INCORPORATING BUSINESS PROCESS MANAGEMENT, BUSINESS
ONTOLOGY AND BUSINESS ARCHITECTURE IN MEDICATION
MANAGEMENT QUALITY

by
Bonnie Sue Urquhart
M.Sc., University of Montreal, 2009

THESIS SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
IN
HEALTH SCIENCE

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
SEPTEMBER 2018
© Bonnie Sue Urquhart, 2018

Abstract
Managers and care providers in the health sector are expected to deliver safe, efficient
and effective services within a resource constrained, complex system. Services are provided
through execution of multiple processes. Healthcare organizations tend to be structured in
functional based silos with process improvement efforts often focused on individual
processes within the discrete silos. This silo based improvement approach fails to take into
account upstream and downstream processes executed and managed in other silos. A
patient’s journey will typically include processes from multiple silos and therefore,
improvement efforts need to focus on end-to-end processes if the goal is to deliver a positive
patient experience. In order to optimize processes in a complex adaptive system like
healthcare and to effect meaningful change a combination of management disciplines is
required. This research explored the use of Business Process Management (BPM), Business
Architecture (BA) and Business Process Management Ontology (BPMO) as a
comprehensive, integrated approach to design, redesign, evaluate, improve and monitor the
safety, efficiency and effectiveness of medication management processes in a multi-site
healthcare organization.
The contribution of the research was threefold. First, identified benefits of applying
BPM, BPMO and BA to increase organization capacity and improve the end-to-end process
of medication management; second, demonstrated the application of an ontology and the
business layer of enterprise architecture used in other sectors could be successfully utilized in
the healthcare sector; and third, developed a process reference model for medication
management processes in acute care and long term care facilities.
Keywords: Business Process Management, Business Architecture, Business
Ontology, Medication Management, Quality Improvement
i

Acknowledgements
Successful completion of my PhD was not a solo journey. There were numerous
people along the way who provided support, mentorship, guidance and love. I am extremely
grateful to each and every person who participated in this journey and enabled my success.
Some have been with me for the entire journey and others have been there only briefly or
intermittently but all deserved to be acknowledged.
Thank you to my supervisor and committee members, Dr. Waqar Haque, Dr. Henry
Harder, Dr. Balbinder Deo and Dr. Craig Mitton for your patience, encouragement and your
commitment to helping me achieve this milestone.
I would like to thank Prof. Mark von Rosing from Global University Alliance. His
knowledge in my field of study and his willingness to share that knowledge has certainly
enriched my journey.
A special thank you to colleagues at Northern Health who actively participated in the
research and gave up their time to attend workshops, working groups and interviews. Your
willingness to join me on this journey was very much appreciated. I would especially like to
acknowledge the members of my team at Northern Health who have worked beside me in
this pursuit.
Words cannot begin to express my appreciation to my husband, Ken Urquhart, my
children, Kimberley and Keith Payne along with my entire family who have always believed
in me and given me strength to pursue my dreams.

ii

Table of Contents
Abstract ...........................................................................................................................i
Acknowledgements....................................................................................................... ii
Table of Contents......................................................................................................... iii
List of Tables ................................................................................................................vi
List of Figures ............................................................................................................. vii
List of Abbreviations ................................................................................................. viii
1

2

3

Introduction ........................................................................................................... 1
1.1

Background .................................................................................................... 1

1.2

Thesis Outline ................................................................................................ 2

1.3

Research Objectives....................................................................................... 5

1.4

Rationale for Research ................................................................................... 7

1.5

Terminology and Definitions....................................................................... 11

1.6

Approach ..................................................................................................... 13

1.7

Context of Host Organization ...................................................................... 16

1.8

Contribution ................................................................................................. 18

Literature Review ................................................................................................ 19
2.1

Medication Errors and Adverse Drug Events .............................................. 19

2.2

Standards, Guidelines and Legislative Requirements ................................. 29

2.3

Business Process Management .................................................................... 31

2.4

Healthcare Organization as a System .......................................................... 45

2.5

Business Ontology ....................................................................................... 47

2.6

Reference Models ........................................................................................ 50

2.7

Literature Review Summary ........................................................................ 51

Methodology ........................................................................................................ 54
3.1

Approach ..................................................................................................... 54

3.2
Strategy & Research Design ........................................................................ 56
3.2.1 Research idea – motivation...................................................................... 62
3.2.2 Literature review...................................................................................... 64
3.2.3 Data collection strategy. .......................................................................... 64
3.2.4 Plan for primary data collection. ............................................................. 65
3.2.5 Ethics approval. ....................................................................................... 67
3.2.6 Delivery of workshops and facilitation of working groups. .................... 67
3.2.7 Interim reporting. ..................................................................................... 71
iii

Collection of data..................................................................................... 72
Analysis of data. ...................................................................................... 72

3.2.8
3.2.9

4

3.3

Reliability, Validity, Generalizability and Limitations ............................... 75

3.4

Trustworthiness............................................................................................ 76

3.5

Authenticity ................................................................................................. 77

3.6

Limitations ................................................................................................... 79

3.7

Summary ...................................................................................................... 80

Results ................................................................................................................. 82
4.1
Business Artefacts ....................................................................................... 82
4.1.1 Strategy map and strategy canvas. ........................................................... 85
4.1.2 Business competency model. ................................................................... 87
4.1.3 Value chain. ............................................................................................. 89
4.1.4 Strategic action plan. ............................................................................... 90
4.1.5 Prioritized improvement initiatives. ........................................................ 91
4.1.6 Performance monitoring plan. ................................................................. 95
4.2
Example of Process Improvement Using BPM Lifecycle ........................... 96
4.2.1 Example. .................................................................................................. 96
4.3
Analysis of Interview Results .................................................................... 100
4.3.1 Workshop participant interviews. .......................................................... 100
4.3.2 Organizational leader interviews. .......................................................... 106
4.3.3 Analysis of language used in survey responses. .................................... 114

5

4.4

Medication Management Process Reference Model ................................. 118

4.5

Summary of Results................................................................................... 125

Discussion and Conclusion ................................................................................ 127
5.1

Integrating BPM, BPMO and BA in a Health Organization ..................... 127

5.2

Proposed Process Reference Model........................................................... 128

5.3

Challenges and Benefits ............................................................................ 129

5.4

Contribution and Future Research ............................................................. 133

5.5

Concluding Comments .............................................................................. 135

References.................................................................................................................. 136
Appendices ................................................................................................................ 154
Appendix 1. Listing of Ontologies.......................................................................... 154
Appendix 2. Interview Guide for NH Leaders........................................................ 158
Appendix 3. Interview Guide for Study Participants .............................................. 159
Appendix 4. Workshop Participant Information Letter and Consent Form............ 160
Appendix 5. Interview Information Letter & Consent Form .................................. 164
iv

Appendix 6. Workshop Attendance Log ................................................................ 168
Appendix 7. List of Recommended Performance Measures................................... 170
Appendix 8. Meta Model of Understanding ........................................................... 173
Appendix 9. Strategy Map ...................................................................................... 174
Appendix 10. Strategy Canvas ................................................................................ 177
Appendix 11. Business Competency Map .............................................................. 180
Appendix 12. Business Competency Model ........................................................... 182
Appendix 13. Value Chain ...................................................................................... 183
Appendix 14. Listing of Criteria Definitions .......................................................... 184
Appendix 15. Initiative Ranking ............................................................................. 185
Appendix 16. Results of Prioritization of Improvement Initiatives ........................ 186
Appendix 17. Reporting Frequency ........................................................................ 187
Appendix 18. Process Reference Model ................................................................. 189
Appendix 19. Listing of Functions with Definitions .............................................. 194

v

List of Tables
Table 1 Research Objectives & Questions ................................................................................ 6
Table 2 Relationship between Objectives and Data Collection................................................. 7
Table 3. Safety Indicators for Medication Use ........................................................................ 37
Table 4. Clinical Pharmacist Key Performance Indicators ...................................................... 38
Table 5 Considerations for Replication of Study .................................................................... 59
Table 6 Simplified Outline of Process ..................................................................................... 81
Table 7. Medication Management Strategy Map Excerpt ....................................................... 86
Table 8. AHP Scoring Approach ............................................................................................. 92
Table 9. Pairwise Comparison of Criteria ............................................................................... 93
Table 10. Medication Management Strategic Level Indicators ............................................... 95
Table 11. Word Count Comparison – Leaders and Workshop Participants .......................... 116
Table 12. Word Comparison - Clinical and Business Leaders .............................................. 118
Table 13. Comparison of Different Views of Process Levels ............................................... 119
Table 14 Process Areas & Process Groups............................................................................ 121
Table 15 Comments on Stages of BPM Lifecycle................................................................. 131
Table 16 Listing of Ontologies .............................................................................................. 157
Table 17 Workshop Attendance Log ..................................................................................... 169
Table 18 Complete List of Suggested Measures ................................................................... 172
Table 19 Strategy Map Objects ............................................................................................. 176
Table 20 Listing of Criteria Definitions ................................................................................ 184
Table 21 Initiative Ranking Tool........................................................................................... 185
Table 22 Results of Prioritization of Improvement Initiatives .............................................. 186
Table 23 Process Reference Model ....................................................................................... 193
vi

Table 24 Listing of Functions with Definitions Source NH internal documents .................. 201

List of Figures
Figure 1. Literature Review Topics & Relationships ................................................................ 4
Figure 2. Evolution of BPM .................................................................................................... 33
Figure 3 Layered Enterprise Architecture Design ................................................................... 42
Figure 4. Combining Qualitative and Quantitative Methods & Techniques ........................... 56
Figure 5. Research Design ...................................................................................................... 58
Figure 6 Statistical Control Chant showing Percentage of Infusions Using MDL Prepared
using Minitab 18 Statistical Software (2018) .................................................................. 74
Figure 7 The 16 basic BPM Ontology process classes and groups where the examples applied
are marked red (Source von Rosing, Scheer and von Scheel, 2015 page 107. Reproduced
with permission.) ............................................................................................................. 83
Figure 8. Excerpt from Medication Management Strategy Canvas ........................................ 87
Figure 9 Current State Map Infusion Pumps ........................................................................... 98
Figure 10 Relationship between Process Reference Model Meta-Objects and Business
Artefacts......................................................................................................................... 123
Figure 11. Meta Model of Understanding ............................................................................. 173
Figure 12 Strategy Canvas ..................................................................................................... 179
Figure 13 Business Competency Map ................................................................................... 181
Figure 14 Business Competency Model ................................................................................ 182
Figure 15 Value Chain ........................................................................................................... 183

vii

List of Abbreviations
ADE
AHP
APQC
BA
BIZBOK
BO
BPE
BPM
BPMH
BPMN
BPMO
BPMS
BPO
BPR
CFHI
CHSRF
CIHI
cpKPIs
CRNBC
CSF
EA
FEAF
FNHA
KPI
LEAD
MDWG
MIS
MSQC
MWG
NH
OMG
PBMA
PHSA
PPI
PSLS
PWG
ROP
SBO
TOGAF
WMS

Adverse Drug Event
Analytical Hierarchy Process
American Productivity and Quality Council
Business Architecture
Business Architecture Guild of the Objects Management Group
Business Ontology
Business Process Engineering
Business Process Management
Best Possible Medication History
Business Process Management Notation
Business Process Management Ontology
Business Process Management System
Business Process Orientation
Business Process Reengineering
Canadian Foundation for Healthcare Improvement
Canadian Health Service Research Foundation
Canadian Institute for Health Information
Clinical Pharmacy Key Performance Indicators
College of Registered Nurses of British Columbia
Critical Success Factor
Enterprise Architecture
The US Federal Architectural Framework
First Nations Health Authority
Key Performance Indicator
Layered Enterprise Architecture Development
Multidisciplinary Working Group
Management Information System
Medication Safety & Quality Committee
Measurement Working Group
Northern Health
Objects Management Group
Program Budgeting and Marginal Analysis
Provincial Heath Service Authority
Process Performance Indicator
Patient Safety Learning System
Prioritization Working Group
Required Organizational Practice
Strategic Business Objective
The Open Group Architectural Framework
Workload Management System

viii

1

Introduction

1.1 Background
Healthcare organizations face challenges delivering services which are safe, effective,
efficient, reliable and compliant with legislation, regulations and standards. Healthcare
providers are expected to provide high quality, patient centered care while meeting growing
demands, changing technologies and constrained resources. A specific area of concern is the
incidence of adverse drug events (ADEs) that are the result of medication errors in
prescribing, dispensing, administering, documenting or inpatient monitoring. The medication
process spans multiple functional units and involves a number of different clinicians and
allied healthcare workers. The functional units include acute care inpatient wards (surgery,
paediatrics, maternity, etc.), emergency rooms, ambulatory care units, operating rooms, long
term care facilities, harm reduction units, and community services. People involved in the
process include prescribers (usually a physician), clinical pharmacists, dispensary
pharmacists, pharmacy technicians, supply chain staff, and point of care staff including
Registered Nurses, Licensed Practical Nurses and specially trained Care Aides. Healthcare
services and prescription medications are highly regulated and clinicians themselves are
responsible for adhering to the regulations and standards set out by their licensing bodies.
The number of people involved, the need to comply with relevant regulation, legislation, and
standards, combined with the high degree of potential harm to patients and competing
demands being placed on clinicians contribute to the complexity of the medication
management processes. In addition to patient safety, there is also a need to consider worker
safety and the increasing costs of pharmaceuticals when designing processes. The problems
with medication management have been well documented (Baker, et al., 2004 & Keers,
Williams, Cooke, Walsh & Ashcroft, 2014); however, no single standardized way of
1

addressing the problem has been identified. This research is an attempt to identify a
systematic approach to deal with patient safety and quality issues within medication
management that could be used in other healthcare service areas.
Business Process Management (BPM) has been described as a key enabler for the
analysis and improvement of health care processes (Antonacci, et al., 2016); however, it has
not yet been widely adopted within healthcare organizations (Mertens, Gailly, & Poels,
2015). This research explored the use of BPM and the introduction of a Business Process
Management Ontology (BPMO) and Business Architecture (BA) as a comprehensive
management approach to improve the quality of medication management processes within a
healthcare organization. In this research it is proposed that high quality medication
management processes would need to meet the following five objectives: 1) Safe (eliminate
or at least reduce medication errors & adverse drug events), 2) Effective (produce desired
results), 3) Efficient (minimum resources and time), 4) Compliant (meet standards,
guidelines and legislation), and 5) Reliable (minimal variation in outcomes). These five
objectives were derived through discussion with working group members and review of host
organization quality improvement efforts specific to pharmacy and medication management
prior to this research. In addition to improving the quality of medication management
processes within the organization, the perceived challenges and benefits of this management
approach were also explored from the perspective of those involved in the improvement
efforts and the organization’s leaders.
1.2 Thesis Outline
There are five chapters included in this thesis: 1) Introduction, 2) Literature Review, 3)
Methodology, 4) Results and 5) Discussion and Conclusion.

2

Chapter 1, the current chapter, establishes and sets the foundation for this research. This
chapter includes background of the problem being studied, the research objectives and
rationale for the research. This chapter includes terminology and definitions used in the
thesis along with the approach that was used in the research. It also provides the context of
the host organization and concludes with the contributions made to the body of knowledge on
Adverse Drug Events and the use of BPM, BPMO and BA in the healthcare sector.
Chapter 2 provides a Literature Review which covers six topic areas. These topics
and the identified relationships represent all the components that formed the basis of the
thesis. Figure 1 provides a visual representation of these topics and their relationships. The
relationships shown within the figure were derived by looking at the overarching goal of high
quality medication management and then determining how each of the research topics
contributed directly or indirectly to achieving that goal.

3

Literature Review Topics – Relationship
2.1 HIGH QUALITY MEDICATION MANAGEMENT PROCESSES
SAFE
Reduction in
Medication Errors &
Adverse Drug
Events
No harm to workers

EFFECTIVE

EFFICIENT

COMPLIANT

Produce Desired
Results

Minimum Resources
& Time

2.2 Standards,
Guidelines &
Legislation

RELIABLE

Minimal Variation in
Outcomes

Enables Business Process Redesign & Continuous
Improvement

MODELING

MEASUREMENT

MANAGEMENT

2.3 BUSINESS PROCESS MANAGEMENT

2.5 BUSINESS (BPM)
ONTOLOGY

2.4 UNDERSTANDING THE
SYSTEM

2.3 ENTERPRISE (BUSINESS)
ARCHITECTURE

2.6 Reference Model

Figure 1. Literature Review Topics & Relationships

Chapter 3 describes the research methodology (mixed methodology) which included both
quantitative and qualitative methods. This chapter also describes the procedures and tools used
in this research.
Chapter 4 describes the results of the research. A total of 7 business artefacts were
developed during the research. These are: 1) strategy map, 2) strategy canvas, 3) business
competency model, 4) value chain, 5) strategic action plan, 6) prioritized list of improvement
initiatives and 7) performance monitoring plan. Semi-structured interviews with workshop
participants and organizational leaders were recorded, transcribed and analyzed. Analytical
4

Hierarchy Process (AHP) was used to prioritize the list of improvement initiatives. A
proposed process reference model for medication management was developed including
processes categorized as core (main), support and management processes in acute care and
long term care facilities.
Finally, chapter 5 summarizes contribution and limitations of the research, in addition to
potential future research topics arising from this work.
1.3 Research Objectives
There were three objectives of this research. The first objective was to determine the
impact of introducing BPM, BPMO and BA to improve medication management quality in a
publicly-funded health care organization. The second objective was to explore the perceived
challenges and benefits of using BPM, BPMO, and BA in a healthcare organization. The
third and most enduring objective was to create a process reference model for medication
management which could potentially be adopted by other healthcare organizations interested
in applying BPM to improve medication management processes within their organization.
The information required to meet the first objective included domain information
specific to medication management service such as current ‘as is’ process and proposed
improved or ’to be’ process along with how the quality of the service would be measured.
The information required to meet the second objective included qualitative information from
the process participants to determine what they perceived were the impact, if any, of using
the comprehensive management approach. This information was gathered from the
workshop participants and organizational leaders through semi structured interview
questions. The information required to meet the third objective required the development of
appropriate business artefacts that provided specific information and definition of business
objects. Examples of business artefacts were strategy map, strategy canvas, process models,
5

and business competency models. Examples of the business objects were: business
competencies, organizational areas and the process groups for medication management
service within the host organization. Business artefacts include business objects and these
were used in this research to develop consensus and increase participants’ understanding of
medication management end-to-end processes within the context of the host organization.
The three objectives were explored from the perspective of the following five research
questions.
1) How can a Business Process Management Ontology used in other industries be
effectively applied to healthcare services?
2) What processes should be included in a process reference model for Medication
Management applicable to hospitals and long term care facilities?
3) What performance measurements in addition to medication errors are appropriate for
monitoring and controlling Medication Management?
4) How can BPM be effectively applied to a situation that involves multiple sites and
multiple business units responsible for Medication Management functions?
5) What are the benefits and challenges of using BPM, BA and BPMO to improve
Medication Management?
The relationship between the three research objectives and the five research questions is
provided in Table 1.
Table 1 Research Objectives & Questions

Objective
Objective 1 - determine the impact of introducing BPM,
BPMO and BA to improve the quality of medication
management in a publicly-funded health care organization.

Research questions



Question 3
Question 4
6

Objective 2 - explore the perceived challenges and benefits
of using BPM, BPMO, and BA in a healthcare organization
Objective 3 - create a process reference model for
medication management




Question 1
Question 5



Question 2

The relationship between research objectives, research questions and data collected is provided in
Table 2.
Table 2 Relationship between Objectives and Data Collection

Objective
Objective 1

Objective 2
Objective 3

Data Collected and Analyzed to Answer Related Research Questions
 Question 3 Performance measures
 Question 4 Business Artefacts based on systems approach and
utilization of Business Architecture principles also example provided
of how BPM was applied to a single business process within
medication management.
 Question 1 As demonstrated by using a comprehensive approach that
included the business ontology along with BPM and BA
 Question 5 Thematic and summative content analysis of participant
and leaders interviews
 Question 2 Processes included in Process Reference Model
developed based on business artefacts

1.4 Rationale for Research
The need to improve delivery of health care services has been well documented in
literature and often discussed in the public forum. There is a belief that quality and patient
safety within current services could be improved and costs could be contained (Canadian
Foundation for Healthcare Improvement, 2011).
Patient safety and specifically adverse events related to medication errors continue to
be a major concern in the health care sector. Medication errors are one of the most common
reported adverse events, it has been estimated that 7.5% of patients admitted to Canadian
hospitals in 2000 experienced an adverse event (Baker, et al., 2004). A subsequent study of a
single hospital in Ontario in 2003 detected 4.4 adverse drug events per 100 patient days
(Forester, Halil, & Tierney, 2004). A systematic review of adverse drug events among adult

7

inpatients showed a range of 3.6% to 60.7% reported in 28 published articles between
January 2000 and June 2013 (Martins, Giordani, & Rozenfeld , 2014). Adverse events cause
harm to patients and tragically in some instances lead to permanent injury or death. There is
also additional cost to the healthcare system as adverse events result in extended length of
stay or readmission to acute care facilities. The medication management process involves
many people including patients, nurses, physicians, pharmacists, pharmacy technicians, and
pharmaceutical companies. The quality of the information used in the medication
management process and the effectiveness of the translation of this information are key to
reducing adverse events.
It has been demonstrated that several healthcare organizations have successfully
transformed their organizations by focusing on quality improvement resulting in better
service at lower cost (Canadian Foundation for Healthcare Improvement, 2011). These
organizations operated from a systems perspective, remained committed to quality
improvement and used information as a critical platform for guiding improvement,
measuring results and monitoring performance. This study reported on outcomes but did not
provide any specifics as to the management approach taken, nor the methods for identifying
and prioritizing process improvement initiatives. Taking a systems view of the organization
requires an understanding of the end-to-end processes that deliver the value in the system.
BPM focuses on end-to-end processes. It is a management discipline that integrates the
quality improvement principles of Deming and Shewart with the business process
reengineering approach promoted by Hammer and Champy (Hammer, 2010).
This research explored the impact of using BPM to develop a process model for
medication management within a regional health authority serving a geographically dispersed
population. BPM has been described as including: management of business processes,
8

measurement of business processes and modeling of business processes (Bandara, Chand,
Chircu, Hintringer, & Karagiannis, 2010). This research included all three elements and
resulted in identification of appropriate measures, a comprehensive process model and
recommendations on management of the processes.
It is important to understand why medication errors occur and how they can be
avoided or detected before any harm is caused. High quality medication management
processes would be safe, effective, efficient, compliant and reliable. Zero medication errors
may not be a realistic expectation due to the complexity of healthcare; however, it is feasible
to mitigate the likelihood or severity of medication errors. Contributing to the complexity of
the medication management processes are the numerous clinicians and technicians involved
in the process and the multitude of standards, guidelines and legislative requirements
applicable to prescription medications. As described in Section 2.1 adverse drug events most
often occur in the Prescribing step or the Medication Administration step in the end-to-end
medication process. The causes of these errors can be categorized as people issues (lapse of
attention or negligence on the part of an individual) or system issues (systemic issues such as
unnecessary complexity in process, poor communication and inadequate information
systems).
BPM has evolved from the three process traditions of 1) management tradition, 2)
quality control tradition and 3) information technology tradition (Harmon, 2014). BPM
requires the process for medication management be explored within the context of the system
it is operating in. This requires an understanding and comprehension of ’systems thinking’ as
it relates to an organization.
The BPM lifecycle consists of six phases: 1) process identification, 2) process
discovery, 3) process analysis, 4) process redesign, 5) process implementation and 6) process
9

monitoring and controlling (Dumas, La Rosa, Mendling, & Reijers, 2013). The process
identification and process discovery phases when combined with a clear understanding of the
system will provide the necessary information to develop a process architecture (Dumas et
al., 2013)
There are a number of domains involved in the medication management process
including the medical domain, information technology domain, information management
domain and the business domain. Each domain has its own unique vocabulary and indeed
the clinicians and professionals within each of the domains often do not share the same
language which can be problematic to successful execution of the process. A shared
vocabulary or common language would increase understanding and decrease confusion when
documenting processes and objects within the medication management process. The
introduction and use of a BPMO would provide a common language and the means for
illustrating the relationship between objects within the processes themselves or between other
objects within the organization. Enterprise Architecture (EA) provides a structure for the
objects within the organization. Examples of objects in a complete EA include: software
application, network server, business area, process owner, strategic business objective, and
critical success factor. The objects included in this research can be found in the business
layer of the Enterprise Architecture and therefore are referred to as Business Architecture
(BA) throughout this dissertation.
Healthcare and healthcare organizations are complex and disciplines such as BPM,
BPMO and BA have the potential to reduce the level of complexity and create a shared
understanding of medication management safety across the organization.

10

1.5 Terminology and Definitions
This section includes definitions and terminology used throughout this document and
is intended to provide clarification on how terms were applied in this specific research.
Medication errors have been defined by the National Coordinating Council for
Medication Error Reporting and Prevention (NCCMERP) as:
“A medication error is any preventable event that may cause or lead to
inappropriate medication use or patient harm while the medication is in the
control of the health care professional, patient, or consumer. Such events may
be related to professional practice, health care products, procedure, and
systems, including prescribing, order, communication, product labeling,
packaging, and nomenclature, compounding, dispensing, distribution,
administration, education, monitoring and use.” (National Coordinating
Council for Medication Error Reporting and Prevention, 2017).
Adverse events have been defined as “adverse events are unintended injuries or
complications resulting in death, disability or prolonged hospital stay that arise from health
care management” (Baker, et al., 2004, p. 1678). Medication errors that lead to an adverse
event are referred to as Adverse Drug Events (ADEs).
Process has been defined as “a collection of interrelated tasks and activities that are
initiated in response to an event which aims to achieve a specific result for the consumer of
the process” (von Rosing, Scheer, & von Scheel, 2014, p. 1). Customers can be external or
internal to the organization and from the perspective of publicly funded health services
external customers are synonymous with clients, patients & consumers.
Over the last ten years the definition of BPM has evolved from being narrowly
defined at the individual business process level to being defined as spanning organizational
11

and system boundaries. The focus of most definitions of BPM, however, is on process
improvement of end-to-end core business processes. It has been defined narrowly by Khan
as “BPM is a methodology for modeling, automating, managing and optimizing a business
process through its lifecycle to increase profitability” (Khan, 2004). The BPM Institute
defines BPM as “the definition, improvement and management of a firm’s end-to-end
enterprise business processes in order to achieve three outcomes crucial to a performancebased, customer –driven firm: 1) clarity on strategic direction, 2) alignment of the firm’s
resources and 3) increased discipline in daily operations” (Business Process Management
Institute, 2016).
Swenson and von Rosing (2015) undertook a review of over 100 articles that included
definitions of BPM. They have proposed the following definition that suggests BPM is to
take a ‘systems thinking approach’ to process management.
“Business process management (BPM) is a discipline involving any
combination of modeling, automation, execution, control, measurement, and
optimization of business activity flows in applicable combination to support
enterprise goals, spanning organizational and system boundaries, and
involving employees, customers, and partners within and beyond the
enterprise boundaries” (Swenson & von Rosing, 2015, p. 87).
It would appear then that BPM could be used to improve a single end-to-end process
or used at a system level to transform and improve an entire organization. This would be
determined by which of the myriad of BPM definitions that a practitioner subscribes to. For
the purposes of this research, the definition offered by Swenson and von Rosing above will
be applied. The medication management process includes many actors and influencers, some
within the organization but many external to the organization including pharmaceutical
12

suppliers, professional standard setting organizations and legislative bodies. The need to
view the end-to-end process including drivers and influencers beyond the enterprise
boundaries is also consistent with the more comprehensive definition of BPM.
BA is defined as “A blueprint of the enterprise that provides a common
understanding of the organization and is used to align strategic objectives and tactical
demands.” (Business Architecture Guild, 2017, p. 1). BA and BPM are two separate but
closely related disciplines. BA is a component of EA. EA has been defined as “a set of
concepts and practices based on holistic systems thinking, principles of shared language, and
the long-standing disciplines of engineering and architecture” (Kappelman & Zachman,
2013, p. 87).
Ontology has been defined as a “formal, explicit, specification of a shared
conceptualization” (Gruber, 1993, p. 199). It has also been defined generally as “a
representation of the entities in reality and the relations between those entities (Blobel,
Goossen, & Brochhausen, 2014, p. 58). A more comprehensive definition is “An ontology is
an artefact, more precisely an intentional semantic structure that encodes the set of objects
and terms that are presumed to exist in some area of interest (i.e. the universe of discourse or
semantic domain), the relationships that hold among them and the implicit rules constraining
the structure of this (piece of) reality” (Giaretta & Guarino, 1995, p. 314).
1.6 Approach
This research employed a mixed methods approach incorporating both quantitative
design and qualitative design. Quantitative design consisted of the use of Analytical
Hierarchy Process (AHP) to rank improvement opportunities while performance data was
collected based on a repeated measures design and analyzed using statistical process control
charts. Qualitative design included workshops and semi-structured interviews.
13

The scheduling of workshops and working group meetings was highly dependent on
availability of participants. Three half day workshops were held over an eight week period.
The invitation to attend was sent to twenty- six individuals recommended by the Chair of NH
Medication Management Safety and Quality Committee. This group included representatives
from management staff of all areas included in the end to end process for medication
management in the organization. The first workshop was attended by twenty-two of the
twenty-six individuals who had been invited. The second workshop included fourteen of the
original twenty-two attendees and the third workshop included thirteen of the original
twenty-two attendees. The workshops consisted of an introduction to BPM, strategy maps,
business competency models and value chains along with discussion and consensus on what
should be included on the medication management business artefacts. At the conclusion of
the workshops two smaller working groups were formed to work on the prioritization of
improvement opportunities and the development of a performance measurement plan for
medication management in the host organization. These working groups met monthly for
five months which was followed by another meeting to finalize the work. The duration of
each meeting was from one to three hours for a total of twelve hours for the prioritization
working group and eleven hours for the measurement working group. The final results from
these working groups were then provided to workshop participants
Two separate sets of semi-structured interviews were also conducted. The first set of
interviews was with individuals who had participated in the medication management
workshops and working groups. These individuals were selected by the Medication Safety &
Quality Committee of the host organization based on their role within medication
management processes. Those identified provided a reasonable representation of the various
clinicians and support staff knowledgeable in medication management issues. It was
14

determined that they constituted a reasonable sample of individuals with responsibility for
medication management. The criteria for inclusion was that individuals had to have
participated in at least one of the workshops. Exclusion criteria was any individual who had
participated in the workshop that had a reporting relationship with the researcher in her
supervisory role within the host organization. In total, twenty individuals were invited to
participate in these interviews and eleven (55%) individuals were interviewed. This group
had a view on the entire process of development of business artefacts, identification of
performance measures, identification of improvement initiatives and prioritization of those
initiatives using AHP. This put them in a unique position to comment on the benefits and
challenges of the comprehensive management approach.
The second set of interviews was with individuals in senior leadership roles within the
host organization. A senior leadership role was defined as a member of the Executive Team
or a staff member reporting directly to a member of the Executive Team. This group
encompassed strategic management roles across all business areas and geographic locations
of the host organization. The only direct report staff who were excluded were individuals in
administrative assistant roles. In total, seventy-three individuals were invited to participate
and twenty-one (29%) agreed to be interviewed. This group had exposure to the business
artefacts across all portfolios and represented those responsible for strategic planning across
the organization. Thus, they provided a valuable perspective on the challenges and benefits
from an organization wide perspective.
The transcribed interviews were analyzed using thematic and summative content
analysis. The following six themes were identified: Capacity Building, Communication,
Collaboration, Competing Priorities, Culture and Connection to Strategy. The summative
content analysis of the transcribed interviews was completed to shed light on differences and
15

similarities in language used by respondents as they described the benefits and challenges of
using BPM, BPMO and BA related to medication management.
1.7 Context of Host Organization
In the province of British Columbia, Canada there are two population based health
authorities and five geographic health authorities. The Provincial Health Services Authority
(PHSA) provides tertiary services province wide including cancer care, renal services,
ambulance services, transplant services, pediatrics, and high risk pregnancy services among
others. The First Nations Health Authority (FNHA) has a mandate to support the health and
wellness of First Nations people in BC. Northern Health (NH) is one of the five geographic
health authorities responsible for providing the full spectrum of publicly funded health care
services from health promotion and protection through to acute care and end of life care.
NH provides health services to a population of approximately three hundred thousand
people spread across six hundred thousand square kilometers in northern British Columbia,
Canada with service provided in mainly rural and remote communities. Acute care and
diagnostic services are provided in eighteen hospitals and nine diagnostic and treatment
centres. Long term complex care residential services are provided in thirteen standalone
facilities and ten of the eighteen hospitals have beds allocated to long term complex care.
Medication management processes in acute and complex care facilities are of concern
to the organization as evidenced in internal documentation that includes medication
management as one of its eight strategic action plans in its 2016/17 to 2018/19 Operational
Plan. Medication error events were the second highest reported event in the Patient Safety
Learning System (PSLS) of the host organization in the fiscal year ended March 31, 2017.
This was second only to reported safety events related to in-facility falls. The PSLS is a
voluntary reporting system where clinicians and health workers can report events related to
16

patient safety. Between April 1, 2016 and March 31, 2017 there were a total of twelve
thousand, three hundred and sixty five safety events reported and three thousand, two
hundred and fifty (26.28%) of these were medication safety events. The events reported
included situations where no harm came to the patient, and the more serious events where
there was harm to a patient. Since this is a voluntary reporting system it is reasonable to
conclude that not all reports of medication errors are being reported.
Publicly funded Canadian healthcare organizations, including Northern Health, report
financial cost based on a standard Management Information System (MIS). The Canadian
Institute for Health Information (CIHI) maintains the standards for the general ledger chart of
accounts which is the basis of the financial and statistical general ledgers used in publicly
funded Canadian healthcare organizations.
Priority setting and resource allocation within NH is a challenge with requests for
resources, both financial and human, exceeding the resources available (Urquhart, Mitton, &
Peacock, 2008). Medication management processes and drug costs are a material portion of
the annual operating expenses. Unfortunately, physician and nursing costs specific to
medication management processes are not available due to the lack of an activity based
costing system or workload measurement system within NH. Pharmacy and drug costs are
available and the annual cost in 2016/2017 was in excess of eighteen million dollars. In
addition to the financial costs, recruitment and retention of clinicians, particularly
pharmacists to a rural setting is an ongoing challenge for NH.
The organization was in the early stages of introducing BPM and BA when the
research commenced with the medication management initiative being the first to officially
adopt this management approach. During the research period an additional organizational

17

BPM initiative was undertaken to address concerns in home based services related to aging
of the population and growing demand for home based services.
1.8 Contribution
Healthcare has been slow to fully adopt BPM despite the success demonstrated in other
sectors. This has been largely attributed to the dynamic, flexible, knowledge intensive
processes within healthcare (Mertens et al., 2015). This research combines BPMO and BA
with BPM to demonstrate a holistic and comprehensive management approach to improve
medication safety and quality within acute care and long term care facilities. Although this
research does not solve all the problems related to complexity of the healthcare system, it
provides a repeatable approach to demystifying the connection between strategies aimed at
patient safety and the underlying processes in need of redesign. Further, this research
included a thematic analysis of healthcare leader’s perceived benefits and challenges of using
BPM, BPMO and BA, as well as, development of a process reference model for medication
management. The reference model could be used by other healthcare organizations
interested in introducing BPM to improve quality of medication management services within
their organization.

