BUSINESS PROCESS RE-ENGINEERING of the EMERGENCY TREATMENT UNIT at THE COLOMBO SOUTH TEACHING HOSPITAL MASTER OF BUSINESS ADMINISTRATION IN E-GOVERNANCE KARUNATILAKA M. N. Department of Computer Science & Engineering University of Moratuwa 2009 BUSINESS PROCESS RE-ENGINEERING of the EMERGENCY TREATMENT UNIT at THE COLOMBO SOUTH TEACHING HOSPITAL By KARUNATILAKA M. N. The dissertation was submitted to the Department of Computer Science & Engineering of the University of Moratuwa in partial fulfilment of the requirement for the Degree of Master of Business Administration. Department of Computer Science & Engineering University of Moratuwa 2009 i DECLARATION “I certify that this thesis does not incorporate without acknowledgement, any material previously submitted for a degree or diploma, in any university, to the best of my knowledge and belief and it does not contain any material previously published, written or orally communicated by another person, or myself, except where due reference is made in the text. I also hereby give consent to my dissertation, if accepted, to be made available for photocopying and for interlibrary loans, and for the title and summary to be made available to outside organizations” …………………………… ………………………….. Signature of the Candidate Date To the best of my knowledge, the above particulars are correct. ……………………………. Supervisor (Dr. Shahani Markus Weerawarana) ii ABSTRACT With the emergence of information and communication technology (ICT), health care institutions too, commenced incorporating new technologies, aimed at efficient delivery of health services. Initiatives of this nature, categorized as 'e-health', have become an important activity area, resulting in many advanced total software solutions, for health care institutions worldwide. Unfortunately the acquisition costs of such solutions are too high, for developing countries such as Sri Lanka, and they continue to be challenged, in trying to overcome this financial barrier. Furthermore, most such solutions are not tailored for the specific needs of health care institutions in developing countries, which themselves, have evolved towards providing affordable health care, with highly limited resources in challenging environments. In response, developing countries could consider adopting alternate approaches to achieve the efficiency goals of e-health, by first, systematically studying and identifying the unique features associated with the hospital sectors in these countries and then, by providing innovative e-health solutions that would specifically address the challenges and issues common to health care systems in developing countries. The objective of this research was to find a practical methodology to systematically study a Sri Lankan health care institution with the view of re-engineering the related processes by utilizing the same limited resources in an efficient and effective manner. A clinical unit – the Emergency Treatment Unit (ETU) of the Colombo South Teaching Hospital - which is one of the largest teaching hospitals in Sri Lanka, was chosen as the sample space to test the theories generated by this research. Following an extensive study to identify the essential processes required for the functioning of the ETU, the researchers formulated a well-structured and iteratively applicable framework to re-engineer the processes in Sri Lankan health care institutions. The proposed framework, defines a methodology to perform a detailed analysis of the existing workflows, in a clinical unit and to then re-engineer, those process-level as well as policy-level workflows. Since every clinical unit of hospitals in Sri Lanka carry out more or less the same functions in different contexts, the fundamental concepts in the iii framework that were derived by re-engineering the processes of the ETU at the Colombo South Teaching Hospital in Sri Lanka, could be systematically extended to other clinical units, as well as to other hospitals, as a ripple effect with minimal customization. The proposed framework can be executed with minimal resources. Furthermore, since the framework was conceptualized and designed with several built-in iterations and feedback loops, the