Are you aware of the three-year cycle in developing, executing, and sustaining an organizational initiative?
The cycle follows a pattern that is frustratingly familiar to healthcare leaders. In Year 1, a problem is identified and a solution is introduced to the team with great fanfare. This exciting new initiative achieves early success as people rally to take part. In Year 2, the program hits some bumps in the road: People are uncertain about how they are supposed to use the new solution, and a key stakeholder raises some prickly questions about the initiative’s viability. Nevertheless, managers tell their teams to “make it work,” and they push ahead. In Year 3, a new priority emerges with another round of fanfare, and the old one fades into the background.
In our experience as consultants working with health systems around the world on projects ranging from quality, compliance, and risk to patient experience, operations, and marketing, we have found that even the best efforts to initiate change fall victim to this cycle for a number of reasons, including the following:
- A misunderstood problem: “They spent all this time on the form, but it’s the process that’s broken.”
- A poor solution: “It was a beautiful new platform, but no one used it.”
- Lack of buy-in: “Yes, it was a good idea, but no one likes being told what to do.”
- Change fatigue: “Another new program?”
- Lack of political support: “It didn’t fit in the new director’s vision.”
- Resource constraints: “Even though there’s positive net present value, we’re constantly told that ‘it isn’t in the budget.”’
- Failure to launch: “We kept hitting roadblocks and eventually lost momentum.”
Even aided by problem-solving tools—whether Lean, the Model for Improvement, or other processes for advancing the delivery of healthcare services—disappointment is common and widespread. Beyond the idea-wrecking organizational antibodies and inertia that make any change difficult in healthcare organizations, two phenomena often are evident:
- Failure to understand the human dimension behind complex problems
- Failure to develop sustainable change strategies that work for the human beings for whom they are intended
Paul Batalden, founding chair of the Institute for Healthcare Improvement board of directors, is credited with saying, “Every system is perfectly designed to get the results it gets” (Institute for Healthcare Improvement, 2015). That insight, adapted countless times, is true. The three-year cycle is a design problem, which means that healthcare desperately needs a better approach to design.
Over the past decade, interest in the creative discipline of design thinking has grown at an extraordinary rate, and evidence is mounting of its effectiveness in producing outsized returns for organizations that successfully embrace it. For example, a McKinsey and Company study found that companies with design-based competencies outperformed their competition by as much as 2:1 (Sheppard, Sarrazin, Kouyoumjian, & Dore, 2018). In a time when healthcare leaders are thinking about how to generate more value for patients, caregivers, communities, and organizations, design thinking represents a significant opportunity to generate and capture outsized returns.
In contrast to traditional business thinking in which a problem is identified and a solution executed, design thinking is a reflective process that starts with learning closely with, and from, the people for whom you are designing. Design thinking generates a rich understanding of the problem, and then uses swift experiments to iterate toward solutions that are tailor-made to meet real needs.
The “thinking” behind design thinking is centered on empathy for the end user. In this approach, designers identify with the lived experiences of the people they are designing for, and then place them in the front and center of efforts to solve complex, systemic challenges. In contrast to engineers, who optimize solutions, designers pay close attention to uncovering the emotions, beliefs, and motivations of frontline end users.
Design, therefore, expands the expertise that is considered relevant to the problem. For example, in a project to improve the experience of families dealing with a fetal cardiac disease diagnosis, we leveraged the perspectives of physicians, nurses, patients, families, behavioral scientists, psychologists, designers, risk managers, education theorists, and others. This exploration allowed our design team to understand the users’ unspoken needs with precision and to apply multiple perspectives to the complex factors that create pain points and system bottlenecks.
WHERE DID DESIGN COME FROM?
The professional practice of design has evolved from bespoke items (craft), to mass-produced goods (product design), to an approach that emphasizes user needs by incorporating ergonomics, human factors, behavioral economics, ethnography, and psychology (i.e., human-centered design). Think of the evolution of the computer: Single-use machines such as the calculator evolved to serve myriad applications, were reshaped for usability and user experience, and then were positioned to create a new sense of value or status (similar to how Apple is now emphasizing concern for privacy to sell its products).
Design thinking has emerged as a generalizable approach for tackling complex social, technical, and business problems. It has been adopted as a core strategy for problem-solving and innovation by leading health systems such as Stanford Health Care, Kaiser Permanente, the Mayo Clinic, Johns Hopkins, and others.
