ANALYSING THE BUSINESS PROCESS MANAGEMENT APPROACH OF MEDICAL WARD ROUNDS IN BELGIAN HOSPITALS Word count: 16165 Rob Steenacker Student number: 01201133 Supervisor: Prof. dr. Frederik Gailly Master’s Dissertation submitted to obtain the degree of:

Master of Science in Business Engineering Academic year: 2016 - 2017

ANALYSING THE BUSINESS PROCESS MANAGEMENT APPROACH OF MEDICAL WARD ROUNDS IN BELGIAN HOSPITALS Word count: 16165 Rob Steenacker Student number: 01201133 Supervisor: Prof. dr. Frederik Gailly Master’s Dissertation submitted to obtain the degree of:

Master of Science in Business Engineering Academic year: 2016 - 2017

I

PERMISSION

I declare that the content of thisMaster’s Dissertationmay be consulted and/or reproduced,

providedthatthesourceisreferenced.

Student’sname:SteenackerRob

II

Foreword

Iwouldliketothankseveralpeople,whichhavehelpedmesignificantlyduringthisresearchand

withoutwhomthisresearchwouldn’thavebeenpossible.

First, I would like to thank my supervisor Prof. dr. Frederik Gailly, who guided me very well

throughouttheresearchandwhowasalwaysavailableforadviceandguidance.

Secondly,IwouldliketothankmybrotherWoutSteenackerforthehelpinthecontactingofLuc

DeMuynckandSimonVanBeveren,whoIwouldalsoliketothankforhelpingmegetincontact

withthedifferenthospitals.

Lastly,IwouldalsoliketothankallthepeoplefromthefivehospitalsinwhichIperformedmy

researchfortheefforttheyputintothisresearch.

III

TableofContents

1. Introduction.......................................................................................................................1

2. ResearchQuestion.............................................................................................................4

3. Literaturereview...............................................................................................................5

3.1MedicalWardround.....................................................................................................................5

3.2BusinessProcessManagement.....................................................................................................7

3.3WardRoundasabusinessprocess..............................................................................................10

4. Methodology...................................................................................................................12

4.1WardRoundOverview...............................................................................................................14

4.2WardRoundProcessMaturity....................................................................................................15

4.2.1BPOMaturityModel...................................................................................................................15

4.2.2HospitalProcessOrientationTool..............................................................................................17

4.2.3UseofHPOTool..........................................................................................................................17

4.3Mind-setofwardroundparticipants..........................................................................................18

5. Resultsempiricalstudy....................................................................................................20

5.1WardRoundOverview...............................................................................................................20

5.2WardRoundProcessMaturity....................................................................................................24

5.3Mind-setofwardroundparticipants..........................................................................................28

5.4Performanceofobservedwardrounds.......................................................................................31

6. HowCanhospitalsimprovetheirBPMmind-set?.............................................................32

6.1ProcessDiscovery.......................................................................................................................32

6.2ProcessAnalysis.........................................................................................................................33

6.2.1Defineperformancemeasuresforyouranalysis........................................................................33

6.2.2Observedproblemsofthecurrentwardround.........................................................................36

6.2.3Generalprocessanalysisrecommendations..............................................................................38

6.3ProcessRedesign........................................................................................................................40

6.3.1Importanceofthesoftwaresystem...........................................................................................40

6.3.2Modelstoguidetheredesign.....................................................................................................43

6.3.3Decisionswhichhaveanimpactonthewardroundprocess.....................................................45

IV

6.3.4Redesigntipstoimprovemicro-problems.................................................................................51

6.4ProcessImplementation.............................................................................................................53

6.5ProcessMonitoring&Controlling...............................................................................................55

7. Conclusion.......................................................................................................................56

7.1Generalconclusion.....................................................................................................................56

7.2Importanceofresearchforhospitals..........................................................................................62

7.3Flawsofresearchandfurtherresearch.......................................................................................64

8. References.......................................................................................................................66

9. Appendix.........................................................................................................................69

9.1Appendix1:DutchversionofusedHPOToolandquestionnaire.................................................69

PROCESSVIEW.....................................................................................................................................69

PROCESSJOB.......................................................................................................................................69

PROCESSMANAGEMENTANDMEASUREMENT..................................................................................70

EXTRAVRAGEN....................................................................................................................................70

9.2Appendix2:EnglishversionofusedHPOToolandquestionnaire...............................................73

PROCESSVIEW.....................................................................................................................................73

PROCESSJOB.......................................................................................................................................73

PROCESSMANAGEMENTANDMEASUREMENT..................................................................................74

EXTRAQUESTIONS...............................................................................................................................74

9.3Appendix3:originalHPOQuestions...........................................................................................77

9.4Appendix4:HPOScores..............................................................................................................78

V

Listofabbreviations

AI ArtificialIntelligence

AR AugmentedReality

AZ AlgemeenZiekenhuis–PrivateHospital

BPM BusinessProcessManagement

BPMN BusinessProcessModelandNotation

BPO BusinessProcessOrientation

CMMI CapabilityMaturityModelIntegrated

HPO HospitalProcessOrientation

Iot InternetofThings

NSW New-South-Wales

PC PersonalComputer

UZ UniversitairZiekenhuis–Universityhospital

WR Wardround

VI

ListofTables

Table 1- Core ward round activities (O’Hare, 2008) ......................................................................... 6Table 2 – Ward round as a business process .................................................................................... 10Table 3 - Hospitals and departments investigated during research .................................................. 13Table 4 - Business Process Maturity Model (McCormack&Johnson,2001) ................................. 15Table 5 – Business Process Orientation Tool .................................................................................. 16Table 6 – Relevant information during preparation phase ............................................................... 21Table 7 – Actions performed during visit phase .............................................................................. 22Table 8 - Actions performed during review phase ........................................................................... 23Table 9 – Hospital Process Orientation Tool scores ........................................................................ 24Table 10 – Capability Maturity Model Integrated (CMMI) ............................................................ 25Table 11 – General questions in HPO Toll ...................................................................................... 26Table 12 – HPO Tool findings ......................................................................................................... 27Table 13 – Differences between surgery and internal disciplines ................................................... 29Table 14 – Questionnaire findings ................................................................................................... 29Table 15 – Examples of micro-problems ......................................................................................... 31Table 16 – Examples of macro-problems ........................................................................................ 31Table 17 – Process discovery techniques ......................................................................................... 32Table 18 – Ward round goals ........................................................................................................... 34Table 19 – Effect of micro-problems on the Devil’s Quadrangle dimensions ................................ 36Table 20 – Macro-problems of the current ward round ................................................................... 37Table 21 – Head nurse implications ................................................................................................. 46Table 22 – Nurse zone implications ................................................................................................. 47Table 23 – No nurse implications .................................................................................................... 47Table 24 – No assistant implications ............................................................................................... 48Table 25 – Assistant follows doctor implications ............................................................................ 49Table 26 – Assistant performs review phase ................................................................................... 49Table 27 – Assistant performs ward round implications ................................................................. 50Table 28 – Solutions for micro-problems ........................................................................................ 51Table 29 - Hospital Process orientation recommendations .............................................................. 59Table 30 - Questionnaire recommendations .................................................................................... 60Table 31 - All recommendations to improve BPM approach .......................................................... 61

ListofFigures

Figure 1- BPM Lifecycle (La Rosa et al., 2013) ................................................................................ 8Figure 2 – Ward round overview model 1 ....................................................................................... 20Figure 3 – Ward round overview model 2 ....................................................................................... 21Figure 4 – Devil’s quadrangle .......................................................................................................... 35Figure 5 – Reference model 1: Perform all three phases separately for all the patients .................. 44Figure 6 – Reference model 2: Perform the tree phases sequentially for every patient before

moving to the next patient ........................................................................................................ 44Figure 7 - Ward round model 1 ........................................................................................................ 58Figure 8 - Ward round model 2 ........................................................................................................ 58

VII

1

1. Introduction Thehealthcareindustryiscontinuouslypushedtomaximizeresourceswhilemaintainingquality

of care. That iswhyhealth care,oneof the fastest growing industries, is turning to thewider

businessworldfortheprinciplesthatinspiretheoptimaltrade-offbetweenefficiencyandpatient

responsiveness(Buttigieg,C.,Dey,P.K.,Gauci,D.,2016).

Companiesinthewiderbusinessworldhaveseenbigimprovementsfromtheimplementationof

Business Process Management (BPM) throughout their organizations. This has led to BPM

becomingamanagementphilosophy.

ThisresearchwillinvestigatehowfarhospitalshavecomeinimplementingthisBPMapproach,by

analysingtheBPMapproachofthewardround,acentralprocessforthetreatmentandqualityof

careofthepatients.

Themaingoalisn’ttoimprovethewardroundsthemselves,butitistolearnhospitalstotakea

BPM approach throughout the whole organization. The goal is to educate the hospital

management and employees about BPM and how they can improve their BPM approach to

increasetheinternalunderstandingandintegrationofbusinessprocesses.

Thisresearchisalsoimportantbecauseofthetrendofhospitalsofbeinglatewiththeadoptionof

newtechnologies.Thislateadoptionofthesenewtechnologiesandtheopportunitiesthatthey

bring,haveledtocurrenthospitalslackingbehindinefficiencyandofferingalowerlevelofpatient

care. Currently, new technologies with potential are popping up, such as Internet of Things,

ArtificialIntelligence,AugmentedRealityandmuchmore.Itisthusimportantthathospitalshave

agoodBPMapproachandunderstandtheirinternalprocesses,theirgoalsandtheirrelationswith

each other. This will allow them to see the opportunities of these technologies and which

opportunitiescanbringaddedvaluetoincreasetheefficiency,thepatientcareorboth.

ThefollowingsectionwilldiscusstheimplementationofBPMinthehealthcareindustry.Section2

willgodeeperintothespecificresearchquestionofthisresearchandsection3willexplainthe

usedterminologybasedonliterature.Section4,themethodology,willgoovertheapproachused

2

duringtheresearchandexplainsthedifferentgoalsoftheusedtechniques.Section5willgivean

overview of the results of these techniques and section 6 then uses these results to make

recommendationsonhowhospitalscanimprovetheirBPMapproach.

BusinessProcessManagementinhealthcare

Before investigating the researchquestion, it is important to analysehowBPMcame into the

healthcareindustryandwhatthechallengesandopportunitiesofBPMare.

Armistead(Armistead,Rowland,1998)discussedhowbusinesseshavechangedtheirfocusfrom

what is done, tohow it is done. This corresponds to a shift fromorganizing their companyas

severaldepartmentstofocusingonbusinessprocesses.TheimplementationofaBPMapproach

mostly results in flatterorganisations,wheremanagersarecloser to thecustomers.These flat

organizations allowmanagers to have a “first-hand” awareness of the reality of the business

(Hammer,Champy,1993).

Inthemedicalworld,thesamefocusondepartmentsiscentraltotheorganizationofthehospitals.

Theyhavehistoricallygrowntogetherfromthecollectionofprofessionalfunctions,tobettercare

forandcurepatients(Gemmel,Vandaele,&Tambeur,2007).

Gemmel(Gemmeletal.,2007)alsoexplainstheconsequencesofthishistoricalgrowtharound

differentfunctionaldepartments:“Theconsequencesoftheseevolutionswerethatpatientsare

residing in small, specialised patient units supported by multiple ancillary and support

departments (Lathrop, J.P., Seufert, G.E., McDonald, R.J., Martin, S.B, 1991). Such a hospital

organisationinvolves"multipleagentswhohavepartial information,disparate(local)goalsand

limitedcommunicationcapabilities"(Kumar,A.,PengSiOw,Prietula,M.J.,1993)“.

Tocombatthisdepartmentalorganization,hospitalshavetriedtoimplementseveraltechniques

toincreasetheintegrationbetweenthedifferentdepartments.Thefirstoneisthepatient-focused

hospital(Lathropetal.,1991),whichstatesthattheservicedeliveryshouldberestructuredsuch

thatthepatientandhisneedsareputcentral.Thesecondstrategywastheuseofmoreintegrated

3

informationsystems,whichcanstimulate integration inacomplexorganisation.Thirdly, in the

nineties critical or clinical pathways were introduced (Zander, 1992). These are schedules of

medical and nursing procedures, including diagnostic tests, medications, and consultations

designedtoperformanefficient,coordinatedprogramoftreatment.Clinicalpathwayswerethe

firststepinconsideringthetreatmentofapatientasasequenceofactivitieswhichareperformed

inateamofdifferentprofessionaldisciplinestocreateacertainoutcome(Coffey,R.,Richards,J.S.,

Remmert, C.S., Leroy, S.S., Shoville, R.R., Baldwin, P.J., 2005). The development and

implementationofclinicalpathwaysareconsideredasamajorstepintheprocessorientationofa

hospital(Vera,A.,Kuntz,L.,2007).

