International Conference on Technology and Business Management March 18-20, 2013

1024
Clinical Service Lines as a Competitive Strategy among Tertiary Eye Care
Hospitals in Urban India Rhetoric to Reality?

Smitha Sarma Ranganathan
sarma.smitha@ibsindia.org
IBS Business School, Bangalore

Consumers (patients) and caregivers today are more engaged with each other in their healthcare decisions than
ever before. With substantial private investments and increased awareness on the need for eye care in urban
India, there is also a heightened sense of competition and consumerism in the tertiary eye care hospital space in
India. Consequently, the focus has now shifted to quality and cost of service delivery, wherein looking beyond
the conventional service delivery model may prove to be crucial. This paper attempts to propose the
introduction of clinical service lines as a conceptual model for eye care hospitals to effectively compete. The
service line model will pave the way to define and deliver services more attuned to consumer needs, thus
creating market-savvy competitors.

1. Introduction

1.1 The Indian Hospital Sector Poised for Growth
Indian healthcare industry is growing rapidly and is among the select few sectors whose growth has not been
impeded by the recent economic slowdown. The healthcare sector comprises pharmaceutical products (both
prophylactic and curative), hospital services, diagnostic services, diagnostic products, medical technology,
clinical trial services and clinical research organizations. As per industry estimates, the Indian hospital industry
is valued at USD 44 billion as of 2010 and is predicted to be worth around USD 280 billion by 2020. Further,
the Indian hospital sector is projected to grow at a compounded annual growth rate of over 9%. (Northbridge
Capital Report, 2010).
Four key irreversible trends in the Indian healthcare space contribute to this growth, inspiring confidence
among investors. These include a demographic transition that involves a four-fold increase in the number of
middle class households largely owing to rise in disposable income. Secondly, research by Mckinsey Global
Institute captures the ongoing trend of rapid urbanization in India. Estimates suggest that 40% of Indias total
population will live in cities by the year 2030. This sizeable urban dwelling middle class consumption pattern
will shift from basic necessities to more discretionary items including that of healthcare. Thirdly, there has been
a dramatic increase in the incidence of chronic and lifestyle driven diseases. Finally, increased government-
driven initiatives to expand access to healthcare across the country, all of which contribute to increased level of
opportunity and growth in the sector. While government investment would be targeted on upgrading facilities in
tier II and rural areas, private players will take interest in building tertiary facilities in metros and secondary care
facilities in tier I cities. (Mckinsey Report, 2010).In this context, it is not surprising that the Indian hospital
sector has recently witnessed a phenomenal number of private investments across multiple deals (Table 1).
Moreover, delivery of a healthcare service combines the nuances and elements of retail, consumer products and
infrastructure areas where private capital has traditionally been invested in.

Table 1: Top Private Investments in Indian Hospital Sector
Hospital Service Players Specialty Investor
Investment Amount
(USD)
Fortis Hospitals* Multispecialty NA 452 million
Care Hospitals Multispecialty Advent International 110 million
DM Healthcare Eye Care Olympus Capital 100 million
Vasan Eye Care Eye Care GIC 100 million
Specialty Hospital Critical Care Halcyon Group 66 million
Apollo Hospitals** Multispecialty
International Finance
Corporation
60 million
Nova Medical Centers
Day Care Surgery
Procedures
Goldman Sachs & New
Enterprise Associates
54 million
Healthcare Global Cancer
Premji, Religare,
Evolvence
35 million
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Medfort Diabetes and Eye Care
TVS Capital, ePlanet
Ventures
14 million
Centre for Sight Eye Care Matrix Partners 11 million
Eye-Q Eye Care
SONG Advisors,
Helios
2 million
Pushpagiri Health Care
Hospitals ***
Eye Care Acumen 2 million
Source: * Economic Times Report, 2012; **Business Standard Report, 2012; *** India Infoline News Service,
November 2009; Venture Intelligence Report, 2012; o3 Capital, Q2, FY2012 Newsletter

1.2 Emergence of Single Specialty Hospitals and Short Stay Formats
It is interesting to note that over the last two decades, private sector healthcare models in India have largely
focused on multispecialty tertiary care in metros. However challenges such as increasing competition in metros,
rising real estate costs and tougher operating environments have paved way for exploring novel innovative
business models that tap into less penetrated geographies and patient segments. Of these innovative formats,
single specialty tertiary hospitals that cater to a specific specialty (e.g., cardiac, ophthalmology, etc) or a type of
patient (e.g., children or women) or type of process (e.g., minimal invasive surgeries) appear to be gaining
ground in urban India. While some of these single specialty hospitals have evolved from multispecialty hospitals
looking to leverage the credibility generated by offering Best in Class treatment in certain defined therapy
areas (e.g., Apollo Cancer Hospital, Cloudnine Hospital) ; others have been traditionally single specialty players
attempting to position themselves as Centers of Excellence in select therapy areas (e.g., Aravind Eye
Hospital).
India has recently seen a surge in the number of such single specialty hospitals. This can be attributed to the
aspect that unlike multispecialty hospitals, they are less capital intensive. Rapid advancements in medical and
surgical technology have led to the emergence of these healthcare centers offering day care medical and surgical
procedures which require the patient to stay in the hospital for less than 24 hours. Thus, many single specialty
centers also double up being Short Stay Medical Centers, further bringing down the investment significantly.
Additionally, faster exit opportunity also works as a key differentiator for investors to look keenly at single
specialty hospitals as an attractive investment proposition. Table 2 provides a comparison between Single
Specialty Hospital Vs Multispecialty Hospitals in India on attributes of investment and model of functioning
(Forbes India, 2012).Thus with the emergence of capital - light business models, single specialty services that
were traditionally under-served by tertiary multi-specialty hospitals, has captured immense investor interest.

