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SUHRUTA KULKARNI, KRIPA MAKHIJA AND U DINESH KUMAR

APOLLO HOSPITALS: DIFFERENTIATION THROUGH HOSPITALITY The ‘‘wow’’ factor in service relies on constant innovation and demands continuous and sensitive focus on all issues that may affect the patient’s stay in a hospital. Every touch touch point of the th e hospital needs to be ‘‘alive’’ and the client must be able to feel feel the warmth offered. The culture of of service is imperative in today’s scenario, where the differentiators could just be the manner in which services are offered. All the major players could replicate infrastructure within a short span of time, but not the the service culture. culture. Dr. Umapat Umapathy hy Panyala, Chief Executive Executive Officer, Apollo Apollo Hospitals, Bangalore Bangalore (March 2013) Dr. Panyala, CEO, Apollo Apollo Hospitals, Bangalore believed believed that in the future, the hospitality aspect aspect of hospitals—the service provided provided to patients—would patients—would differentiate Apollo Hospitals Hospitals from a large number number of equally competent competent competitors competito rs in the growing Indian healthcare industry. industry. He had h ad set up a quality department at the Apollo Hospital in Bangalore, headed headed by Dr. Ananth Rao. Rao. Apart from being an expert on Metabolic Diseases Diseases and Biochemistry, Biochemistry, Dr. Rao was also a Lean Lean Six-Sigma black belt from the Indian Indian Statistical Institute, Chennai. Chennai. You can’t manage what you don’t measure—although this may sound clichéd; I am still a firm believerr of this believe t his philoso philosophy phy and an d want to apply this, espec especially ially in the hospitality h ospitality part of hospitals. Clinical benchmarking is a compulsory requirement and is taken care of; however, patients have so many other touch points in their stay at hospitals—the hospitality part. Some of the world-class hotels (such as the Ritz–Carlton) have performed benchmarking to standardise their hospitality offerings; at the same time, its employees are allowed to use their judgment to provide whatever 1 delights the customer in every visit. We want to internalise this in our culture as well. – Dr. Ananth Rao, Rao, Head–Quality Head–Quality Department, Department, Apollo Hos Hospital, pital, Bangalore (March (March 2013) Dr. Rao also believed that the hospitality aspect would differentiate Apollo Hospitals from its competitors. Patient cure and care played very important roles in hospitals. Many patients were generally anxious when when in a hospital and the sense of disservice disservice increased their anxiety level very easily. Integrating healthcare healthcare and hospitality was essential essential for creating patient-focused care. Hospitality aspects included a smooth admission procedure, friendly medical and non-medicall staff, comfortable furniture, varied choices non-medica choices on the food menu, attractive surroundings, surroundings, recreational recreational 2 facilities, privacy, clear signposting, adequate provisions for visitors, and so on. Important aspects of hospitality were managed by the nursing staff and other non-medical staff, staff, which meant inherent variability variability of service owingto human interventio interventions. ns. Dr. Panyala and Dr. Rao wanted to measure measure the hospitality aspects at Apollo Hospitals Hospitals and improve hospitality to create a world-class hospital. Dr. Rao and his team collected feedback every day from the patients and received a number of complaints, ranging from not having a TV remote to long response time on the part of nursing staff in attending to requests from patients. For Apollo Hospitals, it was important that the patients’ experience in the hospital was not compromised, since it could have a significant financial impact. Managing the hospitality elements of the hospital was as important as managing the clinical aspects. Apollo Hospitals had a stringent process in place to take care of clinical aspects. Dr. Rao wanted to improve the hospitality at Apollo Hospitals by reducing the 1

Harvard Business Review Review,, 2009, 1–9. Hall, J. M. M. and Johnson, M. E., When should should a process be art, not science, Harvard Hepple, Hepp le, J.,Kip J.,Kipps, ps, M. and Thomson, J., The concept concept of hospitality hospitality and an evaluation evaluation of its applicabilit applicability y to the experience of hospital hospital patients, patients, International Journal of Hospitality Managemen t, 1990, 9(4),305–318. 2

Suhruta Kulkarni, Suhruta Kulkarni, Krip Kripaa Makhij Makhijaa and U Dinesh Kumar, Professor Professor of Quantitative Quantitative Methods and Information Information Systems, Systems, prepared this case for classroom class room discuss discussion. ion. V Sandeep assisted assisted in data collection collection and analysis. analysis. This case is not intended intended to serve as an endorsement or source of primary data, or to show effective or inefficient handling of decision or business proce sses. Copyright © 2013 by the Indian Institute of Management Bangalore. No part of the publication may be reproduced or transmitted in any form or by any means – electronic, mechanical, photocopying, recording, or otherwise otherwise (including internet) – without the permission of Indian Indian Institute of Management Bangalore.

