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Blue Ocean Strategy HealthCare Pakistan

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Review of an urban hospital (high density population) OPD processes and how value be created to support a patient experience

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Blue Ocean Strategy HealthCare Pakistan

  1. 1. 2017 MBA (RE): MSVI Zakir Ali Rizwe, Sayyed (20151-19131) BLUE OCEAN STRATEGY – LIAQUAT NATIONAL HOSPITAL This report is prepared in response to term project of the MBA course, MSVI delivered by Dr. Amir Saeed at the IoBM, main campus. The report is an excerpt on the Pakistan Healthcare Industry and focuses on devising a blue ocean strategy for admission, emergency & admission processes of Liaquat National Hospital. Exercise field work & details have been organized in a case-study format and follow the term-report rubric
  2. 2. Blue Ocean Strategy – Healthcare Industry: Insight to Liaquat National Hospital [1] Health play a significant role in building ‘human capital’. Only a healthy nation has the energy to upscale a country economic growth & lead it to sustainable prosperity. Pakistan is a developing Muslim majority country enriched with agriculture, geo planes, minerals, climate & natural resources. It stands as 5th most populous country with a 220 million population with an approximate symmetrical distribution of 49 men to 51 women (Mordor Intelligence, 2016). With an annual growth rate of 2% (compared to 1.24/max of its neighbors), it offers reasonable life expectancy (67 years) & carry 3.2% fertility rate (births per woman/2015) making it a nation enriched with human capital (Healthcare_in_Pakistan, 2016). With all appeasing credentials, Pakistan is also blessed with diversity, potential & talent. It is called the ‘land of doctors and engineers’; it pools 9th largest large educated (English speaking) workforce. On the economic front, its stock market for the last 2-years have outperformed global markets, its GDP risen from 4% in the year 2014 to 5.2% in the year 2017 from which 55% is & expected to be generated from Services (wikipedia, 2017). With a 3-year consistent discount rate, low inflation rate of 3.7%, moderate per capita income considering that almost 36% of economy is undocumented and 6.6% population below poverty line, Pakistan offer high industrial growth and remains progressively supplemented by the China-Pakistan Economic Corridor, resulting tourist influx to gear company economics through industrial evolution most notably in power, welfare, logistics, food, transportation & healthcare (The World Bank, 2016). Pakistan Healthcare Industry Pakistan healthcare industry has shown reasonable grown in services, treatment & technology even with estranged political, ethnic, religious & cultural differences under old colonial laws, bureaucracy, corruption & societal injustice. With all the challenges Pakistan still offer a ‘rich & resilient healthcare structure, expertise & experience’. Masses in Pakistan believe in different mode of treatment, including allopathic, homeopathic, herbal, acupuncture, HIJAMA & HIKMAT. This paper focus on allopathic healthcare industry for operating & surgery procedures, orthopedic, physicians, psychological, physical rehabilitation & focused/specialist treatments for injuries, infectious diseases, accidents, physical/mental trauma & epidemics. Healthcare delivery system includes state (government) and non-state (private) for profit & not for profit provisions. These entities include provincial & district health departments, para-statal organizations, social security institutions, non-governmental organizations and private sector establishments provide healthcare services (Healthcare_in_Pakistan, 2016). While government of Pakistan (GoP) continue to fund and/or subsidized health care programs; focus of this paper is on private sector health care services. Private sector continue to out-perform the less expensive, wide range, government funded public sector healthcare programs as awareness through e-media/social media and mass media campaigns have finally penetrated in lower middle, middle and upper middle class societies especially in urban population mix demanding improved service, hygiene with quality care and drugs for in-patient department and/or out-
