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TheThreeDaySagaat All Saintsl"laspiral

hat farefui r|-._rz. br"eathed Nath irjs iast ar /il1 Sainm l{osprral, i o c a r e dl r : J n e o f t h e n r a j o r crlties South Inciia.in retrospect,the in .ioumev F,om rtre time of his accident to death provideciencugh opporruni, ties and indica-ti,rnsr_hat Narh could ha-,e been saled from death. Kumar (Nattr's brother-rn{arv) was revisiting the whole episodeand wondered as to why hr. did nor ral<.r: correcrivemeasures to save his sil;ter the agony of hearrending bereave:nent. e\nt. NatJlwas on his nl(]torc-vc1e on hrs "nrission inr.itaf ir.'n." clrii.'ing along the Or,rrer Rrnp Roaclat I0"30 a.m., and was hit biua speeding Indica car, driven bya Software Profes" sional (SP), evidendy in his mid, twenties. This SP had recently purchasedhis car and was still a novice, not holding a permanetlt driver's Iicense. The caE speecl:ing fuom behind, hit ltJath fiorn rhe back and dragged hirn fol about 5-6 meters beiore hitrng t}re :-oadclivjder After this acciCent. Nath \vils still consciousand showed his pocket to the SP for contact details in case of an emergency The SP took Nath to All Saints Hospital, one of the comparatively larger, well-equipped and reputed hospitals in rhe ciry As he drove through, he established corrtact with Silvia and Adam, the lone son of Silvia and Nath"

Yhe Fcrefc*E Aee5dent

Septepfsl 79,2AQ6, pleasant a winte-rmoming, and Kumar was whistling his way ro his office.I-Iehad several reasons be happy His sonhad to performed r,r'ell hadsecured disand a tinction in his schocl. Kumar's appraisal went verywell andhewas too expectinga promotion.He was,howjolted from hispleasant eve4 reveries andwasshocked a call on his mo- The ornmer'FalEuatee:r by bile informing tiiat his brother-inlaw of Healthcare had met with an acciderrtand was at The heaithcare landscape India is in *re All Saints Hospital. changing quite fast. Increased Kumer belongedto a big joint privatization and corporatization of family of KaveriBai (Ir-umafsgrand- the healthcaresectorhas led to inmother).Themegafamily wasplan- vesffnentin hospitalsbeing viewed ning a get-togetherfor quite some purely as a cornmercial proposition. time and had decidedon havingthe Medical insurancetoo has played a gala event in a week'stirne. The prominent role in making hospitals event inclrrded pooja and Srinivaso. morebusiness minded.Doctors who Kalyanam in the style of a marriage bring in business,in terms of cusspreadover a period of three days. tomer lifetime value, are appreciated Kumar had requestedeverybodyin and rewarded,rather than thosewho the family to parricipareactiveiyin cure the patient at one sitting by the function. hit iting friends and working out a pemlanent solution. relativeswas one aspectwhich the Even hospitalsgetting grants from family membersdid individually on inissionaries and other charitable behalfof Kumar's grandmother, sources discretelytoldto shoreup are Kumar's lone sister Silvia was the bottomline. happiiymarriedto Nath,an auromoThe huge feesthat the students bile diploma holder, who used ro pay when they get admitted to the work at a renovrne{engineering firm private medicalcolleges seenas are in the city Nath had recentlyretired investments;and an investor obviand had volunteeredto visit friends ouslylooksat RoI (Refurnon investand relatives to invite them for the ment).Sa1ary expectations doctors of NGMAsrERMrno Aprit 2010 ffi

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have, theretbre,gone uP, as Private withoffer bener packages hospitals any resffiction on outside pracout rice. The tamous HiPPocraticoath that a doctor tikes when helshe is has awaruleda degSee almost got degraded to a hypocritical oath, akin to a politician's swearing in at the ParIiament. New businessmodels, like rnedi' cal tourism too have had their impact on the healthcare industryl bY diverting their focus awaY from genuine patient care to servicesthat provide high profit margin and Publiciry in the media. All thesechangeshavc increased competition among the hospitals. In order to survive under such a competitive environment, hospitals are compelled to think of outsourcing several non-core activities, and making the doctors and suPPort staff to's-t-r-e-t-c-h' to their limits, in order to keep the overall costs low. places added a crucial 30 to 40 minutes and one wonders whether avoiding this delaywould have had an impact on saving victim's life.