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number of complaints from patients; he also wanted to achieve significant improvement in sigma levels measured through the Six Sigma performance scale. According According to Dr. Ananth Rao: The immediate challenge is to understand the patients’ sentiment towards the h ospitality provided provided and to design a process improvement plan that is affordable. Apollo takes feedback from patients every day and the quality department staff interviews many patients every week to understand their needs. Dr. Rao was aware that improving hospitality at Apollo Hospitals was going to be a continuous exercise in improvement; improve ment; collecting feedb feedback ack was one way of appr oachi oaching ng the process of continuous improvement. improvement. He treated every complaint as a “defect” and planned to use lean Six Sigma concepts to eliminate defects. Implementing Six Sigma in all departments was likely to be be a challenge since departments such as housekeeping housekeeping faced high attrition rates. His immediate objective objective was to introduce a system where future complaints related to hospitality hospitality could be reduced.Also, how much importance should be given to hospitality by Apollo Hospital was one of the dilemmas faced by Dr Rao and he wanted to set a realistic target for Sigma level level in hospitality at Apollo.

APOLLO HOSPITALS: THE TRENDSETTER Dr. Prathap C. Reddy, Reddy, founder of Apollo Hospital Enterprises Enterprises Ltd. (AHEL) had accomplished a successful successful medical career in the United States. He returned to India in 1972 to contribute to the healthcare system in India. Health infrastructure in India was very poorly developed in the 1970s. In 1971, there were 3,862 hospitals and 12,180 dispensaries with a total of 348,6553 beds for a population of 548,159,6524 —a ratio of 6.36 beds per 10,000 people 5 6 as against the ratio of 9 beds per 10,000 people in 2011. India’s first National Health Policy was declared in 1983, almost 36 years after independence, which was an indication of the neglect faced by the health sector in the country since independence. Dr. Reddy had set up a good medical practice in India and used to send patients outside the country for specific treatments. However, However, in 1979, a young patient died as he could not arrange the money for for treatment in the United States. Dr. Reddy then decided to provide the best of medical treatment from the West to patients in India with an emotional touch, calling it “High Tech with High Touch.” Apollo was a doctor-promoted enterprise—10,000 Indian doctors, 4,700 U.S.-based U.S.-based doctors, and 60 doctors from the United Kingdom investe invested d approximately USD USD 5,000 to start the venture. Dr. Reddy selected the best of the talent available to ensure the best possible service and care. He also ensured that a clear distinction was maintained between business management and clinical 7 management. Apollo pioneered world-class healthcare in India, which was later emulated by several other hospitals. Apollo focused focused on technolog technological ical excellence and garnered many firsts to its credit in the country. Apollo was the first not only in India but also in South Asia to launch Oncological Robotic Surgery, G4 Cyberknife Robotic Radiosurgery System, 320-slice computed tomography scanner, 64-slice positron emission tomography-computed scan system, full-field digital mammography with tomosynthesis, and many such technologies.8 According to Dr. Rao, Apollo intended to carry forward technological excellence in hospitality to provide patients with the best cure and care services. Dr Preetha Reddy, Reddy, Managing Director, Director, Apollo Hospitals Hospitals Enterprises Limited has been been the pioneer and chief chief architect of the tender loving care –TLC ‘‘mantra’’, ‘‘mantra’’, a pillar of the Apollo way, which is affectionately affectionately applied to every patient at Apollo Hospitals. “The patients and staff comprehend this language better,” she points out. The 9,10 concept of TLC integrates service delivery with clinical outcomes resulting in exceptional patient experiences .

3

Background Papers: Financing and Delivery of Healthcare Services in India, National Commission on Macroeconomics and Health, Ministry of Health and Family Welfare Government of India, 2005, p. 47. 4 Source: http://cyberjournalist.org.in/census/cenpop.html, accessed on March11, 2013. 5 Source: http://www.globalhealthfacts.org/data/topic/map.aspx?ind=78, accessed on March11, 2013. 6 Health Research Policy, Indian Council of Medical Research, New Delhi, (October 2007). 7 Mitra, M., The Apollo Mission, Corporate Dossier with The Economic Times, Times, Jun Junee 1, 2012 2012.. 8 Apollo Investor Presentation, www.apollohospitals.com, accessed in January 2013. 9 N Amarnath, and D Ghosh, The Voyage to Excellence: The Ascent of 21 Women Leaders of India Inc., Inc ., Pustak Pustak Maha Mahal, l, pp. 80-95. 10 http://www.apollohospitals.com/apollo_pdf/dr_preetha_reddy_managing_director.pdf

