Since the early years of workflow management systems, they have been applied to the healthcare area to reduce costs and improve quality of care (Russo & Mecella, 2013).
Healthcare processes include both administrative/organisational processes and medical processes. Administrative/organisational processes handle administrative tasks, such as patient admission, discharge, transfer, appointment planning, and scheduling of resources. Medical processes support diagnostic and therapeutic procedures.
Administrative/organisational processes are quite predictable, repetitive and well structured. Exceptional behaviours are limited and can be often anticipated and managed according to predefined handling procedures. However, medical processes are loosely structured or unstructured processes, since they depend on clinical decision-making and case patient data. Clinical decision-making is highly knowledge-driven, as it depends on clinicians' expertise and experience, medical knowledge and evidence, as well as on case patient specific data. They involve frequent deviations to meet individual patient needs (Reichert & Weber 2012; Russo & Mecella, 2013).
Indeed, several studies corroborate that flexibility is an unavoidable feature that determines the success of using business process in the healthcare domain (Reijers et al., 2010; Reichert & Weber 2012; Lenz et al., 2012; Ruiz et al., 2012; Yao & Rumar, 2013). Reichert and Weber (2012) present an overview of several solutions that have been proposed to support exception handling, process adaptation and process evolution.
Since its release in 2004, BPMN (Business Process Model and Notation) (OMG, 2011) is becoming the leader and de-facto standard in business process modeling (Harmon & Wolf, 2014). BPMN has been used to model and execute various healthcare processes, both administrative and medical processes (Svagård & Farshchian, 2009; Rojo et al., 2010; Strasser et al., 2011; Scheuerlein et al., 2012; Cossu et al., 2012; Müller et al., 2014; Braun et al., 2015). Considering flexibility features in BPMN business processes, Yao & Kumar (2013) take advantage of standard BPMN elements, such as the ad-hoc sub-process BPMN element, to define more flexible business processes. In addition, Milanović et al. (2011) extend BPMN with rule-based languages to improve flexibility by design and Said et al. (2010, 2105) extend BPMN with versioning features to support flexibility by changes. The jBPM engine also supports flexibility by change, including the migration of running process instances.
Although flexibility is considered essential so that processes can cope with expected and unexpected exceptions, in the everyday business practice, process participants do not wish for total flexibility, i.e., changing processes without any restrictions or guidance. Instead, designers would like to define which changes can be applied, as well as performers would like to follow advices previously modelled on which and how they can change the elements that compose business processes (Bider, 2005; Borch & Stefansen, 2006; Martinho et al., 2008). Controlled flexibility can be defined as the ability to control which, where, how and by whom the elements that compose a business process can or cannot be changed. This controlled flexibility feature is also aligned with healthcare domain requirements (Weber et al., 2008; Reijers at al., 2010; Yao & Kumar, 2013).