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Nath was moved to the ward the next moming and the ordropedics department wanted a comPlete X-r{ to as- : sess the damage' Nath was to be , moved to a stretcher from his bed F and the nursing staffcould not get the the stretcher to match the height of ward bed. When the'staff tried to force Nath on to the stretcher, there was a snapping sound from the patient's body and he complained of severepain. The staffthen left the patient in the ward and retumed with a mobile X-raY unit. Nath now complained of verysevere backpain and it was near impossible to move the Xrayplate behind Nath's baclq'and this was done forcibly. Even then, the X-ray deparunent was unable to capture a proper image and theY PerhaPs thought that they should postpone the X-ray concerning the backbone. They started treatingminor damages to the rib cage by plastering the damaged area suitably. The entire day went by doing some analYsis or the other. Several doctors and sPecialists were visiting Nath from time to time and were anallzing the Problem in a straight jacketed manner. FamilY members of Nath felt somewhat concerned that no single doctor was responsible for the well-being of the. patient, and theY went about trYing to seekhelp. Kumar then approached Dr. Thomas who was an acq;ain-tance, and requested liim to talk to those concerned, exPlaining thl anxiety. Dr. Thomas sPoke to somebody over phone and assured the , family that Nath was under the best of care and advised them not to worry and be relaxed. The next day, Silvia, after seeing a nurse struggling to read the patient's blood pressure, expressed conceffl regarding ttre capabilities of the support staff to the head nurse.

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crowded as usual and had a lot of patients and very few doctors. As a rule, All Saints allowed the patient and one attendant into the emergency area. This control was at the disposal of a securiry guard who couid not conversein either the local language or English. The cost control measure at the hosPital had forced theseoutsourced serviceproviders to hire inexpensivepersonnel and they looked at the north-eastern part of India for such a solution. For the reasons explained earlier, doctors and support staffon emergency duty were overstretched and were looking tired. The doctors and other staff onduty examined the external wounds and administered first aid. They did mention to the familY of Nath that Nath was forrunate since there were no head injuries. Nath always used to wear a helmet while driving his motorcycle. Furtheq one of the doctors on duty informed *rat further analysis and investigations would be taken up after the orthopedics department took a look at the Patient" TheY did ' express their inability to shift the patient to the ward, due to non availability of beds. Respondingto a question from the familY regarding the need to shift the patient to some other hospital since beds are not available at A11Saints HosPital, the doctors brushed this suggestion aside, stating ttrat the patient was stable and that there was no need for such drastic action. The policeman, who had arrived by then to take a statement, was told by the doctors that this could be done on the next daY.

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When the SP took Nath to the hosPital, the serious emergency on hand could not be understood bY the Person manning the car Park and Perhaps rightly so, since he thought that emergency cases will alwaYs come through ambulance services. Furtheq the securitypersonat the emergency ward insisted that the car be parked at the car park before allowing SP to take the sffetcher/wheel chair. After fetching an available wheel chair, the SP realized that h'eneeded a bigger one and there was nobodY to guide him. Car parking and security services were those non-core activides that the hospital had outsourced in order to focus on its core activities; and the personnel at these Places were not sensitized to emergency sinrations and theY alwaYswent bY the rule book. The delaYin these two

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Ttic Tlrree DaySagaat All SaintsHospital

