CASE - Superstar Leaders

A dead patient could mean a negligible statistical aberration in a

doctor’s career record, but for the patient and the family, it’s 100 per
cent! A doctor has to realizethis. I learnt this the hard way when I lost my
mother in a kidney surgery. That is my sense of responsibility when I go
to perform the surgery, and this is what a 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 at the Dausa Kidney Hospital (DKH). He was
head of the department of urology and managing trustee of DKH. In the last 25
years Dr. Shekhawat’s name had become synonymous with advances in urology
practice in India. He was considered a “master” in treating complicated cases in
urology. His continued success in treating some of the worst complications earned
him respect and accolades from all over the country. He was honoured at various
levels for his skills and services. In 2002 he won the prestigious President’s Gold
Medal recognizing his services to society and the field of urology. He headed the
regional Urological Association and represented India at the Société Internationale
d’Urologie.

Dr. Shekhawat was trusted by colleagues for his skills and ability to handle
patients. His compassion and healing touch gained him admiration from his
patients. Every patient wanted to be his patient. Junior doctors at the hospital
looked up to him and wished to emulate his success and jostled to get a share of
his expertise.

DKH was equipped to provide the most sophisticated care available to kidney
patients of all socio-economic status. The hospital had several qualified
consultants. They were offered salaries and facilities at par with other
charitable hospitals in nearby cities. DKH had national recognition in the area
of patient care and academic training. It had training facilities for post-graduate
students. However, of late, many consultants and young doctors had left the
hospital. Turnover had been very high in the last three-four years. The attritionof
trained and established consultants increased pressure on other doctors and
adversely impacted Dr. Shekhawat’s plans for the new academic centre at
DKH. He had tried to understand the reasons for their exit, but was unable to
explain. He had informally askedthe authors of this case to study the reasons
for high attrition at DKH. As he turned the report over in his mind, he was very
depressed at what he read and also outraged by the perceptions of himself by
some of the consultants. He wondered what it was that he could do to bring
changes in the hospital.

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Background

Dr. Shekhawat got his training in India and UK. While in UK, he became
interested in urology when he came in touch with Dr. Jaideep Singh Rathod,
an Indian urologist then practising in UK. Dr. Rathod returned to India and
started a small hospital - Dausa Kidney Hospital - from a place adjacent to his
residence in Dausa (61 km from Jaipur) in 1978. These parts of Rajasthan had
very high incidence of kidney ailments because of geographic conditions
and lifestyles followed by the people. Most people were very poor and could not
afford treatment and surgery costs. DKH was set up as a charitable institution
to provide high quality treatment to all patients without any discrimination.
No patient would be denied or offered poor quality treatment just because
he/she could not afford the cost oftreatment. Dr. Rathod received help from his
philanthropic friends and acquaintances abroad to meet the running costs of the
hospital.

Dr. Shekhawat returned to India in 1980. He started his own practice in Jaipur.
However, he maintained contacts with Dr. Rathod and also started to work part-
time with DKH. After Dr. Rathod died in 1985, Dr. Shekhawat worked for
three days of the week in his Jaipur clinic and spent three days at DKH, mainly
performing surgeries. The travel time between the two places was about two
hours on one side. For fifteen years, Dr. Shekhawat worked singlemindedly on
the development of treatment capabilities at DKH and in turn created one
success story after another. He came to be respected highly among patients,
doctors, and the trustees. In 2000, he gave up his practice in Jaipur and moved full
time to the hospital in Dausa. The trustees asked his wife to manage the
finances of the hospital. She was designated the financial controller.

Dr. Shekhawat was fully supported by Dr. Jai Singh Rajput who had joined the
hospital in 1979 as a resident nephrologist consultant. He had risen to become
the head of the department of nephrology. Both doctors were highly respected
for their knowledge and experiences and, were regarded as equals. Dr. Rajput’s
wife also worked as medical social worker in the hospital. She looked after
arranging and distributing donations to needy patients, legalities associated with
kidney donations, and approval by authorities.

The Hospital

DKH believed in total patient care in line with its slogan, “Excellence in Patient
Care”. The expertise and infrastructure at the hospital was sophisticated enough
to treat any complex kidney related problems.1 It had top-of-the-line facilities
and very low mortality rate comparable to the best hospitals in the world.

