Improving Supply Chain Management in Public Health and Social Care

Improving Supply Chain Management in Public Health and Social Care
Services with an Agile BPM Approach
Jukka Korpela 1, Kalle Elfvengren 1, Tanja Kaarna 2, Merja Tepponen 2,
Markku Tuominen 1
1
Faculty of Technology Management Lappeenranta University of Technology Skinnarilankatu 34,
FI-53850 Lappeenranta, Finland
[email protected], [email protected], [email protected]
2
South Karelia District of Social and Health Services,
P.O. Box 24, 53101 Lappeenranta, Finland
[email protected], [email protected]
Abstract
This paper presents a case study of implementing new supply chain processes and solutions for patient
placement in the South Karelia District of Social and Health Services (Eksote). Eksote is a forerunner in health
and social care services development in Finland as it combines primary and secondary health care, elderly care
and social care in a totally new way covering eight municipalities that were earlier working independently.
The paper describes how an agile Business Process Management (BPM) approach was utilized for developing
new operating models and supporting process solutions for the short term and long term patient placement
processes. The focus of the short term placement process is to relocate patients from the central hospital to bed
wards at the general practices while the long term placement process aims to place elderly persons to suitable
wards or retirement homes. The BPM approach is based on agile development where end user involvement is
essential in order to capture the true needs and requirements of the users.
The paper describes the empirical experiences received both about the BPM-based development process and
about the actual usage of the solutions in daily operations. On an annual level, thousands of patients are placed
by using the developed solutions which have proved to improve both the efficiency and the effectiveness of the
supply chain operations significantly.
Keywords: supply chain management, SCM, public health care, agile BPM, Business Process Management
1.
Introduction
The public health care and social services sector in Finland is facing increased pressure to
maintain or even improve the service level while decreasing operating costs. Effective supply
chain management processes and supporting IT systems have a major impact on both the
service level and the operating costs, and thus focus must be put on these areas in public
health and social care organizations.
In South Karelia in South-Eastern Finland previously separate municipal health care and
social services (see Figure 1, stage 1) were integrated into a new organization called Eksote in
the beginning of 2010 (Figure 1, stage 2). Health and social services are now closely
integrated together in the South Karelia Region. Eksote combines primary and secondary
health care, care of the elderly and social care in a totally new way. Since then Eksote has
arranged services for its 8 member municipalities with approximately 130 000 inhabitants.
Eksote employs approximately 4 100 people and has a budget of 380 million euros.
The goal of Eksote is to increase the productivity of work by developing the processes
without decreasing the quality of care. Eksote aims to define a new process model based on “a
clean slate” so that the old municipal or organizational borders do not affect the planning
process. The professionals at Eksote are currently working together to create new client
oriented and cost-effective service processes that span over different professional areas. The
functionality of the developed processes is based on jointly agreed operation models and trust
between professions.
At this stage the service structure and electronic patient records have been integrated in the
area of South Karelia. Eksote aims at developing the integrated service structure further into
the next stage (Figure 1, stage 3), where the connections and ties between different actors
within the organization are clear and functional. Additionally, the goal of Eksote is to create a
partnership network and to strengthen flexible and client-oriented cooperation with different
actors, such as Kela - the Social Insurance Institution of Finland, the Employment and
Economic Development Office, the third sector, the private sector, and other municipal actors.
Integrated service processes are more functional, cost effective and client-oriented.
Figure 1. Eksote service structure development (SHC = Secondary health care, Mol = the
Employment and Economic Development Office, Kela = the Social Insurance Institution of
Finland)
The traditional way of thinking, stemming from units and municipalities has to be replaced
with comprehensive client and process -oriented thinking in order to ensure that the strategy
of Eksote will succeed. The new organization has to create commonly agreed operating
models which can steer all actors towards the common goal. In the traditional model, all
social and health care actors functioned in different organizations, and furthermore, the
services were arranged by ten different municipalities separately (Figure 1, stage 1).
Figuratively speaking, Eksote aims to turn the territories into resources. One of the most
essential functional goals is to reduce the use of institutional care radically. The client’s whole
care process has to be seen as one whole continuum which begins from home and continues
fluently back to home again (Figure 2). This requires seamless cooperation in the network of
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actors. Implementing the strategy requires turning the strategic goals into distinct practical
actions. Finding sufficient time for working on strategic goals and new common operating
models was found challenging in the new organization. Those in charge were well aware of
the development needs of the process in their own specialty areas. The development needs
were often connected to the interfaces between the previously separated organizational units.
Figure 2. Client-oriented service process
2.
