draft advance:making radical changes in healthcare, 300 very small, delightful, rewarding steps at a time

If my grandmother had a motto it would have been: anything worth doing, is worth doing to extremes. When the family farm needed a barn, she built one herself. Then she built three more. Herself. Once, she decided to give handmade porcelain gifts to family members for Christmas. So she bought a potting wheel. And a kiln. Sometimes the dining room got turned into an electrical workshop. Sometimes it was full of racks of flowers she was drying. She fixed little annoyances with an ingenuity that would have made MacGuyver proud like rubber bands to improve the grip on slippery salt shakers. It’s tempting to keep listing the projects she took on throughout her life — aside from there being too many to count — but there’s also a singular, holistic view. Whether it was one project or twenty, whether they were big or small, she was always improving her world. She never sat still. There’s no such word as can’t, she’d say.

The thing about that kind of momentum for change is it’s infectious. I remember spending summers following her around the farm trying to keep up. None of us could keep up, but we weren’t going to sit around and loaf. We looked for chores to do or ways to help.

One of her tricks was to make it easily and enjoyable to do projects so they never felt like work. When we were young she taught my cousins and I to walk on stilts. Then she had us clean windows. She’d take me for rides in the bucket of her tractor. And since we were out in the horse fields we might as well pick up rocks and put them in the bucket too.

300… For reals?

This year our innovation team is launching an ambitious effort of our own. We’ve challenged our entire organization to look for ways to make how we deliver healthcare a little bit better. At this point, you may be thinking yeah, just like every other hospital that thinks it’s part of the solution but isn’t… Big, bold, sweeping promises of sea change aren’t new to healthcare (although arguably delivering on those promises would be). So we aren’t aiming for big or bold.

We’re aiming for small, simple, and fast. We’re aiming squarely at the needs of people who directly deliver and receive care. It’s the kind of project I hope would have made my grandmother proud; not only because of the sheer volume and energy, but because it’s the kind of work that feels good to do too.

Together, under the support of our CEO, we’re challenging the organization’s front line to lead 300 human-centered design projects.

I often get asked by colleagues from other innovation centers how many projects we run concurrently. What are y’all doing? Two…three things a year? Nope, our hospital will do 304* projects this year. That’s usually when they ask if we have a staff of 50 designers. (We do not).

What we’ve got is grand experiment. What happens if every supervisor, manager, director, VP and executive leads a team through a human-centered design project? How will that singular focus on addressing the needs of others change how we deliver healthcare?

human-centered what?

Our team, a ragtag group of highly qualified misfits, are passionate about design — a methodology which puts the needs and hopes of people at the center of everything. If we had an office drinking game (for coffee, of course!) it’d be a finish-your-mug-moment every time someone said: well, you asked patients how they’d feel about that? In fact, the proliferation of that phrase through the organization has become our favorite indicator of success.

For us, design has a few core components. We always start with end-user research; tons of interviews to understand how people feel about something like visiting the emergency department. We observe processes over and over looking for patterns, hacks, or roadblocks. We go deep into synthesis to try and make sense of what we’ve learned. Often we learn the problem we’re actually solving isn’t the one we set out to solve, but it’s the right problem to make a process or thing better. Once we set out to see if we could reduce stress related to entering the hospital. It turns out, for most people that stress starts as anxiety or fear before you even leave home. Addressing that source of fear has a much more meaningful impact. In our design process we stoke creativity and try and build on each other’s ideas for solving those problems. We go look at other industries to see how they do it. And we have a quick bias towards action — if we think an app might might, we try it on paper and put it in front of people in minutes. If it’s a new gizmo, we make it out of duct tape and rubber bands and give it to someone to see how they react.

For over two years, we’ve been modeling and teaching that process to our organization of nurses, clinical assistants, radiology techs, environmental service colleagues and executives.

We’ve learned something pretty powerful. The terms don’t matter. The feelings do.

om

What seems to matter for most people is the biofeedback loop of successfully making something better for someone else. Hear a need, have an idea, watch it work — what could feel better than that?