TRADITIONAL VERSUS ALTERNATIVE APPROACH TO DESIGN
As a process, design thinking can be thought of as flowing back and forth through three modes:
- Discover: Learning about the people and system to define the problem
- Develop: Generating new ideas and prototyping change concepts
- Deliver: Implementing and refining the solution
In traditional approaches to improving healthcare, problems across the institution are identified by reviewing a range of data, including risk levels, outcomes metrics, qualitative surveys, and benchmarks. The problems are prioritized by frequency and severity and then are evaluated to determine which ones demand attention and in what order. Next, concepts are devised by looking for existing or evidence-based practices and offerings from trusted vendors. After a mitigation strategy is deemed financially viable, efforts are made to secure funding. Finally, solutions are implemented and monitored over time—and so begins the three-year cycle!
Fortunately, design thinking can meaningfully augment and complement organizational problem-solving and mitigate many of the failure modes we see too often.
Design begins with a deep, empathic understanding of the people involved. To understand the human experience, designers gain insights by listening to people’s stories and observing their behaviors.
In one of our projects, we worked with a risk management team that was looking at ways to reduce liability risks in maternal health after having “tried everything,” including education, process redesign, policy improvements, and teamwork training. Adopting a design-thinking approach, our team interviewed and shadowed surgeons, anesthesiologists, nurses, midwives, techs, and patients to gain insight into the day-to-day experiences on the front line. As we synthesized our findings, we noticed significant gaps between the physician and nursing teams’ perspectives. “It’s like we know what to do,” said one physician, “and we toss the ball over the fence—but no one is catching it on the other side.” Meanwhile, a nurse said, “It’s as if the right hand doesn’t remember what the right hand said they were going to do.” As we shared our findings with the nurses and physicians, the local risk management team realized that everyone was passionate about improving, but there was no mechanism to support interdisciplinary teamwork or to consolidate gains. This insight led to the reimagining of the department’s challenges as design opportunities: “How can we spark effective collaboration? How might we ensure that improvements are sustained?” The result was the creation of a new touch point: an interdisciplinary improvement team cochaired by a physician and a nurse. Three years later, it is going strong. The solution was inspired by best practices at other institutions; in this way, empathy-driven insights helped to uncover a larger design opportunity with a contextually appropriate change model.
One of the key strengths of this approach over structured interviews or surveys is acceptance of the reality that what people say they do and what they actually do can be very different. A team of design consultants led by one of our colleagues spoke to several nurses on a patient–clinician violence reduction project in a psychiatric hospital. One new nurse suggested more training in de-escalation skills; a nurse with 30 years of experience dismissed that idea, pointing out the many hours already spent each day in de-escalation. Shortly after the conversation, the designers observed a developing situation while they shadowed nurses on the unit. A patient had become noticeably agitated and was making threats. The more experienced nurse quickly stepped in to defuse the situation. She used the right words, but her body language and tone of voice only inflamed the situation. Reflecting later on the incident, the design team realized that the nurses’ divergent views were rooted in their narrow frames of reference, whereas the broader perspective gained from observation yielded far more valuable insights.
Designers use a range of proven methods for idea generation, including rule-based brainstorming, rapid prototyping, and learning from analogous situations.
Practiced in a disciplined, structured fashion, brainstorming can be a wellspring of fresh thinking and innovative ideas. Brainstorming, as initially conceived (Osborn, 1942), came with specific rules that designers now embrace in creating a safe environment to take risks, explore new thinking, and increase creativity:
- Go for quantity. Linus Pauling was thinking like a designer when he observed that “the best way to get good ideas is to get lots of ideas, and throw the bad ones away.”
- Withhold criticism. For the first half of the brainstorming session, address ideas in terms of “yes, and” rather than “no” or “but.”
- Welcome wild ideas. It is far easier to adjust a wild idea than to expand something safe. Often the most innovative concepts come from the idea behind the wild idea.
- Combine and improve. Bring together different concepts to create powerfully new thinking. We often tell our teams, “If you don’t like an idea, challenge yourself to find the gold, then build on it to make it better.”
Brainstorming typically begins by gathering a diverse team of clinicians, administrators, and patients; arming them with sticky notes; and asking them to come up with as many different ideas as possible for how to address the human needs identified earlier during discovery. The process may start awkwardly, but with a little encouragement and facilitation, the team starts imagining the future together. As many different directions are explored, several creative, doable, and potentially high-impact ideas emerge—often in combinations.
