Delivering Care in an Efficient Environment by Mr.Joy Chakraborty

1. Delivering Healthcare in
Efficient Environment
Joy Chakraborty
Director - Administration
Hinduja Hospital, Mumbai.

2. The Challenges & Transition
in Healthcare
• Controlling costs
• Government regulations
• Increasing competition
• Implement new procedures and capabilities
• Treatment reimbursement rates are capped
based on diagnosis
• Number of uninsured

3. Contd…..
•New technologies are “Expensive” and adoption in
question
•Staff shortages in some areas continue to drive up
costs
•“Report Cards” on providers – quality, cost,
number of procedures
• Role of the Private Sector in healthcare delivery
• Growth in the number of people age 65 and
older

4. What do our Patients want ?
• Favorable patient outcomes
• Patient safety
• Implement new procedures and capabilities
• Controlling healthcare costs
• Service with a smile

5. What does the hospital want?
What that leads to:
• Available and prompt care
• Better patient outcomes
• Increased patient
satisfaction
• Improved financial viability
• Smooth operations
• Improved patient throughput
• Ensure patient safety • Improved publicly reported
• Provide quality care information
• Higher employee
• Effective patient treatment
involvement and satisfaction
• Utilized staff and resources • Reduced LOS

6. How do we achieve this?
• By Improving QUALITY of health care
• Patient safety and risk management
• Evidence-based practice
• Continuous learning and improvement
• Stimulate and improve integration and
management of health services
• Reduce variation in care and health care costs
• Strengthen the public’s confidence in the quality of
public’
health care

7. How do we achieve this ?

8. MUDA

10. Waste

11. Examples of Waste
•Inventory – unneeded stock or supplies
•Motion – movement of staff and information
•Overproduction - unnecessary tests
•Extra processing – filling out extra paper work
•Transportation – movement of patients & equipment
• Defects– duplicate work, medical errors
•Waiting – delays in diagnosis & treatment

12. What is Lean?
Lean means creating more value for
customers with fewer resources &
elimination of “waste”
Vs

13. Six Sigma is:
 A disciplined, data-driven approach and
methodology for eliminating defects in any
process
 A statistical representation of Six Sigma describes
quantitatively how a process is performing
 At many organizations Six Sigma simply means a
measure of quality that strives for near perfection

14. 6σ Level Performance
• Six Sigma standard of 3.4 problems per million
opportunities
• 3 Sigma standard of 67000 problems per million
opportunities
• 4 Sigma standard of 6200 problems per million
opportunities

15. Nature of Healthcare Business
- Outcomes are Variable in Nature

16. Six Sigma in Health Care
• In a HOSPITAL, processes must run correctly
• The best option for healthcare organizations is to
implement Six Sigma because
• It focuses on total improvement with reducing costs,
• Improving performance and productivity, and
• Ensuring the patient is entirely satisfied with the care he
receives
• It allows professionals to appropriately and successfully
figure the inconsistencies within their operations
• It allows medical professionals the ability to detail processes
within the field and quickly adjust and standardize them

17. Lean
6
Lean Six
Sigma
Total Quality
Management
Quality Assurance
Quality Control
Inspection

18. Lean + Six Sigma
LEAN SIX SIGMA is a business improvement
methodology which combines tools from both Lean and
Six Sigma.
Lean and Six Sigma are complementary in nature
Lean focuses on eliminating non-value added steps
and activities in a process, Six Sigma focuses on
reducing variation.

19. DMAIC: Basics
Define Measure Analyze Improve Control
What is important The process: The process gains:
to the customer: Analyze Data Ensure Solution is
Project Selection Identify Root Causes Sustained
Team Formation
Establish Goal
How well we are doing: The process performance measures:
Collect Data Prioritize root causes
Construct Process Flow Innovate pilot solutions
Validate Measurement System Validate the improvement

20. Disruptive Innovation

21. Benefits of Lean Six Sigma
• Improved patient experience and satisfaction
• Faster response to patient needs
• Increased job satisfaction & reduced stress for
caregivers
• Improved, standardized & repeatable processes that are
more predictable
• Ability to focus resources on more value-added activities
• Improved asset utilization: people, equipment &
technology
• Reduced unit costs through increased capability

22. Benefits of Lean Six Sigma
• Improved flow through elimination of bottlenecks
(delays) and constraints (limiters)
• Dramatic improvement in scheduling predictability
– better process management
• Participative problem-solving
• Engaging the people who know and do the work…
the team
• Recognition of the need to manage change

23. Tools
Fish Bone Analysis
Hypothesis testing
Regression
VOC
Cause & Effect Matrix

24. “It’s not about tools to achieve
success in Lean Six Sigma. It’s about
how to get leaders to believe in and
EMBRACE quality!”

