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Care On The Go
A public-private partnership covers over 750 million Indians with emergency care using project management techniques

Photo courtesy: GVK Foundation
For each emergency incident, GVK EMRI follows an execution plan of “sense, reach, care and follow-up”, and an emergency response center provides support throughout the process

India has a patchy track record in emergency medical care and ambulance services, with a high level of care in metropolitan cities with state-of-the-art ambulances and medical facilities, and inadequate services in other parts of the country. In response to this fragmented emergency network, a public private partnership (PPP) initiative in emergency medical services was launched nine years ago that has had an impressive record. The PPP ambulance service being operated by the GVK Foundation follows project management to plan, execute, and continuously improve service quality and outcome.

Out of the 75,000 emergencies in India every day, only 20-25 percent are estimated to receive immediate medical care. As many as 30 percent of emergency patients in India die before they reach a hospital and over 80 percent of accident victims do not have access to medical care within the golden hour, the first one hour after an accident.

The GVK Emergency Management and Research Institute (EMRI) is an initiative set up for the delivery of emergency response services with a vision to save one million lives annually. According to GVK EMRI, in nine years since it started operation, it has carried out over 30 million emergency services in the country.

Project Objectives
GVK EMRI was launched on 15 August 2005 as a non-profit join initiative by the Government of Andhra Pradesh and the GVK Foundation, which is a part of the GVK Group, an Indian conglomerate. GVK EMRI took over the running of 108 helpline and pressed 15 ambulances into service. Today, it operates similar services in 15 states and two union territories. Around 35,000 paramedics and support staff, and 7,500 ambulances cater to over 750 million people in the country. GVK EMRI is headquartered in Hyderabad with modern facilities for emergency management, research, and training.

Dr. G. V. K. Reddy, founder chairman and managing director, GVK, says, “We strongly believe that developing meaningful propositions beyond just business success is an integral part of our journey to excellence. GVK EMRI is one of our most significant social initiatives and we are happy to be playing our part in saving lives and bettering the healthcare services in the country.”

In this partnership, the state government funds day-to-day operations and ambulance expenses. GVK takes care of the management of the entire service and helplines by funding for leadership, technology, research, collaborations, and new product initiatives.

Photo courtesy: GVK Foundation
(Left to right) Gujarat Khilkhilahat Mother & Child Dropback Ambulance and GVK EMRI 108 Ambulance

During the planning phase, the partners finalize budgets and process protocols, roles and responsibilities, and mechanisms for transparency and joint reviews.

The primary objective of the initiative is to provide a worldclass emergency response system in which states would deploy an end-to-end emergency infrastructure with the help of information and communication technology, emergency response vehicles, emergency care centers, additional trauma care facilities, and skilled personnel. The other objectives include:
Efficient service depends on the ability to provide care during the golden hour, ensuring 24/7 availability of the network and systems, ensuring no downtime in the helpline along with the ability to track calls based on the caller’s location, integrating Geographic Information System (GIS), vector data, and maps with the network for speedy service delivery, and setting global benchmarks and a quality management system for continuous improvement of service quality.

Operational Management
For each emergency incident, GVK EMRI follows an execution plan of “sense, reach, care and follow-up”.

Sense: GVK EMRI has set up a control room in state capitals that coordinate with police, fire department, and district administration during an emergency. The control room has a data center and emergency operators. A computer aided system sorts out the calls based on the type of emergency. The communication officer collects relevant facts, following which the dispatch officers copes out the emergency and assigns a vehicle to the site of the emergency. This is an integrated response system for medical, fire, and other disaster related services.

Reach: The vehicle or emergency team arrives at the location in the shortest possible time. Global Positioning System (GPS) maps for quick response are used in the vehicles.

Care: The emergency medical technician provides immediate care onsite or while transporting the patient to a hospital.

Follow-up: GVK EMRI assesses the quality of emergency care provided by collecting the patient’s or his/her attendant’s feedback after 48 hours.

An emergency response center physician provides support throughout the entire process.

GVK EMRI has a separate department to handle project management activities to improve service delivery.

The company has introduced new services in some states. In association with the Gujarat government, it have launched 181 – Abhayam helpline for women. In Delhi, there is now a mother and child tracking facilitation center to validate and maintain records of pregnant women and newborns. The 104 Health Helpline, a service providing information and advice pertaining to healthcare through paramedics, and Project Dial 100, an integrated, emergency response service mechanism, has been launched in partnership with Andhra Pradesh police department.

An emergency officer at the GVK EMRI control room tracking an ambulance on a GPS map
Besides medical equipment, life-saving drugs, trained technicians, and availability of doctors in real-time through audio conferencing, all ambulances of GVK EMRI are fitted with an automatic vehicle location tracking system and navigational facilities through GIS and GPS systems.