Table 2: Single Specialty Hospital Vs Multispecialty Hospitals: a Comparative Outlook
Parameters of Comparison Single Specialty Hospital Multispecialty Hospitals
Estimated Capital
Expenditure
As low as Rs. 2 crores for
setting up of facility.
A 100 bed hospital requires Rs. 40 Crore as initial
investment.
Exit period considered by
investors
Beginning 18 20 Months After 6- 8 years
Hospital Functioning Model
Functions more like an
outpatient
department, very few
instances of
overnight stay cases.
Personnel intensive, includes various medical
departments, besides diagnostic lab
and pharmacy.
Source: Adapted from Forbes India, 2012

Hospital administrators realize that reducing the average length of stay in a hospital is critical in maintaining
healthy operating margins for hospitals. (Rachoin JS, et al, 2012).From a patient perspective too short stay
single specialty centers offer convenience, cost effectiveness, better insurance coverage, and social advantage,
besides an increased sense of well-being. Figure 1 depicts the breakup of procedure intensive medical
specialties that are being delivered as ambulatory services in short stay formats by single specialty hospitals.






International Conference on Technology and Business Management
Figure 1 : Short Stay Formats
Source: NSSO 60th Round, Technopak Analysis

Thus, owing to the nature of the procedures involved,
appropriate for some medical specialties than others
investors, patients and hospital administrators
(Eye care) hospitals, which at present are involved in offering a
India, is amongst the most popular medical specialty that effectively
perhaps underlines the increased investor involvement and interest in funding single specialty eye care centers
across India.

1.3 Tertiary Eye Care Hospitals in Urban
India - Market Opportunity and
Attractiveness
Industry estimates peg the size of the Indian eye
care market at USD 3 billion and this is expected
to grow at 10% to 15%. Of this, the eye care
hospital sector too is expected to have a growth
rate of 15% year on year (Assocham Report
2012). Uni-specialty hospitals, particularly eye
care hospitals make for an attractive investment
opportunity considering margins as high as 30
50%, since they are mostly surgery driven (Ankur
Bharati, 2012). The market opportunity and
attractiveness of the eye care hospital
garnered investor interest and is currently on an
upsurge. This sector has witnessed a flurry of big
sized investments over USD 215 million over the
last couple of years (Table 1).
Eye care services in India are commonly
categorized into following sub-specialties
Optometry and Refractive correction,
Services, Cornea Services, Lasik & Refractive
Surgery, Vitreo -Retinal Services and Glaucoma
Services. A recent epidemiological survey
estimated the prevalence of unoperated cataract
in people aged over 60 to be 58% in north India
and 53% in south India (Vasisht P,
most eye care establishments revenue comes
from cataract operations. With a
proportion of population needing
operations, this is the sectors main growth
driver.
Altering demographic patterns and lifestyle as
well as rapid urbanization has influenced the
distinction of being the worlds diabetes capital with
in the number of cases of diabetic retinopathy.
8%
7%
3%
10%
5%
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Short Stay Formats Distribution across Medical Specialties

Source: NSSO 60th Round, Technopak Analysis
Thus, owing to the nature of the procedures involved, single specialty short stay centers have proven to be more
appropriate for some medical specialties than others. Also, they are among the most sought out formats by
nistrators alike. Among the various medical specialties, o
are involved in offering a significant proportion of ambulatory services
is amongst the most popular medical specialty that effectively lends itself to a short stay format
perhaps underlines the increased investor involvement and interest in funding single specialty eye care centers
in Urban
Market Opportunity and
Industry estimates peg the size of the Indian eye
care market at USD 3 billion and this is expected
to grow at 10% to 15%. Of this, the eye care
hospital sector too is expected to have a growth
rate of 15% year on year (Assocham Report
hospitals, particularly eye
care hospitals make for an attractive investment
opportunity considering margins as high as 30-
50%, since they are mostly surgery driven (Ankur
Bharati, 2012). The market opportunity and
attractiveness of the eye care hospital sector has
garnered investor interest and is currently on an
upsurge. This sector has witnessed a flurry of big
sized investments over USD 215 million over the
commonly
specialties -
efractive correction, Cataract
Services, Cornea Services, Lasik & Refractive
rvices and Glaucoma
epidemiological survey
of unoperated cataract
in people aged over 60 to be 58% in north India
, 2011). In
most eye care establishments revenue comes
significant
ing cataract
tions, this is the sectors main growth
lifestyle as
influenced the pattern of eye diseases in India. In addition, Indias
diabetes capital with 62.2 million patients has also caused a significant increase
retinopathy. Increased awareness about these medical conditions
25%
24%
14%
5%
4%
Urology
Opthalmology
Gastroenterology
Orthopedics
Gynecology
Plastic Surgery
ENT
General
Oncology
Figure 2: Eye Insights
- India has 12 million blind people
an additional 456 people requiring
vision correction.
- 80 % of blindness in India is
avoidable, yet visual impairities and
blindness remain significant
problems.
- Prevalence of unoperated cataract in
people aged over 60 is 58% in north
India and 53% in south India.*
- Diabetic Retinopathy (blindness
caused by diabetes) is the sixth most
common cause of blindness
with an incidence of 18% in urban
India. **
- India has 11.2 million people aged
over 40 years with Glaucoma,
referred to as the silent sight thief.
***

