Towards engineering performant, innovative and sustainable ... · Figure 7 - Six Sigma's DMAIC and...
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Towards engineering performant, innovative and sustainable health systems Raphaël Wouters Promoter: Prof. Dr. Ir. Jan A.P. Hoogervorst University of Antwerp – Antwerp Management School Delft University of Technology – Delft TopTech A thesis submitted for the degree of “Master of Enterprise IT Architecture” at the Antwerp Management School of the University of Antwerp and Delft TopTech of the Delft University of Technology June 2014
Transcript of Towards engineering performant, innovative and sustainable ... · Figure 7 - Six Sigma's DMAIC and...
Towards engineering performant, innovative
and sustainable health systems
Raphaël Wouters
Promoter: Prof. Dr. Ir. Jan A.P. Hoogervorst
University of Antwerp – Antwerp Management School
Delft University of Technology – Delft TopTech
A thesis submitted for the degree of “Master of Enterprise IT Architecture”
at the Antwerp Management School of the University of Antwerp
and Delft TopTech of the Delft University of Technology
June 2014
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Abstract
Every health system in the world is struggling with constant rising costs, inefficiencies or
irregular quality, and is unable to deal with the growing society dynamics.
Effectively implementing strategic initiatives that tackle the aforementioned challenges
appears a frightening task since the majority of the implementations fail. Current approaches
and frameworks addressing organizational changes are fragmented, heterogeneous and mostly
descriptive.
This research proposes a shift towards the Enterprise Engineering Paradigm, guided by the
Enterprise Engineering Framework, while integrating compatible analysis techniques and
improvement/quantification or innovation methods for avoiding strategic initiatives failure.
We demonstrate our proposal on real health reform proposals and anecdotal scenarios.
Keywords: Enterprise Engineering; Enterprise Governance; Enterprise Ontology; Enterprise
Architecture; Enterprise Design; Health System; Health Care; Health Care Reform; Health
Reform; Strategic Success; Organizational Design; Organizational Engineering
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Executive Summary
In a time of growing health expenditures and inefficiencies, ageing populations, rise of
chronic diseases, co-morbity and technical evolutions, there is a worldwide quest for
performant, innovative and sustainable health systems that are, a.o. effective and cost-
efficient, patient-centric and co-creative and able to deal with the growing society dynamics.
Effectively implementing strategic initiatives that tackle the aforementioned challenges or
dissolve existing problems appears a frightening task since the majority of the
implementations fail.
Current approaches and frameworks addressing organizational changes are fragmented,
heterogeneous and mostly descriptive. In this study, we aim to design and develop a more
prescriptive, holistic and integrated approach.
This research proposes a shift towards the Enterprise Engineering Paradigm, guided by the
Enterprise Engineering Framework, while integrating compatible analysis techniques and
improvement/quantification or innovation methods for avoiding strategic initiatives failure.
The research methodology used to conduct this study is the Design Science Research
Methodology and the demonstration of our proposal is based on real health reform proposals
and (fictitious) anecdotal scenarios.
The Enterprise Engineering Paradigm, guided by the Enterprise Engineering Framework, and
integrated with compatible analysis techniques, improvement and quantification methods;
provide a solid foundational theory and methodology, different and unified approach for
integrating several enterprise aspects that would otherwise be treated incoherently and
inconsistently, causing failures in strategic initiative implementations.
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Acknowledgements
The execution of this master thesis has been a significant undertaking.
Firstly, I want to thank my thesis supervisor, Prof. Dr. Ir. Jan A. P. Hoogervorst, for his
expertise and critical thinking, his valuable feedback and interesting discussions and his
timely and considerate commitments.
Secondly, I express my appreciation to (in alphabetical order) Prof. Dr. Lieven Annemans,
Andy Brogan, Prof. Dr. Jan L.G. Dietz, Noora Jansson, Laleh Rafati, Dr. Marc Sabbe,
Prof. Miguel Mira Da Silva and everyone who delivered input, interest or comments on this
challenge.
And last but not least, I express my gratitude to my close friends, for their love, compromises,
moral support and encouragements.
Raphaël Wouters
June 2014
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Table of Contents
Abstract ..................................................................................................................... ii
Executive Summary ................................................................................................ iii
Acknowledgements ................................................................................................. iv
List of Figures ........................................................................................................ viii
List of Tables ........................................................................................................... ix
List of Abbreviations ................................................................................................ x
Introduction ............................................................................................................... 1
1.1 Background ................................................................................................... 1
1.2 Problem and Motivation ................................................................................. 3
1.3 Research Questions ...................................................................................... 5
1.4 Importance of the Research .......................................................................... 5
Research Methodology ............................................................................................ 6
2.1 Design Science Research Methodology (DSRM) .......................................... 6
2.2 Objectives of the Solution .............................................................................. 8
2.3 Assumptions and Limitations ......................................................................... 8
2.4 Thesis Outline................................................................................................ 8
Literature Review ...................................................................................................... 9
3.1 Health and Health Care System .................................................................... 9
3.1.1 Definition of a Health System ..................................................................... 9
3.1.2 Health System Elements .......................................................................... 10
3.1.3 Health System Classification .................................................................... 11
3.1.4 Reference Health Systems ....................................................................... 11
3.2 Public Services and Entities ........................................................................ 13
3.2.1 Goods vs. Services .................................................................................. 13
3.2.2 Key Distinctions of Public Services .......................................................... 14
3.3 Change Paradigms and Approaches ........................................................... 15
3.3.1 Reductionism vs. Holism .......................................................................... 15
3.3.2 Dissolving the problem ............................................................................. 16
3.3.3 Management vs. Governance .................................................................. 17
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3.3.4 Mechanistic vs. Organismic Viewpoint ..................................................... 18
3.3.5 Core reasons for failure ............................................................................ 20
3.4 Other Approaches ....................................................................................... 20
3.4.1 Plan-Do-Study-Act (PDSA) ...................................................................... 21
3.4.2 Lean Thinking ........................................................................................... 22
3.4.3 Six Sigma ................................................................................................. 24
3.4.4 The Vanguard Method (tVM) .................................................................... 25
3.5 Conclusions ................................................................................................. 27
Theoretical Foundations ........................................................................................ 28
4.1 Enterprise Engineering ................................................................................ 28
4.2 Enterprise Architecture ................................................................................ 29
4.3 Enterprise Governance ................................................................................ 32
4.4 Enterprise Ontology ..................................................................................... 33
4.5 Generic System Development Process ....................................................... 37
4.6 Normalized Systems .................................................................................... 38
Proposed Solution .................................................................................................. 39
5.1 Objectives of the Solution ............................................................................ 39
5.2 Proposed Solution ....................................................................................... 39
5.3 Compatible Techniques and Methods ......................................................... 41
Demonstration ........................................................................................................ 43
6.1 Introduction .................................................................................................. 43
6.1.1 Belgian Health System ............................................................................. 43
6.1.2 Problem Statement................................................................................... 45
6.1.3 Reform Proposals..................................................................................... 47
6.2 Case A – Medication Reconciliation ............................................................ 55
6.2.1 Introduction .............................................................................................. 55
6.2.2 Problem Analysis ..................................................................................... 55
6.2.3 Proposed Solution .................................................................................... 55
6.2.4 Application & Results ............................................................................... 56
6.2.5 Conclusions .............................................................................................. 64
6.3 Case B – Primary Care Subsystem ............................................................. 65
6.3.1 Introduction .............................................................................................. 65
6.3.2 Problem Analysis ..................................................................................... 66
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6.3.3 Proposed Solution .................................................................................... 66
6.3.4 Application & Results ............................................................................... 66
6.3.5 Conclusions .............................................................................................. 73
6.4 Discussion ................................................................................................... 73
Evaluation ............................................................................................................... 75
7.1 Evaluation Strategy ..................................................................................... 75
7.2 Evaluation Results ....................................................................................... 76
Conclusions ............................................................................................................ 79
8.1 Findings and Conclusion ............................................................................. 79
8.2 Implications, Recommendations and Limitations ......................................... 82
8.3 Research Communication ........................................................................... 82
8.4 Recommendations for Future Work ............................................................. 83
Bibliography ............................................................................................................ 84
Appendices ............................................................................................................. 88
Appendix A – Generic Enterprise Design Aspects ................................................ 88
Appendix B – Health System in Belgium ............................................................... 91
Appendix C – Summary of Enterprise Engineering Manifesto ............................... 96
Appendix D – ATD of Case A (Medication Reconciliation) .................................... 98
Appendix E – ATD of Case B (Primary Care Subsystem) ..................................... 99
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List of Figures
Figure 1 - Health expenditure in 2011 as a share of GDP (OECD Health Data 2013) .............. 2
Figure 2 - Process model of the Design Science Research Methodology (DSRM) ................... 7
Figure 3 - The WHO Health System Conceptual Framework ................................................. 10
Figure 4 - Management vs. Governance .................................................................................. 17
Figure 5 - Alternative proposal for the Deming cycle (Hoogervorst, 2014) ............................ 21
Figure 6 - The Five Lean Principles ......................................................................................... 22
Figure 7 - Six Sigma's DMAIC and DMADV cycles .............................................................. 24
Figure 8 - Check model of systems analysis in the Vanguard Method (tVM) ......................... 26
Figure 9 - Main enterprise design domains (Hoogervorst, 2009) ............................................ 30
Figure 10 - Architecturing reference context (Hoogervorst, 2013) and (Hoogervorst, 2014) . 30
Figure 11 - Enterprise Governance core competences (Hoogervorst, 2009) ........................... 32
Figure 12 - The central role of Enterprise Governance competences (Hoogervorst, 2009) .... 32
Figure 13 - Graphical representation of the Operation Axiom (Dietz, 2006) .......................... 33
Figure 14 - Basic pattern (left) and standard pattern (right) of a transaction (Dietz, 2006)..... 34
Figure 15 - Summary of the Distinction Axiom (Dietz, 2006) ................................................ 34
Figure 16 - Representation of the Organization Theorem (Dietz, 2006) ................................. 35
Figure 17 - The layered integration of an organization (Dietz, 2006) ..................................... 35
Figure 18 - Ontological triangle, with aspect models and diagrams of DEMO (Dietz, 2006). 36
Figure 19 - GSDP: design concepts and process (Dietz, 2006) ............................................... 37
Figure 20 - Levels of innovation for sustainability (Brezet, 1997) and (Gaziulusoy, 2010) ... 40
Figure 21 - Health System in Belgium (Gerkens & Merkur, 2010) ......................................... 44
Figure 22 - Belgian health expenditure trend as a share of GDP (OECD Health Data 2013) . 45
Figure 23 - Three packages in a future health system (Annemans, 2014) ............................... 54
Figure 24 - ATD of General Practitioner, Pharmacy, Sickness Fund and A&E Department .. 62
Figure 25 - New transaction type T21: Consume/Apply Pharma Product ............................... 63
Figure 26 - ATD of Primary Care Delivery Subsystem ........................................................... 71
Figure 27 - Collection of Business Design Aspects ................................................................. 88
Figure 28 - Collection of Organizational Design Aspects ....................................................... 89
Figure 29 - Collection of Information Design Aspects ............................................................ 89
Figure 30 - Collection of Environment Design Aspects .......................................................... 90
Figure 31 - Schematic overview of Enterprise Design Domains and its Aspects .................... 90
Figure 32 - ATD of Case A (Medication Reconciliation) ........................................................ 98
Figure 33 - ATD of Case B (Primary Care Subsystem) ........................................................... 99
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List of Tables
Table 1 - Key characteristics of services .................................................................................. 13
Table 2 - Key differences between mechanistic and organismic viewpoint ............................ 19
Table 3 - Examples of waste for health service operations ...................................................... 23
Table 4 - Seven Enterprise Engineering goals and fundamentals (Dietz, et al., 2013) ............ 29
Table 5 - Principles for Normalized Systems ........................................................................... 38
Table 6 - Some recent books and reports about the Belgian health system ............................. 47
Table 7 - Ten Pillars of Change (Annemans, 2014) ................................................................. 48
Table 8 - Sample Functional and Constructional Requirements .............................................. 58
Table 9 - Sample Architecture Principles of Case A ............................................................... 60
Table 10 - Sample Functional and Constructional Requirements ............................................ 68
Table 11 - Sample Architecture Principles of Case B .............................................................. 69
Table 12 - Evaluation of the guidelines of (Hevner, et al., 2004) ............................................ 77
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List of Abbreviations
A&E Accidents & Emergency
(S-)BPM (Subject-oriented) Business Process Management
CT Computed Tomography
CVA Cerebrovascular Accident
DEMO Design and Engineering Methodology for Organizations
DSRM Design Science Research Method
EA Enterprise Architecture
EE Enterprise Engineering
EG Enterprise Governance
EO Enterprise Ontology
ED Emergency Department
GCP Good Clinical Practice
GDP Gross Domestic Product
GP General Practice (or General Practitioner)
HC Health Care
HCP Health Care Provider (or Health Care Professional)
IEP Integrated Emergency Posts
LOS Length of Stay
NIHDI National Institute for Health and Disability Insurance
NS Normalized Systems
OECD Organisation for Economic Co-operation and Development
P4Q Pay-for-Quality
PDSA Plan-Do-Study-Act
PPP Purchasing Power Parity
QALY Quality Adjusted Life-Year
SMART Specific, Measurable, Achievable, Realistic/Relevant, Time-bound
TQM Total Quality Management
tVM The Vanguard Method
WHO World Health Organisation
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Chapter one
Introduction
“Healthcare is broken. […] Despite the best efforts of the workforce, we built it wrong.
It isn’t built for modern times.” – Dr. Donald Berwick
here is not a single nation in the world that is not asking itself whether their health
system can continue to do as it does. Is it effective? Is it efficient? Is it performant?
Are they financially sustainable? Do we realize innovative solutions?
1.1 Background
Every health system in the world is struggling with constant rising costs, inefficiencies or
irregular quality and unequal access, despite the hard work of all health professionals.
Different nations, commissions and individuals have proposed incremental health service
improvement reforms but they have rarely been approved, neither accomplished. Some reform
proposals are intuitive; others are informal and have no solid background to back it up.
Aging populations will cause increases in the number of individuals inflicted with chronic
diseases and disabilities, which will require more health care demand and spending. This
result in polarization effects: will there be shortages of health professionals to deal with this
demand, will the focus and accordingly citizen cooperation shift towards more prevention to
decrease incidence and severity and who gets to decide about the cost-benefit analysis of
keeping aging people with fading quality of live?
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Calculations like the added “quality-adjusted life-years” (QALY) that a treatment or
procedure provides will determine whether this will be administered and paid for at all.
The power or influence over these decisions shifting from health professionals to the payers
(government or private insurance organizations).
Figure 1 - Health expenditure in 2011 as a share of GDP (OECD Health Data 2013)
Available data on outcomes seem to suggest a movement from mainly volume- and judgment-
based medicine (empirical decision-making, often motivated by financial gains) towards an
value- and evidence-based approach (applying the best known medical and clinical evidence
in the decision-making), causing health providers and pharmaceutical companies to rethink
their strategies.
Another reason for the unsustainable cost increases are technological advances which will
cause health care costs throughout the world to continue to rise and will have a widespread
impact on health care expenditure, design of national systems, and delivery of services.
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1.2 Problem and Motivation
Most current health systems were originally designed from a curative perspective as to treat
curative and communicable diseases. The population no longer matches these demographics,
and less healthy lifestyles cause a large increase in long-term chronic conditions, many of
them preventable if healthier behaviors are to be introduced early enough.
Rising costs and divergent1 national expenditures have an effect on the competitiveness at
macroeconomic levels. Moreover, there is no correlation between cost and quality and the
expenditure is mainly driven by hospital or health professional supply instead of citizen or
patient demand, this is evidently an unsustainable financing model. As a consequence, one
might perceive the many health systems reward providers to behave like cowboys. Lack of
financial, performance and process transparency hinders the breakdown of these perceptions.
