|Year : 2020 | Volume
| Issue : 5 | Page : 679-682
Survival tool kit for ophthalmic practices during difficult times: Build your resilience in the face of crisis
Mahipal S Sachdev1, Senthil Tamilarasan2
1 Chairman and Medical Director, Centre for Sight Group of Eye Hospitals, President, All India Ophthalmological Society, India
2 Ophthalmologist and Healthcare Entrepreneur, Founder and CEO, Welcare Health Systems Pvt Ltd Chennai, Tamil Nadu, India
|Date of Web Publication||20-Apr-2020|
Mahipal S Sachdev
Chairman and Medical Director, Centre for Sight Group of Eye Hospitals, President, All India Ophthalmological Society
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sachdev MS, Tamilarasan S. Survival tool kit for ophthalmic practices during difficult times: Build your resilience in the face of crisis. Indian J Ophthalmol 2020;68:679-82
|How to cite this URL:|
Sachdev MS, Tamilarasan S. Survival tool kit for ophthalmic practices during difficult times: Build your resilience in the face of crisis. Indian J Ophthalmol [serial online] 2020 [cited 2020 Sep 21];68:679-82. Available from: http://www.ijo.in/text.asp?2020/68/5/679/282903
"We must accept finite disappointment, but we must never lose infinite hope"
Martin Luther King
Indian Ophthalmology and Healthcare per se is at crossroads today, wherein we are in a sudden, unanticipated, unprecedented crisis of a lockdown of our practices and ensuing uncertainty caused due to COVID-19 Pandemic. Definitely, this is a disappointment and a setback for all of us, but this is also a time to light the candle of Hope and become the beacons of fortitude for our brethren who look upon us for inspiration and pillars of support to the common man who wishes us to continue to deliver the highest standard of Ophthalmic Care in the safest possible environment with the least risk to all involved so that none of them become a victim of this scourge.
India has a rich history of standing together, whenever our great country has faced any crisis, be it a challenge to our borders by our neighboring countries, or a medical emergency from swine flu to dengue to Nipah virus. The common man has always ensured the good of the nation, even at the cost of personal loss and discomfort. Today we stare at the most severe of these tests, with the whole country in a Never-Before situation of paralysis and a Pan-India lockdown.
The whole world has come under the spell of this Devil-like Virus, which paradoxically appears to be wearing a Crown anatomically, and the greatest economies and civilizations have been brought to their knees. The real effect of this earth-shaking pandemic will reverberate for years and decades to come, as mankind tries to limp back to normalcy and redefines social, cultural, geographic and economic parameters of existence.
It would not be wrong to call the last few decades as the golden period for Ophthalmology. With technical innovations and inventions fueling the expansion of the ophthalmic practice, it became a professionally and economically satisfying specialty. We were just about coming to terms with the challenges thrown at us by the recent developments of accreditation, price-capping, and regulatory compliances, that we have been hit by this whammy called COVID. We might just be seeing a slow down in the growth from the times of this golden era.
Most of the Ophthalmologists have redeemed themselves in this difficult hour by voluntarily closing down their practices in the interest of patient and staff safety (some even before the government ordered lockdown), though still offering emergency advice and counseling on a no-cost basis to their patients. However, with each passing day, every one of us is anxious about closed practices, the outgo of fixed costs and expenditure, the prospect of prolonged lockdown, and even a situation where the footfalls in our practice will take a long time to reach the pre-corona numbers due to patient apprehension and frugality. All this is adding mental stress to an already bleak and complicated situation.
The Buddhists say that any time we suffer misfortune, two arrows fly our way. The first arrow is the actual bad event, which can, indeed, cause pain. The second arrow is the suffering brought about by our reaction to the adverse event. That's actually optional. The pain caused by the coronavirus induced morbidity and disruption is unavoidable; the first arrow. But our reaction and attitude towards this unfortunate event and how much misery we allow it to cause us; the second arrow is in our hands. We can drown in the misery and keep lamenting "Why did it have to happen in my watch?" or use this challenge as a trampoline and launch ourselves to be a more relevant asset, ready to tackle whatever the future has in store for us.
