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OPERATIONS MANAGEMENT RELATED ACTIVITIES FOR HOME HEALTH CARE PROVIDERS
OPERATIONS MANAGEMENT RELATED ACTIVITIES FOR HOME HEALTH CARE PROVIDERS Salma Chaheda , Andrea Mattab , Evren Sahina , Yves Dallerya a
Laboratoire Genie Industriel, Ecole Centrale Paris, France Dipartamento di Meccanica, Politecnico di Milano, Italy
b
Abstract: Home heath care sector is a diverse and dynamic service industry. These services include complex cares and psycho-social services in the comfort of home. The goal is to help patients to reach and to keep their best clinical, psychological and social well-being. To our knowledge, there are very few studies that identify operations management type activities involved in the delivery of the service provided by Home Health Care structures. In this paper, we analyze the functioning of Home Health Care structures with a particular interest on identifying decisions related to operations management in the care giving process. c 2006 IFAC Copyright ° Keywords: decision support systems, structured analysis, qualitative analysis, decision making, flow diagrams.
1. INTRODUCTION
The main objective of Operations Management (OM) in the health domain is to determine the most efficient and effective organization of cares production in order to reach the required level of quality at contained cost. The service quality can be considered as the patient quality requirements (e.g. improvement of the quality of care, reduction of the waiting time, satisfaction of the preferences of the patient, etc.) and/or the health professionals’ quality requirements (e.g. equitable distribution of the workloads, execution of high skilled activities, etc.). The service cost deals with all the cost of components incurred to run care and logistic activities (e.g. investment costs for resources, care delivery costs, transportation costs, etc.) and it relates the patient, the health provider, the financiers and the national/regional institutions.
The Home Health Care (HHC) structure is one alternative to the traditional hospitalization. It differs from the other health organizations by considering the patient homes as components of the health supply chain. This organization introduces a new problem which is related to the fact that patients stay at their home, and therefore new constraints are set up (Chahed et al., 2004): - Necessity to provide care to one patient at a fixed time: the patients are not hospitalized inside the same unit but in their respective home, therefore patients are treated individually. - Synchronization of resources during the patient treatment: the simultaneous intervention of several resources required at the time of delivering cares to one patient. - Customized care delivery: the patient environment (home and family) makes specific each delivery of care. Consequently, this organization is faced to OM related issues like the complexity of the processes,
confusion in decisions, confusion in the relationship between logistics and therapeutic activities, etc. However, despite a strong need of OM methods and tools in HHC, there is still a lack of studies on this topic. Few papers are focused on specific technical issues, see (De Angelis, 1998) and (Cheng and Rich, 1998), however they do not provide a macro vision on HHC processes, that is why we aim in this paper to develop a qualitative and general model which enables to represent OM related activities in HHC structures.
an alternative to the traditional hospitalization or a relay to the hospital given that the treatment of a patient, admitted in hospital, can be shortened, and completed by a hospitalization in a HHC structure. The existence of one of these two possibilities depends on the national/regional health policies, and whenever these two solutions exist in the same region, they can be relative to specific pathologies or chosen according to patient (or his family) preference.
The global patient care process requires the development of a systemic analysis to manage and coordinate the human and material resources in order to ensure the continuity of the care provided by this system. In this paper, we try to develop and adapt a method experienced in industrial domain to Home Health Care issues.
3. THE HHC STRUCTURE MODELING
This paper has two goals: to focus the attention of OM researchers on HHC processes where they can face the difficult challenge to apply the existent methods in a very different and peculiar field like HHC is, and to bring the science of management back into health care, i.e. providing a decision support model for a better organization. Our paper is organized as follows: in Section 2, the Home Health Care concept is presented. Section 3 introduces the methods of the systemic analysis to better explain why the IDEF0 1 (IDEF0, 1993) has been chosen for the HHC system modeling before presenting the modeling approach and presenting the IDEF0 model. Finally, the OM decisions are deduced and presented.
