Business process re-engineering –saviour or just another fad?One UK health care perspectiveAnjali PatwardhanHealth Service Management Centre,Birmingham,UK,and Dhruv Patwardhan University of Newcastle,Newcastle upon Tyne,UKAbstractPurpose –Pressure to change is politically driven owing to escalating healthcare costs and an emphasis on efficiency gains,value for money and improved performance proof in terms of productivity and recently to some extent by demands from less satisfied patients and stakeholders.In a background of newly immerging expensive techniques and drugs,there is an increasing consumer expectation,i.e.quality services.At the same time,health system managers and practitioners are finding it difficult to cope with demand and quality expectations.Clinicians are frustrated because they are not recognised for their contribution.Managers are frustrated because meaningful dialogue with clinicians is lacking,which has intensified the need for change to a more efficient system that satisfies all arguments about cost effectiveness and sustainable quality services.Various strategies,originally developed by management quality “gurus”for engineering industries,have been applied to health industries with variable success,which largely depends on the type of health care system to which they are applied.Design/methodology/approach –Business process re-engineering is examined as a quality management tool using past and recent publications.Findings –The paper finds that applying business process re-engineering in the right circumstances and selected settings for quality improvement is critical for its success.It is certainly “not for everybody”.Originality/value –The paper provides a critical appraisal of business process re-engineering experiences in UK healthcare.Lessons learned regarding selecting organisations and agreeing realistic expectations are addressed.Business process re-engineering has been evaluated and reviewed since 1987in US managed health care,with no clear lessons learned possibly because unit selection and simultaneous comparison between two units virtually performing at opposite ends has never been done before.Two UK pilot studies,however,add useful insights.Keywords Business process re-engineering,Total quality management,Continuous improvement,Medical management,Health services,United KingdomPaper type ViewpointHistory of quality management in health careTo know how health care organisations became interested in industrial quality development tools and how business process re-engineering (BPR)emerged as an option,we have to go back to 1987when the Quality Improvement in Health Care National Demonstration Project (NDP)was launched as an experiment (Godfrey,n.d.).A total of 21health-care organisations participated and promised to support this study lasting eight-months.The aim was to look at the applicability of industrial quality-improvement methods to health care.Support included free consulting,The current issue and full text archive of this journal is available at/0952-6862.htmBPR –saviour or just a fad?289Received 29November 2006Revised 10February 2007Accepted 25May 2007International Journal of Health Care Quality Assurance Vol.21No.3,2008pp.289-296q Emerald Group Publishing Limited 0952-6862DOI 10.1108/09526860810868229materials,access to training courses and reviews.The funding companies included many of the USA’s leading organisations such as Corning,Ford,Hewlett-Packard,IBM and Xerox.At the final stages of the project evaluations it was clear that out of 21organisations,15health care organisations made significant progress –mainly financial and patient satisfaction gains,target and project time keeping and investment in research and development.The NDP was extended for three years,which eventuallyevolved into the Institute for Healthcare Improvement,a not-for-profit organisation –dedicated to providing health-care quality management ter,BPR emerged as an alternative for managers in organisations frustrated with slow improvements,not encompassing the whole organisation experiencing total quality management (TQM).The TQM key target was to convert an organisation’s structure,culture and services to patient/consumer rather than organisation-focused goals (Harvey and Millett,1999).Why change?Traditionally health care systems were mostly “governed”by clinicians (Shutt,2003)because patient outcomes;that is,recovery from illness,were the sole responsibility of all professionals directly involved in patient plexity and variance in health care studies reveal that outcome has many determinants;i.e.pharmacy,pathology,technical support and information technology.It was also realised that cost containment and good quality care needed teamwork,communication,time management,etc.(Shutt,2003).Sir Roy Griffiths,in the early 1980s,developed hospital general management and the greater involvement of clinicians in resource management initiatives (DHSS,1984).Today,apart from political motives,change is driven by escalating health care costs,increased demands for quality care,value for money services,patient expectation and third-party payers in managed health care systems.These intensified the need for change to more efficient health care systems.What is BPR?BPR,also known business transformation and process change management,was introduced to the business world by Frederick Taylor in his article The Principles of Scientific Management in the 1900s (wikipedia,2006).In the 1990s,Hammer and Champy (1993)introduced Reengineering the Corporation ,which gave birth to BPR.BPR is “the analysis and design of workflows and processes within and between organizations”(Devenport and Short,1990,p.11).Teng et al.