Utilizing Business Service Management Concepts to Improve Healthcare Information Services
Lessons from the Implementation of the Information Technology Infrastructure Library (ITIL) at a Regional Medical Center
This article presents background information on the Information Technology Infrastructure Library (ITIL) and Business Service Management (BSM), introduces methodology for implementing the ITIL processes in a business, and highlights lessons learned from the initial implementation of these processes at a regional medical center.
Business Service Management (BSM) is a fairly new methodology, which is being used by Information Technology (IT) organizations and businesses to describe a way to organize, operate, and manage IT Services. Specifically, BSM allows an IT organization to properly align critical business services to the underlying IT infrastructure that provides the service, as described by the Information Technology Infrastructure Library (ITIL). This article provides a brief summary of ITIL and BSM, and describes the adoption of BSM concepts in an IT department and a business service unit of a regional healthcare provider that aims to further examine key performance indicators. The goal of the project described in this article is to identify potential points of service failure and proactively prevent these service failures from occurring, create a more efficient information flow, improve patient care, and lower IT costs. The lessons learned from the implementation of BSM at this company will be outlined in the article.
Background – Business Service Management
In order to fully explore BSM, we must also look at ITIL and its goals. The Information Technology Infrastructure Library (ITIL) was first published by the British Office of Government Commerce in the early 1990s, and became widely adopted in the mid-1990s. ITIL was originally conceived of as a way to better align information systems with the business processes they supported. The goal was to improve the management of IT by implementing a more process-oriented model of control. Starting with ITIL version three, ITIL concepts focused on developing the quality of services that IT organizations provide to the business, rather than simply managing and maintaining the business IT infrastructure and technology. ITIL V3 introduces the idea of the “service life-cycle,” with five major components:
1. Service strategy—guidance, policies, and processes that assist in developing service management policies to govern the other service components,
2. Service design—guidance on developing processes that manage how changes and improvements are made to increase and maintain the business value,
3. Service transition—guidance on the development and improvement of capabilities for transitioning new and changed services into operations,
4. Service operations—guidance on achieving effectiveness and efficiency in the delivery and support of services so as to ensure value for the customer, and
5. Continual service improvement—guidance on creating and maintaining value for customers through better design, transition, and operation of services.
With the addition of the “service-life cycle,” ITIL is focused more on the implementation of high levels of IT service for the business.
ITIL is becoming much more widely accepted in the business and IT communities. According to a study by Dimension Data, 85 percent of American CIOs stated that IT service management practices will allow increased optimization of IT “best practices” with 60 percent stating they were focused on implementing the ITIL framework.
Business Service Management enables organizations to implement the ITIL framework, and enables the goals of the business to be more closely related to the IT components that support them. It also represents “a category of IT operations management software products that link the availability and performance status of underlying IT infrastructure and applications components to business-oriented IT services that enable business processes.” Implementing this type of software can improve the service levels provided to the organization by IT, and reduce costs for the IT organization and the business.
According to Marquis, the implementation process for BSM can be broken into four steps:
1. Define IT services and validate business cases.
2. Analyze service value and prioritize services in terms of IT focus.
3. Measure quality externally from the organization to choose improvement opportunities for those services that are not performing as required from the service consumer.
4. Authorize every IT improvement program as a formal project and allocate resources.
Adoption of ITIL and Business Service Management practices
Individual business services are built out of many different processes, policies, functions, systems, and customer interactions. The ability to model these moving parts in a single monitoring system is the real value of BSM, as the organization gains insight into the business service, end to end. In this section, the key module layers in BSM are discussed using the example of a large regional medical center, which benefitted from the flexibility and value that BSM adds to an organization.
In 2007, a large regional medical center began to implement ITIL practices into their IT long-term planning as well as in daily operations. In the fall of 2008, these practices were extended to the hospital’s IT Project Management Office, which specifies the ITIL guidelines implemented for knowledge, change, and service management modules. Goals were established for the BSM services, and several vendor applications were solicited to assist with the implementation of BSM.
The goals and anticipated benefits of the BSM modules were: a) monitor end-user experience to identify IT problems; b) spot pre-failure warnings through trending and historical analysis; c) prevent “finger pointing” through early detection of potential service failures; d) distinguish between vendor points of failure and internal points of failure; and e) provide management dashboards (a user interface to provide a visual representation of multiple key performance indicators) and alerts.