Our emotional and psychological response to crises are natural and very human. But the truth is they often bring us more suffering by narrowing and cluttering our minds and keeping us from seeing clearly the best course of action. The principles which need to be implemented to mitigate the effect of this adversity should include resilience, recouping, and a reset in our practice patterns and mindset.
Staying positive during the crises time is the key to overcoming it and Indian Ophthalmology will rise like a Phoenix from the ashes soon.
| Keeping the Practice Alive and Practitioner Safe- Realise, Reassess, React|| |
In a lockdown period, the best way to keep our business and operations alive would be to display our commitment to patients; that is the responsibility to care for the patients. Maintaining continuity inpatient care is of paramount importance. We need to be accessible to our long-term patients and patients operated by us. We have to continue seeing patients who need emergency care, post-op reviews, etc., as a part of our medical ethics. We should communicate our service timings to all post-operative patients over the phone. Not many may be able to pass through movement restrictions in the town, for whom, we can send out emails/images of doctors advise to be shown to the authorities. This service will go a long way in building trust and belief in our hospitals, and they will be our loyal patients forever.
Having said that, we also need to take care of our doctors and staff safety, who will be servicing these patients. This can be achieved by reducing the operational hours of the clinic, timing these hours according to the partial easing of movement restrictions as and when they occur. Reduced staff effected by implementing rotation/voluntary leave needs to be put on the table as soon as possible. The expertise of the OT staff, who have the concept of facility sterility etched in their ethos, needs to be utilized to ensure no cross-infection in our area of responsibility.
The Staff who are attending to patients in these times should ensure proper COVID-19 Screening protocols are adhered to strictly without any deviations and use appropriate PPE to prevent them from getting infected. This will go a long way in ensuring that medical personnel do not become hot spots and healthcare facilities do not turn into hotbeds for the Corona epidemic, thus driving away already apprehensive patients and consequently further delaying our return to normalcy.
Another constructive step in these times is to use technology and have online training sessions in various aspects of ophthalmic practice for various stakeholders. This will not only keep them engaged but also act as a skill enhancer.
Lest we forget, all our equipment needs to be maintained and turned on periodically to prevent wear and tear. The responsible staff must be instructed to set a schedule for equipment turn-on and maintenance, lest we have to deal with short circuits and spoilt optics once we are operating normally.
| Rejuvenate – Do What You Have Always Wanted to Do|| |
The bright side of this enforced immobility is that the sky is bluer, the air is cleaner and lifestyle unhurried. Throughout our lives, we have been yearning for such an atmosphere and existence. Make the most of it now. Slow down and enjoy nature, even if it is from your balcony or lawn. Catch up on that book you always wanted to read, cook, write or sing. The options are limitless. Above all, use this opportunity to bond with your family again. The family which was always complaining about your busy lifestyle and lack of time for them: makeup to them and make the time you spend in their company memorable and joyous.
| Refresh Your Skills|| |
Use this time to arm yourselves for the time to come. You can reorganize your processes, get the documentation ready for accreditation, move towards automation, take a course in digital marketing or basically top up your skills in any aspect of your professional life. This will ensure you are better prepared to hit the ground running once we have put this blip behind us.
| Financial Management during Difficult Times- Reset and Remodel|| |
Healthcare practices are for the people and run with the people. Staff and doctors are very important for us during crisis and post-crisis like these. Right now, all your employees will be having a lot of insecurity amongst themselves on their job, and cash reserves. It is important that we instill confidence in them, that we are not going to lay off any employee unless the crisis prolongs for very long and if we face a shutdown of our business. Promoters should realize that we need these resources with us, and standby them, during these critical hours.
Conveying Realistic Positivity to your employees is the mantra that can ensure the loyalty of your workforce, which will act as an elixir in helping your practice back on its feet.
A total of 30-40% of most eye care group practices or Corporate practices cost is on salaries of doctors and staff. But with no income, this cost will not be practically possible throughout the shutdown period. It is also important that employees do not stare at a no-pay period after 1 or 2 months, due to the unpredictable prolonging of the pandemic and business slowdown. This is where diligent planning needs to be made to extend the cash reserves at least for 3 months from April to keep the resources alive.
