Fall 10 EZ Transfer Balamurali.k Eldo Zacharia Jenny Wang Dylan Lee E/ME 105
Table of Contents 1. Executive Summary... 3 2. Market Needs... 3 3. Mission Statement... 4 4. Defining the market... 4 5. Product Design... 5 5a. Safety...7 5b. Government approval...8 5c. Ease of use...8 5d. Durability and Maintainability... 11 5e. Manufacturability... 11 5f. Size to Fit Population... 12 6. Business Plan... 12 6a. Comparison of two methods... 12 6b. Costs... 13 6c. Marketing Plan... 15 7. Ethical Plan... 16 8. Major Challenges... 16 9. Future Plans... 17 10. Appendix... 18 10a. Transfers in India and United States... 18 10b. Human Height and Body Weight... 19 10c. Five- year financial plan... 20 10d. Risk analysis... 21 10e. Team Assessment... 21 2
1. Executive Summary EZ Transfer is a start-up company dedicated to improving patient transfers for hospitals in India. Currently, many hospitals in Kerala, India do not have and are not aware of existing patient transfer devices. Lifting patients during transfers is a necessary procedure with the use of our device. In addition, manual transfers expose the patient to further injuries, especially when hospitals are understaffed and the nurses are undertrained. This project was inspired by the experiences of a team member s friend after a severe back injury. With the help of a hospital administrator, a nursing school principle, and hospitals nurses, we gathered information that led to a device meeting all our criteria. We examined the possible methods to introduce the product to the market, and estimated the profitability of our product. We believe that our product can help nurses and patients in addition to making a profit. Our project has the potential to make a valuable social impact. The work we have already put in ensures that we have a well thought-out product as we enter the next phase of our design. The project offers so many positive results that we will definitely continue this project after this term. 2. Market Needs Currently, nurses in India transfer patients by using brute force to lift patients and move them to another bed or a wheelchair. This method is physically difficult for nurses because they have to lift the patient s entire body. Hospitals are often understaffed so the patient s weight may be distributed over only two nurses Figure 1: Brute force transfer method http://www.pe.com/localnews/inland/stories/pe_news_local_s_nursing29.2a4929b.html 3
and each nurse may have to lift up to 37% of their own body weight. Transfers are often uncomfortable for patients because it is impossible for only two nurses to adequately support all parts of the patient s body and nurses sometimes lack adequate training. In American hospitals, the combination of increased personnel and the use of transfer devices alleviate many of the problems Indian hospitals encounter when transferring patients [see section 10a. for comparison of transfers in India and United States]. These devices, however, are not available in India and Indian hospitals and nurses are not even aware that such tools exist. After we described the devices, Indian nurses, patients, and hospitals all showed great interest so a market for alternative patient transfer methods does exist in India. 3. Mission Statement Our goal is to fill market needs and make transfers easier for nurses and more comfortable for patients. We will do so by designing and marketing a device that reduces the amount of force needed to transfer patients while providing better support for the patient s body. Transfer devices used in American hospitals can serve as inspiration for our design, but we must make changes for the Indian market. Our device will accommodate Indian hospitals needs by only requiring two nurses per transfer and by being intuitive to use. We will provide training to our customers to ensure nurses receive the necessary instructions to use the device correctly and safely. 4. Defining the market Our first customer will likely be St. Thomas Mission Hospital in Kerala; its administrator has shown interest in our design from the beginning of the project. We will rely heavily on word of mouth to expand to other hospitals after our first sale. Because this is an entirely new device for the market, testimonials from nurses and hospitals will be very valuable endorsements to convince other hospitals to try our device. We also plan to introduce our product to medical and nursing schools soon after making our first sale. We already have contact with the head of a nursing school. This will allow us to reach many doctors and nurses at the beginning of their careers and familiarize them with our product 4
so they will want to use it in later professional life. Doctors who understand the benefit of our product may suggest it to their hospitals and help us persuade the hospital to invest in the transfer device. As students leave the schools, they will spread word of our device to other regions of India. In the long run, our device could be used in any situation that requires patient transfers, especially when there is a shortage of medical staff. For example, the device may aid the Red Cross and other disaster relief responders to move injured people more efficiently. In addition, the army may be able to use our device to remove injured soldiers from the field. Primary Market St. Thomas Mission Hospital Medical/Nursing schools Secondary Market Other Indian hospitals Hospitals in other countries Tertiary Market Red Cross and other disaster relief organization Army Figure 2: Summary of markets 5. Product Design The current design consists of four boards assembled using hinges to allow the board to bend and equipped with rollers and treads to reduce the friction when sliding the board. The primary concerns for our design are: safety for nurses and patients, obtaining government approval, ease of use, durability, and maintainability. We also need to dimension our device to fit the majority of Indian patients. Although manufacturing costs is important for any design for the developing world, we do not need an extremely cheap product because our device will be 5
