PROCESS MODELING OF THE HEALTH SECTOR USING

BPMN: A CASE STUDY

Elvira Rolón, Félix García, Francisco Ruiz, Mario Piattini

Department of Information Technologies and Systems

Indra-UCLM Research and Development Institute - University of Castilla-La Mancha

Paseo de la Universidad 4, 13071, Ciudad Real, Spain

Luis Calahorra, Marcial García and Rafael Martin

General Hospital of Ciudad Real

Ciudad Real, Spain

Keywords: Business Process, Health Sector, Modeling, Case Study.

Abstract: The importance of the analysis, modeling and management of business process is not restricted to a specific

enterprise sector. In the field of sanitary management, due to the nature of the service offered, sanitary

institutions’ processes are also the basis for decision making focused on achieving their objectives to grant

medical assistance of quality. In this work, we will present the application of business processes modeling

to the processes of an institution of the health sector, using the BPMN notation. The objective of this work

is to show our experience obtained in the elaboration of the conceptual models of some hospital processes

that can be used as a basis for others in the collaboration with hospitals for modeling their processes using

BPMN. Hospital processes are very complex, and with their graphical visualization, their management and

improvements are facilitated by means of the understanding and detection of possible failures.

1 INTRODUCTION

Business processes enable the activities of a

company to be described in a manner which is

understandable to all its users, with the purpose of

analysis and design. Design means explicitly

modeling, designing, simulating and redesigning the

process as the organization learns what is possible.

Due to the need to respond to competitive pressure

or to business opportunities, business analysts need

to restructure processes quickly (Smith et al., 2002).

In business process modeling the main concept is

that of the business processes themselves, which

describe the activities involved in the business and

how they relate to and interact with the necessary

resources to achieve a goal for the organization.

Some specific goals of business process modeling

are: (Beck et al., 2005; Erickson and Penker, 2000):

1. To ease the understanding of the key mechanisms

of an existing business, 2. To serve as a basis for the

creation of appropriate information systems that

support the business, 3. To improve the current

business structure and operation, 4. To show the

structure of an innovated business, 5. To identify

outsourcing opportunities and, 6. To facilitate the

alignment of business specifications with the

technical framework that IT development needs.

Similar to all types of organizations, in the health

sector it is vitally important to keep its business

processes up to date. This objective must not only be

achieved through the continuous improvement of the

services offered but also as a fundamental part of the

quality programs in which it is immersed.

Business processes in hospitals are very complex

and variable, due to the daily work which requires

frequent reactions to the interim results of diagnostic

processes as well as to unexpected medical

instructions. When comparing the business

processes in a hospital to the processes of other

business areas, certain characteristic properties are

evident, such as those pointed out by (Amberg and

Gräber, 1996): a high number of cooperating

organizational units, limited resources, a high ratio

of manual activities, most medical processes can be

173

Rol

on E., Garc

ıa F., Ruiz F., Piattini M., Calahorra L., Garc

ıa M. and Martin R. (2008).

PROCESS MODELING OF THE HEALTH SECTOR USING BPMN: A CASE STUDY.

In Proceedings of the First International Conference on Health Informatics, pages 173-178

 SciTePress

blueprinted only roughly in advance and details of

medical processes are frequently changed.

From the point of view of computer science, the

tendency of clinical practice is to move towards a

shared care environment in which knowledge of

clinical information systems (a combination of

technology, data and people) should include

definitions of all clinical processes’ aspects, as well

as the functions and responsibilities of the people

involved in them (Colreavy, 2000). In this line,

(Osterweil, 2006) argues that more precise and

comprehensive process definitions are more

effective bases for the kinds of definitive analyses

that lead to successful improvement efforts in a

more efficient manner.

