https://orcid.org/0000-0002-7399-622X
Abstract
Coproduction offers a new way of conceptualizing healthcare as a service that is co-created by people (health professionals and people seeking health services) rather than a product that is generated by providers or health systems and delivered to patients. This offers new possibilities for those introducing and testing changes, and it enables additional ways of creating value. Fjeldstad and colleagues describe the architecture of several kinds of value creating systems: (i) Chain; (ii) Shop; (iii) Network and (iv) Access. An international Value Creating Business Model Community of practice (VCBM CoP) was formed by the International Coproduction of Health Network and explored these types of systems and developed a self-assessment guide for health systems to use to assess value.
An international community of practice comprising leaders, clinicians, patients and finance specialists representing 12 health systems from four countries (USA, UK, Israel and Sweden) met monthly for 1 year and used a semi-structured process to iteratively refine and adapt Fjeldstad’s model for use in healthcare and develop a draft self-assessment guide. The process concluded with initial focus group user experience sessions with six health systems.
The community of practice successfully completed a 1-year journey of discovery, development and learning, resulting in two products: (1) a full-version self-assessment guide (detailed) and (2) an abbreviated ‘short-form’ of the guide. Initial focus-group results suggest that there is initial perceived feasibility, acceptability and utility of the guides and that further development and research is reasonable to pursue. Results suggest significant variation and context specificity in the use of the guide, simple and complex knowledge transfer applications in use, and the need for the development of simple and technology supported versions for use in the future.
The VCBM CoP has successfully completed a 1-year collaborative learning cycle, resulting in the development of a self-assessment guide that is now ready for additional investigation using formal research methods. The CO-VALUE study has been designed to build on the work of the CoP and includes qualitative and quantitative assessment phases and a concept mapping study.
Introduction
In 2008, the US National Academy of Medicine gathered a group of experts to explore the future of health systems. One of the roundtable discussions focused on value in healthcare. A speaker concisely summarized the situation:
‘Delivery system advances are generally not thought of in the same way as technology—either information or biomedical—and yet almost every healthcare expert looking at the next chapter of healthcare reform in the United States points out that our delivery system is broken, fragmented, ineffective, redundant, inefficient, and wasteful. It is also inequitable and unable to deal effectively with healthcare disparities and cultural complexity’ [1].
The group examined the questions from multiple perspectives. They suggested what they considered to be ‘Foundational Elements’, ‘Care Improvement Targets’ and the creation of a ‘Supportive Policy Environment.’[1] Their closing questions invited fresh thinking on many fronts, but all seemed within the present framing of the systems for the basic work of health-care service making. Today—in the midst of a pandemic—we have begun to see that our basic structures of work are giving way to some very different frames [2].
More recently, the European Union’s Expert Panel on effective ways of investing in Health (EXPH) suggested that ‘value’-based healthcare encompassed four aspects of value:
personal value (meaning that an individual receives appropriate care);
allocative value (referring to the optimal distribution among patient populations);
technical value (relating to the best outcomes with available resources for all the people in need to mitigate inequity) and
societal value (referring to the intrinsic value of good health as enabler to participate in society and solidarity as contributor to social cohesion of equal individuals).
The panel recommended an action plan, which included the exploration and development of learning communities of professionals and models of co-creation (patients and professionals) [3].
The ‘coproduction’ of health-care services, where patients and professionals work collaboratively to decide on and execute a treatment plan or course of action to benefit the patient’s overall health, enables additional ways of creating value [3, 4]. Stabell and Fjeldstad and, subsequently, Fjeldstad and others have drawn attention to three types of system configurations for the value creation in service organizations [5, 6]:
linked processes (value chain).
customized responses to particular needs (value shop).
flexible responses to emerging needs in a population (value network).
A renal self-dialysis clinic we observed in Jönköping, Sweden, demonstrates a ready example of the three configurations. People receiving standard hemodialysis report to a part of the clinic where they have, by appointment, arranged to have standard dialysis administered and monitored by nurses (value chain). In another part of the clinic, a person struggling to navigate a more complex set of problems with renal disease meets with a nephrologist to further assess the problem and develop a customized treatment plan (value shop). Finally, in a section taking up half of the entire clinic, there is a group of people who have been trained by nurses to self-administer their own dialysis. They are talking with each other about how they do it and how they best cope with living with renal disease, while they self-administer their own dialysis (value network).