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CLINICAL BENCHMARKING Apollo Hospitals had been using a clinical score card called ACE@25 (Apollo Clinical Excellence), which measured and monitored clinical excellence among the group’s hospitals. ACE@25 measured 25 clinical parameters (Exhibit 1) every month, which were benchmarked against global standards. ACE@25 was launched on September18, 2008 and used across 32 hospitals of the group. Clinical benchmarks were published by various institutions and bodies such as Cleveland Clinic, Mayo Clinic, and National Healthcare Safety Network (NHSN), among others. Hospitals were grouped according to their bed strengths, locations, services offered, and so on. Group A hospitals had to report 25 parameters—23 were common parameters, while two were location-specific. Group B and Group C hospitals had to report 15 and 10 parameters, respectively, out of which two were location-specific. ACE@25 was an internally developed clinical scorecard, created by drawing upon the wealth of expertise a vailable within Apollo. An audit committee at the corporate level was set up to validate the data, methodology, and definitions followed at each location. According to Sangita Reddy, Executive Director, Apollo Hospitals Group: We needed a yardstick like ACE@25 that would pit us against international institutes like Cleveland Clinic, Mayo Clinic, and others, and position us on the global healthcare firmament for excellence in clinical quality. This also enables us to assess where we stand and where we need to 11 be, while pursuing excellence in clinical quality. Apart from this internal benchmarking exercise, seven of Apollo’s hospitals were accredited by the Joint Commission International (JCI); and it was the largest group in South Asia to be accredited by the JCI. The JCI was a U.S.-based accreditation body dedicated to improving healthcare quality and safety around the world and recognized as the gold standard for hospitals. Apollo was also accorded the Superbrand status by the Indian Consumer Superbrands Council, which recognised that the best practices were used in the brand. Apollo was the 12 only hospital that was accorded the Superbrand status in India. There were other accreditations that several Apollo hospitals had achieved (Exhibit 2). According to Dr. Panyala, Living the brand should be our focus in every initiative or activity we perform. Apollo Hospitals has been one of the consistent names among the Superbrands. The perceived value of a brand like Apollo Hospitals is set very high in the backdrop of the decades of service and excellence it has offered. Clients need to see and experience that value, and the gap between perceived value and obtained value must be zero at best or at a bare minimum.

PATIENTS’ FEEDBACK AND REAL-TIME ACTION On average, a patient spends 80% of the time in hospital for the care part rather than the cure, and we need to focus on care to ensure speedy recovery and maximum satisfaction. Hospitality is critical in healthcare as the patient and his/her attendants are already distraught and highly anxious. Hospitality is driven mainly by human interventions—in nursing, housekeeping, as well as food and beverages. It is very difficult to ensure consistency of quality and hence, we want to benchmark these to ensure we provide the best quality of hospitality all the time. –Dr. Ananth Rao, Head–Quality Department, Apollo Hospital, Bangalore (December 2012) Dr. Rao believed that although clinical services formed the core of Apollo’s services and brand image, hospitality would support the brand, and in the long run, both would merge to form the Apollo brand (as shown in Exhibit 3). All services that did not require core clinical expertise were classified as hospitality services, including services such as billing, dietician service, food & beverages, facility, housekeeping, nursing, facility, and overall operations. Each service was executed through a variety of processes. All the processes included in each service were identified and defined with regard to the procedure, timelines, required output, and so on. All the processes were mapped and the quality measures defined; these would be used as Sigma metrics. 11 12

Express Healthcare, (2010), http://healthcare.financialexpress.com/201009 /strategy01.shtml Source: http://kolkata.apollohospitals.com/newsroom/271-apollo-hospitals-only-healthcare-super-brand-in-india.html

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The Quality Department, established under the leadership of Dr. Rao, comprised two dedicated staff—Soumi Dutta and Nisha Maria—who looked after a variety of quality-related issues. Soumi and Nisha collected feedback from the patients between March 2011 and December 2012using the form presented in Exhibit 4. Patients were asked to r ate each department on a scale of 1 to 10. Additionally, open-ended feedback such as patients’ comments, opinions, or suggestions was also collected. A schedule was developed for collecting feedback, which ensured that Soumi and Nisha collected feedback from a cross-section of patients; this also ensured that no biases crept into the feedback. The feedback collection methodology is shown in Exhibit 5. Soumi and Nisha were trained to collect frank, free-flowing feedback from the patients. If they received complaints while collecting feedback, they would immediately inform the department concerned and get the errors rectified, whenever possible; or ensure that the complaints were addressed to the patient’s satisfaction in real time. One of them recollected the following anecdote: A patient had complained that the door was not getting locked properly. I got in touch with the facility personnel and they worked on the door and the lock and fixed the problem—all in a matter of 25 minutes from the moment it was brought to my attention. The patient was satisfied with the immediate solution. However, we did not stop there. We teamed up with the facility team and checked every door of the hospital and repaired them if required. We wanted to ensure that such complaints were not repeated. The feedback collection process served multiple objectives such as collecting open-ended feedback from patients, resolving the issues in real time, and further auditing the actions of the service departments. The real-time escalation flowchart is shown in Exhibit 6. The feedback was saved on an MS Excel spread sheet, and stored on a monthly basis for easy retrieval. The data was then analyzed using various parameters and trends were plotted for each service. At Apollo, each service was related to a department; hence, it was easier to deal with the complaints and determine monthly improvements.

