Some practices can’t get two fertility doctors to agree on a set of protocols. How about >250 physicians?
Dr. Kshitiz Murdia, CEO of Indira IVF discusses the enormous growth of the Indira network in India, how their approach to IVF practice management differs from the US’, and how they tackled massive obstacles (such as patient education) along the way.
Listen to hear:
Indira’s massive marketing and awareness programs.
How to transition out of your clinical role, to a director role, and finally, CEO.
The due diligence regarding private equity groups that took place before the majority stake sale of the company.
How Dr. Murdia got out of the ‘conributor seat’ and into the seats of integrator and visionary.
About the standard operating procedures Dr. Murdia and his team built, and the training and management system that backs them up.
Griffin press if standardization in protocols is antithetical to individualized care.
Indira IVF Hospital Pvt Ltd Website: www.Indiraivf.com
Transcript
Kshitiz Murdia 00:00
it was our responsibility to ensure that we have similar protocols similar outcomes across all the doctors because one patient could be meeting two or three doctors in the clinic and different points of time during the same cycle and the protocols should not differ the language that they speak should not differ.
Griffin Jones 00:24
250 fertility doctors 50 IVF labs 60 to 70 satellite offices 27 to 20,000 employees did I get that right? These are my notes from my conversation with the CEO of Indira IVF, one of the largest fertility clinic networks in India. His name is Dr. Kshitiz Murdia. He joined Indira IVF as the second physician in 2010 2011. By 2014, they had 50 locations. We talked about that process first starting with a massive marketing machine doing awareness camps across the country to generate awareness for infertility and fertility solutions. And then for their practice, we'll talk about how after three to four years, Dr. Murdia has stepped out of his clinical role and then transition to CEO first as medical director and then when they sold part of their company, or maybe a majority stake of their company, to ta associates becoming CEO, and the due diligence process with private equity groups before that, that gave him that financial and HR and marketing ops background education. I think this is a really good example. For those of you Doc's that I've talked about when I've pointed the accountability chart before and lots of articles that I've written, I talked about the entrepreneur operating system, and how many of you practice owners are in multiple seats. In the visionary seat, you're in the integrator seat, you're in different seats as contributors in physicians, you're in different management seats as medical directors seems to me that Dr. Murdia has done this, as well as anyone has of getting out of those contributor seats and moving into if not the visionary and integrator seat, the visionary seat, I think really behooves you to pay attention to how he did that in terms of building standard operating procedures, his process for building standard operating procedures in different areas and the training management system that backs up those SOPs, we spend a lot of time talking about creating one way of doing things proven way of doing things, having a training system, hiring management, and not just building the airplane as you're flying it and do IVF is apparently done this so much so that with 250, fertility doctors in counting, they have one set of protocols. There's one protocol for each patient type. I tried to play devil's advocate for you because I could see that driving some of you crazy, but I think the variance in protocols is an issue of scalability in fertility clinic operations, I can't vet whether that's necessary or how necessary it is, but Dr. Murdia responds to it. This is a very large operation that in 2019 ended up selling to ta associates the private equity firm that had owned CCRM and they have a massive HR and operational infrastructure behind them. Dr. Maria details that in this episode, so I hope you enjoy it. Dr. Murdia, Kshitiz Welcome to Inside reproductive health.
Kshitiz Murdia 03:19
Thank you Griffin. Thank you for having me on this show.
Griffin Jones 03:22
I promised my audience that I was going to cover more of the IVF market in India this year, we have you know, the third guests that we've had in 2023 to talk about the Indian IVF market because it seems to be expanding like no other market right now. At least I see. It seems everyone that's quote unquote, industry side, if you look in their LinkedIn profile, there's a picture of them visiting India, there's a picture that I'm talking about their company expanding in India, whether it's a genetics company, or a software company, or one of the pharmaceutical companies and, and so there seems to be a lot of activity, and we'd like to talk about that activity. I'd like to talk more about the present in the future. But in order to talk about the present in the future, I'd like to just talk a little bit about your enterprise in dira IVF. And, and how that got started. And can you give us a little brief history and where you are today?
