2- Debashish Naik - Application of TOC in an Eye Hospital_ Eng

7/31/2019 2- Debashish Naik - Application of TOC in an Eye Hospital_ Eng

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www.tocpractice.com 2nd TOCPA conference, 19-20 May 2012, Moscow

Debashish NaikFounder & Principal Consultant

MEVOCON


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He has a Bachelor in Engineering, (Electronics & Communication) degree, and an MBAfrom a premier institute in India. He has also done Managing Theory of ConstraintsWay from Goldratt School. He is a TOCICO certified practitioner in Project Management

and Supply Chain and Logistics.He is a strong believer of TOC philosophy.

Debashish has over 22 years of experience in ManagementConsulting, Development Sectors, Manufacturing, andGlobal IT delivery services on application development &maintenance. He began his career with Unilever and in his

twenty two years of experience he has worked in variousmanagerial/leadership positions in IBM, Wipro, PerotSystem, PWC, Hindustan Lever Ltd and a very shortspan in United Nations. He has varied and richexperience in different industry and function (including

healthcare domain).His consulting, both SOLUTION AND IMPLEMENTATIONfor performance improvement is based on application ofTheory of Constraints (TOC) and integration ofLEAN,and the Fundamental Management Principles withTOC. His strength is in transformation, implementationand in developing the internal capability of clientorganization for continuous improvement.

Debashish Naik


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Greetings from mevocon Mevocon (mind and evolution of consciousness) a management

consulting firm working on application of TOC and also application of anintegrated approach where Lean and fundamental management principlesare integrated with TOC

Mission: Provide Services and Solutions to both for profit and for not for profit

organizations using the philosophy, tools and applications of Theory ofConstraints, Lean and Fundamental Management Principles blendedwith Innovative Ideas and Thinking Process, that help clients to overcomethe factor that limits their business performance and add real value i.e.improve clients business (bottom line/ profits).

For us our business excellence is when Client perceives higher value of ourservice and product than the value that we perceive as a provider. Vision:

Establish ourselves as a meaningful organization that would beappreciated by the clients, individuals, employees and society for able to

support and create success those are meaningful to them.


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Background

Consultant explained about TOC to the medicaldirector of an eye hospital and further had a meetingwith the CEO

The CEO thought it is like any other improvement

initiative and was reluctantWe promised that we wont put the organization in any

risk and wont bring any kind of employee

dissatisfaction CEO approved and we took up the project in day care

eye surgery process (OT process) as per the suggestionof the medical director


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Day Care Eye Surgery: OT ProcessPre

Operation

OT Complex Post

Operations

Patientarrives at

Hospital

Patientleaves the

Hospital

OT Process : The OT process that we selected starts when the patient arrives at the Operation

floor in the hospital (patient directly comes to Operation floor) for eye surgery(mainly cataract surgery) and leaves after the post surgery dressing

Operation Floor has two block: One is Pre operation activities area and theother is OT complex. In side OT complex there are operation theaters. Pre-Operation:When patient arrives at the OT floor in the hospital he/she goes

through the pre operation activities, wait for dilation to be completed (like checkup of vital signs, payment/insurance, Dilation, wearing OT gown) and then moveto OT complex

OT Complex: OT complex has two parts. One is patients rest and vital check uparea, where the patient lie down on the bed, take little rest and vitals are checkedagain and the other is Operation Theater, where the surgery is done.

When the OT complex nurse finds that the patients vitals signs like BP/sugar areok and the patient is fit then they shift the patient inside the Operation Theater

Post Operation: Once the surgery is over the patient comes out of the operation

Theater and goes for post operation dressing and then they are allowed to leave. Ifany body wants to take rest then they take rest.


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Day Care Eye Surgery: OT Process

Pre Operation activities OT Complex PostOperation

Patientarrives atHospital

Patientleaves theHospital

Admission(5 min)

Dilatation(45 min ormore)

Billing 5 to15 min

OT ComplexPreOperationactivities

PostOperationPatient

arrives atHospital

Patientleaves theHospitalReception

5 minBlock /Vitals15 min

Operation Theater

Presurgeryprep 5

min

Surgery


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OTComplex

Pre Ops Post OPsPatient

arrives atHospital

Patientleaves theHospital

Dressing Eye Check up Counseling


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Lead Time before implementing TOC Solution

13 th Jan 14th Jan 16 th jan 17th Jan 18th Jan 19th Jan 20th Jan 21st Jan 25nd Jan

03:35 02:45 03:00 02:47 04:40 02:00 02:25 03:50 04:0504:55 05:30 03:40 02:25 04:15 02:25 03:35 01:51 02:20

