16 March 2013Where: Indian Institute of Science, Bengaluru

10th Healthcare Executive Management Development ProgrammeWhen: 28 April – 4 May 2013Where: Srinagar

III Internationl congress on patient safetyWhen: 6 – 7 September 2013Where: Hyderabad InternationalConvention Centre, Hyderabad

Smart Healthcare India Summit 201323 - 24 May, 2013, BengaluruContact: Mushrif, general manager, conferences on +91 98201 53334 or [email protected] For speaking opportunities, contact Alysha Lobo, project manager on +91 9769 616685

Bangalore Palace, Bengaluru

14_HCR_March13_Event Calendar.indd 14 21-02-2013 15:49:49

HOTELIER AD PLACE.indd 80 10/29/2012 6:26:57 PM

16 Healthcare Radius March 2013

We have planned to build three multispeciality hospitals, two of which would be in Bengaluru and one in Kolkata”

16-21_HCR_Mar13_Straight Talk.indd 16 21-02-2013 15:51:45

Straight talk


Dr BS Ajai Kumar, chairman, HealthCare Global Enterprise (HCG), speaks about building a robust network of dedicated cancer care hospitals defying the perception that

oncology is a loss-making businessINTERVIEWED BY RITA DUTTA

HCG is South Asia’s largest cancer care network. Head-quartered in Bengaluru, HCG has grown rapidly and in just five years has 25

cancer centres spread across Asia.

How did you manage to build a network of 25 cancer centres in a short time span?Our initial journey was marked with many roadblocks—be it difficulty in procuring funds, delays in getting approvals or lack of clear-cut regulatory guidelines. We went against the prevalent belief that oncology is a loss-making business. We were undeterred when one of our centres operated only on a generator as the cor-rupt electricity board refused to give us power. What got us through the odds was our determi-nation to provide comprehensive oncology care that is affordable and accessible to all. We were also unwavering in our resolve to give good re-turns to our investors. Our determination, early mover advantage, and business acumen have helped us grow fast.

When you forayed into the oncology market in India, what was it like?In the late 80s, when I wanted to return to India

from the US to start a private oncology set-up, the market perception about oncology care was extremely discouraging. I knew there was a big market here for affordable cancer care in private practice due to the high incidence of cancer and acute shortage of beds in govern-ment hospitals. Those who could afford it went abroad for treatment because neither the tech-nology nor the infrastructure was good enough in most centres.

Yet, the road to building a network of cancer centres was not easy. It was difficult to get fi-nance for various reasons. First, it was believed that starting a private for-profit oncology set-up was a recipe for failure. Financers felt that even though existing centres were overburdened, on-cology care was a charitable act, best provided by government or trust hospitals. Oncology was perceived as a loss-making business that catered to patients, who could not afford specialised cancer care.

Second, the 40 per cent custom duty on equipment and 20 per cent high rate of interest levied by the banks proved to be significant bar-riers. Third, it was a challenge to service princi-pal repayment on short-term debt as long-term debt financing was not available at that time.

Fourth, financiers were reluctant to sup-

port high-end technology. When we insisted on going for linear accelerator, they asked us to go for cobalt, which many institutes in the country were using. Not many people know that countries manufacturing cobalt are themselves not using it and dumping it elsewhere. I knew that cobalt was outdated and was thus firm on having linac, despite resistance from financers. Fifth, the financiers held that doctors make poor businessmen and thus we would turn out to be complete failures in managing a business with a high capex and low profitability.

You had even tried to convince the then CM of Karnataka...Yes. As financers were not showing interest, I thought of seeking government help and thus met Ramakrishna Hegde, the then chief minister of Karnataka, during his visit to the US in 1986. When I shared my plan of starting a private cancer centre in Bengaluru with him, he asked me the need for starting another cancer centre when the state already had Kidwai In-stitute of Oncology. I had even met the director of Kidwai during a talk at the institute, but did not receive an encouraging response from him about my proposal. So, I went ahead and started Great River Oncology Center, a cancer centre in

Againstoddsall


Straight talk


HCG was one of the few centres in India to pioneer cyberknife

they often can’t afford travelling to a big city and staying in a hotel. In addition to being expen-sive, it is also inconvenient. So, we wanted take the treatment closer to their homes. We decided to open 12 centres of excellence by 2009-2010. By 2010, we integrated BIO into HCG.

Did you have to tweak your business plan along the way?Yes, we did. Initially, we planned to put up only 13-14 centres, but as we gained experience and realised the great unmet demand, we got more funding and decided to expand further. Being focused in oncology, we are now looking at selective markets in multi speciality.

There were reports about a multi speciality hospital in Pune...We eschewed our plan of building a multi spe-ciality hospital in Pune. Rather, we are building an oncology centre there. However, we have planned to build three multi speciality hospitals, two of which would be in Bengaluru and one in Kolkata. In Bengaluru, we will soon announce a Greenfield multi speciality hospital of around 300 beds. For this, we have taken the land on a long-term lease and would be making an invest-ment of Rs70 to Rs75 crore. I can’t divulge details about the two other projects right now.

Let me add that we are not actively pursu-ing these multi speciality projects. We are keen in these projects only when we find doctors interested in partnering with us and steering such projects and there is a true

Chicago offering radiation oncology. It was built in collaboration with a local hospital. Now, the partner has taken over the institution.

Finally, how did you manage to get approvals in India?As with any entrepreneur, we too were expected to grease palms to obtain various permissions. Fortunately, a few honest politicians and offic-ers helped me get the necessary approvals. Get-ting the nod for linear accelerator was another stumbling block as the technology was still new to India. Along with the Atomic Energy Regula-tory Board, we drafted regulations for using linear accelerator.

When did you finally receive the funding for expansion?Our first institute, Bangalore Institute of Oncol-ogy (BIO), was established in 1989 as a 25-bed unit, which was scaled up to 80 beds by 2000. Encouraged by our success, we acquired a few other centres to further consolidate our pres-ence. We wanted BIO to scale up to 130 beds and install cyberknife, PET scan and cyclotron for the first time in Bengaluru. But for that, we needed a new building, which would cost Rs20 crore. However, despite the steady stream of patients and knowledgeable doctors, we failed to secure finance for many years.

Finally, in 2006, IDFC agreed to pump in Rs500 crore. In 2008, IDFC exited and later, we

received additional funding from Evolvence, Milestone Religare Investment Advisors and Premji Invest.

What did HCG set out to achieve?Our vision was to offer a viable, cost-effective and comprehensive oncology care first in Ben-galuru and then in tier-II, tier-III and even rural areas. Often, cancer patients from tier-III towns and rural areas get delayed treatment because

Patient profile Patient profile

Referrals 30%Word of mouth 20%Walk in 50%

Middle class 60%BPL 20%Affluent class 20%

60%

20%20%

30%

20%

50%


Straight talk

year. In many cities, we have more than one centre. For instance, we have two centres each in Delhi, Ahmedabad, Chennai and Vijaywada, while in Bengaluru, we have as many as four. We have six PET Scans, three in Bengaluru, and one each in Mumbai, Delhi and Chennai. We also have one cyclotron in Bengaluru.

What’s the breakeven time for a centre?Our new cancer centre at Bengaluru became EBITDA positive in two years and we paid off loan principal in five years. Typically, the cash breakeven for a centre is two years and EBIDTA margin is 20 per cent in the steady state.

What's the business model for your centres?We have strategically gone for a hub and spoke model, to extend screening, diagnosis, treat-ment, rehabilitation and supportive care to all patients. Our hubs perform high-end imaging, therapy, and other complicated procedures in major cities, and the spokes provide basic ther-apy and follow-ups in smaller towns. While our central hub is in Bengaluru, in each region,

we have a local hub, which is the first point of contact for the

patient and then the spokes, which are satellite centres. Creating the spokes with facilities of chemo and radiation therapy in smaller

towns eliminates travel and thus reduces the cost

of care to the patient.

Focus on research

Dr Ajai bought Triesta Sciences in 2005 to undertake molecular research as well as offer clinical trials and laboratory services in the field of oncology. It has started investigator initiative trial, a type of research used in treating the patient, where tissue samples are taken and responders and non-responders are analysed.

Innovative projects completed by Triesta:• Molecularmarkerspredictingresponsetotherapy,recurrenceandresistanceindifferentcancers

including breast, lung, head and neck cancer: An approach to derive new targeted therapies. • StudyofHer2-neulocusamplificationandresponsetoTrastuzumabinmetastaticbreastcancer.• Epidemiologicalstudiesonbiomarkersinlungcancer:ApanIndiastudy.• Surveillanceofcommonsolidtumoursfordrugtransporterproteins.• EpigeneticalterationsandgeneexpressionprofilingfrombiopsiesandPBMCsincancer.• Correlationofp53expression,p53mutationandDNAploidywithtreatmentoutcomesinhead

and neck cancer. • Optimisationofdifferentmethodsforcervicalsmearpreparation,afullproofmethodfordigital

pathology platform.• ComparisonofbiomarkerstatusindifferentsamplesubtypessuchasFNAC,tru-cutbiopsyandPleuraleffusion:AcomprehensivestudyonacohortofNSCLC.

Research in the pipeline • Detailedmolecularprofiling(genomics,proteomics,epigeneticalternations,stemcellmarkers)incancerwithafocusontriplenegativebreastcancer:Newleadsfortargetedtherapy.

• Highthroughputcosteffectiveclinicalsequencingforallmalignanciesusingsecondandthirdgenerationsequencingtechnologies.

• PersonalisedXenograftmodelsandstemcellderivedmodelstoenrichclinicaltrialsandperson-alised cancer care and management.

• Circulatingtumorcells(CTC)andcancerstemcellresearch.

We have a network of 25 centres.We cater to over 2,50,000 patients every year and perform 800 radiation treatments, 120 surgeries and 500 chemotherapy infusions per day”

market demand for the projects. For a group founded by doctors, we want to encourage more doctor entrepreneurship.

Would not the group lose its focus by getting into multi speciality?No, we would not lose focus, but would rather strengthen our brand and make optimum use of resources. There is a lot of shared resource between an oncology set-up and a multi special-ity hospital. Anyway, around 70 to 80 per cent of our business would always come from oncology.

How did you grow post PE fund expansion?We grew fivefold, with centres coming up in places like Ahmedabad, Vijaywada, Chennai, Cuttack, Nashik, Delhi and Pune.

Today, we have a network of 25 centres, adding up to 1,000 dedicated oncology beds. We cater to over 2,50,000 patients every year and perform 800 radiation treatments, 120 surgeries and 500 chemotherapy infusions per day. Our rapid expansion reduced our cost per unit and thus made the high-capex business more profitable. Our current revenue is Rs350 crore and we aim to reach Rs500 crore by next


Straight talk


our specialists from the hubs train them. In cen-tres, where we are unable to get local doctors, we rotate doctors on a monthly basis.

What challenges do you face while managing an oncology chain?The usual challenges are the long wait of more than six months to receive reimbursement from government insurance, offering high-end tech-nology at a low-cost and ensuring that investors get returns, though we refrain from giving divi-dends. The time taken to attain breakeven for an oncology centre here is much more than that in the US as the cost of cancer care is cheapest in India. For instance, a centre in the US would charge anything between $16,000 to $25,000 for cyberknife and thus attain breakeven within 15 to 20 patients. In India, we charge $2,000 to $3000 and have to wait for the first 60 patients to attain breakeven.

