Process orientation and digital management contribute significantly to an organization's overall productivity and quality improvement. While this is well-documented across organizations, sectors, and industries, there is little research to validate the leverage of process management and the systematic analysis and standardization of processes in the healthcare sector [1]. This study demonstrates the utilization of business process management (BPM) technology at one of Europe's leading private hospital groups, Hirslanden, to standardize internal processes across almost 500,000 nursing days within 18 clinics. The ambitious “Hirslanden 2020” modularization and transformation program encompasses process models and standardized processes across growth and leadership initiatives to serve as a knowledge base for over 100,000 patients across a variety of specialist disciplines; promoting digitization, automation, and continuously improving internal processes for business and ERP transformation. The leverage [1] of Signavio BPM technology at Hirslanden is delivering the highest standards in medicine and operations, globally. This paper demonstrates the direct and indirect effects on performance (identified as patient satisfaction and financial performance) through enhanced process standardization/optimization and ERP transformation (defined as workforce conditions, operational performance, and clinical quality). The innovative process conditions of Hirslanden 2020's “HIT2020” rollout wave have a significant positive effect on patient satisfaction, workforce conditions and silodismantling, operational efficiency, and financial performance. Through the unique deployment of BPM in a healthcare setting, Hirslanden continually secures business and process transformation by balancing price and quality against efficiency and wellbeing through systematic process testing within modern healthcare continuous improvement projects (CIPs) [2].
The challenges facing healthcare professionals can be matters of life and death. The
consequences of decisions on operational efficiency, service stability, and ROI can break governments
and change communities. Worryingly, even the wealthiest countries are struggling. According to
the UK regulator CQC’s State of Care report, the National Health Service (NHS) is at full stretch
and offers little comfort for those who rely on it functioning efficiently and effectively in the
future [
While process management does not cure personal healthcare problems, the approach can
modernize core processes and systems to support new clinical practices, regulatory standards, cost
reimbursement methods, and corporate governance regulations [
By fine-tuning the business-IT alignment strategy and micro process design, Hirslanden can
better scan best practices and standardize efforts for actionable feedback loops. With this, the clinics
are gradually relieved of administrative back-office tasks and can concentrate on their core work:
Patient care and wellbeing. By unifying processes, the patient journey naturally develops in
tandem with Hirslanden’s modernized core processes and systems to support new clinical practices,
regulatory standards, cost reimbursement methods, and organizational governance [
Signavio CJM technology helps Hirslanden to establish a group-wide business model that furthers the “Patient First” initiative, with uniformed and simplified processes, patient journeys, and a reduction in process variants, IT system complexity, and streamlined organizational structures. This outside-in, patient-centric perspective enables healthcare professionals to better understand what individuals experience throughout the entire patient journey mapping, whilst highlighting touch points for strategic outreach that improves both engagement and satisfaction. By seeing through the eyes of the patient, enhanced “moments of truth” will upgrade efficiency and staff effectiveness by removing operational chokepoints for improved healthcare initiatives––optimizing processes for the rapid response to health, social, and economic needs.
Highlighting Hirslanden’s use of Signavio BPM technology in a healthcare setting, their usage predicts a significant return on investment (ROI) as an effective institution, and in the resulting improvements in patient care and patient journeys.
Key data demonstrate: • The application helped physicians and nurses to reduce the amount of time and resources they devoted to administrative purposes; • Staff reported real benefits regarding resources optimization and quality improvement; • Automatic workflows for staff helped with the planning/performing of medical exams and reduced human error, meaning the quality of data and reliability of the pathway scheduling have been seriously improved.
The hospital group also noted that BPM empowers: • The sharing of knowledge and information across business units with a holistic approach towards problem-solving by reducing silos; • A structural approach to gap AS-IS to To-Be processes; • Collaborative and ad-hoc problem solving, e.g. patient care activities; • Access and integration of clinical repository data for follow-up activities; • Clinical data collection and consolidation in one central repository and patient/data documentation execution in the same IT system.
As this is a developing transformation, the quantitative results of internal Hirslanden process optimization studies have yet to be published. However, internal figures already demonstrate that workforce conditions and clinical quality prove to have a significant positive effect on patient satisfaction. Given that Hirslanden is a joint-stock company and must finance their investments, the potential risk of business transformation is high, and thus new process orientation benefits are an essential antecedent of improved patient experience and financial performance.