FEEDBACK ANALYSIS From March 2011 to December 2012, 1,434 complaints were received from among the 1,38,600 in-patients treated during that period (approximately 1.03%). A Pareto chart was plotted for these complaints (as shown in Exhibit 7). The housekeeping department received the maximum number of complaints, while the dietary service had the least number of complaints. The department-wise spread of complaints is shown in Exhibit 7. Some of the complaints were genuine concerns while some were related to minor discomfort. A few of the complaints were very specific, while some were generic. All of these were analyzed, which would enable the hospital to work towards reducing the overall number of complaints. Some of the sample complaints from each department are provided in Exhibit 8. According to Dr. Rao, Every complaint is an opportunity to improve. We keep looking for the smallest of the complaints, which will help us in improving our quality by several levels. Sometimes it is difficult to interpret the complaints and it is even more complex to develop strategies that will enable a better patient experience. The complete data set was analyzed to determine the word frequency count in the complaints section. The significant words with their frequencies are shown in Exhibit 9. This analysis was used to focus on specific tasks to ensure reduction in the number of complaints. For example, the most significant word was “time” and it was associated with delays in response time for the various services. The twenty-fourth most frequent word was “late,” which is again related to response time. Thus, the word frequency technique helped in focusing on problem areas. Based on the results of the analysis, benchmarks were set in consultation with the respective department for the response time of each service as shown in Exhibit 10. Apart from this quantitative analysis, another approach was used to analyze the feedback and obtain deeper insights for quality improvements. Dr. Rao used the term “defect-defective” from the Six Sigma methodology—one “defective” product/service could be caused by one or several “defects”. According to Dr. Rao,



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Any complaint from a patient is considered as a ‘‘defective’’. For example, consider the complaint: ‘‘Food is not served on time’’. This complaint may arise due to several reasons such as food not being pr epared in time, food not being delivered on time, patient changing his/her order, etc. It is essential to identify these defects in order to eliminate the defective. On receiving a complaint from the patient, which was termed as “defective,” defects that led to the defective (complaint) were identified. Root-cause analysis was performed on all the processes of the identified defects. The processes were re-engineered to eliminate all the defects and a pilot study was conducted using the “Define Measure Analyse Improve Control” (DMAIC) cycle. Once the process was found acceptable, it was then deployed across locations. This was followed by routine and surprise audits to ensure that the process was being followed as defined to ensure customer satisfaction. The flowchart is shown in Exhibit 11a and b. All feedback related to medical services was escalated to the Medical Director’s office. In addition to this, the Quality Department at Apollo Bangalore developed a methodology called the Daily Point © © © Average or DPA . The ratings provided by patients for different departments were used to calculate th e DPA . The © departments had to improve these ratings over a period of time. The DPA effectively captured the “mind of the customers” since the feedback was collected during the patients’ stay and not at the time of discharge.

BENCHMARKING OF HOSPITALITY Hospitality required high human involvement and was very specific not only to local cultures but also to each individual. Since a patient had to stay in a hospital to get cured, hospitality automatically came into the picture. Hospitality in various hospitals was very different owing to the surroundings and differences in customer (patient) requirements. Patients did not walk into a hospital out of volition—they came in only because there was some problem. Under such conditions, the patient would be very agitated and any small thing that was out of place would become a big i ssue. Any kind of delay would be extremely intolerable and all the services had to be perfect all the time. Even in the hotel industry, hospitality was not standardized and benchmarks were not available. The Ritz–Carlton hotels, which are considered the gold standard in the hospitality industry, had used Six Sigma and benchmarking for their hospitality business.13 Although benchmarks for clinical services were well-established, those for hospitality in hospitals were yet to be established. Apollo Bangalore developed benchmarks for several common complaints with three levels of services (as shown in Exhibit 10) by adopting the Kano model, which was developed by Noriaki Kano ( Exhibit 12). This model was used across service industries and it helped in understanding customer expectations from any product or service. The threshold or the basic quality was the minimum requirement of the customer, which would be taken for granted even if it were present; however, if it were not there, the customer would complain about its absence. Normal or performance quality was something that the customer would expect because these were stated either by the product/service provider or by the customer as a requirement. This quality was observed by the customer and its absence would cause discomfort and disappointment. Exciting quality of the service or product was something that would not disappoint the customer; the presence of this would delight the customer, since the customer did not expect this quality. With time, the exciting quality would become performance quality and the performance quality would become a basic quality. Hence, the manufacturer or the service provider should always strive to provide new exciting qualities. Accordingly, several metrics were defined for benchmarking. For example, patients were informed that routine hospital-provided meals would be served within 10 to 20 minutes of every mealtime. This became a performance attribute. The threshold requirement of the patient would be that meals should be served within 20 minutes after placing the order. If the meal was served within 10 minutes, the patient would be delighted. However, if this customer (patient) were to come to the hospital again, she/he would expect the meal to be delivered within 10 minutes; this then would become a performance quality for her/him.