18

2

Literature Review

The medication management process spans organizational boundaries, involves
numerous healthcare professionals, results in high costs, and is governed by a multitude of
standards, guidelines and legislative requirements. Achieving sustainable improvements in
such a complex process requires an understanding of the process itself and the context in
which the process is executed. The literature review explored what is currently known about
medication errors and how management disciplines such as BPM, BPMO and BA could be
employed to create a high quality medication management process. The literature review
includes six areas: 1) medication errors and adverse drug events, 2) standards, guidelines and
legislative requirements, 3) BPM, 4) viewing the healthcare organization as a system, 5)
BPMO, and 6) reference models.
2.1 Medication Errors and Adverse Drug Events
Quality concerns related to medication errors and adverse events occurring in
hospitals and long term care facilities continue to be a subject of interest. Medication errors
can happen anywhere in the medication management process and as a result of rigorous
checks and balances these errors are often caught before they impact the patient. Adverse
drug events occur when the administration of medication results in an unexpected or
unwanted reaction in a patient. An adverse drug event could be the result of an undetected
medication error or a drug reaction that could not have been known in advance (such as an
allergy not known to the patient or an unusual side effect of a medication).
Reported statistics from a United States study showed 39% of medication errors were
the result of inaccurate ordering by physicians, and almost half of those errors were
intercepted by nurses or pharmacists before the medication was administered to the patient.
Meanwhile 38% of errors occurred during medication administration, generally by nurses,
19

and only 2% of those were intercepted (Leape, et al., 1995). It is important to understand
where in the process errors occur and also the possible root causes of the errors. This
knowledge is essential in order to select appropriate and sustainable improvement efforts that
will have positive impact on lowering the number of adverse drug events as well as
mitigating the degree of harm to the patient. The remaining 23% of medication errors
occurred in one of the following steps in the medication management process: dispensing,
documenting or monitoring. It was also reported that nurses intercepted 86% of medication
errors and pharmacists intercepted 12% (Leape, et al., 1995).
A Canadian study of adverse events showed that, in the fiscal year 2000, for every
100 patients admitted to an acute care hospital, 7.5 patients experienced at least one adverse
event. Drug or fluid-related services accounted for the second highest incidence of adverse
events at 23.61% just below surgical service at 34% (Baker, et al., 2004). The 7.5% of
patients who experience one or more adverse events reported in this study are similar to a UK
study (Vincent, Neale, & Woloshynowych, 2001), lower than studies in New Zealand 12.9%
and Australia 16.6% (Wilson, et al., 1995) and higher than two large US studies 3.7%
(Brennan, et al., 1991) and 2.9% (Thomas, et al., 2000). These studies did not all use the
same selection criteria and the US study had focused on finding negligence while the other
studies focused on quality improvement and preventability of adverse events. The authors of
the Canadian study concluded that 58% of all adverse events found were attributed to either
medication safety or surgical services; therefore, efforts to improve these two services would
have considerable positive impact on reducing adverse events in Canadian hospitals (Baker,
et al., 2004).
There are numerous articles that report on the causes of medication errors in acute
and long term care facilities with a focus on the medication administration step in the process
20

(Chircu et al., 2013; Elliott & Liu, 2010; Keers et al. 2014; Poon, et al., 2010; Keers et al.
2013). A systematic review of fifty-four articles relating to causes of medication
administration errors in hospitals was conducted and the authors categorized the causes into
the following three levels based on Reason’s model of accident causation: 1) High Level
Strategy, 2) Error/Violation Provoking Conditions and 3) Unsafe Acts and Omissions (Keers,
et al., 2014; Reason, 2000). Included in the High Level Strategy category were management
decisions, organization policies, economic & regulatory context, safety agenda, and clinical
negligence schemes. The Error/Violation Provoking Conditions category included: training
and experience, patient factors, errors in medicines supply, physical/mental health,
inadequate procedures, poor communication, poor supervision, heavy workload, staffing/skill
mix, unsuitable environment, and local working culture. The Unsafe Acts and Omissions
category included: memory lapses, action slips/failures, knowledge and rule based mistakes
and violations (Keers et al., 2014).
There were several themes that arose in the review of the literature related to
medication errors, and adverse drug events. These themes are also evident in the information
provided by the various accrediting bodies and organizations focused on patient safety and
quality of healthcare. The collection of “best possible medication history” and the
importance of medication reconciliation upon admission and at time of transfer or discharge
is a repeating theme. The “five rights” of medication administration is taught to all nursing
students and is expected to be a standard of practice (Right patient, Right drug, Right time,
Right dose and Right route). Over time the traditional five rights of medication
administration have been expanded to nine rights including Right documentation, Right
action, Right form and Right response (Elliott & Liu, 2010). Northern Health’s internal
policy document on Medication Administration includes a tenth right which is the Right of
21

the client to refuse medication when deemed capable to do so. An interesting point is the
CRNBC practice standard on medication administration includes seven rights. It does not
refer to Right action, Right form or Right of client to refuse medication (College of
Registered Nurses of British Columbia, 2016). Most often the nurse is the last line of
defence in preventing medication errors and it therefore stands to reason that supporting
nurses by providing appropriate information and adequate time to execute evidence informed
processes in medication administration could reduce medication errors (Chircu et al., 2013).
Communication of information among healthcare providers and between patients and
healthcare providers has also been identified in the literature as an area that requires further
study. Liu, Manias & Gerdtz (2011) explored and contrasted six conceptual models to
determine how to improve medication safety practices. The six models include two causal
models and four exploratory models. The two causal models are Human Error Model and
System Analysis Model. The four exploratory models are Shared Decision-Making Model,
Medication Decision-Making and Management Model, Partnership Model and Medication
Communication Model. They concluded that the Medication Communication Model was the
most insightful (Liu, Manias, & Gerdtz, 2011). The model identified antecedents and defined
attributes of actual communication encounters and consequences when tested in an
Australian hospital (Manias, 2010). The application of standard procedures and conceptual
models in healthcare settings are challenging due to diversity of the setting and various
players within the setting (Liu, Manias, & Gerdtz, 2011).
The Human Error Model was used in a systematic review of medication
administration errors to categorize the causes of errors. The authors concluded that
interventions to reduce medication errors should focus on system factors versus person
factors (Almaney, 1974; Keers, Williams, Cooke, & Ashcroft, 2013) . A medication
22

communication framework was developed using the Circle of Care Modeling approach. This
work led the authors to identify that there is a Coordinating step in addition to the other five
steps of Determine Need, Prescribe, Dispense, Administer and Monitor that they had initially
anticipated (Kitson, Price, Lau, & Showler, 2013)
Addressing medication errors could be approached from either a person or a systems
perspective. The Person Approach to addressing medication errors would focus on the
person identified as responsible for creating the error such as the physician, pharmacist, nurse
or technician. This traditional approach assumes there was some lapse of attention or
negligence on the part of an individual resulting in the occurrence of the error. The
underlying assumption in this model is that the ‘safe’ process was not followed. Conversely,
the System Approach to medication errors assumes there are systemic factors which cause
errors and the focus of addressing errors should not be directed at individuals but at the
system in which individuals work (Reason, 2000). The National Coordinating Council for
Medication Error Reporting and Prevention balances both these perspectives in its
publication ‘Reducing Medication Errors Associated with At-risk Behaviours by Healthcare
Professionals’. This document suggests that healthcare providers are willing to take risks
which could result in patient harm because the risk to the patient seems remote and the at-risk
behaviour may save time or be more convenient for the provider. They attribute the at-risk
behaviours to unnecessary complexity in processes and an organizational culture which
tolerates and often rewards at-risk behaviours (National Coordinating Council for Medication
Error Reporting and Prevention, 2017).
A soft systems approach would appear appropriate in addressing a process such as
medication management where there is a high reliance on individual clinicians following a
dynamic process that spans organizational functional boundaries. Siriam (2012) proposes
23

BPM which combines soft systems methodology (qualitative) with hard systems
methodology (quantitative). The author suggests that involving people early in the process
will lead to a higher level of success and demonstrates how to engage people through a case
study of an information technology service, using a combination of developing “rich
pictures” and using Analytical Hierarchy Process (AHP) to identify the most critical
processes for improvement efforts. The rich pictures were developed during workshops with
extensive consultation with individuals involved in the service area which was followed by
applying a hard systems approach of using the AHP methodology to numerically quantify
and rank the options (Siriam, 2012).
A conceptual process map for the medication management process of a hospital
inpatient stay or long term care resident stay may include the following steps: 1)
Registration, 2) Patient Assessment 3) Prescribing including Medication Ordering, 4)
Dispensing, 5) Administering including Documenting, 6) Monitoring and 7) Discharge. This
process reflects the steps as linear when in reality there could be many iterations within the
process as medications are changed or orders are clarified. These steps do not include the
supporting processes or management processes such as inventory management, quality
assurance, drug formulary management or the multitude of other activities that support a high
quality medication management process. A review of eight articles that have incorporated
information related to a conceptual process map for medication management show a range
with a minimum of five steps to a maximum of sixteen steps (Bell, Cretin, Marken, &
Landman, 2004; Bell, et al., 2007; Bepko, Moore, & Coleman, 2009; Chircu, Gogan, Boss, &
Baxter, 2013; Classen & Metzger, 2003; Uberoi & Sibal, 2008; Qian & Yu, 2013; Redley &
Botti, 2013; Uberoi & Sibal, 2008; Verrue, et al., 2011). The article documenting the sixteen
steps was a case study focused on the information quality which would explain the
24

granularity and why the number of steps were higher than the other articles reviewed (Chircu
et al., 2013). The remaining articles contained either five, six or seven steps and
interestingly, registration was not a step in any of the articles. This is a crucial step in the
process as all subsequent steps rely on the accuracy of the registration information,
particularly the information related to any “known” allergies. The four steps included in all
eight of the examples were prescribe, order (transmit), dispense and administer. Not all
processes reviewed included a monitoring step or a documentation step however, both
monitoring and documentation are assumed to be included as part of the Administer step.
Documentation occurs immediately following the administration of medication and
monitoring is an ongoing activity of nursing care.
Information technology is purported to be one of the solutions to address medication
safety issues (Bell et al., 2004; Bepko et al. 2009; Beuscart-Zephir et al., 2010; Chen & Tsai,
2014; Classen & Metzger, 2003; Keers et al., 2014; Keohane, et al., 2008; Pham, et al., 2012;
Poon, et al., 2010). Electronic medication management systems, closed-loop bar coding for
medication administration, automated medication dispensing cabinets, computerized
practitioner order entry, as well as data collection and reporting systems that can provide real
time information to support clinicians in decision making have been shown to reduce
medication errors (Bepko et al., 2009; Keers et al., 2014).
Measurement of medication safety in real time is a key to reducing medication errors
and “surveillance” is the appropriate term to use when considering the reasons for the
measurement. Physicians and pharmacist could benefit by having easy and timely access to
clinical information, such as most recent lab results, when prescribing or reviewing
medication therapy. Real time clinical data could assist the physician in prescribing the most
appropriate medication or dosage level. Likewise, it could assist the pharmacist as they
25

double check appropriateness of the prescription (Classen & Metzger, 2003). Automated
medication dispensing cabinets and closed loop bar coding systems provide clinicians with
valuable information and a secondary check at time of medication administration (Pham, et
al., 2012; Poon, et al., 2010). Automatic alerts can be programmed into medication infusion
pumps which alert a nurse when the dosage being administered is outside normal range and
this would trigger a second check by the nurse before the medication is administered to the
patient.
The prescribing phase of the medication management process has been identified as
one of the more error prone phases. Electronic prescribing shows great promise in reducing
the errors at this phase of the process (Bell et al., 2004). Legibility is an issue with manual
prescribing as are transcribing errors and completeness of information. Electronic
prescribing eliminates the legibility issue as all prescriptions would be entered into the
computer system by the prescriber. Transcription errors could be reduced by the electronic
transfer of data. Electronic prescribing also provides clinicians with drug information,
patient history, drug formulary information and medical records at time of prescribing.
The implementation of information technology within healthcare can be extremely
challenging and a Human Factors Engineering approach is recommended. This approach is
similar to BPM in that one of the first steps is to analyze the work system. The authors found
very few standardized processes in healthcare which made it difficult to introduce the
technology in a way that lead to efficient and effective workflows (Beuscart-Zephir et al.,
2010). A study in Ireland looked at a failed attempt to implement a human resources and
payroll software application for nation-wide healthcare services. The failure was attributed
to the difficulty in implementing a single system in a non-standardized environment (Helfert,
2009).
26

The introduction of technology may reduce certain types of errors but complexity of
the software applications and end-user knowledge could result in the introduction of new
types of errors in the process (Redley & Botti, 2013). This does not mean that new
technology should not be introduced but that it is necessary to fully understand the processes
and relationships so users of the software applications are capable and prepared to use the
new technology effectively. BPM’s focus on the processes within an organization reveals
opportunities to use information technology to automate steps within the process. This
allows clinicians to have access to real time information for clinical decision making thereby
increasing the opportunity for the correct decision to be made and avoid errors. BA provides
the context in which the processes are being executed thereby increasing the understanding of
processes included in specific business areas. It also identifies information systems, data
stores and infrastructure which supports the processes.
Identifying and quantifying medical errors and adverse drug events has relied on
voluntary reporting by clinicians, or on the use of chart reviews or ‘triggers’ for nonvoluntary reporting (Classen & Metzger, 2003). In addition to these two methods six other
approaches were identified in the literature. These include: 1) review of claims data, 2)
patient monitoring, 3) administrative data examination, 4) direct care observation, 5)
computer monitoring and 6) incident reporting of sentinel events (Montesi & Lechi, 2009).
Quality improvement efforts by National Health Services (NHS) in the United
Kingdom (UK) have led to the design, development and implementation of a ‘Medication
Safety Thermometer’ (Rostami, et al., 2017). This approach to improve safety requires data
on harm and potential harm related to medication be collected one day per month and the
data is then used to inform and monitor efforts to improve medication safety. This approach
combines direct care observation, patient monitoring and chart review. Claims data focuses
27

on review of litigation information and incident reporting sentinel events only addresses the
most serious errors where obvious harm has occurred to the patient. The examination of
administrative data is limited due to its retroactive perspective and the absence of clinical
data.
Computer monitoring refers to the use of clinical information systems to harvest
electronic data relevant to medication errors and adverse drug events which has the potential
to provide real time data that could prevent medication errors. Major limitations of computer
monitoring are inserted errors, poor software, poor triggers and undetermined future risks
(Montesi & Lechi, 2009). In addition, there are very high costs to purchase, implement and
maintain clinical information systems.
The Patient Safety Learning System (PSLS) is a software program used in all British
Columbia health authorities. Care providers are expected to voluntarily report all adverse
events or “near misses” within that software application. Reported incidents are then
followed up by management to determine the remedial action required to prevent these or
similar incidents from happening again in the future. Data from the PSLS is analysed by risk
managers to determine where specific organizational improvement efforts are required to
improve overall patient safety. The expectation is for all events to be recorded; however,
there has been some resistance by healthcare providers to report incidents in fear of blame or
repercussions. It is suspected within the host organization that the information recorded and
available for “no harm” incidents is underreported. There is slightly more confidence in the
information reporting of incidents causing moderate to significant harm as these incidents
typically require some escalated medical response as well as discussions with another
clinician or supervisor. A study found several issues with the underreporting of adverse drug
events when voluntary reporting was used. The results revealed only three incident reports
28

had been filed in the same period that case finding showed fifty-four adverse drug events had
occurred (Cullen, et al., 1995). A systematic review of literature related to the causes for
underreporting of adverse drug events by health professionals indicated similar results. The
review included twenty-nine articles from seventeen different countries published between
1992 and 2012. Causes of underreporting were categorized in seven attitudes: 1)
complacency, 2) fear of litigation, 3) guilt, 4) ambition or financial benefit, 5) ignorance on
when or how to report, 6) insecurity and 7) indifference. These have been labelled as the
seven deadly sins of adverse drug events underreporting (Inman, 1976). The authors of the
article concluded there should be an eighth deadly sin added, the lack of training in
pharmacovigilance for health professionals (Varallo, Guimaraes, Abjaude, & Mastroianni,
2014).
2.2 Standards, Guidelines and Legislative Requirements
There are numerous standards, guidelines, industry practices and legislative
requirements that need to be considered in the development of an end-to-end process map for
medication management. Healthcare professionals are registered with their respective
colleges and are expected to meet the standards and ethical conduct set out by their governing
bodies. Physicians, pharmacists and nurses all require a licence to practice their profession;
for example, Nurse Practitioners and Registered Nurses practicing in British Columbia are
required to be members of the College of Registered Nurses of British Columbia (CRNBC)
and both have Professional Standards and Practice Standards they must adhere to. There are
four Professional Standards and seventeen Practice Standards documented on the CRNBC
website. Three of the seventeen Practice Standards are specifically related to the medication
management process. These Practice Standards are Dispensing Medication, Medication
Administration and Medication Inventory Management (College of Registered Nurses of
29

British Columbia, 2015). The CRNBC website also references sixty-seven separate pieces of
legislation including provincial and federal legislation that are relevant to Nurses’ practice
(College of Registered Nurses of British Columbia, 2014). The four specific pieces of
legislation related to medication management are: Controlled Drugs and Substances Act
(Federal), Hospital Act, Pharmaceutical Services Act and Pharmacy Operations and Drug
Scheduling Act. Physicians, Pharmacist, Licenced Practical Nurses and Certified Pharmacy
Technicians also have standards and legislation guiding their work and influencing how they
must perform their duties. These standards and legislative requirements need to be
considered in development of a comprehensive process model for medication management.
In addition to the individual professional responsibilities to meet standards and legislation,
the health care organization is also subject to legislation and standards. The organization
must also operate within the confines of the government mandated practices. Most health
care organizations in Canada also voluntarily participate in Accreditation Programs, the
conditions of which must also be considered when developing a comprehensive process
model for medication management.
Accreditation Canada classifies required organization practices (ROPs) in six major
categories: Safety Culture, Communication, Medication Use, Work life /Workforce,
Infection Control, and Risk Assessment. The purpose of the required organizational
practices is to help guide the provision of safe, high quality health care (Accreditation
Canada, 2015). NH is accredited and is committed to meeting these ROPs. The activities
within the comprehensive medication management process model will need to comply with
the ROPs. An example of one of the ROPs in Medication Use category is the requirement to
obtain a best possible medication history (BPMH) and complete a medication reconciliation

30

upon admission to hospital or long term care facility, and before and after transfers between
and within facilities.
Compliance with standards, guidelines and legislative requirements must be built into
the medication management processes. This can be a challenging task as there is often
conflicting goals between business and control objectives (Sadiq, Governatori, & Naimiri,
2007). The comprehensive management approach of using BPM, BPMO and BA in the
process modeling and process improvement could help facilitate the development of process
models that incorporate business rules and business objects related to compliance.
2.3 Business Process Management
Academics and practitioners have both contributed to the literature on BPM.
Practitioners have contributed a multitude of articles and books providing case studies,
frameworks and “how to” guides of BPM. There has been far less publications in academic
journals on the “why” of BPM (Smart, Maddern, & Maull, 2009; Trkman, 2010). The result
has been that most articles have been atheoretical (Melao & Pidd, 2000). Despite the
imbalance there has been progress in addressing the need to identify the theories
underpinning BPM (Biazzo, 2002; Lacerda, Cassel, & Rodrigues, 2010; Niehaves,
Poeppelbuss, Plattfaut, & Becker, 2014; Trkman, 2010; Trkman, 2013). The five theories
proposed as relevant to BPM are socio-technical theory, theory of constraints, dynamic
capability theory, contingency theory, and task-technology fit theory. Socio-technical theory,
theory of constraints, and dynamic capabilities theory are proposed as being able to
singularly explain the ‘why’ of BPM. Alternatively, a combination of contingency theory,
dynamic capability theory and task-technology fit theory are used to explain the why of
BPM.

31

1. The socio-technical theory referenced by (Biazzo, 2002) and (Xiang, Archer, &
Detlor, 2014) highlighted that for BPM to be successful both technical aspects
(the techniques, tools and methods used) and the socio aspects (attitudes and
beliefs of people) need to be considered in implementation of a design or redesign
process.
2. The limitations of the performance of an organizational system were explored
through the use of the thinking process which is derived from the theory of
constraints and attempts to determine ‘why’ things happen versus ‘how’ they
happen (Lacerda et al., 2010).
3. The dynamic capabilities theory refers to an organization’s ability to change
rapidly in response to changes in the external or internal environment. This is
crucial for an organization that wants to maintain a competitive advantage. If
implemented appropriately, BPM could be considered as a dynamic capability
(Niehaves, Plattfaut, & Becker, 2010; Niehaveset al., 2014).
4. Contingency theory, dynamic capability theory and task-technology fit theory
when taken together provide a theoretical base for BPM (Trkman, 2010). Trkman
was able to draw logical and substantiated alignment between the critical success
factors of BPM and each of the theories. The author further explored this
alignment in 2013 when looking at critical processes that must be in place within
a BPM focused organization (Trkman, 2013).
There is a lack of an agreed upon theoretical base for BPM. Practitioners have taken
the lead in publishing which has resulted in a proliferation of articles espousing best practice.
There is an assumption that these best practices are transferrable. This is not necessarily true
because the design of the service process is driven by contextual factors (Ponsignon, Smart,
32

& Maull, 2012). The existing literature is consistent in understanding of the evolution of
BPM and referencing business re-engineering and workflow management approaches. It has
been expressed that BPM might be considered as simply the repackaging of old ideas that
enabled consultants and management gurus to promote their approaches as novel (Trkman,
2013).
BPM has evolved from three business process traditions (Harmon, 2014). These are:
1) management tradition, 2) the quality control tradition, and 3) the information technology
tradition as shown in Figure 2.

Focus: Improvement of organizational performance

Business management/process redesign

through aligning or changing major business processes
Business
Focus: Improvement of
operational processes

Work simplification/industrial engineering

Quality control, Six Sigma, lean

Process
Management

Focus: Process Automation

Information technology

BPMS

Adapted from: Harmon, P. (2014) Business Process Change, Morgan Kaufman, Massachusetts Figure 1.5 pg 15

Figure 2. Evolution of BPM

The management tradition focuses on overall performance of an organization and
examples of contributions to BPM include the findings of Porter’s Value Chain, Kaplan &
Norton’s Balanced Scorecard, Process Frameworks, Business Process Engineering and
Business Process Reengineering. (Harmon, 2014; Margherita, 2014; von Rosing et al.,
2014).
33

The quality control tradition has focused on the quality and production including
contributions such as, Total Quality Management, Six Sigma, Lean, Lean Six Sigma and
Capability Maturity Models. Notable contributors in this field include Shewart, Deming,
Juran, Ohno and Womack (Harmon, 2014; Margherita, 2014; von Rosing et al., 2014).
The information technology tradition has enabled the automation of work processes
and examples of contributions from this tradition include IT Architectures, Structured
Software Methodologies, CASE tools, Business Process Modeling Tools, Expert Systems,
and Business Process Management Notation (BPMN). Notable names in this tradition
comprise of Martin, Davenport, Hammer, Champy, Gartner, and Object Management Group
(Harmon, 2014).
Business Process Engineering (BPE) and Business Process Reengineering (BPR) are
both business management strategies that focus on the design or redesign of processes for the
purpose of creating maximum value for an organization. This approach to process
improvement has been attributed to Hammer and Champy (Harmon, 2014). The quality
improvement approach proposed and popularized by Shewhart and Deming focused on using
statistical process control to reduce variation in individual processes and supported
continuous quality improvement through monitoring of processes via ongoing measurement
(Hammer, 2010). The process engineering and reengineering approach focuses on end-toend processes which is an improvement over the approach to quality process improvement
proposed by Shewhart and Deming. The primary criticism of the Shewhart and Deming
approach was that it defined process very narrowly as any activity which included an input,
activity steps and an output. The result of this general definition is that an organization could
have thousands of processes. Quality improvement activities that look at individual
processes outside the context of the end-to-end process could yield improvements in one
34

process but create inefficiency in either upstream or downstream processes. BPE and BPR
were an improvement to these approaches as they examined the entire process from the
perspective of producing value for the customer. However, BPE and BPR are perceived as
episodic or radical approaches with a less disciplined approach to performance measurement
and continuous process improvement (Hammer, 2010; Niehaves et al., 2010; Looy, Backer,
& Poels, 2014). BPM combines the strengths of both approaches to quality improvement and
also incorporates the use of information technology. BPM is more consistent with a systems
perspective because it takes into account the interrelationships between the processes being
designed or redesigned and other processes, rules and requirements within the system. The
business process management software applications (BPMS) available in the market have led
to confusion in the interpretation of what BPM actually is. It is not a software program but
rather a management discipline that can be facilitated through the use of technology and
software applications (Palmer, et al., 2014).
Standardization of processes and process automation are a desired outcome of most
BPM projects (Harmon, 2014). Standardization and automation of processes can result in
technical efficiency and has shown to have a positive impact on process time, cost and
quality (Munstermann, Eckhardt, & Weitzel, 2010). Lack of standardization and manual
processes tend to be more expensive and result in unintended variances in both cost and
quality of services (Langley, et al., 2009). Process automation using technology is a common
means of creating an efficient and effective process. It has been shown that hospitals with a
high degree of process orientation are more efficient than the ones without such process
orientation (Vera & Kuntz, 2007).
Measuring quality improvement requires measures be collected on the performance or
output of the service as well as measures such as time and cost (Davenport & Beers, 1995).
35

These measures of both output and process enables an organization to overcome the over
reliance on financial measures only to measure their performance. The development of
process based management information and the ability to incorporate this with financial
management information increases management knowledge of the functioning of the entire
organization and assists in the identification of opportunities for improvement. It also
facilitates an organization to develop a balanced scorecard.
The balanced scorecard approach to performance management requires performance
measures be balanced among four perspectives: 1) financial, 2) customer/market, 3) process
capability, and 4) learning/growth (Kaplan & Norton, 1992). The performance measures of
the medication management process should include measures from all four of these
perspectives. Financial measures report on the financial results and include such
performance measures as return on investment or operating margin. Customer/market
measures include market share and customer satisfaction. Process capability measures
include cost, time to market and quality. Learning/growth measures include employee
engagement and availability of systems ( (Kaplan & Norton, 1992). These four perspectives
or quadrants developed for business use can be appropriately adapted to a publicly funded
health care organization. The financial quadrant focuses on the stewardship of public
funding with the measures being expense variance to budget and annual capital cost
allowance of equipment compared to annual investment in new equipment. Customer/market
measures can be adapted to represent Service Excellence measured by patient and family
satisfaction with services and compliance with legislation or government mandates. Process
capability refers to internal processes and appropriate healthcare system measures can
include clinical outcomes such as hospital readmission rates and hospital mortality rates.
Learning and growth is the perspective on staff and physicians’ ability to maintain
36

professional learning and appropriate measures can include employee engagement and access
to training and education.
Development of safety indicators for medication use was undertaken by a group of
twenty national experts in Canada (Nigam, et al., 2008). Table 3 shows a listing of these
indicators. The indicators all relate to error rate except 16, 17 and 18 which refer to cycle
time or wait time.
Table 3. Safety Indicators for Medication Use

1. Frequency of potentially dangerous medication abbreviations
2. Frequency of potentially dangerous dose abbreviations
3. Frequency of ambiguous prescription dosing instructions
4. Frequency of incorrect prescription dose designations
5. Dosing for pediatric medications that have a narrow therapeutic index
6. Documentation of allergy status
7. Administering protocols for high-alert prescription medications
8. Verification of high-alert prescriptions
9. Machine-readable coding systems for administration
10. Rate of Adverse drug event (ADE)- related hospitalizations
11. Rate of ADE-related ER visits
12. Monitoring and reducing ADEs by assigning pharmacists on rounds
13. Differentiation of high-alert prescription medications
14. Medication histories for inpatients with complex high-risk regimens
15. Medication reconciliation rate
16. Medication reconciliation rate upon admission
17. Medication reconciliation rate prior to discharge
18. Timeliness of discharge medication summary sent to community physicians
19. Discharge medication summaries sent to community physicians (rate)*
20. Safety of compounding sterile medications
*Note item 19 is an interpretation for the safety indicator as the published article showed the same description
for both 18 and 19 (Source Nigam et al., 2008)

37

In addition to the safety indicators noted in Table 3, eight clinical pharmacy key
performance indicators (cpKPIs) have been reported in the literature (Fernandes, et al.,
2015). Using a modified Delphi approach with a group of clinical pharmacists across Canada
they reached consensus on eight cpKPIs Table 4. These cpKPIs are specific to clinical
pharmacists working within the hospital setting and have overlap with the Safety indicators
for Medication Use noted in Table 3. The processes associated with these cpKPIs reflect
how the work of clinical pharmacists contributes to the reduction of medication errors and
adverse drug events.
Table 4. Clinical Pharmacist Key Performance Indicators

1. Proportion of patients who receive formal documented discharge medication
reconciliation and resolution of identified discrepancies by a pharmacist
2. Number (or proportion of patients who receive formal documented admission
medication reconciliation by a pharmacist (includes a pharmacist best-possible
medication history or pharmacist best-possible medication history review as part of
the medication reconciliation process as well as resolution of identified
discrepancies)
3. Number (or proportion) of pharmacists who actively participate in interprofessional
patient care rounds to improve medication management
4. Number (proportion) of patients for whom clinical pharmacists have completed
(executed/implemented) a pharmaceutical care plan
5. Number of total drug therapy problems resolved by pharmacists
6. Number (or proportion) of patients receiving proactive comprehensive direct
patient care by a pharmacist in collaboration with the health care team
7. Number (or proportion) of hospital patients who receive medication counseling by
a pharmacist at discharge
8. Number (or proportion) of Patients who have received in-person education from a
pharmacist about their disease(s) and medication(s) during their hospital stay
Adapted from (Fernandes et al., 2015)

38

The quality of medication management processes can be measured by the number and
frequency of medication errors. There are numerous participants in medication management
processes who transfer information between each other either verbally, electronically or on
paper. The transfer of patients and related information between clinicians or functional
(business) units is referred to as “handoffs”. These handoffs can result in errors and
unnecessary duplication of effort due to incomplete or inaccurate information flows between
the siloed business units (Gemmel, Vamdaele, & Tambeur, 2008). It has been found that the
information quality during handoffs can and often does lead to medication errors. Using
BPM combined with accounting control theory these researchers determined how
information quality impacts medication administration and contributes to medication errors.
The researchers evaluated the information quality in the categories of validity, accuracy,
completeness and timeliness. An interesting finding from the study was that often the
handoffs resulted in errors detected earlier in the process thereby serving as a separate check
by individuals executing the subsequent step in the process. The parameters in the study
were focused on the quality of the information and also identified controls in the process that
acted as preventative, detective or corrective activities (Chircu et al., 2013).
Business orientation is the way an organization looks at itself. If an organization
sees itself as a collection of services it would be classified as having a “service orientation”,
if it saw itself as project based it would have a “project orientation”, likewise, if it saw itself
as a collection of business processes it would have a “business process orientation” (BPO).
An organization can be viewed from an organizational chart perspective based on functional
units and hierarchical reporting relationships or from the business processes being performed
with the latter reflecting a BPO. The traditional business orientation has been described as
having vertical functional units where people providing specialized services are grouped in
39

departments and business units with management roles in each of the departments and
business units (Maddern, Smart, Maull, & Childe, 2014). This approach can result in
suboptimal service for a customer (patient) since they would need to deal with several
functional areas and information does not always flow efficiently between functional areas.
The result is the patient may have to tell their story numerous times or key information is not
transferred accurately or in a timely manner which could lead to serious errors. The
transition of information and decisions between the silos adds waiting time or results in
rework related to incomplete or inaccurate information flow. An alternate orientation has
been described as a “horizontal” view in which the organization is process centric and views
itself based on end-to-end processes that deliver value to their external and internal customers
(Maddern et al., 2014). This business orientation is aligned with BPM because the main
premise of both is that value creation and competitive advantage can be gained through
focusing on business processes. In its purest form, a business process oriented organization
would have an organizational chart that aligns with its business processes rather than the
traditional organization structure based on functional units. In reality many organizations
choose to maintain the traditional structure but incorporate a matrix management whereby
process owners are identified for the core processes (Armistead & Machin, 1997).
Enterprise Architecture (EA) has been defined as “a set of concepts and practices
based on holistic systems thinking, principles of shared language, and the long-standing
disciplines of engineering and architecture” (Kappelman & Zachman, 2013, p. 87). EA
originated when IT experts began developing models demonstrating how all the enterprise
software applications were connected (Harmon, 2014). The discipline has evolved to now
include not just the modeling of software applications but also the technology (hardware)
aspects and the business processes using the applications and technology. EA is a
40

comprehensive description of key enterprise elements and the relationships between those
elements (Kang, Lee, Choi, & Kim, 2010). There are numerous EA frameworks including:
Zachman Framework for Enterprise Architecture, The Open Groups Architecture Framework
(TOGAF), US Federal Enterprise Architecture Framework (FEAF), Business Architecture
Guild of the Objects Management Group (BIZBOK), and Layered Enterprise Architecture
Design (LEAD) to name a few (Harmon, 2014; von Rosing et al., 2014). The literature
references a multitude of “architectures” or layers within the EA frameworks that when
combined would represent a holistic EA. The FEAF framework includes four distinct
architectures: Technology Architecture, Applications Architecture, Data Architecture and
Business Architecture. The TOGAF framework includes three architectures: Technology
Architecture, Information Systems Architecture, and Business Architecture. It has also been
proposed that most frameworks include five layers: Business Architecture, Process
Architecture, Integration Architecture, Software Architecture and Technology (or
Infrastructure) Architecture (Winter & Fischer, 2006).
Layered Enterprise Architecture Design (LEAD) describes three layers of
architecture. Layer 1 is the Business Layer which includes four sub layers: Purpose & Goal,
Competency, Service and Process. Layer 2 is the Application Layer and it includes two sub
layers: Application and Data. Layer 3 is the Technology Layer and it includes two sub
layers: Platform and Infrastructure (Figure 3). This layered approach to enterprise
architecture design enables development of models and meta-models which show the
relationships between objects and meta-objects from one layer to objects and meta-objects
within the same layer and also within the other layers.