  3. 3. Blue Ocean Strategy – Healthcare Industry: Insight to Liaquat National Hospital [2] patient/consultations department discourse commonly abbreviated as IPD and OPD services, respectively (The World Bank, 2016). Pakistan Private Sector (Allopathic) - Healthcare Industry Pakistan healthcare industry remain cognizant to urban-rural demographics where literacy (or patient awareness), services, delivery, technical facilities & acute shortage of trained workforce is a major concern. Pakistan, called the land of doctors, still face dearth of health managers, nurses, paramedics staff & attendants. Following key-points summarize position (Ali, 2016) 1. Compare to summer, health issues increase in winter; sector does not experience cyclical trends 2. Organizations provide employees health care benefits in form of panel hospitals/clinics, medical insurance & treatment disbursements. Whereas individuals continue to opt consulting, advisory, & OPD services using pay-as-required and few through medical insurance 3. Pakistan Medical Association, Dental Council & accompanying professional bodies control and role to connect, articulate & legislate the medical facilities remain inadequate because of outdated laws, bureaucracy & shortage of registered medicine practitioners and care staff 4. Key health care facilities are few and these too in major cities of Pakistan. To name a few, Shaukat Khanum Hospital & National Hospital in Lahore, Agha Khan hospital, Zia Uddin, OMI, South City Hospital & Liaquat National Hospital in Karachi 5. Semi government/ private sector health care facilities drive own initiatives, as well as partner public sector health & epidemic drives. 6. They offer better compensation, are more affluent in medicine research, employ professional work-staff, bring innovation to the life for patient/doctor/hospital service models Pakistan Healthcare Industry – Value Rising costs, expanding market demand and increasing customer dissatisfaction continue to characterize healthcare and redefine roles of patients, providers and payers in Pakistan Healthcare Industry. Simply put, the semi-government & private sector hospitals face a growing imbalance of supply and demand. The healthcare sector is expected to balance divergent needs of demographic segments, some of which will need to cope with all the diseases of the "modern western" world and others with issues, such as basic access to primary healthcare, public health engineering, disease surveillance and monitoring (Price Waterhouse Cooper, 2016). Industry Standards of Value:  Hygiene, ventilation, space, capacity & capability of the facility to investigate & treat patients under one-window/ facility operation  Cost of clinical procedure/ consultation/ advisory/ labor/ discharge services & non-clinical discharge - Is the procedure costing (more/less) compared to similar procedures conducted by other similar scale facilities  IPD readmission/ OPD revisit/ repetitive consultation frequency: Account for customer satisfaction/ loyalty/ need addressed plane  Permanent/ visiting faculty of doctors, surgeons, specialists, physicians and qualified trained nurses, RMO (resident-medical-officers), medicine house-job applicants  Brand reinforcing activities to make provider known; patient satisfaction through delivering prognosis, treatment & discharge services positively impacting brand recognition
  4. 4. Blue Ocean Strategy – Healthcare Industry: Insight to Liaquat National Hospital [3]  Available & true inventory of medicine, peripherals, supplies, vaccines, life-saving drugs. Ensuring that delivery & consumption chains optimize supply management without impacting operational margins Unlocking value, especially in urban pockets, would be key to healthcare facilities where customers are demanding and expect arrangements to facilitate care, experience & attention. Strategy Canvas – Pakistan Healthcare Industry Presented below is the AS-IS strategy profiling of semi-government/private sector Pakistan allopathic healthcare industry for facilities that house admission of at least 500 beds. The canvas highlight key factors Pakistan healthcare industry presently compete and invest, alongside perspective of customers (patients) and 1/Tier non-customers on how healthcare facilities define value. Healthcare Facility - Liaquat National Hospital Liaquat National Hospital (LNH) & Medical College is the largest private sector, tertiary care hospital serving the society since 1958. It started after the Red Cross Fete Committee, chaired by Syed Wajid Ali, raised PKR 0.8M through MEENA Bazaars organized under guidance of Begum Rana Liaquat Ali Khan, wife of the first prime minister (late) of Pakistan, Liaquat Ali Khan (Wikipedia , 2017). The committee established "The National Hospital" and laid the foundation stone on February 23, 1953 by his excellency Mr. Ghulam Muhammad, the Governor General of Pakistan. National Hospital was later renamed, as ‘Liaquat National Hospital’ in memory of late Liaquat Ali Khan, Pakistan first prime minister. 2 1 2 5 4 1 2 4 3 2 5 2 1 2 3 3 2 5 4 3 2 5 3 0 1 2 3 4 5 6 Transparency Out-of-pocketcost Apppointmentavailability Timewithdoctor Patientsatisfaction Reachability Waiting-time Treatment&Diagnostics IPD&OPDProvision Purpose-build Doctors/Physician/Surgeon Research PanelEngagements PaymentChannels Administration Compliance Litigations/Appeals Prognosis drugs/vaccine Transparency RepetitiveVisits Epidemic Hygene Price Availability Ease Facility Faculty Services Reg. Affairs Checkup Price Place Customer/ Patient Perspective Healthcare Industry Non-Customer (1-Tier) Perspective Strategy Canvas - HealthCare Industry Customer, Healthcare Industry & Non-customer Low Impact (1) to High Impact (5)