2. DEFINITIONS OF HOME HEALTH CARE The concept of HHC exists since fifty years, however these structures have begun to grow up and to improve their functioning only these last few years. Their development is accelerated with the ageing of the population, the apparition of chronic pathologies, the advent of new medical technologies and new drugs and the continuous pushing to cost containment by Governments. The actual HHC definition stipulates that these structures are dedicated to complex and coordinated medical and paramedical cares for a limited but reviewed period 2 3 . All pathologies can be concerned. They can be prescribed by hospital/ family doctor or also required by the patient or his family. HHC involves different profiles of resources at different steps of patient care process (design, plan and execution). It can be seen as
In this section, we describe and analyze the HHC model we have developed by following the IDEF0 methodology. 3.1 Methods of Systemic Analysis The providing of health services implies the use of several human and material resources in hospitals as well as in HHC structures. In order to provide coordinated and continuous care to patients whose status is not necessarily stable all these elements interact in a complex way difficult to formalize. Many methods exist in the enterprise modeling domain, thus we attempt to find the way to better understand the functioning of HHC system and to visualize the OM issues. Note that to choose the most suitable technique, we have to consider the users’ requirements and the project context. Generally, for a clear and complete description of a system, it is necessary to combine at least more than one modeling method for having different views which provide different information. Shen et al. (2004) combined the advantages of three modeling methods (IDEF0, IDEF3 and Data Flow Diagrams) in such way that it is possible to establish a set of models at different modeling stages and from different views. In order to analyze the manufacturing system behavior, Santarek and Buseif (1998), developed a high level system design specification using SADT (Structured Analysis and Design Technique)/IDEF0 before transforming it into a dynamic model with PetriNets. The enterprise modeling can be static (e.g. using GRAI, ERM, ABC) 4 or dynamic (e.g. using IDEF2, Petri-Nets, RAD) 5 . The static modeling is used to define and understand the system by portraying generally the possible flow paths of objects through the system. The dynamic modeling, complement to the static one, attempts to capture 4
1 2 3
Integration Definition for Function Modeling Code de la Sant´ e Publique fran¸cais article R. 712-2-1 Ministero della salute, Italy
GRAI: Groupe de Recherche Architecture et Infrastructures; ERM : Entity-Relationship Modeling ; ABC : Activity Based Costing 5 IDEF2: IDEF Dynamic Modeling Method; RAD: Role Activity Diagram
and describe the behavior of the system over a given period of time under different operating conditions. Thus, the complex system modeling can be composed of the following steps: presentation of the general system model (static modeling), description of its different views (static modeling) and analysis of its behavior (dynamic modeling). In this paper, we use SADT/IDEF0 method. In both (Shen et al., 2004) and (Santarek and Buseif, 1998), the use of such a method is approved in the first phase of system modeling. IDEF0 models have a breakdown structure, a hierarchical series of diagrams built based on the Inputs- Controls- Outputs- Mechanisms (ICOM) Code , and a glossary, see (IDEF0, 1993). This method permits to visualize the main functions of a system. The represented functions are decision making activities, information transformation activities or physical transformation activities. To establish an IDEF0 model, it is possible to have as inputs activities and information, decisions or processes. In this study we have only activities and information as initial elements.
3.2 The IDEF0 model The modeling approach; The interest of this study is to provide to the HHC professionals, who focus their attention on the therapeutic aspects of the care service delivered to patients, our point of view concerning their organization. The proposed model addresses the organisational/logistics issues related to the HHC service pointing out the main processes, resources and flows. Such a model could be used as a reference from which it is possible to build a decision support system for HHC providers. A first step of our approach consists in the delimitation of the system analyzed, i.e. which parts/functions of the HHC structure and its environment shall be included in our analysis. All the activities related directly or indirectly to the care delivery and performed by HHC providers have been considered in the model, except for the financial processes that are out of scope of this work. Then, the OM and therapeutic functions, together with their interconnections, have been determined and decomposed into sub-functions until an acceptable level of detail. For limited space reasons, only the decomposition of the principle activity of the HHC structure, i.e. managing patients and their therapeutic projects, is reported in this paper. Each decomposed sub-activity is then interconnected to the others according to the IDEF0 formalism (i.e. inputs, constraints, outputs and mechanisms). Thus, the outputs of some activities represent constraints or inputs for other activities.
Top-down and bottom-up approaches are used to check and adjust the model. The description of the model ; The main functions identified in a HHC organization are ”Define HHC strategy”, ”Plan resources and consumable”, ”Manage projects” and ”Manage quality”. They are represented at the top level of the IDEF0 model (cf. Fig. 1). The top level of the model ”Manage HHC structure” [A0] represents the interactions among the main activities that exist or should exist in the HHC organization: definition of care delivery strategy, management of therapeutic projects, management of organizational activities to support the care delivery (consumable and resources management), and determination of the quality objectives. The HHC provider tries to ensure a good position in the health domain by attracting patients, being complementary to other health establishments according to environmental factors such as national/regional policies or market competitiveness. Principle objectives of the structure are elaborated in consequence [A1] and represent the main control for the running and the management of the HHC structure. For instance, profit companies could provide HHC services trying to maximize their profit compatible to minimum acceptable quality levels; in this case the increase of the number of patients may represent an important objective of the service provider. On the other hand, a public service provider could pursue the goal of covering as much as possible the patient service demand, thus a practical objective could be to enable the birth of new providers, both profit and not. The management deals essentially with two kinds of flows: a ”virtual” one, which is the patient flow, and a ”real” one, which is related to consumable and resource flows. Patients are hospitalized at their homes where they receive all the resources implied in their care delivery. Unlike admittance in/discharge from hospitals, patients do not enter/exit a physical structure; indeed the start of the HHC service is identified by the set up or the remove of the medical equipments and the beginning/end of the HHC professionals visits. That is why we call ”virtual” the patient flow. The flows of consumable and resources are considered to be secondary since they exist only to support patient care. However, a good management of consumable and resources is necessary for a good service level at a minimum cost. Thus, in order to respond adequately to the patient demand, the use of consumable and resources must be planned and controlled [A2]. This activity is essentially constrained by financing, partnership strategy and qualitative/ quantitative requirements.