Most health systems and its entities have a complete lack of understanding where its real costs
are. They provide incorrect or arbitrary measures and indicators, or make only a subset
publicly available. All these wrong costs measurements only increase costs (Kaplan & Porter,
2011), are they worth it? A recent publication of rather meaningless “quality indicators” in
Belgian rest- and nursing facilities or a Great-Britain publication of falsification of waiting list
times show that people will use their ingenuity to do whatever they can to be seen to achieve
targets. Good measures of health services are the ones that show how rarely we need them.
The Digital and Information Age led to empowered patients and an increased demand for
patient-centered and co-creative telehealth and telemedicine services. A recent online survey
(The Chain of Trust Consortium, 2014) revealed that both patients and providers are keen to
play a more active role in managing their own health and condition, e.g. 60% of patients and
70% of health professionals who have never used telehealth would be willing to use it.
1 The OECD Health Data 2013 show a difference in health expenditures between 6% and 17% of the GDP and
estimates that between 5% and 15% of the health expenditure is wasted.
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“Health systems have deployed capabilities of prescribing drugs, perform medical and
surgical procedures. It is simple too much for a single person to know or to do. We are all
specialists now, we only know a piece of the health puzzle. Knowledge has exploded, and it
has brought complexity and specialization. We need to recognize that success in tackling
complexity requires group effort. We need to become pit crews now.“ – Dr. Atul Gawande
All these exterior forces and the innovation needs challenge the health systems around the
globe. Its processes and structures need to improve care paths, eliminate non value-adding
undertakings, reduce waiting time and expenditures, treat more patients, and implement new
technological services. Small and sometimes inconsistent or unsustainable reforms have
yielded a patchwork of health system complexities and chaos increments.
Even besides these challenges, many health systems suffer from operational management
problems, and its processes are considered inefficient (Kaplan & Porter, 2011). Medical
treatment has made amazing developments over the years. But the packaging and delivery of
that treatment are regularly inefficient, ineffective, and patient unfriendly.
“What is missing is this: the power of these interventions is not matched by the power of
health systems to deliver them to those in greatest need, on an adequate scale, in time. In part,
this lack of capacity arises from the failure of governments all around the world to invest
adequately in basic health systems. […] So long as investments in health systems are given
low priority, research in this area will also be neglected. In the absence of sound evidence, we
will have no good way to compel efficient investments in health systems.” – Dr. Margaret
Chan, WHO Director-General (2007).
Society changes and challenges owe the health industry a much needed fundamental
transformation, and as the current approaches don’t seem to be adequately implementing these
changes, shouldn’t we design and deliver a better way to fix our health systems?
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1.3 Research Questions
The problem we presented can be summarized in one main and high-level research question:
Main research question
How to (re)design performant, innovative and sustainable health systems?
Research questions
RQ 1. What is the contribution of the Enterprise Engineering Paradigm to the integrated
design of performant, innovative and sustainable health systems?
RQ 2. How can we objectively assess, compare and draft health system reform proposals
conform the disciplines in the Enterprise Engineering Paradigm?
1.4 Importance of the Research
Health systems and health organizations are forced to make transformational and incremental
improvements to evolving patient needs, global health challenges and trends, technological
evolutions and economic factors.
Both on national and European level, there is a room for improvement of population health,
the accessibility of national health services, and expenditure savings. As Belgium is about to
implement the first stage of a sixth state reform, there is a huge potential for redesigning its
federal, regional and communal health structures and processes.
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Chapter two
Research Methodology
“A goal without a plan is just a wish.”
– Antoine de Saint-Exupery
n this chapter we describe the followed research methodology. It provides an overview of
the research method and its process model, introduces the objectives of the solution and
the proposed artifacts as part of this methodology. It also lists the involved assumptions and
limitations of this study. A final section describes the thesis document outline.
2.1 Design Science Research Methodology (DSRM)
We conducted this study using the “Design Science Research Methodology” (DSRM). It
incorporates principles, practices, and procedures to result in an artifact-centric creation and
evaluation methodology (Hevner, et al., 2004).
This type of research, both in and outside of the Information Systems (IS) discipline, involves
creation of new knowledge (or application thereof) through the design of new or innovative
artifacts and analysis of the use of these artifacts, along with reflection and abstraction to
solve or understand an organization problem.
These artifacts can be categorized in constructs (vocabulary and symbols), models to
represent real-world situations (abstractions and representations), methods to provide
guidance how to solve problems (algorithms and practices) and instantiations that show how
the former artifacts can be implemented (Peffers, et al., 2008).
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The DSRM process model as proposed by Peffers, et al. consists of six distinct activity phases
as summarized below (Peffers, et al., 2008).
Figure 2 - Process model of the Design Science Research Methodology (DSRM)
We take the problem-centered initiated entry point and start with the nominal sequence:
1. Problem identification and motivation: define the specific research problem and
provide justification for the value of the solution;
2. Objectives of a solution: raise feasible objectives of a solution from the problem
definition, the related work and the domain knowledge base;
3. Design and development: design a broad artifactual solution (constructs, models,
methods, instantiations) – it may extend an existing domain knowledge base or apply
existing knowledge in new ways;
4. Demonstration: demonstration of the designed artifact(s) to solve the problem, e.g.
through experimentation, simulation, case study, proof or any appropriate activity;
5. Evaluation: observe and measure how well the artifact(s) support a solution to the
problem (by means of observation, analytics, simulations, tests, or scenario’s);
6. Communication: diffusion of resulting knowledge – present the problem and its
importance, the artifact, its utility and novelty, the rigor of its design, and its
effectiveness to relevant audience;
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2.2 Objectives of the Solution
Current approaches and frameworks to organizational change evaluation are fragmented,
heterogeneous and mostly descriptive. In this study, we aim to design and develop a more
prescriptive holistic and integrated approach.
2.3 Assumptions and Limitations
We incorporated relevant business, organizational and informational domains, aspects and
concerns, e.g. including management styles, ulterior motives or institutionalized distrust.
Clinical and medical domains are out-of-scope, any prerequisite knowledge, expertise or
relevant background is not required. Any real operationalization, implementation or
programmatic execution itself was outside the scope of this thesis.
2.4 Thesis Outline
Each chapter of this document somewhat resembles an activity phase of the DRSM process
model. It is organized in eight different chapters, summarized as follows:
1. Introduction: introduces the background, problem statement and motivation;
2. Research Methodology: provides an overview of the followed methodology;
3. Literature Review: introduces necessary topics and explains referenced concepts;
4. Theoretical Foundations: describes the needed concepts and theoretical background;
5. Proposed Solution: artifact creation from desired functionality and architecture;
6. Demonstration: describes (fictitious) anecdotal scenarios where the proposed artifacts
are applied, evaluates artifacts and discusses the results;
7. Evaluation: provides the evaluation strategy and the evaluation results;
8. Conclusions: general summary of findings, conclusions and proposal for future work;
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Chapter three
Literature Review
“Problems cannot be solved at the same level of awareness that created them.”
– Albert Einstein
his chapter covers an overview of a health system, the reviewed literature of key
elements in the health domain, organizational change paradigms and approaches and
introduces the necessary topics to explain concepts referenced further. It also elaborates on
the notion and characteristics of key elements in the body of knowledge.
3.1 Health and Health Care System
A health system is a complex, dynamic and adaptive system with chaotic behavior and
emergent characteristics. This section introduces and explains structure and purpose behind
various components and payment systems that typically compose a health system.
It is important to note that most health systems are in fact health care systems (a.k.a. “sick”
care systems). For the remainder of this thesis, we take an all-inclusive view of a health
system, including but not limited to health prevention, disease diagnosis, treatment and care.
3.1.1 Definition of a Health System
The most widely-used definition for a health system stems from the World Health
Organization (WHO), which defines health systems functionally as
“all organizations, people and actions whose primary intent is to promote, restore or
maintain health” (World Health Organization, 2000).
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Health systems are conceptualized in numerous ways (Alliance for Health Policy & Systems
Research - World Health Organization, 2012) and are classified as either system frameworks
(focused on the whole health system), sub-frameworks (focused on parts of the health system)
or supra-frameworks (focused on how other societal systems interact with the health system).
These frameworks also serve different purposes: they can offer a better understanding of
health systems, offer a way of comparing them, help with informing changes to health
systems, or shape methods of evaluating the performance or changes to them.
Figure 3 - The WHO Health System Conceptual Framework
3.1.2 Health System Elements
Every country has its own set of organizational arrangements, structures and processes to
keep their population healthy, treat the ones that get sick while protecting them from financial
bankruptcy using, a.o. the following key elements:
Consumers: patients, citizens, or other eligible health and health care receivers;
Providers or producers: hospitals, health care providers, physicians, pharmaceutical
companies, rest-and nursing homes, revalidation centers, organ donor banks, etc...;
Financing and reimbursement: insurers, third-party payers, sponsors, risk-
adjustments, transfers and redistribution of solidarity contributions, etc…;
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3.1.3 Health System Classification
Health Care Delivery
Health and health care delivery usually follows a continuum of primary care, acting as a first
wide range and usually local point of consultation for all patients within a health system, over
a secondary care subsystem that provides, e.g. specialist, acute and emergency care to a third
and fourth subsystem that provide advanced and specialized health services, such as severe
burn treatments and complex surgical intervention as neonatal surgery.
Health System Tiers
Some countries have a “tiered health system”, where a first health care system provides basic,
medical necessities while a secondary tier of care exists for people who can purchase
additional health care services or receive better quality and faster access.
3.1.4 Reference Health Systems
Historically, there are four basic reference (social security and) health system models. Some
countries have clear characteristics of one of these four models, while there is minority of
countries that maintain separate systems for separate classes of people, e.g. the United States.
The Bismarck model
This model is named after Otto von Bismarck, the inventor of the welfare state as part of the
unification of Germany in the 19th
century. It uses sickness funds, financed by general
taxation and individual premiums. These multiple payers offer universal coverage insurance
plans, and are not allowed making a profit. Providers usually operate in private organizations
using a fee-for-service payment model. Charging arrangements are negotiated between the
multiple payers and providers on regularly basis.
Countries applying this model include Germany, France, Belgium, The Netherlands & Japan.
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The Beveridge model
The model named after William Beveridge, the social reformer who designed Britain’s
National Health Service. Health care is universally provided and financed by the government
through tax payments. This single payer owns most, but not all, of the clinics and hospitals,
and employs some providers as government employees, alongside private providers who
collect their fees from the government. The government also controls what they can do and
what they can charge.
Legislations where the Beveridge model has been foundational are Great Britain, Spain,
Australia, New Zealand, Hong Kong, Cuba, Italy, Spain and most Scandinavian countries.
The National Health Insurance model
This model can be summarized as having properties of both the Bismarck and the Beveridge
model. It uses private-sector providers, but imbursement comes from a government-run
insurance program that every citizen pays into.
Key countries that are using this model are Canada, Taiwan and South Korea.
The Out-of-Pocket model
Only developed countries have established a national health system. Most other nations are
too poor or too disorganized to provide mass health services on a social-inclusive basis.
Hence, they operate a strictly market-driven health system where the rich have access to
health services, while the poor have not and stay stick or die.
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3.2 Public Services and Entities
3.2.1 Goods vs. Services
Goods and services are both outcomes of organizations to meet the physical and utility needs
of its consumers. Most economists distinguish between them using a Service-Goods
continuum, where both pure goods and pure services are extreme oversimplifications.
Services have different characteristics than pure physical goods, as summarized below in an
adaptation of “the Five I’s of Services”2.
Table 1 - Key characteristics of services
Characteristic Remarks and Implications
Perishability Most services aren’t physical and can’t be stored before or after delivery or
utilization; they are lost or do not exist.
Intangibility Services can’t be seen, heard, smelled, touched prior to purchase; assessment is
based on past experience, word-of-mouth, location/setting of service delivery, …
Variability Each time a service is performed, it will be performed in a (slightly) different
way; this is due to inherent (natural) and artificial (systemic) variation of both
consumer as provider.
Inseparability Provision and provider are inseparable from consumption and consumer; this
impacts scale of operations, the available distribution channels, …
As services are simultaneously delivered and consumed; they can’t be returned
(although they can be refunded).
Non-ownership Consumer of the service only pays to secure access/usage of the service; they
don’t obtain ownership over the service or provider.
Involvement Consumers usually participate in the service provision or delivery process.
2 Intangibility, Inventory, Inseparability, Inconsistency and Involvement
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3.2.2 Key Distinctions of Public Services
Following is a compiled list of key distinctive characteristics of public services and entities:
Governmental ownership and provisioning (or funding its provision) and regulatory
role (central, state, local governmental or sectorial);
Public accountability, due to funding through public money like taxation (which are
mostly involuntary transactions);
Purpose is to serve the common good, i.e. the public population as a whole;
Private organizations can choose their “customers”, public service organizations are
bound by social inclusivity; universal provision is guaranteed for moral reasons and
fundamental human rights (implying large projects & complex service portfolios);
Usually monopoly or strongly regulated market, hence not all open/free-market
conditions or properties apply, e.g. there are distorted risk/adjustments per social class;
single-payer leads to considerable market power to negotiate lower prices, etc…;
Longevity of entities and services – at sub-national level they can be merged, divided
or fragmented, but basic services will continue to be provided by successive entities;
State ownership of natural sources or intangible items – e.g. mineral reserves,
water, forests, electromagnetic spectrum, …;
However, most but not all public services:
are public sector, e.g. GP’s provide public service, but are self-employed contractors;
have public ownership, e.g. public owned telecom also provides private
goods/services;
are state funded, e.g. some public entities survive solely by donations or e.g. railway
are partly subsidized, services provided to and paid for by individuals;
universal accessible, e.g. public broadcasting; trade missions; national security council
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3.3 Change Paradigms and Approaches
Enterprise transformation concerns fundamental and routine change, which in turn changes an
organization’s relationship with one or more of its key stakeholders. Transformations involve
new value propositions in terms of products and services, how these offerings are to be
delivered, and how the organization must be structured to provide these offerings.
Decades of organizational changes yielded only a 10% success rate (Mintzberg, 1994),
between 70% and 90% of strategic initiatives result in failures (Kaplan & Norton, 2004) and
there is founded criticism to some techniques being used (Seddon & O' Donovan, 2009).
3.3.1 Reductionism vs. Holism
Up until the middle of the 20th
century, reductionism was the dominant method of scientific
inquiry into an organized system such as organizations.
“Reductionism breaks things into parts and attempts to deal with each part in isolation. It has
made and continues to make a significant contribution to traditional science and technology.
The experiment of reductionism in organizational and societal settings, however, has not been
plain sailing. It has struggled primarily because it misunderstands the nature of human beings
(yet it remains a dominant wisdom).” (Flood, 1999)
Contrasting this reductionism is the holism perspective. Holism maintains that the whole is
primary and greater than the sum of its parts. Holism also indicates emergence. An emergent
system property is a property that none of the system components has (as cause for result).
Systems with emergent properties or emergent structures may appear to defy entropic
principles and the second law of thermodynamics, because they form and increase order
despite the lack of command and central control. This has found to be possible because open
systems can extract information and order out of the environment (Kim, 1999).
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3.3.2 Dissolving the problem
There are four ways of treating a problem (Ackoff, et al., 2010) – absolution, resolution,
solution and dissolution – the greatest of these is dissolution.
- to absolve oneself of a problem is to ignore it and hope it will go away; this approach
comes naturally to command-and-control style managers;
- to resolve a problem is to do what was done last time a similar thing arose; it is an
experience-based and common-sense approach; problem resolution does not look for
the best way of treating a problem, only one that is good enough;
- to solve a problem involves a change in the behavior of the organization that has the
problem, but leaves the nature of the organization or its environment unchanged;
- to dissolve a problem is to redesign the organization that has the problem or its
environment so the problem is eliminated and cannot reappear;
By redesigning the system, one aims to dissolve a problem. They then need to explore the
whole, before changing any of its parts.