03:15 02:15 03:10 02:52 02:35 02:55 02:00 04:10 02:00

03:05 03:07 03:05 03:30 02:50 02:05 01:46 01:45 01:35

02:40 02:10 02:27 02:56 01:45 02:30 04:50 02:30 02:10

03:40 02:20 02:55 02:13 01:44 03:50 02:10 01:35 01:15

03:10 04:00 02:25 02:15 02:10 01:30 02:00 02:45 01:35

03:35 03:15 02:47 02:27 04:20 01:30 03:10 02:30 02:1002:00 03:00 01:45 03:23 03:05 03:10 03:15 03:00 04:10

01:55 02:45 02:15 02:13 02:20 03:00 02:10 02:03 05:15

04:21 02:17 01:40 03:30 02:50 01:35 01:40 00:45 02:40

03:56 02:20 03:10 02:20 03:00 01:15 02:30 03:35 02:30

02:55 03:50 04:30 02:02 01:45 02:30 01:30 02:10 01:40

02:15 03:50 02:00 02:35 01:50 02:10 02:45

03:45 03:05 02:30 03:20 02:10 01:50

03:25 02:20 03:05 02:35

02:35 02:00 02:30 02:15

02:20 02:10 01:35

02:05 02:40 04:00

03:50 02:45 02:40

02:05 02:20 01:25

02:25 01:40

02:50

Total Lead Time OT process_ Pre TOC Solution


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Data on Lead Time: Before implementing TOC Solution

Data Pre TOC

Solution

Average Lead Time 2 hr:43 min

Max Lead Time 5 hr: 30 min

Min Lead Time 0 hr: 45 min

Lead Time for % of patients (PreTOC Solution)For around 79% patients the leadtime is more than 2 hr

5 min

o 1 hr

1 hr to 1 hr

30 min

1 hr 30 min

to 2 hr

2 hr to 2 hr

30 min

2 hr 30 min

to 3 hr

3 hr to 3 hr

30 min

3 hr 30 min

to 4 hr

hr to 4 hr

30 min

4 hr 30 min

to 5 hr

5 hr to 5 hr

30 min

Pre

TOC 0.7% 3.9% 17.0% 30.1% 18.3% 12.4% 9.8% 4.6% 2.0% 1.3%

Note: data collected over one week


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Dilemma

The OT Floor manager and staff had the followingdilemma before the TOC solution and were interestedto resolve the dilemma

Not to waste the time of doctor, (i.e. once the surgerystarts the doctor should not be idle at any time because

patient is not ready/ available at the surgery table) callall the patients early and they wait

To have maximum patient satisfaction ensure patientwaiting time is as minimum as possible


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Solution Components Summary Solution Components: The solution is adaptation of the

TOC MTO solution as defined in Ever Improve andfurther Lean is integrated with TOC Doctors surgery time decides the schedule Patients schedule is done as per doctors surgery schedule(so

unnecessary waiting of patient is reduced) All others subordinate to surgery time so doctors time is not

wasted Introduce expedite principles in OT process area

Cycle time of each operation /tasks that subordinate andimpact the lead time are reduced or improved on acontinuous basis applying Lean philosophy /Kaizen

Doctor also put himself on continuous improvement toreduce the surgery time without compromising the quality


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Bringing Improvement

CurrentSystemStopped/Replaced

CurrentSystem

Stay

ProposedSolutionNew

Improved performance

Source: Ever Improve by Oded CohenWhile designing the solution we looked into1. Which parts of the system are erroneous and have to be replaced

2. The new parts that must be introduced to replace the erroneous parts3. All the other parts of the system stay as they are!


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OT ComplexPreOperation

PostOperationPatient

comes toHospital

Patientleaves theHospitalReception

5 minBlock /Vitals15 min

OT

Pre Surgeryprep (5min)

Surgery

DRUM (surgery

schedule is donebased on the

average C/T timetaken by the doctorfor around 80% of

the patients)

Release one hourbefore the surgeryschedule (Patientsarrival schedule is

done as per doctors(DRUM) surgery

schedule)

Based on the surgeryschedule the patientsarrival time is scheduledand it helps to create aFLOW that reduces the

patient waiting time

1: 00 hr


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TOC Solution

Strategy(what do we want to achieve): The patient waiting time is as minimum as possible

without keeping the doctor idle at any time during thesurgery{Reduce the lead time for day care eye surgery to

1.5 hr/2 hrs from around 2.5 hr/3 hr in the beginning forat least 70% of patients}

Why 2 hr was decided to start with in the beginning

Actual touch time at present is 80 min to 90 min for thepatients who are fit and do not develop high BP/Sugar justbefore the surgery or do not take a long time for dilation.

