668 Production and Operations Management eee EGEEREAG CASE STUDY || SgaRRERSS RaERRER ES Narayana Hrudayalaya 10 days old Pakistani child, Ahmad was taken by his mother and uncle to Narayana Hrudayalaya (NH), Bangalore, on 28 July 2004. The child had a complex heart defect, known in medical terms as “transposition of the great arteries’. In Ahmad’s case, the right ventricle of the heart was connected to the aorta and the left ventricle was connected to the pulmonary artery, while in normal conditions, itis the reverse — the right ventricle is connected to the pulmonary artery, the left ventricle to the aorta. This is a severe heart condition and required a complex ‘arterial switch operation’ before Ahmad was two weeks old. His parents had contacted Narayana Hrudyalaya when he was four days old. During the flight to Bangalore, Ahmad developed complications; fortunately a doctor on board examined him and advised immediate intensive medical care. The pilot informed the Hyderabad airport and diverted the flight to Hyderabad. The plane landed there at 10 p.m., where the airport staff and the medical officers rushed him to the nearby Krishna Institute of Medical Sciences (KIMS). Within an hour, the hospital brought the condition of the child to stability. Next day, the airport officials visited the hospital and ater that night, tthe child was brought to Bangalore through another Indian Airlines flight. At Narayana Hrudayalaya, Dr Rajesh Sharma, the paediatric cardiac surgeon successfully operated on the child. Thisincidenthas seta precedent in terms of service operations management in the country, exemplifying aperfect coordination between Indian Airlines, KIMS, and Narayana Hrudayalayain saving the life of the little child. This is no new feat for Narayana Hrudayalaya, which has the mission of making sophisticated healthcare available to the masses, especially in a developing country such as India. One year earlier, a little Pakistani gir, Noor Fatima came to India to repair her imperfectly formed heart at this hospital. She was born with holes in the heart that in turn caused obstructions in the flow of blood to her lungs. Her parents Nadeem and Tayyaba were ecstatic when the hospital cured their daughter. Nearly 30 per cent of the patients at Narayana Hrudayalaya are foreigners hailing from 22 countries including Bangladesh, Pakistan, Mauritius, the Middle East, and African countries. The man behind the creation and success of Narayana Hrudayalaya is Dr Devi Prasad Shetty, who has become synonymous with highest quality humanitarian healthcare in India He operates free forkids below 12 years of age and has performed about 5,000 operations on children out of his 15,000 odd operations ina career spanning almost ‘two decades. He has the distinction of treating Mother Teresa during her ines. His list of achievements seem endless. For the first time in the world, he used a microchip camera inn open heart surgery to close a hole in the heart. He is credited with performing the first dynamic cardiomyoplasty operation in Asia. He is the first surgeon in india to venture into neonatal open heart surgery. He used an artificial heart for the first time in India. He has the distinction of performing the first surgery in India using blood vessels of the stomach to bypass the blocked arteries of the heart. His biggest achievement for the benefit of the poor has been bringing down the cost of heart related operations: drastically. He introduced the concept of ‘assembly: line heart surgery’, which has helped him in achieving zero mortality and is targeted at reducing the cost of operations. Dr Shetty’s persona is clearly reflected in his statement, ‘Ifgivena choice, | would lke to treat only poor patients. Unfortunately, the economic reality does not allow me to do that.’ Itisremarkable to note that the Seva Clinic (a cooperative insurance scheme started in Gujarat in 1992) has funded the operations of about 190 poor patients, who could otherwise have not been able to afford these on their own. Phase 1 of NH is spread over 25 acres. Presently, it has 1,000 beds with 10 operating rooms with the capacity to perform 25 heart surgeries in a single day. With the onset of Phase 2, NH will sprawl over an impressive 100 acres. The structure will accommodate 780 beds and 30 operating rooms to perform75 heart surgeries every day. Besides the hospital, it will also accommodate a teaching institute for cardiologists, cardiac surgeons, cardiac anesthetists, nurses, health technicians, and healthcare specialists. Once completed, the entire project will have 5,000 beds and will be known as the Health City with specialty hospitals for every disease. Currently, the hospital performs heart operations on at least 12 children out of 25 odd operations performed every day. Indian Space Research Organization (ISRO) hashelped the hospital with the funding to realize its dream of ‘telemedicine’. It has provided NH with 13 satellite video links with distant hospitals within the country and terrestrial video links includingintegrated services digital network (ISDN) to connect places outside the country such as Malaysia and Mauritius. ‘The hospitalis in the process of establishing such links with Bangladesh, Mauritius, and Tanzania. Bangalore's central prisonis one of the unique ails in the country, which has a video link-up with the law courts. This enables the court to listen to the inmates’ cases and appeals without the need for their physical presence within the court premises. ‘The hospital has pioneered in providing its telemedicine facility to the prisoners in this prison through this video link. In January 2006, NH extended its telemedicine faclities to Air India passengers, staff, and crewat the Mumbai Airport and the Air India Clinic at Mumbai. Thisis done by installing ECG machines at, these facilities; the datais then interpreted at the NH faclties at Bangalore. The typical characteristic of a heart attack is that without immediate and adequate treatment, there are 50 percent chances ofthe patient succumbing to death. With adequate immediate treatment the mortality rate can be reduced to less than 5 percent. Generally, the rural areashavea general practitioner (GP), who neither