Service Design Prescriptions for Indraprastha Apollo Hospitals

A couple of weeks back I had written about my experiences at the Indraprastha Apollo Hospitals. Following the publication of that post, I received a call from the hospital. I must say I was very surprised. The caller was a lady who said she looked after service quality and was calling to learn more about my experiences at the hospital. While apologising for what we had to go through the hospital, she wanted more details and appeared keen to fix the problem. Subsequently I also received a call from my former colleague Usha Bannerjee, who presently heads nursing at the hospital. She too admitted that they have been having ’service’ issues and they are trying their best to rectify these.

I would like to believe that Apollo’s problems are those typical of enterprises, who have more customers that they can possibly handle. To compound matters, they are stuck with poorly trained people and processes, which make matters infinitely worse. That they are committed to better services is great. However, the problems will not go away in a hurry.

The problem of plenty in a hospital is just as bad as the problem of having very few patients. Apollo Hospitals attracts patients from across the country and pretty much from the whole world. ( I literally live in the hospital’s shadow and keep running into enrobed Arabs, staying in rented digs in Sarita Vihar, where many an enterprising landlords have converted their flats into makeshift guest houses). The sheer numbers mean that the hospital staff is unable to give enough time and attention to each patient and there is always a rush at hospital counters. Thus, the service folks at the hospital are not interested in looking after individual patients, all that they do is ensure that the patient is lobbed in another direction, away from the counter they man. This is all too common in service establishments where there are a surfeit of customers (bus and railway stations, government hospitals, etc.)

Apollo gets away with this because it is a healthcare establishment, which has some of the best known doctors working for it. The patients flock to the doctors looking for succor and inevitably get sucked into the Apollo system. The other thing that works in Apollo’s favour is the simple fact that most Indians still consider doctors and medical establishments as demi Gods and rarely challenge small service failures, lest they offend their doctors who they believe hold the power of life and death over them. I am sure if Apollo was a hotel, its customers would be a lot more demanding and a lot less forgiving of its follies.

How can Apollo improve its services. Here are a few suggestions.

The management team at Apollo Hospitals should be clear in its customer experience goals. They must set the agenda for service excellence and establish clear and measurable goals. They must also demonstrate their willingness to bring about serious change and the ability to stay the course.

Apollo needs a complete makeover in terms of service processes and their flow. While the hospital has embraced the JCI processes, they seem to be more from the perspective of getting a certificate rather than genuinely improving customer experiences. Each process needs to be carefully studied and calibrated in terms of the delivery of the right customer experience.

The hospital needs to look at its people dispassionately and put them in a matrix based on their ’service’ orientation. Any other consideration such as the number of years they have spent working in the hospital should not matter (there is no such thing as loyalty). Only those who demonstrate adequate customer orientation, empathy for patients and the willingness to go the extra mile to ensure patient satisfaction must be retained. Others, who have the potential and need training should be taken through a structured training program focussed on delivering the right customer experience. This process would lead to the elimination of a lot of employees, particularly those who have been with the hospital for long. This should be viewed as an opportunity to induct fresh talent, young and bright people more in tune with the needs of the present-day customers.

The change towards a better customer focus, will also entail a new cultural orientation. The hospital should aim to embrace a more open, customer friendly culture, which rewards team members going out of their way in delivering great customer experiences. The new culture should be transparent, encourage team play and the senior management should lead by example.

I know these prescriptions are easy to suggest. However, the real challenge lies in implementing these and managing the transition. Great customer service must be driven with great force and alignment of every individual including medical folks is a must.

For Apollo Hospitals, I reckon it is really high time they began.

The Hindustan Times and the Hospitals in Delhi

The whole of the last week The Hindustan Times carried a series of stories highlighting incidents of 'negligence' in high profile private hospitals in Delhi. The hospitals featured included Fortis Escorts Hospital, Max Hospitals, Apollo Hospital, Sir Gangaram Hospital and Rajiv Gandhi Cancer Hospital. Now these hospitals in Delhi are the best that we have. While, Hindustan Times has a right to expose cases of negligence in hospitals I am still not sure what purpose was served by these reports.

Here are a couple of points I would like to make about these 'exposes'.

