A high volume, efficiency-driven institution that delivers great care

I visited Safdarjung Hospital in New Delhi recently – an institution with  1,531 beds and 145% occupancy rate.  Yes, 145%.  You do the math.  A lot of bed sharing and asking families to bring in cots.  It’s right across the street from the All India Institute of Medical Sciences (AIIMS), the premier public healthcare institution in India.  While both AIIMS and Safdarjung are run by the federal government, only AIIMS is renowned for famous specialists, world class facilities, and an international reputation to boot.  Safdarjung doesn’t suffer such burdens – its specialists are not well known, facilities are dilapidated, and you probably have never heard of it.

I spent several hours walking around, talking to lots of physicians, visiting ICUs and cath labs.  I visited the outpatient department where 7,000 people show up every day, many lining up the night before, to get a ticket by 11 a.m., when registration closes and those who haven’t gotten a ticket are out of luck.  In the ER, there was a line of between 50 and 100 people waiting to get rabies shots.  This is the hospital where every poor person in Delhi unfortunate enough to get a dog bite is sent.  They have the rabies serum.  Most other public hospitals do not.

Safdarjung has “efficiency” baked in.  In a typical year, they do 800 cardiac surgeries, 2,000 angioplasties, 3,000 echocardiograms, and 100,000 EKGs.  They see tens of thousands of patients in the cardiology clinic.  They have 4 (yes, four) full-time cardiologists on staff.  The rest of the work is done by medical residents, who call when they get into trouble.  Brigham and Women’s Hospital, which probably doesn’t have one quarter the volume of this place, has 140 cardiologists.  The patients at Safdarjung pay essentially nothing.  Even their medications are free.  For those who are not extremely poor (and I doubt there are many non-poor patients who go to Safdarjung), you do have to pay for your own devices.  Need a stent?  Bare metal ones cost $200 to $1000.  Drug eluting stents are $1500 to $2500.  You get to decide which one you want.  They have a chart with pictures and prices that looks a lot like a dinner menu.

What is remarkable about Safdarjung, though, is not its bustling hallways and jam-packed ER.  It’s how well it seems to work.  I visited a large ICU with lots of patients on ventilators, and a single medical resident running the place.  During the time we talked, he scanned the room and gave out orders. Everything seemed under control.  If you believe in the data on the volume-outcome relationship (and you should), it’s clear why this place claims to have terrific outcomes. They very well might.  Yet, as I walked around with the chief of cardiology, I asked him about their cardiac surgery mortality rates.  He assured me mortality was low, “comparable to international standards” (whatever that is).  I pushed him – he said very few patients died after procedures.  When I pushed a little more, he got annoyed, wondering if I was accusing him of running a poor quality hospital.  I backed off.

This is a place that seems to have no time for data.  At each step, I asked if they tracked outcomes.  They didn’t.  They know the latest evidence.  They could easily tell you all the studies that underpin the Hospital Compare quality measures and assured me they did all of those things “always”.  Patients always got antibiotics quickly.  Thrombolysis or primary PCI was never delayed.  No one went home without a beta-blocker.  Yet, several clinicians seemed to grow tired when I asked gently if they tracked their data.  They didn’t.

Safdarjung hospital is a marvel.  It has huge volumes and clinicians who are clearly both incredibly talented and dedicated.  If I were a guessing person, I’d say it probably achieves 80% of the quality of U.S. hospitals at 10% of the cost.  However, while I’m confident on the cost, I’m guessing on the quality.  For some procedures, they probably do better than the average U.S. hospital.  The upside of working in a country where high volume is easy to achieve. Of course, Safdarjung does it with none of the creature comforts we’d want in a hospital (think 145% occupancy rate and patients having to double up).  In the cardiac unit, there’s one monitor for every two patients, and they switch off depending on who is sicker at any given moment.  In the U.S., we obsess if it’s OK for a patient to take off their cardiac monitor for 10 minutes to take a shower.  This is how Safdarjung does so much with so little.  Their clinicians “cut corners” we are not willing to cut.  Its not clear to me that they are practicing worse medicine than I am.  The corners they cut are often of little or no clinical consequence.

Safdarjung is not a place that would score very highly on “quality culture” surveys.  It’s focused on efficiency in a way that few places are, and it probably has no choice but to prioritize this (think 7000 outpatient visits and 400 inpatient hospitalizations every day).  It’s overwhelming.  But, if Safdarjung could put in real metrics for clinical quality, pick some low hanging fruit (a simple EHR would be really helpful) and stop assuming good patient outcomes, it could change the culture of clinical care in India and probably surpass a majority of U.S. hospitals on safety and effectiveness.  Adding private rooms and some decent food would still leave it 85% cheaper than the average U.S. hospital. At what price point would Americans be willing to travel to India for their hip surgery?  I suspect Safdarjung wouldn’t be their destination (it’s too busy caring for the poor to invest in medical tourism).  But, there are lots of hospitals like it in Delhi – high volume centers with an appetite for new technologies and the creature comforts we would want.  Their problem is that they neither reliably measure quality nor make its improvement a priority.  Therefore, we’re left assuming “international standards”.  If there is anything we’ve learned from looking at quality in the U.S., it’s that hospitals across the street from each other can have profoundly different outcomes.  There is, unfortunately, still no international standard.

Safdarjung is an amazing place:  a high volume, efficiency-driven institution that seems to deliver pretty good care.  If it could just sprinkle in some quality measurement and make quality improvement a routine part of how it delivers care, it would likely have a profound effect on how hospital care is delivered across India and beyond.  Who knows, it might even have something to teach U.S. hospitals.

Ashish Jha is an Associate Professor of Health Policy and Management, Harvard School of Public Health.  He blogs at An Ounce of Evidence and can be found on Twitter @ashishkjha.

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