A vendor was selected to provide the core software for the “Business Service Management Model,” which functions as the engine that maps incoming data to the relevant business process it impacts. Once the business service is defined, and the IT components that provide this service are mapped out, data can be collected and used to tailor dashboards to the different end users. This in turn allows users to make informed decisions based on current and historical data. Implementation of this service monitoring module began in early 2009. Key to the implementation was mapping specific hospital workflow practices to the monitoring system.
The first layer inherent in the BSM is the establishment of the proper metrics and standards for the services being monitored. These metrics must be divided between those items that are the responsibility of the IT department and the service level agreements (SLA) with the individual hospital service providers. The IT responsibility arena includes items such as measuring network speed and managing capacity, including utilization of the central processing unit and random-access memory. The service level agreements are based on measurements like transaction or response times, and define the acceptable levels of performance for these metrics and the penalties for failing to meet these performance targets.
The next layer is what really defines BSM. When modeling a line of healthcare services, there are generally clearly defined steps that need to be monitored. For example: measuring the time from when a patient enters the hospital’s emergency room, to when they are provided the needed services and, finally, to release or admittance. A metric that defines this level of performance is called a key performance indicator (KPI). KPI’s are generally built upon SLA’s with additional interaction measurements between the managed service and the customer. Another example of a KPI would be the amount of time it takes for an employee to capture and enter new patient contact information. This time is measured from the time the employee starts entering the information to the time the system returns a complete message back to the employee, acknowledging that the information was captured accurately. This time measurement includes both the system response time and any additional interaction time between the patient and the employee, as the measurement starts as soon as the employee opens the new customer screen and ends only when the data is saved to the system. Thus, business performance is measured in KPI’s, which are an aggregation of system time (as defined by the SLA’s with the business unit) and interaction times.
Building Business Service Management Modules
All of the different layers of criteria and standards may be represented via a tree. Each layer of the tree has a node, which represents a service. In the tree, there is a top node or service, defined as a KPI. Other layers define the measurement standards, locations, and performance standards. Figure 1 represents the model to measure the business service management performance of the hospital’s emergency department (ED). The following definitions will assist in the understanding of the module components:
1. KPI—Key Performance Indicators for this tree are the actual business process definitions, such as “quick registration” to “triage,” which is the time it takes for a patient to go through the quick registration process, and ends when the triage process begins. Each KPI is the next step in the ED process in this service model.
2. Location—This medical center has multiple ED departments.
3. Acuity—Patients are assigned an acuity level or degree of illness.
4. Process—Due to the performance measures being calculated, patients could be divided into different process levels within each KPI. For this example the process levels are “In Process” and “Completed.” A patient is in process if they have a start timestamp for a KPI, but no end timestamp.
5. Performance—In this particular model we are measuring two performance metrics: the number of patients in the business process, and the average wait time for those patients in this business process. Each base node would represent the complete segregation of data we were looking for and as you moved up the tree, the “Patient Count” and “Average Wait Time” would aggregate to give you another view. This means, at the Acuity level, you would see the total number of patients and the average wait time across all of the nodes below Acuity.
Figure 2 represents what one entire leg of the tree would look like once data is entered into the system. The base of the tree, when fully populated, has approximately 300 nodes across. Once data is fed into the system, the tree grows horizontally at each layer of the service model. As messages come into the system via the data feed, the messages are compared to the model template. The model template is essentially a waterfall filter, which determines where the message (the data) fits into the tree. Once the message is fit into a template, it is compared to the other data that has already been fed and fits that template. If the node already exists, it is updated. If the node does not exist, a new node is created. The system then moves on to the next data set: building the message, running the message through the waterfall template filter, and fitting the data into the tree.
IT management, ED management and first-line supervisor dashboards
Once the model is populated, the tracking of performance can be segmented into a series of dashboards to assist IT management as well as ED personnel to identify potential bottlenecks. Several of the key management dashboards are shown below:
Figure 3: An executive summary dashboard that tracks and reports five KPI’s in terms of their current quality, availability, SLA status, and monthly quality trends.
Figure 4: This dashboard shows, by criteria, nodes where there might be service bottlenecks. This figure represents those items previously defined in Figure 2 and those that might be out of compliance for pre-established SLAs. The user can click on any node to drill down and respond to situations where the business might be performing poorly.