  5. 5. Blue Ocean Strategy – Healthcare Industry: Insight to Liaquat National Hospital [4] Liaquat National Hospital – Healthcare Facility LNH is a non-profit organization, started with 04 outpatient services and 50 beds, has now equipped with 700+ beds covering an area of nearly 53 acres with 30 medical and surgical specialties providing both inpatient and outpatient services and excel in providing advanced methods of diagnosis and treatment in nearly all clinical disciplines. It has the latest diagnostic, therapeutic & preventive healthcare facilities and is equipped with state-of-the-art advanced technology and fully-equipped operation theaters. Offer 24-hour emergency, pharmacy, laboratory and radiology services including nuclear medicine facilities (LNH&MC, 2017). LNH strength rest with its faculty, nurses and staff specialized in every aspect of medical care and continue to serve society housing around 25,000 emergencies, 60,000 inpatients and 260,000 outpatients under a one- window facility. LNH has a fleet of clinical departments (stated below), basic sciences departments (anatomy, physiology etc.), other services (academic council, medical education) & compensating facilities:  Medical & allied (cardiology, general medicine, oncology, neurology etc.)  Surgical & allied (accident & emergency, general surgery, ENT etc.)  Diagnostic (biochemistry, microbiology, radiology etc.)  Other clinical departments (pharmacy, occupational therapy unit, speech & pathology unit etc.) Education & Training - Liaquat National Hospital LNH offers residency training programs in most of the existing disciplines recognized by Royal Colleges in United Kingdom. LNH is also recognized for fellowship by College of Physicians & Surgeons Pakistan (CPSP). LNH started imparting medical education in the year 1978 and since then continue to expand in the following disciplines (LNH&MC, 2017):  Liaquat National Medical College o 5-year MBBS course recognized by Pakistan Medical & Dental Council (PMDC) since 2009. Program affiliated with the University of Karachi since September 2006, and can impart training to 100 students each year o National & international affiliations  Affiliated with Jinnah Sindh Medical University  Education Commission for Foreign Medical Graduates (ECFMG) USA  Foundation for Advancement of International Medical Education and Research  International Medical Education Directory (IMED)  General Medical Council (GMC) U.K  Canadian Resident Matching Service  Liaquat National College of Nursing o Established in 1981 and recognized by Pakistan Nursing Council for 100 seats o LNCON offer diploma in midwifery (since 1982), evening school of nursing (since 2004), Post RN BScN degree affiliated with Karachi University (since 2005) & affiliated with Liaquat University of Medical & Health Sciences (LUMHS), Sindh, Pakistan for Post RN BScN program (2-years) and BScN program (4-years)  Liaquat National School of Physiotherapy o Established in the year 1980 and recognized by University of Karachi for Bachelors in Physical Therapy (BSPT) & Masters in Physical Therapy (MSPT) effective from the year 1992 & 2005, respectively
  6. 6. Blue Ocean Strategy – Healthcare Industry: Insight to Liaquat National Hospital [5] o LNSOP scope of services include, outpatient clinics, admitted patients, women health, elderly care, rehabilitation of stroke & orthopedic patients, mental & terminal illness  Liaquat National School for Diagnostic Lab Sciences o In 1991, LNSDSL was recognized by University of Karachi for a 2-year post-graduate technologist training program. This program is only offered by LNH o In 2002, a 2-year program of BSc in Medical Technology program was started under University of Karachi that was upgraded to a 4-year international equivalency program in the year 2006 Patient Services - Liaquat National Hospital Patients (customers) services include (1) estimated treatment cost based upon nature of treatment, (2) surgical procedure and (3) admission duration for self-paying or private patients. Corporate/panel patients are serviced by the facility after necessary verification & validations through patient insurance health card, company approval letter presenting extent of coverage on OPD, IPD, consulting, diagnostics & surgical procedures. During admission, the patient receives services from well-rounded healthcare professionals to enhance care. The team include, (1) attending primary physician, other physicians consulted for additional and or co-existing diseases, (2) resident doctors, (3) fellows, (4) medical interns, (5) registered male/female nurses to plan as well as evaluate daily care, administer medications & treatment, and educate on discharge routines, (6) pharmacists who review medication orders & work with the team to assure optimal dosage & medication therapy, (7) clinical dietitians & (8) physiotherapists. Billing & Clearing of Patient - Liaquat National Hospital LNH billing department facilitate 24/7 payment processing for IPD/private patients whereas corporate patient clearance is managed under a B2B arrangement with insurance companies and claim processing with respective companies/corporations by a separate section under LNH/HIMS. For OPD, patients receive a separate invoice for every service. These services include consultation, any form of clinical diagnostics, day-care surgical procedures. Medical records are limited to IPD services include but