Our interest is based on the conceptual modeling

of the health-care sector processes by using the

philosophy of business process models as a starting

point. There are several important works dealing

with this subject, such as those presented by

(Framiñán et al., 2004) and (Parra et al., 2005a;

Parra et al., 2005b) in which business process

modeling and simulation are applied to the health

sector, particularly in processes such as telemedicine

and hepatic post-transplant. On the other hand,

(Graeber, 1997) had already carried out a similar

work but on the basis of workflow management

systems for the design of hospital information

systems. In (Röhrig, 2002) an approach is presented

through which existing business process descriptions

are reused to analyze health care security

requirements. Additionally, in the literature there are

works related to business processes in the health

sector, for example the presented by (Anyanwu et

al., 2003) as well as (Habing et al., 2001).

In this work, we will present the application of

the Business Process Modeling Notation (BPMN)

for business process modeling in the health sector

with the aim of showing our experience in the

collaboration with the process modeling that can be

applicable to any institution in the health sector.

Our intention when modeling hospital processes

is that of facilitating the visualization and

understanding of the activities that are carried out in

the fulfilment of their mission. Another main target

is to make visible the current processes (as-is

models) for their analysis and comparison with the

target processes (to-be models). This is one of the

main problems that arise when clearly identifying

the logical sequence of the real processes and their

efficiency. This is due to the fact that, in most cases,

hospital employees carry out their activities

mechanically without having a theoretical basis.

This paper is organized as follows: In section 2,

the BPMN notation for business process modeling

will be detailed; in section 3 an overview of the

collaboration context will be shown and in section 4

we will describe and illustrate our first experience in

health-care process modeling. Next in section 5 we

will present some lessons learned from this work.

Finally, in section 6 some of the conclusions drawn

from this work will be put forward.

2 BUSINESS PROCESS

MODELING WITH BPMN

Business process models (BPMs) can be created or

presented by using many different techniques or

languages. These languages are very different from

one to another, since each one studies the processes

in a different way, depending upon the purpose for

which it was created (Dufresne and Martin, 2003).

Among the languages for modeling business

processes mentioned in the literature, special

attention must be paid to the following ones: IDEF 0

(FIPS, 1993), IDEF 3 (Mayer et al., 1995), UML

(Erickson and Penker, 2000), UML 2.0 (OMG,

2003), and BPMN (OMG, 2006).

We are particularly interested in BPMN because

its first goal is to provide a notation that can be

easily understood by all business users, from the

business analysts to the technical developers and

business people (White, 2004). Moreover, it

provides a graphical notation to express business

processes in a Business Process Diagram (BPD),

based on a flowcharting technique tailored to create

graphical models of business process operations

allowing the easy development of simple diagrams.

BPD is composed of two basic categories: the

first one is formed by core elements (Flow Objects,

Connecting Objects, Swimlanes and Artifacts) that

make it possible to develop simple process models

and a complete list of elements that allows the

creation of complex or high-level business process

models. Some of the BPMN elements for business

process modeling are shown in Table 1.

Table 1: BPMN notation elements.

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3 OVERVIEW OF THE

COLLABORATION CONTEXT

With the objective of analyzing the use of BPMN

notation in real cases, a multidisciplinary work

group was created. The group was composed of

software engineers from the Alarcos Research

Group of the University of Castilla-La Mancha

(UCLM) and health professionals and administrative

staff from the General Hospital of Ciudad Real

(GHCR) which is a part of the Health Care Services

of the Spanish region of Castilla-La Mancha.

The main interest of the GHCR group is to build

a state-of-the-art health care system, but it has faced

several challenges in the application of business

process modeling to health care processes. In this

context, a set of work objectives and methodology to

be followed were defined for each group. The

applied research method was Action-Research (A-

R). A-R is a collaborative research method aimed at

joining theory and practice between researchers and

practitioners by means of a process of a cyclical

nature. A-R is focused on new knowledge building

which must be useful in practice and which is

obtained through searching for solutions to real

situations (Avison et al., 1999). Given its qualitative

and cyclic nature, A-R is a very suitable method to

apply to organizations in order to promote the

continuous improvement of their processes. Being

most advisable for our study, this one was the

method that was selected.

