QUESTION:

Help Dr. DiNardo evaluate the current situation at LazerSharp with reference to the Case Study attached

Using the Tasks and Times (Figure 2), calculate the capacity utilization for each category of staff (Receptionist, PCR, Technician, Staff Surgeon, and Cleaner) and for the pre-op, surgical and examination rooms.

Dont forget that DiNardo needs to use this information to make an expansion decision, so take into account what makes sense for this decision.

Hint: use the data given in the table and calculate the yearly capacity as

Annual non-surgeon minutes capacity = 5 days * 48 weeks * 8 hours * 60 min

Annual surgeon capacity = 5 days * 48 weeks * 7 hours * 60 min

Rooms are available for 9 hours a day.

In your report clearly show how you calculate each of the 8 utilizations. (5 staff types, 3 room types)

The global prevalence of vision disorders has increased significantly in recent years. In 2015, close to 285 million people were diagnosed with vision impairment issues and that number has continued to grow. Additionally, lasik surgery was now predominantly covered by health insurance providers. LazerSharp Lasik Clinic Dr. Greg DiNardo stood on the steps of LazerSharp Lasik Clinic and looked at the busy New York city evening traffic rushing by. It was the middle of January, 2020, near the end of the day. The air was chilly, and the pedestrians were hurrying home, bundled up against the evening wind. He had founded Lazer Sharp just 3 years before, leaving his previous position in a private practice to focus entirely on lasik eye surgery and opening his clinic on Grand Concourse in the Bronx. The clinic was doing well, turning a solid profit since the end of its first year. For Greg the shift from patient care to running his own operations had been challenging and rewarding. The lasik operation, obviously, was the core function - the "technology" - but managing all the other tasks, from customer attraction to billing and follow-up, was like managing a small factory, albeit, one with much more variability and uncertainty than a typical manufacturing set-up. DiNardo knew that it was time to think about expansion, but, for the first time, he was uncertain how to move forward. Should simply extend the clinic's hours? Or increase the size of the existing clinic? Or did they need new facilities, and how would that be managed effectively? Meanwhile, manufacturers of lasik eye surgery devices are ramping up investments in research and development activities in order to improve their product portfolio and provide better treatment options. In addition, many of the companies operating in the market are actively implementing merger and acquisition strategies to expand their operations to new markets and create stronger synergies. Over the years, government funding and support in R&D has also increased in the field of ophthalmology, hence creating greater possibilities of providing cost-effective eye care. The aforementioned factors are expected to influence the market throughout the forecast period. On the other hand, reducing the cost of vision correction treatments remains a formidable challenge for market players. Moreover, some lasik companies work with insurance providers and certain large employers to provide lasik discounts to their employees and CareCredit (a healthcare credit card) that covers all medical expenses, including lasik eye surgery. These easy payment plans offered by lasik companies fosters the market growth making lasik as the most preferred surgery. BACKGROUND ON LASIK Source: https://www.webmd.com/eve-health/lasik-laser-eye-surgery#1 Lasik, which stands for laser in-situ keratomileusis, is a popular surgery used to correct vision in people who are nearsighted, farsighted, or have astigmatism. All laser vision correction surgeries work by reshaping the cornea, the clear front part of the eye, so that light traveling through it is properly focused onto the retina located in the back of the eye. Lasik is one of a number of different surgical techniques used to reshape the cornea. OPERATIONS AT LAZERSHARP Even as he was setting up the clinic, DiNardo had made sure that his IT systems were able to track and store data about his operations, and one of his main tasks was to make sure that the data was being correctly and regularly recorded and actively used. For example. DiNardo regularly updated the cost of lasik surgeries from around New York and New Jersey and adjusted his prices to maintain the status Lasik has many benefits, including: . It has been around for over 25 years and it works! It corrects vision. Around 96% of patients will have their desired vision after lasik. An enhancement