A value chain can be defined as a series of interconnected processes (usually used to make a product), a value shop as a context for solving problems in dyads; and a value network as a system for solving problems in a group or population. These system designs seem to be enabled in service systems of coproduced service, but have not yet been systematically explored in working health-care service settings, in diverse payment contexts and in service of diverse types of patients and populations. To better understand them, we created a ‘community of practice.’
Lave and Wenger described ‘communities of practice’ as groups of persons as ‘situated learners’. [7] They placed emphasis on learning as a social practice that holds the whole person, the activity and the context together. Wenger further explored the way these groups worked and were formed [8]. Later, he described the ways in which a digital habitat for a community of practice might enable a community of learners. Many have built on these basic frames, but we found very helpful, practical guidance in Reaburn and McDonald’s work from Australia [9].
Methods
When Stabell and Fjeldstad encountered the challenge of modeling a system for value creation in work firms other than in the work of manufacturing a product, they proposed models or configurations of systems for three different modes of work [10]. In considering how these configurations might be relevant to health-care services, coproduced service work of health-care services in the dialysis program at Ryhöv Hospital in Jönköping, Sweden, and the inflammatory bowel disease network at Cincinnati Children’s Hospital in Cincinnati, Ohio, seemed to resemble ‘value networks’, which were inclusive and more heterogeneous than the value chain–linked processes of product manufacturing. We began to imagine the possible utility of these configurations in coproduced health-care service settings [11, 12]. We quickly realized that any exploration of these models in health-care service settings should involve diverse settings and populations, people actively working in them, and activities grounded in the daily organizational realities of their work. We created a collaborative learning opportunity modeled after Wenger’s ‘community of practice’ (CoP) in a digital habitat and concurrently we drafted a research plan that would over time allow a more formal assessment of the use of these ideas—the CO-VALUE study [13].
The Community of Practice
Each site agreed to participate in the shared learning of a CoP based on a careful description of our shared aim and the way we would work—initially in person and subsequently in monthly virtual sessions. We also anticipated that a diversity of settings would be important for experiential learning about value creation. The community of practice involved the settings identifying health conditions in the relevant populations is shown in Table 1. Therefore, diversity of financing systems, inpatient versus outpatient contexts and patient populations across the participating organizations have all promoted our understanding of how to best move the idea of coproduction value creation from an abstract concept to a useful framework.
Participating health systems and target populations
| Health system | Population |
|---|---|
| Clalit Medical Center and Hospitals (8 hospitals in multiple cities), Israel | Oncology |
| Dartmouth-Hitchcock Health, New Hampshire, USA | MS |
| East London National Health Service Foundation Trust, London, UK | Mental health |
| Eskenazi Health Center, Indiana, USA | Depression in elderly |
| Hennepin Healthcare, Minnesota, USA | Heart failure |
| Houston Housecalls Program, Baylor College of Medicine, Texas, USA | Home care services |
| M Health Fairview, Minnesota, USA | Morbid obesity |
| Maple City Healthcare Center, Indiana, USA | Diabetes mellitus |
| Minneapolis Veterans Affairs Health System, Minneapolis, Minnesota, USA | Heart failure |
| New England Veterans Affairs Health System, Bedford, MA, USA | Opiate use disorder |
| Region Jönköping, Jönköping, Sweden | MS |
| Sheba Hospital, Ramat Gan, Israel | Epilepsy |
| Health system | Population |
|---|---|
| Clalit Medical Center and Hospitals (8 hospitals in multiple cities), Israel | Oncology |
| Dartmouth-Hitchcock Health, New Hampshire, USA | MS |
| East London National Health Service Foundation Trust, London, UK | Mental health |
| Eskenazi Health Center, Indiana, USA | Depression in elderly |
| Hennepin Healthcare, Minnesota, USA | Heart failure |
| Houston Housecalls Program, Baylor College of Medicine, Texas, USA | Home care services |
| M Health Fairview, Minnesota, USA | Morbid obesity |
| Maple City Healthcare Center, Indiana, USA | Diabetes mellitus |
| Minneapolis Veterans Affairs Health System, Minneapolis, Minnesota, USA | Heart failure |
| New England Veterans Affairs Health System, Bedford, MA, USA | Opiate use disorder |
| Region Jönköping, Jönköping, Sweden | MS |
| Sheba Hospital, Ramat Gan, Israel | Epilepsy |
Participating health systems and target populations
| Health system | Population |
|---|---|
