Even before the app rolled out, the team noticed that the average number of long-stay patients had already begun to drop dramatically.
Other Monash Projects
Two other projects currently under way illustrate the breadth of Monash’s use of the design thinking tool kit. One—on hand washing—targets a micro-level set of behaviors, but an important one. Hand washing is a critical defense against hospital infection and its heavy toll in both human and financial terms. Though the project is still in its early stages, the power of reframing their view of noncompliant staff not as villains but as stakeholders who need a better reason to change their behavior became clear to the team and helped members generate ideas they had not previously considered.
At the other end of the spectrum, the hospital’s latest and, in some ways, most ambitious project, Monash Watch, was getting under way as this book went to press. Don noted that they could not have considered a project of this magnitude without having already tested the design thinking waters in the other projects we have talked about in this chapter. Monash Watch targets “super-utilizers”—patients who are estimated to be less than 2 percent of the total patient base but who use 20 to 25 percent of hospital resources. It combines a unique telehealth approach to building rapport and constant monitoring of outpatients’ health, both mental and physical, with new payment mechanisms that will pay for keeping patients out of the hospital rather than for services rendered when they are in it.
The strategy involves nearly daily telephone contact with four hundred super-utilizers, to address social and psychological aspects of their health in an effort to improve the patients’ physical conditions and reduce hospitalizations. Patients will report health issues to telecare guides, who will develop and maintain a personal rapport with them and gather specific information to be fed into an accumulating database. In other tests, such self-reported health data has proven surprisingly accurate. Work in Ireland by Dr. Carmel Martin indicated that telephoning patients halved their hospital visits. “Having done three smaller learning launches—and having discovered an Irish trial of something similar—we’re about 85 percent sure this will work,” Keith noted. To design Monash Watch, two staffers developed deep insights from thirty intensive ethnographic interviews of the generally elderly super-utilizers, learning that, even though the patients experienced multiple hospitalizations annually, physical care was often secondary among their concerns, in the overall context of their lives.
Don and Keith have worked hard to give the project the runway it needs to succeed. The design team backed away from a similar concept last year, when Monash’s former CEO would only fund it for three to six months. But soon thereafter, when Victoria’s Department of Health and Human Services (DHHS) began seeking proposals aimed at decreasing hospital admissions, they were ready. Of the ten hospital groups that could have applied, only Monash and one other decided to try something radically new.
When a new super-utilizer is admitted into the study, DHHS will pay Monash the equivalent of the average cost of three annual hospital visits. The hospital succeeds by keeping the patient healthy and out of the hospital. Estimates suggest that Monash will break even on cost if Monash Watch decreases hospital visits by 15 percent.
Once a person in the at-risk group has been admitted or discharged and meets DHHS requirements, a Monash staffer (a telecare guide) will be assigned to that patient. In regular phone calls, the telecare guide will engage in friendly dialogue focusing on how the patient is feeling. A computer program will analyze the incoming data while the telecare guide develops a social rapport with the patient. If the computer and/or the guide recognize a problem, a health coach (or nurse) can decide whether to send an ambulance to the home, to have the patient seen by a care provider, or to reassess the situation during another day’s call.
Because metadata programs are evolving rapidly, Monash expects that, soon, each patient’s narrative will be analyzed ethnographically in a process of continuous feedback and learning. Every aspect of Monash Watch is an experiment, and the team expects that the questions, the script, and the specific services provided beyond the telephone will all be investigated and iterated throughout the learning launch.
Scaling Design Thinking at Monash
Across the many stories of design thinking at work at Monash, a common theme emerges: mobilizing the clinical staff to look at design thinking’s four questions in order to reframe problems, develop a deeper understanding of needs, translate the needs into new opportunities, and see what works in practice. In fact, the Healthcare InnovationbyDesign team has coined a fifth question—What next?—that we like so much we intend to steal it!
In the larger context of cultural change at Monash, making systemic design thinking core to problem solving has required more than just an invitation to staff to play with ideas and tools; it has necessitated creating a structured process that is accessible to all. “Some people have the view of design thinking that if you get a whole bunch of people in a room with Post-it notes, something magical happens. And afterward, you don’t quite know how you did it,” Don observed. Instead, he said, “You have to make it clear that there’s a rigorous methodology in place that people can learn. We want to be leading edge, not bleeding edge. You need a very structured methodology that lets you safely work through the elements.”
At Monash, that methodology has focused on the four (now five) questions. Having determined that the design thinking methodology works in their medical center setting, Monash is again at the leading edge of health care practice—this time looking at how to diffuse design thinking throughout the organization. They have thought long and hard about how to effectively and cost-efficiently scale their design efforts and build a core competency in design tools and process.