can further increase this number. Lasik is associated with very little pain due to the numbing drops that are used. Vision is corrected nearly by the day after lasik. No stitches are required after lasik. Adjustments can be made years after lasik to further correct vision if vision changes while you age. After having lasik, most patients have a dramatic reduction in eyeglass or contact lens dependence and many patients no longer need them at all. of a low-cost provider. He also kept immaculate records of all his costs, patient retention information, and measured the activity times for the individual tasks of his employees. In 2019, the clinic had performed 5,283 surgeries. The average payment for a surgery was $1,338. The clinic operated five days a week, 48 weeks a year, from 9 a.m. to 6 p.m. and was closed on Sundays and Mondays. Any post-op checks that had to be performed on Sunday were done by a single technician. All staff (other than the staff surgeon) had a half an hour for lunch and two 15-minute breaks during the day. The surgeon had two hours for lunch and breaks combined. The total non-staff, direct variable cost averaged $510 per operation. Despite the pluses, there are some disadvantages to lasik eye surgery: Lasik is technically complex. Rare problems may occur when the doctor creates the flap, which can permanently affect vision. This is one reason to choose a surgeon who is very experienced at performing these surgeries. Lasik can rarely cause a loss of "best" vision. Your best vision is the highest degree of vision that you achieved while wearing your contacts or eyeglasses. FACILITIES The clinic owned a 4,200-square-foot building in the Bronx, New York City, for which, the mortgage, taxes, and utilities were $5,000 per month. The clinic used 60% of the space, and rented the rest to a small company for $2,000 per month. The tenant could be expelled with six month's notice and a onetime payment of $60,000. LASIK SURGERY MARKET Source: https://www.medgadget.com/2019/03/lasik-eye-surgery-market-experiencing-boost-by-demandanalysis- industry-share-size-upcoming-research-advancement-and-forecast-to-2023.html DiNardo had decided to create a clinic which specialized only in lasik. because he was aware of the potential of this niche market. According to one report: As shown in Figure 1. Lazer Sharp had a 600-square-foot waiting area with 40 seats. Each seat took up about 8-square-feet and was equipped with a small flat-screen video monitor (as in an airplane) for individual viewing. Each chair cost $1,100. While waiting patients were asked to watch videos about the lasik procedure and post-operative care. Additionally, there was an option to watch from a large selection of films (including for children) and TV programs. There was a reception area and two private pre-op rooms (11-foot by 11-foot each) where patients. friends, and family members could sit a patient care representative (PCR) helped the complete medical and insurance forms. The layout is shown in Figure 1. The Global Lasik Eye Surgery Market will expand at 6.5% CAGR between 2017 and 2022, projects Market Research Future (MRFR) in its latest report. Lasik stands for Laser-Assisted in Situ Keratomileusis (LASIK) and is one of the most commonly used surgical procedures for treating vision disorders such as hyperopia, astigmatism and myopia among others. L Late Sharp Clinic Figure 2. Process Flow and Task Times by Job Title (Annuel Minute Technician StellSurg Di Nardo Cleaner Pre-Op Pre-Op Telephone 100 495 Exam Exam Surg Surg Surg 11,189 22,378 8,952 169,120 Waiting Room 16,112 6.444 Corridor 52,830 Tesk, Annual Demend, and Job Titles Minutes Demand Receptionist PCR Initial patient call 7 14,345 22% delect after this point Meil paperwork 1 11,189 Call to remind 2 11.189 40% reschedulecall 2 4,476 28% no-show after this point Check in at din 2 8,056 16,112 Pre-Op 20 8,056 74% insured, 26% cash Renind call 2 8,056 10% reschedulacal 2 3,222 30% of Insured no-show, 47% of Cash check in at clinic 2 5,283 10,566 Prep for sury 10 5,283 Surgery Cleanup 15 5,283 Recard Surgery 5,283 Staff surgaon 4,611, Di Narda 672 pa! Bandage, walk to waiting 5 5,283 Room cleaning 3 5,283 PCR checks patient out 5.283 First (next day) follow-up (Tues-Sat) - Checkin 2 4,226 3,453 First net-day follow-up (Tues-Sat) 10 4,226 First (neet-day follow-up (Sun) 10 1,057 Tuesday Saturday room clean 3 4,226 80% Sunday room clean 3 1,057 20% 3-week follow-up checkin) 2 4,276 8,453 3 weckfollowup . 