A Process Reference Model for Enhanced Medication Management

Bonnie Urquhart

and Waqar Haque

Northern Health, Prince George, Canada

Department of Computer Science, University of Northern British Columbia, Prince George, Canada

Keywords: Business Ontology, Business Architecture, Business Process Management, Medication Management, Process

Reference Model.

Abstract: A comprehensive management approach to improve quality and safety of medication management within a

multisite health care organization is explored. The process-oriented approach integrates Business Ontology,

Business Architecture and Business Process Management to develop a reference model for medication

management. The model includes one hundred and sixty-four individual processes categorized in four process

areas and twenty-five process groups. The business artefacts and methodology used in the development of

this reference model are also presented. These artefacts were created and validated through workshops and

working group meetings. The developed methodology could be used to create a similar process architecture

in other organizations and service areas.

1 INTRODUCTION

The delivery of health care services is a complex

operation in which care providers and managers are

expected to deliver safe, high quality services within

a resource constrained system. Patient safety is of

paramount importance. The need for improvement in

the medication management processes is evident

based on the incidence of adverse medication events

reported in the literature (Martins, Giordani, &

Rozenfeld, 2014). There are a multitude of clinicians

and support staff involved in medication management

and there are numerous legislated requirements which

both contribute to the complexity of the processes.

There needs to be a shared understanding among care

providers involved in medication management

processes together with an understanding of how

medication management processes fit within the

larger health care system. Business ontology can be

used to create a shared language and identify the

relationships between business objects (Au-Yong-

Oliveria & Ferreira, 2014). Enterprise architecture

provides the structure in which the ontology can be

used to show relationships between like objects

across the organizational architectural layers or

across domains within the same architectural layer

(Hendrickx, Mahakena, & von Rosing, 2012). When

https://orcid.org/0000-0001-7415-1627

https://orcid.org/0000-0002-6921-8097

combined with Business Process Management

(BPM) (Bandra, et al., 2010) in a healthcare

environment, this yields an integrated approach to

design, evaluate and improve safety of medication

management processes. The business layer of an

enterprise architecture framework is at the core of our

proposed model. The application and technology

layers of the enterprise architecture are important

when considering the automated processes

particularly where technology such as infusion pumps

and bar code scanners are used in the processes.

(Singh)

A reference model is either a narrative or visual

conceptual representation of the recommended (best)

practices of a specific domain. A business process

reference model can be used to inform and guide the

development of a business process where no such

model previously existed or it can be used to compare

current business process to a 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 expensive, reference

models can be used to shorten the time to design or

standardize process models across an organization.

The medication management process reference

model presented in this paper is a narrative

Urquhart, B. and Haque, W.

A Process Reference Model for Enhanced Medication Management.

DOI: 10.5220/0008992705470554

In Proceedings of the 13th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2020) - Volume 5: HEALTHINF, pages 547-554

ISBN: 978-989-758-398-8; ISSN: 2184-4305

547

representation of the processes that we believe should

be included in a process architecture for medication

management.

The challenge with producing generic business

process models is that they may be context specific;

therefore, not necessarily transferrable to other

organizations. It is possible that best practice in one

organization or industry may not translate to best

practice in another organization if there is a significant

difference in the strategy of the two organizations

(Ponsignon, Smart, & Maul, 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 (Supply Chain Council

Inc., 2012), SAP R/3 reference model and the Process

Classification Frameworks developed by the American

Productivity and Quality Council (APQC) (American

Productivity and Quality Centre (APQC), 2014).

In this paper, we present a process reference model

for medication management which consists of the

traditional core, support and management processes,

and a fourth area (Clinical Training and Professional

Development) as some included processes can be

considered to be either support, management, or both.

There were two sources of information considered for

use in validating the proposed model: the APQC

Process Classification Framework (American

Productivity and Quality Centre (APQC), 2014) and

The Supply Chain Operations Reference Model

(Supply Chain Council Inc., 2012).