has the specialist knowledge nor the infrastructure to perform proper diagnosis. In most instances, the GP would diagnose the initial symptoms of a heart problem as indigestion, only to later discover that the patient passed away within the next 24 hours due to a heart attack. The telemedicine facility becomes a boon under such circumstances, whereby the GP can take advice from a heart specialist at NH through telemedicine facility before reaching any conclusions about patient’s illness. Out of the 20,000 odd patients treated by NH 0 far through telemedicine, about a,000 had serious heart problems. It is a common practice for the cardiac experts at NH to see patients through the video links. Simultaneously, they refer to the angiograms, Xrays, and other information of these patients. Dr Shetty is. of the view that the doctor needs to touch the patient only when a surgery is to be performed. Therefore, specialist doctors, who are mostly confined to few prominent cities, can make their services available to the public at distant locations using this technology without their physical presence. At the same time, it is necessary for the doctor to ‘see’ her patients and allow them to see the doctor on the video screen to Service Operations Management 669 strike a sense of relationship and compassion with the patient. ‘The mantra of high quality and cost reduction at NH is the ‘economies of scale.’ It focuses on high productivity by way of utilizing the infrastructure capacity to the fullest. The number of procedures conducted at NH per day is way ahead of any other hospital of comparable size in the country. The hospital has installed latest digital machines, which help in reducing the running cost, for example, the hospital uses digital X-ray machines without the need of Xray films. Narayana Hrudolaya has its sister hospital at Calcutta and the two hospitals, through common bargaining power with suppliers, enjoy heavy discounts due to large volume of supplies sourced by them. Over and above that, Dr Shetty extends his promise of recommending these suppliers to many outside cardiac hospitalsas well, which usually honour his advices. Surprisingly, the hospital does not enter into long-term contracts with its suppliers to keep itself free to explore other better suppliers with better pricing and quality over the period of time. The state-of-the-art software installed on the hospital’s computers helps them keep the inventory levels to the most economical levels. By sourcing of many cardio-diabetes drugs from the local pharmaceutical company at Bangalore, Biocon Ltd helped NH to contain the costs significantly. ‘The doctors are paid salaries in place of the com- mon system of sharing the percentage of revenues with them. The ‘assembly-tine’ approach to cardiac surgeries and long hours put in by doctors every day results in bringing down the cost per operation related to doctors. Thus, an open-heart surgery, which costs about 22,50,000 to 3,00,000in any private hospital in the country, costs about €1,00,000 at NH. In order to fulfil its mission of providing cardiac care to people not having the funding, the hospital has developed a unique system of generating data regarding the net revenue generated every day (after deducting the costs of drugs, pro-rated salaries, etc.). This data is used by the doctors scheduling the operations to schedule below-cost surgeries, which are non-urgent in nature, on days having surplus revenue from the paying patients. This stringent accounting system ensures that the hospitalis ableto pursue its social objective, while keeping itself viable inthe long run. The story does not end here. Dr Shetty's focus ‘on serving the poor and disadvantaged led him to launch Yashasvini, a health insurance scheme, started ee ae ere Oe670. Production and Operations Management with the help of the state government in Karnataka in 2003. He was convinced that a majority of poor farmers could not afford expensive surgeries even after selling their small patches of land and cattle. The cooperative societies are quite strongin this state and Dr Shetty used themasa vehicle to launch this unique insurance scheme among the members of these societies, primarily the farmers of the state. Ameagre premium of %5 per month (60 per year) is charged for comprehensive coverage ofall surgical procedures and outpatient care to be provided through a network of private hospitals. The state government allows him to use the post offices for deposit of the premium and issue of Yashasvini Insurance Cards to the farmers and helped its best to create awareness of this scheme as a ‘government scheme’ among the masses. The scheme enrolled 1.6 million rural farmers in the first year of its operation. The target is to increase it by 2.2 million in its second year. During the first year of operation, around 9,000 surgeries were performed, while about 35,000 patients received outpatient services under this scheme. tis significant to note that a majority of these operations were major surgeries, without which the patients would not have survived. ‘The Yashasvini scheme has become the world’slargest health insurance scheme for the rural poor. Itwould not be exaggeration to say that Dr Shetty has played the role of Narayana (the Almighty) for the poor and underprivileged. His hospital has truly lived up to its name—Narayana Hrudayalaya, which in Sanskrit, means God’s compassionate abode. Discussion Questions 1. Specialist surgeons such as Dr Devi Shetty are always short of time. Do you think experts like him would beable to spare enough time for providing diagnosis advice to distant patients through “telemedicine” ina sustainable manner for along e? 2. Isita right operations strategy to get into short term contract with the suppliers of the hospital? 3. The Yashasvini insurance scheme is based upon the premise that the premium collected from the member farmers would be used for funding the cost of surgeries and OPD for sick patients. The other approachis the one followed by NH in which the net revenues generated by paid-surgeries (mostly by affluent people) is used for partially funding the below cost surgeries. According to you, which model is better in taking care of the poor?