Design Thinking for the Greater Good

by Jeanne Liedtka

  The Monash approach to design thinking.

  “I have a three-legged stool model,” Don explained. “Clinical management is one leg. Operations research is another leg. Systems thinking is the third leg. And the seat, to bring it all together, is design.” Monash has adapted the four-question model to their unique health care environment in powerful ways, thinking deeply about details from the composition of the teams to the pacing of the design conversation. Examining what Monash is accomplishing allows us to consider how design thinking fits into the larger story of system redesign and brings the human voice into operations research. It demonstrates that quantitative and qualitative approaches can work together to create a more complete picture of what is going on today and lay the foundation for a different tomorrow.

  Today, Monash’s projects are delivering powerful results, allowing Don and Keith and their colleagues to tackle ever-broader health care issues. Indeed, as the hospital scales the successes arising from the design process, it faces a challenge not yet experienced by many of the organizations we’ve studied: how to move beyond pilots to scale and integrate these new projects into the everyday work flow.

  Initiative: General Medicine Redesign

  Monash advanced their design journey based on the realization of leaders in the Monash Department of General Practice that continuing “business as usual” would fail to meet the growth in demand driven by an aging population with ever-expanding life expectancies and aspirations for independent living. The design team began their work, in 2007, with a simple premise: place effective patient care center stage and ensure that frontline medical teams can deliver it.

  During the What is stage, the team examined the workload of junior staff, establishing what work could be done with existing staff and whether additional staff would be needed as a result of projected trends in inpatient activity. Surfacing the concerns of key staff members, including nurses, allied health professionals, and both junior and senior medical staff, was critical because the team wanted to understand the issues needing immediate attention. The work practices of junior and senior medical staff, as well as their relationships with other team members, like nursing staff, were reviewed.

  On the basis of the information they gathered, they established an overriding principle that constituted a kind of design criteria for idea generation in the What if stage: Frontline teams are responsible for the delivery of the patient experience, always. Everyone else in the organization is a member of support staff, including the CEO and board members. This principle led to two key questions:

  1. How can we make it possible for the key members of the frontline team to do their jobs every minute, every hour, every day?

  2. How can we empower them to support delivering a joyous patient experience?

  This first redesign identified multiple structural change opportunities:

  • instituting interdisciplinary bedside rounds to enable synchronous and timely information exchange, making nurses and medical leaders jointly accountable for all aspects of care;

  • creating a boundary-spanning role, occupied by senior nurses, to manage overall flow and facilitate transitions in care across boundaries;

  • implementing advanced training to better align the skills of junior medical staff to task complexity; and

  • providing enhancements to existing performance reports to support accountability for flow performance.

  The team started their experiments in an area for which they had responsibility: medical staff operations. The first operational test was the implementation of a morning report with senior medical staff present. Almost immediately, this very first step was challenged, not by frontline staff or management but by the senior staff themselves. “This was incredibly threatening to everyone and was marked by an early open revolt from several members of senior medical staff,” Don explained. Informal attempts to remove the leaders of the contested change ensued. Hospital executives held firm, resisting attempts to have change leaders fired, and innovation efforts continued. “Our biggest challenge was this first one, and it was the hardest,” Don recalled.

  The next step focused on creating a new role for a senior nurse—general medicine liaison coordinator—to act as a boundary spanner, managing relationships with the emergency department, the bed management team, ward-based nurse unit managers, and medical teams. The coordinator was charged with producing daily summaries of activity that were disseminated in personalized e-mails at the end of each day, in a “know the rules and know the score” format. This report provided a simple set of numbers that gave a quick overview indicating whether the workload and patient flow were under control. An automated set of performance indicators that was continuously updated every fifteen minutes was also developed.

  Next, they tackled a serious workload issue that had been identified: the night medical registrar was severely overworked. A decision was made to introduce a night resident medical officer to support the night medical registrar. This change produced immediate results in terms of reduced stress for the night medical registrar, increased safety for admitted patients, and improved timeliness and performance. It also sent a signal to the medical staff that the organization truly intended to be responsive to the needs of junior staff.

  Three full-time senior medical staff were added soon after, “to the shock and amazement of other medical departments,” Don noted. This change put a senior doctor on the ward every morning, providing more support for junior staff and an enhanced sense of coaching and apprenticeship. Senior medical staff now attended ward-based multidisciplinary team meetings at the conclusion of rounds. Their presence signaled that improved performance mattered to the organization and that staffing would be augmented to make this happen.

