Dr. Paul Batalden, one of the founding fathers of health care quality improvement, was driving down a highway in Minneapolis when he spotted the billboard pictured above.
Any woman who’s had a baby knows that what this billboard promises couldn’t be further from the truth. But it’s a pervasive idea in medicine — that health care providers, rather than patients, create health care services. Paul Batalden sent the photo to his daughter, Dr. Maren Batalden, who is championing a new way to see what’s already happening in health care: a process of co-production by patients and providers.
Maren Batalden recounted the billboard story in her opening remarks on a recent WIHI. A hospitalist at the Cambridge Health Alliance, she says that co-production is like a new lens on patient-centered care, because it can help providers more clearly see the potential of working with patients to create better health care.
The co-production concept
The term co-production comes from economics. Back in the 1960s, economists observed that the country’s new service economy (retail, banking, education) was distinct from the old industrial economy (manufacturing and agriculture). Companies may ask customers for input on the design of products, but the user isn’t involved in the creation of the product itself. Services are different: Companies and customers must work together in order to create value.
That’s how it works in health care, Batalden says. Health outcomes are not created by health care professionals acting alone. They’re always co-created with patients.
“In the primary care clinic, for example, my doctor instructs me in managing my diabetes,” Maren Batalden said. “But I decide what to eat, how much to exercise, how well to track my insulin levels, and so on.”
Even with more acute care, such as a knee injury, the patient plays a leading role: the patient has to describe the pain to the doctor, get to the X-ray lab, bring the PT script to the outpatient clinic, and do the required exercises every night.
Batalden called on health care practitioners, both on IHI’s audio talk show and in a recent BMJ Quality & Safety article, to see their work through the lens of co-production. The medical community is beginning to understand this, she said, but it’s slow. The dominant dynamic in health care today is still doctors on top, with the expertise and knowledge to “fix” patients.
She believes that health care improvers can lead the way in adapting the co-production model from industry — as quality improvement pioneers did in launching the quality movement in the 1980s.
Co-production exemplars in pediatric chronic care
Some early co-production successes have come in treatment of pediatric chronic conditions, including inflammatory bowel disease. WIHI panelists, Sarah Myers, Julie Bass, and Jamie Hicks shared the story of how being part of the ImproveCareNow network of 71 centers has co-produced better outcomes for children with inflammatory bowel disease: They’ve seen an increase in clinical remission rates from 60 percent to 79 percent.
Kathy Sabadosa described the lessons from a remarkable collaboration of cystic fibrosis providers, patients, families, and quality improvement leaders to co-create and co-deliver impeccable care.
A new lens on care delivery
As Batalden understood the power and opportunities of co-production, “it felt like putting on new glasses.” It’s helped her see health care delivery not as a process in which value is made by health professionals and pushed out to patients, but one where value is created by patients with help pulled from health professionals. It’s a world, she summarized, of “people — all of us — working together to achieve wellness.”
This shift in outlook has had a profound effect on her own practice, Batalden noted. She’s challenging her assumptions, starting the moment she’s called to her emergency department (ED) when a patient is about to be transferred to a hospital unit.
“In the past,” she said, “I listened to the ED team and took notes about the patient’s condition. Now I start by asking them, ‘Does the patient want to be admitted?’ It turns out that the majority don’t want this, might not understand the risks or other options, and might actually have a better idea about the best path ahead to help them get better.”
So now, she continued, “I’m discharging patients who, left to my own devices, I would never have discharged in the past, and keeping patients I normally would have discharged.”
Taking patient partnerships to a new level
Batalden acknowledges that co-production is similar to patient engagement initiatives and partnerships growing around the world.
The difference is that patient and family advisory panels, for instance, sometimes function like a manufacturer holding focus groups to get customer feedback on a new product. Co-production means having patients on the design team co-creating improvement programs from day one.
Whether providers realize it or not, patients are already involved in the creation of health care services. Imagine what good can come if providers put on the lenses of co-production to see what more they could do with that reality.
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