For Pre dilated patients it is between 40 min to 60 min


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TOC Solution

Tactic (how are we going to achieve the strategy): Implement

Principle of Flow

Mechanism of DBR

Buffer Management

POOGI


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Tactics:ImplementPrinciple of FlowMechanism of DBRBuffer Management

POOGI

Immediateimprovements inLead Time

Continuousimprovement

POOGIProcess of OngoingImprovement

Injection 2

Lead Timebuffer is set tobe challenging

but achievable

Mindset:Patient waiting time is asminimum as possible

and close to touch time

Injection 4Availability of theselected critical RawMaterials (RM) andcomponents is

monitored/managed

Injection 3

Patient Flow isprioritizedaccording to the

buffer status


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Tactics:ImplementPrinciple of FlowMechanism of DBRBuffer Management

Immediateimprovements inLead Time

Continuousimprovement

POOGI

Process of OngoingImprovement

Injection 5

Causes for patients notachieving the target 2hours are identified and

analyzed

Mindset:Patient waiting time is asminimum as possible

and close to touch time

Injection 7

A process is in place togenerate and implement ideasto reduce the touch time of

activities

Injection 6

Doctors and staffs arein a continuouslearning process to

reduce the lead time


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Injection 1

70 to 80% of patients will be through (arrival>Pre

Operation activities>Surgery>Post Operationcare>departure) within 2 hours

It creates a common mind set for the entire OT staff(Pre Operation activities and Surgery) with a singlemeasurement

This is in addition to the quality of clinical service anddealing with patients

Achievement of the reduction in lead time is the prime measurement for the entire

OT staff including doctors which is not on the expense of the quality of thetreatment


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Injection 2

This injection introduces the concept of Lead TimeBuffer (similar to Production Buffer) keeping theuninterrupted patient flow in mind

The injection contains the following components: The definition of Buffer (the Lead Time -patient

arrival till departure)

The size (length) of the Buffer Time status of the Buffer

Patient Release into the system (similar to Material

Release - the signal to start working on the order)

Lead Time buffer is set to be challenging but achievable


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Injection 2

The definition of Buffer (the Lead Time -patientarrival till departure)

The Lead time Buffer is from patient arrival till

departure (arrival>Pre operation

activities>Operation> post operation activities)

The size (length) of Buffer The Lead time initially decided is 2 hours target time, i.e

within 2 hours a patient should be through (arrival>Preoperation activities>Operation> post operation activities)



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Injection 2 In this case it is the Colour Code for prioritization and expediting

OT Complex

Pre Operation activities in OT Floor

The colour code is determined for the patient based on the time spend in Pre operationactivities and accordingly the OT complex In -charge does the prioritization and expedite s

in side the OT Complex to ensure that patient is through within the defined lead time of 2 hours

1hr 1hr 1 hr 15 min< 1hr 45 min

Patientarrives athospital

Operation

Theater

Lead Time buffer is set to be challenging but achievable: The time status of Buffer

1 hour< or = >1hr 1 :15< 1: 45

1 hr in pre operation activities

Between 1 hour and 1 hr 15 min in pre operation activities

Between 1 hour 15 min and 1 hr 45 min in pre operation activities


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Injection 2 The Pre Operation activity in charge put the colour code (Green/Yellow/Red ) on the

patient file

Lead Time buffer is set to be challenging but achievable : The time status of Buffer

If the patient has completed pre operation activities within 1 hour and entering into OTcomplex then the colour code mentioned in the file is GREEN and OT complex in chargeunderstands that expediting is not required for that patient to be through within 2 hours leadtime

If for the patient the pre operation activities takes between 1 hour and 1 hour 15 min and

entering into OT complex then the colour code mentioned in the file is YELLOW and OTcomplex In -charge keeps watch so that further delay does not happen for that patient to bethrough within 2 hours lead time

If for the patient the pre operation activities takes between 1 hour 15 min and 1 hour 45 min

and entering into OT complex then the colour code mentioned in the file is RED and OTcomplex In -charge focuses on that patient and sends the patient inside the OT ASAP to ensurethat patient would be through within 2 hours lead time

Inside OT complex the OT complex In- charge calculates the expected completiontime and accordingly prioritizes and sends the patient inside operation theater to

ensure that patient is through within 2 hr of lead time


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Injection 2

DRUM: The Doctor-The surgery schedule is prepared based on theDoctors average surgery time for about 80% of the patients

Patient Release in to the system (similar to Material Release - thesignal to start working on the order)

In this case the scheduling of patients is done keeping the schedule of

surgery time so that the patient arrives just one hour before the surgeryschedule

Pre-Operation

OT Post-OperationPatient

arrives

Patientleaves

Docto

r

Lead Time buffer is set to be challenging but achievable: Patient Release in to thesystem (similar to Material Release - the signal to start working on the order)

DRUM (surgeryschedule is done

based on theaverage C/T time

taken by the doctorfor around 80% ofthe patients)

Release one hour beforethe surgery schedule

(Patients arrival schedule

is done as per doctors(DRUM) surgeryschedule)

2 hour

1: 00 hr


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Injection 2

The challenge in schedule is that some of the patientsare not able to arrive as per the scheduled time.

