Superstar Leaders
ASIAN CASE RESEARCH JOURNAL, VOL. 12, ISSUE 2, 161–186 (2008)
ACRJ
Superstar Leadersa
This case was prepared by
Abhishek Goel and Neharika
Vohra of the Indian Institute of Management Calcutta as a basis for class discussion rather than to illustrate either effective or ineffective handling of an administrative or business situation.
Please address all correspondence to Abhishek Goel,
E-203, NTB, IIM Calcutta,
Kolkata 700104, India or
Neharika Vohra, Organizational Behavior Area, Indian
Institute of Management,
Ahmedabad 380015, India.
E-mail: agoel@iimcal.ac.in or neharika@iimahd.ernet in.
“A dead patient could mean a negligible statistical aberration in a doctor’s career record, but for the patient and family it’s 100%! A doctor has to realize this. I learnt this the hard way when I lost my mother in a kidney surgery. That is my sense of responsibility when I perform surgery, and this is what any responsible doctor should understand.”
This was Dr. Raghavendra Singh Shekhawat’s lodestar.
Dr. Shekhawat had earned a name for himself in successfully adopting latest practices in urology and being a wizard kidney surgeon. He was the Head of the Department of Urology and Managing Trustee at the Dausa Kidney
Hospital (DKH). His name had become synonymous with advances in urology practice in India over the last 25 years.
Dr. Shekhawat was considered a “master” in treating complicated cases and continued success earned him respect and accolades from all over the country. In 2002, he won the prestigious President’s Gold Medal recognizing his services to society in the field of urology. He headed the regional
Urological Association and represented India at the Société
Internationale d’Urologie.
Dr. Shekhawat was revered by colleagues for his skills and ability to handle patients. His compassion and healing touch gained him admiration from the patients.
Every patient wanted to be treated by him. Junior doctors at the hospital looked up to him and wished to emulate his success and jostled to get a share of his expertise. aNames and places have been changed to protect identity. However, all data
(quantitative and qualitative) are real and accurate.
© 2008 by World Scientific Publishing Co.
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DKH was equipped to provide the most sophisticated care available to kidney patients of all socio-economic strata.
The hospital had several qualified consultants.b They were offered salaries and facilities at par with those in charitable hospitals in nearby cities. DKH had national recognition in patient care and academic training. However, for the last
3–4 years turnover of doctors had been very high. The attrition of trained and established consultants put increased pressure on other doctors and adversely impacted Dr.
Shekhawat’s plans for starting a new academic center at
DKH. He was unable to explain the reasons for their exit. He had informally asked the authors of this case to study the reasons for high attrition at DKH. The case writers’ report had just reached him and he started reading. The report was not very flattering and he was very depressed. He was also outraged after reading some consultants’ perceptions of himself. He wondered what he could do to bring about changes in the hospital.
BACKGROUND
Dr. Shekhawat received his training in India and the UK.
While in the UK, Dr. Shekhawat became interested in urology when he came in touch with Dr. Jaideep Singh
Rathod, an Indian urologist. Dr. Rathod returned to India and started a small hospital — Dausa Kidney Hospital — right next to his residence in Dausa (61 km from Jaipur, the capital city of Rajasthan state in north-western India) in
1978. These parts of Rajasthan had very high incidence of kidney ailments due to geographic conditions and lifestyles.
Most people were very poor and could not afford treatment costs. DKH was set up as a charitable institution with the mission to provide high quality treatment to all patients.
It was decided that no patient would be denied or offered lower quality treatment just because he/she could not afford the cost of treatment. Dr. Rathod received help from his bUnless mentioned otherwise, a consultant refers to a doctor who has successfully completed super-specialization training in a branch of surgery or medicine. A consultant would lead a team of junior doctors for patient care.
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philanthropic friends and acquaintances within and outside
India to meet the running costs of DKH.
Dr. Shekhawat returned to India in 1980. He set up his own practice in Jaipur. However, he maintained contacts with Dr. Rathod and started working part-time at DKH. After Dr. Rathod died in 1985, Dr. Shekhawat started working three days a week in his Jaipur clinic and spent three days at DKH, mainly performing surgeries.
It took him about four hours to commute between Dausa and Jaipur. For 15 years, Dr. Shekhawat worked singlemindedly on developing treatment capabilities at DKH and as a consequence turned out one success story after another.
He became highly respected among patients, doctors, and trustees of DKH. In 2000, he gave up his practice in Jaipur and started full-time practice at DKH. The trustees asked his wife to manage the finances of the hospital. She was designated as the Financial Controller.
Dr. Shekhawat was fully supported by Dr. Jai Singh
Rajput who had joined the hospital in 1979 as a resident nephrology consultant. He had risen to head the Department of Nephrology at DKH. Both Dr. Shekhawat and
Dr. Rajput were highly respected for their knowledge and experiences. Dr. Rajput’s wife was the medical social worker at the hospital. She looked after donations to needy patients, legalities associated with kidney donations, and approvals from concerned authorities.
THE HOSPITAL
DKH believed in total patient care in line with its slogan,
Excellence in Patient Care. The hospital earned its name by providing the best medical care in kidney-related problems. The expertise and infrastructure were sophisticated enough to treat any kind of kidney-related problems.c It had
cSeveral problems arise when the kidney fails to function. Broadly, these include blood in the urine, fluid disorder, cancer, cysts, stones, kidney-failures, and urinary tract infections. Functions of the human kidney and diseases affecting it are described in the Appendix.
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top-of-the-line facilities and a low mortality rate comparable to the best hospitals in the world.
The cost of care comprised two components: cost of medical procedure and care and cost of facilities for staying.
Medical care cost was the same for all patients but the cost of stay depended on the facilities a patient could afford.
The hospital had 140 beds divided into four categories of wards: general, semi-special, special, and deluxe. The wards were divided on the basis of facilities available. Deluxe wards were the most expensive and general wards the least expensive. There were separate general wards for males, females, and children.
DKH was equipped with three operation theatres and a lithotripsyd center. The operation theatres had facilities comparable to the best urological hospitals in the world. In addition, there were special emergency and post-operative wards where patients could go through pre- and postsurgery treatment and care. There was a dialysise ward to accommodate 50 patients a day for performing dialysis.
The hospital had separate facilities for HIV- and hepatitisinfected patients. Cleaning and water management facilities for dialysis were maintained in-house. In addition, the hospital also had resident anesthetists, radiologists, and pathologists. To be able to respond to emergencies not associated with kidney-related diseases, DKH had developed partnerships with good hospitals nearby to share their facilities and personnel. Alongside patient care, DKH was also an accredited center for providing super-specialization training to medical post-graduate students interested in making a career in the treatment of kidney-related diseases. dLithotripsy is a technique that uses shock waves to break up stones that get formed in the kidney, bladder, ureters, or gallbladder. This is normally done by focusing shock waves on the stone to break it into tiny pieces which then pass out of the body naturally during urination.
Sometimes, lasers are used to pulverize the stones with the help of an endoscope.
In some advanced cases, percutaneous lithotripsy is performed when patients do not respond to shock wave treatment or stones are difficult to access. Stones are accessed from the back into the kidney. Dr. Shekhawat was an expert in percutaneous lithotripsy. eDialysis is done when the kidney fails. It filters out waste products and waste fluids.
For more information, see Appendix.
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Management of the Hospital
Principal donors of 1978 had formed the Dausa Kidney
Hospital Trust and continued to oversee the management of the hospital. The trust met from time to time to discuss the progress and future plans of the hospital. The trust maintained its status of being a principal donor. Board meetings were held either at the trust office in New Delhi, or at Dausa and were attended by members of the trust and heads of departments.
There were 45 doctors (including trainee residents) and
300 members of staff (medical, administrative, and other support functions). Mr. N. Reddy (General ManagerAdministration) worked very closely with Dr. Shekhawat and Dr. Rajput. Dr. Shekhawat took decisions about DKH and its future plans in consultation with the members of the trust. For most decisions, Dr. Shekhawat was understood to be the final authority. See Exhibit 1 for the organizational structure of the hospital.
The hospital had two main units, urology and nephrology.f Since 1985, the urology team was headed by
Dr. Shekhawat. He had two to three consultants reporting to him on a regular basis. The team also consisted of trainee residents (hereafter called interns) admitted to the academic program at the hospital. Dr. Rajput headed the nephrology department and he too had consultants and interns.
Academic Activities
In 1993, the hospital became an approved training center for the award of DNBg (Diplomate of National Board) in fNephrology is the medical side of kidney treatment. Nephrologists are specialists in general medicine. Generally, nephrologists treat patients for various infections in the kidney and oversee renal failure cases till they require surgical treatment.
Urologists deal specifically with the urinary system and prostrate. They take care of the surgical side of kidney treatment. Urologists perform kidney removal, transplants, lithotripsy, and other surgeries as needed.
After surgery, post-operative care is given by both nephrologists and urologists.
Close coordination between the two is vital. gCandidates applying for DNB were doctors holding post-graduate degree with an average age of nearly 28 years. They wished to super-specialize in some branch of
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nephrology and urology. The DKH training program was ranked the highest among all privately owned centers offering DNB in urology or nephrology in the country. The program had a clear focus on academics and research. The annual intake was two candidates in nephrology and four in urology. In addition, the hospital had permission to induct a research fellow in urology for the sole purpose of carrying out research. The reputation of the hospital attracted interns from across India and research fellows from other Asian developing countries. This enriched the talent pool at the hospital. The method of instruction was direct observation and/or actual practice followed by intense discussion of the treatment, current practices in the field, future lookout, and writing reports. The interns and consultants were encouraged to write and present their work at various national and international forums and conferences. Presenting papers at various forums provided the necessary performance track record and connected them to a network of doctors and hospitals all over the world.
The interns found balancing patient care and academic performance very demanding. The new interns took some time to get adjusted to the culture and environment. As a senior intern put it:
“It took about six months to train a new resident about the system here, or you can say, the punch bag period was six months.”