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That nigftt. aftt:r *Jre gr:splaiei:*cli-rrp, Nal h st.;:r::rl\iulliil ins vt'ha :i.t )ueared iike f.j1,:.iur,:r ,!iivi-, l-, seel fitis ::i ' hai.'perr:.,c'.-L il;niii rr-:?!rrlret.s bcforelh-' 1e;.:li r.i-l ,L., rr, ,-,e,f-r:i;, sftr, llulli.., ! ho .,, ,r;:d rne rn;a(i enC Said thiit rhe.irwa, rc,rhirgroirui{". Upotl trffil:er i' .,rst.:nce" ntiffie ioid Siii,ia tfre ic comari the dr"r1'doctorhersejl as it .";a-q 10"30p.m. already 'I-hecioctors vvhon Silna met in one clf the cttbiC,-.s vt-:re n1)t illterested in taliing a ir-roliat I-I -:rt,a:^ thr theynLenlioned tlat t]tel were rtoil ?-he n,-rrlu-olo&v department i,'.1 tj-re)-haci no'hing to :1cwith .ir-is.In i;:w mornents, Irlath was nr) ^.-cre anC .:oine do,:tor was rvckerrtrl from ifs sleep. The doctor put Nath,rn artificial irfe support sys_ tem fo4son etime and said SORRy Issues fo",TFscasssaen/ It lvas ;hocking to everl body in_ Teaching t'lof"e cluding th: pclice, nursingstaff, and to Broad outlines are provided here in I)r: Thomas, as to how this cculd hapthe form ofdiscussrorr questions and pen. The ne)ft day the doctors doing possible solutions, in order to guide post-mortem perhips d-roughtth it I fley the reader towards achieving a gen_ neededto idenn$rand disdosc rhe reaeral unders anding of services marscn for death to the farrril"yIt r,ias writketing. Ffowever, ttre material proten in fhe report that the back bone was vided here is neither complete, n<tr brcrken and had punctired the lever/ final and binding. pancreas. NaCr's family - ?s .:t/cnder- Discussion que"tions: ing ',heth .," t+.]i, :,.rt fhe fi(..itrnent 1. Do y'oLi*r,';k :onpetition in the that his ct ,cJ :cndifi:ns dttnanded. hospital industry is the reason fcr They'w:re cluelessregarding handiing the kind of siruaticns seen in this of the patient and the sound hom the case? Analyze this liom the points backbone, and wondered whether this ofview of: could harie heen the cause. They also ts BusinesspropeSs outsourcing wondered whetheq if the doaors had ts Demandmanagement diagnosed the dinical conditions corts Broadened definition of com_ rectl]4 any surgei-y to the backbone peridon. coliid havc savedNatj-r Competjticr, is iike oxygen and i.irirrr::rialt r'h,rL shculd ha.;e as_ the hospitai iie ir,l+sfry r:a.nnot wish this ilrehorrp;talbeticr arid thorrgirt sessed away \Mren tire stilrT analyzing the
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lhat hc u':i: i,r it r^/avtLtlip()5sifuii: jr;r the tragedy. Fle spu-[, 1-L] kriir/7;t ar', quainti:ncesi-rhr; g;rr:ea lair'1i,grilrl feedbackithirrrt rhe hospirai. Florv, eve4his exlr:d+:ncehad given an indicailon Lrlarriings are no'. al1thilt goori atAll SaiitL.; llospjtal. Kum:ir rhought that he shouid hiive a detailed chat with Dr Thoriias on *ris. FIenarrated the wli<.rlc aii.iinr{-) Dr.'Ihorlas. Dr.I ir,;rn,rs's c).i.s wCi.rr sirrce wel h.-: lciew thc fanrrii.i,ell" As lrr teaci riic post..,: :em r'ep()rt detail,he r.,, in menfioneo tu lr,;-imar thaf he (i"e." KumarJ 'was nui at fault. After Kumar left rhe sr:ene, Dr. Thomas wi-rs sitring irr ir!schair and was vis_ ibly distr:-beil He was also the director in chargeof the hospital,saclniinistratiorr ard w;x \ r,lfidering as to how he sl,; l.rici about analyzgo ing the seryices providecl by his l os_ pital and put-tlle h'-,u"gin order He aiso thought, if he u,.as not capable of putting tf,;qg5 righr, he should give up his post-.

case the fbfiowiti;t issues , comet the to fbre, it js, of coursc, ne(:essary fha.t ltc)ll-coreacdr4lii,'s oulsourced to fie keep rhe cr sts 1olr,.. Actjvities, such as security selices, car parking and cafeteria, Otterr are otits0urc-cd ex_ to ternal services providers. Hospital, being a service indtistry ,people'. .'process'and'physicalcvi<fence' are irnportant cotnilcnents of the mar* keting mix. VVhe;rpeople.come to the fore of ir,: .;ctinq.,. variability comes into play and ';his should be used as a differcntiator in a comDeti tive environment. The importanie of contact personnei at the servicescape arrd h..rw it can really make or mar the inrage of a firrn and its businesspr(.,spectc cannot be underestimated. The contact person_ nei should, therefore, be trained well, as some of tire comnton behav_ iors among servire persclnnei such as apathy, brush o1'i,cordness,robot, ism, rule-bookisrn and runaround, irk customers anJ shcluld be consciouslyavoided. Only a_fter ensuri-lrg riese aspects, should hospitals outsource the non_ core activities. Peoplemanrring these activities should be ar,nrare what is of happening in rhe system=kaining is . necessaryto sensidzetiiem to the intemal environment that they are in. They should be made aware that the "rules are.therero facilitatea process and nor to choke the ystenr.,'Iraining is perhapsneeded6 to howto selec_ tivelybreakthe l:les if itcan assistthe objective of facilitating the process. Understaffing in critical areas, like medical care and nursrlng,would be detrimental to the hospital. Inter_ nal customer focus in a selices scenario is cmcial for the surrrival of a hospital. Adequate rest is necessary for the medical and nursing p*.rornel in order to be efficicnt. S:rvice personnei genereliy exhibit high,

