BUS303: Strategic Information Technology

BPM encompasses a long-standing progress spanning several decades with the aim to continuously improve how organizations across contexts manage their business activities. Historically, BPM enables us to appreciate what we have achieved in terms of our comprehensive understanding to date and what future prospects it holds. The application of BPM in health care has proven more difficult because of the highly complex and multi-/interdisciplinary processes within the health care system. Apart from this, the health care sector is continuously facing challenges which require it to respond by adapting these processes as necessary. In health care delivery, strategies are highly dynamic with ad hoc decisions often taken to respond to manage crisis on a day-to-day basis, for example, hospitals' response to unpredicted overcrowding at the accident and emergency departments. On the other hand, the health sector has become more organized in dealing with disasters by developing emergency preparedness plans with detailed processes to put in place in case of need. Indeed, the occurrence of natural disasters over the past decade has triggered massive rethinking in terms of contingency plans and acquisition of professional competencies for health care providers across the world. These natural disasters have provided the best examples of how clinicians and managers can synergistically function often at the levels of perfection. Perhaps, the best recent example on a global scale has been the health sector's response to the Ebola crisis, albeit the massive number of fatalities.

There are three major process traditions, namely, quality control, management, and IT, all with their roots in work simplification and industrial engineering and each characterized by several emerging methodologies. We will review these three traditions and their important impact on BPM development. The quality control tradition is mainly advocated and practiced by production engineers and quality control specialists. In the 1970s, Total Quality Management (TQM) was the top quality control philosophy that too a great extent has remained relevant even today. In the 1980s, continuous quality improvement (CQI) with the application of six sigma emerged as a successful approach that combines process with statistical quality control techniques. In health care, early applications of CQI/TQM in the UK and USA were largely focused on nonclinical management functions to improve care at the organizational level. However, when it came to apply the quality concepts to clinical areas, the overall effect was much more limited, with only small-scale improvements, which were not sustained. Some of the reasons cited were lack of senior management commitment and low clinical ownership.

On the other hand, the use of six sigma in health care was advocated in the 1990s on the basis of the fact that defects, errors, and incidents are prevalent in health care. Indeed, Chassin posed a challenging question "Are human systems so different from others in which six sigma has been achieved or attempted that high levels of reliability are unattainable?" and encouraged its adoption. Furthermore, Sehwail and DeYong advocate the use of six sigma principles, which are aligned with strategic objectives so as to achieve financial and operational performance improvement in health care organizations. Infection control, operating theaters, medication delivery, and administration as well as laboratory processing are some of the clinical areas where six sigma has been applied.

In the new millennium, and against the background of global financial crises, reducing waste in organizations has become a top priority, the focus has turned to the combination of lean management and six sigma, using several techniques, for example, define, measure, analyze, improve, control, and just-in-time but most importantly emphasizing employees' responsibilities for process quality. Lean thinking and six sigma were also combined in health care to tackle the spiraling health care costs and improve quality while cutting down on waste. An example, where this was applied was Red Cross Hospital in the Netherlands in 2002, which led to the development of processes for institutionalized systematic innovation. A more specialized development in the quality control tradition is the development of Capability Maturity Model by Software Engineering Institute in the early 1990s to determine the extent to which organizations understand their processes, with several examples of application in health care. The model is comprised of five levels, namely, initial, repeatable, defined, managed, and optimizing with the latter being the top level found in successful companies like Toyota and GE, whereby managers and team members continuously work to improve their processes.

The beginning of the management tradition can be traced back mainly to Ford and Taylor. However, the academic origin dates back to the 1980s with Porter's value chain, which supports a product line, a market, and its customers, and Rummier-Brache Performance Improvement, which integrates three levels of analysis (organizational, process, and performance levels) with concerns on measures, design and implementation, and management. The 1990s are characterized by the emergence of Business Process Reengineering (BPR) that motivated senior executives to rethink their business strategies. An example where BPR principles are applied in health care is a case study in Canada, where improvement projects were carried out through ehealth and IT to address patient's waiting times, medical errors, high health care costs, and access to health care. Additionally, Kaplan and Norton designed the Balanced Scorecard (BSC), which is a continuously evolving strategic performance management tool to reflect the deficiencies in the currently used methods and to satisfy the particular needs of communities of interest. The first-generation of BSC designs, which mainly satisfied the needs of nondivisional commercial functional organizations, used a four-perspective approach as strategic performance metrics of success, namely, financial, customer, internal business processes, and learning and growth. An improved second-generation emerged in the mid-1990s with measures selected based on the strategic objectives within each of the perspectives, which then define the cause–effect chain among these objectives by drawing links between them to create a "strategic linkage model". A third-generation of BSC, which emerged in the late 1990s, refined the second-generation to give more relevance and functionality to strategic objectives through the incorporation of Destination Statements, namely, to show what "strategic success" or the "strategic end-state" looked like. BSC has been extensively used in health care by a wide range of health care organizations; however, it had to be modified to include perspectives, such as quality of care, outcomes, and access. Furthermore, as part of the management tradition, BPM, Process Frameworks, and Business Process Architectures also emerged in the late 1990s.

The third tradition involves the rapidly evolving IT, namely, through the use of computers and software applications to automate the work processes. This tradition, which spans over 4 decades, completely revolutionized the thought and decision processes in organizations. Perhaps, the major change happened in 1995 with the emergence of the Internet and the Web, such that a paradigm shift occurred from thinking about computers as tools for automating internal business processes to using IT as communication tools that facilitated radically new business models with worldwide integration. Jobs have become more dependent on processes with IT largely operating independently of the core business and conceptualizing itself as a service. The approaches within the IT tradition are numerous and include Structured Software Methodologies, IT Architecture, BPR (Hammer and Davenport emphasizing BPR within IT rather than management tradition), Computer-Assisted Software Engineering Tools, Enterprise Architecture, Business Process Modeling Tools, Object-oriented Software Methodologies, Unified Modeling Language, Business Process Model and Notation, Enterprise Application Integration, Workflow, Business Process Management Software, Enterprise Planning Enterprise, Customer Relationship Management, Expert Systems, Business Rules, and Business Intelligence Tools. Faced with these major advances in IT, organizations strived to assure that business, and IT managers engage in process-focused discussions, and that they embrace a common and comprehensive understanding of process. Despite the fact that many organizations continue to work largely within one of the three traditions, BPM appears to embrace all three traditions.

Health informatics has grown over the years, establishing itself as one of the pillars in the delivery of quality health care. An area of major advancement is in medical imaging technology, namely, picture archiving and communication systems, information systems, image-guided surgery and therapy, computer-aided diagnosis, decision support systems, and the electronic patient record.

It seems that the health sector is still building the body of evidence on the clinical impact of picture archiving and communication system in the working environment that justifies the investment. However, the use of noninvasive digital imaging systems in clinical application is an important consideration (Figure 2).

Figure 2 Historical development of BPM.

Abbreviations: BPM, business process management; IT, information technology; TQM, Top Quality Management; CQI, continuous quality improvement; PCs, personal computers.

In the health care applications discussed earlier, BPM is heralded as a means to improve processes but with the ultimate aim of improving the quality of health care delivery across health systems. Therefore, we will justifiably turn our focus to quality of care and argue in favor of processes without losing focus on the fact that they should be understood as part of a whole system.