In light of severe cost containment and increased competition with the introduction of the DRGbased payment system, Swiss hospitals are more than ever in need of ways to operate effectively. A reason for this is that some interventions are treated as ambulatory, and not stationary, which generates less revenue for hospitals based on tariff systems. Yet, the Swiss healthcare system takes a leading position among the member states of the Organization for Economic Co-operation and Development (OECD), and its high performance is reflected in having the second highest above average life expectancy of all OECD nations, 83.7 years [8a]. Also, the number of primary care doctors and hospital beds per resident are among the highest of all industrialized countries. However, Switzerland also faces significant health care expenditures: In 2017 the costs of health care across the final consumption of health care goods and services was second only to the US, at around 12% of GDP [8b]. 2.1
Patients expect high-quality service on demand, whether they are unfortunate enough to experience an accident or require elective treatment. Still, Swiss hospitals are increasingly being pushed into competitive market structures. Moreover, the healthcare industry has historically been a manually intensive business, with patient admissions, charts, billing, and care performed in a hands-on manner. Against this backdrop, Hirslanden needed to standardize their process models (with restrictions due to DRG regulations) and ERP system towards a more patient-centric approach. This reduces inefficiencies and eliminates waste to keep the cost of healthcare from spiraling, whilst synergizing hospital sites by aligning process and infrastructure. Investing in more robust information systems paved the way for Hirslanden to optimize processes and coordinate the exchange of information required to deliver quality patient care. For example, business-IT alignment has three main ‘directions’ at Hirslanden (fig 2).
In other words, Hirslanden needed to deliver healthcare functions for a common understanding
of strategy targets, while meeting the expectations of an overwhelmingly digital customer base,
who expect a more online service, e.g. patient appointments and care provision. Hirslanden had
to do this whilst balancing difficult change management and acceptance nuances, with staff from
various backgrounds facing process standardization for the first time. Also, competition between
hospitals is rising and the main differentiation factor is quality, so by giving doctors the ability
to focus on their core activities (treatment and diagnosis), Hirslanden has seen a radical
improvement in healthcare delivery and services. But this required the unique process-driven leverage of
“HIT2020” to standardize data, respond to developments in the industry, reduce errors, improve
the bottom line, and provide a higher level of patient care. Indeed, Switzerland has one of the
lowest average lengths of stay in hospitals (ALOS) within the OECD, and this is often used as
an indicator of efficiency and care standard [
However, new process orientation and the organic evolution of healthcare Enterprise
Resource Planning (ERP) systems [
Further challenges faced by Hirslanden include: • Disparate processes in different clinics: Without process standardization, the security of processes decreased, and business operations became too complicated due to a break in the chain of optimization dependencies; • Latest technology: Process management needed to be established as a ‘new language’, because few healthcare providers anywhere in the world adopt the approach; • Heavily regulated environment: Process documentation facilitated the implementation of regulatory requirements (ISO standards, SwissMedic) and quality management; • Change management as a team effort: Required the support of all involved and the fresh understanding of a modern process culture. 2.2
With this, Hirslanden required a holistic ERP platform based on single data points and a process model across finance, supply chain, and human resources to support the emerging operating model. The same platform also needed to be flexible enough to allow for the assimilation of new entities, and support embedded cross-operational best practice, whilst allowing clinic variants in the very infrequent case where standardization was impossible. For example, across different services in different clinics. In a commercial world that revolves around differentiation, it was no longer practical to rely on systems that merely deliver the same results as everyone else. With significant investments already made in ERP systems, healthcare providers across the globe must tackle the challenge of how to refresh, update, or transform legacy ERP systems to better connect with their processes; a further form of systemic differentiation.
Reaching across people, processes, customers, technology, data management, and risk management, Hirslanden’s ERP transformation is nothing less than a company-wide disruption. Starting from the definition of targets on a strategic level to the specification of processes over the nomination of use cases and requirements (Fig. 3). New processes, new ways of working, new paths through the system and questioning the value and need for customization are all critical aspects of such an initiative, whilst avoiding the pain of historical time and revenue issues, and ensuring more manageable cost strategies.
Further situations faced include:
• The need for “Systems of Differentiation” vs. the use of “Systems of Record”;
• Modern ways to analyze and standardize processes;
• The requirement for a process-centric approach to reduce change fatigue;
• A way to make smarter use of process data to evaluate and accelerate change.
