The BP-M* Methodology for Process Analysis in the Health Sector

doi:10.4236/iim.2011.32007

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Intelligent Information Ma nagement, 2011, 3, 56-63

doi:10.4236/iim.2011.32007 Published Online March 2011 (http://www.SciRP.org/journal/iim)

The BP-M* Methodology for Process Analysis in the

Health Sector

Antonio Di Leva, Salvatore Femiano

Dipartimento di Informatica, Università di Torino, Tori no, Italy

E-mail: dileva/[email protected]

Received January 12, 2011; revised January 28, 2011; accepted Marc h 1, 2011

Abstract

In this paper we present the main phases of the BP-M* methodology and its application to a care pathway for

patients in the Oncology Division of a large hospital, to evaluate pros and cons of different drug administra-

tion modalities and the impact of these modalities to the organizational process. BP-M* has been developed

for the manufacturing sector but the relevance of business modeling, analysis and reorganization is not re-

stricted to a specific sector. The aim of this work is to show its application to a real life study of a complex

process in the health sector.

Keywords: Methodology for Business Process Analysis, Process Simulation and Reengineering, Care Path-

way

1. Introduction

This paper presents a methodology, called BP-M* (Busi-

ness Process Methodology*), which is a practical approach

for the modeling, the quantitative analysis and the reengi-

neering of business processes. It will be illustrated by

means of the patient’ s care pathway in the Oncolog y Divi-

sion of the largest hospital in Torino (Italy), the Azienda

Ospedaliera San Giovanni Battista.

The management of an integrated care department in

modern hospitals is not a simple task. Managers have to:

• develop care pathwa ys,

• identify participants and roles in the care process,

• streamline activities, follow progress and respond to

actions and events along the care pathways,

• evaluate efficiency and effectiveness of the care

process.

For an Oncology Division, the relevant process is the

chemotherapy administration. Chemotherapy is the use

of extremely powerful drugs to destroy cancer cells;

therefore it requires a very careful monitoring of patient

conditions during drug infusion. The overall process is

very complex and requires coordination among several

doctors, nurses, pharmacists, laboratory and clerical per-

sonnel, and the patient.

Therefore we need methods that allow a precise defi-

nition of the patient care process and provide qualitative

and quantitative information about the process, e.g. [1,2]:

• the optimal type and number of resources (staff,

rooms, beds, etc.),

• existing anomalies in the process (such as bottle-

necks, long waiting times,…),

• suggestions to improve efficiency, i.e., how to use

resources in a better way, how to decrease patient

length of stay in the department (cycle time),

• type of pro blems if something ne w happens (e.g. t he

workload increases).

In the literature, there is a strong support for the

analysis and reengineering of healthcare organizations.

Enterprise methodologies originally developed for manu-

facturing processes are now used to improve the opera-

tions and competitiveness of hospitals [3,4].

Both qualitative (e.g. SWOT - Strengths, Weaknesses,

Opportunities and Threats) and quan titative (e.g. process

evaluation based on discrete event simulation) analysis

have been exploited in real life applications [5,6,7].

This paper is structured as follows. The second section

presents the BP-M* methodology. The third section il-

lustrates the case study, which aims to improve the effi-

ciency and to optimize the resources management of the

target organization. Finally the fourth section presents

some preliminary conclusions of our analysis.

2. The BP-M* Methodology

BP-M* is based on M*-COMPLEX, a general-purpose

A. D. LEVA ET AL.57

open methodology that has been developed to study

complex manufacturing systems [8,9]. It is a structured

framework which provides a step-by-step strategy en-

suring consistent results for the modeling, the quantita-

tive analysis and the reengineering of general business

processes. It analyses functional, behavioral, and organ-

izational aspects of the object organization, and it

strongly enforces an event-driven process-based ap-

proach as opposed to traditional function-based ap-

proaches for analyzing and designing computer- sup-

ported integrated engineering environments.

BP-M* consists of four logically successive phases

(see Figure 1):

2.1. Context Analysis (F1)

Design the strategy of an enterprise is a task of funda-

mental relevance. The enterprise strateg y is the definition

of long-term goals, the specification of goal-adequate

actions and the assignment of existing and expected re-

sources to these actions. Therefore, the organizational

structure has to be oriented closely to the strategy in or-

der to support strategic evolution.

