This week’s blog is brought to you by: Dr Joe McManners

For privacy reasons SoundCloud needs your permission to be loaded.
I Accept

Full reference and title from the journal:

Fjeldstad, Ø. D., Johnson, J. K., Margolis, P. A., Seid, M., Höglund, P., & Batalden, P. B. (Accepted/In press). Networked health care: Rethinking value creation in learning health care systems. Learning Health Systems, [e10212].

Click here for the link to the paper

Authors conclusion

Attempts to “install” the value chain widely in health care systems have, however, been frustrating. As a result, well-meaning leaders seeking better value have resorted to programs of cost reduction, rather than service redesign. Professionals have not been very happy or willing participants. The work of health care service invites an expanded model of value creation, one that better matches the work.

This paper proposes a networked architecture that can mobilize and integrate the resources of health care professionals, interested patients, family, and other community members in the delivery and improvement of health care systems. It also suggests how this value-creation architecture might contribute to research and the development of new knowledge.

Organizational design facilitates or handicaps efforts to improve otherwise good professional work. Leadership and management can prioritize the design of systems that will mobilize the existing resources in ways that match the needs that individuals and populations present—and do so at a good value. We propose that this begins by rethinking the assumptions underlying value creation in health care service systems. By identifying different ways in which value is created, we can sharpen our efforts to design and improve health care service systems and assess their value.

3V bottom line

  • Need to rethink our idea of value creation, away from processes and standardisation (a supermarket or a car factory) towards networks of professionals and patients
  • Cost saving approaches and standard processes not appropriate for personalised care and professional satisfaction
  • More important as problems become more complex and services fragmented
  • There are clear ways that organisations and leaders can help or hinder

3VH – Implications for value

In resource constrained environments, in the paper described as ‘overarching assumption of resource scarcity’, the natural focus can be on reducing costs. This paper presents a powerful argument for improving value by ‘doing things differently’.

Traditional, perhaps more 20th Century rather than 21st century approaches, have emphasised value improvement as being something that is done through making processes more efficient. This draws from work in manufacturing and can be used reduce costs and improve efficiency.

However in health care, as often is the case, this does not apply. There are examples where improving a chain of processes can result in a better outcome at a lower cost, but as the authors argue, these examples are unusual. What happens more often is that the relentless drive to reduce costs alienates and can be counter-productive, we would strongly agree with:

‘Efforts to reduce costs without care redesign risks making the work of providing health care services more challenging. With mounting levels of burnout, such an approach may make matters worse’.

There are countless examples of this, the key is to use resources better and not to focus on a savings approach which alienates clinicians and as we see below is not suited to more complex systems.

Value creation in the paper is divided into the following taxonomy: ‘value shops’, ‘value chains’, and the addition of ‘value networks’. The latter is the focus of the paper.

‘Value shops’ is used to describe a more traditional model of healthcare, a professional and a patient come together ‘in the shop’ to fix the problem. This model is personalised but suited to clinical situations that are simple and not needing multi-disciplinary teams to manage. We know that 21st century healthcare problems are increasingly encountering ‘multi-morbidity’[i] that need an approach that goes beyond the ‘value shop’ method of improving value. With complex problems comes the need to use a team approach to solve those problems, not least with the key involvement of the patient. The traditional ‘shop’ that fixes the simple problem doesn’t support this approach.

The concept of ‘value chains’ is analogous to shops, or factories,  producing products in straightforward processes which can be standardised and improved to get better value or efficiency in this case. There are limited health problems that fit into this category, although the thinking behind this is used (the paper points out largely unsuccessfully) to tackle more complex problems. A hip operation can be value engineered in this way, but as soon as the problem becomes more complex, or has multiple aspects this approach becomes limited and can potentially introduce unintended consequences.

The idea of ‘value networks’ is used to show how networks of professionals, services and patients can be brought together to solve more complex and enduring health problems. Examples used are firstly networks around children with Crohn’s disease in Cincinatti, and secondly patients needing dialysis in Sweden. In the examples used, value is improved by adding value from ‘actors’ in the network who bring in resource, knowledge and expertise. The networks are self-organising, peer supporting and are less hierarchical than traditional health structures.

They are made up of: ‘actors’ (professionals, patients, institutions), ‘commons’ (where actors share resource and communicate) and protocols, processes and infrastructure that support the network.

Leadership and organisations can enable this or be a barrier and leadership is needed to develop infrastructure, standard policies and resources, incentives, finances, communication methods, technology.

Optimistically the authors argue that by improving value in this way we can solve some of the problems we face of resource scarcity. This model does give hope that the ‘network century’ can lead to a healthcare model that genuinely offers a partnership with patients and brings actors together around populations in a non-hierarchial way that prioritises improving value.

[i] Rising to the challenge of multi-morbidiity.
ChristopherM Whitty, Carrie MacEwen, Andrew Goddard, Derek Alderson, Martin Marshall, Catherine Calderwood, Frank Atherton, Michael McBride, John Atherton, Helen Stokes-Lampard, Wendy Reid, Stephen Powis, Clare Marx
BMJ  2020; 368: l6964  (Published 06 Jan 2020)