The cases reported highlighted horrific experiences consumers had in these hospitals. Most people featured in the story lost a loved one because the hospital failed to deliver adequate care and refused to take responsibility for what went wrong. These I am afraid were random cases picked up by intrepid journalists and made for riveting reading. However, the journalists doing these stories did not investigate the reason for these failures. The question why did these hospitals fail in their duty towards their patients remains unanswered. Was the failure a result of a doctor not discharging his duties properly, or was it a failure of the hospitals processes or both? Or was it negligence or an error of judgement on the part of a doctor? Did he deliberately mistreat a patient, was callous in discharging his duties, wilfully deviated from standard medical practices or just did not care enough?

The reports also did not establish a trend. By picking up five hospitals in the city and highlighting these horrific cases, I am not too sure the point that the newspaper has made. Are all these hospitals equally bad? Do we run a huge risk to life and limb if we trust these hospitals with our care? The stories were short on data. For example the story featuring the eminent cardiologist Dr. Ashok Seth, presently the Chairman of the cardiac program at Fortis did not establish how many times has he messed up an angioplasty. By highlighting a single botched up case amongst the thousands that Dr. Seth does every year, I believe the journalist has been less than fair to him. I would like to know Dr. Seth's success rate in deciding whether I trust him or not rather than go by a sensational story of an angioplasty and the subsequent care going haywire.

As consumers we must understand an ugly truth. There is no running away from the fact that cases of utter negligence and mind boggling errors are a part and parcel of life in a hospital. Even the best hospitals, will have some people who would take their work casually, be negligent in their duties and cause terrible suffering and yes loss of life because of their actions. At best a hospital can try to minimise these as best as it can. It can systematically identify such people and eliminate them, it can put in place systems and processes, which allow it to act before the damage is done. However, it is next to impossible to completely do away with error and negligence.

I just do not understand what point has been established by The Hindustan Times in doing these stories. Yes, it establishes the fact that some of our best hospitals in Delhi have been at times negligent in the discharge of their duties causing untold suffering to people, who trusted these hospitals.

But isn't it something that all of us know and isn't that true of all the hospitals in the world?

Wouldn't it make more sense if the newspaper clearly established a trend of deficient care  in one or all of these hospitals over a period of time and compare the hospital's record with that of other similar hospitals across the world. It would than stand to reason for citizens to avoid the hospital and for the management of the hospital to fix its people and systems.

Hospitals and Hotels

Yesterday I came across a piece in The Hindustan Times, which talked about the 'luxury' that a hospital now offers. The piece had snaps of fancy chefs offering a choice of cuisine to patients, nurses 'requesting' young patients, mostly kids to have their medication and the smiling front office staff making 'guests' welcome.

This made me remember my grandmother, who is all of 104 years old narrating to me her escapades in hospitals run by the British in colonial India. She had great admiration for the no nonsense English doctors, the stern nurses, who followed orders and paid little attention to patient grievances. She remembers these episodes with a mixture of nostalgia and respect for the efficiency that this system stood for. The food was always what the doctor ordered, the medicines were given like clockwork and chores like sponging were a must-the patient had little choice in the matter.

In today's age of the service economy, the patient has become a guest (air passengers too have become guests) to be treated and pampered. Hospitals try their best to provide a luxurious stay, with patients allowed to exercise choice in almost everything except perhaps medical treatment.

While this is great for patients and their attendants, to compare a hospital with a hotel is futile. No one except crooks wishing to evade imminent arrest go to a hospital of their own volition. Illnesses, which drive people to hospitals are universally considered a period of misfortune. Howsoever luxurious the hospital might be, one still wishes to recover and step out of it as soon as possible. The fact is that I am yet to meet anyone, who really wishes to spend  a few nights in the luxury of a 5 star hospital!

The unfortunate part is that a story, which highlights these peripheral services in a hospital tends to trivialise the core services of the hospital, which essentially revolve around medical care. Somehow the patients feel that these hospitals have little substance and a lot of style, which amounts to very little. This perception though (in many cases) unjustified is usually strong and hard to shake off.

The hospitals featured in this story included Indraprastha Apollo Hospitals and Max Hospitals amongst others. As the head of marketing communications of any of these hospitals, I would be very wary of  a story like this.

I have nothing against hospitals treating patients as guests. However, they must remember that talking too much about these is never a good idea. It would be a lot better for customers to spread the word around, about the great experience they had in the hospital. 