The context analysis phase aims to fix the overall

strategic scenario of the enterprise and to determine the

organizational compone nts which will be investigated.

2.2. Organizational Analysis and Process

Engineer ing (F 2)

At the organization level, the methodology views the

world from two orthog onal p oints of view.

Figure 1. The BP-M* overall architecture.

From the first point of view (function viewpoint), an

enterprise can be analyzed in terms of organization ele-

ments that can be classified as organization units (units

for short), which control other units at a subordinated

level, and so on. Units at the bottom level are called

work centers. Units define areas of responsibilities and

authorities and must be analyzed in order to identify th eir

functions, i.e. things to be done and services to be pro-

vided. Top-level functions are decomposed at different

levels of detail, until the bottom level in which activities

are carried on by work centers.

From the process viewpoint, activities are executed by

resources, processing or producing different objects

(pure information or material objects). They are subject

to scheduling or planning and can be coordinated into

organization processes. Thus, an enterprise can be seen

as a collection of concurrent processes that define the

flow of actions and are triggered by stimuli called events.

Each process specifies the complex control flow between

enterprise activities: it shows which activities should be

performed at a time for achieving process objectives.

The Organization Analysis and Process Engineering

phase contains two major steps, Functional Analysis and

Process Specification.

The Functional Analysis step is a top-down task which

provides managers and engineers with an accurate model

of the enterprise. Its goal is to understand the overall

structure of the organization, i.e., to discover the py-

ramidal structure of its decision system, identify the dif-

ferent levels of decision-making and identify deci-

sion-making centers. Outputs of this step are: 1) a gen-

eral functional structure (indicating the functions in-

volved in the company, the related roles and their rela-

tionships in terms of messages and information ex-

change), and 2) for each function, the set of activities and

the resources which are used to execute them.

The Process Specification step is a bottom-up task that

looks for causal relationships between activities and re-

constructs business processes starting from external

in/out events and/or objects. Processes are then validated

with the stakeholder involved in the process, using ani-

mation and simulation of their specifications. Output of

this step is the set of existing processes, the so called

As-Is model. This model provides managers and engi-

neers with an accurate model of the enterprise as it

stands, out of which they can make a good assessment of

its current status and to make an accurate assessment of

available capabilities.

Other than modeling activities and processes, those

tasks also suggest how to report current problems con-

cerning the represented enterprise units, new require-

ments, and how to discover and report potential and un-

known problems.

A. D. LEVA ET AL.

2.3. Pr ocess D i agn osis a nd Re or ga nizat i on (F 3)

The Process Diagnosis task is a step-by-step method for

guiding interviews with the users and indicating the kind

of questions to be asked in order to point out the poten-

tial causes of the current problems reported during the

“As-Is” step. Output of this task is a cause/solution ma-

trix that suggests some guidelines to perform the Reor-

ganization task that modifies existing models. Finally,

adopted solutions are validated against current problems

and new requirements collected during the diagnosis.

The validation step can be easily performed if the

process specification language is executable. In this case,

process simulation is suitable for viewing process in-

stances behavior and to evaluate the structure of the

process “ex-ante”, i.e. prior to implementing the new

model.

The goal of the Reorganization task is to specify the so

called To-Be model, i.e. the set of restructured processes.

Starting from the cause/solution matrix, several modified

versions of a selected process can be tested against dif-

ferent scenarios using a process simulator. The simula-

tion approach helps ensure that transformations applied

to As-Is processes perform as required. Moreover, it al-

lows an effective “what-if” analysis, checking hypo-

thetical business scenarios, and highlighting workloads,

resources (in terms of costs and scheduling), and activi-

ties (durations, costs, resource consumption).

2.4. Information System and Workflow

Implementation (F4)

When the To-Be enterprise model has been approved, it

has to be transmitted to engineers for implementation. In

the BP-M* methodology, two implementation aspects

are considered: 1) the specification of the Information

System environment, and 2) the specification of the

Workflow execution environmen t. These implementation

tasks will not be discussed in this paper.

2.5. Supporting Tools and Languages for BP-M*

BP-M* is supported by a set of modeling languages, i.e.

a set of concepts and constructs which need to be used

and shared both by analysts and business users. The in-

tegrated model that has been adopted consists of a func-

tional model and a process model. These models are

based, respectively, on the IDEF0 [10] and the BPMN

[11] languages.