Kshitiz Murdia 04:18
Yeah. So Griffin in Dr. We have started the routes are started in 1970s 1980. When our chairman Dr. Jim odia, he published his first paper on male infertility, which was published in The Lancet incidentally, in the same issue when the first test tube baby was reported by step two and Edwards back in August 1978. Since then, he has been very active, but particularly on the male side of infertility, because that time it was a big social stigma and a taboo, that males also could be responsible for fertility and everybody would put forward the female for checkups for investigation and the other things. So to bring that concept back in nine Getting a deal and especially in a country like India, it was a big, big problem statement, I would say, to talk about male infertility to ask the male partners to come forward for investigation. So he took this great step, I would say back then, and he's been practicing from 1980s. And then he started his own clinic in 1988, primarily focused on male infertility made diagnostics. You established his one of the first sperm banks in the country in India, where Neil's suffering from a zero sperm count could benefit. I am a gynecologist. I joined him in 2010 2011. That's when we revamped the whole setup, started doing IVF for the first time, in one small town in western part of the country, which is the poor, it's a very beautiful city, I would say I mean, a lot of tourists. So we revamped the setup, we started doing fertility surgeries, we started doing IVF for the first time, back in 2010, my brother, he joined me as an embryologist. And then we used to be home combined jointly, all three of us used to practice from 2010 to 2014, we were pretty much limited one center that we started back in the bowl with the western part of the country. And then we soon realized that there is a lot of awareness gap in the country that people are not aware about the scientific practices. So we should go out to people, we should organize these pre patient awareness camps, run a campaign in the country, educate more and more people about what fertility issues are, what is the medical scientific treatment, how much it could cost, how much days of treatment it might take. And we started taking these awareness camps. And then I think I think in the last one decade, we must have taken more than 2500 camps educated more than 70,000 couples about infertility. And that's what set up the route for our brand, I would say because we now proudly say that we are the we are the only b2c brand of IVF in the country, which is directly to consumers. And it's all started because of these awareness camps that we established long back, I think the second biggest challenge in front of us was around affordability. Because all said and done IVF might be cheaper, in some sense in the country in India compared to the Western world. But if you compare the disposable income of of the people here, for for an average middle class income, it could be, you know, a year or two years of their salary that they would have to spend, and it's all out of pocket, nothing is covered by insurance. So I think the second major challenge for us, apart from increasing awareness was around affordability, how can we make the whole treatment very much affordable. And then the third challenge in the country was around accessibility, because majority of these IVF centers were situated in the metro cities or the bigger towns, and then, you know, people would have to travel all the way stay there. It's a longest treatment, two or three visits, spanning over three months. So again, it was a big, big challenge. So we started opening out clinics in other parts of the country. So the idea from our side was you go to the patients and explain them open a good quality clinic with a better outcomes near to their locality. And that's how we started expanding. So 2014 was our first center outside the base location with paper, which was in Pune, which is in Maharashtra. After that from 2014 to 2018. We were at 50 centers 2018 to 22. We were at 100 centers. And we quickly adopted the hub and spoke model where we said we can't go to the smaller towns and villages with the whole stack of the bigger fertility hospital, let us do something which is a smaller capex a smaller model, which we can also go into the smaller towns and villages are lesser investment I would say. But at the same time ensuring that 70 to 80% of the IVF treatment is being carried out at that one sector and that smaller spool and then only for the critical operative procedures for a day or two days or three days maximum. The patient would have to travel all the way to the hub are the main center. So I think accessibility was a key thing that we quickly addressed back in 2015 16. And then we started having these folks also in the smaller cities
Griffin Jones 09:41
was it retrievals and transfers that were done at the hub and everything else was done at the spoke all the testing the monitoring the console that was all done at the the satellite offices,
Kshitiz Murdia 09:55
so we would have a full time gynecologist working at the spokes also and all week. interpretations, the stimulations, the ultrasounds, the monitorings, everything would happen in this book, only the retrieval and transfer was done at the end that reduced the number of visits at the hub for a patient.
Griffin Jones 10:13
And so you've got three days it sounds like awareness, affordability, accessibility, it sounds like awareness came first that you laid the groundwork of doing some marketing of getting people familiar with what the challenges they were facing, and then what you did and sounds like you did that before you built some of your your spokes. Now, what is involved in those patient awareness camps? Is that something that is it is that an event that they attend,
Kshitiz Murdia 10:44
we organized kind of an event where all the patients are called, we do marketing in the newspaper, digital and other ways of marketing that this kind of doctor is coming for a consultation. And any patient who requires this type of fertility consultation can come there. And at Indy cap, it's a free awareness camp, we take a one hour video session through a PowerPoint presentation explaining the normal fertility process, where could be the problems in the male part and the female pot, and how IUI and IVF and exist can overcome these certain problems. Which patient category should go for conservative for medical management for IUI than for IVF. So at least they are aware, and they are on the scientific path of the journey for treating their their fertility problems. Do you still do the awareness camps? Yes, we still continue to do that. How have they changed
Griffin Jones 11:38
over time. So if you started doing them in 2010, or whatever, this is kind of pretty socialist as as people are getting on social media. Now today, they have all kinds of information in social media. So in 2010, I suspect that that information may have been now to them. Contrast that with 2023 where they've got recordings that you have done, they've got recordings that your Doc's have done and and probably they can watch old camps that awareness camps they can watch on. So how is the awareness camps evolved as social media and digital info is increased?
Kshitiz Murdia 12:15
Pretty good question, Griffin. I think because we've also seen a lot of change in the last 10 years earlier, I think when we used to organize this camp used to have 200 plus couples in all the bigger cities attending the camp because information was not freely available. So those were mega camps, we used to register a lot of people and they used to come forward for treatment. And our our our contribution also from the camps and the print media, which is a newspaper was much much higher, before COVID, I would say, which was around 50% or 50%. Plus, after COVID. What happened in the country, it accelerated the digital adoption of everything, whether it is its digital payments, or consuming the news articles, or seeing all the Facebook's Instagrams and Google and all those things. At present, I think our digital media contributes to almost 56 to 60% of our footfalls that are happening to the center. And now we have slightly changed the format of the camp where we don't go to the places and invite people to marketing. It's very focused with some local doctor there in the community who was famous with the Kinect, and then they would have some patients. So we our doctor would travel to their their center in advance will let them know that we are coming on this date so they can gather all the fertility patients so it's more of a I would say a doctor clinic that way where we would use those camps to be organized. But yes, yeah, I think it's it's dramatically changed from what we used to do. But earlier I think two or three people from from our family were doing these camps and now we have 20 plus doctors and India at one time. So that has added too much of power to the entire organization.