Buttigieg (Buttigieg et al., 2016) states that health caremanagement has increasingly applied

systemsthinkingandbusinessprocessmanagementasareactiontothefinancialcrisistoincrease

thehealthsystemperformance.

The research from Buttigieg however also states one of the major difficulties for these

implementations: the management-physician conflict. Physicians tend to focus on individual

patienttreatment,whereasmanagersfocusmoreontheefficiencyoverallthetreatments.This

has corresponded ina lackof communicationanda lackofunderstandingbetween these two

centralgroupsinthehospitals.

Buttigieg also explains the consequences of this conflict: “The management–clinician conflict

effectively translates in competition for resources such that investing in state-of-the-art

managementandinformationsystemsmaybeinterpretedbymajorstakeholdersinthesectoras

divertingfundsfromdirectpatientcare.Thereishoweverampleevidencethatinvestinginhealth

IT results in health and financial benefits by improving health care processes, efficiency, and

patientsafety.”

ButtigiegarguesthatBPMcanprovidesolutionstoissuesandchallengesfacinghealthcaretoday.

Byprovidingintegratedsystemsformanagingbusinessperformanceaswellasmanagingend-to-

endprocessesonanon-goingbasis.Thisresearchwillinvestigatehowfarhospitalshavecomein

implementingacorrectBPMapproach.

4

2. ResearchQuestion To better understand the research and its objectives, it is important to look at the research

questionitself,thehypothesesandtheusedconcepts.

ResearchQuestion:

“AnalysingtheBusinessProcessManagementapproachof

medicalwardroundsinBelgianhospitals”

This researchwill investigate theBPMapproachof themedicalward rounds to comeupwith

recommendations on how hospitals can improve their overall Business Process Management

approach.ThemaingoalistolearnhospitalshowtheycanimprovetheiroverallBPMapproach,

sotheyunderstandtheirbusinessprocessesandtheimpacttheyhaveoneachother.Thiswillhelp

themtoincreasetheefficiencyandthequalityofthepatientcare.Beforewestarthowever,itis

importanttostatesomehypotheses,whicharegoingtobetestedduringthisresearch.

MainHypothesis:“TheBPMapproachofBelgianhospitalsislackingformedicalwardrounds”

Themainhypothesisisoneofthereasonsbehindthisresearch.Theanalysisoftheperformance

oftheBelgianhospitalshasasgoaltoseewhichpartsoftheBPMLifecycleneedtobeimproved.

Sincethegoalistolookforimprovements,thehypothesisisthattheBPMapproachcanstillbe

improved.

Assumption:“Themedicalwardroundcanbeconsideredasabusinessprocess”

Secondly, itwill be checked if theward round canbe considered as a business process. Since

BusinessProcessManagementcanonlybeperformedonbusinessprocesses, it is importantto

checkifthemedicalwardroundindeedisabusinessprocess.Thedefinitionandcharacteristicsof

abusinessprocesswillbeprovidedinthesectionthatinvestigatesthis.

Theconceptsusedinourresearchquestionwillbeexplainedinthenextsection.

5

3. LiteraturereviewThis section explains the concepts used in the research question and their importance for

hospitals.

3.1MedicalWardround

Let’sstartwiththemedicalwardround.Whatisitexactlyandwhyisitimportant?

TheNSWDepartmentofHealthdefinedthewardroundin2011as(NSWHealth,2011):

“Astructuredroundwherekeycliniciansinvolvedinthepatient'scaremeettodiscussthepatient’s

careandthecoordinationofthatcare.Theroundisaplacewheredialogueandfeedbackoccurs

inrelationtotheneedsofthepatientandprovidesthemultidisciplinaryteamanopportunityto

plan and evaluate the patient’s treatment and transfer of care together. The round is patient

centredandisbasedontheneedsofthepatientandtheircarers.Thefrequencyoftheroundis

determinedbytheneedsofthepatient/carerpopulation.”

A simplified definition is that the ward rounds are an important means by which health

professionalscommunicatewitheachotherandpatientstocoordinateanddelivercare.Weber

statesthatthewardroundisasortofcentralmarketplaceofinformationexchangebetweenall

partiesthat interact intheinterestofthepatient(Weber,Stöckli,Nübling,&Langewitz,2007).

This information exchange is used for patient progress, to review the used treatment and as

medicaleducation(Shankar,2013).

Thewardroundfacilitatesthedevelopmentofacohesiveandappropriatetreatmentplanandsafe

deliveryof care (Kvarnström,2008). It is a forum for reviewingandplanning thepatient care

(Bradfield,2010;O’Hare,2008).Oneofthemaingoalsofthewardroundisalsotocommunicate

this treatment plan to the patient and receive any input or feedback from the patient. This

physician-patientcommunicationgenerallytakesplaceatthebedsideofthepatient.

Inpractice,thewardroundisanefficientmethodtoidentifyanychangesintheclinicalstatusof

thepatients. It is also central to the collaborationbetweendifferent doctors andnurses from

differentshiftsanddisciplines.

6

Thewardroundconsistsofseveralreturningactivitieswhicharegatheredinthefollowingtable

fromthearticle“Anatomyofthewardround”(O’Hare,2008).

Corewardroundactivities

Validatinghistoryandphysicalexamination

Refiningthediagnosis

Prognosisformation

Treatmentplanning

Dischargeplanning

Interdisciplinarycommunication

Costanalysis

Prioritysetting

PatientCommunication

Communicatingwithrelatives

Teaching

Table 1- Core ward round activities (O’Hare, 2008)

Asyounowknow,thewardroundisofessentialimportanceforagoodtreatmentofthepatient

in the hospital. The ward round however can also have its disadvantages, if not performed

correctly.Steeleforexamplestatesthatwhenthewardroundisconductedwithoutregardforthe

patient’sfeelingsanddignity,itcanbeacauseforanxiety,distressandembarrassment(S.J.Steele,

1978).Thiscanhappenwhenthepatientisdiscussedwhenheispresentwithoutacknowledging

him.He feelsneglected.Thiscanbeavoidedbygreetingthepatientand introducingthestaff;

whenmanypeopleareinvolvedintreatment,theirroleshouldbeexplainedaswell(S.J.Steele,

1978).Thefactthatwardroundscanstill improvealotinthisareaisshownbyaSwisssurvey.

ReportsfrompatientsurveysinSwitzerlandhaveshownthat8outof10mostcommondeficits

patients perceive during their hospital stay are related to information and communication

betweenthem,nurses,andphysicians(Langewitz,Cohen,Nubling,&Weber,2002).

7

This is a basic overview ofwhat themedicalward round is and the importance it has on the

effectivecommunicationinhospitalsaswellasontheeffectivetreatmentofpatients.Theward

rounditselfhoweverremainsamuch-neglectedpartoftheplanningandorganisationofhospitals.

Theimpactisoftenoverlookedandpeopleassumethatthewardroundisperfectlyfineasithas

alwaysbeen.

3.2BusinessProcessManagement

BusinessProcessManagement,orBPM,canbedefinedasinthebook“FundamentalsofBusiness

ProcessManagement”(LaRosa,Mendling,&Reijers,2013):

“BPM is a well-designed, implemented, executed, integrated, monitored, and controlled

managementapproach,whichstrivestocontinuouslyimproveandanalysekeyoperationsinline

withorganizations’strategies.”

ThebookfurtherexplainsBPMasfollows:thekeyofBPMistofocusonprocesseswhenorganizing

andmanagingworkinanorganization.Importantly,BPMisnotaboutimprovingthewayindividual

activities are performed. Rather, it is about managing entire chains of events, activities and

decisions that ultimately add value to the organization and its customers. These are called

processes.BPMcanalsobeconsideredastheartandscienceofoverseeinghowworkisperformed

in an organization to ensure consistent outcomes and to take advantage of improvement

opportunities.

8

TheBPMLifecycleconsistof6bigstepswhichyoucanfindinthefigurebelow.

Next,averyshortexplanationofeverystepisprovided.IfyouwouldlikeadeeperexplanationI

canreferyoubacktothebook“FundamentalsofBusinessProcessManagement”(LaRosaetal.,

2013).

1. ProcessIdentification:Inthefirstphase,youmustidentifythedifferentprocessesinyour

companyandanalysethelinksbetweenthem.Aftermakingthisoverviewofthedifferent

processes,youshouldchoosewhichprocessesyouwanttoinvestigatefurtheraccording

toyouroverallcompanystrategy,possiblereturnandfeasibility(oranyotherimportant

measure).

Figure 1- BPM Lifecycle (La Rosa et al., 2013)

9

2. ProcessDiscovery:Afteryouhavechosenaspecificprocesstoinvestigate,itisimportant

togetanoverviewofthisprocess.Whichtasksareperformed?Whoaretheactorsand

howaretheylinkedtogether?Thisstepshouldresultinanas-isoverviewofyourprocess.

3. ProcessAnalysis: Inthethirdphase,youstartanalysingyouras-isprocess.Howarewe

performing?Whatarecurrentproblems?Whichactivitiesarevalueaddingandwhichare

waste?Thisphaseprovidesthenecessaryinformationfortheprocessredesignphase.

4. ProcessRedesign: Inthenextphase,wewillusethe input fromtheprocessanalysis to

adapttheas-isprocesstoato-beprocess.Whatshouldourprocesslooklikeinthefuture

togetridofthewasteandtoimprovetheefficiency?

5. Process Implementation:During this phase, the to-beprocess is implemented into the

company. The structural changes are implemented, new IT systems are installed and

employeesaretrainedtoadapttothenewprocess.

6. ProcessMonitoringandControlling:Thislastphasecanalsobeconsideredasthestartof

thenewcycle.Thenewimplementedprocessshouldbemonitoredtoseehowtheprocess

isperformingand to followupon the improvements.Whenwe findanything that isn’t

accordingtohowitshouldbe,werestartthecycletoimprovetheprocessevenmore.

ThefollowingsectionsanalysehowtheBelgianhospitalsareperformingonthesedifferentBPM

lifecycle phases and make recommendations to improve their BPM approach. The process

identificationphaseisneglectedinourresearchsincewealreadydecidedtoinvestigatetheward

roundprocessbecauseofitscentralimportancetothepatientcare.

10

3.3WardRoundasabusinessprocess

BeforeanalysingtheBusinessProcessManagementapproachoftheBelgianhospitalsaroundthe

wardroundprocess,wemustfirstconsidertheassumptionofthewardroundbeingabusiness

process.

Whatconstitutesabusinessprocess?AccordingtothedefinitionofMcCormack(McCormack&

Johnson,2001),abusinessprocessconsistsof:

“aspecificgroupofactivitiesandsubordinatetasks,whichresultintheperformanceofaservice

thatisofvalue”

OtherdefinitionsincludethoseofDavenport(Davenport,1993),Hammer&Champy’s(Hammer

&Champy,1993),andseveralotherauthors.

Thesenumerousdefinitionsofwhatabusinessprocessexactlyis,areverysimilartoeachother

andarealwaysbuiltonthesamebasicelements.Wewillusethesecharacteristicstocheckifthe

wardroundisindeedabusinessprocess.

ProcessCharacteristic WardRound Example

Tasks Check Informpatient

Events Check Nursepresent?

Decisionpoints Check Adapttreatment?

Actors Check Doctor,nurses

Goal Check Improvepatient

treatment/communication

Repeatability Check Onceeveryday/week

Customers Check Patients

Processowner Check Doctor

Createsvalue Check Improvestreatment

Table 2 – Ward round as a business process

11

Asyoucanseeinthetable2,thewardroundhaseverycharacteristicnecessarytobeconsidered

abusinessprocess.Thismeansthattheassumptioniscorrectandthattheresearchcancontinue.

12

4. Methodology To get an idea about the Business ProcessManagement approach of hospitals in theirWard

rounds,theresearchconsistedofanempiricalstudyinfiveFlemishHospitals.Thesefivehospitals

areagoodrepresentationoftheBelgianhospitalssincetheyconsistedofabigvarietyofhospitals,

includingbothUniversityandprivatehospitals.Duringthisstudy,threemethodswereusedtoget

anoveralloverviewofthewardrounditselfaswellastheorganizationofthesewardrounds.

Thesethreemethodswhere:

§ Observation:togetaprocessoverview

§ HPOTool:toanalysetheBusinessProcessMaturity

§ Questionnaire:toinvestigatethemind-setofthewardroundparticipants

Thesethreemethodswereusedin13departmentsintotal(table3).Itwasimportanttoperform

thesemethodsindifferentdepartmentssincethegoalsofthewardroundvariateaccordingtothe

discipline performed. These different departments allowed us to get an understanding of the

differentinfluencesonthewardroundprocess.

