Hospital Management Insights  · 
probirm@gmail.com  · 
+91 9800899660

Hospital Governance  ·  Satire  ·  Healthcare India

The Three Wise Men

A completely fictional account of three visionary hospital owners and their remarkable institution. Any resemblance to actual hospitals, owners, shadow administrators, spy networks, or commission-collecting ward boys is entirely coincidental. Obviously.

Somewhere in India, there is a hospital.

It has beds. It has patients. It has doctors — at least, doctors arrive occasionally, when the mood takes them, like migratory birds following some internal seasonal logic that no administrator has ever successfully decoded.

What it also has — and this is where things get interesting — is three owners.

Let us call them Owner One, Owner Two, and Owner Three. They started this hospital together, united by a shared vision, a pooled investment, and the unshakeable belief that healthcare was a guaranteed money machine. They were wrong about almost everything except the investment. The money went in. What came back was a masterclass in institutional dysfunction so complete, so thorough, so almost artistically conceived, that one cannot help but admire it.

Owner One believed in aggressive growth. Owner Two believed in aggressive cost-cutting. Owner Three believed in neither, preferring instead to believe that the other two were cheating him — a suspicion he pursued with the energy and dedication that might, in a more functional organisation, have been directed toward running the hospital.

None of the three spent significant time in the facility. They had other businesses. Other interests. The hospital was, in their mental accounting, a revenue-generating asset that should simply produce returns without requiring their attention, like a fixed deposit that occasionally needed a new CEO.

— — —

Every large organisation has informal information networks. People talk. Gossip travels. This is human nature and no amount of policy can fully suppress it.

What our fictional hospital had, however, was something rather more structured. Each of the three owners had cultivated — over time, with patience, with small favours and implied protections — a network of loyal informants embedded throughout the hospital. The accounts clerk who reported to Owner Two. The purchase manager who was Owner Three’s man. The nursing supervisor whose loyalty to Owner One was the worst-kept secret in the building.

These were not random gossips. They were institutionalised intelligence assets, and they took their roles seriously. Daily updates were provided. Incidents were reported. The CEO’s decisions were annotated and transmitted before the relevant memo had finished printing.

The result was a hospital where information moved faster sideways — to the owners — than it moved vertically through the management chain. A department head would make a decision, inform the CEO, and discover, in the subsequent board call, that all three owners already knew about it and had already formed conflicting opinions about it before he had finished his sentence.

The three intelligence networks also, naturally, reported on each other. Owner One’s spy would report that Owner Two’s spy had been seen talking to a vendor. Owner Three’s informant would report that Owner One’s informant had accessed the billing system after hours. The owners would then call each other, exchange accusations, fail to reach any conclusion, and the cycle would begin again.

In thirty-five years, I have never encountered a more efficient system for producing maximum heat with minimum light.

— — —

The hospital had a CEO. On paper, this CEO had full operational authority. In practice, the CEO had the authority of a particularly decorative potted plant — present, visible, occasionally watered, but not consulted on matters of substance.

The real power resided with two individuals. Let us call them Mr. Charcoal and Mr. Chalk — one dark in his methods, one apparently straightforward, both absolutely certain that they, and not the CEO, understood how this hospital should be run.

Mr. Charcoal handled vendor relationships. This is a polite way of saying that no purchase order was raised, no contract was signed, and no supplier was appointed without his involvement and his commission. The finance team reported to him regardless of what the organisational chart said. When the CEO asked for the accounts, they were provided — eventually, partially, and always with at least one line that didn’t reconcile.

Mr. Chalk handled operations. This meant he attended the morning meeting uninvited, overruled the nursing superintendent in front of her team, negotiated directly with consultants without informing the medical director, and once — in a moment of administrative creativity that still astonishes me — hired a housekeeping staff member and processed their salary for three months before the HR department was informed they existed.

When something went well, the owners took credit. When something went wrong, the CEO was summoned and asked to explain himself. The CEO, being professional, would explain the systemic issues — the parallel authority, the bypassed reporting lines, the decisions taken without his knowledge. The owners would nod seriously, agree that something needed to change, and then call Mr. Charcoal to discuss what the CEO had said.

The average tenure of a CEO in this fictional institution was measured in months rather than years. Each departure was followed by a brief period of reflection, a unanimous agreement that the next person needed to be more flexible, and a fresh appointment.

— — —

Patient acquisition is a legitimate challenge for any hospital. Building a referral network, engaging with general practitioners, running health camps, maintaining a visible community presence — these are genuine marketing functions that require skill and investment.

Our fictional hospital had a different approach.

The marketing team operated on a commission-per-patient model. This in itself is not entirely unusual in the Indian hospital context — referral arrangements exist in various forms. What was unusual was the scope. The commission structure had been extended, over time, through a series of informal expansions, to include virtually everyone in the building.

Ward boys. Receptionists. Security guards. The electrician who had been with the hospital since opening day and had apparently developed an impressive side income directing walk-in patients toward the registration desk in exchange for a percentage of their eventual bill.

The result was that a patient who walked through the front door — under their own steam, having made their own decision to visit this hospital — would trigger an immediate scramble. Multiple staff members would converge, each with a prior claim on this patient’s footfall, each armed with a plausible story about how they had either referred this patient, spoken to this patient’s family, or at minimum been standing near the entrance when the patient arrived.

