Winds of Change

(This story is entirely a work of fiction.)

It was nearing 9 o' clock. Vasudha Som was winding up her work. She wondered if Sheshu was done for the day. It had been a tiring day. She was dying to get back home. She called his extension.

"Are you done?"

"Just about. 5 minutes?"

"Sure. See you at the lobby."

She picked up her bag and headed towards the lobby. She went towards the notice board kept in the lobby. She saw the poster about their new Master Health Checkup and wondered if they could create flyers and distribute them as newspaper inserts. People must get to know about this. Her eye caught Seshu walking towards her. 

They both headed towards the entrance. Sheshu called the driver and asked him to bring the car to the entrance of the hospital. As they were getting into the car, Sheshu got a call on his cell phone. He was needed back in the ICU. The 64 year old patient from Polavaram was deteriorating.

"Shit! I need to go to the ICU. You get dropped home and send Murali back."

Vasudha nodded and acknowledged.

Dr. Sheshadri Som, Chairman and Chief Medical Officer of Narayana Hospital rushed back to the ICU. 

Along with Vasudha, his wife of seven years, who was an MBA from IIM Bangalore, Dr. Som had setup Narayana Hospital about three years back. She took on the role of CEO. It quickly became one of Rajahmundry's top hospitals. It was a 250 bedded hospital and had some really good doctors who helped establish this as the go-to destination for quality healthcare in the region. 

The choice was between setting up a hospital in one of the Tier 1 cities like Hyderabad or picking a smaller place like Rajahmundry which had only a few good hospitals. After a lot of consideration, they picked Rajahmundry because they felt that the bigger cities had enough options and they would end up being one among the many options for patients. In Rajahmundry, they could bring good care to people who had fewer options. Also, Rajahmundry was Dr. Som's home town. He wanted to do something in this region.

Dr. Som gave up his job at one of Hyderabad's top corporate hospitals where he was a Nephrologist. Vasudha quit her job as Strategy Consultant at a consulting firm in Hyderabad. The couple chose not to have kids until they settled down. The decision to quit high-paying jobs and plunge into a future, uncertain and risky was not easy by any means. Friends and family dissuaded them. Both of them however, had an itch to do something from scratch. They felt that if they did not venture out at that time, it would never happen. The biggest advantage was, if things did not work out, they could always return to regular jobs.

They finally took the plunge, raised some money from their family and friends, put in their own savings and started the hospital in April 2012. They got some good doctors to join the team. To help manage the hospital well on the administrative side, they got some good MBAs with experience in healthcare to join them. 

Dr. Som got home after midnight. Vasudha was working on some Excel files with revenue figures of the month. They had dinner together and went to bed. By 8 am, the next morning, they were both at the hospital back to work.

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It was a tough life but neither of them complained. Both of them found their work extremely satisfying and intellectually stimulating. The hospital was beginning to do well financially as well. They could see that their efforts were bearing fruit. Having your own hospital, catering to hundreds of patients every month and making some money in the end gave them a sense of achievement, of having done something, of drafting a success story that few could boast of.

Dr. Som saw close to fifty patients every day. People came from Rajahmundry and towns and villages close by. He understood the plight of some of the poorer patients. They barely had money for the commute. The hospital was not yet empanelled with the state government's health insurance scheme, Aarogyasri. Despite that, due to the superior quality of care, many patients came here even though they could barely afford the cost.

Dr. Som was sympathetic to them. He appreciated the fact that they came to him even though they could have gone to another hospital that was empanelled under Aarogyasri and got treated free of cost. Sometimes, he waived off part of the treatment cost for those who could not afford it but needed the quality of care Narayana Hospital offered.

A patient had come to see him from Samarlakota one afternoon, a place about 50 kilometres away. He was in bad shape. He needed dialysis urgently. It was a case of late detection of kidney disease. For years, the symptoms had been building up. As is often the case in places with inadequate medical facilities and awareness, people realise they have kidney disease when it is too late to do anything to save and preserve kidney function. 

Dr. Som told the patient that he would need to get a temporary access for dialysis until a permanent one - an arteriovenous fistula was made. He would need dialysis immediately. He was asked about the cost of the entire treatment. Dr. Som told him that the initial cost would be about five thousand rupees including the temporary access and one session of dialysis. The permanent access would cost about Rupees 7,500 but he could get it all done free of cost under the Aarogyasri scheme if he went to a hospital that covered it.

The patient chose to get the temporary access and the first session of dialysis done at Narayana as he was in a bad shape and did not want to prolong the agony by going elsewhere at this stage. Dr. Som put in a catheter in the jugular vein that would enable the patient to get a dialysis session immediately. Dr. Som decided to waive off the charges of the temporary access and charge only for the dialysis. He made a note to that effect in his file and sent the patient's wife to the billing section.

In the meantime, he started preparing for the minor procedure which was typically done in the dialysis unit itself. 

By the end of the day the patient had undergone his first dialysis session.

Dr. Som was in his chamber when he got a call over the intercom from Vasudha. Vasudha wanted to come over to discuss something. Dr. Som knew what was coming. He called her over.

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"You did it again?", Vasudha asked. 

"He was extremely poor. No money for dialysis either. He will go to an Aarogyasri centre and get dialysis. It was only the jugular charge that I waived off!", Dr. Som responded.

"Exactly my point! If he is anyway not continuing with us, why did you have to waive off the jugular cost?" 

"Come on Vasudha. You know how it is."

"He could have got it done under Aarogyasri. He was going there anyway."

"I know. But I just felt sorry for him. I just felt compelled to do something for him."

"You don't understand, do you? We have taken money from tons of people who expect some decent returns from their investment. We have invested our life's savings in this hospital. We have spent three years working day and night to make this work. This is not a charity for God's sake!"

"We're doing pretty well Vasudha. We are about to break even."

"Break even? Is that all you want? What about our dreams? What about returns to the investors? How much longer do you want to slog without taking a single break? Don't you want to start a family? Don't you want to give our kids a good education? Don't you want to enjoy the fruits of our labour? Is breaking even all you care about?"

"Vasudha, it's not that bad at all. I think you are over-reacting."

"Yeah, right. I am the one who is over reacting. You're the one who turns this hospital into a charity by seeing one poor patient. And no, don't make me the villain here. I am all for helping people. But how many are you going to help?"

"Vasudha, I think once in a way, by doing this, we can at least feel that we have helped someone. I agree that we cannot help everyone. But what is the harm in reminding ourselves about the misery that exists all around us and feeling a little better by helping a few people. Its not like we have changed our policies to change the way this hospital functions, right?"

"I don't deny that. But we cannot get distracted from our main goal of making this hospital commercially successful. And we owe that to our investors, damn it! How would they react if they got to know that we are treating patients free of charge?"

"Not 'patients', Vasudha. Just one patient."

These were tough calls. While medicine was a noble profession, one could argue that doctors are also entitled to a good life. After all the years of hard work and all the toiling, what was wrong if they made a little money for themselves and got themselves some luxuries? At the same time, in a country like India, where a large part of the population had little or no access to quality healthcare and those that did, had to bear all the expenses out of pocket, moral dilemmas like this kept presenting themselves regularly.

Regularly seeing patients succumb to diseases that could have been easily cured but for want of resources made even the softest of hearts hard. For the first few years, you felt bad, you kept thinking of what could have been done better. But after a point, you resign to the fact that these things happen. You get over one patient and move on to the next. There's not much time for grief.

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"May I come in, sir?" The Procurement Manager from the Inventory department asked Dr. Som.

From time to time, the Inventory Department would try to procure, at lower costs, consumables for procedures and various drugs that were used within the hospital. That way, the hospital could make  slightly higher profits without increasing the cost to the patients. However, there was always a risk of unscrupulous manufacturers trying to push some inferior quality products in the guise of reducing costs. To avoid this, Dr. Som had put a process in place where the Head of Department of each specialty would take ownership of the quality of the products being used or prescribed by the department.

The Procurement Manager had come to him that morning to introduce a lower cost catheter that was used to start dialysis on a patient who needed it urgently. Dr. Som took a look at the catheter. He asked the usual questions. 

"Have we used products from this company before?" 

"Yes sir. We use their Foley's Catheters."

"Any feedback gathered from other hospitals or doctors?" 

"No sir, they are introducing this for the first time."

"What is the price benefit?"

"About 15% sir."

"I don't think we should take a chance on a new product for 15%."

"Sir, maybe we can try a few pieces. If it does not work well, we can refuse?"

"No. Catheters are sensitive products. If something goes wrong, it can be very bad."

"Ok, sir."

Within half an hour, Dr. Som got a call from Vasudha. Vasudha asked why he rejected the catheter? Dr. Som explained that this was new to the market and wondered why they should be the guinea pigs. Let someone else try it and and then we can think about it.

Vasudha argued with him about how they need to encourage new manufacturers who are no different from them. She asked Dr. Som how patients had to try Narayana Hospital in the early days for them to even begin being trusted. If everyone would wait for others to try them out, how would they ever begin to succeed? Dr. Som said that trying someone new for catheters was very risky. He was not going to sign off on this. She could do as she pleased as CEO.

Vasudha hung up. She asked the Procurement Manager to go ahead and get some catheters for the hospital to try out.

Dr. Som, however, refused to try those catheters in procedures he did. He allowed other doctors to use them but gave strict instructions to his team not to give him those catheters to use.

Dr. Som kept an eye out on any reports of issues faced with that brand of catheter. Nothing at all was reported. After a few weeks, Vasudha asked Dr. Som if they could change the brand of the catheter to the new one since no reports of issues were found. Dr. Som could not find any reason to refuse. He sheepishly agreed.

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A few weeks later, as Dr. Som was finishing his OP consults for the day, he got an email from Vasudha. The subject was 'Price increase'. In the email, Vasudha had forwarded the Finance department's proposal for price increases for various procedures, investigations and other services the hospital offered. Dr. Som opened the attachment to take a look at the details.

