Monday, August 11, 2014

Book Review: Quality Management in Hospitals (2nd Edition), Dr S K Joshi

Guest article by Dr Ashok Jahnavi Prasad
In no other public activity is the outcome as dependent on efficient management as it is in healthcare delivery. It is therefore completely astounding to note the sparse attention that has been accorded to the crucial discipline of hospital management. Only in the last two decades has the specialty been extended the legitimate attention that is its due.
Quality Management in Hospitals (2nd Edition), Dr S K Joshi
This apathy has been historically global. Hospital administrators were looked upon with a degree of disdain. Most of the hospital superintendents in my medical school days (more than four decades ago) had gravitated to that position after a prolonged clinical career when it was presumed that they had acquired all the skills necessary to function effectively as administrators. The need for specialized training was completely unappreciated. In fairness some of them did demonstrate efficiency but for most it was a welcome sabbatical from years of clinical overload.

Some of the top hospitals in the country had taken to appointing retired senior services personnel in the belief that their stint with the armed forces equipped them with the requisite know-how to run a hospital. Brigadier (Dr) Gaind was the Hospital Administrator at the All India Institute of Medical Sciences for years and by all accounts he did an excellent job. He was an ex Army Medical Corpse Man but the interesting part is that he did not have any formal training as a hospital administrator. Brigadier Ghufran who headed the Tirath Ram Shah Hospital was not even medically qualified.
The important question that had remained unaddressed in those days was whether it was necessary to have a medical background to function as a hospital manager and an administrator. To a large extent, that question is still open not just in India but worldwide. The Griffith Report in the United Kingdom encouraged clinicians as well as non-clinicians to take up managerial responsibilities within the National Health Service way back in the late 1970’s and early 80’s. Collating the results from this experience, it is still unclear whether the medically qualified functioned better than the non-medically qualified. Somewhat similar situation exists in North America where in most states health service management has been the domain of qualified nurses and social workers.
Having said that there are some very good Hospital Administration/Management programmes in the US that have been operational for the last four decades. There are more than 50 that have sprung up in the last twenty years. The choice therefore remains with the physician should he/she wish to divert to management or acquire healthcare managerial skills which may come in handy in clinical healthcare delivery. The author of this review did precisely that when he enrolled for a part-time healthcare management MBA while in the US — at a pretty late stage in his career.
Things also seem to have moved on in India though not at the pace needed. With the rapid proliferation of a private nursing home culture in addition to sophisticated multidisciplinary hospitals in the major metropolitan cities, the need for efficient hospital managers is acute.
It is towards this end that Dr Joshi’s book has made a seminal contribution. It has already moved on to a second edition, which is the one I am reviewing. I am at a loss though as I have not had the opportunity to peruse through the first edition as it was released when I was still abroad. But anyone perusing through the second edition with meticulousness would be left in no doubt that hospital management is a skill that has to be formally learned and a medically qualified person has an advantage over the non-medically qualified person as a hospital manager. Dr Joshi, without actually stating this, makes it very clear.
The book is in six parts dealing with the intricacies of every aspect of hospital management. The Part-3, which deals with accreditation, and the Part-4, which elaborates quality management in all its dimensions, are specially noteworthy and I would so far as to say that the erudition evident over there makes this volume score over others available in India on the same subject. Being a historian of medicine, I also found the adumbration of the history of hospital management as a specialty internationally most interesting. Dr Joshi has also included some very useful annexures towards the end, which are very useful.
The techniques of quality management viz. Lean Sigma, Kaizen and Quality Circles (which should be known to every medical practitioner but is not) have been explained in a very simple manner.
All in all, the book is eminently readable and superlatively informative without being tedious.
The major problem that I personally had was the absence of elaboration of quality management skills needed while providing mental healthcare in India. This omission was surprising, as lack of emphasis on mental healthcare has resulted in a national crisis which needs to be addressed very soon. Readers would agree that the quality of mental healthcare available in India leaves a lot to be desired. I would sincerely hope that Dr Joshi would address this shortcoming in the next issue.
I would highly recommend this volume to every medical school/hospital library. I would also like a copy of this book to be available to the Minister for Health. I have been a long-term advocate of including hospital management in the medical curriculum and as a part of internship training. Managerial skills are mostly acquired and do not spring up spontaneously. And with the pace at which healthcare sector is proliferating, need for medical managers is acute.
Dr Joshi needs to be felicitated for commendable service rendered by him through this second edition.
Quality Management In Hospitals (2nd Edition)
Author: S K Joshi
Language: English
Paperback: 464 pages (Rs 595)
Publisher: Jaypee Brothers (2014)