Griffin Jones 13:59
And I want to talk about what went into that growth the operational logistics behind the growth I do have a side question about involving the local doctors because one debate in the US is how much obg lands that are not Rei what certified they're not Rei fellowship trained how much OBGYN is can and should be upskilled or trained to do things up to an including IVF retrievals. And, and so there's there's debate on how much they should be used. But there's definitely a camp of folks that do want to involve OBGYN more and some of them have had challenges I believe with recruiting OBGYN to be part of their network because when you have someone who's businesses also who is also to do obstetrics, do gynecology, then they feel like their patients are being taken away if if if you're using another OB GYN so how did you navigate that when you were when you're leveraging these local doctors So how did you avoid the rivalry that they might have with other doctors in that area?
Kshitiz Murdia 15:08
So first of all, Griffin, I think there's no concept called reproductive endocrinologist in the country. It's OB GYN only, which would be doing obstetrics and also IVF after a certain amount of training that is required by law. Secondly, our volumes of these kinds of b2b interventions, so called I would say b2b Now, because b2c is direct to consumer b2b. So these beta channels is still in the range of 10 to 15%. The good part is we don't do obstetrics. And we don't do deliveries of our own patients also. So you know, when the patient comes to me for IVF, they would go back for the obstetric work or or the routine antenatal follow up to that particular note. So we don't have a rivalry in in that sense it's a symbiotic relationship.
Griffin Jones 15:55
Well now with neither but if you're if you're using these doctors for your awareness camps in your involving the local OBGYN then how would you not tick off the other OBGYN in that area that say well wire? Oh, well, if Indira is using Dr. So and so then I'm not using Indira
Kshitiz Murdia 16:11
No. So we have a list of top 20 or 30 gynecologist in the in the city who are actively involved into fertility work and we keep rotating between all the doctors we have tie up with all the doctors, we do send delivery patients the obstetric work of our own conceived IVF cycles to all these doctors. So there's a symbiotic relationship. And then we are always there as a as a service provider to help them in their procurement to help them their pathology labs or any audits, any trainings, any any software upgrades, anything that we as a platform can add value to their practice, we are more than willing. And I think that brings me to another important point Griffin is is around the doctor recruitment as to how we have done it because ours is a b2c brand and patients are coming to Indore IVF and not to a particular doctor. I mean, patients don't come with a mindset that I have to go and meet such an such doctor or get treated by such and such a doctor. They just see in the eye we they would come to in HR IVF. And then they would get to know who's the doctor treating them. And every other day we have a roaster. So somebody is consulting today, their pickup might be done by a separate doctor, they impertinence or might be done by a separate doctor. It's as per the these Can you hold the roaster in the clinic. So it was our responsibility to ensure that we have similar protocols similar outcomes across all the doctors because one patient could be meeting two or three doctors in the clinic and different points of time. During the same cycle and the protocols should not differ, the language that they speak should not differ. And that's why we started this in the RAF fertility Academy back in 2016, which is one of the world class adopts in training in fertility. Our training center has been recognized my recently while British fertility society. Our training center is recognized by Merck foundation in Egypt. They regularly send Africa and Indonesia and Malaysia and Vietnam War the Asia Pacific doctors for training we run a fellowship program with them for three months. And 99% of the doctors who are working with us have been trained to our own fertility Academy. And same with the embryologist also. And once we got a hang of it, we understood that you know, IVF is not so difficult. It's not rocket science. You know, every gynecologist and life science postgraduate could be trained into either being a IVF doctor or an embryologist either ways, we developed a structured program and we understood that there are 15 or 20 steps during the whole IVF cycle. Once you have an SOP around each and every step, you just hammer in the training that you just need to follow the SOP don't bother about the final outcomes, final outcomes are bound to come. And we've been very successful. I think the average age of our doctors is 35 or 36, in spite of, you know, a few doctors being with us for almost 10 years now. So that gave us a very good handle on expansion because the expansion the major limiting factor for any clinical enterprise or an organization to expand rapidly is not funds, it's not infrastructure, you everybody has deep pockets everybody has private equity money, you can fund 100 centers in one year, you have the infrastructure available, you can buy a spaces you can rent them you can do I think the critical bottleneck for any organization could be having skilled manpower, you know, and then there's always shortage of skilled manpower in whichever field you go. And we decided that we would not struggle with this part. Let us create our own skilled manpower let us not depend on the market to get skilled manpower or to by practicing from doctor that you know, some such dope some work done or having good practices in it. Nigeria, you just go and acquire them? We said, No, let's have a b2c brand being built up, let's fuel the pipeline for recruiting young talent for for training them adequately ensuring that outcomes are as good as senior doctors. And now we regularly plot the outcomes of every doctor who's working with us, whether it is their one year experience, or six months experience versus their 10 years experience. And we see most of our doctors fall within a very narrow range of success or outcomes or embryo transfer outcomes. And that's all because of the structured training process, I would say and the strict SOP that every doctor has to follow with the team. So I think the overall strategy went to well, when we started expanding is one on a b2c brand, recruiting a very young talent pool, adequate training men, ensuring that they follow the SOPs, and then the outcomes are good, and then the word of outspread. And then again, b2c. So the entire circle went well, with the overall strategy that we wanted to explore.
Griffin Jones 21:02
And finally, it's interesting, because I've been thinking about this from my own business recently, that a shortage of skilled manpower, however you want to phrase skilled talent, or, and skill can be a relative term means meaning the talent that you need in order to fulfill your delivery obligations. But I have been thinking about this a lot for my own company recently, and how that's more important than getting the funding at that particular time, or at least in some instances it is. Now tell me a bit about that. Because many people would say, Well, no, we dive in more do we need the venture capital money in order to be able to build the SOPs, in order to be able to hire the manpower, we need this private equity, we need this debt. So tell me about how it can be more important to to fulfill that need of a shortage of talent and have the training processes the SOPs for them, then then the funding itself.
