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Christian Medical College, Vellore Serving India in the healing ministry of Christ

FOV Board meeting Dr. J.V. Peter, MD, DNB, MAMS, FRACP, FJFICM, FCICM, FICCM Director, Christian Medical College


The Lord is the one who goes ahead of you; He will be with you. He will not fail you or forsake you. Do not fear or be dismayed Deut 31: 8


Outline The gift goes on Update on activities

Introspection The internal and external environment Piecing the puzzle

The way forward


On a positive note! The week magazine – 3rd rank

1st among private colleges 2018 ranking – 2nd by Week


National ranking by HRD


India today ranking (2nd)


Award for Quality The BMJ award – one of 10 categories From among 2000 nominations in 8 countries


NABH nursing excellence award

Function organized in Scudder auditorium


In the newspapers


Shiloh student Christian conference

Touching student’s lives


Confest 2018

3-day event of seminars, lectures, cultural & sports


5th Winter Symposium

Changing paradigms in the practice of pathology


National conference on simulation

Simulation – future of medical education


6th Ida Scudder oration Roger Glass

Weill Cornell University


Allied Health Graduation

Mr. George Abraham – Chief Guest


College of Nursing graduation

Dr. Anne Phillips – Chief Guest


Keep the banner flying high Graham Kendrick


A unique meeting

Unique conference involving doctors and patients


More collaborations


25th Rehab Mela

25th Rehab mela Amazing experience Truly a “home of transformation�


The centenary year celebration • Thanksgiving service (Jan 14) • Scudder Auditorium

• Speaker Dr. Kuruvilla Varkey • Participation by many generations! • Recalling and thanking God for leading through the years


Home of transformation • Song for centenary year

• Competition • Song composed by Dr. Solomon (VP) and Dr. Asha won the award • Sung in many programs


Centenary song


Centenary coverage


The week magazine


The open magazine 12 January 2018 Ida Scudder Lived Here It began100 years ago out of one woman’s kindness. V Shoba chronicles the evolution of the Christian Medical College in Vellore into a unique institution that combines charity, teaching and medical service


Centenary run


Cyclothon 2018

Jointly organized by CMC Vellore and VIT 200 participants


Fund raising concert

Christ University, Bengaluru


Concert in aid of scholarship

Themes and variations


The First luminary lecture


The Second luminary lecture


Coffee table book


Much awaited President’s visit Shri Ram Nath Kovind

EC and Council’s suggestion Inauguration of the Centenary Year of Medical Education


Other activities planned • More luminary lectures

• National conference on medical education • Scudder Oration Dr. Rob Fisch; Book release “Step by Step” • Inter-house music and dance competition • Closing thanksgiving Founder’s day (Dec 9)


Some statistics


Town campus updates


SNH progress • Delays in obtaining approval

• Final go ahead – April 2018 • Structural strengthening completed • Architectural and structural engineers approvals • Planning cell – approved

• End user department meetings


Floor plan

MRI and CT with recovery room


SNH – what do we get? • Operating theatres • 8 + 3 (2 levels) • 10 + 11 recovery beds (2 levels)

• Radiology services • CT, MRI suite, recovery and anesthesia • X-Ray unit • Possibly an US unit

• Others

• Beds • Day care – 18 (1 level) • High dependency beds – 12 (1 level) • Low dependency beds – 150 (3 levels)

• Physiotherapy area • Pharmacy dispensing area • Pharmacy stores


Campus re-organization • Current campus needs to be re-organized; Town campus re-organization committee (CRC) to be formed

• Some buildings very old – safety issues • To be done in phases ones KP campus ready • Broad plans • Reduce beds by about 700 to make more space • Modify existing old theatres – to have total 40 theatres in main town campus (timeline 2020-21) • N1/N2 ward to come down • Fire safety ramps


Theatres in Town campus


St. Jude’s facility


Multi-level car park


33-KVA substation


College area


Ulcer ward at CHAD


Solid waste management


Other activities in College • Extension of Men’s hostel

• Additional floor in Rehab campus • College campus – renovation of old houses, roads • Tree planting • Shuttle court in College campus oval