final e-health solutions are likely to be more accurate, more timely, more cost- effective and more relevant to the local contexts than existing software solutions that are in use worldwide. Thus, this proposed framework maybe helpful for other developing countries with similar health care sector limitations to achieve their e-health goals without undue delay and cost. iv ACKNOWLEDGEMENT I would like to extend sincere thanks to my research supervisor, Dr. Shahani Weerawarana for her disciplined guidance and providing a long term vision to the study. I would also like to thank the Head of the Department of Computer Science and Engineering Mrs. Vishaka Nanayakkara and all the staff members and batch mates of the MBA/IT 2008 and MBA/e-gov 2008 batch. I would like to thank the Management, doctors and other staff members of the Colombo South Teaching Hospital who contributed to my research, by providing me their valuable time, amongst busy working schedules, without which my objectives would not have been fulfilled. Finally I wish to thank my wife Dilani for her understanding and guidance throughout this research. Thank you. Karunatilaka M.N. MBA/e-gov/08/10204 v TABLE OF CONTENTS Page No Declaration i Abstract ii Acknowledgement iv Table of Contents v List of Graphs vii List of Tables viii List of Illustrations x Abbreviations xi 1. Introduction 1 1.1 Background…………………………………………………. 1 1.2 Research Problem ………………………………………….. 4 1.3 Research Objectives………………………………………… 6 1.4 Importance/ Benefits of the Study………………………….. 6 1.5 Limitations and Scope of the Work………………………… 7 2. Literature Review 9 2.1 Introduction…………………………………………………. 9 2.2 Paperless Hospitals………………………………………..... 9 2.3 Business Process Re-Engineering…………………………... 13 2.4 Information Domains……………………………………….. 17 3. Research Methodology 23 3.1 Understanding the Existing Systems And Processes……….. 24 3.2 In-Depth Analysis of the Current Processes………………... 24 3.3 Policy Re-Engineering Stage ………………………………. 24 3.4 Operational Re-Engineering Stage …………………………. 25 3.5 Documentation……………………………………………… 26 3.6 Stakeholder Feedback and Evaluation……………………… 26 3.7 Process Prototyping and Simulation………………………... 26 3.8 Analytical Feedback and Evaluation……………………… 27 4. Existing Systems And Processes 29 4.1 Organizational Structure……………………………………. 29 4.2 The Current Activities/Processes…………………………… 30 4.3 Key Process Stakeholders……………................................... 32 vi 4.4 The Flow of Activities Across Functional Boundaries……... 33 4.5 Process Related Documents………………………………… 37 4.6 Physical Existence of the Different Units…………………... 39 4.7 Issues Encountered Relation To Effectiveness and Efficiency…………………………………………………… 41 5. Re-Engineering the Process 45 5.1 Policy Stage Re-Engineering……………………………….. 45 5.1.1 Proposed Higher Level Organizational Structure… 46 5.1.2 Administration Owners and Higher Level Responsibilities…………………………………… 47 5.1.3 Information Owners and Higher Level Responsibilities…………………………………… 47 5.1.4 Objectives of the Core Processes…………………. 50 5.1.5 Baselines for the Core Processes………………… 52 5.1.6 Stretch Goals……………………………………… 53 5.1.7 Comparison of Stretch Goals with Baseline……… 56 5.2 Process Re-Engineering Stage ……………………………… 60 5.2.1 Re-Engineered Processes…………………………. 60 5.2.2 Re-Engineered Documents……………………….. 77 6. Stakeholder Feedback and Analysis 80 6.1 Development of the Questionnaire…………………………. 80 6.2 Method of Data Collection…………………………………. 80 6.3 Sample……………………………………………………… 80 6.4 Response to the Questionnaire……………………………… 80 6.5 Analysis of Sample Data…………………………………… 81 6.6 Analysis of Operational Effectiveness……………………… 83 6.7 Detailed Analysis of Responses……………………………. 86 7. Recommendations and Conclusions 94 7.1 Recommendations…………………………………………... 94 7.2 Conclusions…………………………………………………. 95 7.3 Future Areas of Study………………………………………. 96 References………………………………………………………… 98 Appendices……………………………………………………………… 100 Appendix I: Current Processes………………………………….. 100 Appendix II: Process Related Documents………………………. 125 Appendix III: Research Questionnaire………………………….. 131 vii LIST OF GRAPHS Page No Graph 6.1: Service Group Distribution………………………………… 81 Graph 6.2: Educational Qualification Distribution…………………….. 