41

Purpose & Goal (Value)
Business

Business Competency

Layer

Business Service
Business Process

Information

Application

Layer

Data

Technology

Platform

Layer

Infrastructure

Figure 3 Layered Enterprise Architecture Design

The LEAD standards provide a comprehensive enterprise architecture and related
business ontology that enables the reuse of business objects across multiple layers of the
architecture. The host organization had used LEAD’s business layer as the principle
enterprise architecture tool prior to commencement of this research. A formal analysis and
comparison of the various enterprise architectures was not undertaken as selection of the
‘best’ enterprise architecture was not the focus of this research. Instead, the focus was the
study of potential benefits and challenges of combining BPM, an ontology and the business
layer of an enterprise architecture as a management approach to quality improvement within
a healthcare organization.
The need to identify a suitable enterprise architecture for a hospital was the subject of
an extensive study in which 17 different enterprise architecture frameworks were reviewed
and 5 were shortlisted for evaluation. (Haghighathoseini, Bobarshad, Saghafi, Rezaei, &
Bagherzadeh, 2018). . LEAD was not included in the list of frameworks reviewed. The
Open Group Architecture Framework (TOGAF) was found to be the best suited to be used in
hospitals. LEAD includes all the architectural elements within TOGAF with the added layer
of Purpose and Goal in the business layer. This along with the convenience of being able to
42

reuse the business artefacts already created within the host organization using LEAD
standards supported its selection for this research.
The BA layer of EA is the most relevant to the current research. BA and BPM are
two different management disciplines which are closely related. However, reconciliation of
the two disciplines is required to ensure the appropriate artefacts and their use is well
understood (Dugan, 2014).
There are six advantages/common values associated with implementing an EA: 1)
Readily available documentation of the enterprise, 2) Ability to unify and integrate the
business processes across the enterprise, 3) Ability to unify and integrate data across the
entries and to link with external partners, 4) Increased agility by lowering the complexity
barrier, 5) Reduced solution delivery time and development costs by maximizing reuse of
enterprise model and 6) Ability to create and maintain a common vision of the future shared
by both the business and IT communities, driving continuous business/IT alignment (Brown,
2004).
Business artefacts such as strategy and business models can be very useful tools in
developing understanding of an organization. The traditional organization chart does not
provide a systems view of the organization. BPM requires that the principal focus of
understanding the organization is through the perspective of its processes. It is important to
understand both the processes and the context in which the processes are being executed
(Harmon, 2014; Margherita, 2014).
BPM is used to better understand end-to-end processes and the relationships of the
process steps to the other processes and objects within a system. Examples of objects would
be location, roles, business rules, controls, cost, etc. This knowledge in turn can be used to
improve processes. Cycle time, wait time, transport time, process cycle efficiency, error rate,
43

throughput and cost have been identified as seven basic measures that should be considered
when undertaking process improvement (Kowalski, 2014). Errors in the medication
management process occur both within the core processes and also within the management
and supporting processes. A comprehensive measurement plan needs to incorporate all
measurement types, not just the error rates. Also process improvement should be undertaken,
not only in core processes, but also in support and management processes. The traditional
focus in BPM is on the core processes only which has been viewed as a shortfall (Van der
Aalst, Hofstede, & Weske, 2003).
There are four main criticisms of BPM identified in the literature. The first is BPM is
merely a repackaging of old ideas by consultants and business gurus who are using it to
promote their own business or “how to” books (Trkman, 2013). Second, there is an absence
of a theoretical base in the literature (Melao & Pidd, 2000) which has since been addressed
by several authors, although there does not appear to be consensus (Biazzo, 2002; Lacerda et
al., 2010; Niehaves et al., 2014; Trkman, 2013). Third, BPM projects can take considerable
time to complete and realize results (Siriam, 2012). Fourth, the majority of the articles are
from practitioners reporting on successful case studies and very few articles reporting on
failed BPM projects (Helfert, 2009).
Several authors have established the connection between BPM and ‘systems thinking’
(Maddern et al., 2014; Margherita, 2014; Siriam, 2012; Smart et al., 2009). Having a
systems perspective requires us to not only measure and monitor the parts of the system but
also requires that we measure the interactions and process between the various components
of the system. This is especially true in healthcare as it has been shown that the greatest risk
to patient safety is in the transitions between the component parts of the system (Chircu et al.,
2013). The reductionist approach to control and performance measurement focuses on the
44

component parts. This approach has been critiqued and the author concludes that
performance management must focus on the interactions between the components and not the
components themselves (Gregory, 2007). This article is very persuasive and fits extremely
well with the ‘systems thinking’ approach to organizational understanding and management.
2.4 Healthcare Organization as a System
In quality improvement literature a system has been defined as “an interdependent
group of items, people or processes with a common purpose” (Langley, et al., 2009, p. 37).
An organization can be perceived as an ‘open system’ or a ‘closed system’ with the main
difference being that in a closed system the organization does not interact with the external
environment whereas in an open system the organization interacts with and is affected by
external environment factors (Khorasai & Almasifard, 2017). Important to note is an open
system is more than a grouping of individual elements; it has an organization and wholeness.
That is, it is more than the mere “sum of its parts”. The concept of an “open system” is
attributable to biologist, Ludwig von Bertalanffy (Peters, 2014). Thinking of the
organization as an open system and realizing that it is more than the sum of its parts is
foundational to BPM and the need to understand the end-to-end processes and the
relationships both within the process and the relationships with the environment in which the
processes are being executed.
A metaphor used to make the distinction between two types of systems underlying
organizations is “Organizations as machines, organizations as conversations” (Suchman,
2011) Suchman claims that an organization can be viewed as a machine (dead - closed)
system or as an adaptive (living - open) system and conversations are the basis for change in
an adaptive system. The expectation of control within a machine type system is realistic as a
machine can be controlled; however, such is not the case in an organization involving people
45

as they are not so easily controlled. Executing change in an adaptive (living) system requires
focus on the human element to a much higher degree than in an organization characterized as
a machine (Suchman, 2011).
Healthcare organizations have been described as complex adaptive systems (Begun,
Zimmerman, & Dooley, 2003). The traditional view of a healthcare organization is the
hierarchical organization chart, the simplicity of which belies the complexity of the nonlinear
relationships and emergent nature of a complex adaptive system. Individual agents acting in
a healthcare organization most often act independently based on their personal knowledge
and the environment they are working in. Interconnectivity exists between the various
functions or subsystems but these tend to be nonlinear and often small changes in one process
or function can have major implications on other functions. Therefore, it is important that a
systems approach be taken when initiating change in a healthcare organization.
W. E. Deming, an early pioneer of quality improvement, proposed that a system could
be described as having three types of processes: Drivers or Influencers, Mainstay Processes
and Support Processes (Langley, et al., 2009). This system of modeling has been used by the
Jonkoping County Council to describe the health care system provided to the residents of
Jonkoping County in Sweden. This organization has been identified as a high performing
healthcare system and renowned for its ability to provide high quality health services at low
cost (Baker, et al., 2008).
Seeing the whole system requires an understanding of structure, function and process
and these must be understood at the same time (Gharajedaghi, 2011). EA and modeling can
be employed to provide such a view. EA has often been viewed from an information
technology perspective but this considers only one aspect of the system. A more holistic
view of EA would include the representation of all elements of the enterprise and the
46

relationships between them (Mykityshyn & Rouse, 2007). Conceptual models provide a
representation of an object or event and can be quite simple or very complex. An example of
a simple conceptual model is a process flowchart that provides the steps in a simple linear
process. An example of a complex conceptual model is a Business Process Model that
depicts a process including the business process, the related information elements, software
applications and technology used to support the business process. EA and the use of BPM
are consistent with system thinking and could provide the tools and methodology to address
the quality and cost challenges inherent in a healthcare organization.
2.5 Business Ontology
An ontology provides a set of terms and describes the relationship between the terms
(O'Leary, 2010). Ontologies are the key building block of enterprise architecture which
enables a holistic view of the enterprise where each functional area uses the same vocabulary
to describe like objects (Kappelman & Zachman, 2013).
Four kinds of ontology have been described based on the level of generality. The
four layers are top-level, domain, task and application (Guarino, 1998). Top–level ontology
describes concepts related to objects, events, actions etc. at a very high level and is not
dependent on a specific domain or particular problem. It is reasonable to assume a top-level
ontology would be useful across a large user group since at the highest level of concepts
everyone can agree on the meaning. A top-level ontology can also be referred to as a
foundational ontology and is needed in any field or domain (von Rosing & Laurier, 2015).
Domain ontology describes concepts using the vocabulary of a generic domain while task
ontology uses the vocabulary of a specific task. Examples of concepts within a domain
ontology are strategy, roles, cost, finance, or medicine. Examples of concepts within task
ontology are analysis, design, investing, diagnosing or selling. Application ontology
47

describes concepts from both the domain and task ontologies and is a specialization of the
ontology used from both (Guarino, 1998). A concept from a domain is a business process
within a specific company and a concept from a task is data analysis within a specific
department.
Business ontology has business as its area of discourse and it attempts to create a
vocabulary that best represents relevant meaning that can then be shared through information
exchange (Au-Yong-Oliveira & Ferreira, 2014). The exchange of information can be human
to human, human to machine or machine to machine. Research in the area of business
ontology has covered two different streams. The first included developing methodologies
that enable practitioners to develop their own unique ontology specific to their domain. The
second includes academic and standard setting bodies building of reference ontologies that
could be tested and adopted by practitioners (von Rosing & Laurier, 2015).
BPMO is a domain ontology built on the top of the business ontology which is a
foundational ontology (von Rosing et al., 2014). Both the business ontology and BPMO are
generic ontologies applicable to various industries including healthcare. von Rosing and
Zachman (2017) argue that the foundational business ontology and with it the BPMO is
applicable to any type of organization, independent of complexity or industry. The business
ontology can then be used as the basis for the development of integrated enterprise standards
for any industry (von Rosing & von Scheel, 2016). Therefore, applying the business
ontology to specific healthcare industry practices (medication management) is a research,
analysis and study into the applicability of the business ontology and concepts in a specific
industry setting. The current research required identifying the many different existing
healthcare concepts from the value chain, the business model, the operating models, service
and process model and applying them to the business ontology.
48

There are numerous ontologies described in the literature (Appendix 1). Ontologies
have been developed by academics, standard setting bodies, architects or practitioners and in
some cases through extensive collaboration between academics, practitioners and standards
setting bodies. Ontologies evolve as they mature and more knowledge is gained due to
expanded use or changes in business and technology. Two of the listed ontologies Health
Language 7 (Health Level Seven International, 2015) and Basic Formal Ontology (Blobel et
al., 2014) have been used in healthcare. The main use of both has been related to
interoperability within and between clinical information systems with process automation as
the goal. HL7 RIM (Reference Information Model) has evolved and is now referred to as
RIM v3. “HL7 v3 has been heavily criticized by the industry for being internally
inconsistent even in its own documentation, too complex and expensive to implement and has
been accused of contributing towards many failed and stalled systems implementations”
(Bender & Sartipi, 2013, p. 326). BFO is a foundational or upper level ontology designed for
use in bio-informatics to guide the development of domain ontologies.
The business ontology and BPMO developed by Global University Alliance was
selected for use in this research as it covers both the clinical and business aspects of
medication management processes. The ontology is designed in layers enabling the
incremental adoption across the organization. This ontology has been adopted by several
software vendors including SAP (Rosenberg, Chase, Omar, Taylor, & von Rosing, 2011),
iGrafx (iGrafx, 2013), and Objects Management Group (OMG) a well-known software
standards organization (Object Management Group, 2014). It has also been academically
well described with published case studies demonstrating its utility (von Rosing & Laurier,
2015; von Rosing & von Scheel, 2016; von Rosing, Urquhart, & Zachman, 2015). A detailed
description of the business ontology and BPMO is provided in Appendix 1.
49

2.6 Reference Models
A reference model is either a narrative or visual conceptual representation of the
recommended (best) practices of a specific domain. In this research, the medication
management process reference model is a narrative representation of the processes that
should be included in a process architecture for medication management. A business process
reference model can be used to inform and guide the development of a business process
where no such business model previously existed or it can be used to compare current
business process to the generic reference model which has incorporated leading or best
practices within the domain (Pajik, Indihar-Stemberger, & Kovacic, 2012). Since developing
business process models is time consuming and can be expensive, reference models can be
used to shorten the time to design or standardize process models across an organization.
The challenge with producing generic business process models is they may be
context specific; therefore, not necessarily transferrable to other organizations. It is possible
that best practice in one organizational or industry may not translate to best practice in
another organization if there is a major difference in the strategy of the two organizations
(Ponsignon et al., 2012). Despite these concerns there are many examples of reference
models for business process in use and referenced in the literature. These include SCOR –
Supply Chain Operations Reference Model, SAP R/3 reference model and the Process
Classification Frameworks developed and published by the American Productivity and
Quality Council (APQC) (Pajik et al., 2012; American Productivity and Quality Centre
(APQC), 2014).
There were two sources of information available for use in validating the business
process reference model for medication management: the APQC Process Classification

50

Framework, and the Supply Chain Operations Reference (SCOR) (Supply Chain Council
Inc., 2012). Further information on how these were used is reported in Section 4.4.
2.7 Literature Review Summary
The occurrence of medication errors and the resulting adverse drug events are a
problem in hospitals and long term care facilities. The literature shows that the medication
administration phase is one of the most error prone and that there is a low likelihood that
these errors will be intercepted. Technology has been proposed as a potential solution for
reducing medication errors; however, simplification and standardization of processes is
required in order for the technology to be effective in reducing medication errors. Clinicians
would need to accept the technology and associated changes to their workflow.
The medication processes are subject to numerous standards, guidelines and
legislative requirements that must be met within the processes. While these controls are
intended to provide for a high quality medication management process they also contribute to
the complexity of the processes.
Researchers and practitioners have contributed to the literature on BPM. The
definition of BPM ranges from very narrow to very comprehensive depending on whether
one is looking at a single process or encompassing an entire organizational view including
suppliers and customers. There has been differing views on the theoretical basis of BPM.
Several authors agree on the evolution of BPM and claim it is an improvement over the
predecessor approaches because it incorporates the benefits of its predecessor traditions. The
applicability of BPM in a complex system such as healthcare has been questioned because of
the high degree of the ‘human element’ that must be considered when designing processes
where individuals may need (or choose) to deviate from ‘standard’ processes. The three

51

elements of modeling, measurement and management of processes are foundational to BPM.
BA provides the structure in which business processes can be explored.
The need to look at processes from a systems perspective has been established as
desirable if maximum value from the organization is to be realized. This ‘systems thinking’
approach is especially important in organizations such as healthcare, which are traditionally
hierarchical organizations that rely on individual clinical expertise to assess, diagnose, treat
and monitor patients.
Business ontology provides the ability to create a shared vocabulary across domains.
This shared vocabulary will create a shared understanding that could contribute to reducing
complexity which in turn would reduce errors related to communication challenges. A
shared understanding of the process and its underlying objects could facilitate process
automation and reduction in variation in outcomes.
Developing process models is a time consuming and costly activity which could be
expedited by having access to a process reference model. Process reference models have
been developed in many business sectors but no process reference model specific to
medication management in hospitals and long term care facilities was discovered in the
literature review.
The literature review provided examples of how BPM had been employed on specific
healthcare processes but there were no articles found that showed the use of a combination of
BPM, EA and business ontology. In order to determine whether a research gap existed in
this area, a comprehensive literature review was conducted using BPM, EA and ontology as
the keywords. Several premier databases were searched for recent peer reviewed articles. It
was observed that while extensive research has been done in the areas of BPM and EA, there
has not been any effort towards using ontology to combine concepts from these two
52

disciplines. Similarly, this concept of using ontology to integrate BPM and EA in the context
of healthcare organizations was found to be non-existent. One article reviewed, however,
made the case for using EA and BPM to improve quality of health care services (Wouters,
2015).

53

3

Methodology

This chapter outlines the methodology and the research design used in the
development of this dissertation. There are three sections in this chapter. The first section
briefly presents the rationale for using the mixed methods research methodology to address
the research questions. The second section outlines the research design. The third section
provides detail on the reliability, validity, generalizability, and limitations of this research.
3.1 Approach
There are two approaches to research: the deductive approach and the inductive
approach. The deductive approach begins with the researcher asserting a theory, he or she
would then develop a hypothesis related to the theory, collect and analyze data to either
confirm or reject the theory and then if appropriate propose a revised theory (Bryman, Bell,
Mills, & Yue, 2011). The inductive approach does not lead with a theory; rather, the
researcher starts with a question(s), collects and interprets the data to develop concepts and
theories based on the interpretation of the data and will often add more specificity to the
research questions as he or she gains additional knowledge from the interpretation of the data
(Bryman et al., 2011).
This research had two purposes; firstly, to determine if an ontology used in other
industries could be successfully applied to the healthcare industry and secondly, identify the
benefits and challenges of introducing BPM, Business Ontology and BA as a comprehensive
approach to address medication management safety and quality concerns within a multifacility healthcare organization. The exploration of introducing the ontology could be
considered to be deductive approach while the identification of benefits and challenges of
introducing the combined approach to quality improvement could be considered to be
inductive approach. The development of the business artefacts and the use of those to
54

develop a generic reference model for medication management was a secondary focus that is
more closely associated with design science. The focus therefore, was theory testing in
respect to introduction of the ontology and problem solving, design and theory generation in
respect to identifying the benefits and challenges.
The methodology selected was mixed methods as opposed to purely quantitative or
purely qualitative methods. The research design employed predominantly qualitative
methods with embedded quantitative methods. Mixed methods has been described as “the
class of research where the researcher mixes or combines quantitative and qualitative
research techniques, methods, approaches, concepts or language into a single study”
(Johnson & Onwuegbuzie, 2004, p. 17). Qualitative design in the form of researcher
facilitated workshops was used to develop business artefacts, select performance measures,
and identify improvement opportunities. Semi-structured interviews were used to identify
the challenges and benefits as perceived by the members of the medication management
working group. Also, leaders of the host organization were interviewed using a different set
of questions to gather data on the benefits and challenges of using BPM, BPMO and BA
from a leader’s perspective. Quantitative design was used to analyze the organizational
performance measures and prioritize the improvement opportunities. Figure 4 shows the
methods used and their classification as either qualitative or quantitative. Each of the
methods is discussed further in the Strategy and Research Design section below.

55

Figure 4. Combining Qualitative and Quantitative Methods & Techniques

3.2 Strategy & Research Design
Mixed methods design is often used in health services research (O'Cathain, Murphy,
& Nicholl, 2007). There are six types of mixed method strategies and it is important to
consider four aspects of the research before selecting which type of mixed method design to
use (Creswell, 2014). The six strategies are: sequential explanatory, sequential exploratory,
sequential transformative, concurrent triangulation, concurrent embedded and concurrent
transformative. The first three sequential strategies are used when the research is conducted
in phases with one of the designs (i.e. quantitative or qualitative) used in one phase followed
by the alternate in subsequent phases. The concurrent strategies are used when the data from
both qualitative and quantitative approach is collected concurrently. The four aspects are:
timing, weighting, mixing and theorizing. In this research, the respective research methods
56

are used concurrently; while the qualitative method weighed more heavily, the quantitative
method was embedded within the more dominant qualitative approach and the theorizing was
implicit. Qualitative methods have been described as suitable to be used when researchers
want to ask more questions than can be answered by quantitative methods, particularly in
complex environments (O'Cathain et al., 2007). The prioritization of improvement initatives,
and measurement and analysis of change were better suited to a quantitaive approach.
Therefore, both approaches were needed which resulted in the selection of a mixed methods
designbased on a concurrent embedded strategy.
Figure 5 provides an overview of the ten step research design that was developed and
used. In addition to the numbered steps, the figure outlines the major tasks included in each
step. The lessons learned in following this design are summarized in Table 5.

57

1. Develop Research Idea

Identify Problem
Identify Potential Solution

Develop Research Question
Identify Research Approach

2. Conduct Literature Review

Review and Analyze Relevant Literature

Revise Research Questions if Required

3. Determine Data Collection Strategy

Data Type - Qualitative & Quantitative
Data Source - Primary & Secondary

Participants - Multidisciplinary Working Group
Identified by Medication Safety & Quality
Committee within Host Organization

Primary Data - Semi-structured Interviews
Primary Data - Workshop Developed Business
Artefacts

Secondary Data - Relevant Documentation of Host
Organization

4. Data Collection Planning

Develop Workshop Schedule
Develop Workshop Materials

Develop Questions for Semi-Structured Interviews

5. Obtain Ethics Approval
6. Deliver Workshops & Facilitate Working Groups

Select and book venue
Invitations to participants
Obtain Informed Consent

Arrange for audio and video conferencing
Conduct Workshops
Facilitate Working Groups

7. Report Preliminary Findings to Workshop Participants
8. Collection of Interview Data

Invite Participants
Schedule Interviews

Obtain Informed Consent
Conduct Interviews

9. Analysis of Data

Transcribe Recorded Interviews

Conduct Analysis of Transcribed Interviews

Review Secondary Data
Refine Business Artefacts to meet Layered
Enterprise Architecture Standards

10. Write Up & Present Findings

Prepare Dissertation

Prepare Journal Articles
Submit for Review

Defence of Dissertation
Prepare and Deliver Executive Level Report on
Findings to Host Organization
Seek opportunities for public presentations of
findings

Figure 5. Research Design

58

Table 5 Considerations for Replication of Study

Stage

Key Points

Develop
Research Idea

Medication Management was
used an example of a quality
improvement focus that might
benefit from the use of the
comprehensive management
approach. Other service areas
could be considered

Opportunities for Improvement and
comments

*Need to identify and confirm *Recommendation to find a host
a host organization willing to organization which the researcher has
engage in the research
no immediate or recent employment
relationship.
*Need to identify and engage
a project sponsor within the
*Executive support is critical as the
host organization
approach requires participation from
the host organization
*An organization considered to be a
“Learning organization” as in most
cases the approach and some of the
concepts will be new to the participants
and leaders

Conduct
Literature
Review

Follow a formal literature
review approach

*Expand the literature to include
relevant sources and white papers that
specifically address the problem to
understand what is currently being
undertaken by practitioners that may
not be included yet in academic
publications.

Determine Data
Collection
Strategy

Work with Project Sponsor to
identify workshop
participants

*Ensure the workshop participant group
is representative of the end to end
process being reviewed
* Include both operational and
management staff if possible.

Primary Data Collection for
use in development of
Business Artefacts

*Engage a research assistant to attend
workshops or arrange for audio
recording and transcription to ensure
complete capture of all ideas and
59

Stage

Key Points

Opportunities for Improvement and
comments
discussions related to the business
objects to be included within the
Business Artefacts.

Data Collection
Planning

Secondary Data – Relevant
documentation of host
organization

Recommend review of all organization
strategic level documents as well as any
specific strategy and planning
document in the focus area.

Develop Workshop Schedule

*The ½ day workshop seemed to work
well so would recommend that
approach but plan on 4 sessions rather
than 3 sessions and have them spread
out over a four week period so
participants have time to review and
reflect on the work but not so far apart
that they lose momentum with the
development of the business artefacts.
*The translation of the ideas into the
relevant business objects and
documentation will take some time so
be sure to leave time available for
transcribing and editing between the
research dates so that participants can
have time to conduct preliminary
review of the draft business artefacts
prior to each work shop.

Develop Workshop Materials

*The introduction to the research and
the orientation to BPM, BA and the
BPMO sets the foundation of the
research and therefore should be
developed such that it is understandable
to those being exposed to it for the first
time.
* Wherever feasible, include examples
relevant to the focus area and also if
possible from review of secondary data
of host organization where it exists.

Develop Questions for SemiStructured Interviews

Validate the interview questions.

60

Stage

Key Points

Obtain Ethics
Approval

Allow for time as this process
can take time depending on
review and approval
processes within host
organization.

Deliver
Workshops &
Facilitate
Working
Groups

Arrange for audio and video
conferencing if participants
are geographically dispersed

Include audio recording since this will
ensure completeness of data collection
of business objects to be included in
business artefacts.

Conduct workshops

A formal consensus developing method
such as modified Delphi approach
could be added as this would strengthen
the “consensus” that the resulting
business objects included within the
business artefacts are agreed to by all
participants.

Facilitate working groups

The working group schedule in the
current study was less than ideal due to
availability of participants. This
extended the duration of the research
significantly. It would be advisable to
have weekly meetings of the working
groups rather than monthly.

Report
Preliminary
Findings to
Workshop
Participants

The working groups were
formed from a sub group of
the Workshop Participants
and it was important to share
the results with the workshop
participants so they had a full
picture of the results
including the prioritization
and performance measures to
be added to the business
artefacts.

Collection of
Interview Data

Voluntary participation was
lower than expected despite
several reminders after initial
invitations were sent.

Opportunities for Improvement and
comments

Try additional recruitment strategies

61

Stage

Key Points

Analysis of
Data

Analysis of interview data
using thematic and content
analysis

Opportunities for Improvement and
comments

Design of business artefacts
based on LEAD standards
Write Up &
Present
Findings

3.2.1

Disseminate results to
research community
periodically to obtain
feedback.