Since the opening of the hospital, prices had never been increased. The focus was on setting up a reputation and getting a good patient base. Three years is a long time. With inflation, everything had become more expensive. Manpower costs, electricity tariffs, the prices of consumables - everything had shot up but the prices that Narayana charged for the services had remained the same. The Finance team had brought this to the notice of Vasudha in a detailed presentation. They explained that a steep price hike was essential to control the financials.

The Finance team had come up with an initial proposal which Vasudha reviewed and asked them to modify. She did not want to take any chances with the patient base. Over the last three years, they had been able to develop a loyal following and many people saw the hospital as a high quality, reasonably priced and ethical institution. Vasudha reviewed the modified price hike proposal and sent it to Sheshu for review.

Dr. Som saw the details. He understood that prices had not been changed for three years. He realised that a price hike at that point was necessary. He went over the list. He made some minor corrections at a few places. However, his eye stopped at a line towards the end of the file. The line indicated that the plan was to increase Inpatient charges for the same services by 50% more than the Outpatient charges. An example was given that to get Hemoglobin tested, an outpatient currently paid Rs. 100, while an inpatient paid Rs. 110. The plan was to increase the outpatient charges to Rs. 110 while the inpatient charges were to be increased to Rs. 165. He found that to be extraordinary. He sent an email back to Vasudha saying that he was ok with everything but he thought there was mistake in the Inpatient charges clause and asked her to get that checked and revert.

Within a minute, Vasudha responded saying that it was correct and that was the plan. Dr. Som responded to the email, "Let us discuss."

Vasudha came over to Dr. Som's cabin. She told him that they did not have too much scope in OP prices because the competition was getting tough. IP prices were the only area they could be a little more ambitious. Sheshu countered, "It is unfair to charge so much higher for IP cases."

Vasudha was getting impatient. "The whole world does this Sheshu. What is wrong with this? When someone is admitted in the hospital, they do not have any other option but to get their investigations and procedures done here. We can and should charge more! For OP, they can go anywhere else so it is important to keep prices low and attract more patients."

"That inflates the bill artificially. When the patient sees his hospital admission bill, they would feel cheated. They can always go to other hospitals the next time because of this. In the long run, we lose their business."

"It does not work that way Sheshu. All other hospitals do the same thing. Everyone does this."

"Exactly. Just because everyone does this does not mean we should do this. It is wrong to charge more for IP just because they don't have any option."

"It's not that alone. IP cases need more care because patients are inherently more sick when they are admitted."

"Taking a Hemoglobin sample involves exactly the same effort whether it is IP or OP"

"The sample has to be collected by visiting the ward or the room. That requires more effort."

"Not 50% more effort as OP."

"Sheshu, every single hospital in the country charges more for IP. That's where everyone makes their money. Why should we be any different?"

"We started this hospital to be different. Not to take the easy way out. We were doing fairly well in comfortable jobs. We did this to do something challenging."

"We have too many challenges already Sheshu. We cannot take on more." Vasudha stormed out of Sheshu's cabin.

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The next morning, at breakfast, Vasudha suggested that they both take a weekend break. Sheshu's eyes light up. He suddenly felt that he badly needed a break. Three years of toiling without any meaningful break whatsoever could take a toll. They both started discussing where they could go. They first thought that it cannot be too long but later felt that the team could handle stuff on their own. They did have a mature team in place. Its just that they felt too scared to let go. What if something happened? What if a crisis came up? 

Starting a new business is like raising a child. For the first few years, the child needs your constant attention. After a certain point, you don't realise that the child has become independent. You are too scared to let go. Unless you actually try, you are never sure. But you feel you cannot let go until you are sure. The Soms were in that phase with Narayana Hospital.

However, with all that had happened in the past few weeks, they both felt that if they did not take a good, meaningful break, things could become much worse. They needed to get away from it all. They needed to find each other. They loved each other so deeply. For the first time in all these years, it looked as if a slight coldness had begun developing between them.

They zeroed in on Coonoor. This little hill station close to Ooty was the perfect place for them to recharge. They had been there once briefly before starting Narayana Hospital. They had always wanted to go back there. The first trip was only a couple of days and they felt they hadn't got enough of it. 

That afternoon, Vasudha called a meeting of her most trusted advisors in the hospital. These were business graduates who had joined them early on and took care of all the administrative and financial aspects of the hospital. She announced that she would be away for a week on a holiday. She was to be disturbed only for something really urgent. Dr. Som also met a few of the hospital's senior most doctors and told them that he was going to be away for a week.

The couple headed out the next morning. A couple of flights and a two-hour drive later they found themselves in the cool climes of Coonoor. They had booked themselves at a homestay. Though they were quite tired with the travel, they decided to take a walk before going to bed. After a long, long time, they held hands and went on a long walk. As they walked along the road, they took in the moist, cold air, free from any smoke. The silence of the night was broken only by the odd bicycle passing by. There was a gentle breeze blowing. What a good decision they had taken to go to that place!

The next few days went by. They would have a hot breakfast and then head out to the middle of town, stroll around, go on treks and return by late evening. They were disturbed only a couple of times for some work from the hospital. Other than that, they could take their minds fully off work and enjoy the time together.

The night before they were supposed to return home, during a walk, Sheshu told Vasudha that they should talk about the IP charges and resolve the issue before heading back. Vasudha nodded. Sheshu said that he understood the pressure on her and that sometimes he did become impractical due to his naivety. He suggested to her that they do an IP price of 30% above the OP price. Vasudha agreed. They smiled at each other and were very happy with the way they reached a compromise and with the way the week had gone by.

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Dr. Som had just finished his consultations for the day. A bunch of Medical Representatives were waiting to meet him. 

Medical Reps, as they are called represented the ugly underbelly of Indian healthcare. At the surface, there was nothing wrong with introducing a doctor to new products and their benefits. However, things were not that simple.  Medical Reps had to meet stringent targets set by their companies. They were encouraged to lure doctors with incentives of all kinds. These ranged from cash, a credit card which would be paid by the company, domestic and foreign holidays albeit in the name of attending conferences, fuel vouchers and some rather not so honourable arrangements. In return for these incentives, doctors had to either prescribe their drugs or use their products for procedures. Of course, these products would have been cleared by the regulatory authorities but some could be inferior to others and these incentives ensured that doctors prescribed them despite having known this.

In a world full of corruption, some doctors felt that the patient is not being harmed, so what was the problem if they made some additional money? They would have usually spent a bomb getting themselves educated. Today, many seats in Post Graduate courses can be obtained only after paying a few crores. Even doctors are human beings with needs. After years of slogging hard, weren't they entitled to some basic privileges? Weren't they entitled to a comfortable life?

Dr. Som saw the Medical Reps quickly, one by one. Usually, these Reps are a little discrete. They would explain the drug and then slide in a sheet that would have, without any overt branding of the company the details of the incentives. Some would be more brazen and talk about the incentive structure openly. One such person who met Dr. Som that day leaned forward after explaining the basic incentives and whispered softly, "If you use 50 catheters by the end of the quarter, we could arrange a holiday for you without ma'am at Pattaya."

Dr. Som was red with rage. "What do you think I am? Get out right now!" He flung the brochure and the incentive sheets on the face of the bewildered Rep. "What are you waiting for? You bloody pimp. Get out right now!" Hearing the noise, Dr. Som's office boy rushed in. "Throw him out!", Dr. Som exclaimed. The Rep was trembling. "Sorry sir. Never again sir. Sorry sir." The office boy ushered the Rep out. Dr. Som drank a glass of water, calmed himself down and called his secretary on the intercom. "No more Reps for today."

Dr. Som got up and went towards the elevator. He went to the terrace of the hospital. He walked over to his favourite spot. He saw the sun setting over the resplendent Godavari. The calm waters of the river wore a golden hue due to the rays of the sun. In the distance he could see a few boats being rowed by lonely fishermen. A gentle breeze was blowing. He stood leaning against the wall and took in the fresh air and the scene that was a natural balm for his anguished mind. He closed his eyes and took a few deep breaths. 

"This must change", he thought to himself. "I will change this."

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The next morning Dr. Som got up earlier than usual. He gave a kiss to Vasudha on her forehead as she was still sleeping. "I'm leaving early. Will have breakfast at the hospital."  Vasudha mumbled, "Hmm, what? Why? Emergency?" 

"No, will explain later."

Dr. Som had an extra bounce in his step that morning as he entered the hospital. The security guard and the sweepers were surprised to see him so early. He went to his cabin, left his things there, took his notepad and pen and took the elevator to the terrace. He called the office boy and asked him to pack up some idlis from a nearby restaurant. He ordered a coffee from the office and got to work. For the next hour or so, Dr. Som jotted down his thoughts vigorously. 

At the end of an hour, he had the high level plan ready. He went back to his cabin satisfied and full of optimism for the future. He went about his daily routine - rounds, procedures, OP consults. 

Over the next week, he made an elaborate plan where he dug one level deeper. He identified problems that might come up. He tried to figure out multiple solutions to each problem. He took copious notes of his entire thought process. He got new ideas as he went along. He discarded some old ones where the newer ones made more sense. He was fully immersed in this process. He worked on the plan whenever he found time.

Dr. Som knew that what he was planning was radical. This was something that he felt would shake the foundations of healthcare in the country and beyond. He realised that there would be many challenges. He was determined to overcome them. In his mind he was confident that what he was doing was the right thing. 

The next morning, Dr. Som drove himself to the Swami Madhavanand Vidhya Peeth, a one hour drive from their home. Swami Keshavanand, the Head of the Ashram was revered by the the couple from the time they set their foot into Rajahmundry. They were introduced by a friend of theirs who was closely associated with the Swami. Swami Keshavanand was a very sincere and devout Sadhu who advised the Soms on various matters from a spiritual angle. He guided them from time to time. He would never interfere in the commercial aspects. That was up to the couple to figure out. Swamiji would only give them advise on how to fight their inner battles, the ones within the mind. The Corporate boardroom battles were beyond his understanding, he professed. 

Dr. Som had called the Ashram the previous evening and requested a meeting with Swamiji. He got an appointment for 7 am.

