Applying BPM for Improved Patient Care

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Many hospitals and other healthcare organisations have been using Lean Six Sigma methodologies for process improvement, but very few have adopted Business Process Management. But could that be about to change?

In this PEX Network interview, based on a recent Process Perspectives podcast, Cameron Keyes, Director of Care Process Management at Ottawa Hospital in Canada, discusses how the hospital has been piloting a new approach that makes use of BPM to help improve some of the processes around patient care.

Editor’s note: the transcript of the podcast has been edited for readability.

What are some of the process problems facing hospitals and healthcare more generally today?

Cameron Keyes: The processes we have were probably built and fine for the 50s, 60s, 70s, perhaps even the 80s as well. But they’re not suitable for the complexity we’re seeing today. Patients have prolonged lives and they’re living with many chronic diseases. As a result the kind of care they require involves large patient-care teams to look after them. The underlying processes in hospitals - and in healthcare in general - have not really adapted to the complexity required now to address the needs of the patients.

That’s one aspect. The other aspect - and in this I think healthcare may be similar to other industries as well – is that sometimes the technologies we’ve introduced in the past has in fact made the processes even worse. For instance, some of the technologies have taken providers (e.g. doctors and nurses) away from the point of care (i.e. the patient and the bedside). Now they have to go to nursing stations to find computers - that’s a problem.

Recently, however, technology has changed to help address this so we can get away from computers on wheels, and workstations on wheels, and have more mobile devices. That means patient care can actually be provided closer to the patient; in this respect still early days.

I think at root of all this is that we’ve not paid enough attention to what the business of healthcare is really about and ensuring that the technology and the underlying processes are optimised to deliver that. We don’t really marry people and processes and technology that well together in healthcare, as it just hasn’t been our focus.

Lean Six Sigma has been big within healthcare for quite a number of years now. Do you find that the process improvements brought by Lean Six Sigma are sustainable? Are they getting results that hospitals and healthcare organisations need?

From my perspective, I think that you absolutely require Lean Six Sigma and other process improvement approaches. BPM is just yet another process improvement approach. But it is an approach that offers the sustainability piece. What I’ve seen in our organisation is we have strong Lean Six Sigma people and a strong philosophy and mandate. Many projects have gone on to improve processes but they are not necessarily improving the entire end-to-end experience. A lot of the improvements are departmental, but the process might cross a couple of departments so we’re not really focused on the end-to-end that a patient really experiences.

Another challenge is that simply adding another policy or offering a bit more education in this area or that area, goes a ways, but it isn’t going to address the bigger problem. We have a really serious underlying process problem and biting away at the edges isn’t really going to work. What we need is a more integrated approach. We definitely need the Lean Six Sigma approach, but then to follow that up with technology-enabled process improvement that is sustainable - that’s our key.

So that’s where the BPM element comes in?

That’s exactly it. We work very closely with the Lean Six Sigma people within our department, and they are in many ways the input. And so they are closer to the business, we complement each other on the discovery phase, and understanding current-stage and future states, and when we do come to the point of recommendations, that’s where we look at what capabilities can BPM offer to help. Then we have an agile platform in order to very quickly leverage our 180 systems to make sure that we are aligning our processes, our people and our technology better and in a sustained way. We are not just adding a policy, we are not just adding education, we are putting in place sustainable solutions with governance models.

What does BPM mean for the patients within a healthcare context?

I think often in healthcare we like to say we’re patient-centric, but we’re not. Each care provider has their own work queues, their own wait lists, their own way of doing business – and they probably do an amazingly good job and are very "heroic" in achieving that - but I’d argue that it’s not patient-centric. Patients can fall between the cracks. Processes run across, not down, and what happens is patients get left behind and they get forgotten. Things take a long time for patients. Some of the people who get admitted to our hospital are often in their last 300 or 400 days of their lives so taking an unnecessary three or four days waiting for a test is significant. We’re not just doing BPM for efficiency; we’re doing it for patients, because those two, three, four days – weeks - can mean a lot to patients. BPM is there to make sure that patients are taken care of smoothly.

I understand you’re still quite in early days, but you’ve had some early successes with some of your pilots, and are now moving into full production. What have you done and how is it working?

It is very early days and in order to test the waters we picked an area that is clinically administrative - not necessarily highly clinical - so that a patient wouldn’t necessarily be affected by these new processes directly. That’s why we focused first on the health record area. This is where they manage the patient chart: when you get admitted to the hospital a chart gets created and the various stakeholders – physicians and nurses and other allied health professionals – document and read the information in the chart. Health Records is responsible for managing that chart and taking the information and bringing it down to their location, assembling it and scanning it and gleaning information from the chart. This department, historically, has been underperforming and it’s not different from most departments in the hospital; they’re just simply not looking and understanding what their process is from the end-to-end perspective.

One important pilot we did was to break down the entire life cycle of the medical record from start to finish, and understand all the key steps along the way. Once we understood what the process was about, we took it to the next step by leveraging BPM. That meant, where possible, we hooked the right information, the right business rules, the right messaging, and the right alerts at the appropriate time for each of the particular steps. Where there wasn’t a system, we made sure that there was a manual way for the Health Records staff to let us know when a certain key task milestone was achieved.