It would really serve the hospital a lot better.

The Marketing of a Doctor

Do doctors need Marketing ?

I have worked for more than 8 years in healthcare services Marketing and am yet to meet a doctor who says that he does not need Marketing support. The funny thing is that all of them believe that the Marketing team always does more for the next guy and all of them collectively believe that the Marketing team does very little work in the hospital!

Dr. Bharat Inder Singh a well known family physician in South Delhi and former colleague at Max Healthcare, once told me that the only marketing he knows is putting a board outside his clinic and start treating patients well. Things have moved on since. Things really have moved on since.

I have learnt that while the hospital needs to quickly establish itself as a centre of excellence, the individual doctors are the most important element in the Marketing of a hospital. In the early phase of a hospital it is mostly the doctors who will draw new patients largely from the pool of patients they have treated earlier. While this may last as a steady stream for a few months, this stream of patients will never be adequate to sustain a new hospital. Thus doctors need to get involved in the Marketing of themselves. The Marketing team's task is to create opportunities of engagement of these doctors with potential patients, referring doctors and increasingly HR managers in large corporates. In this post I will examine the role of the doctors and the medical teams in connecting with the referring physicians.

The success of this effort is largely based on how well this collaboration between a doctor and the Marketing team works.

A doctor, who has joined a new hospital needs to understand that it will take some time for the patients to start trickling in. I have known many a doctor who are extremely chary of going in the 'field' with the sales team. This is somehow considered to be infra-dig. They would much rather be in the hospital and wait for the patients to materialise. Some would rely on expensive advertising rather than 'soiling their hands' with the sales folks, asking for patient referrals.

Rarely has this approach succeeded in generating patient traffic.

Most successful doctors know that their is no shortcut to success. Customers today have choices and those who go out to engage with customers, the local populace and the referring doctors stand a much greater chance of building a thriving practice. They also know one simple truth...there is no shame in asking people to visit them if they need help or taking out a prominent local doctor for dinner to get to know him better and build a relationship, which will culminate in patient referrals.

Continuing Medcal Education (CME) programs generally a euphemism for an evening do, involving local physicians (or those of a particular speciality) are common. These provide a platform for a set of doctors usually from a hospital to engage with local outside doctors. In my experience these are necessary in the initial phases to introduce a set of hospital doctors to referring doctors. It is rare that on these occasions a relationship can be forged, which will culminate in patients for the hospital. The next stage of engagement is generally with a smaller group of doctors (10-12) over cocktails and dinner. Finally the sales team will get the hospital doctors to meet referring physicians one on one. It is of utmost importance that a relationship is established between the doctors themselves. Patient referrals follow automatically.

Once patient referrals start, the hospital doctors must keep the referring doctor in the loop. A thank you letter, a phone call informing of the patient's progress can go a long way in cementing the budding relationship. The sales team's role here is to ensure that nothing slips between the cracks and they usually facilitate the communication between the hospital doctors and the referring physicians.

Medical conferences, paper presentations, academic newsletters also help in establishing the hospital doctor's credibility. It is important that the referring doctors be fully aware of the capabilities of the doctors they are refrring their patients to. The conferences also serve as a networking platform for all the doctors.

While all these help get patients for the first time, a doctor will start referring patients on a continuous basis only once he develops confidence in the doctor he is referring patients to. This can only happen when the medical outcomes are good, the patient has a great experience in the hospital and the communication channels between the referring and the referred doctors are working well. I have known of a hospital, where an orthopaedic surgeon and a laparoscopic GI surgeon will happily get patients from the referring doctors, while the cardiologists and the cardiac surgeons will endlessly struggle. The reasons for this were not far to seek. The medical outcomes in cardiology and cardiac surgery were not as good as those in other areas, the doctors hardly ever communicated and the reasons for poor outcomes were always swept under the carpet. I am afraid the situation in this hospital is unlikely to improve unless the core problem is acknowledged and fixed.

At the end of the day the sales team is just as good as the weakest link in the medical delivery team.