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3.3.3 Management vs. Governance
It is important to distinguish “management” from “governance”. The former term has its
origin in the Latin word manus (hand), whereas the latter stems from the Latin word
gubernáre (to control). Governance is about leadership, and steers an organization toward a
vision and ensures the day-to-day management is aligned with the organizations goals. It is
about setting the right policy and sequences to ensure becoming is done in an appropriate
way, whereas management is about being and doing things in a proper way.
Figure 4 - Management vs. Governance
Management deals with executing activities, whereas governance deals with guiding those
activities to safeguard their adequacy and correct execution. (Dalles & Bell, 2004).
Results and the capability to produce them are different aspects are two fundamentally
different aspects and should not be confused. That’s why Deming emphasizes “focus on
outcomes is not an effective way to improve a process or activity” (Deming, 1986).
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3.3.4 Mechanistic vs. Organismic Viewpoint
People have been managing work for hundreds of years, but the most significant attempts to
apply science to the engineering of processes and to management emerged in the 20th
century
by theorist Frederik Winslow Taylor in his publication “The Principles of Scientific
Management” in 1909.
This Taylorism, was a theory of management that analyzed and synthesized workflows. Its
main objective was improving economic efficiency, especially labor productivity. Typical
characteristics of these approaches are the minute division of work in simple, repetitive tasks,
and the clear separation of thinking and doing.
This “mechanistic” perspective has been heavily criticized for (1) unethical considerations
concerning the deployment of human capacities in enterprises; and (2) considerations
concerning the effectiveness and efficiency of enterprises.
Opposed is the “organismic” viewpoint, based on fundamentally different perspectives on
structures and control. This led to systems thinking and derivatives, as these systems are
function as a wholes and are frequently so complex that their behavior is, or appears,
emergent. These also include organizational artifacts and aspects that do not necessarily
exhibit structure (such as culture).
Over the years, various other approaches have been proposed as a replacement or an addition
to Taylor’s principles of scientific management from the industrial age in order to enhance
enterprise performance, or to manage change. This is also true in the health industry, al be it
with a delay on the other services sector industries.
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Table 2 summarizes some important differences between the mechanistic and holistic view,
adapted from distinctions presented by different authors such as (Dent, 1999) and (Seddon, et
al., 2011).
Table 2 - Key differences between mechanistic and organismic viewpoint
Characteristic Mechanistic viewpoint Organismic viewpoint
Philosophical position Reductionism Holism, Emergence
Perspective Top-down Outside-in
Design Functional specialization Demand, value, flow
Decision-making Separated from work Integrated with work
Measurement Budget, targets, standards,
activity, productivity
Design against demand and
purpose, demonstrate variation
Motivation Extrinsic Intrinsic
Management ethic Manage budgets, people and
resources Act on the system
Attitude to customers Contractual, contingent What matters, problem-solving
Attitude to suppliers Contractual Partnering and cooperation
Change approach Change by project/initiative Adaptive, integral
Emphasis Efficiency Effectiveness
Behavior Specified top-down Emerges bottom-up
Thinking Planning Learning
Focus Discrete entities Relationships
Organization form Bureaucracy Adhocracy
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3.3.5 Core reasons for failure
“All too often, failure is conveniently attributed to unforeseen or uncontrollable external
events. However, failure is seldom the result of external events that cannot be properly
addressed, nor the inevitable consequence of an inherently poor strategy, but first and
foremost the avoidable consequence of poor strategy operationalization. Since, as indicated,
failures are manifest pertinent to a large array of topics, fundamental underlying causes are
likely to play a role. In our view, these causes are: (1) lack of enterprise unity and integration,
and (2) inadequate and dysfunctional perspective on governance and subsequent arrangement.
The second cause significantly contributes to the first cause” (Hoogervorst, 2009).
3.4 Other Approaches
Methodologies, governance techniques, approaches and other “best practices” from a.o. the
manufacturing and generic services sector are being applied to health and health care services.
To name a few: Plan-Do-Study-Act (PDSA), lean methodology, Six Sigma, Theory of
Constraints (TOC), Total Quality Management (TQM) and more recent the Vanguard Method
(tVM), Service Blueprinting, Subject-oriented Business Process Management (S-BPM), etc…
As with every method, technique or tool, one should ask itself a series of questions, such as:
who invented this and in what timeframe?
what was their frame of reference and what were entailed convictions?
why was this invented, what problem did they (try) to solve?
did they succeed, and if yes - was it due to the application?
what type of statements and trade-offs are made, and are they (still) true?
do I have that same problem?
does it work and is it repeatable in my context?
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3.4.1 Plan-Do-Study-Act (PDSA)
The Plan-Do-Study-Act (PDSA) cycle or Deming cycle is an iterative four-step management
technique used for learning and continuous improvement of an artifact (e.g. a service/product,
a process or an organization).
Plan = design and plan a change or test, aimed at improvement;
Do = carry out the change or test, preferably on a small scale, collect data;
Study = of results: what did we learn, what went wrong, compare with predications;
Act = adopt or abandon the change, or run through the cycle again;
Although this technique is used intensively to guide many organizational change or
continuous improvement programs, there are a number of drawbacks. It does not reflect
governance and process establishment activities, suffers from acronym confusions, ignores
the people component of change (e.g. “change fatigue”3) and is mainly intended for small-
scale, incremental changes in a reactive nature.
Moreover, there exist a number of alternative implementation schemes, such as the one
depicted below (Hoogervorst, 2014).
Figure 5 - Alternative proposal for the Deming cycle (Hoogervorst, 2014)
3 Having people adjust to change on a continuous basis
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3.4.2 Lean Thinking
Lean production is a production practice and management philosophy, promoted by Toyota
trough the Toyota Production System (TPS) (Ohno, 1988) and (Womack, et al., 1991), which
focuses on improving the flow of work, thereby eliminating unevenness through the system
and not upon waste reduction per se.
At the core of the lean thinking strategy are the following five principles (Womack, 2003),
summarized and depicted below:
Identify value from the customer’s point of view;
Map the value stream and remove wasted steps;
Enable the customer demand to flow smoothly
and quickly through every step;
Match capacity with demand so work is done in
line with the pull of the customer;
Pursue perfection through continuous
improvement of the value stream;
Lean production in health care is mostly used as a process improvement approach and focuses
on three main areas: (1) defining value from the patient point of view, (2) mapping value
streams, and (3) eliminating waste in an attempt to create continuous flow. Value stream
mapping is a frequently applied Lean tool in health care. The usual implementation steps
include conducting Lean training, initiating pilot projects, and implementing improvements
using interdisciplinary teams.
One of the barriers is lack of educators and consultants who have their roots in the health care
sector and can provide support by sharing experience and giving examples from real-life
applications of Lean in health care (Poksinska, 2010).
Figure 6 - The Five Lean Principles
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The original waste types were defined by Ohno as Muda in the TPS. Table 3 shows examples
of a redefinition of some types of wastes for health service operations.
Table 3 - Examples of waste for health service operations
Waste Examples
Defects and rework incorrect charges and billing; medication administration errors
Delays and waiting waiting on surgical procedures; admission/discharge paperwork to
be completed; waiting on other teams or test results
Duplication duplication of expensive diagnostic tests within or across different
health facilities; multiple forms asking same information
Transportation or movement patients, visitors or staff walking miles around the hospital
Unclear communication unclear route or units for drug administration on dispensing notes;
clarifying orders; patients asking when they can go home
Incorrect inventory nurses keeping a private overstock of frequently out-of-stock
medications or supplies
Human potential
or unused talent
doctors renewing prescriptions, overtreatment due to coordination
issues, employees stop giving suggestions
Searching wrong or old versions of a form being used; looking for
information, materials or people; progress-chasing
Despite its popularity and the considerable development of the concept over time, there still is no
consistent definition of the approach. Some drawbacks that occur: (1) applicants usually seek
improvements within the framework of existing processes and structures; (2) lean in the
services sector has both potential and some important pitfalls (Spanyi, 2008) and (Seddon &
O' Donovan, 2009); (3) there is a tendency to follow a codification and plethora of tools and
techniques, which was never intended; and (4) lack of coping with variability, contingency,
human aspects and strategic perspective (Hines, et al., 2004).
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3.4.3 Six Sigma
Six Sigma (6σ) is a set of tools and techniques for process quality improvement, and is used
in many industrial sectors. It was developed by Motorola in 1986, and propagated by General
Electrics (GE). It refers to the statistical meaning of standard deviation (σ) as a measure of
variation. Reducing this variation as a means to increase quality is the essence of Six Sigma.
“At its foundation lies the paradigm shift from “fixing products” to “fixing process” so that
they produce nothing but perfection, or close to it.” – Jack Welch, CEO of General Electrics
There exist two different and iterative methodologies: one for improving an existing process
(DMAIC) and one when a process needs to be invented (DMADV).
Figure 7 - Six Sigma's DMAIC and DMADV cycles
They also separate responsibility of improvement proposal (green belt) from execution
(champion). When combined with Lean thinking, and therefore removing waste while
improving quality and performance, it is referred to as “Lean Six Sigma”.
However, some Six Sigma program executions tend to be very costly, and despite having a
stringent and codified method, achieve only limited or unsustainable gains. Some critics
claims this methodology is more suited for the industrial manufacturing industry with tangible
results, and should be included in a more holistic improvement strategy.
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3.4.4 The Vanguard Method (tVM)
Vanguard’s method combines aspects of systems thinking, lean methodology, learning theory
and intervention theory to deliver “a method for […] achieving the ideals many managers
aspire to: a learning, improving, innovative, adaptive and energized organization. It provides
the means to develop a customer-driven adaptive organization.” (Seddon, 2005).
Some fundamentals are listed below, as an adaptation and summary of (Seddon & O'
Donovan, 2009) and (Seddon, et al., 2011):
Demand Analysis: they make a clear distinction between value demand (the reason
why the company is in business) and failure demand (demands caused by a failure to
do something or do something right for the customer); not all demand equals activity,
as defined as “work-to-be-done”; one must design against customer demand, not
amplify it; understand purpose, value and waste;
Variation: primary cause of failure demand is the failure of a system to absorb the
variety of customer demands; the single greatest reason for this is standardization;
Toyota has the saying: “we make millions of cars, but the customer buys only one”;
Economies of Flow: industrialization of services based on economies of scales is
understandable, but wrong; manage value and flow, not costs and activity;
Values and Principles: individuals come first; waste (incl. failure demand) is first
understood and reduced; responsibility replaces blame; focus on purpose, not
outcomes; local-by-default; help people to help themselves;
Good measures: use capability measures; all arbitrary measures – targets, service
levels, activity, budget, etc… fail the test “does this help us understand and improve
performance from a customer’s perspective?”; good examples are end-to-end times,
percentage one-stop, on-date-as-required, percentage first-time-right, etc…;
- 26 -
tVM has three cyclic phases: (1) check – understanding the organization as a system,
understanding its purpose, capability and how it operates; (2) plan – to understand the levers
for change, to determine how the system can be improved so that it better meets its purpose;
and (3) do – to take action on the system, to trial proposed solutions, to monitor their effect on
capability, and to fully implement the effective solutions (Seddon, 2005).
Figure 8 - Check model of systems analysis in the Vanguard Method (tVM)
According to this method, determining predictable demand is key as 60-70% of demand is the
same thing. Understand and study demand, as it “opens the whole system up”.
Organizations should then train and design against this demand, with a reduction of the end-
to-end cost as a consequence.
Application of tVM yielded promising results and have achieved numerous and large-scale
success, in both private and public sector organizations (Seddon, et al., 2011), and appear to
be based on a combination of whole system theory, an organismic viewpoint and foundational
theories and good practices.
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3.5 Conclusions
Successfully implementing enterprise strategic initiatives appears a daunting task since the
majority of these initiatives fail. One might observe that most existing approaches are not, or
inadequately concerned with design and share the same underlying mechanistic
characteristics: strongly management and planning oriented, focus on internal control that
supposedly should secure success of future health system organizations.
In the next chapter, we describe the needed concepts and theoretical background underlying
our proposal.
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Chapter four
Theoretical Foundations
“A system’s failure requires a system’s solution – not a temporary remedy.”
– WHO World Health Report, 2008
his chapter summarizes the needed concepts and theoretical background, and focuses
on the Enterprise Engineering discipline, including Enterprise Ontology and the
DEMO methodology, Enterprise Governance and the Normalized Systems theory.
4.1 Enterprise Engineering
“Enterprise Engineering (EE) is the whole Body of Knowledge regarding development,
implementation and operational use of enterprises, as well as its practical application” (Dietz,
2006).
The three generic goals of Enterprise Engineering are (Dietz, et al., 2013):
Intellectual manageability: in order to bring about organizational changes, one must
keep insight & overview, implying a well devised systematic reduction of complexity.
Organizational concinnity: the skillful and harmonious arrangement of
organizational parts, so that it constitutes a coherent and consistent whole. This
implies a well devised design.
Social devotion: Enterprise Engineering takes a human centered view on
organizations. This implies a well devised distribution of authority and responsibility.
T
4
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In order to achieve these generic goals, there are seven fundamentals for dealing with
enterprise design, enterprise governance and enterprise management (Dietz, et al., 2013).
Table 4 - Seven Enterprise Engineering goals and fundamentals (Dietz, et al., 2013)
Number Generic goal Fundamental
F1 Intellectual manageability Strict distinction between function and construction
F2 Intellectual manageability Focus on essential transactions and actors
F3 Organizational concinnity Rigorous distinction between design and implementation
F4 Organizational concinnity Diligent application of design principles
F5 Social devotion Distributed operational responsibility
F6 Social devotion Distributed governance responsibility
F7 Social devotion Human-centered and knowledgeable management
4.2 Enterprise Architecture
Enterprise Architecture reduces the complexity of enterprises by addressing strategic
objectives and areas of concern, and converting them into a coherent and consistent set of
enterprise design principles and standards (Dietz, 2008), thereby ensuring a unified and
integrated design in which the strategic objectives and areas of concern are operationalized
(Hoogervorst, 2009).
Figure 9 shows the four main enterprise design domains, where each of them has an
associated architecture. Note that only the business architecture is concerned with the function
architecture (what does the system do), whereas the organization, information and technology
architectures are defined within the constructional architecture (how the system is
operationalized).
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Figure 9 - Main enterprise design domains (Hoogervorst, 2009)
For defining these architectures, the strategic context, areas of concern and design domains
serve as an interrelated reference context (Hoogervorst, 2009)
Figure 10 - Architecturing reference context (Hoogervorst, 2013) and (Hoogervorst, 2014)
- 31 -
The mentioned concepts can be formally defined as follows (Hoogervorst, 2009) and
(Hoogervorst, 2014):
System purpose: the primary and basic reason for system design, in view of the
relationship of the system with (certain elements of) its environment;
System behavior: the intended or unintended manifestation of the system over time.
Next to system behavior associated with the system function, disturbances and failure
patterns (or their avoidance) are also examples of system behavior;
System goal: an objective to be realized through system behavior. The primary system
goal is the realization of the system function (its purpose);
System function: a subset of intended system behavior, related to the system goal and
intended interaction of the system with (certain elements of) the system environment;
System requirement: the expression of a requisite or a necessity concerning system
behavior. A requirement can relate to the system function, but also to areas of concern;
Area of concern: an area of attention for system design in view of desired system
behavior. Examples are efficiency, culture, employee satisfaction, regulatory
compliance, customer centricity or patient safety;
Design aspect: an area of attention for defining functional and constructional
requirements and areas of concern, given the strategic goals, choices and basic
assumptions. Samples are listed in Appendix A – Generic Enterprise Design Aspects;
Design domain: a functional or constructional system facet for which explicit design
activities are required. The main design domains are visualized in Figure 9;
Architecture: set of coherent and consistent set of enterprise design principles and
standards, pertaining to multiple design domains and addressing multiple areas of
concern;
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4.3 Enterprise Governance
Enterprise Governance is defined as “the organizational capacity for devising and steering
change” (Hoogervorst, 2009). It is therefore an organizational competence for exercising
continuous guiding authority over enterprise strategy and architecture development, and the
subsequent design, implementation and operation of the enterprise.