What is your reaction to the rumour about merger with Medica Synergie?In an earlier interview with your magazine, Dr Alok Roy has suggested the possibility of synergy in the future. But, at this point of time, we are just happy to collaborate with Medica for setting up an oncology centre at Medica Synergie’s premises in Kolkata.

What about your international ventures?Every year, we get over 1,200 patients (both inpatient and outpatients) from Africa. We have already established our presence in Uganda and Nairobi. We have successfully trained doctors there for follow-up care. Soon, we will be pre-sent in Tanzania, Ethiopia, and Kenya. To make cancer care affordable, we negotiated global supply contracts with drug and device manu-facturers and were thus successful in bringing down the cost of some technologies and drugs. Often, our plans are impeded by the corrup-tion and the different set of regulations in these countries. In the coming years, we are keen on exploring the Middle East market. Right now, less than 8 per cent of our revenue comes from our international ventures.

Are you considering going for an IPO?We are exploring that option and will make an announcement, soon.

How do you keep the cost of care and cost of operations low?By using group purchasing, centralised control and planning and maximum use of technology.

Currently, we have hubs in Bengaluru, Chennai and Ahmedabad, and in the coming months will have them in Delhi and Kolkata.

We have gone for a mix of greenfield and JVs. In places like Vijaywada, Hubli, Nashik, Raichur, Chennai and Shimoga, we have opted for greenfield projects, where we lease space and run the hospital. We don’t build centres as it increases the capital investment. In a JV model, we collaborate with a local doctor, who already has a steady practice or an institute. We upgrade existing facilities and install equipment, like radiation equipment, and typically hold 51 per cent ownership. For instance, with MS Ramiah, Bengaluru and two institutes in Delhi, we have chosen a JV model with the institute, while in Cuttack, we have partnered with a doctor. The spokes are connected with the hub by central-ised planning in the domain of telemedicine, teleradiology, telepathology and telephysics.

What’s the budget for building each centre?The budget varies. If we are installing a linear accelerator as well as PET in a hub, we spend around Rs15 to Rs18 crore. When it’s just a linac, the budget is Rs 12 crore. If we go for linac, PET and cyberknife, then the budget is Rs 60 crore. The decision to go for linac or linac as well as PET depends on factors like patient base, incidence of cancer and the economic profile of the city. The budget for a spoke is half of what it is for a hub.

How many more centres are in the pipeline?We are planning to expand our network to 40

In the Limca Book of Records

InNovemberlastyear,HealthCareGlobalinan attempt to spread awareness on breast cancer, formed the largest human awareness chain with pink lights in India. The event was held at Ulsoor Lake, and 5833 people formed the largest human awareness chain. The participants stood around the lake for 10 minutes with a battery illuminated pink light signifying ray of hope in the fight against breastcancer.Cancersurvivors,cancerpa-tients, care givers, nurses, corporates, students and public at large participated in this event. This feat has been recognised by the Limca Book of Records and will be featured in its 2014 edition.

HCG Cancer Centre at Ahmedabad

centres by next year. And for that, we plan to make an investment of over Rs250 crore. This would be a mix of private equity and internal accrual in equal measure. These centres would come up in both tier-II and tier-III cities.

How do you get doctors in tier-III cities?While recruiting doctors at the spoke, we see to it that the doctor belongs to the region and then,


Straight talk


MuchbeforeHCG,in1989alongwithagroup of four doctors, Dr Ajai Kumar started BangaloreInstituteofOncology(BIO)underthe flagship of Banashankari Medical and OncologyResearchCenterLtd(BMORC).The25-bedBIOwasthenBangalore’sonlyprivatecancerhospital.Thenin1990,DrAjaisetupBharathHospitalandInstituteofnon-oncologyatMysore,andin2000,itacquiredafledglingcancercentrecalledCurieCentreofOncologywithinthepremisesofStJohn’sMedicalCollege.ThiswasstartedbyaNewYork-based businessman, which was loss-making.Curiewasturnedaroundwithinayear. Dr Ajai returned to India in 2003, and thendecidedtoexpandHCG.Hewentforcyclotron and then for the merger of Triesta. HCGhasexpandedto350bedsafterfinanc-ingfromIDFC.

To ensure full usage of linac, we use it during the night for poor patients. All our linear ac-celerators are programmed from Bengaluru. We have adopted a group purchasing organisation model from the US to procure cancer drugs. We have opted for generics, which is cheaper for patients. We also conducted trials of generic versions of drugs to reduce costs, besides get-ting free drugs from supplier for poor patients. We owner pharmacies rather than subcontract-ing them as ownership helps direct procure-ment from manufacturers. Since our Cyclotron can cater FDG to over 10 centres at a time in one production, we are providing FDG at nominal rates to other PET-CT centres, once again bringing down cost.

How has the business of oncology care changed over the years?Today, the scenario has changed for the bet-ter. There are many private oncology set-ups, the custom duty is reduced to 12 per cent and finance is available. We were the first to prove that oncology care can be provided in a corpo-rate set-up at an affordable rate with a decent EBITDA margin.

Your thoughts on HCG’s contribution to oncology care...We changed the face of cancer care by taking it to smaller towns. Before HCG, nobody could think that a place like Vijaywada could have an IGRT or IMRT. We were one of the first few centres to pioneer cyberknife. We were the first cancer centres to offer Flattening Free Filter technology, which allows higher dose rate of 2400 radiation as compared to 600 or below in filtered beam. We set up India’s first GMP- and FDA-compliant molecular imaging centre in India at our Bengaluru centre.

We have shown that oncology centres can

be profitable. While we offer advance cancer facilities, through our HCG Foundation we have been able to offer treatment to poor patient, either at subsidised rate or free of cost.

How do you raise funds for HCG Foundation?We established the HCG Foundation in 2006 to offer subsidised and free treatment to patients who can’t afford care. We help by offering concessions on ward nursing charges, providing free medicines, and floating an EMI scheme, whereby the patients pay 25 per cent as down payment and the rest as instalments. As col-lateral for this, we take post-dated cheques from the patient.

The annual budget for the Foundation is about Rs 1 crore and we have allocated around five per cent of our top line for it. Besides en-couraging employees to contribute 0.5 per cent

–1 per cent of their salaries to the Foundation, we raise money through theatre, art auctions, dinners, and other fundraising events. HCG Foundation has established an art gallery called ‘Swasti — Art for cancer care’, the proceeds from which are used to aid poor cancer patients.

Indian oncologists follow international guide-lines for treatment. How can we go about developing India-specific guidelines? Recently, various forums have taken up the issue of developing protocols pertaining to India, and even ICMR and HCG are involved in collaborating with multiple centres for de-veloping protocols. Within the next few years, we will definitely have standards of healthcare set up here.

How has oncology diagnosis and treatment changed?Today, advanced diagnostic tools like digital mammogram or MRI have helped identify suspicious lesions. PET/CT has helped accu-rately stage disease, while tumour markers have helped with an accurate pathological diagnosis. Today, linear accelerator, IMRT, IGRT and high dose rate brachy therapy (HDR) have helped zero in on only the malignant cells. Now, surgery no longer takes the radical approach. The surgi-cal approach is more focused towards organ preservation, and minimally invasive techniques. And in chemotherapy, there are several line of drugs available today than ever before.

What are the future trends in oncology care? Cancer will overtake cardiac disease as the major killer in the next decade. Cancer would cease to be perceived as a terminal disease that requires palliative care. Rather early detection and advanced technologies would make it pos-sible to think about cancer as a disease that one can live with, just like diabetes. Soon, doctors will stop treating just the malignant tumour, but start taking a holistic approach towards patients, by giving him a quality life.

In the coming years, more oncology centres will come up in tier-II and tier-III cities. As against 80 per cent of cancer cases being detect-ed at advanced stages due to inadequate facili-ties, in the years to come, this would change due to increased awareness about screening. There will be greater emphasis on therapies with less side-effects, and those that target only the tumour, leading to improved outcomes. Also, targeted therapy and radio surgery will become more popular.

Building HCG

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HCG's steady growth

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Profile


Gujarat’s leading healthcare chain, the BAPS Hospitals, has recently commissioned the BAPS Shastriji Maharaj Hos-pital, located at Atladara in

Vadodara. The hospital, spread over 1,30,000 square feet, is the group’s third hospital in Gujarat, after Ahmedabad and Surat.

The 100-bed hospital is a greenfield project, which would later be scaled up to 300 beds. This is the group’s second healthcare project in the same city — it’s 45-bed unit BAPS Pra-mukhswami Hospital was established 15 years

ago, but now has been closed down.For the newly commissioned hospital, the

focus areas are general medicine, orthopaedics, OBG, paediatrics, GI medicine, dental, critical care and MAS. The number of doctors roped in the project is 100, including 28 full time doc-tors across all specialities.

A JUDICIOUS BLENDThe hospital is a blend of an efficiently planned infrastructure, modern technology and comprehensive patient care provided by the most renowned doctors in key specialities.

Quality healthcare comes to VadodaraThe new 100-bed hospital, commissioned recently, will soon be scaled up to 300 beds

Says CEO of the hospital, Neeraj Lal, “BAPS Hospital offers a holistic range of medical services to patients from across the city and the state. BAPS’s compassionate approach to medical care is patient centric, with multi-disciplinary teams of highly skilled medical professionals working together to improve the quality of life for patients.”

THE USP This is the only hospital in Vadodara to have four modular operation theatres capable of incorporating not only electrical equipment,

22-23_HCR_MAR13_Profile_Vadodara.indd 22 21-02-2013 15:55:21

Profile


Quality healthcare comes to Vadodara

The central lobby

The ICU cubicle

The emergency roomThe physiotherapy room

The patient waiting area

View from the dome

medical gas system and lighting gears but also other necessary functions and equipment at need. The hospital’s 12- bed ICU has two dedi-cated positive and negative pressure beds— the only hospital in Vadodara to such a facility. The facility helps contain infections of patients.

The hospital has 24X7 medical care across all specialities. It offers special American automated patient beds for all wards including economy ward. It has 24x7 state-of-the- art pathology and radiology departments with 16 Slice CT Scan, pharmacy, accident and emer-gency services.

22-23_HCR_MAR13_Profile_Vadodara.indd 23 21-02-2013 15:55:29

Roundtable


Doctors are the stars of the hospital. But the support staff too are critical to its success. Why then is there disparity in the way both groups are treated?

Patients deify doctors. Many hospital managements too are accused of doing the same. When it comes to highlighting achievements or seeking opin-

ion for crucial business or strategic decisions, hospitals do not think beyond doctors. It’s only doctors who receive untainted man-agement support, lucrative pay packets and preferential treatment. And, why not? It’s the doctors that the patients queue up for, and it’s their popularity that hospitals want to rides on, and it’s them, who generate revenues.

Look beyond the medicos

But along with the doctors, there is an entire workforce comprising nurses, techni-cians and other non-clinical staff who slog no less for patients and effective functioning of the hospital. Why are they deprived of the glory and the adulation? While a doctor’s pay is directly proportional to his market value and the number of patients he attends to, why are nurses and technicians paid meagre salaries?

Why is the non-medicos always getting pulled up for errors, while no disciplinary action is taken against doctors in some hos-

pitals, even for serious breaches of conduct or lapses? It’s about time that hospitals strike a balance, acknowledging and empowering both the medicos and non-medicos.

