Private Practice in Ophthalmology Report
Private practice forms a significant part of the eye care scenario in India it is said that up to 80% of the ophthalmologists are involved in private practice.

Most eye care institutions large or small start out as small private practices. It is only after achieving a certain scale that they are able to grow and consolidate into large institutions such as corporate, private or NGO hospitals. Private practice forms the origin of most established eye care services in the non-government sector.

Given the competition that they face private practitioners are early to adopt new technology and test innovations and in this way become the trend-setters for eye care in the country. Other large institutions remain followers of such change adopting new techniques and technology only when the benefits are proven.

Ophthalmology today has become highly complex in terms of technology, the range and competence of the manpower required and the many regulations that need to be adhered to. Moreover, private practitioners operate typically at a small scale and so, are greatly influenced by the market forces such as competition, staff turnover, changes in technology etc. that they are subjected to. Given this scenario, the challenges faced by the private practitioners are unique to this sector.

However, while there are a lot of issues in private practice, several practitioners have demonstrated how they have been able to rise above these challenges, build and sustain a thriving practice. There is a tremendous amount of knowledge amongst the private practitioners both about the issues as well as the solutions.

LAICO- Aravind Eye Care System brought together private practitioners across the country for a two-day workshop in October 2010 in order to tap into this collective knowledge and to provide a platform to discuss the various issues relating to private practice and to elicit best practices. This report offers a glimpse of the lessons learnt at the workshop.

While several ideas and inputs apply to private practice, this report is confined to the lessons derived from this workshop. Therefore, this report is not an exhaustive guide for ophthalmic private practice. It does not cover certain important issues, for instance, regarding succession planning for private practice. Seeing the amount of learning and interest that this workshop has been able to generate, LAICO recognises that there is a scope for such workshops for private practitioners in ophthalmology on a continuous basis as it provides a platform for them to sound out their concerns, learn from each other and most importantly come together to form a unified body.

This report discusses the challenges faced at different phases of a private practice...

It is recommended that one gains some experience at a larger institution before setting out to start individual practice, to sharpen the clinical skills and learn to build the patient confidence. When setting up practice, it would help first time practitioners to run through a primary checklist in order to ensure that basic aspects of the practice are thought through:

• Where should I register?
• What licences and permits need to be obtained?
• What other paperwork needs to be fulfilled?
• Whom to contact?
• Whether to start with a basic set up or a full-fledged set up?
• Where do I procure the basic ophthalmic equipment? What is the acceptable price for each item?
• How to create an awareness of my practice in the community?

Look for guidance and develop a network with those can provide support for all aspects of the practice auditors, banks, referral doctors, other ophthalmologists, suppliers etc.

Options for a location for your practice can range from outright purchase of a property, to renting to starting small at ones own home.

While investing in a location, keep in mind the space requirements for future expansion and the minimum space requirements for important areas such as the operating room. Also, remember that you will need to provide spacious rooms for your patients you dont want to have cramped outpatient areas or wards.

While striving to finance the capital for your practice seek the support of an auditor and explore the various options available family funds, bank loans etc. Also, look into the option of starting at a smaller scale so that the initial capital required is small. Other options to be explored may include starting up as a partnership with like-minded fellow practitioners.

It is recommended that a detailed business plan is prepared before investing. This would oblige the practitioner to forecast and think through the various expenses involved and the income you expect to generate. This gives an idea of the time period over which the investment can be recovered and allows one to be in a better position to make decisions regarding investments.

Try to develop a basic understanding of the labour laws and regulations. Look within your service area and try to identify who would fit this job and strive to meet their expectations. Where it is not feasible to recruit trained personnel, you can train them on-the-job and orient them for the initial months.

During the initial days, when the practice is still small, one can train each staff to multitask. Focus on building on their strengths and interact with them on regular intervals to receive feedback in how they perceive their work. It is important to develop leadership among your staff and to empower them to take decisions. You can also explore the option of sending them to be trained at other larger institutions.

Maintain a good working atmosphere:

• Treat your staff with respect and dignity
• Pay salaries on time
• Clarify what is expected
• Create a family atmosphere
• Appreciate good work
• Ensure their welfare
• Ensure that you act as a role model for them

s Dont micro-manage, empower the staff to take appropriate decisions and lead Ensure that you communicate your vision to all your staff so that the alignment is strong

To the extent possible, institute systems at the earliest to track cash flows. Review and update these systems as needed. Communicate the system to your staff clearly.

It is strongly recommended that one seeks the guidance of a chartered accountant right from the beginning. S/he can help you start off with the right systems, maintain mandatory records and manage cash flows better.