Figure 11 - Enterprise Governance core competences (Hoogervorst, 2009)
Figure 12 - The central role of Enterprise Governance competences (Hoogervorst, 2009)
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4.4 Enterprise Ontology
Enterprise Ontology (Dietz, 2006) captures the complexity of an enterprise and focuses on the
implementation-independent essence of an enterprise. In doing so, the difficulty of
comprehending the structural-functionalistic aspects of an enterprise is greatly reduced.
The PSI-theory (Performance in Social Interaction) underlying the Enterprise Ontology is
based on four axioms – operation, transaction, composition and distinction – and the
organization theorem. We briefly summarize the four axioms, theorem and the methodology.
The Operation Axiom states that the operation of an enterprise is constituted by the activities
of actor roles that are elementary chunks of authority and responsibility, fulfilled by subjects.
In doing so, these subjects perform two kinds of acts: production acts (P-acts) and
coordination acts (C-acts). These acts have definite results: production facts and coordination
facts, respectively.
Figure 13 - Graphical representation of the Operation Axiom (Dietz, 2006)
The Transaction Axiom states that coordination acts are performed as steps in universal
patterns. These patterns, also called transactions, always involve two actor roles (initiator and
executer), are aimed at achieving a particular result and develop in three phases: the order
phase (O-phase), the execution phase (E-phase), and the result phase (R-phase).
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Figure 14 - Basic pattern (left) and standard pattern (right) of a transaction (Dietz, 2006)
The Composition Axiom establishes the relationships between transactions. This axiom
states that every transaction is either a) enclosed in another transaction, b) is a customer
transaction of another transaction, or c) is a self-activation transaction. The latter case refers
to transactions that give rise to further transactions of the same type.
The Distinction Axiom states there are three distinct human abilities playing a role in the
operation of actors, called performa (new original things), informa (information content), and
forma (information form).
Figure 15 - Summary of the Distinction Axiom (Dietz, 2006)
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The Organization Theorem combines these four axioms, obtaining a notion of enterprise
concise, comprehensive, coherent and consistent. This notion states that the organization of an
enterprise is a heterogeneous system that consists of a layered integration of three different
systems: the B-organization (Business), the I-organization (Information) and the D-
organization (Data).
Figure 16 - Representation of the Organization Theorem (Dietz, 2006)
As mentioned before, the B-organization represents the essence of the organization, since it is
completely independent from the way in which this essence is realized and implemented. The
distinction of the function perspective (F) and the construction perspective (C) serves to
exhibit their layered nesting in a more precise way.
Figure 17 - The layered integration of an organization (Dietz, 2006)
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The DEMO Methodology is a methodology for modeling, (re)designing, (re)engineering
organizations and networks of organizations, which consists of four aspect models
represented by particular diagrams, lists and tables.
Figure 18 - Ontological triangle, with aspect models and diagrams of DEMO (Dietz, 2006)
The Construction Model (CM) specifies the identified transaction types and associated actor
roles, as well as the information links between the actor roles and the information banks.
The Process Model (PM) of an organization is the specification of the state space and the
transition space of the C-world, i.e. the set of lawful or possible or allowed sequences of states
in the C-world. The Process Model contains, for every transaction type in the Construction
Model, the specific transaction pattern of the transaction type and the causal and conditional
relationships between transactions.
The State Model (SM) specifies the state space of the Production World (P-world): the
object classes, the fact types, and the result types, as well as the existential laws that hold
(ontological coexistence rules).
The Action Model (AM) states the action rules that serve as guidelines for the actors in
dealing with every coordination step, which are grouped according to the distinguished actor
roles. It is the most detailed and comprehensive aspect model, and is also atomic on the
ontological level.
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4.5 Generic System Development Process
The Generic System Development Process (GSDP) was introduced as a framework for
Enterprise Engineering. In this GSDP framework, Enterprise Architecture and Enterprise
Ontology are two complementary notions, which ensure that the engineering of the enterprise
as a system is performed coherently and consistently and that the resulting system is a truly
integrated whole.
The GSDP distinguishes two processes: (1) a design process which describes an enterprise
and has functional and constructional models on the enterprise as a result (horizontal). In this
process, Enterprise Architecture as a normative restriction of design freedom guides how the
design must be performed; and (2) an engineering process for creating the enterprise by
constructing the implementation model of enterprise from its ontological models (vertical).
Figure 19 - GSDP: design concepts and process (Dietz, 2006)
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4.6 Normalized Systems
Normalized Systems (NS) is a theory established at the University of Antwerp that aims to
design and engineer systems exhibiting proven evolvability, as they should exhibit stability
towards a set of anticipated changes (Mannaert & Verelst, 2009).
The Normalized Systems approach deduces a set of four principles, or design guidelines, to
identify and circumvent combinatorial effects (i.e. a change requiring more effort as the size
of the system changes), and to accommodate evolvable modularity by using fine-grained
structures.
Table 5 - Principles for Normalized Systems
Principle Description
Separation of Concerns (SoC) implies that every change driver or concern should be separated
from other concerns
Data Version Transparency (DVT) implies that data should be communicated in version transparent
ways between components
Action Version Transparency (AVT) implies that a component can be upgraded without impacting the
calling components
Separation of States (SoS) implies that actions or steps in a workflow should be separated
from each other in time by keeping state after every action or step
One can argue that organizational artifacts such as products, production systems, and
organizational structures can be regarded as modular structures. Agility (and thus
evolvability) at organization level then needs to be designed as well.
Ongoing research deals with extending the Normalized Systems approach to related fields of
Enterprise Architecture (EA), Enterprise Ontology (EO) and Business Process Management
(BPM) and what Normalized Systems means in terms of enterprise and management, and its
implications with respect to competences and organizational modularity.
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Chapter five
Proposed Solution
“Complexity is your enemy. Any fool can make something complicated.
It is hard to make something simple.” – Sir Richard Branson
his chapter belongs to the “Design and development” phase of the DSRM. In order to
tackle the problems that are mentioned in previous chapters, we intend to combine the
Enterprise Engineering discipline, the Enterprise Governance competences and processes,
together with compatible analysis techniques and improvement/quantification methods.
5.1 Objectives of the Solution
A health system is a complex and deliberately crafted socio-technical organization.
The fundamental problem with organized complexity is the necessity of taking into account
numerous aspects and interdependencies that jointly form an organic whole.
In this study, we aim to design and develop a more prescriptive, holistic and integrated
approach. Note that we do not intend to fully codify or formalize a method, as this contradicts
the emerging property and creative characteristic of design.
5.2 Proposed Solution
Many authors argue that the (whole) system approach is the only meaningful way to address
the core problem of organized complexity, hence the only meaningful way to study and
develop health systems, including health organizations, its dynamics, and innovation
challenges.
T
5
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In the previous chapters, we have outlined the Enterprise Engineering theory and
methodology. This enterprise-engineering process is conducted by an enterprise competence,
as outlined in the book (Hoogervorst, 2009) and paper (Hoogervorst, 2011).
We therefore propose a shift towards the Enterprise Engineering Paradigm (see Appendix C –
Summary of Enterprise Engineering Manifesto), using the Enterprise Engineering Framework
(Hoogervorst, 2013) and integrating compatible analysis techniques and improvement or
innovation methods.
We define innovation as “the successful exploitation of ideas and inventions”, which relates to
sustainability when applied at the system level (Brezet, 1997) and (Gaziulusoy, 2010).
Figure 20 - Levels of innovation for sustainability (Brezet, 1997) and (Gaziulusoy, 2010)
In view of the several enterprise aspects, a design approach must be able to address all
aspects. Realization must be intentionally designed, as virtually all causes for poor enterprise
performance are systemic.
Also, a fundamentally different perspective on governance is essential for: (1) addressing
enterprise dynamics, complexity and associated uncertainty; (2) iteratively, evolutionary, and
emergent development of strategic initiatives and their operationalization; and (3) realizing
unified and integrated enterprise organization and operation.
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5.3 Compatible Techniques and Methods
We provide a sample (and non-exhaustive) list of possible analysis techniques and
improvement/quantification methods, in no particular order. They need to be integrated
without compromising the unified and integrated design, which means they do not contradict
the fundamentals underlying the Enterprise Engineering Paradigm and foundational theories.
It is outside of the scope of this thesis to elaborate on each technique or method, as they are
well described in either academic journals, publicly available books or other publication
channels. One can choose the most suitable and appropriate for the concrete context.
Analysis Techniques
- Ask Why Five Times: an iterative question asking technique to explore cause-and-
effect relationships under a particular problem (people do not fail, processes do);
- Demand, Supply & Variation Analysis: analysis of demand type, variance,
frequency, peak times, throughput, volume, utilization, capacity, cost rate, cycle and
lead times, gained and perceived value, etc…;
- Patient Journey Mapping: a time-based diagram of patient’s service experiences and
motivations behind each point of interaction;
- Clinical Pathway Analysis: a joint model between patients and health professionals;
- Process Mining4: an analysis technique to obtain business processes insights through
capturing and inspection of (mainly information systems) event logs;
- Patient Stories & Patient Profiles: or substituted by patient scenarios and patient
personas (i.e. play-acted fictitious characters in order to help solve design questions);
- Service-Oriented Analysis: where the difficult task of defining type and granularity
of services, can e.g. combined with DEMO Process Models (Hoogervorst, 2009);
4 Be aware to not analyze a patient experience trough generalized information footprints alone, “The important
distinction between original (performa) and informational (informa) production is that original production really
creates new products, which didn’t exist before. … [The latter] never creates new facts.” – (Dietz, 2013)
- 42 -
Improvement Methods
- Inter-transactional redesign principles: as described in (Reijswoud, et al., 1999):
o Deletion and replacement: removal or replacement of transaction types, as they
are unnecessary or imply a change to the preposition of the transaction type;
o Change of optimal relationships: finding optimal structure of transaction types
by changing optional and causual relations, e.g. to shorten cycle times;
o Advancing initiating points: changing the structure of transaction types to
reduce the total lead-time;
o Parallelization of transaction types: changing the structure of transaction types
by removing conditional restrictions, so other transactions can start in parallel;
- Normalized Systems theory: applied at business process or organizational level;
aiming at maximal cohesion and minimal coupling between system elements; using a
set of four principles, or design guidelines, to identify and circumvent combinatorial
effects (i.e. a change requiring more effort as the size of the system changes), and to
accommodate evolvable modularity by using fine-grained structures;
- Lean thinking: correct application of lean thinking for (public) services, e.g. tVM
applied to (public) services produces promising and sustainable results, in combining
aspects of systems thinking, lean methodology, learning and intervention theory;
Quantification Methods
- Demand, Experience and Costing models: based on real end-to-end measures;
- Health Cost-Benefit Analysis: using QALY as a measurement for health gains;
- tVM’s “Purpose, Measures, Method”: as a response to e.g. command-and-control
style Activity Based Costing (ABC) where not all activity is considered to be valuable
and productive;
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Chapter six
Demonstration
“It’s not the strongest of species that survives, nor the most intelligent.
It is the one most adaptable to change.” – Charles Darwin
ithin this chapter, our proposal from the previous chapter is applied to a number of
different reform proposals related to the Belgian Health System and fictitious
anecdotal scenarios, and this in order to demonstrate its feasibility and utility. We conclude
this chapter with a discussion.
6.1 Introduction
We first provide a brief overview of the current Belgian Health System, as this is the work
area for each of the mentioned scenario.
6.1.1 Belgian Health System
Belgium has tree government levels – federal government, the federated entities (three regions
and three communities) and the local governments (provinces and municipalities).
Health policy is both a responsible5 of the federal authorities and federated entities.
The Belgian population reached 11.2 million in 2013. Almost the whole population (> 99%)
is covered for a very broad benefits package. The organization of health services is
characterized by the principles of therapeutic freedom for physicians, freedom of choice for
patients, and remuneration based on (mainly) fee-for-service payments.
5 Implementation of the sixth state reform will bring changes to this balance.
W
6
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Figure 21 - Health System in Belgium (Gerkens & Merkur, 2010)
The compulsory health insurance is managed by the National Institute for Health and
Disability Insurance (NIHDI6). All individuals entitled to health insurance must join or
register with a sickness fund. Private profit-making health insurance companies account for
only a small part of the non-compulsory health insurance market. The health insurance system
is regulated by national conventions and agreements between representatives of health care
providers and sickness funds (e.g. determination of fees).
6 English: NIHDI; Dutch: RIZIV; French: INAMI
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In 2011, Belgium’s total health expenditure was approx. € 38.8 billion, which accounts for
10.5% of its gross domestic product (GDP) and considerably higher than the OECD average
of 9.3%. Health expenditure expressed in US$ PPP per capita was 4061 in 2011, again above
the OECD health expenditure average.
Figure 22 - Belgian health expenditure trend as a share of GDP (OECD Health Data 2013)
We refer further to ”Appendix B – Health System in Belgium” for an elaborated observational
description of the Belgian Health System as described in the “Health Systems in Transition –
Belgium: Health system review” profile (Gerkens & Merkur, 2010).
6.1.2 Problem Statement
Many Belgian citizens perceive their health system as one of the best in the world. However,
besides the global trends and challenges, there are other concrete issues a.o. (1) expected
shortage of qualified staff in the future; (2) shift in power balance between government,
sickness funds and professionals; (3) lack of adequacy of e.g. screening and prevention, health
promotion, detection and treatment of certain pathologies (breast cancer, myocardial infarct
and ischemic/hemorrhagic CVA); (4) low penetration of flu vaccination elderly; (5) safety in
surgery, e.g. foreign objects; and (6) imaging overconsumption, e.g. CT;
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Numerous reforms regarding health system are already proposed, to mention only a few:
In his recent book “The Price of Your Health. Is Our Health Care in Danger?” (Annemans,
2014), professor and health economist Lieven Annemans provides an overview of what goes
wrong in Belgian health system, including the insurance and financing system, and includes
ten pillars as an attainable starting point and catalyst to improve the health system;
The Belgian think-tank Itinera Institute proposed “You get what you pay for. Toward a new
business model for healthcare.” (Van Herck, et al., 2013). It presents a middle ground
solution: a combination of fixed and variable payment, independent yet aligned between
physicians and hospitals, based on justifiable costs. Unintended consequences should be
countered by a true performance based payment share based on quality of care as measured;
In “How To Solve The Cost Crisis in Health Care?” (Kaplan & Porter, 2011), Kaplan &
Porter describe a time-driven activity-cased costing to analyze costs that uses patients and
their conditions – not organizational units or narrow diagnostic treatment groups – as the
fundamental unit of analysis for measuring costs and outcomes; in “The Strategy That Will
Fix Health Care” (Porter & Lee, 2013), they urge health professionals to lead the way in
making value the overarching goal;
The Re-Bel7 e-book “Belgium’s health care system: Should the communities/regions take it
over? Or the sickness funds?” (Schokkaert & Van de Voorde, 2011) argues that the issue of
decentralization should be integrated in a broader perspective on the future health system
organization. Regional decentralization is only one option, an alternative is to give more
responsibility to the sickness funds and cautiously move towards regulated competition;
The book “Implementing Health Financing Reform“ (European Observatory on Health
Systems and Policies, 2010) analyses and shares experiences with the financing reforms
implemented by countries of central Europe, eastern Europe, the Caucasus and central Asia;
7 “Rethinking Belgium's institutions in the European context”, online at http://www.rethinkingbelgium.eu
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6.1.3 Reform Proposals
Lots of books and studies are written specifically for the Belgian health system, which at least
indicates the attention to innovation and improvements from, a.o. a performance, innovation
and sustainability perspective.
We list a few recent works in Table 6 (some listed with original Dutch title).