To deliberate and debate on the topic, we have roped in Sheeja Kanade, principal, Hiranandani School of Nursing, Mumbai; Dr Praneet Kumar, CEO, BLK Super-speciality Hospital, Delhi; Joy Chakraborty, director – administration, PD Hinduja Hospital, Mumbai; and Dr Vinay Aggarwal, chairman and managing director, Pushpanjali Healthcare, Ghaziabad.

24-27_HCR_MAR13_Roundtable.indd 24 21-02-2013 15:56:25

Roundtable


Dr Vinay Aggarwal

Joy Chakraborty

Dr Ranjan Pai

SPOTLIGHTING ONLY THE DOCTORS Dr Vinay: There is a huge difference between doctors and nurses when it comes to how they are perceived in society. While doctors and nurses both share the same physical workspace, they play different roles on the field and view their environments in com-pletely different ways. The general mindset is that doctors are broadly the decision makers in a hospital and their closeness to the admin-istration further strengthens their position. Nurses, on the other hand, are mere execu-tors of instructions.

Joy: If we look at the evolution of Indian healthcare, we will find that in the early days, the scene was dominated by doctor-owned clinics or hospitals, either individually or as a group. Being the owners, doctors were natu-rally decision makers in the establishment. The tradition has continued in most hospitals due to a non-institutional approach.

In the present scenario too, doctors are one of the key factors of a hospital’s success. As a result, they have become key decision makers over other professionals. However, few hospitals have successfully brought about a team approach in care delivery in an institutional set-up to ensure a congenial work environment.

Dr Praneet: We must accept the ground reality that healthcare delivery in our country is still individual-driven rather than system-driven. Therefore, the doctor, being the team leader, gets attention and focus. This often takes away the credit that is due to other team members like the nurses, technicians and allied health professionals. In most cases, it is more about a historical legacy that con-tinues rather about bestowing special favours on chosen doctors.

Sheeja: Nurses are extremely critical to the clinical outcome of patients, but it’s always the doctors who receive all the adulation. Unfortunately, when it comes to errors, of-ten, nurses are pulled up by doctors or HODs even for lapse in responsibilities that do not come under their direct purview.

When compared to doctors, nurses spend much more time with the patients, monitor-ing them, administering medicine, changing drips and briefing the doctor among other things. The doctors come and go. However, it’s our society and the very nature of the Indian healthcare industry that does not understand the importance of nursing as a profession. In India, nurses do not get the respect that they deserve for their dedication, sincerity and hard work.

WHY THE BIAS?Dr Vinay: Probably the biggest thing that separates doctors from nurses is their educa-tion. To become a doctor, one obviously has to go through many years of rigorous train-ing. It then takes them several more years to establish themselves in the field and climb their way up the medical ladder. Graduation from specialist to a super specialist’s degree is quite a lengthy process. All these years of

hard work tends to justify their status in society as an

elite professional that brings home the bacon. In com-

parison, the total time spent in obtaining a nursing qualification is

far less and this creates an impres-sion that nursing is a relatively and fairly easier profession to get into.

Dr Praneet: There are several reasons for the bias. First, is the dif-

ference in educational background. Most of our nursing and allied health

professional staff is not a university graduate or post graduate. In fact, majority

Dr Praneet Kumar

Sheeja Kanade


Roundtable


of such staff members are certificate / diploma holders, which they obtain after passing 10th or 12th class. A majority of support staff, including the nurses, sometimes come from institutions that don’t provide adequate training. Many training institutes are not accredited, leading to a wide disparity in the knowledge and train-ing of the individuals coming out of different institutions.

Second, in our country, people insist that most of the processes and interventions including communication and counselling be done by doctors (even if they are senior), leading to a situation wherein, the nursing and allied health professionals does not get the op-portunity to independently discharge the role to the extent that they should.

Sheeja: I beg to differ on the poor qual-ity of nursing education that other panellists are talking about. If students enrol for MBBS after class 12, and entrance exams, and slog for many years to get the degree, the degree train-ing in nursing is no different. For the degree course in nursing, students have to take en-trance tests after class 12 and have to undergo a rigorous four-year course. The merit for medicine and nursing might be different, but the nursing course is equally exhaustive. And the colleges follow the syllabus, standards and regulations as laid down by the Indian Nursing

Council. In fact, during our foreign exchange programme with western countries, we are complemented for the practical knowledge that we impart in clinical areas in nursing colleges. Given the wide patient profile and diversity of diseases in our country, nursing care is all the more critical and crucial to a patient’s wellbeing. The lack of accreditation that my fellow panellists are talking about is also coming in.

Unfortunately, Indian hospitals neither rec-ognise the efforts put in by the nurses nor pay them a decent salary. And this is the reason that Indian nurses, given a chance, prefer to work abroad.

LACK OF PARITY IN PAYMENTJoy: I don’t find anything wrong in the dispar-ity in remuneration between doctors and other

staff. We must accept that in a healthcare setup, among all professionals, doctors are the most qualified than others. Also, the risk and skill involvement in the medical profession is maximum for them. So, they deserve to be paid more. However, when the disparity is too high, then it may need to be corrected.

Dr Praneet: There are multiple reasons for the wide disparity in the compensation of doc-tors and other staff. As pointed out before, ma-jority of such staff members are certificate/di-ploma holders, which they obtain after passing class 10 or 12. Even the training imparted, most of the times, doesn’t even fulfil the minimum requirements needed by hospitals. It is because of the on-the-job training and development they get that these members acquire reasonable competencies able to start contributing as use-ful team members. Failing this, they just remain as hands to do the ‘assigned job’ to a limited extent. Unfortunately, this is the bare truth.

Dr Vinay: The difference is also on account of how much money a doctor makes for the hospital compared to a nurse. Again, it's all relative to how much education the doctor has to go through to achieve his status and also on account of the specialised nature of his job. But it’s true that nurses, despite their great efforts, still remain largely underpaid.

Sheeja: Yes, Indian nurses are paid a pit-tance, when compared to what doctors get. While in the government sector, a nurse at the entry level starts off with Rs30,000 per month, the private sector underpays them. In the private sector, the salary can range from Rs3,000 in a small nursing home to Rs15,000 to Rs20,000 in bigger hospitals. This is not com-mensurate with the effort they put in.

IMPACT OF THE BIASJoy: Lack of empowerment of other healthcare professionals and absence of a team approach in delivery process might create a situation where professionals other than doctors feel unrecognised.

Nurses are as important as doctors

There is a dire need to accord independent privileges of practice to nurses and allied health professionals just as in developed countries to raise their dignity and self-esteem” — DR PRANEET KUMAR


Roundtable


Pushpanjali Healthcare has taken the following steps to recognise efforts of non-medicos:

Employee satisfaction measurements: Periodic assessments are conducted to find out the job satisfaction levels

of employees. The management also takes all possible steps to ensure that grievances, if any, raised by a member in the

organisation, are addressed to the best satisfaction of the concerned employee.

No punishment for errors: The management refrains from taking punitive action against errors on part of the

staff as it believes it would make the staff feel that mistakes and events reported are held against them and that such

incidents are recorded in their personnel files. Also, the nursing and other staff is not reprimanded before doctors/

general public. This helps boosts their morale while also ensuring that they learn from their mistakes and not repeat

them in future.

Communication openness: The staff is encouraged to speak up if they see something that may negatively affect a

patient and also escalate the same to higher management, thus making them a part of hospital functioning.

Open house forums: The management organises an open house session every month, where representatives

from the top management address staff members. This serves as a great platform for the staff to directly share their

concerns/issues with policy makers.

Employee recognition policies: Employees from various departments are identified every month and publicly

recognised for their noteworthy efforts. One of the short-listed members is then recognised as the ‘Employee of the

Month’. The employee not only gets a commendation certificate and a cash reward, but his/her name is also displayed

at prominent locations in the hospital for all to see.

Encouraging teamwork: To encourage the spirit of teamwork among employees at various levels, off site team

building exercises are conducted periodically where members from all departments including doctors participate

together. This helps significantly strengthen the bonds between them.

Work environment: The hospital claims to pay equal attention to making comfortable work areas and providing

recreation facilities for doctors as well as nurses. The nursing stations have been planned meticulously to ensure that

they are spacious and allow comfortable movements.

Authority: The nurses have also been given the authority to refuse performing certain activities like writing medication

order or carrying out documentation, which as per standards, are the principal responsibilities of a doctor. They are also

free to give their feedback and refuse executing orders if not prescribed as per standard protocols.

If the working environment in a hospital is influenced by bias, it leads to a situation where every professional may not be sufficiently motivated to deliver his/her best. The sense of ownership and belongingness to the hospi-tal and the team may get affected and lead to lower levels of productivity and poor job satisfaction.

Dr Praneet: The historical preference towards doctors does not affect the overall functioning of a hospital to a large extent in routine affairs. However, lately, as hospitals are scaling up to provide high-end special-ity care encompassing complex procedures or programmes, wherein specialised skills of nursing and allied health professional staff are required, the doctor-centric legacy is coming in the way of a smooth and harmoni-ous working environment. The saving grace, however, has been the acceptance by doctors leading such programmes or procedures of the fact that unless every team member gets his or her due recognition and place, there is a risk of jeopardising the programme’s success. Therefore, I would observe that the trends indicate tilting towards appropriate balance in this regard.

Sheeja: I would like to point out that the nurses in India feel highly de-motivated and face early burnouts because of their stress-ful work conditions. Forget about words of appreciation, nurses are burdened with work, which falls beyond their duties. It is extremely difficult for nurses to take leave and thus chal-lenging to maintain a healthy wok-life balance.

STEPS TO STOP THE DOCTOR BIAS Dr Vinay: The tools are employee satisfac-tion measurements, non-punitive response to errors of non-medicos, communication openness, open house forums, employee recog-nition policies, encouraging teamwork, com-fortable work environment, adequate staffing and empowerment.

Dr Praneet: There is a dire need to accord independent privileges of practice to nurses and allied health professionals just as in de-veloped countries to raise their dignity and self-esteem. This would lead to a balanced approach in recognition of contribution of all stakeholders in the delivery of care.

Sheeja: As far as nursing is concerned, hos-pitals need to make a conscious effort to de-velop a positive outlook towards nursing. They need to understand the immense contribution nurses make towards healthcare. To reduce

SETTING A GOOD EXAMPLE

attrition in nursing, hospitals need to motivate nurses, give them flexibility and encourage and allow them to take leave when they want to go for upgrade of their skills.

A degree student in nursing pays a few lakh rupees to receive training, so hospitals should pay the nursing cadre more to encourage more young girls to join the noble profession. In today’s age, when hospitals are so hung-ho

about customer satisfaction and delight, they need to pay nurses more and treat them well to ensure that they feel motivated to put in that extra effort towards making the patient feel comfortable and cared for. Finally, hospitals should become more process-driven, the role of nurses needs to clearly defined and they should be acknowledged for their contribution by doctors and management, alike.


Establishing a hospital is a com-plicated process requiring much effort—right from choosing an appropriate site to designing a good hospital building. Putting

up the hospital is a design charrette and is even more challenging if it involves redesigning an existing hospital. It is more than just putting new skin over an existing skeleton. In such projects, the design is often not easily reconfigurable.

We realised this when we decided to upgrade and redesign a brownfield project—The Hai Medicare and Research Institute (HMRI) in Patna. In 2011, HMRI entered into an opera-tions and management agreement with our

company, Paras Health Care Pvt Ltd, for rede-velopment of the project into a 350-bed multi speciality hospital.

