HEALTH CARE PROCESS MODELLING AND IMPROVEMENT
Nadja Damij
Faculty of Economics, University of Ljubljana, Kardeljeva ploscad 17, 1000 Ljubljana, Slovenia
Janez Grad
Faculty of Administration, University of Ljubljana, Gosarjeva 5, 1000 Ljubljana, Slovenia
Keywords: Process Modelling, activity table technique, process improvement.
Abstract: The paper discusses the problem of process modelling and aims to introduce a new technique called the ac-
tivity table to find a better solution for the problem mentioned. The activity table is a technique for process
modelling and improvement. Business process modelling is done by identifying the business processes and
is continued by choosing a process, defining its work processes and activities. Process improvement is
achieved by simulation of the activity table, suggesting changes and improvements, and giving solutions for
existing problems. To do this, we concentrate our work on understanding and analyzing the activity table. A
complete understanding of the activity table is an essential precondition to moving forward with the simula-
tion, which enables us to make improvements of the process modelled. The problem of conducting a surgery
is used as an example to test the technique.
1 INTRODUCTION
Business process modelling is a complex and difficult
problem. A process model, which truly represents
the business process discussed, is essential for carry-
ing out business process improvement and informa-
tion system development successfully. Business
process improvement became a very important way
of ensuring changes in an organisation's structure
and functioning in order to create better and more ef-
ficient processes which consequently lead to a com-
petitive and successful organization.
There are many methods and techniques which
cover the field of business process modelling. The
aim of this work was to introduce a new technique
called the activity table to develop a process model
which truly represents the original business process.
In Section 2, the problem of business process
modelling is discussed, different techniques and ap-
proaches which deal with this field are mentioned,
and the studies of a number of researchers are ad-
dressed. In this section, the activity table technique
is introduced. The activity table enables us to de-
velop a process model by linking each of the process
activities to its resource (performer). In Section 3,
business process improvement is stressed. This is
done by analysis and simulation of the process
model developed. The last section contains some
useful remarks and conclusions. The process is ap-
plied to a specific problem to illustrate the imple-
mentation of the technique.
2 BUSINESS PROCESS
MODELLING
The recent literature offers various definitions of and
the extent of a process or process modelling.
Throughout the last decades, the fields of business
process modelling and consequently business proc-
ess renovation have been gaining recognition and
acceptance. The reasons for such evolution are
found in the literature, academic publications and re-
search studies that deal with the theme, as well as in
the increasing involvement of consultancy and soft-
ware development companies. A comparative study
that closely examined 25 methodologies, 72 tech-
niques and 102 tools was conducted (
Kettinger et al.,
1997). Furthermore, business process modelling is
one of the requirements of the ISO 9000 interna-
tional standard for quality management and assur-
209
Damij N. and Grad J. (2008).
HEALTH CARE PROCESS MODELLING AND IMPROVEMENT.
In Proceedings of the First International Conference on Health Informatics, pages 209-214
Copyright
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ance (Ould, 1995). Both business process modelling
and business process renovation are based on the
fact that a business process is the key element in the
analysis of the organisation.
A process is defined as a structured, measured
sets of activities designed to produce a specified
output for a particular customer or market (Daven-
port, 1993). Hence, a process converts inputs by
summing their value through various activities into
outputs. A business process is a collection of activi-
ties that takes one or more kinds of input and creates
an output that is of value to the customer (Hammer,
1990). However, others stressed that a business
process is related to the enterprise, as it defines the
way in which the goals of the enterprise are achieved
(
Aguilar-Saven, 2003).
Successful business process modelling depends
on the appropriate selection of available modelling
methods, techniques or process flow analyses. There
are many techniques or analyses used in this field,
such as general process charts, process activity
charts, flowcharts, dataflow diagrams, quality func-
tion deployment, the integrated definition of func-
tion modelling, coloured Petri-nets, object-oriented
methods, seven management and planning tools and
so forth.
In this paper, we introduced a technique which
could be used to produce a process model that repre-
sents a true reflection of the reality of the process
discussed.
2.1 Activity Table
Business process modelling is a complex and diffi-
cult task. We are looking for a technique, which
could produce a process model that represents a true
reflection of reality.