To provide academic inputs, Dr. Shekhawat and Dr.
Rajput networked with other leading doctors in the field and invited them as visiting faculty. They were seniors or contemporaries of Dr. Shekhawat and Dr. Rajput. In 2001,
Dr. P. L. Mina, a trusted aide of Dr. Shekhawat for more than two decades, was made in-charge of the academic activities at the hospital. Dr. Mina coordinated with the visiting faculty to ensure maximum inputs to the interns and supervised the progress of the interns.
medicine or surgery. The DNB program lasted for about three and a half years. While the first three years were devoted to theoretical and practical training, the remaining six months were required for various examinations.
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Interns at DKH
The interns were required to work closely with patients as per the norms of medical education. They had the responsibility of carrying out preliminary diagnosis of patients visiting the out-patients department (OPD), supervising patients in the wards allocated to them, and preparing or updating case histories. They accompanied senior doctors on rounds. They also provided assistance in surgeries undertaken by some senior interns and consultants.
An intern was allowed to perform surgeries on his/her own only when Dr. Shekhawat felt that he/she was ready for it.
Dr. Shekhawat’s criteria were not clearly stated. However, he was perceived as a good judge of the readiness of an intern. In addition to these duties, the interns also had to prepare and study for academic discussions held regularly.
The interns looked forward to them and did not mind intense discussions for learning. They were encouraged to discuss patient-related issues with the visiting faculty.
In early 2005, the interns received a stipend of Rs.9,000 a month (approximately USD200) when they entered the program. The amount went up to Rs.11,000 (approximately
USD255) as they progressed in the program. The stipend was decided by the National Board and was the same across the country. At DKH, the interns were entitled to furnished accommodation in a beautifully laid out residential campus located about 800 meters from the hospital. The atmosphere in the residential campus was friendly and the families shared good camaraderie.
Future Plans of DKH
After moving to DKH full-time, Dr. Shekhawat could devote more time to issues related to the hospital. Within the next three years, the department started buzzing with academic activity and there was increased participation of doctors in conferences in India and abroad. Dr. Shekhawat had organized an international conference for urologists at DKH
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in 2004 and convened several conferences and seminars for the Urological Society of India. DKH achieved new heights in the field of patient services and academic activities. Not only did this increase the visibility of the hospital, it also attracted doctors from neighboring countries and helped
DKH establish its credibility in terms of research and other academic activities on the world map.
The hospital was on a growth path not only in terms of patients but also in other patient-related and academic activities. The education initiatives were making DKH known all over the country. DNB graduates from DKH continued with rigorous patient care and services, and academics learnt at DKH in their own practice all over the country. Dr. Shekhawat took pride in his students and their work. He said:
“My success lies NOT [emphasis by Dr. Shekhawat] in being remembered as The Dr. Shekhawat. My success lies in giving another 20 better Dr. Shekhawats to the society.” In early 2004, Dr. Shekhawat decided to start an academic center for advanced studies dedicated to urology and related fields. The center would house facilities for drug trials, simulated training on latest equipment, a large library with study cabins, and large conference halls to hold regular national and international seminars.
Dr. Shekhawat introduced his idea of academic center to his team of consultants and interns thus:
“… you all know we have become a center for excellence in patient services. This is something we started with.
Now we have to become a center for excellence in academics.” The outlay was about Rs.50 million (approximately
USD1.1 million). Dr. Shekhawat had no difficulty in garnering resources for the center from internal reserves, donations, and trust members. His colleagues were quite excited in seeing the progress. A week before the foundation stone for the center was to be laid, a woman professor from
Chandigarh who taught in the nephrology department quipped: 00109.indd 168
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“We thought of having a center where the academically inclined could get together and talk, present our work, get new ideas for practice, get to know about complications, and most important of all, share it with all the doctors at the same platform… The efforts of Dr. Shekhawat are commendable. In less than a year we have moved from an idea to the foundation stone of the center building. In hospitals it generally takes a long time for things to get moved.” DR. SHEKHAWAT’S CONCERNS ABOUT DKH
Dr. Shekhawat was both elated and concerned. As he put it:
“… one of the important resources was the knowledge that could be generated to fuel further generation of knowledge. The doctors in the hospital were similar to knowledge workers in the information technology industry.” He was also worried about the high turnover of consultants especially in the last 3–4 years. Even some colleagues and old time friends of Dr. Shekhawat had left the hospital in late 2003 after working at DKH for about 10 years. The turnover had impacted heavily on the services provided by the hospital.
There was another worrisome trend: the interns were not inclined to stay after they completed their course.
Though they were promised help to attend short term courses in the UK and the US, most preferred to start their own practice. The consultants also did not last long though they had committed themselves to a long stay. Dr.
Shekhawat needed good doctors to turn the Rs. 50 million academic center dream into a reality. He understood that there could be problems if the “producers of knowledge”
(consultants and interns) went missing from the scene.
The high level of attrition had an impact on dayto-day operations and productivity, besides the heavy workload for Dr. Shekhawat and huge training costs.
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DIFFERENCES ACROSS NEPHROLOGY AND
UROLOGY DEPARTMENTS
The pay and prerequisites were similar in both nephrology and urology departments. The work structure was also the same. The interns and consultants shared the same dining facilities. Over lunch or snacks, discussions about work pressures and patients were commonplace. Often, comparisons were made of the heads of the nephrology and urology departments. Both Dr. Shekhawat and Dr. Rajput were considered masters in their fields. Many felt that Dr.
Rajput was not a magician like Dr. Shekhawat but he was a good mentor. He could help young doctors learn and grow. Consultants and interns of the nephrology department felt that Dr. Rajput was a very tough instructor. He gave very clear instructions about the standard of services and key deliverables. On the other hand, Dr. Rajput was compassionate and accommodated interns’ and consultants’ requirements. The nephrology interns and consultants enjoyed the freedom to discuss and receive supervision from
Dr. Rajput. One consultant remarked:
“Dr. Rajput has kind of teacher stories, the kind their students… hearts.” an old world teacher charm. He is the that we always heard of in childhood that draws respect and admiration from these teachers actually live in students’
Consultants at the nephrology department stayed on at DKH for a much longer period. On the other hand, senior consultants in the urology department found Dr.
Shekhawat’s stature intimidating. One consultant remarked:
“Dr. Shekhawat is very bright and very good. But he also makes me feel very inadequate at times.”
The common perception was that there was a marked difference in actual working conditions of the nephrology and urology departments. The nephrology interns and consultants were satisfied and enjoyed their work, while those in the urology department felt that DKH was a very stressful place and had serious complaints of as well as immense praises for Dr. Shekhawat.
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It was common for urology consultants to be told even by non-medical assisting staff during a surgery that:
“… had Dr. Shekhawat been here he would not have done it this way”.
A consultant recalled:
“… on hearing this… my hands were shaking. My previous training of eight years and spotless record held me no more. Here was this patient lying with an open abdomen, and I just lost track of what I had to do. I thank
God; the patient is walking today…”
There was a “Dr. Shekhawat way” of dealing with patients and carrying out procedures. It was expected that everyone would learn it and practice it. These procedures were never directly put across by Dr. Shekhawat himself but were part of the hospital folklore. One consultant shared his views with the case writers:
“The experience counter is reset to zero when you join this hospital. You may have been a good surgeon elsewhere but here the ‘Master’ takes the call on whether you are worth it. It would be a good assumption that a doctor’s being here at this place is proof enough of his/ her capabilities. I wonder often, why should skill set matter at the time of recruitment if DKH is supposed to reset the counter to zero.”
This created a unique challenge: every new expert had to be re-trained!
Other consultants felt that they could not upgrade their skill-set in performing a variety of surgeries in the hospital because of Dr. Shekhawat. He always got to do the complex surgeries and also decided who would do what kind of work.
Another surgeon said:
“Surgeons need to continuously upgrade their skills in new areas that are coming up. This is done by performing surgeries using new methods on willing patients. We also discuss the repertoire of skills that the hospital should have. To have specialists in all methods we divide the work on the basis of surgeries required for the patients.
We were drawing out a plan for training surgeons to
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perform surgeries with laparoscopic technique that would be the standard in future. I discussed with Dr.
Shekhawat about learning laparoscopic surgery and was deeply interested in it. But at the time of allocation Dr.
Shekhawat just forgot about the discussion he had with me. I was given nothing that was discussed with me. It was surprising… and demoralizing!”
As the interns also assisted in surgeries, incidents like the ones noted above were common knowledge to them.
They often found that the consultants were unhappy and were working under pressure in a place to which they had come by choice. The interns felt that the best way to deal with this was to become a “Yes Sir” person. Hierarchy was sanctum-sanctorum. “Either you respect it [hierarchy], or you don’t belong in here.” The residents also sometimes had problems during academic discussions with Dr. Shekhawat.
While they enjoyed their sessions with visiting faculty, they could not do so with Dr. Shekhawat. Dr. Shekhawat did not tolerate any comparison of the hospital’s current practices with other hospitals. Such a step would invite severe criticism from Dr. Shekhawat.
The interns appreciated the latest techniques they learned and treasured them. However, they were worried that the number of cases being treated with open surgery methods was declining steadily. The open surgery method required making a long incision and cutting a rib. Open surgeries took longer to heal and chances of infection were quite high. These required more intensive post-operative care compared to laparoscopic surgeries. Since DKH had state-ofthe-art laparoscopic facilities very few open surgeries were being undertaken. The interns believed that replicating the level of facilities employing the latest techniques available at this hospital at any other place of work would be difficult without huge investment. Even if funds could be arranged, they were not sure if all patients could afford the cost of treatment using laparoscopic techniques. They felt that it was necessary to build sufficient skills in carrying out open surgeries for some renal ailments. In Exhibit 2, descriptions of what the consultants and residents felt about Dr. Shekhawat and their experiences at the hospital are given.