  7. 7. Blue Ocean Strategy – Healthcare Industry: Insight to Liaquat National Hospital [6] not limited to clinical summary, death & birth report (duplicate) with verification letter, duplicate discharge note from LNH/HIMS Department. The department furnishes the requirement after the patient file a request with supporting evidences (LNH&MC, 2015) Service Flow – Liaquat National Hospital In this section, LNH offered services are explained using a top-to-bottom process flow starting from the patient entering the facility, movement to OPD or emergency-response (ER) leading to possible discharge Or IPD followed by treatment, billing, payment and discharge cycle. It is important to note that LNH service different social classes however it also charges premium pricing. The issues presented, the 4-way action framework, buyer utility map and ERRC grid would be true for all patients serviced. LNH Key Challenges – Healthcare Services 1) Patient Entering LNH Facility a. No signage; making it difficult for a customer to timely route the facility b. Information counter is at a central, distant location from the parking space and the public transport drop point. Makes it inconvenient for the customer to reach-out support in quick time c. If the patient seeks an OPD service there is no way to determine the facility, Wajid Ali Shah Complex or J-Block and doctor traceability within. In addition, both OPD blocks are not adjacent and with no signage the task become harder 2) OPD Clinics a. Consultation i. Multiple invoicing counters with separate queues to charge consulting fee for the floor-wise distributed OPD clinics. As there is no information counter or an alternative mechanism to tell patients for: 1. Presence & occupancy of duty doctors & probabilistic waiting time 2. fees and counter to reach for invoicing service of an on-duty specialist 3. permissible time to issue any further OPD patient ii. No process, awareness or a channel to complaint for the long waiting time, less doctor attention, invoice generation & handling issues b. Investigation (Radiology & Laboratory) & Pharmacy i. Pharmacy available in only WAS/OPD facility; ii. Undue-work-process at the pharmacy counter where separate queues (with no information) to present doctor prescription & payment followed by other where the patient collects the required medicine iii. Doctor medicine prescription unaligned to formula/make of the drug available at the LNH pharmacy; this not only causes service delay but also result in customer deferring the order and move out to an outside pharmacy iv. Common laboratories are serviced by mobile counters within both OPD facilities v. Investigation involving radiology/MRI/x-rays are located at a different non- adjacent location, causing system, environment and process inconvenience vi. Counter at the location offer diagnostic invoicing & payment at different queue in a multi-window arrangement. This result in unnecessary patient queueing time, dissatisfaction and potentially, incorrect invoicing. Collection of reports are from a different counter without giving the patient a view on outcome of the run diagnostic
  8. 8. Blue Ocean Strategy – Healthcare Industry: Insight to Liaquat National Hospital [7] 3) Emergency Response (ER) a. Longer stay at ER (4-6 Hours, compared to max 2-hours) as investigations, diagnostic tests are done in place of respective wards. Result in over-occupancy of ER bed & further delay servicing other patients; increase waiting time b. Payment for ER & onward admission are done separately at different counters in advance. Payment for admission to ward/private-room is done at the same counter whereas accompanying details must be moved to the counter at respective ward. c. EMR (electronic-medical-record) is not completely implemented for admission data thereby and produce a MR (medical reference) card number is generated. Counters for the last 1-year are inputting the information in both, AS/400 and EMR application. Dual posting & incomplete implementation of EMR result in out-of-system approvals, notes, decision and information that has resulted in maintaining signed/stamped documents be carried by the customer and slippage may result in possible re-payment and cause delay in admission Four-Way Action Framework – Liaquat National Hospital The four actions framework works to break the trade-off between differentiation and low cost (Mauborgne, 2017). Red oceans strategies focus on either differentiation or low cost, whereas blue ocean strategies concentrate on both. Let's review the four actions briefly.  