4,174 21% no-show after follow-up 3 weckroom clean 3 4,174 69,165 23,055 10 00 3,360 Restrooms Supplies Offices, Break room 26 415 15,849 21,132 42,264 Tues-Sat only (80%) 10,566 Sunday only (20%) Figure 1: Facility Layout at LazerSharp 12,679 Tues-Sat only (0%) 3,170 Sunday only (205) 33,392 12,522 43,585 347,742 92,220 Total anual minutes task time job title: A workers by Job title 168,637 3 13.440 11,050 4 1 1 SCHEDULING SURGERY The typical flow of events for a lasik operation started with a phone call to Lazer Sharn from a prospective patient. The PCR would take the patient's information over the phone, enter it into the clinic's database, and schedule a pre-op appointment. This step took the PCR an average of about 7 DiNardo had worked the team develop a checklist which would asce tain if the lasik surgery was a viable option for the patient and to screen out any patients with complicating medical conditions. About 22% of the callers were screened out. One week before the scheduled pre-op appointment, PCRs mailed medical and insurance forms to the patients and called them a few days ahead to remind them about the appointment. The mailings took 1 minute per patient and calling took 2 minutes on average. About 72% of the patients actually showed up for the appointment, although 40% had to reschedule, which took an additional 2 minutes on average. A list of the task and task-times by type of employee is shown below in Figure 2: 2 Pro Op rooms 2 Examining rooms 3 Surgical rooms *Staff surgeon completes (5,283-672) = 4,611 operations per year; Di Nardo completes 672 Figure 2: Tasks and times. When a patient arrived for his or her pre-op appointment, the receptionist checked them in in about 2 minutes. Then the PCR took over, taking about 20 minutes on average, to discuss the procedure with the patient, answer questions, complete insurance paperwork (if insured) or take a payment (if not insured. The payment would be returned if the surgery was not completed). In 2019, 74% of the clinic's patients were insured, while 26% paid cash. Finally, the PCR would schedule the surgery. PCRs called the patients several days before the surgery, taking 2 minutes per call on average. As before, about 40% of the patients rescheduled the surgery, which took another 2 minutes of the PCR's time. THE NO-SHOW PROBLEM One of DiNardo's biggest headaches was the no-show rate. Even though the patients had made the first inquiry and had taken the time to come to the pre-op appointment (and in the case of noninsured patients. had paid for the surgery), only 70% of the insured patients and 53% of the cash (noninsured) patients actually showed up for their surgery. This high no-show rate was very difficult for the clinic's scheduling, and, with a target market that was mostly lower income, there was no deposit system in place which would cover any operational expenses due to a no-show. Such a deposit system would be very unattractive and hurt the clinic's reputation towards its lower-income base. DiNardo had started to investigate the no-show problem, asking the PCRs to call those patients who either had called to make a pre-op appointment but had not shown up or those who had completed the pre-op but not shown up for surgery. Many patients simply refused to say, but the PCRs managed to get a rough idea, shown in Figure 3 a&b: Figure 3a: Survey on no-shows for Pre-op Figure 3a: Survey on no-shows for Pre-op Reasons after call: Costs reasonable but don't have funds Costs too much Afraid of eye operation, pain, recovery Afraid might not improve much Afraid of INS Family members oppose it Not a real problem Will try a home remedy first Other Total responses 89 61 32 24 22 12 8 6 14 268 339 23% 12% 9% 8% 4% 3% 29 5% SURGERY PROCESS On the day of the surgery, the patient checked in at the reception desk. This took about 2 minutes per patient in order to check the patient identity and check payment and contact information. Lazer Sharp required that each patient be accompanied by an adult who could take the patient home after the surgery. One of the three technicians brought the patient to one of the three surgery rooms, where the patient was prepped for surgery, which took about 10 minutes on average. The staff surgeon, or DiNardo (who operated 672 times in 2019) would then enter the surgery, introduce themselves, and perform the lasik surgery. This took about 12 minutes, including a few reassuring words to the patient. The clinic scheduled 15 minutes for each surgery to give a 3 minute buffer. The surgeon would then leave the surgery room and change gowns, wash up, and record the surgery. This took an additional 5 minutes. The technician would apply the eye bandaging and walk the patient back to the waiting area, which took 5 minutes. Between surgeries, a cleaner took 3 minutes to prepare the rooms for the next surgery. It