1 Revista de Dirección y Administración de Empresas. Númer 20, diciembre 2013 págs. 1-8 Enpresen Zuzendaritza eta Administrazi Aldizkaria. 20. zenbakia, 2013 abendua 1-8 rr. PROCESS MANAGEMENT IN HEALTHCARE. SANT CAMIL HOSPITAL CASE STUDY LIDIA SÁNCHEZ RUIZ Departament Administración Empresas (FPU) Universidad de Cantabria BEATRIZ BLANCO ROJO Departament Administración Empresas Universidad de Cantabria ROSA MARÍA SIMÓN Respnsable de Calidad Hspital Sant Camil ABSTRACT Nwadays due t the crisis, sme gvernment measures are aimed at reducing healthcare spending, affecting in sme level r anther the quality ffered. Prcess management is said t be a useful tl fr reducing healthcare csts by imprving management withut any additinal ecnmic investment. That is ding mre with the same resurces and withut reducing the quality ffered. In this study an empirical case f a Catalan hspital is presented. Overall, the usefulness f prcess management in the healthcare sectr is shwn and sme tips are prvided fr thse managers that want t implement this management system in their hspitals. This wrk is als interesting fr thse managers respnsible fr the Natinal Healthcare System due t a big questin is stated: what wuld happen if prcess management was implemented in the whle healthcare system? Keywrds: prcess management, healthcare, quality, case study. JEL Cdes: M10; I19. 1
2 LIDIA SÁNCHEZ RUIZ, BEATRIZ BLANCO ROJO, ROSA MARÍA SIMÓN 1. INTRODUCTION In recent decades, the percentage f Grss Dmestic Prduct (GDP) that the different cuntries f the Organizatin fr Ecnmic Cperatin and Develpment (OECD) have allcated t health has risen steadily. At the same time there has been an increase in health spending, amng ther reasns due t the need t ffer higher quality services t patients (Helfert, 2009). In the Spanish case, health spending has dubled ver the decade And, during the perid, it increased 16% t an amunt equal t 5% f nminal GDP in In 2010 the figure had already increased by ne percentage pint which, added t the private health expenditure, stands ttal health spending at 8% f GDP (Rubia Vila, 2011). The causes fr this increase are many and varied, in additin t thse mentined, ther reasns are: the aging ppulatin, the phenmenn f immigratin (althugh during the last year is prducing the ppsite ppulatin mvement) r the universal cver care, amng thers. With the advent f the crisis the situatin has wrsened and sustaining the system with its current characteristics is in dubt, as evidenced by the recent measures taken by the Spanish gvernment in this area, riented t reducing healthcare csts and seeking new frms f financing. In this scenari, prcess management is presented, therefre, as a tl fr reducing csts while keeping quality at the same level. This aim is very attractive in crisis time, especially in the Spanish case where healthcare services are publicly financed. Bearing this in mind, the aim f this paper is t present a case study that allws, n ne hand, t reaffirm the usefulness and validity f prcess management in hspitals and, n the ther hand, t present the different stages fllwed in the implementatin s that it culd be used as a guide fr thse hspitals that were interested in prcess management. 2. PROCESS MANAGEMENT IN HEALTHCARE Prcess management is a way f rganizing and running a business aimed at all kinds f cmpanies that simultaneusly pursues an increase in crprate efficiency and an increase in custmer satisfactin. The aim is t create added value fr the custmer by managing the cmpany s prcesses apprpriately. The rigin f prcess management ges back t the 1980s when, kick-started by Japan, tw new management philsphies emerged: Just in Time (JIT) and Ttal Quality Cntrl (TQC). The tw idelgies advcated a prductin system that is mre in tuch with custmers needs and the reductin f prductin defects and waste (Flynn, Sakakibara & Schreder, 1995). These tw new appraches refcused business activity, redirecting cmpanies twards custmer satisfactin and incrprating the cncept f quality as a strategic element fr cmpetitiveness that affects the quality f the prduct, service, delivery, price, management etc. (Pérez Fernández de Velasc, 2004). In this cntext, the traditinal functinal structures present in the majrity f cmpanies, characterised by being rganized int departments with highly specialised 2