13

Hospital Private/University Department #Patientsobserved

AZGroeninge Private Nephrology 10

AZGroeninge Private Thoraxsurgery 3

AZGroeninge Private Gastroenterology 14

AZGroeninge Private Surgery 10

AZMariaMiddelares Private Paediatrics 16

AZMariaMiddelares Private Pulmonology 15

AZAlma Private Geriatrics 16

AZAlma Private Gastroenterology 22

AZAlma Private Surgery 2

UZLeuven University Urology 25

UZLeuven University Thoraxsurgery 22

UZGhent University Nephrology 11

UZGhent University Thoraxsurgery 11

Table 3 - Hospitals and departments investigated during research

Thissectionwillexplaintheusedmethodsandthereasonsforusingthem.

14

4.1WardRoundOverview

Thefirstmethodusedwasobservation.Duringthesepassiveobservations,thedoctorsandnurses

ofthedifferenthospitalswerefollowedduringtheirwardroundsandobservedtoseewhatthe

wardroundprocessforeachofthemlookedlike.Thegoalwastonotedownthedifferenttasks

andinteractionsofthewardroundparticipantsaswellasresearchingtheprocesscharacteristics

ofthesewardroundstogetaglobalwardroundoverview.

Nexttotheobservingofthenormalworkingofthewardround,theobservationsalsohelpedto

getanunderstandingoftheproblemsofthewardroundsandtheinfluencesoftheoverallhospital

structureonthewardround.Whatisgoingwrong?Whyisitgoingwrong?Whatcanwedoabout

it?

Theobservationsofferustheabilitytocheckhowthewardroundprocessisperformedinreallife

settings today. It is also a very good way to spot the different approaches of hospitals and

departmentstowardstheirwardroundsandtogetanideaaboutthereasonsforthesedifferences.

Themaingoalofthismethodwastogetanoverviewofwhatthewardroundprocesslookslike

andtodetermineifwecaneventalkaboutthewardroundasaprocess.

TheseobservationswillalsoformthebasisoftheBPMNmodelsusedlaterinthisresearch.

15

4.2WardRoundProcessMaturity

TheHPOtoolstandsfortheHospitalProcessOrientationtool.Tofullyunderstandthereasonof

choosingthismethod,wefirstlookatthedefinitionofBusinessProcessOrientation(BPO).

BPOdefinedbyMcCormack(McCormack&Johnson,2001):

"anorganizationthat,inallitsthinking,emphasizesprocessasopposedtohierarchieswithspecial

emphasisonoutcomesandcustomersatisfaction"

AwaymorefreelyusedexplanationofBPOistheamountofattentionthatanorganizationputs

on itsprocessesandthemanagementoftheseprocesses.BPOandBPMareclearly interlinked

witheachotherandanorganizationthatwantstoimproveinone,shouldalsofocusontheother.

4.2.1BPOMaturityModel

TheBPOMaturitymodelofMcCormackdefinesthestagesthroughwhichacompanyprogresses

tobecomefullyprocessoriented.These4stages,asexplainedintable4,allsignifyimportantsteps

thatanorganizationshouldgothroughiftheywanttobecomefullyprocessoriented.

Stage Definition BPOScore

AdHoc Processesareunstructuredandilldefined.ProcessMeasuresare

notinplaceandthejobsandorganizationalstructuresarebased

upontraditionalfunctions.

0-2

Defined Thebasicprocessesaredefined,documentedandavailableinflow

charts.

2-3

Linked Thebreakthrough level,managers employprocessmanagement

withstrategicintentandresults.

3-4

Integrated Thecompanyanditsvendorsandsupplierstakecooperationtothe

process level. Process measures and management systems are

deeplyimbeddedintheorganization.

4-5

Table 4 - Business Process Maturity Model (McCormack&Johnson,2001)

16

TheBPOToolisameasurementtooltoseeinwhichstageyourorganizationfitstodayandwhich

approachestheyshouldtaketomovefurtheronthematuritymodel.TheBPOtoolconsistsof11

questionsdividedinto3categories.Allrespondentsneedtoanswerwithascorefrom1(totally

not agree) to 5 (totally agree). The average scores are then comparedwithboth thematurity

modelandthebenchmark(comingfromtheoriginalresearchintheindustrialsector).

CategoryName Definition #questions Benchmark Maximum

Processview Thorough documentation and

understanding from top to

bottomandbeginningtoendofa

process

3 9,40 15

Processjob To what extend the jobs and

responsibilities in the

organizationareprocessoriented

3 12,50 15

Process

Managementand

Measurement

Towhatextendtheperformance

of organizational processes is

measuredandanalysed

5 16,30 25

Totalscore Total Business Process

orientationscore

1 3,16 5

Table 5 – Business Process Orientation Tool

The BPO tool helps to understand a company’s position on the maturity model and guides

attentiontoimprovements.

17

4.2.2HospitalProcessOrientationTool

Asmentionedbefore,thetoolusedwasn’ttheBPOtool,buttheHPOTool.TheHospitalProcess

OrientationtoolisanadaptationoftheBPOtooltobetterfittherequirementsofthehealthcare

industry(Gemmeletal.,2007).Theoverallstructureandworkingofthetoolhasremainedthe

same,butthequestionsthemselveshavebeenadaptedtobeclearerforthespecificindustry.

Someoftheadaptationsare:

§ UseofI-forminthequestions

§ Simplifiedwording

§ Adaptedvocabularyforthehealthcareindustry

InadditiontothechangesmadebyGemmel(Gemmeletal.,2007),wealsochangedthequestions

againtomorecloselyfitthewardroundenvironmentandtranslatedthemtoDutchtofacilitate

thesurveyintheFlemishhospitals.

YoucanfindtheoriginalquestionsfromtheHPOtoolaswellastheEnglishandDutchversionsof

thequestionswhichIusedduringmyresearchintheappendix1,2and3.

4.2.3UseofHPOTool

TheHPOtoolwasusedwith20wardroundparticipants(doctors,assistantsandnurses)fromthese

5 hospitals to get an overall process orientation score of the Belgian hospitals for their ward

rounds.ThiswillhelpusunderstandinwhichmaturityleveltheBelgianhospitalsfindthemselves

infortheirwardroundandwhichimprovementsshouldthusbemadetoimprovethematurity

level.

It is important tomention that both theHPOand theBPO toolweremade to investigate the

processorientationonacompanylevelovertheirdifferentprocesses.Thisresearchontheother

hand used the HPO tool to investigate the process orientation of one process over multiple

hospitals.Thiscouldleadtoincorrectresultsandshouldthusbekeptinmindwhileanalysingthese

results.

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4.3Mind-setofwardroundparticipants

Nexttotheobservations,whichwereusedtogetanoverviewofthewardroundprocess,andthe

HPOtool,whichwasusedtounderstandtheprocessorientation,aregularquestionnairewasalso

usedtoinvestigatethemind-setofthewardroundparticipants.Thesewereagainthedoctors,

assistantsandnursesperformingthewardrounds.

Themainreasonforthisquestionnairewastogetadeeperunderstandingfromthewardround

participantsthemselves.Howdotheyexperiencethewardround?Whatdotheythinkthatthe

processlookslike?Whichproblemsdotheyexperience?

Thequestionnaireexistedof11openquestionsforwhichtherespondentscouldfreelyanswer

withtheirsubjectivepointofview.Theideaisnottomeasureanything,butitisanadditiontothe

othermethods,whichhelpsusunderstandthewardroundprocessfromtheparticipantspointof

view.

YoucanfindtheQuestionnaireintheappendix1and2.(EnglishandDutchversion)

19

20

5. Resultsempiricalstudy

5.1WardRoundOverview

Likemanyotherbusinessprocesses,thewardroundcanhavemultiplestructuresdependingon

the hospital and the department in which it is performed. Later sections discuss what these

differenceslooklikeandwhytheyexist.Thewardroundisdespitethesedifferencesalwaysbuilt

fromthesame3basicelements:

§ Preparationphase

§ Visitpatientphase

§ Reviewphase

Theseelementscanbestructuredinseveralways.Figure2and3,forexamplealreadyshowtwo

differentapproachesforcombiningtheaboveelements.Theadvantagesanddisadvantagesofthe

differentapproacheswillbediscussedlater.

Figure 2 – Ward round overview model 1

Inthestructureabove,thedoctordoesthe3phasesforallpatientsatonce.Hepreparesallthe

patients,thenhevisitsallpatientsaftereachotherandheendshisroundbydoingthereview

phaseforallthepatientsthathevisited.

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Inthesecondstructure,asseenbelow,thedoctorgoesthroughallthreephasesforeverypatient.

Hegoestotheroomofthepatientwithatourcar,looksupthepatientfilesonthecomputerand

discussesitwiththenurse.Thenhegoesintotheroomofthispatientanddoesthevisitphase,

afterwhichheimmediatelydoesthereviewphaseofthispatientbeforemovingontothenext

patient.

Figure 3 – Ward round overview model 2

5.1.1Preparationphase

Duringthepreparationphase,thedoctorsandnursesgooverthepatientfileanddeterminethe

statusofthetreatmentanddiscussanyadaptationsordisruptions.

The doctors go over any relevant information about the patient or the treatment to prepare

themselvestoexplainthesituationtothepatientsandnurses,ortobeabletoadoptthecurrent

treatmentwherenecessary.

Relevantinformationduringpreparationphase

Patienthistory

Testresults

Notesfromotherdoctors

Drughistory

BasicParameters(bloodpressure,…)

Notesfromresponsiblenurses

Etc.

Table 6 – Relevant information during preparation phase

22

Togetherwiththenurses,theytalkaboutanysignificantchangesinbehaviourorstatussincethe

lastwardroundandtheydecideonthefurthertreatmentofthepatient.

Thisphaseissometimesperformedbeforethestartofthetourofthepatientrooms.Butitisalso

sometimesperformedduringtherounditself,everytimebeforethedoctorgoesintotheroomof

thespecificpatient.

5.1.2Visitpatientphase

This is thephaseduringwhich thedoctor,almostalwaysaccompaniedbyoneormorenurses

and/orassistants,visitsthepatientinhisroomandperformsseveraltaskstoinformthepatient

andadoptthetreatmentifnecessary.

Actionsperformedduringvisitphase

Informpatientabouttreatment

Informnurseaboutcertaindecisions

Adapttreatment

Soothepatient(andfamily)

Askandanswerquestions

Performnecessarytests

Checkonwoundsorequipment

Preparepatientforpost-treatment

Etc.

Table 7 – Actions performed during visit phase

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5.1.3Reviewphase

Duringthisphase,thedoctorandthenursesgooverallthenewinfotheygatheredduringthe

patientvisitsandtheydiscussanynecessarychanges.Thenursesmightalsoaskforsomeextra

explanationsaboutcertainmedicalorders.Someadministrativetasksshouldbeperformedduring

thisphase,suchasupdatingthepatientfile,writingprescriptions,askforlabtests,etc.

Actionsperformedduringreviewphase

Discussnewinfogatheredduringvisitphase

Extraexplanationsfornurse

Updatingpatientfile

Writingprescriptions

Requestlabtests

Etc.

Table 8 - Actions performed during review phase

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5.2WardRoundProcessMaturity

ThissectionwilldiscusstheresultsoftheHPOtool,whichwasusedto investigatetheprocess

maturityleveloftheirwardroundsintheobservedhospitals.

Thetablebelowgivesusanoverviewoftheoverallscores.Youcanfindtheindividualscoresin

appendix4:

Category Benchmark WardRoundscore MaximumScore

ProcessView 9,40 12,75 15

ProcessJob 12,50 14,40 15

ProcessManagementand

measurement

13,04 12,13 20

OverallScore 3,16 3,69 5

Table 9 – Hospital Process Orientation Tool scores

TheHPOtoolresultedinscoresfortheprocessview,processjobandoverallscorehigherthanthe

benchmark. These would indicate that the hospitals are already performing well on these

categories.Thescorefortheprocessmanagementandmeasurementontheotherhandisbelow

thebenchmark,whichindicatesroomforimprovement.

Ifwehoweveranalysewhichmaturitylevelthewardrounddepartmentsreachedaccordingtothe

HPOtool,thenwemusttakeacriticalviewontheresult.Accordingtotheoverallscoreof3,69on

5,thematuritylevelwouldbeLinked(Table4,section4.2.1):

“Thebreakthroughlevel,managersemployprocessmanagementwithstrategicintentandresults”

Thiswouldindicatethattheprocessorientationinthesedepartmentsisalreadyverygood,butif

welookatthepre-requisitesofthepreviouslevels,thenwecanclearlyseethatthesedepartments

do not satisfy them. To reach the Defined level, the basic processes should be defined,

documentedandavailableinflowcharts.Thisisnotyetthecaseforthewardrounddepartments,

soweshouldanalysewhatwentwrongandwhichmaturitylevelismorefitting.

