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Organisational matters
ABSTRACT
Background: With healthcare, Lean Thinking encounters
a world, not devoid of value, but awash with
sophisticated and mutually unconnected concepts of
value.
Design: Given a shortage of systematic analysis in the
literature, this paper provides a preliminary analysis of
areas where the read-across from other sectors to
healthcare is relatively well understood, based on a broad
review of its impact on care delivery. It further proposes
areas where conceptual development is needed. In
particular, healthcare, with its many measures of value,
presents an unusual challenge to the central Lean driver
of value to the customer.
Conclusion: We conclude that there is scope for
methodological development, perhaps by defining three
themes associated with valuethe operational, the
clinical and the experiential.
Organisational matters
Figure 1
Pathway of movement of patients through a haematuria clinic from waiting on arrival1 to departure.12
Organisational matters
service-sector experience. The intuitive link between value
streams and patient pathways is compelling, and in fact, it is
exactly this link that drove Ben-Tovim et al19 through the study
in which they report their own, successful, improvement
process. Moreover, examples of benefit are now common.
However, it is more difficult to see exactly what has happened
to the founding concept of value. Given that clinicians have
developed many ways of measuring value-type concepts, such
as quality, it is worth examining how the simple concept of
value to the customer is faring in the world of healthcare.
VALUE IN HEALTHCARE
That Lean can continue systematically and dramatically to
improve a sector as significant as healthcare is still a matter of
belief, rather than proof, and there are some obvious reasons
why healthcare may differ crucially from other sectors. The
staggering, global, scale and complexity of healthcare provision
set healthcare naturally apart from manufacturing, perhaps
from all other service sectors. Although dual lines of authority,
clinical and managerial, need not be a unique factor, they are
certainly a sensitive issue at present,29 but it is perhaps in the
realm of the customer that differences are most obvious.
Shah and Robinsons30 classification of medical device users
shows several levels of users, including carers and healthcare
workers, each exhibiting characteristics that might make them
analogous to the customer. By extension, there are many people
who might, at the same time and with the same particular
patient in mind, have a role as customer for that product or
service, and hold widely different views as to the value of that
product or service. Alongside the personal customers are those
who specify or procure31 attempting to buy the best value for
many services to achieve the maximum health gain for those
most in need.32 In the UK and US, such parties represent an
organised attempt by a private or public sector purchaser to
ensure quality and to improve health outcomes.33 Some
communities have been considering value-type questions for a
long time, and there are sizeable literatures around the sociology
of healthcare and, of course, the business of defining and
measuring clinical and healthcare quality.
A case study is offered to demonstrate the potential for
clashes due to different concepts of quality. In May 2001, one of
the authors (TY) ran a workshop on industrial methods in the
NHS to explore how a cross-disciplinary team of managers,
doctors and nurses might apply improvement thinking. A Lean
Consultant was duly hired to gather information, part of which
was obtained during an observation of a haematuria outpatient
DISCUSSION
Once we move beyond the concept of value-to-a-singlecustomer, we encounter a bewildering array of value-concepts,
reflected in a plethora of quality measures and frameworks. For
instance, Ellis and Whittington34 propose nine dimensions of
healthcare quality; the Dartmouth Clinical Improvement
model35 appeals to a four-point Clinical Value Compass (functional status, cost, satisfaction and clinical audit); while
Brown36 proposes a different set (access, effectiveness, safety
and satisfaction); and Lohr and Harris-Wehling37 analyse
services in terms of their ability to align knowledge with
outcomes. Another community addresses the quality of life.
The Barthel score, for example, may be used to assess the
mobility of a patient on discharge from a hospital. It is an
interesting example, since, while it is widely referred to, there is
considerable debate about its validity,3840 and it is not clear how
it fits alongside other measures.41 Measures related to patient
experiences may even include patient-defined criteria.42
Table 1 Summary of Lean Consultants observations related to patient movements around the clinic illustrated in fig 1
Patient delay observed (1, 2, 3, etc) (min)
Location
Activity
Later
1
2
3
4
5
6
7
8
9
10
11
12
0
5
10
3
1
11
5
9
1
3
9
0
10
5
5
0
11
6
8
1
2
4
0
5
5
2
0
7
1
5
5
0
5
0
5
5
2
9
18
4
3
7
2
4
2
0
5
5
2
0
10
3
5
60
2
5
384
Organisational matters
Some unification of these various concepts may be possible by
considering value in terms of utility. The quality adjusted life
year (QALY) is a convenient way of calibrating health states
onto a single scale from 1 (perfect health) to 0 (worst imaginable
health state, usually death), discounted over the appropriate
period of health improvement or loss.4345 This measure can be
used to compare the outcome improvements effected by quite
different interventions, and critically the measure provides a
means of economic evaluation. For our purposes, the fact that
QALYs focus heavily on outcomes means that the experiential
elements of a process may not be captured. For instance,
Berwick and Weinstein46 discovered that women felt that as
much as half the value of an ultrasound scan was to have the
picture of their unborn babya benefit not traditionally
reflected in QALYs.