82 Graph 6.3: Employee and Re-Engineered Process Relationship………. 82 Graph 6.4: Level of Ability to Use a Computer……………………… 83 Graph 6.5: Response to Question No.05……………………………….. 86 Graph 6.6: Response to Question No.06……………………………….. 87 Graph 6.7: Response to Question No.07……………………………….. 88 Graph 6.8: Response to Question No.08……………………………….. 89 Graph 6.9: Response to Question No.09……………………………….. 90 Graph 6.10: Response to Question No.10……………………………….. 91 Graph 6.11: Response to Question No.11……………………………….. 92 Graph 6.12: Response to Question No.12……………………………….. 93 viii LIST OF TABLES Page No Table 4.1: Key Stakeholders Within Processes……………………….... 32 Table 4.2: Current Process and Process Related Documents…………... 38 Table 4.3: Process Related Issues………………………………………. 41 Table 5.1: Administrative Owners of the Core Processes……………… 47 Table 5.2: Responsibilities of the Administration Owners…………….. 48 Table 5.3: Information Owners of the Core Processes…………………. 49 Table 5.4: Responsibilities of the Information Owners………………... 49 Table 5.5: Objectives of the Core Processes…………………………… 50 Table 5.6: Baselines for the Core Processes…………………………… 52 Table 5.7: Level I Stretch Goals………………………………………... 54 Table 5.8: Level II Stretch Goals………………………………………. 55 Table 5.9: Level III Stretch Goals……………………………………… 56 Table 5.10: Stretch Goals and Baseline - Patient Registration & EHR…. 57 Table 5.11: Stretch Goals and Baseline - Investigations and Results…… 57 Table 5.12: Stretch Goals and Baseline - Supply Chain Management….. 58 Table 5.13: Stretch Goals and Baseline - Support Service Management... 58 Table 5.14: Stretch Goals and Baseline - Death Certification…………... 59 Table 6.1: Response to the Questionnaire……………………………… 81 Table 6.2: Service Group Distribution ………………………………… 81 Table 6.3: Educational Qualification Distribution …………………….. 82 Table 6.4: Employee and Re-Engineered Process Relationship……….. 82 Table 6.5: Level of Ability to Use a Computer ……………………… 83 Table 6.6: Effectiveness Level of Sample……………………………… 84 Table 6.7: Percentage Operational Effectiveness for each Factor……... 85 Table 6.8: Response Pattern to each Question………………………… 86 Table 6.9: Possibility of Delivering Current Level of Service Effectively…………………………………………………... 86 Table 6.10: Possibility of Achieving Stretch Goals……………………... 87 Table 6.11: Practicality of Re-Engineered Processes……………………. 88 ix Table 6.12: Performance Improvement Possibility……………………… 89 Table 6.13: Employee Support for the Proposed Solution………………. 90 Table 6.14: Manageability of User Interfaces…………………………… 91 Table 6.15: Likelihood of Re-Engineering Process Eliminating Undue Delay………………………………………………………... 92 Table 6.16: Likelihood of Re-Engineering Process Reducing Wastage…………………………………………………….. 92 x LIST OF ILLUSTRATIONS Page No Illustration 3.1: Iterative Re-Engineering Model……………………… 23 Illustration 3.2: Evaluation Model for Operational Effectiveness of BPR……………………………………………………. 27 Illustration 4.1: Organizational Structure……………………………….. 29 Illustration 4.2: Ordering Investigations & Receiving Reports…………. 34 Illustration 4.3: DC through Inquest........................................................ 35 Illustration 4.4: Local Purchase………………………………………… 36 Illustration 4.4: Google Maps View of Colombo South Teaching Hospital 40 Illustration 5.1: Proposed Higher Level Administration Structure…….. 46 Illustration 5.2: Process RA1………………………………………….... 61 Illustration 5.3: Process RA2………………………………………….... 63 Illustration 5.4: Process RB1………………………………………….... 64 Illustration 5.5: Process RB2………………………………………….... 66 Illustration 5.6: Process RC1………………………………………….... 67 Illustration 5.7: Process RC2………………………………………….... 69 Illustration 5.8: Process RD1………………………………………….... 70 Illustration 5.9: Process RD2………………………………………….... 72 Illustration 5.10: Process RD3………………………………………….... 73 Illustration 5.11: Process RD4………………………………………….... 75 Illustration 5.12: Process RE…………………………………………….. 76 xi ABBREVIATIONS BPR Business Process Re-engineering ETU Emergency Treatment Unit DC Death Certificate CSTH Colombo South Teaching Hospital ECG Electro Cardiogram IT Information Technology EHR Electronic Health Records