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WORK DAY OF INTERNS AND CONSULTANTS
IN UROLOGY
Appointment diaries of Dr. Shekhawat and consultants in the urology department were full. Every day they performed surgeries on patients with clockwork precision, often handling more than one surgery per consultant per day. The working day of the urology interns usually began at 6.45.
The first task was to receive patient progress reports from the relieving intern, and, if required, make preparations for scheduled surgeries. Dr. Shekhawat usually started the day latest by 7.30, with first surgery scheduled between 8.30 and
8.45.
The interns were also allocated duties in the OPD.
One consultant supervised all OPD work and discussed cases with the interns. Some interns were allocated duties in patient wards as “in-charge.” They monitored the progress of patients and prepared their charts. Several rounds were scheduled during the day for every ward. First, the most junior intern prepared the progress report summaries of the patients in his/her ward. These reports were then checked by a second-year intern followed by a brief examination of the patient. Here, some doubts of the first-year intern (if any) were resolved. The observations of the junior interns were ratified by a senior intern in his/her round. The senior interns also noted any peculiarities in the case, and waited for the consultant’s round to discuss them. These procedures were repeated for every round in the hospital. Dr.
Shekhawat also took rounds of the wards. If Dr. Shekhawat decided to take a round, the consultants and intern(s) incharge would accompany him. The interns found the rounds with Dr. Shekhawat very instructive but very stressful. Dr.
Shekhawat did not tolerate mistakes and was very impatient if he noticed anything was amiss. As one consultant remarked excitedly in an informal meeting with the authors of this case:
“I am glad that Dr. Shekhawat had to leave a little early today. He went for a party in Jaipur. I can play with my kids today and have a lovely dinner at home. For a change, the family would be together at the same table.”
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Usually there were two rounds, one in the morning around lunch time, and the second in the evening before doctors left. Occasionally, Dr. Shekhawat took the last round and it ended sometime between 9.15 and 9.45 pm. This left many interns and consultants wondering when they would go home. It was commonplace for interns to reach home at
10 pm and then be expected to spend another two to three hours with family, study, and prepare for the next day’s academic discussions. The interns did not mind working long hours but did not like to be waiting for Dr. Shekhawat to decide.
Dr. Shekhawat’s own schedules were very hectic and his workload was very huge. However, he showed no signs of weariness or a desire to distribute the patient load. He was still as active as a young surgeon just beginning his/ her career. His touch with patients, as his colleagues and subordinates referred to, was “absolutely magical.” Doctors, staff, and patients were amazed at the care that he could give each patient. There were instances when patients would refuse to undergo treatment with any other consultant or doctor. Everyone wanted Dr. Shekhawat, and he was just one call away.
One intern recalled an incident. Dr. Shekhawat was called at his residence in the middle of the night when he was wanted by a patient. In less than 15 minutes, Dr.
Shekhawat was at the bedside with his senior interns. There were instances of Dr. Shekhawat entering the hospital at 6, straight from his morning walk to simply check some patient! Such care and attention was nothing but exemplary in the field of patient services. He was truly a superstar among his patients, colleagues, and juniors.
The consultants felt that most patients were treated and/or operated by Dr. Shekhawat himself. This resulted in work overload for Dr. Shekhawat, which in turn led to lesser time available for academic discussions with residents and other activities. It also led to remuneration loss for the consultants since they missed out on the incentives given by performing more surgeries.
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PERCEIVED CULTURE AT DKH AND LEADERSHIP
RATINGS OF DR. SHEKHAWAT
The interns and consultants found that even at 60 years of age Dr. Shekhawat was a very tough competitor. He would go for any challenge without caring for the level of competition. When he fought, he did not give up till he got the results in his favor. This spirit was evident at work as well. Complex problems seemed to excite him and made him a better surgeon.
The interns and consultants often commented on how there was so much focus on being the best and providing the best while their remuneration was much below market rates. They agreed that DKH was a charitable hospital and it was their choice to join it, but they felt that they could work for so little and under such pressure for only a short period of time. Some of them even mentioned that there was enough potential for everyone to earn more despite the charitable nature of the hospital. When asked if they would stay if they were paid more, they replied that they may still leave because they would rather have the autonomy. They felt DKH was a good place to learn but not to stay back and work to make a name for oneself.
To assess the culture at DKH in quantitative terms (see details of the cultural dimensions given in Exhibit 3), the case writers administered a questionnaire to the consultants, interns, and Dr. Shekhawat. There were two parts to the questionnaire. One part was designed to collect the perceived present and desired culture of the hospital.
The assessments of the doctors and Dr. Shekhawat about the culture at DKH are given in Exhibit 4. The perceived present culture at the hospital as per doctors is that the hospital is primarily formalized (hierarchical), efficient, and result-oriented (market). Dr. Shekhawat perceived the culture to be primarily familial (clan), fostering autonomy
(adhocracy), and efficient. The differences in the perceptions are instructive. However, the desired culture map of both is quite similar.
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The other part of the study was designed to compare the perception of the doctors with that of Dr. Shekhawat about his leadership. The results are given in Exhibit 5. The differences in the perceptions again are revealing.
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Appendix A
The Kidney, Its Usefulness, and Its Diseases
(Extracted from websites www.users.rcn.com/jkimball.ma. ultranet/BiologyPages/K/Kidney.html, www.kidney.org, and www.kidney.ca) Facts about the Human Kidney
• two bean-shaped organs, each about the size of a fist
• represent about 0.5% of the total weight of the body
• receives 20–25% of the total arterial blood pumped by the heart • each kidney contains one to two million nephrons
Renal vein Renal artery Kidneys
Ureters
Bladder
Urethra
Picture Source: www.kidney.ca
The Kidney and Homeostasis
The kidneys remove wastes and normal components of the blood that are in greater-than-normal concentrations. The kidneys filter and return to the bloodstream about 200 quarts of fluid every 24 hours. About two quarts are removed from the body in the form of urine. The kidneys function as homeostatic device and continuously regulate the chemical composition of the blood within narrow limits.
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The kidneys also balance the body’s fluids; release hormones that regulate blood pressure; produce an active form of vitamin D that promotes strong, healthy bones; and control the production of red blood cells.
Causes of Chronic Kidney Disease
Chronic kidney disease is defined as having some type of kidney abnormality or “marker” such as protein in the urine.
There are many causes of chronic kidney disease including diabetes and high blood pressure. Some kidney conditions are inherited while others are congenital. The following are some of the most common types and causes of kidney damage. Glomerulonephritis is a disease that causes inflammation of the kidney’s tiny filtering units called the glomeruli.
Glomerulonephritis may happen suddenly or the disease may develop gradually, and it may cause progressive loss of kidney function.
Polycystic kidney disease is the most common inherited kidney disease. It is characterized by the formation of kidney cysts that enlarge over time and may cause serious kidney damage and even kidney failure.
Kidney stones are very common, and when they pass, they may cause severe pain in the back and side. Sometimes, medications and diet can help to prevent recurrent stone formation. In cases where stones are too large to pass, treatments may be done to remove the stones or break them down into small pieces that can pass out of the body.
Urinary tract infections occur when germs enter the urinary tract and cause symptoms such as pain and/or burning during urination and more frequent need to urinate.
These infections most often affect the bladder, but they sometimes spread to the kidneys, and they may cause fever and pain in the back.
Congenital diseases may also affect the kidneys. These usually involve some problem that occurs in the urinary tract when a baby is developing in its mother’s womb.
Drugs and toxins can also cause kidney problems. Using
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large numbers of over-the-counter pain relievers for a long time may be harmful to the kidneys.
Treatment of Kidney Diseases
Most kidney diseases, kidney stones, and urinary tract infections can usually be treated successfully. Sometimes, chronic kidney disease may progress to kidney failure, requiring dialysis or kidney transplantation.
Treating Kidney Failure
Kidney failure may be treated with dialysis or kidney transplantation. There are two common forms of dialysis — peritoneal and haemodialysis. In peritoneal dialysis a special solution is run through abdominal cavity that helps filter out waste fluids from the human body. It can be done daily at home. Haemodialysis requires patient’s blood to be filtered of waste products and waste fluids using a dialyzer.
This process is costlier compared to peritoneal dialysis and requires special facilities.
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Personnel
(Administration
matters)
Maintenance
Internal Auditor
Purchase
Stores & Inventory
Housekeeping
Establishment
Statistics, ISO, MR
Matron/Asst. Matron
Pharmacy
Dietetics
G.M Administration
(Mr. N. Reddy)
Consultants
Residents (Interns)
Dialysis (Facilities and Staff )
Radiologists
MSW
Bio-Medical
Engineer
Pathologist
Biochemist
Microbiologist
Sterilization
OPD Coordination
Library
Head – Dept. of Nephrology
(Dr. J. S. Rajput)
Consultans
Residents
(Interns)
Financial Controller
(Mrs. R. S. Shekhawat)
Andrologists
Anesthetist
Operation Theaters
(Facilities & Staff )
Lithotripsy Center
Head – Dept. of Urology
(Dr. R. S. Shekhawat)
Dausa Kidney Hospital
Trust-Managing Trustee
(Dr. R. S. Shekhawat)
Organization Chart
Exhibit 1 p Medical Social
Worker
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Exhibit 2
Comments from interns and consultants on Dr. Shekhawat and his style of working and about his competence and sense of service
“There are times when you, as a trained doctor, say, this is impossible. He should not do it. But, he is one man I have seen would go ahead and makes us realize the difference between a good and a great surgeon.”
“You should learn how to look after a patient by observing him in the rounds. He makes them feel so comfortable even with so complicated procedures. He brings the best out of the patients. Probably, management consultants could learn a few things about managing customers from Dr. Shekhawat.”
“The facilities provided by the hospital are very good. We are given a good comfortable house and a good atmosphere with colleagues’ families. They have taken care of the family’s needs very well.”
