Gurrit K Sethi, Hospital Chief Operating Officer, Care Hospitals; Strategic Advisor for Global Health Services, Global Strategic Analysis

Lean is an ideal way of life, be it in the business world or personal lives. In its most basic form, it means making your assets work more productively, productivity being the tombstone of efficiency. This easily gets ignored in the surge of activities, especially in service operations when with the enthusiasm of completing those or the need to touch the end of line, an easier way of doing things gets lost. All that is required is to stop and think for a moment: how can we better this? Of course, the various techniques of lean working always help, more so with statistical analysis. But the essence remains – how can we achieve more with less or more easily?

Lean is indeed an interesting concept to apply in almost all facets of life, be it weight management, service management, or manufacturing. In a nutshell, to be lean we need to lean towards lean working, and lean living.

Leanness of healthcare practices can hugely benefit many a pocket – the organisations’ itself, the government’s as well as the patient’s, the payer’s. And a lot of the meat depends on the thought process and the way these thoughts are ultimately processed.

Lean in healthcare is ‘critically’ needed at this juncture of the overall civic cycle – in India as well as many other countries. Different illnesses rage us, the ageing population is heavily dependent on government or out of pocket expenses, the health insurance companies are struggling to survive, as are hospitals themselves. The government is heavily dependent on the private sector for widespread provision of this sector, especially in India, thus figuring innovative ways to partner. And at the same time, as a dichotomy, the private sector struggles to match upto the price expectations, especially given the hidden costs.

The scope for better cost management in Indian healthcare is huge:

  • The basics of setting up a facility and its functioning
  • Lean and efficient service delivery processes – trained manpower is critical
  • The archaic rules have a scope for major cost reduction
  • The interconnects between the credit providers – government as well as insurance – insurance delays, government approval loopholes drain a lot of money

I have spoken about the first two points extensively in my earlier series on ‘ ‘The Science of Healthcare Deliver’ y’. While these aspects of the facility layout, internal work flows, employee training and engagement, and, service management is what is largely focused on in the regular models of hospital lean management, there is a huge 0scope is there to introduce leanness in the other two areas as well. Let us examine the costs of these in this paper.

For example, documentation is one of the main requirements to keeping up with statutory compliance for healthcare facilities are documentation. To be precise this involves paper documentation. The laws and statutory regulations mandate that all patient records of every patient be maintained for a minimum amount of time. All out patient department prescriptions are required to be maintained for two years, all in-patient medical records for a minimum of five years, life long lifelong for death cases and MLC cases. All diagnostics records — laboratory investigation as well as radiology need to be maintained lifelong, billing records for five years, in pharmacies prescriptions and receipts for five years. All authenticated books of accounts also need to be maintained for a period of eight years.

Now imagine this: the average approximate footfall for a small sized 100 bed hospital is 200 - 250 out patients in a day. Here they would meet the doctors and get prescriptions. These prescriptions would advice diagnostics and medicines, which creates billing records, diagnostics records, and pharmacy records. Even if we take a low average of five sheets of paper per patient, in a day for only the out-patient department, this entails about 1250 sheets of paper a day. Now, in the in-patient department, each new patient file contains 22 sheets for record keeping by the nurses and doctors on the first day of admission. Approximately 8-10 sheets a day get added on to this file. If a patient stays in the hospital for four days on an average in a hospital, the patient record at time of discharge is approximately 50 paper sheets. These records are for initial assessment by the doctor, drug charts, progress sheet, patient consent, diagnostic requisitions, daily hand over sheets by doctors and nurses etc. Even if this hospital treats 500 in-patients a month, the in-patient records will come to 25000 sheets. Therefore, only for patient records this hospital generates approximately 62000 sheets for storage per month. Add to this the administrative documents, the various mandatory registers etc.

Can we imagine if we could digitise these records, how much paper could be saved? How many trees could be saved? And above all, how much storage space could be saved? In a country struggling to add hospital beds, this space could well be used for additional patient services.

Then why are we still following such archaic norms? Various healthcare laws and regulations have emerged over the years as newer aspects of healthcare have developed. Despite this, there are some that are from the pre-independence era and haven’t been re-looked at. Also, most of our laws are centred around the manufacturing sector. The service sector has come up in just the past two decades. There is a strong case and need for looking at restructuring these regulations to make them work better for the service sector. Meanwhile, the digitisation of healthcare is one area which holds immense potential to resolve such issues. In fact, the digitised records are tamper proof compared to the physical ones. The adoption and usage of Hospital Information Systems (HIS), the Electronic Medical Records (EMRs) and Electronic Health Records (EHRs) need to be speeded up by law, and related laws that mandate documentation should also be upgraded to recognised digital documentation.

In fact, this will also help improve the productivity of our medical staff. When filling out paper forms, each form needs to have clearly written patient details to ensure clear identification. Thus, there happens to be a lot of repeat entries that our nurses and doctors have to do. With digitisation and usage of EMRs, this can be easily avoided and time saved. This saved time can go into better patient care at the patient bedsides. Of course, the efficiency in build of the softwares is critical here.

Coming to the payers’ side, a lot of waste happens while patients wait for approvals for treatments – largely from the insurance and the government bodies. This entails extra payments for both the payers as well as the hospitals, apart from the inconvenience to the patients. On this front, the hospital suffers. While more patients are waiting  for admissions, there are many waiting to go home while awaiting approvals. Hospitals don’t have holidays and illness does not understand them. This problem gets accentuated on such days – while the world enjoys, the hospitals and patients suffer. Needless to say that the hospitals bear the costs of these delays. An efficient approval process that works at all times needs to be instituted to build better partnerships. A pointer to these agencies will also be the payor wise data on the average length of stay of patients in hospitals.

Another aspect that the government health schemes need to look at is how many times their beneficiaries get admitted to the hospitals. There are times that people get admitted, they happily pay their own bills and then miraculously generate low income certificates to avail schemes for the more expensive parts of the treatment. In all this it is the very needy that suffers (and, of course, the tax payers)

It is indeed high time that these inter-connects be looked at so as to get more efficient, in terms of provision of good services as well as the monetary schemes.

This article is meant to throw light on the lesser discussed metrics which are overlooked. To make our healthcare more viable and efficient, we do need to cast a light here.

--Issue 47--

Author Bio

Gurrit K Sethi

Gurrit K Sethi Hospital Chief Operating Officer, Care Hospitals; Strategic Advisor for Global Health Services, Global Strategic Analysis, contributes to healthcare by helping providers build and better business efficiencies and concept development, also strives to contribute socially through the Swiss Foundation, Global Challenges Forum as Strategic Advisor, through conception of sustainable health initiatives. She started her career from the shop floor working her way up to lead and set up different healthcare businesses. In her words, her significant achievements have been in bringing to life different SMEs and SBUs signifying a change in the Indian healthcare scenarios, as the opportunity paved the way along the healthcare growth curve in the country. With over 18 years in healthcare under her belt, across different healthcare verticals, she has carried transformational changes in the projects she has led, four of those being early stage start-ups. Gurrit is an avid traveller and voracious reader of varied genres, attributes which she says, provide her with incisive insights about people and systems and what drives them.

Harvard Medical School - Leadership in Medicine Southeast Asia47th IHF World Hospital Congress