To start a successful program ........

We have the expertise to run a world class hospital with world class outcomes; now we desire to cater to children with heart disease, why not? It is a logical progression.

When the west speaks of value based healthcare, You should look at it from the Indian perspective, as there is a lot of wisdom in our methods to keeping costs down, especially in this field where quality can not be compromised.

I am sure you know that starting a paediatric cardiac program is a major challenge. If you have given it a thought, then this article is written for you.The common hurdles we expect to come across and how to circumvent them is given here.

First stage : We would like to find the depth of the following indicators and how they determine success.

1.  Where:  It will benefit to start the program in a successful hospital with all basic infrastructure and sub specialties preferably with Maternal and paediatric care available. It additionally could be one which has crossed the break-even point.

2.   In the geography we are planning to serve, we would look for a population of >100,000 people, with a Female Fertility Rate (FFR) of approximately 2.0. i.e. each woman bears 2 children on an average. These numbers are based on the incidence of congenital heart disease which is reasonably constant at 0.8 per thousand population per year. 10 % of whom would be affordable patients, Paying from their pockets The best way to pay( reasons in person). This translates to 20 operations per month (for one surgeon). If the population is bigger (150,000) we can look at having a second surgeon and moving towards 30 Cases per month. Low FFR enables families to have greater available income to cover the expenses of surgery however small it is ( USD 3000-5000).

3.   For people and governments to see value in the correction of heart disease, it has to be seen as an important indicator to reduce infant mortality. So, we only consider areas where there is an Infant mortality rate (IMR) of less than 20 (this creates a felt need for the service) It also gives us an idea of the developmental index of the society and whether the government has invested enough in Public health, education and awareness.

4.    Accessibility of the service to the public in terms of geographical location and cost implications would enable continuity of the service, make it viable. Break even for the department should be near 20 cases per month and all financial calculations should start from here.

5.   It would be possible to conceive a cardiac surgical program only with the Presence of Continuous electricity (power), sewerage, waste disposal and water supply with back up options. This is one of the reasons why many other developing countries are unable to build capacity like India.

6. 5000 to 10000 Square foot space across 2 or 3 floors with NABH, JCI design compliant hospital space will be required. Sharing of sterile areas with general specialties should be avoided, especially in the ICU and Operating rooms. Adequate space for parking, waiting, breastfeeding, minor procedures and echocardiography are essential.

6.    A strong in house purchase department and pharmacy with the ability to procure all essential drugs and consumables for the surgical and the cardiology teams from within and outside the country in time for surgery. Stocking, cold chain preservation, logistics, security, accountability are integral to a successful pharmacy department. Another hurdle in many developing countries. The ability to locally produce these items can not be stressed enough.

7.   A HIPAA compliant MRD and a Digitally integrated Radiology services with Ultrasound, ECHO and Mobile X ray facility (should be) made available onsite 24x7x365. Radiology services will not only strengthen the clinical services but also increase revenue from the Emergency Department, which is a growing branch of revenue for all hospitals.

8.    A CT scan machine being expensive is not essential to the program initially, hence an MOU with another center nearby is an option.

9.   It goes without saying that Microbiology, biochemistry and pathology services in house are the norm. They bring revenue from all departments and cross utilisation enables efficiency. these services can also be outsourced (inwards or outwards).

this gets us to

The second stage:

10. In the form of the HR resource direction, we need a functioning Clinical Pediatrics team, a good ICU and anesthesiologists ready to learn Pediatric cardiac anesthesia. Once we offer a service we have to hit the road running. Expertise is unfortunately wasted in many countries because of the lack of infrastructure and consistent supplies.

11. Once the road is clear, recruiting 3 pediatric cardiologists for the first year before starting a surgical program is wise, as they build up a reputation and create the connections needed and build the referral base for cases. They are meanwhile earning their pay without burdening the finances of the program at this stage. The management sees the logic of our plan.

12. Once the cardiologists have created enough clinical work for themselves, they would like to do cardiac interventions. This can be in collaboration with a second hospital too, because, Sharing the cardiac cath lab with the adult cardiologists is possible if they have the provision for interventions, for which we need to be stocked with sufficient hardware and devices.

13. The sterile services department should be able to rapidly turn around instruments and re-usables ( 24x7), for which we would need a couple of Rapid Autoclaves and Ethylene Oxide sterilisation machines in the CSSD. Consumables for the CSSD are to be stocked as well.

14. There can be no compromise on availability of a blood bank within the hospital or in the immediate vicinity run to international standards. Donor awareness programs are not only meant for building a pool, but also to build goodwill and market the hospital's services. NGOs like the Red cross, the Lion's club can help.

15. Once again, the HR manager can not go easy on the availability of experienced Nursing staff and technical manpower. The cost of expertise is not cheap and let me remind you that inexperience can be costly, especially with litigation on the rise, we have to select the team with care and promote retention of (wo)manpower. We have not introduced the surgeon yet (yours truly).

Now we get to

The third stage

16. A separate revenue model for the pediatric cardiac specialty is to be created within the framework of the hospital, to enable sustainability and accountability of the program.

17. Billing for cash, Insurance and government funded cases are to be kept separate, as one should not subsidise the other. Government funded cases are generally done on a "no loss no profit" basis, and they are used to build capacity utilisation of the service, for putting the system in place. I will write about how this generates revenue, later.

18. Once the Pediatric cardiologists find that their work is not growing, we introduce the pediatric cardiac surgeon. He/she is usually in the late 30's early 40's and needs to be supported in many ways. a 5 year contract will be a start. Like in all long term contracts, a detailed background check is essential about his surgical career and results. (FYI, most good surgeons are not good in finance, communication or people skills and vice versa!).

19. A visiting pediatric cardiac surgeon with a proven track record is employed at this stage.

20. Staging the risk categories we operate on, from simple cases initially, to progressively complex ones as the team matures over a variable time frame is the ideal situation.

the final stage is when profits enable re-investment into the department for accreditation. This will be based on the statistics generated and later for academics and training of additional manpower.

P.S. An adult cardiac surgery program, in house, is preferable, to build financial robustness into the program in terms of available medical and surgical hands. this also enables cross-utilisation of infrastructure. The hospital gets the reputation of being a wholesome cardiac center which elevates it above the crowd. Hence Pediatric cardiac surgery is usually the last specialty to be added to the services listed in the hospital.

Hence the term "Pediatric cardiac surgery is the Crown Jewel."

Thank you for reading till the end. Any discussions on the topic are valued.