3 PROCESS MANAGEMENT IN HEALTHCARE. SANT CAMIL HOSPITAL CASE STUDY hmgenus functins, based n hierarchy, cntrl, frmalism and bureaucracy, became insufficient due t their lack f flexibility (Pérez Fernández de Velasc, 2004). Anther reasn that led t the emergence and spread f prcess management was the drastic change in the cnditins f the business envirnment (glbal markets, increased unpredictable markets, cntinuus changes, custmer rientatin, greater cncern fr quality, mre demanding custmers). Therefre, nwadays, prcess management is part f the basis f the mst mdern management philsphies (Lean Management, thery f cnstraints, mass custmizatin) and it is a requirement t cmply with many quality certificates (ISO 9000, EFQM, Malcm Balbridge). As it happened at the turn f the twentieth century with mass prductin, the autmtive industry has pineered the implementatin f this kind f systems (Just in Time prductin, Lean Management, Cntinuus Imprvement) (Wmack, Jnes & Rs, 2007; Wmack & Jnes, 2005). Hwever, as time ges by, mre and mre cmpanies and sectrs are advcating fr prcess management techniques. The health sectr is just ne f the sectrs where prcess management is becming mre imprtant fr its applicatin in hspitals (Ben-Tvim, Bassham, Blch & Martin, 2007; Leu & Huang, 2011). In fact, there are numerus studies that present the implementatin f prcess management in hspitals (see (Helfert, 2009; Leu & Huang, 2011; Varkey & Kllengde, 2011; de Mast, Kemper, Des, Mandjes & van der Bijl, 2011; Gemmel, Vandaele & Tambeur, 2008; Bertlini, Bevilacqua, Ciarapica & Giacchetta, 2011)). In this paper we present a cncrete experience f implementatin f prcess management in a hspital, thus prviding new empirical research t the field. 3. SANT CAMIL HOSPITAL CASE STUDY 3.1. Case Study Sant Camil Hspital is lcated in Sant Pere de Ribes (Barcelna, Spain) and it was funded in It is a reference hspital in the regin and it is integrated within the Hspital Netwrk f Public Use. The hspital has 159 beds distributed in seven inpatient units: surgery and surgical specialties, rthpaedics, paediatrics, intensive care, gynaeclgy and bstetrics. In additin, the hspital has several central services such as emergency rm, perating rms, anaesthesia and resuscitatin, pain unit, day hspital and utpatient. Additinally, tgether with the Sant Antni Abat Hspital lcated in Vilanva I la Geltrú (Barcelna, Spain), it integrates the Garraf Health Cnsrtium. In fact, it was the merger f bth in 2009 what mtivated the implementatin f a prcess management system. After the merger, the management team realized that each hspital had its wn prcesses and prcedures. While they were quite similar, the differences -thugh smallcaused management and crdinatin prblems. The cllectin f infrmatin was dne thrugh several surces. Firstly, the Quality, Planning and Evaluatin Manager f the hspital was interviewed. Secndly, a 3
4 LIDIA SÁNCHEZ RUIZ, BEATRIZ BLANCO ROJO, ROSA MARÍA SIMÓN visit t the hspital was made in rder t bserve sme f the mst visible results derived frm prcess management implementatin. Thirdly, t cmplement the infrmatin frm the interview, sme infrmatin was taken frm the Strategic Plan and ther dcuments that the Quality Manager prvided Implementatin phases Once the decisin f implementing prcess management was taken, the phases fllwed were: setting f the visin, missin and values fr bth hspitals; training; identificatin and descriptin f prcesses; establishment f indicatrs and imprvement. Belw we briefly describe each f the phases: Setting f the visin, missin and values fr bth hspitals When it cmes t establish the three terms, it was decided t d it as participatry as pssible. Thus, members f several grups frm bth hspitals (dctrs, nurses, management team...) wrked tgether t establish the missin, visin and values. The frmatin f these grups imprved the existing wrking relatinships between members f the tw hspitals that, until the merger, had belnged t cmpeting hspitals. As a result the implementatin prcess in the later stages was favured. The results f these meetings were set ut in the Strategic Plan f the hspital, which is revised annually and available n its website (http://www.csg.cat/nsaltres/plaestrategic/). Precisely ne f the main pririties set ut in the strategic plan was the analysis and definitin f prcesses. Training The next step was t train representatives f the different grups that wrked in bth hspitals. Six grups were established, divided in turn in different teams. These teams gathered peple frm different prfessinal grups (dctrs, nurses...), wrking in the same prcess. Training was given in tw phases. In the first phase theretical cncepts f quality (evlutin, Deming imprvement cycle, ISO 9000:2000, EFQM...) and prcess management (key bjectives, prcess wner, prcess map, prcedures, graphical representatin f prcesses, prcess imprvement, indicatrs...) were taught. The aim was t give participants a basic knwledge t enable them t perate better and als establish a cmmn wrking language t avid misunderstandings and waste time at later stages. The secnd stage f training was practical riented. Each team had t apply the knwledge acquired and prceed t the definitin f the actual prcess in which they wrked. 4