A0 Manage HC structure
A1 Define HC strategy
A21 Evaluate
A22 Define HC
patient demand
A231
Adapt internal /external resources capacities
A2
capacity
Top level
Plan consumables and resources
A24 Plan
A23 Plan
resources
A232
A233
A234
A235
Reserve external resources capacities
Manage skills
Maintain material resources
Define availability
A31
Acquire potential projects
consumables
A241
Select consumables providers
A242
A243
Define consumables inventory management
A3321
Plan activities
A4
A3 Manage projects
A3322
Replenish consumables
A3323
Schedule resources
Define routing
A32
Define projects handbook
A331
Engineer projects
A3324
Control activities
Manage quality
A33 Realize patient
projects
A332
A333
Plan projects
A334
Execute projects
A3331
A3332
Execute transports
Execute measures
A3333
Execute cares
Control projects
A3334
Control execution
Fig. 1. Node tree: IDEF0 model of HHC process The management of patient flow is equivalent to the management of patient projects [A3]. For each admitted patient, one project is created combining both therapeutic and organizational activities which will be performed on the patient in order to provide him the adequate care service. This is based on protocols and quality rules, and constrained by environmental conditions and consumable and resource availabilities. There are three ways of recruiting patients [A31]: a patient can ask for HHC by himself, the request can be formulated by his attending physician, or also the ”recruitment” can be made by a nurse who has a ”selling activity” in hospitals, i.e. she searches for the potential HHC patients within hospitals. Patients can even be redirected by the health organization in which they are hospitalized, towards a HHC structure. All of these potential demands are studied to focus on the market segment which is more coherent with the marketing policies of the HHC structure. ”Acquire potential projects” consists in gathering and selecting patient demands. The design, plan and execution of the projects of all selected patients [A33] are constrained by the availabilities of resources and consumable. The HHC project of one patient can be stopped when the care is over or when the Home Health Care provider is not able to satisfy its needs anymore. In order to well develop and organize the service delivered to patients, a project handbook can be created to list the best practices. It is based on the experience of the HHC professionals, the previous observed dysfunctions and the quality standards and rules [A32]. In order to control all these activities and thus, to improve the management of the HHC structure, some rules or standards should be defined. In the IDEF0 model, the quality measurement and the monitoring of the structure and the associated processes are included in the following activities: ”Manage quality”, ”Control projects”, ”Control
activities” and ”Control execution”. The activity ”Manage quality” [A4] deals mainly with: - The development of internal quality rules - The development of a set of indicators and tools to measure the quality level of the care organization and therapy - The monitoring of the providers of consumable and their performance - The analysis of data and the creation of reports to be provided to the strategic committee or to other functions. In tactical and operational levels, the activity ”Control projects” [A334] consists in controlling the whole service delivered to patients during the treatment. This activity, based on the analysis of the current patient state, is performed on different levels of the project cycle. ”Control activities” [A3324] concerns adjustments on planning of project activities, scheduling or routing. ”Control execution” [A3334] is the supervision of operational activities and the checking of the modifications that will be performed on them. Preliminary results obtained from the analysis of the model ; The functional decomposition of the activities described above, has been used to identify processes, flows and the resources involved. To better illustrate the model, two colors are used to refer to therapeutic and logistic functions: gray to therapeutic functions, white to organizational ones and both gray and white to functions which can be broken down into therapeutic and organizational sub functions (cf. Fig. 2). The remainder of this subsection describes the identified processes, flows and resources. Process classification: The major processes are: the development and management of therapeutic projects, the consumable management and the planning and management of human and material resources. With the IDEF0 model, the visualization of the different processes is possible as well
Detailed Activities program
To be transported (human resources, patient, equipment, consumables )
External conditions
Adjustments to execution
Patient project
Adjustments to execution
Transported resources
Execute transports
Execution sheet
1
Transported patient
Consumables Perceived quality Measured patient Wastes Patient info
Execute measures
Patient dossier Patient satisfaction questionnairs
Execution sheet
2 Measures request
Service request
Treated patient Wastes
Execute cares
Patient
Patient dossier
3 Cares request Service request
Transport request
Control execution 4
Autonomous patient
Transporters
Caregiver NODO:
A333
Technical platform
Equipment, Doctors, nurses, ext. specialists , psychologist , social assistant
TITOLO:
Execute projects
Emergency Request for repairs
Doctors, nurses, ext. specialists , psychologist , social assistant N.:
Fig. 2. IDEF0 model: decomposition of the activity ”Execute projects” as the required information and the resources implied in their development. Flow classification: Three kinds of flows are perceivable from the HHC model: - Physical flows (e.g. patients, consumable), - Information flows: either for control (e.g. ”adjustments”/ ”infeasibilities”, ”resources and consumable availabilities”) or as input for activities (e.g. ”patients’ dossiers”, ”human resources performance”) - Decision flows that will be described in detail in the following paragraphs. Resources classification: Internal and/or external resources involved in the different processes at the strategic level (e.g. definition of the HHC strategy) or at the operational level (e.g. execution of cares). Some of these resources can be shared with other structures. - Human resources (medical, paramedical, psychosocial, logisticians) (i) can have care production related activities or not (ii) can be decision makers or operators(leading and following). - Material resources can be technical platform or medical devices. They can be bottleneck or not. - Consumable is material resources which can be used only one time such as drugs, syringes and bandages. The IDEF0 model permits the identification of the necessary resources profiles according to identified functions. Once the different functions carried out in the HHC structure are determined, it is possible to assign to each one the adequate skills and the necessary material resources.