Table 6 - Some recent books and reports about the Belgian health system
Year Book/Report title
2014 “De prijs van uw gezondheid. Is onze gezondheidszorg in gevaar?” – L. Annemans
2013 “Zorgvernieuwers: betere zorg door anders organiseren” – J. Benders & C. Missiaen
2013 “Dokter, ik heb ook iets te zeggen: een volledige stand van zaken van onze
gezondheidszorg” – Y. Nuyens & H. De Ridder
2013 “Slimmer zorgen voor morgen: het organiseren in theorie en praktijk”
– B. Corvers & G. Van Hootegem
2013 “You get what you pay for. Toward a new business model of health care”
– P. Van Herck, W. Sermeus & L. Annemans
2011 Re-Bel e-book “Belgium’s health care system: Should the communities/regions take it over?
Or the sickness funds?” – E. Schokkaert & C. Van de Voorde
2010 “Health Systems in Transition – Belgium: Health system review” – S. Gerkens & S. Merkur
2010 “A first step towards measuring the Belgian health system performance”
– J. Vlayen, K. Vanthomme, C. Camberlin, J. Piérart, D. Walckiers, L. Kohn, I. Vinck, A.
Denis & P. Meeus P
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We assess some of the reform proposals outlined in (Annemans, 2014), not only from an
economical point of view, but also more from a holistic functional and organizational
perspective. It comprises the strategic changes that are proposed, its impact on the system as a
whole and how they can be operationalized.
The author provides an overview of what goes wrong in the Belgian health system and
includes his “Ten Pillars of Change” as an attainable starting point and discussion catalyst.
Table 7 - Ten Pillars of Change (Annemans, 2014)
Pillar Short Title/Description8
Pillar 1 Formulate goals, one cannot have good policies without unambiguous & SMART goals,
and the timely refining of them
Pillar 2 Define a health sector growth path for the decades to come
Pillar 3 General application of cost-efficiency principles (health cost-benefit analysis)
Pillar 4 Free up and allocate budget for (cost-efficient) prevention
Pillar 5 More prominent role of the general practitioner and other primary care health
professionals
Pillar 6 Full informatization of the system aids communication between all actors and enables
policymakers to observe/follow to gain insights
Pillar 7 Increased patient authority and participation, but with great(er) power comes great(er)
responsibility
Pillar 8 Create new professions, to support physicians and health professionals and to allow
everyone to act according to its education
Pillar 9 Change payment systems to enable rewarding quality
Pillar 10 Towards a new and better structure, adapted to the types of care on each level
8 Translated and adapted from (Annemans, 2014)
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Pillar 1 – SMART goals
Policy makers, both on governmental as organizational level, need to introduce SMART9
goals. As of today, only the regional have for the health subdomain “Prevention”, which they
have established in consensus with the relevant stakeholders such as physicians, community
workers and sickness funds. By formulating concrete goals, one can make a concrete action
plan and have everyone involved working in the same direction.
The author proposes a sample set of goals for other health subdomains, e.g. reduce the
number of unnecessary hospital admission with 25% by 2020; reduce the number of hospitals
where operation on certain cancer types can be performed by 2016; reduce the number of
unnecessary emergency visits by with 50% by 2020; reduce the number of CT-scans with
30% by 2016; narrow the gap between life expectancy of poor and rich with 50% by 2020.
Pillar 2 – Growth path: where will we be in 2050?
This pillar has mainly to do with the unsustainable growth in expenditure Belgium
experiences now. Several projections have been made, and the worst case scenarios yield an
expenditure of 30% of the GDP by 2050, mainly due to aging and technological advances.
One proposal is additional financing by means of an additional insurance premium (like is the
case in The Netherlands), but collected by the sickness funds. A concrete simulation of the
Christian Mutuality (CM), one of the largest sickness funds in Flanders yields a monthly
premium of € 20 (or a function of individual income or wealth. Though, one has to make sure
that there won’t be a competition urge that results in e.g. lower accessibility and coverage
(like is the case in The Netherlands). Flanders already has this type of additional and
mandatory insurance premium of €25 per year, which reimburses non-medical expenses for
people who can no longer take care of themselves.
9 Specific, Measurable, Achievable, Realistic/Relevant, Time-bound
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Another proposal is the cancellation of (some of the) additional services provided by the
sickness funds, like organizing group holidays, reimbursement of sauna visits, etc…
However, we tend to forget that health investments also yield (long term) profits: good health
leads to higher employment, an increased life expectancy, which increases consumption and
economic output. Studies have indicated that an increase of life expectancy 1% results in an
increase of 6% of the gross domestic product (GDP).
Pillar 3 – General application of cost-efficiency principles
Health economist tend to express health “gains” as quality-adjusted life year (QALY), which
is a measure of disease or condition burden, including both quality and quantity of live life.
It has the important characteristic of continuous gain satisfaction (as opposed to the
satisfaction we receive, e.g. if we buy a second house).
This measure does not differentiate with respect to the age of the individual (e.g. one aged 3
vs. another aged 90), or the nature of disease (e.g. treatment of cancer vs. depression).
Each society is willing to pay a certain amount per QALY gained, for Belgium this comes
down to roughly €35.000.
Belgium uses this principle only for analyzing the cost-efficiency for reimbursement of
medications and policies for prevention, e.g. community pharmacies receive a fixed fee for a
guidance talk with asthma patients. One can easily extend this policy to other health
professionals.
Another aspect is the increase in consumption and economic output as a result of a re-
activation policy, even if it is part time – e.g. start working part time as treatment or
rehabilitation of depression is still ongoing.
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Pillar 4 – Focus on cost-efficient prevention
The Belgian health system only allocates 2% of their budget to prevention, e.g. general
practitioners are paid an additional fee of more than €10 per patient per year to maintain a
prevention checklist in the general medical record of his patient, the so-called “GMD+”.
The author proposes an increase of this budget by reinvesting the savings that reducing
overconsumption yield. As not all prevention is profitable, they need to adhere to the cost-
efficiency principle.
Known difficulties with health prevention are: (1) cost-benefit distortions and -transfers, as
the compulsory health insurance is a responsibility of the federal government and, e.g. the fall
prevention policy is the responsibility of the Flemish government; and (2) impact of other
sectors on health budget, e.g. smoking yields a federal income of € 2.6 billion per year (taxes
and duties, an increase of € 0.5 billion compared with the former year) – increasing the price
of tobacco products slightly each year, will not result in behavioral changes and a healthier
life style, which in turn leads to health expenditure savings10
.
Pillar 5 – Focus on primary care professionals
Primary care professionals need to be able to take a more prominent and central role as care
coordinator and long term health coach. The author refers to studies that indicate that a strong
focus on primary care leads to a reduction of overconsumption, hospital admission and visits
to emergency services.
Accident and emergency (A&E) departments and general practitioner (GP) posts are often
used inappropriately, leading to overcrowding. Other studies have shown that financial
penalties will not lead to a reduction of emergency service visits, whereas maintaining a strict
policy and formation of integrated emergency posts are effective.
10
The author estimates that Belgium’s overall cost of smoking is € 3.3 billion per year (across all sectors)
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In the Netherlands, increasingly more integrated emergency posts (IEPs) are being created,
integrating the care provided by GP posts and A&E departments, in order to improve the
provision of the emergency care (Mes & Bruens, 2012). Strongly related to this case are
recent issues with Belgian GP extended work and night shifts in GP posts. (Dutch:
“huisartsenwachtdienst”).
To reduce the overconsumption, different remuneration systems need to be introduced.
Already in place, the community health services (Dutch: “wijkgezondheidscentra” or WGC)
have a different payment system, as they are paid an all-in fixed amount per patient per year,
depending on the socio-economic background of the patient. Also in place, are annual fees for
the maintenance of a general medical file (GMD) with one GP. This still allows the patient to
choose (or transfer to) the GP of his choice, but reduces shopping around for health services.
Pillar 6 – Full informatization of the system
Full informatization of compulsory health record and prescribed medications, available on a
single and nation-wide accessible platform. This aids communication between all actors and
enables policymakers to observe and gain insights in the health service consumption.
Maintaining a health record per patient on national level (e.g. the eHealth platform) will also
help to break down the current information silo’s, and can provide single access point for
patients and health professionals.
Recently, government and citizens already gained access to health service “quality indicators”
(although some of them are misleading or poorly defined), the reimbursement agreement of
his/her health professional (i.e. convention status), the patient’s vaccination status, a database
of medications that are still considered to be useful anno 2014 etc…
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Pillar 7 – Increased patient authority and participation
Health professionals need to cooperate in coordination and care with the patient and need to
maintain a strong consumer-partner relationship. Safe and electronic communication channels
can enable and facilitate this cooperation. Increased information and awareness of costs, e.g.
reimbursement conditions for care, upfront cost estimation of surgical procedures and after
care, etc… will result in reduced consumption and behavior changes.
Health guardians (Dutch: “mantelzorgers”) need to be supported to decrease the burden of
taking over some care aspects for his/her patient(s), e.g. benefits and right to be replaced
during vacation as is the case in Finland.
Pillar 8 – New professions
To support physicians and health professionals in their daily working and ever increasing
administrative duties and to allow everyone to act according to its education, we need to
transfer certain work types to, e.g. registered nurses (RN), the patient itself, “case manager” or
safeguard who guards the quality of services, etc… The GP/physician can then act as coach.
Research will lead to new (or adjusted) function profiles and professions, without diminishing
quality of work performed. Notice that this does not simply implies introducing an additional
“flexible employee” who fills in the gaps in inflexible operations and departments of health
practice/facility, as this only temporarily solves the organizational problems at hand.
Pillar 9 – Payment system changes
Most health professionals are compensated using a fee-per-service payment model, which has
strong negative consequences: achieving quality is not rewarded (contrary, overconsumption
and hospital readmissions will lead to higher financial gain). There is also a strong variation
in gross wages of different specialisms and regions, ranging from € 195.000 up to € 636.000
per year (Swartenbroekx, et al., 2012).
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Despite this overconsumption, and the deductions specialists have to pay to be allowed to
work in the hospital, there is still a financial deficit in 30% of our hospitals.
Other proposals are a mix of payment arrangements and compensations, e.g. fee-per-service,
bundled payment (a.k.a. episode-payment), payment per person (capitation), bonuses, shared
savings, pay-for-quality (P4Q)… – all with its own properties, advantages and drawbacks.
Without going into too much detail, the author proposes a carefully selected mixture of
remuneration for each type (or cluster) of integrated care, in combination with the intrinsic
motivation of health professionals to “do good”. This also affects the provisioning model of
health services, e.g. certain procedure types can no longer be performed in certain hospitals
due to lower incidence rates or an anticipated lower quality (centralization of specialist care).
Pillar 10 – New and better structure
In his final pillar, the author proposes a new and better structure, mainly to reduce wastes due
to complexity and confusion around activities and responsibilities, or the current state of
distorted financial incentives.
Three service packages are introduced, adapted to the types of care on each level, as pictured
below - translated from (Annemans, 2014).
Figure 23 - Three packages in a future health system (Annemans, 2014)
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6.2 Case A – Medication Reconciliation
6.2.1 Introduction
Annie has become addictive to codeine, a sedative substance used in a number of pain
medications. Her uncle is a physician and prescribes her regular doses of codeine. To stay
under the radar, Annie visits different pharmacists in rotation.
Suddenly, Annie gets a bad cold. As she is unable to see here uncle, she sees another GP.
He prescribes her coughing syrup. The same evening, Annie and her husband head to the
A&E department of a hospital nearby with symptoms of nausea, heavy sweating, and
shortness of breath, dizziness and episodes of unconsciousness. When asked what medication
she takes, her husband only mentions the prescribed cough syrup. She gets pre-diagnosed as
having a heart condition and gets submitted for additional testing. However, her real
diagnosis is a codeine overdose, as the coughing syrup contained codeine as well.
6.2.2 Problem Analysis
Different interrelated problems have led to a wrong diagnosis, an avoidable hospital
submission and unnecessary tests: (1) Annie’s husband, the hospital’s A&E service and the
pharmacist were unaware of the medication Annie was taking; (2) the pharmacist did not
warn for interactions, again as he was probably unaware of what medication was already
prescribed to her; (3) Annie’s shopping around to feed her seemingly harmless addiction; (4)
unethical behavior of Annie’s family member; (5) insufficient health insurance fraud
protection, as they keep reimbursing the consults and prescribed medication; and (7)
medication adherence, as Annie should read the documentation of the medication she takes.
6.2.3 Proposed Solution
The author’s proposed solution is a “clever and compulsory electronic health record that aids
in fraud detection” (based on pillars 6, 7 and 9).
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6.2.4 Application & Results
Enterprise Reference Context
Enterprise Outlook - Mission and Vision
In the proposals, we did not find concrete expressions of a mission or vision statement for the
reformed health systems and organizations.
However, in real life, most of the organizations have defined some form of a mission
statement, e.g. FPS Health, Food Chain Safety and Environment, most of the hospitals and
clinics, sickness funds, NIDHI, etc…
Enterprise Maxims - Fundamental Convictions, Norms, Core Values
In the proposals, we did not find concrete articulations of convictions, norms or values.
However, there is the Hippocratic Oath, historically taken by physicians and other healthcare
professionals swearing to practice medicine honestly and according to rules of ethic, e.g.
“with utmost respect for human life from its beginning” or “will do no harm deliberately”,
and the intrinsic motivation amongst health professionals to prevent, heal and care.
Secondly, most of the hospitals have mandatory advisory boards, such as medical and ethical
boards and hygiene safety committee, and most of the hospitals have some form of strategy,
norms and core values defined, e.g. Respect, Kindness, Empathy, Compassion …
Nevertheless, they need to be updated, more clearly formulated and differentiated.
Finally, there exist professional and legal policies, as well as good-clinical practices (GCP).
Regarding the hospitals, we can already conclude the following: approximately half of the
hospitals have some kind of mission statement, vision or strategy, but they are either
disconnected, not up-to-date, too generic or not integrated in the daily operations.
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Design context: strategy, areas of concern and requirements
With respect to the proposals and anecdote, we can formulate strategic choices.
Strategic choices
We support active involvement of patients and their family (or guardian) in the health
care delivery or decision-making processes (i.e. patient-centricity);
We focus on maintaining a good relationship with co-creative patients;
We conduct business in a health, environmental and societal conscience manner;
We expand across channels to improve accessibility of our services;
We guide the customer by providing a wide spectrum of pharmaceutical services,
ranging from dispensing, consulting to information providing (related to pharmacy);
Areas of concern
We then identified the following areas of concern:
1. Patient Involvement & Satisfaction (quality focus & service orientation);
2. Health Professional Satisfaction (involvement, motivation, life-work balance);
3. Reliability & Accessibility (universal, timely, according to norms and values);
4. Cost-efficiency (cost containment, avoid waste, overconsumption);
5. Safety, Compliance (no adverse events, compulsory insurance, legislation);
6. Business Intelligence (patients, insurers, policy makers);
7. Accountability (everyone involved in the healthcare process be responsible for their
role in care, whether it’s a patient, a physician or nurse, or an administrator);
8. Quality improvement (reduced LOS, avoidable readmissions, cost containment);
9. Process Excellence and Reduction of Complexity;
10. Privacy (given the sensitive information);
11. Business and Medical Ethics (moral principles that apply values and judgments);
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Functional and constructional requirements
With respect to the proposals and anecdote, and guided by the EE competence, the functional
and constructional requirements have been established, e.g.:
Table 8 - Sample Functional and Constructional Requirements
Functional requirements (Business) Constructional Requirements (Org. & Info)
Patients must be able to access their own health
and medication records
End-to-end process management (O)
Self-service capabilities for patients, health
professionals and insurers (e.g. medication
compliance/adherence and information)
Computer-supported means and methods for
collaboration, decision support, data analysis and
process management (O)
Secure and user-friendly communication
capabilities for health professionals (incl.
pharmacists), insurers, policy makers and
patients
Quality-, service- and patient-centric behavior of
employees (O)
Policymakers and health insurers need to observe
and gain insights in the health service
consumption
Culture directed towards innovation and
improvement (O)
Easy consent management to allow patients to be
informed or treated by health professionals
Internet- and mobile-based communication
technology (I)
Patients are advised about behavior changes,
based on the analysis of patient’s health record
Collection of data during all interactions, for
service and process improvements, and for
devising new services (I)
All registered citizens are covered by compulsory
health, sickness and invalidity insurance
Extended enterprise integration and transparency,
such that patient and operational data is collected
by, and shared with other stakeholders (I)
Emergency services must be able to know what
medication a patient has been taking and when
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A sample requirement publication follows:
Requirement Statement #1 : Status: Proposed
Emergency services must be able to know what medication a patient has been taking and when
Rationale:
Whether a patient should be referred for further medical assessment, observation and treatment cannot be
assessed without knowing medical history, incl. what medication a patient has been taking (if known) and when.
