by Ted Eytan, on 12 Mar 2007 06:37 am
The Journey
What the patient is willing to pay for
I was taken by the image of the HOKS company president on his his hands and knees cleaning the floor, from Got Boondoggle?: Japan Day 4 - HOKS Part I, and reposted by Lean Six Sigma Academy.
As I have been describing the concept of “value = what the customer is willing to pay for,” to others, I have at times stated that if a patient was willing to pay for their physician to clean their hospital room, I would do it.
It might be that if patients paid physicians to clean their hospital rooms in addition to all of the other services they expect of us, the cost of health care would be even more prohibitive than it is now.
It also might be that having a physician clean the hospital room during an admission might increase the patients’ confidence in their ability to get well, or the physician’s understanding of the unique impact of the care experience on each patient, and would therefore improve the accuracy of the history and diagnosis.
I have found it useful for me to think in terms like this. We often make assumptions about what patients are willing to pay for, both by stating that a patient isn’t willing to pay for something when they actually are, and vice versa.
From the HOKS experience, I appreciate that there’s a president of a $50 million company out there willing to rethink assumptions about what his customer is willing to pay for. We’re being supported in thinking that way here, too.
on 14 Mar 2007 at 6:09 pm 1.Mark Graban said …
As a non-doctor, I’m a bit torn:
On the one hand, the fact that Southwest pilots help clean the planes must do great things for the team environment, showing shared commitment to the passengers and company. That said, it’s not a good use of expensive labor, that pilot cleaning the plane. Is there pilot stuff they should be doing instead? Focusing on safety and/or the next flight? Part of me doesn’t like the pilot cleaning.
I have the same mixed feelings about docs and cleaning.
That said, it’s unlikely that pilots on any older airline (American, Delta, etc.) would clean the planes. Teamwork be damned, it’s beneath them. Are most of our hospitals like American and Delta? Would you have to start a new hospital where all of the docs are employees (not contractors) to get that sort of teamwork?
Even if you could get that teamwork, would you want the docs spending time on that instead of direct patient care?
In my healthcare work, we try to prioritize having employees do work that’s the work they trained for. For example, we don’t want Med Techs doing material replenishment runs to the stockroom with kanban cards. Their time is more costly than a lesser-trained lab assistant, who can play material handler. I don’t think this rational division of labor/skill means you can’t have a team environment. Let Med Techs be Med Techs, let Nurses be Nurses. I would guess the same applies to MD’s. Let MD’s do MD work (and get them to respect the role that others play in terms of supporting them).
In a lean factory, we say that all of the support staff (material handlers, engineers, managers) are there to support the value-adding employees (production operators). Do we say that, in healthcare, everyone is there to support the MD doing their job? I’m not sure if that’s a valid comparison. What do you think?
One other point (long comment, sorry):
I struggle sometimes with the “customer is willing to pay for it” part of the value added equation, in healthcare. The patient is pretty unaware of what’s necessary for their care (the root cause of that is a different topic).
If a patient isn’t willing to pay for their tube of blood to be labeled, does that mean the labeling step is NVA? It’s certainly “required NVA” (we need that to ensure quality), but some argue the label is VA because it’s “necessary” (only because we have more than one patient). The hardliner in me says “NVA”, you “shouldn’t” need the label, but you do.
A pathologist on my current client lean team (who’s had previous lean training) put this idea forth:
How about defining medical Value Added in terms of:
“Is this step absolutely required to help the patient recover?”
Labeling a tube: Yes, VA
Searching for a missing tube of blood: NVA in either definition
The pathologist’s definition of VA still captures a TON of waste. That said, I tell my teams to focus less on arguing about definitions and more time spent on the obvious, preventative waste. We can nitpick later, if ever.
on 14 Mar 2007 at 6:16 pm 2.Mark Graban said …
I also posted a link back to this posting on my blog:
http://kanban.blogspot.com/2007/03/lean-and-mds-defining-value.html
on 14 Mar 2007 at 7:11 pm 3.Ted Eytan said …
I love the circular-ness of this learning community. This is a great conversation.
I would say that my example is an extreme one. In an ideal world, though, the patient would be aware of what’s necessary for their care. And in fact, as patients are challenged with more difficult health care issues, they tend to be come very aware very quickly, in some cases more aware than their physicians.
A concept that’s useful here is Information Therapy, which you can learn more about at http://www.ixcenter.org.
I struggle with the idea that we place a proxy in the role of the patient in terms of determining value. The slippery slope that this takes us down is toward paternalism rather than partnership.
What if we assumed that the patients wanted to be aware and that they could have the information in a manner that made sense to them as the default rather than the exception? What would health care be like in the aggregate - more safe, of higher quality, or less so?
I think the idea of Information Therapy - information is part of the care process, makes it more possible that we don’t have this trade-off to make.