Comments indicating respect but sense of discomfort in working with Dr. Shekhawat
“I accepted the offer at this hospital for two reasons. One, the opportunity to work with
Dr. Shekhawat and, two, my love for teaching and academics. Where else in a private hospital kind of setup do I get to involve myself in teaching and academics like this place.” (after a long pause) “I am not sure if I got it all, or it was a wise decision to be here.”
“He is a mastermind at work. He can manipulate people like anything.”
“I don’t know if this is positive or negative. There is tremendous respect for him with the staff and amongst us [consultants]. But sometimes, this gets on to you.”
“He does not care about you. He has a child-like urge to compete. He competes with us! We are nothing compared to him.”
Comments expressing frustration of working with Dr. Shekhawat and the hospital
“He forgets that we have a family at home. We have kids to look after. We need to go home.”
“Someone should realize that the money you get is peanuts. And when you offer peanuts, you get monkeys to dance, not humans. It is not that the hospital is not earning money, but it is not available for sharing with us.”
“He treats us as if we are new. As a consultant we have several years of experience backing us. But, all that is zero when you are here. The day you join your assessment is not based on what you did in the past, but on what Dr. Shekhawat thinks about you.”
“Everything in this hospital moves around the seniors.”
“Shekhawat aur Reddy ki marzi ke bina yahan patta bhi nahin hilta.” (Not even a leaf can move here without the whims or permission from Dr. Shekhawat or Mr. Reddy.)
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Exhibit 3
Culture Assessment of the Hospital
The Competing Values Frameworkhh (CVF) was used to study the culture of the department in the hospital. CVF models an organization’s culture in terms of subcultures in an organization represented across dimensions of Focus (Internal or External) and Control orientation (Flexibility and Tight Control). The subcultures could be represented in a 2*2 table. The four types of subculture are: Clan, Adhocracy, Market, and Hierarchy. The table below shows common characteristics and behavior observed for each subculture of components of organizational culture under CVF.
Flexibility/Discretion
Internal
Focus/
Integration
CLAN
ADHOCRACY
Characteristics — Friendly place, Mentors, Extended family, Loyalty or traditions,
Teamwork
Behaviors: Facilitation,
Human Resource
Development
Characteristics — Dynamic,
Entrepreneurial, Creative workplace, “stick neck out” to take risks, freedom
Behaviors Innovation,
Entrepreneurship
Participation to increase commitment Innovativeness to bring growth HIERARCHY
MARKET
Characteristics — Formalized and structured place,
Efficiency, Stability,
Predictability
Behaviors: Coordination,
Monitoring, Organizing
Characteristics — Resultorientation, Tough demands,
Market leadership, Hard driving competitiveness,
Behaviors: Compete,
Produce, Leader
Control brings efficiency
Competition fosters productivity External
Focus/
Differentiation
Control/Stability
Figure 1. Organizational Culture under Competing Values Framework
Source: Based on discussion in K S Cameron and R E Quinn, 1999, Diagnosing and Changing Organizational Culture based on the Competing Values Framework. Reading: Addison-Wesley.
hThe
Competing Values Framework was proposed by Cameron and Quinn in their book Diagnosing and Changing
Organizational Culture based on the Competing Values Framework (1999).
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Exhibit 4
Using CVF, organizational culture was assessed on all four dimensions using the Organizational
Culture Assessment Instrument (OCAI). This instrument required the participants to allocate
100 points among various subcultures in the hospital’s culture. This brought out the mix of subcultures in the culture of DKH. In addition, the instrument allowed the respondents to suggest what changes they desired in the cultural mix. The respondents for this study were the doctors in the hospital. These responses were then compared with Dr. Shekhawat’s perceptions of the present and future hospital culture. The table here presents the mean scores for the culture of the hospital.
Table 1. Present and Desired Culture in the Hospital as perceived by the Doctors and Dr. Shekhawat
PRESENT
Doctors
DESIRED
Clan
Adhocracy
Market
Hierarchy
Clan
Adhocracy
Market
Hierarchy
14.742
18.800
33.754
33.000
30.606
24.523
22.662
22.015
15.864
5.723
−11.092
−10.985
27.167
24.000
29.667
19.167
2.000
−2.667
−2.833
2.667
Differencesi
Dr. Shekhawat
25.167
26.667
32.500
16.500
Differences
(Minus sign indicates a desired decrease in the dimension)
Diagrammatic representation of above table is given in the figures below.
CLAN
ADHOCRACY
CLAN
HIERARCHY
MARKET
Present Culture Profiles
Doctors (Solid line) vs. Leader (Dotted Lines)
HIERARCHY
ADHOCRACY
MARKET
Desired Culture Profiles
Doctors (Triple line) vs. Leader (Dotted line)
iDifferences
have been calculated as Mean Score (desired state) — Mean Score (present state). Thus, a negative difference would indicate a desired decrease in the dimension. Alternately, a positive difference would indicate a desire to obtain higher scores on a dimension.
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Exhibit 5
Leader Appraisal
Leader appraisal was carried out on a set of behaviors using a 30-item questionnaire. Table 2 presents the items used to appraise Dr. Shekhawat (by his team members and him) and the mean scores by the team and the self-rating of Dr. Shekhawat himself. These 30 statements could also be represented on the 4 subculture dimensions of CVF. The mean scores for assessment of Dr. Shekhawat and his team on the 4 subculture dimensions are also summarized for each dimension. Table 2. Appraisal of Dr. Shekhawat
Mean
for
Doctors
SelfRating
Dr. Shekhawat generates, or helps others obtain, the resources necessary to implement their innovative ideas.
2.75
4
Dr. Shekhawat articulates a clear vision of what can be accomplished in the future.
3.50
5
Dr. Shekhawat regularly comes up with new, creative ideas regarding processes, products, or procedures for his hospital.
4.17
5
Dr. Shekhawat constantly restates and reinforces his vision of the future to members of his department.
3.75
5
Dr. Shekhawat is always working to improve the processes we use to achieve our desired output.
3.75
5
Dr. Shekhawat facilitates a climate of continuous improvement in his department. 2.92
5
Dr. Shekhawat has developed a clear strategy for helping his department successfully accomplish his vision of the future.
3.08
5
Dr. Shekhawat captures the imagination and emotional commitment of others when he talks about his vision of the future.
2.83
4
Dr. Shekhawat creates an environment where experimentation and creativity are rewarded and recognized.
2.58
4
Dr. Shekhawat encourages everyone in his department to constantly improve and update everything they do.
2.83
5
Dr. Shekhawat helps his employees strive for improvement in all aspects of their lives, not just in job related activities.
1.75
5
3.083
4.727
Item Description
Items classified as behaviors reinforcing ADHOCARCY culture
MEAN SCORE (Adhocracy)
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Table 2. (Continued)
Mean
for
Doctors
SelfRating
Dr. Shekhawat communicates in a supportive way when people in his department share their problems with him.
1.92
5
Dr. Shekhawat regularly coaches subordinates to improve their skills so they achieve higher levels of performance.
2.33
5
Dr. Shekhawat builds cohesive, committed teams of people.
2.75
5
Dr. Shekhawat gives his subordinates regular feedback about how he thinks they’re doing.
2.58
4
Dr. Shekhawat creates an environment where involvement and participation are encouraged and rewarded.
2.08
4
When giving negative feedback to others, Dr. Shekhawat fosters their self-improvement rather than defensiveness or anger.
2.42
2
Dr. Shekhawat gives others assignments and responsibilities that provide opportunities for their personal growth and development.
2.75
5
Dr. Shekhawat facilitates a work environment where peers as well as subordinates learn from and help develop one another.
2.17
5
Dr. Shekhawat listens openly and attentively to others who give him their ideas, even when he disagrees.
1.42
2
2.269
4.111
Dr. Shekhawat makes certain that all team members are clear about our policies, values, and objectives.
3.42
5
Dr. Shekhawat assures that regular reports and assessments occur in his department.
3.17
3
Dr. Shekhawat has established a control system that assures consistency in quality, service, cost, and productivity in his department. 3.75
5
Dr. Shekhawat clarifies for members of his department exactly what is expected of them.
3.58
5
MEAN SCORE (Hierarchy)
3.479
4.500
Item Description
Items classified as behaviors reinforcing CLAN culture
MEAN SCORE (Clan)
Items classified as behaviors reinforcing HIERARCHY culture
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Table 2. (Continued)
Mean
for
Doctors
SelfRating
Dr. Shekhawat establishes ambitious goals that challenge his subordinates to achieve performance levels above the standard.
3.42
5
Dr. Shekhawat pushes his department to achieve world-class competitive performance in service and/or products.
4.25
5
By empowering others in his department, Dr. Shekhawat fosters a motivational climate that energizes everyone involved.
2.17
5
Dr. Shekhawat has consistent and frequent personal contact with his internal and his external customers.
3.67
5
Dr. Shekhawat increases the competitiveness of his department by encouraging others to provide services and/or products that surprise and delight customers by exceeding their expectations.
3.42
5
Dr. Shekhawat assures that everything we do is focused on better serving our customers.
4.00
5
3.486
5.000
Item Description
Items classified as behaviors reinforcing MARKET culture
MEAN SCORE (Market)
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Superstar Leadersa
This case was prepared by
Abhishek Goel and Neharika
Vohra of the Indian Institute of Management Calcutta as a basis for class discussion rather than to illustrate either effective or ineffective handling of an administrative or business situation.
Please address all correspondence to Abhishek Goel,
E-203, NTB, IIM Calcutta,
Kolkata 700104, India or
Neharika Vohra, Organizational Behavior Area, Indian
Institute of Management,
Ahmedabad 380015, India.
E-mail: agoel@iimcal.ac.in or neharika@iimahd.ernet in.
“A dead patient could mean a negligible statistical aberration in a doctor’s career record, but for the patient and family it’s 100%! A doctor has to realize this. I learnt this the hard way when I lost my mother in a kidney surgery. That is my sense of responsibility when I perform surgery, and this is what any responsible doctor should understand.”
This was Dr. Raghavendra Singh Shekhawat’s lodestar.