The activity table is a technique for process
modelling, analysis and improvement. This is
achieved by identifying the business processes and is
continued by defining the work processes and activi-
ties of the process discussed. To do that, we have to
conduct interviews with the management at different
levels. The purpose of these interviews is to identify
the organization’s business processes, the work
processes related to each business process, and the
activities related to every work process identified.
The activity table uses the term “entity” to define
a user, group of users or other system of importance
in the organization’s functioning. An entity is any
source of information that is part of the system or is
connected with the system by some interaction.
Therefore, an entity may be internal or external. An
internal entity is inside the system and takes part in
the system’s operation. An external entity is not part
of the system, but it has one or more interactions
with the system (Damij, 2000).
A work process is the lowest-level group activity
within the organisation (Watson, 1994). A work
process is a collection of activities followed in a de-
termined order in carrying out distinguishable work
to produce a certain output.
The activity table is organised as follows: the
first column represents business process, the second
column shows work processes, the activities are
listed in the rows of the third column, and the enti-
ties are introduced in the remaining columns of the
table grouped by the departments to which they be-
long. Such organisation of the activity table enables
us to create a clear and visible picture of every busi-
ness process and its work processes, and also of each
work process and its activities (see Table 1).
Each activity occupies one row of the table. A
non-empty square(i,j) links the activity defined in
row i with its source, this is an entity defined in col-
umn j. Developing the activity table is a result of in-
terviews organised with the internal entities defined
in the columns of the table. In the rows of the activ-
ity table we first register each activity identified dur-
ing an interview and then link this activity with the
entities in the columns, which cooperate in carrying
it out. To make the activity table represent the real
world, we link the activities horizontally and verti-
cally. The purpose of defining horizontal and verti-
cal connections is to define their similarity to the
real world in which they occur.
Horizontal linkage means that each activity must
be connected with those entities in the columns
which are involved in it. To indicate this, symbols □,
◊, → and ← are used. Symbol □ or ◊ in square(i,j)
indicate that entity(j) is a resource of activity(i),
where j ranges from 1 to the number of internal enti-
ties and i ranges from 1 to the number of activities.
An arrow drawn from square(i,j) to square(i,k) indi-
cates an input enters activity(i) from another activity
performed by entity(j), where i ranges from 1 to the
number of activities, j and k rang from 1 to the num-
ber of entities, and j≠k.
Vertical linkage is used to define the order in
which the activities are performed. Vertical linkage
is used only in connection with the internal entities.
This is achieved by using arrows ↑ or ↓ to connect
the activities.
An arrow ↑ or ↓ from square(i,j) to square(m,j)
means that activity(i) is a predecessor to activity(m).
Two activities, which are not indicated in the same
column, may be connected by horizontal and vertical
arrows. For example, to connect square(i,j) to
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square(i,k), we use two arrows. A horizontal arrow
to connect square(i,j) to square(i,k) and then a verti-
cal arrow ↓ to continue from square(i,k) to
square(m,k). This means that activity(i) is a prede-
cessor to activity(m), which is performed by en-
tity(k). Of course, these two horizontal and vertical
arrows can be replaced by a diagonal arrow from
square(i,j) to square(m,k).
The main difference between the introduced
technique and others is that this technique requires
linking each activity defined in the rows of the activ-
ity table with its resource (an internal entity) defined
in the columns.
Linking the activities with their resources in a
visual manner helps a great deal in identifying the
activities and tracing their order, which leads to dis-
cover the process as it occurs in reality, and enables
us to develop a model that is a true reflection of the
original process.
Surgery: The management of a clinic wished to
improve the “Surgery” process by making it more
efficient and less time consuming.
The process Surgery leads the patient, who needs
to have surgery, through a number of activities in
different departments of the hospital such as Recep-
tion Office, Clinic, Laboratory, X-Ray, Anaesthesia
and Surgery Block.
The process “Surgery” was modelled using the
activity table technique, see Table 1. This table
shows that process Surgery consists of 4 work proc-
ess, which contain 36 activities.
2.2 Property Table
As we develop the activity table we simultaneously
develop another table, the property table, which is
very important in describing activities in detail. So,
for each activity inserted in the activity table, we
open a new row in the property table, which shows
detailed information about this activity.
The property table is organized as follows: the
activities are represented in the rows of the table and
the characteristics of the activities are defined in the
columns. Description:
this is used to write a short
description of the activity defined in the current row
of the table.