| Clalit Medical Center and Hospitals (8 hospitals in multiple cities), Israel | Oncology |
| Dartmouth-Hitchcock Health, New Hampshire, USA | MS |
| East London National Health Service Foundation Trust, London, UK | Mental health |
| Eskenazi Health Center, Indiana, USA | Depression in elderly |
| Hennepin Healthcare, Minnesota, USA | Heart failure |
| Houston Housecalls Program, Baylor College of Medicine, Texas, USA | Home care services |
| M Health Fairview, Minnesota, USA | Morbid obesity |
| Maple City Healthcare Center, Indiana, USA | Diabetes mellitus |
| Minneapolis Veterans Affairs Health System, Minneapolis, Minnesota, USA | Heart failure |
| New England Veterans Affairs Health System, Bedford, MA, USA | Opiate use disorder |
| Region Jönköping, Jönköping, Sweden | MS |
| Sheba Hospital, Ramat Gan, Israel | Epilepsy |
| Health system | Population |
|---|---|
| Clalit Medical Center and Hospitals (8 hospitals in multiple cities), Israel | Oncology |
| Dartmouth-Hitchcock Health, New Hampshire, USA | MS |
| East London National Health Service Foundation Trust, London, UK | Mental health |
| Eskenazi Health Center, Indiana, USA | Depression in elderly |
| Hennepin Healthcare, Minnesota, USA | Heart failure |
| Houston Housecalls Program, Baylor College of Medicine, Texas, USA | Home care services |
| M Health Fairview, Minnesota, USA | Morbid obesity |
| Maple City Healthcare Center, Indiana, USA | Diabetes mellitus |
| Minneapolis Veterans Affairs Health System, Minneapolis, Minnesota, USA | Heart failure |
| New England Veterans Affairs Health System, Bedford, MA, USA | Opiate use disorder |
| Region Jönköping, Jönköping, Sweden | MS |
| Sheba Hospital, Ramat Gan, Israel | Epilepsy |
The aim of our CoP was to ‘establish and facilitate a collaborative learning community of practicing professionals and key stakeholders (clinicians, chief financial officers, patients, family members, community leaders, etc.) interested in discovering new approaches to value creation in healthcare service’. People needed to understand the framing of value creation in these system configurations and to see how the coproduction of a health-care service enabled them. Our plan of learning involved a nine-step pedagogical cycle that developed those understandings in the context of their own settings (Figure 1). We began at Step 1 by exploring an overview of the coproduction of health-care service and the configurations of value creation and our learning plan. Subsequently, we explored each step of the learning cycle in greater detail with inquiry and action grounded in the specificity of the various sites and populations. Concurrently, we tallied the useful questions and illustrative exemplars from participating health systems. Our aim was to concurrently and iteratively construct a working draft of a self-assessment guide, which health systems could use to assess coproduction value.
International Coproduction of Health Network Value Creating Business Model CoP discovery and learning cycle.
Early in the learning cycle we invited participants to identify a ‘population’ of persons who shared some common challenges associated with a disease or condition. We invited them to explore the persons and the circumstances of their lives—as individuals and as members of a population. We elaborated on what the coproduction of health-care service actually meant and how it related to the theme of each session. Together, we discovered who ‘owned’ a person’s health and how a professional works with that person to ‘make’ helpful services. By making the learning cycle explicit, we could explore the elements of coproduction and their connections to the value configurations of the model.
For example, we saw how a ‘standardized way’ of assessing the status of a person with diabetes could help. We saw that ‘doing something’ about what was found in an individual’s assessment required a customized response. We were able to see ‘patterns’ of work that were common to several individuals with a common condition and could begin to imagine how such a group might be facilitated to enabled the best use of resources to create services of value. We could see the importance of these individual configurations; at the same time, we recognized the need for agile interconnections among them to make best use of resources.
An emerging self-assessment guide
The organization of the self-assessment guide followed the sequencing of the work of the CoP. After some introductory material, each step in the shared work was itemized and accompanied by a set of potentially useful questions for local use (see Appendix A). We imagined that a user of such a guide might be a person whose role was to lead the work in a health-care system for this sub-population of persons/patients.
As an illustrative step, the section on Step 2, the ‘population,’ is reproduced below:
‘Who are the people in this population? Both demographic descriptive data and a more detailed qualitative, representative, named ‘persona’ that helps bring the population ‘to life.’ Sometimes even more than a single persona is helpful, including a similar way of describing persons-sometimes-known-as-professionals’.
