• Users Online: 177
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2013  |  Volume : 1  |  Issue : 4  |  Page : 229-236

Developing "an integrated business process management and lean"model for improving quality of services in teaching hospitals

1 Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
2 Health Care Services Management, Health Sciences Center, Mashhad University of Medical Science, Mashhad, Iran

Date of Web Publication16-Apr-2014

Correspondence Address:
Farzaneh Doosty
Health Services Administration, Management and Information School, Mashhad
Login to access the Email id

Source of Support: This study is supported by Management Research and Health Economic Center of Isfahan University of Medical Science, Conflict of Interest: None

DOI: 10.4103/2347-9019.130743

Rights and Permissions

Introduction: Rapid great changes in technology specially the increasing role of information technology and computer systems in managing the organizations has changed the management strategies and organization leadership, as a result, in the new world, managing organizations by old strategies has become impossible. Unanimous information systems, new approaches to services, managing the relationship with the customers and the others, all, have one common management feature that is the success in all these systems is based on process perspective. The present study aims at determining the effect of applying an adopted model from business process management (BPM) to modify the discharging hospitalized patients' process in teaching Hospitals. Materials and Methods: The present study is an action research with no control group which its aim is improvement of discharging hospitalized patient's process in teaching hospital. The variables such as waiting period, moving, stocking, and commuting time that the researchers use them for identifying wastes. For collecting data, we used focus group to which help us to determination of prioritize, modeling, and to identify the process problems and find appropriate solutions for them. In the last step, to collect functional indexes, we used observation method and time measurement criteria. Findings: In the last step, after filling out the improvements recommendation's form, the researchers started implementing the suggestions and use the indicators to evaluate the achieved changes. The results of the survey showed that reform implemented the process of discharging hospitalized patients, led to decrease the waiting period to 60 min that this period was 90 before intervention, and waiting time we could save is 30 min in waiting time period. Our result show 17 min decrease in commuting time, before intervention it take 20 min, and after that its time change to 3 min. The last variable was moving time that was reduced from 15 min to 5 min and we could save 10 min in this process. Discussion and Conclusion: Applying this mixed approach, the researchers implemented the recommended focus group solutions and show its effects via significant indexes changes. After that they made model for process to identify the problems or recognize the nonvalue added activities. After implementing the project, a significant improvement was noticed in waiting period, commuting and moving time that waste for relocating patients or documents.

Keywords: Business process model, hospital management, Mashhad, procedure modification, Qaem hospital

How to cite this article:
Yarmohammadian MH, Ebrahimipour H, Doosty F. Developing "an integrated business process management and lean"model for improving quality of services in teaching hospitals. Int J Health Syst Disaster Manage 2013;1:229-36

How to cite this URL:
Yarmohammadian MH, Ebrahimipour H, Doosty F. Developing "an integrated business process management and lean"model for improving quality of services in teaching hospitals. Int J Health Syst Disaster Manage [serial online] 2013 [cited 2021 Jun 21];1:229-36. Available from: https://www.ijhsdm.org/text.asp?2013/1/4/229/130743

  Introduction Top

For many years, industrial and commercial organizations have been using business process management (BPM), engineering, and automation of main processes successfully to consider strategic priorities. [1] However, until few years ago, these principles were strange terms to healthcare organizations. [2] The reasons could be the extraordinary dynamic nature of healthcare industry and high complexities of the process in the organizations. [3] And, in healthcare organizations, the process is not just limited to the organization itself and they include a widespread area of different departments and organizations, these process are divided in two: Administrative and clinical [4] that they include high volume of related data, a great number of patients and the involved staff dealing with their implementation which is done by hand or automatically. [5] On the contrary, the pressures, due to increasing the expenses in healthcare industry as well as increasing the attention to patients' satisfaction, have necessitated implementing the changes and modifications in these organizations. [6] In the recent years, enormous efforts have been made to identify a system or method for management and for automating these processes to improve the efficiency of healthcare organizations. [7],[8]

As the hospitals are professional and social organizations and the common aspect of all these organizations is too much complex processes, these organizations are under two constant pressures which are the reduction of expenses and the increase the quality of services; [9],[10] therefore, for survival, the organizations need to pay special attention to the principles of business processes. [11] Healthcare organizations attain great benefits from applying BPM principles both as a special solution to achieve processes improvement and as a lever to give them an initiative ability in constant improvement of different processes. [12] The improved processes lead to decrease expenses, increase income, motivated staff, and more satisfied customers. [13] The concept of continues improvement is the core of management approach in BPM. [14]