Ensure that a 3 month buffer of liquid funds is available at any given time.At the initial stage salary expenses can be reduced by having your staff take up multiple tasks. While investing in equipment if you can get a group of your friends who also would like to make the purchase place a combined order so that you can negotiate.

What to do when there is a shortage of cash inflow:

• Make sure all cash receivables are followed up (reimbursements, insurance, etc.)
• Defer your payments to your vendors for a while

It is important to maintain a good relationship with your bankers. If your practice is suffering a setback, discuss it with them rather than concealing it. It is likely that they will be willing to help you for e.g. by offering an installment-free period.

Standardise Work flow: It is important to simplify the tasks and create a structured work flow within the practice. It is better to simplify the systems from the patients point of view this not only ensures ease for the patient but also ensures the stability of the system over time. Standardising protocols for clinical and non-clinical processes is important. Otherwise, you will be forced to look into every detail and expected to make even basic decisions. To the extent possible, try to automate the tasks.
Ensure Quality: It is important to set protocols and standards to ensure quality it is important to look into errors and develop systems that will ensure that these errors are avoided. These systems will have to evolve in iterations. While defining and monitoring quality look equally into non-clinical aspects as well is the care that is being provided compassionate and patient-centric?
Monitoring: It is important to establish a system for monitoring. This will help you be informed about performance of the systems, errors and will help you act in time.
Documentation: It is recommended that proper documentation is maintained for both patient case records and for administrative documentation (finance, staff, etc.). To the extent possible, try to computerise the documentation.
Communication: Communicate standards and protocols clearly to your team, clarify what is expected of them and establish accountability.
Resource Utilisation: Continuously deliberate on how to bring down costs by optimising the way you deploy your resources such as manpower, space, time and inventory, money.

Goal-setting: It is important to define your personal goals for effective time management it helps to have a personal mission statement. Understand that each of us has many roles to play professional, spouse, parent, student, teacher, etc. and we have to decide how we are going to balance these roles. Setting personal goals early will help you prioritise things and you will find it easier to make decisions.
Prioritising tasks: Handle important tasks as early as possible dont wait for them to become urgent. This will ensure that you are not continuously in a fire-fighting mode. Remember, when you handle urgent issues you cannot do your best and it can be stressful.
Get into a routine: Get your work life disciplined so that you can spend enough time for your family, friends and your personal hobby. When you clearly define your work timing and stick by it, over time, your patients will come to follow the same. In case you would rather have your clinic open for longer hours, get a colleague with whom you can change shifts with. This will also help you to cover your practice when you have to be away or during emergencies.

The regulations that govern private practice is different depending upon the size of the practice, the number of staff employed, the state in which it is located, etc., and so it is necessary to understand the local requirements. Remember, ignorance of the law is not an excuse.

While enforcement of rules has been weak in many areas we can expect them to become more stringent in the future. It is important to register your organisation and obtain the required licences and permits. Seek guidance from someone with experience. As health is a state subject the regulations vary from state to state

Look into the regulations that are specific to your set up, with respect to:

• Building and Land development Acts
• Registrations related to starting or managing a private practice (such as Shop and Establishment Act/Nursing Home Registration Act/Clinical Establishment Act)
• Display of registration numbers
• Safe and hazard free environment (Prevention and control of pollution Act, Noise pollution, Fire Permit, etc.)
• Indian Medical Councils regulations for Professional Code of Conduct, Etiquette and Ethics
• Regulations governing maintenance of Medical Records
• Medical records pertaining to inpatients have to be maintained for a minimum of 3 years from the date of commencement of treatment
• It is recommended that efforts are made to computerize medical records
• Restrictions on advertising
• Membership and active participation in medical societies
• Bio-medical waste disposal
• Security of patients
• Safe Medication (Drug & Cosmetics Act, Pharmacy Act, NDPS Act, etc.)
• Employment rules labour laws, provident fund
• Protecting the right of the patient (RTI Act, patient consent for procedures)
• Other regulations governing the business aspect (Charitable and Religious Trusts Act, Income Tax Acts, Sales Tax Registration for Opticals and Pharmacy, Vehicles Registration, Insurance Act, etc.)

It is recommended that the discussions on the Clinical Establishment Bill 2010 which is being debated and adopted by different states be followed as it can also have an implication on your practice. Further guidelines are given in the attached document (see: Annexure - Regulations for Private Practitioners.pdf').