We simply made the process visible, and we wanted to understand what the performance of the process actually was, something where there had been no way end-to-end to understand this before. There were Excel spreadsheets, exception reports, all kinds of finger pointing. We’ve turned that around so now we understand on a real-time basis how well the process is performing from all different kinds of levels.

That’s been an excellent first pilot: turnaround times have been cut in 10 in some particular areas, and they now have the ability to manage a process and make people accountable, so we’re moving away from that finger pointing. The process is more evidence based, as healthcare should be.

That all sounds quite logical and intuitive. Why has it taken hospitals so long to start using BPM? Why haven’t hospitals used BPM in the past?

I struggle with that question because now that we’re in it, I keep thinking: why are we starting now, why hasn’t this been done before? We have spent a lot of time, a lot of money, in areas like the medical equipment and the medical technology, and a lot of the focus has been in that area. We have amazing MRIs and PET scanners and CAT scans and minimally invasive surgery and drugs. Technology on that side has been likely the focus - classic IT has been less so. There just really hasn’t been much attention on this particular issue; it’s just never been seen as important, and probably there was a little bit of flex in the system as well.

Now that we have this complex environment - occupancy rates are so high - we’re really noticing that we are not keeping up. So I think in the past we always had these underlying processes that weren’t that effective but now that there’s no more flex in the system it’s more apparent. It’s loud and clear now that they are not performing as well as they should be and that’s one of the reasons we’re doing this now.

What processes do you think are the most important for BPM to attack, in terms of creating those best outcomes for patients, to solving those underlying process problems?

My personal belief is: let’s not talk about back office. I think we have really good systems for the back office – financial, our supply chain, HR systems; that’s not really what we’re talking about. I think we need to go after those processes that are in people’s heads. When you’re in an [IT] system, you are pretty safe. For the most part, these systems will have excellent or very good processes; if not, that’s our fault [in IT]. The problem is you spend so much of your time outside of systems. A doctor, for example, can spend up to 90% of their time outside of systems; nurses, probably very high as well, and other health professionals the same. So we need to concentrate on those processes that aren’t in systems today, because what happens is how they perform those processes is highly variable. Dealing with patients is variable, that’s okay. You can have differences in how you deal with patients, but how you interact with the system, that’s shouldn’t be highly variable.

We need to make sure that the processes that are in operation today that don’t exist in systems, are executed as well as possible, are just not in people’s heads, and not just glued together by paper policies. So we have amazing people doing amazing work, heroic work; execution often fails, and that’s simply because we have no real way to manage the process. We really don’t know compliance rates, we really don’t know where things are falling down. One of the biggest fears of a healthcare provider is: have I forgotten something? Well, there’s no mechanism is place to help them, to assist them. Instead, the processes in place just seem to work against them. So I think what we need to do is we need to expose those processes, make them visible. We need to put them inside of a system, and we need to standardise them as much as possible. So variability is fine, but predictive variability is what we need.

Where are you going next on your BPM healthcare journey?

We’d like to take a deeper dive into the clinical area. We’ve cut our teeth into health records, and we’ve proven that, phase one, it seems like this could fit healthcare. We’d like to take this a little more into the clinical waters now. So we’ll get our feet wet in ambulatory care next, and I think that’s a really good place to go next. I think there are all kinds of processes in place there that can be improved. Probably another area we’d like to look at, and we’re talking about it right now, is taking a pilot area in a very clinical in-patient setting, and really maximise the process improvement technology as much as possible, and really pick a particular unit and a very challenging unit, and see how far can we push CPM in terms of technology, in terms of process improvement. And so we’re in the negotiation stages right now to look at this. If we can do this and prove that this can help facilitate, then I think we can take the next step and broaden this past the pilot stage.

Why do you call it CPM, rather than BPM?

I think Care Process Management suits healthcare better than Business Process Management, and we’re trying to rebrand BPM into CPM for our environment. We are in the business of caring for patients; that’s my job – even though I’m not a clinician, that’s everyone’s job at the Ottawa Hospital, we care for patients. Care Process Management just seems to fit.

My final question: you’re about a year into this process, what to date would you say has been the most critical factors for the success you’ve had so far?

Clearly, having a successful pilot means a lot. Having a very engaged process owner has made the pilot phase go extremely well, and that has provided momentum to go next. And so this is healthcare: there are a lot of balls in the air at the same time, people have short attention spans and you need to demonstrate success. And so I think having initial success has been absolutely fantastic and allowed us to take the next step, and the next step after that. That being said, I think one of the biggest things in my mind, why we’ve had success, is our CIO. Dale Potter is our CIO; he comes from the private sector, and he’s run BPM shops before. He doesn’t come from healthcare; he comes from private, he comes from manufacturing, but he understands that BPM can fit healthcare, and he has been fantastic in his visioning of BPM and its potential fit into healthcare, and spoon-feeding the organisation to adopt this concept and take the vision very, very wide. And I think he has given us a mandate, a very powerful mandate, and requires a lot of nerve. But yes, strong process owners and a very strong senior management support have been fantastic to allow us to get to this step already.

Editor’s Note: PEX Network also recently did a podcast interview with Dale Potter, CIO of Ottawa hospital to discuss in further detail the hospital’s use of ipads for increased mobility of staff. To listen to the podcast, click here: Technology & Mobility: iPads at Ottawa Hospital