Kanigapuram project


Kannigapuram project


Project overview • 1500 beds; 250 ICU beds; 543 houses; A to E, villas, school • Cost 1250 crores ($ 200 million) • Loan $ 140; 500 crores now • Estimated completion time • Housing Dec 2018 • Hospital Jan 2019


Council Executive committee Director

Treasurer

Council Secretary Assoc. Dir. (KP)

KP planning cellâ€

Project team*

Minute planning Transition planning Equipment procurement Laboratory planning Timelines – countdown

On site supervision Oversee project Co-ordination Tenders Non-medical equip

Overseeing committee

Council appointed Oversee project Direction Broad perspectives Timelines kept

Finance committee

Financial planning Cash flow Loan issues Tenders Audit

* Project management team with the organogram already presented in council

KP Campus committees and teams


Kannigapuram project


OPD block March 2018

May 2018


DOT block


IPG March 2018

May 2018


IPP


Service block


Canteen block

March 2018

May 2018


Compound wall


Portico filling


KP housing update


KP housing


KP housing


KP housing


KP Housing


Chittoor campus


Chittoor • Increasing patient numbers • Plan to start the maternity services soon (labour room and Caesarian section) • Approvals for the Housing - tenders • Operating theatres fully functional • Campus master planning completed


4 theatres currently operational till 8.30 pm.

Overnight Emergency surgical Services Shortly Starting a high dependency unit

Instituting the Arogiashree insurance scheme- Chief minister’s scheme


Introspection


Strategic thinking map


Environmental issues

Internal environmental issues

External environmental issues

Situational analysis (challenges)

Mission, Vision, Values (Provides direction) Directional strategy

Adaptive Strategies ďƒ Market entry Strategies ďƒ  Competitive Strategies

Value adding support strategies

Value adding service delivery strategies

Strategy implementation

Unit Action Plans

Evaluation and measurement of the effect of implementation

Strategic control


Key components or areas • Core values

• Internal environment

• External environment


The principles to apply • Situational analysis (challenges)

• Strategic planning

• Implement solutions


Catch phrases • 1oC • Space mission

• Q-less • Operation decongest • i-FAB


The core values


Mission and vision • Core: Mission and vision

• Vision: The Christian Medical College, Vellore seeks to be a witness to the healing ministry of Christ through excellence in education, service and research • Mission statement: Clear


Shared assumption Compassionate Christ-centered Ethical Cost-effective Quality healthcare Enabled by technology Empowered by relevant medical education

Enhanced by translational research


Shared values – 5 E • Ethical

Highest values

• Equity

Everyone has the right to health

• Equality

All workers equally important

• Equanimity

Pleasant to all at all times

• Empowerment


Assumptions and values • Has there been a drift in the shared assumptions or values

• Introspection of nature and extent of drift

• Course correction – 1oC at a time


The internal environment


Internal environment • Clinical services

• Education

• Research


Clinical services • Economies of scale

• Manpower resources

• Finances


Strategies


Economies of scale • Economies of scale • 8500 OP, 2857 IP, 135 ICU beds

• Strengths • Sign of growth, confidence of the patients • Enables cost to be kept lower • Sustainability

• Limitations • Several bottlenecks • Returns not matching growth (law of diminishing returns) • Support services not kept pace with growth


Possible solutions • Address bottlenecks • Space mission • Q-less • Operation decongest


Address bottlenecks • Radiology – long wait times (diagnostic suite SNH) • Lab service (blood collection centres) • Theatres – SNH – addition of theatres • Bed crunches • No space in campus • Some space allocation in SNH • Better utilization of CBMO services (250-300 beds)

• Improving efficiency of support services • TAT (billing time), KPI (re-imbursement time), QI


“Space mission” • Crisis “no room in the inn” • Patients waiting in lodges • Lack of ICU beds • Time slot for surgeries delayed

• Creating space out of nowhere! • • • •

Task force, scout for space (MS office) Nooks and corners Greater good – give a little Planning cell – apportion space