It is essential that one initiates the practice in a sound manner with appropriate infrastructure, adequate and capable human resources and sufficient cash flow. It is also imperative that the work processes are organised and standards are established. It is important to constantly monitor and evaluate the work systems to ensure that one is making the best use of ones resources including funds, staff, equipment and time.

Once these basic elements are in place, it becomes equally important that the practice does not stagnate - is essential to build it up to take it to the next level. There are many perspectives that one can take to grow ones practice:

• Increase patient volume
• Widen the range of services that you provide
• Go beyond single-ophthalmologist practice

Create better awareness: Growing the external patient base can be accomplished through attempts to build the communitys awareness about eye care as well about your service by using brochures, patient education material etc. Though this requires effort and organization, it pays better dividends than investing in hoardings or mass media as they are not only expensive but their impact is also short-lived.

However, one may leverage the opportunities presented by occasions such as World Sight Day, World Glaucoma Day and Eye Donation Fortnight etc. While this is done to promote awareness about eye care and certain eye diseases in specific, it can also help to create better awareness about your services.

Tap the unmet need: It has been estimated that a mere 10% of those who need eye care proactively seek care from an ophthalmologist. It is then apparent that there is a large untapped market. Focussing on the non-customer takes you into untouched population. Doing this requires ingenuity in creating awareness, reaching out, identifying and treating those in need. However, the benefits of doing so are that this is an untouched segment where there is almost no competition and even though these patients pay less this can be more than offset by the patient volume.

Network: It is advisable to reach out into the community and develop strong relationships with key stakeholders - referral doctors, diabetologists, physicians and your potential community partners headmasters, teachers, parents, local clubs, NGOs. You must also consider empanelment by local companies.

Internal marketing: Internal marketing is a good way to build your patient volume. When patients come with attendants to your clinic use the opportunity to offer a free basic vision test to the attendants at no cost. Those who are identified to have deficient vision can then be counselled to register with you as a patient. It has been reported that many attendants have been found to have some defect (but were unaware of the fact) are ultimately grateful that they were screened and appreciate this gesture.

Also ensure that you create a strong internal referral system among the different specialty departments within your hospital. Use counsellors to increase patient compliance to the treatment advised. When you have patients with conditions such as glaucoma, diabetic retinopathy and refractive error, be sure to counsel the patient that it is likely that others in his family also have the same defect and that s/he should have their eyes examined as well.

Your most powerful advertisement: Remember that finally it is the word of your satisfied patients that will create positive awareness for your practice. Word of mouth is the most effective method to increase your patient pool reinforcing the fact that you should focus your resources and efforts to provide good quality treatment with compassion to your patients, to build confidence in your practice and satisfaction.

While striving to develop sub-specialities in addition to the investments in equipment and technology, it is important to develop both the competence to provide the service as well as build up a clientele for it.

You can rope in a colleague trained in a specialty or train yourself to provide such care. In the initial stages it is advisable to develop the referral for this specialty by being a visiting consultant at other practitioners clinics and when you have established a reputation for your services you can ask that they refer the patients to your clinic.

It is recommended that the patient base for your specialty services is built up through extensive outreach work and creating a strong referral network:

• School screening camps train your ophthalmic assistants to screen the entire school and refer only those suspected to you
• Diabetic retinopathy screening link up with a diabetologist who can screen all patients and those identified to have diabetes can be referred to you
• Create awareness about the different eye diseases to increase the number of patients who will seek care.

A good way to start is to get fresh ophthalmology graduates who are interested in gaining experience at the early stages. Ensure, that in whatever way you engage another ophthalmologist, it should be a win-win situation for both.

Spectacle dispensing: This remains an important source of revenue for private practitioners. Given that on an average over 20% of ones outpatient needs refractive correction and that spectacles need to be replaced once every two years, it is advisable to have your own optical dispensing unit. It is important to ensure that your patient receives the advised correction and it is easier to ensure the quality of the spectacle he procures when you yourself are dispensing it. While most practitioners shy away from starting their own optical shop, it is advisable not to outsource this because of the potential revenue it can generate. And the competence for running and managing an optical shop is relatively easy to institute.

Get better mileage: Look at your costs and see which areas can be addressed. Costs are either fixed (rent, salaries, interest, etc.) or variable (consumables, etc.) depending upon the number of patients seen study them to see how you can get more out of a single resource. Try multi-tasking, increasing the efficiency of your staff, price revision ad tweaking the systems in place to experiment if more patients can be seen by the same amount of resources such as time, manpower. Increasing quality and reducing errors go a long way in reducing your costs.

