THE STORY OF CARE
(Paraphrased from Vice Chairman Dr N Krishna Reddy’s talk on “Sharing the Purpose and Vision” on November 16, 2014.)
CARE Hospitals, as an organization, began in 1997 but the conception of this institution building began much earlier – in the ’80s and early ’90s. Just as a child carries the genes of both the parents, an organization carries the DNA of the founding members whose principles, ideas, beliefs and passions form its core. As the organization grows, a lot of people join and a lot of people leave. But the core principles must be preserved, as we keep adapting to changing circumstances. Every member of the organization must carry these principles forward, work towards them and point out where they are being violated. If all 6000 people working in CARE share the same vision, people won’t have any misunderstanding or misrepresentation – they will know exactly what the organization is for.
Non-negotiables: Quality, Cost, Access
In the days of the Nizam, Dr Soma Raju fostered a concept of people working in teams, not at conflict with each other, but all of them working with passion towards a single purpose. That was the first DNA of CARE. That single purpose was that we are caring for the patient, be it teaching, research or education. Did the patient get the best that is possible in the given circumstances?
The three basic objectives, right from the beginning, were: Can we give safe care? Can we make the patient feel safe? Can we make it effective in terms of outcomes, in terms of the quality and what the patient experiences? So quality and safety were the key objectives initially.
The next objective was at what cost can we give it, can we give it at a cost which the patient can afford? Can we refuse patients a life saving procedure because they can’t afford it? Can we do something to optimize the cost of care for the patient and the cost of delivering that care?
The third element was: Can we make it accessible to more and more people – socially or economically or geographically can we enlarge the access?
These were the three core objectives when we began the journey – Quality, Cost and Access. As we evolved, to serve the same objectives we evolved into multiple enterprises – CARE Foundation, Andhra Cardiology Associates, Relisys and CARE Hospitals. In 1995, Andhra Cardiology Associates began and was a first in the country, in terms of bringing professionals together and working as a seamless team.
In 1996, we founded CARE Foundation. It was a kind of serendipity! At that time, we were working on developing the indigenous cardiac “Kalam Raju” stent, because Dr Kalam asked why are we spending 5000 dollars for a simple stent? Why don’t we use the defence research establishments and other research establishments? If it costs 5000 dollars, can we do it in 5000 rupees?
These were simple beginnings. It may have appeared that we are doing some crazy things and there was no link between what we were doing, but the purpose behind each activity was the same three objectives – Can we improve the quality? Can we reduce the cost? Can we improve the access?
A Serendipitous Grant
CARE Foundation was founded because there was a fund available from the Government of India routed through ICICI Corporation (now ICICI Bank). We were working on a modern healthcare delivery model, wherein we were trying to optimize the quality and reduce the cost. If you are doing an angioplasty, what is the best cost you can give it at? Most efficient, safest, with the best outcomes. The second was can we develop own indigenous technology? The third objective was to create an ecosystem for such things in the country, because there was no ecosystem.
When we presented to the ICICI, the theme was “Can we be a model healthcare system, where we try to nurture our own ecosystem?” The seeds of the vision for CARE organization were right there though it was vague. We put our thoughts into a concept note and asked the ICICI for about three crores. The vision was unrealistic; in fact, the dream was so big that we wanted to create a model institution. The ICICI understood the scope and scale of the vision and sanctioned double than what was initially requested for, that too at the interest rate of 1% per annum! So, that needed an organization as a platform. That is how CARE Foundation came into place, it is the mother of the CARE Group.
CARE is Born
From there we started our journey of building our dream institution. At the campus in Shamirpet, 40 km away from the city, we used to go there at 3-4 o’clock in the morning to do the procedures, come back and start the OP and emergency in the city center (Mediciti, ex-Sarovar Hotel). We had started our journey with converting hotels into hospitals, another interesting component of CARE. Subsequently, we left Mediciti and, on the strength of the ICICI fund, CARE Hospitals was born in Nampally in 1997, on June 27th.
On the first Sunday of June 1997, some of us went at night to see the building. It was Sampoorna Hotel, converted into ABM Hospital. On the second Sunday, negotiations were held with the owners of ABM Hospital. On the third Sunday, we signed the agreement. On the fourth Sunday, we started the organization – CARE Hospitals. It was just like labour, delivered in a big rush! We started the ICCU on that day, by evening it was full, because people had trust in the group and what they believed in, especially the emphasis on patient care. Within one month, cardiac surgery, the first surgery was done in Nampally. Efficiency was there because there were no rules, no processes, no systems; everything was just energy and passion to do something urgently.