The cost of care comprised two components: cost of the medical procedure and
care and cost of the facilities for staying, etc. For all patients the cost of medical

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care was the same but the cost of stay was dependent on facilities a patient could
afford. The hospital had 140 beds divided into four categories; general, semi-
special, special, and deluxe wards. Deluxe wards were the most expensive and
general wards the least. There were separate general wards for males, females, and
children.

DKH was equipped with three operation theatres and a lithotripsy2 centre. The
operation theatres had facilities comparable to the best kidney hospitals in the
world. In addition, there were special post-operative and emergency wards where
patients could go through pre-and post-surgery treatment and care. There was a
dialysis to accommodate 50 patients a day for performing dialysis 3 ward. The
hospital had separate facilities for HIV and hepatitis infected patients. Cleaning
and water management facilities for dialysis were maintained in- house. In
addition to these, the hospital also had resident anaesthetists, radiologists, and
pathologists. To be able to respond to emergencies, DKH had developed
partnerships with other good hospitals in the area to share their facilities and
personnel. In addition to patient care, DKH was an accredited centre for providing
super-specialization training to medical post-graduates interested in making a
career in treatment of kidney related diseases.

Management of the Hospital

Principal donors of 1978 were still associated with the hospital. They had formed
the Dausa Kidney Hospital Trust which met from time to time to discuss the
progress and future plans of the hospital. At times, when there was a need for
approval or ratification of a plan by the board, meetings were held either in New
Delhi at the trust office or at Dausa. These meetings were attended by the
members of the trust and the heads of departments of the hospital.

There were 45 doctors (including trainee residents) and 300 members of staff
(medical, administrative and other support functions). N. Reddy (General
Manager-Administration) supervised administration of the hospital. He was
equivalent to department head. He worked very closely with both Dr.
Shekhawat and Dr. Rajput. Dr. Shekhawat, in consultation with the members of
the hospital trust, took decisions about DKH and its future plans. For most
decisions related to the hospital Dr. Shekhawat was understood to be the final
authority. (See Exhibit 1 for the organization structure of the hospital.)

The hospital had two main units, urology and nephrology.4 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 resident doctors
admitted to the academic programme at the hospital. Dr. Rajput headed the
nephrology department and he too had consultants and resident doctors in his
team.

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Academic Activities

In 1993, the hospital got approval to become a training centre for the award of
DNB5 (Diplomate of National Board) in nephrology and urology. The hospital
was ranked the highest among all privately owned centres offering DNB in
urology or nephrology. The programme had a clear focus on academics and
research. Annual intake for the DNB programme was two candidates in
nephrology and four in urology. In addition, the hospital had permission to
induct a research fellow in urology for the exclusive purpose of carrying out
research. The reputation of the hospital attracted resident doctors from across India
and research fellows from 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. The resident doctors and
consultants were encouraged to write and present their papers at national and
international conferences.

Balancing patient care and academic performance was very demanding. The new
resident doctors took some time to get adjusted to the culture and environment of
the hospital. Some resident doctors found it difficult to adjust; however, most of
them adjusted within six months. As one senior resident doctor put it:

It took about six months to train a new resident doctor about the system here,
or youcan 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 included them as visiting faculty. These doctors
were very well established senior practitioners in their respective fields. They
were seniors or contemporaries of Dr. Shekhawat and Dr. Rajput. In 2001 Dr. P.
L. Mina, an old 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 input to the resident doctors and also
oversaw the overall progress of the resident programme.

Trainee Resident Doctors at DKH

The norms of medical education required resident doctors to work closely with
patients. Resident doctors had responsibilities of carrying out preliminary
diagnosis of patients visiting the out-patients department, supervise patients in the
wards allocated to them, look at their progress and response to medicines or
treatment administered, and prepare or update case histories. They accompanied
senior doctors on rounds. The resident doctors also assisted in surgeries carried
out by some senior resident doctors and consultants. A resident doctor 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 clear and stated.

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However, hewas perceived as a good judge of the readiness of a resident doctor.

In addition to duties at the hospital, resident doctors also had to prepare and
study for academic discussions. They looked forward to these sessions. They
could also discuss patient related issues with visiting faculty.

In 2005, the resident doctors got a stipend of Rs. 9,000 a month (approximately
USD 200/ month) when they entered the programme. The amount increased to Rs.
11,000 (approximately USD 255/month) as the resident doctors progressed in the
programme. The stipend was decided by the National Board and was same across
the country. At DKH, the resident doctors were entitled to a furnished
accommodation on the residential campus at about 800 metres from the hospital.
The resident doctors were pleased with the stay provided by the hospital.
Atmosphere in the residential complex was friendly and the families shared good
camaraderie.