On this basis, and in agreement with the research

method, our first move was to approach the GHCR

work team. The work in collaboration was carried

out in different phases that are detailed below:

Phase 1: The first phase was started with three

informative meetings that lasted three hours. In this

first meeting with the hospital manager and the

people in charge of the different areas of the

hospital, the objectives of the process were put

forward and a brief introduction to business process

modeling and its advantages were presented;

moreover team works were defined for choosing the

processes to be modelled. Later on, two other

meetings with the people assigned by the hospital

team work to be responsible for the collaborative

work took place.

Phase 2: In the second phase the personnel of the

hospital received a 20 hours intensive course. This

training session went into depth in the subject of

modeling and the techniques for business processes

modeling specifically BPMN notation, as well as in

the importance of Business Process Management.

Phase 3: In this phase the hospital work group

carried out meetings for the selection of three

possible processes with different degree of

complexity but equal importance level for the

institution. This selection was mainly based on the

following criteria:

• Processes must be well-known by all the

participants in the work group.

• The process must affect multiple departments

• Information technology was considered as an

essential tool during the workflow.

• Necessity of improvement of the process.

Phase 4: The next step was the definition of the

work method by the members of this group. With

the purpose of integrating the knowledge of the

different members of the team, a specific work

group was selected for each process, designing at

least one representative member for each subprocess

or affected organizational unit. Moreover, it was

necessary to carry out the compilation of

information, data and documents (such as textual

definition of the process, paper-based documentation

and electronic forms) that could be used for the

elaboration of the selected process models.

Phase 5: In this phase, two meetings of both

team works were carried out (GHCR and UCLM)

that lasted around 2 hours each. In these meetings,

the selected processes were: a) Programmed

Surgical Patient (PSP), b) incorporation of a new

employee, c) Citation process.

Phase 6: This phase consisted basically of the

development of the PSP process model. The way of

creation of the model was collaborative and

iterative. In order to achieve this goal, there were

necessary work meetings with the person in charge

of the process for the refinement of the model to be

carried out. Also interviews to some of the

participant roles in the process execution took place.

4 MODELING A HOSPITAL

PROCESS

In this work, we used the Business Process

Modeling Notation (BPMN) for the health care

sector processes modeling. We have selected this

notation because it is widely accepted and

recognized in the enterprise market due to the

easiness that it provides for the construction of

simple or high level processes. In this case, the

model has to be as simple, transparent and

understandable as possible for all the stakeholders in

the health sector.

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The process model presented in Figure 1 shows

at a high level abstraction the Programmed Surgical

Patient (PSP) process and the activities that are

carried out when a patient is admitted into the

hospital for the accomplishment of the surgical

treatment of an injury or a disease that has been

previously prescribed by means of diagnosis.

At the construction phase of this model a first

rough draft was elaborated on the basis of the

information that has been previously compiled

(textual description of the process, documents,

forms, etc.). Having elaborated a first version of the

conceptual model of the process, a meeting with the

stakeholder in charge of the process from the GHCR

work group was carried out.

Therefore, simultaneously, the construction of

the final model was possible, by means of the

process description by the group of users to obtain a

continuous feedback of the process. The

construction of the model presented in Figure 1 was

also possible thanks to the interviews made to the

departmental personnel (participant user group and

roles) involved in the process execution. By means

of these interviews users explained to the modeler

the work that they develop and the main activities

that are carried out throughout this health care

process. Once evaluated the PSP process model, the

development of this model in a lower level of

decomposition began. The first subprocess to

develop is that corresponding to the Surgical

Waiting List (SWL).

Similarly, for the construction of this subprocess

the necessary textual and documentary information

was compiled. Moreover, we have counted on the

collaboration of the person in charge of this

subprocess for its description and validation. The

obtained result is shown in Figure 2.

With the development of this first model, and

one of its subprocesses, it was possible to obtain the

As-is model of one of the most representative

processes within the sanitary service that offers the

participant institution.

The work done will be the reference model that

will serve as a basis for the construction of the “to-

be”models. The application of the BPMN notation

was very useful, since due to its characteristics; at

any moment the construction of the processes

models presented was facilitated for both participant

groups (of business and systems).