Average waiting time at OPD pharmacy 1:40 1:26 1:12 0:57 0:43 0:28 0:14 0:00

Express: 5 min Regular: 20 min

1 hr 30 mins 1 hr 19 mins 58 mins 21 mins

18 mins

5 mins At express counter

Mar-13

For more than 2 drug

Oct-13

Feb-14

All counters to gether

Jul-14

Apr-15

Sep-15

Average waiting time in ISSCC pharmacy 0:36 0:28 0:21 0:14 0:07 0:00

30 mins

12 mins

7 mins Less than 3 drugs

Feb 14

More than 3 drugs

Aug 14

Process audits

29 mins

25 mins

8 mins

Time motion study

Overall(Less than 3 drugs + More than 3 drugs)

Apr 15

TIER-hours Improved staffing

Feb 16

Average waiting time in Main Pharmacy 54 minutes

0:57 0:50

Managing crowds and waiting time

0:43

44 minutes

34 minutes

Nov13 Feb14 Nov14

0:36 0:28 0:21 0:14

15 minutes

12 minutes

10 minutes

0:07 0:00 Less than 5 Drugs

More than 5 Drugs

Over all


Operation decongest Diversify into campuses

• Manageable units under one large umbrella • Main campus (Tertiary) • KP campus (Quaternary care) • Chittoor campus (high level secondary) • CHAD, RUHSA (primary), Ophthalmology, Mental health, Rehabilitation, (phased growth, space constraint)


HRM • Human resources management (HRM) buzz word in management circles

• Impacts growth and planning • Broadened structure of HR planning across all appointing authorities


Manpower issues - medical • Student level - recruit early, nurture • UG - Generate interest – student days (1st year to final year) • Intern, non-PG, PG – open door, equitable rosters, teaching

• Junior faculty level – mentor, facilitate growth • Mentor faculty • Opportunities to grow (JTF, Study leave, Conferences) • Centrality of purpose, “A calling to serve with a desire to excel”

• Mid level – engagement, contribution, ownership • Empowerment

• Senior level – vision, planning, administration • Inclusiveness and involvement


Manpower issues - nursing • Key to high quality nursing care • Strength of CMC; however retention difficult • Need to brainstorm strategies with nursing faculty

• New campuses – additional nursing required; nursing college in Chittoor? • Increasing engagement of senior nurses in routine nursing management (supervisory)


Manpower issues - AHS • CMC pioneered many new AHS course • Scope of services enlarged – OT, PT, respiratory, critical care, renal, anesthesia, optometry, cardiac, perfusion, etc. etc. • Higher specialty training for OT, PT • Consider starting a pharmacy college

• AHS representation in Administrative committee


Manpower issues – Category D • Greater engagement with them (GSB) • Part of the team; team-member • Optimize work hours and manpower • Educational opportunities


Soft HR • Housing needs acute – despite KP campus will be short; more E and F • Facilities in campuses (library, games, gym, walking paths etc) • Schooling – major problem – site in KP campus for CBSE school • More ideas welcome


Finances - the way I felt


The delicate balance Several requests for

Income

Increase charity Higher salaries Improved infrastructure Increased education subsidy Provision of more houses Latest equipments Support for conferences Increased research allocation

Patient-source

Reduce tariff

How do we look at finance in the light of these?


CMC Vellore • CMC Vellore Association – Society • Charitable institution • All institutional activities under one big umbrella • • • • •

Hospital (clinical services) Education (medical, nursing, allied health) Outreach (community health, medical) Research (basic, translational, clinical) Fund-raising


Overview of finance • Revenue • Patient care activities (>98.5%) • Education (<1.0%) • Other income (0.5%)

• Expenditure • Salaries (41%) • Drugs and chemicals (30%) • Repairs, maintenance, electricity (5%)


Looking for a different logic • Over dependence on one activity to generate revenue • Increasing financial commitments due to • Enlarging staffing numbers (>9500) • Salary hike, pension, gratuity, housing, medical aid • Educational subsidy • More paramedical courses • Increased medical seats • Other support (hostel, transport, classrooms)

• Tariffs already higher than corporates in some domains; clinicians unhappy with tariff increases


Restrictions • Charitable organization do not want to do commercial activities as we do not want to become a taxable entity • Lack of clarity on how additional resources can be generated and still keep core objectives intact • Single campus bursting at the seams • Saturation of services due to lack of space • Operational challenges • Law of diminishing returns


Some thoughts • Commercial venture – but who? • CSR resources – slow progress • Patents • Manufacturing unit for drugs • Patient accommodation? • Rental properties?


