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As the massive impact of the novel coronavirus began to surge last year, the national value management team at Healthcare Improvement Scotland and NHS Education for Scotland knew that the Value Management Collaborative — launched in November of 2019 to improve the quality and sustainability of care — had to modify its work. What they did not predict, however, was that teams using value management methods would not only improve quality and increase value, but they could also enhance teamwork and staff experience despite the challenges presented by COVID-19.
Value management brings quality and cost data to the point of care to drive sustained improvement. It offers a mechanism to manage and understand quality within a team or area or within an entire system. It enables frontline clinical teams to use quality and cost information to better align their priorities with those of their organization, and to take ownership of the improvement agenda.
Value management can also bring together a range of different improvement or assurance programs that teams and boards might be involved in so they can see them in a more structured or rigorous way. In Scotland, for example, there are programmes focused on patient safety, access, infection prevention and control, and Excellence in Care. Value management offers a way to bring all the work together, focus on what’s important for a team, and connect it back to the organization.
The application of the value management methodology has demonstrated a positive impact in reducing costs, improving staff engagement and morale, and improving patient safety. In Scotland, the national collaborative seeks to test and spread the value management approach across six participating boards within NHS Scotland. The approach was originally developed by IHI in partnership with the NHS Highland Raigmore Hospital in Scotland in 2015.
An interim evaluation of the Value Management Collaborative identified examples where the value management approach is leading to patients receiving care closer to home at increased value, better and safer discharge communications, and reductions in the number of returned referrals thereby supporting patients to get care in the right place at the right time.
“When the collaborative started in 2019, the momentum, speed, rhythm, and pace in which the 18 teams embraced the method and the approach was impressive, demonstrating that the method is applicable in different settings,” says Joe Hands, Principal Lead for Value Management for NHS Education Scotland. Despite significant challenges experienced across the system due to COVID and other knock-on system pressures, four participating teams have demonstrated quantifiable impacts in terms of value improvements and the remaining teams are showing progress in their improvement capability.
The Impact of Value Management on Staff Experience
The ongoing evaluation of the collaborative (which includes interviews with team members for case studies) has surfaced changes that can be difficult to quantify. People talked about improvements in staff experience. They described how powerful it was to regularly congregate (whether in person or virtually) around their visual management boards — a communication tool that provides at-a-glance information about current process performance — to talk about their data together and get insights from team members who have not always been involved in quality improvement work in the past, including other clinicians and finance colleagues.
“We’ve seen that value management can positively impact team communication and cohesion, morale, and staff well-being and create better links and collaboration between different parts of an organization,” notes Benjamin McElwee, Senior Improvement Advisor for the Value Management Collaborative. “Those relationships generate all these possibilities for future quality improvement work beyond the lifetime of the collaborative.”
“Even when times have been difficult during COVID,” Hands adds, “the one thing many value management teams continued to focus on was staff experience. Having that continuous balancing measure of the impact on staff allows you to see the bigger picture rather than just focusing on processes.”
Improving the Value of Care
Value management is not so much about driving cost up or down but about improving value. It is about understanding the costs attributed to the care that is delivered and connecting the costs to improvement work.
The Value Management Collaborative has been using the Box Score to better understand and improve value. The Box Score is a set of performance measures (quality, capacity, and financial) that fits on one sheet of paper. This tool helps convey to clinicians that better understanding their system and models of care can help them identify opportunities to improve quality and value. Using the Box Score highlights the interdependencies between the quality, capacity, and cost.
If teams work on improving processes that impact the cost per patient seen — the referral processes, or how appointments are made or delivered, or the balance of how they spend their time between delivering direct and indirect care, for example — then they can positively influence the number of people they see. This will affect their cost per patient, and potentially generate savings that can be reinvested or spent in a different way, whilst enhancing the access of patients to care and better outcomes. The savings are efficiencies, which can be re-purposed to optimise care delivery and provide better value.
We continue to review how Value Management Collaborative participants are progressing and what they have learned. These are some of the lessons that have emerged so far:
- Look at quality, capacity, and cost together. Teams and systems appreciate how using the Box Score helps them understand how these elements are interconnected.
- Use value management to help align various improvement and assurance programmes. Teams and systems like that they can use one methodology to pull different (but related) work together.
- Invest in improvement education and capability building to build in sustainability. It’s worth considering: What quality improvement expertise do you have within the organization? How can you best mobilize that to support value management? What additional training needs might need to be addressed?
- Identify opportunities to embed value management in the existing infrastructure within the organization. “You don’t want value management to become something that's separate to the quality improvement work that you’re already doing,” McElwee emphasizes.
- Recognize that leadership support is essential. A team can only go so far with the interventions without leadership support for making the connection between value management work and the performance of the system. For optimal impact, this also requires leaders acting as ambassadors for the work. It can be very motivating for a team when people in positions of seniority offer encouragement or insights or recognize a team’s work locally or externally at national events.
- Encourage team ownership. One of the fundamentals of improvement is making sure that the people who work in the processes own the processes so they can provide solutions to improve them, whilst connecting them to the wider organisation.
- Take the necessary time for setup. Build the team. Understand the system and prioritize measures that are going to continue to be useful and important.
- Focus on improvement that aligns with your organization’s strategic priorities. This will ensure greater sustainability and support than picking something that’s only a priority for a week or month.
The experience of the Value Management Collaborative in Scotland highlights the benefits of collaborative learning. Particularly during the times when it is more difficult to make progress, teams gain from shared experiences and peer support. When you are carrying out what can be a challenging role, it can be sustaining to feel like you are not alone and that there are others trying to do similar work elsewhere who might have ideas that could help you.
Benjamin McElwee is Senior Improvement Advisor for Scotland's Value Management Collaborative. Joe Hands is Principal Lead for Value Management for NHS Education Scotland.
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Value Management Collaborative interim learning and impact report