5 PROCESS MANAGEMENT IN HEALTHCARE. SANT CAMIL HOSPITAL CASE STUDY Identificatin and descriptin f prcesses The first descriptin f the prcess undertaken by the varius teams was reviewed by the quality management team. They were respnsible fr checking that the infrmatin was cmplete and, if it was nt crrect, they asked the respnsible team t cmplete the descriptin with the apprpriate infrmatin. The descriptin f each prcess shuld include the fllwing infrmatin: Date f the dcument Start and end f the prcess Custmers and suppliers What is dne in the prcess (target utput) Hw the prcess is carried ut (methd) Prcess indicatrs Standard r reference value f these indicatrs Frequency f review r indicatrs Establishment f indicatrs As it was nted in the previus sectin, the infrmatin abut the prcess shuld cntain infrmatin n prcess indicatrs. The type and number f indicatrs was nt previusly established but each team, depending n their experience, shuld identify as many indicatrs as they cnsidered. Hwever, hspital quality managers checked that amng the indicatrs established were thse required by the Catalan Health Department. Since the hspital had accreditatin frm the Catalan health system, sme indicatrs were already identified and autmatically measured. In this case the data were entered directly int the screcard. The screcard had been specifically designed and created t meet the specific needs f the centre. On the ther hand a newly defined set f indicatrs which were nt yet cmputerized were traditinally cntrlled. And finally, there were sme prcess indicatrs that are nt yet cntrlled. In these cases, actins t imprve the prcesses in questin have fcused precisely in this sense. Prcess imprvement Once the prcesses were identified and described, the next bjective f the hspital was t imprve them. In rder t d it, the management team decided t use Lean Management philsphy. The first cntact they had with this management philsphy went thrugh his manager wh had previusly had a successful implementatin experience at anther centre. Their first decisin was t frm a "facilitatrs grup". This grup wuld receive full training n Lean Management and wuld be respnsible fr assisting and supprting the ther members when implementing Lean Management. The training this time, unlike in the previus stage, wuld be delivered by an external advisry grup specialized in Lean Management in different sectrs. The grup f facilitatrs was integrated by 16 peple belnging t different services f the hspital and als t different categries. All but tw have been chsen by tp management because they were cnsidered the best suited t receive training and act as drivers. The ther tw peple have signed the grup n a vluntary basis because they, due t persnal circumstances, knew the Lean methdlgy and its advantages 5
6 LIDIA SÁNCHEZ RUIZ, BEATRIZ BLANCO ROJO, ROSA MARÍA SIMÓN and they were very interested in participating in this new experience. Having peple persnally invlved is a gd thing because their enthusiasm is an invaluable tl in persuading the ther members and invlving them in the new philsphy. Currently the hspital is in its training phase s this is the last phase t explain s far. Hwever, in parallel t training, they have been making sme imprvements fcused n reducing the existing stck using a KANBAN system and analysing the surgical time. This analysis cnsisted f breaking dwn all the activities perfrmed by prfessinals frm the surgen did the last stitch until the surgical incisin f the next patient was dne, calculating the time required and perfrming a precedence diagram t rganize the activities Barriers and benefits The way thrugh prcess management and prcess imprvement has nt been easy and it has required that all members f the hspital, especially thse wh have been invlved in wrk teams, t make effrts and t invest time t get it. In additin, thrughut the implementatin sme bstacles that have impeded r delayed the prcess have been faced. Cnducting a persnal interview with the tw highest quality managers f the centre, let us knw that the biggest barrier encuntered was the lack f time derived frm daily peratins. The secnd barrier was the internal resistance t change, derived in part frm the existence f tw cultures and tw different frms f management. And the third barrier was the traditinal structure f the cmpany. Despite these bstacles, the hspital managed t g ahead with the implementatin and, althugh its early develpment des nt allw us t d mre detailed analysis f results, quality managers have managed t detect sme imprvements. One f the mst imprtant nes derives, precisely, frm stck cntrl that has resulted in a remarkable reductin f inventries. Fr example, in the area f pharmacy stck value has been reduced frm 1.2 millin t 0.4 millin, maintaining the same level f care and the same level f quality. The ther imprvement, wrthy f mentin, was related t the analysis f the surgical prcess time. After the analysis, sme imprvements were made that reduced the average surgical time abut 62.5%. This has led t an increase f 12% n average the perating rms ccupancy acrss specialties, a factr that has helped t reduce the lists f peple wh are waiting fr surgery. Besides that imprvements, a psitive evlutin n the indicatrs included in the screcard have been detected. With these initial results, after the training perid, its aim is t fcus n prcess cntrl and imprvement. 4. CONCLUSIONS Prcess management, initially used in the manufacturing sectr, is becming increasingly cmmn in services, and specifically in hspitals. 6