Figure 5: This operation dashboard shows another view of the overall throughput of the ED business processes. It provides management and front-line supervisors information on the key KPI’s impacting service levels. The most interesting gauge here is the Acuity Throughput gauge—this is the number of hours, on average, it takes a patient of a specific acuity level to get through the selected ED location.
Usage and Implementation
As this article was written, the dashboards were being introduced to additional IT management and the ED management at the medical center. A key component of using the dashboards is to train all users on their meaning and how responsible individuals may respond to different nodes that may be out of compliance.
Care was taken to involve the end user in the establishment of the KPI’s, the nodes to monitor, and potential responses. The goal is not to track failures and “point the finger,” but rather to assist the ED and IT supervisors in preventing a potential future service failure. For example, the BSM provides the acute care ED nursing supervisors real-time data on how many patients are currently in the queue at each specific level of acute care. This enables the supervisor to shift ED staff to those acute care levels approaching service failure.
The project team at the regional medical center reported success in the adoption of this business service management module. Several lessons were learned from this adoption, which will be applied to future work in expanding the modules and future implementation of ITIL standards. They are:
1. Creating and implementing this solution was more resource-intensive than originally anticipated. The next portion of this implementation will require additional monies more appropriately budgeted. Additional resources applied to develop and maintain the solution, including modeling business processes, creating dashboards, and mapping the information systems, are key to a successful implementation. The development and ongoing maintenance are extremely time-intensive tasks that require focus, especially in a rapidly evolving environment like healthcare.
2. Input from the employees who work the business processes each day is absolutely required from the start of the project. Their feedback allows the model to be more accurate conceptually. Including the business service managers as the KPI’s are discussed and developed on the dashboards is especially crucial, as these are things the business service managers may already be tracking.
3. Finally, this solution is best for process-driven businesses where management is already looking for ways to improve performance. If business lines operate in an organized fashion with clear business processes, the dashboard monitoring and maintenance costs decrease, and the process becomes easier. When starting a BSM project, it would be wise to start with a well-defined business process or unit, as these projects are more likely to succeed.
While this article tracks the implementation of ITIL standards at one medical facility, this method of process-improvement is relevant for any number of businesses and industries. Examples of other industries that may benefit from ITIL include production, shipping operations, financial institutions, and customer service. Management in each of these areas could work with their IT teams to define the key performance indicators, the primary bottlenecks, and the acceptable level of operations and service response times. Once these are defined, the use of dashboards can alert management to potential problem areas in advance, thus permitting managers to respond proactively to problems, rather than simply “fighting fires.”
 Marquis, H., “Business Service Management: What It Is and Why You Should Care,” Global Knowledge, August 2008 [White paper]. Retrieved from http://whitepapers.zdnet.com/abstract.aspx?docid=384727. (link no longer accessible).
 Dubie, D., “ITIL Adoption Increases in U.S., Proficiency Still Lacking,” Network World: Feb. 29, 2008. Retrieved from http://www.networkworld.com/news/2008/022908-itil-adoption.html.
 Compuware. “Vantage Service Manager: A Technical Overview,” 2007 [White paper]. Retrieved from http://whitepapers.techrepublic.com.com/abstract.aspx?docid=347890.
About the Author(s)
Matthew Hernandez, MS, is currently employed in the healthcare industry where he has worked for the past six years. He received his master’s degree in computer science and information systems from the University of North Carolina Wilmington in 2009, where he also obtained a BS degree in 2004. His day-to-day tasks include project management, systems architecture, strategic infrastructure planning, IT, and BSM.
Thomas Janicki, PhD, is an associate professor of information systems at the University of North Carolina Wilmington. He obtained his doctorate at Kent State University. Previously he worked for PPG Industries and several management consultant firms where he specialized in strategic planning. Janicki is the president of the Education Special Interest Group for the Association of Information Technology Professionals, an international organization dedicated to ensuring that IS curriculums stay relevant to industry.
Bryan Reinicke, PhD, is an assistant professor of information systems at the University of North Carolina Wilmington. He obtained his doctorate at Indiana University. Previously, he worked for Accenture in several different roles on enterprise systems implementations for clients in a variety of industries. His research focuses on systems design and implementation and the IS challenges following acquisitions.