BUS303: Strategic Information Technology

BPM is a well-designed, implemented, executed, integrated, monitored, and controlled management approach, which strives to continuously improve and analyze key operations in line with organizations' strategies. BPM is part of a tradition that is decades old whereby the aim of managers and practitioners is to rethink the organization of their business and focus on business process change. A business process is a sequence of executions/steps within a business context, which aims to create goods or a service. This approach differs from the traditional outcome-based approach applied in health care. Ellwood defined outcomes management as "a technology of patient experience designed to help patients, payers and providers make rational medical care-related choices based on better insight into the effect of these choices on the patient's life". So while Ellwood had already highlighted that process life cycle exists between patients, payer, and provider choices and patient outcomes, the focus of management was on the outcomes rather than the processes themselves.

While the historical roots of BPM will be discussed in more detail in the next section, BPM is said to be composed of the following six core elements:

• Strategic alignment – processes within an organization need to be designed, implemented, maintained, and assessed in line with the strategic priorities of the organization.
• Governance – a focus on establishing accountability with respect to the roles and responsibilities within all levels of the management process.
• Methods – within BPM, the set of tools and techniques that are used to support and instigate the activities along the process life cycle. Some of these methods will be discussed in the next section.
• Information technology (IT) – IT-based solutions have become important elements in BPM with a focus on the development of process aware management systems. The importance of the IT wave in BPM will be discussed in the next section.
• People – the human capital of an organization is important for the effective implementation of BPM. Without the skills and knowledge of human resources, improvements in business processes cannot be achieved.
• Culture – the shared values of the people forming part of the organization lead to an environment that can effectively facilitate the implementation of BPM within an organization.

In industry, the use of BPM has become vital to ensure organizational competitiveness through added value by way of improved processes. Total quality management and most recently six sigma and lean approaches have been successfully implemented in manufacturing, process management, construction, and services industries by deploying BPM. Process reengineering, which is part of BPM is adopted for organizational transformation in many industries. Today, most organizations measure business performance through process performance that is based on BPM principles. Brooks et al have applied BPM for project management maturity analysis. Dey et al adopted BPM for implementing enterprise resource planning in the UK-based organization in energy industry. Dey also applied BPM principles in benchmarking project management practices of organizations in Caribbean. To date, clinical decisions in hospital must be based on scientific evidence, socioethical values, and economic factors. Additionally, evidence-based care requires transparency, justification, and accountability. However, achieving this ideal scenario is problematic because clinical decisions can be heavily influenced by the pharmaceutical industry (in view of the financial interests involved in the development and marketing of drugs and devices), as well as by governments. There is ample evidence that shows that "the pharmaceutical industry masterfully influences evidence based production, evidence synthesis, understanding of harms issues, cost-effectiveness evaluations, clinical practice guidelines and health care professional education and also exerts direct influences on professional decisions and health consumers". Health authorities also exert pressure on physicians so as to prescribe generics rather than patented products. The tide, however, appears to be turning. Indeed, in the USA, the Obama administration has released final rules on the reporting of financial relations between drug companies, device manufacturers, and health care providers. This is part of the Affordable Care Act designed to ensure transparency in the health care marketplace. Similarly in Europe, the Stockholm Drug and Therapeutics Committee in cooperation with Department of Clinical Pharmacology at Karolinska Institutet and at Karolinska University Hospital in Stockholm, Sweden, and in collaboration with the World Health Organization developed the "Stockholm model" for the rational use of medicines. By focusing on robust processes in clinical decisions, as well as in prescribing, BPM can provide the optimal pathway for full transparency by including regulation procedures that would ensure objectivity in decisions, which are free from conflict of interests. Shortell and Schmittdiel argue that while health systems may not be limited by a lack of resources – financial, technological or human – they are limited by a lack of organization between these resources that enables more cost-effectiveness.

Shortell and Schmittdiel contend that this can be achieved through integration, namely, functional (extent to which operating units are coordinated), physician (extent to which physicians have mutually shared objectives with organized delivery systems), and clinical (extent to which maximum value in terms of service delivered to patients is achieved through services that are coordinated across people, functions, activities, and sites over time).

Shortell et al emphasize that clinical integration is of crucial and primary significance for organized delivery systems and delivery of integrated care.