Accordingly the scheduling process is modified toimprove the flow by ensuring that patient does notwait unnecessarily

To protect the DRUM the manager schedules little

more patients than the capacity of DRUM so that theDRUM is not starved at any point of time (doctor isnot idle at any point of time during the surgery)



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Injection 3

Patient Flow to Inside Operation Theater is prioritized inOT complex by the OT complex In- charge according to theBuffer Status/Colour code

Inside OT complex the OT complex In- charge calculates theexpected completion time (By calculating the number ofpatients ahead in the queue + preparation time + averagetime for surgery ) and accordingly prioritizes to ensure that

the patient would be through within 2 hour of lead time The OT complex in charge is empowered to take decision to

whom to send inside the Operation Theater, whileconsidering the clinical factors and lead time already spent

Patient Flow is prioritized according to the buffer status

t ti d


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Injection 4

Availability of the required materials and componentsis monitored

There is a person who is responsible for keeping readyall the necessary things before one day of surgery (LikeFull Kit manager in project management)

Availability of the selected critical Raw Materials (RM) and components is

monitored/managed

to ti e o 2nd TOCPA f 19 20 M 2012 M


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Injection 5

Causes for patients not achieving the target lead timeof 2 hour are identified and analyzed

The process is established to identify the causes for

which certain patients are not through within the targetlead time of 2 hour

For each patient who are getting delayed more than 2

hour, the OT floor manager finds and note down thecauses

Once in a week the OT staff sit together and discuss onhow to improve on the lead time

Causes for patients not achieving the target 2 hour are identified and analyzed

www tocpractice com 2nd TOCPA confe ence 19 20 Ma 2012 Mosco


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Injection 6

Doctors and staffs are in a continuous learningprocess to reduce the touch time of certainactivities

The doctor is the DRUM and determines the output

Though there is a variation but for 70 to 80 % ofpatients, the surgery time varies very little

Doctor are continuously enhancing their skill to increasethe speed without compromising the quality ofoperation/surgery

Doctors and staffs are in a continuous learning process to reduce the lead time

www tocpractice com 2nd TOCPA conference 19 20 May 2012 Moscow


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Injection 7

As a continuous process keep on generating ideas and implement toreduce the waste in the value stream and also reduce the touch timethrough innovative ideas /processes/technologies

Example: For pre-dilated patient the waiting time decreases and by the time they

arrive at hospital they are almost ready to move to OT complex and thewaiting time reduces

Study the pattern that what kind of patients are having stabilization(High BP/Sugar) problem before the surgery, because of which theywait for a long time and when their condition stabilizes then only thesurgery happens. For those kind of patients find out possible clinicalsolution that can help to stabilize their condition quickly withouttaking any risk.

A process is in place to generate and implement ideas to reduce the touch time of

activities

www tocpractice com 2nd TOCPA conference 19-20 May 2012 Moscow


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Implementation: Immediate Developed the procedures/guidelines for making schedule

Establish process to ensure adherence to scheduleprocedures/guidelines

Measurement: Establish the measurement (within 2 hours

patients are through) and measure the lead time of eachpatient everyday

Identify the reasons for delay and find out root cause andsolutions

Modify the schedule guidelines based on the result Introduce expedite process and ensure that it is followed

properly

www.tocpractice.com 2nd TOCPA conference 19-20 May 2012 Moscow


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www.tocpractice.com 2 TOCPA conference, 19 20 May 2012, Moscow

Leveraging the improvementAs a continuous improvement process, start working

on how to bring more patients and do more surgerywith the existing resources, increase the revenue andprofit and lower the cost without compromising

quality



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www.tocpractice.com 2 TOCPA conference, 19 20 May 2012, Moscow

