Pathways and chains: Strategy and process mapping for healthcare delivery

by Anjali Sastry on February 23, 2011

Value chain analysis is often applied to businesses, and takes the line of business or business unit as its focus–not the firm as a whole. If you map the sets of activities entailed in delivering a product or service, you can use the analysis to understand how each activity contributes to the value delivered by the end product or service. Businesses often seek to capture value generated by other parts of the value chain, or to redesign how they manage low-value-added components of the value chain. A key idea is that the value is the product of the entire chain–you need to look at the whole system.

In social enterprise, several threads of work take a value chain perspective. Consider its potential application in economic development presented in Upgrading along value chains: Strategies for poverty reduction in Latin America, a 2009 briefing paper by Jonathan Mitchell, Christopher Coles and Jodie Keane that examines how value chain analysis can help the rural poor participate gainfully in local, regional and global trade. Ashoka founder Bill Drayton and Valeria Budinich present their take on hybrid value chains in a September 2010 Harvard Business Review piece entitled “A New Alliance for Global Change” (find it at the MIT Library); here’s a quick overview of the hybrid value chain concept from the Ashoka site.

The Care Delivery Value Chain

In healthcare delivery, such an approach has proved useful for understanding how the various activities entailed in delivering care fit together. An organization can use value chain mapping to figure out how to improve quality (or lower costs) by delivering, or connecting patients to, the right services so that they benefit from the entire set of activities required for proper care. In class, for instance, we talked about how the value of testing is made much greater by connecting patients to treatment.

Value chain analysis is just one element in your toolkit–even if you sort out the potential value of connecting patients to treatment after they are tested, how to actually do that is a new set of challenges involving negotiation, implementation and execution, and many other practical steps.

To get you started in applying value chain analysis to healthcare, I lined up a few resources. First, for a broad introduction to the approach, the 2002 book, The Health Care Value Chain, presents a nice overview. Take a look at Chapter One, entitled The Wharton School Study of the Health Care Value Chain, by Lawton R. Burns, Robert A. DeGraaff, Patricia M. Danzon, John R. Kimberly, William L. Kissick, and Mark V. Pauly.

Once you’ve looked over this introduction, you may want to see some specific examples of value chains. I pulled some out from online materials:

In a September 2010 talk (Princeton Global Health Colloquium), Michael E. Porter drew on the approaches for a presentation on Value-Based Global Health Care Delivery (note the copyright notice on page 1). Check out the Breast Cancer example on slide 9, his outcomes hierarchy on slide 15, HIV/AIDS on slide 26, and prevention slide 28. Note that prevention is different from treatment!  HIV/AIDS treatment is the focus of this 2009 Harvard Business School Working Paper, Applying the Care Delivery Value Chain: HIV/AIDS Care in Resource Poor Settings, by Joseph Rhatigan, Sachin Jain, Joia S. Mukherjee, and Michael E. Porter.

If you would like to see even more examples,  Chronic Kidney Care appears on page 11 of this slide deck again by Michael Porter, and Samuel Bühlmann’s 2009 study of care delivery value chains for ophthalmic clinics in Switzerland presents several examples related to eye care, such as galucoma care (see pages 22-26). Others applications include a 2009 paper on Pulmonary Rehabilitation and Integrated Care.

Clinical or care pathways

Within healthcare, the more clinically-grounded approaches may be worth contrasting with the value chain approach. While they are not designed to shed light on the strategic aspects of care delivery design, clinical or care pathways are finding much use in real-world clinical settings. Pathways depict the sequence of steps in care delivery by condition, based in clinical evidence and made practical by their grounding in practice. Here’s a brief introduction, and for those of you interested in a meta-analysis of their value in use, a Cochrane study of their effects on professional practice, patient outcomes, length of stay and hospital costs. Clinical pathways are intended to be normative: they tell clinical and other employees what steps to take in addressing a given condition.  Implementation research (example) may be useful to consider if you would like to understand their value in use. To make this less abstract, check out some specific pathways designed to improve the quality of patient care. The site called “the map of medicine” presents several examples. Take a look at the normal birth map.

{ 1 comment… read it below or add one }

Erin Sullivan February 24, 2011 at 5:54 pm

To add another perspective to this resource rich post, consider Richard Bohmer’s “care platforms” which provide yet another organizing framework. Bohmer, using experiences and observations from high-risk, high-cost, science- and technology-based industries, proposes a model that is integrated for the patient and increases the quality, reliability, and efficiency of care delivery.

Bohmer, Richard, and David Lawrence. “Care Platforms: A Basic Building Block for Care Delivery.” Health Affairs 27, no. 5 (September – October 2008).

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