Flow in the hospital: Aravind Eye Hospital

One of the key principles of Lean thinking is the creation of flow. Flow as in no waiting time if it has no added value (time to think and reflect or time to process bad news are examples of waiting times with added value).

What would a hospital look like without waiting time? So far, I have only seen this question answered as a “what if…” exercise. However, there appears to be a hospital in India, which seems to know the answer to this question.

On November 13th, Hanneke Molema defended her phd thesis on ‘Hospital system design: creating variabilitiy to match demand variability’. Chapter 5 describes the flow of patients at the Aravind Eye Hospital in India. When you fly to India and visit the hospital without an appointment, you get your diagnosis the same day and when you want a surgery you are asked: When would you like your surgery? Tomorrow?

Her thesis raised the following questions (the responses as described in the thesis can be found behind the questions):

“Right, well I’m sure that only counts for the rich people? They probably have a lot of overcapacity?” This, however, is not the case. Their mission is as follows: “a social organisation committed to the goal of elimination of needless blindness through comprehensive eye care services” (check their website). They operate mostly poor people. Furthermore, people can decide for themselves how much money they can pay for their surgery. 60% of the people is not able to pay and gets the surgery for free. The other 40% have more money and take care of the other 60%. In this way they are able to achieve their mission.

“They probably do not treat many people then? With only a few patients per day I am also able to do this”. At their location called Madurai, they performed 581.000 outpatient consultations and 91.000 surgeries in 2008. For comparison, the largest eye hospital in the Netherlands is in Rotterdam and performed 139.000 outpatient consultations and 12.600 operations that year.

“Because of their large numbers there is almost no variation?” The number of patients ranges from 800 to 2000 per day. This is similar to our hospital, if it is not even more difficult for them, because it is pure naturally variation they have to deal with (it depends on the patients choices). The fluctuation of the number of patients per day in our hospital is for a significant part a result of the way we organize (e.g. patients are told to come back three months later for a check up).

“The quality must definitively be below acceptable standards?” International benchmarks show they can compete with Western hospitals. They provide excellent quality.

“In that case, they probably have more staff?” The same international benchmarks show that they need significantly fewer people to provide the same quality and to realise an even better flow. In Madurai Aravind 983 people work, including 46 senior doctors and 94 junior doctors. In contrast, 313 people, including 29 senior doctors, work in the eye hospital in Rotterdam. While Aravind carries out seven times more operations.

“How do they do this?” Their approach differs on several aspects:

Way of working

-         Far-reaching standardization: everyone performs the same actions in the same manner. Individual preferences are subordinate to the interests of the whole.

-         Far-reaching task delegation: specialists are only doing specialist work. A cataract operation takes five to ten minutes (this varies indeed per surgeon). A specialist operates 60 patients in one morning.

-         Processes are being improved step by step and this refinement process continues. They reduced the time between the end of an operation and the start of the next operation to only a few seconds.

Planning and reaction

-         Strong anticipation: from previous experience (numbers) they know how many patients will come at what month and at what day of the week. They prepare for this by increasing capacity at busy days.

-         Strong reactive capacity: the planning processes are designed in such a way that it is immediately visible when demand is greater than predicted at a moment in time. The employee who sees this gives a signal to people from other departments who are asked to come and help immediately.

Flexibility

-         People are trained to work in different departments. People are constantly trained not only to deliver better quality care and to improve skills, but also to further increase flexibility.

-         Attitudes: people need to work together to ensure that the patients gets what he needs. Not self-interest, not their own department, but demand determines who works at what place (according to knowledge and skills).

An interesting case! I do not know if the methods, used at Aravind, could also be implemented in the Netherlands, but I know no other hospital in the world that comes so close to flow as characterized by Toyota. Take a look at the thesis ‘Hospital system design’ for more information. Click here to contact Hanneke Molema.

P.S. my gratitude goes to Nieki Peerbooms for translating my Dutch blog