‘What is a ‘bird’s eye’ view of the process flow of service for them? Use 10–15 steps to describe the process, including notation of areas of currently active coproduction and areas that might reflect possible opportunities for improving the services.’
‘How is ‘value’ currently thought about in your system and population? Think from the perspective of the person-sometimes-known-as-patient. How is this measured? Sometimes the use of a ‘value-compass’ conceptual model can help elucidate the idea’.
‘Are there any already-identifiable ‘opportunity spaces’, ‘capabilities’, or ‘interest’ for coproduction in the ‘as is’ system? What are they? Where are they? Who gets access to the opportunity spaces?’
‘Are there any current ‘macro’ payment issues—e.g. soon-to-be-enacted reforms—that will bear on an understanding of this particular population in this local setting?’
‘Are there any special technologic or device-related issues that may ‘bear’ on the creation of current or future service for this population?’
After creating a detailed collation of questions, we were able to construct a briefer draft set of questions to create a six-question ‘short-form’ version of the self-assessment guide:
‘Who are the people in this population of patients and how do they interact with professionals?’
‘How do linked-processes (standardized) work to meet the needs of this population?’
‘What ‘custom’ work occurs to meet the particular needs of individual members of this population?’
‘How are networks of relevant people used to meet the emerging needs of this population?’
‘What systems outside of the usual specialized work systems are ‘accessed’ (obviating the need for local infrastructure investment) regularly to meet the needs of this population?’
‘How do leaders develop the full spectrum of system configurations and facilitate the ongoing match between ‘patient’ need and best system configuration to meet that need at best value?’
Focus groups
We conducted 1-hour open-format focus group sessions with a convenience sample of six teams from health systems participating in the CoP (Table 2) in the summer and early fall of 2020. The focus groups were loosely structured to address three general prompts, and participants were allowed significant latitude to comment on aspects of the self-assessment guide that they felt were relevant and important to their local experience:
Focus group summary observations by health system
| Health system | Summary observations |
|---|---|
| Jönköping Region Multiple Sclerosis Center, Jönköping, Sweden | Used full version as an ‘electronic workbook’ to guide inquiry sequentially and to inform planning of overall coproduction strategy, including a mixed-methods development of common MS patient phenotype personas (developed from qualitative interviews) linked to quantitative national care utilization and cost data (derived from national registry data). ‘The guide helped us to structure our work and it has become a living document as we have added our work to it, making it our own’. They also described their use of the guide as a reflection of their intention to develop a stronger coproduction culture in their work |
| Dartmouth-Hitchcock Multiple Sclerosis Center, New Hampshire, USA | Used short-form guide as overview guidance to help the group think about cost and value from a coproduction standpoint. The group focused particularly on ‘three-dimensional coproduction process mapping’ from the perspectives of provider, person with MS and clinical pharmacist, identifying areas in which value is generated (or hindered) and developing linked cost assessment approaches. ‘The value architectures gave us new ways of thinking about MS care and understanding the various perspectives (patient, clinician, pharmacist) simultaneously has helped us to identify new opportunities for understanding value and new targets for improvement’ |
| Bedford VA Medical Center, Massachusetts, USA | Used the guides for overview guidance and ‘perspectives/lenses’ to motivate a different way of thinking about ‘patient engagement’ and ‘activation’ through a coproduction lens. This influenced their decision to emphasize the meaningful involvement of veterans and other stakeholders in a longitudinal strategic planning initiative to develop a ‘veteran centric’ approach for their opiate addiction program. This approach ‘changed the culture of our work’ |
| MHealth Fairview Medical Center, Minnesota, USA | Participation challenged our beliefs about the way we involved people we knew as ‘patients’. The other people in the community of practice and their experience really helped us change our thinking. The exercises and the varying responses of the others in the community helped us. This experience revealed the importance of a deep understanding of health-care services. We used these insights to meet our ‘patient advisory group’ and we had a very different outcome. The guide was less helpful than the stories from participants and provocations by the facilitators |
| East London Trust, UK National Health Service, London, UK | Did not specifically apply the guide for guidance in program development, but instead applied it as a reference point to compare ongoing innovation work to the architectural elements of value creation used in the guide |
| Maple City Health Center, Indiana, USA | These configurations invited fresh thinking. It invited us to engage the work of ‘letting some stuff go’ that we had carried along in our culture—began to give us new ways of living out the culture we have. Reminded us to think of ‘our’ population as more than those who came in our doors. We had difficulty getting the cost data we hoped for and we realized again that our payment systems do not help us work for the entire population in our community. The conversations in the community were keys to our development of new ideas and made us realize we could do more to develop meaningful ‘networks’ |