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Dr. Som reached the Ashram by 6:45 a.m. He first went to the temple within the Ashram. Every time he visited the temple, he felt extremely peaceful. Made out of pure white marble, open on three sides, it gave him a feeling of space, of tranquility and of a calmness that he could go to whenever his mind was agitated. The idol of Lord Krishna inside the Garbha Griha was enchanting. He spent a few minutes in quiet contemplation ending it with a prayer to the Lord to guide him on this important mission.

Dr. Som left the temple and made his way to Swamiji's dwelling. As he reached, he saw Swamiji was sitting and writing something. He went and paid his respects to Swamiji and sat down in front of him. "Radhe Krishna, Radhe Krishna", Swamiji greeted him. "So, what brings you here today, Sheshadri?"

Dr. Som enquired about his health and well-being and then explained his plan in detail. Swamiji heard him very attentively throughout. He stopped him several times to understand the plan better. 

"So, what do you think of the idea, Swamiji?"

"Who can find fault with this plan Sheshadri? This is how healthcare in this country and everywhere in the world should be. The primary goal of any doctor or medical institution should be the well-being of the patients. However, these days it has become just another business and a lot of corrupt practices have crept in. While no one can argue that your plan aims to remove the ills of these corrupt practices, you have to think it through. I'm not sure if you realise that the problems in implementing this will be huge."

"I'm aware of that Swamiji. But someone has to make a beginning. I cannot just let things be the way they are. I feel suffocated at times staying quiet in these circumstances."

"I am not asking you to let things be. But before you begin any battle, you need to be aware of the challenge that lies ahead. There is no point in beginning the battle if you do not have the resources to fight to the end, irrespective of the result. I don't want you to think this is going to be easy."

"I'm aware that this is going to be difficult."

"I think you are underestimating the difficulty. You tend to be an idealist Sheshadri. Have you discussed this with Vasudha?"

"Not yet."

"I thought as much. Talk to her about it. Get her thoughts."

"I will, Swamiji. But what is your gut feel?"

"As I said, Sheshadri, no one can find fault with the intention behind this plan. But I am worried about the implementation. I am worried about the challenges you will face. I am worried about whether you will get support from those you need."

"I am sure Vasudha will support me. I wish she would have come with me today. What problem could she have with this? Despite some initial problems, in the end the hospital is going to do well commercially as well, right?"

"As I said, talk to her. Get her thoughts."

"Sure Swamiji. I will do that. I just wanted your blessings before I begin this important project."

"You always have my blessings Sheshadri. You know that!"

Sheshadri got up and touched Swamiji's feet. 

"Radhe Krishna, Radhe Krishna!"

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Dr. Som did not have a good feeling about this discussion. He sensed the negativity around this from Swamiji's voice. He put those thoughts behind and started thinking about how the entire healthcare system could change. Every revolution begins with a small step. The entire commercial nature of healthcare was something that bothered him right from the days he began practising. He however felt compelled to go with the flow rather than to try and change anything radically. He did feel a tinge of guilt when he went on his first sponsored trip from a pharmaceutical company. He also accepted handouts  from companies on prescription targets with a sense of embarrassment. He would justify these to himself in one way or another. 'Everyone takes this', 'I am only prescribing when necessary', 'Nothing wrong in going on trips'.

As Dr. Som walked into Vasudha's cabin, he found her in a good mood. He was a little relieved. He could do without any additional obstacles. He sat in front of her and opened his laptop. He wasn't very good with presentations but wanted the whole pitch to come across as well-thought. It also helped him give structure to the discussion.

Vasudha was surprised when she saw him start a presentation. "Wow, this must really be something important. You have actually put together a presentation."

"Yes, actually. I also figured you could use this to review later or when you wanted to discuss with others."

Sheshu started the presentation with his experience of dealing with pharmaceutical companies. He explained how embarrassed he would be to accept doles from them. He said that even though he would never prescribe anything unnecessarily or prescribe something that is not genuinely good, he was sure there could be other, more commercial-minded doctors who would not mind doing such things. He had a slide that asked a question, "Is there a way doctors can be compensated in a manner where these incentives could be completely avoided and yet the doctor made enough money to lead a comfortable life?"

Sheshu then detailed the specific contours of his plan. He called for a fixed, high remuneration for doctors based on their degree and experience. He added a variable component that was based on the clinical outcomes of the patients the doctor treated. The plan removed all incentives for pharmaceutical prescriptions and investigations. Another thing which he proposed was to charge for all procedures and investigations for patients admitted to the hospital at the same rate as when they were out-patients.

The plan banked on the hospital improving its reputation by reducing the cost of treatment to the patient and improving outcomes due to these measures and improving the volume of patients treated. This would offset the loss incurred due to a reduction in the volume of investigations per patient. He had also put some proposed remuneration numbers for some of the specialties. He also detailed on how the variable component would be calculated for those specialties. The presentation was silent on how this would impact the hospital but he added, "In the long run, the hospital would benefit due to a much better reputation and better financials - but it would all be very ethically done."

Vasudha listened carefully to the entire presentation. At the end of it, Sheshu asked her if she had any questions. She shook her head and said, "I need some time to digest this. Can you email a copy of the presentation to me?"

"Sure."

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A week had passed by since the day Dr. Som had revealed his plans to Vasudha. Dr. Som got busy in his work. Vasudha was busy with her work. Dr. Som wondered at times what was happening? He was wondering why Vasudha had not mentioned the plan at all. He decided to wait for a few more days.

Another week passed. There was still no discussion. That evening, at the dinner table, Dr. Som asked Vasudha, "Did you get a chance to think about the plan I presented the other day?"

"I actually did go through the presentation again. It is a great plan."

Dr. Som could sense that there was a 'but' coming.

"But, I don't think this is the right time to implement this."

"Why is that?"

"Look, Sheshu, we are barely breaking even now. Implementing something this radical could be very risky. Things could become very bad."

"What are the risks?"

"Patients will like it. That is great. Doctors will get a high fixed salary. They might be ok with it. But what about the hospital? If our equipment does not make money, how do we recover the huge costs we incurred? If doctors are not incentivised to recommend that patients get the tests done, they could potentially send those patients to other hospitals to get the tests done."

"Why would patients go elsewhere when they can get the tests done here?"

"What if a doctor tells his patients that the test is not done here? Or they say things like the test is cheaper elsewhere? Or they could also say that another place does it better?"

"Why would they do that?"

"Oh Sheshu, you are so impractical. The moment other hospitals get to know that the doctors here are not incentivised to get tests done, they will start offering them incentives to get them done there. Is this really that difficult to figure out?"

"I agree that this could be a problem. But this will only be in the short term. In the long term, patients will figure the truth out and then they would insist that they get the tests done here. Trust me on this. We might have to take a short term hit."

"That is why I am saying that we cannot take a chance now. Do you think we can bear the impact of a short term hit?"

"Yes, of course we can, provided we are doing the right thing."

"Sheshu, you don't understand the financial implications. Please, please leave this to me. You please focus on the medical part of running the hospital and leave my responsibility to me."

Sheshu could not understand what problem she could have. He did not say another word. He quietly finished his dinner and then went to bed. He could not sleep however. He thought about what Vasudha said. He tried to look at it from her point of view. He could not justify her stand however. He started thinking that all she cared for was money. How different she was from the girl he knew from about ten years back. They had met at a mutual family friend's wedding. They started talking at the event and hit it off instantly. They dated for a while before realising that they were deeply in love. There was no resistance from the families. It was a very happy marriage. They shared similar interests and values. They were not the party-going type at all. They much rather spent time with their families, going on long walks and had a deep interest in spirituality. 

Sheshu felt that the last three years of struggling with Narayana Hospital had taken its toll on Vasudha. She now desperately wanted to succeed financially. But was financial success the only measure of success? Wasn't there more to life than money? These thoughts lulled him to sleep.

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Vasudha felt bad at how she treated Sheshu's plan. She was torn between doing something that she knew would make him genuinely happy and doing what she thought was right for the hospital. She realised that they had convinced close family and friends to invest their money in this venture. She also realised that they both had worked so hard to set up the hospital and bring it to a position that it was in today. She had a duty to the people who had invested and to themselves as well to make this a commercially successful venture. Was there a way both could be done?

Vasudha recalled what she liked about Sheshu. When she had met Sheshu for the first time, she was deeply drawn by his no-pretence, genuine demeanour. She loved him for his innocence. Here was a guy who was completely what-you-see-is-what-you-get. She had met so many attractive men during her IIM days and later, in her stint in consulting. She found most of them putting on facades. They would say things they did not believe in just to make an impression. People like to have others think about them in a certain way. They say things that reinforced the false personas they have built around themselves. Things became really complicated when the individuals themselves started believing the lies they've been peddling. Their lives became totally messed up at that stage.

Sheshu, on the other hand was like a sheet of glass, completely transparent. After years of living with him, she knew that he could never say something he did not believe in. Vasudha loved this vulnerability. 

Vasudha wanted Sheshu to be happy. She would do something that would pacify him.

The next day, she called a meeting of the Admin Team. Along with the email requesting a meeting, she gave a high level overview of Sheshu's plan and attached the presentation file. She asked them to review the presentation and be ready with comments before the meeting.

The team met at the Conference Room. Vasudha began the discussion. She talked about how change is the only constant in life and how they needed to adapt to the changing times. With patient-centric care becoming the latest buzzword in healthcare, maybe Narayana needed to think things afresh and come up with some new, radical ideas. The team heard her carefully. She then invited comments on the plan that she sent to them. One by one, the team pointed out problems with the plan. The objections were on the same lines as those that Vasudha had voiced to Sheshu. 

One of the team members, Manav Sharma was silent. Vasudha looked towards him and asked, "Manav, you seem to be quiet. What are you thinking?"

"Ma'am, I believe this plan has its merits. The key to this plan is to ensure increased patient walk-ins which will ultimately protect the hospital's revenue and bottomline. We all understand that our numbers eventually depend on volumes. If we come up with an intelligent marketing campaign around  this - for both doctors and patients, we can make this work. But it will not be a short term thing. We will need to be patient. In the end it can work."

"Interesting take Manav. The question is, will we have enough time before panic sets in? Also, do you think we can do something with the government on this?"

