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BPMJ
17,1 Business process re-engineering
in healthcare management:
a case study
42
Massimo Bertolini
Dipartimento di Ingegneria Industriale, Università di Parma,
Parma, Italy, and
M. Bevilacqua, F.E. Ciarapica and G. Giacchetta
Dipartimento di Energetica, Università Politecnica delle Marche,
Ancona, Italy

Abstract
Purpose – The purpose of this paper is to carry out the business process re-engineering (BPR) of a
surgical ward in a hospital in order to improve the efficiency of the ward.
Design/methodology/approach – This work was developed using a case study on a surgical ward.
In this type of ward, in which scheduled and unscheduled operations often have to coexist and be
managed, ways to minimise patient inconvenience need to be studied. A framework based on
event-driven process chains (EPCs) methodology, the entity-relationship model and discrete event
simulation is presented to define and analyse the current state of a surgical ward and design a future
system. The modelling of the processes, activities and sub-activities, which took up a great amount of
ward resources, allowed a what-if analysis to be developed which simulates various scenarios and
assesses their performance.
Findings – Using Delphi methodology, it was possible to identify a number of areas for improvement:
number of operating sessions, preparation of the operating rooms for each operation, availability of
specific surgical instruments. Moreover, the discrete event simulation approach led to an understanding
of the most efficient management choices.
Originality/value – The decision to use Delphi methodology for the information collection stage
before starting the BPR process is not found in other studies in the literature. Moreover, the use of
models based on EPCs methodology allowed the panel of experts to develop models to examine and
understand the resource requirements of medical assessment units and to provide a framework or
develop standards that hospital developers and clinical managers can consult.
Keywords Business process re-engineering, Case studies, Hospitals, Modelling, Simulation
Paper type Research paper

Business Process Management
Journal
Vol. 17 No. 1, 2011
pp. 42-66
q Emerald Group Publishing Limited
1463-7154
DOI 10.1108/14637151111105571
1. Introduction
It can justifiably be said that healthcare has become an extremely complex sector. There
are an increasing number of medical specialisations and professions, complex therapies
and equipment and often several service units revolve around different organisations
(Øvretveit, 2000).
The tricky problem that has to be addressed is that of finding opportunities for
integration and coordination, while at the same time respecting the field of specialisation
which is fundamental for creating and transferring knowledge, above all in contexts like
hospitals which are highly professional and technological.
This problem is not unlike the one faced in other industrial realities where in recent
years attention has been focused on management tools such as total quality
management (TQM), activity-based management and business process re-engineering Business
(BPR). Some of these tools have also occasionally been applied to the healthcare sector process
with often contradictory results.
One empirical study carried out by Lim et al. (1999) showed that 80 per cent of the re-engineering
hospitals in Singapore have adopted some aspects of quality management so as to
provide a service which is more oriented towards customer satisfaction. However,
another empirical study conducted by the same authors (Lim and Tang, 2000) 43
concerning the quality expected and perceived by the patients for the services offered by
the hospitals in Singapore showed that the quality of the services is generally less than
the level of quality which the patients expect. Moreover, 40 per cent of the patients
interviewed defined the quality of the service as insufficient or very bad.
In the USA in 1993, although more than 40 per cent of the hospitals involved in the
Joint Commission on Accreditation of Healthcare Organizations had adopted some
aspects of the quality improvement programme (Reeves and Bedner, 1993; Chaufournier
and St Andree, 1993), critics stated that the quality in most of these hospitals was less
than satisfactory (Nance, 1995).
There are several reasons for this lack of success. Geber (1992) underlined that
doctors are unwilling to accept change and that administrators have a short-term
outlook; Morrison and Heineke (1992) and Boerstler et al. (1996) have underlined that
there is resistance due to lack of motivation in doctors, nurses and other staff. Other
important factors are certainly the failure of healthcare providers to understand
customer requirements or simply that management quality practices have not been
correctly implemented.
Simulation models have been used extensively in literature to study healthcare
operations (Barnes and Quiason, 1997; Sanchez et al., 2000). According to Banks et al.
(2001), one of the main reasons that simulation is becoming a popular technique in
healthcare problem solving is because simulation may be used for dynamic (rather
than static) analysis of the situation, thus presenting stakeholders with a more realistic
picture of the situation.
A number of simulation models have been designed to manage the waiting list for
critical resources, including organs for transplant. Ratcliffe et al. (2001) describe the use
of simulation to model policies for allocating cadaveric livers to patients awaiting
transplants. Wujciak and Opelz (1993) present a study aimed at analysing policy options
for allocating cadaveric kidneys. Dexter and Traub (2002) use a simulation methodology
to suggest next case scheduling policies in operating rooms functioning in parallel with
flexible end times.
Simulation has been used extensively to model operations within surgical units to
improve efficiency and reduce wait times. Blake et al. (1991) describe a model simulating
the flow of surgical patients that was used to test the impact of a master surgical
schedule on inpatient nursing workload. Bowers and Mould (2004) describe a simulation
model to test the potential for increasing operating room utilisation by scheduling
deferrable elective patients into planned orthopaedics blocks.
Simulation has also been frequently applied in publicly financed healthcare systems
to analyse waiting lists for elective procedures. Everett (2002) develops a “what-if”
simulation as a decision support tool to allow managers to experiment with different
resource levels to determine their impact before implementation. Vasilakis and
BPMJ El-Darzi (2001) show that a lack of social services was to blame for a recurring winter
17,1 bed crisis in a British hospital.
Jun et al. (1999) have identified two main areas for the use of simulation, namely, the
management of patient flow and resource allocation. Lagergren (1998) adds to these by
identifying a number of areas for modelling (in general) in healthcare: epidemiology,
healthcare systems design, healthcare systems operation and medical decision making.
44 Although there has been an extensive amount of simulation applied to the healthcare
sector in recent years. Baldwin et al. (2004) use the literature and expert opinion to make
the claim that “the immense potential of simulation has not yet been realised in practice”.
Whilst analysing the expert opinion to understand why this is the case, they highlight
the need to mix modelling techniques more readily.
In this paper, a study conducted in the Neurosurgery Ward of Parma Hospital using
quality management and BPR techniques is reported. The aim in carrying out the
study was to indicate the most critical aspects in ward management processes and to
propose alternative solutions for improving the service offered to the patients.
A framework based on event-driven process chains (EPCs) methodology and discrete
event simulation is used to define and analyse the current state of the neurosurgery ward
and to design a future state of the ward focused on improving service quality and
workflow. The application of simulation in healthcare is not as widely perceived for
problem solving as it is in other application areas. This might be due to the way
simulation is applied in healthcare modelling, as it follows a traditionally based
engineering approach (Baldwin et al., 2004). This may not be a problem in itself; however,
healthcare systems are often complex, because they involve multiple decision makers
and thus understanding and communication between various stakeholders is potentially
problematic. Problem understanding and efficient means of communication can widely
contribute to the solution; consequently a Delphi technique approach is used in this
paper to enhance such understanding and communication. Using this methodology,
it was possible to identify a number of areas for improvement: number of operating
sessions, preparation of the operating rooms for each operation, availability of specific
surgical instruments and so on.
The reminder of the paper is organised as follows. In Section 2, a brief literature
review on the BPR and EPCs techniques is presented. Section 3 is divided into two parts:
the Section 3.1 describes the case study and the modelling of the processes and
sub-processes in the neurosurgery ward, while in Section 3.2 the simulation process is
reported. Section 4 describes the main critical areas in the ward processes using the
Delphi method and new scenarios are proposed and assessed.
Finally, conclusion section reports the main features encountered during the study.