Resource:
this is used to determine the entity,
which performs of the activity defined in the current
row of the table.
Time:
this is used to denote that the activity dis-
cussed needs a determined time to be accomplished.
Time may become a very useful parameter should
we wish to use it to improve business processes.
Rule:
this is used to define when performance of
the activity requires that one or more rules must be
fulfilled. Rule is a precise statement that defines a
constraint, which must be satisfied in order for a cer-
tain activity to be executed.
Input/Output:
this is used to indicate which in-
puts or outputs are connected with the activity de-
scribed.
Cost
: this is the sum of the costs of the resources
needed to accomplish an activity. This parameter is
used to calculate the cost of work and business proc-
esses and therefore is important in improving busi-
ness processes.
Developing the activity and property tables is an
iterative process. Some of the interviews have to be
repeated to arrive at a precise understanding of the
user’s work. If anything is misunderstood, then we
have to organize new interviews with the responsible
users until everything is clear.
Surgery: Because of space limitations, only ten
activities defined in the activity table are described
in detail in the property table, Table 2. The values
shown in the column Time in Table 2 are approxi-
mate values obtained from the medical staff. Unfor-
tunately, we could not get any information concern-
ing the costs of the listed activities from the
management of the hospital.
3 PROCESS IMPROVEMENT
The aim of process improvement is to improve the
organisation’s processes in achieving greater cus-
tomer satisfaction by developing, reforming and ad-
vancing their quality, effectiveness, availability, and
in lowering the cost of business processes within the
organisation. Also, process improvement helps in
increasing the efficiency of the process, improving
customer service, sharing data and information, ef-
fectively deploying information technology, and re-
ducing duplicate processes.
According to Harrington et al. (1997) a great deal of
effort is being focused on continuous improvement
of subprocesses, activities, and tasks. If the man-
agement of the organisation stops the evolution of
the process once process improvement has been
completed, the organisation will lose the value
gained. Consequently, continuous improvement
tasks need to be performed and as a result, as stated
in Harrington et al. (1997), this should result in a 10
– 15 % yearly ongoing improvement in the process.
HEALTH CARE PROCESS MODELLING AND IMPROVEMENT
211

Table 1: Activity table of the process "Surgery".
Entity 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Activity
Reception Office Clinic X-Ray Surgery Block
Surgery
Registration
1. Register
patient
2. Forward
patient
HospitalizationCarrying out Surgery
Business Process
Work Process
Lab Anaesthesia
Nurse Doctor Nurse-In Doctor Doctor
Department
Anaesthetist Surgeon Patient
4. Send
blood
3. Examine
patient
Nurse-Cl Surgeon Technician
5. Test
blood
6. Forward
blood
findings
7. Decide
type of
treatment
8. Issue a
release
report
9. Order
hospitali-
zation
10.Accept
hospitali-
zation order
11. Prepare
examination
order
12.Make x-
ray
examination
13. Create
anaesthetic
report
14. Forward
medical
findings
15. Analyze
findings
16. Decide
on surgery
17. Explain
surgery
18.
Schedule
surgery
19. Get
information
for
anaesthesia
20. Sign
documents
25. Wake
up patient
26. Post-
surgery
recovery
21. Wait for
surgery
22. Prepare
patient
23. Carry
out
anaesthesia
24. Carry
out surgery
YES
NO
YES
NO
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Table 2: Property table of the process "Surgery".
Characteristic
Activity
Description Resourse Time Rule
Input/
Output
Cost
1. Register patient
Nurse in Reception Office accepts
patient’s medical card, Doctor’s or-
der, registers her/him
Nurse
10 min
Check medical
card validity
Doctor’s
order, Medical
card
2. Forward patient Forward the patient and patient’s
documents to the doctor
Nurse 5 min
Medical card
3. Examine patient Doctor in Reception Office exam-
ines the
Patient
Doctor 10-20
min
Check patient
medical record
Medical
record
4. Send blood
Nurse in Reception Office takes pa-
tient’s blood sample and send it to
Laboratory
Nurse
10 min
Indicate needed
blood examina-
tion order
Blood
examination
order
5. Test blood
Technician in Laboratory tests blood
example and sends results back to
reception office
Technician
30 min
Check blood
examination order
Blood exam.