Process provides a common understanding about what is happening: Who does what, when, using what, with the business rules that impact a process flow. When you pair BPM and Lean, you have the foundation for what is needed to bring your processes all the way to automation. [15] Lean and BPM have much to contribute to each other. Unfortunately, most companies have not integrated these initiatives successfully - inhibiting companies from realizing the full potential of their process improvement efforts. [16]

Lean is a philosophy and approach that stresses continuous improvement to reduce waste and streamline operations. It is customer centric and stresses the concept of eliminating any activity that fails to add value to the creation or delivery of a product or service. Lean is focused on providing higher quality, reduced cycle time, and lower costs. Because it produces improved production systems, it is believed to increase production capability and flexibility. But in practice, its concepts can be, and have been, applied in all areas of a business. [17]

While these disciplines and their methods and tools seem to compete at first glance, the fact is they are actually complimentary to one another; and when used together, provide a comprehensive change environment. Part of the reason for this seeming overlap is that these two are based to a large degree on the work and statistics of Edward Deming. But, each also applies methods in a different way and has evolved to focus on a different area in operational improvement. BPM and Lean approaches are an offshoot of the work done by W. Edward Deming as described in his book, "Out of the Crisis", MIT Center for Advanced Engineering Study, 1982. This work by Deming is the foundation for statistical operational improvement and was a key part of the thinking behind the process reengineering movement in the 1990s. That is why all three approaches, while very different, are process centric and are focused on reduction of waste and error in process. [18]

According to national development document in healthcare section of Iran in fourth plan of economical, social, and cultural development of the country, and because of impact of changing of society needs on healthcare systems, it is necessary that healthcare system have readiness, flexibility, and enough facilities to confront the changes. [19] Hence, to achieve these objectives, changes and modify healthcare system is vital and inevitable to meet the critical needs in healthcare organizations. [20] In other words, the newest and greatest challenges proposed in hospitals are the necessity of process management for increase the patients' awareness, equitable distribution of care, solve the problems such as shortage in resources, high expenses, and decreasing the efficiency of hospitals, the necessity to absorb society and patients' trust on services and taken care, change of attitudes and last but not least pace toward customer orientation. [21],[22] The aim of the study is determining the effect of applying an adopted model from BPM to modify the selected procedures in Qaem Hospital, Mashhad in 2012.

  Method of the Study Top

The present study is an action research with no control group, which was done in first half of 2012. The scope of study is dismiss the hospitalized patient's process that it was done in Qaem teaching hospital in Mashhad, Khorasan Razavi located in the northeast of Iran. Qaem hospital is the biggest specialty and subspecialty tertiary referral hospitals includes 19 paraclinic (psychotherapy, laboratory, radiology, endoscopy…) and 21 clinics (general surgery. Gynecology, plastic surgery and….) units and 20 wards (surgery, gynecology, and), research and development section and other administrative sections. [23]

To collect data focus groups were used and the top managers of hospital participated in all sessions of that. In the first session the concept of process, the necessity of process management and the potential benefits that could have obtained of turning to process oriented approaches were explained. In the second session, the members of discharging process team were determined. The team consists of officer of medical records department. Then the workshop was held to draw the process steps, modeling the steps of process, identification the problems and finally find their solutions. In the last step and to gather the appropriate indexes, both methods of observation and time measurement were applied.

As mentioned in above, researchers in first session brought bring the top managers of hospital and especially supervisor of medical record department introduce some concepts such as process, process management, and the necessity of turning toward process-oriented approaches in organizations. Then, the discharging process team consists of medical record department officer, receptionist, and two other members of the staff in this department were determined then new duties and responsibilities in order to process reforms determined for them. After that, they started to gathering necessary data to filling the form of improvement actions, via flow process chart. In the flow process chart, some concepts were used that the team members needed to become familiar with and find a common language for them by teaching the [Table 1] (the Table of identifying the concepts used in the flow process chart has been presented in Appendix No 1) [Additional file 1] After consensus of members group, the flow process chart was completed for that. In the chart, consecutive steps of process were determined and then the objective activity for doing each stage was written.
Table 1: Flow process