Reviewer: Dr Ashok Jahnavi Prasad

Sunday, August 10, 2014

West Bengal’s wait for AIIMS is over

For the residents of West Bengal, the long wait for All India Institute of Medical Sciences (AIIMS) is over as the Narendra Modi-led NDA government has okayed the proposal of setting up of AIIMS in the state.


While informing about the decision over establishment of AIIMS, union health minister Harsh Vardhan on Friday said that the centre has approved the setting up of two AIIMS one each in Uttar Pradesh and West Bengal under Phase-II of Pradhan Mantri Swasthya Surksha Yojna (PMSSY). The scheme aims at correcting the imbalances in availability of affordable tertiary level healthcare and to augment facilities for quality medical education in the under-served states.

The minister further informed the Lok Sabha that AIIMS in Raebareli is under construction, while AIIMS in West Bengal would be set up at Kalyani, about 80 km from Kolkata.

To expedite the setting up of AIIMS, the health ministry has requested the chief ministers of different states to identify three or four suitable locations for the establishment of new AIIMS. ‘Approximately 200 acres of land at a location is required for establishment of one AIIMS-type super-speciality hospital-cum-teaching institution.

The location should have road connectivity, availability of water and electricity,’ a health official said, adding that the state government has to undertake to provide, free of cost land and other required infrastructure such as suitable road connection, sufficient water supply, electricity connection of required load and regulatory clearances for the purpose.

The six new institutions modelled on AIIMS under the Phase-I of PMSSY are located in Bhopal (Madhya Pradesh), Bhubaneshwar (Odisha), Jodhpur (Rajasthan), Patna (Bihar), Raipur (Chhattisgarh) and Rishikesh (Uttarakhand). All these news AIIMS will also have medical and nursing colleges. The Atal Bihari Vajpayee-led NDA government had announced in 2004 the setting up of new hospitals on the lines of AIIMS in New Delhi under the PMSSY.

Under attack over delay in completion of all six AIIMS, health minister Harsh Vardhan had asked all AIIMS directors to complete the institutes within six months, so that PM Narendra Modi can dedicate it to the country on 25 December.

‘Six new AIIMS were the dream of ex-PM Atal Bihari Vajpayee and the foundation stone was laid during his tenure. We want all of them to be inaugurated on his birthday on 25 December,’ Vardhan had said.

Tuesday, July 29, 2014

Doctoring Medicine

The cancer of corruption eating into India’s medical sector is no secret. Reports of patients being prescribed unnecessary tests by unscrupulous doctors in league with labs abound. Alongside there are frequent reports of needless procedures — from caesarean births to the insertion of stents into healthy hearts and replacement of workable knees — thrust upon patients by doctors keen to make a killing off someone’s unease.
Such practices seriously harm the health and finances of Indian patients. In addition such malpractices are gaining India’s medical tourism industry — once tipped to hit six billion dollars by 2018 — infamy around the world. Transparency International ranks India’s medical industry as the second most corrupt institution citizens encounter following the police. This image, of a corrupt, cynical trade preying on patients, is seriously damaging medical tourism to India. Already hit by tight visa rules, a decaying ethical reputation could see India — visited by 350,000-plus overseas patients in 2012 — beaten flat by better-reputed destinations like Singapore, which saw over 600,000 overseas patients.
There are strong global practices and precedents to control medical corruption. In America, only this year, six hospitals have been fined millions of dollars for improper financial ties with diagnostic centres and recommending needless procedures. That included a Kentucky hospital fined 41 million dollars for prescribing unnecessary coronary stents. In contrast to America’s tough action, India’s response is laughable. Health minister Harsh Vardhan is himself a doctor who admits he’s worried by tests forced on patients by doctor-hospital-lab cartels, a recent sting operation showing eight reputed diagnostic centres involved in an alleged commissions scheme with doctors. Yet, his response has been to turn the matter to the ethics committee of the Medical Council of India — ironically, this body is itself in deep controversy over corruption, making it imperative MCI cleans its own reputation first.
For overseeing the medical industry’s practices, India needs a spotless body with professional weight and ethical credibility. If the government is serious about curing Indian medicine’s ills, it should listen to modern groups like The Society for Less Investigative Medicine, founded by AIIMS doctors to counter unnecessary testing. Meanwhile, quick and clear legal procedures for those ripped off by professionals supposed to aid them in their hour of need must be put in place. It is vital government clamps down, through better regulation and serious enforcement of rules, on individuals and institutions who abuse patients.