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Toclearlyunderstandthedifferencesbetweenthematuritylevels,itmightalsobeinterestingto

lookatadifferentmaturitymodel.ThatiswhytheCapabilityMaturityModelIntegrated(CMMI)

framework is introducednext. Thismaturitymodel is similar to theBusiness ProcessMaturity

modelofMcCormack,butithas5separatematuritylevels.

CMMILevels Definition

Level1:Initial Atthisinitialstage,theorganizationrunsitsprocessesinanad-

hoc fashion, without any clear definition of these processes.

Controlismissing.

Level2:Managed Atthisstage,projectplanningalongwithprojectmonitoringand

controlhavebeenputintopractice.Measurementandanalysis

isestablishedaswellasprocessandproductqualityassurance.

Level3:Defined Organizationsatthisstagehaveadoptedafocusonprocesses.

Processdefinitionsareavailableandorganizational training is

providedtoenablestakeholdersacrosstheorganizationtobe

engaged in process documentation and analysis. Integrated

projectandriskmanagementareinplace.Decisionanalysisand

resolutionarealsoinplace.

Level4:Quantitatively

Managed

At this stage, organizational process performance is tracked.

Project management is performed using quantitative

techniques.

Level5:Optimizing At this stage of maturity, the organization has established

organizational performance management accompanied with

causalanalysisandresolution.

Table 10 – Capability Maturity Model Integrated (CMMI)

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Sincethereisnoprocessdocumentationandnoprocessmeasurementofanykindintheward

rounddepartments,thematuritylevelshouldbeofthelowestlevelinboththematuritymodels.

FortheMaturitymodelofMcCormack,thelevelwouldcorrespondtothead-hoclevel.Whilethe

levelintheCMMIwouldbelevel1(Initial).

WhatwentwrongwiththeHPOtoolandhowrelevantaretheresults?

Oneofthefirstthingsthatmightgiveusanincorrectresultisthebenchmarkwhichcameoutof

theindustrialsector.Thisbenchmarkisprobablynotagoodcomparisonforhospitals,whichare

intheserviceindustry.Asecondreasonisthegeneralityofsomequestions.Peoplewhothinkthat

theirjobisvaluable(whichalmosteveryonedoes),willanswerverypositivelyonsomeoftheHPO

toolquestions,whichcanbadlyinfluencetheresults.Thisexplainsthehighscoreontheprocess

jobcategorysinceallthreeofthequestionsinthiscategoryareverygeneral.

Examplesoftoogeneralquestions(Processjob)

MyJobismultidimensionalandnotsimpletasks

Myjobincludesfrequentproblemsolving

Iconstantlylearnnewthingsonthejob

Table 11 – General questions in HPO Toll

Anotherreasonforthewrongscoresisinthewardrounditself.Awardroundisaverybasicand

straightforward process. Because of this, and the daily repetition of these ward rounds, the

participants already have a very good idea about their tasks, goals and expectations. So even

thoughthereisn’tageneraldocumentationofthewardrounds,theparticipantsthemselveshave

aprettygoodideaabouttheProcessview.Thisclearlyexplainswhythescoreforprocessviewis

ashighasitis.

Itisimportanttonoteagain,thattheHPOtoolinthisresearchwasusedtoinvestigatetheprocess

orientationofoneprocessovermultiplehospitals,while the toolwasdesigned toanalyse the

processorientationofonehospitalovermultipleprocesses.Thiscanalsobeanimportantreason

forthewrongscores.

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ConclusionfromHPOtool

Even though the HPO Toolwasn’t the perfect tool tomeasure the process orientation in the

differentdepartments,itcertainlyhelpedusunderstandtheprocessorientationanditalsohelped

usunderstandwhichareas are lackingbehindandhow these canbe improved. Someprocess

orientation is already in place in the minds of the process participants, but this hasn’t been

translatedintothecorrectBPMapproaches.Thewardroundshaven’tbeendocumentedandthe

performancesaren’tbeingmeasuredatall,whichresultsinthelowestmaturitylevel.

Recommendationsonhowthehospitalscanreachahigherbusinessprocessmaturitylevelwillbe

giveninlatersections.

Findings BPMLifecycle

Wardroundprocessshouldbedocumented Processdiscovery

Wardroundperformanceneedstobe

measured

Processanalysis

Wardroundperformanceneedstobe

measured

Processmonitoring&controlling

Table 12 – HPO Tool findings

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5.3Mind-setofwardroundparticipants

Theopenquestionswereaverygoodwaytounderstandthewardroundparticipantsanditgave

usseveral interestinginsightsaboutthewardroundprocess.Thissectionwilldiscussthethree

maininsightsoutofthequestionnaire.

Insight1:thewardrounddifferencesbetweendisciplines

The first insight is about the importance of theward round in the different disciplines in the

hospitals.Whendifferentwardroundparticipantswereaskediftheythoughtthatthewardround

wasanobligationorifitreallyaddedvaluetotheirwork,theresultswereveryinteresting.

Participantsthatworkedinasurgerydepartmentexperiencedthewardroundmoreoftenasan

obligation,whereasparticipants from internaldisciplinesexperience theward roundashaving

trueaddedvalue.

Therewasalsoadifference in thepreference forefficiencyversuspatientattention.People in

surgery leaned towards more efficient ward rounds, while people in internal disciplines

emphasizedtheimportanceoftheattentionforthepatient.

These differences led us to researchwhy surgery and internal disciplines had a very different

stancetowardsthewardround.Themainreasoncanbefoundinthegoalofthewardround.The

wardroundinasurgerydisciplineismostlyperformedtoinformthepatientabouttheprocedure

thathasbeendone(orwillbedone)andtocheckonthewoundsfromthesurgeryitself.

Whereasthewardroundforinternaldisciplinesismoreimportantforthetreatmentofthepatient

itself.Doctorsreallyusethewardroundtoanalyseanddiscussthedifferentpatients,andperform

anynecessaryteststoadoptthetreatmentifnecessary.Thewardroundforinternaldisciplinesis

really the moment when doctors can evaluate the current treatment, see the results and if

necessarycanadapt.

29

Thesedifferenceshavealsoledtodifferentapproachestothewardround.Surgeonsprefertodo

thewardroundasquicklyaspossible,whereasinternaldoctorsreallytaketheirtimeduringthe

wardroundsinceitisanintegralpartoftheirjob.

Wardround Surgery InternalDiscipline

StancetowardsWR Obligation AddedValue

Focus Efficiency Patientattention/treatment

GoaloftheWR Inform&check Followup&adapttreatment

Wardroundduration Asquicklyaspossible Centralpartofjob:longrounds

Table 13 – Differences between surgery and internal disciplines

Insight2:perceptionofthewardround

Thesecondinsightisabouttheperceptionofthewardround.Almostallparticipantsexperienced

thewardroundassomethingobvious. Ithasbeenthesamewayforawhile,theydoitalmost

everydayandtheydon’treallythinkaboutitanymore.Itispartoftheirdailyroutineandhasbeen

forawhile.Thisperceptionhoweverhassomenegativeimpacts.Everyparticipantcouldsumup

several(micro-)problemswiththecurrentwardrounds,buttheyneverdidsomethingaboutit.

Theproblemshavealwaysbeenapartofthewardround,sowhystartadjustingit?Thisinsight

ledustotheimportanceofbothprocessanalysisandprocessredesign.

Findings BPMLifecycle

Knownproblemsshouldbedocumented ProcessAnalysis

Knownproblemsshouldbeimproved ProcessRedesign

Table 14 – Questionnaire findings

Theproblemsof theward round shouldbedocumentedandanalysed tounderstand the root

causesof theseproblemsand tobeable to fix them.Processanalysis shouldalsobeadopted

becausethewardroundparticipantsthemselvesonlymentionthemicro-problemsoftheward

round.Theymentionthesebecausetheycanbeirritatingtodealwitheveryday,buttheydonot

30

think about the macro-problems, which can have a bigger impact. After documenting these

problems,thehospitalshouldthinkaboutthecorrectwaytoredesignthesewardroundswitha

correctprocessredesignapproach.

Insight3:wardroundeducation

Thelastinsightisaboutthewaydoctorsandnurseslearnaboutthewardround.

Thefirstcontactwithawardroundhappensduringtheirinternships.Therearen’tanycoursesthat

teachthesepeopleabouttheimportanceofthewardroundsandhowtheyshouldapproachit.

Thestudentsdon’tlearntothinkaboutthegoalsofthewardroundandhowthewardroundcould

looklikeindifferentdepartmentsorhospitalsaccordingtothechosengoals.

Thishasledtoamaster-apprenticesystem,whereeverydoctorlearnsthewardroundapproach

fromhis‘master’,thedoctorthathefollowsduringhisinternyears.Thedoctors,canlateradapt

theapproachwithfeedbackfromnursesandotherdoctors,ordependingontheapproachtaken

bythedepartmentinwhichheorsheworks.

Thisagainreinforcesinsightnumbertwo,wherepeoplejustacceptthewardroundthattheywork

in,becausetheyhaven’tlearnedtothinkaboutitinalogicalway.

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5.4Performanceofobservedwardrounds

Duringtheobservations,wegotan indicationoftheoverallperformanceofthedifferentward

rounds.Thegeneralview is that theward roundprocesses inmosthospitalsarealreadyquite

efficientandtherearen’tthatmanyimmediateimprovementpossibilities.Therearehoweverstill

severalmicro-andmacro-problemsthatcouldbeimproved.

Examplesofmicro-problems

Wardroundgetsinterruptedbyphonecalls(doctorsandnurses)

Attentionofwardroundparticipantsdropstotheendoftheround(inlongwardrounds)

Somehygienemattersaren’tfollowedupliketheyshouldbe

Patientprivacysometimesgetsneglected

Shortbatteryoftourcar(PCdoesn’tlastthecompleteround)

Slowcomputers

Table 15 – Examples of micro-problems

Examplesofmacro-problems

Lotsofadministrativework

Communicationerrors

Wardroundscheduling–nofixedhours

Table 16 – Examples of macro-problems

Theamountandintensityoftheproblemsreallyvariesbetweenthedifferenthospitals.Oneofthe

hospitalsdidn’thaveWi-Fiandwasstillworkingmainlyonpaper.Thisledtoanimmenseamount

ofadministrative(paper)workthattookalongtime.Thedoctordoesn’tlikethiswork,becauseit

shouldn’tbepartofhisjobanditmakeshimhurryduringtheotherpartsofthewardround.This

methodalsoincreasedtheamountoferrorsthatoccurredbecauseofpapersthatwentmissingor

justbecauseofcommunicationerrors.So, theward roundefficiency ingeneral isalreadyvery

good, but that doesn’t mean that some hospitals can’t really improve their ward rounds

significantly.

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6. HowCanhospitalsimprovetheirBPMmind-set? ThissectionwillgivesomerecommendationsofhowhospitalscanimprovetheirBPMapproach

ofthewardround.Therecommendationsarebaseduponthefindingsintheprevioussectionsand

won’tbeageneraloverviewofpossibleBPMtechniquesthathospitalscanusetoimprovetheir

BPM approach. People that are interested in these techniques can find great explanations in

several BPM textbooks. The onemainly used for this research is the book “Fundamentals of

BusinessProcessManagement”(LaRosaetal.,2013),butotherBPMmanualswillalsoprovide

youwiththenecessaryinformation.

6.1ProcessDiscovery

Our research showed that theward round participants themselves already had a pretty good

overview of their own ward round process. This however hasn’t resulted into a documented

overviewofthewardroundprocess.Hospitalsneedtounderstandthatdocumentingtheprocess

isthefirststepintryingtoimproveit.Theprocessoverviewallowsclearcommunicationbetween

thedifferentparticipantsanditisthebasisofagoodprocessanalysis.

Thisleadsustoourfirst,verysimple,butnecessaryrecommendation:

Recommendation1:StartwithProcessDiscoverytogetanoverviewofthewardroundprocess

The ProcessDiscovery for theward round isn’t any different than it is for any other business

process, sowe recommend the hospitals to use oneof the following techniques or any other

ProcessDiscoveryTechnique.

Processdiscoverytechniques

Evidence-basedDiscovery

Interview-basedDiscovery

Workshop-basedDiscovery

Table 17 – Process discovery techniques

Detailed information about these techniques can be found in every BPM manual/textbook.

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6.2ProcessAnalysis

Afteryouhavemadeanas-isprocessmodel,itisimportanttostartcommunicatingaboutitwith

allthedifferentprocessparticipants.Thenextstepistostartanalysingtheperformanceofthe

wardround.Whatarethecurrentproblemsandhowcanweimprove?