3.3 the mapping of decision In the HHC structure like in any other health establishment, the focus is on the patient flow. Any decision or activity that can be performed in these structures is used to better manage this flow,
and thus, to deliver a good quality of service to patients. The consumable or resource flows are ”secondary”, they are a support to the management of patient flow, see (Huijsman and Vissers, 2004). Information and decision flows concern therapeutic and/or logistics aspects. Some therapeutic information or decisions can affect logistics functions; for example, a nurse who must perform some cares on one patient, e.g. the injection of some medicine, requires a syringe and the drug to administrate. Thus, if any of these resources is not available, this care activity cannot be carried out. All the resources involved in one operation have to be present at the right moment in the right location. This is possible only if we consider organizational and logistics activities in the execution of cares ones. A strong link exists between therapeutic and organizational activities, i.e. both therapeutic and organizational decisions have to be coordinated to well manage the physical process (patient care process) given a possible influence of therapeutic decisions on logistic ones, and vice-versa. Decisions are fed by respectively therapeutic and logistics information resulting from the physical process. This interdependence is true for all health establishments, and especially for organizations providing complex and continuous cares like Home Health Care structures. By considering Operations Management activities identified from the IDEF0 model, we represent the deduced decisions in the diagram shown in Fig. 3. Some of these decisions already exist in the actual HHC organizations, while some others do not exist yet, and their lack can cause dysfunctions in the system. The decisions we identified can be classified into three categories. The first category presents the competitive objectives of a HHC structure: demand satisfaction (the proportion of total demand that the HHC structure wants to satisfy), patient satisfaction (the amenities which a HHC patient
Demand satisfaction
Admittance policy (pathology, location, …)
Patient satisfaction
Competitive objectives
Requirements
Definition of the partnership strategy
Location and Dimension HC structure
Long term
Definition of the marketing strategy
Definition of Internal quality rules
Determination of the Budget
Skill management
External material resources Capacity adaptation
Internal material resources Capacity adaptation
External human resources Capacity adaptation
Internal human resources Capacity adaptation
Selection of Consumables providers
Inventory policies
Maintaince (material resources)
Selection of Consumables type/ estimated annual quantity
Definition of Quality indicators
Definition of Best practices
Project Activities (re)definition
Admittance / dismission patients
Activities planning
Human resources and equipment scheduling
Routing
Consumables orders submission
Medium & Short term
Project activities execution (adjustments)
Fig. 3. The mapping of decisions may require to be completely satisfied) and admittance policy (the criteria that the patient must have to be admitted to the HHC structure). The strategy of the structure consists in performing guide-lines related with this competitive strategy and the national/regional policies. Therefore, the long term issues deal with the partnership strategy, the location and design of the HHC structure, the marketing strategy, the financing and the performance of the HHC structure. The medium and short terms decisions (i.e. tactical and operational) concern essentially the planning of human and material resources, the management of consumable and the management of patient projects.
4. CONCLUSIONS AND PROSPECTS The HHC providers are focused on their core activity which is the delivery of health services to patients that stay at their home. Therefore, professionals require decision support tools to better organize conditions in which they produce cares. OM tools and approaches have been applied to solve some of the issues encountered in health care, especially in hospitals. Nevertheless, HHC structures did not benefit from such approaches yet. We aim at contributing to fill this gap by developing an IDEF0 model which provides a global view of the management of HHC structures by identifying a set of therapeutic and logistics functions connected by information, decision and physical flows. The proposed IDEF0 model is still under validation by French and Italian HHC providers. To ensure its applicability and adaptability under different conditions, several HHC structures that have different properties have been chosen, i.e. public or private structures, with or without profit. Our ongoing work consists in identifying
the decision making process in HHC structures, determining the critical points in this process and devoting our OM efforts to develop methods and tools supporting this process. These results will be published in a future work.