2 METHODS & MATERIALS

Qualitative design, in the form of researcher facilitated

workshops and working groups, was used to develop

business artefacts that were subsequently used to

develop the process reference model. The research

was undertaken in a multi-site publicly funded

Canadian healthcare organization. The business

architecture developed by the Global University

Alliance (GUA) (Global University Alliance, 2018)

and a standard of the LEADing Practice community

(Layered Enterprise Architecture Design) was used

together with the BPM Ontology which was also

developed as part of the foundational business

ontology by GUA (von Rosing, Scheer, & von Scheel,

2014). The architecture is designed in three layers:

business layer, application layer and technology layer.

The business layer has four sub-layers, namely,

purpose and goal, business competency, business

service, and business process. The BPM ontology

includes meta-object groups that have been shown to

apply to almost any process related object and artefact

(von Rosing, Laurier, & Polovina, 2014). The sixteen

meta-object groups are: Service, Business

Competency, Purpose & Goal, Objects, Owner,

Process Flow, Roles, Process Rules, Process Security,

Application, Process Measurement, Channel, Data,

Media, Platform, and Infrastructure. The activities

involved during the design of process reference model

begin by identification of the purpose and goals as

defined by SBOs (Strategic Business Objectives),

CSFs (Critical Success Factors) and KPIs. Business

competencies are then defined and a value chain model

is designed linking processes to each identified

competency. Processes are categorized and results

compared with known relevant reference model, if one

exists, and validated with stakeholders.

3 RESULTS

To be useful, the 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 used the process meta-

objects of the BPMO included in LEADing Practice

standards. 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. 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 behavior that

produce a specific service or product” (von Rosing,

Scheer, & von Scheel, 2014). The process steps and

process activities were not included in the reference

model as this level of detail is context specific at an

organizational and/or department level and could be

different for every organization.

A process can be categorized and tagged according

to the role it fulfils within the organization. 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. The individual roles involved in main

processes are the clinicians and care providers who

assess, diagnose, prescribe, dispense, administer,

monitor and discharge patients. The support processes

support the delivery of the main processes.

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Figure 1: Relationship between Process Reference Model Meta-Objects and Business Artefacts.

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,

A Process Reference Model for Enhanced Medication Management

549

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. A total of four Process Areas were identified:

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. The complete listing

of four Process Areas, twenty-five Process Groups and

one hundred and sixty-four processes is provided in

Appendix 1. Each process is associated with at least

one business competency. The identification of

processes was achieved through review of the

functions included on the Business Competency Model

for Medication Management services.

Each business competency was reviewed and the

processes required to deliver the competency were

listed and included in the process reference model. It

should be noted that a single competency may require

numerous processes to deliver it. Also, some processes

can have a relationship with more than one

competency. An example of this is the process to

“monitor training effectiveness”. This process is

related to more than one competency because they are

separated based on the recipient of the education.

Figure 1 shows the relationship between the

Medication Management Process Reference Model

and the objects included in two business artefacts,

namely, Value Chain and Business Competency

Model.

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

recorded in other relevant reference models. The

second was to review the initial draft of the process

reference model with the stakeholders, including

Regional Director of Pharmacy, within the host

organization. Two reference models were considered

for the purpose of 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). SCOR is specific to supply chain operations and

as such was mainly applicable as a comparator to the

process area of Manage Medication Supply Chain.

SCOR also includes management processes which

were included in the Manage and Administrate process

area. SCOR’s six process groups were mapped to those

included in the reference model. The groups which are

not supply chain specific do not appear in the SCOR

model. The mapping has been excluded from this paper

due to space constraints.

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, the process

owner, reviewed and accepted the process reference

model as a reasonable listing of the processes

associated with medication management and safety.

4 DISCUSSION & CONCLUSION

The proposed Medication Management Process

Reference Model could be employed as a starting point

in other healthcare organizations initiating a process

architecture as it is based on processes which are

relatively standard across healthcare. The processes

are derived from review of the medication

management business competencies included in the

Business Competency Model. These processes are

then categorized into logical groups which are further

categorized into areas.