Agile Business Process Management
Business processes are a fundamental component of any organization. A business process is
an activity or set of activities that will accomplish a specific organizational goal. Effective
setup, execution and development of business processes are essential to successful business
operations. Business process management (BPM) is a systematic approach to making an
organization's workflow more effective, more efficient and more capable of adapting to an
ever-changing environment. BPM is an approach to facilitating business processes that
involves organizations, people and technologies, and which can be executed with varying
levels of automation. The goal of BPM is to reduce human error and miscommunication and
focus stakeholders on the requirements of their roles. The trend is toward more flexible ways
of working, shorter organizational reaction times and fully embracing market and business
unpredictability, along with the increase in distribution and the need to preserve
understandability despite more and more complexity (Rimassa and Burmeister 2007).
Business processes have often been classified into two categories. The first concerns welldefined and often repetitive processes and they have also automation and coordination needs.
The second category concerns loosely structured processes which can be called knowledgeintensive. The essential preoccupation with the latter is the knowledge and information
sharing between the actors implied in the processes. Business processes of this category
require more flexibility. (Nurcan 1996; Nurcan 1998).
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The traditional BPM systems are using formal process models which are used to govern the
execution of business processes. These systems act as a centralized control hub, and invoke
functions in ERP systems and business applications based on a formal plan given by the
process model. (Schatten and Schiefer 2007)
Agile BPM provides automated and managed structures to provide repeatable business
processes, while at the same time, provides the ability to act immediately, in real time to
circumstances that are unforeseen in those processes. Agile BPM moves processes out of a
pre-defined and predictable processes box into handling difficult cases that elude traditional
formalized process management techniques. According to Schatten and Schiefer (2007) the
principles of agile BPM are: (1) empowering individuals by emphasizing flexibility and
responsiveness over efficiency and predictability (2) responding quickly and intelligently to
events in the business environment (3) give highest priority to sense and respond to customer
needs, and preferences in order to continuously deliver value to the customer. Agile process
management is not a technological challenge but a challenge in establishing suitable company
policies and culture. Employees have to be encouraged to try out new ways. (Schatten and
Schiefer 2007)
Serena Business Manager (SBM) is a business process management platform developed by
Serena (www.serena.com), a US-based software development company. SBM is being widely
used by companies and it has proven to enable quick and cost-effective implementation of
business processes. Serena has summarized the advantages of SBM (Serena.com). The most
important advantages are the following:
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•
•
•
With SBM, processes are designed with an intuitive drag-and-drop tool. After defining
the roles for the actors in the process, the designed process can be taken into use
immediately as SBM automatically generates a live, web-browser –based application.
Thus, application development is very quick and allows for an iterative approach in
refining the process.
SBM uses web services for seamless integration to the existing IT infrastructure.
SBM has extensive reporting features which enable process managers to analyze
process lead times and identify process bottlenecks. Every action by the persons
involved in a process is recorded with a time-stamp which gives total transparency to
the efficiency of the process.
Processes usually change and evolve over time, and SBM enables changes to be done
and implemented quickly. SBM has extensive change management capabilities
allowing process managers to track and manage process versions.
The author´s practical experience about process development with SBM has shown that the
SBM is applicable especially to human-centric processes. The implementation time has
ranged from a few days to two months depending on the complexity of the process. The
Serena software was utilized Eksote’s supply chain process development.
3.
Eksote supply chain network
Eksote is working to address the challenges brought by the increasing number of elderly
people and people potentially in need of care. The number of elderly people (aged over 75
years) in South Karelia will double in the next thirty years from approximately 10 000 in year
2010 to over 20 000 in year 2040. Eksote’s Elderly Care Services provides preventive care,
home care, home nursing, day activities and support services. Elderly Care Services arranges
also sheltered housing, housing at the nursing homes and care at the health center hospital bed
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wards. There are various regional health centers with bed wards across the area and one
central hospital in Lappeenranta (Figure 3). Eksote has about 700 acute and long term
hospital beds and approximately 1000 beds in different sheltered housing services and nursing
homes.
The integrated organization creates excellent possibilities for developing social and health
care services for a larger area as a single entity. Financial transactions between municipalities
regarding patient placement decisions are not needed and this is one of the reasons why a
centralized placement, Assess–Qualify–Place (AQP), model can be efficiently utilized by
Eksote. Instead of making the placement decisions locally, Eksote turned the problem into an
area-wide logistical question, how to fill available bed places at GPs with patients that have
the most urgent needs. Eksote formed a centralized AQP office that handles all the patient
placement decisions in the area.