13

Source: http://www.qfdi.org/newsletters/six_sigma_qfd_hotel_application.html



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FINANCIAL IMPLICATIONS The Quality Department required funding for data collection, analysis, and other related activities. These expenses affected the bottom line of the hospital. However, from March 2011 to December 2012, the number of re-visits increased, which implied that customer loyalty had increased. There was a 15% increase in the number of in patients. Earlier, high discounts had been offered to dissatisfied patients owing to errors in service or poor quality of service. Gradually, there was a reduction in the discounts provided, which was a direct result of better satisfied patients. Additionally, owing to better processes, cost of quality (in terms of re-work and consumable wastage) had reduced, which helped in improving the bottom line. Further, owing to better service and higher levels of satisfaction, the patients acted as brand ambassadors for Apollo and provided word-of-mouth publicity, which improved the top line. Another example of decreased turnaround time and a resultant increase in profitability was seen in the Biochemistry Lab at the Apollo Bangalore Hospital. Dr. Rao headed this lab and he understood the patients’ requirement of receiving diagnostics reports in two hours instead of three. Dr. Rao and his team redesigned the process using 5S and lean concepts and managed to reach a turnaround time of two hours. Profits from the Biochemistry Lab nearly doubled after the decrease in turnaround time; while the cost of consumables increased by only 11%. Even though the Apollo team was trying to improve customer satisfaction, it still faced the question of how much satisfaction could be actually provided to the customer considering the room tariffs that were charged. As seen from Exhibit 13 , the charges at the Apollo Bangalore Hospital ranged from USD 25 for a basic room to USD 120 for the Platinum Suite. A Ritz–Carlton basic room would cost USD 799 at Washington, U.S.A. and USD 165 at Kuala 14 Lumpur, Malaysia (per person, per night). The Apollo team might be able to provide high quality hospitality to patients in the Platinum Suites. However, the aspiration to provide the same service to patients in other rooms might not be financially feasible. The team was trying to build high levels of service for the Platinum Suites. However, the volumes in the other rooms were too high to be ignored, especially in the Indian context. Additionally, customer loyalty was extremely important to Apollo; in Dr. Panyala’s words, Customer loyalty and not mere retention is what we need to focus on. It is important to think ahead of the customer to identify issues that may compromise the experience.

QUANTIFYING HOSPITALITY ACROSS APOLLO According to Dr. Rao, Once, we develop the benchmarks and the Sigma metrics, we want to replicate the system across all Apollo hospitals in the country. Each hospital will have to devise its own benchmark and Sigma metrics. However, we want to provide a framework for developing these and then measuring the outcomes. All the hospitals would then be compared by equalisation of scores and would benefit from one another’s learning”. After collecting the feedback and attempting to set benchmarks, Dr. Rao knew that he needed to go deeper and analyze each service through the complaints, set up relevant benchmarks, and target certain Sigma levels for each benchmark. He wondered whether they could collect and analyze data in a better manner. He wanted to arrive at the basis for the cost-benefit analysis of this activity. Looking at the complaints and the analysis, Dr. Rao had two major questions on his mind: 1. 2.

14

What strategy should be used to reduce the number of complaints and sustain the culture of excellence at Apollo Hospitals, Bangalore under the leadership of Dr. Panyala? Given the manual intensive processes involved in addressing the hospitality issues, what is a good Sigma level? Could Apollo set a target for Sigma level in hospitality?

Source: www.ritzcarlton.com, accessed on April 15, 2013.



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Exhibit 1 ACE@25 parameters Sl. Parameter No. 1 Coronary artery bypass grafting (CABG) mortality rate

2

Complication rate post coronary intervention(percutaneous transluminal coronary angioplasty; PTCA)

3

Average length of stay (ALOS) post angioplasty

4

Average length of stay (ALOS) post total hip replacement (THR)

5

Average length of stay (ALOS) post total knee replacement (TKR)

6

Complication rate for total knee replacement (TKR)

7

Average length of stay (ALOS) post renal transplant

8

Average turnaround per dialysis chair per day

9

Average length of stay (ALOS) post transurethral resection of the prostate(TURP)

