Setting up Hospital Quality System-six simple steps

When I was new to the healthcare management, I used to wonder how to initiate and setup quality system in a new hospital? What to do first and what to do next. As I suggested in my previous article, the setting up quality system should be initiate from the stage of civil planning. While looking for information, I came across an article on ‘Ford Assembly line’ and that gave me an idea to develop my own approach, assuming services as product and various execution stages as assembly docks which will refine and bring services in shape. The first and the most important step is to identify the services provided by the hospital and its focus areas.

For the selected services, organization should identify various processes & activities their flow with interdependent activities. Eg. If a high end trauma unit is the in the scope of services then one has to define process of delivering services, which will leads to resource planning (including neuro, ortho, reconstructive surgery as support services which will be requiring man, machine and material) and in turn will impact the civil drawings to accommodate them. This should be done by a cross functional team including quality champions, administrators, architect & doctors. The flow should be patient friendly and should address universal guidelines provided by national or international regulatory bodies. When the activities & detailed workflows are defined, the next step is to define procedures to perform these processes; rules to follow these procedures; how to follow procedures as work instruction. These are collected as documents known as SOPs, Policies and collectively called as manuals. eg. Process of trauma patient care include one procedure as triaging defined stepwise details in SOP; rules to follow during triaging including zoning, colour codes, responsibility matrix etc. will be covered in policy.

Who will execute these processes & policies? Before implementation Staff Awareness is required.  A detailed plan has to be made for training the staff as soon as they join the organization. While training, the points should be clear that how to do it, rules to follow, what if things went wrong & overall expectation. The comprehensive training programme can be divided in Universal Induction, department induction and continuous refresher training. The training content should be customized according to different categories of staff eg. Nursing, doctors etc. for better results. It should not be just dump of information but in small pieces so that the employee can absorb it. This would be time consuming process. Never forget to check the staff understanding towards these processes.

While the staff getting prepared for implementation, a parallel plan to be prepared on how to communicate and make our patients/visitors aware about our system. Patient’s awareness should be aligned to vision & mission of the top management. Eg if hospital is talking about ethical & transparent clinical practices in the mission statement, it should provide information regarding clinician’s protocols; doctor to patient communication, regular counselling during treatment/surgeries, how we take consent and why it’s important; what are the patient rights; how our feedback system works; what are our codes of conduct for patient care etc. Medium of communication is also very important aspect.

It’s very important to follow the process but it is more important to track whether these have been followed correctly with desirable outcome. That’s why key performance indicators and quality indicators come into picture which quantifies the procedures. These can be defined by identifying processes important to the management. For better understanding & for impact analysis, these can be collected in logical fashion under various dashboards with the aim of creating a decision support system. Identification of these QI & KPI can be during the first step but implementation and tracking would be done while hospital is operational.

Tracking & analysis of QI & KPI is a continuous process. Shortcomings or deviation from the assigned benchmark should be evaluated thoroughly. Root Cause Analysis, internal audits are the tools helping us to identify defects in the process or how the things went wrong. These audits must focus on processes not on an individual. Corrective action can be taken by the front team after consent from superiors but the preventive actions must be executed after through discussion amongst multi-disciplinary team. Preventive action will lead to change in the design of the complete system including SOPs & Policies. This will not only impact the hospital operations but also the finances. eg. If hospital identify the cause of decreasing hand hygiene rates as non-availability of disinfectants & training process, preventive measure may include adding-up more locations for keeping disinfectants which will leads to increase in inventory & cost, training staff repeatedly on usage thus impact on working shifts, changing the training process to increase its impact or policy of inclusion of bedside disinfectant bottle charges in bills etc.

This is a cycle and gets repeated during hospital operations for existing services & processes. Even new processes go through same sequence of synthesis.

Hospital Quality System setup

Disclaimer: The views expressed in this post are purely the thought of the author and are not meant to be derogatory to any institution or organisation. The author is open to further discussions. Thank you for your patience and tolerance.


