Discovering and deﬁning sources of evidence Five main processes in healthcare: a citizen perspective Bo Bergman,1 Duncan Neuhauser,2 Lloyd Provost3 1The Centre for Healthcare Improvement, Chalmers University of Technology Gothenburg, Sweden 2Department of Epidemiology and Biostatistics, Medical School, Case Western Reserve University, Cleveland, Ohio, USA 3Associates in Process Improvement, Austin, Texas, USA Correspondence to Professor Bo Bergman, Chalmers University of Technology, Gothenburg, SE 41296, Sweden; bo.bergman@chalmers.se Accepted 24 November 2010 This paper is freely available online under the BMJ Journals unlocked scheme, see http://qualitysafety.bmj. com/site/about/unlocked. xhtml BMJ Qual Saf 2011;20(Suppl 1):i41ei42. doi:10.1136/bmjqs.2010.046409 ABSTRACT A citizen point of view on the healthcare system, its processes and their improvement is emphasised. From this point of view, ﬁve main processes are identiﬁed: Keeping Healthy, Detecting Health Problems, Diagnosing Diseases, Treating Diseases and Providing for a Good End of Life. The citizen should be looked upon as a cocreator of value and improvement of these processes. FIVE MAIN PROCESSES The concept ‘work process’ has been used for a very long time1 to denote sets of repeatable value creating activities subject to improve- ment.2 Shewhart3 4 also emphasised the process as a means to produce value for the customer, but with a varying quality. By identifying and removing assignable causes of variation, the process could be made predictable with only chance causes of varia- tion left in the process. Donabedian5 was an early proponent of the use of the process concept in healthcare. He identiﬁed the importance of looking at the organisational structure6 and the processes involved in producing outcomes for the patients. Batalden and Stoltz,7 basing their contributions very much on Deming,8 9 extended the concept to systems by describing a general framework for quality improvement in healthcare. Processes can be studied from a depart- ment, organisation10 or industry perspective. If we focus on the complete healthcare system, it would be natural also to look upon the processes from a citizen’s point of view. From that perspective, the following ﬁve main processes are identiﬁed (ﬁgure 1). Keeping healthy (prevention) This includes physical ﬁtness, bed nets against malaria, a good diet, clean drinking- water and less use of tobacco; the list goes on. We could have the best hospital care, but it would not achieve much if this ﬁrst process is not functioning well. The use of personal improvement projects is a mechanism to improve health at the individual level. However, the healthcare system also has to engage in proactive prevention of future illness. If a 4-year old with a weight problem is left to habits already well developed, subsequent problems not only with health, such as increased risk of diabetes and subse- quent consequences, but also social problems may arise. Another illustration is smoking cessation: societal support is important, as illustrated by successful legal activities in this area. Detecting health problems If people do not come forward, it can be difﬁcult for the health system to help them. Proactive outreach on the part of the healthcare system is important. Cancer screening is an illustrative example. If a fast-- growing malign melanoma is growing without detection, the effectiveness of the diagnostic and treatment processes might be of little help. The citizens could be more actively engaged in monitoring their own health status. Longitudinal data are more useful if collected regularly. Daily measure- ment of hypertension or blood sugar can provide more information than can be collected once every few months in a doctor’s ofﬁce. Diagnosing diseases This is the process needed to trigger the next process of treatment. There are few things less cost-effective than the wrong diagnosis. Timeliness of diagnosis is critical for many disease paths. The healthcare system provides the knowledge and methods for this process. Treating diseases Curing and caring is at the core of most of today’s discourse on quality improvement in i41