2. Material and methods

In this paper, the BPR approach is used in order to improve the service quality and the
efficiency in the surgical ward of a hospital. Increased competition has led many
organizations to the fundamental rethinking and radical redesign of their age-old
business process called business process redesign (Davenport and Short, 1990), or
business re-engineering (Hammer, 1990). Since the early 1990s, BPR has become one of
the most popular topics in organisational management, creating new ways of making
business (Tumay, 1995). Davenport (1993) highlighted the roles of new organizational
structures and human resource programs in developing process innovation.
Since improving business performance was not achieved by automating existing Business
business activities, many leading organisations have conducted BPR in order to gain a process
competitive advantage. The first wave of BPR was focused on the radical change of
internal business processes. Furthermore, it was particularly suggested that TQM re-engineering
should be integrated with BPR (Al-Mashari and Zairi, 1999).
The second wave of BPR began in 1996 when the internet and world wide web
phenomenon took off and provided an IT infrastructure that enabled electronic business 45
and new forms of web-based business processes (El Sawy, 2001). To meet customer
demand, companies depend on close cooperation with customers and suppliers. BPR
driven by e-business should not be based only on the radical redesign of intra-
organisational processes, but should also be extended to the entire business network
(internal and external).
In this paper, the steps followed in order to develop BPR in the neurosurgery ward
are shown in Figure 1.
The BPR project started from the identification of the strategic objectives and a new
representation using process mapping of how the company works. The critical processes
(those which determine the competitive success of the company) were then identified.
Having set the performance objectives required, these critical processes were then
subjected to re-engineering. As can be seen in Figure 1, the representation of the current
process, the re-engineered process and its experimentation are closely connected activities,
with frequent interaction. Finally, the new process was adopted and continuously
monitored and improved through a feedback process.
BPR tools support the “re-thinking” of business processes, and workflow
management systems are the software applications that make these re-engineered

Starting point

Definition of
objectives

Identification of Definition of Work

critical performance organisation
processes objectives
Process
mapping

Process
representation
Feedback (AS-IS)

Process
representation
(AS-IS)

New process New process Figure 1.

Experimentation Stages in BPR
management start-up
BPMJ processes possible. Each of these tools requires an explicit representation of the business
17,1 processes to hand. According to Davenport and Beer (1995) an ideal process modelling
method for BPR would provide a simple but expressive modelling mechanism that
reflects the customer orientation and cross-functional nature of BPR. Most of the
business process modelling techniques used are vendor specific, i.e. they are supported
by just one tool. Only a few tools use a generic technique such as Petri nets, structured
46 analysis and design technique, integration definition for function modelling, or EPCs.
EPCs are a business process modelling technique, mainly used for analysing
processes for the purpose of an ERP implementation. Businesses use EPC diagrams to
lay out business process workflows, originally in conjunction with SAP R/3 modelling,
but now more widely. There are a number of tools for creating EPC diagrams,
including ARIS Toolset of IDS Scheer AG, ADONIS of BOC Group, Visio of Microsoft
Corp., Semtalk of Semtation GmbH, or Bonapart by Pikos GmbH. Some but not all of
these tools support the tool-independent EPC Markup Language interchange format.
There are also tools that generate EPC diagrams from operational data, such as SAP
logs. EPC diagrams use symbols of several kinds to show the control flow structure
(sequence of decisions, functions, events and other elements) of a business process.
The EPC method was developed within the framework of ARIS by Professor
Wilhelm-August Scheer at the Institut für Wirtschaftsinformatik at the Universität des
Saarlandes in the early 1990s. It is used by many companies for modelling, analyzing and
redesigning business processes. As such it forms the core technique for modelling in
ARIS, which serves to link the different views in the so-called control view, which will be
elaborated in section of ARIS Business Process Modelling. The language is targeted to
describe processes at the level of their business logic, not necessarily at the formal
specification level, and to be easy to understand and use by business people.
The methodology is briefly explained in Appendix 1.
An EPC consists of the following elements:
.
Functions. The basic building blocks are functions. A function corresponds to an
activity (task and process step), which needs to be executed.
.
Events. Events describe the situation before and/or after a function is executed.
Functions are linked by events. An event may correspond to the post-condition of
one function and act as a pre-condition of another function.
.
Logical connectors. Connectors can be used to connect activities and events.
In this way, the flow of control is specified. There are three types of connectors:
L (and), X (exclusive or) and V (or).
These building blocks are shown in Figure 2.
The information captured by the ARIS tool set is stored in a database following the
entity-relationship model. This architecture distinguishes between organisation,
function, information and control views of the system model. It focuses on the
analysis and requirements definition phase during the design of information systems.
The models created with ARIS software were subsequently used for the simulation
process using “ARIS simulation” software.
Figure 2.
The building blocks Function Event
of an EPC
Logical connectors
3. Case study Business
This study was carried out in the Neurosurgery Ward of Parma Hospital. Particular process
attention was paid to this ward since it is surgical. In fact it seemed interesting to study
how scheduled and unscheduled operations often have to coexist and be managed so as re-engineering
to minimise patient inconvenience. The neurosurgery ward deals with surgery of the
central and peripheral nervous system and cranial traumas.
47
3.1 Modelling of the processes
Since it is a surgical ward the first main division made was to separate the “patient
management” processes. Figure 3 shows how the sub-division was made.
Subsequently, the processes and sub-processes identified and the reasons underlying
this type of sub-division were examined in detail. Two main categories of resources were
identified in the neurosurgery ward:
(1) Physical resources. Beds (currently 38) and operating rooms (currently two).
(2) Human resources. Head physician, doctors, unit nursing officer, nursing staff,
and clerical staff.

