Process Management Systems and Public Healthcare in Brazil:
Technology to Improve Service Delivery
D. G. S. dos Santos1; Caroline A. B. Santos2; Marina R. Brochado3
Department of Industrial Engineering, CEFET/RJ, Rio de Janeiro, Brazil
Department of Industrial Management, CEFET/RJ, Rio de Janeiro, Brazil
Department of Civil Engineering, CEFET/RJ, Rio de Janeiro, Brazil
system performance, causing delays in service delivery
Abstract – The reality of healthcare delivery in emerging  . Just in 2009 the investment Brazil made in health
societies are not good enough for most of its population. This was more than three times the investment in Science and
article aims to explore how the analytical and monitoring Technology . Another way to compare is according to
capabilities of information systems know as BPMS (Business , in which the relative investment made by Brazil is
Process Management Systems) could improve the quality of
equal to UK’s. Given the importance of a health
services provided in Brazil. We propose that the adoption of
a service science and process-centric view will be of great assistance rate related to the geographic area of both
value to help the public health manager evaluate its quality countries, it is a good measure of how far we are.
gaps while fostering better comprehension of the system
dynamics and making clear points for policy changes.
Keywords – health service, BPMS, quality management
The Health care sector is one of the most important
areas in one’s life. Therefore it is also a critical point for
the governments and to the whole modern society. The
health sector demands more and more financial resources
every year in the world economy, both in emerging and
developed countries .
Understanding that the public institution is extremely
resistant to change while it tends to be pragmatic, we
propose the use of Business Process Management
technologies as a tool for system analysis, monitoring of
events, cost and quality. With the vision and coordination Fig. 1. Comparative expenditures with Healthcare in 5
different countries (including Brazil)
provided by the technology, management efforts will
become more autonomous and transparent, thus providing
mechanisms for better understanding and operation of The Brazilian Constitution says is the duty of the
Health system. National Health System to take care of life and health
. This commandment should not be flexible,
So this article is structured initially presenting a
review of the main concepts studied: what are services, ranging freely and being changed without any
how to define service quality, the main points of attention involvement by the current government, every four years.
in the stages of design, execution and control of a service, A clear, explicit and transparent understanding and
the paradigm of process view, and the definition of modeling of the system, its performance indicators should
process management systems. Then we discuss the main foster a much more intense debate around the concept of
applications of this kind of tool for the Brazilian public government and, more broadly, organizational
health, the summary a case study at the biggest Cancer governance.
Institutes in Brazil, concluding with the presentation of Although the Brazilian government usually shows
the proposed future developments of the research. commitment to legislate and regulate, historically it is
unable to effectively achieve the desired results .
Discussions to improve the health system are led by
II. THE CONTEXT OF HEALTH IN BRAZIL health professionals, when it should clearly be a
multidisciplinary committee focused on overall
The public health system is one of the biggest improvement of the system, and not on a technical
consumers of Brazil’s GDP and is considered inefficient specialized view (the doctor typically works through
in many ways  : emphasis on the high costs derived functional logic, according to organs or human systems)
from the adopted model, the lack of management skills  .
inside most medical organizations, both affecting the
The practice of the health system in organizations as B. Dimensions of service quality
Mayo Clinic  is essentially a multidisciplinary task,
and coordination must be addressed simultaneously with In general, the literature converges on the definition
the local and global logic as in all complex systems of , which shows the quality of a service involving
(multiple variables and stakeholders) ,. The dimensions (or determinants) that relate the whole
coordination must involve much more than just experience through the resources provided by the service
technology ,,. Into Brazil’s reality it involves provider: human, informational, infrastructural, or
political and organizational effort between layers that relational. Considering the five major areas of quality
usually does not maintain such intense integration . assessment, we understand each one as follows:
Still initiatives were sought in a way to change the current
model strongly focused on services for healing, to another 1) Tangibles:
that focuses on prevention, causes. a. appearance of physical facilities,
c. personnel and
III. METHODOLOGY d. communication materials.
This section presents a summary of the literature a. ability to perform the promised service
review done, and highlighted key points that make up the dependably and
conceptual framework of research, supporting the b. accurately.