also took 3 minutes to prepare between follow-up visits in the examining rooms, as shown in Figure 2. See Figure 4 for an example of a two-hour block of scheduling. Staff Room Surgery 1 End 9:10 9:25 Time 10 15 Tech 1 Records Surgery 1 Surgery1 9:30 9:30 3 Figure 3b: Survey on no-shows for Surgery Reasons after Pre-op: Lack funds Problem getting ride to and from clinic Plan to do it in the future Bad day for unrelated pain, medical problems Afraid of eye operation, pain, recovery Called to work unexpectedly Forgot appointment Other Total responses: 45 38 22 20 18 8 7 11 169 27% 22% 13% 12% 11% 5% 4% 7% 15 Start 9:00 9:10 9:25 9:25 9:30 9:20 9:30 9:45 9:45 9:50 9:40 9:50 10:05 Surgery sen Surgery 2 Surgery 2 Records Surgery 2 Surgery 2 Surgery 1 Surgery 1 Records 9:33 9:30 9:45 9:50 9:50 9:53 9:50 10:09 10:10 Surgeon Surgeon Tech 1 Cleaner Tech 2 Surgeon Surgeon Tech 2 Cleaner Tech 1 Surgeon Surgeon 3 10 15 5 5 3 10 15 5 DiNardo had already tried to tackle the no-show problem for the surgery by working with the PCRs to develop a set of questions to help ascertain if the patient would be a "no-show." During the reminder conversation for the surgery, the PCR would go through the list of questions and together had built up a set of "indicators which would indicate whether or not the patient would return for surgery as "good," "likely," or "weak." The staff would then use over-booking to compensate for probable" and "weak surgeries scheduled on a particular day. Obviously, this entailed some risk, but this approach was working well enough so that the staff surgeon was rarely idle and DiNardo could take over surgeries if needed. Patients rarely waited over an hour from their scheduled arrival time. But, just to be careful, the staff had "Sorry you had to wait" goodies (baskets of gourmet coffees and chocolate) which they gave to patients who had delays. 5 Surgery 1 Surgery 1 Surgery 2 Surgery 2 Records Surgery 2 Surgery 2 Surgery 1 Surgery 1 Records Surgery 1 Surgery 1 10:05 10:10 10:00 10:10 10:25 10:25 10:30 10:20 10:30 10:45 10:45 10:50 10:10 10:13 10:10 10:25 10:30 10:30 10:33 10:30 10:45 10:50 10:50 10:53 Tech 1 Cleaner Tech 2 Surgeon Surgeon Tech 2 Cleaner Tech 1 Surgeon Surgeon Tech 1 Cleaner 3 10 15 5 5 3 Figure 4: Example of Typical Surgery Room and Staff Scheduling at LazerSharp DiNardo also tracked the no-show rate of each PCR, and noticed that one of the new PCRs. Virgilyn Abilas, who had just been hired 6 months ago, had particularly low no-show rate, as shown in Figure 3c: Figure 3c: No-show Percentages by PCR PCR Name Pre-op No-Show % Surgery No-Show % Lee Katron 32 45 Kevin Smatzer 17 32 Katherine Tracet 27 38 Virgilyn Abilas 12 23 Normally the technician would seat the patient in the waiting area with the patients awaiting surgery. However, if the patient seemed anxious or distressed, they were seated with anyone who had accompanied them in another area. All patients were asked to wait 30 minutes, after which, a PCR would help them sign the paperwork that the operation was complete, schedule an appointment for the next day, and remind them of the steps for postoper care. This took about 4 minutes. At the follow-up appointment on the following day, the patient would first check in with the receptionist (2 minutes), then the technician would take ten minutes to bring the patient to an examining room, check the eye, clean and bandage as necessary, walk them back to the receptionist, and schedule the next follow-up appointment for three weeks later. The examining rooms were Lerer Sharp Clinic Figure 2: Process Flow and Task Times by Job Title (Annuel Minutes) Tesk, Annual Demand, and Job Titles Minutes Demand Receptionist PCR Technician 5t/Surg DiNardo Cleaner Initial patient call 7 14,345 100 415 22% delect after this point Meil paperwork 1 11,189 11,189 Call to remind 2 11,189 22,378 40% reschedulecall 2 4.476 8.952 28% no-show after this point Check in at clinic 2 8,056 16.112 Pre-Op 20 8,056 161, 120 74% Insurad, 26% cash Rernind call 2 8,056 16,112 40% reschedulecall 2 3,222 6.444 30% of insured no-show, 47% of Cash check in al clinic 2 5,283 10,566 Prep for surgery 10 5,283 52,830 Surgery, Cleanup 15 5,283 69,165 10,080 Record Surgery 5 5,283 23,055 3,360 (Stalf surgeon 4,611, Di Narda 672 eps) Bandag, walk to waiting 5,283 26,415 Room cleaning 5,283 15,849 PCR checks patient out 5,283 21,132 First nact.day follow-up (Tues-Sat-Checkin 2 4,226 First (neet-day follow-up (Tucs-Sat) 10 4,226 42,264 Tues-Sat only (RON) First (neet-day followup (Sun) 10 1,057 10,566 Sunday only (20%) Tuesday Saturday room clean 3 4,226 80% 12,679 Tues-Sat only IRON Sunday room clean 3 1,057 20% 3,170 Sunday only (208) 3-weck