| Health system | Summary observations |
|---|---|
| Jönköping Region Multiple Sclerosis Center, Jönköping, Sweden | Used full version as an ‘electronic workbook’ to guide inquiry sequentially and to inform planning of overall coproduction strategy, including a mixed-methods development of common MS patient phenotype personas (developed from qualitative interviews) linked to quantitative national care utilization and cost data (derived from national registry data). ‘The guide helped us to structure our work and it has become a living document as we have added our work to it, making it our own’. They also described their use of the guide as a reflection of their intention to develop a stronger coproduction culture in their work |
| Dartmouth-Hitchcock Multiple Sclerosis Center, New Hampshire, USA | Used short-form guide as overview guidance to help the group think about cost and value from a coproduction standpoint. The group focused particularly on ‘three-dimensional coproduction process mapping’ from the perspectives of provider, person with MS and clinical pharmacist, identifying areas in which value is generated (or hindered) and developing linked cost assessment approaches. ‘The value architectures gave us new ways of thinking about MS care and understanding the various perspectives (patient, clinician, pharmacist) simultaneously has helped us to identify new opportunities for understanding value and new targets for improvement’ |
| Bedford VA Medical Center, Massachusetts, USA | Used the guides for overview guidance and ‘perspectives/lenses’ to motivate a different way of thinking about ‘patient engagement’ and ‘activation’ through a coproduction lens. This influenced their decision to emphasize the meaningful involvement of veterans and other stakeholders in a longitudinal strategic planning initiative to develop a ‘veteran centric’ approach for their opiate addiction program. This approach ‘changed the culture of our work’ |
| MHealth Fairview Medical Center, Minnesota, USA | Participation challenged our beliefs about the way we involved people we knew as ‘patients’. The other people in the community of practice and their experience really helped us change our thinking. The exercises and the varying responses of the others in the community helped us. This experience revealed the importance of a deep understanding of health-care services. We used these insights to meet our ‘patient advisory group’ and we had a very different outcome. The guide was less helpful than the stories from participants and provocations by the facilitators |
| East London Trust, UK National Health Service, London, UK | Did not specifically apply the guide for guidance in program development, but instead applied it as a reference point to compare ongoing innovation work to the architectural elements of value creation used in the guide |
| Maple City Health Center, Indiana, USA | These configurations invited fresh thinking. It invited us to engage the work of ‘letting some stuff go’ that we had carried along in our culture—began to give us new ways of living out the culture we have. Reminded us to think of ‘our’ population as more than those who came in our doors. We had difficulty getting the cost data we hoped for and we realized again that our payment systems do not help us work for the entire population in our community. The conversations in the community were keys to our development of new ideas and made us realize we could do more to develop meaningful ‘networks’ |
Focus group summary observations by health system
| Health system | Summary observations |
|---|---|
| Jönköping Region Multiple Sclerosis Center, Jönköping, Sweden | Used full version as an ‘electronic workbook’ to guide inquiry sequentially and to inform planning of overall coproduction strategy, including a mixed-methods development of common MS patient phenotype personas (developed from qualitative interviews) linked to quantitative national care utilization and cost data (derived from national registry data). ‘The guide helped us to structure our work and it has become a living document as we have added our work to it, making it our own’. They also described their use of the guide as a reflection of their intention to develop a stronger coproduction culture in their work |
| Dartmouth-Hitchcock Multiple Sclerosis Center, New Hampshire, USA | Used short-form guide as overview guidance to help the group think about cost and value from a coproduction standpoint. The group focused particularly on ‘three-dimensional coproduction process mapping’ from the perspectives of provider, person with MS and clinical pharmacist, identifying areas in which value is generated (or hindered) and developing linked cost assessment approaches. ‘The value architectures gave us new ways of thinking about MS care and understanding the various perspectives (patient, clinician, pharmacist) simultaneously has helped us to identify new opportunities for understanding value and new targets for improvement’ |
| Bedford VA Medical Center, Massachusetts, USA | Used the guides for overview guidance and ‘perspectives/lenses’ to motivate a different way of thinking about ‘patient engagement’ and ‘activation’ through a coproduction lens. This influenced their decision to emphasize the meaningful involvement of veterans and other stakeholders in a longitudinal strategic planning initiative to develop a ‘veteran centric’ approach for their opiate addiction program. This approach ‘changed the culture of our work’ |
