Lean Healthcare Needs Business Process Management

[This post is prompted by #HITsm chat 6.03.16 Applying Lean principles in healthcare]

I have long advocated combining process improvement methods with workflow technology, such as Business Process Management (BPM). This post assembles content from presentations, blog posts, and tweets stretching over more than a decade.

Let me start with some personal background. I have two masters degrees. One is Industrial Engineering, focusing on workflow, human factors, and productivity. The other is Intelligent Systems (Medical Informatics option). During my MSIE we studied a wide variety of manufacturing workflow, quality, and productivity techniques. During my MSIS we studied theories, principles, and techniques behind many current health IT products.

Guess what? Lean and health IT need each other. However, this can’t happen until two things occur: Lean becomes more informatics like, and health IT becomes more Lean-like.

OK, I know that tweet wasn’t about Lean and BPM… I just like it! (Though to be fair to myself, whenever I think about workflow I automatically think about the related concept, workflow technology, the modern name for which is Business Process Management).

OK, here’s a more interesting tweet. It depicts two rivers, one workflow improvement and then other health IT, diverging and then reconverging, the confluence being healthcare business process management.

Now, let’s drill down on my Lean plus BPM angle.

Above comes from a question at the end of a webinar I gave about healthcare business process management. You’re welcome to read that complete transcript, but this is how I answered this question.

“If you give Lean and Six Sigma professionals [access to workflow mediated by workflow technology], you’ve give them truly plastic, instrumented, malleable healthcare workflow information management tools, I think you’re going to turbo-charge and give a great deal of help to those Lean and Six Sigma activities. In fact, the BPM professionals? They don’t necessarily know the healthcare domain that well. It’s be great to better marry healthcare domain content expertise, the Lean and Six Sigma health professional, to the software that increasingly mediates healthcare workflow.”

Here’s an interesting graphic. I actually used it as my Twitter avatar for a while! It illustrates the relationship between Lean ideas and BPM technology.

Notice any similarities?

From my 2013 webinar, The Power of Process

The Process Optimization Process: Design, Model, Execute, Monitor, Optimize

Okay. Back to workflow of workflow. If you look up business process management in Wikipedia, there’s a phrase there which is, “process optimization process,” again, it sounds meta, the process of optimizing a process. It kind of should remind you of that diagram I showed you of the workflow of workflow, the steps between bad workflow to good workflow.

Well, business process management has a life cycle. Here we have design, model, execute, monitor, optimize. It should be similar to what I just described. Design and model, that’s creating the process definition, the process model. Execute it, that’s what the workflow engine or the orchestration engine or the process engine does. Those are approximate synonyms.

Then you’ve got monitoring so while it’s executing, if there’s an exception, if it falls off the happy path, you want a human to intercede and fix the problem. Then optimization, all this data that gets generated can be fed back into reducing cycle time, increasing throughput, decreasing errors, increasing the accuracy with which the goal is achieved and achieving the same amount of work with fewer resources.

If that cycle reminds you of something called PDCA, Plan, Do, Check, Act or Adjust, it should. It’s software-based PDCA. So much of work today in healthcare is being mediated. It is being in … it’s actually in the software and so if you want to improve that work in that workflow, why not use the software to do it?

Eliminating EMR EHR Non-Value Added Workflow Steps

Over a decade ago I used to teach an annual three-hour tutorial on healthcare workflow technology. Here my slides and speaker notes for Eliminating EMR EHR Non-Value Added Workflow Steps. Note: this is just a small subset of that tutorial. It focuses on eliminating non-valued-added EHR interactions. Workflow technology can also be used to do things in parallel, and to track and monitor and intercede if necessary. It frees users to think creatively and redesign their workflows.

(Take me to the beginning of these slides!)

From EHR Workflow Management Systems: Essentials, History, Healthcare, TEPR Conference, May 19, 2004, Fort Lauderdale.

Value-added activities are typically those that someone will pay for. To use a manufacturing example, an automobile buyer may willingly pay for a leather interior but will be loath to pay for fixing a defect that shouldn’t be there in the first place. Encounter length is determined by a combination of value-added and non-value-added EHR activities. EHR value-added activities include entering data that may be used in a future decision or making a decision that affects the welfare of the patient. Non-value-added activities include navigation from screen to screen and searching for the next person to handover the next activity in the encounter. If these non-value-added activities, and the time required to accomplish them, can be eliminated, encounter length can be reduced.