Research idea – motivation. The research idea evolved from an interest in

resource allocation, quality improvement, and strategy execution in healthcare. The
challenge of meeting healthcare demands within the resources available is an issue for both
healthcare providers and healthcare administrators. There is a constant need to realize as
much benefit as possible from the resources available. This is true from the perspective of
provision of healthcare services and also from the perspective of how we employ resources
engaged in improving the effectiveness and efficiency of healthcare services. At the system
or macro level, resource allocation decisions determine what services will be provided while
at the micro level individual clinicians decide on a case by case basis how they will allocate
their clinical time.
There is little debate on the need for improvement in the quality of healthcare
services. An essential area of interest is medication management due to the frequency of
medication use in the treatment of patients and the high risk posed from adverse medication
events. In addition to patient safety, the efficiency and effectiveness of medication
management processes are extremely important. These processes consume resources in the
62

form of human resources and in pharmaceutical supply costs. Errors in medication
management result in undesirable outcomes which range in significance from extreme such
as the death of a patient due to an adverse medication error to less obvious issues such as
overstocking inventory that results in a waste of money due to expired drugs.
The literature reports on approaches to reduce medication management errors some of
which are included in Chapter 2. The host organization for this research had previously
employed some of those approaches with limited success. The use of more advanced
technology supported solutions that enable automation of processes are extremely expensive.
Although there is a growing movement within the host organization to proceed with that
approach, it is recognized that processes should be improved and standardized in advance of
introducing new technology.
Healthcare organizations have been described as complex adaptive systems. One of
the key attributes of such a system is that a small change in one area can result in unexpected
results in a different area within the system. Therefore, it was critically important to gain a
comprehensive understanding of the system in which medication management operates
before attempting to introduce changes. An additional point to consider was that healthcare
providers have a high degree of autonomy in their work and therefore when changes were
being contemplated it was important to engage individuals involved in the processes in
redesign planning. These two points weighed heavily in the identification of potential
solutions and choice of the research approach. Using workshops as a means of developing
the business artefacts and identifying critical processes for improvement provided
participants the opportunity to engage early in the solution identification. Exposure to the
organizational BA provided participants with the opportunity to increase their understanding
of how medication management processes fit within the larger healthcare system.
63

3.2.2

Literature review. The literature review provided in Chapter 2 evolved from

the initial research idea generation step through to the final step of writing up and presenting
the findings. The research step of conducting a literature review included searching, reading,
and critically appraising the literature on the topic(s) of interest. This process facilitated
achievement of a greater understanding of both the problem and the potential solutions. The
literature review was also instrumental in shaping the research questions and developing the
research design.
3.2.3

Data collection strategy. The data collection strategy included identifying

what type of data would be collected, whom the data would be collected from, and how the
data would be collected. The type of data included both qualitative and quantitative data.
The source of primary data was the workshops and semi-structured interviews. The source of
secondary data was the host organization records and information management systems. The
host organization had established a Medication Safety & Quality Committee (MSQC) and in
recognition of this research the researcher participated as a non-voting member of the group.
Identification of the appropriate individuals to be included in the multi-disciplinary team was
based on the recommendation of that committee. Those individuals recommended included:
Nurse Managers, Medication Safety Nurse, Pharmacists, Information Management Director,
Chief Medication Information Officer, physicians and performance improvement
practitioners, all of whom participated or had knowledge of some aspect of the medication
management processes. Agendas and minutes of the MSQC meetings were reviewed to
identify any additional initiatives or interventions undertaken in medication management

64

during the research period. The results of that review are included in the Chapter 4 and
further discussed in Chapter 5.
3.2.4

Plan for primary data collection. The collection plan for the primary data

included two components. The first was the information and business artefacts derived from
the workshops and working groups’ activities. The second was the data collected through
semi-structured interviews with workshop participants and host organization’s leaders.
Planning for the workshops required preparation of material for presentation to the
group, both on the research project itself, as well as educational material on BPM, BPMO,
and BA. There were initially two full day workshops planned however, due to scheduling
challenges with operational responsibilities of the participants the plan was changed to two
half day workshops to be held one week apart. The scheduling included capacity for video
and audio conferencing to accommodate participation from outside the local area. The host
organization provides services across a large geographic area and it is common practice for
staff of the organization to participate in organization wide activities using these types of
communication technology.
Prior to the formal research, the organization had undertaken to develop strategy
maps and business models both at the organization level and at the organizational area level.
The draft business model and a draft strategy map for the organization area of Pharmacy
served as the starting point for the development of the Medication Management business
model and strategy map presented in Chapter 4. The plan was to have these two documents
reviewed, expanded upon as appropriate and validated by the workshop participants. In
addition to these two business artefacts, there were also numerous process models in a
process repository relevant to this research. Those business artefacts were foundational in
the preparation of the initial workshop material. The draft business model and strategy map
65

had been based on input from individuals in management positions within pharmacy services
so those business artefacts needed to be expanded to include input from other business areas.
There had been a limited number of participants involved in development of the initial draft
of the business model and strategy map. In an effort to promote buy-in and be sure the
artefacts were complete and appropriately represented the service area additional consultation
was required. During the planning for the initial workshop, a draft value chain for
medication management was developed based on the review of the business artefacts noted
above and discussions with the Regional Director of Pharmacy.
The agenda for the first workshop included four items:
1) Introduction to the research
2) Introduction to BPM, BPMO and BA,
3) Review of draft strategy map and business model
4) Discussion on development of an end-to-end process model of medication
management.
Chapter 4 provides further detail on the addition of a third half day workshop and also
the formation of two working groups one focused on measurement and the other focused on
prioritization activities. This level of effort had not been anticipated during the planning of
the research; however, there was a higher level of engagement and discussion during the
workshops than had been planned for initially.
The plan included two separate groups to be invited to participate in semi-structured
interviews. The first group included all participants from the workshops except two
individuals who were support staff within the BPM business unit. Twenty workshop
participants were invited and eleven agreed to be interviewed for a response rate of 55%.
The second group invited to participate in an interview were the senior leaders within the
66

host organization. The senior leaders were identified by reviewing the organizational chart
and invitations were delivered to all members of the Executive Team as well as all leaders
who directly reported to an Executive Team member. Seventy leaders were invited and 23
agreed to be interviewed for a response rate of 33%. Two separate interview instruments
were developed, one for the workshop participants and the other for the leaders. Copies of
both interview instruments are included in the Appendices as Appendix 2 and Appendix 3.
There were two individuals who fit both criteria for inclusion and these two were interviewed
twice using the different interview instruments.
3.2.5

Ethics approval. This research included human subjects and as such ethics

approval for the research was required. Northern Health signed on as a partner in this
research and joint ethics approval was granted by UNBC Research Ethics Board and the NH
Research Ethics Board. Members of the Multi-disciplinary Working Group (MDWG) were
informed of the research. Informed consent was obtained from each member of the MDWG
who participated in the workshops. A copy of the information letter and consent form is
provided as Appendix 4. Informed consent was also received from individuals who agreed to
participate in the semi-structured interviews. Appendix 5 is a copy of the amended
information letter and consent form for the interviews. The initial ethics approval stated that
the researcher would complete all the transcription of the recorded interviews. This decision
was revisited and an amendment of the ethics application was filed and approved. The
transcription of the recorded interviews was achieved by a combination of a hired
transcriptionist and the researcher.
3.2.6

Delivery of workshops and facilitation of working groups. Three half day,

researcher-led, workshops were delivered and these were followed up with monthly working
group meetings. The workshops were held between December 2016 and January 24, 2017
67

and the two working groups met monthly between February and September 2017. Each of
the two working groups focused on finalizing the work that had been initiated in the
workshops. The Measurement Working Group (MWG) focused on the performance
management plan and the Prioritization Working Group (PWG) focused on reviewing the
identified process improvement opportunities and finalizing the prioritization. The PWG
completed the prioritization exercise and all proposed improvement initiatives suitable for
ranking were prioritized. Those initiatives not prioritized had either been completed
previously or were mandatory initiatives. The MWG developed a listing of performance
measures for inclusion in a scorecard for medication management safety and quality but were
challenged to deliver a final complete product because some of the measures were not yet
available
Workshop meeting materials were circulated in advance and both the workshops and
the working group activities were facilitator led. Participants were invited to ask questions or
request clarification on the documents prior to or during the workshops and working group
meetings. The first two workshops were held in December 2016 and the third was held in
January 2017. The attendance varied from a high of twenty-two in the first workshop to a
low of thirteen in the third workshop. Appendix 6 provides a log of the workshop attendees
including position title and professional background. Members of the two working groups
were volunteers from the workshop participants with the exception of a financial business
analyst who had not participated in the workshops but did participate in the measurement
working group. All workshop participants were invited to participate on the working groups
if they were available and interested. The attendance at working group meetings ran between
five and seven individuals with a small group that formed the core of both groups. This core
group included: the Regional Director of Pharmacy, the Antimicrobial Stewardship
68

Pharmacist and the Lead, Regional Quality Processes who consistently participated in both
working groups. Participants were encouraged to challenge both their own assumptions and
ideas as well as those of others. Efforts were made to create an atmosphere of trust and
mutual cooperation during the workshops and working group activities.
The workshop participants finalized the development of the business artefacts that
met the LEADing practice BPMO standards by the end of the second workshop. The
artefacts included the relevant business competency model, organization strategy map, value
chain and some but not all of the process models related to medication management safety
and quality. In addition to the business artefacts listed above, two additional deliverables
were achieved through the working groups. These included the draft performance
management plan and a prioritized list of process improvement opportunities.
A repeated measures design to collect the performance measures was planned. This
included both key process indicators and key performance indicators. The list of selected
performance measures is provided as Appendix 7.
Analytical Hierarchy Process (AHP) is a methodology intended to compare and
contrast alternative options in order to rank the relative contribution each could make towards
achievement of an overall goal (Saaty T. L., 1980). The AHP scoring tool enables the
conversion of a pairwise comparison of decision criteria from a verbal scale to a numerical
value which can then be used to establish a weighting for each criteria being compared
(Table 8). The alternative options can then be rated against the weighted criteria and ranked
based on their relative value.
There are three steps in the AHP. The first step is to identify the numerical weighting
of the decision criteria using a pairwise comparison matrix (Table 9). The second step is to
calculate the relative score of each option (Appendix 15). The third step is to rank the
69

options based on numeric score from highest to lowest (Appendix 16). Further discussion of
how the methodology was used and results of the analysis are provided in Chapters 4 and 5.
AHP is based on four axioms: 1) comparability, 2) hierarchy, 3) homogeneity and 4)
completeness. Comparability refers to the need to measure relative value of two alternatives
when making a pairwise comparison. Hierarchy refers to the need to arrange options in
declining order to support decision making. Homogeneity refers to the need to compare
things of a similar nature. Completeness refers to the expectation that the ranked list includes
all relevant options under consideration (Saaty & Kulakowski, 2016).
3.2.6.1 Procedures and tools. Prior to this research in the host organization,
development of draft organizational business artefacts had been achieved through
consultation with business area subject matter experts in the respective business areas within
the health authority. There were twenty-three organizational areas identified and each area
had a draft business competency model and a draft strategy map. Modeling standards and
objects included in the business artefacts and process models were based on the standards of
LEADing Practice which had been researched and developed by members of the Global
University Alliance and LEADing Practice certified practitioners.
BPM methodology was used in the development of the end-to-end medication
management process model, process measures and outcome measures. Analysis of the
process facilitated the identification of improvement opportunities. It is acknowledged that
the improvement opportunities identified exceeded the available resources; therefore, as
suggested by (Siriam, 2012), AHP was used to identify those that were likely to have the
most benefit to the overall process. The process models were developed using Business
Process Management Notation (BPMN) as the modeling language. Business artefacts

70

including all process models were documented using iGRAFX software system and/or
Microsoft Excel.
Layered Enterprise Architecture Design (LEAD) includes three layers of architecture
as described in section 2.3. Figure 3 shows the three layers and 8 sub layers of LEAD. This
layered approach to enterprise architecture design enables development of models and metamodels illustrating the relationships between objects and meta-objects within, and across
other layers. The ability to identify and model the relationships requires a common
vocabulary be used throughout the layers and sub layers. Researchers associated with the
Global University Alliance and practitioners engaged with LEADing Practice have
developed a Business Ontology that covers all aspects of business including the three layers
as defined in the LEAD (von Rosing & Laurier, 2015). The development of business
artefacts for medication management applied the BPMO to the objects within the business
layer only. The objects within the application and technology layer were considered to be
out of scope and therefore not included in this research.
3.2.7

Interim reporting. Progress reports were provided to the MSQC to keep

them apprised of the progress on development of business artefacts and identification of
improvement initiatives. The MSQC members were provided revised copies of the business
artefacts as they were developed and verbal updates were provided on the activities
undertaken by participants in the workshops and working groups. Workshop participants
were invited to a wrap up meeting in October 2017. This provided an opportunity for
workshop participants who had not participated in the smaller working groups to review and
comment on the final performance measurement plan and the ranked list of improvement
initiatives. The finalized business artefacts including process maturity evaluation results,
prioritized listing of the planned improvements and listing of the performance measures were
71

provided in advance of the meeting. There was a considerable level of discussion on the
prioritized improvement initiative list which will be discussed further in Chapters 4 and 5.
3.2.8

Collection of data. Data collection included both primary data and secondary

data. The primary data included recorded interviews with host organization staff in October
and November 2017. The recorded interviews were subsequently transcribed and analyzed
using a thematic content analysis approach. The workshops and working group provided
primary data consisting of medication management business artefacts, listing of performance
measures and ranked list of process improvement initiatives.
Secondary data consisted of host organization business artefacts, performance
measure values, MSQC meeting minutes, and operational planning documents. This
secondary data and its impact on the results will be discussed further in Chapters 4 and 5.
3.2.9

Analysis of data. In addition to the AHP, two other analytic activities were

undertaken. These included analysis of: 1) the performance measures selected for inclusion
in the performance management plan and 2) the transcriptions of the two sets of recorded
interviews.
The performance measurement data was analyzed using statistical process control
charts or Shewart charts developed in Microsoft Excel. This approach is well suited to
determine whether a change in a process has resulted in an improvement (Benneyan, Lloyd,
& Plesk, 2003). Process control charts were used to analyze the performance measures to
determine if there was a statistical change in the performance measures subsequent to the
implemented process improvements identified during the research. A statistical process
control chart enables determination of the type of cause resulting from the change in the
value of a measurement. The cause is categorized as either due to common cause (random)
variation or special cause variation. It can also be used to determine whether there is a
72

“trend” in the data. The repeated measures are plotted on a run chart and the upper and lower
control limits are calculated based on the standard deviation from the mean. Three deviations
above the mean is used to show the upper control limit and three standard deviations below
the mean is used to show the lower limit. If the lower limit calculation results in a negative
number then zero is used as the lower limit. Two examples of an indication of a “special
cause” would be a single point outside the control limits or a succession of eight data points
in a row either all above or all below the average. Figure 6 provides an example of a process
control chart showing the use of the master drug library (MDL) for medication infusions on
one inpatient ward where a quality improvement initiative had been implemented. The detail
related to that initiative is provided in section 4.2.1. The performance measurement plan
includes those measures reported to senior executive on a fiscal period basis. No measures
other than the one shown in Figure 6 have been reported in this document since the quality
improvement initiatives had not been completed during the research period and many of the
measures were not yet available. The administrative burden of collecting the measures needs
to be addressed and the intent is to develop appropriate software solutions to automate the
process as much as possible.

73

Figure 6 Statistical Control Chant showing Percentage of Infusions Using MDL Prepared using Minitab 18
Statistical Software (2018)

The interview data was analyzed using NVIVO software. The analysis was
undertaken as three separate activities. The first analysis included only the transcripts of the
interviews with the workshop participants. The second analysis included only the transcripts
of the interviews with the leaders. The third analysis used a summative approach to content
analysis which examined and compared the use of language by interview respondents. There
were two comparisons made; the first was the language used between clinical leaders and
non-clinical leaders, and the second was between responses from workshop participants and
those of the leaders.
Thematic content analysis is, “a useful approach for answering questions about the
salient issues for particular groups of respondents or identifying typical responses” (Green &
Thorgood, 2004, p. 177) . Thematic content analysis was employed to analyze the transcripts
74

from both sets of interviews. The coding was undertaken by one coder and the analysis
followed a cyclical process where each transcript was read individually to understand the
text, it was re-read to identify preliminary themes which were coded in NVIVO, the
preliminary themes were grouped into clusters and themes were tabulated in a summary
table, thereby going from specifics to generalizations.
Summative content analysis was used to examine the language used. The preliminary
identification was achieved through the automatic queries available in NVIVO software. The
results of the automatic queries were analyzed using Microsoft Excel.
Other qualitative data analysis approaches considered were Interpretative
Phenomenological Analysis (IPA) and grounded theory. It was decided to use the content
analysis approach (both thematic content analysis and summative content analysis) as it was
more suited to the questions. IPA is more suited when you want to analyze in depth
responses at an individual level and is most often used in psychology studies. Grounded
theory was also a viable methodology; however, this approach requires selection of the
approach at the outset of the research. This methodology had not been selected at the outset;
therefore, the content analysis was a more appropriate choice.
3.3 Reliability, Validity, Generalizability and Limitations
Reliability, validity and generalizability as it refers to quantitative research can be
challenging to achieve in qualitative research. It has been proposed that the definitions
assigned to these terms in the context of quantitative research should be adjusted for
qualitative research (Bryman et al., 2011). It has also been proposed that the two primary
criteria for assessing the quality of a qualitative study should be trustworthiness and
authenticity (Guba, 1985).

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3.4 Trustworthiness
Trustworthiness addresses four criteria that parallel the quantitative research criteria
of internal validity, external validity, reliability and objectivity. The four criteria are
credibility, transferability, dependability and confirmability respectively.
Credibility (or internal validity) can be inferred with respect to the business artefacts
since the researcher worked with a group of clinicians engaged in Medication Management to
develop and validate the artefacts. The credibility of the results of the analysis of the
interview transcripts is less straight forward since there is always a risk the beliefs of the
researcher influenced the results of the analysis despite best efforts to be objective in the
interpretation.
Transferability (or external validity) of the findings to another healthcare organization
or indeed to another organization is questionable since the culture of the organization along
with the experiences, views and beliefs of the participants played a major role in the
outcome. That being said, the medication management process itself is highly regulated so it
is reasonable to believe the process models and business artefacts could be transferable, at
least in part, to other healthcare organizations which are subject to similar regulations and
legislation. The process of engaging the participants, conducting the workshops, developing
the business artefacts and using AHP to rank the improvement initiatives is transferable
although the results would be different based on the social context of the host organization.
Dependability (or reliability) could be shown through an audit of the research
documents, interview recordings and secondary data of the host organization. The research
was overseen by the PhD Supervisory Committee which contributed to the dependability of
the research. An audit is neither reasonable nor feasible and reliance of the dependability of

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the research is attributed to the researcher and the academics who supported it. Ethics review
of the research plan also contributed to the dependability of the research.
Confirmability (or objectivity) with respect to the degree the researcher was
objective throughout the research is, like dependability, difficult to ascertain. The researcher,
was also an employee within the host organization and this in and of itself could be viewed as
compromising objectivity. Steps were taken to mitigate any situations where a participant
may have felt that this dual role influenced them or their contributions. The interviews were
restricted to peer level or senior leaders within the organization. The area of research
’medication management’ is in a different portfolio within the organization then the portfolio
the researcher worked in. The Regional Director of Pharmacy played a meaningful role in all
discussions and review of the final results which would strengthen the objectivity. No
interviews were conducted with members of the researcher’s portfolio so as not to create an
undue influence. The researcher, as an employee of the organization, did enjoy a level of
accessibility to the host organization records and staff which is often not available to external
researchers.
3.5 Authenticity
Authenticity in qualitative research has not been as influential as the trustworthiness
criteria; however, it has been seen to be relevant to action research where practical outcomes
are sought (Bryman et al., 2011). The criteria included in authenticity includes: fairness,
ontological authenticity, educative authenticity, catalytic authenticity and tactical
authenticity.
Fairness requires all levels of organization be involved and in this research there were
participants from senior and middle management levels within the organization. Front line
care providers were not included in the workshops nor were they interviewed. There was not
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a conscious decision to exclude front line practitioners but rather it was a consequence of
operational constraints and the fact participants joined the research on a voluntary basis. It
could be assumed that this lack of front line participation limits the fairness of the process
due to the absence of the opinions and beliefs of this level within the organization. This
would in turn be partially offset since the front line managers themselves were mainly
clinicians some with very recent front line experience.
The analysis of the process from end-to-end brought insight into the social context in
which staff worked and how their actions might affect others participating in the process
either upstream or downstream. This exploration across organizational boundaries
contributed to the ontological authenticity which requires that the research helps people
engaged in the medication management process gain a better understanding of how they fit
into the social context of their environment.
The development of the business artefacts and selection of improvement efforts
generated discussion and varying perspectives were heard by the participants some of which
were not known by all workshop participants prior to this research. This contributed to
educative authenticity which requires the research provide participants with an opportunity to
gain insight into perspectives of other members within the social setting.
This research provided an opportunity for individuals to explore the value being
delivered through medication management and also how that value might be increased
through improvements in the processes. Follow up research would show whether or not
individuals took action subsequent to the research being completed but based on comments
made during the interviews the participants indicate that they have already begun to
implement improvements or were planning to do so. This contributed to catalytic

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authenticity which requires that individuals change their approach or engage in some sort of
action to change their circumstances.
The development of the business artefacts and the increased understanding of the
entire end-to-end medication management process that each of the participants gained could
definitely increase their ability to engage in informed discussion on where changes could or
should be undertaken to increase safety and quality of medication management processes.
Identification and review of the Strategic Business Objectives and the Critical Success
Factors provided clarity and a shared understanding on what was intended to be achieved and
why. This contributed to tactical authenticity that refers to whether participant’s level of
empowerment to take action had increased as a result of the research.
3.6 Limitations
This research has the limitations associated with action research some of which are
referred to in section 3.3.2. The limitations can be categorized into three themes: 1) timing,
2) objectivity and 3) transferability.
There were two issues related to timing. The research was conducted over an eleven
month period which means there were changes happening within the organization during the
time of the research which may or may not have affected the outcomes. The time frame of
the research was not of a duration to fully realize the implementation of the improvement
initiatives and therefore the performance data does not demonstrate the full impact of the
anticipated changes in process outcomes.
Objectivity of the researcher could be a limitation due to the fact that a dual role was
held, both as researcher and employee of the host organization. This situation is referred to
in the literature as an ‘insider researcher’ whose role is explored under three major research
paradigms of positivism, hermeneutics and action research (Brannick & Coglan, 2007). Four
79

areas of concern that might be faced by an insider researcher - access, preunderstanding, role
duality and organizational politics – were explored. It was concluded that insider research is
valuable despite the traditional thinking that the researcher should be external so as to avoid
bias and the risk to objectivity in analysis of the data gathered during the research.
Furthermore, they assert that with appropriate reflexivity, “insider research is not
problematic in itself and is respectable research in whatever paradigm it is undertaken”
(Brannick & Coglan, 2007, p. 72). The disadvantage and potential bias of the researcher
being an insider was in part balanced against the high degree of accessibility the researcher
had to the employees and documentation of the host organization. This level of access is
rarely available to external researchers; not necessarily because the organization is
withholding information, but rather the researcher does not know the information exists and
therefore does not request it. Organizational politics did not factor into the research as an
issue because the organization had officially supported the research and the Regional
Director of Pharmacy, as the organizational sponsor of the research, was very supportive of
the work.
The transferability of the findings to other organizations is of concern particularly
when the strategy of the host organization may be different than that of other organizations.
As noted above, medication management is highly regulated so processes are developed to
ensure compliance with regulations or evidence based practices increase the transferability of
the findings. The transferability of the methodology and the tools used could be applied in
other organizations or in other business areas within the host organization.
3.7 Summary
The methodology used in this research was based on a combination of deductive and
inductive approaches. A selection of methods and techniques found in both qualitative and
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quantitative methodologies were used. The research design was a ten step process that was
undertaken in an organization that provides healthcare services in acute care hospitals, long
term care facilities and community programs. The research included interviews of workshop
participants and organizational leaders; therefore, ethics approval was required and included
in the design. Data collection included both primary data and secondary data. Reliability,
validity and generalizability of the results were considered in the context of trustworthiness
and authenticity. The limitations of the research were also considered particularly from the
aspect of the researcher being employed by the host organization during the research period.
The 8-step process followed in this research is summarized in Table 6.

Table 6 Simplified Outline of Process
Activity

Business Artefact

Identify Strategic Business Objectives, Critical Success
Factors, Key Performance/Process Indicators

Strategy Ma(Figure 2)
Strategy Canvas and
Performance Measures
(Appendix 1)
Value Chain (Figure 4)

Develop End‐to‐End process including core processes,
management processes and support processes along
with the Drivers/Influencers of the process
Identify Business Areas throughout the Organization
that are involved in the End‐to‐End Process
Identify Business Competency Groups and Business
Competencies related to the End‐to‐End Process
Develop Listing of Processes based on Value Chain and
Business Competency Model
Identify Pain Points and potential improvement
initiatives and develop future state End‐to‐End
process if different than current As‐Is process
represented in Value
Rank Improvement Initiatives based on AHP approach
Develop Improvement Plan based on Ranked
Improvement Initiatives

BPM Lifecycle
Phase or BA
Activity
BA Activity

Process Discovery

BA Activity
Business Competency
Model (Figure 3)
Process Reference
Model

BA Activity
BPM Activity
BPM Process
Analysis

Ranked Improvement
Initiatives (Table 5)

Process Analysis
Process Redesign

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4

Results

The results of this research are presented in four sections followed by a summary.
The first section provides the results of the development of the medication management
business artefacts and the relationships between them using the BPMO. The second section
provides an example of a process improvement project undertaken during the research period
that utilized all phases of the BPM lifecycle. The third section provides the result of the
thematic content analysis and summative content analysis of both sets of interviews. These
results are presented based on the workshop participant interviews, organization leader
interviews and analysis of language used in the responses from both sets of interviews. The
fourth section is the proposed process reference model for medication management.
4.1 Business Artefacts
Although relationships are mainly defined at the level of meta-objects (e.g., in
enterprise ontologies), the BPMO contains a set of archetypal relationships that have been
observed to apply to almost any process related object and artefact. These relationships have
been defined at the level of meta-object groups, which means that they apply to object groups
in corporate ontologies, elicited using these meta-objects. The BPMO identifies sixteen
meta-object groups. Although these groups contain meta-objects, they are not meta-objects.
Their relationships with the process meta-object groups are summarized in Figure 7 which is
an overview of these sixteen groups and how they relate to the process objects. These sixteen
groups assemble composition meta-objects, which can be observed in several areas of
business other than processes. Consequently, this template can be reused to represent the
relations between these sixteen groups and other aspects of business (von Rosing et al.,
2014).
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Figure 7 The 16 basic BPM Ontology process classes and groups where the examples applied are marked red
(Source von Rosing, Scheer and von Scheel, 2015 page 107. Reproduced with permission.)

As illustrated in Figure 7, the process meta-objects do not only have relationships to
the central concept of a Business Process, but also with multiple other groups. The
specification of the various BPMO groups and artefact/template relationships provide an
important tool to assess the details of the relationship between multiple concepts, as each
object that belongs to one of these sixteen meta-object groups is expected to be related to any
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business process object in order to obtain a complete business process specification (von
Rosing et al., 2014). This approach is expected to provide a powerful tool to assist in the
identification and capture of all relevant process aspects, providing an overview of how
various concepts and artefacts relate to BPM. The following seven artefacts were key
deliverables from the workshop and will be discussed further:
1. Strategy map
2. Strategy canvas
3. Business competency model
4. Value chain
5. Strategic action plan
6. Prioritized list of improvement initiatives
7. Performance monitoring plan.
The business artefacts were created based on LEADing Practice standards which have
also been created based on the business ontology. The content was developed through
consensus of the workshop participants. These business artefacts are specific to medication
management and are aligned with the overall organization’s BA based on the objects
included in the BPMO. All business artefacts presented in this research were reviewed and
accepted by the working group members as representative of medication management within
the host organization.
There are several business artefacts that could have also been developed including: a
Revenue Model, Cost Model, Process Governance Model, and Process Operating Model.
The limited availability of workshop participants’ time necessitated the selection of business
artefacts for development that were critical to identifying quality improvement opportunities.
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The seven business artefacts chosen were deemed most appropriate. The other relevant
business artefacts that were developed but not presented in the results are the numerous
medication management process models that are included in the process repository of the
host organization. The results do include an example of one such model which is presented
in section 4.1.
The business artefacts included cover the four sub-layers of the business layer of the
layered enterprise architecture. In addition, the business artefacts for the strategic action plan
and prioritization documents show how the objects within the business artefacts were used in
the planning and scheduling of process improvements. Appendix 8 provides a visual
representation of the business objects and how these objects are related to each other.
4.1.1

Strategy map and strategy canvas. The purpose of developing a strategy

map for medication management was to identify the purpose and value of this service. It
enabled alignment of objectives for medication management with the organization level
objectives. The development of the strategy map also enabled consensus building on the
strategic business objectives (SBOs), critical success factors (CSFs) and key performance
indicators (KPIs) which are the objects included in the strategy map.
LEADing Practice describes SBOs, CSFs and KPIs in a Meta Object Taxonomy
which they provide to certified practitioners. Unfortunately this document is not publicly
available. SBOs are used to describe the strategy which is defined as “The direction and
ends which the enterprise seeks, as well as the means and methods by which these ends will
be attained”. CSFs are described as “Time bounded milestones to measure and gauge the
progress towards a strategy or goal”. KPIs are described as “Any of a series of metrics used
by an enterprise to indicate its overall ability to achieve its mission”. Table 7 is an excerpt of
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Appendix 9 Strategy Map objects where the full listing of SBOs, CSFs and KPIs are shown.
The strategy map shows the organization level SBO, the related medication management
SBO, the CSFs associated with each SBO and the KPI(s) associated with each CSF. CSFs
2.1 and 2.2 do not have a KPI identified for them. The group acknowledged these are
important objectives but remained uncertain on how they could be measured.
Table 7. Medication Management Strategy Map Excerpt

Organization SBO
Medication Management SBO(s)
Medication Management CSF(s)
Medication Management KPI(S)
Improve Clinical Outcomes
1.0 Improve Clinical Outcomes
1.1 Ensure medication reconciliation at all transitions in care
% of discrepancies (requiring intervention) found after/during
medication reconciliation
% of patient with Medication Reconciliation completed within 24
hours of admission
% of Patients with Medication Reconciliation Completed at
Discharge

Information from organizational level business artefacts was combined with medication
management specific documents to develop a strategy canvas showing the relationships
between the CSFs on the medication management strategy map and objects from the
organizational level artefacts. This model shows the relationship between CSF and the
following business objects:


Organizational Business Area



Medication Safety Working Groups



2016-2021 NH Strategic Plan Priorities



NH Strategic Business Objectives
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

Medication Management 3 year Strategic Action Plan Initiatives



KPIs

Figure 8 is an excerpt of Appendix 10 Strategy Canvas for Medication Management

Figure 8. Excerpt from Medication Management Strategy Canvas

4.1.2

Business competency model. The purpose of developing the business

competency model was to identify and document the business competencies (functions)
required to deliver the value identified in the strategy map. The business competency model
identified the business areas, the business competency groups within the business areas and
the business functions required to provide medication management services. The business
competency groups are shown in three accountability tiers: strategic, tactical and operational.
The strategic tier includes functions related to governance and long term planning. The
tactical tier includes functions associated with monitoring and controlling. The operational
tier includes functions related to delivery of the service. A business competency model can
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be developed for the entire organization, a single business area or a business service. The
business competency model described below is specific to medication management services
within the host organization. A business competency is defined as “a firm’s ability or
capacity to turn its resources into customer value and profits” (Rosenberg et al., 2011, p. 45).
The term competency created some confusion among workshop participants as they struggled
with delineating the ‘business’ competency from ‘personal or clinical’ competency. The
term function was easier for the group to use so in this document the term ‘competency’ is
interchangeable with the term ‘function’. Similarly, the clinicians struggled with reference to
‘business area’ and preferred to use the term ‘organizational area’.
The medication management business competency model represents a service that has
processes executed in eight organizational areas. These include Pharmacy, Acute Care, Long
Term Care, Home Support, Primary Care, Community Specialized Services, Public Health
and Records Management. Appendix 11 shows the business competency ‘map’ which is a
listing of the competency groups and functions. The map includes all functions within
Pharmacy in addition to medication management functions in other organizational areas.
Appendix 12 is the business competency model which uses the business competency map as
the starting point.
In addition to distinguishing the competencies based on organizational area, the
business competency model also includes rating of the maturity level of the underlying
processes on the operational tier competencies and several of the tactical tier competencies.
Due to time constraints not all competencies were assigned a maturity rating by the workshop
participants. The maturity level was assigned based on a 1 to 5 ranking (von Rosing et al.,
2014, pp. 408-420). The result was that most functions were assigned a very low maturity

88

level either 1 or 2 due to the variability in the processes underlying functions across sites.
The maturity levels are described as:


Level 1 - Typically process & procedures of a function are undocumented and in a
state of dynamic change. Tends to be siloed, ad hoc, uncontrolled and chaotic



Level 2 - Processes & procedures are repeatable, possibly with consistent results,
discipline is unlikely to be rigorous.



Level 3 - Defined and documented process & procedures for function are
established and subject to some degree of improvement over time. Standards are
in place and used to establish consistency of performance.



Level 4 - Performance is measured and function can be effectively managed &
controlled. Management can identify ways to adjust and adapt the function to
meet requirements.



Level 5 - Focus is on continuous improvement of performance, effectiveness &
efficiency through both incremental and innovative changes with feedback &
collaboration.