Medical Equipment Layout Design in Hospital Facility Planning

The following are few examples of problems faced by Hospital authority while commissioning the new facilities wherever medical Equipment is involved.
 The new EMG system installed in Neurology Department was not able to perform test properly due to continuous artifacts as dedicated ground/earthling was missing.
 The brick walls of Mammography unit was found less than 9 inch & doors were not lead lined as it is mandatory to have same wherever X-Ray based equipment are used.
 The total six numbers of electrical sockets were provided per cubicle new cardiac Intensive care unit. It was found insufficient while in use on certain patients.
 The heater coil of Steam autoclave was repeatedly failing due to pH level of incoming water not within prescribed specification by service provider.
 MRI scanner getting aborted frequently due to increased temperature in equipment room against prescribed specification by service provider.
This is more common in Hospital’s where the inputs from Clinical Engineering Department are missing during facility planning stage. This may result in rework in the particular facility. The hospital should actively involve In House Clinical Engineers during any new/renovation of facilities construction.
The Clinical Engineer should review the following checklist after understanding requirement from Equipment supplier before providing inputs to Hospital project planning dept.
1. The patient factor:
a. Space for patient movement through trolley, Wheelchair into Equipment room.
b. Patient positioning during test with reference to interfacing of equipment with patient& also ensuring that patient privacy are maintained during testing.
c. Availability of services like medical gases, Nurse Call bell, Crash Cart with Defibrillator inside the equipment room.
2. The equipment electro-mechanical factor:
Exact location of equipment based on dimension of room, equipment footprint, location of periphery equipment and housing of cables.
a. Type (i.e., single phase or 3 phases, Raw/UPS / DG back up) & Number electrical points needed for equipment and periphery equipment based on power consumption of equipment.
b. Equipment grounding specification like need of dedicated grounding or hospital grounding.
c. Air-conditioning details to be provided based on heat dissipated in equipment operating temperature & % humidity level accepted by equipment.
d. Specific consideration like Piped Medical Gas System, dedicated computer network cable, exhaust fan, drainage duct, plumbing lines etc depending on type of equipment.
e. Government Statutory requirement with respect to equipment.
3. The material factor:
a. Provision in room to keep equipment accessories like patient electrode, probes, transducers, instruction & service manuals, spare parts.
b. Provision to keep essential drugs, medicines etc.
4. The Human factor:
a. Sitting positioning of equipment technician, nursing staff during patient test on equipment.
5. The Equipment maintenance factor:
a. Provision for keeping space in equipment room to carry out routine calibration by technician, preventive and breakdown service by manufacture service engineer.
6. The building factor:
a. Weight bearing capacity of building structure with reference to dimension and weight of equipment.
b. Interior of room like type of flooring, ceiling, lighting etc.
c. Compliance of equipment room as per government bodies regulation.
d. Routing of Equipment from landing at Hospital till arrival at designated room.
7. The change factor:
a. Includes provision flexibility in layout design considering possible up gradation of equipment.
The systematic planning of all medical equipment area by Clinical Engineering Department in consultation with service provider & facility engineering will help Hospital project planning & execution team to reduce blunders during execution stage. This will help hospital to save cost in rework on account of change in MEP plan when equipment arrives to hospital site.

Value Based Healthcare Delivery

I recently came across this talk by Michael Porter about healthcare that he had delivered at Harvard  Business  School though the  talk was  generally about the healthcare system in the US  however  i felt that  it was quite  relevant  to healthcare  systems in general across the globe.

One  of the  most  important things that he talked about was  Value Creation and  improving the  Value delivery system. But then the question which arises is what is the  true value.  How do we  define Value becomes  critical , is it just patient outcomes , is it cost of delivery , could it be a  generalised figure and  he defines  it quite comprehensively  he says that it the patient health outcomes achieved  relative to the money spent to achieve those outcomes.  Which becomes a  simplified outcomes as numerator and cost as denominator.

This is  quite  a shift  in our existing way of  measuring success  which are either  based around profit maximisation, or Volume  delivered, or  access to healthcare in general. Quality as  it stands currently is  based entirely around the  process definition and  improvement. Be it any guideline we  follow NABH or JCI its  mostly process based. Process improvement  is very important  however outcomes  are  even more important.  And  are we really measuring the  clinical outcomes. If the  system is to improve  then the competition has to move from being profit or  process based to becoming outcome based and then to value creation and thats the  only way we can get a  handle on the spiralling costs of healthcare delivery.