Kshitiz Murdia 22:05
By the way, I think carefully, it is a it is a multi stage process, you can't achieve everything on day one. And then you need to decide as per your business, the the line or the field or the vertical that you're in, what is the most critical thing. So, you know, whatever we are today, we were not even 10%, I would say five years back, or 10 years back. So 10 years back, the most critical part, the most shocking part of the bottleneck for us was training, right? So we focus first on training, we never had Oracle or the best ERP systems or the best tech platforms that we would have today. But I think I think that was the need of the hour. So as as a business as a company, you need to decide there could be 10 things that you want to achieve in life, but then it has to be staged in a five to 10 year horizon, that these are the two critical things or one critical thing that I need to achieve immediately in the first year. And that's what we did. I think the first part was force force training. And obviously, we focused very hard very heavily on training demand. But I stepped back within, I would say, three or four years of my medical practice that having done more than 10,000 cases, I had to step back from the active clinical practice. And I used to only and only do training of the new recruits and focus my 90% of the time, ensuring that they follow the right protocols have been trained, they follow the right clinical procedure, their skills are to that level. And fortunately for us, IVF is not a very skilled procedure, I would say normal delivery is much more technically skilled or riskier than doing an IVF cycle. So I think I stepped back from active clinical work from all that thing. And then ensured that, you know, I would provide training to all my new recruits for joining in my brother step back from the active embryology working but involved in training. So I think I think both of us dedicated too much time into the training part, having those SOPs, our SOPs might not be in the form that are there today, like you have a booklet and SOP written by this person, reviewed by this person at this didn't change and that date, but they were very primitive shape. But that's fine. I mean, you know, you need to have some SOP in place that this is how you would work. Maybe it's not in the best of the forms of formats that you would require. But I think that's that's what we did. And then then started the journey of having quality auditors, you know, somebody external parties could come in validate whatever you're doing whatever work. I think the third important thing that we took up is building a solid management team, which got completed three or four years back at we have senior people of experts working in their domain like finance it HR or medical or tech, having worked for a decade or two in various other multinational companies and get all of these people together and showed that there is a chemistry between the entire senior management team, they understand healthcare, they understand IBM, set up the goals with them as to what we need to achieve in the next two or three years. And then once everything is fine, then you look after, I mean, for us, Tech was important, but we consciously delayed it for some time till we had the proper team in place, because you need good quality people to to develop those IT platforms that you would want. And once we've developed the ID platforms in the last two or three years, two years, mostly, then is the is the hard work of ensuring that everybody does a shift in the practice from the pen and paper system to a fully integrated digital end to end system. So I think I think we, we very consciously understood that these are the challenges, but what is critical for the business has to go first, what is good to have could take, you know, little later timelines and that's how we went up. And I'm starting
Griffin Jones 26:00
to feel validated today as you're validating some of what I'm working on for my own business. Right now I've owned fertility bridge as a client services from doing clinic marketing for many years now. But in the last year or so I've been building inside reproductive health, not even really focusing on building inside reproductive health as a trade media company. So the inside of reproductive health is the Wall Street Journal is the Financial Times that everyone director level and above in the fertility industry worldwide, reads every morning listens to every morning. And so in building that my natural tendency is sell, sell and then deliver. And I've realized at some point that way, okay, I don't need to do crazy selling right now I've got enough money, I can figure out a way to do some of this other stuff. And every time I sell, I'm increasing my delivery obligation, meaning what I Griffin have to do in order to fulfill that order that I just sold. And then my bet is that if I sell to an advertiser that could mean 20 hours of my time for that one advertiser. And am I better off selling right now just to get more money in or whatever? And, and then having to use 20 of my hours to fulfill the order for that client? Or am I better off with those 20 hours working on the operational systems, the training systems, so that we have the people in place to be able to fulfill and the answers, obviously, the ladders, like, Okay, now, I'm really just selling a couple people here and there to continue to validate the concept to make sure that the systems we are building are actually applied to real people that they're not just hypothetical, but there's way more emphasis on operations and delivery. And you're the first person I think that I've heard talked about that on the show, I think most of the time, people are very much building delivery while they're building the operations, because they have, you know, they've sold the private equity, or they have so many financial obligations, and they need to meet them right now. Why do you suppose it is that high growth, companies overlook that, that period of really building the SOPs and the training and the hiring of the people and not trying to build the airplane while they fly it?
Kshitiz Murdia 28:25
I think that's one of the very critical things is building a good foundation. And I mean, good foundation, you might not be able to build right from day one, after you progressed a little while and you got success in some area. And that's where you, you start building the solid foundation for a sustainable growth. And I think for us, that insight came from our private equity investment team associates, Boston based private equity firm invested with us in April 2019. And their their philosophy or, or their way of looking at business is always to have a strong management team have a good corporate governance, you know, in order to have a sustainable growth, I would say. So I think a lot of interventions that we did on building or correcting the foundation, which is which is currently now a very rock solid foundation that you know, business is not dependent on one critical function or one critical person. It's an ecosystem that is running on its own that has a great solid foundation. And even if one vertical or one function or one person is not performing well or certainly go out of business, you know, you certainly don't flatter and then your business continuity there. And obviously ensuring that you you are true to your patients you are not, you know, over promising or doing false promises or doing something short term that would help you. It's all about that mindset of having a long term view, having a sustainable view, having good corporate governance, because it's all about wealth creation. and not earning money every day, which is which is much more important for for private equity or even for the shareholders. Once you get to that mindset, you will start thinking your all your actions would start getting pointed towards wealth creation or value creation rather than earning certain dollars every day or every month are looking at the p&l everyday.