This quest has led them to rely heavily on the power of asynchronous online learning to reach busy staff. Don and Keith have led the way, enrolling interested staff in an online course offered by Darden and then mentoring participants as, working in teams, they apply their learning to an actual Monash project. One student was Dr. Cathy McAdam, head of general pediatrics at Monash Children’s Hospital. “The key to it for me,” she said, “was actually having the group do it, so that we were learning together.” She and her classmates watched videos at home and then gathered to review them. Commitment to the group gave her the accountability she needed to push forward on assignments, despite her busy schedule.
Keith observed, “This approach has given us a way to inquire which we didn’t have before.” Cathy echoed Keith when she noted that the online course provided her with the tools to devise the type of services her patients needed most. Important to her specialty, she adds, the course helped her to devise ways to measure how pediatricians could better meet the needs of consumers, patients, and families. For example, in one design thinking project during the online class, Cathy prototyped and experimented with several iterations of a survey for pediatric visitors, observing:
What I wanted to do was create a way of measuring impact so that if we put in new innovative models of care services, like video conferencing appointments, we can actually see whether it’s had an impact that’s measurable to families. Because otherwise the hospital will only look at how much it costs and how much clinician time it involves.
The online course discussions helped Cathy become comfortable with “the idea of testing something that may not be perfect and actually moving forward, rather than waiting until you’ve got everything ‘perfect’ and then launching something and wondering, ‘Aw, gee, why did that flop?’”
Reflections on the Process
At Monash, we see the value of introducing a rigorous, structured design thinking process that couples deep quantitative and qualitative analysis of patient needs with a spirit of engaged experimentation, all facilitated by medical leaders who walk the talk, fight the battles for change, and provide capability-building opportunities through online instruction that focuses on real projects.
As
Monash looks forward to taking design thinking to new levels, the HealthCare InnovationbyDesign team does not lack for dreams. Besides consistently drawing additional Monash staff and expertise into an ever-growing human-centered conversation, the team’s ambition is to play a leading role in health care innovation by creating an international hub for design education and applied research and practice.
Diagram of Monash’s five-year vision.
But, throughout his forty years as a clinician, Don’s focus has remained the same: to help people get better. He refused to be distracted by the goal of reducing cost in and of itself:
Cost will be stripped out by doing the right things and thinking in a designerly way. You can’t focus on cost as your objective. Your objective is to provide high-quality health care and support people to remain well throughout the community. You can never lose sight of that.
Accomplishing the change, Monash leaders know, will take time. As Melissa observed, “Clinicians need to trust their leader. There is no quick way to building a trusting relationship—it takes time. There is no quick fix. It’s taken five years of team building demonstrating predictability to get here.”
“We’re on a big learning curve,” Keith noted, underlining the ways in which both the conversation and the culture at Monash have begun to shift. But significant challenges remain:
Our view is maturing. We now need to think about on-ramps and the political systems in which we sit. We’ve found a way to get good ideas; now we have to figure out how to influence the system around us to actually do the work.
CHAPTER SIX
Turning Debate into Dialogue at the US Food and Drug Administration
THE CHALLENGE TO THE GREATER GOOD
Creating change in the social sector often involves more than just achieving more effective collaboration across differences within the organization; it requires engaging multiple organizations with differing missions and perspectives to work together as well. How do we ensure that conversations don’t deteriorate into arguments that push these stakeholders farther apart instead of closer together? Assuming we can get the right parties into dialogue and conversation, how do we keep their different worldviews from paralyzing progress? Productive conversation across organizations can be difficult to achieve. Add in a highly politicized climate and potentially controversial topics and you have the makings of adversarial relationships.
DESIGN THINKING’S CONTRIBUTION
Avoiding divisive debates and encouraging dialogue across difference is a strength of design thinking, as this story from the US Food and Drug Administration (FDA) illustrates. Because of the nature of regulations limiting engagement with the public, federal agencies often hold public meetings to communicate with their diverse constituencies. Often, participants formulate their messages prior to the meeting, based on already-entrenched positions. In this sequential model, there is little listening and interaction. Human-centered design, as the FDA discovered, provides a process for ensuring that organizations engage in deeper, truly interactive discussions that produce greater possibilities for alignment and higher-order solutions.
At the US Department of Health and Human Services, profiled in chapter 3, we saw a federal agency using design thinking to reach out and invite frontline employees into the innovation process. At the US Food and Drug Administration we see a different but equally compelling use of design thinking: to convene a conversation across a diverse set of constituents, both internal and external. At the FDA, which often finds itself at the epicenter of controversy, dedicated innovators are turning debates into dialogues, using design thinking to break the gridlock that can accompany working across seemingly entrenched interests.
Ken Skodacek, a policy analyst in the FDA’s clinical trials program, joined the agency in 2008 with a mandate to ensure the safety and effectiveness of medical devices. A biomedical engineer by training, Ken brought more than a decade of experience in the implantable medical device industry and—equally important—a passion for partnering with others in creative conversations. Like many US federal agency employees implementing human-centered design, Ken got his initial taste of the new approach at the Office of Personnel Management’s innovation lab, which we talked about in chapter 1.