REFERENCES Chahed, S., E. Sahin and Y. Dallery (2004). L’hospitalisation `a domicile: quel(s) int´erˆet(s) et quelle(s) organisation(s) ?. Actes de la 2`eme Conf´erence Francophone en Gestion et Ing´enierie des Syst`emes Hospitaliers. FUCAM, Mons. Cheng, E. and J. L. Rich (1998). A home health care routing and scheduling problem. Technical Report, CAAM TR98-04, Rice University. De Angelis, V. (1998). Planning home assistance for aids patients in the city of rome, italy. Interfaces 28, 75–83. Huijsman, R. and J. M. H. Vissers (2004). Supply chain management in health care: State of the art and potential. In: The Emerging World of Chains and Networks. Bridging Theory and Practice (Th. Camps, P. Diederen, G-J. Hofstede, and B. Vos (Ed)). pp. 147–167. The Hague: Reed Business Information. IDEF0 (1993). Announcing the standard for integration definition for function modelling. Draft Federal Information Processing Standards Publication 183, http://www.idef.com/pdf/idef0.pdf. Santarek, K. and I. M. Buseif (1998). Modelling and design of flexible manufacturing systems using sadt and petri nets tools. Journal of material processing technology 76, 212–218. Shen, H., B. Wall, M. Zaremba, Y. Chen and J. Browne (2004). Integration of business modelling methods for enterprise information system analysis and user requirements gathering. Computers in Industry 54, 307–323.
Laboratoire Genie Industriel, Ecole Centrale Paris, France Dipartamento di Meccanica, Politecnico di Milano, Italy
b
Abstract: Home heath care sector is a diverse and dynamic service industry. These services include complex cares and psycho-social services in the comfort of home. The goal is to help patients to reach and to keep their best clinical, psychological and social well-being. To our knowledge, there are very few studies that identify operations management type activities involved in the delivery of the service provided by Home Health Care structures. In this paper, we analyze the functioning of Home Health Care structures with a particular interest on identifying decisions related to operations management in the care giving process. c 2006 IFAC Copyright ° Keywords: decision support systems, structured analysis, qualitative analysis, decision making, flow diagrams.
1. INTRODUCTION
The main objective of Operations Management (OM) in the health domain is to determine the most efficient and effective organization of cares production in order to reach the required level of quality at contained cost. The service quality can be considered as the patient quality requirements (e.g. improvement of the quality of care, reduction of the waiting time, satisfaction of the preferences of the patient, etc.) and/or the health professionals’ quality requirements (e.g. equitable distribution of the workloads, execution of high skilled activities, etc.). The service cost deals with all the cost of components incurred to run care and logistic activities (e.g. investment costs for resources, care delivery costs, transportation costs, etc.) and it relates the patient, the health provider, the financiers and the national/regional institutions.
The Home Health Care (HHC) structure is one alternative to the traditional hospitalization. It differs from the other health organizations by considering the patient homes as components of the health supply chain. This organization introduces a new problem which is related to the fact that patients stay at their home, and therefore new constraints are set up (Chahed et al., 2004): - Necessity to provide care to one patient at a fixed time: the patients are not hospitalized inside the same unit but in their respective home, therefore patients are treated individually. - Synchronization of resources during the patient treatment: the simultaneous intervention of several resources required at the time of delivering cares to one patient. - Customized care delivery: the patient environment (home and family) makes specific each delivery of care. Consequently, this organization is faced to OM related issues like the complexity of the processes,
confusion in decisions, confusion in the relationship between logistics and therapeutic activities, etc. However, despite a strong need of OM methods and tools in HHC, there is still a lack of studies on this topic. Few papers are focused on specific technical issues, see (De Angelis, 1998) and (Cheng and Rich, 1998), however they do not provide a macro vision on HHC processes, that is why we aim in this paper to develop a qualitative and general model which enables to represent OM related activities in HHC structures.
an alternative to the traditional hospitalization or a relay to the hospital given that the treatment of a patient, admitted in hospital, can be shortened, and completed by a hospitalization in a HHC structure. The existence of one of these two possibilities depends on the national/regional health policies, and whenever these two solutions exist in the same region, they can be relative to specific pathologies or chosen according to patient (or his family) preference.
The global patient care process requires the development of a systemic analysis to manage and coordinate the human and material resources in order to ensure the continuity of the care provided by this system. In this paper, we try to develop and adapt a method experienced in industrial domain to Home Health Care issues.
3. THE HHC STRUCTURE MODELING
This paper has two goals: to focus the attention of OM researchers on HHC processes where they can face the difficult challenge to apply the existent methods in a very different and peculiar field like HHC is, and to bring the science of management back into health care, i.e. providing a decision support model for a better organization. Our paper is organized as follows: in Section 2, the Home Health Care concept is presented. Section 3 introduces the methods of the systemic analysis to better explain why the IDEF0 1 (IDEF0, 1993) has been chosen for the HHC system modeling before presenting the modeling approach and presenting the IDEF0 model. Finally, the OM decisions are deduced and presented.