EZ Transfer, Team 4 an investment purchased by hospitals rather than an item purchased by low-income individuals. However, we still took cost into account in our design. Figure 3: Current design 6
5a. Safety Our device will protect nurses backs by eliminating the need to lift patients during transfers. The full board design will protect patients by providing complete support during transfers. This is especially important for patients with head, neck, and back injuries because their spine needs to be immobilized. To ensure patients will not fall from the board, we included straps that can be used in a variety of combinations depending on the types and location of injury. We anticipate that straps will be used primarily for bed to wheelchair transfers because the sliding motion of a bed to bed transfer should not present a risk of patients falling unless the beds have very different heights. Like most medical equipment, the safety of our device depends heavily on nurses using it correctly. Therefore, we will provide live training to all our customers and will require that hospital staff undergo our training before we deliver the boards. In addition, we will produce a set of written manuals, picture-based instruction posters, and demonstration videos. We will also print warnings against common mistakes directly on the board in picture form so nurses can look over them before using the device. The device has no self-propelled parts, but the rollers and treads are a source of concern for us. There is a chance that patients or nurses can get hair and fingers stuck in these moving parts. We reduce this risk by placing the rollers and treads at the edge of the device, where there is less chance that nurses or patients will come into contact with them. However, we will need tests with a full-size prototype to determine if this is enough protection, but we do not want to add additional parts until tests show that they are needed. The severest potential injury caused by our device will occur if the board breaks during use. The board must be designed to have graceful failure and be able to warn nurses of potential catastrophic failure. We accomplish this by using materials that can provide a visual indication of failure before the board actually breaks and that would break slowly enough to give nurses time to lower the patient. We are using a molded resin that is reinforced with fiber. Cracks in the resin will indicate when the board is damaged and should not be used. If the board begins to break during use, the fibers will ensure that the board does not snap in half. Instead, the board will begin to soften as the resin cracks. The fibers will slow down breakage and support the patient as nurses lower the board back to the bed. 7
5b. Government approval Marketing our device is contingent on obtaining medical board approval. We modeled our device off products available in the United States. Since these devices were approved in the United States, we expect that our device will be approved in India. We have also received feedback from medical professionals in Kerala that have helped us to refine our design for the Indian market. Figure 4: a) roller board (http://www.universalmedicalinc.com/photogallery.asp?productcode=7417) and b) modified folding roller board from Hill-Rom (http://www.hill-rom.com/usa/patienttransferboard.htm) 5c. Ease of use We are aware of current difficulties in training nurses, so we want our device to be intuitive to use and not require much training. Reduced training would have several additional benefits: reduced cost for us, decreased barrier to hospitals using the device, and increased safety. The following diagrams show how the device would be used. 8
Figure 5: Bed to bed transfer 9
Figure 6: Bed to wheelchair transfer The boards will be color coded to indicate attachment points and there will be pictorial instructions printed directly on the board in case nurses need a reminder before using the device. However, the best way to determine whether our device is intuitive and easy to use will be human testing with actual nurses, which can only be done after we have a full-scale prototype. 10
5d. Durability and Maintainability Durability is a high priority for us for two reasons: 1) the patient s safety depends on the board not breaking while in use, and 2) we want the device to be a investment that will benefit our customers for years. The board has several features to ensure durability. First, the hinge is integrated into the boards. This allows a thicker pin in the hinge and eliminates the possibility of the hinge detaching from the boards due to the forces from the patient s weight. Second, we have picked a material that is reinforced with fibers for improved strength. The shop we are working with routinely makes beds from this material. Third, all moving parts are relatively large so they will withstand more wear. In addition to durability, we are also concerned about maintainability. Our product is can be easily maintained because all parts of the device can be assembled so worn out parts can be easily replaced easily by swapping them out for a new one. We will ensure that the board can withstand normal use and reasonable rough treatment through extensive testing of the prototype. We will load weights onto the prototype before human testing to ensure that the board can hold a person s weight and the pins in the hinges will not deform. To ensure a good safety margin, we will load the board to 200 kg. We can further test the prototype by dropping the device about 2 m onto concrete to see what happens when the board receives a sharp impact. 