Figure 3. South Karelia district of social and health care services
Eksote’s AQP office has handled all the patient placement decisions in the area since
November 2010. The AQP office uses Eksote`s common Electronic Patient Health Record
and Electronic Social Service Client system. The AQP office is responsible for both shortterm and long-term placements. The short-term placement process focuses on organizing
further care for patients that don´t need special health care in a hospital anymore. The longterm placement process focuses on organizing long-term care for elderly persons in retirement
homes, assisted living homes or long-term wards in hospitals either in publicly or privately
owned facilities.
The AQP office consists of multiple specialized discharge and placement nurses and social
workers who focus solely on patient placement. These AQP nurses assess the patients’ needs
and make the placement decisions instead of doctors and nurses in the wards. Different parties
have clear responsibilities and therefore the use of the professionals’ time is more productive.
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The queues shorten and customer needs can be taken into account better as the patients are
getting the needed treatment as quickly as possible. The benefits of this exceed the downside
of sometimes possibly having to be placed some 100 kilometers from home.
4.
The challenges in the short-term AQP -process
The limited amount of beds especially in the special health care wards caused a growing need
to pay attention to discharging patients home or to send them to receive further treatment to
GP bed wards as early as possible. The problem was that doctors and nurses lacked the
understanding of bed resource availability in the area. This resulted to a great amount of
inefficient point-to-point communication for finding a suitable further treatment ward for the
patients and too much time spent on non-care related activities.
The original short-term AQP -process was also too heavy and unstructured. There were no
clear rules or screening on who could be submitted to assessment. This caused lack of process
control and discipline. Information exchange happened through phone calls and e-mails and
proved to be time-consuming and stressful for each party.
At first, patient placements were handled by using an Excel-spreadsheet but it was not
adequate. It lacked up-to-date availability information of beds in GPs, overall control and
auditability of the process were at an unsatisfactory level, there were no clear ownerships and
roles in the process, process metrics were missing, and the data content was not properly
structured. The overall comparison between the original way of working and the targeted way
of working is presented in Figure 4.
Figure 4. Comparison between the original and targeted way of working (Roce Partners,
2011)
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5.
New process design and supporting computer solution
In order to improve the efficiency of the short-term AQP -process (Figure 5), Eksote made the
decision to utilize an agile BPM approach to develop a new computer-based solution for the
process. Based on earlier experiments, Serena Business Manager was selected as the platform
to build the new solution on. Eksote decided to utilize an external partner, ROCE Partners
(www.roce.com), to support in process and solution development.
Figure 5. Short-term placement process (Roce Partners, 2011)
The essential actor in the development project was the core project team that consisted of
about ten representatives of the special health care wards, the AQP office and the GP bed
wards. One external consultant was working intensively with the core project group. The
project consisted of the following main phases:
• Process definition: The most important phase of the project was the process definition.
The objective of this phase was to analyze the current short-term AQP -process, to
define the needed improvement areas and to agree on the new, improved process
design (Figure 6). The new process design formed the basis for the new computerbased solution. The process definition phase lasted about two weeks and consisted of
interviews of multiple stakeholders in addition to the core project team workshops.
• Solution development: Once the new process design had been agreed on, the external
consultant created the initial version of the computer-based solution with the Serena
Business Manager (SBM) within a couple of days. The initial version was used as the
basis for the iterative development process with the core project team. The core
project team had frequent meetings where they went through the existing version of
the solution and defined the needed changes, adjustments and additions. Based on the
core team feedback, the external consultant created a new version of the solution for
the core project team to review. This iterative approach to solution development
proved to be very efficient as the core project team was able to see a live system, to
give their comments and to see the impact of their feedback in the solution almost
instantly. The iterative solution development process lasts about three weeks.
• User acceptance testing and training: When the core project team was satisfied with
the features of the developed solution for the short-term AQP -process, the solution
was put into user acceptance testing. The objective was to test the usability of the
solution with a wider user group and to identify potential errors. As the core project
team had been able to work very closely with the solution for three weeks, the
developed solution proved to be quite well-working and no major errors or lacking
features were identified.
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•
User training and implementation: The user base for the short-term AQP -process
consists of about 500 persons, and thus the user training could have been an extensive
effort. However, the solution created with SBM proved to be so easy to use that a brief
2-hour introduction was basically enough for others but a few nominated key users.
The user roles in SBM-based solutions are so strictly and clearly defined that the users
can only see the functionalities they are allowed to access. Furthermore, the webbrowser –based user interface is very clear and intuitive and guides the user very
effectively. An illustrative example of the user interface is shown in Figure 7. The user
trainings took about two weeks in calendar time, and thus after eight weeks from the
start of the project, the new solution for the short-term AQP -process was successfully
implemented in the organization.