Implications:
Availability of comprehensive and accurate medication history needs to be improved.
Key Actions:
Establish medication history information sharing contracts between health professionals.
Research personal medication adherence monitoring arrangements.
Requirement Statement #2: Status: Approved
Policymakers and health insurers need to observe and gain insights in the health service consumption
Rationale:
In order to effectively reimburse health services, assess impact or draft policies, policymakers and health insurers
need to observe and gain insights in the service consumption. This includes volume, lead times, cycle times,
variances, and aggregates of this anonymous information etc…
Implications:
From a privacy, solidarity and confidentiality perspective, health service consumption needs to be anonymized,
as patients need to be protected from risk selection practices (i.e. likelihood that a citizen will incur costs due to
increased risk obtaining a particular condition).
Key Actions:
Establish information sharing contracts with policymakers and insurers.
Create overall privacy policies and awareness.
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Architecture Principles
With respect to the proposals and anecdote, and guided by the EE competence, the
architecture principles were drafted. In the table below, we list a few.
Good architectural principles must be (Hoogervorst, 2009):
Understandable for the designers who must apply the principles;
Unambiguous, excluding multiple, or even erroneous interpretations;
Mutually coherent and consistent;
Applicable to one or more system design domain;
Traceable to areas of concern deemed relevant for the system;
Table 9 - Sample Architecture Principles of Case A
Design Domain Architecture principle Area of Concern
Business All patient interaction channels must be fully integrated 1, 7, 8, 9
Health professionals maintain a good and long-term
relationship with patients
1, 4, 7, 9, 11
Organisation “Local-by-default” decision making and activity execution 1, 2, 4, 5, 7, 9
Reward systems must evoke and support patient and service
behavior and adherence to norms and values
1, 2, 7, 11
Maximal self-service for patients, as patient is the most
underutilized resource
1, 2, 4, 7, 9
Patient identity must be established at all times 3, 5, 7, 8
Information Access to patient record must always be under consent 1, 3, 11
Applications must enable multi-channel access 1, 2, 9
Patients must be informed about their health status 1, 3, 5, 7, 11
Information Systems must provide data analysis and trends
prediction for external and/or internal data
5, 6
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A sample architecture principle publication is as follows:
Principle Statement #1: Status: Under Investigation
“Local-by-default” decision making and activity execution
Rationale:
Decisions and activities need to be made at the lowest possible level. By eliminating the decision making
hierarchy, processes are executed faster and patients are served more responsive, organizational flexibility and
speed are enhanced and complexity reduced. Moreover, it reduces failure demand, which in turn diverts
resources back to productive acts and thrive costs downwards. The principle causes higher patient and employee
involvement, which in turn increases their motivation.
Implications:
The practice should be prepared for patient self-service. Focus on helping patients to help themselves. Focus on
the underlying purpose of their encounter, rather than on the outcome.
Key Actions:
Investigate and reengineer operational and end-to-end patient processes.
Investigate function roles, regulatory requirements, delegation and authority for each service area.
Define and arrange employee training and patient knowledge sharing.
Set up feedback channels for patients and employees to allow continuously improvement.
Define necessary information supply and associated Information Systems for supporting employees and patients.
Ontological Model
On the basis of the PSI-theory, only human actors execute transactions. Despite the fact that
implementation will most certainly involve support of Information Systems for executing
(parts of) the transactions, humans are finally responsible for enterprise performance.
We therefore limit the modeling of our case to the B-organization, i.e. only showing essential
transactions and human actor roles, and refer to “Appendix D – ATD of Case A (Medication
Reconciliation)” for an overview of the Actor-Transaction Diagram of this case.
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Analysis & Improvement
The author’s proposed solution is a “clever and compulsory electronic health record that aids
in fraud detection”. It is unclear if this means a sharing of medication data between different
information silos, or the consolidation of storing the information within one (national) health
record Information System.
If we abstract from this fact, there is still a crucial element missing: how does the Emergency
Problem Handler know what medication a patient effectively has been taken and when?
Figure 24 - ATD of General Practitioner, Pharmacy, Sickness Fund and A&E Department
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As depicted above, the (current) ontology only contains the following essential facts:
T01, T02 and T03 only indicates medication that has been dispensed and paid for;
T18 only indicates the medication that has been prescribed;
T23 only indicates the medication that has been reimbursed
(with only anonymized information available to the insurer);
Regarding the I-Organization (i.e. Information System) that is about to be designed as a result
of the proposal, there is still essential information missing: what has been taken and when?
A typical and mostly implemented solution is to have the Emergency Problem Handler
(possibly using delegation as a transfer of authority to participate in a transaction, i.e. asking
Annie’s husband instead of herself). As seen, this can be inconclusive or incorrect as well.
We therefore introduce a new ontological transaction T21. The result of this transaction is
“R21 - Pharma Order O Applied/Consumed in Dosage D”.
Figure 25 - New transaction type T21: Consume/Apply Pharma Product
If the essential facts of this transaction are made available to the Emergency Problem Handler,
he will then know what medication a patient has been taking and when.
Regarding the “[…] that aids in fraud detection” claim of the author’s proposal: we did not
find an explicit mention how the information regarding medication prescription, dispensing,
reimbursement and consumption will be made available to different parties.
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Will it be stored in/retrieved from a single central health record, or is it about to be exchanged
between the different existing health record systems, with possible aggregation or
anonymization applied?
We can only assume that the author means the former, and that the role of fraud detection will
be fulfilled by a Primary Care health professional, e.g. the General Practitioner.
Please observe that we did not include any ontological transactions related to fraud detection.
6.2.5 Conclusions
In relation to the proposal, and using the information we have gathered using the enterprise-
engineering approach we can already assess the author’s proposal as follows:
the different government levels and approximately half of the hospitals have some
kind of mission statement, vision or strategy, but they are either disconnected, not
up-to-date, too generic or not integrated; we have not found a formal strategy
definition for pharmacies or physicians; as most strategic initiatives fail, it can be no
wonder that not having any (or no clear) formulation will not help to resolve it;
the proposal lacks different concrete elements and arrangements, it is for instance
not explicitly mentioning how the information regarding medication prescription,
dispensing and reimbursement will be made available to different parties;
the proposal does not take into account that besides prescription, dispensing and
reimbursement, a new essential transaction has to be taken into account, namely
the “consumption/application of the pharmaceutical product”; there exist medication
adherence, reminder, logging and monitoring tools (e.g. as part of the I-Organization
supporting this B-Organization) that can store this information on e.g. Annie’s
smartphone or connect to a third-party service in the cloud;
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6.3 Case B – Primary Care Subsystem
6.3.1 Introduction
John is a home physician in a small, but very successful private practice. He is working from
6am until 21pm every day, doing administrative tasks, filing reimbursement papers, preparing
and receiving lab and test results, drawing blood, giving vaccinations, updating medical
records, answering phones to create appointments and inquire about test or lab results, etc…
To maintain his income, he wants to see about 5 patients an hour, from 8am until 20pm every
weekday. Every patient needs to book an appointment in a time slot of 12 minutes, but some
patients never show up. A lot of new patients show up, as they heard that John easily
prescribes sickness leave. Others only ask to receive a renewal of their medication
subscription. He sometimes asks patients, without having a patient consultation, to drop an
envelope with his fee in his mailbox upon collecting a medication renewal prescription.
Around noon every day, the waiting room is filling up, as John is unable to keep the tight
schedule of 12 minutes per patient (remember: patients call for appointments, inquire about
lab results, call to cancel their appointment, etc…). Patients are not satisfied when they have
to wait a long time before they can see him, even though they made an appointment.
As part of a new government initiative, he is incentivized to maintain a prevention checklist
for each patient that has a medical health record at his office, and talk about possible
behavioral changes, e.g. quit smoking.
In his haste to wrap up a patient encounter, he fills in a wrong reimbursement code for his
action. The patient calls the next week, with the complaint that the sickness fund has not
reimbursed the action. John promises to correct this upon the patient’s next visit.
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6.3.2 Problem Analysis
As in the previous case, there are different, but interrelated problems: (1) he is mainly paid in
fee-per-service model, which leads him to thrive patient encounter volume, and over- and
underconsumption; (2) lack of patient relationship, as he has almost no time for a real
conversation with his patient; (3) increased burden and lack of capacity (time), leading to
errors and burnouts; (4) lots of none-medical tasks are being performed (administration,
nursing tasks, etc…); and (5) unethical and fraudulent behavior too maintain his income
level.
6.3.3 Proposed Solution
The author’s proposed solution is “reform of primary care subsystem, make the GP the
medical coach; increased patient participation; introduce new professions; and payment
systems change” (based on pillars 5, 6, 7, 8 and 9).
6.3.4 Application & Results
Enterprise Reference Context
Enterprise Outlook – Mission and Vision
In the proposals, we did not find concrete expressions of a mission or vision statement for the
reformed primary health care. We can however propose the following mission and vision
statement for the “Primary Care health professional”:
Mission:
“Providing high-quality and universally accessible primary health and health care services,
to best standards and including the latest medical knowledge and technology.“
Vision:
“To be the preferred supplier of primary health services within the local community.”
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Enterprise Maxims – Fundamental Convictions, Norms and Core Values
Design context: strategy, areas of concern and requirements
With respect to the proposal and anecdotal case, we established following design context.
Strategic choices
We support active involvement of patients and their family (or guardian) in the health
care delivery or decision-making processes (i.e. patient-centricity);
We focus on maintaining a good relationship with co-creative patients;
We conduct business in a health, environmental and societal conscience manner;
We position “Primary Care” as the medical coach and gatekeeper of “Secondary Care”
(e.g. to reduce overconsumption, hospital admission and visits to emergency services);
Profit is not our main business goal, but a necessary condition for sustainability and
the capability of maintaining a high level of qualitative health care;
Areas of concern
We then identified the following areas of concern, with respect to the proposals and anecdote:
1. Patient Involvement & Satisfaction (quality focus & service orientation);
2. Health Professional Satisfaction (involvement, motivation, life-work balance);
3. Accessibility (universal, timely and appropriate length; to norms and values);
4. Safety, Compliance (no adverse events, compulsory insurance);
5. Accountability (everyone in the healthcare process is responsible for their role);
6. Quality improvement (reduce avoidable mistakes, cost containment; reduced waiting
time of patients in waiting room);
7. Privacy (given sensitive health information);
8. Sustainability (incomes and profit a means for business survival and growth);
9. Business and Medical Ethics (moral principles that apply values and judgments);
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Functional and Constructional Requirements
With respect to the proposals and anecdote, and guided by the EE competence, the following
functional and constructional requirements have been established, e.g.:
Table 10 - Sample Functional and Constructional Requirements
Functional requirements (Business) Constructional Requirements (Org. & Info)
Online and self-service capabilities for patients
(e.g. to book appointments, view health records
and test results, or update measurements …).
Computer-supported means and methods for
collaboration, decision support, data analysis and
process management (O)
Self-service capabilities for other health
professionals (e.g. update record with test results,
imaging data, referral results …).
Quality-, service- and patient-centric behavior of
employees (O)
Secure and user-friendly communication
capabilities for health professionals (incl.
pharmacists), insurers and patients.
Individual health professional work planning
overviews with ability of personal activity
planning within work roster planning
functionality (O)
Policymakers need to observe and gain insights
in the health service consumption.
End-to-end measures for the practice’s inherent
performance capability (O)
Effective relationship building with patients and
other health professionals11
.
Internet- and mobile-based communication
technology (I)
Citizens subscribe to an (obligatory) health
record maintenance agreement with a single
general practitioner of choice
Collection of data during all interactions, for
service and process improvements, and devising
new services (I)
Primary health professionals give advice about
behavior changes, based on the analysis of a
patient’s health record and history.
Extended enterprise integration and transparency,
such that patient and operational data is collected
by, and shared with other stakeholders (I)
All citizens are given the opportunity to choose
(or switch) sickness funds.
Availability of health information at all patient ‘s
interaction points, with respect for privacy (I)
11
Different studies have shown a positive correlation between effective and empathic relationships with
improved outcomes and reduced provision or consumption.
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Architecture Principles
With respect to the proposals and anecdote, and guided by the EE competence, the
architecture principles were drafted. We list a few in the table below, and elaborate further on
two sample architecture principle publications.
Table 11 - Sample Architecture Principles of Case B
Design Domain Architecture principle Area of Concern
Business Appointments and agreements will be adhered to 1, 3, 5, 6
Health professionals maintain a good relationship with citizens 1, 2, 3, 5, 6, 7
Organisation “Local-by-default” decision making (at lowest possible level) 1, 2, 3, 5, 6
Functional units of health professionals is based on
maximizing individual’s competences and preferences and
minimized cross-boundary relationships
2, 3, 5, 6, 8
Reward systems must evoke and support patient and service
behavior and adherence to norms and values
2, 3, 6
Maximal self-service for patients, as patient is the most
underutilized resource
1, 2, 3, 5, 7, 8
Patient identity must be established at all times 1, 4, 5, 7
(Cost-)efficiency, but not at the expense of safety or
effectiveness
5, 6, 8
Health professionals personal financial gain must not be
influenced by service volume
2, 5, 6, 8
Information Access to health information must be based on authentication
and role-based authorization
3, 4, 5, 7
Access to patient record must always be under consent 1, 3, 4, 5, 7
Patients must be informed about their health status 1, 3, 5, 6, 8
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Principle Statement #1: Status: Under Investigation
Appointments and agreements will be adhered to
Rationale:
In modern times, time is a currency. This is often neglected by people or organizations, indicating lack of respect
for the other individual’s time, and thus not delivering a patient-centric service, as one values their own time
more than the time of another. This might in turn lead to a day of work without payment, being late for pickup at
school, being late for other appointments, leading to dissatisfied patients, cancelled appointments or “no shows”.
Implications:
Measures need to be taken to better manage patient waiting times.
Key Actions:
Establish, report and follow-up on measurements for patient experience, including lead and waiting times.
Map and balance service supply capacity with demand, including demand variance analysis.
Develop procedures for handling as much administrative work as possible before or after the patient arrives.
Principle Statement #2: Status: Under Investigation
Access to patient record must always be under consent
Rationale:
Given the sensitivity of the contents of the patient record, the patient must give his/her consent before any data is
made available and accessible for health professionals, be it for collection, statistical or operational use.
Implications:
Different user groups must comply with stringent patient and data privacy and consent arrangements.
Key Actions:
Establish essential organizational roles.
Investigate possible methods for authentication, authorization and consent management.
Study authorization levels for individual patient record’s data segments.
Develop identity management and access services.
Create overall security and privacy policies and awareness.
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Ontological Model
We again limit the modeling of our case to the B-organization, i.e. only showing essential
transactions and human actor roles, and refer to “Appendix E – ATD of Case B (Primary Care
Subsystem)” for a full page overview of the Actor-Transaction Diagram of this case.
Figure 26 - ATD of Primary Care Delivery Subsystem
Analysis & Improvement
In the case of John, the private general practitioner, all the essential transactions within the
Primary Care Delivery Subsystem are executed and all human actor roles are fulfilled by one
person: John himself.
We can easily see that the limited capacity of one single person has an enormous impact on
the cycle and lead time of the transactions and end-to-end patient journey.
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The ATD of the Primary Care Subsystem shows the GP’s practice essential actor roles.
These roles might be clustered logically, e.g. based on the architecture principle “Functional
units of health professionals is based on maximizing individual’s competences and
preferences and minimized cross-boundary relationships”.
