Wednesday, 31 October 2012

Guarantees in Healthcare

I would like you to take a moment to think about what is the longest guarantee period offered for a product that you know of. Months, years, decades? What about life-time guarantee? For instance Toyota offers an 8 year guarantee for their Prius battery for the electrical motor part of their hybrid system. Some manufacturers and some body works repairers offer life time rust proof guarantee. Pizza companies say that you can have the pizza for free if it does not reach you within a defined time after your order. Well you can surely name a few more yourself.

Here is a jaw dropping guarantee. 2000 years.

Yes, you read it right The Sweet Little Sugar Softener offers a 2000 year guarantee. Yes that is offered for a product that is very simple. Okay, I am not sure if any of us are going to be around for 2000 years to vouch for this. But just imagine the confidence of the manufacturers in their product that they are able to offer it. It is a product made by simple artisans in rural America, not highly educated, with no great facilities etc

Guarantees in Healthcare

Health care is full of educated, highly intelligent and motivated people. Many if not all clinicians would have two post-graduate degrees. Healthcare managers and insurers are very large players in terms of the total money spent on healthcare especially in the western world. What kind of guarantees can healthcare offer to patients? As far as I know, none. In fact, professional bodies may not look at you very kindly if you started offering any guarantees, they will come down on you with a tonne of heavy scientific bricks and with a high moralistic tone accuse you of potentially misleading patients. Why is that? Why is it that healthcare which consumes so much of our resources unable to offer any sort of guarantees to our patients?

It is high time that we started backing our intelligence, education and skills and experience to think about what guarantees we can offer our patients and how we can make those guarantees work. We then need to put some money to back those guarantees. Doctors should perhaps take the lead on this one. Doctors always claim that they are consistently in the top 2% of the top performers in the society - well that is indeed true. If the top 2% performers cannot guarantee any of the activity they do and back it with some money we do need to either question their performance or their motives.

Healthcare needs some guarantees, patients need some guarantees. Yes, you healthcare folks, time to up your game, I know you cannot yet reach the level of guarantee offered by rural native American artisans but surely you could start with something small. How about no charge for patients if their bowel anastamosis leaked? How about completely free care if you did not meet the expected discharge date? How about paying a penalty to the patient every time you cancel or postpone their appointment/operation/etc.

Healthcare just dazzling and blinding people with asymmetrical power, high intelligence and skills is not simply good enough any longer. It has to be matched with some performance guarantees.

Being the change you want to see - the oft repeated Gandhian saying; on that basis let me go first.

(possibly for the first time in the world)

One day the whole of healthcare especially doctors including me may be able to offer guaranteed clinical end results; right now it seems we cannot. So what can I guarantee can I give my patients? Before we get into that let me also explain that I work in the NHS on a salaried basis in a surgical department. NHS allows me to do private practice but I am not in regular/routine private practice. I cannot as an NHS doctor offer any individual guarantees to my patients. I am like the rest of the British people, own the NHS but do not run it. However I can offer some guarantees to my potential private patients.

Here are the guarantees I am willing to offer to any private patient who cares to find me and pay me a fee for service (self paying private patients).
Open primary inguinal hernia repair: if you have a recurrence within 3 years I will refund you the my fee i.e. the surgeon's fee.
Colonoscopy: if I do not reach the caecum (provided it was not poor bowel preparation or a confirmed bowel narrowing) and hence you had an incomplete colonoscopy I will not charge you my personal fee for the procedure.
Obviously all other charges will apply, have to be paid for and not be refunded.

As I have already said, right now I am not in active private practice. But if there were any patients who paid me privately for these two procedures that is the money back guarantee I am able to offer. If there were takers for this service/offer I might be stimulated to think of what further guarantees can be designed in healthcare.

What is important is if many others in healthcare provision are able to offer firm money back guarantees in healthcare. That might be a disruptive innovation in clinical provision. Let us go for it.

What are the guarantees that you are able to offer your patients?

Update: 1 Nov 2012: W Fischer informs me that there are guarantees in healthcare at Geisinger, Danville, PA since 2006. Very nice to know. So obviously I am not the first or the only. Here is a write up on their warranty: There are press stories about it, find it on the net. They do not seem to pay the patients any money back (I suppose that will be an issue for the insurers) but they do not charge the insurer to fix any complications.

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Wednesday, 17 October 2012

Mark the site campaign


A Surgeon's interaction in the Operating Theatre

This is a real conversation that happened in a real surgical operating theatre in India a few weeks ago. It probably happens every day.

Surgeon, standing to the right of a patient under general anaesthesia for hernia repair asks: 'which side is the hernia?'

Assisting surgeon: 'I don't know. I did not see the patient.'