Wednesday, July 2, 2014

Born with a stethoscope

How do you learn to give injections? Join a nursing school, become a compounder or enrol for MBBS. But, if you ask the Sabharwals, a Delhi-based family of 140 doctors, chances are that they would hand you a banana stem instead. “Our grandfather Dr Bodhraj Sabharwal was so obsessed with making us doctors that, when we were young, he used to make us inject banana stems to teach how to administer injections,” says Dr Vijay Sabharwal, owner of Shree Jeewan Hospital, one of the five hospitals owned by the family in Delhi.
The 63-year-old eye surgeon does not believe in the method. Even without it, his 11-year-old granddaughter Diya has grown adept at giving injections. For the last five generations, every single member of the family has become a doctor. And Diya, too, has no other goal. The World Health Organisation says there is one doctor for 1,700 people in India. If you go by that estimate, the Sabharwals take care of 2,38,000 Indians.
The family entered the profession 95 years ago. Stirred by a speech of Mahatma Gandhi, Vijay's great-grandfather Lala Jeewanmal Sabharwal decided to become a doctor and serve the nation. A station master at Jakhal railway station in Gujrat district (now in Pakistan), he saw people suffering for lack of medical facilities. So he thought the best way to alleviate misery was by making all his children doctors. “He insisted that his four sons study medicine,” says Vijay.
His eldest son, Bodhraj, became a surgeon in 1919. His brothers Rajinder Nath, Trilok Nath and Mohinder Nath followed suit. In 1922, Jeewanlal quit his government job, sold all his property and wife Malan Devi's jewellery to open a hospital in Jalalpur Jattan in Gujrat district, in Khyber Pakhtunkhwa of present-day Pakistan. After the partition of India, the family moved to Delhi and opened five hospitals¯all named after their great-grandfather¯under the Jeewan Trust.
Bodhraj set up a hospital on Rohtak Road, which is now run by his son Ved Prakash's eldest son Vijay. Bodhraj's other two sons, Vinay and Vikesh, have their own hospitals nearby. Rajinder Nath established a hospital at Jeewan Nagar, which was taken over by his sons Ravinder, Davinder and Satinder¯all doctors. It is now run by Ravinder's son, Dr Arvinder. Satinder's son Dr Venu and Davinder's sons Dr Shailender and Dr Vitender have now opened a hospital adjacent to the original one.
The hospital set up by Trilok Nath at Rohtak Road was taken over by his son Dr Omprakash, whose son Dr Sandeep now heads it. Mohinder Nath set up a hospital at Pusa Road, which is now headed by his son Dr Vivek, who has four daughters¯all of them doctors. As the fourth generation Sabharwals hone their management skills, the third generation runs the family hospitals.
  
Call it the family's devotion for the profession, Dr Bodhraj even trained his wife Leelawanti, a homemaker, as his surgery assistant and anaesthetist. Leelawanti also used to cook for patients.