Some activities which required significant ward resources were analysed in greater
detail. The division of the sub-processes allowed the development of a “what-if” study
which simulated various scenarios. The “management of elective patients” is a process
in which “elective” refers to the operation which can be scheduled and if necessary
postponed for a few days without endangering the life of the patient. The procedure for
this type of patient is characterised by putting the name on a waiting list which generally
happens after a period of observation. These patients arrive on the ward from various
places such as other hospitals or private clinics. The hospital waiting list is managed by
the hospital IT services (SIO). The process “management of surgical operations”
concerns the scheduled surgical activity of the ward, i.e. operations on elective patients.
Scheduling this type of operation starts with consultation of the waiting list. Having
selected the names these patients are contacted and are generally admitted to the ward
on the following day. On average there are about three/four scheduled surgical
operations every day. All “patient management processes” were modelled and analysed
although in this paper only the process “management of patients on arrival” is presented
(Section 3.1.1), in order to highlight the BPR method.

Patient
management

Management Management Management

of elective of patients on of surgical
patients arrival operations

Level 1 Level 1 Level 1

Management of patients
Management of patients Patient
needing further Management of
to be kept undergoes
clinical and emergencies
in observation surgical operation Figure 3.
laboratory investigation
Value-added chain
Level 2 Level 2 Level 2 Level 2
BPMJ 3.1.1 Patient management: management of patients on arrival. “Patients on arrival”
17,1 includes all those patients who are not admitted to hospital but who need neurosurgical
medical assessment. These patients are likely to arrive from accident and emergency
department (A&E) or from other wards and may later be admitted to the neurosurgery
ward. As can be seen in Figure 4, the neurosurgeon makes a preliminary assessment of
the patient’s clinical condition and, on the basis of the information derived from this
48 examination, may decide for one of the following types of action:
(1) patient to be kept in observation;
(2) patient needing further clinical and laboratory investigation;
(3) emergency; and
(4) patient to be re-directed.
(1) Management of patients to be kept in observation. After informing the patient of the
need to be kept in observation the hospitalisation procedure is started leading to

Patient
proposed

Level 1

Clinical
assessment

Patient needing
Patient
further Emergency Other destination
in observation
investigation

Management of patients
Management of Management of
needing
patients in observation emergencies
further
investigation

Level 2 Level 2 Level 2

Figure 4. Patient
Level 1 – “management of discharged
patient on arrival”
admission of the patient to the ward. The period of observation generally leads to one of Business
three scenarios: neurological deterioration, stationary conditions or patient improvement. process
The first case, neurological deterioration, is a serious situation requiring emergency
radiological examination, on the basis of which a diagnosis will be formulated which may re-engineering
or may not involve surgery. A recommendation for surgery, subsequent to neurological
deterioration, determines the need to operate immediately. In fact, after examination by
the anaesthetist the surgical operation is carried out (Figure 5). The end of the operation is 49
the start of the post-operative stay in hospital, which ends when the patient is discharged
from the ward. On the contrary, when the diagnosis does not require surgery after
neurological deterioration, the patient will be kept in observation for the following period
in which three events may occur: further neurological deterioration, stationary conditions
or improvement of the clinical condition.
In the event of either a stationary situation or improvement in the patient’s clinical
condition during observation, after a further stay in the ward a diagnosis will be
formulated which may or may not recognise the need for the patient to undergo surgery.
If surgery is not needed the patient will be transferred or discharged and subsequently
leave the hospital. On the contrary, if surgery is recommended the patient is described as
“elective”, that is to say needs to be operated on not urgently but in the middle/long-term.
Elective patients may therefore be discharged or transferred, according to their clinical
conditions, and later leave the ward.
(2) Management of patients who need further investigation. As can be seen in
Figure 6, after informing the patient of the need to carry out further investigation, the
hospitalisation procedure starts. Having admitted the patient, the tests needed will be
requested and carried out. The subsequent findings may determine one of two different
situations: impossibility to formulate a diagnosis, leading to the need to carry out new
analyses or formulation of a diagnosis.
The formulation of a diagnosis may or may not indicate the need for surgery. We will
first examine the situation of diagnosis requiring surgery and then the case in which no
surgery is required. Subsequent to the diagnosis requiring surgery it is necessary to
decide whether to operate immediately or to wait. In the latter case, we have an elective
patient who can be discharged and leave the ward. On the contrary, if it is necessary to
operate immediately the pre-surgery process is set in motion and the operation is
performed. At the end of the operation, the post-operative hospitalisation starts, ending
when the patient leaves the ward. If the diagnosis does not recommend surgery, the
patient must be discharged, transferred to another ward or kept in the ward for a period
of observation. The first two possibilities involve activation of the respective procedures,
which end when the patient leaves the ward. On the contrary, the patient kept in
observation calls for the sub-process named “patient in observation”. In this case, the
path is exactly the same as the one followed for patients on arrival who are considered
patients to be kept in observation. “Patients kept in observation” and “management
of patients kept in observation” are two very similar sub-processes. In fact, the only
difference is that the former lacks the hospitalisation procedure (the patients who
activate this microprocess have in fact already been admitted to the ward).
(3) Management of emergencies. As can be seen in Figure 7, the first thing that happens
to a patient who is recognised as an emergency case is the formulation of the diagnosis
with recommendation for surgery and examination by the anaesthetist. At this stage,
the hospitalisation procedure is activated in parallel with preparation for surgery. In fact,
BPMJ Patient needing
17,1 observation
Level 2
Communication to
patient need
for periodof
observation