"Government would be very interested in this model. With Aarogyasri bleeding like crazy, I am sure they would be keen to see how this model works", Manav said.

"Ok. Thanks all of you for your inputs. Let me think about this."

------------------------

The next day, both Dr. Som and Vasudha called a meeting of the Administrative team in the conference room. Vasudha told the team that they have decided to do a pilot of the plan. They would try the plan in one department of the hospital for three months and see the results. At the end of the pilot, they would take a call based on the results. The results would include the results of a patient satisfaction survey. This would be necessary as three months would not be sufficient to assess the full impact of the plan.

Vasudha asked the team which department they thought would be ideal for this pilot? Everyone came up with different suggestions based on different reasons. Dr. Som said, "Let's start with Nephrology." "Yes", Vasudha agreed, "let's start with Nephrology."

"Manav will lead the pilot implementation and we will have monthly review meetings to discuss the progress."

"Sure ma'am." Manav was happy at being given this responsibility.

The meeting ended. Dr. Som walked up to Manav and told him, "Looking forward to working with you Manav." "Same here, sir", said Manav. "Come to my cabin. Let's get started right away."

Dr. Som was excited as they entered his cabin. He went over to the white board that was put up on one of the walls and wrote the high level plan:

1. High fixed salary for doctors
2. No incentives for investigations and prescriptions
3. No targets for investigations
4. No referral fees to refer to other consultations
5. OP and IP investigations and drugs to be charged at the same rates
6. Medical Representatives to send all new product details to a common email id which would be screened by a Vigilance Committee
7. Outcomes of the patients being treated to be tracked electronically and monitored closely
8. Patients to take a satisfaction survey at the end of their visit

"Sir, this is quite radical, to be honest with you."

"I know Manav. That is why it is important that we have to make it work. For how long are we going to continue like this? Currently I feel like I have sold my soul to the devil. Someone needs to make a beginning. What I am trying to prove using this model is that doctors and hospitals will both gain at the end of the day. Patients of course will gain. But even doctors and hospitals will be able to make as much money as they do currently and they need not feel guilty about it."

"Let's hope we are able to make it work, sir."

"We don't have a choice Manav. I want you to get me the payouts to all the doctors in the Nephrology department in the last twelve months. Then also get me a summary of investigations prescribed by doctors and the revenue by investigation per month for the last twelve months. Also send me number of dialysis sessions and payout on that account. We can use these numbers as a baseline and work from there."

Manav had all this data in his laptop. He opened his laptop and showed the data one by one to Dr. Som. 

"Now do this Manav. Come up with the average payout to each doctor, add 10% to that and make that the fixed salary for the doctors from next month. Remove the referral fee from all investigations and procedures including dialysis and come up with a new nephrology tariff keeping the profit to the hospital the same. Also come up with a patient survey on about 3-4 parameters which is very easy to take and captures the most important points related to pricing, time with doctor, NPS and comments."

"Got it, sir", said Manav as he noted all these. "Give me time till tomorrow morning, sir."

"Sure Manav. See you at 9 a.m tomorrow."

------------------------

Manav worked until late that night and got all the numbers and the survey questions ready by the next morning. 

Dr. Som and he discussed the numbers, made a few tweaks here and there. They decided to run the numbers by Vasudha. Dr. Som sent the file to Vasudha who said they looked good and that they should roll it out as soon as possible. 

Dr. Som and Manav felt they should explain the move to the doctors in the department and get their thoughts as well. So, they had a meeting with the doctors where they went over each of the points. They took pains to assuage any concerns the doctors might have on any of the aspects of the plan. The doctors seemed to be on board. However, by the end of the day, doctors in the other departments got to know of this. Some of the senior doctors went to speak to Vasudha. The main concern they had was that having different rules for different departments was not the right thing to do. They were wondering how inter-departmental referrals would work? For example, if they referred patients to the nephrology department, would they get their referral fee? Vasudha said that would not be the case. Anything pertaining to the nephrology department would now work as per the rules of the pilot. The doctors were against such a partial implementation. Vasudha convinced them to give the pilot three months of time.

Dr. Som and Manav decided that the plan would be rolled out on the first of the following month, about two weeks away. This would give enough time for the other departments to gear up for implementation. They put up notices on the board informing the patients about the changed tariff. They made it very clear that this was for a period of three months only. The patients were pleasantly surprised. For the first time, they had seen prices actually go down for services at a hospital, even if only temporarily.

The pilot began with little fanfare. Not much change was seen on the ground. Things went on like before. Dr. Som and Manav reasoned that the real impact was in the patient satisfaction survey numbers which would indicate if the number of patients would eventually increase or not. Dr. Som and Manav did some informal feedback gathering as well. There was a generally positive feedback on the new prices. Doctors were also happy because their earnings from the hospital remained intact. 

Dr. Som and Manav conducted a weekly review of all the numbers including those related to patient satisfaction. For the first few weeks, there was no change at all in any of the numbers. At the  beginning of the second month however, hospital revenues from the department began going down. The profit from the department also dipped. Dr. Som and Manav were worried. They tried to analyse the reasons behind this. Manav dug deeper and found that the new patients added for dialysis had dropped. He also noticed that the revenues from investigations from the department had also dropped.  He discussed his findings with Dr. Som. He told Dr. Som that it was likely that other doctors in the department were referring cases elsewhere. That way they would get their fixed income from Narayana Hospital and get a referral on these cases from other places.

Dr. Som called a meeting of the doctors of the department. He discussed the findings with them. Each of them sounded surprised. They assured Dr. Som that none of the cases were going outside. They thought this could be a temporary thing and that things would pick up once other patients got to know. Dr. Som and Manav agreed.

------------------------

During their weekly reviews, they saw the same trend continuing. Numbers kept dipping. At the beginning of the third month, however, the numbers were quite alarming. The nephrology department as a whole became loss-making. Patient satisfaction ratings remained about the same. Dr. Som and Manav were very nervous. They were losing the only opportunity they had to make this work. They had a meeting where they brainstormed how they could fix things. They rolled out a patient-referral scheme for patients. If an existing patient referred another patient, he or she would get a one time referral incentive. They also decided to roll back the drop in dialysis prices. This would help improve the profitability of the department. 

Patients were very upset with the rollback of the dialysis price decrease. They argued with the staff that they were promised that the drop would be there for at least three months. Why this change, they questioned? The satisfaction numbers plummeted as a result of this. Dr. Som and Manav thought that if the hospital numbers cold be improved, they could explain that away. 

At the end of the three month pilot, Dr. Som and Manav reviewed all the numbers in detail. The hospital numbers did not improve at all. The nephrology department's revenues and profitability both went down even further. The reasons were unclear. The patient satisfaction numbers were also lower than before. They thought through the plan of action. Dr. Som told Manav that this kind of plan needed at least one year of piloting. Three months was too short. Manav could sense the desperation in his voice. A meeting was called with Vasudha to discuss the results of the pilot. Vasudha got the other members of the Administration team in as well. Manav presented the numbers and in his conclusion said that they should pilot this for one year because three months was too short for such a radical change.

The other members voiced their opposition to continuing the pilot any longer. Manav argued that news about the change in prices took time to spread and patients would get to know in some more time. One of the Administrators pointed out that if this was true, at least the patient satisfaction numbers should have shown an increase. Manav said patients would generally be cautious while giving too much good feedback too soon. They would wait to see if this was sustained. No one in the room seemed to agree. If anything, they argued, patients would give good feedback to ensure that the hospital kept the prices low.

Vasudha heard everyone out. Dr. Som was quiet throughout. Vasudha concluded the meeting saying she would discuss with Dr. Som and then decide by the next day.

That evening, Vasudha asked Sheshu just one question, "What would you do if you were in my place?"

Sheshu replied, "Continue the pilot for a year."

"You're not being truthful Sheshu. I know this project is close to your heart. But we need to be practical. I promise you we will revisit this in thee years when our financials are more stable. We're just too shaky right now. I listened to you and despite my doubts, agreed to the pilot. But the numbers speak for themselves."

"Ok, shelve it then."

"Is it our decision?"

"Does it make a difference?"

"Yes, of course, it does."

Sheshu was silent.

Vasudha sent an email to the team asking for the pilot to be rolled back and everything to move back to how it was three months back. She had to do what was right for the hospital. Despite loving Sheshu deeply, she had to decide based on what her duty as head of the hospital was. She needed to balance the multiple roles she played in her life. She needed to separate her personal life from her professional life, however difficult that may have been.

------------------------

Dr. Som got back into his daily routine soon after the project so close to his heart was shelved. This was the best way he could help get over the heart-break he suffered. Within a couple of weeks, things were all back to normal between the couple and at Narayana Hospital.

One evening, after a particularly gruelling day at the hospital, as Dr. Som took off his shoes and socks at home, he noticed that his feet were swollen. He thought it was due to the long hours he spent on his desk without walking. He made a mental note to walk around his room every hour or so. The next day, during his OP hours, he got up every hour between two patients and took a walk in his room. He felt a little tired within a few steps. He found that weird. He ignored it however and just stood up, took a few small steps and then continued to see the patients.

This went on for a few days. He however felt that his discomfort was getting worse. One evening, as he completed his consultations, he got up and as he was going towards the door of his cabin, he suddenly felt a huge rush of blood towards his head. He felt suffocated. He reached out to hold onto something. He felt his vision becoming blurred and then totally black. Within a moment, he lost consciousness and fell onto the floor. 

Hearing the noise of his falling, the office buy rushed in. He was shocked to see Dr. Som on the floor, lying motionless. He rushed to the intercom telephone and called the ICU. Within a few minutes,  Dr. Som was rushed to the ICU and the intensivist attended to him. 

Dr. Som opened his eyes after about fifteen minutes. He was surprised to find himself in the hospital ICU, Vasudha looking over him anxiously and almost all the senior doctors of the hospital surrounding his bed.

"What happened?"

"Sir, don't worry. You must relax. Your BP was high and you collapsed."

"What? My BP? High? How much?"

"Sir, please don't worry."

"What, don't worry? Tell me. What exactly happened to me?"