| MHealth Fairview Medical Center, Minnesota, USA | Participation challenged our beliefs about the way we involved people we knew as ‘patients’. The other people in the community of practice and their experience really helped us change our thinking. The exercises and the varying responses of the others in the community helped us. This experience revealed the importance of a deep understanding of health-care services. We used these insights to meet our ‘patient advisory group’ and we had a very different outcome. The guide was less helpful than the stories from participants and provocations by the facilitators |
| East London Trust, UK National Health Service, London, UK | Did not specifically apply the guide for guidance in program development, but instead applied it as a reference point to compare ongoing innovation work to the architectural elements of value creation used in the guide |
| Maple City Health Center, Indiana, USA | These configurations invited fresh thinking. It invited us to engage the work of ‘letting some stuff go’ that we had carried along in our culture—began to give us new ways of living out the culture we have. Reminded us to think of ‘our’ population as more than those who came in our doors. We had difficulty getting the cost data we hoped for and we realized again that our payment systems do not help us work for the entire population in our community. The conversations in the community were keys to our development of new ideas and made us realize we could do more to develop meaningful ‘networks’ |
| Health system | Summary observations |
|---|---|
| Jönköping Region Multiple Sclerosis Center, Jönköping, Sweden | Used full version as an ‘electronic workbook’ to guide inquiry sequentially and to inform planning of overall coproduction strategy, including a mixed-methods development of common MS patient phenotype personas (developed from qualitative interviews) linked to quantitative national care utilization and cost data (derived from national registry data). ‘The guide helped us to structure our work and it has become a living document as we have added our work to it, making it our own’. They also described their use of the guide as a reflection of their intention to develop a stronger coproduction culture in their work |
| Dartmouth-Hitchcock Multiple Sclerosis Center, New Hampshire, USA | Used short-form guide as overview guidance to help the group think about cost and value from a coproduction standpoint. The group focused particularly on ‘three-dimensional coproduction process mapping’ from the perspectives of provider, person with MS and clinical pharmacist, identifying areas in which value is generated (or hindered) and developing linked cost assessment approaches. ‘The value architectures gave us new ways of thinking about MS care and understanding the various perspectives (patient, clinician, pharmacist) simultaneously has helped us to identify new opportunities for understanding value and new targets for improvement’ |
| Bedford VA Medical Center, Massachusetts, USA | Used the guides for overview guidance and ‘perspectives/lenses’ to motivate a different way of thinking about ‘patient engagement’ and ‘activation’ through a coproduction lens. This influenced their decision to emphasize the meaningful involvement of veterans and other stakeholders in a longitudinal strategic planning initiative to develop a ‘veteran centric’ approach for their opiate addiction program. This approach ‘changed the culture of our work’ |
| MHealth Fairview Medical Center, Minnesota, USA | Participation challenged our beliefs about the way we involved people we knew as ‘patients’. The other people in the community of practice and their experience really helped us change our thinking. The exercises and the varying responses of the others in the community helped us. This experience revealed the importance of a deep understanding of health-care services. We used these insights to meet our ‘patient advisory group’ and we had a very different outcome. The guide was less helpful than the stories from participants and provocations by the facilitators |
| East London Trust, UK National Health Service, London, UK | Did not specifically apply the guide for guidance in program development, but instead applied it as a reference point to compare ongoing innovation work to the architectural elements of value creation used in the guide |
| Maple City Health Center, Indiana, USA | These configurations invited fresh thinking. It invited us to engage the work of ‘letting some stuff go’ that we had carried along in our culture—began to give us new ways of living out the culture we have. Reminded us to think of ‘our’ population as more than those who came in our doors. We had difficulty getting the cost data we hoped for and we realized again that our payment systems do not help us work for the entire population in our community. The conversations in the community were keys to our development of new ideas and made us realize we could do more to develop meaningful ‘networks’ |
‘What was most useful and helpful?’
‘What was hardest to use or understand?’
‘What contributed most significantly to developing understanding and insight?’
Participant responses were de-identified, grouped by health system and summarized. General themes were gleaned from the responses via a general consensus review process by four evaluators using basic thematic analysis methods.