The IDEF0 language, due to the simplicity and intui-

tive appeal of its graphical notations, represents the most

widespread formalism for the functional modeling and

analysis of enterprises

Complying with business process standards, the BPMN

(Business Process Modeling Notation) language has been

selected for the description of the process model. BPMN

provides a graphical notation easily understandable by all

business users (from analysts to business people) that can

be used to describe a process in a Business Process Dia-

gram (BPD). It has been specifically designed to coordi-

nate the sequence of processes and the messages that

flow between different process participants in a related

set of activities [11].

The basic categories of elements in a BPD are Flow

Objects, Connecting Objects, Swimlanes and Artifacts

(the symbols of core elements are shown in Table 1).

With these elements is possible to construct simple

process models. In addition, within each category there is

a more extensive list of business process constructors

that allows the production of complex or high-level

business models.

Moreover, BPMN specifications can be simulated by

means of discrete event simulation tools, nowadays

available on the market, e.g. the iGrafxProcess tool that

has been used in our research [12]. Through simulation,

the process analyst can manipulate process diagrams to

check their semantic correctness and to se e where ineffi -

ciencies lie. It is also important to remember that BPMN

objects can be mapped to BPEL, the Business Process

Execution La n guage for Web Service s [ 13]. For instance ,

iGrafxProcess, is able to convert BPMN diagrams into

BPEL files that specify the sequence of Web Services to

be executed.

3. Case Study: The Patient Care Process in

the Oncology Division

In this study we paid attention to the Out-Patients’ De-

partment (OPDept for short) of the Oncology Division.

In this division many research activities take place

among several medical specialties (e.g., oncology, hema-

tology, endocrinology), diagnostics specialties (molecular

Table 1. Core element set in a business process diagram.

A. D. LEVA ET AL.

biology, tutor immunology, cytogenetic), and radiant

treatment. In the OPDept usually antiblastic therapies for

the care of all solid tumors are administrated.

Due to space reasons, we will only discuss the two

major tasks in the F2 and F3 phases: Process Specifica-

tion and Reorgan ization.

3.1. Process Specification

This task is implemented by means of a set of meetings

with the department manager and people (medical and

nursing staff) in charge of different services. During the

meetings people received training sessions on business

modeling, process data and requirements were collected,

and problems concerning the patient care management

inside the OPDept were pointed out. The patient care

process in the OPDept can be summarized as follows.

A patient is accepted and is prepared for blood test.

Blood test-tubes are sent to the Laboratory (by auxiliary

staff), the doctor visits the patient and prepares a draft of

the chemotherapy to optimize waiting times.

When the doctor receives test results, he goes on with

the study of results, with the aim of customize and fix the

therapy. If the results show some problems (i.e. toxicity,

fever, and few neutrophils) the doctor could decide to

prescribe a support therapy and the chemotherapy is de-

ferred to the next week, otherwise the doctor prints the

request of the chemotherapy and sends it to the internal

Pharmacy by fax.

Waiting times for Drug preparation and result arrivals

take usually a rather long time. As a consequence, the

cycle time of a patient in the OPDept is very long.

In Figure 2 the “As-Is” model for the intravenous ad-

ministration of Navelbina is shown.

The process uses 5 nurses and 3 doctors with different

schedules, as illustrated in Table 2.

Figure 2. As-Is analysis: the “Intravenous administration” process.

A. D. LEVA ET AL.

Table 2. – Resources.

Resource n.of Schedule

Doctor 1 from 8 am. to 3 pm.

Doctor 2 from 9.15 am. to 4.30 pm.

Nurse 2 from 8 am. to 3 pm.

Nurse 2 from 8.30 am. to 4.30 pm.

Nurse 1 from 3 am. to 11 pm.

After the As-Is process was modeled, we prepared

an observation chart where, for patients that used the

Navelbina drug, times related to all activities of the

process were collected for several weeks in different

situa tio ns .

For each activity, starting, ending and arrival time of

patients, sending fax time, and results and drugs arrival

times have been measured. A normal distribution has

been used in the event that the Kolmogorov-Smirnov &

Shapiro-Wilk test returns positive values. Otherwise, a

triangular distribution based on min, max, and mode

values of the sample has been selected. Results of this

analysis are displayed in Table 3.

