I’m the Team Leader for an RPIW this week. I listened in on a discussion between some participants, that focused on value, and the meaning of the term in Lean. As Mark Graban puts it, they were finding it difficult to separate motion (the things we do), from value (the things we do that help the patients). It is not surprising that people found the definition difficult, however, as the definitions used in Lean do not always lend themselves to some services.
In health and social care services, some of the traditional definitions of value can cause difficulties, particularly for people working in publically funded services. ‘A service for which the person has to be willing to pay’ seems to sit oddly when the person is not paying at point of delivery – although they will be paying through taxes, of course. It can still be useful to use it as a question, however – anyone who has experienced health services will have a view on whether the service would be worth paying for.
It can be trickier in public health services, where the benefit may be less immediately obvious – advice to stop smoking may be good advice, but is it something for which a person would necessarily be prepared to pay? Similarly, in a mental health service, if someone is acutely unwell and does not want to come in to a hospital, does that mean the admission has no possible value to them? I would argue that both these services have a value, and are worth providing.
So, what definitions of value make sense in health and social care?
Mark Dean, the author of the excellent book, ‘Lean Healthcare Deployment and Sustainability‘, has a useful definition of value. He suggests that ‘value added activities are activities performed during the production or delivery of a service or product that increases it’s value to the customer’. So far, so good.
Dean goes on to suggest that the action must meet the following criteria:
- it meets a customer need
- it must be done right the first time
- the action must change the product or service in some manner
Taking these one at a time, meeting a customer need is broader than willingness to pay. It does, however, continue the focus on benefit to the service user. This has some similarities with Thomas Jackson’s comment, in ‘Mapping Clinical Value Streams‘ that willingness to pay has the implication that funders and patient’s have the patient’s best interests at heart.
Doing things right the first time is a central tenet of Lean: defects result in re-work, and in health care, they can result in harm. Processes that are not done correctly cannot be regarded as value, no matter how much effort went in to them,
Finally, Dean argues that the action ‘must change the product or service in some way’. This is similar to Mark Graban’s statement in ‘Lean Hospitals’ that ‘the activity must transform the product or service in some way’. The point of this is that if material is only moved from one place to another, then this is often waste disguised as activity. For example, taking data from one system and moving it to another may be necessary because of problems in systems, but it does not transform the data. Similarly, taking a patient from one department to another may be required, but there is no value in the journey itself. These would fall in the category of ‘necessary non-value added activities’ – you need to do them at present, but you can try to reduce them as opportunity permits.
Value, then, requires benefit to the patient, doing it right first time, and transforming the product in some way. If it doesn’t do these things, it’s not value.