Case Management, the new BPMN?

Patients in an emergency room are really no different from e.g. subsidies, payments, licenses and claims which are typical examples of processes that benefit from case management.
Sofie De Coninck

It was with a heavy heart that I watched the last episode of ‘Topdokters’. As far as I’m concerned, this is by far the best show that’s been on Flemish TV in years. With every episode, you get a look behind the scenes of how doctors do their job and try to achieve the best possible results for every patient, the one more arrogant than the other, and filmed in a beautiful and subtle manner. A truly heart-warming show. Every time I watch Topdokters, I regret not having studied medicine and, of course, that I can’t stand the sight of blood.

I am also surprised every time about the diversity of patients, with problems ranging from obstructed arteries to severe burns and even a plea for euthanasia. Each episode also makes clear to me that emergency room doctors are interesting ‘Renaissance men’ to follow. A few facts and figures emphasize the tremendous diversity of activities in an emergency room:

  • 224 emergency room visits take place every year in Belgium per 1,000 inhabitants, which is quite high compared to neighbouring countries.
  • 60% of patients go to the emergency room without a referral from another medical professional. From a medical perspective, these patients could often just as well have been treated by a general practitioner.
  • 30% of visits to the emergency room result in hospitalisation, with these patients ending up being treated in different wards of the hospital

The process of mapping out the activities in an emergency room is a task I could very well be confronted with in my daily reality. Full of confidence, I would start by modelling the ‘arrival at the emergency room’, for instance, as a process with standardised activities (e.g. registering the patient, providing the patient with a wristband, etc.) and few exceptions that can easily be modelled using traditional BPMN notation.

But should the hospital ask for a modelling of the entire patient process in the emergency room, ranging from screening by the triage nurse and emergency doctor with regard to any additional examinations and consultations with doctors to returning home or moving to a nursing ward in the hospital, the process would be slightly more complex. Here, too, a number of activities could be identified quite quickly, such as listening to the patient’s story, measuring blood pressure, performing a CT scan, and so on. But you might also quickly arrive at the conclusion that you would rather not be the one who has to model this using BPMN notation. All different kinds of patients who visit an emergency room follow a different pathway and there would be quite a few activities that would only be carried out for a limited number of patients.

If eventually, after a lot of hard work, we nevertheless succeeded in modelling this process in BPMN, another difficulty would arise if we would have to indicate for each optional activity whether or not this activity needs to be carried out. Often these decisions are, in fact, not made based on strict criteria established in advance, but rather by the doctors themselves based, on the one hand, on the patient’s specific situation and, on the other hand, on their knowledge and/or experience.

In a situation like this, in which much experience and/or knowledge is required and where human intervention or decisions are needed, it might be better to model using CMMN notation and the principles of case management. That’s because this type of notation makes it possible to model activities as separate elements instead of sequentially. Not only that, but it can also be indicated for each of these activities whether they are mandatory or optional.

In carrying out the task, this notation on the doctor level would also indicate the mandatory activities, but after that, the doctor would be free to add the optional activities, more than once if desired, depending on the patient’s specific situation. So, from a modelling perspective, patients in an emergency room are really no different from subsidies, payments, licenses, claims, and so on, all of which are typical examples of processes that benefit from case management.

If you would like to learn more about case management after reading this blog, I recommend a book (Swenson, K.D. (2010). Mastering the unpredictable: how adaptive Case Management will revolutionize the way that knowledge workers get things done.) and a thesis (Mestdagh, C. (2015). Case Management theory, modelling, limitations and tools: an overview. Ghent University, Faculty of Economics and Business Administration.) or you might want to take a look on the website of our colleagues at Ground lion, but it might be best start with an episode of Topdokters, since it’s sure to be a little more relaxing.

Thanks for reading

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