The Patient Centered Value System: Transforming Healthcare through Co-Design by Anthony M. DiGioia, MD and Eve Shapiro was recently published. The forward was written by Don Berwick. I had the honor of authoring the preface. It was fun to have a really good professional writer, Eve Shapiro, help me shape my ideas. I hope that you will read the preface which is reproduced below and become enthusiastic about exploring the potential it has to support your efforts in care delivery.

I have known many healthcare thinkers and doers, and none of them has thought more about the optimal delivery of care based on the highest ideals of professionalism than Tony DiGioia. I hope that you will read the book with colleagues and then become enthusiastic about forming a “guiding  coalition” of enthusiasts in management and practice to enable these ideas to help you transform care where you work.

I need to comment on the forward by Don Berwick. First, if Don Berwick is enthusiastic about this work, it should be a clue that you should look at it also. Second, as usual, what Don writes is both inspiring and insightful.

Don begins:

Excellence in healthcare depends on the quality of relationships with patients and families—really listening to what they want and need— and remembering the values that led healthcare professionals to their calling in the first place. Gone are the days when the simple view that “the doctor knows best” suffices. Now, if we listen carefully and with open minds to what patients and families tell us, we can find the best compass toward improving our delivery of care and their care experience. This is healthcare “co-design,” and it is the wave of the future.

Don also emphasizes that the spiraling cost of care needs to be understood and “brought under control for the benefit of patients, families, communities, providers, and organizations.” He reminds us that none of us know the true cost of care. His conclusion is that, “Providers and organizations need to know what it really costs to deliver care if they are to reduce costs while at the same time improving quality and experiences and providing real value.”

Don ends his forward by telling us:

The Patient Centered Value System as the new operating system for healthcare points the way to personal and professional satisfaction and the experience of joy in work while helping patients and families become true partners in care through co-design.


Preface to The Patient Centered Value System: Transforming Healthcare Through Co-Design

The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.

—Robert Ebert, Dean, Harvard Medical School, 1965

In the more than 50 years between that statement and this moment we have been on a frustrating journey, searching for an operating system and finance mechanism that could “provide optimally for the health needs of the nation.” In 2007, the Institute for Healthcare Improvement (IHI) crystallized Ebert’s vision as the “Triple Aim”:

  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the health of populations; and
  • Reducing the per capita cost of health care.

More recently that terse description has been given greater meaning by being restated as,

“Care better than we’ve seen, health better than we’ve ever known, cost we can afford…for every person, every time.”

Institute for Healthcare Improvement Leadership Alliance, Year 2 (September 2015 – August 2016)

Since recasting Ebert’s description of the “deficiencies in healthcare” into a pursuable objective that we can all accept and understand, we have diligently searched for easily spreadable methodologies in pursuit of the Triple Aim. Many of us have tried hard to adopt and spread Lean as this operating system and some have succeeded, but always there has been significant resistance as clinicians struggle to see how methodologies developed in manufacturing can be applied to the care of people.

Healthcare professionals have often been unable to connect the industrial methodologies of process improvement to their work without a sense that they are losing the essence of why they became clinicians in the first place. The “adaptive work” of continuous improvement, which seems to require them to give up what they value most, has often felt like a poor fit. Many a Lean transformation has stalled because of the perceived tension between clinical values and continuous process improvement toward the Triple Aim.

Since 2006, Anthony M. DiGioia, M.D. and colleagues at Magee-Womens Hospital, University of Pittsburgh Medical Center (UPMC), have been working to bring clinicians and medical institutions a continuous performance improvement methodology that has its roots in the values of good clinical practice. This book presents the outcome of this work, called the Patient Centered Value System. The Patient Centered Value System is a comprehensive approach to healthcare delivery that comprises three essential tools: Shadowing, the Patient and Family Centered Care Methodology, and Time-Driven Activity-Based Costing— while complementing and fully embracing current process improvement efforts such as Lean and the Toyota Production System as described later. The Patient Centered Value System integrates the scientific method, clinical values, and the science and objectives of continuous improvement. Reading about the Patient Centered Value System should feel familiar to anyone interested in quality, safety, efficiency, and the traditions of professionalism. The Patient Centered Value System feels as though it has evolved organically from a desire to improve the experience of care by seeing the entire care experience through the eyes of patients and families.