One of the senior most doctors who was to his right responded, "Sheshadri, it was 210/110. You collapsed. We have put you on..."

Dr. Som drifted to sleep again.

The next time he woke was after about an hour. By then the doctors had drawn samples of his blood and sent them to the lab for testing. This time, only Vasudha was by his side apart from some nurses. He asked her, "What's happening Vasudha? Where is everyone?"

Vasudha responded, "Sheshu, you are fine. They have drawn some blood to get some tests done. Dr. Murthy is at the lab and he will be back with the results soon."

At the lab, Dr. Murthy couldn't believe what he saw in front of him. Dr. Som's kidney function was severely compromised. For the first time in his life, he had encountered a doctor, and that too a nephrologist with kidney failure. He was at a loss now. How would he explain this to Dr. Som and his wife? What would he say to them? How would they react? 

Dr. Murthy immediately called a meeting of the senior nephrologists in his cabin and updated them about the test results. He assigned the senior most among them, Dr. V. Sampath, the chief duty of treating Dr. Som for the moment. They decided that the two of them would go to the ICU and talk to Vasudha first.

------------------------

When the two doctors entered the ICU, they saw Dr. Som was asleep. Vasudha was sitting next to him. She sprung up as soon as she saw them and asked them what the matter was. They signalled to the ICU Duty Doctor to look after Dr. Som and they ushered her into a chamber.

Vasudha was anxious. "What do the test results say, Doctor?"

"Ma'am, Dr. Som's creatinine is 8.4."

"What? How can that be? He did not have any signs of this until now? Suddenly? How can it be? Send a repeat sample."

"Already done ma'am."

"I'm sure there is something wrong."

"Let us hope ma'am."

The Serum Creatinine test was one of the basic tests of kidney function. The normal range is between 0.5 to 1.2 mg/dl. Dr. Som's was about seven times the upper limit of normal.

The doctors went back to the lab to personally supervise the testing.

Vasudha returned to the chair. She remembered the bits and pieces of her conversations with Sheshu about kidney disease. She remembered him saying that Kidney Failure was almost always progressive. It started slowly when there would be no symptoms. Gradually the symptoms would build up and the kidneys would lose more and more of their function. She tried recollecting if there was anything unusual with Sheshu's health over the past few weeks. She couldn't remember anything out of the ordinary. "There must be something wrong with the report. It cannot come suddenly like this. Maybe its just exhaustion. Once the report comes and he becomes stable, we should go for another holiday. Hospital be damned. Health comes first. This has made me so scared. What is the point of all this?"

Sheshu opened his eyes again. "Vasudha, I want some water." Vasudha signalled to the nurse. The nurse brought some water and gave it to him. 

"What is happening here Vasudha? Where are the doctors?"

"They are at the lab. Just getting the reports. Once they come and everything is ok, we can go home."

Even though Narayana was their own hospital, Vasudha felt suffocated inside the ICU. She just wanted to be back home with Sheshu. She could not bear the sight and feel of the place. Monitors beeping, an eerie silence otherwise, Sheshu on the bed lying like a patient, various probes connected to him. The entire feeling was terrifying. Even though she had come numerous times to the ICU in the past, for the first time in her life she was experiencing it as a patient's attender. She would do anything to get out of there as soon as possible.

Sheshu looked around him. He was also experiencing the ICU for the first time from a patient's bed. He saw the nurses attending to the other patients. He noticed the probes attached to his finger, to his chest and the monitors beeping next to him. He felt quite intimidated. He had walked into the ICU multiple times every day to check on his patients. He felt completely weird being on the receiving end. He started wondering what he could change about the setting to make it more friendly and less scary?

Maybe, the beeping of the machines could be muted? Maybe the lighting could be brighter? The probes, what could he do about the probes? Maybe a television? He needed to give this place a makeover! He discussed his thoughts with Vasudha. He asked her to pull out her phone and take some notes. "This is a great opportunity Vasu. Let's note down what all we can change here!" Vasudha played along. He dictated and she typed out into her phone. They had about eight or nine items on the list when the doctors returned from the lab.

------------------------

"Dr. Murthy, we need to change things around here a little. It was probably good that I had to spend some time here. I got to see things from a patient's perspective." Dr. Som said excitedly.

"Yes of course."

Vasudha asked the doctors whether the reports were ready. Dr. Sampath nodded. "Sheshu, let me just take a look at the reports and come back." Vasudha had this uneasy feeling suddenly by looking at the doctors' faces. 

"Sampath, what's wrong? Tell me. I am a doctor in case you've forgotten." Dr. Som began to get a little anxious.

The two doctors were in a quandary. How could they tell him? On the other hand, how much longer could they hide from him? He was a nephrologist, after all!

Dr. Murthy came and stood next to Dr. Som's bed. He said, "Dr. Som, you need to be strong now. Being a doctor, I am not going to hide anything from you. But you need to understand that if you are not strong, it will be difficult for everyone, most of all, for you."

"What is it? Just tell me!"

"Your creatinine is 8.4."

"What? 8.4?"

Dr. Som felt his heart becoming heavy. Vasudha felt her eyes moisten. 

"We've repeated the entire set of tests. Your kidney function is compromised Doctor."

"How can that be? I have had no symptoms. Nothing at all. There must be some mistake. Somewhere. How can it be?"

Vasudha held his hand. "Be strong Sheshu." She could not stop the tears rolling down her cheek.

"Show me all the reports."

Dr. Sampath handed over the entire set to Dr. Som. Dr. Som went over each one of them. Once, twice, thrice.

Dr. Som just could not believe what he was seeing. It seemed like he was going over the reports of one of his patients. But every now and then his eyes moved to the name of the patient on the report and the name "Dr. Sheshadri Som" stared back at him. He kept thinking back to see if there was any symptom of kidney disease he could recollect. He couldn't remember any symptom. The reports could not be wrong either. They had repeated the samples. What should he do now? Should he treat himself? Rely on his team? Move to Hyderabad? No, that would be ridiculous. That would send a very bad signal. Also, he trusted his team. They had good experience. They were efficient. He needed to have confidence in his team. He needed to have complete faith in them. He had to surrender to them.

Dr. Som gathered himself. "So, what's the plan Sampath?"

Dr. Sampath was a little startled. Would he be treating his own boss? 

"Sir?"

"What are you planning to do now? I am your patient. Please forget that I am a doctor. Please forget that I own this hospital. Please treat me like a new patient. Let me know what you are planning to do now?"

"Y...yes sir. Please excuse me sir. I will be back in a few minutes."

"Sure."

Dr. Sampath hurried out of the ICU and went to the nephrology department. He called the doctors for a meeting. It wasn't a very big department. Dr. Som and Dr. Sampath were the only nephrologists by qualification. There were two other MBBS doctors, Dr. Rahul Kumar and Dr. Suhail Ahmad who were being trained for the last couple of years. Both were quite sincere and hardworking. Dr. Sampath gave them an update on Dr. Som's diagnosis and told them that they all together needed to offer the best possible care to him. 

They brainstormed on the plan. They decided to plan a kidney biopsy in the next 2-3 days. They also decided to put in a temporary catheter the next morning for dialysis which Dr. Som would need immediately.

Dr. Sampath headed back to the ICU. He informed Dr. Som about the plan. He added at the end, "Any thoughts, sir?"

"No Sampath. Sounds good. You go home and get some rest. It's already midnight." 

Dr. Sampath called out to the nurse on duty and asked her to call Dr. Rahul to the ICU.  

"Vasudha, you go home as well. Get some rest. You can come back tomorrow morning."

"No Sheshu. I would like to stay. I will not be comfortable at home."

They argued for some time on the subject. In the end Vasudha had her way. She would sleep in the doctor's cabin within the ICU.

In the meantime, Dr. Rahul came to the ICU. Dr.Sampath instructed him to be stationed in the ICU the whole night and watch over Dr. Som.

Dr. Som then tried to sleep. It was a very tiring day, a life-changing day. Dr. Som began to understand what his patients felt when they were initially diagnosed with kidney disease. He felt uncertain about his future. He had no clue how this would turn out? What would the biopsy say? Would he need dialysis or a kidney transplant? Where would the kidney come from?

------------------------

The next morning, Dr. Sampath came to the ICU by around 7. Vasudha was already up and was sitting beside Dr. Som. The plan was to put in a temporary catheter into the jugular vein to enable quick dialysis. A permanent access for dialysis called an Arteriovenous fistula takes about 4-5 weeks to mature and be usable. A temporary catheter is often used to enable the patient to get dialysis immediately. 

Dr. Sampath had a nurse assist to him. He requested Vasudha to wait outside. Vasudha readily complied. He opened the catheterisation kit and the catheter. He told Dr. Som that he was giving a small injection which was  local anaesthetic which would numb the area and allow Dr. Sampath to put in the catheter comfortably. Dr. Som had done hundreds of such procedures himself. He felt it weird that it was he who was now at the sharp end of the needle!

Dr. Sampath had also done this procedure many, many times and tried hard to not feel any pressure and treat Dr. Som just as another of his patients. That way he would confidently complete the procedure in a few minutes. He inserted the catheter into the site and tried placing it into the right position. He felt some resistance to the catheter. He nudged a little. No luck. Dr. Som started getting anxious. But he did not want to say anything and disturb Dr. Sampath. He could not see what was happening. He had to surrender completely to Dr. Sampath at that time. He knew something was amiss. The catheters generally just go in without any problem.

Five minutes passed since Dr. Sampath tried to insert the catheter. He tried nudging and pushing. The catheter wouldn't budge. Dr. Sampat became tense. He could feel droplets of sweat form on his forehead. At one point, his hands started shaking. He did not utter a word. After another few minutes, Dr. Sampath decided that he would give up and remove the catheter. He told Dr. Som, "Sir, there seems to be something blocking it. I am withdrawing."

Dr. Som was surprised. "Ok", he said.

Dr. Sampath began withdrawing the catheter. When he was gently pulling the catheter out, he felt something snip. As he pulled the catheter out, he realised to his horror, that the tip of the catheter had broken and the piece that broke was left inside. By looking at the catheter, Dr. Sampath figured that the tip that was left inside was about an inch long. He started shivering. His hand was on a thick piece of gauze that he had placed on the site to prevent bleeding. Dr. Som asked, "Why are you trembling Sampath?" 