Hospitalisation
50 decision

Nurse

Bed
Hospitalisation SIO
procedure

Doctor Clinical
record
Patient
hospitalised

Clinical
observation
of patients

Neurological Patient Patient

deterioration improves stationary

Radiological
examination
Hospitalisation
continues

No No
Surgical Elective
surgical surgical
recommendation patient
recommendation recommendation

Examination by
anaesthetist

Start preparation
for operation Decision-making
Surgical instrument process
technician

Nurse

Operating Surgical
roon operation

Doctor
Patient can be Patient to be
Anaesthetist discharged tranferred

Patient
Discharge
End of Death of Doctor Doctor transferred to
procedure
operation patient other ward SIO

Post operative Bed

Death
hospitalisation Bed
procedure
SIO

Bed

Figure 5.
Level 2 – “management of Patient
patients in observation” leaves ward
 Patient
needs
Business
further
investigation
Level 2
process
Communicate to
patient need
for further
re-engineering
investigation

Hospitalisation
decision
Nurse

Hospitalisation SIO
51
Bed
procedure

Doctor Clinical
record

Patient
hospitalised

Request for
analysis

Analysis
planned

Analysis
developed

Analysis
completed

Results of
analysis

Possibility to
Need for further
make
analysis
diagnosis

Diagnosis
made

Surgical No
recommendation surgical
recommendation

Decision
Decision-making
hoperate
process
immediately

Surgical instrument
technician

Nurse Start preparation Elective Patient can Decision to Patient to be

for operation patient be discharged transfer patient kept in observation
Operating
Room Doctor

Surgical Decision-making
Doctor process Patient transferred
operation Discharge Patient in
to other
procedure observation
ward
Anaesthetist
Patient can
be discharged
Level 3
Doctor SIO
Doctor
Bed
End of Death of
Discharge
operation patient
procedure
SIO

Post-operative Bed
Death
hospitalisation Bed procedure Bed

SIO
Figure 6.
Level 2 – management of
Patient leaves patient who need further
ward
investigation
BPMJ
17,1 Emergency

Level 2

Surgical
recommendation
52

Patient to be
operated

Examination by
anaesthetist

Hospitalisation Surgical instrument Start preparation

technician
decision for operation
Nurse Nurse

Bed Hospitalisation Operating Surgical

procedure room operation

Doctor
SIO Doctor

Patient Clinical
Anaesthetist End of
hospitalised record operation

End of Death of
operation patient

Post-operative
Death
hospitalisation Bed
Bed procedure

Figure 7. Patient leaves

Level 2 – management of ward
emergencies
the patient must be operated on in the shortest time possible whether or not there is a Business
hospital bed immediately available on the ward. Proceeding as described there is the process
possibility to carry out the operation at the same time as the administrative procedure for
hospitalisation. The surgery and hospitalisation procedure are followed by post-operative re-engineering
hospitalisation and subsequent discharge from the ward.
3.2 Simulation process 53
The models created were used to set up a simulation process. The first step involved
simulations of the As-Is processes to gather information about: throughput time for
processes with certain resources, process delays, identification of bottlenecks, use of
resources and number of processes completed in a certain period of time.
The following step was to create process targets so as to obtain: removal of
bottlenecks, assessment of process variations, reduction of throughput time, increase in
the number of achievable processes, optimisation of resource utilisation and cost
reduction. ARIS simulation software was used for the simulation.
The main starting data needed for the simulations were:
.
Frequency. Number of process instances started at regular intervals per day,
week, month or year. Historical data were used to define the rates of Poisson
functions which represented the expected number of “events” or “arrivals” that
occur per unit time.
.
Probability. The probability that an event or a certain type of connection will
happen. These probabilities have been used when logical connectors are inserted
into the models. For instance, taking into consideration Figure 4, it is necessary to
define the probability to have “patient in observation”, “patient needing further
investigation”, “emergency” and “other destination”, after a clinical assessment.
.
Priority. Assigns the priority to the process folder for each process instance that
the event goes through.
.
Shift calendar. Periods of time during which the daily work is carried out by the
human resources and during which the material resources are available for
carrying out the functions.

There are many procedures suggested in literature for constructing a point estimate
and a confidence interval (CI) for the steady-state mean v ¼ E(Y) of a simulation output
process Y1, Y2 . . . , for instance Meketon and Schmeiser (1984) introduced the method
of overlapping batch means, Bischak (1988) studied the idea of weighted batch means,
Fishman (1978) developed the autoregressive method.
In this work was proposed a replication/deletion approach. This method is based on n
independent replication of length m observations. This method tends to suffer from bias
in the point estimator v^ , while the other approaches are based on one long replication, and
tend to have a problem with bias in the estimator Varðv^ Þ of the variance of the point
estimator v^ .
Initially, there was a simulation start-up phase. To calculate this period of time, also
known as “warm-up” the method proposed by Welch (1983) was applied. This phase
allows the model to reach a steady state. A warm-up period of l ¼ 25 days was chosen
on the basis of Figure 8.
In order to analyse steady-state performance from the output of the simulation the
replication/deletion approach (Law and Kelton, 1991) was used. The method was
BPMJ 4
17,1

Number of surgical operations

3.5
3
2.5
2
54
1.5
1
0.5
Figure 8.
0
Trend in average number
1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85
of surgical operations
Days (i)

applied for obtaining a point estimate and CI for the steady-state mean v ¼ E(Y).
Only those observations beyond the warm-up period l ¼ 25 in each replication are used
to form estimates; n ¼ 10 replications of the simulation were carried out each of length
m ¼ 365 days. Let Yji be the number of surgical operations per day (elective and
emergency operations) carried out and let Xj be given by:
Pm
Y ji
X j ¼ i¼lþ1 for j ¼ 1; 2; . . . ; n
ðm 2 l Þ
Xj are independent and identically distributed random variables with E(Xj) < v, and
an approximate 100(1-a) per cent CI for v is given by[1]:
rffiffiffiffiffiffiffiffiffiffiffi

S 2 ðnÞ
XðnÞ ^ tn21;12a=2 1
n
With a 95 per cent CI, we obtained v ¼ Xð10Þ
¼ 3:246 and:
rffiffiffiffiffiffiffiffiffi