5e. Manufacturability Working closely with a shop in Kerala during our design development allows us to ensure that our design can be easily manufactured. We reduce manufacturing costs by using repeating units and choosing readily available materials. The board is assembled from two each of two distinct pieces. Using two distinct pieces instead of four reduces the cost for molds and will give us a faster learning curve so manufacturing costs will decrease faster with increased production. The hinge pins can be made from readily available stock metal rods and the straps are made from flat rope intended for rock-climbing. In addition, the pins for the hinge and the axle for the rollers are the same diameter and can be made from the same stock metal to reduce costs of supplies. 11
5f. Size to Fit Population The dimensions of our device must be appropriate for the Indian market. We will need information about height and weight distributions as well as body proportions. The current device is intended for use with teenage and adult patients because children are lighter so the need for transfer devices for child patients is not as urgent [see section 10b. for information on human height and body weight]. We will design our device to hold 150 kg. The average height in India is around 150 cm and we should design to accommodate patients who are 135 to 165 cm. The standard deviation of human height is around 7 cm, so this range will allow us to cover more than two standard deviations and thus over 95% of the Indian population. To accomplish this goal, we would need to make the head and foot boards sufficiently long for a 165 cm person but the middle board sufficiently short for a 135 cm person. The fit on the middle board does not need to be exact; as long as it is shorter than the patient s upper leg, the patient should be able to sit comfortably on the board during a bed to wheelchair transfer. 6. Business Plan We determined the cost of manufacturing our device. Also, we have met our initial design goals, but we have to consider an appropriate product price to build a self-sustaining business. We are considering two methods to put our product in the market: (1) start a company, and (2) apply for patent and license our idea to another company. 6a. Comparison of two methods There are several advantages to starting our own company. We will have complete control over our product, so we can modify and improve it and then sell it anytime. With successfully sales, we can build our brand name, earning our customers trust. With our brand name, we can market other products with less difficulty. However, starting a new company requires a great deal of money. If we fail to sell our product, we will lose our investment. It is not guaranteed that we could have enough profits to cover our costs. If we choose to apply for patent and let a company bring the device to market, we would not have to worry about the production and marketing process. This method requires less work and money on our part. However, we have rights over only the patent product. We would not be 12
able to modify our device in response to customer feedback. Since we receive only the royalties, we will not make as large a profit if our device becomes very successful. Each method has its own benefits and drawbacks. However, it is more profitable to start a company since we can control our product and decide our target consumer. However, we plan to obtain provisional patent to protect our intellectual property. The application costs about 5,000 INR. Obtaining a patent will allow us to secure our product from being used without our permission. 6b. Costs The product cost includes not only the materials but also the labor, shipping, and training costs. There is a small manufacturing shop in Kerala that builds plastic-based structures, and has machines and materials that are appropriate for building our product. This method will allow local production of our product. In India, each state has to pay a tariff when businesses purchase a material or product outside of their state. Therefore, local manufacturing will not only reduce the material cost, but also eliminated the raw material shipping cost. In addition, our customers can easily repair or replace the product without having to pay for shipping charges for repaired or new product parts. In addition to manufacturing costs, our product will also have training costs. Our product is intuitive and would not require much training, but we do need to ensure that hospital staff will use the board correctly. Our initial training will be live demonstrations by us, the product creators. We will not train and hire a group of instructors for our product initially due to costs. Due to prohibitive travel costs from the United States to India, the training will be performed by our St. GITS partners. We will also produce the user manuals and demonstration videos ourselves to reduce cost. Our St. GITS partners can translate as necessary. These training material will also be good advertising for our product. For our initial product sales, we will visit local Kerala hospitals that we have already contacted. This process requires traveling expenses and transportation fees. But because of the proximity, such travel costs will be relatively low. 13