So how do we really shift the  focus to value.

Lets Look at Outcomes outcomes need to defined per  patient and  his / her medical condition. We need to look at survival,  functional status, independence, residual defect / illness. Yes it is an intensive  exercise  but the  results would truly be  enlightening and  a true move towards the  goal  of quality. Define the  Outcome parameters for any surgery / medical treatment that is meted out including survival rates, extension of survival period, dependence of medication etc etc.

Secondly identify your costs. For some strange reason healthcare seems to shy away from a  practice which is so commonly followed in the manufacturing  sector and this is ABC (Activity based Costing ) .For Healthcare i would suggest a  time related Activity based  costing. Whats even more  specific is that it will  be a  patient based time related activity based costing.  We tend to see ourselves as distinct departments and subunits and we tend to do our costings similarly too(that  is if we do our costings). However a  true costing exercise must capture the entire cost related to the  patients  journey through  care  pathways. And through this way we should be able to define  the true value of a  patient outcome. The focus needs to be on the  Outcome , and  existing technology in terms of HIS  systems must integrate these costing parameters  but  the  end result could truly be transformational .

I personally look  forward to a  day where  we will focus on the right performance indicators though that  is a  different post in itself. But  i think this could very well be a move  in the right direction be it for a private hospital, a charitable trust or a  public trust.  Efficiency , effectiveness  both would be  effectively measured and  documented and  true value would lead to better profits / access/ volumes so this is a  win win no matter  which way you take  it.

Here is the  Video if you are  interested , apologies for the poor sound quality.

Disclaimer: The views expressed in this  post are my own and  are  not meant to be derogatory  to any institution or organisation. These are just my thoughts and  these are open for further  discussion and  development. Please do comment and  share and  let’s get some universal cognition into this. Thank you for your patience and  tolerance.

Going Cellular on healthcare – an exploration

According to mobile analytics firm Flurry India’s connected device installed (smart phones and tablets for the uninitiated) base grew by a whooping 160% from April 2012 to April 2013. According to the latest report of IAMAI and IMRB, till Oct. 2012there  are a total of  76 million mobile internet users  ie accessing internet from their  mobile devices  in India and this doesnt include  dongles and data cards.  This number is expected to reach 130.6 million by march 2014 and 164.8 million by march 2015.

Now those  are  crazy  stats but the  question here  is  are  you on the  smart phone  yet. Applicability for   smart devices in hospitals is just  at its infancy but the  possibillities are just enormous.

A Hospital Based  App  –  this is for marketers as well as for  operational convenience. Though i have thought of other  applicability ill leave that for another post.

Developing one  basic downloadable hospital application with various utility parameters set into it. So lets get my thoughts straight here these  are just some random ideas that  i have  worked  upon or come across which work or should work you can always add  more in the  comment section.

a) Pill Reminders  – once a  prescriptions been filled  out and dispatched from the pharmacy this application can be downloaded and it will remind you when you need to take your  medicines  could be used for both in and  outpatient. I think this application is already being used  by Wallgreen  (part of the wall mart enterprise)

b) Health check reminders once you have booked  a  health checkup this does a basic count down to the  health check reminding you from three days  prior to the HC . and  one day before it sends you details as to what is expected from you . Also allows  you to give an online feedback

c) Virtual consultant  feed your query get an answer and  tie in for fixing up an appointment

d) Appointment  scheduler no calls required like an online consultation allows you to choose a speciality a consultant and an available time slot maybe about a  month in advance again a  reminder system can be put in for when your consultation is due

e) Diet check – basic calorie / special need diets  includes interesting recipes as well as  a basic calorie calculator such apps already exist on  the  ios and  android markets and can be integrated they are  for free  usually.

f) im not to sure if this can be done but basically an emergency helpline number that  the  app can directly feed into your mobile and  which will be  accessible at the  touch one button

g) Promotions any new  promotion pass it on  to your existing customer , though this is a  bit of an issue but can be

h) Disease research  – if you need to know anything about a  particular disease  get the data here

i) Patient connect  – connecting with patients suffering from similar disorders successfully treated by the  hospital with contacts if required like mobile testimonials and brand ambassadors. also mention best times to contact.