Eliminate: Remove factors that are no-longer required  Reduce: Move down less called-for services  Create: Come up with new factor to differentiate from competition  Raise: Move factors above industry standards Creating a blue ocean strategy for healthcare is less about what patients need and more about what patients don’t need. It’s about eliminating waste and removing what is not necessary or required for a healthcare interaction. The new value curve is created after making use of 6-Path: Exploration Outside Traditional Boundaries (Mauborgne, 2017). Referred herein is path-3/looking across chain of buyers where patient attendants/dependents have been focused, path-5/ transforming LNH emotional to functional appeal and path-6/ looking across time value of business  Signage & information booths (create): LNH facility with a wide clutter of operating blocks providing education centers, residential fixture, operating & treatment
  9. 9. Blue Ocean Strategy – Healthcare Industry: Insight to Liaquat National Hospital [8] facilities, diagnostic centers and OPD centers without signage, maps, directions & information booths leave customer disturbed and frustrated. Using spot kiosks with trained/resident staff, road map brochure, land-mark directions & distance in English/native language would not only enhance customer experience but also reinforce LNH brand for premier services, excellence & gratitude.  Information availability & transparency (raise): Doctor/physicians/dentist/specialist clinic block/room place, schedule, consulting charges, queue length alongside beds availability at ER, executive & private wards to be made available through a smartphone application.  Checkups, Investigation & Health Counseling (create): Through a smart-app, LNH to advertise executive services (as above) on pedometric applications, move-through notifications and healthcare campaigns to tract non-customers  Information counter (reduce): role of information counters to be limited for receiving & processing administrative actions and routine coordination  Paper work (eliminate): Patient history for used OPD, referred ER, IPD, treatment, diagnostics, laboratory tests, transcription encoding, clinical detail, billing & payment & all possible history delivered by state of art EMR solutions through a customer MR number. The resolve to replace the large historical data maintained for life by the patient and reduce physical retention of record at the facility resulting in not only process optimization & transparency but also free space, reduce stationary expenses and physical retention of records and reduce overhead costs  Waiting time in OPD/ER (reduce): optimize inter & intra processes, less administration and timely processing  Patient IPD service package & price flexibility (raise): services extended to be marginalized through need assessment and patient/attendant acceptance. Create transparency in billing and expedite invoice payments. Part of admission counselling  Monitor doctor patient engagement (raise): patient satisfaction is driven on doctor attention, behavior and time. Improving the ambiance & support of the facility would do less if this key attribute is not addressed. A smart app to objectively record customer feedback on OPD & IPD doctors time & behavior and use the information to improve facility care scale ERRC Grid – Liaquat National Hospital Eliminate-Reduce-Raise-Create (ERRC) grid is a simple matrix like tool that drives companies to focus simultaneously on eliminating and reducing, as well as raising and creating while unlocking a new blue ocean (Mauborgne, 2017). Eliminate Paper work Reduce Information counter Waiting time in OPD/ER Raise Information availability & transparency Patient IPD service package & price flexibility Monitor doctor patient engagement Create Signage & information booths Checkups, investigation & health counselling
  10. 10. Blue Ocean Strategy – Healthcare Industry: Insight to Liaquat National Hospital [9] Buyer Utility Map – Liaquat National Hospital The Buyer Utility Map, assist managers to think from a demand-side perspective. It outlines all the levers companies can pull to deliver exceptional utility to buyers as well as the various experiences buyers can have with a product or service. This mindset helps managers identify the full range of utility spaces that a product or service can potentially fill. It has two dimensions: The Buyer Experience Cycle (BEC) and the Utility levers (Mauborgne, 2017). Six-stages of Buyer Experience Cycle Six Utility Levers Purchase Delivery Use Supplements Maintenance Disposal Customer productivity Simplicity Convenience Risk Fun & Image Environment Friendliness Pakistan healthcare industry compete on patient facility use (higher OPDs/IPD/diagnostics/lab/filed ER) and is heavily burdened by socio, litigation & compliance barriers that translate service purchase a risk-filled engagement in which both parties press to underdog the others through not servicing, coerce and legal means.