The Marketing of a Hospital

Before I get into the business of writing about the Marketing of a Hospital in India I must establish my credentials.
I have been working in the arena of Marketing of Heathcare Services for the last 8 years or so. I have been involved with Apollo Health and Lifestyle Ltd., which is the franchisor of Apollo Clinics part of the Apollo Hospitals Group, headed the Marketing and later the Corporate and International Sales for Max Healthcare a large healthcare services company based in Delhi and for the last two years have been heading the Sales and Marketing function at Artemis Health Institute, a tertiary care hospital based in Gurgaon and promoted by the Apollo Tyres group.
When I started working for Apollo Hospitals as the Marketing Manager for The Apollo Clinics and later at Max Healthcare I was often asked the question as to what really a Marketing person did in a hospital. Marketing of hospitals was understood to be a big no no. If you had a good hospital infrastructure and some well known doctors working for you the conventional wisdom dictated that the patients will follow.
Over the years this line of thinking has completely changed. Healthcare Services Marketing is gradually coming of age. We now even have advertising agencies dedicated to healthcare!
Some of the reasons for this sea change are not far to seek.
Patients to Customers
Patients are fast metamorphing into customers. They are just not satisfied with being a passive presence in their treatment. Increasingly they are demanding that they be included as active partners in their care. They are far more knowledgable and willing to question their care givers including the doctors. Hospitals are realising that for them to succeed in today’s environment they have to engage with patients/customers in a manner which they appreciate and understand. The communication, which engages with customers is generally the prerogative of the Marketing folks. This often translates into Patient Information booklets, detailed instructions before admission, during hospital stay and after the discharge. Extensive websites provide authentic information and hospitals like Artemis also provide interactive websites (http://www.artemisinteractive.in/), which allow patients to communicate freely with each other. Artemis also engages with customers by organising Public Forums, where eminent doctors interact with the public at large.
The Need to Standout
The healthcare revolution is truly underway in India now. The great urban middle class in large metros has multiple choices for their healthcare needs. Most of these hospitals have a lot going for them. However, most of them do not have much to differentiate them from each other. The failure rate of a bypass surgery in Apollo, Escorts, Max and Fortis Hospital is less than 2% and would compare favourably with any hospital across the world. Increasingly the medical expertise is becoming a given. The battle for differentiation is now gradually moving towards the overall customer experience that a hospital is able to deliver to its customers at all touchpoints. The Marketing teams in a hospital defines customer experience parameters and oversee the delivery of this experience at various touchpoints.
The Advertising Conundrum
Advertising in healthcare services have always been a contentious issue. Many people see hospitals splurging money on slick advertising as an effort to profit from some people’s misery. Afterall no one goes to a hospital to enjoy themselves. Hospitals are quite aware of this latent sentiment and try to be discreet about their marketing communication. However, with the patients gradually moving towards becoming customers the old taboos are disappearing fast. An increasing number of customers see private hospitals as commercial enterprise and understand that the stakeholders do need profits. (What they continue to object to and rightly so is to reckless profiteering) In the future healthcare advertising will gain more prominence and we will see more hospitals and probably doctors advertising their services in various media.
The Health Insurance
Presently Health Insurance has a miniscule penetration (4%) in India. With pureplay health insurance companies (Star Health, Apollo DKV and yet to start Max BUPA) commencing operations and with MNC’s offering health insurance coverage to their employees and their families, health insurance is poised for explosive growth. From the perspective of the customers cashless services at all corporate hospitals have taken the all important issue of price out of the customer equation. Thus in this unfolding scenario the differentiation will be through communication salience and top of the mind recall.
The Constant Customer Engagement Paradigm
In the days of yore a hospital interacted with patients only when they came to the hospital and stayed as inpatients. In today’s dynamic environment hospitals engage with customers throughout their lifestyle. Specialised programs are being devised, which enrol customers who are high risk for a disease (cardiac diseases-people with a family history, sedantary lifestyle, high stress levels, smokers and hypertensives). The hospital endeavours to be in constant touch with this group of people. The idea is to remain engaged so that God forbid if something happens the hospital is not too far off. The hospitals are now also devising Post Discharge Care Programs, which allows them to maintain a dialogue with patients even after they have been discharged from the hospital.
These in reality are another version of ‘loyalty programs’. (More on this in a separate post) adapted to the needs of the healthcare industry.
The Marketing function in hospitals is thus fast emerging as a critical function. The Marketing folks are tasked with engaging with customers (no more patients) both outside and inside the hospital. Happily for customers this can only mean a far better hospital experience and not just better care