In 1995, the Cardiology Associates came into the picture, in 1996 CARE Foundation was set up, in 1997 CARE Hospitals was set up. By 1998 we had established CARE Polymed Limited, basically to carry forward the success we had in developing the cardiac coil stent, named after Dr Soma Raju and Dr Abdul Kalam, the Kalam-Raju Stent. Each of these enterprises subserves the same objectives. CARE Foundation is trying to model the outreach delivery models in terms of access and also focusing on education. CARE Hospitals’ focus is on tertiary healthcare delivery and CARE Polymed, renamed later as Relysis Medical Devices, focuses on indigenous device development.
In the beginning everybody knows what they are doing because everybody follows the same values, everybody knows the purpose without making a purpose statement. We never had a purpose statement or a vision statement. It was intuitively understood that this has to be done for the organization to grow. It is important to review what we believed in the beginning and if we are wavering from that?
Our Core Ideology
Hence, in 2013, we deliberated and involved more people to crystallize what the organization stands for. It led to certain sentences to symbolize and conceptualize very powerful statements that communicate the entire philosophy of the organization. Great institutions have a core ideology, from which they never waver. They stick to it and continuously communicate that ideology.
Core ideology has two elements – the core purpose and the values that you believe in. First, what values do we really believe in? If there is any violation, each one of us has the responsibility to bring the organization back onto those values. The second is the core purpose, the WHY of our organization, why we exist. This core ideology remains constant, though the vision may change every 10 or 20 years, in response to changing circumstances. Our mortality meetings or clinical audits or transparent discussions are some elements which define and characterize CARE.
Continuous working towards quality and affordability is the key. We need to be consciously aware of the fundamental founding principle and the value on how to make it as affordable as possible. That has to be a continuous, driving principle.
Right Practice of Medicine
When society is going in a wrong direction, we reaffirm the principle: Are we violating the interest of the patient? Are we interested only in our money and business? To keep the interest of the patient above our own cannot be re-emphasized enough. It is our responsibility to not only believe this, but also transmit this belief to the people working with us, so everybody will work towards the patient’s interest.
This is in the context of the patient. In the context of medical professionals, the second theme was “to practice medicine as it should be practiced”. You must have the ethos of a medical professional, compassion and love towards the patient. We have always believed in these things.
Many academic institutions lose the best talent when people reach their peak performance in their late 40s and 50s. We must have that intellectual stimulation, the satisfaction of teaching a student. The best professionals are attracted to an organization where there is a culture of learning and training. We need people who are stimulated not by money, but by continuous learning or ability or an opportunity to teach a student the right practices.
This organization gives a different advantage, the advantage of teams. Which other hospital has specialists sleeping in the hospitals 24×7? You can go back home, confident that your patient will be taken care of. That is the advantage of an academic medical center. In an academic medical center, every decision – an echo, an angiogram, an angioplasty – is peer reviewed by an equally competent colleague, which is essential to ensure that you are on the path of correct medical practices.
To Provide Care That People Trust
Once we realize all these things, it becomes very straightforward to state the “why” of an organization, the purpose. Once we understand the purpose, “where” we want to go is the vision and “how” we realize that dream to take the organization to a particular position. This simple sentence crystallizes the purpose of the organization, “To provide care that people trust.” The two simple, most powerful words are ‘care’ and ‘trust’. ‘Care’ means a type of care that we are promising the people. The ‘trust’ comes when you honour and uphold that promise, that you want it to be the safest care, the best outcomes, as affordable as possible and as timely as possible.
It is not simple to state this purpose, unless we walk the talk and give the type of care we want to provide. When we claim that we are the most cost effective, it does not mean cheap medicine. Cost effective is if a hundred patients come with chest pain, at what cost per person are we able to give the best diagnosis, the best outcomes, the most cost effective, the most efficient in terms of processes and the safest. The trust builds only when you honour this commitment.
WHO Healthcare Guidelines
The World Health Organization says that every healthcare provider has to give this type of care. Anybody who wants to work in a healthcare organization has to believe in this type of care – safe, effective, efficient, affordable, timely, accessible and sustainable.
Affordability is another issue. Suppose a poor patient comes and he can afford only Rs 5000 for an angioplasty or for a bypass surgery or a rich person says I can afford anything, even Rs 5 lakhs, we should not differentiate. At the same time, we must be aware of our responsibility for the financial sustenance of this organization, wherein we ensure that the organization gets its break-even cost. Right from 1993 or the early nineties we have been doing it. We strive to make it possible so that the patient gets care, especially if it is life saving care. Don’t refuse somebody, rather develop the system. As an organization, there are other methods to make it sustainable.