10 Complication rate transurethral resection of the prostate(TURP) 11 Endoscopy complication rate 12 Patient satisfaction with pain management 13 Door to thrombolysis time in ischemic stroke in emergency room (ER) 14 Percentage conversion of coronary angiographies to coronary artery bypass grafting (CABG) 15 Catheter-related blood stream infection (CR-BSI) 16 Ventilator associated pneumonia (VAP) 17 Catheter-related urinary tract infection (CR-UTI) 18 Average length of stay (ALOS) in hospital 19 Average length of stay (ALOS) in intensive care unit (ICU) 20 Door to CT time in stroke cases in emergency room (ER) 21 Surgical site infection (SSI – Clean wound) 22 Medication errors 23 Average length of stay (ALOS) post modified radical mastectomy (MRM) 24 Average length of stay (ALOS) post microdisectomy 25 Average urea reduction ratio* 26

Percentage of patients achieving/maintaining haemoglobin level of 11gram or higher after 3 months of dialysis in end stage renal disease (ESRD)

*Optional



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Exhibit 2 Accreditation of Apollo Hospitals Accreditation Joint Commission Internation al (JCI)

Delhi,

Apollo Hospital Location Chennai, Hyderabad, Ludhiana,

Bangalor e,

Kolkata, Dhaka National

Accreditation

Board

for

Hospitals

&

Madurai, Chennai

Healthcare Providers (NABH) National Accreditation Board for Laboratories (NABL)

Chennai

ISO 9002

Chennai

Source: Apollo Investor Presentation (retrieved from www.apollohospitals.com in January 2013)

Exhibit 3 Apollo Brand–Clinical and Hospitality Services

Core Clinical Services

Hospitality Source: Interview with Dr. Ananth Rao



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Exhibit 4 Feedback Form

YOUR FEEDBACK Thank you for choosing Apollo Hospitals for your healthcare needs. As a quality improvement initiative, we are looking for improvements in parameters towards ‘‘Service Excellence’’ of our hospital. Please provide a few minutes of your valuable time for a personal interaction.

How satisfied are you with your experience and the services provided by our hospital on a scale of 1 to 10?

1. MEDICAL SERVICES

1

2

3

4

5

6

Poor 2. NURSING SERVICES

1

2

3

7

8

Good 4

5

6

3. OPERATIONS & ADMINISTRATION

1

2

3

8

5

6

7

1

2

3

1

2

4

3

5

6

7

1

2

3

10

Excellent 8

9

10

Good 4

5

6

Poor 6. FACILITY & MAINTENANCE

9

Good

Poor 5. HOUSEKEEPING SERVICES

10

Excellent 8

Poor 4. FOOD & BEVERAGES

9

Good 4

7

Excellent 8

9

Good 4

Poor

5

6

10

Excellent

7

Poor

9

7

10

Excellent 8

Good

9

10

Excellent

COMMENTS (OVERALL):

Patient Name (Optional): UHID: Date of Admission: Room No:

Signature:

Date:



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Exhibit 5 Feedback collection methodology A Typical Process Map: DPA Daily Data Collection Method

1:00pm–2:30pm Data consolidated; DPA Score developed*

11:00am–1:00pm Survey conducted

Point of Data Colle ction

Score given to IT Dept. & disseminated to individual stakeholders via SMS by 3:00pm

Details of complaints mailed to i ndividual stakeholders by 3:00pm

th

15 day consolidated DPA Score calculated

Data submitted to CEO & DMS

Data submitted to CEO & DMS Patients staying for 1 day or more

Discharged patients Monthly Analysis

Quarterly Analysis

Sustenance Audits

*The lower the score, the better



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Exhibit 6 Flow for real-time complaint escalation

Survey conducted

Real-time escalation of issues within 15 minutes to stakeholders concerned

R esolution turnaround time (TAT) given by respective stakeholders

Closure audits conducted at the end of TAT

Patient surveyed

NO

Issue rectified?

Stakeholder/representative meets patient for better understanding of issue

YES

Issue closed

Plan preventive action



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Exhibit 7 Department-wise complaints

Department

No. of Complaints

HK

373

F&B

318

Facility

236

Operations

189

Nursing

173

Medical

92

Billing

34

Dietary

19



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Exhibit 8 Sample complaints from each department in Apollo Hospitals Housekeeping: Sample Complaints

Housekeeping service needed to be improved. The dustbin was broken. The patient’s relative went to the housekeeping desk and got a new one, but housekeeping staff came and took the new dustbin away and replaced it with broken dustbin. Linen was not changed in 24 hours. Today morning, when we requested for fresh linen, they said it would be provided in 5 minutes; it was not changed till 3:15 pm. The TV remote was not provided in the room. We asked for it 3 to 4 times, but there was no response. The toilet was stinking. Yesterday evening, the floor was dirty. Drinking water was not provided when we asked for it, so finally we had to get it from home. Housekeeping came to clean only once a day. The inpatient guide book said that they would come twice a day. The clock battery had to be replaced. Yesterday, I did not get a blanket the entire day. It took 20 minutes to get a blanket. Food & Beverages: Sample Complaints

