In Lean work, value is defined as a process or activity that takes the service user or internal customer closer to their goal. In commercial settings, the test of whether the customer would be willing to pay for the activity is often used. Most authors add in the test that the action should be right first time.
Activity which does not meet these tests is waste, or muda. (There are other types of waste, related to over-stressing of systems, and to variation – I’ll post about them in a later entry). Waste can be complete waste – there’s no value to the activity at all – or it can be waste that is currently necessary, but can be reduced over time.
In mental health services, examples of the first type of waste could include time spent gathering information that is already in the case notes, or stages in a referral process that are no longer necessary. For example, one service with which I worked had a system in which 18 separate administrative steps happened between receiving a referral and issuing an appointment. Some of these steps related to different clinicians who wanted slightly different procedures, with no obvious benefit to the patient, but considerable additional work for administrative staff. Eliminating these steps made no difference at all to the value of the process, but shortened delays by several weeks.
In the second case, waste that is currently necessary, present systems make the activity necessary. Examples might be two electronic systems that do not exchange data, and so produce a requirement for double entry of the same information, or an equipment store that is distant from the area in which an OT works, but which has to be used until something closer is found. The distant equipment store increases travel, but adds no value to the service being delivered to the service user. The usual practice with this type of waste is to reduce it as much as possible, even if it cannot be removed.
A focus on value necessarily involves the service user or final customer. This needs an understanding of what they value. It is easy to make assumptions about this, but the only way to be sure is to take the time to ask people. Charles Srour provides an interesting discussion of ways of measuring the Voice of the Customer in a commercial environment: many of the methods are relevant to health care settings.
In Lean it is easy to focus only on efficiency of processes, and to make the assumption that the efficient and effective delivery of a service is the main thing of interest to a patient. It’s certainly true that few people are likely to place value on an inefficient or ineffective service, but active involvement of service users often identifies the importance of the way in which services are delivered.
Penny Bee and colleagues reviewed the literature on service user satisfaction with psychiatric nurses. They concluded that ‘UK-registered mental health nurses should be equipped with both therapeutic clinical skills and generic skills associated with relationship building, engagement and communication.’ Softer, harder to measure skills were valued along side technical expertise in treatment delivery.
What aspects of your service do users value? If you are a service user, what is important to you? If you deliver a service, and don’t know what aspects service users regard as important, how could you find out?
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