Griffin Jones 30:20
So there's two routes that I want to go with this conversation one has to do with your background and the other has to do with the SOP and and building that structure for SOP. So let's do the second one. First, let's talk about how you built the structure for SOPs. Because as I'm building more standard operating procedures, I'm also realizing Okay, I need an umbrella governance for how SOPs are created. Because if you have sales team creating sales SOPs, and you have operations, folks creating operations, SOPs, and HR people creating EHR SOPs, they could start to look different from each other. And then they have to be Jigsaw together later. And so it's better to have a certain governance where you have a master process for how processes were made. How did you approach that?
Kshitiz Murdia 31:09
So I think my personal view, Griffin is start from the very basic things that you could achieve very quickly, rather than waiting for the entire structure to fall through from the top because you know, that will involve a lot of skilled manpower, we might or many companies are not at that stage, when they start on middle of their journey. I would say even if you're able to achieve 60%, up 70% of what you want to achieve tomorrow, let's do that, rather than waiting for one year to achieve 80 90% 100%. And that's the philosophy that we followed in all the tech developments. Also, you would want a certain page to look like in a particular way you need 10 fields, here are five fields there are the critical are they showstoppers yes or no? If it is, yes, otherwise, even with that 50% of the period, if I'm good to go, whatever I'm doing today, I'm able to do 80% of that on a digital platform or an SOP or any other thing, we would just go ahead do it. Because there are multiple challenges once you put it to the user, there are bound to have all these questions and debates that would come up that they need certain changes that they need this, they need that, you know, and it will be a continuous process of development. So don't wait for the final end stage of how a corporate governance structure should look like and ditching trying to stitch it on the very first day, it is very difficult to achieve to that level. So I mean, all of us are very fragile in the leadership team at Indore IVF that we very quickly adopt the process let us start knowing fully well that we need to reach to this stage 100% But not to be or tomorrow, maybe after three months or six months or depending one year. But this is what we want to start today. And let's go ahead and build it up.
Griffin Jones 32:56
Did you have the embryology team making their own processes? Did you have the nursing team making nursing processes and physicians making the metal starting with the Medical Director presumably making protocols? How did how did individual process areas come to be?
Kshitiz Murdia 33:16
So we had different different verticals, making their different policies and processes and then, you know, problems are bound to happen whenever problems come all of us would assimilate as a group and see what changes we need to make in the various processes, but certain of the medical and the medical excellence so we have one medical department who's responsible for all the clinical and embryology processes, we have a separate medical excellence department who looks after all the medical protocols, whether they are safe for the patient, whether they are done rightly, in our patient identification, facility management, all the we screen our centers across 498 points spread across 12 different chapters of a credentialing program, and then everybody has to match that program and and the medical excellence runs very independently of the medical core function. So they would very closely interact as in when if there are problems, so I left it we have 70% Correct. But you know, all these issues would keep coming up every now and then in you sit together as a group and align the overall strategy. What is the culture? What is the DNA of the organization? How should in the IVF react in a particular situation? Is is what would govern the changes in the SOPs if required?
Griffin Jones 34:32
Did you put this all into one master document or didn't live All in One Drive? Where does that does each SOP area live with its own department?
Kshitiz Murdia 34:46
So it's mostly in the HR we have a learning management system. So all the policies procedures, everything has been feeding into the learning management system, and different people based their job roles and their category or We create, they keep receiving periodic emails of certain courses that they need to complete. And also we have a very active learning environment. So every week or every 10 days, there's a separate team learning team separate over take care of all the new join is the new recruits, take them to the entire mission vision values, to the basic trainings, the clinical aspects and other things. When did vision
Griffin Jones 35:23
mission and values come in as a central part of the training did that come after you had been building some SOPs? And and then you needed to start gluing all of the different areas together? Or did it come from the beginning?
Kshitiz Murdia 35:41
No, you it came in? I think I would say three, three and a half years back and not 10 years back? Yeah. feverishly add some SOP some I will also not say a full fledged SOP document, it's a way of working could be some verbal trainings or other things or some PPTs that we would have. It all eventually came in the last five years, I would say one by one.
Griffin Jones 36:06
And so your training management system? Is that proprietary Training Management System that it for India? IVF? Or do you use something like train you will or loom or any of those softwares?
Kshitiz Murdia 36:19
Yeah, we have a software from adrenaline, which is an HR software, which is our HRMS, which has the learning modules when we have all the videos being uploaded on the learning module, and then it periodically keep sending reminders to all these.
Griffin Jones 36:34
How involved were you in selecting that solution? Did you have your HR folks do it? Or were you personally involved in choosing that solution?
Kshitiz Murdia 36:43
Yeah, I got involved in most of these softwares selection. And obviously, then the implementation and the customization, we involve more the business side rather than the IT side. So all our our, our eh is the EMR the medical function has developed, it has supported our ERP implementation the finance team has done it has supported similar to the HR system. So we had this very different approach that let the business drive the implementation of software's rather than it doing it and then they send it to business and business will have 10 things to circle back to the it. So we thought let's involve the business on the very first day, and it will be like a support function of converting the thoughts into the ID language. That's it.