order, blood
findings
6. Forward blood
findings
Nurse in Reception Office prints pa-
tient’s blood findings and gives it to
Doctor
Nurse
5 min
Blood
findings
7. Decide type of
treatment
Doctor in Reception Office decides
for a
conservative treatment or for sur-
gery after analyzing blood findings
Doctor
10 min
Check blood
findings
Medical
record,Blood
findings
8. Issue a release
report
Doctor in Reception Office issues a
release report and prescribes needed
medications
Doctor 20-40
min
Prescribe
medications
Medical
report
9. Order
hospitalization
Doctor in Reception Office asks
Nurse to prepare hospitalization or-
der
Doctor
30 min
Hospitaliza-
tion order
10. Accept
hospitalization
order
Nurse in Clinic accepts hospitaliza-
tion order from Nurse in Reception
office to hospitalize the patient
Nurse
30-60
min
Check hospit
orders & register
the patient
Hospitaliza-
tion order
Entity 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Activity
36. Issue a
release form
35. Check
recovery
34. Resting
33. Treat
patient
32. Place in
Clinic
31. Check
recovery_IN
30.
Resting_IN
29. Observe
patient
Recovery
27. Place in
intensive
28. Treat
patient_IN
Anaesthetist Surgeon PatientDoctor
Surgery
Surgery Block
Nurse Doctor Nurse-In Nurse-Cl Surgeon Technician Doctor
Clinic Lab X-Ray Anaesthesia
Business Process
Work Process
Department Reception Office
HEALTH CARE PROCESS MODELLING AND IMPROVEMENT
213

The relationship between the essence of process
modelling and overall business effectiveness and the
efficiency of the organization depends on the con-
sumer’s satisfaction with the desired output. If the
latter is everything the consumer required and aimed
for, business processes are well-designed, efficient,
as well as effective and will in time result in suc-
cessful organizations (Aguilar-Saven, 2003). On the
other hand, if the consumer lacks appropriate satis-
faction or the organization’s growth and profit are
decreasing, it is crucial to understand that improve-
ment of business processes has to be planned and
carefully carried out.
The goal of process improvement is achieved by
simulation of the process presented in activity and
property tables in order to suggest changes and im-
provements, and giving solutions for existing prob-
lems.
3.1 Simulation
Business processes are modelled with the aim of
analyzing their current states within the organiza-
tion, as well as improving them through the execu-
tion of potential “what-if” simulation scenarios.
Simulation modeling according to Pidd (1998) is
based on very simple principles: the analyst builds a
model of the system of interest, writes a computer
program which embodies the model and uses a com-
puter to initiate the system’s behaviour when subject
to a variety of operating policies.
Simulation is the imitation of the operation of a
real-world process or system over time (Banks et al.,
2001). A simulation model enables the analyst to ob-
serve and study the system’s behaviour as it ad-
vances through time.
Surgery: We ran the simulation of the process
“Surgery” shown in Table 1, taking into considera-
tion a Clinic for abdominal surgery with a capacity
of 30 beds. We simulated the process “Surgery” with
20 patients, who were already in the Clinic in differ-
ent phases of the process, and with 30 patients who
were scheduled for different operations. In addition
to this, we postulated that 3 patients, from the
planned 30 patients were hospitalized every day.
4 CONCLUSIONS
The aim of this work was to study the possibility of
developing an effective technique for carrying out
business process modeling and improvement. The
technique has to enable the analyst to develop a visi-
ble and comprehensible model, which represents a
true reflection of the real business process. This fact
is essential in making the task of process analysis
and identification of the necessary changes possible,
so as to carry out a successful business process im-
provement.
We are certain that including resources (entities)
in the process model is a new and important addi-
tional modelling dimension, which makes the mod-
elling process easier and more precise.
To continue with the improvement of the busi-
ness process “Surgery”, Table 1 was transformed
into a diagram of iGrafx software to run a simulation
of the process. The results of the process simulation
are very encouraging and show that the process
“Surgery” is well planned and does not have major
problems. Nevertheless, the process could be im-
proved by shortening the time of 2.94 days spent be-
fore surgery. Some of the medical examinations
could be done before hospitalization and also the
time of waiting for surgery could be shortened. We
are aware that these suggestions cannot be general-
ized for all patients, but they are good points for the
medical staff to rethink.
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