Section I of The Patient Centered Value System: Transforming Healthcare through Co-Design uses the technique of storytelling to quickly connect with readers facing new and challenging learning curves of their own. Over the course of a long career I have played many of the roles depicted in the story: the enthusiastic CEO, the physician leader, and the reluctant and skeptical clinician. The roles that I have not played I have observed in others in numerous efforts to improve care and advance the mission of our organization against significant internal resistance and harsh externalities. I can testify that the characterizations in the story are effective presentations of the many ways that real people react to the challenges of change. The story demonstrates that adaptive change is both an interactive process and a challenging learning curve that must be climbed for both individuals and groups.

The book begins with a story that demonstrates the principles and objectives of Shadowing in action. As a former leader who has struggled with introducing the need for change, the dialog and the actions described in the story feel realistic. It is easy to recognize the leadership challenges and the need to build a guiding coalition of diverse stakeholders. What is most powerful about the story, for me, is how the CEO of Exemplar Memorial Hospital, Dr. Ben Highland, keeps bringing the reasons for change back to the best care of the patient, the hospital’s mission, and the foundational principles of professionalism. As he introduces his colleagues to the what, why, and how of the Patient Centered Value System, the reader learns right along with them. The detail that Dr. Highland presents is so complete that readers should be encouraged to introduce the Patient Centered Value System in their own organizations simply by emulation.

Sections II and III, serve as the didactic resource written in the usual tradition of the medical literature that Dr. Ben Highland might have used in leading his colleagues to understand the power of the Patient Centered Value System. The story portion of the book and the technical portion cover the same issues in a highly complementary way. Repetition and review are the keys to learning.

The information in the Introduction is so useful to understanding the evolving state of healthcare and the theory and science of continuous change that it deserves special mention. If the book just began without some set-up to the story many readers might miss some of the messages that the story delivers. The Introduction should not be quickly glossed over. It has great merit as a stand-alone piece.

My favorite chapter is Chapter 8, “Time-Driven Activity-Costing in the Patient Centered Value System: A User’s Manual,” which demonstrates how to use shadowing long with the costing approach developed by Robert S. Kaplan and Steven R. Anderson (2007) to determine the true cost of care delivery. Any organization that hopes to lower its costs to succeed in the era of value-based reimbursement needs to develop consistency in combining Shadowing with Time-Driven Activity-Based Costing. This “monograph” within a book makes the subject easy to understand and demonstrates nicely how it can be implemented.

Chapter 10, “Patient Centered Value System + Lean or Other Process Improvement Approaches = Rapid Improvement,” is also of particular interest because it explains how to add the Patient Centered Value System to other process improvement approaches you may already be using to accelerate the pace of change. Lean is a management philosophy in continuous evolution. Just as the English language has continuously become richer and more effective by adopting new words and expressions from other cultures and languages, Lean too has always been in a process of continuous acquisition. Ever since a rainy Saturday morning when I first met Dr. DiGioia in downtown Boston to hear about the Patient Centered Value system, I have stressed how compatible his work is with our Lean efforts. How does “going to the gemba” really differ from Shadowing? The projects that are chosen as the focus for improvement in the Patient Centered Value System are quite similar to kaizen, or rapid improvement, events.

What is different about the Patient Centered Value System is the explicit focus on the patient and family as the core concern. In this book, the elimination of waste and the improvement of the care process are articulated more clearly as an extension of our professional accountability and values than often comes through to clinicians as they struggle with their prejudices against Lean as a form of “medical Taylorism.” In Chapter 10 the authors embrace this compatibility between their methodology and other forms of continuous improvement, including Lean. This is huge!

Perhaps the two greatest barriers to success with any improvement methodology are “today’s work” and the time and effort that individuals must devote to learning how to use any new methodology. Competent and committed leadership that extends deep into the enterprise can lower those barriers, yet patients and families who are given the opportunity to co-design the healthcare experience are the true catalysts for change.

Two additional barriers to change in many organizations are the costs of consultant help in managing the change process and revenue lost when frontline staff is required to learn the methodology. If one considers the broad spectrum of healthcare organizations across the nation, it is easy to realize that many just do not have the resources to invest in consulting and their staff doesn’t have time to read and digest the message of a long technical treatise describing a new approach to practice.  The authors of The Patient Centered Value System: Transforming Healthcare through Co-Design definitely were considering these realities as they wrote this book. An interested reader can easily consume several chapters at one sitting and it is quite possible to cover the whole book over one weekend. It is easy to imagine a group of concerned clinicians or a senior management team going through this book in preparation for a strategic retreat that is scheduled when collectively they realize that the time has come when they must recognize that business as usual is in its eleventh hour.

Read it as a story. Read it as a resource. Read it as a training manual. Just read it. This is a must read for anyone who cares about the future of healthcare.