Click here to view

Next, team members suggest some possible practical solutions through "engineering process analysis and identify improvement opportunities" form. Filling out this form was an opportunity for participants to review the current ways used to complete individual steps of process and to find practical solutions in the case of improvement opportunity and nonvalue added activities (sample form was presented in the Appendix No 2) [Additional file 2][Table 2].
Table 2: The form of identifying improvement opportunities

Click here to view

  Results Top

After completing all above-mentioned stages, the researchers filled out the "planning for improvement actions" form. In the form, the problems identified by members team and proposed solutions were developed. Then the form was seen by top managers and supervisors and their ultimate agreement to implement the solutions with regard to hospital's financial resources and other conditions was achieved. In fact, the actual work in this study started after gathering related data and statistics and records them. Before doing reforms, the researchers attended medical records and admission departments and started to gather needed and related information and data to analyze obtained results from doing reforms. The information was obtained on the basis of index list of mentioned department via observation and the noticeable process. After implementing the modifying actions, the table of per and post changing indexes of implementing the project and the related charts to process was drawn [Figure 1], [Table 3] and [Table 4].
Figure 1: The stages of modification of discharging procedure

Click here to view
Table 3: The form of identifying problems and providing solutions

Click here to view
Table 4: Adjustable indexes after implementing the solutions

Click here to view

  Discussion and Conclusion Top

In recent years, due to severe competition and changing environment of healthcare industry, the organizations are increasingly seeking for using intelligent and creative approaches which lead to an increase in efficiency and customers' satisfaction. [28],[29] The given approach in the present study is integrating BPM and lean methods which is one of the latest modifying approaches. [30]

Today, the Deming concepts and their derivatives expressed in Lean, and others, are a key part of BPM's continuous improvement promise. We say "promise" because few companies have implemented BPM to the point, where they can use it for continuous improvement. However, we believe that without the operational framework and information that BPM provides, the Lean approach can only provide temporary results and those at a high price in terms of analysis, change design, and implementation. This approach is not for solving the new problems, but it is for solving the exits problems through new ways which are less expensive, faster, and more efficient. [31] Many are asking how BPM, Lean, and other change methods fit together and how they differ. It is our belief that these two disciplines work best when used to create a new business change environment, where BPM provides the overall framework to support ongoing change and Lean technique and method are used to support continuous improvement.

By using the approach, researchers could implement proposed solutions and show its effects in the form of adjustable indexes after a model making the process identifying the problems and activities without added value. As well as by implementing the project a noticeable improvement actually about 57 min in whole process was seen in waiting period of patients, commuting time and time needs to moving patient and patients' documents. Last but not least, researchers suggest that after applying this method and survey the reliability of that, other hospitals can get specially benefits of identified acceptable result from this method.


The most important limitation of the current study is impossibility of generalize the results to other hospitals because of different conditions and high changing environment of the organizations. The other limitations of the study are lack of control group and exist the interfering variables which are out of researcher's control.