Surgeon: 'Who saw the patient?'

Assisting Surgeon: 'The house surgeon from the previous shift'

Surgeon: 'What does it say in the notes and consent?'

Assisting Surgeon: 'Hernia repair, obviously'

Surgeon in anger: 'Obviously!! But which bloody side?'

There were a large group of people in that operating theatre, junior nurses, medical students and other staff. None of them will speak to the chief unless they are spoken to. Silence for a few moments.

Surgeon in exasperation: 'Does anybody know the side?'

Medical Student puts her hand up.

Surgeon very impatiently: 'Tell us. What are you waiting for?'

Medical student says: 'I don't know for sure, but I was standing on the right of the patient's bed when I examined him and I had to reach out across to feel the hernia. So it must be the left side.'

Surgeon: 'Left it is then. Let us get this done'

Very lucky day. The patient did have a left hernia. The medical students had seen two other hernia pre-op patients the same day and extremely fortunately they were all left groin hernia.

Wrong Site Surgery WSS
(and wrong site procedures: wrong site anaesthetic, implement fitting, etc)

Sadly not all patients have lucky days like the above patient.

Wrong site surgery is estimated to happen once a year in a typical hospital with 300 beds Clarke, J.R., Johnston, J., and Finley, E.D.  Getting surgery right.  Annals of Surgery;246(3):395-405, Sept. 2007.

Surgeons have a 1 in 4 chance (i.e a very high chance) of being involved in a wrong site incident

Wrong Site Procedures: Wrong side anaesthetic – is happening more and more with not much attention paid to it. There are a number of interventions done in wrong patients, a large number of unnecessary procedures done on right patients. Even the statistics for these are difficult to find.

Though the evidence comes from the west there is no reason to believe that other countries (such as India) have any less incidents or better practices.

The impact of these are dreadful with life long suffering. Life long dialysis if the wrong kidney is taken out or a kidney transplant with the complex lifelong medication to be taken after that, wrong eye – blindness, wrong leg, etc. It does not need to be major operations even after lesser wrong procedures it is possible to have wound infections, chronic wound pain etc. These are just physical. The psychological effects are much worse and affects not just the patient but families, friends and whole communities. Trust in healthcare providers – hospitals, doctors, nurses – irreversibly damaged.

The internet is full of events, episodes and tragic histories of patients who have suffered wrong site surgery. If you want examples they are only a couple of clicks away.


It is very easy to write about solutions but it is well recognised that any solutions against wrong site surgery is very difficult to put into place, difficult to practice and not always successful. That is no reason not to try to reduce it by any means possible.

Some of the more effective solutions are thought to be:

The operating surgeon to see the patient on the day of the surgery and MARK THE SITE on the incision or as close to the incision as possible.

If the procedure involved a symmetrical organ the opposite side i.e. the side without the pathology is marked with a big NO; that may help.

Some surgeons write the name of the procedure (including the side if appropriate) on the incision line – that helps.

Check lists that include surgical site marking

Improving the culture so that any member of staff however low down in hierarchy is able to speak up when WSS issue is suspected

Our own suggestion (though not research based) is to empower the patient by asking a competent patient (any one who is able to give consent should be a competent patient) or a competent relative to mark the site of the procedure in the presence of the operating surgeon. After all it is reasonable to assume that the patients have a vested interest in the surgeon not operating on the wrong part of their body.

Even if it is a non-symmetrical organ procedure or a midline procedure make it a habit to mark the patient so that you can have standardised preparation protocol. It will really help a patient some day, if you are a doctor it will surely help save your career.


This is a campaign we are specifically starting for South Asian countries (e.g. India) but is also relevant to many developing healthcare systems (e.g. African continent).


Please pledge today that you will mark the site of the incision on all patients on the day of the surgery.


Please pledge today that you will not begin anaesthetising a patient unless you see the site marked on the patient's body. If there is no mark please ask your surgeon to check and mark it before anaesthesia is commenced.


Ward Nurses: Please pledge today that you will not let any surgical patient leave your ward to go to operating theatres unless their surgical incision site is marked by the operating surgeon.

Theatre Nurses and allied theatre staff: Please pledge today that you will not allow patients through the main doors of the theatre unless you see the surgical incision site marked.

PATIENTS (and relatives)
Please pledge today that you will not leave the ward/bed and enter operating theatres unless there is a mark on your body at the surgical incision site.

Pharma companies and their sales reps
Please provide doctors with a skin marker pen as a part of the various complimentary items that you provide and ask the doctors to use them to mark the surgical incision site


Please forward the link for this blog to at least two persons. Alternatively cut and paste and send the information to at least two persons.