Dr. Shekhawat had earned a name for himself in successfully adopting latest practices in urology and being a wizard kidney surgeon. He was the Head of the Department of Urology and Managing Trustee at the Dausa Kidney
Hospital (DKH). His name had become synonymous with advances in urology practice in India over the last 25 years.
Dr. Shekhawat was considered a “master” in treating complicated cases and continued success earned him respect and accolades from all over the country. In 2002, he won the prestigious President’s Gold Medal recognizing his services to society in the field of urology. He headed the regional
Urological Association and represented India at the Société
Internationale d’Urologie.
Dr. Shekhawat was revered by colleagues for his skills and ability to handle patients. His compassion and healing touch gained him admiration from the patients.
Every patient wanted to be treated by him. Junior doctors at the hospital looked up to him and wished to emulate his success and jostled to get a share of his expertise. aNames and places have been changed to protect identity. However, all data
(quantitative and qualitative) are real and accurate.
© 2008 by World Scientific Publishing Co.
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DKH was equipped to provide the most sophisticated care available to kidney patients of all socio-economic strata.
The hospital had several qualified consultants.b They were offered salaries and facilities at par with those in charitable hospitals in nearby cities. DKH had national recognition in patient care and academic training. However, for the last
3–4 years turnover of doctors had been very high. The attrition of trained and established consultants put increased pressure on other doctors and adversely impacted Dr.
Shekhawat’s plans for starting a new academic center at
DKH. He was unable to explain the reasons for their exit. He had informally asked the authors of this case to study the reasons for high attrition at DKH. The case writers’ report had just reached him and he started reading. The report was not very flattering and he was very depressed. He was also outraged after reading some consultants’ perceptions of himself. He wondered what he could do to bring about changes in the hospital.
BACKGROUND
Dr. Shekhawat received his training in India and the UK.
While in the UK, Dr. Shekhawat became interested in urology when he came in touch with Dr. Jaideep Singh
Rathod, an Indian urologist. Dr. Rathod returned to India and started a small hospital — Dausa Kidney Hospital — right next to his residence in Dausa (61 km from Jaipur, the capital city of Rajasthan state in north-western India) in
1978. These parts of Rajasthan had very high incidence of kidney ailments due to geographic conditions and lifestyles.
Most people were very poor and could not afford treatment costs. DKH was set up as a charitable institution with the mission to provide high quality treatment to all patients.
It was decided that no patient would be denied or offered lower quality treatment just because he/she could not afford the cost of treatment. Dr. Rathod received help from his bUnless mentioned otherwise, a consultant refers to a doctor who has successfully completed super-specialization training in a branch of surgery or medicine. A consultant would lead a team of junior doctors for patient care.
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philanthropic friends and acquaintances within and outside
India to meet the running costs of DKH.
Dr. Shekhawat returned to India in 1980. He set up his own practice in Jaipur. However, he maintained contacts with Dr. Rathod and started working part-time at DKH. After Dr. Rathod died in 1985, Dr. Shekhawat started working three days a week in his Jaipur clinic and spent three days at DKH, mainly performing surgeries.
It took him about four hours to commute between Dausa and Jaipur. For 15 years, Dr. Shekhawat worked singlemindedly on developing treatment capabilities at DKH and as a consequence turned out one success story after another.
He became highly respected among patients, doctors, and trustees of DKH. In 2000, he gave up his practice in Jaipur and started full-time practice at DKH. The trustees asked his wife to manage the finances of the hospital. She was designated as the Financial Controller.
Dr. Shekhawat was fully supported by Dr. Jai Singh
Rajput who had joined the hospital in 1979 as a resident nephrology consultant. He had risen to head the Department of Nephrology at DKH. Both Dr. Shekhawat and
Dr. Rajput were highly respected for their knowledge and experiences. Dr. Rajput’s wife was the medical social worker at the hospital. She looked after donations to needy patients, legalities associated with kidney donations, and approvals from concerned authorities.
THE HOSPITAL
DKH believed in total patient care in line with its slogan,
Excellence in Patient Care. The hospital earned its name by providing the best medical care in kidney-related problems. The expertise and infrastructure were sophisticated enough to treat any kind of kidney-related problems.c It had
cSeveral problems arise when the kidney fails to function. Broadly, these include blood in the urine, fluid disorder, cancer, cysts, stones, kidney-failures, and urinary tract infections. Functions of the human kidney and diseases affecting it are described in the Appendix.
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top-of-the-line facilities and a low mortality rate comparable to the best hospitals in the world.
The cost of care comprised two components: cost of medical procedure and care and cost of facilities for staying.
Medical care cost was the same for all patients but the cost of stay depended on the facilities a patient could afford.
The hospital had 140 beds divided into four categories of wards: general, semi-special, special, and deluxe. The wards were divided on the basis of facilities available. Deluxe wards were the most expensive and general wards the least expensive. There were separate general wards for males, females, and children.
DKH was equipped with three operation theatres and a lithotripsyd center. The operation theatres had facilities comparable to the best urological hospitals in the world. In addition, there were special emergency and post-operative wards where patients could go through pre- and postsurgery treatment and care. There was a dialysise ward to accommodate 50 patients a day for performing dialysis.
The hospital had separate facilities for HIV- and hepatitisinfected patients. Cleaning and water management facilities for dialysis were maintained in-house. In addition, the hospital also had resident anesthetists, radiologists, and pathologists. To be able to respond to emergencies not associated with kidney-related diseases, DKH had developed partnerships with good hospitals nearby to share their facilities and personnel. Alongside patient care, DKH was also an accredited center for providing super-specialization training to medical post-graduate students interested in making a career in the treatment of kidney-related diseases. dLithotripsy is a technique that uses shock waves to break up stones that get formed in the kidney, bladder, ureters, or gallbladder. This is normally done by focusing shock waves on the stone to break it into tiny pieces which then pass out of the body naturally during urination.
Sometimes, lasers are used to pulverize the stones with the help of an endoscope.
In some advanced cases, percutaneous lithotripsy is performed when patients do not respond to shock wave treatment or stones are difficult to access. Stones are accessed from the back into the kidney. Dr. Shekhawat was an expert in percutaneous lithotripsy. eDialysis is done when the kidney fails. It filters out waste products and waste fluids.
For more information, see Appendix.
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Management of the Hospital
Principal donors of 1978 had formed the Dausa Kidney
Hospital Trust and continued to oversee the management of the hospital. The trust met from time to time to discuss the progress and future plans of the hospital. The trust maintained its status of being a principal donor. Board meetings were held either at the trust office in New Delhi, or at Dausa and were attended by members of the trust and heads of departments.
There were 45 doctors (including trainee residents) and
300 members of staff (medical, administrative, and other support functions). Mr. N. Reddy (General ManagerAdministration) worked very closely with Dr. Shekhawat and Dr. Rajput. Dr. Shekhawat took decisions about DKH and its future plans in consultation with the members of the trust. For most decisions, Dr. Shekhawat was understood to be the final authority. See Exhibit 1 for the organizational structure of the hospital.
The hospital had two main units, urology and nephrology.f Since 1985, the urology team was headed by
Dr. Shekhawat. He had two to three consultants reporting to him on a regular basis. The team also consisted of trainee residents (hereafter called interns) admitted to the academic program at the hospital. Dr. Rajput headed the nephrology department and he too had consultants and interns.
Academic Activities
In 1993, the hospital became an approved training center for the award of DNBg (Diplomate of National Board) in fNephrology is the medical side of kidney treatment. Nephrologists are specialists in general medicine. Generally, nephrologists treat patients for various infections in the kidney and oversee renal failure cases till they require surgical treatment.
Urologists deal specifically with the urinary system and prostrate. They take care of the surgical side of kidney treatment. Urologists perform kidney removal, transplants, lithotripsy, and other surgeries as needed.
After surgery, post-operative care is given by both nephrologists and urologists.
Close coordination between the two is vital. gCandidates applying for DNB were doctors holding post-graduate degree with an average age of nearly 28 years. They wished to super-specialize in some branch of
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nephrology and urology. The DKH training program was ranked the highest among all privately owned centers offering DNB in urology or nephrology in the country. The program had a clear focus on academics and research. The annual intake was two candidates in nephrology and four in urology. In addition, the hospital had permission to induct a research fellow in urology for the sole purpose of carrying out research. The reputation of the hospital attracted interns from across India and research fellows from other Asian developing countries. This enriched the talent pool at the hospital. The method of instruction was direct observation and/or actual practice followed by intense discussion of the treatment, current practices in the field, future lookout, and writing reports. The interns and consultants were encouraged to write and present their work at various national and international forums and conferences. Presenting papers at various forums provided the necessary performance track record and connected them to a network of doctors and hospitals all over the world.
The interns found balancing patient care and academic performance very demanding. The new interns took some time to get adjusted to the culture and environment. As a senior intern put it:
“It took about six months to train a new resident about the system here, or you can say, the punch bag period was six months.”
To provide academic inputs, Dr. Shekhawat and Dr.
Rajput networked with other leading doctors in the field and invited them as visiting faculty. They were seniors or contemporaries of Dr. Shekhawat and Dr. Rajput. In 2001,
Dr. P. L. Mina, a trusted aide of Dr. Shekhawat for more than two decades, was made in-charge of the academic activities at the hospital. Dr. Mina coordinated with the visiting faculty to ensure maximum inputs to the interns and supervised the progress of the interns.
medicine or surgery. The DNB program lasted for about three and a half years. While the first three years were devoted to theoretical and practical training, the remaining six months were required for various examinations.
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Interns at DKH
The interns were required to work closely with patients as per the norms of medical education. They had the responsibility of carrying out preliminary diagnosis of patients visiting the out-patients department (OPD), supervising patients in the wards allocated to them, and preparing or updating case histories. They accompanied senior doctors on rounds. They also provided assistance in surgeries undertaken by some senior interns and consultants.