We are redesigning the hospital as per the ‘Paras experience’ and are investing over Rs120 crore in the project that will be commissioned by July 2013.

WINDS OF CHANGEWe encountered many obstacles while redesign-ing the project. The existing grid size of the build-ing was irregular and the floor-to-floor height was just 2.85 metres. The building shell was severely rigid and clearly not designed keeping in mind future expansion, advancements or flex-

ibility. Getting an uninterrupted department was a challenge and needed a lot of thinking.Floor plates: The existing floor plate was small (only 18,000 square feet) and not consistent with the new medical programme. This meant adding new floor space. For this we had two choices: horizontal expansion or vertical expansion by putting up an independent tower. We went with the second option and the floor plate was increased to 30,000 square feet. This also allowed enormous energy savings by utilising natural day-light. No corridor in the new hospital is without natural daylight.Floor height: The existing floor height of 2.85 metres (approximately. 9’-3”) resulted in restric-

HMRI’s makeover story

Case study


Redeveloping Paras HMRI Hospital in Patna was a formidable challenge for which the team had to return to the drawing table

An artistic impression of the upcoming Paras HMRI Hospital, to be commissioned in July 2013

BY DR GOPAL SHARAN AND AR. MANU MALHOTRA

28-30_HCR_MAR13_Case study.indd 28 21-02-2013 16:06:41

Case study


tions on accommodating most functional areas. This meant that duct sizes had to be reduced and it further caused an increase in number of Air Handling Units (AHU). The AHUs were designed to operate flexibly. The areas served by single AHU were chosen carefully and engineered intelligently from an operational point of view. Depending on the usage of daytime operations, we planned the location and the size of the AHUs. Meaningful and tangible performance criteria were used to design the services.

The low height also meant that innovative structural solutions had to be worked out for constructing newer floor plates. In one such instance, we adopted post tensioning instead of convention structural systems to avoid beams and yet allow passage of services. Design of hospital shape/ footprint: The shape of a hospital has a profound effect on its energy consumption. In urban areas, the size of plot usually restricts saving energy in terms of building orientation. Limitations are further placed when the task involves retrofitting. We took advantage of the natural light and shading to reduce energy consumption by using ‘lean buildings’ instead of opting for simpler ‘fat building’. During daytime, the usage of artificial lighting has been reduced by over 80 per cent. The air conditioning load has been consider-ably reduced by using courtyards and recessed windows that provide shade. The cladding on external walls reduces heat gain caused by direct solar insolation.

Type: Multi super speciality hospital

Nature of the project: Brownfield project,

developed by Gurgaon-based Paras Hospitals

Built up area: 2,60,000 square feet

Commissioning date: July 2013

Cost of the redeveloped project: Rs150

crore (inclusive of equipment)

Bed strength: Phase one will have 265 beds,

and phase two will add 85 beds

Plans: Installing latest medical equipment and

providing necessary infrastructure, such as MRI,

CT Scan and a modern pathological laboratory

for up-gradation of the hospital. This facility

will house a PET scan equipment and two

linear accelerators, a first in the state of Bihar.

Apart from cancer- related medical care, the

hospital will also house equipment suitable to

other specialities. Future plans include housing

a medical college in the campus.

ABOUT PARAS HMRI

Patient rooms: Artificially controlled environ-ment has its advantages in recovery, but it also has a negative impact on the patient’s psycho-logical health. We designed all the rooms/wards to receive natural light and that allowed the pa-tients to get exterior views while being confined to beds. The view was either of the courtyard or the city. For inpatients, who would be mobile, we created courtyards that allowed them to interact with others as we believe this would aid in healing.Visitor areas: Since IPD and OPD visitors

have different needs and traffic patterns, we wanted a clear segregation. We incorporated this need by restricting the OPD blocks to two floors with a dedicated entry. Despite this segregation, the clinical staff and the doctors have unrestricted access to other parts of the hospital. The plan developed is fully compli-ant with travel distance restrictions as per the fire norms. The elevators in these OPD areas are dedicated and other elevators have limited stoppages on OPD floor.Blood banks: For blood banks, we created a


Case study


separate access for donors. Since blood bank generates a voluminous haz-ardous liquid bio waste, its collection is separate from rest of the hospital. For integration with hospital, connectivity has been planned for direct approach (access) and dispensing.Fire & smoke: After the recent incidences of smoke/fire related deaths and the risk involved for both patients and management, comprehensive plan-ning to reduce such risk has been undertaken at the Paras HMRI. The ICUs have been placed on higher floors near the OTs from the operational point of view, but this poses a challenge if patients have to be evacuated from such higher floors. A refuge area has been designed and located, so that it allows access from lower terraces and would aid in evacuation. On the smoke control front, an extraction system has been designed and is further aided by a system of differential pressures in corridors and rooms.Site movement, wayfinding and signages: One of the most important de-sign elements of this hospital was establishing site movement and exter-nal signages. Since the site is located on a heavy traffic road, the possibil-ity of a user taking a wrong entry cannot be ruled out. It meant putting up visible signage and tighter access control. The OPD and visitor entry was physically separated from the emergency department entry.

The entry for staff and doctors was separated and an area was demar-cated for them to park their vehicles. A separate emergency entry was pro-vided with sufficient parking for ambulances and emergency parking. The site movement also allowed for fire tender movement and adequate turning radius for all vehicles. The signage was also designed for proper function-ing and visibility at night.Oncology: Since oncology equipment needs unique structural require-ments and space, the unit will be housed in the new block. The new base-ment was made to house two linear accelerators, Brachy-Therapy Bunker and other advanced equipment. The PET scan was housed with a Gamma Camera room. The oncology department was spread over three floors.

The treatment area and healing area were designed based on their needs. The chemotherapy area allowed the privacy needed and, at the same time, was provided with spaces that could be used by patients for interaction.Structural designing: The most challenging aspect of the retrofitting project has been the structural designing, which involves visualising the unseen and unforeseen reinforcement and foundations. In the absence of complete set of structural drawings and the deviation (from the drawings) made during con-struction, added to the challenge. Further, the existing building was made in three different phases and therefore had expansion joints at odd locations. Joining of new and old concrete has its own set of challenges. Columns had to be jacketed and beams strengthened for newer loads. The water table being high (almost 14’) complicated the entire scenario and effective solu-tions were adopted to ensure water proofing, especially in areas adjacent to existing building.Constructability: When retrofit construction commences, unforeseen difficulties emerge. Planning that seemed perfect on paper doesn’t seem so in reality. For instance, in some locations the existing foundation was inadequate for new loads. This meant adding pile foundations next to the existing piles. But the location was such that no tall equipment could reach without demolition of the entire slab panel. Such instances required new solutions to be worked out within confines of the budget.

Dr Gopal Sharan is project head at Paras HMRI Hospital, Patna.

Manu Malhotra is director, healthcare, RSMS Architects, Delhi.

The old hospital building posed many design challenges for redevelopment

The aesthetically designed waiting area outside the ICU

The state-of-the-art ICU

The OPD block is designed keeping in mind patient comfort

The reception area of the hospital is planned to look inviting


Analysis


A nation’s scale of development is not measured by its GDP, but by its literacy level and its citizen’s access to basic healthcare. A well-developed

and thriving primary healthcare system is the biggest indicator of a nation’s overall social and economic wellbeing.

Primary healthcare is a person’s first point of contact with the healthcare system. It com-prises three aspects of basic medical care: pre-ventive, promotive and curative. Good primary care with a comprehensive preventive strategy clearly leads to better health outcomes, lower costs and more equity in healthcare. Developed countries that have a strong primary care focus have a higher life expectancy, lower all-cause mortality rates, fewer low birth-weight infants and lower infant mortality rates.

There is ample evidence from surveys conducted in the US to show that individuals and families who have a primary care physi-cian as their main healthcare provider, rather than a specialist, have lower annual healthcare expenditure. In one specific national survey in the US, this instance was less by almost 33

The primary prescription The only way to mitigate the country’s health woes is through private-public partnerships for offering healthcare at the grassroots

per cent. The same survey also showed that having a primary care physician have 50 per cent less emergency room visits and 35 per cent less hospital inpatient care requirement by the same set of population. An increase of just 1 primary care physician is associated with

1.44 fewer deaths per 10,000 population in the US. Although this association of primary care with decreased mortality is stronger in the African-American population than the white population, nevertheless, it clearly shows that healthcare systems that have more primary

10

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* Rank based on patient satisfaction, expenditures per person, 14 health indicators, and medications per person in Australia, Belgium, Canada, Denmark, Finland, Germany, Netherlands, Spain, Sweden, United Kingdom, United States

11 12

Primary Care Score vs Rank in Outcomes

BY DR SANTANU CHATTOPADHYAY

32-33_HCR_Mar13_Analysis.indd 32 22-02-2013 13:31:09

Analysis


4,000

1 2 3 4 5

8,000

7,000

6,000

5,000

GENERAL PRACTITIONERS PER 10,000

With the advent of specialty doctors and big hospitals, the age-old tradition of family physicians has taken a back seat. For a problem like headache, a patient now just goes straight to a multi-specialty clinic and ends up getting prescribed a laundry list of diagnostic tests, often leading to no specific diagnosis at the end of this exercise. The traditional gate-keeper function of primary care is largely disregarded and leads to escalating healthcare costs, patient dissatisfaction and overburdening of secondary and tertiary care centres.

Healthcare costs are likely to rise with an increase in life expectancy because the aged will become vulnerable to chronic non-communi-cable diseases (NCDs) and will need expensive treatment. In a country with a rising burden of NCDs and lifestyle-related ailments, prevention strategies are of prime importance. Without an organised primary care system in place, it is not possible to effectively manage chronic diseases and their complications in our populace. The High Level Expert Group on Universal Health-care appointed by the Government of India, in its recent report, has recommend that as much as 70 per cent of the total healthcare budget needs to be reserved for primary care. But even this may not be enough to achieve the goals of providing universal health care.

PPP: THE FUTURE OF PRIMARY HEALTHCARE Neither the government nor the private sector can resolve the health problems of our country alone and it is high time that both partner with each other. Universal healthcare can become a reality if the resources come from the govern-ment and the operational capabilities of private players are used optimally.

care doctors, offer greater benefits in terms of reducing deaths due to non-communicable diseases (NCDs). Interestingly, evidence also shows that above a certain level of specialist doctor supply, the more specialists per popula-tion, the worse is the health outcome.

WHERE DOES INDIA STAND? In the Indian scenario, there is an estimated 17 per cent shortfall in health sub-centres and an 18 per cent shortfall in Primary Healthcare Centres (PHCs). The shortfall in terms of gov-ernment doctors is even steeper at 76 per cent. Most of these vacant positions are at PHCs and community health centres (CHCs). Although we have less specialist doctors than needed, the gap is wider when we look at the overall requirement for primary care physicians. In a survey conducted among medical interns and recently graduated MBBS students in Bengalu-ru, we found that only two per cent of the medi-cal graduates would even consider a long-term career in primary care and that too, only as a last-resort if they aren’t able to get into training for other branches of specialisation. Clearly, the dearth of qualified primary care practitioners puts us way behind other developed nations as we are unable to offer comprehensive basic medical care to our billion-plus population.

Inequity in healthcare provision is another factor at play in our country. Primary health-care is quite fragmented across the length and breadth of the country, with urban areas doing slightly better than the rural belts. Villages are either deprived of basic care or have poor quality services. Even in the urban and semi-urban areas, there is a lack of awareness among people about the need to visit a physician for preventive and promotive health.