The process analysis should both be done in a quantitativemanner aswell as in a qualitative

manner.Thequantitativemeasurescanbeusefultounderstandwhatthecostdriversoftheward

roundsareandwherethedoctorslosethemosttime.Thequalitativeanalysisontheotherhand

mightshowsomelackinqualityofcare,whichisalsoveryessentialtothewardround.

Previous sections already showed that the ward rounds have two big problems for process

analysis.Thefirstoneisthatnothinggetsmeasured,soyoujustdon’tknowtheperformanceof

theprocess.Thesecondoneisthatknownproblemsaren’tdocumented.Thissectionwillgivean

overviewofhowhospitalscanimprovetheirprocessanalysisapproach.

6.2.1Defineperformancemeasuresforyouranalysis

Everythingstartswithunderstandingthegoalsoftheprocessyouaretryingtoanalyse.Whatis

importantforthewardround?Itisessentialthatyouthinkaboutthegoalsofthedifferentlevels

inyourhospital.Whatarethehospitalwidegoals?Whatarethegoalsforourdepartment?What

are the goals for theward round itself? This is essential, because theward roundalsohas an

influenceonthedepartmentgoalsandthegoalsofthehospitalitself.

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6.2.1.1WardRoundGoals Themostobviousgoalsarethegoalsofthewardrounditself.Whatdowewanttoaccomplishby

doingthesewardrounds?

Wehavemadeanoverviewofseveralwardroundgoals thatwere foundduringour research.

Thesecomemainlyfromthequestionnaireandpartlyfromtheliteratureresearch.

WardRoundGoals

ObservePatient:checktreatment,wounds,…

Getaholisticoverviewofthepatient:

understandpatientanddon’tjustbasetreatmentontestresults

Communicationofmedicalorders

Extraexplanationfornurses

Explaintreatmenttopatient

Signingofdocuments:medication,workabsence,assurance,dischargepapers,…

Createanaccuratepatientfile

Preparepatientfordischarge

Listentopatientsandnurses

Createapersonalbondwithpatients

Overallcommunication

Guidepatientforpost-hospitaltreatment

Receiveupdatesfromnurses

Table 18 – Ward round goals

35

6.2.1.2Devil’sQuadrangle Nexttothewardroundgoals, it isalsoimportanttothinkabouttheoverallhospitalgoals.The

ultimategoalofageneralhospitalistoofferthebestpossiblecaretopatientsatthelowestcost.

WewillincorporatethesegoalsintotheprocessanalysisbyintroducingtheDevil’sQuadrangle,

whichisageneralprocessanalysismethodthatfocussesonfourmaingoals.

ItiscalledtheDevil’squadranglebecauseofthetrade-offbetweenthedifferentgoals.Morefocus

oncostwillgenerallyresultinlowerqualityorlowerflexibility.Theideabehinditisthatwewant

toimprovetheprocessasmuchaspossibletoimproveallfourofthedimensions.Fromthatpoint,

we want to make changes according to trade-offs and the preferences of the hospital

management.Dowewantmorefocusoncost?Ormorefocusonquality?Orononeoftheother

twodimensions.

Time Flexibility

Quality Cost

Figure 4 – Devil’s quadrangle

36

6.2.2Observedproblemsofthecurrentwardround

During the60hoursspend inhospitals for this research,severalproblemsof thecurrentward

roundwerenoteddown.Thissectionwillgiveanoverviewoftheseproblemsanddiscusstheir

effectonthegoalspreviouslydiscussed.Thisisnotanexhaustivelistoftheproblemsofcurrent

wardrounds,sohospitalsshouldstillperformprocessanalysisontheirownwardroundtogeta

goodideaabouttheproblemsoftheirownwardroundsandtheimpactofthemontheirgoals.

6.2.2.1Micro-problems Someofthesmallerproblemsofthewardrounds,thatcanmostlybefixedrathereasyarelisted

inthetablebelow.

Micro-problemsofthecurrentwardround Time Flexibility Quality Cost

Wardroundgetsinterruptedbyphonecalls

(doctorsandnurses)

X X

Attentionofwardroundparticipantsdropsto

theendoftheround(inlongwardrounds)

X

Somehygienemattersaren’tfollowedup

liketheyshouldbe

X X

Patientprivacysometimesgetsneglected X

Shortbatteryoftourcar

(Pcdoesn’tlastthecompleteround)

X X

Slowcomputers X X X Table 19 – Effect of micro-problems on the Devil’s Quadrangle dimensions

Recommendations on how to solve these problems can be found in the section on Process

Redesign (Section 6.3.4 Redesign tips to improve micro-problems). It remains important for

hospitalstoconsidertheimpactofthedifferentproblemsonthewardroundandthedifferent

performancemeasurestoindicatewhichproblemsrequirethemostattention.

37

6.2.2.2Macro-problems Theproblemsthathaveabiggerimpactandaren’taseasytofixarelistedbelow.

Macro-problemsofthecurrentwardround Time Flexibility Quality Cost

Lotsofadministrativework X X X X

Communicationerrors X X X X

Wardroundscheduling–nofixedhours X X X XTable 20 – Macro-problems of the current ward round

Theseproblemshaveamuchbiggerimpactthantheonesdiscussedbeforeandthatiswhywewill

godeeper intoall threemacro-problems.Theseproblemsdonotoccur inall thehospitalsand

most hospitals already have found a way to deal with these problems. It remains however

important to discuss them tomake surewe understand the reasons of their existence in the

hospitalwhichhaven’tfixedthemyet.

1. Administrativework:Becauseoftheresponsibilityoftheirjob,doctorscurrentlymustfill

inalotofpaperworkand/orsignoffonit.Althoughthereasonsbehinditarebasedonthe

goalsofthewardroundandaretheretomakesurethatlessmistakesinthewardround

occur,theimplementationhasn’tbeenadaptedtonewtechnologies.Thisproblemhasa

negativeimpactonallfourdimensionsoftheDevil’sQuadrangleandisaccordinglyvery

importanttofix.

2. Communicationerrors:Somehospitalsstillworkinaveryoldfashionedwaywherequite

somecommunicationhappensviaoralorpapercommunication.Thishasaclearimpacton

theamountofcommunicationerrorsanddiminishesthecareofferedtothepatients. It

alsoisthereasonfordoublework,doublecheckingandrework,whichallhaveaverybad

impactonthefourdimensionsoftheDevil’sQuadrangle.

38

3. Ward round scheduling: One of the returning problems in multiple hospitals is the

organizationofthewardroundinthedailyworkingroutineofthedoctorsandnurses.In

severalhospitals,thewardroundsaren’tplannedinonafixedtimeschedule.Thedoctors

justpassbythedepartmentwhenitfitsintotheirownschedule.Thisisverybadasitmakes

ithard for thenurses tobereadythemselvesandtopreparethepatients for theward

round.Itisalsotheoneoftherootcauseofthemicroproblemsofgettingdisturbedduring

thewardround.Ifyoucanperformthewardroundonascheduledmoment,theneveryone

in the hospitalwill knowwhen they can reach the doctor/nurse, orwhen they should

postponeit.Thismacro-problemalsoincreasesthevariabilityofthewardrounds,whichis

againverybadforthefourdimensionsoftheDevil’sQuadrangle.

Asyoucansee,allthreeoftheseproblemshaveanegativeimpactonallfourdimensionsofthe

Devil’sQuadrangle.Thismakesthemveryimportantandthatiswhyhospitalsshouldreallyfocus

tofixtheseissues.Asmentionedbefore,somehospitalshavedonethisandtheirwardroundsare

workingsignificantlybetter thantheotherones.Possiblesolutionswillalsobeprovided inthe

processRedesignsection(Section6.3).

6.2.3Generalprocessanalysisrecommendations

Theprocessanalysisphase indicatedthreeextrarecommendations for theBelgianhospitals to

improvetheirBPMapproach:

Recommendation2:Getanoverviewoftherelevantgoals

Hospitalsshouldclearlydefinetheirperformancemeasurestobeabletoanalysetheperformance

oftheirwardroundandtobeabletoprioritizethebiggestproblems.Itisimportanttodecideon

therelevantgoalsforyourhospitalandyourdepartment.Thegoalslistedinthissectioncanbe

usedasaguide,butaren’tfittingforeverywardround.Asmentionedbefore,wardroundsinan

internaldisciplinewillforexampleputmoreemphasisonreallycheckinguponthetreatmentwith

thepatientinsteadofjustinformingthepatient,whichismainlythegoalforsurgerydepartments.

39

Recommendation 3: Measure the relevant performance measures both quantitative and

qualitative.

It is also important tomeasure those performancemeasures, since just having them doesn’t

provideyouwiththerelevantinformation.

Recommendation4:Documenttheperformancesandtheproblems.

Following recommendation3, it is of course also important todocument theseperformances,

sinceyouotherwisecan’tperformanyanalysisonthem.Hospitalsingeneralalreadyhavestarted

todothesekindsofthingsfortheiraccreditationefforts.Butthisisn’tenough.Accreditationis

veryimportantforhospitalsandisaverygoodstart,butitisn’tasubstituteforagoodbusiness

process management. Hospitals should invest in both accreditation and BPM since both can

improvetheeffectoftheother.Accreditationstandardscanforexamplebeusedtodefinethe

goalsandperformancemeasuresoftheBPManalyses.

Ifyouarelookingforspecifictechniquestouseduringtheprocessanalysisphase,wecanagain

referyoutogeneralBPMmanualswhichcangiveyouanoverviewofdifferentquantitativeand

qualitativemethodstouseduringtheprocessanalysisphase.

40

6.3ProcessRedesign

Thissectionwillindicatehowhospitalsshouldperformtheredesignoftheirwardrounds.Howcan

certainproblemsbefixedandwhatshouldthewardroundlooklikeaccordingtothechosengoals?

6.3.1Importanceofthesoftwaresystem

Oneofthemainobservationthatwasmadeduringtheempiricalresearchwastheeffectofagood

computersystemontheefficiencyofthewardrounds.Theimplementationofacorrectsystem

cansignificantlyimproveseveralofthemicro-andmacro-problemsofthewardrounds.Wewill

gooversomeofthelistedmacroproblemsandmentionhowagoodsystemcanimprovethem.

1. Administrative work: the implementation of a good system allows the doctor to

automatically generate the correct files and to digitally sign off on them by using his

account.Thissavesanimmenseamountoftimeforthedoctoranditalsofacilitateseasier

useofthesedocuments.Dischargepapersforexamplecanbeautomaticallyfilledinfrom

thepatientfileandprintedinsteadofhavingthedoctorfillinthepapersmanuallyforevery

patient.Thedigitalizationalsolowerstheamountoferrorsmadeinthesedocuments.The

samegoesforlabrequests,whichhadtobefilledinmanuallybefore,andthenhadtobe

transportedtothecorrectdepartment.Thesepaperseasilygotlost,ortheinformationon

themwasn’talwayseasytoread,whichcould leadtosignificanterrorsordoublework.

Thiscaneasilybechangedbydoingthelabrequestviathecomputersystem,whichalso

allowsthepeoplefromtheotherdepartmenttoimmediatelyaskifsomethingisn’tclear.

2. Communicationerrors: Oneofthebiggestadvantagesofagoodsoftwaresystemisthe

information overview it provides, not only to the doctor, but also to all other people

involvedinthecareofthepatients.Thesystemallowsdoctorstodigitallyinformnursesof

medicalordersandexplainwhycertainordersaremade.Allrelevantdoctorsandnurses

fromthesamedepartmenthaveaccesstothesameorders,whichdiminishestheamount

ofcommunicationerrorssignificantly.Italsoallowscommunicationtohappeninbetween

wardroundsandallowsdifferentdoctorstotakeoverthepatientsofcolleagues.

41

3. Information overview:Althoughthiswasn’toneofthemacroproblems,theimpactof

a good software system on the information overview should also be mentioned. The

informationoverviewisveryessentialtothewardroundsincethewardroundisallabout

communicatingandgatheringthecorrectinformation.Thewholepreparationphaseofthe

ward round can be significantly improved if the doctor has access to all the necessary

informationinamatterofseconds.Inhospitalswherethesystemislacking,doctorsmust

searchthroughseveralpilesofdocumentstofindallnecessaryinformationonthepatients

andtheyaren’talwayssurethattheyhaveaccesstothelatestresults.Agoodinformation

overviewalsoallowsnursestomorecloselyfollowthetreatmentandthedecisionsofthe

doctors.Nursesknowwhytheyareperformingseveralordersandaren’trelayinganymore

ontheshortexplanationfromthedoctorsduringthewardrounditself.

