Claude ROCHET, Bruno TIBERGHIEN, Anas SAINT,

AixMarseille Universit, CERGAM, IMPGT

Philippe AGOPIAN, Catherine PARIS-LAPORTE, Valery SOULLEIHET, SDIS 13

! The

framework: Streamlining and monitoring the processes using BPMN approach, applied to an emergency service ! The case: : optimizing the cerebrovascular accident (CVA) channel services coordination in the Bouches du Rhne ! The actors: the Fire department (SDIS) and the medical emergency service (SAMU) coordinate their processes with hospitals

! Three
" We

operational steps :

first have to produce the global modelling of the channel (processes, sub processes and procedures) according to the BPMN rules. we will choose and drag out the relevant indicators indicators will permit us to build up the balanced scorecard

" Then

" These

! Then

three vision levels of the process :

" COST:

What is the cost of this rescue channel compared to a classical one? What are the impacts of this process on the Fire department budget? What kind of organizational change is required? How to join up public services that have been split in silos?

" MANAGEMENT:

" IMPACT

& EXTERNALITIES:

What are the costs saved for the health care system? What are the quality of life of the relieved patient? How to evaluate the pertinence of such an approach?
4

! WHY
" To

A PROCESS MODELING?

save people of paralysis for life (20% of CVA are eligible to a thrombolysis) highlight the benefits of the channel for society (costs/benefits) understand the role of the information system in organizational innovation in this public service

" To

" To

Average age is 73 " Third cause of adult death " Around 150.000 strokes per year in France " We expect this number to raise because of the ageing of the population
"
!

Also called stroke, a cerebrovascular accident (CVA) is a disturbance in the blood supply to the brain. Without treatment, the patient will suffer non-reversible diseases as severe paralysis.

->

It is a public health issue

6

! The

lack of an appropriate treatment has for years made room for a contemplative and wait-and-see attitude (Canault et al., 2005) we have discovered a treatment: a thrombolysis can dissolve a blood clot (detected by MRI) in the brain if it is applied in the four hours following the first symptoms:
" Paralysis

! Nowadays,

on one side of the body, aphasia, legs which steal/fall, paralysis on one side of the face, headaches.
7

! Because

of this particular and frequent pathology, health care system actors need to coordinate in a way that anyone on the territory can reach a thrombolysis within four hours if necessary. universitary hospital center is supposed to have a stroke center. In the Bouches du Rhne, it is located in Marseille (la Timone)
" In

! Each

this stroke center, an MRI and a neurologist will always be available to practice a thrombolysis
8

But several actors: SAMU, the firemen and their first responders, the hospital and the stroke center. there is a need to coordinate all the actors and monitor the whole channel in real time: thats why we need the process modeling and the BSC!

! So

According to the French Neurovascular Society (2001):

"

"

the organization of stroke units avoids 1 death or disability for 20 patients treated (120 deaths or disabilities avoided per year). The benefits due to such units is not based on the action of a drug, but on the effectiveness of an interactive multidisciplinary team.

The economic aspect of stroke management can be measured through the average length of hospital :
" "

The specialized units enable a reduction in length of stay of almost 8% (0,3 days) (Hommel et al., 1999). A Cochrane meta-analysis revealed that for every 100 patients treated in a stroke unit, there is a reduction of 26 days (Bowen & Yaste, 1994).
10

! But

the expected economic impact of the development of stroke units is insufficiently studied in the literature. public health challenge is to implement a rational therapeutic strategy as early as possible coordinating the different actors of the chain. If there is an added cost, it appears justified by the clinical benefits observed (Launois et al., 2002). a significant increase in the implementation of stroke units in France, we observe a lag between the recommendations adopted by the government and the reality.
11

! The

! D e s p i t e

! The
"

prime functions of an information system:

"

To provide a unique standard of data for all the actors involved in the channel (Rochet et al., 2011): that way every process could be standardized and useable by every actor To inform people with reliable data (required for our BSC). (Elidrissi & Elidrissi, 2010)

! The

Business Process Modeling (BPM) approach: represents the processes of an organization to be able to analyze the global system, which allows us to work on different levels of granularity (Rochet, 2010).
12

! What

is a process?
With%WHAT? Material& Informa7on&system& With%WHO? What&abili7es&are& required&?required?& Availability What%have%I%got%to%supply% with? Costs,&quality,&deadline New&orders Requirements

What%do%I%need?% Costs,&quality,& deadline New&orders

Requirements How%much?
Op7miza7on&of&the& means&use& Opera7ng&delay& Material&availability

Process

How?%%
Procedures&and&control&plans Informa7on&systems Purchases Recruitment,&training Insurance 13

Eciency&measurement

! So

a business process is a set of activities assembled to produce specific outputs for specific customers. start to draw the processes without using any hardware and then we use technology in order to get digitalized processes which will reflect what the humans initially drew.
14

! Humans

! Drawing

a status report: a preliminary search through the literature

" Information

system in public organization, BPM approach and performance measurement throughout BSC in the public sector.

! An

important phase of observation and an abductive work:

" Back

and forths between theory and fieldwork (Avenier & Gavard-Perret, 2007) " to produce sense thanks to comparisons (Charreire Petit & Durieux, 2007)
15

! A

research-action approach:

" Immersion

of the researcher who will directly work on the problems resolution (Allard-Poesi & Marchal, 2007) " but non-separability of the researcher and the object of study (Giordano & Jolibert, 2008) " and, therefore, an amplification of the bias effect due to behaviour of the actors in relation to the problem (Journ, 2008).