  The project team also looked at the broader system surrounding what happened in the wards, arguing that the major downstream service supplier, the Rehabilitation and Aged Care Service, needed to change its service model. This recommendation was based on the recognition that, in a connected system, improved length of stay in the downstream compartment would have a significant effect on performance in the first upstream compartment, the emergency department. After initial success, they had a setback when an unexpected change in senior management in the Rehabilitation and Aged Care Service removed the changes. Length of stay and responsiveness deteriorated again as a result. Later, however, changes were reinstated, and within twelve months, length of stay was reduced from twenty-four days to eighteen days, again by paying attention to the small number of patients who stayed longer than was clinically necessary.

  The cumulative results of these efforts—a 40 percent reduction in length of stay, with significant efficiency gains in bed capacity, and reduced sick leave in junior medical staff—were impressive and led to additional ventures.

  But “two steps forward, one step back” was a reality that the Monash team grew to accept as their work moved into other areas. The reality of politics was always present. In the team’s experience, achieving change was a political process that required the development of its own strategy. That strategy had to be supported by attention to strong metrics and reporting relationships—as well as a willingness to be blunt, as necessary. Don commented on the intersection of politics and design:

  All change in a closed system is a political process. The biggest opportunity for change is present when the internal narrative inside the heads of the chief actors changes. In each individual’s mind, they are the hero of their own story. Understanding this simple concept has provided the greatest benefit in terms of leverage to achieve change. This has been relatively easy to achieve for members of the frontline staff, moderately easy to achieve for senior medical staff (the option to “fit in or farewell” is always available, and in some instances was exercised), and much harder to achieve for senior executives.

  Initiative: Agile Psychological Medicine Clinics

  In 2013, a Monash mental health team decided to focus on their adult psychiatric walk-in service,
motivated by concerns that neither patients nor caregivers were well served by the existing system. Led by Dr. Melissa Casey, the Monash team was responding to troubling signals: a significant increase in adults arriving to the emergency room in crisis; a growing relapse rate, indicated by shortening intervals between visits; and clinician frustration resulting from spending too much time filling out paperwork rather than seeing patients. The hospital’s existing emphasis was on triaging at the front end of the patient’s journey, with a focus on containing the damage—people were presenting in crisis, and many were suicidal. That logic seemed compelling, but the team wondered if there was a better way.

  Melissa’s involvement in the redesign grew out of her frustration that previous attempts at reform had only explored one side of the story—the organization’s “wants.” She knew of many workshops over the past five years in which clinicians had been asked what they wanted in a new design. Documents were written and debated, over and over, but no agreement had ever been reached.

  In 2012, she had joined the executive steering committee, where yet another version of a draft document was debated without achieving agreement. Her belief was that the supply-side focus—in a system where everyone was delivering different parts within the supply chain—had too many competing needs and perspectives involved. There could be no alignment, Melissa believed, without the voice of the consumer.

  Though she was not responsible for adult community mental health, Melissa offered to do an intensive one-month analysis of demand (on top of her normal job). She got the go-ahead from the mental health program head, Anne Doherty, and enlisted the help of Keith and Dr. David Clarke to do a deep dive into the demand side of the design story, with the aim of better understanding the patient experience. Unlike nearly all of the other studies we talk about in this book, their work did not start with ethnographic research, because of political challenges in gaining permission to interview emergency room patients. Instead, they turned to data analytics and mining, using existing data contained in Monash’s information technology systems. They complemented this analysis with direct observation, shadowing clinicians. We believe that their experience provides an important counterargument to the quantitative versus qualitative research dichotomy we so often accept in the innovation field, demonstrating how either research methodology can be used to inform the design thinking process and illustrating ways that the two approaches can work together.

  Melissa’s analysis—quantitative and qualitative—uncovered many hot spots of opportunity for redesign in mental health. She then ran a series of workshops with the front-end clinicians, and together they formed a hypothesis to be tested in the form of a service prototype. They bonded into a team based on unity of purpose, with the senior and most expert psychologists wanting to come on board.

  Their first task was to examine the demand for service by looking at patient volumes by clinical diagnosis and access point. This research meant accessing three different, unlinked information technology systems that did not communicate with each other. The first was PTS, the front-end triage phone database. PTS was the entry point for people engaging from their homes, a 24/7 service that literally provided a lifeline to those in crisis. The second database belonged to the emergency department. It captured information about patients who physically arrived at Monash’s three emergency rooms and was not connected with other data systems. Finally, there was CMI, a third database, belonging to the mental health system, both inpatient and outpatient. To develop any sense of what was happening at the front end of mental health, Melissa had to link data from these three unrelated systems.

