A system engineering model for the health care

services performance analysis

A case study on a Territorial Health Care Agency

Teresa Taurino

Dario Bellomo

Department of Management and Production Engineering

Politecnico di Torino
Corso Duca degli Abruzzi, 24, 10129 Torino, Italy
teresa.taurino@polito.it

S.O.S, Penitentiary Medicine

Azienda Sanitaria Locale di Asti ASL AT
Via Conte Verde, 125, 14100 Asti, Italy

AbstractIn present work, an analogy between the

maintenance function and the health care system has been
identified and justified. The modeling has been translated into an
ontology at a macro level of territorial health services that
provides a key to understanding organically various aspects to be
taken into account in the analysis and evaluation of system
performance on an area. The proposed ontology has been used as
a guide in conducting the analysis of the characteristics and
performance of a regional health care system in a city in
northern Italy. The analysis is performed on the basis of real data
about the user population and the benefits provided by the
system.
Keywords health care system, process
performance, KPI, essential level of assistance.

I.

maintenance,

INTRODUCTION

The system of health care services includes all the

organizations, institutions and resources whose primary
objective is to promote, maintain and restore health [1].
Evaluating the performance of a health system involves two
key issues, the first is to assess whether the health care system,
as it is organized, is able to reach its objectives and the second
is to compare achievements with what the system is capable to
do, evaluating the level of performance delivered. The health
care demand is strictly related to territorial peculiarity that can
influence the answer of the system. In order to guarantee an
essential level of offered health care services for all citizens, in
Italy, the decree of the President of the Council of Ministers of
29 November 2001, defined the Essential Levels of Assistance
(ELA) that establish the health services guaranteed by the
national health service [2]. The status of health, is, also,
strongly influenced by other aspects such as the level of
education, economic independence, the health of the
environment [3]. The performances of the educational system,
the environmental protection and the economic growth of a
state, even if they do not have as their main objective the
improvement of health status, are important influences on
outcomes [4]. Health services are provided to the population on
the basis of three different levels of care [5]. The first level of
care (primary health care) is the first contact between the health
system and the citizen and must be accessible to all. The
performances that belong to this level of care include

prevention, maternal and childcare, control on safety of water

and food, prevention through vaccination and education on
specific risks or diseases. Qualified personnel who do not have
the first contact with the citizen and who intervenes for acute
cares short periods provide the second level of care (secondary
health care). In such treatments are included outpatient services
provided by medical specialists, and services provided by the
hospital emergency department. The third level of care (tertiary
health care) includes all services that must be provided within
the hospital to inpatients The need and importance of the
evaluation of the performance of a health system cannot be
fully satisfied without a model that guides the analysis and the
performance evaluation [6]. The analysis of complex systems
is a well-known topic in industrial environment where a lot of
modelling techniques have been developed in order to give a
correct evaluation of the system and support the managers in
the decision making process [7]. The engineering education
received and the experience in modelling of industrial networks
gained in the European project CODESNET (COllaborative
DEmand and Supply NETwork) [8, 9], allowed to mature
knowledge, with a sufficient level of confidence, in the
definition of models that can describe industries [10]. In this
paper, we introduce a model for the health services system
through an analogy with the function of maintenance of
processes. Having explained the conceptual analogy, the tools
used for modelling in industrial environments are adapted to
the modelling of the healthcare system, introducing in this way
an ontology that can be used as a guide in the analysis phase.
The conceptual analogy was then transferred on key
performance indicators used to measure performance in their
respective fields, in order to provide immediate guidance in the
analysis.
Finally, the performance of a health system linked to a
Territorial Healthcare Agency (THA) in north of Italy is
analyzed [11]. The analysis was performed on the data base of
the Asti THA, available since its participation to the Research
Project of National Interest [12] Innovation of Healthcare
Systems by Supply Chain Management techniques Data are
referred to the year 2007. Using these data as a basis and by
applying an estimation on the evolutionary trends, a realistic
projections for the year 2012 is obtained.

In this paper, Section 2 introduces the conceptual analogy

between the healths services and the process maintenance. In
Section 3 an analysis on a territorial health care is described.
The conclusion are given in the last section.
II.

