How sushi, basketball & Boaty McBoatface can impact patient safety

Using design to solve problems in healthcare

On April 7, 2017 I gave a talk on alternative approaches to solving patient safety related problems at a Symposium hosted by the Swiss Patient Safety Foundation in Zürich. I was asked to distribute my slides, but since they mostly contained images, I thought I would write up the stories I shared.

I self-identify as a graphic designer, mostly because it’s quick to “get” when I introduce myself, and partly because that’s what I studied at university. So you can imagine, as someone who studied Swiss design, I jumped at the opportunity to feast my eyes on a bunch of beautifully set Helvetica in Zürich.

And as my colleague Matt pointed out, the Swiss flag nears perfection when you mash together healthcare and design.

In a room filled with surgeons, nurses, physicians, architects, behavioural economists and academics, I felt honoured to be sharing my thoughts. Brief note: I’m an American living in London and so am forever conflicted on British vs. American English in my writing. I’ll go with British here as I could count the Americans in the room on one hand.

I’m a design strategist at Helix Centre, a design studio embedded inside a NHS Hospital in London. We’re part of the Institute of Global Health Innovation at Imperial College London and jointly run by the post-graduate art and design college, Royal College of Art. The centre is a multidisciplinary dream team come true: design and digital expertise working with clinical, scientific and engineering academics, all in partnership with patients and staff on the front lines of the NHS. Our goal is to merge these disciplines together to create new, sustainable innovations in (and beyond) the NHS.

Allcroft Ward c.1898 (St. Mary’s Hospital Archive)

This is the Allcroft Ward at St. Mary’s Hospital in 1898. The physical space is largely the same today, but there are some notable differences (beyond the fact that there are some available beds). In 1898, the Allcroft Ward had pictures on the walls, a fireplace in the corner and a plant in the centre of the room – there was even a bowl of fruit and a jug of water. The windows could open more than ten centimetres. The bed sheets hinted at being decorative. The space felt human.

Life expectancy at birth in 1898 was about 44 years – now it’s 81 in the UK. In 119 years we have nearly doubled the length of time people can expect to live. For that alone, I think we would all be happy replacing a bowl of fruit and a couple pictures on the wall for reduced risk of infection and the addition of next generation medical devices.

The progress that technology has enabled in that time is remarkable, but what have we lost in the process?

All of the things that felt inherently human have been removed from this space. Technology has enabled us to double life expectancy in a century. But in the process of laying the infrastructure for medicine to advance, we have stripped our healthcare environments from anything familiar, anything human.

My great friend and former colleague Aaron Sklar poses the question perfectly: in healthcare, if technology is the enabler, what can design do to engage our clinicians, patients and staff? What impact would technology have on health and healthcare if it were designed with peoples’ motivations and behaviours as a first priority?

Design?

It’s important that we put some boundaries around the discipline that has unfortunately become a buzz word. The two behaviours that we employ as designers in this setting are empathy and prototyping. We need to deeply understand people to design for them and rapidly make our learnings tangible to get multidisciplinary teams on the same page. This isn’t unique to Helix or to healthcare – it’s what designers everywhere are practicing. But what I find particularly unique is the transformation that can happen when a “healthcare native” (the term Aaron and I coined over at Prescribe Design) sees and believes in an alternative approach to a problem they’ve been struggling with for decades. This is where design can have an impact far beyond the artefact at the “end” of the design process.

And with that, I’d like to share three stories I have recently come across that feel particularly relevant to patient safety.


California Rolls

In 1970, eating raw fish in America was taboo. Americans were very happy with their European-influenced diets, and with the dramatic rise in processed foods, anything new had a hard time sticking. In Nir Eyal’s book Hooked, he discusses how one chef bucked the trend and inspired what is now a multi-billion dollar industry.

Eyal says, “people don’t want something truly new, they want the familiar done differently.”

So what did the chef do? He took four ingredients people recognised: rice, avocado, cucumber and crab, and wrapped them up together, making the foreign ingredient (seaweed) barely visible. The California Roll was born – a gateway to more adventurous sushi.

I came across this story from my colleague Mikkel while we were designing a digital platform for women undergoing a hysterectomy. I was hooked on this story when Mikkel asked “what’s our California Roll?” In other words, what elements were familiar to our end user that would reduce the barriers of engagement?

