Healthcare: the Value Stream of care

In Lean process improvement, one of the first steps you ever take is to walk the process. For manufacturing this means to go down to the floor where the product is made and walk with one piece from beginning to end. This provides the manufacturer insight into where there's a great deal of waiting for product to come, leading to idle workers, where there's a lot of inventory piled up - a bottle neck, if there's a lot of rework - fixing defects like re-etching a person's name on the back of an iPhone, and how the material flows around the floor. This works pretty well with doctor's offices too. You can draw a map to all the different places the Dr. walks, the nurses walks, and where the patient walks. Any transportation in a Lean system is waste, so reducing that is important.

Mapping value streams essentially take this to the next level. You map all the major steps that the material that goes into your product step through before and after you. This allows a manufacturer to see all the waste before and after them, enabling them to partner with their suppliers and customers to reduce waste and unnecessary processing. For example, many of us have worked retail. Some times when you do stocking you'll find shirts that are in bags that are in a box. This is non-value add because it's highly unlikely that the bag would protect the shirt from getting wet in the case of a flood. So, it's a waste of plastic for the bag, putting the bags on the shirts, and removing the bags from the shirts are all waste. Which increases the cost of a shirt. However, there's a beginning and end of the value stream likely starting with cotton and ending with the final sale to the customer. In the case of a can of cola, it takes 319 days from the mining of bauxite to the consumption of the cola with only a total of 3 hours of actual processing of the material (Lean Thinking, Womack).

Value Stream for a can of cola through bottling (Womak Lean Thinking)

Why such a long introduction? Well, the value stream for healthcare is completely different. The beginning is when you're born and the end is when you die. Otherwise, every activity you partake in impacts your health and the eventual cost of any episode of care. An episode of care is what happens when you directly interact with a provider, hospital, or health insurer. Arguably, these are the exception to your normal behavior and take you out of your normal routine.

Thinking about health in a value stream like this is non-intuitive for providers and insurers alike. As both have accounting practices and treatment plans that focus mainly on the episodes of care and minimize the remainder of the activities a member does. Thinking in this manner places more importance on preventative care, longer term plans for mental and physical rehabilitation, and care networks for long term diseases. This is a serious shift that is starting to occur in many insurance organizations, but aren't very effective yet. The most effective portion of those three are the networks of patients that have a similar disease, such as Crohn's Disease.

I believe that looking at care in this fashion will help redesign the manner that care is designed as it will focus on different portions. As my friend Rachel pointed out, behavioral health issues are typically undervalued in the value stream of healthcare. However, with this model long term care issues should be given priorities as they impact the highest percentage of the value stream. It would also force insurers and providers to look at addressing care holistically and providing the best care in the best way when they can. Sending patients to clinics that can quickly treat conditions as cheap as possible.

I'm extremely interested in how this will play out at my company as we think more holistically about value streams for health care. Checkout my last two blogs about health care:
http://scitechkapsar.blogspot.com/2013/11/heathcare-how-insurance-company-decides.html

http://scitechkapsar.blogspot.com/2013/11/healthcare-why-do-we-need-medical.html

Lean as a tool for new and mature companies

Today, I finished the book "The Lean Startup" by Eric Ries. Despite the focus on entrepreneurship, I think this book has applications at many levels. First though, I must say that I've been using Lean for several years and I walked into this book with an understanding of Lean and how  to apply it at a company. What does Lean mean though? Well, it certainly doesn't mean cutting staff, reducing the amount of money you have or anything along those lines. It's a methodology for managing projects, processes and products. It does this by basing decisions on actionable data.

What is actionable data? Well, it's data that you can do react to quickly if the data is showing trends. This could be a positive trend or a negative trend. If you see something going well and a process is improving over time, (which is abnormal processes typically go out of control over time) then you want to understand how and why it is improving. If it is getting worse over time, you want to understand why and work to improve the process. This isn't just for machines but also for business processes.

Once you have valid metrics there are several different things you can do. You can simply jump in and try to fix whatever problem is there or you can take a different track. The other track is to do some root cause analysis of the situation. This is called the Five Whys. This is a series of questions that ask Why to understand the real cause of the problem. In one case you may have had a new employee upload something to the production server and it kills the production server. Understanding why might not be as simple as saying, don't do that again. First you might want to know why the action of the employee took down the server, was it something he did that no one else would have done or was it something else. As you dive down you may realize part of the problem was lack of training but there were issues that would have arisen eventually from someone else. This deeper understanding allows you to make changes at multiple levels rather than installing knee jerk reactions.

That's a reactionary use of Lean, some other interesting uses of Lean have to deal with experimenting with your product. Ries argues that most companies wait to long to engage customers and put too much effort into the first version of the software. He argues that a company should create a minimum viable product that can be tested to get the basic point across of the end product. Doing this early allows for experimentation with customer feedback. In the software world this is pretty easy to do. You can get to something that early adopters can use and then test changes. As you can route different users to different versions of your website for the product you can have slightly different tests to see what increases the metric that matters. Getting people to continue using your product, but you need to have very targeted metrics to understand what is actually happening with your software. If you use the incorrect metric you will do a lot of work that isn't driving usage and isn't driving your revenue.

If you decide to change the way users interact with your GUI, it would be useful to have a goal metric to truly understand if the GUI is an improvement over the previous GUI. This could be tracking the number of clicks it takes to get to an important function. The number of times the user uses your product, the number of times a new user uses the product, but stops using a specific GUI. Once you see your metric moving in the correct direction and you can be sure that it is the result of your changes, then you should end you experiment understand why the users reacted the way they did and try to learn what you should test next.

The early goal is rapid experimentation with purpose and data to back up the decisions you make. These techniques will work with any company, but will also be very successful for a startup.