0:21
Xð10Þ ^ t9;0:975 ¼ 3:246 ^ 0:328
10
this is an acceptable precision because is about 10 per cent of the steady-state mean.
The initial n runs of m observations were used both to determine l and to construct a
CI; in this case because m is much larger than l the observations beyond the warm-up
period l do not contain significant bias relative to v.
For the validation of the model, so as to verify the ability to reproduce with
reasonable precision the real trend in the ward activities, the main variable chosen was
the number of surgical operations per day carried out.
In order to validate the simulation model the output of the simulation has been
compared with the historical data (of the same year) collected from neurosurgery ward.
For the days between l and m the difference between real value of operations (Xi) and
predicted value of operations (Yi)[2] has been assessed; then were calculated the mean
absolute deviation (MAD), mean absolute percentage error (MAPE), BIAS, tracking
signal (TS) and correlation coefficient (R) values. In this work, the formulae used to
assess the accuracy of the simulation are shown in Appendix 2. Table I shows the results
of the simulation concerning “elective operations” and “emergency operations”.
 The MAD values indicate that the average error in the simulation model developed is Business
between 0.72 and 0.21 for the “elective operations” and “emergency operations”, process
respectively. Moreover, the MAPE values indicate that, in terms of percentages of real
values, this error is of about 18.53 and 19.08 per cent. The bias value fluctuates around 0 re-engineering
and therefore the error is truly random and not biased one way or the other. The tracking
signal value for any period is not outside the range ^ 3, indicating that the simulation
result is not biased and is neither underforecasting (TS below 2 3) nor overforecasting 55
(TS above þ 3). All the performance indices show that simulation output is in agreement
with the number of operations carried out in the neurosurgery ward.
The processes analysed bring to light some fundamental constraints and
considerable complexity. The limited number both of people involved in the processes
and of spaces/plants used during the procedures, in fact make the system extremely
critical. The simulations have shown for example that the anaesthetists are the most
critical point. The complexity is connected with the intricacy which is normal in hospital
ward management procedures and with the division into macroprocesses of some basic
sub-processes such as: admission procedure, discharge procedure, surgical operation
and post-operative hospitalisation.

4. Delphi methodology
The approach proposed in this work has tried to take into account the real problems of a
surgical ward, considering problems connected with the availability of human
resources, space, plants and finances. An ad hoc panel of experts was created in order to
encourage communication and meetings during which the members could contribute
their knowledge and information about the processes. The panel was made up of seven
participants, and included two academics, whose research studies are mainly focused on
BPR, one head physician, two doctors, one nurse and one representative from Health
Authority Administration. This number of participants, which at first sight may seem
rather large, derives from the Delphi technique (Linstone and Turoff, 1975) adopted for
working with panels. The Delphi technique is a structured process which investigates a
complex or ill-defined issue by means of a panel of experts. This methodology proves to
be an appropriate design for this type of research and permits individual opinions to be
obtained within a structured group and using a communicative process. The panel
worked for a period of about two weeks, and the sessions were planned on a three-round
Delphi process. At first a series of statements concerning the requirements of ward
processes was generated individually and anonymously by the experts. The panel was
involved in developing models for the activities of the neurosurgery ward and in defining
the critical points in the processes and possible “what-if” scenarios. All the statements
were then collected and delivered to the members of the panel, who were required to
indicate their level of agreement; answers were finally fed back to the panel.
The study carried out allowed the identification of so-called “bottlenecks”. The critical
aspects which came to light are indicated in Table II:

MAD MAPE (%) BIAS TS R

Table I.
Elective operation 0.72 18.53 2 0.91 21.26 0.935 Simulation model
Emergency operation 0.21 19.08 2 0.43 22.04 0.918 performance indices
BPMJ
17,1 Bottlenecks Description

Number of operating sessions This number may not be sufficient if compared with the
real number of patients who have to undergo surgery.
This is connected with: availability of the operating
rooms (technical or electrical failures or problems
56 involving the equipment used slow down or make the
use of the operating room impossible on that day);
presence of sufficient medical, nursing or auxiliary staff
to meet requirements; time for carrying out the single
operations (in fact it must be remembered that some
neurosurgical operations last for a long time and that,
when scheduled, occupy the operating room for the
whole session on that day, thereby increasing the
waiting list time for other patients)
Preparation of the operating rooms for each Each surgical operation, whether simple and short or
operation complex, requires a clean working environment which
is comfortable for the patient and above all for the staff
that work there. It must also be equipped with
everything needed at each stage of the operation. These
stages require the presence and cooperation of an
adequate number of people and the use of special
equipment. If the number of people is not sufficient or if
there are failures the time needed becomes even longer,
thereby delaying the start of the following session
Availability of special surgical instruments In order to carry out some types of surgical operation
specific surgical instruments as well as the basic
provisions may be necessary. These must therefore be
ordered by the staff in charge, delivered and finally
tested by the Health Physics Department. In fact,
authorisation is needed before this equipment can be
used. This contributes to making the operation waiting
time longer
Availability of beds in intensive care Before starting a surgical operation which, because of
its own complexity or because of the clinical condition
of the patient, requires post-operative hospitalisation in
intensive care, the medical staff (surgeon and
anaesthetist) must consult the staff of the intensive care
unit and make sure that there is a bed available on the
day of the operation. Because of the limited resources
and beds available in intensive care (ten in the
reanimation room and six in post-operative intensive
care), as well as the unpredictability of emergencies
(traumatology, cardiac and pulmonary emergencies),
an operating session is likely to be changed or even
postponed because of a lack of adequate post-operative
monitoring. All this contributes to slowing down the
scheduled operations. During the simulations carried
out, 12 per cent of the total number of people contacted
in a year were discharged and then contacted again
because of the lack of a bed available in the reanimation
Table II. room
Delphi analysis (continued)
Bottlenecks
Transfer of treated patients to other wards
or hospitals
Unpredictable surgical complications
Waiting time for check ups and further
investigations
Physiatric assessment for post-operative
rehabilitation
Unpredictability of emergencies
4.1 Proposal for what-if scenarios
In the light of the previously described problems, new scenarios were proposed so as to
assess the possible attainable results. Since the ward examined is surgical it seemed
appropriate to study the current system so as to modify those parameters which have
the greatest direct influence on the surgical operations. In fact, if a greater number of
Description
Business
process
After having received neurosurgical treatment a patient
may be transferred to another ward or hospital to
re-engineering
continue and complete the hospitalisation. However, if
the final destination ward has no beds available the
transfer is delayed for an indefinite period of time. This
situation naturally means a protracted stay in the
57
neurosurgery ward for patients who no longer need
specific neurosurgical treatment but continue to occupy
beds which could have been used for new patients. The
simulation carried out showed that a patient waits for a
bed in another ward for two days, 22 hours. This aspect
has a considerable influence on the efficiency of the
ward, since, because the coordination between wards is
not perfect, it limits a priori the possibility to admit
patients who are waiting to be operated
These lead to protracted hospitalisation
Analyses carried out for check ups or further
investigations which must be carried out have both
planning and execution times. These waiting times
often become longer, above all because of a lack of
machinery or staff
The physiatric assessment is unlikely to be carried out
at the time it is requested. In fact the neurosurgeon who
decides that the patient needs a physiatric assessment
will usually have to forward a written request to the
Physiatry Service. On average this type of request is
satisfied within a few days. The above described
procedure leads to a waiting time for the patient and a
protracted stay in the hospital
The unexpected arrival of an emergency may lead to
delays in the treatment of elective patients. This is due
to the fact that a surgical emergency immediately
occupies one of the two operating rooms available for
this ward, thereby postponing the operating sessions
scheduled for that day. Postponed operating sessions
cannot always be made up the same day, and therefore
generate further delays. One immediate visible effect of
this is that the waiting list of patients due to be operated
on becomes longer. For this reason the simulation tried
to calculate the overall delay time deriving from the
various scheduled elective operations. During the year
of simulation the following results were obtained for
delay time of elective patients: 17 days, 2 hours, 43
minutes Table II.
BPMJ operations are carried out we reduce the inconvenience for all those patients who are
17,1 waiting to be operated on and are on long waiting lists. One of the methods which can
clear the waiting list is obviously to increase the productivity of the ward in terms of
operations carried out.
In order to assess the benefits deriving from alternative scenarios four different
aspects were considered regarding:
58 (1) Operating rooms. An operating room was set up to deal only with emergencies
so as not to influence in any way the scheduled surgical activity.
(2) Beds in the reanimation room. An ideal situation was hypothesised in which
there is always either one bed available in the reanimation room (B).
(3) or one bed in another ward, should it be needed (C).
(4) Number of operating sessions. A situation was proposed with a greater number
of operating sessions per week. This naturally leads to the need for greater
availability of human resources, including the anaesthetists who are the critical
resource in this case.