Source: World Health Organization
(WHO), 2012 Statistics. * Vashisht P,
2011;
** Proceedings from Conference of
Association of Research in Vision and
Ophthalmology, 2010; Raman R, 2009;
***George R, 2010
March 18-20, 2013
short stay centers have proven to be more
are among the most sought out formats by
the various medical specialties, ophthalmology
ambulatory services in
lends itself to a short stay format. This
perhaps underlines the increased investor involvement and interest in funding single specialty eye care centers
India. In addition, Indias dubious
significant increase
Increased awareness about these medical conditions and demand
India has 12 million blind people and
an additional 456 people requiring
80 % of blindness in India is
avoidable, yet visual impairities and
blindness remain significant
revalence of unoperated cataract in
58% in north
.*
Diabetic Retinopathy (blindness
caused by diabetes) is the sixth most
blindness in India
with an incidence of 18% in urban
India has 11.2 million people aged
over 40 years with Glaucoma,
ht thief.
: World Health Organization
* Vashisht P,
** Proceedings from Conference of
Association of Research in Vision and
; Raman R, 2009;
International Conference on Technology and Business Management March 18-20, 2013
1027
for cosmetic considerations relating to the eye, backed by the ability to pay a premium has fuelled the growth of
quality eye care in metros and tier I cities.
The Indian eye care space is marked by the presence of government run institutions as well as private players,
each of whom have a distinct modus and focus of operation. Of these, RP Centre of Opthalmic Sciences part of
All India Institute of Medical Science (AIIMS) and Guru Nanak Eye Centre are flagship government run
institutions with longstanding service record in the domain. National Programme for Control of Blindness has
been among the most successful public private partnership that has offered quality eye care services across the
country. Amongst the private players there are around 1000 eye hospitals and 300 medical colleges spread
across India (IMRB survey 2011). The popular ones include - Aravind Eye Care System, LV Prasad Eye
Institute, Narayana Nethralaya and Sankara Nethralaya that function in specific geographical areas as well as
Vasan Eye Care and Agarwals Eye Hospital that has a pan India presence. Figure 3 provides a zone wise
listing of leading eye care hospitals in India. The increasing penetration of medical insurance in urban India has
made medical care affordable to many more, with the downside of increased risk of litigation. Hence the need of
the hour is to combine clinical excellence with managerial and administrative capability. Increased infusion of
private investments in the eye care hospital sector can now form the basis of broadening the focus of the
services by eye care hospitals by intelligent use of technology and intuitive service deliverables.
While increased demand for eye care fuels growth opportunities, from a sector perspective, competition is
getting intense, particularly in the urban tertiary care context. Eye care hospitals also seem to offer
Sustainability, Scalability and Standardization of care, all of which have resulted in intensifying competition in
the sector. Increasing competition and rising costs now compel healthcare organizations to look for novel ways
to increase their market share. One approach that is being proposed by way of this work is to develop and
position the service offerings at tertiary eye care hospitals as distinct clinical service lines through service line
planning. This involves development of a business plan for specific service lines within the broader portfolio of
services offered by the hospital.

Table 3 - Zone wise listing of leading Eye care Hospitals in India
Zones Key players- Eye Care Hospitals
North

Centre For Sight; Eye Q Vision; Shroff Eye Centre; Thind Eye Hospital
South

Aravind Eye Hospital; LV Prasad Eye Institute ; Narayana Nethralaya ;
Sankara Nethralaya
East

Disha Eye Hospitals; Sushrut Eye Foundation & Research Centre; M P
Birla Eye Foundation
West
Aditya Jyot Eye Hospital; Aggarwal Eye Hospital;
Lazer Vision; Rushabh Eye Hospital; Shroff Eye Hospital; Lotus Hospital
Hospital Chains with Pan India
Presence
Dr. Agarwals Eye Hospital; Vasan Eye Care

2. Clinical Service Lines as a Competitive Strategy for Eye care Hospitals

2.1 Defining Clinical Service lines as Distinct Offerings
As healthcare becomes specialized and more complex, redefining the clinical landscape and scope of service
delivery become critical. This involves reorganizing resources both in terms of financial and human capital in
order to achieve favorable outcomes that are relevant at both the organizational and patient care level. Shortell et
al (1996) proposes service line strategy as a modus to achieve clinical integration across facilities.
Clinical service lines in healthcare can be equated to a product-line model in the manufacturing context. Each
of the product lines are often a result of diversification by the organization and represent a set of related
products/services. Thus, theoretically, product/service line divisional model calls for effective working
relationships and promotes greater role flexibility across disciplines and professions (Parker, 2001). Service
lines in a healthcare context have been defined in various perspectives. Commonly cited definitions include the
following
Clinical service lines may be defined as a family of organizational arrangements based on a hospitals
outputs, rather than on its inputs (Charns, Wray, Byrne, Meterko, Parker, Pucci, Fonseca, and
Wubbenhorst, 2001, p. 2, also cited by WHO).
A service line is an arrangement of elements that act cohesively to satisfy a distinct set of needs (Birrer
et al. 2000, p. 2).
A service line model integrates multiple departments, functions, or services that relate to a particular
International Conference on Technology and Business Management
clinical specialty or subspecialty (Ronning, Meyer, Franc as cited in Clancy, 2002, p. 25).
Service Line Management is a method for aligning and coordinating the necessary staff efforts and
services for a particular patient population