Overall Cost Item Cost (INR) Production Cost Material cost 1,250 (head, foot, and middle boards, and pins for hinges) Rollers (wheels) 400 Belts (for rollers) 200 Straps (5 pairs) 500 Labor cost 2,000 Shipping and Travel Costs Product packing 20 Training guide material 50 (user manual guide and instructional poster) Training expense 100 Product shipping 50 Travel and transportation Air travel: $ 960 Local travel: 300 INR Total 4,820 (not including air travel) Table 1: Overall business costs The raw materials for our product are listed below. The table shows total cost for the first product. The manufacturing process includes building reusable molds for our parts and the material cost includes the molding cost. Once the mold is built, material cost will reduce. One product takes about two days to complete. The majority of production time is waiting for the material to dry. With more molds, we can build the device in parallel and complete multiple devices each day. Material Cost Item Cost (INR) Fiber mat (1kg x135) 135 Iso- resin (3kgx145) 435 Isogel coat (0.5kgx170) 85 Accelator (250ml) 115 Catalyst 100 PVA 50 Wax 75 Rubbing wool 30 Pigment 140 Others 125 Total 1,300 Table 2: Manufacturing raw materials costs 14
Our final costumer price (7,000 INR) is 17% lower than our initial target price (9,000 INR). However, we do not have an established reputation and brand name to easily sell our product. Our product is a medical equipment that requires absolute safety for patients and nurses. Without trust from our customers, we are planning a risky business. However, demands for safer patient transfer methods are high. Nursing schools and hospitals are eager to try out our new device. Hospital administrators showed willingness to pay for transferring devices if they were safe. However, their decisions are contingent on nurses liking the product. 6c. Marketing Plan Initial Production Plan Total expense per product = 4,420 INR Production volume first year = 100 Initial customer price = 7,000 INR Gross Profit = 700,000 INR Table 3: Initial production plan In order to start our company, we would ask for funds or donations from organizations, such as NGOs, disability associations, nursing associations, and the military. During our first year, we would depend mainly on donations. We would need about 1,600,000 INR or $35,000 to start basic manufacturing. Since the shop in Kerala can produce one product in two days from one set of molds, we will aim for 30 devices per month using two sets of molds. In order to cover the overall cost, we decided on 7,000 INR as our maximum customer price. If we could achieve this sales goal, we earn an annual profit of about 928,800 INR. This profit will cover most of our production costs and other expenses. Each product cost a great deal of money (7,000 INR). In order to let buyers to feel comfortable purchasing the product, we will offer a trial period with one device per hospital, and train only 3~4 nurses to use the product. This strategy will give hospitals opportunities to try out the product instead of dismissing it as unnecessary investment. During the trial period, the hospitals can use the devices for free. If they lose the device or damage it beyond repair, they have to pay us the price of the device. We will have a customer referral program to encourage 15
our customers to recommend our product to other hospitals. This will allow us to use our customers as sales agents and reduce our sales costs. [see section 10c. for five year financial plan] 7. Ethical Plan We are against government corruption and so we will seek medical board approval without resorting to bribery. We believe that corruption, especially related to medical devices is dangerous and may lead to harm for patients. Instead of bribery, we will build popular opinion in favor of our product by getting the support of respected medical professionals and by emphasizing statistics showing how beneficial our device will be. This will personalize our device to members of the medical board because our device may eventually help them or someone they know. 8. Major Challenges The difficulty in obtaining accurate information from hospitals was very high. We had difficulty deciding on the team s mission statement. We began the project assuming that there are significant numbers of patients exposed to the risk of being injured during transfers. However, initial market research showed that patients suffered from only general discomfort and did not mention any injuries during transfers. It seemed like hospitals did not have any problem with transferring patients except nurses having to lift and move patients from a bed to another. From our initial mission statement, we changed our project direction to building a transferring device that could be easily used by nurses. However, we were informed by a nurse in India that there are cases on patients getting injured during transfers because some nurses were not fully trained. The process of obtaining accurate information was more difficult than we expected. Regular meeting attendance was not a problem. However, verbal communication between Caltech and St. GITS partners was sometimes difficult. It seems like some words have slightly different meanings and this discrepancy influenced our understanding of each other s ideas and thoughts. Due to static noise in Skype, sometimes it was challenging to clearly hear voices. 16