4.1.3

Value chain. A value chain provides a high level view of the functions and

underlying processes that create value for the customer. The Medication Management
Services value chain developed by the workshop participants includes four groupings of
functions: the core functions are categorized as 1) Manage Medication at Point of Care, 2)
Provide Clinical Training & Professional Development, 3) Manage Medication Supply Chain
and 4) Manage & Administrate.
The medication management core functions include the seven steps showing the endto-end process for a patient receiving medication therapy. These seven steps are: Patient
89

Registration, Patient Assessment, Prescribing, Point of Care Dispensing, Medication
Administration, Patient Monitoring and Patient Discharge. The value chain is shown as
linear, however, the process is iterative between Patient Assessment and Patient Monitoring
based on patient response to medication therapy.
The three groups categorized as either support or management functions include: 1)
medication supply chain functions, 2) provide clinical training & professional development,
and 3) manage & administrate. Medication supply chain functions include: medication
sourcing, inventory management, medication packaging/repackaging, medication distribution
and medication returns. Provide clinical training & professional development functions
include: provide pharmacy staff training, provide clinical pharmacy competency
development, provide clinical education and manage clinical student placement. Manage and
administrate functions include: planning, risk management, compliance management,
contract management, human resource management, financial management, information
management, procure and maintain equipment & facilities, and provide operational oversight.
The value chain also shows fifteen external influencers or drivers which are known
to have an impact on how medication management services are organized, delivered and
governed. Examples of influencers and drivers include; Community Partners, Labour
Unions, Ministry of Health, Geography, Consumer Expectation, Legislation and Professional
Regulatory Colleges. The medication management value chain is included as Appendix 13.
4.1.4

Strategic action plan. The host organization developed an operational plan

with eight operational priorities one of which was medication safety and quality (Northern
Health, 2016). The Regional Director of Pharmacy was identified as the process owner and
responsible for the development of a three year strategic action plan to improve medication
safety and quality throughout the organization. The initiatives identified were based on
90

selected critical success factors (CSFs) from the medication management strategy map.
There were a total of twenty-nine initiatives identified based on the review of the end-to-end
medication management process and the maturity levels of the core, management and support
processes.
The strategic action plan business artefact showed the relationship of each of the
twenty-nine initiatives to the Medication Management CSFs, and SBOs as well as the
organizational level SBOs and CSFs. It also illustrated the alignment to one of the five
Strategic Plan Priorities included in the 2016-2021 Strategic Plan. The KPIs from the
respective medication management CSFs were included in addition to some specific process
performance indicators (PPIs) depending on the initiative. The resource requirements to
achieve the twenty-nine initiatives exceeded those available so there was a need to prioritize
the initiatives. This was achieved by the prioritization working group based on criteria
established by the workshop participants. The results of the analytical hierarchy process used
to prioritize the initiatives are presented in the next section.
4.1.5

Prioritized improvement initiatives. The objective of the prioritization

exercise was to develop a ranked listing of the improvement initiatives based on which
initiatives would contribute the most benefit to medication management safety and quality.
This was achieved as a three step process. The first step was to identify and define the
appropriate criteria for comparison. The second step was to establish the weighting of the
criteria. The third step was to rate each initiative against the criteria. The result was a ranked
list of initiatives based on how well each initiative satisfied the criteria.
The workshop participants identified seven criteria to evaluate each of the initiatives.
The seven criteria were 1) Business Continuity, 2) Feasibility, 3) Patient Safety, 4) Worker
Safety, 5) Process Maturity, 6) Strategic Alignment and 7) Financial Impact. Criteria
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questions and definitions were established to assist in creating a shared understanding of each
of the criteria. Each of the criteria was explored from the perspective of questions related to
that criteria. Appendix 14 provides a table showing the complete listing of the criteria,
criteria questions and definition of each criteria.
The weighting of the criteria was achieved through a pairwise comparison of the
criteria based on an AHP scoring approach shown in Table 8. This scoring approach and the
excel template are based on an AHP example presented by Dr. Michael Cochrane from Value
Function Analytics.1 The approach used a one to nine scoring scale (Saaty T. L., 1980).
When the criteria being scored was higher in value than the criteria it was being compared to,
a value between 1 and 9 was assigned. When the criteria being compared was lower in value
than the criteria it was being compared to, the reciprocal value was assigned.
Table 8. AHP Scoring Approach
Intensity of Value

Interpretation

1

Criteria being compared are of equal value

3

Criteria being ranked has a slightly higher value than the comparator criteria

5

Criteria being ranked has a strongly higher value than the comparator criteria

7

Criteria being ranked has a very strongly higher value than the comparator criteria

9

Criteria being ranked has an absolutely higher value than the comparator criteria

2,4,6,8
Reciprocals

Intermediate scales between two adjacent judgements
If the criteria being ranked has a lower value than the comparator criteria

Each of the criteria when compared to itself would have equal value and as a result
was assigned a value of 1. When business continuity was compared to feasibility, the
prioritization working group decided business continuity had a slightly higher value than
feasibility and assigned a score of 3. When they compared business continuity to patient
safety, they decided patient safety was of a higher value and assigned a score of 1/5 which

1

available at https://www.youtube.com/watch?v=zsld4TQacBU

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was the same score assigned to worker safety. When business continuity was compared with
process maturity and strategic alignment, they assigned a score of 1/2 to each of those criteria
as they determined business continuity was of a lower value. They determined financial
impact was equal in value to business continuity and assigned a score of 1. This process was
completed for each of the criteria. Table 9 shows the results of the pairwise comparison of
all seven criteria and the resulting criteria weighting based on the AHP approach. Not
surprising that the criteria of Patient Safety and Worker Safety were rated higher in value
than the other five criteria at 29.5% and 28.9%, respectively.
Table 9. Pairwise Comparison of Criteria
Item
Number

Item Number
Item Description

1
Business
Continuity

2
Feasibility

3
Patient
Safety

4
Process
Maturity

5
Strategic
Alignment

6
Financial
Impact

Worker
safety

7

1

Business Continuity

1.00

3.00000

0.20000

0.50000

0.50000

1.00000

0.20000

2

Feasibility

0.33

1.00

0.14286

3.00000

0.20000

3.00000

0.33333

3

Patient Safety

5.00

7.00

1.00

5.00000

5.00000

5.00000

1.00000

4

Process Maturity

2.00

0.33

0.20

1.00

0.14286

0.14286

0.14286

5

Strategic Alignment

2.00

5.00

0.20

7.00

1.00

0.14286

0.14286

6

Financial Impact

1.00

0.33

0.20

7.00

7.00

1.00

0.20000

7

Worker safety

5.00

3.00

1.00

7.00

7.00

5.00

1.00

Sum

16.33

19.67

2.94

30.50

20.84

15.29

3.02

Business
Continuity

Feasibility

Patient
Safety

Strategic
Alignment

Financial
Impact

STANDARDIZED MATRIX
Process
Maturity

Worker
safety

Weight

1

Business Continuity

0.06

0.15

0.07

0.02

0.02

0.07

0.07

6.5%

2

Feasibility

0.02

0.05

0.05

0.10

0.01

0.20

0.11

7.6%

3

Patient Safety

0.31

0.36

0.34

0.16

0.24

0.33

0.33

29.5%

4

Process Maturity

0.12

0.02

0.07

0.03

0.01

0.01

0.05

4.3%

5

Strategic Alignment

0.12

0.25

0.07

0.23

0.05

0.01

0.05

11.1%

6

Financial Impact

0.06

0.02

0.07

0.23

0.34

0.07

0.07

12.0%

7

Worker safety

0.31

0.15

0.34

0.23

0.34

0.33

0.33

28.9%

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This criteria weighting was included in the tool used to rank each of the improvement
initiatives. The tool was developed in Microsoft Excel. The tool rated the initiative against
each of the criteria on a 7 point scale of -3 to +3. If there was a negative impact anticipated,
the initiative was given a rating of -3 and the maximum optimistic positive impact was rated
as +3. If there was no or minimal impact based on the criteria, the initiative was rated as 0.
Appendix 15 is a copy of the ranking tool used. The 7 point scale was used because it
provided sufficient opportunity for respondents to distinguish and rate the improvement
opportunities. A 5 point scale would have resulted in less variance in the rating between the
initiatives. A larger scale required respondents to answer with more precision and in some
cases information was not available to be able to provide the level of precision that would be
required to respond in a reliable and consistent manner in respect to all initiatives. Appendix
16 provides the results of the ranking exercise. Of the twenty-nine initiatives seventeen were
included in the ranking activity. The remaining twelve initiatives were not ranked because
some had been completed, others were mandatory, and therefore excluded, and the remainder
did not provide enough information to complete the exercise.
The ranked list was presented to the workshop participants at the final meeting. The
participants thought the final list appeared reasonable with the exception of Medication
Administration rating of 424.7 which ranked it 10th out of the seventeen initiatives. The
workshop participant who raised this as an issue had not participated in the prioritization
working group so was not as familiar with the process and the criteria as those who had
participated. One of the participants addressed this concern by referring to the feasibility and
financial impact criteria explaining that this initiative would require a financial cost and, in
addition, it would necessitate a change in the practice of all front line nursing staff. This
issue was also raised during the interviews and is discussed further in Chapter 5.
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4.1.6

Performance monitoring plan. The workshop participants and the

measurement working group developed a list of ninety-one KPIs and PPIs. The full list of
measures is provided in Appendix 7. The majority of these measures are tactical, meaning
they are intended to be used to monitor or control medication management processes and
practices. Eighteen of the measures have been identified as appropriate for Executive level
reporting. These are shown in Table 10.
Table 10. Medication Management Strategic Level Indicators

The strategy map includes forty-eight of the ninety-one identified indicators and the
strategic action plan includes sixty-one of the indicators. There is an overlap of twenty-seven
indicators that appear on both the strategy map and the strategic action plan.
A review of availability of the indicators was undertaken and there are forty-three
indicators currently available in electronic format with thirteen available from manual
sources. During the research period, an internally developed application to collect clinical
pharmacy related indicators was being trialed at the host organization. This application
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provides values for an additional ten indicators on a fiscal period basis. The performance
reporting is expected to include the sixty-six available indicators. The remaining twenty-five
indicators will not be considered for reporting unless an efficient method can be developed to
gather the information. Appendix 17 provides the anticipated reporting frequency of the
sixty-six available indicators.
The performance monitoring report had not been developed but the future design will
follow similar organizational reporting that provides indicators at the organizational level
with the ability to drill down to specific facility indicators. Visualization will include
statistical process control charts for each of the indicators at the organization wide level and
at the facility level.
4.2 Example of Process Improvement Using BPM Lifecycle
The BPM lifecycle consists of six phases: 1) Process Identification and Opportunity
Assessment, 2) Process Discovery (AS IS or Current State Process Mapping), 3) Process
Analysis, 4) Process Re-design 5) Process Implementation and 6) Process Monitoring and
Controlling. This research has covered phases one through three with limited activities in the
remaining three phases. The process re-design and the process implementation phases were
not completed due to time constraints and although a performance monitoring plan was
developed it was not fully implemented. This work however did set the stage within the
organization for others to explore opportunities at a detail level which employed BPM and
demonstrated use of all six phases of the lifecycle.
4.2.1

Example. An example of this is a process improvement project that improved

safety of medication administration for those medications administered through an infusion
pump. A brief summary of that project is included to demonstrate the use of BPM and how

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the selection of the initiative can be directly related back to the strategy map and business
competency model presented above.
Process Identification & Opportunity Assessment: Process identification requires the
systematic identification of processes in an organization. This example was restricted to a
function within the medication management processes specific to the use of infusion pumps.
The processes identified were those specific to the use of infusion pumps. Three processes
were identified for opportunity assessment: 1) development of master drug library, 2)
education of nurses on the use of the infusion pump and 3) administration of medication
using an infusion pump. The opportunity identified and addressed was the education of
nurses on the use of infusion pumps. The master drug library is intended to improve the
safety of the administration of medications when using an infusion pump. The appropriate
dosage and duration of the medication to be infused is pre-set in the software application of
the infusion pump. The nurse is able to set the infusion pump based on pre-set dosage and
duration or override it and manually program the infusion pump. The improvement
undertaken was to increase the use of the master drug library as this would eliminate any risk
of medication error related to programming either wrong dose or wrong duration. The initial
project focused on one nursing unit that had an average of seven thousand seven hundred
infusions per month with a compliance rate of 74%. There would be times for it to be
appropriate for a nurse to override the master drug library and a target of 90% compliance
was established.
Process Discovery: Current state mapping was undertaken to gain a better
understanding of the current process used by nurses to administer medication using the
infusion pumps. Current state mapping was also undertaken to explore the process used to

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train nurses on the use of infusion pumps. Figure 9 provides a current state map of the
infusion pump process.

Figure 9 Current State Map Infusion Pumps

Process Analysis: Several activities were undertaken in this phase including
interviews with nursing staff on why they were not using the master drug library and
exploration of data available for monitoring the use of the master drug library. It was
suggested that non-compliance may be associated with a specific set of medications but the
data was not available to confirm or refute this theory. This phase revealed the main
contributor to the non-compliance related to lack of adequate training on the use of infusion
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pumps. There was a common practice among the nurses to select basic mode and bypass the
use of medication drug library when IV fluid was to be used in delivery of the medication.
Figure 9 shows where in the process this decision point occurred.
Process Redesign: The current process for training nurses on the infusion pump was
revised and the future state process was developed. The future state process required revision
of training material and incorporated an annual retesting step to ensure nurses maintained
their skill level in using the infusion pumps. There was training provided and an immediate
change was realized in practice related to IV Fluids and how to use the infusion pump. The
decision point was changed to “is this an emergency” if yes bypass of medication drug
library was appropriate if no use medication drug library.
Process Implementation: The new process for training nurses on the use of infusion
pumps was implemented in the single unit where the project had been undertaken. Feedback
from the nurses was used to revise and improve the training before it was implemented in
other nursing units. This process has since become standard training across the organization.
Process Monitoring and Control: There are two aspects relevant to the process
monitoring and control phase in this project. There is a report issued quarterly on the level of
compliance with the use of the medication drug library during medication administration
using the infusion pumps. There is a requirement for retraining of nurses practicing in units
with low compliance. The results in the original nursing unit have shown an improvement in
compliance from the initial 74.15% in January 2017 to 88.63% in December 2017. Figure 6
provides a process control chart that shows the monthly changes in this indicator.
This BPM project can be directly related to SBO 1.0 (Improve Clinical Outcomes),
CSF 1.5 (Ensure Medications are Accurately & Appropriately Administered) and the KPI
1.5.2 (Percentage of IV medications infused through MDL (medication drug library)). The
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researcher was the Executive Sponsor of this project providing guidance and oversight to the
project lead.
4.3 Analysis of Interview Results
Semi-structured interviews were conducted with eleven of the twenty workshop
participants and twenty-one of the seventy-three organizational leaders. The transcribed
results were analyzed using NVIVO software and a content analysis approach (thematic and
summative). There were a total of six themes identified between the two sets of interviews.
These themes were explored through the lens of whether the respondent was identifying a
challenge or a benefit within each of the themes. The six themes identified were Capacity
Building, Communication, Collaboration, Competing Priorities, Connection to Strategy and
Culture. The results of the analysis are presented individually for each of the interview
groups followed by an analysis of the language used by survey respondents.
4.3.1

Workshop participant interviews. The workshop participants engaged in a

process to develop business artefacts expected to assist in the identification and prioritization
of initiatives that would support improving the safety and quality of medication management
within the host organization. There was a 55% response rate to the invitation to workshop
participants with eleven of the twenty individuals invited agreeing to be interviewed.
Participants included clinicians and non-clinicians engaged in either the management or
support for front line staff responsible for the core processes and support processes associated
with medication management in acute care and long term care facilities. The eleven

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respondents had all been involved in either the workshops only or on the two working groups
derived from the workshop participants.
4.3.1.1 Capacity building. The United Nations (2018) defines capacity building as
“the process of developing and strengthening the skills, instincts, processes and resources
that organizations and communities need to survive, adapt and thrive in a fast-changing
world.” Workshop participants expressed their perceptions of the benefits, potential benefits
and challenges of implementing and using the three methodologies. Their responses included
the use of the methodologies as well as the business artefacts. They also expressed interest in
taking the work to the next phase of the BPM life cycle of process redesign and
implementation.
Using the business artefacts as resources for others outside the workshop participants
was seen to be a definite benefit. “I learned a lot, and I think people coming in and looking
at this work will be able to take bits and pieces or the whole thing and take it back to their
sites and start working with what we have identified.” The documentation provided by the
business artefacts was seen as contributing value both from facilitating improvement of the
maturity levels of the processes and also from an organizational knowledge perspective. “It
(documented processes) would be a good review and a good teaching model to use with new
staff.” “The BPM, to me, gives you that higher level view and that along with the Business
Architecture actually gives you a much richer picture of what you are dealing with.”” You
need to understand the inner workings of that process in order to apply a solution, because I
know from my past experience that applying an IT solution to a process that you don’t know
all of the details of, usually results in a more broken process.”
It was perceived very important to standardize medication management processes that
are evidence based. The modeling of the “current as-is process” and of the “future state
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process” is of benefit when establishing standardized processes. The need for standardized
processes was a definite recurring desire. “It’s a pretty clear science. Pharmacy and
medication management. It’s not gray. I don’t see why we wouldn’t be standardized. The
least amount of variation (in process) is better for patient safety”. “If we standardize a
process through nine different sites. Then one of the sites has an issue, we can highlight it
and fix it for all the other sites. Along with that it’s great for employees and staff that move
from one site to another.” “If you do not have standardized processes you run the risk of
providing less than optimal care and unbalanced care… If you have totally different
standards and systems then you run the risk of increasing errors and having decreased
patient outcomes.”” I believe medication management and the processes should be evidence
based…and should reflect practices for all stakeholders that ensure the best outcomes for
patients and are cost effective and to me standardization helps to fulfill that.” It was
acknowledged that establishing standardized processes alone would not be enough. People
would need to actually follow the established standard process and some suggestions were
made on how this could be achieved. “Having a documented process that people have to
follow, if there’s an understanding underneath it of why you’re following that process, I think
it makes things safer.”” That’s right it’s got to be safe, and it’s got to make sense, and it’s
got to be easy for people to do the right thing, and want to do the right thing. If it doesn’t
make sense, they either won’t do it or they’ll push back.” “Yeah absolutely we need standard
processes, and then within that, wherever it’s possible have flexibility.”
Complexity and challenges with understanding the methodologies and the language
was a theme expressed by workshop participants. “I must admit, some of it I did feel like it
was way over my head. I did try and read the documents ahead of time but I think you did a
very good job of trying to lay it out for us and explain it for us.” “So, one of the things I
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think people feel when they’re first exposed to this is that they don’t understand it and they
don’t understand it for a while.”” And to compound that, another layer that sits on top of
that, I think, is that I’m learning new concepts and I’m learning new language at the same
time so I’m not saying, That’s a dog. How do you say that in Cantonese?” One participant
described the methodology as a “bit of a brain teaser.” The AHP process was a challenge
for at least one of the participants. “Don’t ever make me do that number thing again.”
4.3.1.2 Communication. Benefits of the documentation and business artefacts as a
communication tool were frequently expressed. “I think the documentation forms a review
and that is the work you want to do and I think it helps with communicating out to staff
clarifying roles and responsibilities and communicating what those are to staff.” ”So I think
that’s going to be the interesting part, is the translation from taking it from the mapping and
all the work that we’ve done, how do we communicate that to the sites? Make it usable.”
”We have to document the process so that we can see where they’re doing things that may
introduce risk.”
4.3.1.3 Collaboration. The business artefacts support collaboration by identifying
gaps which may not otherwise be visible within single silos. “It’s easy to work in silos and
not realize where the gaps are.” “Siloing between departments. It’s a big one. Making sure
the right information gets to the right person at the right time without overloading people.”
“The lack of understanding of why it’s so important in one department to do it this way and
so to follow through so it is a seamless system. That’s a very high importance because there
again if you don’t have that seamless across the different continuums that’s where you have
your gaps and that’s where you have your highest points of risk.”
Challenges identified with gaining collaboration included differences in interest level
and lack of willingness to participate. “Well, one, is just getting input from all the people
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that touch it, particularly when people don’t necessarily see the importance or have an
interest in it.” ”So the complexity of the med system is one that makes it challenging
particularly when dealing with a large number of stakeholders and sometimes one
stakeholder may not be able to have their own or all their interests met by making changes in
the system.”
4.3.1.4 Competing priorities. A potential benefit was identified related to
establishment of the performance measurement plan. This provides information to support
the selection and prioritization of improvement initiatives. “As we continue to collect these
metrics, we can try to figure out where we can get the most bang for our buck, like the best
outcomes for the limited time and resources we have.”
The participants expressed a challenge concerning the competing priorities in respect
to being able to complete this initiative in a fulsome and timely way. “I don’t feel like we
have necessarily had the extra resources available to make it feasible.” “It’s very labor
intensive and probably requires a lot of financial commitment in the organization to make
significant change. “If you don’t think these initiatives provide more value than the stuff
you’re doing currently, you’re not going to spend time on them.” ”But maybe the fact that we
did spread it out so having shorter sessions spread out was in respect to we all have other,
we have main jobs to get back to, right, and if you dedicate a whole week to this you are not
paying attention to your own job.”
4.3.1.5 Connection to strategy. Participants expressed their understanding of how
BPM and the business artefacts were beneficial in assisting them in connecting their
processes to strategy of the organization. “I am thinking when you first document a process
you are probably reviewing that process to ensure that process steps that you want to
participate in to achieve your goals.” ”I think now that we have the metrics lined up to the
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actual strategic action plan, the strategy map, will help drive which ones we should be
doing.” “Make sure that we’re meeting our goals, make sure we’re efficient and not wasting
time on other things like busy work.”
The respondents did not indicate any challenges regarding connection to strategy.
This may be related to the lack of representation from front line service delivery clinicians.
Workshop participants were mainly drawn from management positions with some having
limited responsibility to provide front line service.
4.3.1.6 Culture. The workshop participants who agreed to be interviewed made
several comments that suggest the host organization could be described as a “learning
organization” where people are willing to try new approaches to problem solving. “I lacked
the insight of what I didn’t know at the time and I trust that the work that you are doing, like
right off the bat, I trust that it was going to help us and it was going to work, even when I
didn’t quite understand it, because I respected you.” “Hats off to you and your team for
taking the complexity of it all and somehow, I call it your magic, being able to turn the
concept into something practical and useful.”
The participants identified aspects of the culture they felt were challenges to
improving medication safety. One of the most frequently mentioned aspects was
accountability. “Because when it’s everybody’s job, it’s no one’s responsibility.” ”I am not
sure how good the follow up is and are they adhering to those standards. That’s something
we have to look at is really the accountability in the system.” “ There still seems to be this
sense that a report (referring to self-reporting of medication errors) is going to get someone
in trouble and that is one of the things getting in the way of people reporting.” Another
aspect expressed related to risk tolerance. “The quality piece is not being recognized in what
people are doing. They are focusing on getting it done rather than doing it right.”
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4.3.2

Organizational leader interviews. The organizational leaders have had

varying degrees of exposure to BPM, BPMO and BA which was evident in the responses to
the interview questions. This may also have contributed to the low response rate at 29% of
those invited to participate. All those who were invited to participate had been involved in
presentations of information based on the BA and BPMO; however, not all had been engaged
or familiar with the BPM methodology. To date the use of the methodology had been limited
within the organization. Despite the lack of familiarity, those who responded to the interview
were able to recognize the challenges along with the benefits or potential benefits of using
the methodologies within the organization.
4.3.2.1 Capacity building. The major theme identified was in the area of capacity
building. Interviewees consistently referred to the value of the methodologies in increasing
their understanding of their program area. This increased understanding and the
reusability/transferability of the business artefacts are a potential valuable resource to the
organization.
One of the most notable quotes that demonstrates this perspective was from a
Program Director who had developed BA artefacts for his program areas and based his
annual planning on the SBOs and CSFs “I always kind of thought I knew the program but
when you actually have to peel back the layers of the onion, so to speak, you know, you get
all the aroma, you get your eyes stung out a little bit and it’s the full feel, right. Versus
basically picking up an onion, which was where I was at, and saying this is an onion “.
Likewise another leader who had used the approach to gain clarity on an initiative that was
spread across several portfolios provided the following quote indicating the approach does
increase organizational knowledge. “So we were doing the work without knowing why we
were doing the work and the process allowed us to identify why are we actually doing this
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work which allowed us to figure out what the strategic objectives are and the KPI’s would be
that made sense for that. And we had been spinning, thinking we knew what we were doing
without really knowing what we were trying to accomplish.” A third perspective was
provided by a leader who had the opportunity to review business artefacts for a program
within her portfolio including an end-to-end process model, strategy map and business
competency model. “It’s that great visual to really identify where the barriers are, where
the opportunities are and again to be able to go from high level down to the real micro level
depending on the work that you’re doing”. A fourth perspective addressed the potential
benefits of the business artefacts. “So I think once you get the basic documents, if you
allowed yourself to continue to use them , you get incredible value looking then at certain
aspects, like where are we mature, where are we not mature? Where are we spending money
that we don’t get value from? Where are we under resourcing? Where should we innovate,
where should we standardize? Like I think the potential and I’ve seen elements of all those
kinds of discussions going forward.” A leader provided the following succinct comment in
reference to the value of the business artefacts. “At their best they definitely help with
planning and monitoring and evaluation and then can also inform the various clinical
operational and organizational shifts that need to occur to carry out the process as it is
mapped. So I think that, at their best, they can kind of really help the whole planning,
implementation, and evaluation component.”
There were also challenges identified in the area of capacity building which included
the complexity of such a comprehensive approach. This concern was raised both by those
who had invested time using the approach and those who had only been involved at the
periphery of the initiatives that used the methodologies. Examples of quotes that
demonstrate the challenge related to complexity of the methodologies. “I think it has to be
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still more intuitive to the different levels.” “Unless I see what it (strategy map) looks like,
because these things just confuse me”. “I don’t know if we’ve done a very good job of
teaching people what it really means.” I’ll be frank with you, it makes me feel, not stupid, but
it makes me feel challenged that I’m not able to understand. And I mean I have a graduate
degree.”
There were also suggestions on how the methodologies could be introduced so they
were more understandable by the end user. These included suggestions to ’Fisher Price It’ or
‘Develop a BPM and BA 101’. “I know that just in my former role how many times you guys
came and in, it probably took second or third time of hearing it to really get it and so I don’t
need to be the knowledge expert in it, but a 101 on how to tap into the knowledge expert who
can help me.” Several leaders also suggested it would be an improvement to separate the
work from the methodology by using an information gathering approach without reference to
the technical aspects of BPM, BPMO and BA. Their idea suggested an approach to gather
the necessary detail so the Business Architects and Process Architects could develop the
underlying detail and then share the information with the user groups in a simplified way that
most participants would easily grasp. “Instead of having the people, the subject experts
learning another subject matter they’re actually just able to spit out what they do and
someone captures that because they understand the healthcare system and the business
architecture.” There certainly was not consensus on this aspect as other leaders suggested
they would require an increased understanding of the methodology before they would
support the implementation in the organization or their portfolio.
4.3.2.2 Communication. The development of the business artefacts within the
organization have been achieved by interviews and workshops with those directly involved in
the business or service area the artefacts are intended to represent. This approach has
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provided an excellent opportunity for increasing the communication both within program
areas and across program areas.
Leaders interviewed commonly spoke of the value these interactions have had on the
participants. One leader who had participated in the process modeling of the information
request and report development process spoke of her personal experience. “But had we not
gone through that process of having the conversations and depicting it visually in front of
people and what that looks like day to day work effort. We would not have gotten there just
in conversation alone. I think it provides evidence but also provides a starting point for a
much deeper conversation”. The business artefacts themselves have also been described as
beneficial to enhancing communication. “It was actually one day that in a Directors meeting
with just coordinating it that we put up the business map (Business Competency Model) and
we showed how many of us overlap and it definitely improved communication to know when
to involve people in what.” One leader who had her group work with a Process Architect to
develop a complete end-to-end process and use the BPMO to expand the process model to
include competencies and risks in the clinical process described her thoughts on the benefits
of the approach. “It includes layers of information in a clear way and for me to be able to
get to that level of detail with the chemo nursing has been probably the only way in which
we’ve actually been able to fully articulate not only the process that the nurses follow but
what competencies are needed and what risks there are if those competencies aren’t there.
So I think it’s a really key communication piece, but it keeps you honest and it keeps us
objective.” The same leader spoke to using the business artefact as a communication tool.
“The primary value of it for me is that it’s my source of truth for communicating within my
team as to how things work.”

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The introduction of new terminology to the organization was a major challenge and a
common theme in the leader responses. One leader in particular challenged the need for the
terminology. “And so why we’re forcing terminology that people are clearly having trouble
with is something we might need to clarify”. Another suggested that “it needs to be thought
through to not create a lot of unnecessary confusion.” Another leader stated “I think one of
the challenges is that if I take the overall end-to-end thing and I presented it to a Chief
Operating Officer that is not going to work.”
These challenges with the terminology were also offset by at least one leader who
thought the standardization of terminology was a definite benefit. “So I think it helps us to
have a common language that we can communicate in, Kind of a visual, but a kind of uniform
way that now people are getting used to the different streams and they’re using them to some
degree.”
4.3.2.3 Collaboration. Healthcare services tend to be siloed and collaboration
between business units is vital to developing and delivering services that are safe and
effective for patients. Promoting collaboration requires the mutual engagement and
understanding of the organization to recognize where duplications of effort and gaps in
services exist for the patient. BPM and BA are effective in supporting collaboration.
Speaking specifically of the business competency models and the strategy maps at the
program level, one leader expressed his thoughts on the benefit of the approach. “The great
thing too is if the program is one of those programs that touches upon or overlaps with say
my department, then I can see where we can collaborate on, right.” When asked whether the
methodologies helped identify improvement opportunities, a leader responded positively.
“Where I could see improvements is if you are doing one bit of things here that’s assigned
and there is another group doing similar things you can maybe say well let’s try and see how
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we can consolidate the functions.” Speaking specifically about the challenges of the current
siloed approach to healthcare and the potential of these methodologies to identify
opportunities for improvement one respondent commented: “It takes resources, right and
capacity to promote and align with other groups, because if we are just in our silos doing our
own thing. And just where are the opportunities?” There were no challenges identified in
respect to how the use of the methodologies might negatively impact collaboration; however,
there were challenges identified related to how to address the issue of collaboration when the
methodology reveals the goals of one business area are seemingly in conflict with those of
another business area.
4.3.2.4 Competing priorities. There are limited resources available and the time
demands on human resources is a constant challenge. The use of these methodologies can
support the prioritization of initiatives by identifying which processes are contributing more
value than others. However, the development of the business artefacts does require focused
time from operational leaders and clinicians.
The benefit of strategy mapping and clearly articulating the Critical Success Factors
can support prioritization. A leader articulated this quite succinctly. “So, it’s been a
challenge to respond to demand and without going through the strategy mapping process, I
wouldn’t be able to say no, I don’t have the resources to do that. Maybe next year.” Another
benefit or potential benefit was expressed by a leader in respect to the knowledge gained
from the identification of functions using the Business Competency Model. “Because we
have capacity issues everywhere and if we find that through this process we identify that our
subject matter experts are spending 50% of their time on work that could be done by a
centralized shop, whether it’s place at HR or Finance, those kind of things, just there might
be some efficiencies there”.
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One leader specifically spoke to the time it takes to understand the methodology. “I
feel that I need time to be able to absorb, digest and use this and that in and of itself can also
be a barrier for frontline staff and physicians who have all kinds of demands on their time.”
This was reiterated by another leader who had explained why the process modeling she had
started was not completed. “I think we’ve just got a little bit more work to do, that piece of
work for me has stalled just a tiny bit, not because of the mapping piece, but just because we
had just a whole bunch of other things come up.”
4.3.2.5 Connection to strategy. One of the purported benefits of BA is that an
organization can gain insight into the relationship between business objects. Specifically by
combining the BPMO Ontology with BPM it is possible to show the relationship between
processes and organizational strategy. Leaders who had been involved in the initiatives
undertaken to date realized this as a benefit to the organization. In the words of one leader: “
so that’s the really strong piece of the business architecture and that approach of looking at
the process and saying which processes are actually delivering value to the organization”.
In reference to the development of a strategy map at the portfolio level one leader made the
following observation. “We didn’t really know what our strategic business objective was.
We kind of did, so by identifying all that, now I can take all that work and say oh yes we are
actually moving the yardsticks towards that objective that we’re trying to achieve. So it was
helpful.” One leader spoke about how the artefacts could be used to show front line staff how
their work plan connected to the organization’s five year Strategic Plan. “The next steps
would be once we have that work plan finally finalized, right and then we decide on what are
the focus areas we’re going to take on, then it’s basic. Presenting it to the staff, to the
internal staff and showing them. This is what has developed in terms of work plan this is how
it all ties in and integrates with the Northern Health Strategic Plan.” Leaders who had been
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active participants in the development of business artefacts were more likely to be able to
make the connection between the business artefacts and the strategy of the organization.
4.3.2.6 Culture. The culture of an organization needs to be considered when
implementing these methodologies. The degree to which an organization is considered to be
a “learning organization” and whether there is a culture of “systems thinking” and
commitment to quality, all contribute to the success of these methodologies. Leaders spoke
to the organizational culture both from the perspective of the benefits of the current culture
and also the challenges of implementing change.
The “learning organization” concepts were evident based on responses from several
leaders within the organization indicating they would share their learning from their
participation in using the methodologies with other leaders within the organization. “And
now I’m going to tell another Executive Lead this is what we did, and they’ll be okay, they‘re
going to start and so it’s that use of it and that peer approach, peer promotion“. “Because I
have been lucky enough to be involved in the methodology for a couple of years now, I can
speak to a certain extent, the language. And sometimes I think I can and should and do take
the opportunity to try and explain it to my fellow clinicians in a way I think will make more
sense to them. I think the other contribution I make, as a leader, I really value the
methodology so I try to be a very good ambassador.” Willingness to accept the methodology
has been mixed but for the most part those who have engaged expressed they did gain value
from their participation as indicated in the previous sections.
Readiness of the culture within the organization to accept the new methodologies was
expressed by another leader. He felt the recent introduction of Business Owner Working
Groups charged with understanding the business functions and business requirements for
technology solutions has set the organization on a good path to incorporate these
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methodologies. “Business Owner Working Groups, I think we need to be opportunistic
because right now my read on the organization is that it is ready. That is like they’ve all
done good work, I saw it in a recent all-day conference a couple of days ago, it’s all right
there, so it’s low hanging fruit now to pick, organize and move it forward.”
There were also challenges to the introduction and acceptance of the methodologies
with leaders citing cultural issues such as: a reactive approach vs a proactive approach, and
ineffective planning processes. “We’re not going to get the big changes in healthcare that
we need if we just keep tweaking”. “I’m finding it really slow to get uptake actually because
I don’t know that we do much formal planning...We’re still very reactive.”
4.3.3

Analysis of language used in survey responses. A word count query of the

survey responses of leaders was compared to the survey responses of workshop participants.
The top twenty words accounted for 22.57% of the words in leaders’ responses and 21.83%
of the words in workshop participant responses. Looking at the top twenty words in each
query result showed that there were thirteen words or similar words on both sets of
responses. Looking at the top ten words in each query result showed six words or similar
words on both sets of responses. The top three words on responses from both sets of
interviews were the same. Think (think, thinks, thinking) was number one with a weighted
average of 3.1% by workshop participants and 2.88% by leaders. Process (process,
processing, processed) was second on both sets of surveys with a weighted average of 2.02%
by workshop participants and 1.42% by leaders. The third most frequent word used on both
was like (like, liked, likely, likes) with a weighted average of 1.37% by workshop

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participants and 1.33% by leaders. Table 11 provides a comparison of top twenty words in
leaders responses compared to workshop participant responses.
Interestingly, the respondents’ use of the word “think” could be interpreted as a
benefit or a challenge. If respondents use the word “think” to indicate uncertainty then it
could be perceived as a challenge since this usage indicated a lack of understanding of the
concepts included in the management approaches introduced. On the other hand if the
respondents used the word “think” to indicate these concepts are resulting in them revisiting
their assumptions about how services are being delivered this then would definitely be
considered a benefit. It is a benefit to any organization to have staff and managers think
critically about the processes being followed unless the status quo is already producing
excellent results and there is no change in the external environment. This is not the case in
any sector and particularly not true in healthcare. There is room for improvement in the
processes related to medication management as shown by the medication errors occurring
and the cost of delivering the service.