Even this limited and rather arbitrary survey shows that there
is no single customer with a simple view of value that can drive
Lean Thinking in healthcare, but that the field is full of
advanced views of value that have yet to be interconnected in a
systematic way.
The first major attempt to link some clinical values with
some other value-concepts in healthcare is reported by the
Institute of Medicine,47 which has proposed 10 rules for the
delivery of care. This endorses a multifaceted view of value,
while suggesting that there is a manageable limit to the
number of facets. What the rules do not do is to specify the
trade-off between them when time, money, or access to other
resources forces the case. Moreover, one might argue that
there are some other, unspoken, desirable values, such as
access or affordability that would feature highly for most
people. The Institute of Medicine48 also proposed six criteria
for quality assessment, namely that treatment be safe,
effective, patient centred, timely, efficient and equitable.
More recently, Gray48 suggests there are five important value
perspectives to consider (the payers, the patients, the
clinicians, the managers and industrys). Mainstream Lean
literature is alert to these issues,49 but the healthcare paradigm
is particularly difficult in this respect. However, there is some
evidence that patients do better when they value the
experience more.50 51
The reason this matters is that most choices in healthcare
service design include unintended outcomes. Until we have a
connect-up view of value, it is impossible to know whether
some aspect of waste-saving outweighs some other loss, or
depth of diagnosis, for instance. It is critical, therefore, to find
the minimum set of values required to proceed with Lean
Thinking; to understand how this value set connects to existing
value-concepts in healthcare; and to determine how value gains
in one dimension equate to losses in another. It is possible that
Lean is genuinely virtuous in all dimensions, but without a
framework it will be impossible to know.
A proposal that is consistent with all of the above is that
there are at least three critical dimensions to value:
c Clinical: The prime clinical value is to achieve the best
patient outcome (and is likely to be shared by clinicians and
patients alike).
c Operational: The prime operational value is likely to be the
effectiveness of the service, measured primarily in terms of
cost (including that which is lost through delay and poor
quality). Clearly, this matters most to service providers and
their managers, although clinicians and patients will also
buy into this view of value. Our contention is that most, if
not all, Lean Healthcare has been driven by an Operational
view of value.
Qual Saf Health Care 2008;17:382386. doi:10.1136/qshc.2006.020131
CONCLUSIONS
The way in which Lean Thinking is being adopted in healthcare
appears to follow a trajectory consistent with the way in which
other industrial methodologies have been taken up in other
sectors, where uptake is mixed, and practice may be pragmatic
rather than pure.
Having briefly reviewed the attempts to distil out a smaller
set of common values, we propose that there are three key
themes, or dimensions, to value in healthcare: the clinical, the
operational, and the experiential. Moreover, since all three are
subject to economic evaluation, it should, in principle, be
possible to undertake a comparative analysis between benefits
along these separate axes.
For Lean, however, the absence of a single customer with a
compelling view of value is perhaps the most important feature
of healthcare, and consideration of value within the many
customer communities reveals a complex and fragmented
scene. We contend that having demonstrated value in the
sector, Lean must now engage with these many value concepts
in a rigorous and, if possible, homogeneous fashion.
Acknowledgements: The authors wish to thank P Hines (Cardiff University), K Young
(Warwick University) and N Proudlove (Manchester Business School) for helpful
comments, and T Grocott (Kings College London), J Hobart (Derriford Hospital),
R Lilford (Birmingham University) and the referees, for helpful pointers to the literature.
They especially wish to thank D Bensley and the Department of Health for access to
the Improvement Partnership for Hospitals Evaluation interviews. K Silvester and
P Walley have also been very supportive in preparing this paper, and we thank them
for their help. Finally, TY would like to thank M Feneley (University College London
Hospitals) and G Sutton (Sutton Kaizen Consulting) for data and help with the
haematuria example. L Steuten, with her excellent proofreading, along with J Eatock
and C Weekes, with their help with the references, have provided invaluable support
at Brunel University. The views expressed are entirely those of the authors.
Funding: This work has not been supported by any specific programme. However,
much of this thinking has benefited from the involvement of TY in the MATCH
Programme (EPSRC Grant GR/S29874/01) and SMcC and TY in the RIGHT proposal
and programme (EPSRC Grant EP/E019900/01).
Competing interests: TY has received fees and research funding for work on process
improvement, simulation and information technology in relation to healthcare.
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doi: 10.1136/qshc.2006.020131
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Notes