The food served was not hot. I asked for kichidi but got only rice. Around 8:30 pm last night, the patient asked for milk. We were told it would be served it by 9 pm, but the patient did not get milk. Today, we asked for milk again. The food served was too spicy and dry. The food served was not what we had ordered. The food served was not tasty, so we brought food from home. The quantity of food served was not sufficient. The quality of roti was bad—it was dry and hard. Coffee and milk were always served cold, even after complaints. Food quality was not good It took 1.5–2 hours for the plates taken away. The cafeteria menu card was spoiled. They should get a new one. Despite the patient informing the staff that she did not eat food with garlic or onions, the food served contained garlic and onions. After endoscopy was done, it took 1 hour for the food to be served despite repeated reminders. There was too much pepper in the child’s food. Facility: Sample Complaints

The nursing call bell did not work properly. The nursing call bell wire was short and did not reach the patient’s bed. The room was too congested and stuffy. The temperature in the room should be checked regularly. In the semi-private room, the light from the next room was too bright; the glass partition should be covered with curtains. The TV remote was taken away since the TV disturbed the other patient.



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Exhibit 8 (Contd.) The staff members in the parking area were not cooperative. They were very arrogant. Last time, the patient was admitted to the ER at 11:30pm, but we were not allowed to park even for a few minutes. The balcony was not clean. When we felt suffocated in the a.c. room, we opened the window. There was stagnant water outside, which led to a lot of mosquitoes coming in. Hot water was not available in the bathroom. Extra curtains should be provided. There were hooks for extra curtains. I had asked for curtains, but they were not provided. This hampered my privacy. The door made too much noise, which disturbed my sleep. The flush was not working properly. The attendant’s cot size should be a little bigger. Operations: Sample Complaints

The doctor advised the patient undergo bronchoscopy; and the patient was asked not to eat anything from 8:30 am that day. At 12:30 pm, when the patient’s attender enquired with the bronchoscopy department, the attender was told that the procedure was postponed to the next day. No communication was provided to the patient regarding this; information was given only when the attender specifically asked for it. The patient’s attender was told that the patient would be shifted to the ward from the OT recovery only after 1 hour, so the patient’s attender went for lunch. However, the patient was shifted in 20minutes. The insurance staff left at 3:00pm on Sunday and there was nobody to assist us with the formalities. We came to the Emergency Room at 10am. We were told we would get a room around 2pm. The room was finally allotted at 9pm. A Telugu translator was required. A “silence please” board should be put in each room. The transport boy’s shoes were stinking. The hygiene of shoes should be improved. All the staff should close the door while leaving the room. We had to wait for the discharge summary as it was not updated on time. The patient or the attenders should be made aware of what to bring to the hospital. When we asked the doctor what all we should bring, the doctor told us to get some clothes for the baby. Nobody informed us about the other things that would be required and were not included in the package. Information and orientation should be given beforehand and not at the time of an emergency. Three days ago, while making an appointment over the phone, the receptionist made me wait for 3–4 minutes the first time. When I called again, the same person made me wait for 7–8 minutes. The appointment was finally given only when I called the third time.



Page 15 of 20

Exhibit 8 (Contd.) Medical: Sample Complaints

The patient was in severe pain. We expected the doctor to visit the patient in the morning. He had not come on rounds till 3 pm. We were waiting for the treatment plan and discharge. Many staff members were seen walking into the canteen wearing OT gowns and shoe covers. The operation theatre was available earlier, but was not allotted due to coordination issue (the surgery was scheduled at 12pm,but the patient was not shifted even at 3 pm). The patient was suffering from pain in the stomach. Backup treatment should be available for oncology patients in the ER and even in the ward. Nursing: Sample Complaints

The nurses should attend to patients more frequently, especially on Sundays and other holidays. HDU: there was a slight delay in service. Some of the nursing staff members were not prompt. Blood sample had already been taken in the morning, but the staff came and took the sample again; they said that the previous blood sample could not be used as the blood had clotted. The sample collection process was extremely painful. Yesterday night, around 11:30pm, the nurse on duty pulled out the IV line in a rough manner, which caused a lot of pain, even though the patient kept asking the nurse to do it slowly. The response time of nurses was bad. It took them at least half an hour to come after being called 2–3times. It would be nice to have a specific set of nurses to take care of me regularly. The nursing staff seemed to be overworked. A checklist/patient education material for the plan of care should be available for patients’ convenience. The staff should try to find out the patient's needs. The response time was very high. There should be additional staff, as the staff seemed to be overburdened. Today morning, the nurse tried thrice but could not find a vein. She then called another nurse, who completed the procedure. My hand hurt for a long time after this. Billing: Sample Complaints

Billing took a long time. It should be monitored and abnormal delays should be avoided. During admission, the credit cell department staff behaved very rudely. The discharge process took more than 2 hours. What all were included in the package was not very clear to us. The cost of surgery should be informed beforehand, rather than calling us at short notice and telling us to pay immediately. If we had been informed earlier, it would have been easier for us to arrange the finance and settle it. We had to wait for 40 minutes for the finalization of the bill.