arguments presented in Part III. According to  this 3) Responsiveness:
research has its research question define as: how can we a. willingness to help customers and
improve the service quality of a health operation. Then b. provide prompt service.
points that the method used here is qualitative and the 4) Assurance:
research is exploratory . In this section it is shown a. knowledge and courtesy of employees
briefly the research done. b. and their ability to inspire trust and
A. Defining Professional Services 5) Empathy:
Services are defined here as in : “any act or b. individualized attention the firm provides
performance that one party can offer to another that is its customers.
essentially intangible, and does not result in the
ownership of anything”. We also consider that services The five dimensions of quality listed are deployed in
can be divided into 2 broad categories that can help to ten attributes ,. The specific aims of these
balance the complexity level of the decisions : attributes increase the effectiveness of actions to increase
the quality of services, considering subtle aspects that
1) Information based services: this type of service might otherwise not be noticed. Once when designed,
can be delivered electronically. By definition is implemented and managed the service, these quality
also known that ICT improves this type of characteristics must be met in order to keep a constant
service productivity continuous. They are related search for best practices in providing services .
to 70% of the GDP.
2) Traditional services: this kind of service needs to C. The Service Gap model
be delivered locally because it is labor-intensive,
and can usually achieve limited productivity Now we present the model that encompasses all
development. It counts for 70% of the perspectives of the approach of Service Design, namely:
employment. Define, Execute and Control. It features integrated design
logic for services, ranging from the moment it is being
The Service Science, Management and Engineering planned, until the moment that is actually delivered
(SSME) approach is defined by the mutual dependence ,. The model considers the following gaps:
and interaction between several “isolated” sciences and
arts in the conception and improvement of any given 1) Understanding the expectations and the
service system. This provides better results while consumer perspective the service. This gap
fostering the systems approach to develop and sustain an believes that a lack of understanding of who
improved status to the quality; a status based on the is the customer's organization (including
results achieved, and different points-of-view comprised geographic and demographic variations) can
in the design, execution stages. Some of the most lead to wrong decisions in the design of the
important areas in the SSME framework are Arts & service.
Design Sciences, Management, Cognitive Science, 2) Inadequate requirements definition and
Engineering, Computer Science . quality being offered. At this point there
may be cases like the equivocal definition of
quality standards in the service-organization prioritized and resources are planned according to a
relationship. broader landscape.
3) Low capacity for implementation. One
reason for the low performance hit may be E. Business Process Management Systems (BPMS)
the poor relationship between the team
members, who usually lack the horizontal We note the migration behavior increasingly evident
channels of communication. in the organizations in pursuit of transparency and
4) Communication with consumers. In many organizational agility provided by the process approach.
organizations the vision of "where I'm going Soon technologies to support this change become
'is not clear to users of the process. extremely necessary. Information systems known as
Decision Support Systems ,, and the BPMS
This model attempts to relate the main causes and aim to facilitate coordination, planning and monitoring of
points of failure in the delivery of a service. Deploying resources involved in a given organizational process .
these indicators can generate goals with the objective of They are not intended to replace the manager's role, but
minimizing the potential points of failure. Among the its mission is to assist professional staff to see all parts of
common steps for the improvement of a service can find the whole system to make better decisions.
activities such as Training Programs, Consumer research, The nature of this technology is very new that
Process mapping, Resource Planning, Internal compels us to find a definition for it. Research conducted
communication. So with these notes we can draw by  which relate the main features expected and
correlations between what we need to do, what priority offered by various tools in stakeholder processes, such as
for our organization’s context and how we should make academics, consultants, suppliers and the health
that change. professionals in Brazilian markets. Below is a compilation
of all the features founded in the literature, excluded the
D. Process management view ones with just one reference.
The approach known as process view derives from IV. DISCUSSION
the necessity to integrate in a more agile and less costly
activities of an organization . The operations are The information systems are so useful nowadays
traditionally structured in accordance with the mentality mostly because of 3 characteristics: centralization,
of the experts group because they can become specialists structure and integration. The health system needs this
in narrow topic, and in similar units so they can perform type of organizational capacity: integrating health care
faster . What happens is that this operation logic initiatives so that there is maximizing resources spent
gives benefits to the efficiency of the specific task, while without an increase in costs generated by the duplication
decreasing the ability to solve most of the systems more of efforts. Other consequences of the desired information
complex processes decreasing the overall operation is the structuring of the system, together with associated
performance  . access them, for different levels of analysis require
Thus the traditional approach linked to functional different sets of information and they should be
organizational structures of specialists in areas of low consistent. The approach brought by ,, also
capacity lateral coordination is not so efficient anymore. points out other perspectives, or capabilities, that the
According to  this approach promotes low market technologies should have.