Traditionally, the private sector players have kept away from primary healthcare initiatives because they feared that it is not a sustainable business model. Of late, several private play-ers are willing to enter this field, signalling a cost-effective and value-added primary care delivery in the times to come. However, most private players are only willing to operate in urban and semi-urban areas, catering only to paying customers. This effectively marginalises any benefit to the underprivileged customer.

Public-private-partnerships (PPP) are possi-bly the best solution to ensure that the bottom-of-pyramid customer receives high-quality pri-mary care. Already, several state governments are exploring different forms of PPPs to help them run primary care models in both urban and rural areas. The Government of Arunachal Pradesh has an on-going PPP initiative with a private trust to manage 11 PHCs and provide healthcare facilities to the local population. However, it is important to understand what sort of incentives can drive successful PPP initiatives. One of the best examples of a suc-cessful primary healthcare PPP model is the UK National Health Service (NHS) GP model. In this model, the Government contracts out the primary care to local general practitioners (GPs). These GP practices are incentivised on three different types of healthcare parameters.

The input-type parameters relate to routine deliverables such as number of children im-munised, number of patients serviced and surgeries conducted. The output-type pa-rameters relate to improvement in healthcare outcomes such as decreased blood sugar levels for diabetics, better blood-pressure control in hypertensive patients and decrease in number of low-birth-weight babies. Finally, measure-ment of patient satisfaction is a key metrics of the healthcare service delivery.

If the government is serious about providing quality primary care at the grass-root level, it is imperative that it encourages private players in PPP models with incentives based on achieving good healthcare outcomes and improving the healthcare indicators, as well as improved patient satisfaction. To achieve this, partnering with the right private player is important. As is obvious, the social and economic health of the

country depends on this.

Dr Santanu Chattopadhyay is founder and CEO, NationWide Primary Healthcare Services.

Total Cost of Healthcare vs Availability of Primary Care

SPENDING PER BENEFICIARY (DOLLARS)

32-33_HCR_Mar13_Analysis.indd 33 22-02-2013 13:31:33

Innovation


Small measures, big benefitsHow Ahmedabad’s BAPS Yogiji Maharaj Hospital improved process outcomes, attained higher savings and enhanced productivity BY LALIT MISTRY

Often, processes fail due to the gap between process designers and pro-cess executors. A process may look great on paper, but more often than desired, those who execute the process are not qualified enough to read the documented process or have framework that ensures its effective im-plementation. If the people involved in a process are unable to understand every step involved and its importance, it will fail. We need to design a process, keeping in mind the people, who will be its part, train them, and inspire them to stick to the system and standard operating procedure. Or else, hospital executives will end up spending most of their time resolving day-to-day issues arising due to process failures.

Process mapping and critical analysis can help identify the process barriers and factors resulting in the failure of a process. A re-look at each activity of the process, people involved in it and the infrastructure can help understand process barriers. Often, fine-tuning and innovative small measures can translate into successful implementation of the process, like in the case of our hospital. Efforts in our hospital helped us engage and involve people in the processes to ensure that they were executed by users as designed by our executives.

FOCUS CHANGEWe adopted process-based management instead of department-based management, with intention of eliminating and replacing functional silos of departments with services heads. Service heads were process owners responsible for managing the entire process from start to end and all de-partments connected with process were grouped under the service head. For instance, we had an in-patient service head responsible for managing admission-billing-discharge process, food service, housekeeping services and laundry services that helped to eliminate functional silos and inter-departmental conflicts. Our process-based management approach helped us reduce number of middle management executives and we had more junior management executives.

SMALL MEASURES TO IMPROVE COMMUNICATION

Constantly training support service staff (housekeeping staff, security staff, laundry staff, and support service staff ) was a huge challenge. We realised that staff members forgot the various key steps in a process soon after the training, leading to day-to-day process failures. We wanted to communicate the processes in a manner and language that ground level user could easily comprehend, and this has resulted in bet-ter process outcome.

Towards that, job responsibilities for housekeeping staff, security staff and support service staff were depicted in pictures. For instance, each security point in the hospital displays pictorial job responsibilities of the staff with regards to security checks, visitors polices, assisting patient with wheelchairs, switching on-off lights and important dos and don’ts. The security supervisor ensures at the start of each shift that the staff reads the pictorial job responsibilities, which has resulted in better process outcome.

SMALL MEASURES TO SAVE ELECTRICITY COSTIn every area, lighting has been colour coded as per requirement — yel-low colour for lights to be kept on during the day, black for lights to be kept on at night and half yellow and half black for lights to be kept on 24 hours. It now becomes easy for the staff to keep only the required lights on and other lights are off, and this has helped to reduce electricity cost.

Pictorial description

of job responsibility

The support service staff can now discharge duties as intended by the management as their roles are depicted pictorially at strategic locations

34-35_HCR_Mar13_Innovation.indd 34 21-02-2013 16:09:25

Innovation


SMALL MEASURES TO SAVE MANPOWER COST

We have designed equipment to help us save time and manpower. For example, instead of increasing the number of staff to cope with staff shortage, we designed instrument trolleys that would roll over to the OT table enabling the surgeon to work with one scrub nurse. This helped us to reduce one staff nurse per surgery.

INTERNAL LEADS THE EXTERNAL All processes are interlinked and interdependent; failure of even one ac-tivity of a process may affect quality of other process. Process improve-ment rests upon a deep understanding of how people work together in processes and work together to improve processes. Re-engineering core processes, looking at things with a fresh perspective, adopting newer

approach and making best possible use of available resources can bring in significant differences to process outcome.

SMALL MEASURES TO SAVE TIME AND EFFORTS

We identified that our paramedical and support staff in the patient care areas spent lot of time locating critical equipment, patient service related items and files. Even trying to find equipment assets such as stretcher, wheelchairs, dressing trolley and pulse oximeter drains staff productivity and affects the quality of patient care. Quality of patient care improves when patients don’t have to wait until equipment or things can be located. We demarcated the location for critical equip-ment and important items pertaining to patient care that helped the staff to locate them easily. The staff was instructed to keep the items back at the same demarcated location.

SMALL MEASURES TO IMPROVE PATIENT SERVICE

Patients often complained about the staff walking into patient rooms, causing unnecessary disturbance. We put up colour-coded door hangers like in hotels—each colour signifies the category of the patient like general patient, privileged patient, foreign national patient and immune-compro-mised patient. The staff can now identify the patient and take necessary precaution while rendering service.

Lalit Mistry is CEO, BAPS Yogiji Maharaj Hospital, Ahmedabad.

SMALL MEASURES TO ENHANCE QUALITY

Process variation is often observed in biomedical waste management due to a mix up of waste collec-tion bins by staff members, who keep wrong colour or wrong size bins at the wrong place. The biomed-ical waste department demarcated every location of waste bins across all areas with an arrow indicating colour and size of the waste bins that helped staff to dispose waste in the correct manner.

Important equipment is now kept at a designated place, which makes locating it easier

Keeping equipment such as wheelchairs in a proper place has helped improve patient care

Arrows assist in proper disposal of waste

Equipment is designed to reduce the number of staff required in surgeries

Colour coding depicting the privacy requirements of patient rooms

34-35_HCR_Mar13_Innovation.indd 35 21-02-2013 16:09:31

Event report


After being held successfully held at Chennai, Hyderabad, Mumbai, Bengaluru, Kochi and Delhi, HospiArch, the premiere conference on hospital plan-

ning, design and architecture, was recently held at Vijaywada, Andhra Pradesh. The event, for which, Healthcare Radius was the media part-ner, received an overwhelming response.

Here’s a glimpse into who spoke on what topic.Dr M Veeraprasad, medical superintendent & COO, Narayana Medical College & Hospital, Nellore Topic: Architectural challenges involved in building a new hospital. Gist: A functionally designed hospital can pro-mote skill, economy, conveniences and comforts, while a non-functional design can impede activi-ties of all types, impair quality of care, and raise costs to intolerable levels.

Hospital architecture has to take into consid-eration enhanced patient expectations, epide-miological and demographic changes, changing lifestyles and non-communicable diseases, emphasis on ambulatory and day care services, enhanced standards, changing function of hospi-tals and advancement in medical sciences.

Hospital designs have been guided by certain norms, such as MCI, NABH and JCI, which require a patient-centric approach. These norms have been identified and implemented in hospital designs so that there is proper space

How design mattersHospiArch in Vijaywada introduced an array of interesting concepts related tohospital planning, design and architecture

utilisation. In addition, they ensure that hospitals follow safety features relating to the patients and the staff. It is critical for a hospital design to following such norms due to the strict guidelines set forth by various agencies.

The strategic essentials are to anticipate change in demand, create a healing architecture, and factor in flexibility, expandability and adapt-ability. The design also needs to focus on aesthet-ics, and energy conservation, assisted living and build healthcare hotels or ‘hospitels’.

In addition, it has to be cost-effective. The de-sign of a hospital has a lot to do with the operating cost, however, many people do not understand the co-relation between the two. For instance, the inclusion of single patient rooms, hand washing sinks in all patient rooms and enhanced indoor air quality adds 10 per cent to the cost of a 100-bed hospital, but the design could cut down 10 per cent operating cost annually by cutting ALOS and

the number of staff members required. Besides, it can enhance patient satisfaction, patient safety and reduction in the rate of infection .

M RadhakrishnaCOO, Narayana Hrudayalaya Topic: Financial planning for a new hospital. Gist: A list of statutory approvals required for a new hospital are building permit, trade license, labour license, drug license, fire compliance, NOC from Pollution Control Board (Air, Water, Environmental), lift license, food license, PNDT License, blood bank license, excise license, VAT, Luxury Tax, PF, PT and ST registrations among others. Market research should include demo-graphics performance analysis of four to five leading corporate hospitals, availability or identi-fication of specialist doctors, financial feasibility, and project report. The utility planning would include power, water, AC, generator, STP and ETP, biomedical waste management, medical gases, elevators and access control systems.

Dr Vijay PV, associate consultant, Medica Synergie Topic: Planning and designing a new hospital. Gist: Step-by-step schedule for hospital planning includes many things such as survey, feasibility and functional evaluation, workload projec-tion, master and space programme, master site planning and preparation of schematic drawings elevations, preparation of outline specification and cost estimate, review by local body, design development, and bidding. It is a complex pro-

Anuj Jindal, senior consultant, Hospaccx India Systems, Bengaluru

Hospital designs are guided by certain norms, such as MCI, NABH and JCI, which require a patient-centric approach”— Dr M Veeraprasad

36-37_HCR_Mar13_Event Report.indd 36 21-02-2013 16:10:39

Event report


Dr M Veeraprasad

Dr Vijay PV M Radhakrishna Dr AV Ratnam Ravishankar Iyer

(L) M Bhaskara Rao, director, KLUBS; Dr R Srihari Rao, vice chancellor, K L University, Vijayawada; Paniel Jayanth, founder and chief strategist, AMEN

T Gayatri Bhargavi Topic: Hospitals of future: Virtually integrated Indianised setup. Gist: In India, the term healthcare, is usually associated with hospitals, but comprises multiple aspects like pharmaceuticals, hospitals, diagnos-tic centres, ancillary centres, health insurance, telemedicine healthcare software, medical tour-ism and medical equipment. At present, hospital

structure is integrated (AYUSH). Hospitals use advanced software to bring efficiency in the process). The prescription process is optimised. Networking of the data base includes personal-ised software, care centres (like that of ATMs) and restructuring of the local non-performing units into SBUs to reach out to emergency needs.