Dr. Sampath started sweating profusely. He had no clue what to say. He felt the floor slipping from under his feet.

"S...sir..... The t...t....tip of the c....c.....c.....catheter broke and is left inside."

Dr. Som closed his eyes in disbelief. Dr. Sampath quickly fixed a plaster to the site tight to prevent bleeding and rushed out of the ICU to tell Vasudha and the other doctors. Within minutes, the senior doctors all assembled in the ICU.  They all had an eye on the vitals being thrown out on the monitor attached to Dr. Som. The worry was where the needle would go and what damage it would create. They had absolutely no control over this. They had to now do a CT scan to determine where the needle was and figure out a way to remove it.

Dr. Som could not utter a word. Vasudha was dazed. She pulled Dr. Murthy and Dr. Sampath aside and asked, "Should we shift him to Hyderabad?"

Dr. Sampath had regained composure by then. "Risky, ma'am. We should try to see where the piece is now. After that we can decide." Dr. Murty nodded. "Let us do the CT and then decide."

------------------------

Dr. Som was rushed to the CT scan room. They hurriedly shifted him to the platform and strapped him to begin the scan. The team was watching anxiously from the monitoring room. The radiologist started the process. One by one, he checked different areas of the body. At one point, he felt like he spotted something. He signalled to the other doctors to see. They quickly ruled that out. Where could the needle piece be? Finding it was the first step. If they found it in a difficult place, the next step would be much more difficult. 

They saw images of the brain, the heart, the arms, legs, the stomach. Nothing at all. They repeated the whole procedure again. The entire team was intently watching the screen throwing out images one by one. Vasudha was pacing up and down the room. She could not make out the images. She stopped to look at them at times but it did not help at all. After a while she sat on a chair. When she heard  a murmur from the radiologist, she got up with a start and looked at the doctors for any hint of success.

During the second round of images, when they were seeing images of the heart, suddenly, the radiologist spotted the needle piece. It was unmistakable. He pointed to the screen. To everyone's horror, they noticed that the piece had pierced one of the valves of the heart and blood was gushing out of the tear. They looked at each other and rushed into the room where Dr. Som was kept. Dr. Murthy shouted out, "Dr. Som! Dr. Som!"

Dr. Som did not move. "Quick, get the stretcher. To the ICU."

Two boys brought the stretcher that was kept aside and placed it right next to the CT scan machine platform. They got hold of the bed sheet that Dr. Som lay on and carried it along with Dr. Som and placed it on the stretcher. They ran with the stretcher towards the elevator. The entire team ran behind them. They had to stop the blood somehow. All the time, the doctors tried waking Dr. Som up. He did not move one bit. They feared that the continuing blood leak was reducing his Blood Pressure. They had to get him to the ICU and push in enormous amounts of saline immediately to prevent the heart from failing.

They reached the ICU within minutes. One of the doctors had already called the ICU and informed them of the situation. The team there had the bed and the saline bottles and the infusion set ready. As soon as they reached, one nurse connected Dr. Som to a bottle of saline and began the infusion. Another nurse connected the vitals monitor. Dr. Murthy was shocked to see that the Blood Pressure of Dr. Som was a dangerously low 80/50. The heart rate was dropping as well.

The saline was not making too much of a difference. They then decided to give an injection of Adrenaline. The syringe was filled and a shot was given directly into the heart. There was no improvement in the Blood pressure and heart rate. The intensivist brought a defibrillator and took the two plates and thrust them on Dr. Som's chest. Dr. Som's upper body jumped up in the air and landed back on the bed with force. No improvement in the Blood Pressure and heart rate.

Blood pressure was now 50/30. Heart rate was around 45. One more try with the defibrillator. The body went up in the air and back on the bed.

The line on the monitor was now straight. They tried the defibrillator one more time. The body went up in the air and back on the bed. The line on the monitor remained straight. 

It was all over.

------------------------

The cremation was to take place at Swami Madhavanand Ashram, by the banks of the River Godavari. Swami Keshavanad was going to supervise the cremation. Both, Vasudha's and Dr. Som's parents had already arrived. Several other close relatives had arrived. Everyone was in complete shock. Vasudha had not yet come to terms with Sheshadri's death. She was going through the motions of the cremation and accepting condolences of various relatives and friends who had gathered. For a moment, she would wonder where Sheshu was? And then the next moment, her eyes would fall on his body and her heart would become heavy and she would realise what had just happened. 

The cremation was performed by Dr. Som's father who was completely broken. They say, the biggest burden a father can ever carry is that of his son's dead body. The elder Dr. Som could barely believe that his son, whom he was so proud of was no more. Vasudha was standing beside her parents. With no tears in her eyes, her face was almost lifeless. It was as if she had no clue about what was happening. 

When the cremation was completed, the family was wished by the hundreds of visitors. At the end of it all, the family sat around Sami Keshavanand. Swamiji explained the ethos of the Bhagavad Gita and the concept of death according to the Hindu scriptures. He stressed that though Sheshadri's soul had left his body, it was by no means dead. By remembering that, they all had to keep in mind what he stood for and what he believed in. He advised them to continue the good work that he had done in his lifetime. 

"Think about what he wanted to do. Think about what he wanted to accomplish. Was there anything he left undone which he wanted to do? Work towards achieving that. That would be the best way of remembering him."

The rest of the family bowed to Swamiji and walked towards the car. Vasudha stayed back for a few more moments. She addressed Swamiji and said, "I know what you mean Swamiji. It was I who had stopped him from achieving his dreams. I was the one responsible for his death. The catheter that broke - I, I was the one that fought with him to use that catheter in our hospital. Who knew that this would happen? Who knew that my decision would be the one that would kill poor Sheshu?" Tears started gushing down her cheeks as she said these words.

Swamiji calmed Vasudha. "Don't blame yourself Vasudha. When someone's ayushya is completed, only excuses are needed for death. So, if it wouldn't have happened because of the catheter, it would have happened in some other manner. What is important is for us to realise what is right and what is wrong and then act accordingly. There really is no point in putting the blame on anything or anyone."

Vasudha nodded and wiped her tears. She stood up and bowed to Swamiji and headed towards the car.

Once they reached home, the family rested for some time. Sheshadri's parents would leave the next morning while Vasudha's parents decided to stay for a few weeks to support her in recovering from the trauma and coming to terms with her loss.

Vasudha could barely sleep that night. She kept tossing and turning in her bed. Swamiji's words kept ringing in her ears. 

"Think about what he wanted to do. Think about what he wanted to accomplish. Was there anything he left undone which he wanted to do? Work towards achieving that. That would be the best way of remembering him."

------------------------

The next morning, Vasudha got ready and came out of her room quite early. Her mother who was already awake, asked her, "Where are you going?"

"I'm going to the ashram ma and then to the hospital."

"Ashram is ok Vasudha but you should rest for a few days. What is the hurry to go to the hospital?"

"No ma, I will feel worse if I stay at home. Going to the hospital will keep my mind busy and I will not think about this."

Her father hearing the discussion came out of the room and said, "Let her go. She is right. Her mind needs to be busy. She will feel worse sitting at home."

Vasudha reached the ashram and went to the cremation site. She spent a few quiet moments there and then headed towards Swamiji.

She bowed before him and said, "I need your blessings Swamiji. Make me strong. Bless me that I do not break."

Swamiji said, "You are strong Vasudha. I know you are. Obviously, my blessings are always with you."

Vasudha left the ashram and drove straight to the hospital. The staff there was surprised to see her. She took a round of the wards and the various OTs and ICUs and then headed towards her cabin. She checked her email and responded where needed and then called Manav.

"Manav, can I see you now, please?"

"Of course, ma'am. Coming there."

Manav knocked at the cabin door and opened it. Vasudha asked him to come and sit. He was quite surprised that she was back at work.

"Manav, can you put all the plans and analyses you and Dr. Som did for the pilot and send it to me? Every single file, every single dataset."

"Sure ma'am. I have everything in one folder. I can send that to you very soon."

Manav went back to his table and quickly pulled out the folder and sent it in an email to Vasudha. He was wondering what she was planning to do. The pilot had failed so badly. Could Dr. Som's passing have caused her to change her mind?

Vasudha called the head of procurement, Sateesh Kumar to her cabin next. She asked him to stop using the catheter that had costed Dr. Som his life. She also asked for a complete review of all consumables. She asked him to come up with a complete list of brands being used at the hospital grouped by department and consumable.

The Head of Finance was the next person to be called. Vasudha asked him for a one page snapshot of the company's financials comparison since inception, year on year. She wanted this by the end of the day.

The entire hospital was agog with all the happenings. "Maybe she is going to close the hospital?", said one. "No, she might be thinking of selling it off to someone", countered another. "Maybe she is planning to become a sanyasin at the ashram. She went there this morning!"

Manav heard all this and thought, "What bullshit! People just need an excuse to gossip. She is definitely not going anywhere. Why would she ask for the pilot files? She may not implement the pilot because it failed. But she's not going anywhere. For now at least!"

------------------------

Three days later, a meeting was called of all the Heads of Departments and the Admin team at 9 in the morning. Vasudha addressed them in the Conference Hall.

"Good morning everyone. Thanks for taking the time out and coming in for this meeting. Our hospital has gone through many tough phases but none can compare, at least for me at a personal level to that we have just faced. When Dr. Som and I started this hospital, we really thought we could bring quality healthcare to Rajahmundry and the surrounding areas. This was lacking and we thought we could fulfil a real need.

We raised money from many people who had faith in our capability. Over the years we have built a solid team. We are doing fairly well for our age and our size. Somewhere down the line, however, I got a little paranoid about the financial viability and sustainability of the hospital. In that process, certain compromises were made. I now realise how dangerous even a single compromise can be in healthcare.