Several simulation runs were carried out for each of the proposed scenarios recording the
increase of predicted operations in the year between To-Be and As-Is situations.
The uncertainty was calculated using statistical inference. Standard deviation and a
95 per cent CI was computed for the difference between the operations with new scenario
and operations with the As-Is situations. The results are summarised in Table III.
The values of standard deviation and CIs show a low uncertainty in results.
It is possible to make a general analysis of the results since the observations are
similar for the different cases. The simulation brings to light the fact that it is impossible
to obtain a real benefit by acting only on one single aspect. In general, it was possible to
obtain an increase in the total number of operations which varies on average from 3 to
23.9 per cent. There are many factors which justify a result of this type. The situation
examined, the hospital ward, is an extremely complex system, characterised by
variables which are largely correlated to each other and therefore in no way can be
examined considering each aspect as a single element isolated from the others. To clarify
this statement, the single scenarios are discussed below, highlighting the correlations
which exist between the various aspects:

Average increase SD Upper 95% CI Lower 95% CI

Scenario (in the number of operations, %) (%) (%) (%)

A 14.02 1.14 14.38 13.66

B 6.83 0.75 7.07 6.59
C 3.03 0.51 3.19 2.87
D 15.04 1.88 15.63 14.45
AB 19.11 1.76 19.67 18.55
AC 16.39 0.99 16.70 16.08
AD 23.86 2.13 24.53 23.19
Table III. BC 7.13 1.03 7.46 6.80
“What-if” analysis BD 16.10 1.22 16.49 15.71
scenarios CD 15.81 2.01 16.45 15.17
.
In this case, a third operating room was set up to deal exclusively with emergencies Business
using specific human resources. Neurosurgery ward has an operating room in process
disuse. The scenario A takes into consideration the reactivation of this operating
room without any increase of the human resource number in the ward[3]. In order to re-engineering
repair the operating room, the hospital economic department estimated a cost of
about e150,000. The simulation carried out shows that, in this context, there would
be an increase of about 14 per cent in the number of surgical operations. The reasons 59
for this can be attributed to the number of operating sessions which remain the same
in the normal schedule since there is no corresponding increase in human resources.
This means that in this way it is possible to limit delays since the weekly scheduling
does not have to be modified. The advantage in terms of greater number of
operations carried out is to be attributed solely to this solution. It is therefore clear
that the result is a very limited benefit if compared with the type of solution adopted.
.
B. A sensitivity analysis, carried out by simulation in As-Is model, showed that
with an increase of beds from ten to 15 in Reanimation room, this variable is never
a bottleneck, because no saturation of this resource was experienced in simulated
operating time. Scenario B analysis has been performed without any increase of
the human resource in the ward. With the hypothetical availability of a bed when
needed it is not necessary to postpone elective operations and consequently a
certain type of planning can be respected. In quantitative terms there is an increase
of about 6.8 per cent in the total number of annual operations. It should also be
noted that in this way there is no unnecessary occupation of beds by patients who,
before their operation, must wait for the availability of a bed in the reanimation
room and there is no need to discharge patients who will then have to be contacted
again to re-schedule the operation. However, even in this case it should be
remembered that only one of the causes which contribute to altering the operation
schedule has been acted on. The other causes (emergencies, delays, etc.) continue to
exist and that is why, even in this situation, the benefit derived is not enough to
justify the solution proposed (which is in itself extremely difficult to organise).
.
C. Having a bed free in the ward which a certain patient should be transferred to
allows the stay in neurosurgery to be reduced, thereby freeing the bed more
quickly. This means that more patients can be admitted to the ward even if, since it
is not possible to change the number of operating sessions (the resources are
constant), there are still waiting times which shift from the post-operative to the
pre-operative stage. The results obtained confirm this: the number of operations
varies only slightly, by about 3 per cent, while the value which is subject to the
greatest variation is the average availability of beds. If in the real situation, this
value is between 0.6 and 1 (indicating how difficult it is to find beds available in
the ward), in the above-mentioned scenario, there is an almost fourfold increase
indicating how the period of hospitalisation and therefore of bed occupancy is
strongly influenced by this wait.
.
D. The scenario D as apposed to the previous three scenarios, takes into
consideration an increase of the level of human resource. The availability of more
operating sessions and of the resources needed to carry them out leads to the
possibility to carry out a greater number of surgical operations. In this case study,
the shift calendars of the anaesthetists (considered the most important critical
BPMJ resource when scheduling the operations) were modified, increasing by 43 per cent
17,1 their availability in terms of time[4]. Moreover, it was considered the hiring of a
doctor and two nurses. However, this did not result in an equivalent increase in
operations carried out (which was about 15 per cent). In fact, in this case, the factor
that most limits the number of operations which can be carried out is the
availability of the operating rooms which is unchanged. The result is a situation in
60 which the specialised medical staff cannot work because of the lack of structures to
work in. In fact the utilization rate of the resource “doctors” decreased of about
20 per cent changing from 76 to 61 per cent, while the utilization rate of the resource
“nurses” changed from 84 to 78 per cent. These observations are confirmed by the
fact that the best result is obtained using a combination of scenarios A and B which
leads to a 23.9 per cent increase in the number of operations.

