NextBillion - An Initiative of the William Davidson Institute at the University of Michigan

patients – even poor ones – represent an opportunity FOR EYE SURGERY EXPERTS

Aravind Eye Care System was designed to be the McDonald’s of healthcare providers. These days, the slumping fast-food giant would do well to study Aravind’s “secret sauce.”

In the volatile world of healthcare, Aravind is performing ever-more surgeries with fewer complications, adding facilities and making money – all while giving away half of its offerings. Its efficiency and scale are legendary in social enterprise circles, and the focus of scores of stories and case studies.

There’s certainly a “sauce” that makes Aravind special, according to Dr. R.D. Ravindran, Aravind’s chairman and director of quality, but it’s not secret. It all boils down to the organization’s culture of respect, and Aravind isn’t shy in talking about it. “Whatever quality led us to this level of excellence, we are sharing,” Ravindran said. Aravind regularly conducts education and training programs throughout India and abroad.

It started with Dr. G. Venkataswamy, or “Dr. V,” who founded Aravind as an 11-bed hospital in Madurai, India, in 1976 – six beds for people who couldn’t pay and five for those who could. Dr. V admired the efficiency, consistency and quality control of McDonald’s and wanted to recreate the model in pursuit of his dream of eliminating needless blindness, even if that meant treating people too poor to pay.

He succeeded. Today, Aravind includes six outpatient eye care centers, six secondary and five tertiary centers, 2,518 eye-screening camps and 51 primary eye care centers for comprehensive eye exams … plus lens-manufacturer Aurolab and a training program for all levels of eye-care personnel. Last year, Aravind facilities performed more than 400,000 surgeries – 70 percent of which were for cataracts – and half of them were free. The complication rate for those surgeries is less than half what it is for similar surgeries in the United Kingdom.

Ravindran, whom I interviewed as he visited the University of Michigan Health System’s Kellogg Eye Center, said Aravind’s culture of respect starts with how employees view the poor; they’re not a burden, but an opportunity.

(Dr. Ravindran, left, with Paul Clyde, president of the William Davidson Institute at the University of Michigan.)

“The whole organizational philosophy is we are not making a distinction between poor and the paying,” Ravindran said. “We talk about ourselves. When we are helping, it is ourselves we are healing. … It’s not about helping that particular patient. It’s only by giving treatment, taking care of the patient, that we are helping ourselves. … We get a lot more spiritual strength and internal satisfaction (that way).”

It’s a more-the-merrier attitude that permeates the staff, Ravindran said. “If you come to a hospital, the day we see the maximum number of patients, there is more happiness. The day we see 3,000 patients, they are very happy. The day we see 1,500 patients, the people are very unhappy. The challenges make (the staff) happier. Positive energy is there within the organization.”

It begins with doctors and nurses, Ravindran said, and trickles down. The senior staff all work late and see all the patients.

Aravind’s doctors come from the ranks of its interns and fellows, and the initial part of their orientation is always spent discussing organizational values. “When they meet the senior leaders over a two-week period, everybody  talks only about not distinguishing between paying and non-paying patients,” Ravindran said.

Ravindran said Aravind’s market penetration is about 30 percent, and the organization is working hard to improve that. It holds dozens of eye camps every week in rural villages, where it conducts exams, offers basic treatment and identifies people who might need surgery. “We talk (to our doctors) about not only respecting the patients but the community leaders who organize those camps,” Ravindran said.

The senior nurses, Ravindran said, are “even more motivated than the doctors,” constantly suggesting ways Aravind could perform even more surgeries. In fact, the system is already remarkably refined; the average cataract surgery in the U.S. takes 21 minutes, but only 6 minutes at Aravind.

According to Ravindran, in the typical Aravind hospital setting, two doctors operate simultaneously in the same room, with two patients each. One is usually a senior doctor and the other a junior doctor, Ravindran explained, with the more experienced doctor keeping an eye on the work of his peer. In the U.S., there can be only one patient per operating room.

“In India today, we don’t have as many regulations,” Ravindran said. “Each hospital has to take the moral responsibility for the safety and the outcome for the patient. It is not enforced on us.”

Another key difference is that Aravind’s cataract eye surgeons typically don’t wash their hands as they move from patient to patient; they simply apply antiseptic gel to their gloves at each rotation. In the U.S., surgeons wash their hands, apply the gel, add gloves and apply the gel again, Ravindran said, adding that’s an unnecessary step that slows the process.

“It’s not about saving money, it’s about evidence,” Ravindran said. “Based on evidence we know we are not compromising quality.” And that matters: Since they do 400,000 surgeries a year, he says, even small complication percentages can add up to large numbers of problems that have to be dealt with.

The system, he said, means three employees at Aravind facilities in India can do the same amount of work as a team of eight at Kellogg. Bottom line, he said, Aravind can do before lunch what it takes Kellogg all day to do. (Note: Kellogg reported 138,967 patient visits and more than 6,319 surgical procedures in 2012). That means, in theoretical terms, that Aravind – even though it doesn’t charge half of its patients – has the same number of paying patients, and less overhead, compared to Kellogg.

Ravindran said he’s frustrated by what he sees in the U.S. – not the doctors, but the rules that hold them back. “What sometimes upsets me is the regulations. Sometimes the regulations aren’t based on evidence. If a regulation is based on strong evidence then it’s OK. Like the two-table system. We are not compromising the quality or (increasing) infection.” He said cataract surgery is “clean” and “neat” and done largely via sterile machine – as compared to, say, cardiac surgery – and “there’s no harm in having two tables.”

“To me, it’s all only about how do we improve productivity?” he says. That focus on improving a system that is already lauded around the world is part of Aravind’s success, for sure. Another part, Ravindra adds, is cultural: “In India, the element of compassion is always there.”

And it’s that compassion, one could argue, that leads a chain of hospitals to not just endure poor patients, but seek them out and value them as a way to help improve its overall delivery of healthcare – and probably why the Aravind system is yet to be duplicated.

Kyle Poplin is the editor of NextBillion Health Care.

Photo: Dr. Tyson Kim, left, a first-year resident at the Kellogg Eye Center, University of Michigan Health System, and Dr. R.D. Ravindran. Photo by Donna Donato