Process definitions can be used by the workflow engine to accomplish exactly this. Instead of users having to proceed through multiple clicks to search for the next data or order entry screen, the workflow can be controlled by the process definition and the user merely needs to click ‘Next’, ‘Next’, ‘Next’…. (Of course, a user always has the option of jumping out of an executing definition to manually access a different screen than the one presented. Over time, with process definition refinement, this usually happens less and less.) Similarly, instead of a user having to find the next user to hand off the next activity, the workflow engine can do this instead, perhaps by forwarding items into a user’s To-Do list or onto a generally available status screen of pending tasks.

A general strategic principle is to shift as many value-added, and non-value-added activies from the manual to the automated category, while preserving and enhancing value-added manual activies that increase effectiveness, efficiency, and (user and patient) satisfaction.


Here is a generic representation of a workflow or process. Tasks/activities are the circles and arrows combos. Processes are networks (in this case a very simple network) of interconnected activities. Roles are kinds of resources required to accomplish each step. There are different kinds of resources, some human and some automated. The role is a container and that person (or other resource) must fit, but as long as a resource fits it is interchangeable with other resources.

By the way, this is my own dead-simple notation, intended to convey basic ideas about EHR workflow. Business process management, research and industry, is full of notations (such as Petri nets and BPM Notation) and machine readable formats. My purpose and method here is to emphasize relevance to EHR usability and eschew methodological complexity. This is what I call my cat-dog-tree approach: what are the simplest ideas expressed most simply that only combine in one simple manner.

Suppose step two is navigating from screen to screen or searching for the next person required to complete the process or an opportunity to acomplish the task automatically without relying on expensive manual human labor.


Now the following is a little complicated. I included a number of animations in the original EHR Workflow Management Systems: Key to Usability PowerPoint slides. It was easy to trigger the animations and talk about them. It’s a little different here on the Web. There are ways to include embed animations in web pages. I’ve done elsewhere on this blog. However, I’ve found, these are not usually very cross-platform friendly, and especially so with advent of smartphones. So I decided to screen-capture intermediate animation states and publish a series of screen captures from the original slides.


The slide generically shows customer value incrementally growing during execution of workflow. I’ve only labeled the three steps from the previous slide. Steps 1, 3, and (implied) 5 are value-added so their execution moves graphed customer value up and to the right. Steps 2 and (implied) 4 (in green) consume resources and, especially, time, but do not contribute to accumulated customer value.


This is just a visual representation of the previous paragraph. The phrase “Value-Added” points to steps 1, 3, and 5. The phrase “Non-Value-Added” points to steps 2 and 4. (If this slide reminds you of Value Stream Mapping. It should.)


In the original slide animation steps 2 and 4 disappeared and steps 3 and 5 slipped to the left. The result is a graph that shows steadily increasing accumulated EHR value during execution of workflow and a new, shorter, cycle time (length of patient encounter).

The following slides depict intermediate animation states showing essentially the same idea as above: elimination of non-value added EHR steps results in a shorter patient encounter. The slides look different because I took them from the 2004 tutorial slides.


Animation Step 1


Animation Step 2


Animation Step 3


Animation Step 4


Animation Step 5


Animation Step 6


Animation Step 7

In Conclusion (applause…)

My basic point is two-fold. First, traditional process improvement techniques don’t scale without leveraging information technology. The most relevant IT is what academics call “process-aware” informations systems. More generally, it used to be called workflow management systems. It is now called Business Process Management.

Second, for BPM to become most successful in healthcare, it must incorporate, support, and enable sophisticated healthcare “process optimization processes”. I’m reminded of the Reese’s commercial: Better Together!

Hey You Got Peanut Butter (Lean) in My Chocolate (BPM)

Here are the questions for #HITsm chat 6.03.16, plus some notes to myself I’ll probably tweet.

Topic 1: Without the use of Google, what is your definition of #Lean techniques? #HITsm

“be in or move into a sloping position…a deviation from the perpendicular”

Just kidding. Since I filter everything through the lens of workflow…

IMO Lean should include giving health IT users tools to systematically eliminate waste & increase value & usability (AKA workflow tech)

Topic 2: What are some areas of healthcare where #Lean principles can have the most benefit? #HITsm

What healthcare areas can benefit from combining #Lean & workflow tech? All areas, literally cannot think of any exceptions

Topic 3: What’s the biggest challenge in adopting or practicing #Lean? #HITsm

Biggest challenge adopting #Lean? IMO Role of health IT mediating HC work. The workflows are frozen! Must unfreeze!

Topic 4: How can health system create a culture of continuous improvement? #HITsm

Many do not think there is a connection between culture and workflow. They are so wrong!

Topic 5: What are some ways you’ve seen technology companies support #Lean efforts? #HITsm

Workflow tech companies providing ability to users to systematically improve workflow efficiency, effectiveness, and usability.

@wareFLO On Periscope!


P.S. Here are a bunch more of my tweets re Lean and BPM!

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