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For a guy whose working life has been all about packaging tape and cleaning supplies, Angelo Psellas is unusually well informed about hernias.

Mr. Psellas, a veteran plant manager at 3M Canada Inc., can discuss hernia surgery, waiting periods and recovery times -- even though he's never gone under the knife for a hernia operation himself.

Such extensive knowledge about a medical procedure that repairs painful protrusions of body tissue caused by weakness in the abdomen or groin may seem perverse.

But Mr. Psellas, 42, is a recent convert to one of the most popular management teaching tools in the world -- the Harvard Business School case study based on the Toronto area's renowned Shouldice Hernia Centre.

"It is a piece of learning that has shaped and tempered me a bit," says Mr. Psellas, who was first exposed to the study last summer while pursuing his Queen's University executive MBA.

Over the past 23 years, the 14-page Shouldice case study has become a cornerstone of Harvard's management curriculum, built on case studies as a learning tool.

Harvard sells its studies to other schools, which has turned Shouldice into a global brand name.

The Shouldice case is the university's fourth all-time bestseller, with 259,000 copies sold and annual sales of 20,000 copies or more -- for about $6.50 (U.S.) apiece.

The Shouldice model of service delivery has helped train hundreds of thousands of future managers in about 500 business schools. The hernia repair process is part of the basic toolkit on customer service that the world's senior executives carry to the corner office.

In fact, Shouldice's reputation as an executive learning tool rivals its medical stature. "I've maintained that the hospital will not be famous for hernias in 50 years--it will be famous for its service delivery model," says Daryl Urquhart, the private, non-profit hospital's director of business development.

What it teaches are the benefits of doing one thing extremely well and building all processes and infrastructure around achieving that result. In Shouldice's case, the "product" is a three-day admission-to-release process that puts gimpy-groined customers on their feet and back to normal as quickly as possible.

The 60-year-old hospital, a unique private institution operating in a public health system, was founded by Mr. Urquhart's grandfather Dr. Earle Shouldice. Based in the Toronto suburb of Thornhill, it fixes 7,500 hernias a year.

Everything about the hospital is designed toward that end. Shouldice believes recovering hernia patients should walk around. Thus, there are no televisions or telephones in patient rooms.

Meals are not taken to the rooms but provided in a central dining area, for which access requires some traversing of stairs. But the stairs are built with lower risers than normal, and the extensive grounds are gently sloped for easy walking. What's more, the participation of patients in their own recovery cuts Shouldice's costs for things like service to rooms and one-on-one physiotherapy.

It is, in essence, a hernia factory. Harvard calls it "a focused factory," which gives the case a relevance that extends beyond health care and customer service and into manufacturing and processing.

Mr. Psellas first learned about the case in Queen's adjunct professor Paul Roman's operations management class last summer.

He was a rare manufacturing person in a session dominated by technology and government managers. But he found the case speaks in a terminology every manager could understand and discuss.

One aspect sums up the Shouldice ethos, says Harvard business professor Jim Heskett. "It is the focus built into their operating strategy in which everything is designed to support a particular result which is important to clients. That's typical of all good service organizations."

That aspect became apparent to Prof. Heskett 25 years ago when he first read about the hospital in a magazine. He decided it would make a good case, visited Toronto and wrote his study with the help of Shouldice managers, led by current managing director Allan O'Dell.

For the hospital, the case has been a marketing gold mine. Nearly 10 per cent of its patients come from outside Ontario, providing an important cash supplement to Ontario's health insurance system.

Not all students find the case edifying. Prof. Heskett often shows a TV documentary about the hospital that graphically portrays a hernia operation. Several students have fainted during the screening.

In the past decade, Mr. Urquhart, whose family still owns the hospital, has taken to visiting MBA classes in major business schools to provide personal testimony. He now makes up to a dozen class visits a year, as well as several teleconferencing appearances.

The effort clearly pays off. Regina Herzlinger, a Harvard specialist in health care management, was in Munich attending a medical conference when she ran into a European health official who had just visited Toronto. He explained he had gone for a hernia procedure. Asked how he found out about Shouldice, he said: "I read the case."

But Prof. Herzlinger says Shouldice's global influence goes much farther. The case, combined with various academic writings on the Canadian hospital, has been a major influence on health care delivery in the United States.

The irony is how little the case has changed Shouldice. The study asks students to suggest strategies by which the hospital can expand beyond current capacity, and various options are suggested, such as diversifying into other procedures or going global.

Yet the hospital remains a single-purpose hernia factory with the same 89 beds as 25 years ago -- although it has been able to increase the number of patients per year. As a private hospital, it can't expand under Canadian health legislation, and Mr. Urquhart says it rejects international growth because of quality-control concerns.

Yet its impact remains far-reaching because of people like Mr. Psellas. This month, he relocated to 3M Canada's London, Ont., head office, where he will be a "master black belt" helping to drive the company's critical Six Sigma quality program.

Although he will no longer direct production on a plant floor, he will continue to ask questions with the case study in mind. After all, he says, Six Sigma is all about improving processes, and so is Shouldice.

Harvard's bestseller case-study list

Daryl Urquhart, Shouldice Hospital's director of business development, says in 50 years the hospital will be famous as a model of service delivery.

1. Lincoln Electric Co., published in 1975. Management practices at a Cleveland manufacturer, 296,507 copies sold.

2. Benihana of Tokyo, published in 1972. Operating strategies in a U.S. theme restaurant chain, 280,976 copies sold.

3. Wal-Mart Stores, published in 1994. Evolution of the world's biggest retailer, 279,529 copies sold.

4. Shouldice Hospital, published in 1983. 258,902 copies sold.

5. Sealed Air, published in 1982. New Jersey firm competes in the protective packaging market, 242,892 copies sold.

6. People Express, Case A, published in 1983. The rise of a now-defunct discount airline, 236,165 copies sold.

7. Optical Distortion, Case A, published in 1975. The launch of a product -- contact lenses for chickens, 224,330 copies sold.

8. Caterpillar Tractor Co., published in 1985. The structure of the earth-moving industry, 215,338 copies sold.

9. Cumberland Metal, published in 1980. New product helps contractors drive piles faster, 207,183 copies sold.

10. Toyota Motor Manufacturing USA, published in 1992. How a U.S. subsidiary deals with a product defect, 205,727 copies sold.

Harvard Business School


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