The definitions quoted herein primarily fall into two categories namely
centric description of service lines. However,
these aspects. Thus, we propose that a
across functions with an objective of creating an ecosystem of care that delivers
involving re-engineering of organizational structure at a
and manpower allocation at an operational level.

2.2 Delineating Effective Service line Strategies
Formulating a clinical service line involves creating structures consisting of people from different disciplines
and professions, and binding them with a common purpose of delivering a comprehensive set of clinical
services. Key defining characteristics of
clinical care mission, and they lend themselves for integrating personnel and services across disciplines. Service
line model benefits nearly all stakeholders involved in healthcare d
Model include the following
Better Patient Experience
continuum are valued by patients and is often reflected in increased satisfaction amon
their care givers. Thus, it translates into more organized, coordinated and quality
Improvement in Organizational
promotes accountability in the system, result
noise. For physicians, benefits include a coordinated and standardized approach that embarks on
efficiency and strong sense of purpose.
Breaking functional Silos - Organizational
cause inefficiencies by teams working independently to their own functional interests and goals.
Service lines can help break these functional silos through improved communication as well as
minimizing data duplication and process bottlenecks.
Sharper focus to Growth -Service line framework helps track key metrics of growth that include
quality of care, volumes serviced, patient satisfaction, financial performance and market share on a
continual basis. Consequently, the healthcare
focus, reduction of service duplication and more importantly achieves market differentiation.

Figure 3: Importance of Clinical Service
Adapted from Tara Tesch, Alexis Levy (2008)

PATIENTS
Easy access to
service
Consistency in
service delivery
Informed approach
of what is being
done (treatment)
Clinician attitude
and time
PHYSICIANS
Standardized
evidence
measures that
account for
deviations in
management of
comorbidities in
practice settings
Reliable clinical
measures
appropriate to the
service line
Involvement in
development of
measures and
information Sharing
International Conference on Technology and Business Management March 18
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clinical specialty or subspecialty (Ronning, Meyer, Franc as cited in Clancy, 2002, p. 25).
Service Line Management is a method for aligning and coordinating the necessary staff efforts and
lar patient population. (Anderson, 1998, p. 23).
primarily fall into two categories namely - organization centric or patient
However, for a service line model to be effective, it should
that a clinical service line is system of integrating organizational
with an objective of creating an ecosystem of care that delivers patient-centered services
of organizational structure at a strategic level and facilities planning at a tactical
operational level.
Delineating Effective Service line Strategies
Formulating a clinical service line involves creating structures consisting of people from different disciplines
them with a common purpose of delivering a comprehensive set of clinical
services. Key defining characteristics of clinical service lines are that they are multidisciplinary, they have a
clinical care mission, and they lend themselves for integrating personnel and services across disciplines. Service
line model benefits nearly all stakeholders involved in healthcare delivery (Figure 3). Benefits of Service line
Patient care outcomes and co-ordination of care across the service
continuum are valued by patients and is often reflected in increased satisfaction amon
their care givers. Thus, it translates into more organized, coordinated and quality-patient experience.
Organizational Leadership, Agility and Decision making Service line model
promotes accountability in the system, resulting in reduction of operational inefficiencies, conflicts and
noise. For physicians, benefits include a coordinated and standardized approach that embarks on
efficiency and strong sense of purpose.
Organizational silos or vertical functions within a business are known to
cause inefficiencies by teams working independently to their own functional interests and goals.
Service lines can help break these functional silos through improved communication as well as
plication and process bottlenecks.
Service line framework helps track key metrics of growth that include
quality of care, volumes serviced, patient satisfaction, financial performance and market share on a
ntly, the healthcare organization derives benefits by having a sharp growth
focus, reduction of service duplication and more importantly achieves market differentiation.
of Clinical Service Lines to Stakeholders in Healthcare Delivery