Asyoucansee,agoodsoftwaresystemcanalreadyimprovetheworstperformingwardrounds

toalmostperfectefficiency.Thiswasalsothedifferencewhichseparatedtheworstfromthebest

performingwardroundsduringtheresearch.Itishoweverimportanttomentionthatjustbuying

anewsystemwon’tmagicallysolvethewardroundprocessforthesehospitals.Wecanmention

thequotefromBillGates:

“The first rule in any technologyused in abusiness is that automationapplied to anefficient

operationwill magnify the efficiency. The second is that automation applied to an inefficient

operationwillmagnifytheinefficiency.”

Recommendation5:implementasoftwaresystemthatfitsthewardroundrequirements.

This insightfromBillGates isalsocorrectforthewardround,hospitalsshouldthinkaboutthe

wardroundprocessandlookhowacomputersystemcanfitintoimprovetheprocessasmuchas

possible. They should think about the requirements, thenecessary trainingof theward round

participants,theimplementationandtheintroductionofthenewsystemandmanymorethings.

42

Oneexample is thesecondstructureof thewardroundgiven insection5.1,wherethedoctor

always performs the three phases for every patient separately. This structurewasn’t possible

beforetheimplementationofagoodcomputersystemsincethedoctorsrequiresatourcarwith

acomputertotakewithhimduringthewardround.Thisisagoodexampleofhowthehospitals

havethoughtaboutthenewpossibilitiesandhowtheycanimprovetheunderlyingprocess.

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6.3.2Modelstoguidetheredesign

Itisimportanttohaveagoodstartingmodeltomakeato-bemodelofyourprocess.Youcould

alsostartfromscratchtocreateatotallynewprocessmodel,buttheresearchindicatedthatthe

wardrounddoesn’tneedtobedramaticallychanged.Thisleavesuswithtwomainoptions.

Option1:AS-ISModel:startfromthemodelfromyourProcessDiscovery(seesection6.1).

Option2:ReferenceModel:startfromoneoftheprovidedreferencemodels.

Youcanstartyourredesignfromtheas-ismodel,whichyoumadeduringthediscoveryphase.You

adapt theoriginalmodel to leaveoutpossiblewasteandproblems thatyoudiscovered in the

processanalysesphase.

For the secondoption,wehaveprovided two referencemodelsbelow.Onewhere thedoctor

performs all three phases for all patients at once (figure 5) and one where the phases are

performedforeverypatient(figure6).Thesearecertainlynottheonlypossibleconfigurations,

buttheyarethemostcommonones.Theprovidedmodelsdon’tmodeltheactionsofthenurses

orotherwardroundparticipants.Thisisdonebecauseoftheinfluenceofthedecisionswhichwill

bediscussednext.Thesedecisionsimpacthowtoprocesslookslike.Youcanstartyourredesign

from these referencemodels and adapt it to cover the necessary problems and goals of your

specificwardround.

Next,severaldecisionsthatmustbemadeandwhattheirimpactisonthewardroundprocesswill

bediscussed.Thesedecisionsaren’tonlywardrounddecisions,buttheyconcernhospitalwide

decisions,whichwillalsohaveanimpactondifferentprocesses

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Figure 5 – Reference model 1: Perform all three phases separately for all the patients

Figure 6 – Reference model 2: Perform the tree phases sequentially for every patient before moving to the next patient

45

6.3.3Decisionswhichhaveanimpactonthewardroundprocess

Surgeryvsinternaldiscipline

Thefirst importantdifferentiationpoint isthedepartmentitself.This isn’treallyadecisionyou

havetomake,butitmustbementionedbecauseoftheimpactithasonthewardroundprocess.

Thedifferencebetweensurgerydepartmentsandinternaldisciplineshasalreadybeendiscussed

insection5.3.Themaindifferenceisthepurposeofthewardround.Surgeryroundsarefocused

oninformingthepatientandcheckingwounds,whileinternalwardsaremorefocusedonforming

andadaptingthecorrecttreatmentforthepatient.

Thisdifferencedoesn’treallyresultinadifferentprocessoverview,butthetasksthemselvestake

considerablymoretimeforinternalroundsinsteadofsurgeryrounds.Theinternaldoctorreally

takeshis time for everypatient andwants tomake sure that they areperforming the correct

treatments.Thewardround isacriticalpartofhis jobandhelpshimtodecideonthecorrect

treatment.Thesurgerydoctorontheotherhand justneedsto informthepatient,butdoesn’t

needthewardrounditselftoperformhisjob.Wardroundsinsurgerydepartmentscanbeasshort

as 15 minutes, while internal rounds often take up more than two hours (this also depends

significantlyonthenumberofpatientsseenduringtheround).Itcanhoweverbesaidthatsurgery

wardroundsaremoreoftenperformedasreferencemodel1,whileinternalroundsmostlyfollow

thesecondmodel.

Thisdifferencealso isn’t theonly importantdisciplinedifference.Ward rounds in thegeriatric

departmentforexamplearemuchmorefocusedonthementalhealthofthepatientandrequire

timefromthedoctortohaveapersonaltalkwiththepatients.Itisthusveryimportanttothink

aboutthegoalsofyourdepartmentandwhattheir influence isontheprocess.Patients inthe

geriatricdepartmentmightforexamplepreferthispersonaltalkwithoutthenurseintheroomto

freelydiscusstheirfeelingstowardsthecaretheyreceive.

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Nurseorganisation

Duringtheobservations,threedifferentnurseorganisationsconsideringthewardroundswere

noticed.Allthreeofthem,theirimpactonthewardroundprocessandwhattheir(dis)advantages

arewillbeexplainednext.

1. Headnurse:theheadnursefollowsthecompletetourwiththedoctorandlaterinforms

theothernursesaboutthemedicalordersandthepatientstatus.

Advantage Doctor saves time and head nurse has all

relevantinformation.

Disadvantage Increasedchanceofmiscommunicationdueto

intermediateperson.

Impactonprocess Thedoctoronlymustlookfortheheadnurse

onceanddoesn’tlosetimesearchingforother

nurses. Very important that the system and

head nurse can convey the necessary

informationtothecorrectnursesafterwards.

Face-to-face time between other nurses and

doctorshouldalsobefacilitated,forexample

duringthepreparationorreviewphase.

Table 21 – Head nurse implications

2. Nursezone:differentnursesareresponsiblefordifferentzonesofthedepartment.Every

nurse followsthedoctor inhisorherzone(acoupleof rooms).Thedoctor in thiscase

needsto‘search’forthecorrectnurseeverytimehemovestoanewzone.

Advantage Nurses receive specific information and can

askquestionsface-to-face.

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Disadvantage Doctorcanlosetimesearchingfornurses.The

headnursemightalsobelessinformedabout

thepatients.

Impactonprocess Thedoctoralwaysmustfindthecorrectnurse.

It is thus important to make sure that the

nursesarepresent/reachablewhenthedoctor

needsthem.

Table 22 – Nurse zone implications

3. Nonurse:somedoctorsperformedthewardroundswithoutanynursepresentduringthe

touritself.

Advantage Bothnursesanddoctorswintime.Nursescan

continuewiththeirjob.

Disadvantage Possible lossofcommunication.This losscan

be double, since doctors can also lose

informationwhichtheynormallyreceivefrom

thenurses.Thisalsoleadstolesseducationof

the nurses, which can learn a lot from the

doctors.

Impactonprocess The tour without the nurses facilitates the

doctor to tour when he wants. It however

increases the importanceof a good software

systemthatallowsforagoodcommunication

betweentheparticipants. It isalso important

tomakesurethatthereisenoughopportunity

for face-to-face communication. This can be

facilitatedduringbothpreparationandreview

phase,orjustduringthetourwhenthedoctor

passesbythenurses.

Table 23 – No nurse implications

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Thischoiceismostlymadeonadifferentlevelsincethenurseorganisationhasabigimpacton

manyprocessesinthehospital.Itishoweverimportanttohaveanideaabouttheimpactofthis

decisiononthewardround.

Assistantsorganisation

The incorporation of assistants in the ward round can also have an impact on the process.

Assistantsaremostlyfoundinuniversityhospitalssincetheyarestillintheprocessofgraduating.

Theassistantcantakeonseveraldifferentrolesduringthewardroundwhichwillbediscussed

next.

1. Noassistant:mostpublichospitalsdonothaveaccesstoassistants,thedoctorperforms

allthetaskshimself.

Advantage Doctorperformsalltaskspersonally.

Disadvantage Doctormustperformallthetaskshimselfand

thuslosestime.

Impactonprocess Theprocessremainsthesameasbefore.

Table 24 – No assistant implications

2. Assistantfollowsdoctor:theassistant(orintern)justfollowsthedoctorduringtheward

roundtolearnhowtobecomeadoctor.Thedoctorcanexplaindifferentdecisionsandthe

assistantor interncancheck thewoundsorperformtestsunder thesupervisionof the

doctor.

Advantage Assistant/interncanlearn.

Disadvantage Doctorstillmustperformallthetaskshimself

andthus losestime.Might loseextratimeto

educateassistant/intern.

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Impactonprocess Theprocessremainsthesameasbefore,but

severaltasksmighttakemoretimebecauseof

theextragoalofeducation.

Table 25 – Assistant follows doctor implications

3. Assistantperformsreviewphase:theassistantfollowsthedoctorduringapartoftheward

round to learn how to become a doctor. He/she is responsible for the input of new

informationand/ormedicalordersintothesystem.Theassistantalsoisresponsibleforthe

dischargepapersandtestrequests.

Advantage Doctor saves time because he/she doesn’t

needtoperformthetasksthatdonotrequire

his/herlevelofcompetency.

Disadvantage Assistantdoesn’tgetthesameopportunityto

learnfromthewardroundsincehistimegoes

tothelessvalueaddingtasks.

Impactonprocess Thedoctoronlyperformstwooutofthethree

main phases and the assistant is responsible

forthereviewphase.

Table 26 – Assistant performs review phase

4. Assistantperformswardround:theassistanttakesontheroleofthedoctorandperforms

thecompletewardround.Theassistantcancheckinwiththedoctorduringthepreparation

andreviewphase,orevenduringthevisitphaseifnecessary.

Advantage Doctor saves a lot of time. Happens in

university hospitals so the doctors (who are

alsoprofessors)can focusmoreontheother

partsoftheir job.Assistantgetspreparedfor

whenhewillbeadoctorhimself.

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Disadvantage Doctorneedstobereachablesoassistantcan

checkupondecisions.Thedoctormightbeless

involved with his patients. The skill of the

assistantisalsolowerthanthatofthedoctor.

Impactonprocess Theprocess itself remains the same, but the

assistant performs all the tasks which are

normally performed by the doctor. It is

important that the doctor still performs the

ward roundoccasionally, to personally check

uponhispatientsandtoseeiftheassistantis

performingasrequired.

Table 27 – Assistant performs ward round implications

Thisdecisionmostlydependsontheavailabilityofassistantsforthehospitals.Themoremature

yourassistantsare, themoreresponsibilityyoucangivethem.Firstyearassistantsmostly just

followthewardrounds,whereaslastyearassistantscantakeoverthetotalwardround.Youcan

also have combinations, where for example first year assistant can follow the ward rounds

performedbylastyearassistantsandwheresecondyearassistantsperformthereviewphase.

Recommendation6:Thinkabouttheimpactofdecisionsontheprocessandtheimpactofthis

processonotherprocesses.

Thisrecommendationstatesthatyoualwaysshouldanalysetheimpactofdifferentdecisionson

theprocessesof thehospital. It is very important to takeabroadviewof the impactof these

decisions,sincesomedecisionscanhaveanimpactonprocessesindifferentdepartments.The

decisionsforexampletouseafixedstartingtimeforthewardroundofsurgerydisciplineswill

haveanimpactonthesurgeryschedulesforthedoctorsandmightrequireanotherdoctortobe

standby.

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6.3.4Redesigntipstoimprovemicro-problems Several micro-problems where already listed in previous sections, but the solutions to these

problemsweren’tdiscussedyet.Severalsmalltipstoimprovetheseproblemswillbegivennext.

Micro-problem Solution

Disturbances:calls,… Fixedwardroundschedules

Drop in attention towards the

endofthewardround.

Shorter ward rounds or split up the ward rounds between

differentdoctors/assistants.

Hygiene Disinfectantineveryroom.

Patientprivacy Automaticloginsystemwithprivatebadge.

Table 28 – Solutions for micro-problems

Disturbances

Micro-problem one can be fixed rather easily by implementing fixed schedules for the ward

rounds.Doctorswillstillgetdisturbedforimportantandurgentmatters,butothercallswillbe

delayeduntilafterthewardround.

Attentiondrop

Theattentiondropcanonlybefixedbyloweringthetimeadoctormustfocusduringhisward

round.Thiscanbeachievedbyimprovingthewardrounditself,orbysplittingthewardround

betweenseveraldoctors.