Internal finance advisory board • I-FAB expanded to 12 • Meet periodically

• Brainstorm several matters • Solutions to problems


Finances


Finance Parameter Gross income Net income Total expenditure Cash expenditure* Depreciation Allocationâ&#x20AC; Deficit

2016-2017 1177.58 1015.91

2017-2018 1118.63

Change Rs 130.52 102.72

Change % + 13.1% + 10.1%

1061.10 929.24 54.12 84.95 32.80

1149.53 982.45 58.32 88.75 11.49

88.43 53.21 4.2 3.8 -21.31

+ 8.3% + 5.7% + 7.8% + 4.5% -65%

1308.10

* Excludes depreciation and allocations â&#x20AC; Excludes SSSB allocation 17 cr in 2017, 20 cr in 2018


The analysis • Net income increase by 10.1% • Total expenditure increase by 8.3% • Deficit 11.49 crores • Adjusted by decrease in allocations

• Allocations not reached target; 88.75 crores (projected 112 crores)


Income side • OP numbers – on an average reduction by 500 per day due to no HS postgraduates

• IP numbers status quo since peak capacity • No increase in tariff with the GST • Reduction in margin on drugs (VAT subsumed) • Growth in all campuses (main, Eye, MHC, CHAD, RUHSA) lower than budgeted; partly offset by higher growth in Chittoor


The expenditure side • Slope of growth of expenditure blunted to 8.3% • Partly due to restraint on new employment • Incremental increase of salary annually is 4% • Cost of equipment, services higher with GST (impact around 30 crores totally; 1 crore/month net of input) • Increased allocation to SSSB scheme (13 20 cr. in 2 yrs)

• Capital budget not done last year


OP statistics

Week 02-Apr to 08-Apr

OP General 2017 2018 24702 25987

OP Private 2017 2018 17922 18688

Billed amount 2017 2018 24.40 26.47

09-Apr to 15-Apr

20543

25199

14235

17863

21.41

26.88

16-Apr to 22-Apr

23986

24067

16618

18174

24.00

26.64

23-Apr to 29-Apr

24377

24125

16172

17869

23.79

26.27

30-Apr to 6-May 7-May to 13-May 14-May to 20-May 21-May to 27-May

24707 24843 25107 24752

23976 24553 23633 24640

15730 15995 16477 16309

17936 16766 15943 16658

23.85 24.39 23.53 23.70

25.54 26.07 26.02 25.30

Average Change

24127

24523 +1.6%

16182

17487 +8.1%

23.63

26.15 +10.7%


Charity schemes


Overview • Moved from paper to electronic scheme in 2017 • Overall free work dropped to about 13%; partly result of more accountability • FC ↑ allocation from 17 to 28 crores; number of beneficiaries from 1700 to 2800 • Data for the 9 months in 2017-18 encouraging • P-MAP scheme 6.1 crore balance (10 crores allotted)


Data for 9 months Sanctioned:2800 patients; No. admitted: 2013; Parameter

Survived 1911 (94.9%)

HF 75000

HF 150000

1238

775

33.6 (20.2); 0 to 93

31.5 (19.1); 0 to 84

554:684

364:411

416 (33.6) 59 (4.8) 743 (60.0) 19 (1.5) 1 (0.1)

223 (28.8) 63 (8.1) 462 (59.6) 26 (3.4) 1 (0.1)

519 (41.9%) 719 (58.1%)

365 (47.1%) 410 (52.9%)

Billed amount, Mean (SD) Range

69164 (55323) 500 to 493320

151361 (104295) 715 to 1363586

Outcome, Alive (%)

1197 (96.7%)

714 (92.1%)

Number of patients Age, Mean (SD) years; range Gender (M: F) Socio-economic class, n (%) Lower Lower middle Upper lower Upper middle Upper Medical diagnosis Surgical diagnosis

Amount spent 19.2 crores Well within allotted amount!


