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Think Like a Designer to Make Care Safe

By Tom A. Augello, CRICO

Related to: Ambulatory, Obstetrics, Surgery

An expert in process design describes obstacles and solutions when improving health care delivery.

Guest Commentator

  • Peter Coughlan; IDEO; Palo Alto, CA


For anyone driving change in a health care organization today, the need to make health care safer and reduce medical error is a bright, red, flashing light on the dashboard. Regulatory agencies and payors are demanding improvements. So are patients.

But health care leaders and frontline providers have learned from bitter experience that change—improvements to clinical process or quality—is painful in their industry. Doctors, nurses, and administrators have seen interventions come and interventions go…with mixed results at best. Outside industries are frequently held up for comparison. But hospitals and ambulatory care sites are unique service facilities that seem at first, and even second, blush to be a poor match for strategies that succeed in any other industry.

In the summer of 2009, Peter Coughlan took on a room of potential skeptics at a Harvard-sponsored patient safety summit in Boston. Health care providers and administrators were there to hear accounts from colleagues about what has worked and what hasn't worked to make patient care more reliably safe. Coughlan was there to tell them why—why their intervention ideas may fail, and why they might succeed.

He is a partner at IDEO, a global consultancy with clients in diverse sectors like government, biotech, automotive, and health care. IDEO uses an approach called "Design Thinking" to help hospitals improve. Design Thinking focuses on how people interact with their environment.

Coughlan's group helps health organizations create their own innovation processes internally by using design principles. Clients have included Brigham and Women's Hospital in Boston improving its pre-surgery preparation and postpartum care…and Massachusetts General Hospital, which engaged IDEO for help with its ambulatory care of the future project. At the Brigham, waiting time was reduced between 11 and 31 percent in the surgery area, and satisfaction with post-partum services sky-rocketed. In addition, projects that once took up to two years to implement are completed in two months or less.

"In health care it is always a bit surprising to me that folks don't get out much. It's not surprising because I know how hard you work. We would be running ideation sessions and people would say ‘oh if only we had this,' and we would say ‘but it's already out there.' So one of the things that we'll do is bring our client teams out and our own design teams out to go experience other things from outside the industry and say ‘is there something you can borrow from there.'"

As Coughlan broke his talk into two sections—why your intervention will fail, and why your intervention will succeed—he described a series of obstacles to success that are especially challenging in health care. Coughlan said that the good news is that each obstacle can be overcome, but they must be recognized first. One obstacle is a strong aversion to failure.

"And having heard some of these heart-rending stories today, I can understand why you have that relationship with failure. Failure, for you, means death or maiming, right, killing people, maiming people often and that's horrible stuff. What we have to do when we work with our clients is say, ‘Yes, there's that kind of failure, but there is also another kind of failure that can really be useful for you.' We have a saying at IDEO, ‘Fail early to succeed sooner.' First of all, getting people to use this word ‘failure' in a hospital is a big deal, but once we do, people start to get it."

First, failure is not allowed to hurt patients, obviously. Second, in order for failure to be acceptable in hospitals trying to improve care processes, it has to be on a small scale. This requires rapid cycles of intervention, incrementalism, and localized changes.

"It's the small test of change, this notion of contextual experimentation and really taking ideas out in the field. Because it's only, we say this, every time you put a prototype into the world, it takes a 90 degree change. It's almost automatic. You say ‘I'm going for this,' and something happens. The only way to find that out is to actually insert things into the system."

A tool that helps start this process is rapid prototyping. Coughlan said a rapid prototype should be very, very simple and easy to put into the environment quickly to learn from its almost inevitable failure. He also said it shouldn't cost a lot, sometimes not much more than a dollar.

"This particular prototype is something that was created by physicians and nurses at the Brigham, when we were looking at the presurgery process and realizing we actually need a new space to deal with all these processes that are running through here. Okay, so let's just create that right away, and within an hour using some paper, color paper, the team had created this sort of idealized vision of the presurgery cente. And this later went on to actually become a template for how they envision that center as they were rebuilding it."

Direct observation of a process is another good starting point. He recalled a Chicago health facility that was looking for ways to improve the patient experience. After engaging Coughlan's firm, the hospital happened to care for one of his colleagues, who brought a camera to him when he sought care for a broken foot.

"He put a video camera to his head and sort of recorded the proceedings. We then took the film of that, and we shared it with the physicians and the nurses and said as you're watching the video, just make a list of the kinds of questions that you have that emerge for you, questions that you think the patients might be wanting to ask you at this point. Well within 10 minutes, the collective group had generated 200 questions, and we all agreed that there was probably an opportunity to keep patients better informed in the process."

Often in health care, what people do about something is just added to something else they implemented, and nothing is taken away. This is an obstacle that Coughlan identified as peculiar to hospitals…in part, because of the many isolated demands and varying lines of authority—and a culture that has become highly skilled at "work-arounds."

"I was talking to someone in the audience yesterday, and she said you mean people don't purge things? So I actually stole the idea from her. They do it on an every three years. They go through and they purge things that don't work. So I upped the game a little bit. Imagine if you held a yearly purge to eliminate redundant or inefficient or broken, outdated tools and processes. So this became a part of what you did. It's almost like spring cleaning. Let's clean out that useless process. Let's clean out that equipment in the storeroom that never gets used. Imagine if you could only add a new process or tool if you removed one or better yet in the beginning years if you removed two."

Coughlan says work-arounds are so prevalent in health care that manufacturers have gotten away with very poor design. He implored the audience to stop putting up with it. Get people involved in the design itself. He pointed to Kaiser Permanente in California, which has encouraged doctors and nurses to use their natural talents as inventors.

An audience member expressed some pessimism that health care is so bad at improving processes. This gave Coughlan an opportunity to turn that around to see the natural strengths in health care for innovation once it is properly focused. He said the first reason he is optimistic is that people are extremely motivated in health care.

"A second reason is that actually you are the only people who can redesign the systems. You are the only ones who can do it. All those technologies that get put in there, they are put in by technology people out in, you know, Silicon Valley, who have never visited a hospital. Or if they have, they have done sort of the formal almost JCAHO tour of the hospital to try to understand things. If we bring a prototype into a hospital setting, it gets kicked to crap instantly because everyone know exactly how it will work, why it will work, why it won't work, etc.

"So for those reasons, I think, you know, I'm really hopeful. And design is not a tough process. You need to come up with new ideas. How do you do that? Well, okay, go out on a field trip, right. At the Brigham we were doing some work around patient transport, so we took the group out to visit a local taxi dispatcher. They came back like we had gone to Mars or something. Taxi dispatcher has it all figured out. Just go there, and look at that. So really simple things, again it's a question of time; it's a question of getting space and permission to go out and explore those things. But you are great designers, and the process is not difficult to learn."

January 1, 2009
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