Hygiene

Thethirdmicro-problemfocussesonthehygiene.Thisisonewhichalreadyhasreceivedalotof

attention inhospitalsand is thusalready improveda lotby implementingdisinfectant inevery

room.Itnowremainsimportanttoincreasetheawarenessofthestafftoutilisethisdisinfectant

everytime.

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PatientPrivacy

Thelastproblemoccursinwardroundsofthesecondmodelwheretheyopttotakeatourcar

with themduring thewardround.Thedoctoroftengoes into thepatient roomand leaveshis

computerunlockedoutsideof the room.Thismakes itpossible forpeople thatpassby to see

privateinformation.Thiscanbefixedbyutilizingasystemwhichautomaticallylocksifitisn’tused

andunlocksverysmoothlyifthedoctorreturns.Tomakesurethatthedoctordoesn’tlosetime

whileloggingineverytimeafterhehasvisitedapatient,youcanworkwithpersonalbadgeswhich

automaticallyunlocksthesystem.Oneoftheobservedhospitalsalreadyusedsuchasystem.

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6.4ProcessImplementation Asalreadymentionedbefore,inthesectionaboutthecorrectsoftwaresystem,justbuyingnew

systemsorchangingthingsdoesn’tworkordoesn’thelpyoureachmaximumpotential.Ifyouwant

toimproveyourwardroundsignificantly,youreallymustthinkabouttheimplementationofthe

to-beprocess.Whataretherequirementsforthenewprocess?Whatarethechanges?Howlong

doesittaketoimplementthesechanges?Howcanthewardroundparticipantslearntoworkwith

thenewprocess?…

SeveralrecommendationsfortheimplementationphaseoftheBPMlifecyclewillbedescribed,

butweagainwanttoreferyoutomanualsonBPMforabroaderoverviewoftheimportanceof

theimplementationphase.

Recommendation7:Providesufficienttrainingforthewardroundparticipantstohelpthemadapt

tothenewprocess.

Achangecanonlyworkifitissupportedbytheprocessparticipantsthemselves.Oneimportant

pointistomakesurethattheseparticipantsknowtheirnewrolesandthattheyunderstandhow

thenewprocesswilllooklikeandwhatisexpectedfromthem.Itisstraightforwardthatanew

wardroundprocesscanonlyworkiftheparticipantsknowhowtheyshouldperformtheirnew

tasks.Itisalsoimportanttoshowtheseindividualsthetotalprocessoverview,sotheyunderstand

theirpartintheoverallprocess.Thiscanhelpthemunderstandtheimpacttheyhaveontheother

wardroundparticipantsaswellasontheoverallprocess.

Recommendation8:Provideexplanationsforthedifferentchangesandhighlighttheimportance

andtheadvantagesofimplementingthem.

Asecond importantpart inconsolidatingtheprocessparticipants’cooperation ishelpingthem

understandwhichchangesarehappeningandwhythesearehappening.Peopledonotgenerally

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likechange,butifyoucanhighlighttheadvantagesofthechangesandyoucanshowthemthe

impactitwillhaveontheirsituation,thenpeoplewillmoreeasilycooperate.

Recommendation9:Providewardroundparticipantswithaclearchangeplan,sotheyknowwhat

willhappenandwhenitwillhappen.

Afteryouhavemadecleartotheparticipantswhythechangesarenecessary,itisalsoimportant

toletthemknowhowthesechangeswillbeimplementedandwhen.Peoplecanonlycooperateif

theyeffectivelyknowwhatishappeningandwhenitishappening.

Recommendation10:Provideguidelinesforthetransitionfromtheoldtothenewprocess.

One of the things that most people overlook in the implementation of a new process is the

transitionfromtheoldtothenew.Youcannotforgetthatyoudonotreachyournewprocessfrom

thedayyoudecidetoimplementit.Ifyouforexamplewouldimplementanewcomputersystem,

thenalltherelevantinformationshouldbegatheredandshouldbeputintothesystem.Whatwill

youdowithallthestoredinformationfromoldpatients?Doyourdoctorsstartworkingwiththe

newsystemimmediatelyordotheystillusetheoldsystemuntileverythinghasbeendocumented?

Ordotheyusebothsimultaneously?Itisveryimportanttotaketransitionintoconsiderationand

toguideyourprocessparticipantswiththistransition.Aninternalpersonshouldalsobeappointed

asaresponsibleforthechangetransition.

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6.5ProcessMonitoring&Controlling TheBPMapproachdoesn’tstopafterthe implementationofthenewsystemandprocess.The

BPMapproachisaBPMcycle.Aftertheimplementationofthenewprocess,thisprocessshould

bemonitoredtocontrol theperformanceof theprocess.This isvery importantbecauseevery

processoritgoalschangesovertime.

ItisasMichaelHammeronceputit:“everygoodprocesseventuallybecomesabadprocess”.

This process monitoring should be done according to the dimensions chosen in the process

analysesphase.Bothquantitativeandqualitativeperformancemeasuresshouldbefollowedup

ontoseeiftheintendedimprovementsarereachedoriftheperformanceoftheprocessstartsto

falloff.

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7. Conclusion

7.1Generalconclusion ThisresearchindicatedthattheBPMapproachofthewardroundsinBelgianhospitalsisindeed,

ashypothesised,notyetonpoint.

Duringthisresearch,thegoalwastoeducatethehospitalmanagementandemployeesaboutBPM

andtouseitonaknownprocessforthem,thewardround.Theprinciplegoesbacktotheold

saying:

“Giveamanafishandhecaneatforaday,showamanhowtofishandhecaneatforalifetime”.

ThisresearchshowedhowhospitalscanimprovetheirBPMapproachforthewardroundprocess.

Themaingoalisn’ttoimprovethewardroundsthemselves,butitistolearnhospitalstotakea

BPM approach throughout thewhole organization. The goal was to help hospitals realise the

impactofdecisionsonthisprocessaswellas the impactofdifferentprocessesoneachother.

Hospitals shouldgrow toaBPMapproachwhere theycan improve theefficiencyof individual

processes,whilegeneratingsynergiesbetweenthedifferentprocesses.Thiswillhelpthemtooffer

thebestpossiblecaretothepatientsatthelowestcost.

Theresearchdoesn’tsayhowthecurrentwardroundshouldlooklike,sincethisalldependson

thegoalsofthespecificdepartmentandhospitalandontheimplementationwithinthedifferent

processes.Butitdoessayhowhospitalmanagersandwardroundparticipantsshouldlookatthe

wardroundtohelpitevolvethroughouttime.

Itisalsoimportanttomentionthathospitalsshouldn’tallimmediatelystartwithimplementinga

BPMapproachfortheirwardrounds.Thisisbecausethewardroundsinmosthospitalsarealready

quiteefficientandthuswouldn’twarrantytheneededinvestmentsfortheBPMapproach.

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Itishoweverimportantthatthesehospitalsfocusondifferentprocessesandthattheyatleastget

anoverviewofthewardroundprocessandthattheyregularlymonitortheperformanceofthis

process,sincethewardroundprocesswillstillevolveovertime.

Forthehospitalswherethecurrentperformanceofthewardroundisstill lackingontheother

hand,theBPMapproachforthewardroundisveryimportanttoimprovetheefficiencyofthis

coreprocess.

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ResultsofempiricalstudyTheresearchfirstanalysedthecurrentBPMapproachoftheBelgianhospitalsandcameupwith

someproblemsoftheseapproaches.Afterwards,itgaveseveralrecommendationsonhowthese

hospitalscanimprovetheirBPMapproach.

Wewillshortlygoovertheseinsightsandrecommendations.

Theresearchfirstgaveusabetterunderstandingofthewardrounditselfandshowedusthatthe

wardroundalwaysconsistsofthreephases,whicharemostlycombinedintwowaysasshown

below.(Section5.1WardRoundOverview).

Figure 7 - Ward round model 1

Figure 8 - Ward round model 2

TheHospitalsProcessOrientationToolwasusedtoanalysetheProcessMaturityoftheseBelgian

hospitals.Andalthoughthehighscoresonthetoolitself,itwasfoundthatthematuritylevelis

actuallyverylow.FortheMaturitymodelofMcCormack,thelevelwouldcorrespondtothead-

hoclevel,whichistheinitiallevel.WhilethelevelintheCMMIwouldalsobethelowestlevel,level

1(Initial).

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Thisdistinctionbetweenthescoreandthematurityisduetoseveralreasons.Anexampleisthe

misuse of the tool itself during the research,wherewe analysed the processmaturity of one

process overmultiple hospitals instead of the processmaturity of one hospital overmultiple

processes.

Nevertheless,thisstillleadustosomeimportantinsights.

Findings BPMLifecycle

Wardroundprocessshouldbedocumented Processdiscovery

Wardroundperformanceneedstobe

measured

Processanalysis

Wardroundperformanceneedstobe

measured

Processmonitoring&controlling

Table 29 - Hospital Process orientation findings

Thequestionnairehelpedtofindthreeimportantinsightsaboutthewardrounds.

Insight1:thewardrounddifferencesbetweendisciplines

Thefirstoneindicatesthedifferencesbetweenseveraldisciplines,likethedifferentwardround

goalsofsurgerydisciplinesandinternaldisciplines.

Insight2:perceptionofthewardroundThesecondinsighthighlightedthatwardroundparticipantsareusedtohowthewardroundsare

currentlyperformedandthattheyaren’ttryingtofixtheproblemsofthecurrentprocess,even

thoughtheyknowwhichproblemsexist.

Insight3:wardroundeducation

Thethirdinsightindicatedthatcurrentmedicalstudentsaren’teducatedabouttheimportanceof

the ward round and how this process should look like. We can say that they use a Master-

apprenticeapproach.Theyjustadoptthewardroundprinciplesofthedoctorwhichtheyfollow

duringtheirinternships.

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Findings BPMLifecycle

Knownproblemsshouldbedocumented ProcessAnalysis

Knownproblemsshouldbeimproved ProcessRedesign

Table 30 - Questionnaire findings

Theseinsightsletustothesetwoimportantconclusions.

Theresearchalsoshowedsomecurrentmicro-andmacro-problemsofthewardrounds,which

wereobservedduringtheobservations.

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RecommendationsTheseleadto10recommendationsforthehospitalstoimprovetheirBPMapproachfortheward

round.

RecommendationstoimproveBPMapproach

ProcessDiscovery

Recommendation1:StartwithProcessDiscoverytogetanoverviewofthewardroundprocess

ProcessAnalysis

Recommendation2:Getanoverviewoftherelevantgoals

Recommendation 3: Measure the relevant performance measures both quantitative and

qualitative.

Recommendation4:Documenttheperformancesandtheproblems.

ProcessRedesign

Recommendation5:implementasoftwaresystemthatfitsthewardroundrequirements.

Recommendation6:Thinkabouttheimpactofdecisionsontheprocessandtheimpactofthis

processonotherprocesses.

ProcessImplementation:

Recommendation7:Providesufficienttrainingforthewardroundparticipantstohelpthem

adapttothenewprocess.

Recommendation 8: Provide explanations for the different changes and highlight the

importanceandtheadvantagesofimplementingthem.

Recommendation9:Providewardroundparticipantswithaclearchangeplan,sotheyknow

whatwillhappenandwhenitwillhappen.

Recommendation10:Provideguidelinesforthetransitionfromtheoldtothenewprocess.

Table 31 - All recommendations to improve BPM approach

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7.2Importanceofresearchforhospitals

Theonethingthathospitalsshouldtakeawayfromthisresearchisthatitisessentialforthefuture

ofhealthcarethattheyunderstandalltheirprocessesthoroughly.Theyneedtounderstandthe

goalsandtheperformanceofalltheseprocessesandtheinfluencetheyallhaveoneachother.

This isessentialbecauseofthedynamiccharacterofthecurrentsociety.Newtechnologiesare

evolvingatanincrediblepaceandtheyarebringingnewopportunitiestoimprovethehealthcare

anditsefficiencyimmensely.

It is thus important forhospitals topreparethemselves for thesenewopportunitiesandtobe

readytoimplementthemwhentheyarriveinsteadofbeingastepbehindbusinessesandindustry

ashasbeenthecaseinthepast.

Awell implemented BPM approach is a very good starting point for this and that iswhy this

researchisimportanttohelphospitalsgettothatpoint.Ontopofthat,theyshouldbelookingout

forthesenewopportunitiesandshouldevenstimulatethesetechnologiestofindtheirplacein

thehealthcareindustry.

Anotherimportantpartistheeducationofcurrentmedicalstudents,whichshouldnotonlylearn

howtoperformprocesses(likethewardround),buttheyshouldlearnwhatthedifferentgoals

areandlearntothinkabouthownewtechnologiescanhelpimprovetheseprocessestodelivera

higherqualityofcareata lowercost.Aprocessmind-set isalsoveryvaluableto learnmedical

studentstotakeaholisticviewonproblems.

