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The hospital model that is offered in Sri Lanka revolves around the patient or customer physically visiting the hospital and consulting the relevant doctor. This involves travelling to and from the hospital, booking and waiting to see the appropriate specialist. The current model is a tripartite model of hospital, doctor and patient and is still focused more on the hospital and doctor rather than the patient. The patient is at the mercy of the doctor and so is the hospital.
This has arisen because in Sri Lanka many doctors work in a range of hospitals during the same week. In addition, medical insurance payments are based around the hospital/doctor giving instructions and medication. This traditional model of the customer/patient centres around a person who is told “what to do” for his/her best interest and is a passive party.
The existing model is a fee-for-service system requiring office visits, tests, and procedures for providers and hospitals. Traditionally, medical education has focused its efforts on content and procedure training, with little time and energy spent on training for the necessary skills to form effective patient relationships. Doctors are paid for the number of patients they consult rather than the time spent on each.
Comparison with other services
It is interesting to compare the medical service with other types of services. Whilst is it true that medicine has undergone huge transformations in terms of equipment used to diagnose and perform surgery, when it comes to patient or customer relationships, the type of service offered to the patient/customer has not evolved to the same extent.
Internationally, the health sector is moving towards using smart devices on a much more wide-scale basis. Smart phones will be used in the future to monitor diabetes, pulse rate, pressure, and other critical factors. Apple has just launched a smart watch/phone which will take critical readings of a patient’s pulse, etc. Apple will also partner with the Mayo Clinic and other health institutions in the USA, allowing healthcare providers to receive and transmit data from their checkups with deep privacy protections in place to secure those sensitive records.
In the future, ‘smart’ clothing is also evolving to monitor heat levels of patients and a whole gamut of smart solutions using watches, phones, glasses and clothing are currently being brought or being released onto the market in America and Europe which will monitor and transmit the necessary bodily data and can be remitted electronically, immediately and at any time.
As we are aware, telecommunications and banking, for instance, are focusing more on electronic means to ease delivery and increase speed and convenience to the customer. For instance, airline tickets, foreign travel, international telephone calls, banking and downloading movies and songs can all be done online. In Sri Lanka, booking and paying for a doctor is possible online, but there is not much more than this on offer.
‘Participatory’ care
In the new model, as documented by The National Committee for Quality Assurance (NCQA) the healthcare system should offer six basic standards: better access, population management, planning care, self support using community centres, tracking care, measuring and improving performance.
These need to revolve around ‘participatory’ care which does not mean simply ‘patient visits’. Doctors will be reimbursed for ‘monitoring’ their overall practice population and will receive incentive payments for agreed-upon, desired outcomes. Since payment to providers will not be based solely on office visit charges, there will be greater incentives to communicate in other ways, including phone, e-mail, text messages and social media. This is the model that is evolving in the US.
For participatory medicine to gain a major foothold, patients will need to receive guidance as well as tools, information, and data that allow them to be active participants in their care and work effectively with their providers to determine the care they receive. In addition to engaging in online research about their health and their medical conditions, patients will need to network with online communities to discover which treatments, providers, and facilities work best to address their condition.
Through the encouragement of their providers and the network effect of communicating with other engaged patients, they will have to become more cognisant of their responsibilities toward maintaining their health and will more completely understand their medical conditions.
This will become more feasible as home monitoring devices, patient health data visualisations, and associated medical costs become routinely available. Patients should also be able to participate in group visits to gain a greater understanding of their illnesses and to provide stimulating interaction with the provider team and patients with similar conditions.
‘Care anywhere’ model
As providers increasingly adopt electronic communication options, clinical care will shift to a ‘care anywhere’ model. Hospital visits will become much less important and less frequent. Most routine follow-up, medication refills, review of blood pressure, adjustment of medications, and other former hospital-based interactions will become routinely conducted online, rather than in a hospital environment.
Hospital visits will only be necessary when a hands-on examination, patient-centred, more convenient, and will lower barriers to care. These electronic methods of communication may include e-mail, web-based secure messaging, videoconferencing, mobile phone conversations, text messaging, and instant messaging.
It will be commonplace for doctors to give patients a business card at each new patient visit which may include the doctor’s e-mail address and/or mobile phone number, along with an invitation for the patient to follow up using one of these channels. In addition, office nurses and other staff will often follow up with patients after encounters, either electronically or by phone, to assess progress and learn whether there are any questions or complications.
