Value in Healthcare
In a recent health care improvement project, I worked with the definition of health care value proposed by Michael Porter in 2010 (link to New England Journal of Medicine perspective article here).
Porter stressed the idea of value as a conceptual ratio of outcomes to costs. He described three tiers of health outcomes, all from the patient perspective: Tier 1 focuses on health status like level of pain and ability to work; Tier 2 includes time to recover from procedures; Tier 3 focuses on sustainability of health and long-term consequences of procedures.
Our project aims to decrease costs associated with joint replacement surgeries, so we looked to hit the bottom two boxes in the value table.
Porter’s value description as a function of patient outcomes and costs looks straightforward.
In our project, participants worked to reduce direct costs (like costs of implants), to decrease length of stay in the hospital, to increase discharge to home rather than skilled nursing facilities, all the while maintaining low rates of re-admissions and complications.
Increased value --improvement--requires changes to the care process, which means the way doctors and other members of the care team work every day with their patients.
What makes it likely that those changes will stick?
Dr. Chris Hayes has reviewed a number of improvement interventions and observed that two key factors affect sustainability of the changes: (1) the value of the intervention as perceived by the point of care staff who are supposed to apply the changes day to day and (2) the impact on workload. Interventions valued by the point of care staff that did not add to the workload (or better yet, reduced workload) are the sweet spot for sustainability.
Here’s the sunmmary image that Dr. Hayes shows on his useful project website, Highly Adoptable Improvement Projects:
The bottom line: we have to pay attention to the value perceptions by the people asked to do the work as well as the value defined by Porter in order to sustain improvements in health care.