  References Top

1.In: Mintchev S, editor. Open IT for Business: Transforming Information System Infrastructure with a Commercial BPM Suite. Business Information Systems. Berlin: Springer;  2011.  Back to cited text no. 1
2.Addison R, Haig C, Kearny L. Performance architecture: The art and science of improving organizations: Pfeiffer; 2009.  Back to cited text no. 2
3.Doosty F. The investigating of barrier and challenges to implementation of Business Process Management in healthcare institutions. [online]. Available from: http://www. congress.mums.ac.ir/images/file/./47119800.docx. [Last cited on 2012 Dec 25].  Back to cited text no. 3
4.Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: Systematic review and recommendations. Milbank Q 2004;82:581-629.  Back to cited text no. 4
5.Weisbrod B. The health care quadrilemma: An essay on technological change, insurance, quality of care, and cost containment. J Eco Literat 1991;29:523-52.  Back to cited text no. 5
6.Doosty F, Yarmohammadian M. Risk management and reduction human error using Business process management in healthcare organizations. The national congress on health system risk management and disasters, Isfahan University of Medical Science, Feb 28;  2012.  Back to cited text no. 6
7.Bertolini M, Bevilacqua M, Ciarapica F, Giacchetta G. Business process re-engineering in healthcare management: a case study. Business Process Manage J 2011;17:42-66.  Back to cited text no. 7
8.Andersson A, Hallberg N, Timpka T. A model for interpreting work and information management in process-oriented healthcare organisations. Int J Med Inform 2003;72:47-56.  Back to cited text no. 8
9.McNulty T, Ferlie E. Process transformation: Limitations to radical organizational change within public service organizations. Organ Stud 2004;25:1389-412.  Back to cited text no. 9
10.Poirier CC. The Networked Supply Chain: Applying Breakthrough BPM Technology to Meet Relentless Customer Demands: J Ross Pub; 2004.  Back to cited text no. 10
11.Doosty F, Yarmohammadian M, Mohammadinia L. Business Process Management: The third wave of quality improvement methods in healthcare, Yeditepe International Research Conference on Business Strategies, June 13-15;  2012.  Back to cited text no. 11
12.Kim CS, Spahlinger DA, Kin JM, Billi JE. Lean health care: What can hospitals learn from a world‐class automaker? J Hosp Med 2006;1:191-9.  Back to cited text no. 12
13.Gunasekaran A, Kobu B. Modelling and analysis of business process reengineering. Int J Prod Res 2002;40:2521-46.  Back to cited text no. 13
14.Goldstein SM, Schweikhart SB. Empirical supp ort for the Baldrige Award framework in US hospitals. Health Care Manage Rev 2002;27:62-75.  Back to cited text no. 14
15.Dicken C, Walker C. BPM and Lean: Part 1-The Plan. BPM Trends. October;  2011.  Back to cited text no. 15
16.Fliedner G. Sustainability: A new lean principle. Proceeding of the 39 th annual meeting of the decision sciences institute, Baltimore, Maryland 2008:3321- 6.  Back to cited text no. 16
17.Tupa J. Performance management for efficient lean management. Advances in Sustainable and Competitive Manufacturing Systems: Springer: 1375- 84.  Back to cited text no. 17
18.Skalle H, Ramachandran S, Schuster M, Szaloky V, Antoun S. Aliging business process management, service-oriented architecture, and lean Six Sigma for real business results;  2009.  Back to cited text no. 18
19.The Fourth Development Plan ofIslamic Republicof Iran, [online]. Available from: http://www.dadkhahi.net/./ghanoon_barnameh_4.htm. [Last cited 2012 Dec 8].  Back to cited text no. 19
20.Srivardhana T, Pawlowski SD. ERP systems as an enabler of sustained business process innovation: A knowledge-based view. J Strategic Inform Systems 2007;16:51-69.  Back to cited text no. 20
21.Chou WL. A Study on Implementing Bussiness Process Management for M Life Insurance Company;  2010.  Back to cited text no. 21
22.Bruin T, Doebeli G. An organizational approach to BPM: The experience of an Australian transport provider. Handbook on Business Process Management 2. 2010:559- 77.  Back to cited text no. 22
23.Qaem hospital official website, Teaching, Research and Treatment center of Mashhad University of Medical Sciences [online]. Available from: http://www.mums.ac.ir/quaem. [Last cited 2012 Dec 8].  Back to cited text no. 23
24.Venkatraman N. 14 IT-enabled Business Transformation: From Automation to Business Scope Redefinition. Operat Manage 2005: 145.  Back to cited text no. 24
25.Van der Aalst W, ter Hofstede A, Weske M. Business process management: A survey. Business Process Manage 2003: 1019.  Back to cited text no. 25
26.Jeston J, Nelis J. Business process management: Practical guidelines to successful implementations: Routledge;  2008.  Back to cited text no. 26
27.Box S, Platts K. Business process management: Establishing and maintaining project alignment. Business Process Manage J 2005;11:370-87.  Back to cited text no. 27
28.Lockamy III A, McCormack K. The development of a supply chain management process maturity model using the concepts of business process orientation. Supply Chain Manage 2004;9:272-8.  Back to cited text no. 28
29.Harrington DH. Business process improvement: The breakthrough strategy for total quality, productivity, and competitiveness;  2011.  Back to cited text no. 29
30.Pourshahid A, Amyot D, Peyton L, Ghanavati S, Chen P, Weiss M, et al. Business process management with the user requirements notation. Electron Commerce Res 2009;9:269-316.  Back to cited text no. 30
31.Anyanwu K, Sheth A, Cardoso J, Miller J, Kochut K. Healthcare enterprise process development and integration. J Res Pract Inform Technol 2003;35:83-98.  Back to cited text no. 31


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Method of the Study
Discussion and C...
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded349    
    Comments [Add]    

Recommend this journal