2. DEFINITIONS OF HOME HEALTH CARE The concept of HHC exists since fifty years, however these structures have begun to grow up and to improve their functioning only these last few years. Their development is accelerated with the ageing of the population, the apparition of chronic pathologies, the advent of new medical technologies and new drugs and the continuous pushing to cost containment by Governments. The actual HHC definition stipulates that these structures are dedicated to complex and coordinated medical and paramedical cares for a limited but reviewed period 2 3 . All pathologies can be concerned. They can be prescribed by hospital/ family doctor or also required by the patient or his family. HHC involves different profiles of resources at different steps of patient care process (design, plan and execution). It can be seen as
In this section, we describe and analyze the HHC model we have developed by following the IDEF0 methodology. 3.1 Methods of Systemic Analysis The providing of health services implies the use of several human and material resources in hospitals as well as in HHC structures. In order to provide coordinated and continuous care to patients whose status is not necessarily stable all these elements interact in a complex way difficult to formalize. Many methods exist in the enterprise modeling domain, thus we attempt to find the way to better understand the functioning of HHC system and to visualize the OM issues. Note that to choose the most suitable technique, we have to consider the users’ requirements and the project context. Generally, for a clear and complete description of a system, it is necessary to combine at least more than one modeling method for having different views which provide different information. Shen et al. (2004) combined the advantages of three modeling methods (IDEF0, IDEF3 and Data Flow Diagrams) in such way that it is possible to establish a set of models at different modeling stages and from different views. In order to analyze the manufacturing system behavior, Santarek and Buseif (1998), developed a high level system design specification using SADT (Structured Analysis and Design Technique)/IDEF0 before transforming it into a dynamic model with PetriNets. The enterprise modeling can be static (e.g. using GRAI, ERM, ABC) 4 or dynamic (e.g. using IDEF2, Petri-Nets, RAD) 5 . The static modeling is used to define and understand the system by portraying generally the possible flow paths of objects through the system. The dynamic modeling, complement to the static one, attempts to capture 4
1 2 3
Integration Definition for Function Modeling Code de la Sant´ e Publique fran¸cais article R. 712-2-1 Ministero della salute, Italy
GRAI: Groupe de Recherche Architecture et Infrastructures; ERM : Entity-Relationship Modeling ; ABC : Activity Based Costing 5 IDEF2: IDEF Dynamic Modeling Method; RAD: Role Activity Diagram
and describe the behavior of the system over a given period of time under different operating conditions. Thus, the complex system modeling can be composed of the following steps: presentation of the general system model (static modeling), description of its different views (static modeling) and analysis of its behavior (dynamic modeling). In this paper, we use SADT/IDEF0 method. In both (Shen et al., 2004) and (Santarek and Buseif, 1998), the use of such a method is approved in the first phase of system modeling. IDEF0 models have a breakdown structure, a hierarchical series of diagrams built based on the Inputs- Controls- Outputs- Mechanisms (ICOM) Code , and a glossary, see (IDEF0, 1993). This method permits to visualize the main functions of a system. The represented functions are decision making activities, information transformation activities or physical transformation activities. To establish an IDEF0 model, it is possible to have as inputs activities and information, decisions or processes. In this study we have only activities and information as initial elements.
3.2 The IDEF0 model The modeling approach; The interest of this study is to provide to the HHC professionals, who focus their attention on the therapeutic aspects of the care service delivered to patients, our point of view concerning their organization. The proposed model addresses the organisational/logistics issues related to the HHC service pointing out the main processes, resources and flows. Such a model could be used as a reference from which it is possible to build a decision support system for HHC providers. A first step of our approach consists in the delimitation of the system analyzed, i.e. which parts/functions of the HHC structure and its environment shall be included in our analysis. All the activities related directly or indirectly to the care delivery and performed by HHC providers have been considered in the model, except for the financial processes that are out of scope of this work. Then, the OM and therapeutic functions, together with their interconnections, have been determined and decomposed into sub-functions until an acceptable level of detail. For limited space reasons, only the decomposition of the principle activity of the HHC structure, i.e. managing patients and their therapeutic projects, is reported in this paper. Each decomposed sub-activity is then interconnected to the others according to the IDEF0 formalism (i.e. inputs, constraints, outputs and mechanisms). Thus, the outputs of some activities represent constraints or inputs for other activities.
Top-down and bottom-up approaches are used to check and adjust the model. The description of the model ; The main functions identified in a HHC organization are ”Define HHC strategy”, ”Plan resources and consumable”, ”Manage projects” and ”Manage quality”. They are represented at the top level of the IDEF0 model (cf. Fig. 1). The top level of the model ”Manage HHC structure” [A0] represents the interactions among the main activities that exist or should exist in the HHC organization: definition of care delivery strategy, management of therapeutic projects, management of organizational activities to support the care delivery (consumable and resources management), and determination of the quality objectives. The HHC provider tries to ensure a good position in the health domain by attracting patients, being complementary to other health establishments according to environmental factors such as national/regional policies or market competitiveness. Principle objectives of the structure are elaborated in consequence [A1] and represent the main control for the running and the management of the HHC structure. For instance, profit companies could provide HHC services trying to maximize their profit compatible to minimum acceptable quality levels; in this case the increase of the number of patients may represent an important objective of the service provider. On the other hand, a public service provider could pursue the goal of covering as much as possible the patient service demand, thus a practical objective could be to enable the birth of new providers, both profit and not. The management deals essentially with two kinds of flows: a ”virtual” one, which is the patient flow, and a ”real” one, which is related to consumable and resource flows. Patients are hospitalized at their homes where they receive all the resources implied in their care delivery. Unlike admittance in/discharge from hospitals, patients do not enter/exit a physical structure; indeed the start of the HHC service is identified by the set up or the remove of the medical equipments and the beginning/end of the HHC professionals visits. That is why we call ”virtual” the patient flow. The flows of consumable and resources are considered to be secondary since they exist only to support patient care. However, a good management of consumable and resources is necessary for a good service level at a minimum cost. Thus, in order to respond adequately to the patient demand, the use of consumable and resources must be planned and controlled [A2]. This activity is essentially constrained by financing, partnership strategy and qualitative/ quantitative requirements.