In general, it can be stated that the combination of different scenarios improves the
situation although the benefits are fewer than the sum of the increases in the number of
operations for the single scenarios. This happens since there is overlapping of the
benefits deriving from different scenarios.

5. Discussion and conclusions

This BPR study started from the acquisition of the As-Is situation to describe the system.
The As-Is analysis was based on the identification of the system objectives in order to set
up a correct analytical approach. This has been made easier by the classification of the
activities and the objectives according to the role they have in the analysis. In our opinion,
the As-Is analysis stage is of fundamental importance in the health sector where it is
inconceivable to apply the radical approach to process re-engineering, as it is theorised in
some literature. On the contrary, the incremental approach is the most appropriate
because of the “sedimentation of knowledge accumulated up to that point and considering
the characteristics and capacity of the organisation to provide certain processes according
to the professional, structural and technological resources at its disposal”.
According to Barjis (2008) the leading causes for the high failure rate of software project
is still poor process modelling (requirements’ specification). Moreover, lack of direct model
checking (verification) feature is one of the main shortcomings in conventional process
modelling methods. Barjis (2008) dealt with this problem introducing a business process
modelling method that is amenable to automatic analysis (simulation). Many researches
have assigned formal semantics to EPCs and are using these semantics for execution and
verification. van Dongen et al. (2005) proposed a two-step approach where first the
informal model and rules are reduced and then verified in an interactive manner using
Petri nets. They found that this approach acknowledged that some constructs were correct
or incorrect no matter what interpretation was used and that the remaining constructs
required human judgement to assess correctness.
In this work, the validation of the created EPC models was carried out in a subsequent
phase, using the simulation on EPC model of the As-Is situation. The main problem of
this approach is that EPC models required to be translated to other formal diagrams for
checking the validity.
For the validation of the simulation, so as to verify the ability to reproduce the real
trend of the ward activities the results obtained were compared with the historical data
of neurosurgery ward. The comparison showed that simulation output, in terms of type
and numbers of surgical operations, are equivalent to those carried out really in the Business
neurosurgery ward. process
The results obtained were discussed with the panel of experts during the three
round of Delphi process. re-engineering
The possibility to make up a panel of experts large enough (seven participants in
this work) and to work with the experts for an adequate period (two weeks in this
work) was one of the main problems to overcome in this BPR project. 61
In this work, using Delphi approach, there was an attempt to overcome the
traditional approach, where modelers and analysts are the players and the rest (process
owners, mangers, stakeholders and experts) are either passive participants or even
absent from the scene.
According to Barjis (2009) traditional approach has a number of problems:
.
As the interaction of the analysts with the enterprise employees become more
and more often, the enterprise becomes more reluctant and less interested to
allocate their most needed human resources to be involved in the project, which
will be seen as waste of time.
.
In turn, modellers, not having sufficient rounds of iteration, will end up with a model
that is either incomplete, or there are many assumptions that are intuitively made
by the modellers. As a result, the model may contain a lot of flaws. These flaws
remain quite undetected as majority of enterprise process modelling is not based on
formal semantics to check the models and simulate their dynamic behavior.

In literature, in order to address these challenges in enterprise modelling, innovative