An intern was allowed to perform surgeries on his/her own only when Dr. Shekhawat felt that he/she was ready for it.
Dr. Shekhawat’s criteria were not clearly stated. However, he was perceived as a good judge of the readiness of an intern. In addition to these duties, the interns also had to prepare and study for academic discussions held regularly.
The interns looked forward to them and did not mind intense discussions for learning. They were encouraged to discuss patient-related issues with the visiting faculty.
In early 2005, the interns received a stipend of Rs.9,000 a month (approximately USD200) when they entered the program. The amount went up to Rs.11,000 (approximately
USD255) as they progressed in the program. The stipend was decided by the National Board and was the same across the country. At DKH, the interns were entitled to furnished accommodation in a beautifully laid out residential campus located about 800 meters from the hospital. The atmosphere in the residential campus was friendly and the families shared good camaraderie.
Future Plans of DKH
After moving to DKH full-time, Dr. Shekhawat could devote more time to issues related to the hospital. Within the next three years, the department started buzzing with academic activity and there was increased participation of doctors in conferences in India and abroad. Dr. Shekhawat had organized an international conference for urologists at DKH
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in 2004 and convened several conferences and seminars for the Urological Society of India. DKH achieved new heights in the field of patient services and academic activities. Not only did this increase the visibility of the hospital, it also attracted doctors from neighboring countries and helped
DKH establish its credibility in terms of research and other academic activities on the world map.
The hospital was on a growth path not only in terms of patients but also in other patient-related and academic activities. The education initiatives were making DKH known all over the country. DNB graduates from DKH continued with rigorous patient care and services, and academics learnt at DKH in their own practice all over the country. Dr. Shekhawat took pride in his students and their work. He said:
“My success lies NOT [emphasis by Dr. Shekhawat] in being remembered as The Dr. Shekhawat. My success lies in giving another 20 better Dr. Shekhawats to the society.” In early 2004, Dr. Shekhawat decided to start an academic center for advanced studies dedicated to urology and related fields. The center would house facilities for drug trials, simulated training on latest equipment, a large library with study cabins, and large conference halls to hold regular national and international seminars.
Dr. Shekhawat introduced his idea of academic center to his team of consultants and interns thus:
“… you all know we have become a center for excellence in patient services. This is something we started with.
Now we have to become a center for excellence in academics.” The outlay was about Rs.50 million (approximately
USD1.1 million). Dr. Shekhawat had no difficulty in garnering resources for the center from internal reserves, donations, and trust members. His colleagues were quite excited in seeing the progress. A week before the foundation stone for the center was to be laid, a woman professor from
Chandigarh who taught in the nephrology department quipped: 00109.indd 168
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“We thought of having a center where the academically inclined could get together and talk, present our work, get new ideas for practice, get to know about complications, and most important of all, share it with all the doctors at the same platform… The efforts of Dr. Shekhawat are commendable. In less than a year we have moved from an idea to the foundation stone of the center building. In hospitals it generally takes a long time for things to get moved.” DR. SHEKHAWAT’S CONCERNS ABOUT DKH
Dr. Shekhawat was both elated and concerned. As he put it:
“… one of the important resources was the knowledge that could be generated to fuel further generation of knowledge. The doctors in the hospital were similar to knowledge workers in the information technology industry.” He was also worried about the high turnover of consultants especially in the last 3–4 years. Even some colleagues and old time friends of Dr. Shekhawat had left the hospital in late 2003 after working at DKH for about 10 years. The turnover had impacted heavily on the services provided by the hospital.
There was another worrisome trend: the interns were not inclined to stay after they completed their course.
Though they were promised help to attend short term courses in the UK and the US, most preferred to start their own practice. The consultants also did not last long though they had committed themselves to a long stay. Dr.
Shekhawat needed good doctors to turn the Rs. 50 million academic center dream into a reality. He understood that there could be problems if the “producers of knowledge”
(consultants and interns) went missing from the scene.
The high level of attrition had an impact on dayto-day operations and productivity, besides the heavy workload for Dr. Shekhawat and huge training costs.
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DIFFERENCES ACROSS NEPHROLOGY AND
UROLOGY DEPARTMENTS
The pay and prerequisites were similar in both nephrology and urology departments. The work structure was also the same. The interns and consultants shared the same dining facilities. Over lunch or snacks, discussions about work pressures and patients were commonplace. Often, comparisons were made of the heads of the nephrology and urology departments. Both Dr. Shekhawat and Dr. Rajput were considered masters in their fields. Many felt that Dr.
Rajput was not a magician like Dr. Shekhawat but he was a good mentor. He could help young doctors learn and grow. Consultants and interns of the nephrology department felt that Dr. Rajput was a very tough instructor. He gave very clear instructions about the standard of services and key deliverables. On the other hand, Dr. Rajput was compassionate and accommodated interns’ and consultants’ requirements. The nephrology interns and consultants enjoyed the freedom to discuss and receive supervision from
Dr. Rajput. One consultant remarked:
“Dr. Rajput has kind of teacher stories, the kind their students… hearts.” an old world teacher charm. He is the that we always heard of in childhood that draws respect and admiration from these teachers actually live in students’
Consultants at the nephrology department stayed on at DKH for a much longer period. On the other hand, senior consultants in the urology department found Dr.
Shekhawat’s stature intimidating. One consultant remarked:
“Dr. Shekhawat is very bright and very good. But he also makes me feel very inadequate at times.”
The common perception was that there was a marked difference in actual working conditions of the nephrology and urology departments. The nephrology interns and consultants were satisfied and enjoyed their work, while those in the urology department felt that DKH was a very stressful place and had serious complaints of as well as immense praises for Dr. Shekhawat.
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It was common for urology consultants to be told even by non-medical assisting staff during a surgery that:
“… had Dr. Shekhawat been here he would not have done it this way”.
A consultant recalled:
“… on hearing this… my hands were shaking. My previous training of eight years and spotless record held me no more. Here was this patient lying with an open abdomen, and I just lost track of what I had to do. I thank
God; the patient is walking today…”
There was a “Dr. Shekhawat way” of dealing with patients and carrying out procedures. It was expected that everyone would learn it and practice it. These procedures were never directly put across by Dr. Shekhawat himself but were part of the hospital folklore. One consultant shared his views with the case writers:
“The experience counter is reset to zero when you join this hospital. You may have been a good surgeon elsewhere but here the ‘Master’ takes the call on whether you are worth it. It would be a good assumption that a doctor’s being here at this place is proof enough of his/ her capabilities. I wonder often, why should skill set matter at the time of recruitment if DKH is supposed to reset the counter to zero.”
This created a unique challenge: every new expert had to be re-trained!
Other consultants felt that they could not upgrade their skill-set in performing a variety of surgeries in the hospital because of Dr. Shekhawat. He always got to do the complex surgeries and also decided who would do what kind of work.
Another surgeon said:
“Surgeons need to continuously upgrade their skills in new areas that are coming up. This is done by performing surgeries using new methods on willing patients. We also discuss the repertoire of skills that the hospital should have. To have specialists in all methods we divide the work on the basis of surgeries required for the patients.
We were drawing out a plan for training surgeons to
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perform surgeries with laparoscopic technique that would be the standard in future. I discussed with Dr.
Shekhawat about learning laparoscopic surgery and was deeply interested in it. But at the time of allocation Dr.
Shekhawat just forgot about the discussion he had with me. I was given nothing that was discussed with me. It was surprising… and demoralizing!”
As the interns also assisted in surgeries, incidents like the ones noted above were common knowledge to them.
They often found that the consultants were unhappy and were working under pressure in a place to which they had come by choice. The interns felt that the best way to deal with this was to become a “Yes Sir” person. Hierarchy was sanctum-sanctorum. “Either you respect it [hierarchy], or you don’t belong in here.” The residents also sometimes had problems during academic discussions with Dr. Shekhawat.
While they enjoyed their sessions with visiting faculty, they could not do so with Dr. Shekhawat. Dr. Shekhawat did not tolerate any comparison of the hospital’s current practices with other hospitals. Such a step would invite severe criticism from Dr. Shekhawat.
The interns appreciated the latest techniques they learned and treasured them. However, they were worried that the number of cases being treated with open surgery methods was declining steadily. The open surgery method required making a long incision and cutting a rib. Open surgeries took longer to heal and chances of infection were quite high. These required more intensive post-operative care compared to laparoscopic surgeries. Since DKH had state-ofthe-art laparoscopic facilities very few open surgeries were being undertaken. The interns believed that replicating the level of facilities employing the latest techniques available at this hospital at any other place of work would be difficult without huge investment. Even if funds could be arranged, they were not sure if all patients could afford the cost of treatment using laparoscopic techniques. They felt that it was necessary to build sufficient skills in carrying out open surgeries for some renal ailments. In Exhibit 2, descriptions of what the consultants and residents felt about Dr. Shekhawat and their experiences at the hospital are given.
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WORK DAY OF INTERNS AND CONSULTANTS
IN UROLOGY
Appointment diaries of Dr. Shekhawat and consultants in the urology department were full. Every day they performed surgeries on patients with clockwork precision, often handling more than one surgery per consultant per day. The working day of the urology interns usually began at 6.45.
The first task was to receive patient progress reports from the relieving intern, and, if required, make preparations for scheduled surgeries. Dr. Shekhawat usually started the day latest by 7.30, with first surgery scheduled between 8.30 and
8.45.
The interns were also allocated duties in the OPD.
One consultant supervised all OPD work and discussed cases with the interns. Some interns were allocated duties in patient wards as “in-charge.” They monitored the progress of patients and prepared their charts. Several rounds were scheduled during the day for every ward. First, the most junior intern prepared the progress report summaries of the patients in his/her ward. These reports were then checked by a second-year intern followed by a brief examination of the patient. Here, some doubts of the first-year intern (if any) were resolved. The observations of the junior interns were ratified by a senior intern in his/her round. The senior interns also noted any peculiarities in the case, and waited for the consultant’s round to discuss them. These procedures were repeated for every round in the hospital. Dr.