CONCEPTUAL ANALOGY

The OECD has defined maintenance like the function that

has to constantly control production plants and all the
necessary work activities that can assure the smooth operation
of the system and the good conditions of production facilities,
services and equipment for plants [13]. By applying the process
maintenance definition to a specific process, maintenance is
referred to the whole set of activities that can assure a proper
usage of the process by the user and to reach the goals of
effectiveness, efficiency in their present operating context.
The WHO has defined health like the state of complete
physical, mental and social well-being and not merely the
absence of disease or infirmity [14]. The national health care
system is constituted by the whole set of functions, services
and activities dedicated to the promotion, the maintenance and
the recovery of the physical and mental status of a person with
no distinction due by individual or social conditions and with
an equal treatment of all citizens [1].
In Table I the analogy between the two definitions, where
the maintenance definition is considered applied to the specific
concept of process maintenance, is schematically summarized.
TABLE I.

CONCEPTUAL ANALOGY

Process Maintenance

Health Care Service

Is a function that has

constantly to control process
usage.
Is a function which has
constantly to control the
whole set of works for
repairing and reviewing.

Is a function that has

constantly to control the
health status of persons.
Is a function that has
constantly to identify, control
and change the whole set of
factors that adversely affect
the collective health.
Is a function that has to
assure the promotion of
favorable factors that
improve the health
conditions of persons.
Is a function that has to
assure the maintenance of a
good health status for
persons.

Is a function that has to

assure the proper operation
of process.
Is a function that has to
assure the good performance
of the process.

The analogy can be also transferred to a modelling point of

view in order to have a formal model that can guide during the
analysis of the systems. In the next subsection, a model of the
health care system activities is introduced.
A. Model of Health care services activities
Models for the maintenance function can be found in works
concerning the product lifecycle management [15]. In the
documents of the European project, amePLM (advanced

platform for manufacturing engineering and Product Lifecycle

Management) (http://www.ameplm.eu/), is proposed an
ontology model for the process maintenance activities. The
health care services function includes activities that represent
actions done by the health care system, on a specific territorial
area, in order to reach the objective of improvement of the
health status. To identify those activities the model of the
process maintenance function is used and a transfer of concepts
from the industrial context to the health care one is proposed in
the scheme in Fig. 1. Health care services must take into
account the territorial conditions and people life style, so the
first action needed to supply the right services is an analysis in
the socio-economic context. The input for this analysis
contains data and information about the social conditions, the
economical characteristic of population and their life style. The
output of this analysis is reported in the Socio-economic
context report containing Key Performance indicators on the
determinants of the health status. The output of the health
status analysis collect information about the population health
status with key performance indicators on the health care
demand. The THAs manager uses the outputs of the two
previous analysis to identify a strategy of prevention and to
plan the resource allocation on the territory. The health care is
the service supplied by doctors to preserve good health
conditions of a person or population or to improve the health
status with the available tools and cares procedures. A specific
analysis is required for chronic patients affected by diseases of
long duration and, generally, slow progression. The outcome is
quantified, respectively, by set of KPI of effectiveness and by a
set of KPI on the chronic diseases.
B. Key Performance Indicators for health care systems
KPI that can describe the characteristics of the population
are classified as KPI on health determinants, like the indicators
of the population size, the average age, the average socioeconomic level.
TABLE II.

SETS OF KPI

KPI HEALTH CARE

KPI on health determinants
Population
Socio-economic condition
Average age
KPI on health demand
Average DRG
Hospital admissions
Average hospitalization
Access to health care
Trend of access to health care
KPI on effectiveness
Turnover index
Occupancy rate of beds
% incidence of ordinary activity
Patients satisfaction
N of customer complaints
% adherence to regional standards
On-time deliveries
N of late orders
Waiting time / Waiting list
Waiting time reduction
KPI on chronic diseases
Chronicity index

Fig. 1. Health care services scheme

KPIs that can describe the demand of health are the number
of requests of health care services, the number of hospital
admissions, the average hospitalization, the number of accesses
to the health care assistance. All the services are weighted with
the services cost: the average DRG (Diagnosis Related Group)
that give an average cost to each group of services. KPI on
effectiveness can describe the behaviors of the system in terms
of waiting time, waiting list, patients satisfaction, adherence to
regional standards. KPI on chronic patients, like the chronicity
index, can describe the health status of the considered
population.
III.

can access to the health care services without paying. The

exemption from the fee is permitted from the Italian law in
order to improve the accessibility to the health care system and
assure cares to all citizens; the distribution of the average
values of the KPI is represented in Fig. 4.
Fig. 2. Population distribution