25. Real Life Application
Organization Project Outcome Achievement
Charleston Area Supply chain for Lower inventory, Improved Saved:
supplier relations $163,410 immediately $841,540
Medical Center surgical supplies future
Commonwealth Radiology Decreased time between $800,000 savings, 25% better
dictation and signature, throughput and eliminated 14
Health Corporation Improved wait times and positions
staff scheduling
Froedtert Memorial ICU lab times Reduced turnaround Cut turnaround times from
Lutheran Hospital times 52 to 23 minutes
Mount Carmel Medicare+ Choice Redefined coding Profit $857,000
Hospital Plan working-aged Medicare
reimbursement recipients
Wellmark Inc. Physician addition Reduced time for Savings: $3 million per
to managed care adding physicians to year
network medical plan
Scottsdale Over crowded Improved transfer Profits: $600,000
Healthcare ED time from ED to
inpatient hospital
bed

26. An Overview
 381 beds, including 53 ICU beds; 19 Short Stay Service;
11 Operation Theatres and 6 EICU beds
 Not for Profit Hospital
 140 Consultants; 510 nurses and other support staff
 Exclusive area for Preventive Health Checks
 Promoting Medical Education along with attached Nursing College
 State of the Art Technology Application
 Group is entering into For Profit Segment in Healthcare
 Well stocked library with over 417 latest online and
offline journals. 26

27. Pioneering
Best Practices movement @ HNH
• College of American Pathologists (CAP) (1st hospital
laboratory to be accredited among the SAARC
region countries);
• ISO certification in 1996
• Recipient of Ramakrishna Bajaj award for
healthcare quality.
• Participation in Best prax Club competition
• ISO 27001 for IT Department for Information
Security
• Hospital accreditation

28. Hinduja hospital six sigma
success story……

29. FIRST HOSPITAL to adopt six sigma in Healthcare in India
Recently, concept of Lean Six Sigma has been applied too.
Some Studies :
• Turnaround time for patient discharges
• Outpatient Satisfaction
• Turnaround time for Imaging reports
• Satisfaction for Peri - operative care
• Average Length of Stay
• Operation Theatre support services
• OPD waiting time
• Discharge waiting time
• X Ray turnaround time
• Pharmacy items turnaround time

30. Case Study # 1
Short Stay Services.
1. 300 identified surgeries across 8 surgical specialties
in scope.
2. 19 bedded dedicated self dependent unit with two
units
3. Preoperative investigations and post-operative
follow-up done at home.
4. 24 hrs in house dedicated call centre managed by
nursing personnel.

31. Care @ Home Services
1. Expansion of reach.
2. Range of services provided

32. Measurable Outcome
Year Installed No. of Avg Length
Bed Surgeries of Stay
Capacity done
09 -10 383 11089 4.9 Days
10 - 11 372 12149 4.7 Days

33. Case Sudy # 2
Lean Six Sigma Process Improvement Project
at Hinduja Hospital
Project Name : Reducing the Turn Around Time for
Outpatient (OPD) Services
Project Goal : To reduce the Idle Waiting time in
the Outpatient process by 30-50%

34. Define Phase
Problem Statement: Over the past few months it has been observed that
the Turn Around Time for patients to avail OPD services has been an
issue of concern for the patients and Hinduja Hospital.
Voice of Customer
Selection of the project on Reducing the waiting time in Out Patient
Services is based on the concern raised by patients on waiting time in
the regular OPD feed back forms & verbal communication to our customer
care.
Voice of the customer was used to determine the acceptable Idle Waiting
Time.

35. Measure Phase
Data collection : The entire process flow for consultation / investigation
was tracked throughout the OPD working hours using tracking sheets.
The activity was divided into sub processes & the overall findings
were :
• Queue Time : 5-7 min
• Vouchering Time : 3-4 min
• Travel Time : 5-7 min
• Idle Waiting Time : 40-50 min
All TAT other than the Idle waiting time are within their respective
acceptable limits and hence not taken up for further study
Acceptable limit for the Idle Waiting Time is considered to be 30 minutes.