Statement of principal findings
While coronavirus disease-2019 (COVID-19) limited CoP participation by some sites in 2020, each of the six health system teams participating in focus groups found the guide to be helpful and accessible. Some teams utilized the full assessment guide and others appreciated the abbreviated version. Some used the guide more concretely as a literal step-by-step roadmap and others used it in a more abstract manner to guide how they framed their approach to assessing and improving coproduction-derived value in their settings. Two general themes emerged: (i) complex ‘high road’ transfer versus simple ‘low road’ transfer and (ii) context-specific application.
‘High’ and ‘low road’ knowledge transfer
We anticipated that the self-assessment guide might be utilized in two different ways to help facilitate knowledge transfer—‘low’ and ‘high’ road applications [14]. The ‘low road’ application provides concrete guidance about key tasks to complete (e.g. development of personas or process maps) and key questions to deliberate when trying to develop an understanding of a context and population from a coproduction value creation standpoint and then endeavoring to improve that understanding. Only one of the six interviewed groups applied the guide at least to some extent in this way. The ‘high road’ approach was used at least to some degree across all six groups and reflected a more global and abstract application. Groups reported using the guide to generate new ways of framing their perspectives on health and health-care service, and many utilized it as a foundation to examine long-held assumptions about their practice culture. In the ‘high-road’ application, the guide was viewed as a starting point and reference resource rather than an endpoint or pathway from start to finish.
Context-specific application
A consistent observation across all focus group sites was the context-specific application of the guides. There was a substantial degree of depth and richness of application in each site and a great degree of variation in application across sites. Some used it in a ‘high-tech fashion’, employing it in an electronic format, such as might be done using an interactive website application. A number of centers followed a ‘low-tech’ application pathway, utilizing printed hard copies of the guide (especially the short-form version) or passive use of the electronic versions to guide their own development of team discussions, meeting agendas and strategic plans for their work.
The Jönköping multiple sclerosis (MS) team used the guide as an infrastructure and entered information into it directly and sequentially as they progressed through the guide and developed their work. The guide helped them to think at the level of individual patient and at the population level when thinking about design of services and measurement of services/costs. They began with using a coproduction view of their population, which used stratified epidemiological data from the national MS registry to identify clinical and utilization characteristics and created ‘personas’ developed based on qualitative interviews of people with MS in each category. This created a ‘mixed-methods’-derived characterization of their population, which were able to ‘walk through’ each of the value configurations using the guided assessment approach to structure their inquiries.
The guide also offers options for facilitators/encouragement to think in generative ways regarding problem-solving possibilities. Employing this exercise, the Jönköping team was able to conceptualize ways in which these ‘epidemiological personas’ might interact with each of the configurations. A young woman recently diagnosed with MS might interface with the value chain for management of her disease-modifying therapy treatment, the shop to develop a comprehensive symptom management approach and the network to learn with peers about how to integrate her new life with MS with the rest of her life as a single mother of two small children and a full-time job. In each scenario, the team explored how coproduction might occur, under what conditions that might happen, how that might generate value for her and what ways might be best to measure that.
Across groups, we observed a few uniform characteristics. First, the use of the guide as a reference, ‘guide post,’ or starting point was common across groups. Second, the value configurations (shop, chain and network) described in the guide were cited by all groups as an extremely helpful aspect. Third, the guide was generally perceived as accessible, understandable and generally useful. Finally, all groups appeared to orient around using the guide in some way to inform organized improvement or implementation activities targeting population health outcomes for specified groups. This suggests that future development of the guides should have multi-use capability including both static options and electronic and/or online interactive options that can be used flexibly to inform teams in action.
Interpretation within the context of the wider literature
Our dedicated community of practice has successfully completed the first phase of collaborative inquiry, discovery and learning in the exploration of coproduction value creation amidst substantive challenges from competing demands placed on participating health systems by the COVID-19 pandemic. While certainly imperfect, our effort has drawn upon a diverse and rich group of perspectives to fit Fjeldstad’s value creation architectures to health-care coproduction and develop a prototype self-assessment guide that is now ready for subsequent formalized development and research in the CO-VALUE study. The intent of CO-VALUE is to first qualitatively assess the feasibility, usability and acceptability of the self-assessment guide in actual use by health systems seeking to improve coproduction capability and then to inform the development of a quantitative coproduction value measure set, which health systems could use to evaluate coproduction improvement efforts.
