Table 1

Key elements for successfully developing system-wide value improvement activities within health systems

Key element	Explanation	Example(s)
Health system leadership explicitly identifies value improvement as a strategic priority.	Dedication to value improvement is clearly stated and communicated at multiple levels of leadership and is integrated within the organisation’s business model.	At the University of Utah, value improvement became the organisation’s business model.20 At NYU, the Dean (who also serves as the CEO of the health system) convened hospital leaders in 2013 and recommended a roadmap to value improvement.16
Investment in robust cost and quality analytics and accounting systems.	Providing access to accurate cost data using analytical tools that allow users to report, visualise and investigate cost and outcomes data.	The University of Utah invested 8–16 core team members providing 0.6–1.0 full-time equivalent effort each to build and maintain a cost data model and visualisation tool.28 NYU used a customised activity-based costing system.16
Engagement of front-line clinicians in identifying and refining value improvement opportunities and priorities.	Involving interprofessional clinicians in identifying and monitoring priority areas for improvement including cost and outcome measures.	UCSF hosted an open platform to collect and curate ideas for value improvement from anybody on the medical centre staff, allowing for bottom-up ideas to align with institutional priorities.14 The University of Utah tasked multidisciplinary improvement teams including clinicians, administrative leaders and process engineers to define key metrics for quality for their own domain(s).15
A centralised team for providing project support and coaching.	Significant resources of interdisciplinary personnel are prioritised for direct support of value improvement initiatives, including data analysts, statisticians, administrators and improvement experts.	Both the Caring Wisely programme at UCSF and the VBM programme at NYU dedicated significant resources to a team with diverse expertise (including programme managers, data scientists, implementation experts and electronic health record programmers) to provide project support, data analyses and implementation coaching to clinician-led project teams.14 16
Regular feedback on performance at individual and/or group levels.	Performance data on cost and outcomes data are presented at regular intervals to both groups of providers and/or individuals where appropriate.	UCSF provided individualised ‘scorecards’ for surgical supply costs to surgeons at regular intervals, supporting changes in behaviours that resulted in significant direct cost savings.29
Dynamic leadership driven by accountability to strategic priority.	Leaders at various levels— programme, department, practice group—are held accountable for measurable value improvement and report this progress to institutional leaders.	At NYU, chairs ‘were held accountable to their goals in semi-annual meetings with the Dean, during which VBM performance was specifically reviewed and requests for improvement made if necessary’.16

CEO, Chief Executive Officer; NYU, New York University;UCSF, University of California at San Francisco;VBM, value-based management.