SHOULDICE

SHOULDICE HOSPITAL
HOSPITAL
 Dr. Shouldice’s Problem
1945

No ORs
No beds
No nurses
No hospital

 “Deconstruct the problem into its parts”

 Cartesian Analogic
Deconstruction Solution

No ORs ER
No beds Fraternity house
No nurses Medical students
and other patients
No hospital Clinic – healthy patients

 “Change your way of thinking”

 FOCUSED HOSPITAL

Focus Abdominal hernias

Optimize Physical environment -

stairs, hills, billiards, shower
Less capital in the OR
One technique

Continuous Learning Consultation / Follow-up

 “Constraints can facilitate

solutions”
 SHOULDICE MODEL

Corporate Structure

Shouldice Hospital Limited

Medical Division Hospital Division Corporate Division

Private Practice Employees License
Global Budget Assets
Supplies
 Management
Management Philosophy
Philosophy

 We repair Hernias ! Nothing else !

 “The patient’s welfare is our
responsibility”
 Employee empowerment
 Track activity and outcomes
SHOULDICE HOSPITAL

  

Now multiple stand alone
clinics… outside the mothership

Heart Institute
 PRODUCTIVITY
PRODUCTIVITY from
from the
the
FOCUSED
FOCUSED HEALTH
HEALTH CARE
CARE
MODEL
MODEL
Can the Focused Health Care model provide for
the three main tenets of the modern health care
system?

•High Quality (Better)

•Affordability (Cheaper)
•Accessibility (Faster)
Quality Control
SCIENTIFIC
SCIENTIFIC MANAGEMENT
MANAGEMENT

•Principles developed in 1911

•Frederick Taylor - Labourer & Engineer
•Midvale Steel Company
•Specialization and repetition lead to
improved performance
•True for individuals and for
organizations
 THE
THE FOCUSED
FOCUSED FACTORY
FACTORY

“Simplicity and Repetition Breed

Competence”
Wickham Skinner 1974

An organization totally dedicated to a single, simple

process, achieving superior quality through high
volumes.
 SUCCESS
SUCCESS FROM
FROM DETAIL
DETAIL

“…while the “focused” part of the focused factory

is essential, it is the details of the factory’s
operating system that makes the difference
between success and failure.”

Regina Herzlinger 1997

 SHOULDICE TOTAL CASES
315,000
8000
7000
6000
5000
4000
3000
2000
1000
0
1945 1953 1961 1969 1977 1985 1993 2001
 SHOULDICE CUMULATIVE
RECURRENCE RATE BY
PERCENTAGE (1.05%)
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
1945 1953 1961 1969 1977 1985 1993 2001
 OPERATING
OPERATING SYSTEM
SYSTEM
DETAILS
DETAILS

1) Direct access :
no referral
necessary
 OPERATING
OPERATING SYSTEM
SYSTEM
DETAILS
DETAILS

1) Direct access : 2) Screening

no referral system : qualifies
necessary patients
MEDICAL QUESTIONNAIRE
MEDICAL QUESTIONNAIRE
 OPERATING
OPERATING SYSTEM
SYSTEM
DETAILS
DETAILS

1) Direct access : 2) Screening 3)Booking

no referral system : qualifies system: insures
necessary patients consistent flow
 OPERATING
OPERATING SYSTEM
SYSTEM
DETAILS
DETAILS
1) Direct access : 2) Screening 3) Booking
no referral system : qualifies system: insures
necessary patients consistent flow

4) Admitting
system: individual
process > funnel
 OPERATING
OPERATING SYSTEM
SYSTEM
DETAILS
DETAILS
1) Direct access : 2) Screening 3) Booking
no referral system : qualifies system: insures
necessary patients consistent flow

4) Admitting 5) Orientation :
system: individual group process,
process > funnel surgery assigned
 THE SHOULDICE EXPERIENCE
ORIENTATION

 A bonding process
 OPERATING
OPERATING SYSTEM
SYSTEM
DETAILS
DETAILS
1) Direct access : 2) Screening 3) Booking
no referral system : qualifies system: insures
necessary patients consistent flow

4) Admitting 5) Orientation : 6) Pre-op therapy:

system: individual group process, dinner, buddy
process > funnel surgery assigned system
BUDDY SYSTEM - THERAPY
 OPERATING
OPERATING SYSTEM
SYSTEM
DETAILS
DETAILS
1) Direct access : 2) Screening 3) Booking
no referral system : qualifies system: insures
necessary patients consistent flow

4) Admitting 5) Orientation : 6) Pre-op therapy:

system: individual group process, dinner, buddy
process > funnel surgery assigned system

7) Surgery:
assembly line
process, 5 ORs
PRE-OP / RECOVERY
OPERATING ROOM
PROCESS
OPERATING ROOM SET-UP
 SURGERY
LOCAL ANAESTHESIA
PORTABLE CRASH CART &
ANAESTHESIA EQUIPMENT
PATIENT DRAPE
SURGICAL PACK
SURGICAL BUNDLES
SURGICAL BUNDLE
CUPBOARD
SUTURE MANUNFACTURING
SUTURE MANUFACTURING