36. Measure Phase Waiting time for the OPD Services (in mins)
Idle Total
Queue Vouchering Travel Waiting Waiting
Service Time Time Time Time Time
Pulmonology 5 4 5 19 33
Cardiology 3 3 4 10 20
Neurology 4 4 10 45 63
Laboratory 6 3 2 10 21
X Ray 8 1 3 17 29
Physiotherapy Retrospective billing 8 8
Urodynamics Retrospective billing 29 29
Scopy (UGI, LGI) Retrospective billing 47 47
Bronchoscopy Retrospective billing 28 28
Consultation 4 4 3 33 44

37. Analyze Phase
A further investigation was done of the services
which have Idle Waiting Time beyond 30
minutes
• Neurology
• UGI / LGI Scopy
• Consultation

38. Analyze Phase
Neurology services Idle Waiting Time
EMG 101
EEG/ BERA/ VEP/ SSEP 21
EMG
Idle Waiting Time– EMG is done in 2 steps :
1.NCV
2.Complete EMG
First step is conducted by the Neurology Technician & the second step is
done by the Consultant. The increased Idle waiting time was observed in
specific cases of pediatric neurology wherein the patients were
uncooperative & had to wait for patient to settle down.

39. Analyze Phase : Conversion of EX Dr. Delayed for
Consultation patient to HH patient miscellaneous
reasons
Wrong Time
Wrong HH no. File not requested
entered at time of Dr. gone for
vouchering File archived Emergency Dr. in OT
Wrong Dr.'s
Name Requested file
Wrong Date
Appts after 8pm not reflecting
not reflected in in MRD Delta
appt list since list report
Wrong Wrong details captured at Dr. on
HH no. time of giving Appointment printed before 8pm
Rounds /
Procedure
WRONG APPOINTMENT BILLING MRD FILE NOT RECEIVED DR NOT AVAILABLE
DOUBLE APPOINTMENT PATIENT LOST NURSE NOT AVAILABLE PATIENT DELAYED
Previous
patient
Slot not Nurse busy with taken in late
Dr. or Patient
available Patient cannot find Tea Break
Training of new
location Patient
staff
came late
Dr.'s
Shortage of
Nursing Staff
Instructions
Dr.'s Wrong allowing Non
Instructions Appointment Wrong Appointment
Instructions given Patients – Emergency
Walk-ins Patient

40. Improve Phase : Solution Matrix – Consultation Idle Waiting Time
Process Step Constraint Cause Solution
Non appointment
patients to be seen
after the appointment
patients as per Dr.
instructions
Non appointment
Slot not available patients taken in
Appointment Checking Slot Patient called as advance only if the next
Scheduling Availability non appointment patient has not arrived
patients
Reserve specific slots
in between
appointment slots for
non appointment
patients
Slot is available but cannot System change to
take appointments on same reflect the file request
day due to system limitations for same day
for file retrieval appointments

41. Improve Phase : Solution Matrix – Consultation Idle Waiting Time
Process Step Constraint Cause Solution
File request not System change to
Appointments could reflected in the MRD reflect the file request
Printing of not be taken on report for the same for same day
Delta report same day day appointments
File retrieval
in MRD
Any additional
appointments after
the list is printed are
Appts after 8pm not added by the Nurse in
Printing of Updated reflected in appt list the appointment list
Appointment appointment list not since list printed and informed to the
list available before 8pm Doctor

42. Analyze Phase
:UGI/LGI Scopy
Aerated Lime drink
Endoscopy Suite
not available not available Dr. Delayed for
miscellaneous
Wrong Time reasons
Training of
Wrong Dr.'s Call Centre
Wrong Patient Delayed
Name Staff
Date
Emergency Dr. in
patient taken Dr. gone for Procedure
Patient did not
Emergency
follow given Wrong instructions given
Wrong HH instructions Patient arrived
no.
Dr. Delayed late for
Patient
preparation Dr. on
misunderstood
Rounds
instructions PATIENT NOT PROCEDURE DELAYED
WRONG APPOINTMENT PREPARED DR NOT AVAILABLE
DR.'S PRESCRIPTION NOT SCOPY SUITE PATIENT
DOUBLE APPOINTMENT
AVAILABLE NOT AVAILABLE DELAYED
Previous
Outpatient Wilkins
patient Inpatients
Patient forgot Dr;'s Previous taken in late sent
prescription patients randomly
Consecutive procedure Non Appointment
slots for ongoing Patients- Wilkins
No Appts
Multiple Dr. not available Cleaning
Inpatient sent given to
procedures to give fresh Previous patients
randomly inpatients
not available prescription procedure ongoing
Overlapping U. P. patient taken Patient Emergency
Appointments previously came late Patient

