On India, industry, and attaining quality in healthcare delivery

By Richard Irving, PhD

I am currently writing this column from Hydrabad, India, where I am teaching in the Schulich MBA program for eight weeks. During my visit, I was invited to a conference at the Indian School of Business and attended a session on healthcare. The general discussion would be familiar to most of you, though the problems faced in healthcare in India are orders of magnitude more difficult that we face in Ontario.

The quote I heard most often was that you went to a private hospital to get better and went to a public hospital to die. I hope that this is an exaggeration, but given that doctors receive a very low wage at public institutions in India, most of them do spend the bulk of their time and effort in the private sector.

One speaker I found to be of particular interest was Dr. Santam Chattapadhay, who is the CEO of Nationwide Doctors, an organization that focuses on primary healthcare. He spoke about quality and how to incentivize doctors to provide quality care. He first addressed the question of how to measure quality in primary care. When Dr. Chattapadhay spoke with patients he discovered results that may strike a chord with you. The patients’ main concerns were getting better, about long wait times and wanting to be heard by the doctor.

Interestingly those same concerns were described by the CEO of a private US clinic who spoke at a conference I attended last winter.

Dr. Chattapadhay went on to discuss the issue of changing behavior. Measuring concerns is one thing, addressing them is more difficult. Nationwide Doctors believes that the way to change behavior is to change the remuneration model. Nationwide has created a remuneration scheme whereby a doctor receives a 25 percent bonus if the patient is satisfied, based on exit interviews, and follow-up appointments that measure waiting time, effectiveness of treatment and the degree to which their concerns and complaints were heard and dealt with.

Patient satisfaction is only one dimension of quality healthcare; however it is an important one for private systems and should be a concern for public healthcare systems as well.

A second speaker at the conference, Dr. Stephen Samutt, the co-chair of the Wharton healthcare program, also addressed the issue of quality of healthcare. His conclusion was that the cost of poor quality is very high. While he did not allude directly to Total Quality Management (TQM), his comments were in line with the principles of TQM and Lean Systems. Some of these principles are beginning to appear in healthcare in Canada. I see articles and case studies about redesigning workspaces to make clinical care more efficient. Examples include restructuring laboratories and clinical spaces to reduce movement and handling of patients, samples, and information.

One element I have not heard discussed is the issue of ‘rework’ or defects. In manufacturing, defects are variations from specifications and such programs as Six Sigma are designed to either eliminate rework and defects or reduce them to a vanishing small percentage. In healthcare, we all hear about the dramatic events of a botched surgery, inappropriate drug prescriptions and so on. I think a bigger issue is a different form of rework.

When you go to see your physician about a complaint, wait 20 to 60 minutes, and then while seeing the physician voice another complaint, what do you hear? Often, it is to make an appointment and come back. This is essentially rework, and I believe that it is taking a significant toll on healthcare resources as well as your time. This of course ties into physician remuneration. So your homework is this. What has to change in how we pay doctors, how we schedule patients and how the basic healthcare system is organized to achieve TQM, Six Sigma and Lean Systems? Consulting studies and government reports have their place, but until the frontline healthcare professionals embrace these principles, I doubt much will change.