Invest in sturdy, long lasting equipment, try to adopt free open-source software, negotiate annual and comprehensive maintenance contracts. Invest time in maintaining your equipment so that they serve you longer and suffer fewer breakdowns. It also pays to keep a tab on the performance of the equipment both the clinical performance as well as financial performance whether you are able to get a good return on the investment.

One may look at maximising the usage of your capacity such as pooling surgical cases to utilise your OT better can save autoclave and air conditioner expenses. Decrease hospital stay to increase bed utilisation rate. With good networking with other practitioners you can share the use of expensive equipment so that the machine is not underutilised.

Task-shifting: Another way to lower your manpower costs is to see if you can shift tasks downwards can some of the simple, routine tasks such as refraction and counselling be done by an ophthalmic assistant rather than by an ophthalmologist?

Pace your growth plans: Make sure that your plans for growth are not overambitious estimate your ability to take risks and handle unforeseen setbacks.

Make sure you have an annual budget. Try to estimate if you will have any major expenditure such as equipment purchase during the year and prepare a purchase plan.

It is important to stay updated about the changing scenarios within which we operate and understand the implications to our practice. It is essential that we are proactive in responding to these changes.

With regulations on the increase and becoming more stringent it is important to ensure that one is compliant with the legal requirements. With more and more patients taking to insurance one needs to gear up the internal systems to handle the necessary formalities for this. With technology improvements at a rapid rate, one should be able to stay informed and also be able to evaluate when to adopt the innovation.

In todays highly competitive market, it is both important to maintain a competitive edge as well as maintain a healthy relationship with fellow practitioners. It is in this scenario that it is important to provide service that is patient centric it should be compassionate and the patient finds the service complete and comprehensive.

Stay in touch with your patients and watch out for their feedback. With the increase in affordability and the choice that the patients have to access eye care it is important to respond to the changing expectations of the patient.

An important challenge in private practice is the lack of a unified body to voice the concerns of the private practitioner. While 80% of the countrys ophthalmologists operate in the private sector, there is no platform where they can come together to advocate for their concerns. It is advised that the private practitioners should network with one another to create better synergy among the individual practitioners.

Acknowledgement
This report presents insights and lessons drawn from the workshop, Private Practice in Ophthalmology Making it Work, organised by LAICO-Aravind Eye Care System at Madurai, in collaboration with AIOS during Oct 2-3, 2010.

This report is a direct result of the workshop which saw many practical insights put forth by the speakers who generously shared their experiences and innovative ideas through lectures and panel discussions. This report also captures the wealth of knowledge generated through the rich discussion with the participants.

We thank the key facilitators and speakers who made this workshop constructive and useful and to the participants who made the workshop meaningful with their active involvement.

We also thank AIOS for the support extended to make this workshop successful. Lions Aravind Institute of Community Ophthalmology (LAICO) is the training and consultancy arm of Aravind. Established in 1992, with a mandate to support eye care programmes globally, in order improve eye care services, LAICO has worked with over 270 eye hospitals from India and other developing countries through a collaborative process of consultancy and capacity building. Over 1,800 eye care professionals from 70 countries have been trained in the management courses and other more specific task-oriented training programmes. LAICO has developed several need-based management tools in eye care and has also been involved in the design of national eye care programmes for India and other developing countries.

Key Facilitators: Dr. Sourav Sinha Kolkata Dr. V. Siddharthan Salem Dr. Ashok Grover New Delhi Dr. Babu Rajendran Chennai Special Lectures: Dr. R. Pararajasegaram Former WHO Consultant Mr. R. D. Thulasiraj Executive Director, LAICO

Guest Faculty: Dr. V. Velayudham Chennai Dr. Satish Chennai Dr. V. Panneerselvam Erode Dr. K. G. R. Nair Trivandrum Dr. Ravishankar Chennai Dr. Nirmal Fredrick Chennai Dr. Ramesh Karur Dr. O. Gopalakrishna Nellore Dr. Sathia Albert Trichy Dr. Ramesh Trichy Dr. Murali Ariga Chennai

Lions Aravind Institute of Community Ophthalmology (LAICO) is the training and consultancy arm of Aravind. Established in 1992, with a mandate to support eye care programmes globally, in order improve eye care services, LAICO has worked with over 270 eye hospitals from India and other developing countries through a collaborative process of consultancy and capacity building.

Over 1,800 eye care professionals from 70 countries have been trained in the management courses and other more specific task-oriented training programmes. LAICO has developed several need-based management tools in eye care and has also been involved in the design of national eye care programmes for India and other developing countries.