orientation, creating local performance indicators, the
skills of individuals do not go beyond functional 1) Transactional - Ability to transform unstructured
boundaries, the budget is defined and implemented processes into standardized transactions.
without considering the transverse processes and no A hospital should be able to quickly treat and promote
organizational units responsible for process as a whole. access and use of its resources to patients.
So everything goes towards forgetting who the Through the functionality of the structure of workflow
organization is supposed to serve . procedures and approvals are recorded and clearly
The literature also presents characteristics of the BPM defined.
(business process management) approach as a more
broadly management initiative than the traditional and 2) Geographical - It can transmit data quickly over
functional management techniques ,. In process long distances, creating geographic
management, there are changes in organizational structure independence.
and other elements of the organizational design in order to The process of access to vital information, such as
prioritize management processes as an axis of major transplants, must be allowed even in different
importance that the functional axis. There are bigger geographical units.
changes than just being an organization that emphasizes The architecture of computer networks and centralized
process as opposed to hierarchy and that puts a special databases allow processes to communicate in different
emphasis on results and customers. So by the organization units around the country.
and the client processes the result and the indicators are
3) Automational - Potential to reduce human labor Technologies associated with methods such as joint
in a process . purchasing, electronic auctions or supply chains Kaizen
The extent to which a new event is entered into the maximize the gains and economies of scale in
system a whole set of actions can be taken can be taken government..
automatically by well-defined business rules.
The prioritization within a list of activities that demand These are some of functions that BPMS technology
resources in a family health unit should be scripted can do for the health chain in Brazil, significantly
automatically according to the latest information from improving the use of resources, and consequently the
epidemiological demands. service rendered to the population.
4) Analytical – Incorporate complex methods of
analysis. V. CONCLUSION
Linear programming methods are notoriously known for
their efficiency in achieving optimal solutions to complex This article aimed to present the scenario of public
problems. health in Brazil from the viewpoint of quality of services
The sizing of doctors in an emergency care unit at specific provided. The specific focus was given considering the
periods could generate a much higher level of service than possibility of using information systems oriented to
the traditional planning. processes (BPMS) for coordination, monitoring and
analysis of this complex system. Thus, the fundamental
5) Informational - Processes large volume of data. concepts were presented through a review of the literature
The capacity of analyzing multiple variables at once is
and then we analyzed the benefits of integration of
limited resources like computers .
scientific management with ICT ,.
The emergence of patterns within a particular geographic
As a final consideration, we believe that technology
location is able to highlight features and trends that were
considered locally would not be perceived. management processes that exist today already have
features and functions that allow a significant
6) Sequential - Allows reorganization of activities in performance improvement in the quality of services
relation to its temporal flow. provided and managed. Therefore, the management model
The redesign of processes is one of the most fundamental and implementation of public health policies in Brazil
capabilities of these tools for organizations that live in the should be revised to promote social development based on
current context of global changes. technologies available on the frontier of knowledge
Issuing a new law or protocol of the national regulatory (following the trend of evidence-based medicine),
agency (ANVISA) immediately demand a change in changing the paradigm of technical specialist (doctor)
current flow of the process. centralizing the management decisions of the system. We
believe that with explicit rules, values and promoting a
7) Knowledge management - Allows the capture policy of transparency and responsive governance,
and dissemination of knowledge. political influence time will be minimized, giving rise to
Tools for knowledge management are seen as the basis long-term public policy and focusing on the population.
for high performance over time.
The ability to capture and share best practices and
medical procedures has the potential to be one of the most ACKNOWLEDGMENT
important agents in reducing inequality between medical
treatments in different locations (rural and urban areas, for The author thanks the support of Professor Raquel
example.) Flexa, MSc. and all the professors from CEFET/RJ and
8) Tracking - Tracking capability of resources,
products and states.
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