5 LESSONS LEARNED

In the development of the “as-is” models of the

process selected, there were some difficulties and

limitations, mainly the following ones:

• Due to the nature of the work in the health sector,

management in hospitals is oriented towards

functions and not towards processes. This is

because of the high degree of specialization of the

different activities which frequently are made up

of units with a high level of decentralization.

Figure 1: Programmed surgical patient process model.

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Figure 2: Surgical waiting list subprocess model.

• In the chosen process, diverse roles from different

organizational departments which also work with

certain degree of autonomy with respect to the

others take part. This fact represented a problem at

the time of efficiently designing the process.

• Variability of the process: Due to the fact that it is

applicable to all surgical services of the hospital

and to all patients who are going to take part in

any surgical pathology except for urgent surgery,

which entails many exceptions in decision

making.

• There were some discrepancies between the

participant professionals in the process at the time

of the description of its activities, which partly

reflects the absence of a model bases for the

process.

• When the roles of the active people in charge in

the process were not well defined a conflict was

generated in the identification of the activities.

• In some cases the asynchronous communication

by means of email was necessary.

Nevertheless, it is also important to emphasize the

advantages that the application of business process

modeling using BPMN in the health sector provides

such as:

• The most important aspect was than with the

training on BPMN that received the hospital staff,

they had a clearer vision of their processes and the

form in which they had to express it.

• Before creating the business process model, the

textual description of processes had not a clear

structure. After receiving the course, the personnel

from the hospital could develop a more structured

description of their processes in accordance with

our objective consisting of modeling them by

using BPMN.

• The process modeling serves as a reference as well

as a starting point for the documentation of the

processes that it carries out. In addition, the

process modeling is able to be the basis for the

certification of this process within the program of

continuous improvement of the hospital.

• Through the graphical representation of the

processes, the understandability of the model is

facilitated being in addition a basis for decision

making, as well as for redesigning future new

processes.

• Having the models of the processes facilitates the

incorporation and integration of new personnel

into the working areas and processes of the

hospital.

• Within the phase of analysis, some steps of the

process were clarified such as that stating that

members of the work group were different.

• It was possible to identify the different roles

interacting between themselves within the process.

• Being a practically recently opened hospital it has

inherited processes of the sanitary institutions that

previously formed it. This is the reason why the

design and modeling of its present processes come

to represent an evolution approaching the quality

of the service.

• With the detection of failures and bottle-necks in

the present process will allow us to take corrective

measures in the rules from this process, therefore,

facilitating the management of its processes.

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6 CONCLUSIONS AND

FURTHER WORK

In this work we have presented an example of the

application of business process modeling to the

health sector. The main objective is in the first

instance, to show on the basis of the accomplishment

of this work the experience acquired in business

process modeling applied to health sector processes

and with the active participation of hospital staff

(business people), and on the other hand to show the

results obtained in the modelled and graphical

visualization of some of their processes to starting

off mainly by the received training. Once the first

selected model was created, it was possible not only

to determine the utility of process models for

managing these processes but also to propose

improvements of the same.

The experience in process modeling using the

BPMN notation in the health sector has been

interesting and fruitful for the work group. In

addition, it was demonstrated that it is easily

applicable and also, that it would be easily

applicable in any other enterprise field and

simultaneously understandable by all the users of the

process.

This work and the lessons learned will be the

starting point for the development of the models of

those processes that the institution considers to be

the most relevant ones in the fulfilment of its

mission. Besides, this will allow the institution to

have reference models that will be, among other

things, the basis for: the certification within the

program of continuous improvement of the hospital,

the analysis and redesign of its processes, the

evaluation of the efficiency of the process, the

elaboration of hospital information systems, etc. In

future works, we will complete the three processes

chosen by the GHCR work group.

ACKNOWLEDGEMENTS

This work has been partially financed by the

ENIGMAS Project (Junta de Comunidades de

Castilla-La Mancha, Consejería de Educación y

Ciencia, reference PBI-05-058), ESFINGE Project

(Ministerio de Educación y Ciencia, Dirección

General de Investigación/Fondos Europeos de

Desarrollo Regional (FEDER), reference TIN2006-

15175-C05-05).

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