  11. 11. Blue Ocean Strategy – Healthcare Industry: Insight to Liaquat National Hospital [10] The envisaged utility map takes in to purview an open, customer competitive and less bureaucratic health care facility excelling on its simplicity of operations, improved convenience and environment friendly use of its services. Strategy canvas of LNH mark key factors (limited view) starting from a patient entering the facility for a service, ER, OPD services, investigation & IPD admission. It does not important topics including payment channels, claim processing, bio-medical technological details, prescription encoding, research, education, medical forensics & surgical audits. Hurdles in Strategy Execution – Liaquat National Hospital Had a detailed discussion on hurdles in implementing this blue-ocean strategy at LNH with Mr. Amjad Rizvi, managing Admissions & Home Health Services. Same is summarized below  LNH has a diverse mix of customers from all pockets of the metropolis of all social classes. Significant portion of the customers are from lower to lower middle class who are neither service sensitive nor adequately versed or literate to distinguish service. On the same end, LNH with the founding charitable structure after 6-decades of medical service find it hard to realistically place itself as o an entity providing health services to masses irrespective of the cost it incurs o or a premier priced facility providing healthcare to middle & upper class customers  This dichotomy remains a big challenge for LNH to implement value innovation.  This can be witnessed unequivocally at LNH that at one end is investing heavily in education, training, research, symposium, executive wards, state of the art facilities, parking space but on 0 1 2 3 4 5 6 Patientsatisfaction Waiting-time Treatment&Diagnostics IPD&OPDProvision Signage&Informationbooths Doctorfeedback Checkup&healthcounseling Administration ElectronicMedicalRecord Paperwork Transparency Ease Facility Operations Price Raise Reduce Create Create Create Raise Strategy Canvas - Liaquat National Hospital Low Impact (1) to High Impact (5) Red Ocean Blue Ocean
  12. 12. Blue Ocean Strategy – Healthcare Industry: Insight to Liaquat National Hospital [11] the same facilities find itself constrained to adhere & implement the already made investments in technological advancements such as EMR (electronic-medical-record), standardize medical encoding, payment channels & human capital  Executive ownership is yet another factor in driving value innovation to sustainability. LNH governing body and serving directors are geared-up for constructive change delivering competitive advantage however the teams/departments below are in absolute need for a significant cultural revive to put meritocracy ahead of bureaucracy, standard ahead of practice, act of excellence not an occurrence but a habit to transform accountability to the next level of medical professionalism  Change management is both a resource challenge & a process challenge that has its stake for digitization, transformation & automation. The cultural change must be lived by LNH to transpire action by visiting faculties, doctors, interns, RMOs & nursing fraternity  Political, socio-political, ethnic, religious & legal challenges are areas to undertake to make ER and admission process transparent, candid and connected  EMR implementation and speaking ahead, EHR (electronic-health-record, providing cross facilities medical record) would require simplified processes to deliver the expected productivity and advantage. Making all corners connect, integrate and process data-on-wire with a higher correct processing rate is the challenge However, Mr. Rizvi was of the view that change is inevitable and referred the adjacently located AKUH healthcare facility as a true example as how investing ahead of time made the facility today years ahead of LNH and all other contemporaries. Stressed that competition is growing, and digitization, mega health trends shaping our world today, growing bio-tech genetic engineering achievements would soon be calling shots on healthcare facilities & doctors to provide other than routine treatment engagements and at the time only those facilities would sustain who have started investing in future today.

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