Lead Time after implementing TOC Solution

26th Mar 27th Mar 28th Mar 29th Mar 30th Mar 31st Mar 5th April 6th April

2:00 1;55 1:45 1:15 1:40 0:55 1:55 4:05

2:00 2:00 1:50 0:45 2:00 1:25 1:30 1:40

2:00 1:50 2:00 1:40 2:00 1:30 0:55 1:302:00 1:10 1:55 2:45 1:25 1:50 1:40 1:55

2:00 1:25 2:15 1:55 1:35 1:50 1:20 1:50

3:20 2:30 1:50 1:25 1:55 1:55 1:20 1:05

3:35 2:00 2:00 1:25 1:50 2:00 1:35 2:45

2:35 1:40 2:00 1:15 1:50 2:00 1:35 0:55

2:00 1:40 2:00 1:30 2:00 2:00 3:00 1:00

1:10 1:40 2:00 1:50 2:40 1:50 1:20

1:40 1:25 2:00 1:15 2:00 1:05 2:00

1:20 1:25 2:25 1:25 1:55 1:50 1:45

1:45 2:40 1:25 1:50 1:55 1:35 1:55

01:55 01:30 1:10 2:00 1:20 2:00

1:40 2:40 1:15 2:00 1:55 3:25

02:35 01:30 1:10 1:55 1:30

01:50 01:45 1:10 1:25 1:55

01:35 1:05 1:50 2:00

01:50 2:35 2:00

01:55 2:50 1:45

01:50 1:55

03:10 1:55

02:00 2:25

1:25

1:30

2:001:25

Total Lead Time OT process_Post TOC solution



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p 2 TOCPA conference, 19 20 May 2012, Moscow

Data on Lead Time: After implementing TOC Solution

Data Post TOC

SolutionAverage Lead time 1 hr: 57 min

Max Lead Time 4 hr: 05 min

Min Lead Time 0 hr: 45 min

Around 86% patients are throughwithin 2 hour (improved from 22%)Lead Time for % of patients (PostTOC Solution)

5 min

o 1 hr

1 hr to 1 hr

30 min

1 hr 30 min

to 2 hr

2 hr to 2 hr

30 min

2 hr 30 min

to 3 hr

3 hr to 3 hr

30 min

3 hr 30 min

to 4 hr

hr to 4 hr

30 min

4 hr 30 min

to 5 hr

5 hr to 5 hr

30 min

Post

TOC 3.5% 26.1% 57.0% 2.8% 7.0% 2.1% 0.7% 0.7% 0.0% 0.0%



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p , y ,

Data on Lead Time: Pre and Post TOC Solution

Data Pre TOC Solution Post TOC Solution

Average Lead time 2 hr:43 min 1 hr: 57 min

Max Lead Time 5 hr: 30 min 4 hr: 05 min

Min Lead Time 0 hr: 45 min 0 hr: 45 min

Lead Time for % of patients (Pre and Post TOC Solution)Average lead Time reduced by 28%

HH:MM 0:00-0:45 1:00-1:30 1:30-2:00 2:00-2:30 2:30-3:00 3:00-3:30 3:30-4:00 4:00-4:30 4:30-5:00 5:00-5:30

Pre TOC 0.7% 3.9% 17.0% 30.1% 18.3% 12.4% 9.8% 4.6% 2.0% 1.3%

Post TOC 3.5% 26.1% 57.0% 2.8% 7.0% 2.1% 0.7% 0.7% 0.0% 0.0%

Pre TOC, for around 49% patients the lead time was more than 2 hour 30 minand Post TOC for around 86% patients the lead time is less than 2 hour



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y

Benefits derived from the project Reduction in Lead time

Entire OT staff started working as One Team Increase in Patient satisfaction A few measurement that drives improvement and hence does not

create any confusion

Bringing further improvement becomes easy as team knows whereto Focus Many small issues got resolved Team feels motivated

CEO is quite happy and now showing interest to take the journeyforward Doctors and staffs are able to visualize more capacity And many more..



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The Key to TOC Develop a Mindset for continuous improvement My learning:

Focus

Drive through Measurement

Engage people and get buy in Think on how to achieve Flow and exploit constraint

Work out simple solution: the key to success

Bring change/improvement through realization, acceptance and respect buy In from all the stakeholders in the end to end process

Challenge the fundamental assumption and the way thingsare done



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How a hospital can benefit from TOC Improve patient flow and reduce waiting time Establish Right measurement for better performance Focused approach to Service Delivery Excellence (Achieve

Operational Excellence and build a competitive edge) Increase satisfaction of patients and all other stakeholders Holistic improvement of the system(Improving quality and

reducing cost) Harmony in the system (motivated employee and

integrated departments) Improve in culture of continuous improvement Treat more patients with the existing resources Improve financial performance



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Thank You

Documents

2- Debashish Naik - Application of TOC in an Eye Hospital_ Eng