Vijay says when her mother, Sarla, a gynaecologist, came to their home after marriage, she was first taken to the hospital reception. As luck would have it, just before the new bahu could be welcomed, an emergency delivery case came. “My grandfather insisted that Sarla attend to the patient first and then perform the rituals. So, my mother performed the first delivery of her life here in this hospital,” he says.
Before his death, Bodhraj directed that every family member must study medicine and get married to a doctor. “You can find sons-in-law and daughters-in-law of several castes, states and communities in our family, because being a doctor is the only criterion to get married into our family,” says Dr Suman, Vijay's wife, who takes care of the gynaecology department with her daughter-in-law, Dr Ramneek, a Sikh.
Of course, there have been rebels in the family. But, perhaps because of the desire of the rebels to fit into the family or the encouragement they received from other members, “things never went out of hand,” says Vijay. For instance, one of the sons in the family recently married a biochemist. But, after two years, the daughter-in-law herself decided to study medicine.
“Your family and peers have such high expectations from you that, at times, it gets difficult to manage,” says Dr Ashish, the eldest son of Vijay. Though he respects the family's mission to serve patients, he is willing to let his two daughters take up any profession of their choice. “Their happiness matters most to me,” he says.
Thanks in part to luck and to the spurt in the number of private medical colleges, no Sabharwal has ever failed to get a medical degree. “So far, no one has ever flunked. When there are so many medical professionals to guide you at home, the exam result has to be good,” says Suman. The family believes that the members are “naturally tuned” to become doctors, but it does not stop them from taking coaching classes.
While the thought of visiting an operation theatre leaves most of us sweating, children of the Sabharwal family do their homework in the operation theatre. They are named keeping in mind the roll call in medical colleges, so that the teacher is not tired by the time their name comes in the attendance register. They also enjoy the benefit of being ahead of their classmates in knowledge of subjects like anatomy. “The biggest advantage is that in case of an emergency, a pool of doctors is just a phone call away. And they don't even charge for it,” says Vijay.
Suman recalls a particularly hectic day in the hospital. Twelve hours after giving birth to her younger son Akash, she was resting in the hospital when an emergency delivery case came early in the morning. “There was no gynaecologist in the hospital. So I attended to the patient, and then returned to my bed,” she says, laughing.
The benefit of marrying into such a family is that you have seniors to consult on critical matters, says Ramneek. Besides, as all women in the family are working doctors, it is easier to balance work and life. “Not everyone is lucky to have a mom-in-law who not only understands the pressures of your profession, but also helps you grow as a professional,” she says.
The fourth generation of the family is not keen to push the family tradition on the next generation, but the young Sabharwals are nevertheless determined to emulate their elders. Ask Ashish's three-year-old daughter her name, and she lisps “Dr Naina”. Bodhraj, perhaps, is smiling in heaven.

Black armband silent protest on Doctor’s Day by UCMS doctors

As India celebrated Doctors Day on July 1, doctors at the University College of Medical Sciences (UCMS) here sat quite gloomy while trying to find out reasons to celebrate.
“This observance is a way to show the society how important doctors are in our lives but has everybody thought how, even, we are denied our basic rights by the autocratic Delhi University administration,” said Dr Satendra Singh, assistant professor of physiology at the UCMS.
According to Dr Singh, the UCMS doctors are under the University of Delhi and henceforth the University Grants Commission (UGC) and the Ministry of Human Resource Development (MHRD), while other sister medical institutions like Maulana Azad Medical College (MAMC), Lady Hardinge Medical College (LHMC) and even all other state run medical colleges are under the Centre or State run Ministries of Health and Family Welfare (MOHFW). There the faculty can concentrate on quality of medical teaching and patient care as the promotions and pay scales of teaching medical faculty are determined by the Dynamic Assured Career Progression [DACP] scheme as laid down by the 6th Central Pay Commission Report, i.e. time bound promotions.
“The terms and conditions of DACP were brought into enforcement vide notification to UGC gazetted on 18th September 2010. The notification categorically directed UGC under clause no 1.1.1 that all medical faculties appointed medical teachers in Central Universities shall be governed by the norms of MOHFW i.e. time bound promotions. This was to be made effective for medical teachers of UCMS, AMU (Aligarh Muslim University) and BHU (Banaras Hindu University) from 31st December 2008. However, the dictatorial administrations of DU have not taken any heed to this constitutional right of medical teachers of UCMS,” he said.
Dr Singh further said, “Being under DU, no pay protection is given to doctors who have to join at salaries lower than what they were given under the residency scheme of MOHFW. Unlike medical colleges under MOHFW which safeguard the financial and promotional interests of medical faculty, DU equates medical faculty to any other faculty in colleges under DU.”
“The VC of BHU provided pay protection to medical faculty in BHU, but the VC of DU even denied that. Faculty members having completed even upto eight years of service are given salaries less than resident doctors. This has made UCMS one medical college with the highest faculty attrition rate. In the last three months, 17 permanent faculty members have left UCMS and joined as assistant professor by sacrificing their current experience on which they should have been either associate professor or professor. In the past three years, almost 25 faculty members have left for Centre or State run MOHFW medical institutes like MAMC, LHMC, new AIIMS, state medical colleges and even private practice,” said Dr Singh.
“The university system focuses purely on research for promotion of their faculty, while as medical teachers, faculty at UCMS and all medical colleges should be focussing on teaching medical students and patient care. Lack of transparency in the promotions in DU has made it one of the worst career options for medical faculty, who quit UCMS for greener pastures which offer them time bound promotions and better salaries. Every doctor is under the Hippocrates Oath, swearing for patient care and teaching his peers and juniors. But we are humans too and not demigods. Denial or delay of our constitutional rights has forced many to seek judicial help and tangent us away from the oath,” he added.