A common approach to developing a process

architecture is to separate the processes into one of

three types: core, support or management and then

assign these as the highest level of the architecture.

The proposed reference model includes a fourth area

(Clinical Training and Professional Development)

because some processes contained in it 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.

The literature review conducted prior to this

research did not reveal a process reference model

specifically for medication management. The methods

and tools used to create the proposed process reference

model could potentially be used to identify processes

in other service areas or indeed across an entire

organization. Further research could include testing of

the proposed model in other healthcare organizations

and also testing and refinement of the methods and

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tools through application in other service areas or

organizations.

REFERENCES

American Productivity and Quality Centre (APQC). (2014).

apqc process classification framework pcf healthcare

provider members excel. Retrieved November 2014,

from apqc.org.

Au-Yong-Oliveria, M., & Ferreira, J. (2014). World future

review, What if colorful images become more

important than works? Visual represenations as the

basic building blocks of human communication and

dynamic storytelling. World Future Review, 6(1), 48-

54.

Bandra, W., Chand, D., Chircu, A. M., Hintringer, S.,

Karagiannis, D., Recker, J. C., . . . Welke, R. J. (2010).

Business Process Management Education in Academia:

Status, challenges, and recommendations.

Communications of the Association for Information

Systems, 27, pp. 743-776.

Global University Alliance. (2018). Enterprise

Architecture. Retrieved November 2018, from

http://www.globaluniversityalliance.org/research/enter

prise-architecture/

Hendrickx, H. H., Mahakena, S. K., & von Rosing, M.

(2012). The business architecture profession.

Commerce and Enterprise Computing (CED, IEEE

12th Conference. doi:10.1109/CEC.2011.55

Martins, A. C., Giordani, F., & Rozenfeld, S. (2014).

Adverse Drug Events among adult inpatients: a meta

analysis of observational studies. Joournal of Clinical

Pharmacy Therapeutics, 39, 609-620.

Pajik, D., Indihar-Stemberger, M., & Kovacic, A. (2012).

Reference model design: An approach and its

application. IEEE, (pp. 455-460).

Ponsignon, F., Smart, P., & Maul, R. (2012). Process design

principles in service firms: Universal or context

dependent? A literature review and new research

directions. 23(11), 1273-1296.

Singh, K. (n.d.). Integration of Intravenous Infusion pumps

and RFID/NFC-safeguard: the NextGen Infusion

Pumps. Retrieved December 30, 2019, from

http://ks.kanadasoft.ca/pumps

Supply Chain Council Inc. (2012). Supply Chain

Operations Reference Model Revision 11.0. Retrieved

November 2017, from www.supply-chain.org.

von Rosing, M., Laurier, W., & Polovina, S. (2014). The

BPM Ontology. In M. von Rosing, M. Scheer, & H.

Scheel, The Complete Business Process Handbook,

Body of Knowledge from Process Modeling to BPM

Volume 1 (pp. 102-107). USA: Morgan Kaufmann

Publishers Inc.

von Rosing, M., Scheer, A. W., & von Scheel, H. (2014).

The Complete Business Process Handbook Body of

Knowledge from Process Modeling to BPM (Vol. 1).

USA: Morgan Kaufmann.