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Table 11. Word Count Comparison – Leaders and Workshop Participants

Workshop
Participants
Weighted Percentage
2.88
3.1
1.42
2.02
1.33
1.37
1.31
1.08
1.26
1.21
1.15
1.15
1.1
0.82
1.06
1.03
1.06
0.98
0.95
1.04
0.91
1.09
0.84
1.31
0.84
1.01
0.79
0.79
0.68
0.75
0.74
Leaders

Word
think (think, thinks, thinking)
process (process, processes, processing)
like (like, likes)
working (worked, work, works, working)
business
know (know, knows, knowing)
using (use, used, useful, using)
right
just
one (one, ones)
people
need (need, needs, needed)
things (thing, things)
get
map (map, maps, mapped, mapping)
really
model (model, models, modelled, modelling)
going
organization (organized, organizing, organize,
organization)
end (end, ended, ends)
yeah
medications (medication, medications)
well
manager (manage, managed, management, manager,
managers)
times (time, timely, timing, times)
efficient (efficient, efficiency, efficiencies)
make (make, makes, making)
Grand Total

0.73
0.71
1.3
0.89
0.68
0.63

21.83

0.86
0.69
0.84
22.57

There were twenty-three leaders interviewed, twelve had a clinical background and
eleven had a business background. The management approach introduced is based on a
collection of management, technology and quality improvement traditions as shown in Figure
2. Leaders with a business background would most likely have had exposure in their
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education with components of all these traditions while clinical leaders would most likely
have had minimal exposure to management and technology traditions in their clinical
education. Therefore, it was important to determine whether or not this difference in
foundational education between the two sub-groups would lead to a difference in words used
in responses to the interview questions. An additional analysis was conducted to identify
whether there was any evidence of a difference in responses based on foundational education
of the respondents. The result of the top twenty words in each category of leader showed that
the same eighteen words were in the top twenty words in the responses by both groups. This
result does not provide any evidence that the difference existed. Table 12 shows the results
of the comparison of the weighted average of the top twenty words between clinical leaders
and business leaders.

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Table 12. Word Comparison - Clinical and Business Leaders

Word
think (think, thinks, thinking)
process (process, processes, processing)
like (like, likes)
business
right
using (use, used, useful, using)
one (one, ones)
know (know, knows, knowing)
just
working (worked, work, works, working)
people
end (end, ended, ends)
area (area, areas)
get (get, gets, getting)
need (need, needs, needed)
map (map, maps, mapped, mapping)
organization (organized, organizing, organize,
organization)
things (thing, things)
model model, models, modelled, modelling)
understanding (understand, understanding)
artifacts (artifact, artifacts)
really
Grand Total

Clinical
Business
Leaders
Leaders
Weighted Percentage
2.68
2.6
1.57
1.4
1.43
1.26
1.36
1.69
1.25
1.26
1.17
1.21
1.17
0.89
1.1
1.15
1.01
1.07
0.99
1.37
0.88
0.84
0.88
0.86
0.82
0.82
0.85
0.81
0.89
0.75
0.82
0.74

1.03

0.72
0.69
0.67

0.78
1.09

21.51

0.72
0.85
22.63

4.4 Medication Management Process Reference Model
To be useful, a process reference model for medication management should be
generic enough for use as a starting point for the development of any health organization’s
process architecture. The proposed reference model for medication management resulting
from this research used the process meta-objects of the BPMO described in section 3.2.6.1.
The reference model created as part of this research includes one hundred and sixty-four
individual processes categorized in four process areas and twenty-five process groups.
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Process Area is defined as “the highest level of an abstract categorization of processes”.
Process Group is defined as “a categorization and collection of processes into common
groups”. Process is defined as “a set of structured activities or tasks with logical behaviour
that produce a specific service or product” (Rosing, Scheer, & Scheel 2015, p.102). The
process steps and process activities were not included in the process reference model as this
level of detail is context specific at an organizational and/or department level and could be
different for every organization.
Table 13 provides a comparison of LEAD process levels to APQC and SCOR process
levels.
Table 13. Comparison of Different Views of Process Levels
SCOR (Supply Chain

APQC Process

LEAD Process

Classification Framework

Levels

1

Category

Process Area

2

Process Group

Process Group

Level 1

3

Process

Process

Level 2

4

Activity

Process Step

Level 3

Process Activity

Level 4

Levels

5

Operations Reference
Model)

Adapted from Table 1 page 133 The Complete Business Handbook (von Rosing, Scheer & von Scheel, 2015)

A process can be categorized and tagged according to the role it fulfills within the
organization. There are three types of processes including: 1) core (or main) processes, 2)
supporting processes and 3) management processes. Process architectures including the
process reference model are designed based on the process type.
The core (or main processes) are defined as those processes that provide a service. In
the case of medication management this includes the processes provided at the point of care.

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The individual roles involved in main processes are the clinicians and care providers that
assess, diagnose, prescribe, dispense, administer, monitor and discharge patients.
The supporting processes support the delivery of the main processes. In the proposed
reference model, the support processes are categorized into two areas depending on whether
the processes were related to management of medication supply chain or provision of training
and education. The recipients of training and education include both staff and external
students who are placed in the organization as part of their formal education. A separate
grouping of these processes was deemed appropriate since they could be considered to be
either support or management processes depending on the recipient. The individual roles
involved in support processes are the pharmacy staff with respect to medication supply chain
and clinical pharmacist in respect to clinical education.
Management processes include administrative processes and the processes required to
manage the core and support processes. The process reference model for medication
management further categorizes these into nine groups based on the business function. The
individual roles involved in management processes are the Regional Director, Pharmacy
Managers, Anti-Microbial Stewardship Pharmacists, Drug Utilization Pharmacist and
Administrative Assistants.
The Process Areas and the Process Groups used in the reference model were derived
from the Value Chain described in section 4.1.3 and presented as Appendix 13. A total of
four Process Areas were identified. These are: 1) Manage Medication at Point of Care, 2)
Provide Clinical Training & Professional Development, 3) Manage Medication Supply Chain
and 4) Manage & Administrate. In addition, a total of twenty-five Process Groups were
identified Table 14.

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Table 14 Process Areas & Process Groups

Areas
Groups
1. Manage Medication at Point of Care
1.1 Register Patient
1.2 Assess Patient
1.3 Prescribe Medication
1.4 Dispense Medication at Point of Care
1.5 Administer Medication
1.6 Monitor Patient
1.7 Transfer or Discharge Patient
2. Provide Clinical Training & Professional Development
2.1 Provide Pharmacy Staff Training
2.2 Provide Clinical Pharmacy Competency Development
2.3 Provide Clinical Education(External to Pharmacy)
2.4 Manage Clinical Student Placement
3. Manage Medication Supply Chain
3.1 Source Medication
3.2 Maintain Medication Inventory
3.3 Mix & Repackage Medication
3.4 Distribute Medication
3.5 Return Medication
4. Manage & Administrate
4.1 Plan
4.2 Manage Risk
4.3 Monitor Compliance
4.4 Manage Contracts
4.5 Manage Human Resources
4.6 Manage Financial Resources
4.7 Manage Information
4.8 Procure & Maintain Equipment & Facilities
4.9 Provide Operational Oversight

Appendix 18 shows the Process Areas, Process Groups and the one hundred and
sixty-four Processes included in the proposed process reference model. Each of the
processes are associated with at least one business function. Appendix 19 provides a

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definition of each business function included in the business competency model. The source
of these definitions is an internal document of the host organization.
The identification of processes was achieved through review of the functions included
on the Business Competency Model for Medication Management Services (Appendix 12).
Each function was reviewed and the processes required to deliver the function were listed
and included in the process reference model. A single function may require numerous
processes to deliver it. Also, some processes can have a relationship with more than one
function. An example of this is the process to “monitor training effectiveness”. This process
is related to more than one function because the functions are separated based on the
recipient of the education. Figure 10 Relationship between Process Reference Model MetaObjects and Business ArtefactsFigure 10 shows the relationship between the Medication
Management Process Reference Model and the objects included on two business artefacts
Value Chain and Business Competency Model.

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Figure 10 Relationship between Process Reference Model Meta-Objects and Business Artefacts

Two approaches were taken in an effort to validate the completeness of the process
reference model. The first was to compare the listed processes to those listed in other
relevant reference models. The second was to review the initial draft of the process reference
model with the Regional Director of Pharmacy within the host organization. External
validation of the process reference model was not undertaken.

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Two relevant reference models were used for comparison: 1) SCOR reference model
(Supply Chain Council Inc., 2012) and 2) the APQC (PCF) Process Classification
Framework (American Productivity and Quality Centre (APQC), 2014). The reason these
two were used was because these are both open source. In addition, the SCOR reference
model could be closely aligned with the supply chain operations included in medication
management and the APQC PCF was intended to be used by health care organizations.
The SCOR is specific to supply chain operations and as such was used in respect to
the process area of Manage Medication Supply Chain. SCOR also includes management
processes which were included in the Manage and Administrate process area. The processes
included on the SCOR could be related to the processes in two process areas of the
medication management reference model. The four groups of Source, Make, Deliver and
Return from the SCOR model could be compared to the five groups on the medication
management reference model of Source Medication, Maintain Medication Inventory, Mix &
Repackage Medication, Distribute Medication and Return Medication. The remaining two
groups from the SCOR specifically Plan and Enable could be compared to the nine groups in
Manage & Administrate and three of the four groups under Provide Clinical Training &
Professional Development on the medication management reference model. The seven
process groups included in Manage Medication at Point of Care and one group from the
Provide Clinical Training & Professional Development could not be compared to the SCOR
model. Therefore it would appear that at the process group level all process groups from
SCOR can be found on the medication management reference model. The additional groups
included on the Management reference model are not supply chain specific so it is reasonable
they would not be on the SCOR model.

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APQC has developed numerous industry specific Process Classification Frameworks
(PCF) including one related specifically to the provision of health care. This PCF does not
differentiate pharmaceutical inventory management between centralized inventory or point of
care inventory which have different processes and specific legislated considerations.
Although it can be used as a general guide it was not specific enough for use as a medication
management process reference model.
The Regional Director of Pharmacy reviewed and accepted the process reference
model as a reasonable listing of the processes associated with medication management and
safety. Additional validation with other workshop members was anticipated but was not
undertaken prior to the completion of the research due to availability of workshop
participants.
4.5 Summary of Results
Chapter 4 included results in four areas: 1) medication management business
artefacts, 2) a completed BPM project in medication management, 3) thematic and
summative content analysis of interviews and 4) a proposed process reference model for
medication management. The comprehensive approach using BPM, BPMO and BA
represented in this research has yielded some interesting results. Despite some challenges,
both host organization participants and leaders acknowledge the benefits of the approach.
The business artefacts represent foundational documents which could be valuable knowledge
management and communication tools. They could help create a better understanding of
how medication management could be viewed from the perspective of value, business
competency and process. The AHP approach to prioritization of the improvement initiatives
could be useful in any service area in the healthcare organization. Knowledge from the
workshop and leader interviews could be used to modify and improve how BPM, BPMO and
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BA are introduced in other healthcare organizations. The proposed Process Reference Model
for Medication Management could be used by other healthcare organizations as they strive to
understand the processes related to medication management or introduce BPM.

126

5

Discussion and Conclusion

The primary intention of this research was to expand on the current body of
knowledge related to the introduction of a combination of BPM, BPMO and BA as a
comprehensive management approach to improve operational processes in a complex
adaptive system such as healthcare. This chapter consists of five sections which discuss
findings and conclusions derived from the research undertaken. The first section discusses
the impact of introducing three management disciplines; specifically, BPM, BPMO and BA
in a healthcare organization. The second section discusses the proposed medication
management Process Reference Model developed as part of this research. The third section
discusses the perceived challenges and benefits of using these three management disciplines
in the host organization. The fourth section presents the contribution of this research to the
current body of knowledge and potential avenues for future research and finally, the fifth
section provides concluding remarks on the research.
5.1 Integrating BPM, BPMO and BA in a Health Organization
BPM is a management discipline that has “process” as its focus and more specifically
end-to-end processes which often span business units and even organizational boundaries.
Medication management processes within a multi-facility healthcare organization were at the
centre of this research. Understanding the processes associated with medication management
and how those processes fit within the larger organizational context was explored, however,
no attempt was made to investigate processes outside the organizational boundaries of the
host organization. The established BPMO of LEADing Practice was employed to create a
shared language related to the process objects. The business artefacts presented in Chapter 4
included objects related to the process level in addition to objects related to value, business

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competency and services. The BPMO includes all these objects demonstrating it could be
effectively and successfully applied to industries such as healthcare.
There were four significant impacts realized from the introduction of BPM, BPMO
and BA in the host organization. The first was creation of knowledge assets in the form of
business artefacts to support improvement of medication management in the organization.
The second was the adoption of a common language that increases understanding across
organizational areas and facilitates improved communication. The third was establishment of
a repeatable process that would support creation of similar business artefacts in other
organizational service areas. The fourth was the changed perspective of the individual
participants which has led to their adoption of new approaches to service planning. This
comprehensive approach has led to development of business artefacts that increase
organizational knowledge which in turn results in an increase in organizational capacity
previously discussed in section 4.3.2.1. In reference to research question 1, this research
demonstrated how a business ontology used in other industries could be effectively applied to
healthcare services.
5.2 Proposed Process Reference Model
Research question 2 asked what processes should be included in a process reference
model for medication management applicable to both hospitals and long term care facilities.
The proposed Process Reference Model uses the BPMO of LEADing Practice. It could be
employed as a starting point in other healthcare organizations initiating a process architecture
as it is based on medication management processes which are relatively standard across
healthcare. The processes are derived from review of the medication management functions
(business competencies) included in the Business Competency Model and these are then
categorized into logical groups. The groups are then categorized into areas.
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A common approach to developing a process architecture is to separate the processes
into one of three types: core, support or management. These three types form Level 1 in the
architecture. The BPMO refers to this level as an area. The reference model developed in
this research has four areas: 1) Manage Medication at Point of Care, 2) Manage Medication
Supply Chain, 3) Manage and Administrate and 4) Provide Clinical Training and
Professional Development. The rationale for including the fourth area is the processes within
Provide Clinical Training and Professional Development do not align with only one process
type. There are processes within the area that could be considered to be support or
management. The clinical nature of medication education and clinician’s reliance on
education being provided by clinical pharmacists warranted it as an area on its own. This
area also includes a process group related to training of students and residents from academic
institutions who complete practicums in the host organization facilities.
5.3 Challenges and Benefits
This section summarizes the perceived challenges and benefits of using BPM, BPMO
and BA in a healthcare organization. It addresses three of the five research questions from
Chapter 1.
3) What performance measurements in addition to medication errors are appropriate
for monitoring and controlling medication management?
4) How can BPM be effectively applied to a situation that involves multiple sites and
multiple business units responsible for Medication Management functions?
5) What are the benefits and challenges of using BPM and Business Ontology to
improve Medication Management?

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In response to question 3, the Measurement Working Group (MWG) identified
ninety-one key performance indicators and process performance indicators they considered
appropriate for monitoring and controlling medication management. The full listing is shown
in Appendix 7. Examples of measures related to monitoring include measures of compliance
with known procedural steps to prevent a medication error such as: “percentage of orders
compliant with Safe Medication Order Writing Policy” and “percentage of medications
infused through Medication Drug Library”. Examples of measures related to controlling
include: “cost of expired drugs” and “number of average turns of inventory”. The MWG
participants identified eighteen of these indicators that were thought to be relevant at the
executive level given the relationship of those indicators to the current organizational
strategy and directions. A listing of these indicators are provided in Table 10.
In response to question 4, it is the inclusion of BPMO and BA combined with BPM
that enabled the adoption of BPM across the multiple sites and business units. Despite the
challenges, the workshop participants developed business artefacts and a process architecture
that incorporated all sites and business units within the host organization. The full lifecycle
of BPM was not achieved in this research due to time constraints and availability of
resources. However, implementation of BPMO and BA of medication management
processes was achieved. Organization wide business artefacts were created and development
of a process architecture for medication management was accomplished. Table 15 shows the
stages of the BPM life cycle and comments on specific aspects achieved during the research
period.

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Table 15 Comments on Stages of BPM Lifecycle

Stage

Comments

Process Identification

Initial phase includes identifying processes and relationships
which lead to development of a process architecture. In
addition this phase includes identification of process
performance measures. Both these objectives were achieved
as shown by the Medication Management Process Reference
Model and the Performance Management Plan

Process Discovery

Achieved through the development of current state ‘as is’
modeling using BPMN. Selected medication management
processes prioritized for improvement have been modeled as
part of this research.

Process Analysis

Achieved as shown by the ranking of maturity levels and
identification of improvement initiatives. The prioritized list
of initiatives is shown in the Appendix 16.

Process Redesign

Partially completed as described by the example provided in
Chapter 4 and the design of a medication reconciliation
process currently being implemented.

Process Implementation

Minimally with a few examples available where the process
redesign was implemented including the process for training
on the infusion pumps, development of medication order sets
and process for establishing inventory levels.

Monitoring & Controlling

Minimally due to the challenges related to developing the
collection mechanism for the metrics.

In response to question 5, results reported in Chapter 4 revealed organization leaders
and workshop participants perceived both challenges and benefits in using BPM, BPMO and
BA. The responses were themed into six categories: Capacity Building, Communication,
Collaboration, Competing Priorities, Connection to Strategy and Culture. Some of the
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identified challenges related to the concepts themselves while others related to the process
used to introduce the concepts. One recurring concern was that the process followed was
inadequately resourced resulting in a longer than ideal timeframe to complete the work. This
was a legitimate challenge as all members of the working group were contributing to the
work on an ‘as time permitted basis’. However, for most participants it was seen to be a
worthwhile undertaking and they were actively engaged in the development of business
artefacts.
There were important lessons learned from introducing BPMO in the healthcare
sector. The use of language, in other words, how the concepts related to BPMO are
communicated, must resonate with those involved with the work. In this case, the use of
terms such as ‘competency’ and ‘business area’ were not intuitively understood or accepted
by clinicians in the host organization and became contentious. Further investigation revealed
that healthcare clinicians in a publicly funded healthcare organization do not perceive
themselves to be ‘in business’ which contributed to their resistance and reluctance to describe
their clinical work as a ‘business area’. Similarly, there is a significant focus in the clinical
world on personal competency to safely and effectively deliver specific treatments or
interventions.
Notwithstanding the issue with ‘competency’, there was no difficulty observed with
the BPMO language related to the objects introduced from the other business layers. One
example is the group’s rapid adoption of the terms ‘strategic business objective’, ‘critical
success factor’ and ‘key performance indicator’ including freely referring to these in the
corresponding acronyms SBOs, CSFs and KPIs.
Worthy of note in assessing the benefits and challenges of this approach, was the
emphasis placed on ‘thinking’ by both interview groups. The benefit of stimulating non132

traditional thinking and approaches in the health care sector was that the organization was
able to achieve results and perspectives hitherto unattainable. Without this fundamental
change in ‘thinking’ that this approach generated, it is doubtful that notable benefits would
have been realized.
There are benefits both to the organization and to the workshop participants resulting
from the research. The AHP approach to prioritize the identified improvement initiatives
was effective and the process can be used in other organizational areas needing to prioritize
improvement initiatives. The business artefacts can be reused for numerous purposes
including employee orientation, monitoring of performance, alignment of activities to
strategic objectives, business planning and other activities where organizational knowledge
related to medication management is required. This research has built capacity within the
organization and set the stage for future process improvements in medication management.
The research participants were provided with the opportunity to develop business
artefacts and contribute their clinical knowledge to advance the information assets of the
organization. The discussions and information sharing provided a rare opportunity to look at
the clinical work from a different perspective.
5.4 Contribution and Future Research
There are three notable contributions arising from this research. The first relates to
the increase in organizational knowledge and understanding of the medication management
process within the host organization, the second is the development and documentation of a
process reference model for medication management and the third is the demonstration that a
comprehensive management approach combining BPM, BPMO and BA can be achieved in a
healthcare organization. The fundamental catalyst in achieving these results was the
stimulation of non-traditional thinking.
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This research and non-traditional thinking has led to, and continues to support,
transformative change in both individuals and the organization. It has been a journey of
discovery for those involved in the research, it has armed them with a new language, new
lines of communication and new vision to see their organization and how it functions.
Healthcare has been slow to adopt new management practices and this holistic approach
supports mindful and deliberate change. It provides powerful linkages between day to day
work of the individuals on the front lines with the overall organization’s strategies and goals.
The recipients of healthcare services are the ultimate beneficiaries of improvements in the
healthcare system.
Further research is recommended, specifically in the following two areas:
1) Expanding the breadth and depth of the use of this comprehensive management
approach in healthcare. It is recommended that research be undertaken to:


Test and validate the medication management process reference model in
other organizations;



Complete a longitudinal research study by repeating the interview process
with organizational leaders in the host organization one year out and two
years out to identify to what degree the potential benefits were realized
and/or challenges overcome; and,



Expand use of the comprehensive approach to other end-to-end healthcare
processes.

2) Explore the challenges associated with clinicians viewing their practice from a
business perspective.

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5.5 Concluding Comments
Despite the challenges identified, the host organization has embraced the
comprehensive management approach of using BPM, BPMO and BA to improve services.
Process identification is currently underway in three other end-to-end processes within the
host organization: 1) A redesign of home support services that will improve care to clients
and more closely align home support services with primary care in the organization, 2)
Design and implementation of a family practice twenty-five bed inpatient unit, and 3)
Improvement and standardization of the inpatient registration process with the desired
outcome of improving data quality and information flow.
On a personal note, I would say leading any organization through adoption of a
comprehensive approach such as this is not for the fainthearted. The benefits however, far
outweighed the challenges. I was provided with an exceptional opportunity to contribute to
the body of knowledge related to transferring management approaches from other industries
into the healthcare sector and at the same time increase the knowledge assets of the host
organization.

135

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Appendices

Appendix 1. Listing of Ontologies
Ontology Name
Business Ontology

Brief Description
References
The Business Ontology is a
von Rosing, M., & Laurier,
foundational ontology
W., (2015), An
applicable to various domains.
Introduction to the
It defines basic notions like
Business Ontology,
objects, relations, structure,
International Journal of
arrangements and so on. It
Conceptual Structure
provides a meta model of a
and Smart Applications,
conceptual schema with a
3, : 20-41
system of meta-level
categories. Providing real-word
enterprise semantics for
von Rosing, Zachman, J.
general enterprise modelling
(2017). The Need for a
languages. It was designed in
Role Ontology.
collaboration between
International Journal of
academics and industry
Conceptual Structures
practitioners
and Smart Applications.
Volume 5, Issue 1

BPM Ontology

The BPM Ontology is a
domain ontology based on the
business ontology by
specializing the terms to
process concepts introduced in
the core-reference ontology. As
a domain ontology, the BPM
Ontology could be linked to a
specific application or task.
Described as a business
conceptual ontology that
provides a shared language for
those involved in the financial
industry. It was developed
through collaboration of
vendors and members of the
financial industry.
Based on a conceptual
accounting framework and
used in development of
accounting systems. The

FIBO – Financial Industry
Business ontology

REA – Resource Event
Actor Business Ontology

von Rosing, M., Scheer, A.
W., von Scheel, H., (2015)
The Business Process
Management Handbook.
Boston: Morgan
Kaufmann. doi:10.1016/
B978-0-12-7999593.00007-0
http://www.edmcouncil.or
g/financialbusiness

O’Leary, D.E. (2010)
Enterprise ontologies:
Review and an activity
theory approach,
154

original REA ontology
included core economic
phenomena of exchanges,
resource-agent dependencies,
resource dependencies, agent
dependencies and
commitments. REA continues
to be developed and has
become embedded in some
software standards.

International Journal of
Accounting Information
Systems, 11: 336-352
Geerts, G.L. (2000) The
Ontological Foundation of
REA Enterprise
Information Systems
retrieved March 28 from
https://www.researchgate.n
et/profile/Cheryl_Dunn/pu
blication/228583572_The_
ontological_foundation_of
_REA_enterprise_informat
ion_systems/links/5425839
20cf238c6ea7411b7.pdf

SBMO Strategic Business
Model Ontology

The focus of the ontology is on
the goals of the business which
is in contrast to the other
business model ontologies that
focus more on the value
creation and participants within
business

TOVE – Toronto Virtual
Enterprise

This is a formal ontology with
the capability of describing
enterprise in general. It is
made up of a set of 13 sub
ontologies as follows:
Activity, Time, Cost, Resource
Inventory, Quality,
transportation, Manufacturing
Resource, Order,
Organizational, Manufacturing

TEO - The Edinburgh
Enterprise Ontology

The Edinburgh group has
developed an ontology that can
be used to describe enterprises
generally and can also be used

Samavi, R., Yu, E. and
Topaloglou, T. (2009)
Strategic Reasoning about
business models: a
conceptual modeling
approach, Information
Systems and e-Business
Management, 7:171-198
Osterwalder, A., (2004)
The Business Model
Ontology A Proposition in
a Design Science
Approach retrieved March
25 from
http://www.uniempre.org.b
r/userfiles/files/TheBusinessModel-Ontology.pdf
O’Leary, D.E. (2010)
Enterprise ontologies:
Review and an activity
theory approach,
International Journal of
Accounting Information
Systems, 11:336-352
Osterwalder, A., (2004)
The Business Model
Ontology A Proposition in
a Design Science
155

to specify software system
requirements. This ontology
has been described as being
less formal then TOVE.

BFO – Basic Formal
Ontology

e3Value

Business Model Ontology

HL7 – Health Language 7

BFO is an upper level ontology
widely used in the healthcare
domain. It consists of many
sub ontologies which are
divided into two categories:
continuant and occurrent.
Continuant (snapshot or point
in time) or occurrent (process
which occurs over time).
Focus is e-commerce and is
based on Value creation. It
supports a high level
perspective and includes Actor,
Value Object, Value Transfer,
Value Port and Value
Interface. These core building
blocks are then used to
represent value chains.
Business Model Ontology that
is built on nine building blocks
within four areas. The four
areas are: Product, Customer
Interface, Infrastructure
Management and Financial
Aspects, The nine building
blocks are: Value Proposition,
Target Customer, Distribution
Channel, Relationship, Value
Configuration, Capability,
Partnership, Cost Structure and
Revenue Model
Service oriented architecture
healthcare ontology which

Approach retrieved March
25 from
http://www.uniempre.org.b
r/userfiles/files/TheBusinessModel-Ontology.pdf
O’Leary, D.E. (2010)
Enterprise ontologies:
Review and an activity
theory approach,
International Journal of
Accounting Information
Systems, 11:336-352
Blobel, B., Goossen, W., &
Brochhausen, M., (2014),
Clinical modeling-A
critical analysis,
International Journal of
Medical Informatics 83:
57-69
Pombinho, J., Aveiro, D.,
& Tribolet, J. (2014) A
Matching Ontology for
e3Value and DEMO A
sound bridging of Business
Modelling and Enterprise
Engineering
Osterwalder, A., (2004)
The Business Model
Ontology A Proposition in
a Design Science
Approach retrieved March
25 from
http://www.uniempre.org.b
r/userfiles/files/TheBusinessModel-Ontology.pdf

(HL7) Health Level Seven
International (2015) About
156

ARIS – Architecture of
Integrated Information
Systems

SAP – Shape Acquisition
and Processing

Table 16 Listing of Ontologies

focuses on electronic
information exchange. Health
Level Seven International is a
standard setting organization
that focuses on setting
standards that enable exchange,
integration, sharing and
retrieval of electronic health
information
Enterprise ontology consisting
of 12 classes Function,
Organizational Unit Human
output, goal, event, application
software, output, input,
environmental data, event,
hardware, and machine

HL7, accessed January
2016 from
http://www.hl7.org/about/i
ndex.cfm?ref=nav

Scheer, AW, (1998b)
Business Process
Engineering, Berlin
Springer Verlag, as cited
by O’Leary, D.E. (2010)
Enterprise ontologies:
Review and an activity
theory approach,
International Journal of
Accounting Information
Systems, 11: 336-352
Commercial based and
O’Leary, D.E. (2010)
provides an extensive
Enterprise ontologies:
vocabulary to be used in the
Review and an activity
SAP enterprise software. It has theory approach,
been compared to REA.
International Journal of
Accounting Information
Systems, 11:336-352

157

Appendix 2. Interview Guide for NH Leaders
Interview guide: Post development of Business Architecture Artefacts:
1.

Have you been involved in the development of any of the following artefacts:
a.
Strategy Map,
b.
Business Model
i.
Value Chain
ii.
Accountability Model
iii.
Operating Model
iv.
Performance Model
2.
Was the artefact developed for an organizational business area or for an endto-end process within the organization?
a.
Which area or process?
3.
How confident are you that each of the artefacts is complete and appropriately
represents the organizational business area or end-to-end process for which it was
created?
4.
What benefits, if any, do you think these artefacts have for the organization?
5.
Are the artefacts helpful in increasing your understanding of how the overall
organization is structured?
6.
Do the artefacts provide insight into where improvement efforts should be
directed?
7.
Does the Performance Model assist you in understanding or communicating
with others how the day to day processes are contributing to the realization of the
organizations strategy?
8.
What did you find useful about your participation in this activity?
9.
Do you have any suggestions on how the process could have been improved?
10.
What would you suggest as next steps in the communication or use of
business architecture artefacts within the organization?
11.
Are there any additional comments you would like to make in respect to the
development or use of Business Architecture within Northern Health?

158

Appendix 3. Interview Guide for Study Participants
Interview guide: Post development of the medication management process model:
1. Have you been involved in the development of the end-to-end process model for
medication management? What role did you play?
2. Are you aware of the performance measures being reported within the organization in
respect to medication management? How confident are you that the current performance
measures being reported for medication management are appropriate? Why?
3. How confident are you that the medication management practices in your facility
minimize the risk of medication errors? What changes do you think would further reduce
the risk of medication errors?
4. Do you think documented processes would be helpful in reducing errors related to
medication management? How?
5. How important is it for process to be both effective (achieve what it was intended to
achieve) and efficient (deliver quality at lowest cost)?
6. What are your thoughts on the efficiency of the medication management process in
your facility?
7. Do you have any suggestions on how the process could be made more efficient?
8. The medication management process spans several organizational departments. What
challenges do you perceive exist in developing an end-to-end process model for processes
such as medication management that span multiple departments?
9. How important do you perceive the need for standard processes to be in respect to
the medication management process?
10. Are there any additional comments you would like to make in respect to the
development or use of the end-to-end process model for medication management?