Write to hospitals, politicians, news media outlets or any other action that spreads the message.

Let this be a campaign be owned by us the normal public (such campaigns are normally lead by institutions/organisations/etc)

Primum non nocere is a fundamental principle of medical practise. Causing permanent harm by wrong site surgery is against that principle. It may not have happened to you yet but look at the numbers it is happening all over the world, it may happen to you unless you take definite action about it; irrespective of whether you are a healthcare professional or general public.


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Sunday, 7 October 2012

Increased Quality and Reduced Cost - Possible in India

I have a long held view that quality is inversely proportional to cost which means as for a given activity as the quality improves cost decreases. This is actually possible in India as well.

Let me share a clinical anecdote that may illustrate my point. It may be dated and trivial to many current readers but was very relevant to the patients and clinicians at that time.

In the late 1990s I was working as a surgeon in Sir Ivan Stedford Hospital, Ambattur, Chennai, India ( This is a charitable hospital where we used to charge very small nominal amounts of money to provide services. A few rupees for out-patients, few tens of rupees for scans and so on. Being India, one of the commonest operations performed happened to be surgery for hydrocele. The way it was conventionally performed may be very familiar to many of you. The operation of course ended with a large bandage tightly applied to the scrotum with the purposes of avoiding problems like pain, infection, haematoma, oedema etc. These patients were also put on antibiotics for 10 days or more. Many of these patients used to come back with soiled dressings and the exact problems that doctors were trying to avoid. Doctors used to wonder what else could be done to improve the situation.

Not using a bandage was thought to remove an all important barrier that avoided exposure of the scrotal wound to the unhygienic toilet situation in India and despite using 10 days or more of antibiotics infections were happening. Barrier and antibiotics thought to be bulwarks against contamination and infections were not working.

I actually thought the tightness of the bandage caused oedema and increased pain. The presence of the bandage increased sweat and moisture in an already humid perineal area in a warm country. The bandage also easily became wet because of the toilet washing habits of the country and acted as a rich environment to create infections.

Having worked in England where the scrotal bandage was not routinely used after scrotal surgery, I took the bold step of not using scrotal bandages to hydrocelectomy patients much against the advise of my friends and colleagues. Of course, I suggested the use of the proper scrotal support clinical hosiery which was either not available or when available was very expensive. An alternative had to be found. I simply asked my patients to buy 7 of the cheapest 'A' or 'Y' front underpants from the shops opposite the hospital otherwise I would not operate on them. I used these normal commercially sold underpants over a couple of pieces of sterile gauze placed on the scar, changed once a day by the patients themselves, in the place of scrotal bandages for my patients changed by clinical people. Most of my patients found this very amusing. Some were resistant, perhaps hesitant, because the had not worn such a type of undergarment before. My colleagues were of course greatly humoured by what they thought was my naivety and enthusiasm.

In a few weeks, post operative follow up clinics were showing that my patients were walking in and walking out in super speed and for the rest of the surgical team there remained the usual levels of post op problems with pain, oedema, infections. Having eliminated the scrotal bandage which I thought was causing the problems, I then moved to single dose prophylactic antibiotic as I used to do in Britain.

Word of mouth and social observations in a local context those days was of course as fast as twitter or facebook now. The talk was about how patients spent less money on changing bandages and buying antibiotics while getting good results. Soon my colleagues avoided scrotal bandages, used undergarments as I recommended and moved to a shorter course of antibiotics often just 3 doses (instead of the usual 10 days).

Of course the people who charged for the change of dressings and the people who sold antibiotics were not happy. But I can tell you who were happy, the guys who sold the undergarments. They were really happy. 7 undergarments per hydrocelectomy patient in a hospital that did hundreds of hydrocelectomies, they must have been ecstatic. Well, I know they were, as one of them approached me and offered a commission to me (his bloody nerve) if I could recommend patients to buy the undergarments specifically from his shop – no different from the drug store chap then!

Clinical complications reduced – i.e. quality improved. Cost reduced.

Okay, this example is not about whole systems, scientific proof, published evidence and other high & mighty things. It is one little example. What I cared and what our patients cared is that we had lesser clinical problems and we achieved it by doing/using/costing less. Perhaps hydrocele surgeons in India are no longer using scrotal bandages and 10 days antibiotics - that is why this anecdote may be very dated but the general lessons are in my view still valid.

Increasing quality while decreasing costs can be achieved in India as well. Perhaps due to the large number of people who are around the poverty line this concept becomes even more relevant to India. We must remember that though the GDP is high the per-capita money is very low in India. Individual doctors are not dealing with the mighty high GDP India; individual doctors deal with the individual patients of low per-capita India. That is why low cost high quality care becomes essential.
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