By means of simulation of the “As-Is” process, it is

possible to obtain some key performance indicators as

cycle time (range of time that a patient spends in the

OPDept) and resource utilization of the more critical

resources (doctors and nurses). In our case, the fol-

lowing results have been obtained:

Resource utilization doctor: 57% nurse: 53%

Cycle time 205 minutes

Table 3. Resources and duration of activities.

Activity name Resources Time (min)

Receiv e p at ien t 1 nurse UnifDist(1;2)

Prepare patient (blood test preparation) 1 nurse TriangleDist(35;41;38)

Execute blood test 1 nurse UnifDist(2;3)

Signal test-tube transfer 1 nurse UnifDist(1;3)

Visit patient 1 doctor TriangleDist(5;8;7)

Prepare draft therapy 1 doctor UnifDist(5;7)

Send tes t-tub e (s end test-tu be to Laboratory) Staff UnifDist(26;35)

Execute tests Labora to ry TriangleDist(37;63;47)

Evaluate results (evaluation of exams and patient examination) 1 doctor UnifDist(3;5)

Define support therapy 1 doctor TriangleDist(3;7;5)

Prepare therapy (prepare support therapy) 1 nurse TriangleDist(2;5;3)

Therapy administration 1 nurse TriangleDist(10;20;12)

Therapy ending 1 nurse TriangleDist(3;5;4)

Fix therapy and sending (the therapy is fixed and then will be sent by fax to the

Pharmacy) 1 doctor UnifDist(7;12)

Analyze therapy Pharmacy UnifDist(4;7)

Navelbina pr ep aration Pharmacy NormDist(52;14)

Mistake analysis (the doctor settles any problems in the drug preparation) 1 doctor TriangleDist(5;7;6)

Patient preparation 1 nurse TriangleDist(2;5;3)

Navelbina administration 1 nurse UnifDist(10;15)

Therapy ending 1 nurse TriangleDist(3;5;4)

Next reservation 1 doctor UnifDist(3;5)

Discharge patient 1 nurse UnifDist(6;8)

A. D. LEVA ET AL.

It must be pointed out that the resource utilization ap-

plies to the particular care process we have studied and

not to the whole activity executed in the OPDept. Indeed

if we insert in the process any other kind of chemother-

apy, all resources turn out to be heavily used.

In analyzing simulation results it must be pointed out

that the main problem is related to the long waiting times

to obtain drugs from the Pharmacy and exams results of

analysis from the Laboratory. Let us analyze these prob-

lems separately.

3.1.1. Laboratory

Waiting time to receive results from the Laboratory de-

pends on three factors:

• Test-tube labeling.

• Test-tube transport from OPDept to Laboratory.

• Test result availability notification.

Test-tube labeling is a process that influ ences the wait-

ing time to obtain exam results. Indeed, bad printing of

the label or its wrong positioning on test-tube results in

the arrest of the analysis automated line. This requires

intervention by a technician to resume the line. In order

to prevent this event, robots have been developed to pro-

duce test-tubes in which the labels are correctly printed

and positioned.

Test-tubes are currently transported from OPDept to

Laboratory by auxiliary staff. This process is time con-

suming (it requires about 30 minutes) and this is a rele-

vant part of the total waiting time. A good solution to

this problem would be the employment of a Pneumatic

Mail tube system in substitution of the auxiliary staff;

this would result in a considerable save in transport time.

Regarding test result no tification, at presen t doctors, in

order to know test results, have to repeatedly check the

result availability with queries to a software application.

A possible solution would be the use of acoustic and

visual signals to let the doctors know as soon as test re-

sults are ready. This way, waiting time would be reduced

from the current 26-35 minutes to about 4-5 minutes.

3.1.2. Pharmacy

Waiting time to receive drugs depends on two factors:

• Transmission of therapy requests.

• Drug preparation and transport.

At present, doctors have to insert a therapy request

into the local Information System, print it and then send

it by fax to the Pharmacy. It might h app en th at th e doctor

decides to make some changes to a therapy on the base

of the patient’s condition. Some times the doctor intro-

duces these changes by sending on paper and not using

the information system. Since the paper form is the only

request form officially accepted in the Pharmacy, the

pharmacist has to add further effort to his job, and intro-

duces new manual activities in the procedure. This also

introduces in the process an element of risk! A possible

solution would be the use of a new certified computer-

ized procedure in place of the fax procedure.

