Health systems are increasingly challenged with numerous problems associated with issues of quality and rising costs of healthcare provided. These challenges result from scarcity of resources, increased consumption of health care and permanent introduction of technological innovation.
The concept of value-based health care (VBHC) is an approach to respond to the challenges mentioned above (M. Porter & Teisberg, 2006), suggesting a transformation of health systems focusing on outcomes that matter to the patients (Körber et al., 2016).
VBHC is a strategic framework that focus on the importance of restructuring the health sector in an attempt to maximize outcomes in relation to costs; advocating a change in healthcare systems is comprised of six interdependent elements (M. E. Porter & Lee, 2013):
- Organize care into integrated practice units;
- Measure outcomes and costs for every patient;
- Move to bundled payments for care cycles;
- Integrate care delivery across separate facilities;
- Expand excellent services across geography;
- Build an enabling information technology platform.
In short, VBHC is based on the following assumption, that by focusing on (wanted and potential) outcomes costs per patient cycle can be controlled and lowered in most cases and that variations in patient needs can be addressed is an effort to align the healthcare delivery model, including financial incentives, with delivering the best outcomes, which may seem obvious. However, the healthcare system is complex, with multiple reimbursement models, regulatory requirements, and sometimes contrasting objectives and incentives (Palopoli, 2020).
A VBHC assumption is that only outcomes matter to patients. The outcomes can be divided into 3 categories: results achieved, time to obtain these results, and their sustainability, and finally the importance of standardization tools when the achievement of a given outcome becomes operational (Ebbevi, 2016).
The current and growing popularity of VBHC is accompanied by an increasing ambiguity about the concept of value in health and about the concept of the VBHC itself (Steinmann et al., 2020). It is also accompanied with a difficulty to implement VBHC and therefore to translate the concept into practice (Colldén & Hellström, 2018). In the Netherlands, three main challenges were identified in its implementation: 1) the need to start seeing outcomes as plans to improve the quality of care provided, 2) the tools that allow linking the results to quality processes, allowing for faster improvement cycles and ongoing, 3) ways to ensure benchmarking in a transparent way, where clinicians can discuss good care delivery practices (Nat et al., 2020).
The difficulty led to the development of models to increase understanding of implementation to achieve VBHC. Among others also the European Institute of Innovation & Technology (EIT) Health launched a framework, which includes a clear “Implementation Matrix” (figure 1) for healthcare providers to follow to activate and accelerate VBHC. The Matrix details five key steps made up of 9 building blocks (EIT Health, 2020):
- Recording: measuring processes and outcomes through a scorecard and data platform;
- Comparing: benchmarking teams through internal and external reports;
- Rewarding: investing resources and creating outcome-based incentives;
- Improving: organizing improvement cycles through collective learning;
- Partnering: aligning internal forces and forging collaborations with external partners.
This framework outlines how to measure and maximize the outcomes, and addresses the main challenges, such as lack of standardized outcome data and resistance to change (EIT Health Launches Guidance on Value-Based Health Care, 2020).
Figure 1. Implementation Matrix. Adapted from (EIT Health, 2020)
In particular, the building blocks Learning community, within the Improving dimension, and the Scorecard, within the Recording dimension, establish the bridge with a fundamental aspect that, due to unawareness, has often been seen as an aspect of lesser relevance when approaching the VBHC framework, which is continuous improvement.
In various forums, and not only in the literature, VBHC is commonly referred to as the way to ensure the transformation of health systems focusing on the health value for patients, devaluing other methodologies, with a higher focus on continuous improvement, also used to seek to increase the value for patients, such as the Lean methodology, as one a continuous improvement approach.
It is therefore important to understand what the Lean methodology is, its role in health and how this methodology can strengthen VBHC and vice-versa.
Therefore, what is the Lean methodology and how did it appear? The Lean methodology follows a process initiated at Japan after World War II, at the same time, several specialists in quality management, among them Joseph Juran and W. Deming, were in that country developing training actions.