To prioritize, HR Cost needs to be evaluated against our next 3 months' cash flow, our cash reserves and forecasted income from our credit business. Accordingly, a slab wise salary deduction (retention) should be made. In total, 20% to 30% of salaries of most of the salaried class go towards EMI's against home loans, vehicle loans, etc., As there is a moratorium announced by the government for the next 3 months, deductions can start from 20%, which can be reduced or increased as per the grade and pay structure.
Wherever Bank loans have been taken, banks have given an option to avail special 3 months moratorium on such loans. This means that if opted for EMI payment will not be debited for 3 months. However, interest will be charged at the contracted rate during this period. The similar moratorium can be availed on credit card dues.
Our HR team should personally counsel all the staff to take a slab wise, salary deductions, during the crisis period. All incentives, special allowances can be deferred and paid after we get into comfort of regular business.
It is also very important to go by the Government regulations regarding staff payment. We can also use this time to analyze the manpower in our organization and restructure when we get back to business. We should also motivate our staff to attend the online training course and it is very important to stay in touch with all our staff and reassure them that the organization will be with them during difficult times.
Building rentals is the second major cost for most Eye Hospitals housed in rented premises. We should personally request and document a request of moratorium or deferring of rental payments till June, quoting the Force majeure clause or the Doctrine of Frustration Impossibility of Contract (In case Force Majeure clause has not been built up in the contract) in reference to your rental contract and in consultation with your legal advisor. This is very critical, and the force majeure clause in many lease agreements will help insulate us from legal implications. However, we need to handle this issue very carefully since maintaining a good relationship with the landlord is of utmost importance for our future practice.
All other EMIs to equipment companies and other vendors and payments to creditors can be deferred till we regain our business, through properly documented request letters explicitly stating that the organization would not be in a position to pay interest on deferred payments. All AMC payments, CMC payments to medical equipment vendors can be deferred or an extension for at least 3 months requested. All these savings will help us maintain a cash reserve towards paying salaries of employees on above slab wise retaining pattern and also keep enough working capital to sustain the first two months of slow down, post-pandemic control.
For all practices, more fearful than the virus would be the uncertainty in resuming business and reviving. The most critical worry is how to manage costs on a 'no income period'. We should also aggressively pursue Public Sector Undertakings (PSU). Panels like Central Government Health Service (CGHS), Ex-servicemen Contributory Health Scheme (ECHS) as also various Third Party Administrators (TPAs) for the recovery of dues to help cash flow in these critical times
Let us assume that there will be no income generated in the month of April, and probably 30% of regular income during the month of May, and 75% of regular income in the month of June. Typically, Ophthalmology practices are 30 to 50% credit business and cash flows will go for a toss on this kind of indefinite business vacuum. We should smartly plan our cash flows to sustain the cash balances, to ensure no bankruptcy, while we start again
At this critical crisis the entire nation is staring at, much-ignored healthcare sector has come to foremost attention now from all bodies of government. The Ministry of Health and Family Welfare is being much looked upon by the population on preventive and corrective measures and policies.
Doctors and paramedics have risen to the occasion braving the risks associated with themselves and rendering humanitarian service in detection tests and critical care. We all look upon the Government to focus on reviving the health care segment and prepare all medical fraternity for any such future crisis the Nation may have to battle collectively.
Much is expected from the Government to subsidize the input costs of surgical consumables, medical equipment costs, and also support indigenous manufacturing houses of medical equipment, peripherals, and consumables. Also, the snail-paced payment systems of CGHS and State government healthcare schemes need a quick redressal and a permanent solution wherein their payments also come to the Healthcare Providers like Private Insurances handle through TPAs. Many hospitals are facing financial crisis, due to substantial receivables from healthcare schemes of the government. The All India Ophthalmological society has already initiated representations in this regard to the various authorities that matter.
