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  • 1. BPR Case Study Nethrajyoth International Hospital Source: Business Process Reengineering, Jayaraman M S; Natarajan Ganesh; Rangaramanujan A V, TATA Mcgraw Hill Punblishing Co.Ltd. 1998)BACKGROUND SCENARIO Nethrajyoth International Hospital (Nethra) is reputed institution in southern Indiacommitted to providing high quality ophthalmic care services. It is managed as a voluntarynon-profit service institution focused at serving the economically weaker sections of thesociety. With this objective in mind. Nethra provides free treatment to nearly 30 percent ofthe patients. About 50 percent of the cataract surgeries performed in one particular yearwere done free of charge. In view of the excellent reputation of the Institution, patients from all over Indiaflock to Nethra for treatment with the result that the number of patients is increasing at therate of 25 percent per annum. The hospital wishes to increase the number of poor patientscared 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 serviceobjective.  They simply can‟t recruit more surgeons or consultants. Their team consists of internationally reputed professionals who are deeply committed to a social cause, and are wiling to work for long hours and weekends without looking for extra benefits or compensation. It is difficult to find such socially committed individuals.  The modern medical equipment (for example, Excimer Laser which costs Rs.15 million) is quite expensive to acquire and maintain. Nethra has to think several times before making such high investments, as this can lead to either one or all of the following: -- An increase in the charges paid by the „paying patients‟ -- A decrease in the number of „free patients‟ -- A 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 raisedonations from the public, and currently provide all treatment (for paying patients) at acharge 10 –15 percent below the rates prevailing in other hospitals. The percentage of freepatients is also increasing slowly. THE OLD PROCESS The hospital system found it difficult to cope with the ever-increasing number ofpatients pouring in. Computers were there but were discrete islands, One for fixing upappointments, one for registration, one for payments and accounts, and so on.
  • 2. A patient had to first report at registration. After registration, he was given aregistration slip and sent to one of the junior consultants for the preliminary examination. Ifthe patient were lucky, he would join a small queue thereby going through the preliminaryfaster. 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 wouldmove on to the consultant‟s chamber. The consultant, after examining the patient, woulddecide upon a treatment. The consultant would either perform minor remedial treatment himself or completethe treatment procedure. Or, he would prescribe certain medical procedures, like lasertreatment., to be carried out. In which case, the secretary would write it down on a piece ofpaper and hand it over to the patient, requesting him to go down to the cash counter, payfor the treatment and get the receipt. After this, a ward boy would take him to theconcerned person who would administer the medical procedure. If any surgery was needed, its nature was indicated. The patient would then go backto the appointment desk to fix up dates for the surgery and all the medical tests to beundergone prior to the surgery. The patient had a tough time running here and there and often waited for longdurations to fix up further appointments, make payments, etc. The patients‟ moving back and forth crated a problem for the hospital too. When apatient‟s name was called out for a medical procedure/consultation, the person would bemissing. He would return, and wait again, not knowing that his name had already beencalled out, and feel frustrated with such delays, The hospital staff felt equally frustrated withsuch delays, vanishing acts and the like. On certain days, the schedule went haywire due to the chain reaction of such delays.Also, the consultants‟ time and equipment utilization seemed to be affected because of suchincidents. This created a concern that a non-profit institution like Nethra could really notafford to waste resources. Maybe, seeing each patient continuously through the wholeprocess, by cutting out wasteful delays, was the key to attending to more patients and alsomakes better utilization of resources. Thus, the attention of hospital administration got focused on eliminating wastefulwaiting time in the patient service fulfillment process. THE ANALYSIS The overall patient waiting time was dependent not only on the waiting time betweentwo medical procedures, but also on the time taken for each procedure, which could varycase to case. The time spent on the procedure per se was dependent on several factors like thepatient‟s general health, the condition of his eyes, etc. The reengineering initiative at Nethrawas therefore restricted to eliminating the waiting time between medical procedures. The methodology adopted at Nethra, for eliminating patient waiting time, comprisedjust three steps:
  • 3. 1. Identify causes/situations/activities contributing to the waiting time between procedures. 2. Examine each of these and try to eliminate the cause or obliterate the activity using IT. 3. Obliterate every activity, which merely increases the waiting time without adding value to the service. HOW REENGINEERING WAS CARRIED OUT? As a first step, many patients were asked to give feedback and suggestions forcutting down the waiting time. Simultaneously, three meeting sessions were conducted with select people at alllevels: 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 notmerely go by the clock time, but must cut down what is actually perceived as waiting timeby the patient. He quoted several instances where patients, who were seen through allprocedures most expeditiously, except the initial registration, complained bitterly over thefive-minute delay in registration. “ As against that,” he observed, “ patients who arepromptly registered and put through the preliminary examination followed by dilatation donot complain seriously about delays.” The Patient’s Point of View -- In process waiting (like waiting to see the consultant after dilatation) did not upset the patients but out of process waiting did (like being asked to wait before registration). -- After all procedures were completed, making a patient wait for any formalities., even for a very short time, left a bad impression. Such waiting was seen as purposeless and the patient became most „impatient‟ at that point. A comprehensive list of all possible instances/ causes/activities that could beeliminated was generated based on the discussions and feedback. After the study, aprototype of the reengineered system was developed with these inputs. THE REENGINEERED NETHRAJYOTH In the smoothly implemented reengineered system, there are about 60 terminals,spread throughout the Nethra complex, linked to a central database,. Each terminal has thefacility to give appointments, register patients, collect payments, schedule surgery, and soon. Appointments can now be given for a six-month window as opposed to the two-month window that existed earlier. When an appointment is cancelled/delayed by a patient,another waiting patient is quickly routed through to fill the slot. Patients coming in to register at the reception desk can make an advance paymentat any one of the 16 counters. They are then allocated to one of the junior consultants (the
  • 4. system does the allocation by round –robin method to ensure equal distribution of patientsto all consultants). On completion of the preliminary, they are led to the consultant‟s lounge fordilatation. If there is any unexpected delay, the patient is kept informed in the consultant‟slounge for dilatation. If there is any unexpected delay, the patient is kept informed. Theconsultant‟s secretary takes charge of the patient and organizes the dilatation, followed byan examination by the consultant. Further to the examination, if the patient needs to undergoe any medical procedures,the secretary organizes the payment, gives the receipt, and personally „hands over‟ thepatient to the next service representative --- the specialist in charge of the medicalprocedure. Any cross consultation, if required, are quickly fixed up and the patient isescorted to the other consultant‟s cabin. If surgery is required, the secretary, using a terminal, fixes dates for the surgery andfor all prior medical check-ups. The nerve center of the reengineered system is the software that constantly keepstrack of the patient as he goes through the treatment process. Any delay beyond a certainlimit, in any process, is flashed as an amber alert to the public relations officer who meetsthe patient personally, and takes mid-course corrective action by seeing him through thesystem expeditiously. The PRO, in turn, converts the amber alerts, into red alerts when heneeds the intervention of the Superintendent or the Chief. Since each patient is continuously monitored through the process, the system atNethra resembles a WIP (Work In Process) monitoring system on a shopfloor, rather than aroutine hospital management system. BENEFITS OF REENGINEERING By continuously optimizing the patient waiting time, the system has-- Resulted in nearly 80 percent increase in the productivity of the scarcest resource –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 servicerepresentatives, which enables them to track the patient and see him through all therequired procedures quickly. The patients are also free of stress as they do not have to runfrom one end to another, and are treated and seen through swiftly The system has clearly achieved the following significant benefits out of thereengineering exercise: Cost reduction and surplus generation for investment in basic research. o More number (and percentage) of free patients. o No increase in costs for paying patients. o Charges maintained at 20 percent below the charges levied at other hospitals. o More investment directed towards prevention of eye ailments and basic research. o Service quality enhancement for patients.
  • 5. o They are attended to quickly and feel more secure and comfortable. o No running around for appointment/payment etc.` o Work life enrichment for staff. o Smooth flow of work without „zigzag‟ patient movement. o Better ambience to handle patients leading to qualitative improvement in the self-esteem of the staff. REFLECTIONSReengineering at Nethra conveys a few interesting thoughts. Reengineering initiatives may not seem to provide dramatic improvements involuntary non-profit institutions like Nethra, or such institutions. Anyway, use theirresources in the most optimal manner within the limits of available technology. Moreover,they operate with minimum overheads. The process objective, viz., „cut down patient waiting time‟ was simple enough to beeasily understood and internalized by everyone down the line in the institution. The choice of methodology depends upon the context of the situation, culture of theorganization, etc. What was adopted at Nethra, for instance, does not religiously follow thefive-step methodology detailed there. This only reaffirms: reengineering is much like aspiritual experience often eluding hard core clearly defined methodologies and procedures. An innovative move in reengineering the layout of the hospital, while shifting to theirnewly – built premises, has in a way obliterated the use of software to keep track of eachpatient. The waiting lounge for each consultant now consists of an optimal number of chairsto accommodate the waiting patients and their support persons, restricting the entry to thepatient and the support person per patient. About 20 percent of the patients come withoutsupport persons, and that leaves some cushion. If, in any lounge, a patient can‟t find avacant seat, the PRO knows that the waiting time is increasing in that lounge or bay. Noneed for an amber or red alert!