Future Plans of DKH

After Dr. Shekhawat moved to DKH in 2000, he started devoting 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 by doctors in
conferences in India and abroad. Dr. Shekhawat organized an international
conference for urologists at DKH in 2004, several national conferences, and
convened seminars for the Urological Society of India. DKH achieved new
heights in patient services and academic activities. This increased the visibility of
DKH and Dr. Shekhawat’s pioneering work in the field of urology attracted
research fellows from neighbouring countries like Mongolia, Bahrain, etc. They
brought with them knowledge, techniques, observations, experiences, and
expertise. These activities helpedDKH establish its credibility on the world map.

The hospital was on its 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 were
spread 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
twenty better Dr. Shekhawats to society.

In early 2004, Dr. Shekhawat discussed plans to start an academic centre

dedicated to urology and other related fields. It was planned that the centre
would become an extension of the learning programmes at the hospital. It
would house facilities for drug trials, simulated training on latest equipment, a
large library with study cabins, and large conference halls for holding national
and international level seminars. It would have put DKH amongst the best

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centres for advanced studies in nephrology and urology. The outlay was about
Rs. 50 million (approximately USD 1.1 million). Dr. Shekhawat had no
difficulty in garnering resources for the centre from internal reserves, donations,
and trust members. A week before the foundation stone for the centre was to be
laid in March 2005, a woman professor from Chandigarh who used to visit the
hospital for teaching in the nephrology department quipped:

We thought of having a centre 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 on the same platform… The efforts of Dr. Shekhawat are
commendable. In less than a year we have moved from an idea to laying
the foundation stone. In hospitals it generally takes a long time for things
to get moved.

Dr. Shekhawat introduced the idea of the academic centre to his team of
consultants and resident doctors thus:

…you all know we have become a centre for excellence in patient

services. This is something we started with. Now we have to become a
centre for excellence in academics.

Dr. Shekhawat’s Concerns

With the new academic centre coming up, 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.

One of Dr. Shekhawat’s concerns was the high level of turnover of doctors
especially in the last 3-4 years. Some of them had worked for about 10 years. This
was a big blow to the teaching and care giving resources at the hospital.

Another worrisome trend was that the resident doctors were not inclined to work
in the hospital after they completed their course. Though they were promised
further growth, most preferred to start their own practice nearer their hometown
than work at the hospital. Dr. Shekhawat needed good doctors to make the Rs. 50
million academic centre dream a reality. He knew that there could be problems if
the “producers of knowledge” (consultants and resident doctors) went missing
from the scene.

The high level of attrition had led to difficulties in day-to-day operations, loss of
productivity, heavy workload on Dr. Shekhawat, and huge training costs. Every

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time a new consultant joined, the system had to be rebooted.
Differences across Units

The pay and perquisites were similar in nephrology and urology departments.
The work structure was also similar. The resident doctors and consultants
shared the same dining facilities. Over lunch or snacks, discussions about
work pressure and patients were commonplace. Often, comparisons were
made of the level of leadership in nephrologyand 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, he was a good
mentor. He could help young doctors learn and grow. Dr. Rajput was a very
tough instructor. He provided very clear instructions about the standard of
services and key deliverables. He was compassionate and accommodated
resident doctors’ and consultants’ requirements. Resident doctors and
consultants in the nephrology department enjoyed the freedom to discuss and
receive supervision from Dr. Rajput.One consultant remarked:

Dr. Rajput has the old teacher charm. He is the kind of teacher that we
always heard of in childhood stories, the kind that draws respect and
admiration from students…they actually live in students’ hearts.

Consultants in the nephrology department stayed on much longer. A senior

nephrologist who had been with the hospital for almost ten years had no
plans to switchfor any reason.

On the other hand, senior consultants in the urology department found Dr.
Shekhawat’s stature very intimidating. One consultant remarked:

Dr. Shekhawat is very bright and very good. But he also makes me feel
veryinadequate at times.

The common perception was that there was a marked difference in the actual
work conditions of nephrology and urology departments. The nephrology
resident doctors and consultants were satisfied and enjoyed their work, while
those in the urology department felt DKH was a very stressful place and had
serious complaints and immense praises for Dr. Shekhawat.