Our solution – which we’re in the throes of designing – is to leverage the familiarity of social feeds (the likes of Facebook or Instagram) to deliver information about the upcoming surgery from the hospital. In our user testing, we’ve heard people tell us how they instantly “got it.” We’re wrapping up the familiar in a new way, ensuring patients don’t have to learn an entirely new interface before digging into what matters most: information about their recovery.

Healthcare has served up foreign ingredients in our most urgent and important moments.

The lesson of the California Roll is that if we force people – clinicians, patients, carers, etc. – to learn a new interaction, we can unintentionally create friction and barriers. All of a sudden the evidence base behind the content is locked behind the ego of the design team. Poor user interface design can create patient safety disasters.


Basketball

The next story was a feature on Malcolm Gladwell’s brilliant series, Revisionist History, where he looks at impactful moments of the past and reinterprets them for the future.

I can’t claim to be the biggest basketball fan, but in the podcast Gladwell makes you fall in love with the game. He shares the story of Wilt “the Stilt” Chamberlain — arguably the greatest basketball player of all time (save for Michael Jordan). He’s the only player to score 100 points in a single game. He’s a two-time NBA champion, thirteen-time NBA all star, four-time most valuable player. Chamberlain entered the Basketball Hall of Fame in 1978 and was chosen as one of the 50 greatest players in NBA History of 1996. Wilt Chamberlain was awesome

…until he got to the free throw line.

A free throw is called free for a reason. You stand at a line directly in front of the basket with nobody waving their arms in front of you. You have complete concentration — every shot should go in. For you U.K. footballers, it’s a penalty kick without the keeper.

Notice how Chamberlain takes his shot:

Wilt Chamberlain Archive

Chamberlain pushes the ball up over his head — a quintessential basketball shot. He couldn’t hit a free throw to save his life. In fact, he was the second worst free throw shooter in NBA history. Compare this to his teammate Rick Barry, who is the fourth best in the NBA (he made 89.3%). Chamberlain missed nearly half of his free throws (he made only 51.1%).

By contrast, look at how Barry takes his free throw:

NBA

Barry takes the ball down from under his legs and lobs the ball up — what’s referred to as “the granny shot.” I have to admit, I laughed a bit when I saw this for the first time.

If we look at the physics of the shot, we’re asking a 25cm ball to go into a 45cm basket. The ball is quite bouncy, so it doesn’t leave a lot of margin for error. When the ball is thrown at the basket — unavoidable with Chamberlain’s overhanded throw — there is no margin for error because, according to Peter Brancazio author of SportsScience: Physical Laws and Optimum Performance, “the rim of the basket, from the perspective of the ball, resembles a tight ellipse.” By contrast, Barry’s underhanded shot allows the ball to drop down into the basket, allowing the margin to reappear.

Interestingly, Chamberlain took the advice of Barry and the next season dramatically increased his percentage of free throw shots made. It was that season he scored 100 points in a single game — the most scored by a basketball player in NBA history. Remarkable! So did Chamberlain become the best free throw shooter in the NBA?

No.

There was a problem with the oft-successful underhanded throw: it was considered “uncool.”

Chamberlain did it for a season, and though it improved his game, he stopped and went back to his quintessential overhanded shot. He couldn’t be seen shooting like a granny, even if it meant improving his performance.

From time to time, players have tried to resurrect the underhanded shot. In Gladwell’s podcast, his team interview the women’s basketball team at Columbia University to get their opinion. They confirmed the uncool-factor and — unprompted — they called it a “granny shot.”

When someone tries to break the mould, social pressures can reinforce bad behaviour.

Chamberlain had a higher threshold for looking the part than he did playing the part. He allowed the culture of the game to get in the way of his performance. He happens to be an outlier in that he was so skilled in other parts of the game that he still managed to succeed, but the message is simple: social pressures can drive behaviour forcing smart people to do foolish things. What happens when we apply these dimensions to the healthcare context? What prevents evidence-based practices with known benefits from spreading?

Orthopedic drills cost $30,000 or more, leaving surgeons in low-resource areas with two options to perform surgery: 1) use non-sterile drills; or 2) use hand cranked drills which simply don’t work as well.