Wecanforexampleconsiderthefutureofthewardround.

WhatwillbetheimpactofInternetofThings(IoT),ArtificialIntelligence(AI),AugmentedReality

(AR) and all sorts of different technologies? IoT will allow hospitals to get more real time

parametersofpatients,whichwillfacilitateasmootherwardroundforthedoctorandnurses.AI

willhelpdoctorstocomeupwiththecorrecttreatmentandcanhelppatientsbetterunderstand

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theirmedicalcondition,forexamplewiththeuseofchatbotsorvirtualassistants.ARontheother

handcanhelpthedoctortovisualizethemedicalcondition,whichcansignificantlyhelpthepatient

understandthetreatment. Itcanalsobeusedtoshownurseswhatthedoctorexactlyexpects

fromthemorhelpthedoctortoeducatetheassistantsandinterns.Severalothertechnologies

alreadyexisttostayintouchwiththepatientafterthedischargeofthehospital.

Allthesenewtechnologiescanhelptoimprovethequalityofcareforthepatients,buthospitals

needtobeactive,tofindtheprocessesonwhichtheycanhavethebiggestimpactandreturn.

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7.3FlawsofresearchandfurtherresearchTheflawsoftheHPOtoolhavealreadybeendiscussedbefore,butitisimportanttohighlighta

differentflawofourresearch.

Duetothedynamiccharacterofthisresearch,theoriginalgoalandresearchquestionhasbeen

adaptedseveraltimes.Theresearchstartedoutoftherequirementtoknowifthewardround

processindeedwasabusinessprocess.Butbecausewequicklyconcludedthatthiswasthecase,

wewantedtoinvestigatemoreaboutthewardround.Thisleadustoinvestigatehowtheward

roundlookedlikeinthedifferenthospitalsanddepartments.

During the research however, it became clear that our research could havemore value ifwe

focusedtheresearchontheBPMapproachofthewardroundsinthesehospitals.Whichleadus

toourcurrentresearchquestion.

Theadaptationoftheresearchquestiondoesbringaproblemwithit.Becauseourresearchwas

alreadyperformed,our focuswas100percenton theprocessparticipants themselvesandwe

didn’t get any interaction with the management team. This is a clear flaw since it is the

managementteamthatshouldperformandguidetheBPMapproach.Itisthuspossiblethatthe

managementalreadyperformsseveraloftherecommendationswhichweremade.Thishowever

doesn’ttakeawayanyofourfindings,sinceitisveryimportantthattheBPMapproachisused

throughouttheorganizationandnotonlyinsidethemanagementteam.

FutureresearchcanthusbefocusedonanalysingtheBPMapproachwithinthemanagementteam

ofhospitalsandonthecommunicationbetweenthemanagementteamandtheclinicians.Other

subjectsforfutureresearcharethemappingofotherhospitalprocessesandtheinfluenceofthese

processesoneachother.Sinceweindicatedthatasoftwaresystemcanhaveanimmenseimpact

ontheefficiencyofthewardround,futureresearchcanalsoconsidertherequirementsofthis

softwareforthewardroundsandforotherprocesses.Lastly,asmentionedintheprevioussection

7.2itisalsoimportanttoresearchthenewopportunitieswithinhospitalsfromnewtechnologies.

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8. ReferencesArmistead,C.,Rowland,P.(1998),ManagingBusinessProcess:BPRandBeyond(JohnWileyand Sons)Bradfield(2010),Wardrounds:Thenextfocusforqualityimprovement?Buttigieg,C.,Dey,P.K.,&Gauci,D.(2016),Businessprocessmanagementinhealthcare:current challengesandfutureprospects.Coffey,R.,Richards,J.S.,Remmert,C.S.,Leroy,S.S.,Shoville,R.R.,Baldwin,P.J.(2005),An

IntroductiontoCriticalPaths,QualityManagementinHealthcare,14(1),pp.46-55.

Davenport,T.(1993).ProcessInnovation:Reengineeringworkthroughinformationtechnology. HarvardBusinessSchoolPress,BostonGemmel,P.,&Vandaele,D.,&Tambeur,W.(2007),HospitalProcessOrientation(HPO): thedevelopmentofameasurementtool,VlerickLeuvenGentManagementSchool.Hammer,M.,&Champy,J.(1993).ReengineeringtheCorporation:AManifestoforBusiness Revolution,HarperBusinessKumar,A.,PengSiOw,Prietula,M.J.(1993),Organizationalsimulationandinformationsystems

design:anoperationslevelexample,ManagementScience,39(2),pp.218-239.

Kvarnström(2008),Difficultiesincollaboration:Acriticalincidentstudyofinterprofessional healthcareteamwork.LaRosa,M.,Mendling,J.,&Reijers,H.A.(2013).FundamentalsofBusinessProcess

Management.Langewitz,W.,Cohen,D.,Nubling,M.,&Weber(2002),H.Communicationmatters–deficitsin hospitalcarefromthepatients’perspective.PsychotherPsychosomMedPsychol 2002;52:348–54Lathrop,J.P.,Seufert,G.E.,McDonald,R.J.,Martin,S.B.(1991),ThePatient-focusedHospital:a

PatientCareConcept,JournaloftheSocietyforHealthSystems,3(2),pp.33-50.

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McCormack,K.P.,&Johnson,W.C.(2001),"BusinessProcessOrientation,supplychain management,andthee-corporation",IIESolutions,http://solutions.iienet.org <http://solutions.iienet.org/>McCormack,K.P.,Johnson,W.C.(2001)BusinessProcessOrientation:GainingtheE-business CompetitiveAdvantage,BocaRatonLLC,CRCpress.Morrison,C.,Fitzpatrick,G.,&Blackwell,A.(2011),Multi-disciplinarycollaborationduringward rounds:Embodiedaspectsofelectronicmedicalrecordusage.NSWHealth.(2011).MultidisciplinaryWardRounds.NswDepartmentofHealth.O’Hare,J.A.(2008).Anatomyofthewardround.EuropeanJournalofInternalMedicine,19(5),

309–313.https://doi.org/10.1016/j.ejim.2007.09.016Raza,N.(2012),ProductiveWardRound:OurexperienceonPrestonMAU.RoyalCollegeofPhysicians,&RoyalCollegeofNursing(2012),Wardroundsinmedicine: Principlesforbestpractice.Sanson-Fisher,R.W.(1979),Behaviouralanalysisofwardroundswithinageneralhospital psychiatricunit.Shankar,P.S.(2013),“Wardroundsinmedicine”,RajivGandhiUniversityofHealthSciences JournalofMedicalSciences,Vol.3No.3,pp.135-137.Steele,S.J.,&Morton,D.J.B.(1978),TheWardRound.Sweet,G.S.,&Wilson,H.J.(2010),Apatient’sexperienceofwardrounds.VanDeGlind,I.,VanDulmen,S.,&Goossensen,A.(2008),Physician–patientcommunicationin single-beddedversusfour-beddedhospitalrooms.Vera,A.,Kuntz,L.(2007),Process-basedorganizationdesignandhospitalefficiency,HealthCare

ManagementReview,32(1),pp.55-65.

Walton(2016),Articleofwardrounds,participants,rolesandperceptions:literaturereview.Weber,H.,Stöckli,M.,Nübling,M.,&Langewitz,W.A.(2007).Communicationduringward

roundsinInternalMedicine.Ananalysisofpatient-nurse-physicianinteractionsusingRIAS.PatientEducationandCounseling,67(3SPEC.ISS.),343–348.https://doi.org/10.1016/j.pec.2007.04.011

68

Zander,K.(1992),CriticalPathways,in:M.M.Melium,M.K.Sinioris(Eds.)TotalQuality

Management:TheHealthCarePioneers,pp.305-314(AmericanHospitalPublishing,Inc.).

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9. Appendix

9.1Appendix1:DutchversionofusedHPOToolandquestionnaire

PROCESSVIEW

1. De dokter ronde in het ziekenhuis is vastgelegd en gedocumenteerd rekening houdend met

de invloed op de patiënt.

Niet Akkoord Neutraal Akkoord

2. De dokter ronde is genoeg gedefinieerd zodat ik weet wat ik moet doen en wat er van mij

wordt verwacht.

Niet Akkoord Neutraal Akkoord

3. Ik kan de stappen van de dokter ronde binnen mijn afdeling opnoemen en beschrijven.

Niet Akkoord Neutraal Akkoord

PROCESSJOB

4. Mijn job is multidimensionaal en bestaat niet louter uit het uitvoeren van vastgelegde

taken.

Niet Akkoord Neutraal Akkoord

5. Mijn job vereist een probleem oplossende aanpak.

Niet Akkoord Neutraal Akkoord

The HPO Tool

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6. Ik leer continu nieuwe zaken tijdens mijn job.

Niet Akkoord Neutraal Akkoord

PROCESSMANAGEMENTANDMEASUREMENT

7. De prestatie (efficiëntie en effectiviteit) van de dokter ronde wordt gemeten.

Niet Akkoord Neutraal Akkoord

8. Prestatie indicatoren zijn gedefinieerd voor de dokter ronde.

Niet Akkoord Neutraal Akkoord

9. Er zijn duidelijke doelstellingen gezet voor de dokter ronde.

Niet Akkoord Neutraal Akkoord

10. De resultaten van de dokter ronde worden gemeten.

Niet Akkoord Neutraal Akkoord

EXTRAVRAGEN

11. Waar heb je geleerd hoe je je dokter ronde aanpakt?

12. Hebben uw dokter rondes veel variatie?

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13. Zie je verschillen tussen de dokter rondes van verschillende afdelingen? Zo ja, welke?

14. Beschouw je de dokter ronde als een verplichting of als een echte meerwaarde?

15. Moet de dokter ronde volgens u meer gefocust worden op efficiëntie of op de patiënten?

16. Wat beschouwt u als problemen van de dokter ronde?

17. Wat zijn volgens u de doelen van de dokter ronde?

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18. Heb je een evolutie gezien in de dokter rondes gedurende uw loopbaan?

19. Denk je dat de dokter ronde veel kan verbeterd worden?

20. Beschrijf kort de stappen van de dokter ronde binnen uw afdeling?

21. Heb je nog andere opmerkingen?

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9.2Appendix2:EnglishversionofusedHPOToolandquestionnaire

PROCESSVIEW

1. The ward round in the hospital is defined, documented with the input of the patient

and in terms of benefits for the patient.

Disagree Neutral Agree

2. The ward round is sufficiently defined so that I know how I must work.

Disagree Neutral Agree

3. I am able to name and describe the different ward round steps of patients on the

unit where I belong to.

Disagree Neutral Agree

PROCESSJOB

4. My job is multidimensional and not simple tasks

Disagree Neutral Agree

5. My job includes frequent problem solving

Disagree Neutral Agree

6. I learn constantly new things on the job

Disagree Neutral Agree

The HPO Tool

74

PROCESSMANAGEMENTANDMEASUREMENT

7. The performance (efficiency and effectiveness) of the ward round is measured.

Disagree Neutral Agree

8. Performance indicators are defined for the ward round.

Disagree Neutral Agree

9. Specific performance goals are in place for the ward round.

Disagree Neutral Agree

10. The outcomes of the ward round are measured.

Disagree Neutral Agree

EXTRAQUESTIONS

11. Where did you learn how to structure your ward round?

12. Do your ward rounds have a lot of variation?

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13. Do you see differences between the ward rounds of departments? (Only answer if you work or have worked in different departments)

14. Do you consider a ward round as a duty or as a valuable part of your job?

15. Do you think ward rounds should be more focused on efficiency or more on the patients?

16. What do you consider as ward round problems?

17. What are for you the goals of a ward round?

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18. Have you seen any evolution in the ward round? Please explain if relevant.

19. Do you think your ward round can be improved?

20. Shortly describe the steps of the ward round in your department.

21. Do you have any other comments?

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9.3Appendix3:originalHPOQuestions

PROCESS VIEW

• The (care) processes in the hospital are defined, documented with the input of the patient and in terms of benefits for the patient.

• The (care) processes are sufficiently defined so that I know how I must work. • I am able to name and describe the different (care) processes of patients on the unit

where I belong to.

PROCESS JOB

• My job is multidimensional and not simple tasks (PJ1) • My job includes frequent problem solving (PJ2) • I learn constantly new things on the job (PJ3)

PROCESS MANAGEMENT AND MEASUREMENT

• The performance (efficiency and effectiveness) of the (care) processes is measured. • Performance indicators are defined for the (care) processes. • Specific performance goals are in place for the (care) processes. • The outcomes of the (care) processes are measured.

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9.4Appendix4:HPOScores