APPENDIX 1: THE REFERENCE MODEL

1 Manage Medication at Point of Care

1.1 Register Patient

1.1.1 Enrol Patient in Appropriate Information

ste

1.1.2 Confirm Patient Identification and

Identif

for Clinical Pharmac

Services

1.2 Assess Patient

1.2.1 Interview Patien

1.2.2 Order Dia

nostic Tests

1.2.3 Interpret Results of Dia

nostic Tests

1.2.4 Dia

nose Patien

1.3 Prescribe Medication

1.3.1 Conduct Best Possible Medication

Histor

Interview

1.3.2 Conduct Medication Reconciliation

1.3.3 Order Medication

1.3.4 Tria

e medication orders

1.3.5 Perform Clinical assessment of

medication orde

1.4 Dispense Medication at Point of Care

1.4.1 Maintain Point of Care Inventor

1.4.2 Mana

e Patient Owned Medications

1.4.3 Dispense Medication

1.5 Administer Medication

1.5.1 Prepare medication if require

1.5.2 Administer Medication to Patients

1.5.3 Complete Medication Administration

Recor

1.6 Monitor Patient

1.6.1 Provide Pharmaceutical Care to Patients

1.6.2 Deliver Patient Education on Medication

Therap

1.6.3 Monitor Patient Response to Medication

Therap

1.7 Transfer or Discharge Patient

1.7.1 Plan for Patient Dischar

1.7.2 Dischar

e Patien

2 Provide Clinical Training & Professional

Development

2.1 Provide Pharmacy Staff Training

2.1.1 Identif

Trainin

Needs

2.1.2 Develop Trainin

Materials

2.1.3 Deliver Trainin

A Process Reference Model for Enhanced Medication Management

551

2.1.4 Monitor Learner Progress and Provide

Feedbac

2.1.5 Monitor Trainin

Effectiveness

2.2 Provide Clinical Pharmacy Competency

Development

2.2.1 Establish Clinical Pharmacy

Competencies

2.2.2 Develop Competenc

Evaluation

2.2.3 Develop Competenc

Trainin

2.2.4 Deliver Clinical Pharmac

Trainin

2.2.5 Monitor Learner Progress & Provide

Feedbac

2.2.6 Monitor Trainin

Effectiveness

2.3 Provide Clinical Education(External to

Pharmacy)

2.3.1 Identif

Trainin

Needs

2.3.2 Develop Trainin

Materials

2.3.3 Deliver Trainin

2.3.4 Monitor Learner Progress and Provide

Feedbac

2.3.5 Monitor Trainin

Effectiveness

2.4 Manage Clinical Student Placement

2.4.1 En

e with Education Providers

2.4.2 Identify Potential Candidates & Make

Selection

2.4.3 Develop Trainin

Plan

2.4.4 Monitor Student Progress & Provide

Feedbac

2.4.5 Evaluate Effectiveness of Trainin

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 Identif

and Maintain Supplier Lis

3.1.4 Ne

otiate with Suppliers

3.1.5 Collaborate with Suppliers

3.1.6 Monitor Supplier Performance

3.1.7 Perform Analysis and Response to Drug

Shorta

3.1.8 Purchase Medication

3.1.9 Receive purchased medication

3.1.10 Initiate Pa

men

3.1.11 Pa

Suppliers

3.2 Maintain Medication Inventory

3.2.1 Define Inventor

Strate

ies

3.2.2 Define Inventor

Deman

3.2.3 Create Inventor

Plan

3.2.4 Define Performance Metrics

3.2.5 Establish Standards for Medication

Stora

3.2.6 Ship Inventory to secondary inventory

locations

3.2.7 Store purchased medication

3.2.8 Monitor medication stora

e procedures

3.2.9 Perform Inventor

Coun

3.3 Mix & Repackage Medication

3.3.1 Issue components from inventor

3.3.2 Compound Medications Outside Laminar

Hoo

3.3.3 Compound Medications within Laminar

Hoo

3.3.4 Packa

e Compounded Medication

3.3.5 Add Compounded Medications to

Inventor

3.3.6 Remove bulk packaged goods from

inventor

location

3.3.7 Repacka

e into sin

le use doses

3.3.8 Restore unit dose packa

es in inventor

3.3.9 Repackage medications for 24 hour Batch

( patient specific)