Griffin Jones 37:31
So that makes sense of why business would be involved in choosing the talent management or the resuming the Training Management System. But why you personally what is it that you were looking for?
Kshitiz Murdia 37:44
So because we, me and my brother, we had seen various systems in the last 10 years, we tried implementing EMRs, we failed on three attempts, I think. And that was to do because one, it was not thoroughly evaluated. Second, when we were growing very rapidly, from five centers to 25, to 50, to 100, your requirements kept changing every six months. So by the time you evaluate the software, you feel happy, they come back, they start implementation customizations, your requirements have gone, then x of what they were six months back. And that's why we were not able to you know, properly implement it. Secondly, we never had a good management team or leadership team. Because you require enough bandwidth to implement all the IT processes. It's not just implementation or customizations, you require good change management that should happen at every level, every person was using the software. So I think I think that because of all those things, we could not implement great it or tech platforms five, six years back when we tried and we failed twice or thrice. But once we have a good leadership team good management below us, we are also grown to 80 or 90 100 centers, pretty much our requirements was fixed, I would still not say we were 100% clear on what we were now also as you go, and then you know, business would require 10 More things. So anyways, if you're 80% there, just go in and implement it. These things would keep coming in people would want the moon and the stars. And then you can keep building on it in the next phase. Yeah, they'll
Griffin Jones 39:19
always want something more. So they always will be in a next phase. How did you go on this journey to CEO? What were the milestones as you look back now because your training is as a physician, right? So you started off seeing patients and you're trained as an OB GYN. And then how did you become a CEO? What do you look back and see as the most significant milestones.
Kshitiz Murdia 39:45
So I think initial three or four years I was practicing as a as a gynecologist as a physician doing active clinical work while all the ultrasound pick up after surgery is everything. After three or four years when we started expanding In, I took a little back seat from the active work started working as the as the trainer, I would say for all the physicians and other things. But once we had five or six or seven centers, I started acting as the medical director, being responsible for all the protocols being responsible for all the trainings, being responsible for what medications they would use, what would be the doors, what would be the prescriptions like and all those things, after being the medical director for maybe two or three years, and then ta invested with us and T was wanting to put a proper governance and a corporate structure that any private equity would want. The idea was to select somebody working with the company for for last few years. Because you know, when T invested, we were already at 50 Center, we were the largest in the country, in terms of number of centers, in terms of doctors being trained in terms of business. And in the overall top line. I think the idea from the side was nobody has done good work in the country in India in the IVF suite apart from Indore IVF, let us have somebody from the group internally and promote them to the to be the CEO. And I think because of some of the diligence is being done on the company before they invested. So there were a couple of private equities, looking at us and in all the big force coming and doing diligence. So I got exposed to many more financial aspects, many more HR and marketing aspects as well. So I think I think it was because everybody, all the shareholders thought that I had a very broad based idea about the business and not just the medical function. And obviously, we are very strong believers that our medical organization should always be headed by a doctor, because that gives you much more leverage in terms of talking to the doctors, because ultimately, all these businesses are built on the ground in the clinics and not sitting in the corporate office in your air conditioned chambers and working on Excel or laptops or you can't build a business, their business is actually being done at the clinic level by the clinicians, by the nurses by the embryologist. So you will need somebody who could have that wavelength of talking to these doctors who the doctors will also respond to and respect. And it's not just about number number number that you need to clock certain revenue, you need to block certain number of patients being treated. It's always more to do with the medical outcomes, and how do you treat and how do you excel in, in the overall outcomes, I strongly still feel that a non medical person, no one sounds very commercial to the doctors, doctors would not give that much of respect. Because, again, they feel the other person has no knowledge about medicine, and is just come here and just telling us all the numbers on Excel. And we feel it's not like that. And you know, patients are different, the actual clinical life is different. So I think a good balance between the medical and the financial work is required when you want to control the doctors and when I say control because ours is a very different culture in DNA. It's not doctors independently practice in in their own world. And they have a different protocol. And they have a different business mindset. All of us all the 250 Plus doctors are run on a single platform, run on a single protocol, everybody is in very close touch, I would say everybody's using the similar protocol.
Griffin Jones 43:30
So you need a doc at the top in order to get that many Doc's to buy into similar protocols. I think I think that's hard enough for you even if you have a doctor at the top. And so that makes sense to have a physician as the CEO, but you said that it was doing some of the due diligence, with the private equity companies that you were talking to prior to ta associates that gave you more education and finance and HR, how much education, finance and HR did you have prior to those due diligence process?
Kshitiz Murdia 44:04
I think nothing I had no background about an ENT and other things. I think those diligence process exposed me to many more technical terms in the finance, what is revenue, what is collection and you know, EBIT da and all those things I started learning, of course, now having being the CEO and interacting with all these lovely professionals that report to me and are experts in their field. I have much more now control and handle and knowledge on the various marketing functions, the HR, the tech, the operations, the finance, the medical excellence, everything is, is pretty much there because they've they've they've taken the company to an extremely high level in terms of governance and compliance beat any field, whether it is HR or medical excellence or idea of finance. So I think I think that initial exposure helped me a lot.
Griffin Jones 44:54
How did you adapt to what it must have been drinking from a firehose with That level of information trying to keep up with those folks, what resources or education? Or how did you lose it just articles on the internet? How did you get up to speed?