follow-up (Checkin) 2 4,226 2,453 3-work follow-up 4,174 33,392 21% no-show after fir follow-up 3-weckroom clean 3 4,174 12,522 un m 347,742 92,220 Total annual minutes task time/job title: #workers by job title 43,585 1 168,637 3 13 440 41,050 1 1 1 2 Pre-Op rooms 2 Examining rooms 3 Surgical rooms * Staff surgeon completes (5,283-672)=4,611 operations per year; Di Nardo completes 672 Figure 2: Tasks and times. The global prevalence of vision disorders has increased significantly in recent years. In 2015, close to 285 million people were diagnosed with vision impairment issues and that number has continued to grow. Additionally, lasik surgery was now predominantly covered by health insurance providers. LazerSharp Lasik Clinic Dr. Greg DiNardo stood on the steps of LazerSharp Lasik Clinic and looked at the busy New York city evening traffic rushing by. It was the middle of January, 2020, near the end of the day. The air was chilly, and the pedestrians were hurrying home, bundled up against the evening wind. He had founded Lazer Sharp just 3 years before, leaving his previous position in a private practice to focus entirely on lasik eye surgery and opening his clinic on Grand Concourse in the Bronx. The clinic was doing well, turning a solid profit since the end of its first year. For Greg the shift from patient care to running his own operations had been challenging and rewarding. The lasik operation, obviously, was the core function - the "technology" - but managing all the other tasks, from customer attraction to billing and follow-up, was like managing a small factory, albeit, one with much more variability and uncertainty than a typical manufacturing set-up. DiNardo knew that it was time to think about expansion, but, for the first time, he was uncertain how to move forward. Should simply extend the clinic's hours? Or increase the size of the existing clinic? Or did they need new facilities, and how would that be managed effectively? Meanwhile, manufacturers of lasik eye surgery devices are ramping up investments in research and development activities in order to improve their product portfolio and provide better treatment options. In addition, many of the companies operating in the market are actively implementing merger and acquisition strategies to expand their operations to new markets and create stronger synergies. Over the years, government funding and support in R&D has also increased in the field of ophthalmology, hence creating greater possibilities of providing cost-effective eye care. The aforementioned factors are expected to influence the market throughout the forecast period. On the other hand, reducing the cost of vision correction treatments remains a formidable challenge for market players. Moreover, some lasik companies work with insurance providers and certain large employers to provide lasik discounts to their employees and CareCredit (a healthcare credit card) that covers all medical expenses, including lasik eye surgery. These easy payment plans offered by lasik companies fosters the market growth making lasik as the most preferred surgery. BACKGROUND ON LASIK Source: https://www.webmd.com/eve-health/lasik-laser-eye-surgery#1 Lasik, which stands for laser in-situ keratomileusis, is a popular surgery used to correct vision in people who are nearsighted, farsighted, or have astigmatism. All laser vision correction surgeries work by reshaping the cornea, the clear front part of the eye, so that light traveling through it is properly focused onto the retina located in the back of the eye. Lasik is one of a number of different surgical techniques used to reshape the cornea. OPERATIONS AT LAZERSHARP Even as he was setting up the clinic, DiNardo had made sure that his IT systems were able to track and store data about his operations, and one of his main tasks was to make sure that the data was being correctly and regularly recorded and actively used. For example. DiNardo regularly updated the cost of lasik surgeries from around New York and New Jersey and adjusted his prices to maintain the status Lasik has many benefits, including: . It has been around for over 25 years and it works! It corrects vision. Around 96% of patients will have their desired vision after lasik. An enhancement can further increase this number. Lasik is associated with very little pain due to the numbing drops that are used. Vision is corrected nearly by the day after lasik. No stitches are required after lasik. Adjustments can be made years after lasik to further correct vision if vision changes while you age. After having lasik, most patients have a dramatic reduction in eyeglass or contact lens dependence and many