16

17

This lag is critical and may be reduced only by the patient and his natural helpers thanks to basic and generalized education to recognize the symptoms and to have the appropriate reflexes

18

PRE+HOSPITAL/PHASE:/Laws
FAINTNESS COMMUNICATION SENT/OF/THE/MEANS INTERVENTION ORIENTATION TRANFER

Appel du" Emergency" patient"/"de" Call l'entourage

15":"MEDICAL EMERGENCIES

Medical Bilan"mdical Control

local"hospital

18"or"112":"FIRE" DEPARTEMENT

An"ambulance" is"sent
Alert processing

Arrival"on"scene":" firstUaid"checkUup"&"" conference"for"three

Choiceof"the" patient" orientation

neurovascular unit

Intensive care"unit

"The"law"requires"interconnexion":" the"different"emergency"units"must" share"all"their"information"anytime

"Reglementation/requires/a/ "National/decree"about" first/diagnosis/with"the"patient CVA"prossessing:"2005///////////////////////////////////////////////////// "National/ recommendations"of"the" "Haute"Autorit"de" Sant":"2009////////////////////////////////////////////////////////////// "Regional/ recommendations"by"the" SROS:"2012

19

Vers"la"phase"hospitalire Toward"hospital"phase

PRE2HOSPITAL"PHASE:"Procedures
FAINTNESS COMMUNICATION SENT"OF"THE"MEANS INTERVENTION ORIENTATION TRANFER

Appel du" Emergency" patient"/"de" Call l'entourage

15":"MEDICAL EMERGENCIES

Medical Bilan"mdical Diagnosis

local"hospital

An"ambulance" is"sent Alert processing

18"or"112":"FIRE" DEPARTEMENT

Arrival"on"scene":" firstWaid"checkWup"&"" conference"for"three

Choix"de" Choiceof"the" patient" l'orientation" orientation du"patient

neurovascular unit

Intensive care"unit

"Quality"procedures"concerning" "Procedure"concerning" "Diagnosis"procedures"and" answers"to"emergency"calls""""""""""""""""""""""""""""""""""""" medicalization"of"the"vehicle":" first2aid" "Calls"medical"control"procedures will"it"contain"a"doctor"?" (increases"the"duration"of"the" process)"A"doctor"is"needed"in" case"of":fluctuating"level"of" consciousness,"respiratory" failure"or"high"blood"pressure."""""""""""""""""""""""""""""""""""" "Ambulances"procedures

"Diagnosis"procedures""""""""""""""""""""""""""""""""""""""""""""""""" "Transport"procedure:" "Possible"medical" the"patient"has"to"be" support watched"over

20

Vers"la"phase"hospitalire Toward"hospital"phase

PRE7HOSPITAL'PHASE:'Initiatives/Innovations
FAINTNESS COMMUNICATION SENT'OF'THE'MEANS INTERVENTION ORIENTATION TRANFER

Emergency" Call

15":"MEDICAL EMERGENCIES

Medical Diagnosis
An"ambulance" is"sent Alert processing

local"hospital

18"or"112":"FIRE" DEPARTEMENT

Arrival"on"scene":" firstPaid"checkPup"&"" conference"for"three

Choiceof"the" patient" orientation

neurovascular unit

Intensive care"unit

"Awareness'campaigns' intended'for'the'general' public:"circulation"of" informations"about"CVA"so" everyone"can"recognize"a" stroke

"Answerers'training

"Preliminary'training'about' CVA'for'the'Fire'Department' actors

'Quality'informations' "Training'on'transport' passed'on'the' conditions'''''''''''''''''''''''''''''''' neurologist'of'the' "Training'on'patient' neurovascular'unit:'will" surveyance"during"the" he"treat"this"patient?"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" transfer""""""""""""""""""""""""""""""""""""""" "Constant'work'with' "Informations"about" hospital"and"SAMU" stroke'center' doctors'for' localisation organisational'change

21

Toward"hospital"phase

This method has made it possible to obtain different indicators to begin with an evaluation of the channels benefits:
Specific costs Level of activities

Impacts of specific activities - After an awareness campaign, calls of a s p e c i f i c pathology approximately increase by 20%.

- One patient of this channel costs the SDIS 200 -For the hospital it represents 1 300 (treatment) and an additional cost around 300 for neurologist supervision. Total: around 1 800 - Duration of the patient stay in the hospital: around 5 days for a treated patient; around 30 days for a non-treated one.

- In one year, on 120 000 health emergency calls, around 60 000 may lead to the conference for three. - On this 60 000, only around 600 patients will launch the CVA process. - The SDIS 13 transported 380 patients in this channel in 2011 - Around 20 patients per month are treated while 100 are received to the stroke center (80 cannot be treated). - Around 4 or 5 patients per month escape from the channel (because of non-appropriate diagnostics for example)
22

! Because

of our conviction of the reproducibility of this channel, we can conclude with a roadmap to build up and conduct such an undertaking:
"

" "

"

The crucial point in the functioning of this channel was the coordination needed between the different actors: it led to an organizational change. The information quality and the training also played an important role. It will be necessary to inform the institutions to obtain the support of higher organizations, and to inform the public by awareness campaigns. At the edge, technical aspects may have their importance.
23

Benefits of extra stroke centers costs

Calling the rescue

Prehospital phase

hospital phase

Short term output

Lon term outcome

Deciding an education campaign

The number of stokes is a constant in an homogeneous set of population. If the number fails, it means that patients have escape the process Socio economic impact

24

! We

proposed an overview of a real stroke channel. BSC is required to pursue this work. channel is reproducible

! A

! The

" Without

modifications, in any hospital for strokes " With modifications, to be applied to other pathologies as heart attack.

25

Thank you for your attention.