Engineering performant, innovative and sustainable health systems - an integrated approach

Engineering performant, innovative and sustainable health systemsresearch and master thesis submitted for the degree of Executive Master of Enterprise and IT Architecture

Raphael WoutersEnterprise Architect & Consultant [email protected] linkedin.com/in/raphaelwouters @raphaelwouters

Health System Change DriversAging PopulationsChronic DiseasesPower/Influence shiftsTechnological AdvancesTackling ComplexityRising CostsInefficienciesIrregular QualityUnequal AccessCoverageetc…

Problem & MotivationHealth services- Many change drivers, both transformational and

incremental- Rarely formal, approved or 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 QuestionsHow can we (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?

Research MethodologyDSRM (Hevner, et al., 2004) DSRM Process Model (Peffers, et al., 2008)

Objectives of the SolutionOrganizational change evaluation

DescriptiveFragmentedHeterogeneous

PrescriptiveHolisticIntegrated

?

Definition of a Health System

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

– World Health Organization, 2000

Mechanistic vs. Organismic Viewpoint“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).”

– Robert L. Flood, 1999

Problem Dissolving

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

– Dr. Russel Ackoff

Classical Approaches

PDCA

Lean Thinking

Six Sigma

tVM

Choosing a Method, Technique or Tool- Who invented it and in what timeframe? - What was their frame of reference and their entailed

convictions? - Why was this invented, what problem did they (try) to

solve?- Do we have that same problem? - Did they succeed, and was it due to the application? - What type of statements and trade-offs are made and are

they (still) true? - Does it work and is it repeatable in our context?

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

http://www.ee-institute.org

Enterprise OntologyCaptures complexity of enterprises and focuses on implementation-independent essenceDifficulty of comprehending structural-functionalistic aspects of enterprises is greatly reduced

Theoretical Foundations

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

Management vs. GovernanceManagement deals with executing activitiesGovernance deals with steering and guiding change

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

activity.” – Deming, 1986

Generic System Development Process

Dietz, 2006

Enterprise Engineering Manifesto

Seven Postulates1. Unity & Integration2. Enterprises as Socio-Technical Systems3. Functional vs. Constructional Perspectives4. The Essence of Organizations5. Operationalization of the Enterprise6. Enterprise Architecture & Principles7. Enterprise Governance

http://www.ciaonetwork.org/publications/EEManifesto.pdf

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 Analysis (QALY)tVM’s “Purpose, Measure, Method”…

Inter-transactional redesignNormalized Systems TheoryLean thinking, e.g. tVM…

Demonstration in the Belgian Health System

Prof. Lieven Annemans

(Health Economist)

Belgian Health System – Some Reform Proposals

Case XCase C – IEP Reforms

Book Reform Proposals Anecdotal Scenarios

Case A – Medication Reconciliation

Case B – Primary Care Subsystem

Case Approach1. Introduction2. Problem Analysis3. Proposed Solution4. Application & Results

Case Example – Scenario

Case Example – Architecture Principles

Case Example – Ontological Model

FindingsRelation to theory- steep learning curve into Enterprise Engineering

paradigm - emergence of the Enterprise Engineering discipline- not all activities are transaction-based (e.g. emergent)- understandable, but after adaptation period- desire for (unattainable) fully codified method

Relation to domain- strong pull towards financing and expenditure context- public availability and scarcity of up-to-date and

reliable data

ConclusionsThe Enterprise Engineering Paradigm together with compatible techniques, tools and methods helps to prevent failures in strategic initiative implementations- solid foundational theory and

methodology- different and unified approach- integrates several enterprise aspects and

activities coherently and consistently- can be applied at different (health) system

levels- just-in-time, just enough detail +

attractive ROME

Future Work- improve and extend Enterprise Ontology

modelling- 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

(local, national and European level)

Thank you!