Thats  just the  tip of the iceberg i am certain as we go ahead we can find more utility.

Whats important for a particular app to be successful is that its  patient centric and understands  what purpose in patient care or patient  information provision it serves.  The  App has to be utility focussed and  not just there because  everyone is moving onto the  mobile platform or because  you want  to push messages to your community  from your hospital. If thats the  approach you have  then even if people do  download your app  they will get  rid of it faster than you can say flu. So remember friends utility is king and thats the only way you can create a  successful app.

Disclaimer: The views expressed in this  post are my own and  are  not meant to be derogatory  to any institution or organisation. These are just my thoughts and  these are open for further  discussion and  development. Please do comment and  share and  let’s get some universal cognition into this. Thank you for your patience and  tolerance.

Primary Healthcare in Rural Areas- A collective approach

As awareness is increasing towards health related issues, entrepreneurs & companies are coming forward with various initiatives for providing healthcare services in urban & rural India. Urban landscape is still satisfactory but rural areas are still void of such services.  These Initiatives vary from use of technology like telemedicine to tackling financial issue through rural insurance with microfinance or public-private partnership to setup health centres and many more. But sometime I wonder that what would be chances of setting up a successful rural healthcare model when the efforts are made in isolation keeping specific areas in mind. Is it feasible to apply it across country without understanding what the rural India wants & what is their needs?

I prefer to see the issue from patient’s perspective as what they require from healthcare delivery system. In my view, basic but affordable treatment at appropriate time by an adequately skilled physician is enough for the most of the rural population. For preventing diseases we should also address issues like basic hygiene, malnutrition & sanitation.

Incidence of non-communicable disease is around 35% in rural areas which contribute almost 68% of total Indian population in 2009. NCD anyways require tertiary care with advance intervention but must be diagnosed in early stage to reduce the adverse impact. Major cause of mortality among rural population is communicable diseases which usually require medical treatment not surgical intervention hence a basic infrastructure with proper medication in sufficient.

Then what are the obstacles for providing primary healthcare to rural India? Do we require magic to get it changed? I see it’s a mix of Infrastructure, Financing, cost of care and administrative policies issues. This is combined with absence of people awareness towards their health needs.

We already have an old infrastructure but needs to be expended so that PHC get setup in every small town having mix of doctors from different discipline of medicine (Allopath, Ayurveda, Homeopathy) to have cross discipline plan of care. These PHC to be covered by BLS equipped ambulances stationed strategically and shared between nearby villages. Cluster of PHCs to be supported by secondary care hospital. These PHC & secondary care hospital can be run by private healthcare providers on a contract basis that will give efficiency and effectiveness to the system. Comprehensive system to be setup for collecting, evaluating & monitoring healthcare performance indicators to be setup for future planning & identifying the effectiveness.

There is a need of various awareness campaigns focusing separately on preventive aspect of communicable diseases & life style alterations to prevent non-communicable disease. A nation-wide network of NGOs, healthcare providers should be built for training and developing local resources.

Policy makers should focus on promoting innovation in field of affordable medical consumable, equipment & technology by creating favourable environment for entrepreneurs & investors. Separate tax structure for the doctor and health care workers working in rural area, Conducive environment for pharmaceutical companies supplying in rural areas, tax exemptions for equipment used in rural areas & promoting new comers in healthcare delivery are some of the measures that may inspire service providers to work in rural areas. Healthcare should be priority in the local government’s agenda.

Promoting & structuring medical tourism is important to strengthen private sector financially and make them to lower indigenous pricing by cross subsidization. State sponsored health insurance coverage including medicines and making health insurance as mandatory. NGOs can initiate and create a pool of volunteers willing to support rural family for their healthcare needs by financing their health insurance.

Controlling the cost of care is the most important aspect for continuing primary healthcare delivery model. Now it’s time to realize the power of indigenous medicines system (AYUSH) which is known to most of the rural India. Focusing on preventive medicine & lifestyle improvements, wide use of technology for communication and information sharing and developing resources in local community for spreading awareness can help us to reduce the cost of care. Inventory management system to be developed & run by the private sector including medicine & consumable.