The types of ambulances include mother and child dropback facility for maternity service, boat ambulances for flood affected or riverine areas, doli-palki (hand carriage) service for hilly areas with minimal or no road connectivity, mobile medical units for those with poor hospital access, and neonatal ambulances to attend to newborn babies. The doli-palki ambulance is a low cost innovation by GVK EMRI to reach inaccessible regions.

Though the service has spread to cover a large section of population, it has not been smooth sailing. There have been instances of payment delays by state governments and reports of high expenses being incurred by the state to run the service.

A year ago, GVK took over the reins in Rajasthan from another agency. There had been a standoff between the state government and the previous agency over long pending demands of contractual employees of the ambulance service. Mr. Siddhartha Bhattacharya, chief operating officer, GVK EMRI, says, “GVK is currently trying to resolve the issue. There must be no gaps between the state and GVK’s responsibilities. We have built a review mechanism to address issues around staff on ongoing operations. We’re also regularly reviewing expenses, hospital efficiency, and medical systems.”

In Andhra Pradesh, there have been reports of improper allocation of funds and non-payment of dues by the state government. Today, only 69 percent of 108 emergency vehicles are on road; the rest are held up due to insufficient funds for diesel. Negotiations are currently on.

Solution techniques
GVK EMRI has over 25 tie-ups with external agencies for its research, training, and certification programs, such as Stanford University School of Medicine, US, for emergency protocols, Tech Mahindra for technology and software integration, Google for GIS maps, American Heart Association for cardiac emergencies, American Association of Obstetricians and Gynecologists for new training for obstetrics, and GEO Germany for syndromic surveillance for early detection of bioterrorism outbreaks and disease trends. GVK EMRI has received financial support from the Indian Council of Medical Research.

Telecom service providers played a major role in facilitating the setup of the 108 toll free number that routes free calls to emergency call response centers. McKinsey & Company provided support for ambulance design and process formulation, ensuring improvements in safety measures.

The launch of service in a state begins with an understanding of the demographics of the state, acquiring GIS maps, data about hospitals, police and fire department, allocation of medical teams, and familiarizing the team to field operations. GVK identifies the number of ambulances to be stationed and the types of ambulances to be used, through calculating demand and supply based on response time taken, total cycle time taken by an ambulance from the time it is called for, and the average number of cases in that state.

International standards recommend one ambulance for every 60,000 people and when GVK started its services in Bengaluru in 2006, they arrived at a benchmark of one ambulance for 100,000 people.

Mr. Bhattacharya explains, “For a diversified country like India, there is no fixed benchmark. It revolves around factors like population density and the type of region — hilly areas, metro city, remote villages etc.”

Regular meetings are held with local government medical teams, police department, fire services, healthcare partners, and telecom service providers to understand local challenges and fine-tune solutions.

GVK EMRI has integrated continuous quality improvement practices into its operations through informal as well as a structured feedback mechanism. The dolipalki ambulance is a result of this. “GVK EMRI introduced doli-palki ambulances in Uttarakhand and Andhra Pradesh around three years ago to take care of situations arising out of inaccessibility of remote areas,” says Mr. Bhattacharya. There are now also neonatal ambulances in Goa, Tamil Nadu, Madhya Pradesh, and Andhra Pradesh to reduce instances of infant mortality.

The company conducts audits, manages support desks, and generates daily reports to ensure efficiency in operation. There are constant attempts to maintain high quality and minimize by implementing new testing mechanisms to ensure reliability of applications being used, and documentation and publication of cases as part of its knowledge bank. A dedicated research team uses a wide range of problem-solving techniques, data analysis, and statistical studies to recommend new routes by ambulance to reduce response time, and optimize and resolve issues pertaining to processes to improve overall efficiency.

The success story

GVK EMRI is estimated to be the world’s largest, integrated emergency response service with a team of around 170,000 people comprising of GVK employees, contractors, external agencies, knowledge collaborators, and medical professionals trained in medical emergencies who handle around 170,300 calls a day. The organization says 91 percent of the calls are picked up in the first ring and the remaining in the second ring. It covers a total of 75 crore people in 17 states. Mr. K. Krishnam Raju, director, GVK EMRI states, “GVK EMRI has created a unique value proposition over the last decade in partnerships with governments across India. It is looked at as one of the most innovative PPP ventures around the world that is worth emulating.”

Some success metrics that GVK provided Manage India are: The key behind the expansion and success of GVK EMRI has been partnership sit has drawn with key central and state government departments, private hospitals, and volunteer bodies.This involved creating a state-wise taskforce to manage the first phase rollout within six months.

Says Mr. Reddy, “GVK EMRI’s ability to successfully replicate and scale its programs across 17 states in India is a testimony to its project management experience and its ability to innovate while retaining the end-to-end implementation structure. GVK EMRI has won several awards for social innovation, emergency medical care, and corporate excellence.”

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