Discovering and deﬁning sources of evidence Figure 1 Five main processes in healthcare. healthcare. Through self-management, the citizen can work as a stronger partner with the healthcare system to improve this process. Providing for a good end of life An effective, but endless treatment process is not always consistent with a good end of life. One shortcoming of an effective treatment process that is often not discussed is when the treatment obstructs the patients’ quality of life in their last period of life. For many diseases, ageing is the root cause leading to the deterioration of all human systemsdsome slower, some faster. The medical specialties are divided by organ/symptom area: the heart, eyes, hearing, mental health, etc. What is consid- ered good care from a symptom area specialist may not create a good end of life. A holistic point of view is required; therefore, there is a need for more physicians in the specialty of geriatric care. DISCUSSION Of course, these processes do not occur in neat succes- sion; they may be in operation simultaneously, in parallel or iteratively. In happy situations, the ﬁrst transforms into the last one. However, if any one of the four ﬁrst processes goes wrong, subsequent processes will suffer as indicated in the illustrations above. When planning for improvement and allocating resources to the healthcare system, a systems view should be taken, and each and all of these interconnected processes should be consid- ered; improvements made that impact citizens earlier in their life will be more valuable and usually more cost-efﬁcient. In the west of Sweden, steps have been taken to organise cancer processes from a patient/citizen point of view. This work is part of an action research project to gain more knowledge on improvement programmes that take this broad view of health. Process owners have been identiﬁed for each of 23 types of cancer. These owners have responsibility for the complete cancer system for their assigned cancer type. In addition, improvement work has begun on two generic subpro- cesses that span all the cancer types. The adoption of learning mechanisms to foster continual improvement of these processes is crucial.11 Taking the citizen’s perspective on healthcare processes also requires a systems view and is an impor- tant step in the increased involvement of the citizens/ patients in the improvement of healthcare processes. The citizens are not just receiving value from the healthcare system; they are also active partners in their operation and should be important partners in its improvement. They should be seen as cocreators of value12 rather than only subjects to the production in the healthcare processes. Acknowledgements We want to express our gratitude to the editors, anonymous reviewers and S Lifvergren, for valuable comments and suggestions. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed. REFERENCES 1. Babbage C. On the Economy of Machinery and Manufactures, 1832. http://www.gutenberg.org/dirs/etext03/cnmmm10.txt (accessed 22 Jul 2010). 2. Gilbreth LM. Psychology of Management 1914. http://www. gutenberg.org/ﬁles/16256/16256-h/16256-h.htm (accessed 22 Jul 2010). 3. Shewhart WA. Economic Control of Quality of Manufactured Product. Milwaukee, WI: American Society for Quality Control, 1980 (originally published 1931). 4. Shewhart WA. Statistical Method from the Viewpoint of Quality Control. Washington, DC: Graduate School of the Department of Agriculture, 1939. 5. Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q 1966;44(Suppl):166e206. 6. Glickman SW, Baggett KA, Krubert CG, et al. Promoting quality: the health-care organization from a management perspective. Int J Qual Health Care 2007;19:341e8. 7. Batalden PB, Stoltz PK. A framework for the continual improvement of health care. Jt Comm J Qual Improv 1993;19:424e47. 8. Deming WE. Out of the Crisis. Cambridge, MA: Center for Advanced Engineering Study, Massachusetts Institute of Technology, 1986. 9. Deming WE. New Economics for Industry, Government and Education. Cambridge, MA: MIT Press, 1993. 10. Hellstro¨m A, Lifvergren S, Quist J. Process management in healthcare: investigating why it’s easier said than done. J Manuf Techn Management 2010;21:499e511. 11. Shani AB, Docherty P. Learning by design. Key mechanisms in organization development. In: Cummings TG, ed. Handbook of Organization Development. Thousand Oaks, CA: Sage Publications, 2008. 12. Iedema R, Merrick E, Piper D, et al. Co-designing as discursive practice in emergency health services: the architecture of deliberation. J Appl Behav Sci 2010;46:73e91. i42 BMJ Qual Saf 2011;20(Suppl 1):i41ei42. doi:10.1136/bmjqs.2010.046409