We all should never forget that the lives of our patients is in our hands. For us, the death of a patient merely becomes a statistic. A number in an Excel spreadsheet somewhere goes up by one. However, when you think, of the impact on the patient and his or her family, this means a lot, lot more than that spreadsheet number. The patient's life is over and with it, all her dreams, all her ambitions also die. For the family, it could mean a tumultuous change. They could be faced with uncertainty over their future. Many families lose their sole breadwinners. Imagine their plight!

Healthcare companies and especially hospitals like ours should never lose sight of the overarching goal of providing and sustaining life. Everything else is secondary. If we put financials above life, then we are doomed to fail. Unfortunately I have realised this a little late.

Dr. Som had a vision - quality healthcare at affordable prices. I am going to work towards achieving that vision at this hospital from this moment onwards. He had come up with a plan a few months back which I and many of us in this room had felt was not sustainable. We tried a pilot which failed and was scrapped. I have decided to reinstate that pilot. It was not a perfect plan. But at least the intent was right. We need to work together as a team and iron out the kinks in the plan and make it work.

We have lost Dr. Som. Whether we had control over that or not is a matter of debate. We still have his ideals. Whether we lose them or not is completely in our control. I need the co-operation of each and every individual in this room. Without that we will fail. I will be sending a detailed plan over email. This is, by no means, a final plan. This is for your thoughts and inputs. Please go over the plan in detail and get back to me with your thoughts by the end of this week. We will meet again on Monday to discuss specific aspects of the plan and your suggestions. Rollout will happen on the first of next month.

And yes, Manav Sharma will lead the implementation of this plan. Thanks all of you."

Many people in the room had become a little emotional. Some felt their eyes turn moist. They all got up, came and wished Vasudha and then left one by one.

Manav was the last person left. He walked up to Vasudha and said, "Ma'am, thanks so much for doing this. And thanks for putting your faith in me. I promise I won't let you down. I will work hard to make this plan a success. I promise you, you've done the right thing."

A tear rolled down Manav's right cheek. He was embarrassed. He quickly wiped it and left the hall.

------------------------

Manav worked hard on the plan. This plan would be much bigger and riskier to implement because it would not be restricted to the nephrology department. Vasudha felt that this had to be done across all departments for it to be effective. Manav wore down the high level points that Dr. Som had proposed:

1. High fixed salary for doctors
2. No incentives for investigations and prescriptions
3. No monthly targets for investigations
4. No referral fees to refer to other consultations
5. OP and IP investigations and drugs to be charged at the same rates
6. Medical Representatives to send all new product details to a common email id which would be screened by a Vigilance Committee
7. Outcomes of the patients being treated to be tracked electronically and monitored closely
8. Patients to take a satisfaction survey at the end of their visit

He thought over each of these items and came up with the problems they had encountered in each of them. He wrote down the set of problems and possible solutions for each problem. He worked without taking a single break except for meals and sleep. After three gruelling days, he emailed the document to Vasudha. 

Vasudha took a day to review the document, making notes and adding comments. She called Manav and discussed each of the points. They had several discussions over the next few days and about a week after Vasudha addressed the team in the conference hall, she emailed them the plan. She asked them to review in detail and said that they would meet in three days for a detailed discussion.

The email read:

"Dear team,

I appreciate your co-operation in running Narayana Hospital for all these years. As we discussed the other day, we would like to change the way we operate in this hospital. We would like to make sure that every department here practices in the most ethical way possible. At the same time, we obviously need to ensure the financial sustainability of the hospital and also ensure that any of the stakeholders, especially you are not financially affected. Keeping all this in mind, Manav Sharma and I have come up with a draft of the plan. I am putting down the high level details here for your perusal. Please review this and keep your questions and comments ready which we will review on Monday morning at 9 am in the Conference Hall.

1. Fixed salary for all doctors: computed as average monthly income from hospital for last 3 months plus 10%
2. No incentives would be paid for prescribing investigations, pharmacy products and procedures
3. No additional fees will be paid for monthly targets for investigations; no monthly targets would be set
4. All referral fees for other consultants would be scrapped
5. IP investigations and drugs would be charged at OP rates
6. A Vigilance Team would be created whose job would be to ensure and monitor adherence to the new plan
7. A committee would be formed for each department which would consist of the head of the department, one member from the Admin team and one member from the Vigilance Team
8. Medical Representatives would need to send details of all new products to this committee which would then pass on the information to the doctors based on the merits
9. The Vigilance Team would be authorised to conduct checks on patient prescriptions and medical records
10. Each Head of Department would come up with the list of outcomes to be tracked for various conditions and these outcomes would be tracked on a regular basis. Doctors would get an outcome based incentive
11. A Patient Satisfaction Survey would be administered to most patients from time to time using a mix of paper based and telephonic surveys. Doctors would get incentivised based on the results of these surveys

All these points are open for discussion. Please come up with questions and comments and we will discuss on Monday.

Thanks
Vasudha Som"

------------------------

On the following Monday, at 9 am, all the Heads of Departments along with the Admin team assembled at the Conference Hall. Vasudha greeted them and started asking for comments on each of the points identified in the email that outlined the plan.

Dr. Samba Murthy spoke first. "Ma'am, this plan is almost the same as that which Dr. Som had piloted. The only difference is that it is being implemented across all departments rather than one department. I am just concerned that when the pilot failed, how will this project, which is an extended implementation of the same pilot, work?"

Vasudha turned to Manav. "Manav you want to take that?"

"Yes ma'am. Dr. Murthy, alongside these changes, we have planned a massive marketing campaign in the entire state of Andhra Pradesh. The problem we faced in the implementation of the pilot was that we did not see an increase in footfalls in the hospital. We were doing a great job from the patient's perspective but that was not being communicated to the patients. We will be having a special budget allocated for marketing. We will he working with a very reputed firm from Bangalore for this."

The Head of the Orthopaedics Department said, "The project is very good ma'am. However, one concern we all have is on the Vigilance Team. What would be the powers of the this team? Who would be the members of this team? Would they be doctors?"

"They will not be doctors. Doctors would not have time for this," Vasudha responded curtly.

"If they are not doctors, how will they understand medical records? We are worried that they would overstep their mandate. They would become a superpower within the hospital and question everything we do."

Vasudha softened a little. "Don't worry about that Doctor. We will ensure that proper guidelines are given to the Vigilance Team. Honestly, we have not decided who will form this team. We just realise that we need someone to check that the new rules are not misused." She needed to make sure everyone was genuinely on board for this plan to work.

Dr. Sampath from Nephrology then said, "Ma'am, there are two points that talk about additional incentives - one is based on the outcomes and the other is based on patient satisfaction surveys. No details have been given on how those incentives would be calculated."

Manav responded, "Dr. Sampath, these incentives will be pegged at 5% of each doctor's fixed salary. So, each doctor can earn a total of 10% over and above the 10% additional over your last three month's average. Let's say a doctor receives a patient satisfaction score of 90% during a month, that doctor would be eligible for a 4.5% additional salary."

"What about the outcomes? How would that be linked to the salary?"

Vasudha interjected, "As you know, each HoD is going to come up with a set of outcomes for their department. The proportion of patients who achieve those outcomes would determine the outcomes based incentive. For example, in dialysis, one of the outcomes, I am told, could be the Hemoglobin. If the Hemoglobin target range is 9 to 11.5, the % of the doctor's patients that achieve this target value would affect the doctor's incentive. A weighted average of all the outcomes would be used."

Suddenly there were a lot of murmurs in the hall. People started talking with one another. Vasudha raised her hand, "One at a time please."

One by one the doctors started raising their concerns about this incentive. 

"These outcomes are not solely in the doctor's control. If patients cannot pay for the drugs prescribed, how can we be blamed?" 

"How will they be measured? If patients don't do investigations, how will the outcomes be measured?"

"If anything is going to be outcomes based, doctors will refuse to take critical cases! Who will be responsible for this?"

Vasudha raised her hand again and spoke loudly this time. "Please, please remember that this is over and above your base salary. If these things don't work, you will get your base salary."

"That is not the point ma'am. The system should be fair. If the hospital has a policy for outcomes based incentive, the rules should be fair for those incentives."

"Let us scrap the outcomes based incentive," Vasudha said loudly.

"Ma'am, maybe we can delay the implementation until we figure out a fair way. Outcomes based incentives are a great way to link performance to pay," Manav said.

"Yes, sure, let's do that."

Vasudha asked if there were any other questions.

"Let us start with this ma'am. We can hold a monthly review of this group and discuss." Dr. Samba Murthy concluded.

"Sure. This plan starts from first of next month."

------------------------

All the necessary changes in the hospital software were made over the next few days. All these changes would become applicable on the first of the next month. There was a lot of excitement in the hospital. Everyone was speculating on how things would go. Vasudha and Manav were extremely tense. They met multiple times every day to check how the preparation was going on. They decided to give some time for things to fall in place before constituting the Vigilance Team. They also decided to roll out the project on the first and then over the next few weeks, once everything got streamlined in the operations of the hospital, they could start the marketing. They did not want anything to affect the project in the initial days. 

Vasudha visited the ashram and updated Swamiji about the plan. He was very happy that Vasudha had kept Sheshadri's dream alive. He somehow had a good feeling about how Vasudha was implementing it. She blessed Vasudha and wished her the very best.

The first of the next month was finally there. Nothing visible changed in the workings of the hospital. Patients came, consulted the doctors, got their procedures and investigations as usual. Some were admitted and were then discharged. Things were going on as usual.

Vasudha and Manav met every morning to review the previous day's numbers. Things seemed to be normal. Nothing much changed. No visible upward or downward trends were observed.

Now was time for the second phase of activities to begin. The Vigilance Team, the marketing campaign, the department committees and the Patient Satisfaction Surveys.

The main job of the Vigilance Team would be to scrutinise if doctors were referring patients elsewhere for investigations and procedures. Since doctors were on a fixed salary here, other hospitals could offer incentives on such things to get them done there rather than Narayana Hospital. Another aspect they would need to look into was if Medical Representatives were contacting doctors directly rather than through the hospital department committees.

