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Doing fine: post-cataract surgery at the AEH free- hospital, 2016

How McDonald's inspired the success of an extraordinary eye hospital

06/07/2017By Ingrid Diep
Can you imagine how a McDonald’s restaurant could motivate an ophthalmologist to start a new hospital in an ancient city? No! Well, nor could INGRID DIEP, an Australian optometrist, so she decided to visit the hospital to see for herself.

Prologue"So, how do you find the food?” my colleague, Dr Sam asks. “Hmm. A little spicy,” I reply sheepishly, which makes us both laugh. We are having lunch at Inspiration, Aravind Eye Hospital’s hostel for international guests.

Lunch is green chilli and pepper curry and I’m wiping my eyes with my third batch of tissues. Dr Sam laughs again; he's from Mauritius completing a course in vitreo-retinal surgery and has been in Madurai, this ancient city in South India where the hospital is located, for four months.

“It’s typical India," Dr Sam explains, "You’ve got a constant drone of honking in the background, dusty roads missing footpaths and the occasional stray dog. However, when you walk into the hospital, it’s like another world – and you know, I’ve been to big university hospitals in France and the US, but this is something in an entirely different league.

Aravind Eye Hospital (AEH) in Madurai, India, demonstrates the wonders that can be achieved when good management and good medicine unite. Dr Govindappa Venkataswamy – or Dr V as he is known – founded AEH in 1976, when he was a 58-year-old just-retired professor of ophthalmology. Two years before his retirement Dr V had visited a McDonald’s restaurant for the first time and was inspired by the fast food chain’s business model.

He had a vision to eliminate needless blindness, and he decided he was going to ‘sell’ people good eyesight the same way McDonald’s sold hamburgers. “If Coca-Cola can sell billions of sodas and McDonald’s can sell billions of burgers, why can’t Aravind sell millions of sight-restoring operations, and, eventually, the belief in human perfection?” he said.

For Dr V, lack of financial means was not going to be a barrier because people who could afford cataract surgery would subsidise the costs for those who couldn’t.

The project started operating from the family home as an 11-bed clinic but fast forward 40 years and AEH now boasts five tertiary care hospitals where about 5,000 staff complete more than 400,000 surgeries a year, half of which are free or heavily subsidised.

Hundreds of doctors and nurses from around the world come here annually for ophthalmic training.

What enabled such a transformation?

A nurse checks-in with waiting patients
A nurse checks-in with waiting patients

I’ve come to AEH to volunteer for a month to help standardise assessment materials for the vision technician training program. Vision technicians are nurses trained in basic optometric and ophthalmic care at the hospital’s network of vision centres – primary care clinics located in regional areas distant to the base hospital.

On my first day I received a tour of the hospital and discovered it’s really more like a campus. There are separate buildings for paying and free patients, an in-patient building for both, a medical research building, and the LAICO building for management and administrative teams. There are also separate hostels for nurses, local trainees and international trainees.

The efficiency and quality of the hospital services is uncanny. In the seating area, electronic medical record software displays estimated patient waiting times, all the refraction lanes have digital charts and patients diagnosed with cataract today are admitted for surgery tomorrow. The hospital even sends corneas to other hospitals because its eye bank has no wait-list, a situation fairly unusual in most parts of the world, including the ‘first world’.

The level of staff communication is astounding; everybody knows what’s going on and everybody works together as a team.

Six Sigma discipline

1-day post-op review following cataract surgery
1-day post-op review following cataract surgery

This collective culture – a curious mix of Six Sigma spirituality, service and start-up mentality – has been instrumental in the hospital’s success. Organisations with a larger-than-life founder often have a tendency to stagnate or decline with his or her departure. Dr V died more than 10 years ago however his organisation has continued to flourish, in part because he had the foresight to set its foundations in a dedicated team rather than on the individual.

Six Sigma is a disciplined, data-driven approach and methodology for eliminating defects in any process – from manufacturing to transactional and from product to service. It was developed in the 1980s by the US technology giant Motorola and quickly spread to other Fortune 500 companies after General Electric adopted it in the early 1990s.

Why shouldn’t the same principles apply to managing a hospital? After all, medical treatments stem from evidence-based research and clinical trials therefore it made sense to translate this premise to other facets of the hospital.

AEH is not strictly a Six Sigma proponent however, it is an organisation that recognises the importance of data. 

The introduction of the Electronic Medical Record System has made it even easier for trends and anomalies to be flagged at every stage of any process. For example, a biostatistics team member can easily review the day’s total outpatients, the number of those who were refracted, how many refracted patients needed glasses (prescriptions issued), how many prescriptions were processed through the optical store, and then how many purchases were actually made, so that the dropout rate can be measured at every stage.

This means changes in policy or methodology can be made confidently, with data to support the changes not just because of empirical feedback from one or two staff members, or at the whim of an executive.