(1994)on the other hand,defined BPR as critical analysis and radical redesign of existing business processes to achieve breakthrough improvements in performance measures.Hammer and Champy (1993),similarly,defined BPR as fundamentally rethinking and radically redesigning business processes to achieve dramatic improvements in critical contemporary performance measures such as cost,quality,service and speed.From a health care viewpoint,BPR is a management approach that rethinks present practices and processes in business and its interactions.It attempts to improve underlying process efficiency by applying fundamental and radical approaches by either modifying or eliminating non-value adding activities and redeveloping the process/structure/culture (McNulty and Ferlie,2000).However,in the health sector,a wide variety of patient groups make the health care service a complex project to redesign along these lines,thereby rendering changes context and time sensitive.IJHCQA 21,3290BPR key featuresHealth care’s BPR approach means starting with clean slate and rethinking services using a patient-focused approach.With the benefit of hindsight BPR identifies delays caused by unnecessary steps or potential errors that are built into processes.It is presumed that redesigning processes by removing these errors dramatically improves care quality.The BPR approach,therefore,raises expectations about dramatic results. Consequently,high returns on investment are anticipated.The process,planned strategically,is explained in Taylor’s BPR framework(wikipedia,2006): .defining BPR’s purpose and goal;.identifying requirements that meet clients’needs;.defining project scope,including appropriate activities such as process mapping;.assessing the environment using,for example,force-field analyses;.re-engineering business processes and activities;.implementing redesigned processes;and.monitoring redesign success and failure.BPR vs TQMComparing BPR with other popular quality management methods helps us to appreciate and highlight key features in a health care context(Harvey and Millett,1999).TQM or continuous quality improvement(CQI)refers to programmes and initiatives that emphasise incremental improvement in work processes and outputs over an open-ended time period.In contrast,BPR refers to discrete initiatives intended to radically redesign and improve work processes within a time frame.Some people think TQM is best suited to quality in health care improvement though it is an incremental stepwise,slow but holistic approach.In practice,TQM and BPR are customer-oriented and both encourage managers and practitioners to take a customer view point.Both are team approaches that involve process control.The TQM protagonists assume that existing health care practices and systems are principally right but improvements are needed.The BPR supporters,on the other hand,assume that health care systems and practices areflawed and need replacing.Those using TQM expect and believe in stepwise increments in performance as opposed to BPR experts who look for dramatic results.TQM aims to improve all levels for all stakeholders and at all steps,while BPR aims at specified areas only.Standardisation and supporting documentation is a TQM key point.Believing in consistent and cost-effective performance and minimising process or system defects, prevents rather than corrects problems(Field and Swift,1996).Those that use the BPR approach,on the other hand,areflexible and assume that standardisation increases process complexity(Harvey and Millett,1999).Nevertheless,BPR is a drastic change leading to staff resistance.Moreover,it is a top-down approach,so management support and commitment is vital to success.Innovation,therefore,is a risky process when used for“sick organisations”.The TQM incremental method,on the other hand,follows a gradual approach that is mostly bottom-up.It involves employees and often based on Deming’s principles that direct improvements through plan-do-study-act(PDSA)cycle.TQM,therefore,is suitable for improving quality in any organisation,although some amendments to suit context may be needed.Application in managed health care generated different results BPR–saviour or just a fad?291when dissimilar processes were applied in different scenarios.Business process re-engineering,therefore,may not suite everyone because it works better when applied to sick organisations or in fundamentally defective systems (Bashein et al.,1994).The TQM approach is about a cultural change as it is built into practices hooked on daily routines.The BPR method is a target-oriented process that is time sensitive because if not completed as planned then success may be jeopardised.The TQM primary enableris statistical process control,while in BPR it is information and technology (Harvey and