Way forward • Increase beneficiaries from 2800 to 3500

• Budget around 35 crores for same • Make PTP scheme electronic – FOV (1 crore); others 1.5 crores; FOV committed to doubling contribution • Bring in an intermediate category with PTP – partial subsidy – drugs 10,000 bill cap @ 40,000/50,000 (additional allocation about 15 crores)


Education


The challenges • How to support and sustain increasing educational subsidy? (70-80 crores pa) • How to enlarge the scope of education to meet increasing campus and mission needs? • How to make education relevant and contemporary?


Educational subsidy • Subject of much discussion and debate • Low fee structure (3000 pa) strong point for institutional uniqueness in Supreme court rulings • When education offered at low cost, expectation graduant would not charge unreasonably to recover cost

• Increase in fees may not dent finances • Probably best left untouched for now


Enlarging educational scope • Enlarge scope of medical education

• Uniquely placed, skills and abilities present • Need manpower for campuses and missions • 100 optimal; probably Chittoor – when?


Making education relevant • Pioneer in contemporary education

• COP, CHP, SHP, clerkship, etc. • Curriculum renewal in progress • Simulation and sonology based learning • Integrated learning programs


Admissions • Truly experienced the hand of God • So much value in community brainstorming (Senatus, AO, EC, Council, well-wishers)

• Next step – UG and HS (challenges different) • Solicit continued prayers and support


Research


Research domain • Poverty amidst plenty; Few publications for the quantum of material • Strengths – Structured courses – Good faculty to guide – Biostatistics department

• Limitations – Opportunities not utilized – Funding challenges – Lack of time


Solutions • Greater financial allocation (1% proposed) • Part funded by overheads of external grants; partly by internal allocation • Creation of a research and development and patents unit now and expand to a department (think-tank) • Engagement with FOV US for partnerships


Administration and governance


Administrative officers • Greater engagement and dialogue with administrative officers • Independence of function of different domains

• Focus on team work, team building, team player • Encourage strategic planning for the next few years • Work closely with Assoc. Dir (Admin) Dr. Vikram to streamline policies and processes (CASBI, GATT, Quality, Safety etc. etc.)


Community • Community has high achievers, thinkers • More inclusiveness and participation of the community in decision making (e.g. task force, think-tank, etc. etc.) • Get the community excited about • The new KP project • The centenary year of education • Chittoor campus


Ownership circle • Be accountable for all decisions • Ensure proper systems and processes in place • Transparency in activities • Receive comments, suggestions for improvement


Other matters


Other matters • Community worship – engaging students and staff, retreats, praise and worship • Staff – student activities – bridging the gap • Commitment to build a team of leaders • Engage: citizens of Vellore, local officials, state and governmental


The external environment


High 10

External environmental trends and issues plot

Impact on the organization

Health care providers* (GH, private, Other colleges)

High impact Low probability

Key stake holders (Internal: Council, missions)

Regulatory (MCI, NABH, NITI Ayog)

5

High impact High probability

Secondary providers (NE region)

Low impact Low probability Provider representatives (Insurance, PSU)

0

Low

Low impact High probability Key stake holders (External: MOU overseas training, Research MOH)

5 Probability of trend continuing

10 High


Competitor analysis - mapping

Practice size/scope

5

Group 1: GP S: 4; I 2

4

Group 4: College S: 3.5; I 4 Group 3: Specialty (Narayani, HF, Apollo) S: 3; I: 3

3

Group 2: NH S: 2; I 3

2

Group 5: CMC S: 4; I 5

BE AWARE Pull up our socks

1

0

1

2

3

4

Range of procedures/services (Impact)