Kshitiz Murdia 45:11
I think I was very open to all of them during the journey. If I don't understand anything, even being the CEO, I will be very open and upfront, and I don't understand this, pardon me, I'm a doctor. So I might not understand just explain me. And obviously the the you are running the business from day one. So you have that business sense. And you could catch up things which is in the interest of the business or not in the interests of the business. So they would say that I then simplify those films for me and explain me a you know, if I'm not able to understand, you must have
Griffin Jones 45:45
caught up and in you did so in a way that has really allowed you to scale and pretty darn quickly, it seems from especially starting around 2014. And then seems to have escalated quite a bit. You talked about having a one protocol, one set of protocols for all of the doctors and you said 52 Doctors was
Kshitiz Murdia 46:06
that goal goal? 52 plus 250 plus two. Okay,
Griffin Jones 46:09
so over 250 Doctors Wow. And everyone's using the same set of protocols. In the United States, it seems that people are resistant to do that. And I'm not clinically trained. And I come from a sales and marketing background. And I just kind of observe and it seems to me, like people are very reluctant to have any kind of uniform protocol. That's all we always let the doctor practice how they want to. And I think as a business person, I think what's pretty darn inefficient, it seems fine, but I'm not clinically trained. You you decided that that was the right way to go. What do you what do you what made you decide that? And what do you think the resistance to that idea is
Kshitiz Murdia 46:50
very interesting, when I think when I started practicing I was 29 or 30 years, when I recruited the first doctor, I was 33 or 34. And then purposefully, I would want to recruit a younger doctor who was little junior to me. So they would come and listen to what I'm saying, you know, and eventually it happened that we were recruiting all junior people, you know, 2830 31 and then ensuring that we train them efficiently. But later we realized, if I if I recruit a younger person who just graduated yesterday, from OB GYN, he or she is blank in his mind, or her mind about IVF, they don't know anything about IVF, right? Whatever files, you need to insert in their mind and block it, they will be stuck there. You know, somebody who's practice in IVF, for 1015 years might be a good clinician, but they come with their own baggage that this is what I think is right. You know, this is what I've been doing in my last decade or so. And this is what I swear by. And I will not change whether you tell me that this is good or this is bad, I have not changed my practice. And that's why, you know, if somebody would come for an application, or we can see application comes, somebody says I have 15 years of experience in IVF and wonderful clinician, good business, good outcomes, somebody comes and tells me I have just graduated yesterday with my OBGYN, we'll pick up the later one and not select the first one because you know, we are a rapidly changing organization is what I was doing as a clinician 10 years back, we have changed the complete protocol in today, if I see today, and what I was doing 10 years back is completely different. So one should have that flexibility in their mind to keep adapting to the newer protocols, evidence based medicine that comes in. And I feel this younger Lord, having gone through that process of working with us getting trained with us, following one single protocol. Every time a new protocol comes in, we do a pilot tested at one, report the outcomes to all the people and then say, Okay, let's go and change this protocol from tomorrow morning. You know, because this is better. This is the evidence based reports. This is the pilot that we've done. So the entire culture of the organization has said from day one, that it has to be young people moldable whatever we have taught them, I think I think most of our people would not know the various five or 10 different types of protocols that exist. And if they would just know, one protocol that they've been taught because they had no background about it. I think that's that's the plus point that we gain, recruiting younger people because we were not depending on experienced clinicians for getting patients, patients are being sourced by the marketing function. And we were very confident any clinician, we were trained to get similar outcomes, you know, so I think our work of a trained doctor was being handled by the marketing function and the training function to get more patients and ensure once you get those patients the outcomes have to be good.
Griffin Jones 49:44
There could be a couple of reasons why people don't have one protocol where it's because well, we need older docks in order to have them do their own marketing or we don't have the training infrastructure to bring everyone up to do this one protocol or it could simply be that There are dogs that are set in their ways that and they're not receptive to change. And that could be very difficult and having one universal protocol. What about someone that would say, That's too rigid? Dr. Marty, that's too it's that doesn't allow the clinician to be a clinician at that point. They're just a, they're just a cog in the machine. And it doesn't allow them to provide individualized care to the patient, how would you respond to that?
Kshitiz Murdia 50:31
So Griffin, we we're not saying one protocol, it could be multiple protocols, but one protocol for one type of patient. So we are individualized yet standardized, I would say, you know, for a different type of a patient, young patient, you would use a different protocol for the older patient, you would use a different protocol. But I would not have 10 protocols for my older patients or five protocols. For my younger patients, we do allow some kind of flexibility, but not to a very great extent, I would not say they can choose between three or four protocols, or three different types of medicine, we would maximum have one particular medicine being prescribed for a particular compound. At max very, very rarely, I would say two different types of brands are medicine. So everything is being systematically put in Europe, people, people are okay with it doctors because they are getting outcomes, you know, if something is wrong in my system, in my protocols in my SOP, you will not get outcomes. And then you know, I would also want to change if you're getting good outcomes. If everything is well, why would you want to change a particular protocol. And slowly, we are now getting to a point where we would now be enforcing it to our system to AI EMR, which would be much more intelligent. And we are feeding all our SOPs and protocols into the EMR. So it would keep assisting, keep alerting keep stopping the doctors at any point of time, if they are going in the wrong direction.
Griffin Jones 51:55
And so how would you respond to someone that says that ties my hands too much?
Kshitiz Murdia 51:59
I mean, it's okay. I mean, if there is any protocol that you think is better, let us know we'll do a pilot in your center with few patients and see if the outcomes are good, we are happy to change the entire country on that protocol. We are open to that. But it has to result in better outcomes or reduce the risk of complications to the patient, or reduce the expenses of the patient, then we are open to it.