Time zone difference was another challenge. When we have an urgent message or urgent meeting, it was difficult to reach the teammates in the other time zone instantly. Whenever we needed extra meetings, it was difficult to find a time that worked for everyone. In addition, Skype is banned on the St. GITS campus, which further limited our meeting times. 9. Future Plans Prototype: In order to finalize our product design, our initial goal is to build a rapid prototype. The prototype will be 1/5 of the actual product size. An artists doll will be used to test whether the prototype will work as we expected. The artists doll has the same body proportion as a human. This doll will give us a better idea of how the transferring device will work. We were unable to do this earlier due to high demand on the rapid prototyping machine. Building the Product: We are in contact with the owner of a small manufacturing shop in Kerala. He showed special interest in our product and is eager to build an actual size product to see how it works. Since the production of real size product model will take place in India, load test, durability test, strength test and other tests will be performed in India. Introduction of product: Our St. GITS partners will visit the local hospitals, and nursing schools that we are in contact with to introduce our product. Caltech partners are planning to visit Kerala in spring in order to check the progress of the product introduction process. We plan to continue this project. 17
10. Appendix 10a. Transfers in India and United States India United States # of nurses per 2-3 3-4 transfer Time spent per 120-180 15 transfer (seconds) Use devices? No Yes Table 4: Vital statistics of transfer in India and United States Overall, transfers in the United States rely more on technology and transfers in India rely more on man-power, but Indian hospitals use fewer nurses per transfer. This apparent paradox can be explained by higher medical standards in the United States; the extra nurses in American transfers are used to stabilize the patient during the process, not to bear the patient s weight. The transfer devices and extra personnel make the process significantly faster. In addition, American hospital personnel tend to be better trained than their counterparts in India. There are two strategies to improving patient transfers in India: 1) improve training and increase the number of hospital personnel in Indian hospitals and 2) introduce a transfer device that provides better support for patients and will require only two nurses to operate. Our business will pursue the latter strategy because there is no product associated with the former. 18
10b. Human Height and Body Weight Figure 7: Weight distribution of six annual cohorts (Germans born 1940, 1950, 1960, and 1970, Austrians born 1970, and Norwegians born 1977. Hermanussen, M.; Danker-Hopfe, H., and Weber, G.W. Int. J. of Obesity, 2001, 25, pp 1550-1553. The above weight distribution represents an upper bound for our device. The plot shows that there is almost no one above 150 kg. Indians, on average, weigh less than Germans, Austrians, and Norwegians, so 150 kg will include almost our entire target population. Women s heights 151 152 153 154 155 156 Men (right scale) Slope is 0.050 cm per year Women (left scale) Slope is 0.016 cm per year 161 162 163 164 165 166 Men s heights 10 20 30 40 50 age Figure 8: Average height in India 2005-2006 American Economics Association Annual Meeting (http://www.aeaweb.org/annual_mtg_papers/2008/2008_543.pdf) 19
10c. Five- year financial plan Expected Cash Flow Statement for Five Years OUTPUT 100 750 1500 2500 3000 AMOUNT IN (INR) EXPENDITURE YEAR 1 YEAR 2 YEAR 3 YEAR 4 YEAR 5 COST OF RAW MATERIALS 130000 956250 1837500 3000000 3540000 ROLLERS 40000 262500 487500 800000 960000 BELT 20000 142500 262500 375000 450000 PACKING 7500 60000 127500 212500 255000 USER GUIDE 500 3750 7500 12500 15000 TRAINING 10000 10000 10000 10000 10000 FACTORY BUILDING (RENT) 10000 10000 10000 10000 10000 MARKETING 25000 30000 25000 25000 25000 LABOUR 50000 50000 75000 75000 75000 MEDICAL BOARD APPROVAL 15000 0 0 0 0 PATENT (legal fees and application fee for full patent) 15000 0 0 0 0 TOTAL EXPENSES BEFORE TAX 323000 1525000 2842500 4520000 5340000 TAX (12%) 38760 183000 341100 542400 640800 TOTAL EXPENSE AFTER TAX 361760 1708000 3183600 5062400 5980800 EXPENSE PER UNIT 3620 2280 2120 2030 1990 INCOME SALES COST PER UNIT 7000 7000 7000 7000 7000 TOTAL SALES COST 700000 5250000 10500000 17500000 21000000 PROFIT/LOSS 68240 5079200 10181640 12437600 15019200 Annual Pro*it (INR) 16,000,000 14,000,000 12,000,000 10,000,000 8,000,000 6,000,000 4,000,000 2,000,000 0 Expected Cash Flow for Five Years 15019200 12437600 10181640 5079200 68240 1 2 3 Years 4 5 20
10d. Risk analysis Risk Severity (S) Likelihood (L) Importance (SxL) Mitigation Not getting medical board approval Insufficient demand Inability to raise funds Inaccurate cost assessment and unexpected additional costs 10 1 10 Consult medical practitioners in India about our design before prototyping and applying for approval 10 3 30 Get feedback from hospital administrators and medical/nursing school principals on what they would like in a device; aggressively spread the word about our device 8 6 48 Reduce costs wherever possible; explore multiple sources of funding 5 8 40 Leave a large profit margin in our business plan to account for additional expenses 10e. Team Assessment Overall, team meeting attendance was good. Despite the technical problems or internet connection problems, our team tried our best to communicate. Our team is aware of some problems in the team and knows the general team temperature. Most of work, especially the writing aspect of assignments, was done by Caltech teammates. Although there was unfair division of work, St. GITS teammates tried to gather information about cost distribution and business start-up finance. 21