Saturday, 27 April 2013

Some thoughts on future healthcare

BMJ's doc2doc social media website's Matthew Billingsley recorded my interview at the 2013 International Forum for Quality and Safety in Healthcare at London for a podcast.

We discussed crowd sourcing healthcare, learning from other healthcare systems, the gate keeper role of UK general practitioners, etc. I hope you enjoy the podcast.

The future of healthcare is changing and could be unrecognisably different. How willing or ready or you to cope with it?

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PS: This podcast was originally posted on the doc2doc website and is reposted here.

Wednesday, 24 April 2013

My Conversation with Dr Ravindran, Chairman of Aravind Eye Care

I had the privilege of meeting Dr Ravindran, Ophthalmologist and Chairman of Aravind Eye Hospitals, India, at the International Forum for Quality and Safety in Healthcare London 2013. I had a general informal conversation but it was of course an eye opener - you bet he has experience in that!

I share some of the conversation here. 

Clinicians' Selection processes at Aravind


It is well known that Aravind has processes that are followed really well by the staff, especially doctors who work there. Protocols and processes are very important for their pathways and systems to work. It is also well known in healthcare that it is very difficult to get doctors to follow organisational protocols. I asked Dr Ravindran on how they do that.

Aravind appoints doctors after a 3 day selection process. Applicant to appointment ratio is a minimum of 3:1. Fellows and residents work and spend time with staff on those three days. Doctors then provide feedback to the appointments panel on the suitability of applicants. Anyone blackballed by existing staff are not selected. The main if not the only criteria for appointment is if the doctor is 'suitable for our culture and basic values'.

They obviously get people who are already high flyers with research credentials, publications, etc but Aravind's attitude seems to be that they want only normal average people to work with them and their system and culture will then make them do good work. (This sounds very similar to Toyota Chairman Cho's statement that they get brilliant results from average/normal people when other car manufacturers get average results from brilliant people). These high flyers, if they are not suitable for the Aravind culture are told that they are likely to be very successful outside the Aravind systems.

Chairman Ravindran says 'we want everyone to be pleasant and professional to each other. If we detect even a small amount of arrogance during the selection process, we will not appoint the person. Arrogant people can offend and upset others which will disrupt team work and increase staff turnover - we cannot have that'.


Student Nurses are selected after a written test and an interview. The test is a hand written test where they answer a question on a social concept. Hand writing is thought to be important (if you cannot read a person's writing the value of their documentation and written communication becomes a future problem). As for the content, it is thought that if a young aspiring nurse cannot write with genuine empathy about a socially important issue they would not fit in with Aravind's culture and communication.

Now comes the interesting part of the process. While interviewing the applicants is what everyone does anyway, Aravind interviews the parents of the applicants. They see this as very important. Attitudes of parents and aspects from home have an influence on how people behave and work. This is accounted for in the interview and selection process.

Once they are selected to be nursing students, Aravind pays for their training, accommodation etc. These students after graduation get to work for Aravind.

I probed their thinking - I said that the society will have many different types of people and their organisation will/should have different type of people; including and excluding some types will not reflect the society. Dr Ravindran was very clear with his answer, he said that of course the society  will have many types of people but in his organisation they only want the type of persons who can share their basic value.

Their basic value is compassion.
He also said that many in the organisation including the senior people continue to engage with the staff and their lives, he said 'I know a lot about many people who work with us, what they enjoy, what problems they have at work, what issues they have outside work and in general a lot about their lives. Due to this we are able to support them very early.'


I specifically asked him about where and whom he and his organisation learns from. He says that their main learning is from within their organisation, they try to improve everyday and share it with their internal colleagues -  mutual learning within the organisation. (This blog has in a previous post stated this as the fourth fundamental condition if healthcare is to be successful )

No external consultant has even been contracted. No lean specialist, no management consultant. They get regular visitors trying to learn from the Aravind system. Aravind staff do visit hospitals around the world to explore what might be suitable for adaptation.