It doesn’t require Magic to create primary healthcare as right to every citizen. It can be achieved by a collective & systemic approach with full commitment. This has to be a joint effort from policy makers, healthcare industry, NGOs and every individual that can make a difference.

Disclaimer: The views expressed in this post are purely the thought of the author and are not meant to be derogatory to any institution or organisation. The author is open to further discussions. Thank you for your patience and tolerance.

Health Care Communication – Keeping it simple

I really do love this video, it just appeals to me in so many ways.  Recently i was  following this conversation on Linked in it’s on the group it’s called the  Healthcare marketing community  join it if you  are  interested. The  conversation that I was being a  part of was the complexity of communication in healthcare and it indeed is very important to understand as  Marketers the intricacies of the  message that we are sending out.

In recent times i have come across a  lot of  institution centric  advertising,  or speciality centric  approaches  specially in india. But that’s not it sometimes we do use a  patient centric approach but somehow the brand behind the  patient treatment seems to become to loud.

Heres another video by Pfizer around which the  discussion was based

But then how are these advertisements different .   I think they are different  because  they work on the following two levels .

They are clear  about their understanding of  who they are  looking at  reaching out to , or  what phase  of the see- think – do stage there at.

More importantly they understand the whole emotional tumult that s associated with a disease not just  for the  patient but also his care givers, friends and family.

That,s what really ties in both the advertisements for me . While the first is fact based  and the other  more emotion based  i still feel that somehow they follow the  same line  of thought.

It’s so simple at times but we seem to get  lost in the complexities  of our brand,  So here’s to keeping it simple

Disclaimer: The views expressed in this  post are my own and  are  not meant to be derogatory  to any institution or organisation. These are just my thoughts and  these are open for further  discussion and  development. Please do comment and  share and  let’s get some universal cognition into this. Thank you for your patience and  tolerance.

The SEE – THINK – DO Marketing framework for Hospitals

Let  me  be  honest the  ideas  here in terms  of application might be  mine  , but this  models  been developed by Mr. Avinash Kaushik , author  of Web Analytics an Hour a  Day and  Web Analytics 2.0 . i haven’t had the  privilege of reading these  books as of yet however  i do frequent  his blog Occam’s Razor and  i would suggest that  having read  this do visit his  site. Its  a  highly intelligent and informative blog  and a  must for all marketers. You could visit  his  site  before  hand  and  develop your own thoughts  about the  model too.

So  lets  get started whats the  SEE-THINK-DO framework all about.

We all know  how as marketers we  view  the  purchase  decision  / Funnel , be  it the  AIDA concept (Awareness, Interest, Desire, Action) or the  CAB (Cognition, Affect, Behaviour) or any other but that’s  basically it. I would say See – think- Do is the  same thing but  its thinking from the consumer’s point of view. The other  two are  very marketer oriented terminology, and  believe you me terminology  at times can change  our thought and behaviour.  Also when it comes to Healthcare other than maybe some cosmetic procedures and  maybe birthing , the  desire is usually amiss. However  the  decision funnel still retains the same  shape. We as individuals  do consider which hospitals  we would like to go to, be  it consciously or subconsciously.

So in the  SEE phase are people  who will require healthcare,  specifically the specialities you  cater too. this  is a  very broad category, and a very large part  of the  population will belong to this category  . The purpose of this categorization is not inclusion but rather  exclusion people who will not use your  services must be excluded. So maybe a generalist target population could be considered here

The Think phase has  people who use healthcare  services and are thinking about it,  this is evident by even a  slight intent . They necessarily are  not  planning to use healthcare services immediately but think they might do so sometime  in the  future.  this is a part  of the see population. So might be  people who are health aware  , who seek out  information regarding health.

The  Do segment  are  people who are actively  seeking healthcare providers. Who are shopping for care and are  in need for it.  this  is a  subset of the  think people eg If  it’s an elective  procedure we actively assimilated information, listen talk and  shop.