  Such a data mining task would have daunted the most courageous and committed clinician, but not Melissa, who had an unusual repertoire of past experiences and skills to call on. Though extensively schooled and experienced in neuropsychiatry, she had also managed large-scale change in the Australian Taxation Office’s data-intensive environment for fifteen years.

  Melissa selected a sample of patients and followed their journeys across all four experiences—phone, emergency room, inpatient clinic, and outpatient clinic. Focusing on a twelve-month period, she began with the PTS phone triage database, looking at each patient engagement. Then, armed with individual patient numbers, the team linked PTS patients with the emergency department system, and for every person engaged with both the emergency department and PTS they found the overlap with the third database, the CMI mental health system.

  Having pulled together the engagement data, she faced the challenge of how to make sense of it. A design consultancy Monash was working with, ThoughtWorks, suggested using a timeline to lay out each patient interaction in sequence, a technique they had recently applied in another consulting engagement for a telecommunications client. This suggestion led to the creation of a journey map that integrated all of a patient’s mental health experiences with Monash.

  The results were surprising and triggered an “aha” moment for the team. The story of one particular patient, Tom, really hit home. Following a suicide attempt, Tom was referred by another hospital’s acute psychiatric ward to Monash’s adult mental health service for outpatient treatment. Just two months later, after treatment, Tom was readmitted to the hospital with another overdose. During that period, the timeline revealed, Tom experienced significant activity as a patient, having thirteen different case managers, seventy touch points, and eighteen handoffs.

  What Tom hadn’t experienced, it seemed, was treatment that made a difference in the longer term. When David looked at Tom’s story, he had a revelation: “There was no care there.” Clinicians realized that their present system was providing patients with an experience that was not at all like the one they wanted to deliver. Christine Miller, Monash’s deputy director of psychology, observed:

  BENEFITS OF A BROAD REPERTOIRE

  Melissa Casey offers a great example of the important role played by an innovator’s set of life experiences, or repertoire, and the benefits of exposure to a diverse set of experiences.

  Remember Geoffrey’s broad background? We see it here with Melissa as well. Her past work encompasses both highly analytical work and patient care. As a result, she is able to bring a unique mindset and skill set that allow her to identify opportunities that highly capable individuals with exposure to only one of these areas cannot see. She studied economics and accounting in college and took a job in tax as an auditor after graduation. Finding it unsatisfying, she transferred to the management team doing large-scale change work in the central taxation office. In that role, she was introduced to design thinking more than twenty years ago, while working to redesign Australia’s income tax system, with an eye on the human dimension.

  Wanting to go deeper on the human side, Melissa pursued doctoral and postdoctoral studies in neuropsychiatry and became a therapist. While doing clinical work, she saw a colleague struggling with a major restructuring. Putting her old hat back on, she offered advice. And from that, she came full circle back into change work, this time in health care rather than taxation.

  A journey map of one patient’s experience.

  We can think all kinds of things about how we believe the system is working, but then, seeing the reality of how it was really working, it was shocking to see how far from our intentions reality had come. Patients needed someone to be present for them. Despite a flurry of activity, nothing was changing for them. We needed to feel the blockages and struggles.

  Furthermore, Tom’s information was recorded in five different information management systems and fifteen different patient records. Clinicians’ sense of overwhelming paperwork, it seemed, was also well founded.

  The team was ready to design—almost. Before turning to ideation, spurred by stories like Tom’s, the team members decided they needed to revisit the basic purpose of their work. Melissa explained:

  In health care, we often think of purpose on the supply side, around what suits the organization. But that only gives you half the story; the reason why we exist is to
meet the purpose of clients. Despite a wealth of data, we still haven’t gotten to the heart of purpose. We’re only going to get that when we understand from our client’s point of view what it’s like engaging with us. And not just clinically. Especially in mental health, it’s the nature of their experience as well.

  Often, systems drive to their own purpose, however unintended, which may or may not match the mission of the organization. This is what Monash’s mental health data demonstrated. Mapping their patient processes and examining the patient experience over time revealed the true nature of the system. What the Monash mental health service was delivering was completely different from what the clinicians—and the organization—wanted. Melissa observed:

  We were viewing each contact between staff and patients as episodes of care and not seeing the whole system. In the moment, we were treating the consumer in what we thought was the best way possible. But, from their perspective, and looking at the cumulative sum of their experiences and needs, we weren’t responding well.