Millett,1999).Advantages of applying BPR to health service quality improvementUsing BPR in the health sector was a response to frustrations amongst managers in organisations who perceived TQM’s incrementalism and ability to achieve organisation-wide change had failed.King’s College Hospital experience (Grimes,2000;Harrison et al.,1992)suggests that BPR could be best tried to achieve previously unachieved levels of efficiency in scenarios when other efforts/methods had been unsuccessful.The driving forces for change were aspirations to develop a more efficient system that satisfies consumers’demands for service quality and value for money (Bowns and McNulty,1999).At the same time,BPR makes it possible to sustain such quality without necessarily costing more,even though we know that health care costs are rising steeply.The third and most important aspiration in the King’s project was to improve professionals’job satisfaction,what they felt they always deserved.The aim was to orient health care towards and focus on patients rather than organisation needs.The BPR approach focuses on rethinking and redesigning processes from scratch,giving staff opportunities to revisit services in detail,thereby pointing out improvement areas.It strips all non-value adding and unnecessary steps from the process to make services more efficient.Although it is managed top-down and dominated by managers and leaders,decision making is done at the coal-face,thereby empowering the team.The BPR approach provides a flexible work environment,culture and work practices.It can be valuable for organisations in deep difficulties and performing poorly.In such a crisis,re-engineering may be the only way organisations can survive (Harvey and Millett,1999).Where major structural and cultural deficiencies are identified or are obvious as a poor performance cause,BPR is the best way to handle that scenario –evident from King’s College Hospital experiences (Bowns and McNulty,1999).BPR limitations in health care quality improvementWe know that BPR is a top-down approach that staff may resist.It is cited by autonomous clinical professionals as “a brutal and inappropriate technique”(Jones,1996,p.4284).Implementing BPR in health care scenarios,where clinicians are key players,therefore,is not only difficult but also unsafe (McNulty and Ferlie,2000).Thus,BPR may lead to ownership loss and employee de-motivation because they are not involved in planning and change management.Generally,change processes are less-well understood by employees (Jones,1996,p.4284):Quality would seem unlikely to be forthcoming if re-engineering is imposed from the top down in a rigid and mechanistic fashion ...If organizational change is to be effective and sustainable,this will also require the active engagement of,and learning by,employees rather than grudging compliance with management diktat.IJHCQA 21,3292Quality improvement in European public services elaborated health care TQM and BPR as quality improvement tools.It was acknowledged that many business approaches to quality improvement,including TQM and re-engineering,failed to take account of health care’s complexity and the nature of professionalised knowledge.The language and values used in most of these projects were alien to clinicians and so were rejected as management fads.It seems that BPR requires massive culture and structure change if it is to improve quality of the same magnitude.It may be that radical overnight transformation may sound impressive but unrealistic.Structural and cultural change needs time to develop,be accepted and absorbed at all levels, particularly in health care settings.In short,BPR is a high-cost and high-risk project. Seventy-percent of all industries could not achieve their targets–a BPR success rate around30per cent.In the health care sector,on the other hand,from the literature we reviewed,there is no successfigure available.BPR carries an unrealistic scope and expectation most of the time,which may be a reason for its70per cent failure rate.Its top-down nature and success depends on sustained management commitment and inspirational leadership,which is not easily measured and may not be available up to the threshold needed.BPR may make only a unit change in time.To be meaningful,it needs to be followed by a CQI exercise.Once changes are brought about,BPR-based change needs CQI projects to have sustained results.It is always contested that BPR does not take account of human processes–evident from Jones’(1996,p.4284) quotation:Such a perspective is seen as promoting the idea that you can design a perfect process, implement it exactly as you planned and the organizational machine will carry it out faultlessly.Setting on one side questions about the reliability of this whole process,it is evident that BPR neglects the important role of human creativity in making process work. As we raised earlier,BPR usually innovates one process at a time rather than a whole organisation approach.The process that is changed,therefore,might not have an effect on overall organisational performance that can be measured especially those perceived by consumers.In other words,BPR may have a drastic effect on one specific process but none or very little on total