patients no longer need them at all. of a low-cost provider. He also kept immaculate records of all his costs, patient retention information, and measured the activity times for the individual tasks of his employees. In 2019, the clinic had performed 5,283 surgeries. The average payment for a surgery was $1,338. The clinic operated five days a week, 48 weeks a year, from 9 a.m. to 6 p.m. and was closed on Sundays and Mondays. Any post-op checks that had to be performed on Sunday were done by a single technician. All staff (other than the staff surgeon) had a half an hour for lunch and two 15-minute breaks during the day. The surgeon had two hours for lunch and breaks combined. The total non-staff, direct variable cost averaged $510 per operation. Despite the pluses, there are some disadvantages to lasik eye surgery: Lasik is technically complex. Rare problems may occur when the doctor creates the flap, which can permanently affect vision. This is one reason to choose a surgeon who is very experienced at performing these surgeries. Lasik can rarely cause a loss of "best" vision. Your best vision is the highest degree of vision that you achieved while wearing your contacts or eyeglasses. FACILITIES The clinic owned a 4,200-square-foot building in the Bronx, New York City, for which, the mortgage, taxes, and utilities were $5,000 per month. The clinic used 60% of the space, and rented the rest to a small company for $2,000 per month. The tenant could be expelled with six month's notice and a onetime payment of $60,000. LASIK SURGERY MARKET Source: https://www.medgadget.com/2019/03/lasik-eye-surgery-market-experiencing-boost-by-demandanalysis- industry-share-size-upcoming-research-advancement-and-forecast-to-2023.html DiNardo had decided to create a clinic which specialized only in lasik. because he was aware of the potential of this niche market. According to one report: As shown in Figure 1. Lazer Sharp had a 600-square-foot waiting area with 40 seats. Each seat took up about 8-square-feet and was equipped with a small flat-screen video monitor (as in an airplane) for individual viewing. Each chair cost $1,100. While waiting patients were asked to watch videos about the lasik procedure and post-operative care. Additionally, there was an option to watch from a large selection of films (including for children) and TV programs. There was a reception area and two private pre-op rooms (11-foot by 11-foot each) where patients. friends, and family members could sit a patient care representative (PCR) helped the complete medical and insurance forms. The layout is shown in Figure 1. The Global Lasik Eye Surgery Market will expand at 6.5% CAGR between 2017 and 2022, projects Market Research Future (MRFR) in its latest report. Lasik stands for Laser-Assisted in Situ Keratomileusis (LASIK) and is one of the most commonly used surgical procedures for treating vision disorders such as hyperopia, astigmatism and myopia among others. L Late Sharp Clinic Figure 2. Process Flow and Task Times by Job Title (Annuel Minute Technician StellSurg Di Nardo Cleaner Pre-Op Pre-Op Telephone 100 495 Exam Exam Surg Surg Surg 11,189 22,378 8,952 169,120 Waiting Room 16,112 6.444 Corridor 52,830 Tesk, Annual Demend, and Job Titles Minutes Demand Receptionist PCR Initial patient call 7 14,345 22% delect after this point Meil paperwork 1 11,189 Call to remind 2 11.189 40% reschedulecall 2 4,476 28% no-show after this point Check in at din 2 8,056 16,112 Pre-Op 20 8,056 74% insured, 26% cash Renind call 2 8,056 10% reschedulacal 2 3,222 30% of Insured no-show, 47% of Cash check in at clinic 2 5,283 10,566 Prep for sury 10 5,283 Surgery Cleanup 15 5,283 Recard Surgery 5,283 Staff surgaon 4,611, Di Narda 672 pa! Bandage, walk to waiting 5 5,283 Room cleaning 3 5,283 PCR checks patient out 5.283 First (next day) follow-up (Tues-Sat) - Checkin 2 4,226 3,453 First net-day follow-up (Tues-Sat) 10 4,226 First (neet-day follow-up (Sun) 10 1,057 Tuesday Saturday room clean 3 4,226 80% Sunday room clean 3 1,057 20% 3-week follow-up checkin) 2 4,276 8,453 3 weckfollowup . 