Personalised software includes technology that helps track patients performance, integrat-ing their medical history with identity cards and

cess, where the form of building has to conform to function, should encompass philosophy of care, be friendly to the community and should facilitate functioning. Steps in hospital planning include the following: • To proceed in an orderly manner through the

stages in the planning and building a hospital• To have appropriately qualified planning staff

available at each stage• Allow sufficient time in the early stages of

planning as it is expensive to scrap a complete set of architectural drawings. Time spent thinking about the hospital’s requirement will save money and time in the long run.

Dr AV Ratnam, president, Parirakshana, Hyderabad Topic: HRM planning for new hospital. Gist: Before recruitment, one needs to assess the need in terms of number of personnel for each type of job. Roughly, we need three to five personnel/bed. So, for 100 bed hospital the mini-mum staff shall be 300 - 400.

This includes doctors, administrators, nurses and lab technicians. The hiring requirements for nursing, doctors, lab technicians, CSSD, lab bank, ECG technicians and radio imaging departments are equally crucial. The nurse-patient ratio as per INC is based on hospital beds—one chief nursing officer per 500 beds and nursing superintendent should be one per 400 beds or above DNS.

information about a third party or the various schemes the individual has registered for and provides for the good relationships and effective schemes that are profitable to patients.

Restructuring local non-performing hospitals, which have their own technical expertise and individuality but under the name of the institu-tion, reduces the cost of establishing a total new structure. It offers online consultation, saves time and resources, is convenient to patients and doc-tors, and offers standardised prescription.

The hospital can concentrate on critical care and emergency treatments, better mobilisation of resources and extended access to the healthcare services. The limiting factor is the scope for physical malpractice, integrating the data and computerising the data base and need of invest-ment in terms of money, time and expertise.

Anuj Jindal, senior consultant, Hospaccx India SystemsTopic: Quality standards applicable to hospital planning. Gist: Some areas where planning suffers the most are patient care areas that are crowded, patient flow/services flow, healthcare associated infections, air-conditioning, air-locks that are ab-sent in entrance to critical care areas, waste man-agement and cleanliness standards and hand-wash facilities. Other challenges are unfriendly architecture for physically-challenged patients, width of corridors, room entrances, fire exits, fire safety equipment, smoke detection, housekeep-ing, linen, maintenance, CSSD, biomed, MRD, lab, imaging, staff/common toilets, administra-tion areas, storage areas and server rooms.

For design evaluation, risk assessment has to include patient, staff and visitor safety, infec-tion prevention and control, patient and services movement, compliance with NBC and other statutory norms and review by a hospital planner.

M Ravishanker Iyer, founder & principal consultant, SPHINX Project Consultancy Topic: Re-planning and redesigning an existing hospital. Gist: This should ensure that the entry of the hospital is efficiently planned and aestheti-cally designed in a way that achieves maximum customer satisfaction. It also helps to create early adaptability and flexibility towards growth and changing technology, while allowing creation of new specialties based on technology advance-ment. It should create efficient and adequate space in the building, leading to optimal utilisa-tion of resources.

Allow sufficient time in the early stages of planning as it is expensive to scrap the architectural drawings” — Dr Vijay PV

36-37_HCR_Mar13_Event Report.indd 37 21-02-2013 16:10:47

Infrastructure


Lighter, smoother, faster Several hospitals are choosing drywalls over traditional construction for internal walling

BY RITA DUTTA

The healthcare industry is always embracing newer trends and technology, which are focused on quicker turnaround, better outcomes, improved

efficiency and enhanced patient care. The emergence of drywalls in building solution in hospitals is one such crucial trend that today’s hospitals are gravitating towards. Several hospitals like the Asian Heart Institute and Seven Hills in Mumbai; BEAMS in Bengaluru; Medanta and Fortis Memorial Research Insti-tute (FMRI) in Gurgaon; Wockhardt Hospital (now Fortis) in Kolkata and Mumbai; Vasan Eye in Surat and hospitals from Narayana Hrudayalaya group have opted for drywall, preferring it over traditional construction in various sections.

WHAT’S THE TREND?It is estimated that over 80 per cent of all interior construction in developed countries across all applications is with drywalls. Drywall, used in all construction segments in the country since the last decade, first came to India as light-weight interior partition systems in addition to traditional masonry walls. In the healthcare domain, Saint-Gobain Gyproc claims to have pioneered drywall in 2007-08, with Fortis Hos-pital (earlier Wockhardt), Mumbai, being the first to opt for it.

Experts point out that with the introduc-tion of new products and systems, designed to handle greater loads and withstand high impact, drywalls can now be used in both critical and non-critical areas of a hospital. In non-critical areas, it is being used in common areas, pharmacies, canteens, patient cabins, diagnostic rooms, MRI areas (which includes lead shield drywalls for X-ray rooms), and OPDs. In critical areas, it used with a protec-tive coating of PU, epoxy and vinyl. Moisture

resistant drywall systems are being used in wet areas of the hospital.

INDIAN PREFERENCEIndian hospitals use drywalls in all areas including room to room, corridors, wet areas, OTs and ICUs. Asian Heart Institute, Mumbai, for instance, uses dry walls in both patient and utility rooms, while FMRI uses it in office spaces. Fourteen of 17 Narayana Hrudayalaya hospitals use drywalls in corridors, OPD areas, wards, offices, cafeteria, IT and conference rooms. According to Viren Shetty, senior vice president, strategy and planning, Narayana Hrudayalaya, “The areas that are built conventionally by drywalls are OTs, dialysis rooms, ICU/ITU, bathrooms, scrub rooms, CSSD, stairwells and lift shafts.”

POPULARITY FACTORAs per estimates, in all major cities of the coun-try, there is at least one ongoing hospital project that uses drywalls. So, what’s making drywalls popular? It’s the following advantages they offer over traditional options. Lightweight: Drywalls are eight to 10 times lighter than bricks or blocks, thus reducing the weight on the slab. It then doesn’t become man-datory for building a beam below it for support. Dr Ramakanta Panda, vice chairman, Asian Heart Institute, informs, “Reduction in weight

There are many types of drywalls — fibre cement board and solid wall panels, calcium silicate, gypsum plaster boards, green board, blue board, fire resistant, sound resistant and mould resistant. How does one select what’s suitable? Says Hemant Khurana, vice president, sales & marketing, Saint-Gobain Gyproc India, “The selection is based on the kind of activity planned for the space. Patient rooms are designed with walls rated for heavy to severe rating, which lends the walls the strength to cater to the different use and abuse of the surroundings.” Depending on the place, drywalls can be designed to take care of acoustics, fire, strength, moisture, flexibility, and ease of parameters associated with the location.

SELECTION CRITERIA

38-40_HCR_Mar13_Infrastructure_drywalls.indd 38 21-02-2013 16:12:35

Infrastructure


resulting in reduction of structural load was one of the primary reasons we went for drywalls.” Since drywalls are practically weightless, they don’t need to follow the profiles of underlying beams and can be placed anywhere.Time-saving: Erecting a drywall takes about 70 per cent less time than it takes to raise a brick wall of the same thickness. The faster turnaround time provides huge labour sav-ings and expedites the process of utilisation of space. The fast pace of construction was one the primary reasons that made Narayana Hrudayalaya opt for drywalls. Like many oth-ers, the group first went for 9” or 4.5” brick and cement type of masonry because masons were considered an inexpensive resource. However, the bricklaying and plastering work at its pro-jects got frequently delayed because masons would not be available during festive, election or harvest seasons. “When we switched over to drywalls, we were able to complete a job that used to be measured in months, in a few days,” informs Shetty.Ease of use and passage: Drywalls offer pre-provided slots and creation of cavities between two separating walls easily to accommodate all required services. Another key area, where drywalls make a difference is the passing of services through walls. Says Hemant Khurana, vice president, sales and marketing, Saint-Gobain Gyproc India, “Hospitals have an extensive network of power cables and piping for oxygen, air and vacuum running across. The hollow cavity of drywalls facilitates easy passage for services without disturbing the integrity of the wall. This also facilitates main-tenance needed on the services with minimal disturbance to the wall structure.” Further-more, cut-outs and windows in drywalls can be made in several designs and needn’t follow a rectangular geometry. However, Narayana Hrudayalaya is not convinced. It has refrained from using drywalls in sections that require heavy plumbing or requires services running within the walls. Better performance parameters: Compared to conventional walls, like wooden, brick, block or concrete, which offer poor sound insulation, drywalls made from gypsum plasterboards offer a higher acoustic performance (with insula-tion rating up to 74 dB). They have a fire rating (between 1/2 – 4 hour) at a thickness much less than brick walls. According to Biloy Mohapatra, senior manager, marketing, Everest Industries, “Through better acoustics and fire protection, drywalls contribute towards better working am-

Cleaning: There are stringent cleaning regimes in place for hospital buildings. “To cater to such stringent norms for the cleaning regimes of the internal environment of a hospital building, the design of gypsum board drywalls and ceilings is based on HTM 60 document,” says Khurana.

According to him, repairing and maintaining drywalls is easier than cleaning conventional form of construction as it requires less time and is less labour intensive. Drywalls with water resistant paints, PU, epoxy, vinyl and wall tiles surface finishes can be easily cleaned.Maintenance: Experts claim that unlike conventional walls, drywalls are easy to maintain. They give accessibility to point of maintenance without interfering in the day-to-day activities or occupant's comfort.

“Drywalls with normal emulsion surface coat need to be repainted as and when required,” Mohapatra recommends.

Shetty suggests that they either be repainted every few years or be coated with stain-resistant enamel paint. In high traffic locations, one may install tiles on the walls up to four feet so that the walls don’t get stained. “In the case of drywall areas, we simply mount the tiles directly on the frame,” says he.

CLEANING AND REPAIRING When we switched to drywalls,

we were able to complete a job that used to be measured in months, in days” – VIREN SHETTY, SENIOR VICE PRESIDENT, STRATEGY

AND PLANNING NARAYANA HRUDAYALAYA

Reduction in weight resulting in

reduction of structural load was why we opted for drywalls”– DR RAMAKANTA PANDA, VICE CHAIRMAN, ASIAN

HEART INSTITUTE

Drywalls come fitted with slots for wiring, which

makes installing cables easy

bience and occupant's comfort and protection.” Experts say that its low thermal conductivity

and high thermal resistance results in reduced electrical consumption, thus reducing the load on the AC units.

They also facilitate a disturbance-free envi-ronment in hospitals, thus ensuring faster pa-tient recovery. Says Surender Kumar Dhiman, general manager, projects, FMRI, Gurgaon, “We have used gypsum board drywall on the fifth floor of our hospital as this an area, which is slated for modifications at a later stage. Since dry walls are sound-proof, laying of services in these walls would be easier.”Flexibility: Drywalls allow design layout changes, a crucial factor as hospitals go for frequent upgrades. Moisture-resistant: As the plasterboards and steel framework used in drywalls are moisture resistant, there are less chances of microbial growth. Special water-resistant drywalls, or green boards are available that come with an additive, which makes them mould resistant.