There is evidence that integrated care improves processes of care. On the other hand, Tsasis et al claim that although numerous initiatives of integrated care have succeeded in producing positive outcomes, many have not. The reason being that integration is a learning process, which dictates that professionals should "learn how to learn" so as to effectively exchange knowledge and self-organize within health care organizations that are conceptualized as complex adaptive systems. We argue in favor of adopting BPM principles not only in hospitals but also across services within regional and national health systems. This is to ensure successful integration so as to achieve organized delivery systems that provide a coordinated continuum of services.

When compared to manufacturing industries, planning and control in health care operations management seem to lag behind. Houy et al reviewed empirical research in BPM – an area they call "an emerging field of research". The aim of their research was to analyze empirical work in BPM and identify any research gaps for further development in the field. In their systematic review, a search through two search engines (Science Citation Index and Business Source Premier) found 1,260 articles published between 1991 and 2008, which addressed the BPM approach within industry and public service. The earliest research was in 1992 with peaks in 1995 and 1998. From 2000 onward, Houy et al reported an overall upward trend with the highest number of contributions per year being in 2007 and 2008. For the secondary data sources relevant to this paper, we replicated the search strategy by Houy et al, by using the same search terms in PubMed. Figure 1 graphically represents the development of BPM research in health care as extracted from a PubMed search. Between 1991 and 2008, only 145 articles were published within the health care field, which broadly referenced BPM. A small peak of research is observed in 1997 but the first large peak occurred in the year 2000. This peak was not maintained between 2001 and 2004 with a resurgence of research being seen from 2005 onward. The highest number of articles published in a year was in 2008 with 20 health-related BPM references found. In general, the trend shows a lower presence of BPM in the health care field as compared to that reported by Houy et al. Additionally, there appears to be delays in reaching peaks of submitted work on BPM when compared to other sectors such as industry and public service. To assess the trend further, the search was extended to research published up to 2014, which totaled 316 articles. The empirical research seems to show an increase in BPM-related health research from 2010 onward with the number of work published in the 6 years between 2009 and 2014 being nearly equal to the amount of work published over the 18 years between 1991 and 2008.

Figure 1 Research indexed in PubMed, which broadly references BPM published up to end of 2014.

Notes: Horizontal reference lines indicate three peaks in number of publications. Between 1991 and 2008, only 145 articles were published within the health care field, which broadly referenced BPM (gray bars). To assess the trend further, the search was extended to research published up to 2014, which totaled 316 articles (black bars).

Abbreviation: BPM, business process management.

The apparent slower uptake of BPM research in health care is a reflection of the fragmented health care systems often with separate data sets for various settings/providers, thereby preventing in-depth and system-wide process examinations. This fragmentation has been somewhat reversed in the new millennium by the creation of acquisitions, mergers, and consolidations in the health sector. Additionally, the focus is mostly on hospitals as opposed to a health system-wide approach and on single managerial areas such as resource capacity planning, while ignoring hierarchical levels and supply chains, thereby resulting in piecemeal nonintegrated approaches in process management. A silo mentality in the manner in which some hospital departments are reportedly managed is also an example of this.

Furthermore, a major reason for the difficulties in health care management appears to stem from lack of proper communication and understanding between managers and clinicians, who by virtue of their professional training, tend to focus on individual patient care often at the expense of population-based health care and efficiency/effectiveness of health systems in which they operate. Shortell and Schmittidiel define this as "disintegration in the health care system". This means that physicians may not be functioning synergistically to achieve a common goal, namely, that of achieving optimal quality-of-care delivery to patients, efficiently utilizing health services, and receiving personalized care from clinicians.

The management–clinician conflict effectively translates in competition for resources such that investing in state-of-the-art management and information systems may be interpreted by major stakeholders in the sector as diverting funds from direct patient care. There is however ample evidence that investing in health IT results in health and financial benefits by improving health care processes, efficiency, and patient safety. For example, the use of health IT in the prevention and management of chronic diseases can lead to considerable savings.

Hans et al propose a four-by-four positioning framework for health care planning and control that would facilitate the much needed dialogue between managers and clinicians. The framework integrates four managerial areas of planning (medical, resource capacity, materials, and financial) and four hierarchical levels of control (strategic, tactical, offline operational, and online operational) involved in health care delivery operations. This ensures identification and positioning of managerial problems, as well as consistency and implementation of managerial responsibilities, at every level and along the entire supply chain of cure and care providers. Hans et al contend that the generic dimensions of the framework assist managers and clinicians to apply specific content based on the context of the specific application, for example, at departmental level (emergency room or operating room) or hospital wide, rendering it widely applicable.