A TERRITORIAL HEALTHCARE AGENCY ANALYSIS

In this section an analysis of a territorial healthcare agency

is provided. The analysis has been performed by taking into
account relations in the health care services scheme in order to
compute a set of performance indicators able to describe the
characteristics of the demand of health care services.
A. Source of Data
In Italy, the THAs (Territorial Health Agency) have a huge
amount of data about the supplied services and the flow of
patients in the health care system. These data are a precious
resource for analysts in order to analyze the structure of the
health system, to evaluate its performances, to plan the
investment allocation and to determine and monitoring costs.
The THA collects data in a standard format, the same format in
each Territorial Health Agency, in Italy, so the data base
construction and the analysis is replicable at the same way in
each THA or on regional or national levels by considering set
of THAs. Data are collected from the National Health System
in a standardized framework by periodic flows of data,
scheduled in specific days of the year for each sub-service.
Collected data have been organized and stored in a database
and are at disposal of the THA's managers for internal analysis
that can support the strategic and decision making processes.
Data concerns services supplied and patients that live in a
big area that cover a province of the north of Italy. Since the
analysis has the goal to put in evidence the performance of the
Territorial Health Agency in the main city in the considered
province in order to support the THAs managers in the
management, data concern patients that live in the six districts
of the city. In this study, a database consisting of 5 million of
records and 113 fields was built. The dimension can give an
idea of the amount of healthcare data that must be managed in
order to be easily accessible with queries with high informative
power. The collected data refer to the entire year 2007 and a
projection, determined on the basis of public data, was
estimated and applied in order to have estimations referred to
the 2012.
B. KPIs definition and computation
In this work a map representation of the KPIs values in the
analyzed area is used, divided into 6 districts. In Fig. 2 a map
that represents the population distribution in the city is shown.
In Fig. 3 the average age of population in each district is
represented on the map. An indicator of the socio-economic
characteristic of population can be the number of citizen that

Fig. 3. Average Age

Fig. 4. Population with exemption socio-economic

The analysis on the use of levels of care was conducted

using the global indicators that take into account the number of
different access to various services of the health system, the
number of days of hospitalization for admissions combined
with the average weight of the DRG [16].
The ELA indicator for the hospital recovery (Fig. 5) for the
evaluation of the use of the hospitalization is computed by
considering the days of hospital recovery dH pondered with a
weight equal to 15 plus a dichotomous variable IS, equal to 1 if
the patient receive a surgical intervention, 0 otherwise,
pondered with a weight equal to 10.

TABLE III.

ELAH=15*dH+10*IS

(1)

WEIGHTS OF SPECIALIST SERVICES

Service
Specialist visit
Laboratory Exam

Weigh
1
4

Fig. 5. Distribution of utilization of hospital admissions

Wheigts in Table III an in Eq.(1) are related to the costs of the specific service
for the National Health System.
Fig. 7. Distribution Chronicity Index

Fig. 6. Distribution of accesses to specialist services

CONCLUSION

The ELA indicator for the specialist services is computed

by considering the number of access to each kind of service
pondered with the weights of Table III.
ELAS=1*NV+4*NE

(2)

Where NV is the number of specialist visits and NE is the

number of Laboratory exams. The distribution of the ELAS
index is shown in Fig. 6. Fig. 5 and Fig. 6 show how the use of
hospital services is complementary to the use of specialist
services. The hospital and specialist interventions belong to
two different hierarchical levels of the organization of the
health service, so a complementary behaviour cannot be
accepted as the proper functioning of the system. Chronic
diseases are very important to be analysed for at least two
reasons: the first is because, usually, chronic patients dont pay
the health care services and the total cost of services is covered
by public resources, the second reason is that chronic patients
constantly and periodically use the health care services, so the
evaluation of the number of chronic patients give information
about the demand of health care services. The KPI that
evaluate the incidence of chronic diseases in the area is the
Chronicity Index. The index is calculated by considering the
number of chronic diseases for a single patient, so its an index
computed on an individual level. The distribution of the mean
value of the chronicity index is represented in Fig. 7.