Adapted from Tara Tesch, Alexis Levy (2008)
PHYSICIANS
Standardized
evidence-based
measures that
account for
deviations in
management of
comorbidities in
practice settings
Reliable clinical
measures
appropriate to the
service line
Involvement in
development of
measures and
information Sharing
HOSPITAL
Ability to
provide, high
quality care
Ability to contain
cost and improve
margin
Ability to
demonstrate value
Strengthened
hospital physician
alignment
Patient safety and
satisfaction
Alignment of
financial incentives
with quality/lower
cost outcomes
Minimal variations
in quality
March 18-20, 2013
clinical specialty or subspecialty (Ronning, Meyer, Franc as cited in Clancy, 2002, p. 25).
Service Line Management is a method for aligning and coordinating the necessary staff efforts and
centric or patient
should combine both
service line is system of integrating organizational outputs
centered services
and facilities planning at a tactical
Formulating a clinical service line involves creating structures consisting of people from different disciplines
them with a common purpose of delivering a comprehensive set of clinical
clinical service lines are that they are multidisciplinary, they have a
clinical care mission, and they lend themselves for integrating personnel and services across disciplines. Service
). Benefits of Service line
ordination of care across the service
continuum are valued by patients and is often reflected in increased satisfaction among patients and
patient experience.
Service line model
ing in reduction of operational inefficiencies, conflicts and
noise. For physicians, benefits include a coordinated and standardized approach that embarks on
tical functions within a business are known to
cause inefficiencies by teams working independently to their own functional interests and goals.
Service lines can help break these functional silos through improved communication as well as
Service line framework helps track key metrics of growth that include
quality of care, volumes serviced, patient satisfaction, financial performance and market share on a
derives benefits by having a sharp growth
focus, reduction of service duplication and more importantly achieves market differentiation.
livery
PAYERS
Patient safety and
satisfaction
Alignment of
financial incentives
with quality/lower-
cost outcomes
Minimal variations
in quality
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2.3 Clinical Service Lines as a competitive strategy for
Eye care space in India is rather fragmented g
models dictated by their focus areas. In this context, clinical
market patient-centric services, particularly in urban
and sharply crafted clinical service lines have the ability to transform the mar
lines to provide competitive edge, they need to be sharply f
Clearly Differentiated service offering
Unique and Niche Segmentatio
Innovative Delivery Models

a.) Clearly Differentiated Service offering
differentiated core concept needs to be transl
competition. In case of clinical service lines
the most challenging aspect in developing one. It is common to find markets crowded with competing
services in the most sought out and profitable s
Service in most of these hospitals are almost always positioned based on
on how they are offer a different experience to a patient and their caregivers
features of the service allows easy replication by competition, thus giving a noti
only short-term advantages. On the contrary, a sustainable approach would be to differentiate the service
line solely based on its unique core positioning. The distinctiveness in the offering could resonate with
specific physical, emotional, and lifestyle needs of the patients. This could include but not be limited to
competent and empathetic physicians, a responsive system of
and develop listening to patients perspectives.

Figure 4: Patient Centered Clinical Service Line Model
questions about whom to target and how to target them form the fou
clinical service lines.

c.) Innovative Delivery Models: Traditionally hospitals and healthcare
force-fitted existing elements of a service in an attempt to construct an acceptable delivery model. A more
inventive approach would be to craft a service delivery model that captures the needs, values and
preferences of target segments and then put the clinical and operational pieces together. With lead time for
delivery and convenience of accessing the service being key determinants for acceptance of any new
service, new service lines need to capture these attribu
lines does not necessarily mean multiple sites of operation. Convenience to patients may just mean seamless
integration of information, hassle free scheduling of appointments and paperless billing optio
delivery models that embrace technology to empower patients
accessing care is sure to find takers.

2.4 Implementing a successful Clinical Service Line
Transition to service lines needs a paradigm shift
level. Charns and Tewksbury (1993, p. 20
PATIENT
DIFFERENTIATED
SERVICE
OFFERING
UNIQUE & NICHE
SEGMENTATION
INNOVATIVE
DELIVERY
MODELS
International Conference on Technology and Business Management March 18
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as a competitive strategy for Tertiary Eye Care Hospitals in Urban India
Eye care space in India is rather fragmented geographically and key players function on the b
eas. In this context, clinical service lines may form the key to organize and
, particularly in urban areas where competition is high. While, well
vice lines have the ability to transform the market, for these p
edge, they need to be sharply focused on the following (Figure 4)
learly Differentiated service offering
entation
Service offering: Good service lines have a clear, core offering at their heart. This
differentiated core concept needs to be translated into to a service experience valued by consumers
case of clinical service lines while this may seem like the most obvious step
the most challenging aspect in developing one. It is common to find markets crowded with competing
services in the most sought out and profitable segments, such as tertiary eye care hospitals in urban India
are almost always positioned based on what they do and not necessarily
how they are offer a different experience to a patient and their caregivers. Furthermore, empha
features of the service allows easy replication by competition, thus giving a notion that service lines offer
term advantages. On the contrary, a sustainable approach would be to differentiate the service
its unique core positioning. The distinctiveness in the offering could resonate with
specific physical, emotional, and lifestyle needs of the patients. This could include but not be limited to
competent and empathetic physicians, a responsive system of care and paramedic staff trained deliver care
and develop listening to patients perspectives.
: Patient Centered Clinical Service Line Model
b.) Unique and Niche Segmentation: Targeting relevant
consumer segments is inevitable to increase market share and
boost growth. Unfortunately, it is common to see hospitals
limit their offerings to cover only medical
disease states. This modus disregards the realities of pa
with co-morbid conditions at specific life-stages leading to a
piecemeal approach in service delivery, translating into poor
value of service. Instead, being perceptive to the clinical and
lifestyle driven attributes at different stages of life open
whole new possibility to create and deliver services that may
rank high in terms of relevance and acceptance. Summing up,
to achieve long-term success and sustainable profitability,
hospitals will need to target the right services to the right
customer with the right message at the right time. Hence,
questions about whom to target and how to target them form the foundation of strategic marketing of
Traditionally hospitals and healthcare institutions have assembled or at times
fitted existing elements of a service in an attempt to construct an acceptable delivery model. A more
inventive approach would be to craft a service delivery model that captures the needs, values and
ces of target segments and then put the clinical and operational pieces together. With lead time for
delivery and convenience of accessing the service being key determinants for acceptance of any new
service, new service lines need to capture these attributes. However, convenience in case of clinical service
lines does not necessarily mean multiple sites of operation. Convenience to patients may just mean seamless
integration of information, hassle free scheduling of appointments and paperless billing optio
echnology to empower patients and enable them explore possibilities of
g care is sure to find takers.
Implementing a successful Clinical Service Line
Transition to service lines needs a paradigm shift in thought and approach at both the strategy and operational
level. Charns and Tewksbury (1993, p. 20 - 43) opine that there are five primary prototype organizational
UNIQUE & NICHE
SEGMENTATION
March 18-20, 2013
Tertiary Eye Care Hospitals in Urban India
unction on the basis of different
service lines may form the key to organize and
. While, well-thought out
for these powerful service