Designers then find ways to bring tangible expression to ideas quickly and cheaply to gather feedback on whether the idea has value. This process is called “rapid prototyping” and can take the form of storyboards, drawings, simulations, or role playing. Gathering constant feedback allows the designers to test assumptions quickly and inexpensively. For example, one of our colleagues was working on a project to develop a new pharmacy tool for organizing medications. The design team noticed that pharmacists often work at high counters, so they devised a simple cardboard prototype of a system to be mounted underneath the countertop. The senior manager thought it was great, but the pharmacists hated it. Although the new system resolved the clutter, it added a step to the workflow by requiring the pharmacist to push out from the counter to reach the new receptacle, thus decreasing the likelihood of use. If the design team had not prototyped and tested the tool with the intended user group, it might have been implemented, with unhappy results.
Learning to build is simply building to learn. Prototyping solves a pragmatic and substantive challenge. It is pragmatic because it ensures the collaboration and buy-in of the people for whom a solution is being designed; it is substantive because it increases the likelihood that the chosen strategy will be effective for the people and the context for which it is intended.
Finally, the implementation stage of design can begin. Once a project team identifies a winning solution, they might be tempted to develop a comprehensive rollout strategy across the entire organization. However, the designer’s approach is to devise several small, safe, and focused strategies for piloting and refining new ideas in context. The aim is to iterate toward the scalable solution that will achieve its intended goal or, if it is a dead end, to find that out as soon as possible. As David Kelley, founder of the design company IDEO, often advises, “Fail quickly in order to succeed sooner.”
In one of our projects, we took new concepts for engaging patients and families in medication therapies and pilot-tested them on an inpatient unit. In Phase 1, we tested the ideas with a few nurses and patients one-on-one, then collected feedback, refined the designs, and returned the next day. In Phase 2, the nurses tested the concepts on their own and provided feedback and improvements. In Phase 3, we tested across the unit. The concepts proved promising—they reduced observed interruptions in medication administration by 55%, increased family awareness of safety practices by 40%, and saved approximately 6 minutes per shift per nurse. In a postimplementation survey, an astounding 100% of the nurses involved said they were more likely to volunteer for future improvement work as a result of the project (which speaks to the meaningful engagement and ownership the design process creates). After seeing the results, the department head suggested we scale and spread the program throughout the hospital. However, we were not sure that the concepts, although promising, would be effective in other settings, nor had we engaged other patient care units in the design process.
The wisdom of design suggested implementing the concepts locally first, and then engaging other units in prototyping before spreading the concepts hospital-wide. It can be tempting in improvement work to see an opening and jump. But the wisdom of design is to elevate end users to the forefront of creative efforts, to design the right thing, and to design the right things right.
How might you get started with design thinking? Here are a few suggestions.
Ask the Right Questions
With or without design consultants, posing design-driven questions can be part of your day-to-day practice. For example, if someone in your organization comes to you with a new idea, you could ask:
- Have you spent time listening and learning from end users?
- How many alternatives have you explored before choosing this one?
- What is the smallest, cheapest, and quickest way you can test the assumptions behind this idea?
Start a Project
Put together a small, diverse team of passionate individuals and ask them to use design thinking on a project. Outlines for the process can be found online by searching on the term “design thinking” and are also explained in books such as Discovery Design: Design Thinking for Healthcare Improvement (Driver, Katz, Mawer, & Future Medical Systems, 2017). The team should select a small problem that no one really cares about—one that they can solve in a week. Ask them to report back to leadership on what they learned. If the results are promising, assign them something bigger and build from there.
Integrate User Insights
You will manage what you measure. Consider incorporating design-related metrics into your organization’s key dashboards, decision-making processes, and key performance indicators. For example, a risk manager is likely serving clinicians, administrators, and patients. What might these stakeholders reveal about the timeliness, helpfulness, and overall quality of the risk management services provided? Instead of relying on surveys alone, consider asking five or six stakeholders if they would be willing to share and reflect on their experiences. Listening will almost always yield responses that are rich with hidden sources of value and opportunities for improvement.
The ideas and approaches presented here may feel familiar. Many are based in common sense and should exist in any good problem-solving approach. Unfortunately, common sense is not all that common, and day-to-day pressures can make people feel they need to move quickly from problem identification to solutions. As an alternative, design thinking is a coordinated strategy rather than a simple accumulation of tricks. It addresses many of the most common pitfalls that drive the traditional three-year cycle and can help healthcare leaders develop value-creating strategies that are grounded in human needs, responsive to actual practices, and attuned to the organization’s goals.