On the one hand, clinicians are trained to manage patients and as part of their clinical workout, they need to go through various "clinical" processes. On the other hand, they may be averse to adopting pure management principles if they feel these are in conflict with their clinical practice, which remains centered around individualized patient care. Lega et al claim "clinicians focus on the individual patient, the effectiveness of the care, and evidence-based practices with little attention to cost control". This may conflict with the role of managers who are sometimes faced with an ethical dilemma – as increasing financial challenges lead to scarce resources, thus necessitating health rationing of services. Despite the fact that both managers and clinicians are dealing with processes, the methods utilized are grounded in different philosophies, thereby leading to diversity in perspectives with regard to the achievement of quality. Indeed, Lega et al contend, "Historically, the professional and cultural autonomy claimed by clinicians largely meant that clinical processes were treated as a ‘black box' with which managers should not interfere". However over the years, in particular because of the pressures of the financial crisis, it has become increasingly evident that a wider perspective of quality of care is emerging and that managers and clinicians are increasingly appreciating the importance and integration of both operational and clinical processes. For example, in the UK the National Health System (NHS) is urging managers and clinicians to work together as it came up with the best care for best value indicators in an attempt to target efficiency savings over the next decade. In other words, a hospital may have the best clinical expertise, but unless this is adequately supported by robust operating systems with inputs, processes, and outputs, it will be difficult to close the loop in quality-of-care delivery. These operating systems need to have detailed process mapping so as to accurately design integrated care patient pathways with full clarity of roles of health providers and supporting professionals. Moreover, Vanhaecht et al tackle the physician's buy-in problem in patient care pathways by developing the seven-phase method (screening, project management, diagnostic and objectification, development, implementation, evaluation, and continuous follow-up) akin to the patient management processes (history, examination, clinical investigations, differential diagnosis, definite diagnosis, care plan, and follow-up) to design, implement, and evaluate care pathways so as to improve the quality of health care processes.

Different disciplines, for example, managers and clinicians, view processes differently. By speaking the same language as physicians and using the seven-phase method, management can find common ground with multidisciplinary health care teams so as to enable them to design and implement safe, efficient, effective, person-centered, timely, equitable, continuous, and integrated care flow processes, which need to be supported, controlled, and monitored. Despite the fact that over the years, we have experienced innovation in health information and technology by way of, for example, electronic case summaries and Diagnostic Related Groups, their focus is largely on clinical and financial information with poor integration with operational information systems. This can be achieved by focusing on processes that are used in operations management, and which from a business perspective, define in detail the transformation of inputs to outputs. Schmiedel and vom Brocke clearly state, "BPM has evolved from a technology-focused into a holistic and principle-oriented discipline concerned with efficient and effective business processes". Furthermore, these authors have grounded BPM in the digital world by claiming that BPM institutionalizes digital technologies in business processes. In health care, improved health IT, for example, more complete electronic medical records and computerized physician order entry, helps in avoiding medical errors, tracking adverse events, and drug interactions/adverse drug events, thereby resulting in cost-saving safety benefits. Indeed, van der Aalst identifies three paradigm shifts in information systems that have become relevant for BPM. They are from programming to assembly, from data orientation to process orientation, and from design to redesign and organic growth. Rising health care costs have put pressure on health policy makers and organizations to ensure that processes in operating systems run efficiently and cut wastage.

By providing integrated systems for managing business performance as well as managing end-to-end processes on an on-going basis, we argue that BPM can provide solutions to issues and challenges facing health care today. As a counter argument, we however maintain that BPM is not the panacea of all the problems facing health care systems and hospitals today. As amply highlighted in this section, BPM needs the right conditions for its successful implementation. Apart from software that needs to be flexible to automate and to adapt to changing business processes, health care organizations require optimal leadership to create the right conditions in terms of discipline, commitment, alignment, motivation, and integration. Moreover, even where and when BPM is introduced, clinical governance and continuous monitoring/evaluation of results are needed to assure improvement and optimal patient outcomes. Furthermore, the success of BPM depends on the continuity with which predetermined goals are achieved in the short term, for example, in a project, as well as in the long-term when dealing with operating systems. We will provide a historical account of BPM and how it evolved largely over the past 30–40 years. Applications of BPM are found in industry across contexts but in this paper, we will focus particularly on the health care applications.