43. Improve Phase : Solution Matrix – Scopy Idle waiting Time
Process Step Constraint Cause Solution
Appointments taken for
Inpatients
Reserve slots specifically for
Inpatients / Inpatients only
taken in vacant slots
Inpatients being
Appt for In patient No appointments
taken randomly in Inpatient taken after all Out
Procedure Appt taken for Inpatients
between scheduled patient Appts
patients
Assign point of contact in Scopy
who will co-ordinate with Floor
Nurses to ensure the Inpatients
are taken in a scheduled manner

44. Improve Phase : Solution Matrix – Scopy Idle Waiting Time
Process Step Constraint Cause Solution
Changes in slot scheduling : 1
UGI is a shorter Only single slot
Slot 30 minutes for shorter
procedure than LGI but allotment done in
procedures and 2 slots of 30
the same single slot system:
minutes each for longer
(of 30 min) is given Overlapping
procedures e.g. Colonoscopy
when scheduling all appointments
will be given 2 slots instead of 1
the appointments
slot
Appt for Appt
Procedure Scheduling Separate slot timings
given for multiple
procedures on same Multiple process should be
Slot not available
patient when If given consecutive slots and if
consecutively for
continuous slots not required rescheduling of next
multiple procedures
available but patient
procedure done
consecutively

45. Improve Phase : Solution Matrix – Scopy Idle Waiting Time
Process Step Constraint Cause Solution
When preparation to be done in
Hospital, Appointment Cell to ask
Patient came late for patient to follow Dr.'s instruction
Delay for next patient
preparation / Patient at time of giving appointment
when patient is ready
If Scopy did not follow Dr. and call a day prior to confirm
Patient given for procedure
patient is instruction the same i.e. patient to come to
preparation at Hospital at least 2 hrs earlier /as
not
Hinduja per requirement
prepared
Hospital
Patient did not bring
Requisite preparation along the requisite Cafeteria to deliver the aerated
solution not available aerated drink required drink for the patient
for preparation

46. Performance: Consultation and Scopy
Idle Waiting Mean
SD Sigma Level
Time
(in min)
BEFORE TARGET AFTER BEFORE TARGET AFTER BEFORE TARGET AFTER
Consultation 33 15 14 36 5 11 -0.06  3 1.45 
Scopy 47 30 25 35 5 21 -0.07  3 1.70 

47. Waiting time for the OPD Services (in mins) - YR 2010 vs YR 2011
PRE LSS POST LSS FOLLOW UP
Idle Idle Idle
Waiting Time Waiting Time Waiting Time
Service 2010 2010 2011
Pulmonology 19 19
Cardiology 10 10
Neurology 45 25
Laboratory 10 05
X Ray 17 09
Physiotherapy 08 01
Urodynamics 29 46
Scopy (UGI, LGI) 47 25 30
Bronchoscopy 28 35
Consultation 33 14 18

48. Case Study # 3
Project Name : Reducing the Turn Around Time for
Patient Discharge
Project Goal : To reduce the Patient Discharge Time by
30-50%
Average TAT for Patient Discharge beyond 2 hours is
considered as a defect.

49. Average Times (in minutes)
BEFORE AFTER
y1= Written order to Finance folder sent
85 18
y2 = Finance Folder sent to received in Billing
9 7
y3= Finance folder received to taken for billing
8 8
y4= Finance folder taken for Billing to Discharge
Slip given to relative
50 48
y5= Discharge Slip given to relative to receipt by
nurse
21 19
y6= Discharge Slip received by nurse to patient
physically leaves bed 22 21
Y = Written Intimation to Patient leaves floor 194 121

50. Performance: Discharge Process
Mean Max SD
BEFORE TARGET AFTER BEFORE TARGET AFTER BEFORE TARGET AFTER
y1
85 40 18 385 50 45 94 5 9
(in min)
y4
50 30 48 188 50 89 36 5 16
(in min)
Y
195 120 121 525 150 205 108 5 22
(in min)

51. DID YOU KNOW.....??
. .Do you Know ?
• “Hospitals report that the biggest challenges in
implementing lean or six sigma include sustaining
improvements, competition from other initiatives,
leadership commitment and availability of resources”
- American Society for Quality, 2009

54. The Week – IMRB Exclusive
survey ranks Hinduja Hospital as
no. 1 in the region for the 4th
year consecutively
54

55. Thank You