For instance, transactions T02 and T05, can be executed by the patient itself, if he/she is
supported by the appropriate I-Organization transactions and matching Information Systems
(e.g. through the use of an online appointment managing application; or filling in an
electronic questionnaire on a tablet computer, while in the waiting room).
Another example, are transactions T01, T04, T05, T13, T14 and T15 which might be executed
by (or at least delegated to) a nurse or nurse practitioner.
As a last and final example, one can assign the administrative transactions T01, T02 and T17
(and possibly the delegation of T15) to an administrative assistant.
We can map the result of a Demand Analysis of a real general practitioner onto the
ontological transactions: demand type, variance, frequency, peak times, throughput, volume,
utilization, capacity, cost rate, cycle and lead times, failure vs. value etc… Given the limited
public availability of the detailed transaction information, we have not elaborated upon this.
All of these interventions can be extended with e.g. inter-transactional redesign principles
(deletion and replacement; change of optimal relationships; advancing initiating points;
parallelization of transaction types), Normalized Systems Business Processes or with other
improvement and quantification methods as described in Section 5.3 of this document.
One can estimate this can free up capacity for the Primary Care health professional (i.e. the
general practitioner), leading to shorter waiting room times, a more strict appointment
adherence, less burden on the GP, more time for patient-physician relationship building etc…
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6.3.5 Conclusions
Enterprise Ontology allows us to focus on aspects like responsibilities, co-ordination, and
delegation of activities and perceives the patient as an active participant in the care process.
Regarding the payment reform: the fee-for-service model (with small percentage of
capitation12
for maintaining a general medical record of his patient) can be altered towards a
payment consisting of a larger amount of capitation in combination with e.g. fee-per-service
for particular tests, diagnostic procedure or intervention, and certain quality incentives (P4Q).
A similar payment system is already in place in most recent community health centers
(Dutch: “wijkgezondheidscentra”), where different Primary Care professionals such as
general practitioners, dentists, nurse practitioners, etc… all work together under one roof.
A more detailed payment reform description would allow us to use the Enterprise Engineering
discipline (i.e. Enterprise Architecture and Enterprise Ontology, and Enterprise Governance
competences) to assess it for inconsistencies or missing elements, given the strategic context
and areas of concern for each organization (or subsystem) in the health system.
6.4 Discussion
As the two example anecdotal cases have shown, formal publication of architectural
principles and requirements according to the Enterprise Architecture discipline aids in:
correlating enterprise design principles to areas of concern, and further to strategic
choices, norms and values, and policies;
providing coherent and consistent attention to the various implications of architecture;
defining a coherent and consistent set of follow-up activities defined as key actions
(studies, pilots, projects) to enable the architecture to be effective;
12
Payment based per patient per period (usually per month or per year)
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As main characteristics of using Enterprise Ontology, we demonstrated:
it ensures completeness in unambiguously discerning all activities required to deliver
health services (although we only elaborated on the B-Organization);
it aids considering and comparing different implementations of these activities and
their executing actor roles in organizations, people and automation;
the models can be used in “just in time, just enough detail”-mode;
creating the models is possible with an attractive return-on-modeling-effort (ROME);
Different strategic choices, areas of concern, as well as functional and constructional
requirements are not met at the implementation-independent level (i.e. the B-Organization). In
order to perform optimally and to implement changes successfully, these organizations must
operate as a unified and integrated whole, which can only be achieved through deliberate
Enterprise Development and Enterprise Governance.
Furthermore, we showed it is possible to integrate compatible and relevant analysis
techniques and improvement/quantification methods to prepare a better, more objective and
more “calculated” change reform proposal, or to assess the impact of an existing one.
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Chapter seven
Evaluation
“The pure and simple truth is rarely pure and never simple.”
– Mark Twain
ollowing chapter represents the “Evaluation” phase of the DSRM, where we evaluate
and assess if and how effective and efficient our proposal provides an answer to our
research questions. We first explain the developed evaluation strategy, followed by the
evaluation results.
7.1 Evaluation Strategy
In order to evaluate artifacts, (Hevner, et al., 2004) proposed five different types of methods:
Observational (case study or field study); Analytical (static analysis, architecture analysis,
optimization or dynamic analysis), Experimental (controlled experiment or simulation),
Testing (functional or structural testing) and Descriptive (informed argument or scenarios).
The authors also propose seven guidelines that should be addresses in some manner for
design-science research to be complete: (1) Design as an artifact; (2) Problem Relevance; (3)
Design Evaluation; (4) Research Contributions; (5) Research Rigor; (6) Design as a Search
Process; and (7) Communication of Research.
In (Pries-Heje, et al., 2004), the authors developed a framework, supporting the evaluation of
DSRM research outcomes. This framework ascertains the following criteria: (1) What is
actually evaluated; (2) When the evaluation takes place; and (3) How it is evaluated.
F
7
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This framework distinguishes evaluation in three dimensions: (1) the approach to the
evaluation (artificial or naturalistic); (2) the moment of the evaluation (ex-ante or ex-post
or both); and (3) design product (the result of a process) vs. design process (the set of
activities, tools, methods and practices to guide the flow of design product creation).
For the “How” question, we applied the Österle Principles in (Österle, et al., 2011) to evaluate
the artifact utility and quality, and its compliancy with Scientific Research:
1. Abstraction: the artifact must be applicable to a class of problems;
2. Originality: the artifact must largely contribute to progress of the body of knowledge;
3. Justification: the artifact must be justified in a comprehensible manner and must
allow for its validation;
4. Benefit: each artifact must yield benefit – either immediately or in the future – for the
respective stakeholder groups;
7.2 Evaluation Results
First step in our evaluation is the framework proposed by (Pries-Heje, et al., 2004), that
answers three basic questions:
What was evaluated? The evaluated artifact was the approach described in chapter 5,
which can be considered a design science research artifact method. The evaluation
represents a design process, since it defines a set of activities, methods and practices
to guide the assessment, comparison or draft of health system reform proposals;
When was it evaluated? It was evaluated after the artifact development, and after the
demonstration in this chapter. Therefore, the evaluation strategy is ex-post;
How is it evaluated? The evaluation approach represents a naturalistic evaluation, as
we explore the utility in a real health system, where real reform proposals can be
assessed or drafted;
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As a second step, we evaluate the guidelines, (Hevner, et al., 2004) in the table below:
Table 12 - Evaluation of the guidelines of (Hevner, et al., 2004)
Guideline Evaluation/Argumentation
1 - Design as an artifact Our produced artifact is a framework to assess, compare or draft
health system reform proposals.
2 - Problem Relevance Health systems are forced to successfully implement strategic
changes, considering evolving customer needs, global health
challenges, technological evolutions and economic factors.
3 - Design Evaluation We used mainly the descriptive evaluation method to assess our
artifact, which uses relevant research to build convincing
arguments, and constructs scenarios around the artifact to
demonstrate the utility.
4 - Research Contributions Current approaches and frameworks addressing organizational
change are fragmented, heterogeneous and mostly descriptive. In
this study, we aimed to design and develop a more prescriptive,
holistic and integrated approach by combining the Enterprise
Engineering Paradigm, in combination with existing but
compatible analysis and improvement/quantification methods.
5 - Research Rigor Our research is based on two fundamental theories, all published
in multiple academic papers: (1) (whole) systems theory; and (2)
fundamental theories and definitions in organizational science,
Enterprise Governance and Enterprise Engineering, and its
derivatives.
6 - Design as a Search Process We performed a number of anecdotal scenarios in which we
aimed to acquire new insights.
7 - Communication of Research The results of this research can be communicated using the usual
communication channels for academic research, such as
publication, presenting or teaching courses.
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As a third evaluation step, we evaluate the Four Principles in (Österle, et al., 2011).
1. Abstraction: the artifact can be applied to any reform proposal for a health care
system, given a description of the health system, the description of the proposal, the
relevant strategic context and challenges (indicating requirements, areas of concern
and design aspects) – they can easily be obtained from available documents or from
interviews with domain experts and relevant stakeholders;
2. Originality: the artifact was not yet available in the Body of Knowledge as we
combined theoretically founded Enterprise Engineering discipline, the Enterprise
Governance competences and processes, together with compatible analysis techniques
and improvement/quantification methods;
3. Justification: the artifact is supported by the literature review and theoretical
foundations underlying the Enterprise Engineering discipline, such as the Ψ-theory,
and was demonstrated to allow for explanation and justification;
4. Benefit: the artifact allows to design and develop a more prescriptive, holistic and
integrated approach to assess, compare or draft health system reform proposals; we
expect health policy makers, organizations and professionals to use it to guide them in
the necessary shift towards performant, innovative and sustainable health system;
As a fourth and final step, we want to mention that we received positive feedback, criticism
and attention of several participants at different medical and health related conferences, e.g.
the European eHealth Week 2013 (Dublin, Ireland), Hospital + Innovation congress (Odense,
Denmark), European Telemedicine Conference 2013 (Edinburgh, Scotland) and finally the
Arctic Light e-He@lth Conference (Kiruna, Sweden).
This can be seen as an indication of consensus towards the importance of the research
problem, and to the proposed solution approach.
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Chapter eight
Conclusions
“The first of the fundamental impediments to the adoption of systems thinking
is that we are prisoners of our frame of reference.” – Barry Richmond
his final chapter summarizes the findings to the research questions, its practical
implications and limitations. This chapter also embeds the communication activity
phase of the research methodology and provides some directions for future work.
8.1 Findings and Conclusion
In a time of ageing populations, rise of chronic diseases and co-morbity, there is a worldwide
quest for performant, innovative and sustainable health systems that are, a.o. cost-efficient,
patient-centric and co-creative and that are able to deal with growing business and society
dynamics.
Effectively implementing strategic initiatives that tackle the aforementioned challenges or
dissolve existing problems appears a frightening task since the majority of the
implementations fail.
We observed the existing organizational science literature and found that most existing
approaches are not, or inadequately concerned with design and many share the same
underlying mechanistic characteristics: strongly management and planning oriented, focus on
internal control that apparently should secure success of future health system organizations.
T
8
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Lack of enterprise integration and coherence has thereby been identified as one of the core
reasons for not successfully operationalizing strategic initiatives. In view of the several
enterprise aspects, a design approach must be able to address all aspects. Realization must be
intentionally designed, as virtually all causes for poor enterprise performance are systemic.
Also, a fundamentally different perspective on governance is essential for: (1) addressing
enterprise dynamics, complexity and associated uncertainty; (2) iteratively, evolutionary, and
emergent development of strategic initiatives and their operationalization and (3) realizing a
unified and integrated enterprise organization and operation.
The European Commission (Public Health Evaluation and Impact Assessment Consortium,
2011) and the World Health Organization (World Health Organization, 2009) also underline
the importance of an integrated and systemic approach to implement strategic changes and
avoid inefficiencies from different viewpoints such as patients, professionals and insurers.
This research proposed a shift towards the Enterprise Engineering Paradigm (see Appendix C
– Summary of Enterprise Engineering Manifesto), guided by the Enterprise Engineering
Framework, while integrating compatible analysis techniques and improvement/quantification
or innovation methods for avoiding strategic initiatives failure.
In relation to the theories underlying our proposal, we experienced: (1) an initial steep
learning curve and emergence of the Enterprise Engineering Discipline; (2) that not all
activities in organizations are transaction based as they experience emergent properties, and
can therefore not be expressed in the current EO theory, e.g. strategy development, decision
making processes, knowledge workers or enterprise design itself; (3) that the
understandability of the produced EO models by the stakeholders must not be taken for
granted, an adaptation period is required; (4) a strong desire for an (unattainable) fully
codified method, i.e. to go from “what” statements to “how” statements in a predefined way.
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During our research, we also experienced a strong pull towards the financing and expenditure
context, both in literature interviews, reform proposals, demonstrative cases and interviews.
Another phenomena, was the lack of public availability and scarcity of up-to-date, reliable
and comparable data and measures to work with.
We conclude this section with answering each research question:
RQ 1. What is the contribution of the Enterprise Engineering Paradigm to the integrated
design of performant, innovative and sustainable health systems?
The Enterprise Engineering Paradigm, guided by the Enterprise Engineering Framework, and
integrated with compatible analysis techniques, improvement and quantification methods,
provide a solid foundational theory and methodology, and a different and unified approach for
integrating several enterprise aspects that would otherwise be treated incoherently and
inconsistently, causing failures in strategic initiative implementations.
RQ 2. How can we objectively assess, compare and draft health system reform proposals
conform the disciplines in the Enterprise Engineering Paradigm?
Using a real reform proposal and two anecdotal scenarios, we have shown that adherence to
the Enterprise Engineering Paradigm enables thorough assessing, comparing or drafting
health system reform proposals, and supports searching for discrepancies regarding
statements, missing elements, contradictions or strategic gaps.
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8.2 Implications, Recommendations and Limitations
We expect health policy makers, health organizations and health professionals to use (at least
parts of) our proposal to guide them in the necessary shift towards performant, innovative and
sustainable health system. However, one should be willing to review its frame of reference
and way of thinking.
As within other private and public sectors, there is an immense potential of collaboration that
can be seen as a natural evolution and dynamics of a participating European Union (EU)
member state. Regions, communities and health professionals remain the most important
actors in a national health system, but EU policies and legislation can influence these health
system elements, both within the health sector as across different sectors.
Mainly due to the sensitive and private nature of the information we needed to obtain, the
complexity of the domain and the limited time frame available, we made use of a wide variety
of observational and descriptive evaluation methods, such as publicly available reports, case
studies, observations and anecdotes. However, we cannot rely on these alone, because they
cannot completely rule out alternative explanations or theories.
Nevertheless, we have high confidence in the application of our proposal to address problems
of inefficiency and unsustainability in health system organization using a deliberate enterprise
development and governance approach.
8.3 Research Communication
The results of this research can be communicated using the usual communication channels,
such as publishing articles in relevant journals, presenting at academic or medical
conferences or symposia, or familiarize students and interested practitioners with the
guidelines through courses and seminars.
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8.4 Recommendations for Future Work
In the course of this master project, we have retained the following (non-exhaustive list of)
recommendations for key actions and future work:
improve the Enterprise Ontology (EO) modeling phase by adding transactions of the I-
organization (informa) and D-organization (forma) or adding other aspect models such
as the Process Model, Fact Model and Action Model;
improve the Design phase by adding additional design domains or design aspects; by
adding high-level construction models, including state and process rules and end-to-
end measures;
integrate Body of Knowledge and evolution of the “Business Process Engineering”
domain (Sanz, 2014), e.g. process- and decision management, case management,
customer journey modeling, (S)-BPM, …;
expand the scope of the assessment or redesign context by integrating health policies
with social and welfare policies, or integrate with socioeconomic determinants of
health, e.g. where people live, where they work, where they are born and grow up,
their wealth, social status and gender, etc…;
expand the scope of the assessment or redesign context by adding (or segregating)
other health services; or by adding (or segregating) other care clusters;
repeat the application to integrate, assess or draft other reform proposals (both at
national and European level);
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Bibliography
Ackoff, R. L., Addison, H. J., Carey, A. & Gharajedaghi, J., 2010. Systems Thinking for
Curious Managers: With 40 New Management F-laws. sl:Triarchy Press Limited.
Alliance for Health Policy & Systems Research - World Health Organization, 2012. A Review
of Conceptual Barriers and Opportunities, sl: Alliance for Health Policy & Systems
Research.
Annemans, L., 2014. De Prijs Van Uw Gezondheid - Is onze gezondheidszorg in gevaar?.
sl:Lannoo Campus.
Brezet, H., 1997. Dynamics in ecodesign practice. Industry and Environment, 20(1-2), pp. 21-
24.
Dalles, S. & Bell, M., 2004. The Need for IT Governance: Now More Than Ever, sl: Gartner
Research.
Deming, W. E., 1986. Out of the Crisis. Cambridge: Cambridge University Press.
Dent, E. B., 1999. Complexity Science : A Worldview Shift. Emergence.
Dietz, J. L., 2011. Enterprise Engineering Manifesto, sl: CIAO! Network.