3.3.10 Pick medication from inventor

3.3.11 Issue medication from perpetual

inventor

3.4 Distribute Medication

3.4.1 Transport purchased medication to

secondar

inventor

location

3.4.2 Document Patient Specific Medication

Orders

3.4.3 Verif

Patient Specific Medication Orders

3.4.4 Dispense Patient Specific Medication

3.4.5 Replenish Ward Stoc

3.5 Return Medication

3.5.1 Identify expired medications in Pharmacy

Inventor

3.5.2 Return Expired Dru

s to Pharmac

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 Strate

ic 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 Mana

emen

4.1.6 Establish Population Level Surveillance

Plan

4.1.7 Develop & Communicate Regional

Services Plan

4.1.8 Plan Research Strate

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4.1.9 Develop Medication Research Strate

4.1.10 Establish Formular

Mana

ement Plan

4.1.11 Establish Business Operatin

Plan

4.1.12 Establish Standards for Pharmacy &

Medication Mana

emen

4.1.13 Establish Plan for Clinical Trials

4.1.14 Identif

Qualit

Improvement Plan

4.1.15 Plan for lon

term business operations

4.1.16 Establish Performance Measurement

Plan

4.1.17 Maintain Dru

Formular

4.2 Manage Risk

4.2.1 Establish Risk Anal

sis Framewor

4.2.2 Establish Risk Measures

4.2.3 Establish Risk Monitorin

Plan

4.2.4 Establish Risk Reportin

4.2.5 Establish & Maintain Response to

Adverse Events

4.2.6 Establish & Maintain Risk Rules &

ulations

4.2.7 Establish & Mana

e Risk Compliance

4.3 Monitor Compliance

4.3.1 Manage and Monitor Progress related to

Governance Plan

4.3.2 Establish Compliance Plan and Reportin

4.3.3 Validate medication orders adhere to Safe

Medication Order Writin

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 Ne

otiate contracts

4.4.2 Mana

e contract Bud

4.4.3 Evaluate and monitor contract liabilit

4.4.4 Evaluate and monitor contract

erformance and compliance

4.5 Manage Human Resources

4.5.1 Identif

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 Mana

e Staff Performance

4.5.7 Mana

e Staff Reco

nition Pro

4.6 Manage Financial Resources

4.6.1 Identif

Operatin

Bud

et Requirements

4.6.2 Monitor Operatin

Expenditures

4.6.3 Initiate Operating Budget Remediation

Actions

4.6.4 Identif

Capital Bud

et Requirements

4.6.5 Monitor Capital Expenditures

4.6.6 Initiate Capital Budget Remediation

Actions

4.6.7 Forecast operating and capital budget

erformance

4.6.8 Initiate Accounts Receivable

4.6.9 Collect Accounts Receivable

4.6.10 Mana

e Emplo

ee Travel Expenses

4.7 Manage Information

4.7.1 Establish Information S

stem Standards

4.7.2 Mana

e Information S

stem Access

4.7.3 Mana

e Patient Records

4.7.4 Monitor & Improve Data Qualit

4.7.5 Maintain clinical pharmac

patient recor

4.7.6 Maintain Medication information

resources

4.7.7 Maintain Inventor

Data

4.7.8 Manage Master Drug Library for Infusion

Pumps

4.7.9 Develop and Maintain medication order

sets

4.7.10 Develop & Maintain Performance

Monitorin

Reports

4.8 Procure & Maintain Equipment &

Facilities

4.8.1 Establish & Mana

e Equipment Schedule

4.8.2 Procure Equipment through Renting or

Leasin

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 Mana

e 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 Improvemen

4.9.7 Implement and Maintain Anti-Microbial

Stewardship Pro

4.9.8 Promote Integration & Practice

Mana

emen

4.9.9 Develop & Maintain Community &

Emergency Response Plan

4.9.10 Research Best Practice

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553

4.9.11 Establish Emergency Response Policies

& Procedures

4.9.12 Mana

e Fleet Vehicles

4.9.13 Develop & Monitor Administrative

Reports

4.9.14 Develop & Monitor Clinical Reports

4.9.15 Develop & Publish Performance Reports

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