It was common for urology consultants to be told even by non-medical assisting

staff duringan operation in the theater 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

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 thank God; the patient is walking today…

There was a “Dr. Shekhawat way” of dealing with patients and carrying out the
procedures. It was expected that everyone would learn it and practise it. These
procedures were never directly put across by Dr. Shekhawat himself but were
part of the folklore in the hospital.One consultant said:

The experience counter is reset to zero when you join this hospital. You
may havebeen a good surgeon elsewhere but here the ‘Master’ takes a call
on whether you are worth it. It would be a good assumption that a
doctor’s being here at this place is aproof 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 at DKH. 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 decided who would do what kind of work.

Another surgeon said:

Surgeons need to continuously upgrade their skills. 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 to
be done. We were drawing out a plan for training surgeons to 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.
Shekhawatjust forgot about the discussion he had with me. I was given
nothing that was discussed with me. It was surprising… and
demoralizing!

As resident doctors also assisted in surgeries, incidents like the ones noted above
were common knowledge to resident doctors in urology. They often found that the
consultants were unhappy and were working under pressure in a place where they
had come by choice. The resident doctors felt that the best way to deal was to
become a “Yes Sir” person. Hierarchy was sanctum-sanctorum. “Either you
respect it [hierarchy], or you don’t belong here.” The resident doctors also
sometimes had problems in academic discussions with Dr. Shekhawat. Though
they enjoyed their sessions with visiting faculty members but were unable to do
so with Dr. Shekhawat. They felt that any comparison of the hospital’s current
practices with past or other hospitals was not tolerated and invited severe criticism
from Dr. Shekhawat.

The resident doctors appreciated the latest techniques learnt at the hospital and

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treasured them. However, they were worried that the number of cases being
treated with open surgery methods was declining steadily. Open surgery methods
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 the newer laparoscopic surgeries. Since DKH had
state-of-the-art laparoscopic facilities very few open surgeries were undertaken.
The resident doctors believed that it was difficult to replicate the level of facilities
employing latest techniques available in DKH in any other place of work without
huge investments. Even if funds could be arranged, it was not sure if all patients
could afford the cost of treatment using laparoscopic techniques. They felt that it
was necessary to build sufficient skill in carrying out open surgeries for some
renal ailments. Exhibit 2 presents comments from consultants and resident
doctors about Dr. Shekhawatand their experiences at the hospital.

Work day of Resident doctors and Consultants under Dr. Shekhawat

Appointment diaries of Dr. Shekhawat and other consultants in the urology

department were full. Everyday they performed surgeries with clockwork
precision, often handling more than one surgery per consultant per day. The
working day of the urology resident doctors usually began at 6.45 am. The first
task was to receive patient progress reports from the relieving resident doctor and,
if required, make preparations for scheduled surgeries. Dr. Shekhawat usually
started the day latest by 7.30 am, with first surgery scheduled between 8.30 and
8.45 am.

Resident doctors were also allocated duties in the out-patients department. One
consultant was available to supervise all OPD work and discuss cases with the
resident doctors. Some resident doctors were allocated duties in patient wards
as “in-charge”. These resident doctors monitored patients’ progress and
prepared their charts. For every ward several rounds were scheduled during the
day. First, the junior most resident doctor prepared the progress report
summaries of the patients in his/her ward. These reports were then checked by a
second year resident doctor followed by a brief examination of the patient. Here,
some doubts (if any) of the first year resident doctor were resolved. The
observations of the junior resident doctors were ratified by a senior resident
doctor in his/her round. The senior resident doctors also noted any
peculiarities in the case and waited for the consultant’s round to discuss. 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
resident doctor(s) in-charge would accompany him. The resident doctors found the
rounds with Dr. Shekhawat very instructive but also 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

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 to attend a party. I can play with my kids today and have dinner at
home. For a change, the family would be together at the table.

Usually there were two rounds, one in the morning, around lunch time, and the
second one in the evening before the doctors left for home. Occasionally,
Dr. Shekhawat took the last round and it ended sometime between 9.15 and
9.45 pm. This introduced a lot of uncertainty about the time of returning home
for the resident doctors and consultants. It was common for resident doctors to
reach home at 10 pm spend some time with family, study, and prepare for next
day’s academic discussions. The resident doctors 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 work load was very
high. 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, ashis colleagues and subordinates referred to, was
“absolutely magical”. Doctors, staff, and patients were amazed with the care that
he could give to each patient. Very often, patients would refuse to be treated by
other consultants. Everyone wanted Dr. Shekhawat, and he was just one call
away for a patient.