approaches have been discussed and introduced such as participative enterprise
modelling (Persson, 2001). A central goal of enterprise modelling is to discover domain
knowledge and document the enterprise existing business processes. The role of
participative modelling is to represent this knowledge in a coherent and comprehensive
model, create shared understanding, consolidate different stakeholder views and in
order to do so an extended participation of stakeholders is crucial (Stirna et al., 2007).
In order to expedite the modelling process and validity of the models, Barjis (2009)
proposed an approach called collaborative, participative and interactive modelling (CPI
Modelling). The main objective of the CPI approach is to furnish an extended
participation of actors that have valuable insight into the enterprise operations and
business processes. Three aspects constitute the CPI Modelling approach, where each
aspect is a dimension: the collaboration aspect represent the “Experts” (analysts)
dimension; the participation aspect represents the “Users” (stakeholders) dimension
and the interaction aspect represents the “Technology” (tools) dimension.
In this work, the process of data collection, using Delphi method (Section 4), was
carried out from two academics that had “facilitators” role. The participants of panel of
experts worked almost independently and together with the academics and thus
reducing the amount of time to develop the models of the processes.
The use of Delphi methodology, in order to incorporate expert opinions in the
re-engineering process, was one of the main points of this work. This technique allowed
the academics to access to the positive attributes of interacting groups (knowledge from
a variety of sources, creative synthesis, etc.), while pre-empting their negative aspects
(attributable to social, personal and political conflicts, etc.). From a practical perspective,
the method allowed to collect input from a larger number of participants than could
BPMJ feasibly be included in a group or committee meeting, and from members who are
17,1 geographically dispersed. Important feature introduced by Delphi techniques was the
anonymity of answers. Anonymity was achieved through the use of questionnaires.
By allowing the individual group members the opportunity to express their opinions and
judgments privately, undue social pressures – as from dominant or dogmatic
individuals, or from a majority – were avoided. Furthermore, with the iteration of the
62 questionnaire over a number of rounds, the individuals were given the opportunity to
change their opinions and judgments without fear of losing face in the eyes of the
(anonymous) others in the group. Between each questionnaire iteration, controlled
feedback was provided through which the group members were informed of the opinions
of their anonymous colleagues. In this phase, additional information, regarding
arguments from individuals whose judgments fall outside certain pre-specified limits,
were provided. In this manner, feedback comprised the opinions and judgments of all
group members and not just the most vocal.
The identification of the critical processes using the Delphi method proved to be
helpful in defining new scenarios and in interpreting the results. In general, the benefits
provided by the combination of different scenarios are fewer than the sum of the
increases in the number of operations for the single scenarios. This happens since an
increase of the level of one or two resources produces an increase of operations until a
third resource (with limited capacity) become a new bottleneck. In every what-if scenario
the resource that became new bottleneck has been identified analysing the utilization
rates of all resources that have not changed their levels. The resources that first
saturated their levels and that blocked an increase of operations in the days of the
simulation period were considered as bottleneck.
In the health sector, the problem to deal with is much more complicated because of
the very nature of the sector. The autonomy of the doctors, how to measure health
results (i.e. the efficacy or outcome of the treatment), the personalisation of treatment
and the difficulty to standardise the processes are only some of the aspects which make
it more difficult to activate management tools.
From this overall picture, it is clear that the real competitive advantage is determined
by the totality of the results of the various functions involved in the sector. In fact, the aim
is to make sure that the mechanisms which allow the ward processes to work are clear
and transparent. Documenting the way in which things work satisfies above all the need
for clarity (sometimes, in particular with complex processes which involve different
types of professional competences or organisational areas, the chain of responsibility is
not always well defined) and transparency (even if the single actors know their own
actions and competences they do not always fully understand the role of those who act
before or after them in the process) and prevents the most frequent shortcomings
connected with lack of process visibility.
The next step in this research project will be to carry out a wider ranging analysis
perhaps involving the whole hospital structure. In fact there is a considerable amount
of interaction between wards which is difficult to understand if analysed separately.

Notes Pn Pn 

2
Xi X i 2 XðnÞ


1. XðnÞ ¼ i¼1 ; S 2 ðnÞ ¼ i¼1
Pn n n21
j¼1 Y ji
2. Y i ¼ for i ¼ l; . . . ; m
n
 3. At the moment the Italian laws provide for freeze of new appointments in the public sector. Business
4. The anaesthetists are in Anaesthesia and Resuscitation Operative Unit and their shifts process
concern, by turns, all hospital surgery wards.
re-engineering
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65
Appendix 1
The EPC is a dynamic model which connects the static resources of the system (systems, data,
organisation, etc.) and organises them so as to arrive at a sequence of activities or tasks
(the process) which create value for the company.
An EPC shows the chronological sequence of the company processes, in the shape of chains of
events or functions. An event activates a function which in turn creates one or more new events.
Each function is therefore characterised by an initial event and a final event which, respectively,
correspond with the input and output of the function itself.
By event we refer to an important change in state in the company process. It may consist in an
external change which gives rise to the process (for example, the receipt of an order from a client),
an internal change (for example, the production of a specific type of goods), or the final output of the
process which has external effects (for example, the order delivered to the consumer).
Unlike the functions, which need a certain amount of execution time, the events are connected
with a specific moment in time.
In reality, the processes are often not simple chains of events and functions which alternate in
sequence, but may in fact be alternative paths followed in order to perform a company task.
The decisions which change the flow of the process are always made on the basis of the
functions, but to represent the possible results and the various events that may lead to the
execution of a function it is necessary to introduce some rules.
There are three basic logical operators which have slightly different uses according to
whether they follow or precede the functions, as described in Table AI.
It is also possible to add to the process model, as a chain of events and functions, a set of
information, generally called resources, which concerns: the organisation; the application
systems; the data; the know-how; the information providers; the products; the aims and the
measures; and the general resources. For example, considering the function develop the order it

After a function Before a function

Operator (single input, various output) (various input, single output)

OR Decision OR Start OR
One or more paths may be followed as a Each Event, or combination of Events, will
result of the decision give rise to the Function

XOR Decision OR Exclusive Start OR Exclusive

One, and only one, of the possible paths will One, and only one, of the possible Events
be followed will give rise to the Function
AND Branch AND Start AND
The flow of the process branches into two or All the events must occur in order to trigger
more parallel paths the following Functiona
Note: aIt may be necessary to consider the period in which the events occur for the meaning of the Table AI.
AND to be valid The rules
BPMJ is possible to model the organisation that executes the order (commercial sector) and the types of
data needed to execute the order (data about the customer, data about the order).
17,1
Appendix 2
The formulae used to assess the accuracy of the simulation are, respectively:
MAD is the mean absolute deviation over the whole period and is expressed by:
66 1 X m2l
MAD ¼ j E i j;
m 2 l i¼1
where Ei ¼ real value of operations (Xi) – predicted value of operations (Yi); n ¼ 365 days;
MAPE is the average absolute error as a percentage of real value and is given by:
m2l  
1 X  E i  · 100:
MAPE ¼
m 2 l i¼1 X i 
To determine whether a forecast method consistently over- or underestimates real value it is
possible to use the sum of forecast errors to evaluate the bias:
X
m2l
BIAS ¼ Ei:
i¼1

The tracking signal (TS) is the ratio of the bias and the MAD and is given as follows:
BIAS
TS ¼ :
MAD
Finally, the correlation coefficient (R) is calculated as:
P
ð1=ðm 2 l ÞÞ m2l i¼1 ð yi 2 y
Þ · ðxi 2 x
Þ
R ¼ rffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
P   r ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
P  ;
m2l 2 m2l 2
i¼1 ðxi 2 x
Þ =m 2 l · i¼1 ð yi 2 y
Þ =m 2 l

1 X m2l
1 X m2l
for x
¼ jxi j and y
¼ j yi j
m 2 l i¼1 m 2 l i¼1

Corresponding author
M. Bevilacqua can be contacted at: m.bevilacqua@univpm.it

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