When asked about how they deal with the high volume of patients Dr Ravindran said 'If we have more patients we simply start early - all of us. We do not put patients on a waiting list, we do not turn patients away'.
I asked about being lean and quick and his response was 'It is not about being quick. It is the attitude of not wasting anything. So if we don't waste time it looks like we are quick. We do not throw away anything; if a bed sheet is torn you can be sure it will re-appear in some other form to help with some other function'.

I think my commentary is not really needed as the conversation is very illuminating and self-explanatory. Their website shows that eight out of ten directors of their board are doctors - does that say something? I think we can learn a great many things from Aravind Eye Care and their practices. I wonder what we can actually adapt and use for healthcare delivery in the western world?

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Aravind Eye Care

Tuesday, 9 April 2013

Breaking down monuments

Here are a few examples of monuments that we can break down.

Ultra-sound scan room

There is no real need for in-patient diagnostic USS to be done in a specific room. Put them on wheels and take them to the patient on-demand. Doctors get bleeped for opinions for in-patients and they go to the patient, no reason why diagnostic USS cannot be done by the bedside after drawing the curtains around. This spares physical space for more work do be done (I think the managers call it creating capacity).

USS for outpatients - could it not be done at patients' home? District nurses do dressings at home why not USS?

Flexible Sigmoidoscopy

For in-patients diagnostic flexible sigmoidoscopy can be done in their own beds during ward rounds. For outpatients it should be done during the consultation at which it was thought to be required and in that same consultation's examination room. Why do we think we have the right to ask the patient to come back for something that can be done then and there?


In-patient diagnostic gastroscopy could very easily be done at the bedside or in the relevant ward's treatment room. Outpatient gastroscopy should be done in the consultation room at the same time as the consultation at which the gastroscopy was thought to be needed. Have we not heard of ENT surgeons doing nasal endoscopy in OPD? Have we not heard of ultra-thin scopes? Have we not heard of oral sedation if it was indeed necessary?

Oh, by the way, we have not obviously heard of companies willing to provide clean scopes by motorcycle courier delivery wherever we want.

We have this rigid old-world belief that patients should be moved around to where the 'facility' is and when that is not possible clinicians and others should become runners to connect patients and a variety of facilities. We have to stop such thinking and move with the modern world. We used to run to telephones

Arterial Blood Gas analysis

Hand held ABG analysers are available and these ought to be used as POCT (point of care testing). It is well known that blood gas results have to be acted upon within minutes if it needs to make any difference to patients. ABG analysers are situated as some centralised monuments when they should be available near the bedside of any acute patient anywhere in the hospital. We call for a demolition of this monument.
This blog has already argued for improved ABG turn around times as an example of clinical lean

Bedside Hemoglobin, WBC and other testing

Hemocue POCT hemoglobin testing has been available for a few decades and has been used by many para-medical services but still not used routinely in many hospital operating theatres and other areas. There is really no reason why this should not be available anywhere in the hospital or be carried around by doctors and nurses. When we can provide treatment in life and death situations using POCT blood sugar testing, we could do these couldn't we?

General Practitioners as Gate Keepers

In the modern world where information is provided in plenty by Dr Google, where patients are far too knowledgeable than when the NHS was created 60 years ago, patients must have the liberty of seeing any specialists of their choice without having to go through a general practitioner. Seeing the specialist directly happens in other parts of the world especially with post service self-pay patients, in UK having pre-paid patients do not get the same liberties or choices. There are innumerable myths on the gate keeper role of UK GPs which need to be challenged if clinical practice is to be compatible with current expectations.

This in no way an attack on the role of GPs as clinicians providing an invaluable service and is essential; I am only questioning if any value is really provided by the gate keeper function and whether there is any sense in putting hurdles in a particular patient's chosen pathway.

There will always be a 'this is too risky and against the rules/regulations' brigade. I am looking at how we can innovate and improve safely. Yes, if we put it that way, risk and improvement do not make comfortable bedfellows. 

Please add your ideas on what monuments that you would seen broken down in your hospital/clinic by leaving a comment below.

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