Coproduction of Health by Patients and Providers

Dr Maren Batalden and co-authors in “Coproduction of healthcare services” (BMJ Quality and Safety, published online16 September 2015) (http://qualitysafety.bmj.com/content/early/2015/09/16/bmjqs-2015-004315.full) remind readers that production and delivery of products and services are different.

In particular, “[h]ealthcare is not a product manufactured by the healthcare system, but rather a service, which is cocreated by healthcare professionals in relationship with one another and with people seeking help to restore or maintain health for themselves and their families.” (p. 7).

The authors cite with approval three defining features of services (Osborne SP, Radnor Z, Nasi G. “A new theory for public service management? Toward a (public) service-dominant approach”, Am Rev Pub Adm 2012; 43,135–58) :

“(1) a product is invariably concrete, while a service is an intangible process; (2) unlike goods, services are produced and consumed simultaneously and (3) in services, users are obligate coproducers of service outcomes.”

Dr Batalden explores her perspective on a March 24 2016 WIHI podcast.

While health outcomes are always produced by provider and patient working together, Dr Batalden notes that there is a range of relative contribution over time and across patients. On the WIHI podcast, she used the blue and green pictures at the top of this post to show schematically the degree of agency of the two participants: blue for patient agency and green for health professional agency, with the horizontal dimension representing time.

As Dr Batalden says, “You can play with the shapes over time to imagine the way in which the agency and dynamics might change over time or in different situations.”

For example the middle stripe could represent a patient who mostly operates without assistance from the health care professional, with occasional acute events in which the patient has little agency, e.g. in emergency surgery events.

Improvement by What Method?

Once you accept that products and services are different, you’re ready to consider a key point raised by the authors:

Should we expect theory and methods of management and improvement developed and deployed in the world of product manufacturing to apply directly to management and improvement of services?

One literature review article suggests the answer is “No.” (D. Arfmann et al. (2014), “The Value of Lean in the Service Sector: A Critique of Theory and Practice”, International Journal of Business and Social Science, 5, No. 2, 18-24) (http://ijbssnet.com/journals/Vol_5_No_2_February_2014/3.pdf)

Nonetheless, there are numerous examples of Toyota Production System applications in healthcare, with strong advocates and compelling stories. Interestingly, many of the most compelling examples I’ve learned about involve application of TPS methods in hospitals, diagnostic laboratories, and pharmacies.

Dr. Bataldan’s green and blue pictures hold a clue that may explain why.

For episodes or events in which healthcare professionals have most of the agency, over a short period of time, health services behave less like pure services. For example, specific interventions like hip or knee joint replacements, cataract surgery, or implant of ear tubes in children might be called “product-like” services.

In particular, product-like services are dominated by a concrete procedure and may involve a specific physical item like a replacement joint or a drain tube.

For product-like services, I expect that theory and methods of operations management and improvement developed in manufacturing like the Toyota Production System will be useful.

For healthcare experiences that are far removed from products—like chronic disease experience and management involving adults with diabetes or children with irritable bowel syndrome—direct application of Toyota Production System methods seem less immediately appropriate. For example, trying to map chronic disease management into a standardized linear value stream with specific inputs and outputs and meaningful cycle time measurements can lose vital complexity and meaning.

Dr Bataldan and her co-authors conclude:

“Improving healthcare service using [the construct of coproduction] invites us to consider new ways of preparing health professionals and socialising patients, new organisational forms and structures for healthcare service delivery, and new metrics for measuring success. Like any paradigm, the construct of coproduced healthcare service is imperfect and contains its own pragmatic challenges and moral hazards, but these limitations do not negate its utility. Marcel Proust suggested that the real voyage of discovery consists not in seeking new landscapes, but in having new eyes. Perhaps this lens of coproduction will help us see healthcare service with new eyes.” (p. 9)

It’s a worthy challenge to understand how to manage and improve health services like those discussed by Bataldan and her co-authors. The lens of coproduction should indeed help us see better.