159

Appendix 4. Workshop Participant Information Letter and Consent Form

Date _________________________________
Incorporating Business Process Management and Business Ontology to Improve Medication
Management Safety and Quality
Project Lead: Bonnie Urquhart
University of Northern British Columbia
Prince George, BC V2N 4Z9
e-mail Urquha2@unbc.ca and/or (250) 565-2493

-

I am conducting a research study that will explore how Business Process
Management and Business Ontology can be incorporated into an approach to
improve medication management safety and quality. This research study is
undertaken in partial fulfillment of the requirements of my Doctorate of Philosophy
(PhD) in Health Sciences from the College of Arts, Social and Health Sciences at the
University of Northern British Columbia. The application for research regarding this
study has been reviewed by the Research Ethics Board of both UNBC and Northern
Health.
I will be carrying a dual role during the study, one as the researcher and the other as
Regional Director of Planning and Performance Improvement. My role in respect to
this study will be to facilitate information sharing related to Business Process
Management and Business Ontology with staff and physicians as well as collect
participants perspectives on the barriers and benefits of this approach to support
quality and process improvement. All necessary steps will be taken to manage any
potential conflict of interest arising from my dual role as researcher and Regional
Director, Planning and Performance Improvement
Purpose of Project

Northern Health has committed to improve medication management safety and
quality. An oversight governance committee, Medication Safety and Quality
Committee (MSQC), has been formed under the leadership of Dr. Dana Cole,
Regional Director Pharmacy Services. Members of the MSQC as well as members
of the working groups reporting to that Committee will be invited to participate in this
study along with staff that engaged in one or more of the quality improvement
projects endorsed by the Committee during the period of this study.
Two workshops are planned as part of the study. Workshop invitees will include
members of the MSQC as well as subject matter experts leading working groups
reporting to the MSQC.
160

What will happen during the study?

Your participation will consist of attendance at one or two of 3 to 4 hour workshops
to be held at a Northern Health site.

The first workshop will be used to review and validate business
artefacts related to medication management in Northern Health. The
business artefacts to be validated include business competency models,
strategy maps, performance models, operating models and an end-to-end
process model for medication management. The first workshop will also
include orientation and introduction to Business Process Management,
business ontology and the business artefacts currently in use in Northern
Health.

The second workshop will be used to identify, prioritize, select,
sequence and assign quality and process improvement projects related to
medication management safety and quality.
You are not obligated in any way to participate in this study. Your participation in the
research is strictly voluntary. Participation will consist of your participation in one or
more workshops where medication management relevant business artefacts will be
developed and specific processes for improvement will be identified. Given the
nature of workshops and group participation confidentiality of the opinions and
information you share during the workshop(s) cannot be assured. At no time will any
specific comments be attributed to an individual in any report out of this study
without prior consent of that individual. The study report will include the business
artefacts derived from the workshop and will also include a record of the process
used to rank the medication management processes selected for improvement
projects.
In addition to these two workshops two sets of interviews will be conducted as part of
this study.

The first group of interviewees will be individuals who have
participated in a quality improvement project during the duration of this
study.

The second group will be senior leaders within Northern Health
who have had an opportunity to develop or review business artefacts
using the Layered Enterprise Architecture Design standards for
business architecture.
These interviews are currently planned to be held in May to June of 2017. A
separate information letter and consent form will be provided should you fit the
selection criteria for either of the interview groups.
Risks or benefits to participating in the project

161

I do not anticipate that there will be any personal benefit or risk to participants in this
study. The interviews will be conducted during your regular worked hours and the
interview time will be included in your regular compensation.
Physician time will be compensated based on Northern Health practices related to
physician time spent on quality improvement initiatives.
I anticipate that results from this study will benefit Northern Health and the academic
community at large by providing insight into the barriers, benefits and challenges of
using Business Process Management and Business Ontology in addressing safety
and quality in the healthcare system overall and more specifically in the area of safe
and high quality medication management services.
Study Results

I will be submitting a final report on the study to UNBC as well as sharing the result
of the study within Northern Health. I may also pursue academic publication of
portions of the study in relevant academic journals or present results at academic or
health related conferences.
Questions or Concerns about the project

If you have any questions regarding this study or your participation please contact
the Project Lead at the email address or phone number at the top of this document.
If you have any concerns or complaints about your rights as a research participant
and/or your experiences while participating in this study, contact the UNBC Office of
Research at 250-960-6735 or by e-mail at reb@unbc.ca.

162

Participant Consent and Withdrawal – Workshop Participants
CONSENT
I have read or been described the information presented in the information letter about the
project:
YES

NO

I have had the opportunity to ask questions about my involvement in this project and to receive
additional details I requested.
YES

NO

I understand that if I agree to participate in this project, I may withdraw from the project at any
time up until the report completion, with no consequences of any kind. I have been given a copy
of this form.
YES

NO

I agree to be recorded (if applicable).
YES

NO

I agree that my name can be used (if applicable).
YES

NO

Follow-up information can be sent to me at the following e-mail address:
Email: _____________________________________________________
YES

NO

Signature (or note of verbal consent):
Name of Participant (Printed):
Date:

163

Appendix 5. Interview Information Letter & Consent Form
Information Letter / Consent Form for Interviewees
Date ________________________________
Incorporating Business Process Management and Business Ontology to Improve Medication
Management Safety and Quality
Project Lead: Bonnie Urquhart
University of Northern British Columbia
Prince George, BC V2N 4Z9
e-mail Urquha2@unbc.ca and/or (250)613-5581

-

I am conducting a research study that will explore how Business Process
Management and Business Ontology can be incorporated into an approach to
improve medication management safety and quality. This research study is
undertaken in partial fulfillment of the requirements of my Doctorate of Philosophy
(PhD) in Health Sciences from the College of Arts, Social and Health Sciences at the
University of Northern British Columbia. The application for research regarding this
study has been reviewed by the Research Ethics Board of UNBC and Northern
Health.

Purpose of Project

Managers and healthcare practitioners are responsible to provide safe, effective and
efficient service to their patients. Services such as medication management span
numerous providers and organizational groups. It is proposed that having a shared
understanding of end-to-end process and being able to connect the individual
processes to the larger system of services could facilitate quality improvement and
identification of technical efficiencies within a healthcare organization.
This study will specifically focus on the end-to-end process of medication
management in Acute Care and Long Term Care facilities. The study will explore
the benefits & challenges of using Business Ontology and Business Process
Management in a multi-site geographically dispersed healthcare organization.
Northern Health has committed to improve medication management safety and
quality. An oversight governance committee, Medication Safety and Quality
Committee (MSQC), has been formed under the leadership of Dr. Dana Cole,
Regional Director Pharmacy Service. Members of the MSQC as well as members of
the working groups reporting to that Committee will be invited to participate in this
164

study along with staff that engaged in one or more of the quality improvement
projects endorsed by the Committee during the period of this study. I have been
invited to sit in on MSQC meetings as a non-voting member.
Your Participation
You are being invited to participate in this project because you have participated in a
quality improvement project in medication management or you are one of the senior
leaders within Northern Health who have had an opportunity to develop or review
business artefacts using the Layered Enterprise Architecture Design standards for
business architecture.
What will happen during the project?

Participation will consist of one audio taped interview with the principal investigator
(Bonnie Urquhart). It is anticipated that the interview will take between 30 and 60
minutes of your time. The interview will be conducted during your regular scheduled
worked hours. The audio tapes will be transcribed by me as the researcher or by a
transcriptionist who has signed a confidentiality agreement. Any expense in hiring of
a transcriptionist will be paid by me as the principal researcher. The transcribed
information will be analyzed to identify barriers and benefits of incorporating
Business Process Management and Business Ontology to support improvements in
medication management safety and quality.
You are not obligated in any way to participate in this study. Your participation in the
research is strictly voluntary. Anonymity cannot be guaranteed.
All data collected, including the audio tapes of the interviews and the transcribed
data will be kept secured in a locked cabinet during the study period and destroyed
upon completion of the study and acceptance of the final report by UNBC. Data
collected from your interview will not be made available to anyone other than the
transcriptionist or me. All comments will be treated as confidential information and
any quotes used in the final report will not include identifiable data. If you participate
in the study and subsequently decide to withdraw prior to the acceptance of the final
report by UNBC the data collected from your interview will be removed from the
report and destroyed within 30 days of your notification to me of your decision to
withdraw.
Risks or benefits to participating in the project

I do not anticipate that there will be any personal benefit or risk to participants in this
study. The interviews will be conducted during your regular worked hours and the
interview time will be included in your regular compensation.
I anticipate that results from this study will benefit Northern Health and the academic
community at large by providing insight into the barriers, benefits and challenges of
165

using Business Process Management and Business Ontology in addressing safety
and quality in the healthcare system overall and more specifically in the area of safe
and high quality medication management services.
Potential Conflict of Interest
In addition to my role as Principal Investigator on this study I hold the position of
Regional Director, Planning and Performance Improvement in Northern Health. In my role
as Principal Investigator I will be responsible for conducting workshops and interviews in
addition to creating and reviewing documentation and business artefact related to the
medication management processes within Northern Health. The content of the
documents will be provided by staff and physicians within Northern Health who are
directly involved in medication management processes or have participated in quality
improvement projects related to medication management processes.
In my role as Regional Director, Planning and Performance Improvement I may also, as
time permits, participate in medication management quality improvement projects during
the study.
All necessary steps will be taken to manage any conflict of issues arising from my role as
Principal Investigator and Regional Director, Planning and Performance Improvement.

Study Results

I will be submitting a final report on the study to UNBC as well as sharing the result
of the study within Northern Health. I may also pursue academic publication of
portions of the study in relevant academic journals or present results at academic or
health related conferences.
Findings from this study will be made available to all participants. If you are
interested in receiving a copy of the final report please contact me via email and I will
provide you with a copy of the final report.
Questions or Concerns about the project

If you have any questions regarding this study or your participation please contact
the Project Lead at the email address or phone number on the first page.
If you have any concerns or complaints about your rights as a research participant
and/or your experiences while participating in this study, contact the UNBC Office of
Research at 250-960-6735 or by e-mail at reb@unbc.ca.
Participant Consent and Withdrawal

166

Taking part in this study is entirely up to you. You have the right to refuse to
participate in this study. You have the right to refuse to answer any questions that
make you feel uncomfortable. If you decide to take part, you may choose to pull out
of the study at any time before the acceptance of the final report by UNBC without
giving a reason and without any negative impact on your employment with Northern
Health.
CONSENT
I have read or been described the information presented in the information letter about the
project:
YES

NO

I have had the opportunity to ask questions about my involvement in this project and to receive
additional details I requested.
YES

NO

I understand that if I agree to participate in this project, I may withdraw from the project at any
time up until the report completion, with no consequences of any kind. I have been given a copy
of this form.
YES

NO

I agree to be recorded (if applicable).
YES

NO

I agree that my name can be used (if applicable).
YES

NO

Signature (or note of verbal consent):
Name of Participant (Printed):
Date:

167

Appendix 6. Workshop Attendance Log
Position Title
Regional
Director
Pharmacy
Chief Operating
Officer Northern
Interior
Director,
Clinical
Information
Systems
Chief Medical
Information
Officer and
Family
Physician
Regional
Medication
Safety Officer
Regional
Medication
Safety &
Informatics
Pharmacist
Director
Inpatient and
Restorative
Services
Pharmacy
Manager
Northeast
HSDA
Administrative
Assistant to
Regional
Director
Pharmacy
Director of Care
Fort St. John
Hospital
Chief Nursing
Officer, Lead
Professional

Professional
Background
Pharmacist

Consent
on file
Yes

Dec 8

Dec 15

Jan 24

Interviewed

Yes

Yes

Yes

Yes

Nurse
Executive

Yes

Yes

Yes

Declined

No

IT
Administrati
on

Yes

Yes

Yes

Yes

No

Physician

Yes

Yes

Yes

Declined

No

Nurse

Yes

Yes

Yes

Yes

Yes

Pharmacist

Yes

Yes

Yes

Yes

No

Nurse

Yes

Yes

Declined

Declined

No

Pharmacist

Yes

Yes

Yes

Declined

Yes

Administrati
on

Yes

Yes

Yes

Declined

No

Nurse

Yes

Yes

Declined

Declined

Yes

Nurse

Yes

Yes

Declined

Yes

No

168

Practice
Strategy
Professional
Practice Leader
Clinical
Pharmacy
Services
Medication Use
Management
Pharmacist
Antimicrobial
Stewardship
Pharmacist
Health Service
Administrator
FSJ Hospital
Process
Architect
Process
Architect
Pharmacy
Manager
University
Hospital of
Northern BC
Regional
Manager, Risk
and Compliance
Regional
Medication Use
Management
Pharmacist
Regional
Manager
Pharmacy
Solutions
Lead, Regional
Quality
Processes

Pharmacist

Yes

Yes

Yes

Yes

Yes

Pharmacist

Yes

Yes

Declined

Yes

No

Pharmacist

Yes

Yes

Yes

Yes

Yes

Nurse

yes

Yes

Declined

Declined

Yes

Business

Yes

Yes

Yes

Yes

Business

Yes

Yes

Declined

Yes

Pharmacist

Yes

Yes

Declined

Declined

Not
Asked
Not
Asked
No

Risk
Yes
Management

Yes

Yes

Yes

Yes

Pharmacist

Yes

Yes

Declined

Declined

Yes

IT

Yes

Yes

Yes

Yes

Yes

Business

Yes

Yes

Yes

Yes

Yes

Table 17 Workshop Attendance Log

169

Appendix 7. List of Recommended Performance Measures
# of physician specific order sets;
% of compliance with privacy and confidentiality audits
# of active order sets that are up to date
# of average turns of inventory
# of clinical pharmacy hours per 100 inpatient days
# of facilities meeting National Association of Pharmacy Regulatory Authorities (NAPRA) standards
# of interventions per hour clinical pharmacist time
# of IV to PO step down interventions
# of Medication Utilization Reviews Completed Annually
# of Medication Utilization Reviews Completed Annually for AMS;
# of anti‐infective Drug Therapy Problems resolved per inpatient admission
# of CQI projects completed that identified and realized efficiency gains
# of identified Drug Therapy Problems per 100 inpatient admissions
# of medical students receiving clinical education during their 3rd year rotation
# of medication doses administered in error per PSLS resulting in harm level greater than or equal
to level 3 harm
# of pharmacy residents in NH
# of pharmacy technician students receiving education annually
# of regional order sets;
# of resolved drug therapy problems per 100 outpatient visits
# of resolved drug therapy problems per 100 resident days
# of Resolved DTPs per 100 inpatient admissions
# of staff who have had a performance review in past 24 months
# of Patient assessments completed by pharmacists or pharmacy technician
# of site specific order sets
# of incident reports of staff exposure
% of facilities with infusion pumps meeting established standard
% of identified critical processes with process maturity level 3 or above
% of Interventions accepted in prospective audit and feedback regarding antibiotics
% of IV medications infused through MDL
% of meds delivered late per PSLS reports
% of meds dispensed in unit dose format including ward stock
% of meetings where all NH representatives attended
% of nursing units with narcotic and controlled drugs stored in AMDCs
% of alignment NH formulary to Provincial formulary
% of discrepancies (requiring intervention) found after/during medication reconciliation
% of documented processes with Standard Operating Procedures
% of facilities dispensing patient specific medications on 24 hour batch
% of formulary reviews completed by NH
% of individuals expected to complete SMOW education who have taken SMOW
% of internal shipping errors

170

% of medication errors while AMDC on override
% of medication orders entered accurately as assessed by pharmacist at verification
% of medications accessed through AMDC on over‐ride
% of nurses who have completed SMOW education module
% of oral to IV of high bioequivalent
% of orders clarified by Pharmacist ( not therapeutic interchange)
% of patients educated on Medications by a pharmacist
% of patients with medication therapy plan documented as part of "care plan" (longitudinal plan)
% of pharmacists who have completed SMOW education module
% of pharmacy technicians who have completed SMOW education module
% of physicians who have completed SMOW education module
% of staff/physicians accessing education opportunities
% of unit clerks who have completed SMOW education module
% of VTE audits where patients received appropriate prophylaxis
% of oral solid meds with bar code on unit dose packaging;
% of patients with Medication Reconciliation Completed within 24 hours of admission
% of Patients with Medication Reconciliation Completed at Discharge
% of patients with medication therapy plan documented as part of "plan of care" (episodic plan)
% of products with appropriate Beyond Use Dating according to NAPRA standards
Actual inventory value or estimate based on Value on Hand reported in Cerner for all NH
Pharmacies
Average Length of Stay per acute inpatient admission
Average Turnaround time of medications from order scan to release of medication (Pyxis)
Cost of antimicrobials per 100 inpatient days
Cost of expired drugs as % of inventory cost
Cost of expired drugs as percentage of drug budget
Cost of expired drugs for credit
Cost of expired drugs not for Credit as a % of inventory
Cost of expired drugs not for credit as a % of total expired drugs
Cost of expired drugs not for credit in pharmacy inventory
Cost of IV antibiotics per 100 inpatient days
Cost of oral antibiotics per 100 inpatient days
Defined Daily Dose (DDD) per 100 patient days for targeted antibiotic
Door to needle time for thrombolytic
Drug Cost per 100 inpatient days
Drug cost per 100 resident days in LTC facilities (non Plan B)
Drug Costs per inpatient day
High cost antineoplastic drug utilization in pharmacy
Order entry average time per pharmacy department (% variance from benchmark)
Rate of discrepancies from best practice identified during pharmacy audit of narcotics books
Reported patient satisfaction on medication education provided
Reported patient satisfaction with pain management during hospital stay
Student Satisfaction Survey

171

Time of antibiotic administration from ordering
Total Cost of Expired Drugs
Turnaround time of internal medication inventory transfers based on established benchmark
standards.
Work life Survey ‐ level of satisfaction
% of orders compliant with Safe Medication Order Writing (SMOW)
# of pharmacist clinical training weeks provided
% of pharmacists who meet competency measures for clinical pharmacy
% of reported errors per orders entered as per PSLS reports
Order verification average time per pharmacy department (% variance from benchmark)
Table 18 Complete List of Suggested Measures

172

Appendix 8. Meta Model of Understanding

Figure 11. Meta Model of Understanding

173

Appendix 9. Strategy Map
Medication Management Strategy Map
Organization Strategic Business Objective
Medication Management Strategic Business Objective
Medication Management Critical Success Factor
Medication Management Key Performance Indicator
Improve Clinical Outcomes
1.0 Improve Clinical Outcomes
1.1 Ensure medication reconciliation at all transitions in care
% of discrepancies (requiring intervention) found after/during medication
reconciliation
% of patient with Medication Reconciliation completed within 24 hours of
admission
% of Patients with Medication Reconciliation Completed at Discharge
1.2 Improve communication of medication care plan and plan of care at all transitions
% of patients with medication therapy plan documented as part of "plan of care"
(episodic plan)
% of patients with medication therapy plan documented as part of "care plan"
(longitudinal plan)
1.3 Ensure Optimal Medication is Prescribed
# of resolved Drug Therapy Problems per 100 inpatient admissions
# of resolved drug therapy problems per 100 resident days
# of resolved drug therapy problems per 100 outpatient visits (need numerator to
exclude diagnostic outpatient visit)
% of orders clarified by Pharmacist (not therapeutic interchange)
Average Length of Stay per acute inpatient admission
# of clinical Rx hours per 100 inpatient days
# of active order sets that are up to date
1.4 Ensure medications accurately and appropriately dispensed
Average turnaround time of medications from order scan to release of medication
(Pyxis)
% of medications dispensed in unit dose format including ward stock
% of medication orders entered accurately as assessed by pharmacist at
verification
% of facilities dispensing patient specific medications on 24 hour batch
% of reporter errors per order entered as per PSLS reports
Order entry average time per pharmacy department (% variance from
benchmark)
1.5 Ensure medications are accurately and appropriately administered
# of medication doses administered in error per PSLS per 100 patient days
% of medications infused through MDL
% of medications accessed through AMDC on over‐ride
% of medication errors while AMDC on override
1.6 Improve Antimicrobial Stewardship

174

# of IV to PO step‐down interventions
# of anti‐infective Drug Therapy Problems resolved per inpatient admission
% of oral to IV of high bioequivalent drugs
% of Interventions accepted in prospective audit and feedback regarding
antibiotics
Defined Daily Dose (DDD) per 100 patient days for targeted antibiotic
DDD of IV vs PO formulations of high bioequivalence antimicrobials
# of Medication Utilization Reviews Completed Annually for AMS;
1.7 Optimize Medication Education and Self‐Management
% of patients educated by a pharmacist on Medications
Reported patient satisfaction on medication education provided
Improve patient and family experience
2.0 Improve patient and family experience
2.1 Ensure informed shared decision making regarding medication therapy
2.2 Ensure appropriate information is shared regarding timelines and access
Improve Provider Engagement
3.0 Improve Staff, Physician and Clinical Student Experience
3.1 Ensure they have the tools they need to do the job
Work Life survey ‐ level of satisfaction
3.2 Provide appropriate development opportunities
% of staff/physicians accessing education opportunities
3.3 Improve and share information on performance both personal and medication safety
# of staff who have had a performance review in past 24 months
3.4 Appropriately match resources to need
# of clinical pharmacy hours per 100 inpatient days
3.5 Provide meaningful clinical education experience
# of medical students receiving clinical education during their 3rd year rotation
# of pharmacy technician students receiving education annually
# of clinicians receiving education on clinical pharmacy at orientation
Student Satisfaction Survey Scores
Control per capita cost
4.0 Control per patient cost
4.1 Increase standardization to reduce arbitrary variation
% of documented processes with Standard Operating Procedures
4.2 Increase focus on CQI to Improve efficiency through reducing non‐value added
activity
# of CQI projects completed that identified and realized efficiency gains
4.3 Minimize inventory cost
Cost of expired drugs in pharmacy inventory
Actual inventory value for all NH Pharmacies
# of average turns of inventory
4.4 Ensure lowest cost/most effective drug therapy management
Drug cost per 100 resident days in LT facilities (non Plan B)

175

Drug cost per inpatient day
4.5 Participate effectively on BCHA P&T, BCSS & HealthPro collaborations
% of meetings where all NH representatives attended
% of formulary reviews completed by NH
% of alignment NH formulary to Provincial formulary

Table 19 Strategy Map Objects

176

Appendix 10. Strategy Canvas

177

178

Figure 12 Strategy Canvas

179

TACTICAL

STRATEGIC

Appendix 11. Business Competency Map
Pharmacy & Medication Management Planning
Strategic Direction
Portfolio Management
Strategic Plan and Goals
Key Measurements and Performance Indicators
Resource Allocations
Pharmacy & Medication Management Strategy Development
Pharmacy & Medication Management Governance Planning
Regional Services Planning
Research Best Practice
Medication Research
Medication Research Strategy
Medication Research Planning
Relationship Management
Pharmacy Partner Management
Community Management
Government Relationship
Pharmacy Public‐Private Partnership
Service Delivery Planning
Population Level Surveillance
Standardize Process and Practice
Formulary Management Planning
Clinical Trial Planning and Coordination
Business Operations Planning
Quality Improvement
Pharmacy & Medication Management Risk Management
Pharmacy & Medication Management Risk Control (Adverse
Pharmacy & Medication Management Risk Analysis
Events)
Pharmacy & Medication Management Risk Measures
Pharmacy & Medication Management Risk Rule & Regulations
Pharmacy & Medication Management Risk Monitoring
Pharmacy & Medication Management Risk Compliance
Pharmacy & Medication Management Risk Reporting
Equipment Management
Equipment Scheduling
Equipment Maintenance
Equipment Renting/Leasing
Equipment Tracking & Asset Management
Supplier Management
Supplier Collaboration
Supplier Evaluation
Supplier Sourcing
Supplier Monitoring
Supplier Requirement Management
Supplier Negotiation
Pharmacy & Medication Management Governance Management
Pharmacy & Medication Management Access Management
Pharmacy & Medication Management Knowledge Management
Pharmacy & Medication Management Governance Control &
Pharmacy & Medication Management Information Management
Monitor
Pharmacy & Medication Management Governance Evaluation &
Pharmacy & Medication Management Governance Planning
Audit
Pharmacy & Medication Management Governance Compliance
Integration & Practice Management
Operational Budget Management
Capital Budget Management
Contract Negotiations
Contract Budget Management
Human Resource Staffing
Staff Performance Management
Retention

Pharmacy & Medication Management Continuous Improvement

Pharmacy Clinical Practice Management
Patient Records Management
Pharmacy Services Financial Management
Forecasting
Long term business planning
Pharmacy Services Contract Management
Contract Liability Management
Contract Compliance Management
Pharmacy Human Resources Management
Staffing Compliment Management
Recruitment
Staff Development

180

Order Triage
Patient ID and Registration
Medication Reconciliation
Clinical Support
Discharge Planning

OPERATIONAL

Community Emergency Response
Equipment Maintenance and Cleaning
Pharmaceutical Inventory Management
Medication Inventory storage
Controlled Substance Management
Transportation
Medication Distribution to Point of Care
Medication Assessment

Clinical Pharmacy Access Management
Safe Medication Order Writing
Order Set Development & Management
Pharmaceutical Care
Medication Administration
Drug Therapy Monitoring
Emergency Preparedness
Contract Management and emergency execution
Inventory and Equipment Management
Purchasing
Shipping and Receiving
Medication Mixing & Repackaging
Dispensing and Distribution (Pharmacy)
Medication Preparation
Medication Documentation

Internal clinical education pharmacy staff
Internal clinical education for non pharmacy staff
Fleet Vehicle Mangement
Billing
Travel Management

Education
External clinical education
Administration
Data Quality Improvement
Administrative Reporting
Clinical Reporting

Extract from other Business Area Business Models specific operational competencies related to Medication
Management
Medication Inventory Management
Medication Dispensing
Medication Administration
Drug Therapy Monitoring
Drug Therapy Prescribing

OPERATIONAL

Medication Inventory Management
Medication Dispensing
Medication Administration
Drug Therapy Monitoring
Drug Therapy Prescribing
Medication Administration
Controlled Substance Management
Medication Inventory Management

Long Term Care Medication Management
Medication Documentation
Controlled Substance Management
Medication Reconciliation & Best Possible Medication History
Patient Assessment
Acute Care Medication Management
Medication Documentation
Controlled Substance Management
Medication Reconciliation & Best Possible Medication History
Patient Assessment
Home Support Medication Management
Medication Documentation
Medication Reconciliation & Best Possible Medication History

Primary Care Medication & Biological Management
Medication & Biological Inventory Management
Medication & Biological Documentation
Medication & Biological Dispensing
Controlled Substance Management
Medication Administration
Medication Reconciliation & BPMH
Community Specialized Medication Management
Medication Inventory Management
Medication Documentation
Medication Dispensing
Controlled Substance Reporting
Medication Administration
Medication Reconciliation & Best Possible Medication History
Drug Therapy Monitoring
Patient Assessment
Drug Therapy Prescribing
Public Health
Medication Documentation
Medication Inventory Management
Medication Dispensing
Controlled Substance Reporting
Medication Administration
Medication Reconciliation & Best Possible Medication History
Drug Therapy Monitoring
Patient Assessment
Drug Therapy Prescribing
Records Management
Client Registration
Records Reporting & Analysis
Records Management Services

Figure 13 Business Competency Map

181

Appendix 12. Business Competency Model

Figure 14 Business Competency Model

182

Appendix 13. Value Chain

Figure 15 Value Chain

183

Appendix 14. Listing of Criteria Definitions
Criteria for Prioritization of Improvement Initiatives

Definition of Criteria

Business Continuity

Criteria Criteria Questions
What impact will this initiative have on department level stability
and sustainability?

What impact will this initiative have on system stability and
sustainability?

System stability refers to looking at the system as a whole and considers risk/benefit to other parts
of the system. The proposed change will have a long standing impact on the system.
Sustainability refers to the ability for the proposed service change to continue into the future.

What is the expected impact on Employee and/or Physician
Engagement?

Impact from the perspective of our staff and physicians, on workplace environment including:
1) Teamwork and morale
2) Tools and equipment
3) Opportunities to Learn and Grow
4) Well-being and safety

How will this initiative impact patient safety?

This criterion focuses on reduction in risk of harm to the patient/client from care/service being
provided. Risk of harm and also potential degree of harm need to be considered. This criterion does
not include factors that have been addressed in other criteria such as accessibility, continuum of
care and upstream risk factors.

# of patients/residents potentially affected

This criteria measures the number of patients/residents whose risk of an adverse event could
potntially be impacted by the proposed change

What level of evidence exists that improvements in selected
process will reduce adverse events?

This criteria measures the level (quality) of evidence that the proposed intervention will result in the
intended outcomes.

How will this initiative impact worker safety?

This criterion focuses on reduction in risk of harm to workers in the workplace. Risk of harm and also
potential degree of harm need to be considered. This criterion does not include factors that have
been addressed in other criteria such as accessibility, continuum of care and upstream risk factors.

The number of staff or physicians who could have an increase or
decrease in work related injuries as a result of the proposed
initiative?

This criteria measures the number of workers/physicians whose risk of a workplace injury or illness
could potentially be impacted by the proposed change

To what degree will the initiative result in an increase to process
maturity across the system?

Process Maturity is measured on a scale of 1 to 5 with 1 being the most immature and 5 being the
most mature. The level of process maturity in most cases should be at least at level 3. There are
processes where it is feasible and desirable to get to level 5 maturity.

Is the process one that needs to be standardized in order to take
advantage of available automation opportunities?

Automation of workflow is known to be an effective strategy to increase efficiency and reduce errors
however automation of poor processes can have the opposite impact. In order to take advantage of
opportunities for automation of tasks the processes being automated need to be documented,
standardized and monitored to ensure compliance with standardization prior to undertaking
automation of the tasks.

Is the process improvement directly related to NH three year
strategic action plans?

NH has eight strategic action plans it has proposed to complete over the upcoming 3 years. The
proposed process improvement could address more than one of these plans. Negative impact could
be considered where the resources required to carry out the process improvement will be diverted
away from working on the Strategic Action Plan elements.

Is there an anticipated net savings to the organization?

This criterion refers to the optimal use of resources to yield maximum benefits and results.
Evidence of estimated cost of alternative solutions considered should be included in the proposal
documentation.

Process Maturity

Worker Safety

Patient Safety

Is there organizational capacity to implement the initiative?

Challenges or Facilitators to the implementation of proposed initiatives based on the following:
1) Risks assessed
2) Barriers assessed
3) Mitigation Plan developed
4) Organizational experience in leading similar initiative
5) Experienced resource is readily available

Strategic
Alignment

What number of employees and or physicians will be impacted by Change management is a significant component of the feasibility of successful implementation. One
the proposed change?
of the major considerations in change is the number of individuals involved in the change.

Financial
Impact

Feasibility

Department level stability and sustainability refers to the current operations and whether the process
improvement proposed will jeopardize the ability of the department to meet its mandate in the long
term.

Table 20 Listing of Criteria Definitions

184

Appendix 15. Initiative Ranking
Initiative/Project Title:

Business Continuity

Rating

Criteria Questions

Strategic Action Plan Ref #
Criteria
Weights

Feasibility
Patient Safety

-1

0

Minimal negative
impact at the
No impact on system
department level is
stability/sustainability
short term and has
been addressed in the
implementation plan

minimal positive
impact on department
level
stability/sustainability

Moderate positive
impact on department
stability/sustainability

Significant positive
impact on department
stability/sustainability

Minimal negative
Moderate negative
impact at the system
impact on system level
level is short term and No impact on system
stability/ sustainability
has been addressed in stability/sustainability
with strategy in place
the implementation
to address
plan

Minimal positive
impact on system
stability/sustainability

Moderate positive
impact on system
stability/sustainability

Significant positive
impact on system
stability/sustainability

6.48%
Negatively Impacts 4 of Negatively Impacts 2 - Negatively Impacts 1 of
the 4 objectives
3 of the 4 objectives
the 4 objectives

What number of
employees and or
physicians will be
impacted by the
proposed change?

