a thesis submitted for the degree of

Executive Master of Enterprise Architecture

Raphaël WoutersJune 2014

Towards engineering performant, innovative and sustainable health systems

Agenda

• Introduction

• Research Methodology

• Literature Review

• Theoretical Foundations

• Proposed Solution

• Demonstration

• Conclusions

link

Agenda

• Introduction

• Research Methodology

• Literature Review

• Theoretical Foundations

• Proposed Solution

• Demonstration

• Conclusions

Introduction

Aging Populations

Chronic Diseases

Power/Influence shifts

Technological Advances

Rising Costs

Inefficiencies

Irregular Quality

Unequal Access

Problem & Motivation

Health services

- Many change drivers (transformational & incremental)

- Rarely formal/approved/accomplished health reforms

- Methodology, metaphors, governance and management style & other “best practices” from secondary sector

Current approaches don’t seem to be

(adequately) implementing these changes

Isn’t there a better way?

Research Questions

How to (re)design performant, innovative and sustainable health systems?

RQ1. What is the contribution of the Enterprise Engineering Paradigm to the integrated design of performant, innovative and sustainable health systems?

RQ2. How can we objectively assess, compare an draft health system reform proposals conform the disciplines in the Enterprise Engineering Paradigm?

Agenda

• Introduction

• Research Methodology

• Literature Review

• Theoretical Foundations

• Proposed Solution

• Demonstration

• Conclusions

Research Methodology

DSRM (Hevner, et al., 2004)

DSRM Process Model (Peffers, et al., 2008)

Objectives of the Solution

Organizational change evaluation

DescriptiveFragmentedHeterogeneous

PrescriptiveHolisticIntegrated

?

Agenda

• Introduction

• Research Methodology

• Literature Review

• Theoretical Foundations

• Proposed Solution

• Demonstration

• Conclusions

Literature Review

Definition of a Health System

“All organizations, people and actions whose primary intent is to promote, restore or maintain health.”

– World Health Organization, 2000

Reductionism vs. Holism

“Reductionism breaks things into parts and attempts to deal with each part in isolation. […] in organizational and societal settings, however, it has not been plain sailing and struggled primarily because it misunderstands the nature of human beings (yet it remains a dominant wisdom).”

– Flood, 1999

Holism: the whole is primary and greater than the sum of its parts and indicates emergence

Problem Dissolving

“To dissolve a problem is to redesign the system or its environment so the problem is eliminated and cannot reappear.”

– Russel Ackoff

Management vs. Governance

Management deals with executing activitiesGovernance deals with guiding those activities (adequacy, correctness)

“[…] focus on outcomes is not an effective way to improve a process or activity.”

– Deming, 1986

Mechanistic vs. Organismic

Other Approaches

PDCA

Lean Thinking

Six Sigma

tVM

Agenda

• Introduction

• Research Methodology

• Literature Review

• Theoretical Foundations

• Proposed Solution

• Demonstration

• Conclusions

Enterprise Engineering

“The whole Body of Knowledge regarding development, implementation and operational use of enterprises, as well as its practical application.”

– Dietz, 2006

Generic goals

- Intellectual manageability

- Organizational concinnity

- Social devotion

Enterprise Architecture

“Reduction of enterprise complexity by addressing strategic objectives and areas of concern, and converting them into coherent/consistent set of enterprise design principles and standards.”

– Dietz, 2008 & Hoogervorst, 2009

Enterprise Architecture

Reference Context

– Hoogervorst, 2013-2014

Enterprise Governance

“The organizational capacity for devising and steering change.” – Hoogervorst, 2009

Enterprise Ontology

Captures complexity of enterprises and focuses on implementation-independent essence.

Difficulty of comprehending structural-functionalistic aspects of enterprises is greatly reduced.

Generic System Development Process

– Dietz, 2006

Agenda

• Introduction

• Research Methodology

• Literature Review

• Theoretical Foundations

• Proposed Solution

• Demonstration

• Conclusions

Proposed Solution

QuantificationMethods

AnalysisTechniques

Enterprise Engineering

Paradigm

ImprovementMethods

Enterprise EngineeringEnterprise GovernanceEnterprise Ontology

Ask why five timesDemand/Supply/Variation analysisPatient Journey MappingClinical Pathway AnalysisProcess Mining (!)Patient Stories/ProfilesService-Oriented Analysis

Demand, Experience, CostingHealth Cost-Benefit AnalysistVM’s “Purpose, Measure, Method”

Inter-transactional redesignNS TheoryLean thinking

Agenda

• Introduction

• Research Methodology

• Literature Review

• Theoretical Foundations

• Proposed Solution

• Demonstration

• Conclusions

Belgian Health System

Global challenges, and:

- expected staff shortage

- power balance shift

- lack of adequacy (screening/prevention, pathologies)

- surgery safety

- overconsumption

Reform Proposals

Reform & Anecdotal Scenarios

Case A – Medication Reconciliation

Case B – Primary Care Subsystem

Case Approaches

Introduction

Problem Analysis

Proposed Solution

Application & Results

Agenda

• Introduction

• Research Methodology

• Literature Review

• Theoretical Foundations

• Proposed Solution

• Demonstration

• Conclusions

Findings

Relation to theory

- steep learning curve and emergence of EE discipline

- not all activities are transaction-based

- understandable, but after adaptation period

- desire for (unattainable) fully codified method

Relation to domain

- strong pull towards financing/expenditure

- public availability and scarcity of up-to-date/reliable data

Conclusions

EEP & compatible techniques/methods prevents failures in strategic initiative implementations:

- solid foundational theory and methodology

- different and unified approach

- integrates several enterprise aspects coherently and consistently

- applied at different health system levels

Future Work

- improve and extend EO modeling phase- improve design phase (domains, aspects, models)- integrate BoK of “Business Process Engineering”- expand scope, e.g. integrate with social/welfare- expand scope, e.g. by adding or segregating other

health services/care clusters- repeat application to other reform proposals

(national and European level)

Thank you!