Infrastructure


Aesthetic: The smooth finish and crack-free surfaces give drywalls a pleasant appearance. Eco-friendly: Being dry construction, dry-walls save precious water. Drywalls, which are made of gypsum, can be sourced from natural reserves. Stable: Drywall-covered wall may sound hollow when one knocks on it, but it is capable of resisting high impact. Interestingly, when Narayana Hrudayalaya was considering drywalls, many people in the organisations were sceptical about the drywalls’ ability to absorb the impact of trolleys hitting them. “That may have been true of drywalls from decades ago, but as we used high-quality sheets, the wall didn’t dent even after we ran a trolley into it many times,” says Shetty.

Less messy: For a functional hospital, using brick and mortar construction for expansion is a huge challenge as traditional construction material not only occupies a large amount of space at the site, but the shifting of the mate-rial always creates disturbance in the hospital. It also results waste being accumulated at the site. Also, conventional brick / block wall, material are heavy and components like sand cement slurry are in wet stage. In contrast, drywall material is light in weight and both the input material and waste material are in dry state. “Drywall components can be easily handled and wastage can be easily and economically disposed. In case of conventional wall, labour component are much more higher for handling material and waste, which in-cludes removal of dried slurry on the floor and cleaning the area. Drywall components can be easily handled and wastage can be easily and economically disposed,” says Mohapatra.

THE HITCHESCautions Dr Panda, “The straightness of the partition proves to be a challenge in some cases and a tendency to bend is not uncommon. Also, the skill of the installer is crucial in terms of correctness of joint ceiling as the finishing of the wall, either paint or wall paper, is contin-gent on product quality and correctness of in-stallation.” It is also to be noted that these walls cannot carry weight and hence, if any heavy installation (say a television, sink or shelf ) is required to be supported by this wall, appropri-

ate reinforcements have to be provided to allow to wall to withstand the weight.

While some users consider using high qual-ity drywalls much more expensive than regular brickwork, others point out to the dearth of skilled people to install them. “Skilled people are important because improperly installed drywall will develop cracks along shearing edges, especially around the door frames,” informs Shetty.

AN EXPANDING MARKET While European and other western countries have leveraged the drywall advantage for all types of interior solutions, India is yet to catch up. The present drywall market in India is about 5 lakh square meter, excluding wood-based partitions. Currently, healthcare contributes 5 - 7 per cent to this market. “By next year, the market size would increase to 10 - 12 per cent,” says Mohapatra. “Through a combination of efforts made by the manufacturers, architects and designers, adoption of modern construction techniques by builders and greater demands by end clients for high performing environmen-tally friendly buildings, the dry wall market is set for a significant growth,” says Khurana.

In the coming years, the boom in new pri-vate hospitals, along with factors like depletion of natural resources like sand and water, rising costs of labour and construction material and escalating costs for projects due to time delays are likely to spike the demand for drywalls, across all industries inclusive of healthcare.

The hollow cavity of drywalls

facilitates easy passage for services without disturbing the integrity of the wall” – HEMANT KHURANA, VICE PRESIDENT, SALES &

MARKETING, SAINT-GOBAIN GYPROC INDIA

Through better acoustics and fire

protection, drywalls contribute towards better comfort and protection for the occupants”– BILOY MOHAPATRA, SENIOR MANAGER,

MARKETING, EVEREST INDUSTRIES

The smooth finish and crack-free surface of drywalls gives the patient lobby of Vasan Eye, Surat, a pleasant look

Phot

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urte

sy: S

t G

obai

n


Our cost-effective approach and financing has helped us to earn the trust of the Indian healthcare market

Consumer Connect Initiative


‘MRI systems lead the sales in India’Anwar M Mithavayani, CEO, Reliant Medical Systems speaks about his company’s performance in the Indian market

When did you foray into the Indian diagnos-tic imaging market and with what kind of product range? We entered India in 2010 with MRI and digital X-ray.

How has the Indian diagnostic imaging mar-ket grown since the last decade and what has been Reliant’s contribution? Reliant has been working on educating the consumer on image quality and that’s our contribution to the imaging industry. Creating cost-effective solutions, while maintaining im-age quality will be our long-term contribution.

What is the USP of Reliant’s products?Our products and service is of western quality, which means high and pricing is eastern, which means affordable.

In which countries does the company have its footprints?Since the last 15 years our company has been headquartered in Florida and our manufactur-ing is in Georgia. Our UAE office manages sales in the Middle East Asia region while South America is managed through our sales office in Santiago, Dominican Republic.

Which products are leading in sales in India? MRI systems lead the sales in India with CT and X-ray being a close second. Our cost-effective approach and financing has helped us to earn the trust of the Indian market.

What led to the group setting up a manufac-turing unit in India? India has a huge growth potential. Currently, there are many medical services and hospi-tals that are looking at upgrading their older technology. Current trends indicate a worldwide

potential for our quality-based products.

How has the company’s market grown in India? We initially started selling to our distributors only refurbished MRI and CT. Currently, we di-rectly supply new MRI, X-ray systems and digital solutions with fast inexpensive PACS system. Today, we manufacture quality X-ray systems to complement our Digital Radiography line to increase throughput with low dose in X-ray and to insure safety of patients.

How many employees and offices do you have in India?We have one main office in India and satellite offices in Pune, Ahmedabad and Jabalpur. We had 12 employees in 2012 and will have over

25 by end 2013. Our projection for India is 200 employees by 2016 with the new manufactur-ing wing currently being developed in Ambar-nath, which will be operational in 2014.

Please share details about your extensive parts department. MRI and CT require huge parts and currently in the USA and Dubai, we have a market of over $10,000,000 in parts. In India, there is a shift that will start in July 2013 to delivery over $2,000,000 worth of parts alone for X-ray and CT.

Please share details about your repairing division.Our Florida operations currently repairs over 100,000,000 parts annually and cannot keep up with our current customer growth. Therefore, the training in 2014 and transfer of repair for Asia will have to shift to India.

What kind of support services do you offer?Online support for our direct customers is free of charge for CMC customers only, and in India, we are looking to bring the trend and the training to help reduce downtime for our customers. We also offer Magnet online and direct support to hospitals that need to monitor and maintain their Magnet cooling system at a reasonable fee.

What’s in the pipeline? A new 0.5T open MRI will debut before end of this year at RSNA, after which it will be released in India and then at Arab Health for worldwide mar-kets. In addition, new quality and affordable DR systems in mobile and fixed hospital settings with improved functionality are on the cards. We will also release a newer version of Electronic Medical Records system for smaller hospitals (100 to 500 beds) that will help them go paperless.

41_HCR_March13_Consumer Connect initiative.indd 41 21-02-2013 16:14:32

Viewpoint


Health Technology Assessment (HTA) is a multi-disciplinary activity that systematically examines the safety, clinical efficacy, clinical effective-

ness, cost and cost-effectiveness, organisational implications, social consequences, legal and ethical concerns, for enhanced health technol-ogy delivery and application. Today, as we focus on growth, we need to bring in scientific and evidence-based concepts, such as HTA, to aid overall decision-making and planning of health-care delivery services. HTA application at the governmental level (national and state) as well as at the institutional level aids in proper alloca-tion of resources and making the right choices.

THE BASICSHTA couples the evidence with decision mak-ing and thus has similarities with evidence-based healthcare and evidence-based policy making. While early assessment tended to focus on large, expensive, machine-based technolo-gies, the scope has gradually widened to include smaller technologies/softer methodologies (counselling) and clinical healthcare needs.

HTA focuses on two key issues: clinical effectiveness and cost effectiveness. Clini-cal effectiveness involves understanding how health outcomes of a technology compare with available treatment alternatives. And cost ef-fectiveness means understanding whether the improvements in health outcomes are commen-surate with additional costs of the technology or the intervention planned.

HTA is borne out of the gap between cost of acquiring new health technologies and limited health budgets. It is known as a bridge between evidence-based policy making with accessible,

usable and evidence-based information that will guide the decisions about technology and effi-cient allocation or utilisation of resources. HTA applications include drugs, medical devices, clinical and surgical procedures and manage-ment of clinical guidelines.

THE NEED Public expenditure on healthcare in India is low by international standards and HTA is the right tool to obtain maximum benefit for the popula-tion. Despite the predominance of out of pocket payments, payers are increasingly demanding value for money from their healthcare spends. HTA methodology will help demonstrate how a new treatment for patients, say with a trial fibrillation, although more expensive than the current standards of care, improves clinical outcomes and represents a cost-effective use of public health resources.

THE THREE PILLARSEvidence: Any new technology or intervention is appraised using well-established evaluative techniques of systematic reviews, meta-analysis, clinical trial design, epidemiology and eco-nomic evaluation, which should be applied to all aspects of healthcare if the evidence base is to be expanded and applied by decision mak-ers. Without such application, society’s scarce resources will continue to be wasted.

Cochrane Collaboration (CC) is a worldwide network that critically reviews the literature on a variety of healthcare interventions to produce the evidence needed to improve health policy and practice. The collaboration’s goal is to as-semble an updated register of all randomised controlled trials and a database of structured and evidence-based reviews derived from the

CC. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evi-dence from systematic research. Each of it is an overlapping cornerstone for HTA, which when merged together, helps improving healthcare with faster and scientific decision making.

Economics: Economic evaluation of the bene-fits of new technology is based not only on health gains versus monetary expenditure required, but also on its effect on the quality of life of the treated population. The allocation of healthcare resources needs to be prioritised on the basis of cost benefit analysis, cost effectiveness analysis, cost utility analysis, QALY (quality adjusted life years), DALY (disability adjusted life years) and ICER (incremental cost effectiveness ratio).

Ethical and legal aspects: In view of selecting the topic for a comprehensive evaluation of HTA, the decisions taken should meet with principles of medical code of ethics and fulfil all statuette and legal standings, even though it may sound scientific and cost effective. Although healthcare expenditure may be seen as an economic burden, this philosophy underlines the need to view spending on healthcare as an investment in the long-term economic wellbeing of the popula-tion. Policymakers can make informed choices regarding the most productive use of investment in health and wellbeing of the nation, by employ-ing adequate and rigorous methodologies such as HTA.

Get the HTA advantageHealth technology assessment is a valuable tool that can help prioritise technology spends and improve utilisation of technological resources

Dr Sanjeev Singh is medical superintendent of Amrita Institute of Medical Sciences, Kochi, which had recently organised the 1st international fellowship on HTA.

BY DR SANJEEV SINGH

42_HCR_Mar13_Viewpoint.indd 42 21-02-2013 18:27:33

Medicall 2013


From February 8 – 10, healthcare professionals from western India knew where they needed to head to acquire knowledge about latest and advanced medical

and dental products, equipment and interact with vendors—Gujarat University Hall in Ahmedabad. For it was here that Medicall, the premier medical equipment expo, was being held. Healthcare Radius was one of the media partners for the expo.

Be it doctors, medical administrators, procurement personnel of hospitals, nursing homes owners and administrators, biomedical engineers, HODs of hospitals, trade dealers and distributors—the expo catered to all, at-tracting as many as 4,500 visitors in the three-day show.

This was the second time Medicall was held in Gujarat with an exclusive dental pavilion called Famdent with live conference and seminars for the vertical. According to Dr S Manivannan, founder, Medicall, “From 80 exhibitors last year, this year we had over 150 medical equipment manufacturers from India, Germany and China.” The event, held in Chen-nai, Ahmedabad and Sri Lanka, was started in

From good to greatMedicall 2013, held in Ahmedabad, was aimed at helping small and medium hospitals grow their business

2006 in Chennai as a result of Dr Mannivan-non’s efforts to learn about newer strategies and advanced technologies in an attempt to scale up his Trichy-based Kauvery Hospital from a 30-bed to 800-bed hospital chain.