Furthermore, after changes have been made, there’s more data to collect and analyse to ascertain whether the change has resulted in a positive difference.

AFT Pharmaceuticals

Spirituality and Service

Two doctors operate together in the one theatre. While one patient is undergoing cataract extraction, another patient is prepped to minimise time between surgeries.
Two doctors operate together in the one theatre. While one patient is undergoing cataract extraction, another patient is prepped to minimise time between surgeries.

The hospital has no religious affiliation, however; Dr V was a deeply spiritual person. He was a follower of two of India’s leading 20th century gurus: Sri Aurobindo and The Mother.

He created AEH to underpin a greater cause and believed in viewing things as part of a larger whole, putting ego aside, and being humbled by the opportunity to serve others.

TAMIL THANKS: A wordless “thank-you” after cataract surgery at the AEH free hospital
TAMIL THANKS: A wordless “thank-you” after cataract surgery at the AEH free hospital

During an old interview Dr V described his experience with an elderly patient and tells the tale of how she had put her complete trust in him saying, “Doctor, I will do anything you say.”

How could he not do his best for her?

Many of AEH’s initiatives can be attributed to this holistic and servant-like approach. Eye camps took eyecare to people in remote locations and who were unable to visit the hospital in the city. When patients refused free surgery despite having blinding cataracts, the hospital investigated the underlying barriers to access, and then introduced counselling, transport, food, and shelter for patients attending from rural areas.

The hospital’s ethos of compassionate care remains today, but it’s not easy to maintain. With every year, younger recruits become further removed from the original founding tenets in both time and place. Today’s Indian society is very different to that of the 1970s.

Sister Alees, coordinator of academic and training for the first and second-year nursing recruits, credits the patience and vigilance of older staff for the preservation of the hospital culture. “When I first started 20 years ago, they [nursing recruits] were so interested, so full of questions. These days it is less so. So whenever we see them disinterested or bored we need to talk to them to remind them about the mission of service. Otherwise what will happen? It trickles down.”

Start-up mentality

Aravind Eye Hospital in-patient block, in Madurai, Tamil Nadu, India
Aravind Eye Hospital in-patient block, in Madurai, Tamil Nadu, India

AEH is a far cry from any Silicon Valley tech venture, however, it shares a surprising number of qualities with small, up-and-coming firms. For one thing, the management team welcomes feedback and is willing to change.

It’s unrelated to my primary project, but Ms Dhivya, a senior manager co-ordinating the hospital’s optical stores, suggests I visit them while I’m here to give some feedback. I offered a few casual comments about the way they manage spectacle remakes compared to the way we do in Australia (I used to work for a process-driven corporate franchise) and the next thing I know I’m meeting with the head of the entire optical department and a small assembly of her most senior staff!

It demonstrates that striving for constant improvement is a part of the hospital’s fabric.

A few days later I’m invited to the annual meeting where staff from the Madurai hospital’s 25 vision centres have gathered to review their performance and discuss strategies for the New Year. Dr. Usha Kim, who’s managed the vision centres for four years but worked at the hospital for 25, chairs the meeting. Incidentally, she also holds the record for most number of surgeries in a day – 153 to be exact.

“But, am I going to keep doing 150 cases every day? Of course not! I need to use my position now to prevent that from happening,” she says.

Even the tech world’s start-up mantra of ‘Fail fast, fail often’ has a place here. Not in the operating theatre, but in the way new strategies or programs are implemented. The managers are big on rapid prototyping, field-testing, and then refinement before a large-scale roll out. This is the way they transitioned to electronic medical records. This is the way my project works.

Nothing goes live without a field test or a pilot. Compared to the traditional model where plans are kept secret until perfected, the start-up way ensures that time and money aren’t wasted on ideas which don’t work in real life.

Many organisations with a goal as lofty as that of AEH often get lost in the broad scope of their mission. They spread themselves too thinly, often without any concrete targets or strategy. On the flipside, those that mine as much data as this hospital sometimes miss the forest for the trees and become too focused on driving improvement by numbers.

United by a culture that is open to positive change but resistant to detractors, AEH is a place that’s moving, professional, humbling, and spiritual — all at once.

Epilogue: While I am enjoying my lunch I begin to wonder who came up with the name for the guesthouse. I ask Dr Sam if they were referring to the hospital, the people we’d meet there, or the friends we’d make at the guesthouse?

“Nah,” he says. “It’s a gift from Aravind. Everybody who comes here finds Inspiration."

About the author: Ingrid Diep is a Australian optometrist who volunteered her time at Aravind Eye Hospital in Madurai, India during December 2016 and January 2017. She says this article does not go anywhere near doing the hospital and its staff justice.

More reading: Infinite Vision: how Aravind became the world’s greatest business case for compassion

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