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TheThreeDaYSageat Ali Seintsl-laspital

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',:;; 'V;r:a,'.: tirliIenta,iieo''vrill not jirtr 1,r lr:t.r:Jidt tbr i{:t-',tcrpuilils. ft':lln rng t<.rl'rrcc?i;-ltcand iclv passion L:"ielo be plariiied, it t'1;"14 ix:isr)r^[1.ii ,:lte liosi-tital is not atry tl3tr i'r.tr-;.i i,ihig}, to dq'iaLr'{irliife.nufitllF'} 4I,Ir ' I fiirit. citslJnlel dei:.r>slofi.'t,t.. r i t . h l t : .a V e f \ ' , i p [ , , a ! l t! i , ' I i ( r t ' e j . 1'liet:ommilCatiolis :-uLlng]I:l/isj: ;;tc-iith p'illriir-ity*in a a: r(l'"vr:r l1-.t;i,nj np( tiili"c+'.:fi,:I itr' if the hosf.i'aliclemifi':s an imbaia n e ei r w o r k l o a d . s a y a t t h c e l n e l 'lt,d staff dgcnry r'&-1ng, "'1.:;-.] s""ii;port rgshotild '1t'ich1i ctller lr"^;ir: fi,rm to anci.rn.,:,r,'e del.iver servicesat a Lr6;n the clernan,ie.r'ecliion Doctors and s,,r'f despite their speci.rlizat;cns, ntuitiiar'kingcapashould have:basic oiiit;.:s and thc iitciination to do sc. ql5bqrvr,;e, hospital (in the event the of its "taif an j beds being fully occupieclJsht rrlc 'tave the heart to direct Lhep,.deirt tJ arother hospital after adrninisterir,; first aid. The ternr'broadening the competition', refers to healthcare and tourism bein' lubbed together.The Yery ide?. of r..imbining these is to provide better vaiue to the customer. It is lot that tourjsm should talte prioriq. 31the expense of quality of service et the tr'lspital. To qirore lhe e:riinent ma"'gement g-uru,Peter F Druclie4 "Tiic purpose of an organization is to he responsible and.not just growing the wealth of shareholdcrs." a 2. Having recognized seriousservice lapse in this case, how shoulJ Dr. Thomas caPture the cLlslclner expectations, develop tmci cieiivl-. qualirv se.r'ic. s t2 the spi*l's EtlstcmeKs? ft i-r modci of seryjce 1'he c'.otrt:eputral q ualitv cr thrr Sc'tvqua| Mociel (Refer

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Exhibit) hv Paras,lraman, Zeithaml arr,JBeny coutd ire used to answer this question. Dr. Thomas shruid get a clear understanding of c;-trtomers' expectations (CE) in a ianguage that the customer understands .,id not just in the medical language i/nowledge of CE cones out of past experience,word-ofmouth and external communication' He needsto analyze the gap befin'een view of CE' This CE and the hospitailS {,ap (Gap i). !sthe Knowledge From this, Dr lttomas should focus on developing standards and correct processes.This was missing at and the hospital. Proper processes standards,wheh established,will ensure fault free selvice delivery Nath's backbone problem could have been noticed earlier. This Gap is the Standards Gap (Gap 2i. Ficw n'el1 drese .sysielrls and procedures stanciards, are understood by thc servicepersonnel and trow they wil1be rielivered is
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the next aspect. This is the Delivety Gap (Gap 3). Basedon the qualitY of service received, patients will develop a perception about the hospital. The gap berweentitcir perceplion and expectation is the Service GaP (Gap 5). There is also a gaPbetween eliternal communications of tfte ser:vice provider to consumersand the service delivery which is the Communication Gap (Gap 4). The Servqual factors of Reliabilit-14 Assurance, Tangibles, EmPathY and (referre,'l a-s to RATLR) Responsiveness also be discussedhere'r: could
Note: This case study draws upon some experiences of the author. However; the hospital and the individuals referred to are not meant to represent any actual hospital or persons in particular.
5uk*5[r Ku*ar S R Faculit,l4enrlrer, IBS-Bangal0r?. -fi-re author tai be reaci:edal llom ot 5ui(heshkilmarOhctnail suishkGibsirCia.oi-c

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