BUSINESS TRANSFORMATION VINEETA KUMARJUNE - SEPTEMBER 2015Page 1 1.Nethrajyoth International Hospital Jayaraman M S; Natarajan Ganesh Rangaramanujan A V, TATA Mcgraw Hill Punblishing Co.Ltd. 1998) BACKGROUND SCENARIO NethrajyothInternationalHospital(Nethra)isreputedinstitutioninsouthernIndia committed toproviding high qualityophthalmic careservices.Itismanagedasavoluntary non-profitserviceinstitutionfocusedatservingtheeconomicallyweakersectionsofthe society. With this objective in mind, Nethra provides free treatment to nearly 30 percent of thepatients.About50percentofthecataractsurgeriesperformedinoneparticularyear were done free of charge. InviewoftheexcellentreputationoftheInstitution,patientsfromalloverIndiaflockto Nethra for treatment with the result that the number of patients is increasing at the rate of 25percentperannum.Thehospitalwishestoincreasethenumberofpoorpatientscared for without charging an excess fee for patients who pay for the services. The hospital has the following resource constraints in trying to meet its service objective. Theysimplycan'trecruitmoresurgeonsorconsultants.Theirteamconsistsof internationallyreputedprofessionalswhoaredeeplycommittedtoasocialcause, andarewilingtoworkforlonghoursandweekendswithoutlookingforextra benefits or compensation. It is difficult to find such socially committed individuals. Themodernmedicalequipment(forexample,ExcimerLaserwhichcostsRs.15 million) is quite expensive to acquire and maintain. Nethra has to think several times beforemakingsuchhighinvestments,asthiscanleadtoeitheroneorallofthe following: o An increase in the charges paid by the 'paying patients' o A decrease in the number of 'free patients' oA combination of both Which would all go against the mission and objectives of the institution? Even these high costs of hospital equipment, Nethra have managed to raise donations from thepublic,andcurrentlyprovidealltreatment(forpayingpatients)atacharge10-15 percent below the rates prevailing in other hospitals. The percentage of free patients is also increasing slowly. THE OLD PROCESS Thehospitalsystemfounditdifficulttocopewiththeever-increasingnumberofpatients pouringin.Computersweretherebutwerediscreteislands,Oneforfixingup appointments, one for registration, one for payments and accounts, and so on. A patient had to first report at registration. After registration, he was given a registration BUSINESS TRANSFORMATION VINEETA KUMARJUNE - SEPTEMBER 2015Page 2 slip and sent to one of the junior consultants for the preliminary examination. If the patient were lucky, he would join a small queue thereby going through the preliminary faster. If the queue was long, it could take an hour or more. After the prelim, the patient was sent to the dilatation lounge from where he would move onto theconsultant'schamber.Theconsultant,afterexamining the patient,woulddecide upon a treatment. Theconsultantwouldeitherperformminorremedialtreatmenthimselforcompletethe treatmentprocedure.Or,hewouldprescribecertainmedicalprocedures,likelaser treatment., to be carried out. In which case, the secretary would write it down on a piece of paper and hand it over to the patient, requesting him to go down to the cash counter, pay forthetreatmentandgetthereceipt.Afterthis,awardboywouldtakehimtothe concerned person who would administer the medical procedure. If any surgery was needed, its nature was indicated. The patient would then go back to the appointment desk to fix up dates for the surgery and all the medical tests to be undergone prior to the surgery. The patient had a tough time running here and there and often waited for long durations to fix up further appointments, make payments, etc. The patients' moving back and forth crated a problem for the hospital too. When a patient's name was called out for a medical procedure/consultation, the person would be missing. He wouldreturn, andwait again, notknowing that hisname hadalreadybeencalledout,and feelfrustratedwithsuchdelays,Thehospitalstafffeltequallyfrustratedwithsuchdelays, vanishing acts and the like. On certain days, the schedule went haywire due to the chain reaction of such delays. Also, theconsultants'timeandequipmentutilizationseemedtobeaffectedbecauseofsuch incidents.Thiscreatedaconcernthatanon-profitinstitutionlikeNethracouldreallynot affordtowasteresources.Maybe,seeingeachpatientcontinuouslythroughthewhole process, by cutting out wasteful delays, was the key to attending to more patients and also makes better utilization of resources. Thus,theattentionofhospitaladministrationgotfocusedoneliminatingwastefulwaiting time in the patient service fulfillment process. THE ANALYSIS The overall patient waiting time was dependent not only on the waiting time between two medicalprocedures, butalsoonthetimetaken foreachprocedure,whichcouldvarycase to case. The time spent on the procedure per se was dependent on several factors like the patient's generalhealth,theconditionofhiseyes,etc.ThereengineeringinitiativeatNethrawas therefore restricted to eliminating the waiting time between medical procedures. BUSINESS TRANSFORMATION VINEETA KUMARJUNE - SEPTEMBER 2015Page 3 ThemethodologyadoptedatNethra,foreliminatingpatientwaitingtime,comprisedjust three steps: 1.Identifycauses/situations/activitiescontributingtothewaitingtimebetween procedures. 2.Examine each of these and try to eliminate the cause or obliterate the activity using IT. 3.Obliterateeveryactivity,whichmerelyincreasesthewaitingtimewithoutadding value to the service. HOW REENGINEERING WAS CARRIED OUT? As a first step, many patients were asked to give feedback and suggestions for cutting down the waiting time. Simultaneously, three meeting sessions were conducted with select people at all levels: the ward boys, secretaries, nursing staff, consultants, and the Chief himself. 