offering at their heart. This
ce valued by consumers vis-a-vis
seem like the most obvious step, it is perhaps
the most challenging aspect in developing one. It is common to find markets crowded with competing
hospitals in urban India.
and not necessarily
ermore, emphasis on
on that service lines offer
term advantages. On the contrary, a sustainable approach would be to differentiate the service
its unique core positioning. The distinctiveness in the offering could resonate with
specific physical, emotional, and lifestyle needs of the patients. This could include but not be limited to
care and paramedic staff trained deliver care
Targeting relevant
consumer segments is inevitable to increase market share and
boost growth. Unfortunately, it is common to see hospitals
limit their offerings to cover only medical specialties and
disease states. This modus disregards the realities of patients
stages leading to a
piecemeal approach in service delivery, translating into poor
value of service. Instead, being perceptive to the clinical and
lifestyle driven attributes at different stages of life opens up a
whole new possibility to create and deliver services that may
rank high in terms of relevance and acceptance. Summing up,
term success and sustainable profitability,
hospitals will need to target the right services to the right
mer with the right message at the right time. Hence,
ndation of strategic marketing of
institutions have assembled or at times
fitted existing elements of a service in an attempt to construct an acceptable delivery model. A more
inventive approach would be to craft a service delivery model that captures the needs, values and
ces of target segments and then put the clinical and operational pieces together. With lead time for
delivery and convenience of accessing the service being key determinants for acceptance of any new
tes. However, convenience in case of clinical service
lines does not necessarily mean multiple sites of operation. Convenience to patients may just mean seamless
integration of information, hassle free scheduling of appointments and paperless billing options. Innovative
plore possibilities of
in thought and approach at both the strategy and operational
43) opine that there are five primary prototype organizational
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designs commonly seen in hospitals (Figure 5)
functional to the fully integrated service line model, referred to as program organization.


A pure functional organization is at the extreme left end
of the organizational continuum. The major
organizational units in a hospital are departments, which
represent different professional and non
functions. This type of structure provides no integration
of functions to help achieve coordinated comprehensive
care. Some hospitals that follow the parallel organization
have added new roles or added new departments to assist
the functional departments to traditional depa
true matrix organization provides balance between the
strengths of the program and the functional forms.
and responsibilities are organized in two dimensions
simultaneously and function effectively
a modified program organization in order to have similar
functions across programs, a department may be created
to handle organization-wide issues. The program
organization model is made up of divisions, which include key personnel to deliver and manage its services. All
functions directly involved in providing care for a given program (service line) are contained within the program
division. In the pure program or service line, each division is a mini
structure to be adopted is dictated by the organizational dynamics, core competency and economics of the
setting.

2.5 Implementation of Dry Eye Disease
from Bangalore, India
Holistic Management of Dry Eye Disease
Dry eye disease is perhaps the most common condition that eye care providers encounter in daily practice.
International Dry Eye WorkShop (DEWS) defines dry eye disorder as a multifactorial disease of the tears and
ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability with potential
damage to the ocular surface. (DEWS Report, 2007).
3.5% to 33% across different patient popula
substantiates the claim that dry eye disease is highly p
of ageing, environmental conditions (dry climate, air conditioning), occupational factors such as use of
computers over long period of time, prolonged contact lens usage, refractive eye surgery, frequent air travel, all
contribute to the development of dry e
imperative to prevent long-term sequelae and sight
Bangalore, India has created a clinical serv
exclusively. This appears to be a first of its kind clinical service line that is clearly differentiated
dedicated for the management of dry eye
includes all aspects of care beginning from diagnosis, medical intervention for management to long
and counseling of the patient.

Unique Segmentation - Patient Profile for Dry Eye Diseases
Lasik surgeries (Murakami Y, 2012), an ageing population (Tsubota K, 2012) and computer vision syndrome
(Portello JK, 2012) have been strongly linked to dry eye disease. Besides these specific groups, dry eye disease
has also been implicated in patients with glaucoma (Leung EW, 2008) and cataract (Roberts CW, 2007). Hence,
these sub-sections of patients can form niche segments for the
The clinical service line offering created by the
Vision Syndrome besides routinely scanning patients over the age of
patient groups form important target clusters who
impact on the quality of life of patients with dry eye
diseases such as cataract and glaucoma. This mode of segmentation ensures that the right
derive benefit from the clinical service line.