5


Strengths and its strategic implications Competitively relevant component

Strategic implication

1. Top notch holistic healthcare 2. Reputation 3. Pricing and cost leadership 4. Process innovation and quality 5. Marketing 6. Education and research 7. Extended care program 8. Strong employee engagement

Strengths Long term competitive advantage Competitive advantage Economies of scale, volumes High quality, low cost healthcare Word of mouth, high trust factor (impact) Innovators in healthcare Rehab, MHC, Pall. home care, Comm. Health High retention of employees

1. Marketing 2. Low expansion 3. Financial dependence

Weakness No active marketing Limited penetration nationally Single revenue stream


Strategies for external • Regulatory • Need 100% legal compliance; up to date with new laws, rules; legal experts

• Competitors • Focus on our strengths; diversify to quaternary care (KP campus) • Venture into new domains (Public health, GOI training of technical staff) • Network with satellite mission hospitals • Improve cost-effectiveness of care


Strategies for external • Provider representation • Make processes easier for insurance companies, PSU, reimbursements – meetings with TPI • Foreign patients (Separate office – strengthen)

• Stake holders • Internal stakeholders – Council – greater engagement, transparency – Missions – greater participation

• External stakeholders – Research, Training, Education - strong


Missions Domain

Ownership

Partnership

Associate

Affiliate

Council CMC

Trust CMC involvement

Diocese/ Mission

Diocese/ Mission

Administration

CMC

Institution

Institution

Institution

Clinical CMC contribution

CMC

Institution Short sabbatical* Deputation

Institution Deputation

Institution Deputation

Education

All

SHP

SHP

No postings

Financials

CMC

Institution ?CMC help

Institution

Institution

Governance

Only a proposed grid; To be expanded further Meeting on 2nd June 2018 to take it further! * CMC Short sabbatical â&#x20AC;&#x201C; 3 months to missions CMC Deputation â&#x20AC;&#x201C; 7 days from Deputation leave


Presently Nearly 3000 beds Multiple campuses Strong community work Outreach


Moving forwards


Need for a unified and cohesive identity

across all communication channels (to minimise risk and maximise opportunities)


Logo


Organogram for legal cell 1. 2. 3. 4. 5. 6. 7. 8.

Legal cell

Civil – MLC, Land, Money Criminal – MLC, Attacks, accidents Consumer courts Labour – ESI/PF/Domestic enquiry Academic - admissions Opinions – MoU. Responses, etc. Customs - duty, purchase School - permissions, society

MoU committee (Already formed)

Associate Director (Admin) Deputy Director (Legal)

Internal team

Empanelled lawyers

Admission Matters

Mr. Krishna Mr. Kumar Senior Counsel

Labour Consumer

Mr. Ramanan Mr. Sampath

Criminal Cases

School Customs

Mr. Paul Sudesh Mr. Narasimhan Mr. Samuel

Land Issues

To identify

Faculty (Diploma In Law)

Legal Officer (Lawyers)

National law school Diploma in medical law

Concept similar to internal financial advisory board


Schools • Major HR exercise • Ida Scudder, CKC, Bala Vihar, playschool • CMC Faculty involved in running of schools; spend a lot of time and effort • Shortage of classrooms, difficulties in getting permissions • Options • • •

We build more schools (us or through a group) Ask Christian group to help in administration (still owned by CMC) Ask Christian group to build and run other schools (we run the ones we have now)


Other activities • Bridge house (cancer patients), Annexe, Dormitory, accommodation (for patients) • Manufacturing unit – medications • Research facility under Section 35 (1) • Shopping complex • Laboratories /Radiology suites in town • Commercial entity (trust with members from Alumni with ex-officio)


Concluding remarks


Concluding remarks • Honoured to be associated with CMC and be called to lead this great institution • There are numerous challenges • Really blessed with – – – –

A dynamic administrative team Dedicated faculty members and staff Strong reputation of CMC in the country and abroad Support of Alumni, retired staff, FOV

• Above all, “The God who has led us thus far will continue to lead us”


The harvest is plentiful but the workers are few. Ask the Lord of the harvest, therefore, to send out workers into his harvest field. Mathew 9: 37-38


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