WE’RE LIKE A
LITTLE FACTORY
IN-HOUSE LAUNDRY
 DISPOSABLE COSTS PER
OPERATION Cdn$

 Average General Hospital - $250.00 - $850

 Mesh Repair - Trelex - $ 140.00
 Mesh Repair - Composix S- $345.00
 Mesh Repair - Composix L- $945.00
 Standard Shouldice Repair - $17.82
 OPERATING
OPERATING SYSTEM
SYSTEM
DETAILS
DETAILS
1) Direct access : 2) Screening 3) Booking
no referral system : qualifies system: insures
necessary patients consistent flow

4) Admitting 5) Orientation : 6) Pre-op therapy:

system: individual group process, dinner, buddy
process > funnel surgery assigned system

7) Surgery: 8) Post-op care:

assembly line routine process,
process, 5 ORs buddy system
THE ROAD TO RECOVERY

 Morning stretches help patients

with day-to-day mobility
BASIC ROOM
 OPERATING
OPERATING SYSTEM
SYSTEM
DETAILS
DETAILS
1) Direct access : 2) Screening 3) Booking
no referral system : qualifies system: insures
necessary patients consistent flow

4) Admitting 5) Orientation : 6) Pre-op therapy:

system: individual group process, dinner, buddy
process > funnel surgery assigned system

7) Surgery: 8) Post-op care: 9) Follow-up:

assembly line routine process, annual contact for
process, 5 ORs buddy system life of patient
 FOLLOW-UP

 Annual Follow-Up With Every Patient

For The Rest of Their Life

 What is the value of follow-up?

 Provides Professional Medical Research
 Helps us to Deliver our Service
 Allows us to Touch the Patient Regularly
 Provides Continuing Confidence in the Service Product
for Both Provider and Client
 FOLLOW-UP

 How Far Do We Go to Follow-up?

 Over 130,000 Follow-up Letters Annually
 Five Travelling Clinics Annually
 Daily Internet / E-mail Service
 Annual Shouldice Patient Alumni Reunion
 Up to 1500 have attended
 Annually since 1947
 12,000 Patient Follow-Up Exams per Year
 Free Exams for International Patients
CUSTOMER SATISFACTION

WHAT IS IT?

 I got what I expected?

 They did what they said they would do?
 A great experience?
 Its not good enough!
 Create an Apostle!
RELATIONSHIP TREE

Shouldice Apostle
Referral
Follow-
Follow-up

Shouldice
Experience
Admission

Booking for
surgery

Second
contact

Internal
coordination
Initial
contact
Patient referral

Government funding and licensing, Marketing, Private financing,

Management/ownership, Human resources, Suppliers, Lawyers, etc..
 THE FRUITS
of
The RELATIONSHIP TREE

 Apostles!
 RELATIONSHIP TREE

Shouldice Apostle
Referral
Follow-
Follow-up
Competitors
Shouldice
Procrastinators Experience


Admission Complications

Booking for
surgery

Second
contact

Internal
coordination
Initial
contact
Patient referral

Government funding and licensing, Marketing, Private financing,

Management/ownership, Human resources, Suppliers, Lawyers, etc..
APPOSTLES !
THIRD PARTY REFERRALS
 


SURGERY
2-3 days post 1-Month post
At Admission Surgery Surgery

Q1 Q2 Q3
n = 490 n = 445 n = 391
Canadian patients
Level of Satisfaction and
Overall Service Quality

10
9.5 Delighted Extremely
9 High Quality
8.5 9.1 9.2
8
7.5
7
6.5
6 Satisfied Good
5.5 Quality
5
4.5
4
Level of Overall
Satisfaction Service
Quality



Service Quality Satisfaction

9.6
9.4 9.6 9.6
9.2 9.3
9 9.2
8.8
8.6
8.4 8.6
8.5
8.2
8
7.8
Average Good Excellent
PATIENTS’ REUNION
 CIHI
CIHI Comparison
Comparison
Resource
Resource Intensity
Intensity Weighted
Weighted

General Hospital Shouldice Hospital

Total RIW = .83 RIW = .8
Avg cost/case = $2,800 Avg cost/case = $1,100
Incl. in & out patient 100% in-patient
Cost/diem = $1000.00 Cost/diem = $350.00

Total Savings per case = $1,700.00

Potential cost savings in Ontario @ 31,000 cases

per year > $50,000,000/yr
 Results
Results Analysis
Analysis

Consistently higher quality of health care

 <0.5% vs.>10% avg recurrence rate (ten yrs)
 <0.5% vs >30% average complication rate as
per NEJM April 2004
Lower Costs
 < 35% of average per diem cost per case
Employee and Customer Loyalty
 > 12 yrs. avg. tenure
 > 96% of patients are referrals. Previous
patients (49%), professionals (34%),
acquaintances (13%), web & articles (4%)
 Conclusion
Conclusion

The Focused Health Care Model can

meet the three main tenets of a
modern health care delivery system.

•High quality (Better)

•Affordability (Cheaper)
•Accessibility (Faster)
 THE SHOULDICE EXPERIENCE

 A manifestation of emotional, physical and interactive

relationships, orchestrated in a safe environment, built on
focus, confidence, trust and success.