International Conference on Technology and Business Management March 18
1030
(Figure 5). They start at the basic traditional hospital model, labeled as
functional to the fully integrated service line model, referred to as program organization.
Figure 5: Organizational Designs in Hospitals
A pure functional organization is at the extreme left end
of the organizational continuum. The major
organizational units in a hospital are departments, which
represent different professional and non-professional
e of structure provides no integration
of functions to help achieve coordinated comprehensive
care. Some hospitals that follow the parallel organization
have added new roles or added new departments to assist
the functional departments to traditional departments. A
true matrix organization provides balance between the
strengths of the program and the functional forms. People
and responsibilities are organized in two dimensions
simultaneously and function effectively in this model. In
anization in order to have similar
functions across programs, a department may be created
wide issues. The program
organization model is made up of divisions, which include key personnel to deliver and manage its services. All
ions directly involved in providing care for a given program (service line) are contained within the program
division. In the pure program or service line, each division is a mini-hospital. The type of organizational
by the organizational dynamics, core competency and economics of the
Implementation of Dry Eye Disease Management as a distinct Clinical Service Line
Holistic Management of Dry Eye Disease a Differentiated clinical Service line Offering
Dry eye disease is perhaps the most common condition that eye care providers encounter in daily practice.
International Dry Eye WorkShop (DEWS) defines dry eye disorder as a multifactorial disease of the tears and
face that results in symptoms of discomfort, visual disturbance, and tear film instability with potential
damage to the ocular surface. (DEWS Report, 2007). The overall prevalence of dry eye varies anywhere from
erent patient populations (Gayton, 2009). Study conducted by in India (
the claim that dry eye disease is highly prevalent in the Indian context. Besides the natural process
of ageing, environmental conditions (dry climate, air conditioning), occupational factors such as use of
computers over long period of time, prolonged contact lens usage, refractive eye surgery, frequent air travel, all
eye disease. Early detection and timely management of this condition is
term sequelae and sight-threatening complications. A tertiary eye care hospital in
Bangalore, India has created a clinical service line that focuses on the management of dry eye diseases
to be a first of its kind clinical service line that is clearly differentiated
for the management of dry eye disease across the country. The dry eye management service line
includes all aspects of care beginning from diagnosis, medical intervention for management to long
Patient Profile for Dry Eye Diseases
Lasik surgeries (Murakami Y, 2012), an ageing population (Tsubota K, 2012) and computer vision syndrome
have been strongly linked to dry eye disease. Besides these specific groups, dry eye disease
th glaucoma (Leung EW, 2008) and cataract (Roberts CW, 2007). Hence,
ts can form niche segments for the service line that focuses on dry eye management.
clinical service line offering created by the eye care hospital targets patients who are at risk of
routinely scanning patients over the age of 50 for symptoms of dry eye.
clusters who can be approached from the perspective of making a palpabl
of patients with dry eye as well from that of improving the outcome
such as cataract and glaucoma. This mode of segmentation ensures that the right patient
ice line.
Program Organization
Modified Program
Organizations
Matrix Organizations
Parallel Organizations
Functional Organizations
March 18-20, 2013
al model, labeled as
Designs in Hospitals
organization model is made up of divisions, which include key personnel to deliver and manage its services. All
ions directly involved in providing care for a given program (service line) are contained within the program
The type of organizational
by the organizational dynamics, core competency and economics of the
A Case Study
Dry eye disease is perhaps the most common condition that eye care providers encounter in daily practice.
International Dry Eye WorkShop (DEWS) defines dry eye disorder as a multifactorial disease of the tears and
face that results in symptoms of discomfort, visual disturbance, and tear film instability with potential
The overall prevalence of dry eye varies anywhere from
tudy conducted by in India (Gupta, 2010)
Besides the natural process
of ageing, environmental conditions (dry climate, air conditioning), occupational factors such as use of
computers over long period of time, prolonged contact lens usage, refractive eye surgery, frequent air travel, all
isease. Early detection and timely management of this condition is
A tertiary eye care hospital in
ice line that focuses on the management of dry eye diseases
to be a first of its kind clinical service line that is clearly differentiated and is
agement service line
includes all aspects of care beginning from diagnosis, medical intervention for management to long-term care
Lasik surgeries (Murakami Y, 2012), an ageing population (Tsubota K, 2012) and computer vision syndrome
have been strongly linked to dry eye disease. Besides these specific groups, dry eye disease
th glaucoma (Leung EW, 2008) and cataract (Roberts CW, 2007). Hence,
service line that focuses on dry eye management.
at risk of Computer
for symptoms of dry eye. Each of these
can be approached from the perspective of making a palpable
as well from that of improving the outcome in other eye
patient segments
Program Organization
Modified Program
Organizations
Matrix Organizations
Parallel Organizations
Functional Organizations
International Conference on Technology and Business Management March 18-20, 2013
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Using Technology as an Enabler
Considering the chronic nature of the condition, consumer (patient) inertia often impedes seeking active
treatment for dry eye. This aspect has been overcome by way of using an innovative model that also works as a
CRM touch point. The eye care hospital being discussed has deployed a web-based preliminary self-assessment
questionnaire to assess the symptoms of dry eye of a patient. This simple to administer tool which also collates
patient profiling data including contact details computes and informs the prospect of their dry eye disease
scores, a marker of symptom severity. This process is integrated with an appointment scheduling system at the
hospital. Thus, besides engaging the prospective patient on the importance of timely management of the dry eye
condition depending on the dry eye score, the web based tool also triggers an email to the service line manager
and the counselor in charge with the relevant details. Thus, this model paves the way to seamless integration of
patient centric data that facilitates a more detailed assessment. Upon arrival at the hospital a detailed diagnosis
and counseling on the necessary interventions follows. Besides appreciating clinical excellence, patients tend to
regard novelty and perceive value in integration of various aspects of the care system. The medical management
of dry eye disease involves ambulatory care and hence facility planning plays a major role in patients
perception of the service offering.