4,174 21% no-show after follow-up 3 weckroom clean 3 4,174 69,165 23,055 10 00 3,360 Restrooms Supplies Offices, Break room 26 415 15,849 21,132 42,264 Tues-Sat only (80%) 10,566 Sunday only (20%) Figure 1: Facility Layout at LazerSharp 12,679 Tues-Sat only (0%) 3,170 Sunday only (205) 33,392 12,522 43,585 347,742 92,220 Total anual minutes task time job title: A workers by Job title 168,637 3 13.440 11,050 4 1 1 SCHEDULING SURGERY The typical flow of events for a lasik operation started with a phone call to Lazer Sharn from a prospective patient. The PCR would take the patient's information over the phone, enter it into the clinic's database, and schedule a pre-op appointment. This step took the PCR an average of about 7 DiNardo had worked the team develop a checklist which would asce tain if the lasik surgery was a viable option for the patient and to screen out any patients with complicating medical conditions. About 22% of the callers were screened out. One week before the scheduled pre-op appointment, PCRs mailed medical and insurance forms to the patients and called them a few days ahead to remind them about the appointment. The mailings took 1 minute per patient and calling took 2 minutes on average. About 72% of the patients actually showed up for the appointment, although 40% had to reschedule, which took an additional 2 minutes on average. A list of the task and task-times by type of employee is shown below in Figure 2: 2 Pro Op rooms 2 Examining rooms 3 Surgical rooms *Staff surgeon completes (5,283-672) = 4,611 operations per year; Di Nardo completes 672 Figure 2: Tasks and times. When a patient arrived for his or her pre-op appointment, the receptionist checked them in in about 2 minutes. Then the PCR took over, taking about 20 minutes on average, to discuss the procedure with the patient, answer questions, complete insurance paperwork (if insured) or take a payment (if not insured. The payment would be returned if the surgery was not completed). In 2019, 74% of the clinic's patients were insured, while 26% paid cash. Finally, the PCR would schedule the surgery. PCRs called the patients several days before the surgery, taking 2 minutes per call on average. As before, about 40% of the patients rescheduled the surgery, which took another 2 minutes of the PCR's time. THE NO-SHOW PROBLEM One of DiNardo's biggest headaches was the no-show rate. Even though the patients had made the first inquiry and had taken the time to come to the pre-op appointment (and in the case of noninsured patients. had paid for the surgery), only 70% of the insured patients and 53% of the cash (noninsured) patients actually showed up for their surgery. This high no-show rate was very difficult for the clinic's scheduling, and, with a target market that was mostly lower income, there was no deposit system in place which would cover any operational expenses due to a no-show. Such a deposit system would be very unattractive and hurt the clinic's reputation towards its lower-income base. DiNardo had started to investigate the no-show problem, asking the PCRs to call those patients who either had called to make a pre-op appointment but had not shown up or those who had completed the pre-op but not shown up for surgery. Many patients simply refused to say, but the PCRs managed to get a rough idea, shown in Figure 3 a&b: Figure 3a: Survey on no-shows for Pre-op Figure 3a: Survey on no-shows for Pre-op Reasons after call: Costs reasonable but don't have funds Costs too much Afraid of eye operation, pain, recovery Afraid might not improve much Afraid of INS Family members oppose it Not a real problem Will try a home remedy first Other Total responses 89 61 32 24 22 12 8 6 14 268 339 23% 12% 9% 8% 4% 3% 29 5% SURGERY PROCESS On the day of the surgery, the patient checked in at the reception desk. This took about 2 minutes per patient in order to check the patient identity and check payment and contact information. Lazer Sharp required that each patient be accompanied by an adult who could take the patient home after the surgery. One of the three technicians brought the patient to one of the three surgery rooms, where the patient was prepped for surgery, which took about 10 minutes on average. The staff surgeon, or DiNardo (who operated 672 times in 2019) would then enter the surgery, introduce themselves, and perform the lasik surgery. This took about 12 minutes, including a few reassuring words to the patient. The clinic scheduled 15 minutes for each surgery to give a 3 minute buffer. The surgeon would then leave the surgery room and change gowns, wash up, and record the surgery. This took an additional 5 minutes. The technician would apply the eye bandaging and walk the patient back to the waiting area, which took 5 minutes. Between surgeries, a cleaner took 3 minutes to prepare the rooms for the next surgery. It also took 3 minutes to prepare between follow-up visits in the examining rooms, as shown in Figure 2. See Figure 4 for an example of a two-hour block of scheduling. Staff Room Surgery 1 End 9:10 9:25 Time 10 15 Tech 1 Records Surgery 1 Surgery1 9:30 9:30 3 Figure 3b: Survey on no-shows for Surgery Reasons after Pre-op: Lack funds Problem getting ride to and from clinic Plan to do it in the future Bad day for unrelated