Dietz, J. L. G., 2006. Enterprise Ontology: Theory and Methodology. sl:Springer.
Dietz, J. L. G., 2008. Architecture, Building Strategy into Design. The Hague: Academic
Service.
Dietz, J. L. G., 2013. Enterprise Ontology - Lecture Notes. sl:Delft TopTech - Delft
University of Technology.
Dietz, J. L., Hoogervorst, J. A. & al, e., 2013. The discipline of Enterprise Engineering.
International Journal of Organisational Design and Engineering, pp. 86-114.
European Observatory on Health Systems and Policies, 2010. Implementing Health Financing
Reform: Lessons from countries in transition., sl: World Health Organization.
- 85 -
Flood, R. L., 1999. Rethinking the Fifth Discipline - Learning Within the Unknowable.
sl:Routledge.
Gaziulusoy, A. I., 2010. System Innovation for Sustainability: A Scenario Method and a
Workshop Process for Product Development Teams (PhD Thesis), Auckland: University of
Auckland.
Gerkens, S. & Merkur, S., 2010. Belgium: Health system review. Health Systems in
Transition, 12(5).
Hevner, A. R., March, S. T., Park, J. & Ram, S., 2004. Design Science in Information
Systems Research. MIS Quarterly.
Hines, P., Holweg, M. & Rich, N., 2004. Learning to evolve: a review of contemporary lean
thinking. International Journal of Operations & Production Management, 24(10), pp. 994-
1011.
Hoogervorst, J. A., 2011. A Framework for Enterprise Engineering. International Journal of
Internet and Enterprise Management, 7(1).
Hoogervorst, J. A. P., 2009. Enterprise Governance and Enterprise Engineering. sl:Springer.
Hoogervorst, J. A. P., 2013. Enterprise Governance and Enterprise Engineering - Lecture
Notes. sl:University of Antwerp Management School.
Hoogervorst, J. A. P., 2014. Personal Communication. sl:sn
Kaplan, R. S. & Norton, D. P., 2004. Strategy Maps: Converting Intangible Assets into
Tangible Outcomes. sl:Harvard Business Review Press.
Kaplan, R. S. & Porter, M. E., 2011. How to solve the cost crisis in health care. Harvard
Business Review.
Kim, J., 1999. Making Sense of Emergence. Philosophical Studies, 95(1-2), pp. 3-36.
Mannaert, H. & Verelst, J., 2009. Normalized Systems: Re-creating Information Technology
Based on Laws for Software Evolvability. sl:Koppa.
Mes, M. & Bruens, M., 2012. A generalized simulation model of an integrated emergency
post. sl, sn
- 86 -
Mintzberg, H., 1994. The Rise and Fall of Strategic Planning.
Ohno, T., 1988. Toyota Production System: Beyond Large-Scale Production. sl:Productivity
Press.
Österle, H. et al., 2011. Memorandum on Design-Oriented Information Systems Research.
European Journal on Information Systems, 20(7-10).
Peffers, K., Tuunanen, T., Rothenberger, M. A. & Chatterjee, S., 2008. A Design Science
Research Methodology for Information Systems Research. Journal of Management
Information Systems, 24(3), pp. 45-78.
Poksinska, B., 2010. The current state of Lean implementation in health care: literature
overview. Quality Management in Health Care, 19(4), pp. 319-329.
Porter, M. E. & Lee, T. H., 2013. The Strategy That Will Fix Health Care. Harvard Business
Review.
Pries-Heje, J., Baskerville, R. & Venable, J., 2004. Strategies for Design Science Research
Evaluation. 16th European Conference on Information Systems (ECIS), pp. 255-266.
Public Health Evaluation and Impact Assessment Consortium, 2011. Report on the Mid-Term
Evaluation of the EU Health Strategy 2008-2013, sl: sn
Reijswoud, V., Mulder, H. & Dietz, J., 1999. Communicative Action Based Business Process
and Information Systems Modelling with DEMO. International Journal of Information
Systems, 9(2), pp. 177-138.
Sanz, J. L. C., 2014. The Pretense of Knowing the Customer as the Vehicle to Improve
Customer Experience: Repositioning Process in the Front Office of Organizations. Eichstätt,
Germany, sn
Schokkaert, E. & Van de Voorde, K., 2011. Belgium's health care system: should the
communities/regions take over? Or the sickness funds?, sl: Re-Bel Initiative.
Seddon, J., 2005. Freedom from Command and Control. 2nd red. sl:Vanguard Consulting Ltd.
Seddon, J. & O' Donovan, B., 2009. Rethinking Lean Service. [Online]
Available at: http://www.systemsthinking.co.uk
- 87 -
Seddon, J., O'Donovan, B. & Zokaei, K., 2011. Systems Thinking: From Heresy to Practice.
sl:Palgrave Macmillan.
Spanyi, A., 2008. Management, More for Less: The Power of Process. sl:Meghan-Kiffer
Press.
Swartenbroekx, N. et al., 2012. Manual for cost-based pricing of hospital interventions,
Brussels: Belgian Health Care Knowledge Centre (KCE).
The Chain of Trust Consortium, 2014. Understanding patients' and health professional'
perspective on telehealth and building confidence and acceptance, sl: European Patients'
Forum.
Van Herck, P., Sermeus, W. & Annemans, L., 2013. You get what you pay for. Toward a new
business model for healthcare., sl: Itinera Institute.
Womack, J., 2003. Lean Thinking. London: Simon & Schuster UK Ltd..
Womack, J., Jones, D. & Roos, D., 1991. The Machine That Changed The World. 2nd red.
sl:Productivity Press.
World Health Organization, 2000. World Health Report 2000. Health Systems: Improving
Performance, Geneva: World Health Organization.
World Health Organization, 2009. Systems Thinking for Health Systems Strengthening,
Geneva: WHO Press.
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Appendices
Appendix A – Generic Enterprise Design Aspects
This section provides an overview of different design aspects in each Enterprise Design
Domain, as provided by (Hoogervorst, 2009), (Hoogervorst, 2013) and (Hoogervorst, 2014).
Business Design Aspects
Figure 27 - Collection of Business Design Aspects
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Organization Design Aspects
Figure 28 - Collection of Organizational Design Aspects
Information Design Aspects
Figure 29 - Collection of Information Design Aspects
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Environment Design Aspects
Figure 30 - Collection of Environment Design Aspects
Overview of Enterprise Design Domains and Aspects
Figure 31 - Schematic overview of Enterprise Design Domains and its Aspects
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Appendix B – Health System in Belgium
What follows is the (updated13
) summary of the Belgian Health System as described in the
“Health Systems in Transition” profile (Gerkens & Merkur, 2010).
“Belgium is a federal state with three levels of government – the federal government, the
federated entities (three regions and three communities) and the local governments (provinces
and municipalities). Health policy is both a responsibility of the federal authorities and
federated entities.
The federal authorities are responsible for the regulation and financing of the compulsory
health insurance; the determination of accreditation criteria (i.e. minimum standards for the
running of hospital services); the financing of hospital budgets and heavy medical care units;
legislation covering different professional qualifications; and the registration of
pharmaceuticals and their price control.
Federated entities are responsible for health promotion and prevention; maternity and child
health care and social services; different aspects of community care; coordination and
collaboration in primary health care and palliative care; the implementation of accreditation
standards and the determination of additional accreditation criteria; and the financing of
hospital investment.
The Belgian population reached 11.2 million in 2013. In 2012, life expectancy at birth was
83.1 years for females and 76.6 years for males. Almost the whole population (> 99%) is
covered for a very broad benefits package. Since January 2008, there is no longer any
difference between health insurance coverage in the general scheme and the scheme for the
self-employed, as the latter now includes the coverage of minor risks.
13
We updated the relevant data, figures and statistics to the last available year and shortened a few sentences.
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The organization of health services is characterized by the principles of therapeutic freedom
for physicians, freedom of choice for patients, and remuneration based on fee-for-service
payments.
The compulsory health insurance is managed by the National Institute for Health and
Disability Insurance (NIHDI-RIZIV-INAMI), which allocates a prospective budget to the
sickness funds to finance the health care costs of their members. All individuals entitled to
health insurance must join or register with a sickness fund: either one of the six national
associations of sickness funds, including the Health Insurance Fund of the Belgian railway
company, or a regional service of the public Auxiliary Fund for Sickness and Disability
Insurance. Private profit-making health insurance companies account for only a small part of
the non-compulsory health insurance market. In the past, sickness funds received the budget
they needed to reimburse their members but since 1995, they have been held financially
accountable for a proportion (25%) of any discrepancy between their actual spending and
their budget, for which 30% is determined according to a normative risk-adjusted allocation.
Decision-making in the Belgian health system mainly relies on negotiations between several
stakeholders. General policy matters concerning health insurance and its budget are decided
by representatives of the government and the sickness funds but also by representatives of
employers, salaried employees and self-employed workers. The health insurance system is
also regulated by national conventions and agreements between representatives of health care
providers and sickness funds (e.g. fees determination).
The Belgian health system is based on the principle of social insurance characterized by
horizontal solidarity (between healthy and sick people) and vertical solidarity (based to a large
extent on the labor incomes) and without risk selection. Financing is based mostly on
proportional social security contributions related to taxable income and, to a lesser extent, on
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progressive direct taxation, and a growing area of alternative financing related to the
consumption of goods and services (mainly value added tax).
In 2011, Belgian total health expenditure was 10.5% of gross domestic product (GDP), higher
than the OECD average over 9.3%. Health expenditure expressed in US$ PPP per capita was
4061 in 2011, again above the OECD health expenditure average.
Patients in Belgium participate in health care financing through official co-payments and
diverse supplements. The main payment mechanism is the fee-for-service payment. There are
two systems of payments: (1) a direct payment (mainly for ambulatory care), where the
patient pays for the full cost of the service and then obtains a reimbursement from the
sickness fund for part of the expense; and (2) a third-party payer system (mainly for
ambulatory drugs and hospitals), where the sickness fund pays the provider directly and the
patient is only responsible for paying any co-payments, supplements or non-reimbursed
services. However, the third-party payer system can be applied under specific conditions for
ambulatory care to ameliorate the financial access for vulnerable population groups.
The reimbursement of services depends on the type of service provided, the income and social
status of the patient (preferential reimbursement or not), as well as the accumulated amount of
co-payments already paid for that year. For more vulnerable population groups, several
measures were taken to ensure their access to high-quality care (OMNIO, maximum billing
(MAB) system, etc.)
A significant proportion of health care providers are paid on a fee-for-service basis. For
salaried employees in the health sector, salaries and career evolution are negotiated through a
series of collective agreements. The number of health care professionals has been quite stable
since 2000. Planning for physicians, dentists and other health care personnel are undertaken
by the Committee for Medical Supply Planning. This committee is responsible for
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formulating proposals for the federal Minister of Public Health on the annual number of
candidates per community that are eligible to be granted the professional title of physician,
dentist or physiotherapist, after obtaining the relevant diploma.
Based on the committee’s work, a proposal was made to establish a quota mechanism. The
quota mechanism is applied immediately after the completion of basic training, at the moment
of application for recognition as a dentist or physiotherapist, and at the time of application for
specialization for a physician (general practitioner (GP) or specialist). In order to achieve the
quotas, the communities, which are responsible for education policy, were requested to take
measures to limit the number of students. Some measures to increase the attractiveness of the
GP and nursing professions, to make health care providers more accountable, to strengthen
primary care and to promote the integration of health services and multidisciplinarity have
also been undertaken.
In Belgium, hospitals can be classified into two categories: general and psychiatric. In 2008,
there were 207 hospitals, of which 139 were general and 68 psychiatric. The general hospital
sector consists of acute (112), specialized (19) and geriatric hospitals (8). The basic feature of
Belgian hospital financing is its dual remuneration structure according to the type of services
provided: accommodation costs, nursing activities in the nursing units, operating room, and
sterilization are financed via a fixed prospective budget system; while medical services,
polyclinics and medico-technical services (laboratories, medical imaging and technical
procedures) and paramedical activities (physiotherapy) are mainly paid via a fee-for-service
system to the service provider.
As an alternative to hospitalization, intermediary structures and services have been developed.
These alternatives include day hospitalizations and long-term care centers. For specific
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groups, such as the elderly and persons suffering from mental illnesses, a wide range of
community services are available as an alternative to residential long-term care.
Pharmaceuticals are exclusively distributed through community and hospital pharmacies.
Only physicians and (to the extent that their profession requires) dentists and midwives can
prescribe pharmaceuticals. About 2500 pharmaceutical products are on a positive list and
therefore are partly or fully reimbursable. The percentage of the cost that is reimbursable
varies, depending on the therapeutic importance of the pharmaceutical. To reduce expenditure
on pharmaceuticals several measures have been undertaken. These include a further reduction
in prices for products within the reference price system and establishment of prescription
quotas for low-cost drugs, among others.
Overall, the health system was recently assessed as having good accessibility and an
appropriate level of safety. However, further improvements in effectiveness of preventive
care, appropriateness of care, efficiency and sustainability could further enhance the
performance of the overall system.
Recent reforms to the health system essentially aim to provide a high quality of care to the
whole population and, at the same time, protect the sustainability of the system. The reforms
that will be carried out in the coming years will likely continue to promote the objectives of
accessibility, quality and sustainability. Further changes will also aim at simplifying the
system in order to make it more homogeneous.”
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Appendix C – Summary of Enterprise Engineering Manifesto
The Enterprise Engineering Manifesto (Dietz, 2011) presents the focal points and objectives
of the emerging discipline of enterprise engineering, as it is currently theorized and developed
within the CIAO! Network. It comprises seven postulates, which collectively constitute the
Enterprise Engineering Paradigm (EEP). We provide an adaptation of this manifesto below.
Postulate 1
In order to perform optimally and to implement changes successfully, enterprises must
operate as a unified and integrated whole. Unity and integration can only be achieved through
deliberate enterprise development (comprising design, engineering, and implementation) and
governance.
Postulate 2
Enterprises are essentially social systems, of which the elements are human beings in their
role of social individuals, bestowed with appropriate authority and bearing the corresponding
responsibility. The operating principle of enterprises is that these human beings enter into and
comply with commitments regarding the products (services) that they create (deliver), and are
the results of coordination acts, which occur in universal patterns, called transactions.
Postulate 3
There are two distinct perspectives on enterprises (as on all systems): function and
construction. All other perspectives are a subdivision of one of these. Accordingly, there are
two distinct kinds of models: black-box models (subjective; regard the function of a system)
and white-box models (objective; regard the construction of a system). Function is not a
system property but a relationship between the system and some stakeholder(s). Both
perspectives are needed for developing enterprises.
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Postulate 4
In order to manage the complexity of a system (and to reduce and manage its entropy), one
must start the constructional design of the system with its ontological model. This is a fully
implementation independent model of the construction and the operation of the system.
Moreover, an ontological model has a modular structure and its elements are (ontologically)
atomic. For enterprises the meta model of such models is called enterprise ontology.
Postulate 5
It is an ethical necessity for bestowing authorities on the people in an enterprise, and having
them bear the corresponding responsibility, that these people are able to internalize the
(relevant parts of the) ontological model of the enterprise, and to constantly validate the
correspondence of the model with the operational reality.
Postulate 6
To ensure that an enterprise operates in compliance with its strategic concerns, these concerns
must be transformed into generic functional and constructional normative principles, which
guide the (re-) development of the enterprise, in addition to the applicable specific
requirements. A coherent, consistent, and hierarchically ordered set of such principles for a
particular class of systems is called an architecture. The collective architectures of an
enterprise are called its enterprise architecture.
Postulate 7
For achieving and maintaining unity and integration in the (re-)development and operation of
an enterprise, organizational measures are needed, collectively called governance. The
organizational competence to take and apply these measures on a continuous basis is called
enterprise governance.
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Appendix D – ATD of Case A (Medication Reconciliation)
Figure 32 - ATD of Case A (Medication Reconciliation)
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Appendix E – ATD of Case B (Primary Care Subsystem)
Figure 33 - ATD of Case B (Primary Care Subsystem)