The conceptual analogy between the process maintenance

function and the health care services supply, in this work, is the
starting point to justify an transfer the analogy on the
modelling scheme and the set of KPIs. This result represent an
important guide to analyze the health care service systems and
identify the kind of KPI that can give quantitative information
about the territorial conditions where the system deliver
services and the performance of the health care system in terms
of effectiveness, achievement of the goal to improve health,
and in terms of performances, do the best with the available
resources. The proposed model enables to give a guided
interpretation of KPI values, in this way the THAs manager
can have at disposal useful information for the decision making
process required by the strategic decisions and allocation of
resources. In the present work the distribution of the KPI is
provided. The purpose of the graphical representation of the
KPI on a map representing the analyzed area is to give an
immediate key of lecture of results. Its easier, for the THAs
manager to understand and interpret results if they are
graphically represented on a map that can suggest way of
intervention. Fig. 5 and Fig. 6 provide an estimation of the
demand of health care services, the average age and the socioeconomic conditions are two determinants of the health status,
so their values are strictly related to the need of health care
interventions. The services that are defined as essential from
the WHO are considered. A critical lecture of the result can
suggest that the use of the health care services is not properly
correct in the analyzed area and strategic interventions must be
done from the THAs manager. By considering an evolution of
the proposed KPI and monitoring the health status of the
population on different and consecutive time period, its
possible to have a dynamic trend of evolution in order to
predict the consequences of the adopted politic and change if
necessary.

REFERENCES
[1]
[2]
[3]
[4]

[5]
[6]
[7]

[8]

[9]

WHO (2000). WHO report: Health Systems: improving performance.

World Health Organization.
DPCM (2001). Definizione dei Livelli Essenziali di Assistenza. Decreto
del Presidente del Consiglio dei Ministri 29/11/2001.
Marmot M., (2006), Social Determinants of Health. Oxford University
Press. ISBN: 9780198565895.
Institute of Medicine (1997). Improving health in the community: a role
for performance monitoring. Washington (DC): National Academies
Press.
Declaration of Alma-Ata (1978). International Conference on Primary
Health Care, Alma-Ata, USSR, 6-12 September.
Murray CJL. & Frenk J. (1999). A WHO framework for health system
performance assessment. Geneva, World Health Organization.
Villa, A. (2006). Collaborative organizations: the keyword for future
development of industrial networks A brief presentation of the special
issue, Foreword of the Special Issue on Organizing Collaborative Supply
Chains and Networks, International Journal of Networking and Virtual
Organizations, Inderscience Publishers, Vol. 3, N. 2. pp. 125-127,
(ISSN: 1470-9503).
Villa A. & Taurino T. (2011). SME networks and clusters: an approach
to their performance evaluation. In: Managing Cooperation in Supply
Network Structures and Small or Medium-sized Enterprises: Main
criteria and tools for managers, Villa A., Springer-Verlag (DEU), pp. 24,
2011, pp 65 - 88, ISBN: 9780857292421.
Villa A., Taurino T., Ukovich W. (2012), Supporting collaboration in
European Industrial Districts The CODESNET approach, JOURNAL

[10]

[11]

[12]
[13]

[14]
[15]

[16]

OF INTELLIGENT MANUFACTURING, Springer, Vol. 23, pp 2497 2506, ISSN: 0956-5515, DOI:10.1007/s10845-011-0516-6.
Antonelli, D. , Cassarino, I., and Villa, A. (2006). Analyzing
Collaborative Demand & Supply Networks of SMEs, Special Issue on
Organizing Collaborative Supply Chains and Networks, International
Journal of Networking and Virtual Organizations, Inderscience
Publishers, Vol. 3, N. 2, pp. 128-141, (ISSN: 1470-9503).
Millet C.A.; Moore K.S., Richards T.B.,& Monk J.D. (1994). A
Proposed Method for Assessing the Performance of Local Public Health
Functions and Practices. American Journal of Public Health. Vol 84, No
11.
PRIN (2007). http://www.lep.polito.it/prinsalute/default.aspx.
Cattaneo M., Di Sivo M., & Furlanetto L. (2007). Cultura di
manutenzione. Firenze: Alinea, collana II Processo Edilizio. ISBN:
8860552311.
WHO (1946). Constitution of the World Health Organization.
International Health Conference, New York. 1946.
Matsokis, A. & Kiritsis, D. (2010). An ontology-based approach for
Product Lifecycle Management. Computers in Industry, Elsevier, Vol.
61, No. 8, pp. 787-797.
Costa G., Landriscina T., Marinacci C., Petrelli A., Vannoni F. (2008). I
determinanti del fabbisogno di salute e di assistenza. In:
approfondimenti sullindagine multiscopo ISTAT salute 2005. Agenas
ed. AnnoVII Numero 22 (3) 2008.