Page 16 of 20

Exhibit 8 (Contd.) Dietary: Sample Complaints

Food should be less spicy and should be according to the child's taste. The dietician did not visit the patient until 4:10pm. The patient was admitted on 9/6; the surgery (knee replacement) was performed on 10/6. The patient would be discharged the next day, and we needed to meet the dietician. The doctor suggested normal diet but yesterday morning, the dietician changed it to soft diet. In the evening, the doctor changed it to normal diet. However, soft diet was continued until lunch today. After we complained, the F&B boy changed it to normal diet, but I had already finished my lunch by then. The doctor told us not to give chutney and sambar to the patient. After having the food suggested by the dietician, the patient had stomach pain. The dietician has not come to my room yet.

Exhibit 9 Text analytics–word frequency count Sl. No. 1

Word Time

Count 271

Sl. No. 19

Word Good

Count 64

2

Food

220

20

Response

62

3

Nurse

214

21

Proper

58

4

Clean

206

22

Said

57

5

Toilet

139

23

Hot water

54

6

Water

129

24

Late

48

7

Doctor

107

25

Bedsheet

47

8

Improve

106

26

Quality

46

9

Wait

98

27

Floor

43

10

Staff

95

28

Serve

43

11

Bed

94

29

Lunch

41

12

Morning

94

30

Response time

41

13

Night

87

14

Attend

79

15

Work

79

16

Hot

78

17

HK

69

18

Minute

66



Page 17 of 20

Exhibit 10 Benchmarks for hospitality developed by Apollo Hospitals, Bangalore

SN KPI DEPT

MEASUREMENT

COLOUR CODE

TARGET

FREQUENCY

RED

YELL OW

GREEN

KPI SCORE

PROCESS

1

F&B

ROUTINE MEAL DELAY

RED

>20MINS

YELLOW

10-20MINS

GREEN

<10 MINS

RED

>20MINS

YELLOW

5-20MINS

GREEN

<5 MINS

RED

>30MINS

YELLOW

15-30MINS

GREEN

5-15MINS

RED

NA

YELLOW

NA

GREEN

0

RED

>120MINS

FORTNIGHTLY

IN BETWEEN ORDERS DELAY FOOD

WEEKLY

IN BETWEEN ORDERS DELAY BEVERAGES

WRONG DIET

2 DIETARY

POST ADMISSION DIETICIAN CONSULTATION DELAY

YELLOW 60-120 MINS

3 FACILITY

GREEN

<60 MINS

RED

>30 MINS

YELLOW

15-30 MINS

GREEN

<15 MINS

RED

>60 MINS

YELLOW

30-60 MINS

GREEN

<30 MINS

RED

11-15 MINS

YELLOW

6-10 MINS

GREEN

0-5 MINS

RED

>3 MINS

YELLOW

1.5-3 MINS

GREEN

0.7-1.5 MIN

WEEKLY

DAILY

DAILY

REPAIR TIME MINOR

WEEKLY

REPAIR TIME MAJOR

4

HK

5 NURSING

RESPONSE TIME

RESPONSE TIME

DAILY

DAILY

DAILY



Page 18 of 20

Exhibit 11a Defective/Defects analysis and process re-engineering flowchart

Patient complaint/feedb ack

Identify defect(s) leading to defective

Defective

Root Cause Analysis

Repeated Complaints Process Changes (Reengineering)

Pilot Study (PDCA)

If solution acceptable

Sustenance Audit

Deploy at all locations

If solution not acceptable



Page 19 of 20

Exhibit 11b Defective/Defects analysis and process re-engineering flowchart

Delay in food service

Patient did not get food within 20 minutes

Detailed Root Cause Analysis

Delay due to various touch points involved

Solutions proposed

Repeated Complaints

Direct phone line provided to F&B which can be contacted 24*7 from all patient rooms

Manager on duty to follow up

Pilot Study (PDCA) for private rooms

Sustenance Audit

Deploy at all the wards

Solution Accepted



Page 20 of 20

Exhibit 12 Kano Model

Exhibit 13 Room tariffs at Apollo Bangalore (as of January 2013) Bed Type

Charges (USD)

Shared Bed Category-1

25

Shared Bed Category-2

36

Twin Sharing Bed

48

High Dependency Unit (HDU)

48

Private Bed

77

Executive

92

Platinum Suite

120

Intensive Care Unit (ICU)/Critical Care Unit (CCU)

80


Imb425 PDF Eng

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