Toyota then challenged one of its engineers, Taiichi Ohno, to find the best way to recover the competitive disadvantage it had for US brands. That was how the Toyota Production System emerged, and Ohno identified seven types of waste: transport, inventory, displacement, time, overproduction, overprocessing and defects.
Later, Womack and Jones dedicated themselves to studying the Toyota Production System, thus giving rise to the Lean concept, reinforcing the idea that Lean involves increasing the efficiency of processes through a consistent elimination of waste. Lean is also described as a systematic approach to process improvement through waste reduction, seeking to create value for the customer, and reduce variability in each process.
There are many examples of Lean implementation, both in large organizations and in national health systems, with positive results being obtained in terms of care delivery time, costs, quality and productivity of the organizations involved, which contrasts with the VBHC. As mentioned above, although VBHC is increasingly disseminated in several countries, very little is known about its practical implementation in healthcare institutions, and the reason for this fact may rely on the main difference of the two approaches: whereas Lean is a method, VBHC is an integral vision, a concept, of how to organize healthcare delivery based on a set of key principles (Klop & Rutte, 2021).
The VBHC framework is more focused on the outcomes, while the Lean methodology is more focused on the processes to achieve these outcomes, one determines “what”, whereas the other determines “how” we are going to achieve it, and the complementarity of both approaches is found precisely because they answer different questions with the same objective in mind: to add value to the patients, as referred at an article focus on the combination between Lean and VBHC. (Dillamnn & Eenennaam, 2018).
As mentioned above, the relation of the two conceptual models is evidenced by the Implementation Matrix of the EIT Health Framework, the building blocks Learning community, within the Improving dimension, and the Scorecard, within the Recording dimension.
The Scorecard building block highlights the relevance of the definition of process, outcome and costs indicators to measure and manage performance.
The Learning community building block emphasizes the importance of the dialogue between the outcome and the process, with the active participation of the multidisciplinary team, to achieve better outcomes. The Plan-Do-Study-Act (PDSA) improvement cycle, commonly used as an important tool of the Lean methodology, is referred to as a team approach that contributes to the VBHC implementation.
The first step on every PDSA cycle is to “Plan”, which refers to setting objectives and indicators and predicting the results (Langley et al., 2009). According to Porter, obtaining better outcomes depends, in any area of activity, on the existence of clear objectives, and the lack of this clarity conditions the achievement of the intended improvements (M. E. Porter, 2010). Therefore, the importance of having clear objectives is evident in both conceptual models (Veghel et al., 2021).
The second step of PDSA cycle is to “Do”, where the teams identify improvement ideas to improve their work and contribute to the objectives defined in the previous step; or at least, as referred above, to decrease the variability along the processes. If we want to ensure the right outcomes, we need to avoid variability, and this is one of the reasons why it is so critical to have good indicators in VBHC, but also in Lean.
After the “Do” is the “Study” step where the teams analyze if the improvement ideas attain the expected results. It will also contribute to the defined outcomes in each case. The PDSA cycle ends with the “Act” step, looking for standard definition and implementation of each change in the process.
However, as Sensei Nakao used to say, one of Thaichi Ohno disciples, “humans kill processes”, and it is critical to have a clear monitoring plan, to implement visual management, in order to keep teams engaged with the process and aligned with the objectives and identify issues where they can develop new “PDSA” cycles, if necessary, in a continuous improvement approach.
Through the above it is possible to understand the link between VBHC and continuous improvement, and that these approaches not only can, but should be used together, as complementary concepts that mutually enhance each other to bring value to the patient, improving their care experience and health outcomes, while reducing costs.
Conclusion
Both centered on patients and the excellence of health care, VBHC and the Lean methodology have more that unites them than divides them.
The VBHC framework is more focused on the outcomes, while the Lean methodology is more focused on the processes to achieve these outcomes, in other words, VBHC focuses on determining “what”, whereas Lean focuses on determining “how” we are going to achieve it. The fact that these methodologies respond to different questions, having the same objective, makes them complementary and not incompatible.
In our perspective, the master key to achieving value in healthcare is in working with both the VBHC framework and the Lean methodology, side by side, and design a framework conceptual and operational that can be used to staff training.