Figure 6. The process design for the short-term AQP process
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Figure 7. An illustrative example of the user interface (ROCE Partners, 2011)
The agile BPM- and SBM-based approach to the short-term AQP -process development
proved to be quick and cost-effective. Within a time span of 8 weeks, the new process design
was defined and a new computer-based solution was created and implemented. The main
success factor for the project was the iterative development approach which allowed the core
project team to have a constant impact on the developed solution. The design of the process
and the features of the solution were based on exact requirements and needs of the users, and
the SBM platform proved to be flexible enough to accommodate all of the user needs into the
solution. Another benefit of the iterative approach was that the core project team was not
required to finalize a set of requirements and specifications for the solution in one step but
their requirements were also allowed to evolve by seeing the various versions of the solution
over time. The feedback by the core project team was very positive at the end of the project as
they noted that for the first time they got a solution that exactly met their expectations and
requirements.
The utilization of the new solution started very smoothly in Eksote. Despite the big number of
users, there were only minor technical or user-related issues to be resolved. The change
management was handled efficiently and basically all users started using the solution from the
day one. Thus, the benefits of the system started to be seen almost instantly:
• The number of phone calls between the AQP office and the other actors in the shortterm AQP -process decreased dramatically. Information about the patients and
available beds in GP wards was visible to all parties in real-time through the new
solution, and thus phone calls were only needed in exceptional situations. The
decreased number of phone calls released lots of working time for more effective use
for all parties in the process.
• The effectiveness and lead time of the short-term AQP -process improved drastically
and the queues in the process practically disappeared. If there were queues, they were
caused by the fact that there were no available beds for placement and not by the fact
that the AQP office didn´t have time to process all patients in a timely manner.
• The created solution helped in clarifying the roles of each party in the process. The
computer-based solution didn´t allow any deviations from the intended role for any of
the actors, and thus the process was implemented according to the agreed design. This
is a major challenge in many organizations as defining a process is quite
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•
straightforward while the actual implementation of the process in the organization can
be quite slow and difficult.
The new solution gave transparency to the process and enabled measurability of the
process. All actions in the process are recorded with a time stamp, and thus the
duration of each process step and the overall process lead time can be measured. After
couple of months, there was already enough data to help in identifying the bottlenecks
in the process and to take corrective action. An illustrative example of process steps
can be seen in Figure 8.
Figure 8. An illustrative example of process steps (ROCE Partners, 2011)
6.
Conclusions
The agile BPM-based approach to the development of the new solution for the short-term
AQP –process was applied successfully in the South Karelia District of Social and Health
Services (Eksote). A new process design was defined and it was implemented by utilizing the
Serena Business Manager (SBM) software platform to create a computer solution for the
process. The development project was based on an iterative approach that enabled the users of
the process and the solution to ensure that the final outcome matches their specifications and
requirements exactly. The implementation of the new process and solution was executed
smoothly and the benefits of the new way of working started to be seen immediately. The new
solution decreased the time used on value-adding activities, improved the process lead time
and enabled overall management of the process.
The positive experiences and results from the short-term AQP process encouraged Eksote to
apply the agile BPM and SBM approach to other processes as well. Since the first process
implementation, new process designs and supporting SBM-based solutions have been created
in areas like the long-term AQP –process, the AQP-process for mental health care patients,
the AQP process in child welfare and even the diagnostics process of ADHD patients. Based
on wider discussions within the public health care and social services organizations in Finland,
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the agile BPM approach shows a lot of potential in improving the effectiveness of their
operations. Furthermore, we can assume that this approach is applicable to all public health
care and social services internationally.
References
Nurcan, S., 1996. A method for cooperative information systems analysis and design: CISAD.
Proceedings of the Second International Conference on the Design of Cooperative Systems,
Juan-Les-Pins, France, 12–14 June.
Nurcan, S., 1998. Analysis and design of co-operative work processes: A framework.
Information and Software Technology, 40(3), 143–156.
Rimassa, G., Burmeister, B., 2007. Achieving business process agility in engineering change
management with agent technology. Agenti e Industria: Applicazioni tecnologiche degli
agenti software, Genova, Italy, 24-25 September.
Roce Partners, 2011. AQP process presentation, internal report, www.roce.com.
Serena.com, 2012. Top ten reasons to leverage SBM, internet document,
http://www.serena.com/docs/repository/sbm/SBM-Solution-Sheet-November-2010.pdf.
Schatten, A., Schiefer, J., 2007. Agile business process management with sense and respond.
IEEE International Conference on e-Business Engineering, Hong Kong, China, 24-26
October.
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