Shekhawat also took rounds of the wards. If Dr. Shekhawat decided to take a round, the consultants and intern(s) incharge would accompany him. The interns found the rounds with Dr. Shekhawat very instructive but very stressful. Dr.
Shekhawat did not tolerate mistakes and was very impatient if he noticed anything was amiss. As one consultant remarked excitedly in an informal meeting with the authors of this case:
“I am glad that Dr. Shekhawat had to leave a little early today. He went for a party in Jaipur. I can play with my kids today and have a lovely dinner at home. For a change, the family would be together at the same table.”
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Usually there were two rounds, one in the morning around lunch time, and the second in the evening before doctors left. Occasionally, Dr. Shekhawat took the last round and it ended sometime between 9.15 and 9.45 pm. This left many interns and consultants wondering when they would go home. It was commonplace for interns to reach home at
10 pm and then be expected to spend another two to three hours with family, study, and prepare for the next day’s academic discussions. The interns did not mind working long hours but did not like to be waiting for Dr. Shekhawat to decide.
Dr. Shekhawat’s own schedules were very hectic and his workload was very huge. However, he showed no signs of weariness or a desire to distribute the patient load. He was still as active as a young surgeon just beginning his/ her career. His touch with patients, as his colleagues and subordinates referred to, was “absolutely magical.” Doctors, staff, and patients were amazed at the care that he could give each patient. There were instances when patients would refuse to undergo treatment with any other consultant or doctor. Everyone wanted Dr. Shekhawat, and he was just one call away.
One intern recalled an incident. Dr. Shekhawat was called at his residence in the middle of the night when he was wanted by a patient. In less than 15 minutes, Dr.
Shekhawat was at the bedside with his senior interns. There were instances of Dr. Shekhawat entering the hospital at 6, straight from his morning walk to simply check some patient! Such care and attention was nothing but exemplary in the field of patient services. He was truly a superstar among his patients, colleagues, and juniors.
The consultants felt that most patients were treated and/or operated by Dr. Shekhawat himself. This resulted in work overload for Dr. Shekhawat, which in turn led to lesser time available for academic discussions with residents and other activities. It also led to remuneration loss for the consultants since they missed out on the incentives given by performing more surgeries.
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PERCEIVED CULTURE AT DKH AND LEADERSHIP
RATINGS OF DR. SHEKHAWAT
The interns and consultants found that even at 60 years of age Dr. Shekhawat was a very tough competitor. He would go for any challenge without caring for the level of competition. When he fought, he did not give up till he got the results in his favor. This spirit was evident at work as well. Complex problems seemed to excite him and made him a better surgeon.
The interns and consultants often commented on how there was so much focus on being the best and providing the best while their remuneration was much below market rates. They agreed that DKH was a charitable hospital and it was their choice to join it, but they felt that they could work for so little and under such pressure for only a short period of time. Some of them even mentioned that there was enough potential for everyone to earn more despite the charitable nature of the hospital. When asked if they would stay if they were paid more, they replied that they may still leave because they would rather have the autonomy. They felt DKH was a good place to learn but not to stay back and work to make a name for oneself.
To assess the culture at DKH in quantitative terms (see details of the cultural dimensions given in Exhibit 3), the case writers administered a questionnaire to the consultants, interns, and Dr. Shekhawat. There were two parts to the questionnaire. One part was designed to collect the perceived present and desired culture of the hospital.
The assessments of the doctors and Dr. Shekhawat about the culture at DKH are given in Exhibit 4. The perceived present culture at the hospital as per doctors is that the hospital is primarily formalized (hierarchical), efficient, and result-oriented (market). Dr. Shekhawat perceived the culture to be primarily familial (clan), fostering autonomy
(adhocracy), and efficient. The differences in the perceptions are instructive. However, the desired culture map of both is quite similar.
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The other part of the study was designed to compare the perception of the doctors with that of Dr. Shekhawat about his leadership. The results are given in Exhibit 5. The differences in the perceptions again are revealing.
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Appendix A
The Kidney, Its Usefulness, and Its Diseases
(Extracted from websites www.users.rcn.com/jkimball.ma. ultranet/BiologyPages/K/Kidney.html, www.kidney.org, and www.kidney.ca) Facts about the Human Kidney
• two bean-shaped organs, each about the size of a fist
• represent about 0.5% of the total weight of the body
• receives 20–25% of the total arterial blood pumped by the heart • each kidney contains one to two million nephrons
Renal vein Renal artery Kidneys
Ureters
Bladder
Urethra
Picture Source: www.kidney.ca
The Kidney and Homeostasis
The kidneys remove wastes and normal components of the blood that are in greater-than-normal concentrations. The kidneys filter and return to the bloodstream about 200 quarts of fluid every 24 hours. About two quarts are removed from the body in the form of urine. The kidneys function as homeostatic device and continuously regulate the chemical composition of the blood within narrow limits.
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The kidneys also balance the body’s fluids; release hormones that regulate blood pressure; produce an active form of vitamin D that promotes strong, healthy bones; and control the production of red blood cells.
Causes of Chronic Kidney Disease
Chronic kidney disease is defined as having some type of kidney abnormality or “marker” such as protein in the urine.
There are many causes of chronic kidney disease including diabetes and high blood pressure. Some kidney conditions are inherited while others are congenital. The following are some of the most common types and causes of kidney damage. Glomerulonephritis is a disease that causes inflammation of the kidney’s tiny filtering units called the glomeruli.
Glomerulonephritis may happen suddenly or the disease may develop gradually, and it may cause progressive loss of kidney function.
Polycystic kidney disease is the most common inherited kidney disease. It is characterized by the formation of kidney cysts that enlarge over time and may cause serious kidney damage and even kidney failure.
Kidney stones are very common, and when they pass, they may cause severe pain in the back and side. Sometimes, medications and diet can help to prevent recurrent stone formation. In cases where stones are too large to pass, treatments may be done to remove the stones or break them down into small pieces that can pass out of the body.
Urinary tract infections occur when germs enter the urinary tract and cause symptoms such as pain and/or burning during urination and more frequent need to urinate.
These infections most often affect the bladder, but they sometimes spread to the kidneys, and they may cause fever and pain in the back.
Congenital diseases may also affect the kidneys. These usually involve some problem that occurs in the urinary tract when a baby is developing in its mother’s womb.
Drugs and toxins can also cause kidney problems. Using
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large numbers of over-the-counter pain relievers for a long time may be harmful to the kidneys.
Treatment of Kidney Diseases
Most kidney diseases, kidney stones, and urinary tract infections can usually be treated successfully. Sometimes, chronic kidney disease may progress to kidney failure, requiring dialysis or kidney transplantation.
Treating Kidney Failure
Kidney failure may be treated with dialysis or kidney transplantation. There are two common forms of dialysis — peritoneal and haemodialysis. In peritoneal dialysis a special solution is run through abdominal cavity that helps filter out waste fluids from the human body. It can be done daily at home. Haemodialysis requires patient’s blood to be filtered of waste products and waste fluids using a dialyzer.
This process is costlier compared to peritoneal dialysis and requires special facilities.
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Personnel
(Administration
matters)
Maintenance
Internal Auditor
Purchase
Stores & Inventory
Housekeeping
Establishment
Statistics, ISO, MR
Matron/Asst. Matron
Pharmacy
Dietetics
G.M Administration
(Mr. N. Reddy)
Consultants
Residents (Interns)
Dialysis (Facilities and Staff )
Radiologists
MSW
Bio-Medical
Engineer
Pathologist
Biochemist
Microbiologist
Sterilization
OPD Coordination
Library
Head – Dept. of Nephrology
(Dr. J. S. Rajput)
Consultans
Residents
(Interns)
Financial Controller
(Mrs. R. S. Shekhawat)
Andrologists
Anesthetist
Operation Theaters
(Facilities & Staff )
Lithotripsy Center
Head – Dept. of Urology
(Dr. R. S. Shekhawat)
Dausa Kidney Hospital
Trust-Managing Trustee
(Dr. R. S. Shekhawat)
Organization Chart
Exhibit 1 p Medical Social
Worker
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Exhibit 2
Comments from interns and consultants on Dr. Shekhawat and his style of working and about his competence and sense of service
“There are times when you, as a trained doctor, say, this is impossible. He should not do it. But, he is one man I have seen would go ahead and makes us realize the difference between a good and a great surgeon.”
“You should learn how to look after a patient by observing him in the rounds. He makes them feel so comfortable even with so complicated procedures. He brings the best out of the patients. Probably, management consultants could learn a few things about managing customers from Dr. Shekhawat.”
“The facilities provided by the hospital are very good. We are given a good comfortable house and a good atmosphere with colleagues’ families. They have taken care of the family’s needs very well.”
Comments indicating respect but sense of discomfort in working with Dr. Shekhawat
“I accepted the offer at this hospital for two reasons. One, the opportunity to work with
Dr. Shekhawat and, two, my love for teaching and academics. Where else in a private hospital kind of setup do I get to involve myself in teaching and academics like this place.” (after a long pause) “I am not sure if I got it all, or it was a wise decision to be here.”
“He is a mastermind at work. He can manipulate people like anything.”
“I don’t know if this is positive or negative. There is tremendous respect for him with the staff and amongst us [consultants]. But sometimes, this gets on to you.”
“He does not care about you. He has a child-like urge to compete. He competes with us! We are nothing compared to him.”
Comments expressing frustration of working with Dr. Shekhawat and the hospital
“He forgets that we have a family at home. We have kids to look after. We need to go home.”
“Someone should realize that the money you get is peanuts. And when you offer peanuts, you get monkeys to dance, not humans. It is not that the hospital is not earning money, but it is not available for sharing with us.”
“He treats us as if we are new. As a consultant we have several years of experience backing us. But, all that is zero when you are here. The day you join your assessment is not based on what you did in the past, but on what Dr. Shekhawat thinks about you.”