Facilities Planning to deliver clinical service line focusing on dry eye management
The goal in facility planning is to ensure the strategic functionality of the physical environment by integrating
people, places, processes, and technology (Ellen D. Hoadley, 2010). The hospital under consideration in this
discussion has a moderate floor space of about 2000 sq feet dedicated to relay the processes relevant to patients
approaching for dry management. This includes areas for pre-treatment counseling, doctors chamber for
assessment, treatment suite, and a recovery room. Using technology as an enabler to schedule appointments
effectively reduces the average wait time for service delivery. Furthermore, sharp patient segmentation with real
needs more or less helps predict usage rates of the facility. Thus this treatment facility draws profitable patient
groups while optimizing resources, reducing wait times and minimizing process bottlenecks, all of which result
in better return on investment and increased patient satisfaction.

Organizational Structure facilitating delivering of dry eye services as clinical service line
The facilities plan framework at the hospital incorporates factors such as the current business mission, future
vision, current facilities base, and projects currently underway. Thus, it has helped gain organizational support
and credibility internally and externally while strengthening the competitive position and performance.

2.6 Riding the Service Line Wave
Considering the benefits associated with introduction of a strong service line, healthcare organizations in the
west have been experimenting with this model. However, implementation of service line strategy is no mean
feat. Synthesis of experiences shared by executives committed to implementation of clinical service line
strategies make for valuable insights (Kathy A. Miller, 2002; Debbie Reczynski, 2008,). These include the
following
a.) Clinical service line implementation calls for a significant organizational Change: Adopting a clinical
service line strategy means a change in the way an organization does business and not merely adding
another delivery channel to the existing structure. Usually, components of care such as laboratory,
radiology and the operating room are managed as independent silos in a hospital set up. Effective service
line implementation involves designating relevant service stops for patients along the continuum of care.
Additionally, the responsibilities of clinical and non-clinical staff associated with the service line must be
clearly delineated and understood by everyone. This calls for the organizational leadership team to commit
its complete support to the service line initiative.
b.) Collaboration is the key to success: For clinical service lines to be effective, they need to be collaborative
and multidisciplinary in nature. Medical and patient care personnel must get hands on with service delivery
and clinical improvement initiatives. Furthermore, the service line lead must be able to garner support from
domains such as marketing, finance and planning on an ongoing basis.
c.) Managing a clinical service line is a dynamic process: Stakeholders of clinical service line initiatives
should assess reports on inpatient and outpatient activity as well as the market share of the service line on a
regular basis. This process of tracking helps streamline the selection, definition and planning of service line
attributes.
d.) Physician support is critical for managing a successful clinical service line: The service line strategy
will unarguably fail without physician support. Right from planning to decision making to continual
management and leadership, physicians should champion the cause, for a clinical service line to be
successful.
International Conference on Technology and Business Management March 18-20, 2013
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3. Inference
3.1 Conclusion
Tertiary eye care hospitals in urban India seem to offer Sustainability, Scalability and Standardization of care,
all of which have resulted in attracting a flurry of investment activity in the sector. With increased investment
flowing into this segment coupled with increased demand for eye care services, the competition in this segment
has just about got intense. To effectively compete in this space, eye care hospitals need to get more focused and
organize themselves by clinical service lines. Clearly differentiated service lines that allow unique segmentation
and can be delivered using innovative methods increase the chances of success in a competitive landscape.
However choosing the right clinical service line requires superior understanding of the hospitals competency
and its competitive environment. Physician support and leadership teams commitment to drive the success of
clinical service lines is imperative. Thus, by focusing on relevant clinical service lines, eye care hospitals can
bring about improvement in their operations, thereby raising quality of care and adding value to their patients.

3.2 Directions for Future Research
Further research can focus on evaluating the profitability of pure service line models in the urban eye care areas
as well as on aspects that promote economies of scale in delivering these services may be useful. Also,
considering short stay formats are increasingly becoming popular for offering ambulatory services in urban
India, further research may also be useful to understand the commitment of specialty short stay formats to
offering pure clinical service lines across other specialties as well.

3.3 Limitations
a) The paper proposes a conceptual model to achieve strategic advantage in an urban eye care setting that
is marked by presence of many healthcare players. However, in rural India, demand exceeds supply,
hence there may be little need to organize eye care services using clinical service lines.
b) This paper also has delineated strategies to implement only Dry Eye Disease Management as a distinct
Clinical Service Line and has not looked at other conditions that might benefit from similar organizing.

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