A0 Manage HC structure
A1 Define HC strategy
A21 Evaluate
A22 Define HC
patient demand
A231
Adapt internal /external resources capacities
A2
capacity
Top level
Plan consumables and resources
A24 Plan
A23 Plan
resources
A232
A233
A234
A235
Reserve external resources capacities
Manage skills
Maintain material resources
Define availability
A31
Acquire potential projects
consumables
A241
Select consumables providers
A242
A243
Define consumables inventory management
A3321
Plan activities
A4
A3 Manage projects
A3322
Replenish consumables
A3323
Schedule resources
Define routing
A32
Define projects handbook
A331
Engineer projects
A3324
Control activities
Manage quality
A33 Realize patient
projects
A332
A333
Plan projects
A334
Execute projects
A3331
A3332
Execute transports
Execute measures
A3333
Execute cares
Control projects
A3334
Control execution
Fig. 1. Node tree: IDEF0 model of HHC process The management of patient flow is equivalent to the management of patient projects [A3]. For each admitted patient, one project is created combining both therapeutic and organizational activities which will be performed on the patient in order to provide him the adequate care service. This is based on protocols and quality rules, and constrained by environmental conditions and consumable and resource availabilities. There are three ways of recruiting patients [A31]: a patient can ask for HHC by himself, the request can be formulated by his attending physician, or also the ”recruitment” can be made by a nurse who has a ”selling activity” in hospitals, i.e. she searches for the potential HHC patients within hospitals. Patients can even be redirected by the health organization in which they are hospitalized, towards a HHC structure. All of these potential demands are studied to focus on the market segment which is more coherent with the marketing policies of the HHC structure. ”Acquire potential projects” consists in gathering and selecting patient demands. The design, plan and execution of the projects of all selected patients [A33] are constrained by the availabilities of resources and consumable. The HHC project of one patient can be stopped when the care is over or when the Home Health Care provider is not able to satisfy its needs anymore. In order to well develop and organize the service delivered to patients, a project handbook can be created to list the best practices. It is based on the experience of the HHC professionals, the previous observed dysfunctions and the quality standards and rules [A32]. In order to control all these activities and thus, to improve the management of the HHC structure, some rules or standards should be defined. In the IDEF0 model, the quality measurement and the monitoring of the structure and the associated processes are included in the following activities: ”Manage quality”, ”Control projects”, ”Control
activities” and ”Control execution”. The activity ”Manage quality” [A4] deals mainly with: - The development of internal quality rules - The development of a set of indicators and tools to measure the quality level of the care organization and therapy - The monitoring of the providers of consumable and their performance - The analysis of data and the creation of reports to be provided to the strategic committee or to other functions. In tactical and operational levels, the activity ”Control projects” [A334] consists in controlling the whole service delivered to patients during the treatment. This activity, based on the analysis of the current patient state, is performed on different levels of the project cycle. ”Control activities” [A3324] concerns adjustments on planning of project activities, scheduling or routing. ”Control execution” [A3334] is the supervision of operational activities and the checking of the modifications that will be performed on them. Preliminary results obtained from the analysis of the model ; The functional decomposition of the activities described above, has been used to identify processes, flows and the resources involved. To better illustrate the model, two colors are used to refer to therapeutic and logistic functions: gray to therapeutic functions, white to organizational ones and both gray and white to functions which can be broken down into therapeutic and organizational sub functions (cf. Fig. 2). The remainder of this subsection describes the identified processes, flows and resources. Process classification: The major processes are: the development and management of therapeutic projects, the consumable management and the planning and management of human and material resources. With the IDEF0 model, the visualization of the different processes is possible as well
Detailed Activities program
To be transported (human resources, patient, equipment, consumables )
External conditions
Adjustments to execution
Patient project
Adjustments to execution
Transported resources
Execute transports
Execution sheet
1
Transported patient
Consumables Perceived quality Measured patient Wastes Patient info
Execute measures
Patient dossier Patient satisfaction questionnairs
Execution sheet
2 Measures request
Service request
Treated patient Wastes
Execute cares
Patient
Patient dossier
3 Cares request Service request
Transport request
Control execution 4
Autonomous patient
Transporters
Caregiver NODO:
A333
Technical platform
Equipment, Doctors, nurses, ext. specialists , psychologist , social assistant
TITOLO:
Execute projects
Emergency Request for repairs
Doctors, nurses, ext. specialists , psychologist , social assistant N.:
Fig. 2. IDEF0 model: decomposition of the activity ”Execute projects” as the required information and the resources implied in their development. Flow classification: Three kinds of flows are perceivable from the HHC model: - Physical flows (e.g. patients, consumable), - Information flows: either for control (e.g. ”adjustments”/ ”infeasibilities”, ”resources and consumable availabilities”) or as input for activities (e.g. ”patients’ dossiers”, ”human resources performance”) - Decision flows that will be described in detail in the following paragraphs. Resources classification: Internal and/or external resources involved in the different processes at the strategic level (e.g. definition of the HHC strategy) or at the operational level (e.g. execution of cares). Some of these resources can be shared with other structures. - Human resources (medical, paramedical, psychosocial, logisticians) (i) can have care production related activities or not (ii) can be decision makers or operators(leading and following). - Material resources can be technical platform or medical devices. They can be bottleneck or not. - Consumable is material resources which can be used only one time such as drugs, syringes and bandages. The IDEF0 model permits the identification of the necessary resources profiles according to identified functions. Once the different functions carried out in the HHC structure are determined, it is possible to assign to each one the adequate skills and the necessary material resources.
