Shouldice Presentation Outline

04/13/23

Shouldice Hospital

Anna SwansonPhillip

Dean

Ben Gierok

What is Shouldice Hospital?

•Hospital that specializes in hernia repair

•Small facility (89 beds)

•Built on a 130-acre estate

•Located in Thornhill, Ontario

•Privately owned

How do they compete?

•“Shouldice Method”•Local Anesthetic•Procedure Technique•Facility Layout•Early Ambulation

•Patient relaxation, comfort, and quick recovery

•FTQ of 99.2% for 30 year history

Shouldice Hospital

Shouldice Hospital

Shouldice Hospital

Shouldice Hospital

3 Challenges to Shouldice

•Strategy •Government regulation on healthcare•Leave Canada?

•Ethical•Misuse of the Shouldice name by competitors

•Process and Quantitative•Large backlog of potential patients

Assigning Priority

• Based on a worse case scenario…

• First Priority: Government intervention

• Second Priority: Misuse of “Shouldice”

• Third Priority: Patient backlog

Government Intervention

• Threat of legislation against private healthcare

• Ruling could support public-only coverage under OHIP

• Intervention actually not a threat• New Democratic Party leader Jack Layton• Grandfather clause (founded in 1945)

Misuse of Shouldice Name

• Ethical obligation of surgeons

• Oath to help others learn vs. protection of competitive advantage

• Recommendation•Establish a certification for “Shouldice Trained”•Allow other doctors to observe

The Final Challenge

• 2400 patients on backlog and growing

• How can Shouldice reduce backlog without impacting the quality of service?

• Consider the Theory of Constraints

The Goal by Eli Goldratt • Novel about a wasteful production process• Lessons about constraints from bottlenecks• “The Goal”

• Reduce operational expense • Reduce inventory (Muda)• Increasing throughput

•Shouldice constraints:• Surgeons• Patient Bedrooms• Operating Rooms

• Apply lessons to reduce waste and backlog!

Quality Control Location

• Quality control in front of process bottleneck

• Shouldice QC is pre-screening and diagnosis

• Current practice allows for misdiagnosis• Medical Information Questionnaire • Self diagnosis

• Surgeons, Rooms, and ORs are then scheduled for patients who end up being sent home

Backlog Impact

• Also consider financial impact!• 200 classes per year• Even if there is only one misdiagnosis per class: -$416,000/year• If there is consistently five misdiagnosis per class: -$2,080,000/year• Recommend all patients receive physician pre-screen

Analysis Backlog Reduction

Input Data Revenue per

Class Amount LossPatients

Misdiagnosed Week Month Year

33 Average Class Size $68,640.00 $0.00 0 0 0 0

$2,080 Average Revenue per Patient $66,560.00 ($2,080.00) 1 4 16 200

$68,640 Average Revenue per Class $64,480.00 ($4,160.00) 2 8 32 400

4 Classes Per Week $62,400.00 ($6,240.00) 3 12 48 600

200 Classes Per Year $60,320.00 ($8,320.00) 4 16 64 800

$58,240.00 ($10,400.00) 5 20 80 1000

Do All Patients Need Day 1 Processes?

• To help ID what patients need:•Refer to Process Flow Map

• What percent of the time is:• Necessary Value-Add• Unnecessary Value-Add• Necessary Non Value-Add• Unnecessary Non Value-Add

Process Flow

Do All Patients Need Day 1 Processes?

• To help ID what patients need:•Refer to Process Flow Map

• What percent of the time is:• Necessary Value-Add• Unnecessary Value-Add• Necessary Non Value-Add• Unnecessary Non Value-Add

Value Add Analysis

Classification Time (Minutes) Percent to Total ProcessValue Add 56.25 1.30% Surgery

Unnecessary Valued Add 260.00 6.02% Exam and Exercise Necessary Non Value Add 390.00 9.03% Meals, Check In, and Discharge

Unnecessary Non Value Add 3613.75 83.65% Everything Else

Total Minutes Available 4320.00 100.00%    

* Exercise assumes awake for 12 hours on day 3 (180 min exercise on day 3 and 60 min on day 2) ** Assumes 1 hour/meal and three meals on day three*** Assumes 45 min for check in and discharge

Recommendations and Impact

• Allow up to 10 patients option of attending Unnecessary Non Value-Add:

• Predetermined amount helps control variability

• If patients opt out:• Decrease Cycle Time• Increased Capacity on all process bottlenecks• Reduced Operating Cost

Additional Tools for Improvement • Perform “5 Why” on bottleneck to ID root cause

• Affinity Diagram in to Fishbone

• Continuous Improvement•Prepare for more bottlenecks to surface!

Backlog Reduction—Last Resort

• Go forward with $4 million expansion• Significant cost• Only addresses one bottleneck

• New weekly scheduling process• Fits in a 5th class• Requires more Bed rooms• Requires more staff

• Increase Prices

New Weekly Scheduling ProcessWeekly Process Schedule – Shouldice Hospital

Thu

rsda

yF

riday

Sat

urda

yS

unda

yW

edne

sday

Tue

sday

Mon

day

Class 1 Operations

Class 1 Rooms/Orientation

Class 1 Examinations

MORNING ACTIVITIES AFTERNOON ACTIVITIES

Class 2Examinations

Class 2 Checks In

Class 2 Rooms/Orientation

Class 1Exercise/Post Op

Class 1Exercise/Post Op

Class 2 Operations

Class 3 Checks In

Class 3Examinations

Class 2Exercise/Post Op

Class 3 Rooms/Orientation

Class 1 Discharged

Class 3 Operations

Class 2Exercise/Post Op

Class 3Exercise/Post Op

Class 1 Checks In

Class 4 Checks In

Class 4Examinations

Class 4 Rooms/Orientation

Class 2 Discharged

Class 3Exercise/Post Op

Class 4 Operations

Class 4Exercise/Post Op

Class 5 Checks In

Class 5 Operations

Class 4 Exercise/Post Op

Class 3 Discharged

Class 5 Rooms/Orientation

Class 5 Examinations

Class 4 Discharged

Class 5 Exercise/Post Op

Class 5 Exercise/Post Op

Class 5 Discharged

Backlog Reduction—Last Resort

• Go forward with $4 million expansion• Significant cost• Only addresses one bottleneck

• New weekly scheduling process• Fits in a 5th class• Requires more Bed rooms• Requires more staff

• Increase Prices

Thank You!

Any questions?