Post this crisis, we should request the government to take concrete steps to release outstanding payments to healthcare players, to dilute the cash crisis and revamp the operations leading to normalcy.
| Getting Back to Form After the Lockdown – Reimagine and Reform|| |
As being primarily a Specialty with elective surgeries, the patients who need vision care surgeries like Cataract or Glaucoma, will wait for the dangerous time to pass, which will largely depend on the public messaging and government ease of restrictions on the community. Post this crisis, there would be a lot of concerns on the possibility of infection from hospitals during the surgeries. This is where our Communication and Quality Department should work aggressively on individually communicating and reassuring the general public and prospective patients about the safety protocols we have always been following in our operation theaters.
Patients may also have developed a mentality to defer elective surgeries for a certain period of time, and choice of premium procedures may become lesser, we should hence focus more on counseling patients to get our procedures on track.
Other important point to consider is when to resume surgery; immediately after the lockdown period or wait for some time. Should we do COVID testing for all surgical patients? How do we protect ourselves and staff in the future from such infections? Answers to all these questions will be much clearer in the coming days and months, as we get a more realistic picture of the magnitude and duration of this calamity.
We should rethink the way we are practicing and move to become a smart practitioner. Some points to consider for growth are:
- Redefining our growth strategy and plan for the next 5 years
- Embracing Technology, having a good EMR, Data analysis, Teleconsulting software, etc
- Creating smart, focused and trained manpower in our organization
- Joining or creating Group Practices so our financial exposure in infrastructure and equipment, which we don't utilize 100% reduces.
To summarize, these are action plans during this crisis period:
- Continue limited mode operations of Hospitals to service emergency care and Post Operative patients during lockdown and retain data of these patients to call back after resuming normalcy
- Explore options of patient care through Telemedicine to provide critical care diagnosis, advices, post-op care, etc.
- Retain staff and doctors displaying continued financial support by paying salaries, advances etc., within the cash flow capacity
- Support government preventive control measures, by volunteering your extra space for isolation wards, etc
- Request landlords, creditors and equipment companies for deferred payments
- Aggressively work on receiving the monies from empanelments
- Implement diligent measures on regular spends, incentives, etc., to preserve cash balances
- Redefine growth strategy and plan for the future.
Definitely, there is hope and Light at the end of the tunnel and we are sure Indian Ophthalmology will emerge ever stronger from the experience this Pandemic has given us. Stay Strong! Stay Positive! And Stay United!
| Authors|| |
Prof. (Dr.) Mahipal Singh Sachdev
Prof. (Dr.) Mahipal Singh Sachdev, a Padmashri awardee, is the Founding Chairman and Medical Director of the Centre for Sight Group of Eye Hospitals, a network of 43 specialized eye care centres across the country. He is an illustrious alumnus of and a former faculty at the Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi. He received specialty training in Cornea at the Georgetown University, USA. Dr Sachdev is an ophthalmic entrepreneur with deep academic passion. He was one of the youngest to chair the All India Ophthalmological Society (AIOS) Scientific Committee; he was also the Secretary and President of Delhi Ophthalmological Society, and Secretary and Chairman, Scientific Committee of the Intraocular Implant and Refractive Society of India, and is currently the President of the AIOS, the largest national professional ophthalmological society in the world. As the Managing Editor of IJO, Dr Sachdev takes very keen interest in its vision and mission, and is passionate about empowering the Indian Ophthalmologists through his robust and timely articles in the Journal.
Dr. Senthil Tamilarasan
Dr. Senthil Tamilarasan is the Founder and CEO, Welcare Health Systems Pvt Ltd and the Director of Pranav Eye Care Hospitals. Senthil is an Ophthalmologist and Healthcare Entrepreneur with about two decades of experience. His passionate venture Welcare Health Systems has grown to become one of India's largest Teleophthalmology companies in a short span of 5 years. Senthil has extensive experience in managing Eye Hospitals and Ophthalmology Businesses. He believes in empowering practicing ophthalmologists by disseminating his expertise in Ophthalmology Practice Management by providing strategic consulting for Eye Hospitals in India and abroad. His innovative Ophthall conferences and events focus purely on the business of Ophthalmology and are extremely popular. Senthil distills his passion and management expertise in providing a path for sustaining and rebuilding practices post-COVID-19 in this Guest Editorial. His words of wisdom will be useful in these difficult times and beyond.