The CO-VALUE study
Building on our community of practice learning sessions, the focus group feedback and the self-assessment guide outlined above, we will conduct two additional phases of development via a formal research mechanism—the CO-VALUE study [13]. The development of the self-assessment guide via the CoP described previously constitutes the first phase of the study. In the second phase of the study (to begin in 2021), we will iteratively test and optimize the self-assessment guide in a sub-sample of four health systems from the original CoP. We will also use this testing phase to develop conceptual measurement domains from which quantitative value metrics could be developed. In the third phase of the study, we will use a modified Delphi process to develop a core set of value creation measures and test and optimize these in a sample of participating sites. We will also develop a user’s guide to familiarize new users with the ideas of coproduction and value creation and help them make use of the self-assessment guide. This research could establish a foundation for subsequent improvement and implementation science studies focused on the improvement of coproduction value and population health outcomes.
CO-VALUE also includes sub-studies, which will investigate specific aspects of coproduction value creation, including a concept mapping study that will launch in 2021. The concept mapping method [15] combines qualitative and quantitative methods to create a new conceptual framework from the ideas and beliefs of a sample of individuals in the CoP. We expect that this study will help to distinguish coproduction from related concepts such as patient centeredness, patient activation, shared decision-making and patient empowerment and help to establish future priorities for action in health coproduction value creation.
Strengths and limitations
The CoP learning approach we adopted for this work had important limitations. Balancing the need to present content with the need to optimize opportunities for discovery by participating sites was a challenge. Value creation through coproduction of health-care services involves a dual imperative to understand both the concept of coproduction (the ‘what’) and the ways it can take shape to contribute to improved health for service users (the ‘how’). This approach may be most useful in capitated health systems seeking to improve patient outcomes and experience at lowest cost. While learning can often benefit from a template, coproduction of healthcare requires transitioning between value chain activities, value shop activities and value network activities at the appropriate times—and, in some cases, improvising. More than a paradigm shift to match a specific model of care delivery, this requires adopting new habits of thought through which one builds on the framework of coproduction value creation.
Finally, at this stage of our work, we have developed an initial understanding and articulation of the value configurations as applied to healthcare across settings participating in the CoP, including the development of a guided self-assessment approach. A necessary next step will be to study how this can be applied in settings and how coproduction efforts occur, are enabled by, or hindered by the different configurations. These nuances will need further investigation in later phases of development in the CO-VALUE study.
Conclusion: implications for policy, practice and research
We have described successful initial work conducted by an international community of practice to develop a guided self-assessment approach for health systems seeking to understand health-care service coproduction and some new configurations of systems to assess and improve coproduction value in health and healthcare. This work sets a foundation upon which more formalized development and inquiry can take place via the CO-VALUE study and opens several avenues for further exploration. Most critical of these is defining and measuring coproduction quality and value. Understanding that if services are by nature coproduced between service user and professional, it is the quality of that coproduction that can vary and thus can be improved. This understanding—that coproduction is inherent to health-care services—shifts the planned CO-VALUE activities from that of an additional burden placed on busy professionals to developing an important approach for improving the quality of health-care coproduction and, ultimately, the value of coproduced services aimed at improving health.
Supplementary material
Supplementary material is available at International Journal for Quality in Health Care online.
Acknowledgements
The authors wish to acknowledge the contributions of the larger International Coproduction Health Network in helping to create the conditions for the successful development and facilitation of the international CoP, and especially the participation, contribution and dedication of the teams from all of the participating health systems in our CoP toward the development of the self-assessment guides during this first phase of developmental work.
Funding
This work has been supported by the International Coproduction Health Network funded through a program development award from the Rx Foundation and a program grant from the Robert Wood Johnson Foundation (Grant ID#75081) in the USA and a linked grant via CAF America (Grant ID#4182-51) in Sweden.
Contributions
P.B.B.—conceptualization, writing/review/editing and data curation/analysis. R.C.F—writing/review/editing and data curation/analysis. B.J.O.—oversight, conceptualization, writing/review/editing and data curation/analysis.
Ethics and other permissions
Activities reported in this manuscript are part of the ongoing CO-VALUE study. CO-VALUE is approved as a minimal risk research study by the Dartmouth-Hitchcock Health Institutional Review Board, Lebanon, New Hampshire, USA.
Data availability
Qualitative data discussed in this work are not publicly available and are stored with appropriate protections as required by protocol via the IRB approval for the CO-VALUE study. Data inquiries can be made to the authors.