The second factor which influences the waiting time

depends on the time that is necessary to prepare the drug

and to transport it by means of an auxiliary staff. We

have measured it takes about 50 minutes to obtain the

drug. A possible corrective action would be the use of

the same drug, but administered by oral way instead of

intravenous way. Since the OPdept can manage the oral

chemotherapy in a local warehouse, inquiry, preparation

and delivery times can be eliminated.

3.2. “What-If” Analysis and Reorganization

Starting from the current “Oral administration” process

we defined two reo rganizatio n sce narios:

• Scenario A: In this scenario, the oral administra-

tion of the drug has bee n intr od uced.

• Scenario B: In addition to the oral administration,

the corrective actions described above (i.e. the use

of a robot for test-tube labeling, the pneumatic mail

test-tube system and the certified computerized

system to advice doctors) have been introduced in

the model.

In the Scenario A, the oral administration of Navelbina

implies a significant variation of the interactions between

OPDept and Pharmacy. The OPDept has to manage a

local warehouse with the oral chemotherapy (Navelbina)

supplied by the Pharmacy, but all the steps of drug re-

quest, drug preparation and waiting time, and all the

backup procedures necessary in case of faulty delivery

can be removed. The doctor as soon as receives test re-

sults can deliver the oral chemotherapy to the patient.

The oral administration can be conducted according to

the care pathway illustrated in Figure 3. The new activi-

ties, Fix therapy and Oral administration, are illustrated

in Table 4.

The simulation of the “Oral administration” process

shows the following results:

Resource utilization doctor: 47% nurse: 48%

Cycle time 141minutes

We observe an overall reduction in the patient cycle

time of about 31%.

Let’s now study the Scenario B. The process is the

same as in Scenario A, we just have changed the tempo-

ral characteristics of the activities that are involved in the

adoption of new technologies. The simulation of the new

process shows the following results:

Resource utilization docto r: 43% nurse: 42%

Cycle time 107 minutes

A. D. LEVA ET AL.

Figure 3. To-Be analysis: the “Oral administration” process.

Table 4. Resources and duration of activities.

Activity name Resources Time (min)

Fix therapy (the therapy is fixed and then the oral drug is delivered to patient) 1 nurse UnifDist(2;3)

Oral administration 1 doctor UnifDist(1;2)

Thus the overall reduction in the patient cycle time is

about 48%. Based on these results, the Director of the

Organization unit approved the implementation of the

Scenario A; after a transitory period of time, experi-

mental results were in good accordance with simulation

outcome.

4. Conclusions

In this paper we present a methodology that responds to

some of the problems organizations are faced with in

their process analysis projects. The main objective of the

paper is to investigate some potential benefits and out-

comes of introducing new processes that could be as-

sessed in advance by using simulation modeling.

A complex process, the patient’s care pathway in the

Oncology Division of a large hospital, has been modeled

using BP-M* and a process mapping and simulation tool.

This approach has been proved to be a very useful tool

for business process analysis and design which offers a

way to understand the behavior of existing and restruc-

tured processes without be invo lved in costly dep loyment

procedures.

This analysis is still under study and the results ob-

tained are influenced by low cardinality of statistical

units analyzed. Nevertheless these results seem to be a

good estimation of the reality. The benefits of the re-

structured process have been analyzed and two different

scenarios were compared.

The first solution just changes the way to administrate

the therapy, with no changes in the OPdept organization.

The second solution is based on the first one, but intro-

duces a set of technological innovations. We observe that

both solutions provide relevant improvements with re-

spect to the original process.

Specifically, referring to the patient cycle time (the

A. D. LEVA ET AL.63

overall time a patient spends in the OPDept), the two

solutions allow reducing the cycle time of about 31% and

48% respectively.

It must be pointed out that the development trend of

pharmaceutical companies is based on investments on

new molecules with oral administration that can be de-

livered at patient home. In the near future we intend to

investigate how this trend could impact on the organiza-

tion of the oncology division and to analyze the benefits

of a solution that take into account this new kind of ad-

ministration.

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