However, process orientation—especially in healthcare—cannot be achieved in a “big bang’’
[
For Hirslanden, Enterprise Resource Planning refers to the integrated, real-time management of core business processes to better support the assimilation of new entities with embedded crossoperational best practices. The problem is many infrastructure and operations (I&O) leaders don’t know where to begin when initiating an IT monitoring strategy for evolved business intelligence, which Hirslanden is establishing based on Signavio processes.
Further demonstrating the uniqueness of Hirslanden’s strategy of standardized ERP
transformation across clinics, a 2016 US report found that fewer than 30 percent of hospitals
had an ERP system in place [
Initiated in 2014, Hirslanden’s ERP transformation is based upon five steps across effective
planning, testing, and change management within a scalable ERP transformation project (Fig. 4). The
business transformation model has increased the efficiency of technology investments, the
understanding of business-IT alignment challenges, and significantly reduced the financial and
operational risks associated with healthcare and technical change [
With this unique process standardization, Hirslanden employees can operate across various locations to provide their patients with the care they need and deserve (Fig. 5). This includes administrative processes like an admission of new patients or invoicing, as well as crucial processes such as the coordination of doctors and attending physicians. Although these processes are fundamentally similar, in the past they were carried out differently at different Hirslanden sites. The long-term aim of process standardization across all Hirslanden clinics is to drive the flagship value of “Patient First”, and offer superior services for improved wellbeing. With this, process standardization at the medical group helps: • Improve patient care / Improve patient security / Drive patient value; • Relieve the individual clinics of administrative burden for increased patient focus; • Develop universal standards for patient care / Act more efficiently / Simplify processes; • Harmonize the application landscape of the group.
Against this backdrop, standardizing Hirslanden’s processes also contributes to strengthening
data security and process improvement initiatives, especially in relation to the General Data
Protection Regulation (GDPR) [
To increase the value of process management in healthcare, the implementation of business intelligence must include KPIs, risk-management information, and then be mapped with corresponding processes. Signavio’s process mining technology can then detect bottlenecks and foster CPI support with process standardization and optimization.
To support process standardization throughout the group, Hirslanden uses Signavio (Fig. 6). • Signavio Process Manager: Full project support across the whole corporation using processdriven requirements engineering, and the entire documentation of core administrative processes, as well as other medical and nursing processes; • Signavio Workflow Accelerator: Automation catalyst for numerous functionalities across information routing, escalation management, and task distribution; • Signavio Collaboration Hub: Involvement of all employees in process documentation and active process development using a collaborative commenting function.
This utilization can also cross different IT architectures or any ERP system, including SAP®, which has the added benefit of making networks more scalable. Cloud-based IT infrastructure can also enable rapid computing for different types of data and systems from the physical network across all nodes of the healthcare supply chain. Signavio offers integration with next-generation S/4HANA enabling even simpler business-IT alignment at Hirslanden. In this context, ROI comes from the reduction in the total cost of ownership, the increase in productivity of business and process intelligence, and the application of development and improved business processes. For example: Hosted workspaces can modernize IT infrastructure, without adding significant capital expenditure. Healthcare companies can then work to customize and implement a secure and effective cloud-based enterprise quality management (EQM) strategy. 3.3
As part of Hirslanden’s standardization journey, the organizational structure of process management is critical, with representatives in clinics as well as process owners and managers from specific business units, collaborating closely (Fig. 7). By utilizing BPM, the implementation includes both a process management and a document management system (DMS), which goes hand-in-hand with user acceptance of process standardization, because DMS functionalities are linked and processes occur within Signavio technologies.
“HIT2020” is establishing a unique group-wide business model for standardized and
simplified processes across IT systems and organizational structures. This is increasing the efficiency
of existing care so that clinics can dedicate time to core business models.
Less than a year since the introduction of Signavio software, the first successes of
Hirslanden’s organization-wide process initiative are evident. With over 1,700 BPMN
processes created, 425 process maps produced, and 8,245 documents filed, process
management is greatly facilitating day-to-day tasks. These outcomes will continue to increase
in scale and benefits as more clinics onboard, especially for cross-departmental processes, as
digital needs grow and transform, and the need to renovate the operational environment with
new functions becomes apparent. According to Gartner, “business alignment will need to be
redefined to deliver successful digital experiences” [
Just consider the move away from traditional on-premises solutions. As unification becomes
more widespread, business-IT alignment within healthcare will increasingly be impacted by
the consumerization of IT, where corporate and personal technology, such as mobile
technology, will dramatically change the provision and consumption of healthcare [
To back this, healthcare stakeholders struggling to manage clinical, operational, and
financial challenges envision a future in which new business and care delivery models, aided by
digital technologies, may help to solve today’s health problems. This goes hand-in-hand with
building a sustainable foundation for affordable, accessible, high-quality healthcare [
However, Hirslanden is not only differentiating itself through technological progress, but foremost through their understanding of patients’ needs, human behavior, organizational structure, and drive for effective organizational change and governance. Through better business-IT alignment, BPM has improved the efficiency of health services to provide a higher quality of care and patient journey. Radical process standardization supports Hirslanden to deliver and enhance their capabilities through self-service and improved case management, whilst keeping pace with policy changes and patient needs.
