case study

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 India
committed to providing high quality ophthalmic care services. It is managed as a voluntary
non-profit service institution focused at serving the economically weaker sections of the
society. With this objective in mind. Nethra provides free treatment to nearly 30 percent of
the patients. About 50 percent of the cataract surgeries performed in one particular year
were done free of charge.
In view of the excellent reputation of the Institution, patients from all over India
flock to Nethra for treatment with the result that the number of patients is increasing at the
rate of 25 percent per annum. The hospital wishes to increase the number of poor patients
cared 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.
 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 raise
donations from the public, and currently provide all treatment (for paying patients) at a
charge 10 –15 percent below the rates prevailing in other hospitals. The percentage of free
patients is also increasing slowly.
THE OLD PROCESS
The hospital system found it difficult to cope with the ever-increasing number of
patients pouring in. Computers were there but were discrete islands, One for fixing up
appointments, 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 a
registration 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 on to the consultant‟s chamber. The consultant, after examining the patient, would
decide upon a treatment.
The consultant would either perform minor remedial treatment himself or complete
the treatment procedure. Or, he would prescribe certain medical procedures, like laser
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
for the treatment and get the receipt. After this, a ward boy would take him to the
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 would return, and wait again, not knowing that his name had already been
called out, and feel frustrated with such delays, The hospital staff felt equally frustrated with
such 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 such
incidents. This created a concern that a non-profit institution like Nethra could really not
afford to waste resources. Maybe, seeing each patient continuously through the whole
process, by cutting out wasteful delays, was the key to attending to more patients and also
makes better utilization of resources.
Thus, the attention of hospital administration got focused on eliminating wasteful
waiting time in the patient service fulfillment process.
THE ANALYSIS
The overall patient waiting time was dependent not only on the waiting time between
two medical procedures, but also on the time taken for each procedure, which could vary
case to case.
The time spent on the procedure per se was dependent on several factors like the
patient‟s general health, the condition of his eyes, etc. The reengineering initiative at Nethra
was therefore restricted to eliminating the waiting time between medical procedures.
The methodology adopted at Nethra, for eliminating patient waiting time, comprised
just 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 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. He quoted several instances where patients, who were seen through all
procedures most 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 put through the preliminary examination followed by dilatation do
not 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 be
eliminated was generated based on the discussions and feedback. After the study, a
prototype 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 the
facility to give appointments, register patients, collect payments, schedule surgery, and so
on.
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 payment
at 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 patients
to all consultants).
On completion of the preliminary, they are led to the consultant‟s lounge for
dilatation. If there is any unexpected delay, the patient is kept informed in the consultant‟s
lounge for dilatation. If there is any unexpected delay, the patient is kept informed. The
consultant‟s secretary takes charge of the patient and organizes the dilatation, followed by
an 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‟ the
patient to the next service representative --- the specialist in charge of the medical
procedure. Any cross consultation, if required, are quickly fixed up 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 patient as he goes through the treatment process. Any delay beyond a certain
limit, in any process, is flashed as an amber alert to the public relations officer who meets
the patient personally, and takes mid-course corrective action by seeing him through the
system expeditiously. The PRO, in turn, converts the amber alerts, into red alerts when he
needs the intervention of the Superintendent or the Chief.
Since each patient is continuously monitored through the process, the system at
Nethra resembles a WIP (Work In Process) monitoring system on a shopfloor, rather than a
routine 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 service
representatives, which enables them to track the patient and see him through all the
required procedures quickly. The patients are also free of stress as they do not have to run
from one end to another, and are treated and seen through swiftly
The system has clearly achieved the following significant benefits out of the
reengineering 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.
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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.
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 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 be
easily understood and internalized by everyone down the line in the institution.
The choice of methodology depends upon the context of the situation, culture of the
organization, etc. What was adopted at Nethra, for instance, does not religiously follow the
five-step methodology detailed there. This only reaffirms: reengineering is much like a
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. The waiting lounge for each consultant now consists of an optimal number of chairs
to accommodate the waiting patients and their support persons, restricting the entry to the
patient and the support person per patient. About 20 percent of the patients come without
support persons, and that leaves some cushion. If, in any lounge, a patient can‟t find a
vacant seat, the PRO knows that the waiting time is increasing in that lounge or bay. No
need for an amber or red alert!