organisational performance.A simple illustration for improving inpatient admissions shows that BPR alone cannot improve services.There will be need also to improve day care,outpatient,primary care and emergency services. All have an effect on an organisation’s inpatient services because they are interlinked and interdependent.Moreover,BPR’s effect can be difficult to assess in this context since NHS organisations lack specific measures(Bowns and McNulty,1999).The extent to which BPR is applicable to health care systemsThe UK BPR health care experience comes from two centrally funded pilot studies:(1)King’s College Hospital,London(KCH);and(2)Leicester Royal Infirmary(LRI).The KCH project was evaluated by a Brunel team(Packwood et al.,1998;Grimes,2000) and the LRI scheme by Sheffield and Warwick(Bowns and McNulty,1999).Employees in these organisations shared their BPR experiences during evaluation.Consequently, both studies generated interesting and valuablefindings as they highlighted to what extent BPR could be applied to health care systems.However,the two hospitals were BPR–saviour or just a fad?293extremes,i.e.KCH was a “sick”unit at the time of the study.LRI,on the other hand,was one of the best teaching hospitals (McNulty and Ferlie,2000)with little scope to improve.At the end of the pilot studies it was evident from reports that both hospitals could not reach expectations especially the drastic changes and improvements anticipated at the beginning of the BPR projects.Both reduced waiting times and length of stay along with faster diagnostic processes.King’s,over and above theseimprovements,also made £1million savings (Grimes,2000)–attributed to “waste reduction”by process mapping followed by removing non-value adding activities and by increasing efficiency in the renewed system (Packwood et al.1998).This suggests that BPR is not for everybody and that selecting units to which BPR can be applied is important to achieve desired results.When the two trusts ran the pilot,they also continued to work on their generic and core improvement initiatives at different levels in the process and so it was difficult to attribute success to BPR alone or to assess its relative contribution to overall improvements.One approach to identify suitable sub processes for applying BPR is process mapping from “door to door”,which helps capture all the process components and applying a lean approach (Jones and Mitchell,2006,p.23).Identifying value-added activities highlights the non-value-added ones.Each non-value-added activity can be measured and analysed to assess its impact and ways to eliminate activity.Resource availability,deadline,cost,generic skills and above all,urgency to change help users select the right improvement tool.Also,as raised earlier,change management success is closely related to team morale,ownership and motivation.To achieve quality in health care services,therefore,two key staff groups –managers and clinicians,who come from different cultural backgrounds and are knowledgeable in different ways,need to work as a team.Understanding and cooperation are crucial if difficult tasks are to be accomplished (Shortell et al.1998).However,BPR’s failure to consider the human aspects of processes may make it difficult to integrate BPR into health care services.The BPR approach sounds impressive but unrealistic because soft structural and cultural change need time to develop particularly in health care settings.We believe that BPR can help to improve health services if it is meticulously planned and applied diligently.In short,even with all BPR’s limitations,it is still capable of delivering dramatic results not least because it forces staff to think from outside the scenario or process as a whole and work to deadlines (Bowns and McNulty,1999).Conclusions and recommendationsHealth care is a more complex system than any manufacturing industry.As a service provider with a major human component there are safety and efficiency issues rather than cost and efficacy,which separates health care from industry.BPR,like other single approaches to improve service quality,are likely to be unsuitable for health care (Shortell and Ferlie,2001),which is comprised of a number of sub processes.It has many stakeholders at different levels and there is wide variation in its internal customer (e.g.,fellow professionals)and external customer (i.e.patients)needs.We accept that BPR can be used as a tool for improving some sub-process or sub-unit activity.An example could be what happened in the LRI where BPR was tried as a quality improvement tool in bed management,pathology and OPD service innovation,etc.;but not applied in areas where clinician’s precision was paramount or where BPR was accepted less-well.In these areas,therefore,views on the methods’suitability forIJHCQA 21,3294quality improvements were mixed.That is,TQM and BPR ideally should always be followed by CQI methods for service improvement to be sustainable and effective.In short,quality management tools designed for industry should be applied to health services with proper selection,caution and care.ReferencesBashein,B.J.,Markus,M.L.and Riley,P.(1994),“Preconditions for BPR success:and 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