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Five main processes
The concept 'work process' has been used for a very long time 1 to denote sets of repeatable value creating activities subject to improvement. 2 Shewhart 3 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 variation left in the process. Donabedian 5 was an early proponent of the use of the process concept in healthcare. He identified the importance of looking at the organisational structure 6 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 department, organisation 10 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 subsequent...