Wednesday, June 11, 2014

In a first, docs to kill patients to save their lives

Trauma patients arriving at an emergency room here after sustaining a gunshot or knife wound may find themselves enrolled in a startling medical experiment.
Surgeons will drain their blood and replace it with freezing saltwater. Without heartbeat and brain activity , the patients will be clinically dead.
And then the surgeons will try to save their lives.Researchers at the University of Pittsburgh Medical Center have begun a clinical trial that pushes the boundaries of conventional surgery -and, some say , medical ethics.
By inducing hypothermia and slowing metabolism in dying patients, doctors hope to buy valuable time in which to mend the victims' wounds.
But scientists have never tried anything like this in humans, and the unconscious patients will not be able to give consent for the procedure. Indeed, the medical centre has been providing free bracelets to be worn by skittish citizens here who do not want to participate should they somehow wind up in the ER. “This is `Star Wars' stuff,“ said Dr Thomas M Scalea, a trauma specialist at the University of Maryland. “If you told people we would be doing this a few years ago, they'd tell you to stop smoking whatever you're smoking, because you've clearly lost your mind.“
Submerged in a frozen lake or stowed away in the wheel well of a jumbo jet at 38,000 feet, people can survive for hours with little or no oxygen if their bodies are kept cold. In the 1960s, surgeons in Siberia began putting babies in snow banks before heart surgery to improve their chances of survival. Patients are routinely cooled before surgical procedures that involve stopping the heart. But so-called therapeutic hypothermia has never been tried in patients when the injury has already occurred, and until now doctors have never tried to replace a patient's blood entirely with cold saltwater. In their trial, funded by the department of defence, doctors at the University of Pittsburgh Medical Center will be performing the procedure only on patients who arrive at the ER with “catastrophic penetrating trauma“ and who have lost so much blood that they have gone into cardiac arrest.
At normal body temperatures, surgeons typically have less than five minutes to restore blood flow before brain damage occurs. “In these situations, less than one in 10 survive,“ said Dr Samuel A Tisherman, the lead researcher of the study . “We want to give people better odds.“ Dr Tisherman and his team will insert a tube called a cannula into the patient's aorta, flushing the circulatory system with a cold saline solution until body temperature falls to 50 degrees Fahrenheit. As the patient enters a sort of suspended animation, without vital signs, the surgeons will have perhaps one hour to repair the injuries before brain damage occurs.
After the operation, the team will use a heart-lung bypass machine with a heat exchanger to return blood to the patient. The blood will warm the body gradually , which should circumvent injuries that can happen when tissue is suddenly subjected to oxygen after a period of deprivation.
If the procedure works, the patient's heart should resume beating when body temperature reaches 85 to 90 degrees.
But regaining consciousness may take several hours or several days. Dr Tisherman and his colleagues plan to try the technique on 10 subjects, then review the data, consider changes in their approach, and enroll another 10. For every patient who has the operation, there will be a control subject for comparison.
The experiment officially began in April and the surgeons predict they will see about one qualifying patient a month. It may take a couple of years to complete the study .
Citing the preliminary nature of the research, Dr Tisherman declined to say whether he had already operated on a patient.