Griffin Jones 52:22
Let's recap some of this meteoric growth that you've had. So that so you join in 2010. For at the time, there was one center in the western part of India, and from 2010 to 2014, you had that one location, and you're practicing as a as a clinician, there's no second location, second location opens up in 2014. And that's when you start with the awareness camps and starting to grow the marketing. And then by 2018, you had 50 centers, or at least 50 offices. So at this time, is there still one hub? And in the other 49 or so are spokes?
Kshitiz Murdia 53:04
No no majority of them, but hubs
Griffin Jones 53:07
is IVF labs?
Kshitiz Murdia 53:09
Yes.
Griffin Jones 53:10
Across the country?
Kshitiz Murdia 53:11
Across the country. Yes.
Griffin Jones 53:13
And so what is it today? How many IVF labs does Indira fertility have
Kshitiz Murdia 53:18
this for labs? Well, most 49 or 50, and rest 65 66? Whatever 67 number would be spokes.
Griffin Jones 53:27
Wow. So So somewhere around 50, IVF labs, and then somewhere between 60 and 70 offices in more remote areas where they do everything except retrieval and transfer.
Kshitiz Murdia 53:40
Yeah.
Griffin Jones 53:40
And 250 physicians about maybe a little more?
Kshitiz Murdia 53:46
Yes.
Griffin Jones 53:47
And how many employees
Kshitiz Murdia 53:49
Roughly 2700 2800 employees?
Griffin Jones 53:49
Wow, so there was a there was a dramatic growth that that went from 2014 to 2019. It sounds like it was largely fueled by the awareness camps that you were doing that marketing, building the SOP and the training. And then at what point did you decide okay, we need a financier behind this and because it sounds like you were talking to some private equity folks before TA and that it sounds like ta happened in 2019. So, what year was it when you decided okay, we need a financier behind this.
Kshitiz Murdia 54:26
So, Griffin, I think the the requirement was not from the financing point of view because fortunately IVF is a good business to be in the margins are better and then you know, your own internal accruals could fund the the future growth of this interest. The requirement to have a private equity was more from a global exposure point of view, having good governance, good systems, good processes, attracting good talent to your company and then obviously building that solid foundation. You know, as a family as a promoter, we brought the company to one level. Now to go Further, we need some partner who can instill those values, though that culture in the company attract talent, build a solid foundation. And then obviously, we can take it to the next level. So I think that was one of the major requirements. So with the DA investment, nothing came in into the company, it was all secondary money being passed to the shareholders. But if we had a partner who could, you know, structure the whole organization for the future?
Griffin Jones 55:25
Why did you need their help for that? Why? Why couldn't you do that? On your own the culture that normally it seems that's what what comes from the organic side? What do you what do you think you needed their help with?
Kshitiz Murdia 55:37
I think as a as a family, as a promoter, you are not exposed to that global expertise. And, you know, once you have private equity people coming in, they you get to learn a lot on on corporate governance, on structure on sustainability of the business on building a platform, as a family as a promoter, you are very much involved into day to day operations. And I said, the difference between a value creation or a wealth creation versus difference between, you know, looking at your p&l every day, every month, every year on how many profits or much profits you make. So that's a basic mindset difference. And I mean, we've been exposed with deer for the last four years, and now the mindset has changed dramatically. If you were to talk to me five years back, my mindset would have been different. So today's
Griffin Jones 56:23
associate at that time was behind CCRM. Is that right?
Kshitiz Murdia 56:28
They used to want CCRM. till last year, I think last year, they sold it off somebody.
Griffin Jones 56:33
So when they came in, they had a good bit of experience in the fertility space. What things did you say, Okay, we want to do we want to learn from the CCRM way and what other things you say, no, we want to protect this and do this our way?
Kshitiz Murdia 56:49
I think I think there was no technical exchange of information that happened from the CCRM. I think it was the global expertise of tea associates, having worked on multiple businesses across different geographies, and also some experience on fertility business. But I think it's very difficult to replicate practices from one country to another country, and then you know, expect good outcome is the general know how of building a good foundation that helped us to a great extent, I would say if I look back at their partnership, the value and that they have created I think it's it's building out that solid foundation, then building out that leadership team, and developing that culture that DNA, the organization that is very future ready for any kind of growth, it kind of shocks that might come along our way.
Griffin Jones 57:35
There's so much more I could ask you, but we'll save that for a future episode. I'd love to have you back on the show. If you're open to that idea, at some point in the future have any summary of what you're talking about? Or maybe Indira has plans for the future putting thoughts?
Kshitiz Murdia 57:48
Well, we are open to some acquisitions in some parts of the country as well. We also looking at senses to our businesses, which is getting into genetics getting into pathology, we have Axos lot of pharma products, which are directly being manufactured for us from the cdmos. We are looking at adjacent businesses like mother and child as well. We have already started our expansion medicine countries, which is Nepal and Bangladesh and Southeast Asia being a very attractive market. We are very open to you know, having a partner who could take us or help us in that area. I think this is broadly the plan that we're looking at for the future growth. But
Griffin Jones 58:29
Kshitiz Murdia, thank you so much for coming on inside reproductive health.
Kshitiz Murdia 58:33
Pleasure, Griffin, I enjoyed the conversation. Thank you for inviting me.
Sponsor 58:38
You've been listening to the inside reproductive health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health