pain, medical problems Afraid of eye operation, pain, recovery Called to work unexpectedly Forgot appointment Other Total responses: 45 38 22 20 18 8 7 11 169 27% 22% 13% 12% 11% 5% 4% 7% 15 Start 9:00 9:10 9:25 9:25 9:30 9:20 9:30 9:45 9:45 9:50 9:40 9:50 10:05 Surgery sen Surgery 2 Surgery 2 Records Surgery 2 Surgery 2 Surgery 1 Surgery 1 Records 9:33 9:30 9:45 9:50 9:50 9:53 9:50 10:09 10:10 Surgeon Surgeon Tech 1 Cleaner Tech 2 Surgeon Surgeon Tech 2 Cleaner Tech 1 Surgeon Surgeon 3 10 15 5 5 3 10 15 5 DiNardo had already tried to tackle the no-show problem for the surgery by working with the PCRs to develop a set of questions to help ascertain if the patient would be a "no-show." During the reminder conversation for the surgery, the PCR would go through the list of questions and together had built up a set of "indicators which would indicate whether or not the patient would return for surgery as "good," "likely," or "weak." The staff would then use over-booking to compensate for probable" and "weak surgeries scheduled on a particular day. Obviously, this entailed some risk, but this approach was working well enough so that the staff surgeon was rarely idle and DiNardo could take over surgeries if needed. Patients rarely waited over an hour from their scheduled arrival time. But, just to be careful, the staff had "Sorry you had to wait" goodies (baskets of gourmet coffees and chocolate) which they gave to patients who had delays. 5 Surgery 1 Surgery 1 Surgery 2 Surgery 2 Records Surgery 2 Surgery 2 Surgery 1 Surgery 1 Records Surgery 1 Surgery 1 10:05 10:10 10:00 10:10 10:25 10:25 10:30 10:20 10:30 10:45 10:45 10:50 10:10 10:13 10:10 10:25 10:30 10:30 10:33 10:30 10:45 10:50 10:50 10:53 Tech 1 Cleaner Tech 2 Surgeon Surgeon Tech 2 Cleaner Tech 1 Surgeon Surgeon Tech 1 Cleaner 3 10 15 5 5 3 Figure 4: Example of Typical Surgery Room and Staff Scheduling at LazerSharp DiNardo also tracked the no-show rate of each PCR, and noticed that one of the new PCRs. Virgilyn Abilas, who had just been hired 6 months ago, had particularly low no-show rate, as shown in Figure 3c: Figure 3c: No-show Percentages by PCR PCR Name Pre-op No-Show % Surgery No-Show % Lee Katron 32 45 Kevin Smatzer 17 32 Katherine Tracet 27 38 Virgilyn Abilas 12 23 Normally the technician would seat the patient in the waiting area with the patients awaiting surgery. However, if the patient seemed anxious or distressed, they were seated with anyone who had accompanied them in another area. All patients were asked to wait 30 minutes, after which, a PCR would help them sign the paperwork that the operation was complete, schedule an appointment for the next day, and remind them of the steps for postoper care. This took about 4 minutes. At the follow-up appointment on the following day, the patient would first check in with the receptionist (2 minutes), then the technician would take ten minutes to bring the patient to an examining room, check the eye, clean and bandage as necessary, walk them back to the receptionist, and schedule the next follow-up appointment for three weeks later. The examining rooms were Lerer Sharp Clinic Figure 2: Process Flow and Task Times by Job Title (Annuel Minutes) Tesk, Annual Demand, and Job Titles Minutes Demand Receptionist PCR Technician 5t/Surg DiNardo Cleaner Initial patient call 7 14,345 100 415 22% delect after this point Meil paperwork 1 11,189 11,189 Call to remind 2 11,189 22,378 40% reschedulecall 2 4.476 8.952 28% no-show after this point Check in at clinic 2 8,056 16.112 Pre-Op 20 8,056 161, 120 74% Insurad, 26% cash Rernind call 2 8,056 16,112 40% reschedulecall 2 3,222 6.444 30% of insured no-show, 47% of Cash check in al clinic 2 5,283 10,566 Prep for surgery 10 5,283 52,830 Surgery, Cleanup 15 5,283 69,165 10,080 Record Surgery 5 5,283 23,055 3,360 (Stalf surgeon 4,611, Di Narda 672 eps) Bandag, walk to waiting 5,283 26,415 Room cleaning 5,283 15,849 PCR checks patient out 5,283 21,132 First nact.day follow-up (Tues-Sat-Checkin 2 4,226 First (neet-day follow-up (Tucs-Sat) 10 4,226 42,264 Tues-Sat only (RON) First (neet-day followup (Sun) 10 1,057 10,566 Sunday only (20%) Tuesday Saturday room clean 3 4,226 80% 12,679 Tues-Sat only IRON Sunday room clean 3 1,057 20% 3,170 Sunday only (208) 3-weck follow-up (Checkin) 2 4,226 2,453 3-work follow-up 4,174 33,392 21% no-show after fir follow-up 3-weckroom clean 3 4,174 12,522 un m 347,742 92,220 Total annual minutes task time/job title: #workers by job title 43,585 1 168,637 3 13 440 41,050 1 1 1 2 Pre-Op rooms 2 Examining rooms 3 Surgical rooms * Staff surgeon completes (5,283-672)=4,611 operations per year; Di Nardo completes 672 Figure 2: Tasks and times