Services such as E-Consult already offer this. Patients and providers will increasingly adopt the notion that follow up and repeated communication is the norm and that it serves as the best means of achieving optimum outcomes, avoiding diagnostic errors, and obtaining high quality healthcare at the lowest price.
Provider-patient relationship
Although the ‘new model’ will rely less on the hospital visit, some face-to-face encounters will still be necessary to establish and maintain a provider-patient relationship. Indeed, it will be very unlikely that such a partnership can be successful without the personal, human interaction that occurs during an office visit – and these will remain periodically necessary and beneficial. There will always be a subset of patients who, because of personal preference or special needs, will be best cared for by coming to the office.
Sri Lankan hospitals today find it difficult to differentiate themselves, other than by the specialities they offer. To date there is no external body to rank hospitals as is available in USA for instance. The Index of Hospital Quality (IHQ) reflects performance in three interlocking dimensions of healthcare: structure, process, and outcomes.
Examples factored into the Best Hospitals rankings include intensity of nurse staffing, availability of desirable technologies and patient services, and special status conferred by a recognised external organisation. Excellent healthcare also is shaped by the process of delivering care, encompassing diagnosis, treatment, prevention, and patient education.
Structure and process are related to outcomes, the most obvious of which is whether patients live or die. Outcomes are typically measured by risk-adjusted mortality rates (i.e., the likelihood of mortality given the complexity of the case) and, increasingly, related indicators such as complications, readmissions, and infection rates.
International medical tourism
A potential growth sector in Sri Lanka is international medical tourism. Whilst it is important to have certifications such as Joint Commission International, it is an evaluation and review of the non-clinical processes and services which is benchmarked against international standards.
Medical tourism certification is independent third party recognition that the hospital, clinic or service meets the international standard of excellence for care and services to international patients and medical tourists. By certifying the non-clinical operations, processes and protocols of the hospital, clinic or service, one is declaring to patients around the world that they can trust the relevant hospital to provide the high quality services and care management that promote good results.
Quality improvement
Quality improvement still is not part and parcel of most service organisations though it is one of the most critical factors in a manufacturing organisation. Lean/Six Sigma or Service Quality teams do not exist in the health sector in Sri Lanka as of today as a separate division. Whilst some of the hospitals are using international standards for quality, these are more related to patient safety standards rather than offering the customer a seamless experience. That offer of ‘delighting a customer’ in the health sector is not a concept which is used as yet.
Six Sigma techniques use a wide range of tools, to drill down on to ‘waste’ in the Service sector. Today one can say that 40% of an average process in a hospital is classified as waste – i.e. something that the patient would not pay for. This include waiting times for customers, time spent paying, time spent collecting medicines, time spent in getting the bills, time spent waiting for the doctor, etc. From the hospital’s perspective, it can be transport of medicines, waiting for cleaners, nursing staff, getting the relevant drugs to the rooms or operating theatres, etc.
The first step a hospital can take to offer customers a better experience is to drill down the number and type of service offerings and the average time taken for each. Surveys and quantitative and qualitative feedback from customers are a critical input. Six Sigma techniques focus on reducing variability of a product/service. However it can also be used to focus on cash flow for example, with the objective of improving the hospital’s cash flow.
Disruptive innovations
Disruptive innovations – such as online consulting with doctors – will involve totally new processes are also part of the re-design concept in Six Sigma. Unlike accounting or marketing, Six Sigma enables one to get a detailed understanding of the trends in the business and customer purchasing patterns, enabling the hospital to move in the right direction.
The healthcare sector in Sri Lanka needs to seriously consider using electronic means to build databases of customers with their records and usage of services, consider variable pricing, customer loyalty programs, and look at opening up services to the rural sector – as the majority of the population do not have access to timely medical services.
Preventative healthcare is developing and this is also an area to focus on with nutrition advice, fitness advice, etc., especially for the corporate sector, which is heavily dependent on the health of its workforce. Healthcare in Sri Lanka is evolving with customers changing their behaviour patterns and the hospital sector in Sri Lanka needs to be receptive to this and to see where they can add value to their customer and patient.
(The writer, a Six Sigma Consultant, conducts Six Sigma training for the Institute of Lean Management.)