Arbutus DrillCover Hex

The Arbutus DrillCover is a “sterilisable and reusable fully-sealed barrier that transforms a household drill into surgical grade drill.” Most of all, it’s a fraction of the cost of a traditional orthopaedic drill.

So why would it be difficult to bring the the Arbutus Drill Cover pictured here from low-resource settings to somewhere like Zürich or the United Kingdom? How would an orthopaedic surgeon respond when she enters the operating theatre only to find the same drill she used at home to hang some shelves? We can get wrapped up in the inertia of norms and be blind to more sensible solutions. Hospital procurement would have every consultant surgeon banging down their door asking for their expert, expensive tools back.

In Wilt Chamberlain’s autobiography, he says “I know I was wrong, but the underhanded shot just didn’t feel right.” In the healthcare context — and particularly related to patient safety — we can use design to address not just the immediate problem, but also how clinicians or members of staff feel using a solution.


Boaty McBoatface

The final story made some headlines recently, certainly here in the U.K., but also abroad. The Natural Environment Research Council (NERC) built a £200m Arctic Explorer ship. Before setting it off to sail, they decided it needed a name. Rather than hiring an expert in the field of naming or branding, they put it up for a competition to the public. What better way to raise the profile of the research they were doing, right? The entries started coming in:

NERC Arctic Explorer entries

They sure got the attention they were looking for. But the reality was that the general public, with little incentive (or expertise) to take the project seriously, ended up with a silly name. The most popular entry was (drum roll, please): Boaty McBoatface.

Naming is different than many of the practices we commonly associate with design, but I see parallels with the increasing number of design contests put out to the public (often with little or no reward). The brilliant designer and design critic Jessica Helfand wrote about this at Design Observer (where she too points out the NERC example).

NERC

While it may feel inclusive to open up the design process, not everybody has the skill set necessary to do it properly.

The NERC ended up calling the ship the RRS Sir David Attenborough. They still felt a need to please the public and cutely named this little drone sub Boaty McBoatface.

There are two lessons in this story: 1) include great designers on multidisciplinary teams if you want to design great things; and 2) the end user will know if something has been thoughtfully designed.

When we indicate that an artefact, a space or an experience has been thoughtfully designed, we use and experience those things differently.

The philosophy of my design hero, William McDonough is “design is the first signal of human intention.”

With this in mind, imagine a child having an MRI scan. If design is the first signal of human intention, what message are we sending to a child before they enter this machine?

By Jan Ainali (Own work) [CC BY 3.0 (http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons

How might they react to the loud noises the machine makes, or the fact that they must stay very, very still? By contrast, what might a child think before boarding a fantastic voyage on a pirate ship?

GE MRI scanner at Children’s Hospital of Pittsburgh of UPMC, via Slate and Creative Confidence

This is a boat that got it right — the MRI scanner by GE at the Children’s Hospital of Pittsburgh UPMC is designed around the motivations, behaviours and desires of children. It recognises a need (to mitigate fear) and responds to it with design (a story, expressed through illustration).


Design in healthcare

There is massive opportunity to bring the creative practice of design to the healthcare setting. Along the design process we gather insights into the needs, motivations and behaviours of people. We must use those insights as a filter, whether we’re procuring and implementing an available solution or crafting something bespoke.

There are design briefs scattered all around our healthcare settings, but the only way to find them is to make sure you’re set up to see them.

The standard “two-week-discovery” process is insufficient when so much of what we — as designers—need to see and understand is cultural. To walk to our studio in the Paterson Wing at St. Mary’s Hospital, you must first walk through an outpatient waiting area. Nothing we see on a daily basis is particularly significant, but insights develop over time. The passing conversations we have with visitors asking for directions are not only insightful from a wayfinding perspective, but they also give us a glimpse into the emotions surrounding a visit. Sometimes we’re told a story. Other times it’s purely functional. These interactions make every day a design research activity. The non-event to get from the front door to the lifts has taught us a great deal about the context we’re designing for.

If design is to succeed in making a major impact on how people engage with healthcare we must create teams with a multitude of experts—designers, clinicians, engineers, policymakers and of course, patients.