'Perceived Waiting Time' During the discussions, a young ward assistant pointed out that one should not merely go by the clock time, but must cut down what is actually perceived as waiting time by the patient. Hequotedseveralinstanceswherepatients,whowereseenthroughallproceduresmost expeditiously, except the initial registration, complained bitterly over the five-minute delay in registration. " As against that," he observed, " patients who are promptly registered and putthroughthepreliminaryexaminationfollowedbydilatationdonotcomplainseriously about delays." The Patient's Point of View Inprocesswaiting(likewaitingtoseetheconsultantafterdilatation)didnotupset thepatientsbutoutofprocesswaitingdid(likebeingaskedtowaitbefore registration). After all procedures were completed, making a patient wait for any formalities., even foraveryshorttime,leftabadimpression.Suchwaitingwasseenaspurposeless and the patient became most 'impatient' at that point. A comprehensive list of all possible instances/ causes/activities that could be eliminated was generatedbasedonthediscussionsandfeedback.Afterthestudy,aprototypeofthe reengineered system was developed with these inputs. THE REENGINEERED NETHRAJYOTH Inthesmoothlyimplementedreengineeredsystem,thereareabout60terminals,spread through out the Nethra complex, linked to a central database,. Each terminal has the facility to give appointments, register patients, collect payments, schedule surgery, and so on. Appointmentscannowbegivenforasix-monthwindowasopposedtothetwo-month windowthatexistedearlier.Whenanappointmentiscancelled/delayedbyapatient, another waiting patient is quickly routed through to fill the slot. BUSINESS TRANSFORMATION VINEETA KUMARJUNE - SEPTEMBER 2015Page 4 Patientscomingintoregisteratthereceptiondeskcanmakeanadvancepaymentatany one of the 16 counters. They are then allocated to one of the junior consultants (the system doestheallocationbyround-robinmethodtoensureequaldistributionofpatientstoall consultants). Oncompletionofthepreliminary,theyareledtotheconsultant'sloungefordilatation.If thereisanyunexpecteddelay,thepatientiskeptinformedintheconsultant'sloungefor dilatation.Ifthereisanyunexpecteddelay,thepatientiskeptinformed.Theconsultant's secretarytakeschargeofthepatientandorganizesthedilatation,followedbyan examination by the consultant. Furthertotheexamination,ifthepatientneedstoundergoanymedicalprocedures,the secretary organizes the payment, gives the receipt, and personally 'hands over' the patient tothenextservicerepresentative-thespecialistinchargeofthemedicalprocedure.Any cross consultation, if required, are quickly fixedup and the patient is escorted to the other consultant's cabin. If surgery is required, the secretary, using a terminal, fixes dates for the surgery and for all prior medical check-ups. The nerve center of the reengineered system is the software that constantly keeps track of the patientashegoes throughthe treatmentprocess.Anydelaybeyondacertainlimit,in anyprocess,isflashedasanamberalerttothepublicrelationsofficerwhomeetsthe patient personally, and takes mid-course corrective action by seeing him through the system expeditiously.ThePRO,inturn,convertstheamberalerts,intoredalertswhenheneeds the intervention of the Superintendent or the Chief. Sinceeachpatientiscontinuouslymonitoredthroughtheprocess,thesystematNethra resembles a WIP (Work In Process) monitoring system on a shop floor, rather than a routine hospital management system. BENEFITS OF REENGINEERING By continuously optimizing the patient waiting time, the system has Resultedinnearly80percentincreaseintheproductivityofthescarcestresource the consultants. Achieved a matching increase in the utilization of expensive medical equipment. The system gives complete control over the patient to the hospital's service representatives, whichenablesthemtotrackthepatientandseehimthroughalltherequiredprocedures quickly.Thepatientsarealsofreeofstressastheydonothavetorunfromoneendto another, and are treated and seen through swiftly Thesystemhasclearlyachievedthefollowingsignificantbenefitsoutofthereengineering exercise: Cost reduction and surplus generation for investment in basic research. More number (and percentage) of free patients. BUSINESS TRANSFORMATION VINEETA KUMARJUNE - SEPTEMBER 2015Page 5 No increase in costs for paying patients. Charges maintained at 20 percent below the charges levied at other hospitals. More investment directed towards prevention of eye ailments and basic research. Service quality enhancement for patients. They are attended to quickly and feel more secure and comfortable. No running around for appointment/payment etc. Work life enrichment for staff. Smooth flow of work without 'zigzag' patient movement. Betterambiencetohandlepatientsleadingtoqualitativeimprovementintheself esteem of the staff. REFLECTIONS Reengineering at Nethra conveys a few interesting thoughts. Reengineering initiatives may not seem to provide dramatic improvements in voluntary non-profit institutions like Nethra, or such institutions. Anyway, use their resources in the most optimalmannerwithinthelimitsofavailabletechnology.Moreover,theyoperatewith minimum overheads. The processobjective,viz.,'cut down patientwaiting time'wassimpleenough to be easily understood and internalized by everyone down the line in the institution. Thechoiceofmethodologydependsuponthecontextofthesituation,cultureofthe organization, etc. What was adopted at Nethra, for instance, does not religiously follow the five-stepmethodologydetailedthere.Thisonlyreaffirms:reengineeringismuchlikea spiritual experience often eluding hard core clearly defined methodologies and procedures. An innovative move in reengineering the layout of the hospital, while shifting to their newly - built premises, has in a way obliterated the use of software to keep track of each patient. Thewaitingloungeforeachconsultantnowconsistsofanoptimalnumberofchairsto accommodatethewaitingpatientsandtheirsupportpersons,restrictingtheentrytothe patient and the support person per patient. About 20 percent of the patients come without supportpersons,andthatleavessomecushion.If,inanylounge,apatientcan'tfinda vacantseat,thePROknowsthatthewaitingtimeisincreasinginthatloungeorbay.No need for an amber or red alert!