Vision of CARE
The next question is where do we want to go, where do we want to take this organization, what do we want to be in the future? When we presented to the ICICI, the vision was that we wanted to create a model institution, a model for global health. The trust factor is already stated in the purpose. Integrated is in terms of the academic medical integration, that means integration of healthcare delivery, education, training, research and development.
Another element of the vision statement needs elaboration, ‘healthcare systems’. We think we are a chain of hospitals mainly focused on tertiary care. But medicine, globally, is going in a different direction, especially because of cost issues and changing disease patterns. Most of these diseases are lifetime diseases, which means patients require a continuity of care, a care continuum. More and more disease will be managed out of hospitals, at the community level. For that you need not just a chain of hospitals, but a network of healthcare delivery systems, at the secondary, primary, home and individual levels.
A Continuum of Care
The vision is to evolve this organization into that type of network system so that patient care is administered in a continuum. When the patient comes to you, you become responsible for the care of that patient, whether in or out of the hospital. So that is the future vision for this organization – a network system.
You can train a healthcare worker, because now the technology, the point-of-care diagnostics and the monitoring systems at the point-of-care all permit this, without losing the basic standard of care.
There is nothing wrong about dreaming big. If you don’t dream big, you can’t grow. President Kalam used to say that you should dream, but dream with your eyes open. Don’t dream with the eyes closed because the moment your eyes open, the dream disappears. When you have a dream with eyes open, you are dreaming continuously, you are seeing your organization there.
The vision looks very ambitious and unachievable in our lifetimes, but we are not building this organization for 5 or 10 years. The purpose is that we have to build this organization to last a hundred years. It is important that all of us make it sustainable, without compromising on the fundamental issues of patient care, safety, quality and outcomes.
Missions Levers of CARE
To achieve this vision, we need to crystallize the five mission projects. Mission means a goal post. We have stated five missions – Mission 20:20:90, CARE Process Reengineering, Employees First, CARE Continuum and Learning Organisation.
Mission 20:20:90 – This basically has two objectives – 20:20 is to make the organization sustainable. It is an economic objective of what is the margin required to sustain it.
The 90% score is ultimately what the patient experiences. He won’t say what is my best outcome, or CARE is the safest or its success rate is 100%. What matters to him is how his experience is, right from entering the gate… how challenging is it to park his car, register himself or find the canteen or the toilets. While excellent clinicians are giving the best care, these are the things which make the patient’s ultimate experience. When you score on various parameters – experience with nursing care, technical care, food, cleanliness, everything is summated as an ultimate score of what is called the Net Promoter Score (NPS). What needs to be done to reach 90%, make a plan – find the gaps, fill them and continuously monitor.
CARE Process Reengineering – This has been going on for 2-3 years. Business process reengineering means optimizing managerial systems and processes. Now, some hospitals in the US are taking up clinical process reengineering exercises. It is about steps and processes being streamlined so that the patient gets the best experience, the best outcomes, the lowest risk and the lowest cost. We must persevere in this, because it is a long journey.
Employees First – The third mission is it is not enough to say patient first or patient centric. The people who take care of the patients are equally important. As a group, we must do justice to the people working in the organization and provide them the best facilities they deserve. In mission mode, there is sensitization that can we do something for our own people because if my employee is happy, he/she will make the patient happy. Each one of us can do something at the department level, unit level or organizational level.
CARE Continuum – The fourth mission is in terms of the vision that is evolving into a model healthcare system, not a chain of hospitals but a model healthcare system, with care continuity at the community level.
Learning Organization – The final fifth mission is can we transform this organization into a truly learning organization. We are far better than many hospitals in terms of education, training, research but it must be made a culture.
Right Values & Practices
To re-emphasize the values of the organization (honesty & integrity, teamwork, empathy and compassion, education, citizenship, equity, dignity & respect), because this organisation wanted to create a platform where people can practice the right values, right practices. We are a different organization; we should be proud to practice on this platform and sustain it because the world needs such platforms. One of the values, which the Chairman repeatedly emphasized, is the lack of equity, not equality.
Hope everyone working at CARE is clear about the purpose shares the same vision and cooperates in executing these missions. Each one of you has a role to play in realizing all the missions. Your whole-hearted participation is essential so that the missions succeed and we realize our vision.