“Everything in this hospital moves around the seniors.”
“Shekhawat aur Reddy ki marzi ke bina yahan patta bhi nahin hilta.” (Not even a leaf can move here without the whims or permission from Dr. Shekhawat or Mr. Reddy.)
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Exhibit 3
Culture Assessment of the Hospital
The Competing Values Frameworkhh (CVF) was used to study the culture of the department in the hospital. CVF models an organization’s culture in terms of subcultures in an organization represented across dimensions of Focus (Internal or External) and Control orientation (Flexibility and Tight Control). The subcultures could be represented in a 2*2 table. The four types of subculture are: Clan, Adhocracy, Market, and Hierarchy. The table below shows common characteristics and behavior observed for each subculture of components of organizational culture under CVF.
Flexibility/Discretion
Internal
Focus/
Integration
CLAN
ADHOCRACY
Characteristics — Friendly place, Mentors, Extended family, Loyalty or traditions,
Teamwork
Behaviors: Facilitation,
Human Resource
Development
Characteristics — Dynamic,
Entrepreneurial, Creative workplace, “stick neck out” to take risks, freedom
Behaviors Innovation,
Entrepreneurship
Participation to increase commitment Innovativeness to bring growth HIERARCHY
MARKET
Characteristics — Formalized and structured place,
Efficiency, Stability,
Predictability
Behaviors: Coordination,
Monitoring, Organizing
Characteristics — Resultorientation, Tough demands,
Market leadership, Hard driving competitiveness,
Behaviors: Compete,
Produce, Leader
Control brings efficiency
Competition fosters productivity External
Focus/
Differentiation
Control/Stability
Figure 1. Organizational Culture under Competing Values Framework
Source: Based on discussion in K S Cameron and R E Quinn, 1999, Diagnosing and Changing Organizational Culture based on the Competing Values Framework. Reading: Addison-Wesley.
hThe
Competing Values Framework was proposed by Cameron and Quinn in their book Diagnosing and Changing
Organizational Culture based on the Competing Values Framework (1999).
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Exhibit 4
Using CVF, organizational culture was assessed on all four dimensions using the Organizational
Culture Assessment Instrument (OCAI). This instrument required the participants to allocate
100 points among various subcultures in the hospital’s culture. This brought out the mix of subcultures in the culture of DKH. In addition, the instrument allowed the respondents to suggest what changes they desired in the cultural mix. The respondents for this study were the doctors in the hospital. These responses were then compared with Dr. Shekhawat’s perceptions of the present and future hospital culture. The table here presents the mean scores for the culture of the hospital.
Table 1. Present and Desired Culture in the Hospital as perceived by the Doctors and Dr. Shekhawat
PRESENT
Doctors
DESIRED
Clan
Adhocracy
Market
Hierarchy
Clan
Adhocracy
Market
Hierarchy
14.742
18.800
33.754
33.000
30.606
24.523
22.662
22.015
15.864
5.723
−11.092
−10.985
27.167
24.000
29.667
19.167
2.000
−2.667
−2.833
2.667
Differencesi
Dr. Shekhawat
25.167
26.667
32.500
16.500
Differences
(Minus sign indicates a desired decrease in the dimension)
Diagrammatic representation of above table is given in the figures below.
CLAN
ADHOCRACY
CLAN
HIERARCHY
MARKET
Present Culture Profiles
Doctors (Solid line) vs. Leader (Dotted Lines)
HIERARCHY
ADHOCRACY
MARKET
Desired Culture Profiles
Doctors (Triple line) vs. Leader (Dotted line)
iDifferences
have been calculated as Mean Score (desired state) — Mean Score (present state). Thus, a negative difference would indicate a desired decrease in the dimension. Alternately, a positive difference would indicate a desire to obtain higher scores on a dimension.
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Exhibit 5
Leader Appraisal
Leader appraisal was carried out on a set of behaviors using a 30-item questionnaire. Table 2 presents the items used to appraise Dr. Shekhawat (by his team members and him) and the mean scores by the team and the self-rating of Dr. Shekhawat himself. These 30 statements could also be represented on the 4 subculture dimensions of CVF. The mean scores for assessment of Dr. Shekhawat and his team on the 4 subculture dimensions are also summarized for each dimension. Table 2. Appraisal of Dr. Shekhawat
Mean
for
Doctors
SelfRating
Dr. Shekhawat generates, or helps others obtain, the resources necessary to implement their innovative ideas.
2.75
4
Dr. Shekhawat articulates a clear vision of what can be accomplished in the future.
3.50
5
Dr. Shekhawat regularly comes up with new, creative ideas regarding processes, products, or procedures for his hospital.
4.17
5
Dr. Shekhawat constantly restates and reinforces his vision of the future to members of his department.
3.75
5
Dr. Shekhawat is always working to improve the processes we use to achieve our desired output.
3.75
5
Dr. Shekhawat facilitates a climate of continuous improvement in his department. 2.92
5
Dr. Shekhawat has developed a clear strategy for helping his department successfully accomplish his vision of the future.
3.08
5
Dr. Shekhawat captures the imagination and emotional commitment of others when he talks about his vision of the future.
2.83
4
Dr. Shekhawat creates an environment where experimentation and creativity are rewarded and recognized.
2.58
4
Dr. Shekhawat encourages everyone in his department to constantly improve and update everything they do.
2.83
5
Dr. Shekhawat helps his employees strive for improvement in all aspects of their lives, not just in job related activities.
1.75
5
3.083
4.727
Item Description
Items classified as behaviors reinforcing ADHOCARCY culture
MEAN SCORE (Adhocracy)
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Table 2. (Continued)
Mean
for
Doctors
SelfRating
Dr. Shekhawat communicates in a supportive way when people in his department share their problems with him.
1.92
5
Dr. Shekhawat regularly coaches subordinates to improve their skills so they achieve higher levels of performance.
2.33
5
Dr. Shekhawat builds cohesive, committed teams of people.
2.75
5
Dr. Shekhawat gives his subordinates regular feedback about how he thinks they’re doing.
2.58
4
Dr. Shekhawat creates an environment where involvement and participation are encouraged and rewarded.
2.08
4
When giving negative feedback to others, Dr. Shekhawat fosters their self-improvement rather than defensiveness or anger.
2.42
2
Dr. Shekhawat gives others assignments and responsibilities that provide opportunities for their personal growth and development.
2.75
5
Dr. Shekhawat facilitates a work environment where peers as well as subordinates learn from and help develop one another.
2.17
5
Dr. Shekhawat listens openly and attentively to others who give him their ideas, even when he disagrees.
1.42
2
2.269
4.111
Dr. Shekhawat makes certain that all team members are clear about our policies, values, and objectives.
3.42
5
Dr. Shekhawat assures that regular reports and assessments occur in his department.
3.17
3
Dr. Shekhawat has established a control system that assures consistency in quality, service, cost, and productivity in his department. 3.75
5
Dr. Shekhawat clarifies for members of his department exactly what is expected of them.
3.58
5
MEAN SCORE (Hierarchy)
3.479
4.500
Item Description
Items classified as behaviors reinforcing CLAN culture
MEAN SCORE (Clan)
Items classified as behaviors reinforcing HIERARCHY culture
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Table 2. (Continued)
Mean
for
Doctors
SelfRating
Dr. Shekhawat establishes ambitious goals that challenge his subordinates to achieve performance levels above the standard.
3.42
5
Dr. Shekhawat pushes his department to achieve world-class competitive performance in service and/or products.
4.25
5
By empowering others in his department, Dr. Shekhawat fosters a motivational climate that energizes everyone involved.
2.17
5
Dr. Shekhawat has consistent and frequent personal contact with his internal and his external customers.
3.67
5
Dr. Shekhawat increases the competitiveness of his department by encouraging others to provide services and/or products that surprise and delight customers by exceeding their expectations.
3.42
5
Dr. Shekhawat assures that everything we do is focused on better serving our customers.
4.00
5
3.486
5.000
Item Description
Items classified as behaviors reinforcing MARKET culture
MEAN SCORE (Market)
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The dictionary defines a leader as someone who leads. This definition in not helpful for anyone wanting to become a leader themselves because a leader is so much more than someone who leads. A leader has great virtues that allow them to obtain the trust of others. Through leadership experiences, one will learn the qualities needed to be a leader. I have gained leadership experiences through hockey, work and student government. These experiences taught me to be calm, passionate, and gain the respect of others. I have learned how to express these traits through integrity and the desire of becoming a better leader.…
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Doyle D, Hanks G, Cherny N, et al. Introduction. In: Doyle D, ed. Oxford Textbook of Medicine, 2nd ed. New York: Historical Perspective: What Has Changed? Oxford University Press, pp 1-5.…
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Rajan Madhok (2011) Rapid Response Letter to the BMJ - White C. Why doctors can 't always be leaders. BMJ Careers 2011; 342: 195-6.…
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This statement said by Prince of Songkla, Father of Thai modern medicine. Thai doctors should always remember it to use for their profession. To be a good doctor consists of several things. From the statement, he did not hope a doctor only has ability and knowledge to treat patients. The doctors need to have a humanism, ethics for themselves, their patients and community.…
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Becoming an expert in the field of medicine is a long process that will turn away most people, particularly because doctors gain their abilities exclusively by practicing on other people. “The moral burden of practicing on people is always with us, but for the most part unspoken” (Gawade, 2003). Besides the moral burden that is created by practicing on others, when their lives might depend on the doctor's skills, doctors need to constantly keep up with the advances in the field. In addition, they need to adapt to different patients constantly. Even if there are no advances in the medical field, the doctor must always remain flexible and accept that something unexpected might happen at any given moment. Atul Gawade (2003) states that the incredible pace of advances in medicine do not always keep up with the advances in human conditions. A doctor could encounter a new condition which he knows nothing about. On the other hand, he could also encounter a well-known condition, but in different circumstances. This will also affect the course of the…
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