Greater than 500
people affected

200 to 500 people
affected

Significant Risk to
successful
implementation and no
opportunity for
mitigation identified

Significant Risk to
successful
implementation and
with some degree of
mitigation identified

100 to 200 people
affected

no impacts

50 to 100 People
affected

25 to 50 people
affected

Moderate Risk to
Moderate Risk to
Minimal Risk to
successful
successful
implementation and no implementation and a successful
implementation
mitigation plan has
opportunity for
been developed
mitigation identified

Less than 25 people
affected

No people affected

Minimal Risk to
successful
Implementation and a
mitigation plan has
been developed

Risk Assessment has
been completed and
no risks have been
identified

No impact on patient
safety

Potential minimal
positive impact on
patient safety

Potential of moderate
positive impact on
patient safety

Potential of significant
positive impact on
patient safety

greater than 10% of
patients/residentshave
potential to be
negatively impacted

less than 5% of
5 to 10% of
patients/residents have patients have potentiall no impact to any
to be negatively
residents or patients
potential to be
impacted
negaively impacted

less than 25% have
potential to be
positively impacted

25% to 50% have
potential to be
positively impacted

50% and greater have
potential to be
positively impacted

No evidence

clinical/expert Opinion

Local quality
improvement results

Low reliability evidence Moderately reliable
(not peer reviewed)
evidence

How will this initiative
impact worker safety?

Potential of significant Potential of moderate
negative impact on
negative impact on
workplace safety
workplace safety

Potential of minimal
negative impact on
workplace safety

No impact on
workplace safety

Potential minimal
positive impact on
workplace safety

The number of staff or
physicians who could
have an increase or
decrease in work related
injuries as a result of the
proposed initiative?

greater than 10% of
workers/physicians
potentially negatively
impacted in respect to
workplace safety

5 to 10% of
workers/physicians
potentially negatively
impacted in respect to
workplace safety

less than 5% of
workers/physicians
have potentially
negative impact on
workplace safety

less than 25% of
no workers/physicians
workers/physicians
are expected to incur a
potentially will be
change in likelihodd of
positively impacted in
workplace injury or
respect to workplace
illness
safety

To what degree will the
initiative result in an
increase to process
maturity across the
system?

Process maturity will
decrease to Level 1

Process maturity will Process maturity will
No change in process
decrease but not lower decrease but not lower
maturity
than Level 3
than Level 2

Is the process one that
needs to be standardized
in order to take
advantage of available
automation
opportunities?

Implementation of
Implementation of
Standardization of
Standardization of
initiative would result in initiative would result in Implementation of
process is beneficial
initiative would result in process would not
disruption of current
disruption of current
but automation
result in efficency gains
automation already in automation already in short term loss of
opportunity minimally
related to automation
automation .
place without potential place with planned
impacted
remediation or
for remediation or

Standardization of
Standardization of
Process is essential to
Process is essential to
implement current
implement future
automation
automation and realize
opportunitites and
efficiencies
realize efficiencies

Expected to negatively
Expected to negatively
impact the
impact the
achievement of more
achievement of one
than one element of
element of the
the Strategic Action
Strategic Action Plans
Plans

Identifed the potenital
risk that it may delay
acheivement of an
element of the
Strategic Action Plan

Moderate (between
Significant (>$100k)net
$50k and $100k)
financial cost to the
financial cost to the
organization in annual
organization in annual
operating expenses.
operating expenses.

Minimal (<$50k)
financial cost to the
organization in annual
operating expenses

Potential of significant Potential of moderate
negative impact on
negative impact on
patient safety
patient safety

# of patients/residents
potentially affected

What level of evidence
exists that improvements
in selected process will
reduce adverse events?

Potential of minimal
negative impact on
patient safety

Potential of moderate
positive impact on
workplace safety

4.34%
Is the process
improvement directly
related to NH three year
strategic action plans?

Subtotal

0.0000

0

0.0000

Potential to move the
process maturity level
from level 1 to level 2

0

0.0000

0

0.0000

0

0.0000

50% and greater of
25% to 50% of workers
workers/physicians
/ physicians potentially
potentially will be
will be positively
positively impacted in
impacted in respect to
respect to workplace
workplace safety
safety

Potential to move the
process maturity level
from level 1 or 2 to
Level 3

Potential to move the
process maturity level
above Level 3.

Not specifically related
to any element within
the Strategic Action
Plan

Indirectly related to at
least one element in
the Strategic Action
Plans

Directly addresses a
Strategic Action Plan
element

Addresses more than
one element of
Strategic Action Plans

No financial impact to
the annual operating
expenses

Minimal (<$50k)
financial gain to the
organization in annual
operating expenses

Moderate (between
$50k and $100k)
financial gain to the
organization in annual
operating expenses.

Significant (>$100k)net
financial gain to the
organization in annual
operating expenses.

11.13%
Is there an anticipated
net savings to the
organization?

0

Potential of significant
positive impact on
workplace safety

28.89%

Subtotal

0.0000

0

12.05%
100.00%

Weighted
Score

Highly reliable evidence
Large randomized
exists in the form of
control trial results
peer reviewed studies.

29.48%

Subtotal

Rating

Positively Impacts 1 of Positively Impacts 2 - 3 Positively Impacts 4 of
the 4 objectives
of the 4 objectives
the 4 objectives

7.63%
How will this initiative
impact patient safety?

Subtotal

Worker Safety

3

Significant negative
impact at the system
level with no strategy
available to mitigate

Subtotal

Process Maturity

2

What impact will this
initiative have on system
stability and
sustainability?

Is there organizational
capacity to implement the
initiative?

Strategic
Alignment

1

Moderate negative
Significant negative
impact on department
impact at the
level stability/
department level with
sustainability with
no strategy available to
strategy in place to
mitigate
address

What is the expected
impact on Employee
and/or Physician
Engagement?

Financial
Impact

-2

What impact will this
initiative have on
department level stability
and sustainability?

Subtotal

Subtotal
Total

-3

0.0000

0.0000

0
0.00

0.0000
0.0000

Table 21 Initiative Ranking Tool

185

Appendix 16. Results of Prioritization of Improvement Initiatives
Medication Safety and Quality Improvement Initiatives
3 Year Strategic Action Plans
Ranked based on MCDA tool
Focus
Proposal Title
1. Medication reconciliation
#1‐0001 1.1 Ensure standard clinical workflows and processes include BPMH and Med Rec at all transitions
3. Medication Prescribing
#1‐0005 3.1 Ensure all medication orders adhere to Safe Medication Order Writing (SMOW)
4. Improve AMS
#1‐0009 4.1 Develop and maintain AMS interdisciplinary committee to provide oversight and governance
4. Improve AMS
#1‐0010 4.2 Implement standard processes to ensure improved AMS
4. Improve AMS
#1‐0011 4.3 Establish and maintain process to collect and reporting AMS program metrics
3. Medication Prescribing
#1‐0008 3.4 Facilitate clinical pharmacists involvement in prescribing decision making process
2. Comm care plan & POC
#1‐0003 2.1 Med therapy is effectively communicated in plan of care appropriate patients
2. Comm care plan & POC
#1‐0004 2.2 Med therapy is effectively communicated in care plans for appropriate patients
5. Medication Dispensing
#1‐0016 5.5 Ensure timely and accurate verification and dispensing processes
8. Medication administration #1‐0026 8.5 Reduce the gap between current and best practice guidelines
7. Minimize inventory costs
#1‐0020 7.1 Implement best practice standard inventory management processes
3. Medication Prescribing
#1‐0006 3.2 Develop and maintain appropriate medication order sets
8. Medication administration #1‐0024 8.3 Implement quality assurance process for infusion pumps
3. Medication Prescribing
#1‐0007 3.3 Conduct medication use evaluation (MUE) reviews to assess adherence to best practice
5. Medication Dispensing
#1‐0012 5.1 Develop a regional central intravenous admixture (CIVA) plan compliant with standards
5. Medication Dispensing
#1‐0013 5.2 Implement a regional CIVA plan compliant with standards
8. Medication administration #1‐0022 8.1 Ensure safe handling of hazardous drugs according to provincial guidelines
Initiatvies Not Ranked
1. Medication reconciliation

#1‐0002

1.2 Establish quality assurance processes related to BPMH and Med Rec

6. Increase standarization
7. Minimize inventory costs
8. Medication administration

#1‐0019
#1‐0021
#1‐0025

6.3 Achieve maturity level 3 or above for identified critical processes
7.2 Manage drug shortages in order to minimize patient impact
8.4 Establish process for monitoring use of AMDC access using Knowledge Portal

Inititatives completed prior to Ranking exercise
5. Medication Dispensing
#1‐0014 5.3 Develop ranking tool for Automated Medication Dispensing Cabinets and apply to all facilitites
5. Medication Dispensing
#1‐0015 5.4 Implement AMDCs in accordance with the ranking tool
6. Increase standarization
#1‐0017 6.1 Develop service model for provision of pharmacy services to residential LTC facilities
6. Increase standarization
#1‐0018 6.2 Implement service model for provision of pharmacy services to residential LTC facilities
8. Medication administration #1‐0023 8.2 Implement regional standard for infusion pumps
8. Medication administration #1‐0027 8.6 Develop neonatal parenteral therapy manual
8. Medication administration #1‐0028 8.7 Implement neonatal parenteral therapy manual for use in Northern Health
8. Medication administration #1‐0029 8.8 Establish audit processes for quality assurance of narcotic handling outside pharmacy

Rated Score
617.5
586.3
586.3
586.3
586.3
486.6
464.8
464.8
457.8
424.7
370.6
367.4
363.1
277.9
158.9
158.9
95.4
mandatory
critical processes not
identified
mandatory
audit function
complete
complete
complete
complete
complete
complete
complete
complete

Table 22 Results of Prioritization of Improvement Initiatives

186

Appendix 17. Reporting Frequency
Proposed Reporting Frequency of Available Indicators
Adhoc
% compliance with privacy and confidentiality audits
# of Patient assessments completed by pharmacists or pharmacy technician
% of nurses who have completed SMOW education module
% of pharmacists who have completed SMOW education module
% of pharmacy technicians who have completed SMOW education module
% of physicians who have completed SMOW education module
% of unit clerks who have completed SMOW education module
Annual
# of clinical pharmacy hours per 100 inpatient days
# of Medication Utilization Reviews Completed Annually for AMS;
# of medical students receiving clinical education during their 3rd year rotation
# of pharmacy residents in NH
# of pharmacy technician students receiving education annually
% of facilities with infusion pumps meeting established standard
% of identified critical processes with process maturity level 3 or above
% of meetings where all NH representatives attended
% of facilities dispensing patient specific medications on 24 hour batch
% of formulary reviews completed by NH
% of staff/physicians accessing education opportunities
% oral solid meds with bar code on unit dose packaging;
Reported patient satisfaction on medication education provided
Reported patient satisfaction with pain management during hospital stay
Worklife Survey ‐ level of satisfaction
# of pharmacist clinical training weeks provided
% of pharmacists who meet competency measures for clinical pharmacy
Period
# of interventions per hour clinical pharmacist time
% of discrepancies (requiring intervention) found after/during medication reconciliation
% of VTE audits where patients received appropriate prophylaxis
% of patients with Med Rec Completed within 24 hours of admission
Cost of expired drugs for credit
Total Cost of Expired Drugs
Quarterly
# of average turns of inventory
# of IV to PO step‐down interventions
# of anti‐infective Drug Therapy Problems resolved per inpatient admission

187

# of medication doses administered in error per PSLS resulting in harm level greater
than or equal to level 3 harm
# of resolved drug therapy problems per 100 outpatient visits
# of resolved drug therapy problems per 100 resident days
# of Resolved DTPs per 100 inpatient admissions
%of Interventions accepted in prospective audit and feedback regarding antibiotics
% of individuals expected to complete SMOW education who have taken SMOW
% of medication orders entered accurately as assessed by pharmacist at verification
Actual inventory value or estimate based on Value on Hand reported in Cerner for all
NH Pharmacies
Average Length of Stay per acute inpatient admission
Cost of antimicrobials per 100 inpatient days
Cost of expired drugs as percentage of drug budget
Cost of expired drugs not for credit as a % of total expired drugs
Cost of IV antibiotics per 100 inpatient days
Cost of oral antibiotics per 100 inpatient days
Defined Daily Dose (DDD) per 100 patient days for targeted antibiotic
Drug Cost per 100 inpatient days
Drug cost per 100 resident days in LTC facilities (non Plan B)
Drug Costs per inpatient day
High cost antineoplastic drug utilization in pharmacy
Turnaround time of internal medication inventory transfers based on established
benchmark standards.
% of orders compliant with Safe Medication Order Writing (SMOW)
% of reported errors per orders entered as per PSLS reports
Semi‐annual
# of physician specific order sets;
# of active order sets that are up to date
# of regional order sets;
# of site specific order sets
# of incident reports of staff exposure
% of meds delivered late per PSLS reports
% of alignment NH formulary to Provincial formulary
% of medications accessed through AMDC on over‐ride
% of patients educated on Medications by a pharmacist
Average Turnaround time of medications from order scan to release of medication
(Pyxis)
Door to needle time for thrombolytic

188

Appendix 18. Process Reference Model
1 Manage Medication at Point of Care
1.1 Register Patient
1.1.1 Enroll Patient in Appropriate Information System
1.1.2 Confirm Patient Identification and Identify for Clinical Pharmacy Services
1.2 Assess Patient
1.2.1 Interview Patient
1.2.2 Order Diagnostic Tests
1.2.3 Interpret Results of Diagnostic Tests
1.2.4 Diagnose Patient
1.3 Prescribe Medication
1.3.1 Conduct Best Possible Medication History Interview
1.3.2 Conduct Medication Reconciliation
1.3.3 Order Medication
1.3.4 Triage medication orders
1.3.5 Perform Clinical assessment of medication order
1.4 Dispense Medication at Point of Care
1.4.1 Maintain Point of Care Inventory
1.4.2 Manage Patient Owned Medications
1.4.3 Dispense Medication
1.5 Administer Medication
1.5.1 Prepare medication if required
1.5.2 Administer Medication to Patients
1.5.3 Complete Medication Administration Record
1.6 Monitor Patient
1.6.1 Provide Pharmaceutical Care to Patients
1.6.2 Deliver Patient Education on Medication Therapy
1.6.3 Monitor Patient Response to Medication Therapy
1.7 Transfer or Discharge Patient
1.7.1 Plan for Patient Discharge
1.7.2 Discharge Patient
2 Provide Clinical Training & Professional Development
2.1 Provide Pharmacy Staff Training
2.1.1 Identify Training Needs
2.1.2 Develop Training Materials
2.1.3 Deliver Training
2.1.4 Monitor Learner Progress and Provide Feedback
2.1.5 Monitor Training Effectiveness
2.2 Provide Clinical Pharmacy Competency Development
2.2.1 Establish Clinical Pharmacy Competencies
2.2.2 Develop Competency Evaluation
2.2.3 Develop Competency Training

189

2.2.4 Deliver Clinical Pharmacy Training
2.2.5 Monitor Learner Progress & Provide Feedback
2.2.6 Monitor Training Effectiveness
2.3 Provide Clinical Education(External to Pharmacy)
2.3.1 Identify Training Needs
2.3.2 Develop Training Materials
2.3.3 Deliver Training
2.3.4 Monitor Learner Progress and Provide Feedback
2.3.5 Monitor Training Effectiveness
2.4 Manage Clinical Student Placement
2.4.1 Engage with Education Providers
2.4.2 Identify Potential Candidates & Make Selection
2.4.3 Develop Training Plan
2.4.4 Monitor Student Progress & Provide Feedback
2.4.5 Evaluate Effectiveness of Training Plan
3 Manage Medication Supply Chain
3.1 Source Medication
3.1.1 Establish & Maintain Supplier Requirements
3.1.2 Evaluate and Approve Potential Suppliers
3.1.3 Identify and Maintain Supplier List
3.1.4 Negotiate with Suppliers
3.1.5 Collaborate with Suppliers
3.1.6 Monitor Supplier Performance
3.1.7 Perform Analysis and Response to Drug Shortages
3.1.8 Purchase Medication
3.1.9 Receive purchased medication
3.1.10 Initiate Payment
3.1.11 Pay Suppliers
3.2 Maintain Medication Inventory
3.2.1 Define Inventory Strategies
3.2.2 Define Inventory Demand
3.2.3 Create Inventory Plan
3.2.4 Define Performance Metrics
3.2.5 Establish Standards for Medication Storage
3.2.6 Ship Inventory to secondary inventory locations
3.2.7 Store purchased medication
3.2.8 Monitor medication storage procedures
3.2.9 Perform Inventory Count
3.3 Mix & Repackage Medication
3.3.1 Issue components from inventory
3.3.2 Compound Medications Outside Laminar Hood
3.3.3 Compound Medications within Laminar Hood
3.3.5 Add Compounded Medications to Inventory

190

3.3.6 Remove bulk packaged goods from inventory location
3.3.7 Repackage into single use doses
3.3.8 Restore unit dose packages in inventory
3.3.9 Repackage medications for 24 hour Batch ( patient specific)
3.3.10 Pick medication from inventory
3.3.11 Issue medication from perpetual inventory
3.4 Distribute Medication
3.4.1 Transport purchased medication to secondary inventory location
3.4.2 Document Patient Specific Medication Orders
3.4.3 Verify Patient Specific Medication Orders
3.4.4 Dispense Patient Specific Medication
3.4.5 Replenish Ward Stock
3.5 Return Medication
3.5.1 Identify expired medications in Pharmacy Inventory
3.5.2 Return Expired Drugs to Pharmacy
3.5.3 Return Expired Drugs eligible for refund to Suppliers
3.5.4 Dispose of expired controlled substances
3.5.5 Dispose of expired medications
4 Manage & Administrate
4.1 Plan
4.1.1 Develop Strategic Plan & Goals
4.1.2 Establish Portfolio Priorities
4.1.3 Establish Governance Plans
4.1.4 Allocate Resources
4.1.5 Develop Strategy for Pharmacy & Medication Management
4.1.6 Establish Population Level Surveillance Plan
4.1.7 Develop & Communicate Regional Services Plan
4.1.8 Plan Research Strategy
4.1.9 Develop Medication Research Strategy
4.1.10 Establish Formulary Management Plan
4.1.11 Establish Business Operating Plan
4.1.12 Establish Standards for Pharmacy & Medication Management
4.1.13 Establish Plan for Clinical Trials
4.1.14 Identify Quality Improvement Plan
4.1.15 Plan for long term business operations
4.1.16 Establish Performance Measurement Plan
4.1.17 Maintain Drug Formulary
4.2 Manage Risk
4.2.1 Establish Risk Analysis Framework
4.2.2 Establish Risk Measures
4.2.3 Establish Risk Monitoring Plan
4.2.4 Establish Risk Reporting
4.2.5 Establish & Maintain Response to Adverse Events

191

4.2.6 Establish & Maintain Risk Rules & Regulations
4.2.7 Establish & Manage Risk Compliance
4.3 Monitor Compliance
4.3.1 Manage and Monitor Progress related to Governance Plan
4.3.2 Establish Compliance Plan and Reporting
4.3.3 Validate medication orders adhere to Safe Medication Order Writing
4.3.4 Document receipt, administration and disposal of controlled substances
4.3.5 Document receipt, administration and disposal of controlled substances
4.3.6 Monitor & Control compliance with Policies & Procedures
4.3.7 Evaluate & Audit effectiveness of Policies & Procedures
4.4 Manage Contracts
4.4.1 Negotiate contracts
4.4.2 Manage contract Budget
4.4.3 Evaluate and monitor contract liability
4.4.4 Evaluate and monitor contract performance and compliance
4.5 Manage Human Resources
4.5.1 Identify Human Resource Requirements
4.5.2 Recruit Staff to meet Identified Needs
4.5.3 Recruit Staff to identified Needs
4.5.4 Orientate Staff
4.5.5 Schedule Staff
4.5.6 Manage Staff Performance
4.5.7 Manage Staff Recognition Program
4.6 Manage Financial Resources
4.6.1 Identify Operating Budget Requirements
4.6.2 Monitor Operating Expenditures
4.6.3 Initiate Operating Budget Remediation Actions
4.6.4 Identify Capital Budget Requirements
4.6.5 Monitor Capital Expenditures
4.6.6 Initiate Capital Budget Remediation Actions
4.6.7 Forecast operating and capital budget performance
4.6.8 Initiate Accounts Receivable
4.6.9 Collect Accounts Receivable
4.6.10 Manage Employee Travel Expenses
4.7 Manage Information
4.7.1 Establish Information System Standards
4.7.2 Manage Information System Access
4.7.3 Manage Patient Records
4.7.4 Monitor & Improve Data Quality
4.7.5 Maintain clinical pharmacy patient record
4.7.6 Maintain Medication information resources
4.7.7 Maintain Inventory Data
4.7.8 Manage Master Drug Library for Infusion Pumps

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4.7.9 Develop and Maintain medication order sets
4.7.10 Develop & Maintain Performance Monitoring Reports
4.8 Procure & Maintain Equipment & Facilities
4.8.1 Establish & Manage Equipment Schedule
4.8.2 Procure Equipment through Renting or Leasing Option
4.8.3 Establish & Manage Plan for Equipment Maintenance
4.8.4 Establish & Maintain Asset Tracking Policies & Procedures
4.9 Provide Operational Oversight
4.9.1 Establish and Manage Partnerships
4.9.2 Establish & Manage Provincial Government Relationship
4.9.3 Establish & Manage Municipal Government Relationships
4.9.4 Establish & Manage Public Private Partnerships
4.9.5 Establish & Staff Pharmacy Hours of Operation
4.9.6 Promote continuous Improvement
4.9.7 Implement and Maintain Anti‐Microbial Stewardship Program
4.9.8 Promote Integration & Practice Management
4.9.9 Develop & Maintain Community & Emergency Response Plan
4.9.9 Research Best Practice
4.9.10 Establish Emergency Response Policies & Procedures
4.9.11 Manage Fleet Vehicles
4.9.12 Develop & Monitor Administrative Reports
4.9.13 Develop & Monitor Clinical Reports
4.9.14 Develop & Publish Performance Reports

Table 23 Process Reference Model

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Appendix 19. Listing of Functions with Definitions
STRATEGIC LEVEL FUNCTIONS
Pharmacy & Medication Management Planning
Strategic Direction

Development of an operational strategic course of action that leads to the achievement
of organizational strategic objectives

Strategic Plan and Goals

Development and definition of strategic actions and targets for achievement of the
operational strategic direction

Resource Allocations
Pharmacy & Medication
Management Governance Planning
Research Best Practice

Development and management of a plan for assigning and managing available
resources (human resources, hardware, etc.) for optimizing operations.
Executive and Board governance planning to ensure long term safety and
effectiveness of mediation management both in the pharmacy and throughout the
organization.
Identifying superior methods of achieving a

Portfolio Management

Centralized management of one or more portfolios which includes identifying,
prioritizing, authorizing, managing and controlling programs and other related work to
achieve strategic business objectives

Key Measurements and Performance
Indicators

Establish and monitor business metrics used to evaluate operational factors that are
crucial to the success of the organization and align with organizational strategic goals.

Pharmacy & Medication
Management Strategy Development

Identifying objectives and the (strategies) means that will be undertaken to achieve
those objectives

Regional Services Planning

Planning for pharmacy services across the region of particular importance is how
pharmacy services will be provided to small sites who do not have on site pharmacists.

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Medication Research
Medication Research Strategy
Medication Research Planning

Pharmacy Partner Management
Government Relationship
Community Management
Pharmacy Public-Private Partnership
Population Level Surveillance
Formulary Management Planning

Providing an environment of opportunities, options and methodologies for appropriate
research (as well as continual development of channels for application of research
findings) that meet applicable ethics and standards
Establishing research objectives, types (quantitative and qualitative), and processes for
research in work environment.
Relationship Management
Management of relationships, communications and services with internal and external
stakeholders and partners
Organizational representation / stakeholder participation, communication development
and coordination of policy and legislative efforts by local, provincial and federal
governments
Development and management of long term contracts between a private party and a
governmental entity for providing a public service
Service Delivery Planning
Surveillance of medication usage and potential need at the population level
Setting objectives, policies and processes for establishing and maintaining medication
formulary to be used in the organization.

Business Operations Planning

Establishing objectives, policies and processes for maintaining or adjusting service
levels for medication management.

Standardize Process and Practice

Continuous improvement and implementation of evidence based practices within
medication management

Clinical Trial Planning and
Coordination
Quality Improvement

Establishing objectives, policies and processes when medication related clinical trials
are being conducted within the organization.
The practice of monitoring, evaluating and improving the quality of services provided.

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TACTICAL LEVEL FUNCTIONS
Pharmacy & Medication Management Risk Management
Pharmacy & Medication
Management Risk Analysis

Defining and analyzing the dangers to individuals or business posed by a potential
natural and/or human-caused adverse event

Pharmacy & Medication
Management Risk Measures

Statistical measures to assess performance to its benchmark index within and
accepted standard deviation

Pharmacy & Medication
Management Risk Monitoring

Control projects applied to monitor identified risks, identify new risks, and ensure
proper execution of planned risks

Pharmacy & Medication
Management Risk Reporting

Development and implementation of a risk measurement performance and reporting
framework

Pharmacy & Medication
Management Risk Control (Adverse
Events)
Pharmacy & Medication
Management Risk Rule &
Regulations
Pharmacy & Medication
Management Risk Compliance

Equipment Scheduling
Equipment Renting/Leasing
Equipment Maintenance

Proactively identify and respond to manage, reduce or eliminate risk
Rules and regulations that are identified and applied to mitigate, manage risk
Management of process which identify the applicable requirements (defined in laws,
regulations, contracts, strategies and policies), assessment of the state of compliance
to confirm with requirements, and initiation of any corrective actions deemed
necessary
Equipment Management
The booking and scheduling of equipment as requested/required
Managing rental or short term usage agreements of required equipment that is not
owned by the organization
Managing, scheduling and monitoring of equipment maintenance requirements as
defined within standard operating agreements or recommended maintenance
schedules.
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Equipment Tracking & Asset
Management
Supplier Collaboration

Management and monitoring of equipment inventory, frequency of use, and
evaluation of equipment life cycle requirements
Supplier Management
Joint pursuit of competitive advantages for the parties involved with appropriate
parties working together to maximize the benefit for all.

Supplier Sourcing

Proactive management of a supply market to identify relevant and potential suppliers
that meet organizational objectives and ensure access to adequate resources required
for the long term needs of the organization.

Supplier Requirement Management

Management of specifications to optimize external resources to frame agreement with
suppliers.

Supplier Evaluation

Assessment of potential suppliers (product quality, cost and ability to meet demand) to
meet organizational needs, policies, and budgets.

Supplier Monitoring

Ongoing evaluation of supplier's ability to meet organizational needs, policies and
value for money.

Supplier Negotiation

Setting of objectives, development of strategy, understanding supplier's ability to meet
objectives, and development supplier and cost agreements.

Pharmacy & Medication Management Governance Management
Pharmacy & Medication
Establishing criteria for admission to service including routine hours of operation, and
Management Access Management
processes to access after hour services where applicable.
Pharmacy & Medication
The custodianship, quality, security and distribution of information to people or
Management Information
systems who need/use it.
Management
Pharmacy & Medication
Efforts by managerial level to ensure governance requirements are included in
Management Governance Planning
planning activates related to medication management.
Pharmacy & Medication
Management Governance
Monitoring of compliance with standards established in governance plan.
Compliance
Pharmacy & Medication
Management Knowledge
Capturing, distributing and effectively using knowledge
Management
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Pharmacy & Medication
Management Governance Control &
Monitor
Pharmacy & Medication
Management Governance Evaluation
& Audit
Pharmacy & Medication
Management Continuous
Improvement
Integration & Practice Management
Patient Records Management

Operational Budget Management
Capital Budget Management
Forecasting

Review and evaluate processes for preventing an unacceptable level of uncertainty in
business objectives
Systematic review of processes to improve the effectiveness of risk management and
control.
Quality management that focuses on process, rather than individual, recognizing both
internal and external stakeholders and promoting the use of objective data to analyze
and improve processes.
Pharmacy Clinical Practice Management
Clinical pharmacist efforts to work with other care providers to maximize benefits of
medication therapy.
Clinical Pharmacists records related to patient care which are not part of the patient
chart which eventually are used for Data Abstract Discharge purposes.
Pharmacy Services Financial Management
Analysis, organization and oversight of costs and expenditures for an organizational
business unit
Analysis, evaluation and oversight of cost, expenses and potential investments for
organizational business unit plant and equipment over a period greater than a year.
Use of historic data and current plans to determine the direction of future trends

Long term business planning
Contract Negotiations
Contract Budget Management
Contract Liability Management

Pharmacy Services Contract Management
Discussing points of potential partnership arrangement to meet organizational goals
under a formalized terms of agreement.
Planning, managing and controlling costs against an agreed budget
Management of contracts against organizational governance documents such as
operating agreements, employment agreements, contractor agreement, licensing
agreements, etc.

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Contract Compliance Management

Human Resource Staffing

Management and monitoring of key components in achieving compliance, managing
risks, and enhancing performance of vendors, partners and employees related to a
contract.
Pharmacy Human Resources Management
Staffing management includes utilizing HR information, tools, procedures, guidelines
and providing advice to employees related to staffing. Ensuring that the hiring of right
people when and where they are needed, respecting the values of fairness,
transparency, access and representativeness.
Develop, manage and routinely evaluate staff ability to meet role performance
expectations.

Staff Performance Management

Retention
Staffing Compliment Management
Recruitment

Staff Development

Provide recognition directly to employees individually or organizationally where/
when appropriate.
Effectively support employee through appropriate corrective action if required, i.e.
review of role expectations, appropriate disciplinary steps, labour relations, attendance
management, etc.
Ensure working environment supports current staff to remain and develop within an
organization
Identifying human resources needs and effectively managing the scheduling of the
staff.
Attracting, selecting and appointing suitable candidates for jobs (permanent,
temporary or casual). Could also include choosing suitable candidates for volunteer
positions or trainee roles.
Managing, mentoring and providing support/leadership for common learning to enable
a healthy workplace which supports continuous employee learning, formal and
informal, and the application of new knowledge and skills to the workplace.

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OPERATIONAL LEVEL FUNCTIONS
Clinical Pharmacy Access Management
Order Triage
Patient ID and Registration
Medication Reconciliation
Clinical Support
Safe Medication Order Writing
Order Management
Diagnostic & Treatment Activities
Coordination
Community Emergency Response
Contract Management and
emergency execution
Equipment Maintenance and
Cleaning
Pharmaceutical Inventory
Management
Medication Inventory storage
Purchasing
Shipping and Receiving

Sequencing of medication orders
Identifying patients who will be provided with clinical pharmacy services
Reconcile patient’s medication through effective interview techniques and record
review including documenting best possible medication history.
Provision of clinical pharmacy expertise to selected patients
Ensuring the appropriate documentation of medication orders to minimize risk of
incorrect interpretation of the medication order.
Manage medication orders to optimize medication therapy.
Coordinate diagnostic testing and treatment related to medication therapy.
Emergency Preparedness
Ensuring that patients have access to needed medications when the supply chain is
affected
Manage contracts during an emergency such as shortages of critical medications
Inventory and Equipment Management
Maintenance and cleaning of medication related equipment such as Automated
Medication Dispensing Cabinets and medication infusion pumps
Manage centralized inventory of medications
Establishing appropriate storage of medication to ensure access and safekeeping of
medications
Purchase of medications and related equipment
Receipt of ordered goods and shipping to other facilities where medication inventory
is located.
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Transportation
Medication Distribution
Medication Assessment
Medication Documentation
Medication Preparation
Medication Administration
Drug Therapy Monitoring
Discharge Planning
Internal clinical education
(Pharmacy)
Internal clinical education for nonpharmacy staff
External clinical education
Fleet Vehicle Management
Billing
Travel Management
Data Quality Improvement
Administrative Reporting
Clinical Reporting

`
Transporting medication within a site from central pharmacy to point of care
Distributing medication to point of care
Assessment of medication orders to determine whether there are any problems with
the medication order. Complete and appropriate.
Document on the patients file when drugs are administered
Prepare medication including repackaging or compounding.
Administer medication to patient
Monitor patient to ensure medication therapy is achieving the desired outcome.
Plan with the patient and physician for discharge
Education
Development and delivery of clinical education to staff within the pharmacy.
Development and delivery of clinical education specific to medication management to
staff outside the pharmacy such as nurses, and physicians.
Development and delivery of clinical education and practicum experience for clinical
students such as pharmacy residents.
Administration
Manage access for staff to use fleet vehicles
Generating and transferring information for billing purposes to Finance department.
Manage staff travel including authorization and reconciliation of travel expenses
Improve the quality of data at source
Ensure that where applicable administrative reporting meets organizations
expectations.
Ensure clinical reporting meets standards.

Table 24 Listing of Functions with Definitions Source NH internal documents

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