Lab personnel facilitated a conversation between FDA officials and a set of thought leaders on temporary assignment to federal agencies in 2012. At the FDA’s Center for Devices and Radiological Health, this group included CEOs of medical device companies, heads of investment teams, venture capitalists in the medical device space, clinicians, and electronic health record experts. Ken explained the program’s purpose:
At the FDA, we are very patient focused—for us it’s all about getting the devices to the patient. And that means that we want to try to streamline our processes, like clinical trials, for making that happen. But it also means that we have to figure out what other obstacles—like reimbursement—are in the way. So we had a lot of really experienced people coming together, tackling big problems that we really didn’t understand very well.
The team of about thirty FDA insiders and outsiders assembled at the lab for a “meet and greet” icebreaker, with a focus on identifying key issues. Lab personnel facilitated the conversation by using design tools. Ken described the experience:
It was really enlightening! It helped us to better understand each other, think outside the box, and develop a picture for what we wanted to do next. Normally, you put all those different people with different perspectives in a room and they mostly come up with ideas they don’t agree on. What we found, instead, was that design thinking methods helped us step away from our roles and focus on the issues—we got to know the other person’s perspective and understand how they thought. That helped the teams work together after the meeting. Usually when you’re tackling a problem, it’s the senior person or the more forceful person that dominates the conversation—the rest of the people aren’t really engaged and so they don’t really support the outcomes. This conversation totally changed that dynamic—people were on equal footing, and interested in learning different perspectives on how to address the issues at hand.
The Challenge of Government
Entrenched interests can lead either to the kind of decision-making gridlock that we saw in our earlier discussions of psychiatric care at Monash or to the adoption of “satisficed” solutions that sacrifice decision quality. Core to the challenge is the diverse array of stakeholders involved. Innovation in the FDA requires the cooperation of manufacturers, patients, health care providers, industry associations, academics, and other federal agencies. As is so often the case, attempts to improve one aspect of the system can have negative repercussions in other parts. The US Paperwork Reduction Act, passed by Congress in 1980 with the intention of reducing the burden on citizens, resulted in unintended consequences for federal agencies’ ability to engage these stakeholders. This law requires evaluation of the overall impact on public resources of any government request for information. Surveying more than nine individuals on a topic necessitates completion of a formidable approval process, making it hard for agencies to engage outside stakeholders except in open public meetings, which can devolve into a handful of people speaking from already-entrenched positions on the topic and the remainder awaiting their turn to talk.
Typically, in a federal workshop, speakers prepare remarks in advance, come to the microphone at their allotted times, and present their views. When each speaker finishes, the next speaker offers a different opinion. This point/counterpoint style can be polarizing: people arrive at the meeting with their positions solidified, and any listening is filtered through their own preferences. Though useful for soliciting views, this serial engagement rarely leads to alignment and consensus. The use of human-centered design techniques can help avoid setting up such polarizing debates. Ken explained:
In our typical federal workshop, the messages are often formed before the meeting. There’s eventually an outcome, but there’s not a lot of engagement gettin
g there—or commitment to where we end up. Human-centered design allows us to bring people together to engage and learn from each other in a way that we hadn’t seen as possible before.
Conflict is not introduced solely by the differing views of citizen groups, however. Government agencies have overlapping duties as well, with the result that some products are regulated by multiple agencies, each of which may view the situation from a different perspective. For instance, a helmet worn to protect a person with a medical condition like epilepsy is regulated by the FDA. A helmet worn in professional sports is regulated by the Occupational Safety and Health Administration. Put a similar helmet on a high school student and it will be regulated by the Consumer Product Safety Commission. Stakeholders can feel caught in the middle as they try to satisfy different agencies’ requirements, which may not overlap. Here again, design thinking can improve and accelerate decision making by helping the agencies involved find a common focus rooted in the problem itself, rather than the more parochial perspectives that so easily form within expert silos. Let’s examine some specific examples at the FDA.
WHAT IS “SATISFICING”?
Satisficing is a term that, to us, perfectly captures the flawed decision-making process we so often see in the face of different views. We think of satisficing as selecting the least-worst solution everyone will agree to. Noted economist Herb Simon coined the term as part of his work on bounded rationality. He saw satisficing as positive: it allowed decision makers to act despite their information processing limitations, by accepting satisfactory solutions rather than continuing to seek optimal ones. Satisficing is decidedly negative in the innovation space, however, where we are looking for new higher-order solutions that are better than what anyone brought into the room in the first place. The urge to satisfice, to negotiate solutions that accommodate difference by cobbling together pieces of different stakeholders’ original solutions to create one that is minimally acceptable to all, rarely leads to breakthroughs.
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