Manav and Vasudha debated a lot about who should be a part of the Vigilance Team and how big it should be. They finally decided to hire a retired Army Doctor who was known to Vasudha. Major General (Retd.) Dr. Madhusudhan was about fifty years old, very fit and stayed in Hyderabad. He was very sharp and intelligent, had ethics that were above board and was looking for an opportunity to work somewhere in a role that fitted his profile. Vasudha talked to him and immediately got him on board. Once he joined, the three of them brainstormed on the composition of the rest of the team. They finally decided to make it a four member team including Dr. Madhusudhan. The other three members would be Management Graduates from the Admin team. Manav was assigned the responsibility of doing the co-ordination and identifying potential candidates. The final selection was left to Dr. Madhusudhan.

Vasudha and Manav also got in touch with the Marketing Agency they had identified. The team came down to Rajahmundry and had a day long meeting with the two of them to understand the requirement. They would go back to Bangalore and come up with a comprehensive marketing plan in a week.

Each Department was asked to come up with the committee that would interface with Medical Representatives. They were to pick one doctor from the department, one member from the Admin Team and one from the Vigilance Team.

Manav worked on the Patient Satisfaction Survey and made it very simple. There was only one mandatory question - "How likely are you to recommend Narayana Hospital to others?" to which patients had to respond on a scale of one to five stars. Rather than have an elaborate set of questions, he felt that asking one simple question would be a good indicator of patient satisfaction. There were other optional questions which asked for more details in case respondents gave a score of 1 or 2 stars.

This next phase was the most critical phase of the project. This was when all the cogs of the wheel would be in place and the real effect would start becoming visible.

------------------------

Over the next few days, each of the remaining parts of the plan got rolled out. 

The Vigilance committee got into action. They would pick up the copies of the prescriptions and check. The Departmental Committees started interfacing with the Medical Representatives to evaluate new products and other consumables. The surveys were also rolled out.

The Marketing Campaign was the most visible aspect of the project. Huge hoardings of the hospital were set up in the city's busy junctions and nearby towns. A TV and radio campaign was also run simultaneously. The goal was to get people aware of the way the hospital was being run and encourage them to try it out.

Vasudha and Manav would review the numbers on a daily basis.

Soon, the first month of the project drew to a close. At the end of the review, Vasudha and Manav did a detailed review of all the numbers. They were disappointed to see nothing much had changed overall. They decided to do a department by department analysis. They found that while all other departments had shown a minor growth compared to previous numbers, the orthopaedic and cardiology departments had actually shown significant dips. 

Vasudha asked Manav to get doctor wise figures for these two departments, Manav took a day to drill down further and then reported back to Vasudha. They found that while some doctors in the department had shown better numbers, there was one doctor each in both the departments who had shown huge declines in the numbers. Vasudha and Manav started brainstorming on what the problem could be. They called Dr. Madhusudhan to discuss the findings. It was important that confidentiality be maintained around this in order to be able to figure out the problem and fix it.

Dr. Madhusudhan was instructed to have one person each from his team closely follow each of these two doctors and their activities during the next two weeks. They were asked to be extremely careful in their work so as not to raise any suspicion.

At the end of two weeks, a beaming Dr. Madhusudhan walked into Vasudha's cabin and presented his findings. The two doctors were regularly sending their cases to other hospitals. One of them had already started performing some surgeries in other hospitals. Dr. Madhusudhan handed over documentary evidence in the form of prescriptions, notes made on rough paper in the doctors' handwriting, CCTV evidence and recorded patient voices.

Vasudha called Manav over and showed the report to him. Now the question was how they should handle this? Manav suggested that they talk to the doctors in private, confront them with the evidence and give them a last warning. Dr. Madhusudhan, on the other hand, felt that terminating them was the only way they could send a strong message to the entire hospital that they meant business.

Vasudha said she agreed with Dr. Madhusudhan. Termination letters were typed out and sent to the two doctors immediately. The other doctors were also informed about the decision along with the rationale behind the decision. The two heads of departments came to meet her and requested her to give the two doctors another chance. Vasudha refused to listen. 

Manav then had a brainwave. He suggested that they hold a press conference and announce the termination. They would also go into the reasons behind the termination. They could cover in detail how they were trying to bring a change in the way healthcare was delivered. That way they would get a lot of publicity  and that too for free!

Vasudha loved the idea.

------------------------

Manav ensured that the top newspapers and television channels were invited for the press conference. Vasudha made a detailed presentation on their model of healthcare delivery and how it addressed the ills present in the current models. Then she would bring in how the two doctors tried to thwart an honest attempt at beginning a revolution.

On the morning of the press conference, Vasudha and Manav were extremely tense. This was their one big chance. If the press caught on to the story and gave it widespread coverage, it could mean the success of their plan.

They intentionally did not release the press note that is customary before a press conference saying that it would be released after the hospital representatives spoke. The conference hall soon filled up with journalists and AV crew from the top newspapers and television channels.

Vasudha began with poise. She thanked the journalists for coming and attending the meet. She then went over her presentation. Once she started covering the part about the two dishonest doctors, there was a lot of commotion in the room. Manav noticed people getting on to their cell phones. Soon, more and more journalists started coming in. Manav knew that they had succeeded. 

Once the presentation was completed, Vasudha and Manav fielded questions from the journalists present on the finer details of the plan and the action being taken against the doctors.

By that evening, the medical community of Rajahmundry and in fact the entire state of Andhra Pradesh was shaken with the news emanating from Narayana Hospital. The national television channels also gave coverage to the news which was huge as generally, national channels do not cover even big stories from a place like Rajahmundry. The next morning, all newspapers of the state carried this story as the headline. Narayana Hospital, its new healthcare delivery model and the corrupt doctors were on everyone's mind that day.

The hospital got numerous calls. Vasudha's cell phone was flooded with congratulatory messages and messages of support. Almost all the doctors of the hospital got calls from people they knew asking about the new model and the corrupt doctors. 

That evening, Vasudha and Manav met in Vasudha's cabin. They reviewed the status of the plan. They discussed the possible impact of the press conference and the wide publicity they had got. They decided to keep their expectations low since they knew how the press behaved. One new story the next day and everyone would forget about the hospital.

Vasudha sent an email to all the doctors and Admin team of the hospital thanking them for the support during this crisis. She encouraged them to go back to their regular work and not get distracted with all the hullabaloo that was caused by the events of the past few days.

The careers of the two doctors in Rajahmundry was finished. No one wanted to be associated with them. Even the hospitals they were engaged with while working for Narayana refused to continue their relationship as it would be a major image problem for them. They left Rajahmundry for good and started their practice elsewhere.

------------------------

Immediately after the press conference, the footfalls into the hospital started shooting up. People felt that this was a hospital that stood for the ethical practice of medicine. This was a place they could trust. 

During the daily reviews of the numbers, Vasudha and Manav were elated to see the impact of all their efforts coming together. They carefully reviewed all the data to ensure they were not missing anything. They also reviewed department and doctor-wise figures weekly to see if anything was amiss. 

At the end of the second month, the hospital showed a very healthy growth compared to the previous month. 

This trend continued month on month. Vasudha called a meeting of all the doctors and the Admin team. She shared the results with all of them and thanked them for their co-operation. Without their co-operation, this would never have been possible. The doctors were also very happy. They were earning more than what they were earlier. They felt really nice that all this was possible without succumbing to the unethical practices that had become so prevalent in the profession of late.

Soon, the hospital felt that it was running short of space. They had to regularly refuse patients due to this. They began having a wait-list for procedures and treatments like dialysis. Vasudha decided to expand the hospital, A new block would be constructed. She scheduled a meeting with the old investors and discussed the high level details. Soon, a plan was put together. The old investors decided to fund the entire expansion in return for a further stake in the company.

In under two years, the new block was ready. Swami Keshavanand inaugurated the new block. Vasudha was extremely happy with the progress being made. She realised that what they were doing in Narayana Hospital was breaking new ground in healthcare delivery in the country. She hoped that other hospitals would follow suit in implementing their model.

She heard informal reports of hospitals in other cities adapting the so-called 'Narayana Model'. People were very intrigued by this new paradigm being seen for the first time in the healthcare sector.

Vasudha never felt the need to keep the intricacies of her model secret. She felt that the entire healthcare industry could benefit by moving to this model. She strongly felt that there was space for everyone and not one or two but even a hundred Narayana Hospitals would not be enough to cater to the growing needs of Indian patients. She joined the board of some hospitals which wanted her to guide them to implement the 'Narayana Model'. 

Soon, several such hospitals started switching the way they worked and Vasudha advised many of their founders and owners on running their hospitals. 

She kept stopping by at the ashram to pay her respects to Swamiji who always guided her to do the right thing. She believed that the peace she felt at the ashram helped her connect to the ideals of her late husband and this proved to be a very important reason behind her success.

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Epilogue

Vasudha was sitting in her cabin one day when she got a call from the PA of the Union Health Minister. Apparently, the Health Minister had got to know about the new model of healthcare that Narayana had adopted. The minister wanted to meet Vasudha to understand the 'Narayana Model'.

Vasudha flew down to Delhi the following week and met with the Health Minister. They discussed the Narayana model at length. She also discussed the various problems she had encountered, some in her own hospital and others while helping other hospitals adopt the model. The minister was intrigued.

The minister told Vasudha that the PM was very keen on exploring the possibility of rolling out Universal Healthcare in the country. He wanted her to be associated with the project. Vasudha was thrilled. She agreed immediately.

On the flight on the way back, her mind wandered to the day when Sheshu talked about his plan. She felt very sad that she had not allowed it to be implemented for a while longer. The truth, she realised, was that she had never thought it would work and that is why she did not even help in the implementation. Had she thought of all the ideas she came up with when the plan was being rolled out the second time, perhaps, Sheshu would be alive today!

She wiped off the tear from her cheek as she looked out of the window into the clouds.

2 comments:

Abhinav said...

Hi Kamal... This is Abhinav..Sandeep's friend. Hope you remember me😀 Just read this story. You write like a boss!! The story was super inspirational. Sort of related to Sheshu's character!! That says a lot about the quality of your writing which makes readers relate to the characters. Great job Kamal. Hope to see a full fledged novel out soon. My best wishes

Kamal Shah said...

Thanks Abhinav! Of course I remember you. :-)