His life was gentle, and the elements
So mixd in him that Nature might stand up
And say to all the world, This was a man!"

Wiliam Shakespeare, "Julius Caesar"

A scion of one of the largest industrial houses in this country, Dr S Rangarajan first prepared himself to enter the world of business. He qualified as a chartered accountant and then obtained an MBA from the University of California, Berkeley, USA. There was, however, a deeper calling in him that compelled him to do something that would be of service to those around him. He left the family business and entered medical school. He obtained his MBBS from the Kasturba Medical College, Manipal and an MD in Medicine from the Madras Medical College.

He was the Founder Chairman and Managing Trustee of Sundaram Medical Foundation. His vision was to set up a healthcare system that would be cost-effective and community centred, It would provide its services in an environment which is clean, caring and responsive to the needs of the patient. Sundaram Medical Foundation is a role model for healthcare delivery systems in India.

The hospital opened to the public in 1994. In 1996, Dr Rangarajan was struck by cancer. He passed away in 1997.

Hospitals are complex industrial organisations. They are complex in the range of medical services they provide, in their physical infrastructure or plant, and also from the organizational view point. Centuries ago, hospices evolved as centres where dedicated men and women toiled, ministering to the comforts of the sick and the dying. In the modern context, hospitals are viewed as temples of technological excellence, where the latest innovations in drugs, medical equipment and therapeutic interventions, are employed by highly trained specialists and physicians, in combating the onslaught of various diseases. Shorn of the technical gloss, and viewed from the human dimension, hospitals are essentially service organizations dedicated to the relief of pain and suffering and the curing of illness or disease.

Hospitals differ in terms of their size, in the range of services provided, and in their target patient population and geographical location. When we discuss minimum standards for hospitals, we must be clear about what type of hospital we are referring to? Are we planning on establishing a large tertiary care teaching institution, which would call for expensive equipment and infrastructure and
specialised staff, with the focus on "high-tech" services such as coronary artery by-pass surgery and organ transplantation? Alternatively is our hospital model that of a medium sized community hospital catering to the majority of health care needs of a local community? The requirements of rural hospitals and semi-urban peripheral primary medical centres, would be significantly different.

The health care scenario in India has changed dramatically over the past decade, largely due to the advent of corporate hospitals. With the vast resources at their command, they have ushered in the latest in diagnostic equipment and therapeutic interventions and have been able to attract qualified physicians from abroad. The middle class today, has a limited but definite capacity to pay for its
medical care. Better education and increasing affluence have fueled expectations for the latest and best in medical care. In the absence of an effective third party medical insurance system, the middle class has been literally pushed to the wall in paying for their health care costs. The public perception, faced with the reality of mounting health care bills, is that corporate "for profit" hospitals pursue a policy of maximising revenues, by charging exorbitant rates for their services and encourage increased utilisation by performing unnecessary tests and procedures. The reality, however, is that, faced with a competitive environment, the cost per test or procedure in India, is only a fraction of what they would cost in the West.

The changing economics of health care has brought the issue of consumerism to the forefront over the past decade. Physicians and hospitals are viewed as providers of health care services, and the public at large, employer groups and third party payment groups who pay for the hospital charges, are regarded as consumers. With skyrocketing health care costs, there has been a general feeling that the overall standards of medical ethics have been declining, and hospitals have increasingly begun to conduct their affairs on commercial lines. The public therefore has demanded greater accountability from hospitals and members of the profession and a procedure for securing prompt redressal of grievances.

Traditionally, the patient-physician relationship was considered sacrosanct, and members of the medical profession were viewed with great respect in society. Bound by a strict code of medical ethics imposed by their professional bodies, doctors were expected to act according to their best judgement and skill, with compassion and dedication, and without doing any harm to the patient. These
were the time-honoured code of professional ethics, as enshrined in the Hippocratic Oath. One of the frequent criticisms levelled against the inclusion of doctors under the CPA, is that it would significantly erode the integrity of the doctor-patient relationship and create an adversarial element requiring the doctor to pursue "risk-avoiding" and "defensive" strategies - which would contribute to further increasing the costs of care.

Patients, as consumers, even within the confines of the traditional "patient-physician" relationship were viewed as enjoying certain rights and privileges. The patient's Bill of Rights includes:

• The right to be informed about their condition and about the treatment choices and the proposed plan for treatment.
• The right to choose and provide informed consent to the treatment planned.
• The right to redressal in the event of deficiency of service, by way of gross negligence or lack of care.

Since, under the law, doctors as well as hospitals, where the services were rendered would become liable, if an act of negligence could be established, it becomes necessary to question, as a hospital planner, what minimum standards should hospitals confirm to, with respect to the following matters:

• Building standards, relating to space requirements and design features for different types of facilities.
• Infrastructure requirements such as back-up power sources, air-conditioning, central medical gas delivery systems, water treatment systems etc.
• Medical equipment considered essential for providing certain types of special services (e.g) ICU, OT etc.
• Manpower requirements especially with regard to their qualification, training, and staffing pattern.

In India, hospitals, nursing homes, diagnostic centres etc., can be established without the need for any accreditation or certification to ensure compliance with minimum standards, unlike in the case of the American Hospital Association (AHA) standards. In the absence of such minimum standards, what guidelines should hospital planners follow in the matter of selection of medical equipment,
infrastructure services, medical and nursing skills to be recruited and the range of medical services to be provided?

Is there a need for minimum standards to be evolved and enforced for hospitals? The question would naturally arise - which agency would formulate and enforce such standards, especially in the context of the reality that our professional, bodies have been notoriously lax in enforcing professional standards over the years? And would the prescription be more than the malady? Any such attempt at evolving and policing uniform standards would smack of arbitrariness and mitigate against the development of a rational private health care delivery system that would provide quality medical care at affordable costs for major segments of our
population, who are today denied access to such care. The imposition of expensive technological standards, on all hospitals, large or small, rural or urban would escalate the costs of setting up hospitals and price health care beyond the reach of target populations.

The hospital industry could make a beginning in developing a set of recommendatory guidelines for minimum standards to be followed in the establishment of various types of services - operating theatres, intensive care units, laboratory set-ups etc.

A more innovative approach would be to focus on a quality process that would be independent of the technology input and would look at issues such as completeness in documentation of medical records, medical audits, peer reviews, informed consent procedures, and standardised treatment protocols, - the essential building blocks of a Quality Assurance programme. We should look at the Industry model, where the ISO 9000 certification process and the concept of
TQM (Total Quality Management), has significantly upgraded the quality perspective of an organization, from mere quality control of the final product, to control over the quality of the entire process, backed up by proper documentation and the commitment of the management. ISO certification standards have also been established for service organizations, such as hotels, banks and health care institutions, and the hospital industry should be moving in this direction in the future.

Hospitals and doctors who pursue this path would have no reason to feel insecure about the consumer movement, inspite of the several inequities inherent in the process.