7 PROCESS MANAGEMENT IN HEALTHCARE. SANT CAMIL HOSPITAL CASE STUDY In crisis time, where health care budget cuts are cmmn, it is interesting t knw a management system that allws us t d mre with the same resurces by ding a mre efficient use f them and always fcusing n the patient. The implementatin prcess is nt easy and requires active participatin frm all members f the rganizatin. It is imperative that managers and middle managers supprt the iniciative frm the beginning and encurage ther emplyees t actively participate. As in the case study presented, the existence f a grup f facilitatrs is recmmended. Given the undeniable rle that emplyees play in the success f the implementatin, it is necessary that they are aware f the usefulness f prcess management and its benefits. At this pint training is a key element. Due t reluctance t change is ne f the main barriers t implementatin, the training prcess shuld help emplyees discver the benefits f prcess management system, s that they participate knwing why and nt just ut f bligatin. It is true, hwever, that it is smetimes a matter f first seeing then believing, s it is advisable t make simple imprvements that shw the ptential benefits f the system in the initial stages. On the ther hand, althugh it is true that prcess management des nt invlve new ecnmic investments, it takes time. The management team, therefre, must be willing t invest and t let ther members f the rganizatin invest their time. The case presented validates the usefulness and applicatin f prcess management in the health sectr leading t the fllwing questin What if, instead f being used in islatin in a hspital, it is applied t the entire health system? Obviusly the effrts wuld be much greater, but s be the benefits. The prcess wuld be mre cmplex but ptential benefits may deserve it, especially in a scenari like the current ne where the sustainabily f the system is in dubt. Prcess management in cmbinatin with ther enhancement techniques such as Lean Management, as set ut abve, culd alleviate the effects the crisis is having n the health system. N claim is made here that this is a panacea as there are mre fundamental causes f the health system, hwever, prcess management can be a help, the beginning f change. One limitatin f this study is that the full cycle f implementatin has nt been analyzed because it is still nt cmplete. This causes that the ptential advantages f prcess management have nt been fully detected yet in this study, althugh this is a sign f the great ptential that remains untapped. Therefre, future research lines will be aimed at analyzing the results in greater depth and learn abut the next phases f implementatin. This will be achieved using a survey that will be cnducted amng hspital staff invlved in imprvement teams. Frm their respnses, we will be able t btain a mre cmprehensive view f the hspital experience expsing, in additin t the phases f prcess management implementatin, the benefits, barriers and drivers assciated with it. 5. REFERENCES BEN-TOVIM, D.I.; BASSHAM, J.E.; BOLCH, D. & MARTIN, M.A. (2007): Lean thinking acrss a hspital: redesigning care at the Flinders Medical Centre. Australian Health Review, 31 (1),
8 LIDIA SÁNCHEZ RUIZ, BEATRIZ BLANCO ROJO, ROSA MARÍA SIMÓN BERTOLINI, M.; BEVILACQUA, M.; CIARAPICA, F.E. & GIACCHETTA, G. (2011): Business prcess re-engineering in healthcare management: a case study. Business Prcess Management Jurnal, 17(1), DE MAST, J.; KEMPER, B.; DOES, R.J.M.M.; MANDJES, M. & VAN DER BIJL, Y. (2011): Prcess Imprvement in Healthcare: Overall Resurce Efficiency. Quality and Reliability Engineering Internatinal, 27(8), FLYNN, B.B.; SAKAKIBARA, S. & SCHROEDER, R.G. (1995): Relatinship between JIT and TQM: Practices and Perfrmance. The Academy f Management Jurnal, 38(5), GEMMEL, P.; VANDAELE, D. & TAMBEUR, W. (2008): Hspital Prcess Orientatin (HPO): The develpment f a measurement tl. Ttal Quality Management, 19(12), HELFERT, M. (2009): Challenges f business prcesses management in healthcare. Experience in the Irish healthcare sectr. Business Prcess Management Jurnal, 15 (6), LEU, J. & HUANG, Y. (2011). An Applicatin f Business Prcess Methd t the Clinical Efficiency f Hspital. Jurnal f medical systems, 35(3), PÉREZ FERNÁNDEZ DE VELASCO, J.A. (2004): Gestión pr prcess: cóm utilizar ISO 9001:2000 para mejrar la gestión de la rganización. Madrid: ESIC. RUBIA VILA, F.J. (2011): Libr Blanc sbre el Sistema Sanitari Españl. Madrid: Academia Eurpea de Ciencia y Artes. VARKEY, P. & KOLLENGODE, A. (2011): A framewrk fr healthcare quality imprvement in India: The time is here and nw!. Jurnal f pstgraduate medicine, 57(3), WOMACK, J.P. & JONES, D.T. (2005): Lean Thinking. Cóm utilizar el pensamient lean para eliminar ls despilfarrs y crear valr en la empresa. Barcelna: Edicines Gestión WOMACK, J.P.; JONES, D.T. & ROOS, D. (2007): The Machine that Changed the Wrld. Hw lean prductin Revlutinized the Glbal Car Wars. Great Britain: Simn & Schuster UK Ltd. 8
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