This includes: • Process optimization in 18 clinics for almost 10,500 employees; • Intuitive process modeling with Signavio Process Manager; • Better collaborative functions with employee participation and inclusion; • A central knowledge base using Signavio Collaboration Hub, enabling the team to develop their processes further; • More transparency, efficiency, and security through standardization; • Web-based software solution, available around the clock, 365 days-a-year, making it suitable for the complex operations of medical needs.
Globalization. Consolidation. Regulation. To nail global healthcare challenges, Hirslanden is
continually evolving and learning through reassessed and standardized business processes to
better align with the changing economic environment [
A process management approach is also modernizing core processes and systems to support
new clinical practices, personalized outreach, regulatory standards, cost reimbursement
methods, and to meet government regulations. Indeed, the BPM framework offers all this whilst
optimizing Hirslanden’s processes for the rapid response to changing healthcare and life sciences
attributes. Another lesson of implementing process management at Hirslanden, has been to
identify segments of a business process that can be automated. Often, these were employee
choke points where information was collected and handled manually. In such cases, the system
now provides email notifications and reminders, in combination with web-based forms, to
prompt workers to perform tasks and keep things moving [
This layer of workflow automation at Hirslanden also provides visibility across processes that
otherwise would occur out of sight of the eagle eye of corporate information systems. Since the
healthcare sector is so regulated, having better-documented processes, along with auditing of
how they are carried out, helps the hospital group with compliance issues. Business process
management technology is also providing significantly improved levels of management,
collaboration, and timeliness for clinical research studies [
Adapt: Reducing the time to implement change; Align: Providing visibility & governance across the decision management life cycle; Act: Sensing and responding to actionable situations, based on precise information about any detected event. 5.2
In the future, Signavio’s process mining initiatives will further enable Hirslanden to manage
process challenges beyond the boundaries of implementation, with evaluation across the proof
of concept (PoC) for any proposed improvements, and by extracting relevant information from
a homogenous data set. By harnessing this raw data and continuously monitoring end-to-end
processes, the group can further regulate potential risks and ongoing improvement
opportunities, too. The powerful combination of process discovery, healthcare robotics, and conformance
checking supports a future-state collaborative approach to process improvement at Hirslanden
[
A further example of where process mining and strategic alignment will enable Hirslanden, is IT incident management. Here, “incident” is an unplanned interruption to an IT service, which may be complete unavailability or merely a reduction in quality. The goal of the incident management process is to restore a normal service operation as quickly as possible, and to minimize the impact on business operations. Incident management is a critical process in Information Technology Infrastructure Library (ITIL).
If we consider the UK-based CQC report once again [
Hirslanden also notes the improved: ─ Understanding of the hospital ecosystem and urgency of issues: Since ineffective behavior often results from a lack of knowledge of one’s actions, the analysis helped clarify how current practice results in problems and complexity in the organization and IT ecosystem. This analysis was critical to avoid chasing silver bullets and to align all the stakeholders around a shared understanding of the issues they needed to address. ─ Sharing of a company vision to challenge the existing business model: A key driver behind the Hirslanden ERP and business transformation program was uniting the entire company around one shared vision, enabling the new business model to be tested under any number of conditions. It was essential to examine the internal part of the business model and the relation to patients. Forming systematic steps enabled a transparent and flexible change agenda, where the shared vision functions as a long-term guide. ─ Agile implementation of processes via focused sprints and multidisciplinary teams: Given that business transformation involves change across organizational boundaries; it logically requires interdisciplinary teams for success. This is a part of the Hirslanden ERP transformation where the use of certain agile principles helped because multidisciplinary teams were deployed in iterations and could continuously learn and adjust. [1] Andellini, M., et al. Experimental application of Business Process Management technology to manage clinical pathways: a pediatric kidney transplantation follow up case. BMC medical informatics and decision making, 17(1), 1-9 (2017).