One resident doctor recalled an incident. Dr. Shekhawat was called by a

patient in the middle of the night. In less than 15 minutes, Dr. Shekhawat was
in the hospital standing beside the patient with his senior resident doctors. Some
third year resident doctors gave examples of Dr. Shekhawat entering the hospital
at 6 am in the morning, straight from his morning walk, to simply check on 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 undergoing urological treatment 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
discussion with the resident doctors and other activities. Also it led to
remuneration loss for the consultants since they missed out on the incentive for
performing surgeries.

Perceived Culture at DKH and Leadership Ratings of Dr. Shekhawat

The resident doctors and consultants found that even at 60 years of age Dr.
Shekhawat was a very tough competitor. When he fought, he fought till he got the
results in his favour. This spirit was evident at work as well. Complex problems
seemed to excite him and made him a better surgeon.

The resident doctors and consultants also often commented on how there was so
much focus on being the best and providing the best while their own
remuneration was much below the market rates. They agreed that it was a

10
charitable hospital and it was their choice to join DKH but they felt that they
could only 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 despite the charitable nature of the hospital. When asked if
they would stay if they were paid more, many said they might still leave
because they would rather have the autonomy.

To assess the culture at DKH (the details of cultural dimensions are included
in Exhibit 3) the case writers administered a questionnaire to the consultants,
resident doctors, and Dr. Shekhawat. There were two parts to the questionnaire.
One part was designed to collect the perceived present and ideal culture of the
hospital. The obtained assessments of doctors and Dr. Shekhawat of the culture at
DKH is presented in Exhibit 4. The perceived present culture according to the
doctors is that the hospital is primarily formalized (hierarchical), efficient, and
result oriented (market). Dr. Shekhawat perceived it to be primarily formalized,
efficient, and hierarchical. The differences in the perceptions are instructive.
However, the desired culture map of both is quite similar.

The other part of the questionnaire was designed to compare the perceptions of the
doctors with that of Dr. Shekhawat about his leadership. The results are given in
Exhibit 5. The differences between the doctors’ ratings and the self-rating of Dr.
Shekhawat are stark and revealing.

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 CHARTS AND DIAGRAMS AND SUIPPORTING ORGANIZAITONAL INFORMATION

ORGANIZATION CHART

Dausa Kidney Hospital Trust-

Managing Trustee
(Dr. R. S. Shekhawat)

G.M Administration Head – Head – Finance Controller Medical Social

(Mr. N. Reddy) Deptt. of Nephrology Deptt. of Urology (Mrs. R. S. Shekhawat) Worker
(Dr. J. S. Rajput) (Dr. R. S. Shekhawat) (Mrs. J. S. Rajput)

Consultants Radiologists Consultants Andrologists

Residents MSW Residents Anesthetist
Personnel (lnterns) Bio-Medical Engineer (lnterns) Operation
(Administration Dialysis (Facilities Pathologist Theaters (facilities
matters) and Staff) Biochemist & staff)
Maintenance Microbiologist Lithotripsy Center
lnternal Auditor Sterilization
Purchase OPD Coordination
Stores & lnventory Library
Housekeeping
Establishment
Statistics, lSO, MR
Matron/ Asst. Matron
Pharmacy
Dietetics

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 Comments on Dr. Shekhawat and His Style of Working

Comments about Dr. Shekhawat's 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 l have seen would go ahead and make 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 needs very
well.”

Comments indicating respect but sense of discomfort in working with Dr. Shekhawat

“l 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 set-up do l get to involve myself in teaching and academics like this place.” (…after a long
pause…) “l am not sure if l got it all, or it was a wise decision to be here.”

“He is a mastermind at work. He can manipulate people like anything.”

“l 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 you when offer peanuts, you
get monkeys to dance, not humans. lt 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.”, and

“Shekhawat aur Reddy ki marzi ke bina yahan patta bhi nahin hilta.” (Not even a leaf can
move here without permission from Dr. Shekhawat or Mr. Reddy.)

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 Culture Assessment of the Hospital

The Competing Values Framework (CVF)6 was used to study the culture 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 2x2 table. The four types of subculture are Clan,
Adhocracy, Market, and Hierarchy. The table below shows common characteristics and
behaviour observed for each subculture of the components of organizational culture under
CVF.