The marketing team themselves had no geographic boundaries, no specialty focus, no defined target audience, and no reporting metrics beyond the number of patients they claimed credit for. They operated across the city with the freedom of independent contractors and the accountability of none.

One marketing executive, in a moment of entrepreneurial initiative, established a referral arrangement with a local dhaba — reasoning, not entirely without logic, that people who ate there might at some point need medical attention. The arrangement lasted six weeks before it came to the CEO’s attention. The CEO raised it with Mr. Charcoal. Mr. Charcoal said he would look into it. The arrangement continued for another four months.

— — —

Consultant management in any hospital requires careful balance. Doctors have legitimate autonomy over clinical decisions, and that autonomy must be respected. But they also operate within an institutional framework — schedules, billing systems, quality protocols, and conduct standards — and that framework requires adherence.

In our fictional hospital, the framework was largely theoretical.

Consultants arrived when they chose to arrive. They departed when they chose to depart. The OT schedule was a document of aspirational fiction, revised daily to accommodate the reality that the surgeon who was listed for 9 AM had, in fact, been in a different city since Tuesday and had not mentioned this to anyone.

Each doctor had individually negotiated their billing arrangements — not with the finance department, not with the CEO, but directly with whichever owner they had the closest relationship with. The result was that no two doctors billed on the same basis. Some charged fixed consultation fees. Some charged percentages. Some charged differently for different categories of patient based on criteria that existed only in their own heads and were revealed, partially, at the point of billing.

The ICU and emergency department were staffed predominantly by RMOs — Resident Medical Officers, typically junior doctors working under supervision. The supervision, in theory, came from senior consultants. In practice, serious patients in the ICU at 2 AM were managed by doctors who had qualified relatively recently and were doing their best in conditions that made their best genuinely heroic. No formal arrangement existed for what happened when a case exceeded their scope. The arrangement was informal. The informal arrangement was: call the consultant. The consultant’s phone was sometimes answered.

— — —

The three owners received a monthly revenue figure. This figure was produced by the accounts department and represented the gross billing of the hospital for the month. It was a real number, accurately calculated, and entirely misleading.

What the revenue figure did not represent was what the hospital would actually receive. Discounts had been granted — by the owners individually, by Mr. Charcoal in his capacity as the person who handled relationships, by the marketing team as part of referral arrangements, by the front desk as a goodwill gesture, and occasionally by a ward boy who had decided that a particular patient deserved a break. These discounts were not always recorded at the time they were granted. They were discovered later, at the point of collection, as a series of surprises.

The billing system — which existed, and was in theory connected to every department — was used primarily for generating invoices. Its reporting functions, its receivables tracking, its MIS capabilities were largely unexplored, like rooms in a house that had been furnished and then forgotten. The data sat in the system. Nobody pulled it. Nobody read it. The system knew everything. The management knew what they had been told, which was considerably less.

— — —

Every hospital operates within a regulatory framework. Fire safety certificates. Building usage permissions. Biomedical waste licences. Pollution control clearances. Clinical establishment registrations. The list is long, the processes are tedious, and compliance requires sustained administrative attention.

Our fictional hospital had approached this framework with a philosophy best described as selective engagement. Some licences had been obtained. Others had been applied for and were, technically, pending — a state that had persisted for longer than the licensing authorities themselves might have considered normal. Others had not been applied for at all, operating on the theory that an inspection not yet conducted is a problem not yet existing.

The building itself occupied a plot that had been, at the time of construction, designated for a different purpose. The transition from original designation to hospital had been managed through a series of permissions, amendments, and — let us say — municipal relationships that reflected the creative regulatory navigation available in smaller cities. The building stood. Patients were admitted. The plot’s formal status was a matter best not examined in detail.

This arrangement worked, in the sense that the hospital continued to function. It worked because of relationships, because of the tolerance that exists in any system that is under-resourced for enforcement, and because the three owners were locally significant enough that certain questions were not pressed. This is not a sustainable situation. It is a liability waiting to be called.

— — —

Every hospital I have described — and let me be clear, this hospital does not exist — exists in some form across India. Some have one of these features. Some have several. A few remarkable institutions have managed, through a combination of mismanagement so comprehensive it becomes almost systematic, to incorporate all of them simultaneously.

The lessons, for those who need them:

And if, after asking all of these questions, you still decide to proceed — then you deserve everything that follows. Not because you are foolish, but because you believe, as professionals sometimes do, that you can be the exception. That your skills and your experience and your leadership will be sufficient to transform the untransformable.

Sometimes you are right.

More often, you are the next person whose LinkedIn profile will list a tenure of seven months at an institution you will thereafter describe as a consulting engagement.

— — —

The Three Wise Men is a work of complete fiction. The author has spent 35 years in hospital administration and has absolutely no idea what inspired it.

Probir Mukerjee
Healthcare Consultant  ·  Hospital Administration  ·  West Bengal
probirm@gmail.com  · 
+91 9800899660
Durgapur & Kolkata  ·  Available for consultancy engagements across West Bengal