3.3 the mapping of decision In the HHC structure like in any other health establishment, the focus is on the patient flow. Any decision or activity that can be performed in these structures is used to better manage this flow,
and thus, to deliver a good quality of service to patients. The consumable or resource flows are ”secondary”, they are a support to the management of patient flow, see (Huijsman and Vissers, 2004). Information and decision flows concern therapeutic and/or logistics aspects. Some therapeutic information or decisions can affect logistics functions; for example, a nurse who must perform some cares on one patient, e.g. the injection of some medicine, requires a syringe and the drug to administrate. Thus, if any of these resources is not available, this care activity cannot be carried out. All the resources involved in one operation have to be present at the right moment in the right location. This is possible only if we consider organizational and logistics activities in the execution of cares ones. A strong link exists between therapeutic and organizational activities, i.e. both therapeutic and organizational decisions have to be coordinated to well manage the physical process (patient care process) given a possible influence of therapeutic decisions on logistic ones, and vice-versa. Decisions are fed by respectively therapeutic and logistics information resulting from the physical process. This interdependence is true for all health establishments, and especially for organizations providing complex and continuous cares like Home Health Care structures. By considering Operations Management activities identified from the IDEF0 model, we represent the deduced decisions in the diagram shown in Fig. 3. Some of these decisions already exist in the actual HHC organizations, while some others do not exist yet, and their lack can cause dysfunctions in the system. The decisions we identified can be classified into three categories. The first category presents the competitive objectives of a HHC structure: demand satisfaction (the proportion of total demand that the HHC structure wants to satisfy), patient satisfaction (the amenities which a HHC patient
Demand satisfaction
Admittance policy (pathology, location, …)
Patient satisfaction
Competitive objectives
Requirements
Definition of the partnership strategy
Location and Dimension HC structure
Long term
Definition of the marketing strategy
Definition of Internal quality rules
Determination of the Budget
Skill management
External material resources Capacity adaptation
Internal material resources Capacity adaptation
External human resources Capacity adaptation
Internal human resources Capacity adaptation
Selection of Consumables providers
Inventory policies
Maintaince (material resources)
Selection of Consumables type/ estimated annual quantity
Definition of Quality indicators
Definition of Best practices
Project Activities (re)definition
Admittance / dismission patients
Activities planning
Human resources and equipment scheduling
Routing
Consumables orders submission
Medium & Short term
Project activities execution (adjustments)
Fig. 3. The mapping of decisions may require to be completely satisfied) and admittance policy (the criteria that the patient must have to be admitted to the HHC structure). The strategy of the structure consists in performing guide-lines related with this competitive strategy and the national/regional policies. Therefore, the long term issues deal with the partnership strategy, the location and design of the HHC structure, the marketing strategy, the financing and the performance of the HHC structure. The medium and short terms decisions (i.e. tactical and operational) concern essentially the planning of human and material resources, the management of consumable and the management of patient projects.
4. CONCLUSIONS AND PROSPECTS The HHC providers are focused on their core activity which is the delivery of health services to patients that stay at their home. Therefore, professionals require decision support tools to better organize conditions in which they produce cares. OM tools and approaches have been applied to solve some of the issues encountered in health care, especially in hospitals. Nevertheless, HHC structures did not benefit from such approaches yet. We aim at contributing to fill this gap by developing an IDEF0 model which provides a global view of the management of HHC structures by identifying a set of therapeutic and logistics functions connected by information, decision and physical flows. The proposed IDEF0 model is still under validation by French and Italian HHC providers. To ensure its applicability and adaptability under different conditions, several HHC structures that have different properties have been chosen, i.e. public or private structures, with or without profit. Our ongoing work consists in identifying
the decision making process in HHC structures, determining the critical points in this process and devoting our OM efforts to develop methods and tools supporting this process. These results will be published in a future work.
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