So we have these  stages what next. The  whole point to this framework is that it allows for us to consider each of these segments in our marketing plan, it helps us in creating content which is  specific and  yet broad  enough for these categories. It allows us to select channels which would be most effective. Now remember  this is not a  prescriptive frame  of reference  like all frames of references its  basically  a concept  an idea to increase your understanding of your customer and for optimising your  marketing  plans and strategies to  maximise benefit. The  key word  here  is yours.

Basing  our Content  Strategy around  The  Framework

Before  we  go to market and  decide  on what channels we  will engage in its  important  to have a  definitive  content strategy based around the  Framework. If  your  call to  action at all times is  buy buy  buy , then you are catering to a  very specific do segment. This is a  small segment and you  would lose out on the  opportunity to engage the  Think and to attract the  SEE people. Thus  your content the  way it’s housed or structured needs to be as broad and as  specific as  possible . This  is  much easily achieved on  a website  , however offline media is a slightly different ball game  however  , i  do believe depending on whom you are reaching out to there are  components that can be added to your print advertisement  or bill board which do more  than just cater to one single segment.

Eg Heart Care, lets say we are  targeting a very specific cardiac care population, while you run a  general solid copy introducing care “1000,000 hearts beat  under our care”,  for the  see public you could also integrate a  Facebook / blog address for the  think population to connect with our stories visit and  integrate  a  website  and  telephone for the  do population simple facts but are we doing them. Digital media provides us  with a  much better  opportunity to create these touch points and must be considered while creating our content  structure and design. And then there  could be specific campaigns which cater individually to each of these  segments individually for the see stage the campaigns will be brand oriented, for the  think stage they could be  narrower speciality or  disease  oriented and for the do stage they could be  action oriented and  need to be further  narrowed down .

Basing our Channel strategy around the  framework.

We need to consider what channels are we looking at to help us in reaching out to our target population and  more importantly which segment are we looking at reaching out  to through what channels. these  will dictate the creatives we  go ahead with.

Also probably an important  thought here  would be can we  actually increase the utility for a  particular channel to go across multiple  segments  through maybe changing our content.

The end result should be more effective  campaigns and better utility of channels.

Eg again ill take  it offline bill boards  when we  enter  a  market at times you might have  basic billboards  which initially are  for the  see  population but with time these can be effectively used to engage.

Similarly your keyword clusters would be  perfect for the same  , broader  keywords for the see population and narrower keywords for the think and do population.

Basing our measurements around the  framework

The third  stage would be to measure  for what we are trying to achieve. Somehow we  tend to focus on one core  measure and that  is conversion. Thats all we  talk about that’s  all we  know that’s  all we  measure  against. But  as was  stated before if the  core purpose of the campaign is to target the see population then how can we expect them to convert , conversions might happen and  probably  will happen but  in exceptional cases  in this case conversions is not the right measure. As Avinash states we cant really judge fish on their ability  to climb trees, lets measure them on their ability to swim. The  major concern here  is that perceived failure  leads to squashed campaigns and then there’s nothing left to do we  and  we miss  out on  an opportunity to engage a  potential customer because  we were measuring for conversion.  So its important to develop metrics for each of these stages

eg See – brand awareness, increased community, site  visits, conversations

Think  – interactions, query resolution, blog hits, call ins , page  depth , conversations,

Do – the part we love conversions, revenue, cost  per  conversion an   likes.

Well now you have the tool to measure the performance  of any particular campaign  and if id doesn’t work kill it  and if  it does hit it. Also i think some of these considerations can then further be applied to other  sales channels such as  doctor referrals, what stage is the  doctor at and what particular strategy we will have for him. Is that not brilliant  would it not naturally work much more efficiently.

So do try it and  see  of t works, whats there to lose if we engage with our customers as we  do currently im certain a time will come where nothing will work and people would just be put off because we are not sending out a  message that they are  ready for. Anyway with  social media and other reciprocal channels coming in people  are  selecting what they choose to listen to , so lets base our campaigns around our clients needs rather than ours and lets  cater to their selective attentions.


The views expressed in this  post are my own and  are  not meant to be derogatory  to any institution or organisation. These are just my thoughts and  these are open for further  discussion and  development. Please do comment and  share and  let’s get some universal cognition into this. Thank you for your patience and  tolerance.