TARGETING THE MIDDLE AND SMALL SIZED HOSPITALSThe Ahmedabad event that had a wide range of medical equipment and technologies on display, was targeted towards the middle and small sized healthcare institutes. It offered them a three-day focused business platform to reach an exclusive B2B audience. The theme of the conference ‘Good to Great’ too was conceived, with the same visitor profile in mind.

TAPPING THE WESTERN REGIONThe expo was an ideal platform for many vendors to reach out to the western region. Said Nikunj Gada from Konica Minolta and Medion Healthcare, which had put up two stalls, “We have been participating in Medicall, Chennai, since the last five years. This was the first time that we participated in Medicall at Ahmedabad. The reason for participation is to strengthen our presence in the western region.”

Echoed Fahad Siddiqui, manager, marketing, RD Plast, “We wanted to strategically tap the western healthcare market through the event.”

A WIDE RANGE Medicall brought together the best in the busi-ness of ALS ambulances, clean room, climate control systems, hospital kitchen equipment, ICU and OT equipments, refurbished equip-ment, trolleys, wheel chairs, cots and other furniture, hospital linen and laundry, hospital charts and stationary, office automation equip-ment, printers dealing with pamphlet and file designing, communication equipment, medical disposables, Hospital Information Systems, solutions, surgical and examination furniture, rescue and emergency equipment, to diagnos-tic/laboratory, OT equipment and cleaning equipment.

Special products displayed were ambu-lances, mannequins and other teaching aids for nursing, hospital management software, energy saving equipment, hospital flooring, housekeeping equipment, nurses alarm system, liquid oxygen and central pipeline, physiother-apy equipment, autoclaves and sterilisers.

43-46_HCR_MAR13_Medicall_events.indd 43 21-02-2013 17:46:50

Medicall 2013


Leading healthcare equipment vendors and service providers and consultant firms participated in Medicall 2013, held in Ahmedabad. Here’s is a peek into what a key exhibitors displayed at the event.

Ziqitza Health Care Limited (ZHL) has been a pioneer in the emergency medical response services and patient transport services in India since 2005. ZHL’s vision is to assist in saving human lives by providing a leading network of fully-equipped advanced and basic life sup-port ambulances across the developing world. ZHL provides fully-equipped ambulance with trained drivers and paramedics to hospitals/

RD Plast specialises in the design and manu-facture of support systems for healthcare and audio video industry, including mount-ing supports for flat panels and medical equipment since 1993. Its Fastrack range of products caters to the healthcare industry largely, while Swiveltelli, serves the audio video industry with few mounts designed for healthcare industry as well.

At Medicall, it showcased the following range of products from the Fastrack and Swiveltelli ranges:• High-specification cubicle track system• Overhead intravenous track systems• Mobile rail cubicle track systems• Curtains• Wall mount TV/monitor support systems

Said Fahad Siddiqui, manager, marketing, RD Plast, “RD Plast is a professionally managed, leading manufacturer and supplier of high specification innovative products for health-care industry, supported by unmatched in-stallation and customer support services. Our ability to adapt to quick changes to techno-logical advancements enables us to become the loyal partners of our esteemed customers. Our strong market presence countrywide advocates the quality and services we render to our old and new partners.”

Medion Healthcare, a reputed manu-facturer and supplier of operating room equipment and life support equipment with presence of more than 30 years in the Indian market, displayed anaesthe-sia delivery systems, anaesthesia work stations, intensive care ventilators and syringe pumps. The products showcased were: Asteros Lite (Anaesthesia delivery system), Asteros Royale & Asteros Sap-phire (Anaesthesia workstations), Altima (intensive care ventilators), High end: Oricare V8800, Greasby 2000 & Greasby 2100 (Syringe infusion Pumps) and Transport Ventilator (Flight 60).

Spotlighting exhibitors

Ziqitza Health Care Limited

RD Plast Pvt Ltd

Medion Healthcare

A glimpse into what leading exhibitors showcased and highlighted

Asteros Lite (Anesthesia delivery system) • Two gas based (O2 & N2O) with dual cascaded four-tube rotameter.• Designed for low flow anaesthesia delivery.• Anti-hypoxic guard for controlling gas ratio.• Cylinder and pipeline gas connectivity for O2 and N2O• Large diameter high pressure gauge -1each for O2, N2O and air.• Second stage pressure regulation to ensure abso-lute accuracy of gas delivery.• Autoclavable twin jar CO2 absorber (optional).• Selected compatible vaporizer.Asteros Lite model is available in various configura-tions to suit user needs from basic to mid- level market segment.

Highlights

organisations to cater to their outsourcing requirements.

At Medicall, ZHL displayed its Dial ‘1298’ for Ambulance, which is a fee-for-service model with cross subsidy, where the rich and affordable pay more and the poor pay less. Said Praveen Menezes, Head-1298, India, “For the very poor and accidents/emergencies, the service is free of cost. Currently, this service is operational in Maharashtra (Mumbai), Odisha, Punjab, Bihar and Kerala.”

ZHL also highlighted its ambulance out-sourced wing. “One of the key management issues faced by hospitals is managing their am-bulance fleet. To cater to the acute need of well-equipped and maintained fleet of ambulances in Kerala’s hospitals, ZHL, with its vast experience in life-support ambulance management, has ini-tiated the concept of outsourcing of advanced life-support ambulance service by hospitals and other institutions to ZHL,” said Menezes.


Medicall 2013


Hospaccx India Systems is a Bengaluru-based hospital consultancy firm, which offers a wide array of services for various healthcare setups, ranging from nursing homes to multi specialty and super specialty set-ups. At Medicall, Hospaccx highlighted its services, which include: hospital planning and designing, hospital accreditation, busi-ness development and strategies, hospital management consulting, inventory and bio-medical equipment consulting, HIS, human resource management and public healthcare consulting.

According to Tarun Katiyar, principal consultant, Hospaccx India Systems, “We also spoke about our key projects and the achievements that we made in a short span.” He added that Hospaccx has been participating in Medicall since 2007. “We have come across genuine buyers during the show,” he added.

Hospaccx India Systems is staffed with people aiming to make a paradigm shift in hospital industry/sector through innova-tion as well as out-of-the-box thinking. The company provides entire range of services that any healthcare service provider may require through the large numbers of spe-cialists and associates, imparting practical insights to make projects viable.

The company operates in four main business areas: diagnostic imaging systems; patient care and clinical informatics; customer services; and home healthcare and is present at every major event.

In Medicall 2013 too, the company par-ticipated with gusto by unveiling a slew of products. They were:a. ClearVue 650 Ultrasound for Ob-GYN

practiceb. Colposcope – SLC2000B for Cervical cancer

screeningc. UT4000A bed side monitor

Agora Climate Control Systems

Hospaccx India SystemsPhilips Healthcare

Agora Climate Control Systems designs, man-ufactures and installs hygienic air condition-ing system, which helps in controlling post operative infections occurring from environ-mental contamination. Agora CCS does layout planning, designing and detailed HVAC engineering calculation for the management of perfect specific thermo hygrometric condi-tions (Temperature, Humidity, Particle con-trols and Pattern of air movement). AGORA’s main areas of activities are operation theatre, IVF Lab, ICU, PICU and isolation rooms etc in a hospital. Each of these departments has their own environmental need. For some, it is safety, while in others it is process need. A wide range of guidelines (as set by NABH, JCI, HTM, DIN, GOST), various specification of equipment and broad range of initial in-vestment create a challenge in its own while deciding.

The products the company showcased include:1. Critical care solution a. Patient monitors – mid acuity monitoring

range (Goldway and Suresigns) b. DECG – C3i and TC20 c. Defibrillator – Heartstart XL and AED d. Ventilator – Trilogy 202 and V2002. OT solutions a. Anesthesia – Siesta Whispa b. C-arm – Surgico series c. OT lights3. Home healthcare respiratory solutions


Medicall 2013


Most healthcare profes-sionals are voracious readers, who often seek knowledge and inspi-ration from popular

management books to improve the efficiency of their organisations and its processes. An example of this was evident in the novel theme of ‘Good to Great’ seminar for the recently concluded Medicall expo. The theme was in-spired by the book of the same name by James C Collins. The theme was apt for Medicall, Ahmedabad as it suggested multifarious ways in which small and medium sized hospitals could improve efficiency, operations and also scale up. The seminar was concurrently held with the expo at Gujarat University Hall in Ahmedabad on February 9 and 10.

DAY ONEThe conference kick-started with Dr S Ma-nivannan, joint managing director, Kauvery

Hospitals, speaking on trans-forming a hospital from family-owned management to a professionally-managed brand. He said that while creating organisations, one

often trusts and relies only on their fam-ily and friends and gives them the management rein. It is only in the long run, that one re-alises the folly

Path to professionalismThe seminar at Medicall 2013, Ahmedabad, addressed many critical areas of hospital operations and development

of the decision. “We lose friends and business partners often due to roping in family members in management of institutes,” he said.

According to him, big organisations have been successful because of unconven-tional thinking, and managing such oraginsiations requires disciplined people. Regard-ing family-owned hospi-tals, he said it was essen-tial to formulate a system for family-run hospitals to provide measureable outcome benefits to the patients, stakeholders, vari-ous healthcare providers, and business partners.

CA Ravi Kumar P, director, Bio Vedas Consultantancy, spoke on ‘Person-dependent organisation to system-dependent organisa-tion’. He said that systems run the business and people run the systems. He added, “90 per cent organisatons in India do not follow a systemic approach. Systems should be pro-active and not reactive, while doctors should adopt a reactive approach.” Condemning person-dependent organisations, he said such organisations take delayed decision, impart little or no training, indulge in blame games, hide errors, create a few heroes, and hoard information, resulting in fire-fighting and disappointed customers. On the other hand, a system-dependent organisa-tion takes quick decision even at the lowest level, encourages error reporting, imparts train-ing, follows predictable process, resulting in pro-active approach and customer delight.

This was followed an informative panel discussion on the session’s theme. The panelists

were Dr Manivannan, CA Ravikumar P and Dr Chandra Kumar S, MD, Kauvery Hospitals.

The next session was on hospital materials management, where management consult-ant Prof Ramachandran V spoke on vendor

management. Dr S Manivannan spoke on ‘How to leverage IT in materials

management’. He stated that IT is needed in material manage-ment due to the contribution of materials to overall expenses, the critical nature of materials,

frequent change in pricing and lack of professional managers.This was followed by a panel

discussion on materials management. The panelists were Prof Ramachandran, Dr

Rungta and Dr Manivannan.

DAY TWOThe second day started with the session on audit. Speaking on clinical audits, Dr B Krishnamurthy from Baby Memorial Hospital, Kozhikode, said clinical audits are a quality improvement process that seeks to improve patient care and outcomes through systemic review of care against explicit criteria and implementation of change. “Aspects of structure, process and outcomes of care are se-lected and systemically evaluated against explicit criteria,” said he.

Manivannan S, director, Parama Healthcare, spoke on performance audits. He said that they assesses whether hospitals are undertaking their functions efficiently, effectively and economi-cally. A performance audit helps to compare planned outcomes with actual outcomes.

The interesting topics and discussions were well-received by delegates.

90% Organisatons in India that do not follow a systemic

approach

Dr S Manivannan


healthcare radius magazine march 2013

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