Figure 1: Organizational Culture under Competing Values

Framework Flexibility/ Discretion

CLAN ADHOCRACY
Characteristics - Friendly Characteristics –
place, Mentors, Extended Dynamic, Entrepreneurial,
family, Loyalty or traditions, Creative workplace, “stick
Teamwork neck out” to take risks,
Behaviors Facilitation, Human freedom
Resource Development, Behaviors lnnovation,
Participation to increase Entrepreneurship
commitment lnnovativeness to bring
Internal growth
HIERARCHY MARKET External Focus/
Focus/ Characteristics Formalized Characteristics Result-
Integratio and structured place, orientation, Tough
Differentiation
n Efficiency, stability, demands, Market
Predictability Leadership, Hard Driving
Behaviors Coordination, Competitiveness,
Monitoring, Organizing Behaviors Compete,
Control brings efficiency Produce, leader
Competition fosters
productivity

Control/
Stability

14
Using the CVF, organizational culture was assessed on all four dimensions using the
Organizational Culture Assessment lnstrument (OCAl). 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 DKH. ln 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 presents the
mean scores for the hospital culture.

Table 1: Present and Desired Culture in the Hospital

PRESENT DESIRED
Clan Adhocra Mark Hierarch Clan Adhocra Mark Hierarch
cy et y cy et y
Doctors 14.742 18.800 33.75 33.000 30.60 24.523 22.66 22.015
4 6 2
Differences7
15.86 5.723 - -10.985
4 11.09
2
Dr. Shekhawat 25.167 26.667 32.50 16.500 27.16 24.000 29.66 19.167
0 7 7
Differences 2.000 -2.667 -2.833 2.667
(Minus sign indicates a desired decrease in the dimension)

CLAN ADHOCRACY

Present Culture Profiles

Doctors (Solid line) vs. Leader (Dotted Lines)

MARKET
HlERARCHY

Diagrammatic representation is given below.

CLAN ADHOCRACY

Desired Culture Profiles

Doctors (Triple line) vs. Leader (Dotted line)

HlERARCHY MARKET

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 Leader Appraisal

Leader appraisal was carried out on a set of behaviors using a thirty 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. These thirty
statements could also be represented on the four subculture dimensions of CVF. The mean
scores for assessment of Dr. Shekhawat and his team on the four subculture dimensions are
also summarized for each dimension.

Table 2: Appraisal of Dr. Shekhawat

Mean Self-
Item Description for Rating
Doctors
ltems classified as behaviours reinforcing Adhocarcy culture
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 3.50 5
future.
Dr. Shekhawat regularly comes up with new, creative ideas
regardingprocesses, products, or procedures for his hospital. 4.17 5
Dr. Shekhawat constantly restates and reinforces his vision of the
future to 3.75 5
members of his department.
Dr. Shekhawat is always working to improve the processes we use to
achieve our desired output. 3.75 5
Dr. facilitate a climat of continuou improveme in his
Shekhawat s e s nt 2.92 5
department.
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 2.83 4
when he talks about his vision of the future.
Dr. Shekhawat creates an environment where experimentation and
creativityare rewarded and recognized. 2.58 4
Dr. Shekhawat encourages everyone in his department to constantly
improve 2.83 5
and update everything they do.
Dr. Shekhawat helps his employees strive for improvement in all
aspects of their lives, not just in job related activities. 1.75 5
MEAN SCORE (Adhocracy) 3.083 4.727
ltems classified as behaviors reinforcing CLAN culture
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 2.33 5
achieve higher levels of performance.
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 2.08 4
are encouraged and rewarded.
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 2.75 5
opportunities for their personal growth and development.
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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 1.42 2
ideas, even when he disagrees.
MEAN SCORE (Clan) 2.269 4.111
ltems classified as behaviors reinforcing HlERARCHY culture
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 3.17 3
department.
Dr. Shekhawat has established a control system that assures
consistency in quality, service, cost, and productivity in his 3.75 5
department.
Dr. Shekhawat clarifies for members of his department exactly
what is 3.58 5
expected of them.
MEAN SCORE (Hierarchy) 3.479 4.500
ltems classified as behaviors reinforcing MARKET culture
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 4.25 5
performance in service and/or products.
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 3.67 5
and his external customers.
Dr. Shekhawat increases the competitiveness of his department by
encouraging others to provide services and / or products that 3.42 5
surprise and
Dr. Shekhawat assures that everything we do is focused on better
serving our 4.00 5
customers.
MEAN SCORE (Market) 3.486 5.000

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