I had a music teacher once who had a theory about the syllable people repeat when meditating, om. When you hear it, particularly by a practiced meditator, it gets elongated, becoming three sounds: oh, ah, umm. Those are the same three sounds which universally make up the human experience of having an observation about the world, coming to understand it, and feeling satisfied. And that is the essence of designing for other people.

Oh, I see a problem or a need! Sometimes that “oh” moment comes from listening to people, sometimes it comes from observing, and sometimes it comes from our own experiences.

Ah-ha!, I have an idea! It’s the universal proclamation of creativity. It practically comes with a cartoon lightbulb to hold over your head when you shout it. Ah-ha moments come in the shower when we’re thinking about something else, they come when we see how a different company solves problems, or they come when we’ve let our minds relax and expand into something artistic.

Ummm… says every person who’s ever pushed themselves back from the Thanksgiving table after thirds. It’s the sound we make when we’re deeply satisfied. It’s the sound of understanding and reflecting and feeling good.

Om is the sound of designing for others.

When we spoke to our front line caregivers, we learned they don’t care about ethnographic end-user empathy research. They do, however, have a calling to care for those in need and they do it every day.

listen, imagine, do

We came to see our job differently. We don’t have to make heavy-rimmed glasses wearing, all dark clothing owning, sketch notebook carrying designers out of our entire hospital. No, we just have to clear the way for the om moments. We have to make it so easy to have that biofeedback loop of successfully solving for the needs of others that it becomes addictive; never work, never hard, always delightful.

Our design team began building a process with the goal of making the pathway so easy, you’d have to work to fail. We call it listen, imagine, do and it’s based on that om feeling of creatively solving for others’ needs.

And, as it turns out, it’s what most frontline caregivers do every day. Once after some of our nurses had gone through design thinking training, they told us: this end-user interview thing? That’s just called listening to patients’ needs…we do that every day, it’s why we do this job! And they aren’t strangers to creatively solving problems and putting those solutions into the field quickly.

Modeling our design process after what they already do helps make it feel approachable and easy.

One of the keys to producing the om moments, is to help people work on problems which lead to success quickly. Most of us aren’t coders and can’t write an app. And most solutions don’t actually need an app. But we can get that om feeling by creating a new form, or a new greeting or a new process and putting into play quickly.

We’re into helping people find things individuals or teams can do in their own departments, without creating larger workgroups or layers bureaucracy. It feels really good to produce something and and see it tested quickly. It’s not a surprise to learn endless meetings and painful approval steps don’t feel good and stifle innovation.

One of our nursing colleagues wanted to improve communication during physician rounding in the ICU. There was thoughts of big display monitors, smart phone apps, the works. After some quick conversations with her coworkers, she instead imagined a color-coded board. She bought a white board, some colored magnets and in less than a week had made a huge impact on how people entering the ICU received information on the status of patients. The impact was a huge reduction in one-off conversations which interrupt bedside care and were confined to the people having the conversations. Now there’s a board everyone can see, it doesn’t interrupt care, and everyone is on the same page. Total work hours — maybe 5? Total cost — $50.

one question at a time…

Surely we’ve got at least 134 projects that have made HCAHPS scores better, right? Well, probably, if we want to measure success that way. But what if the problem isn’t quietness at night but instead fear and anxiety about a procedure or early morning lab draw that keeps people up at night? What if it’s not about feeling like the care team was competent, but feeling deep grief for the loss of one’s health and autonomy?

So we’ve adopted our own measurements of impact. We listen for key phrases. The more we hear them across the organization, the more we know we’re on track.

Let’s ask some patients or families first… — it’s almost become a mantra in the organization. Have we eradicated healthcare’s long-standing disease of believing we know what’s best for others? By no means, but we have a growing culture of asking end users first. If nothing else came of this grand experiment, I’d consider that a huge success.

How would Apple do it?… — while I was drafting this, a nurse leader emailed a group of colleagues with pictures of the Seattle Space Needle’s visitor center. Apparently, while you wait in line to go up, a series of monitors tell you the history and what to expect at the top. Her thought: what if we used displays in elevators to help people know what to expect when recovering from illness? Woah! Easy to test with some large print outs.

Let’s just try it! — The great thing about helping people focus on challenges where they can produce impact themselves is there’s isn’t much risk. Once people have a taste for success, it’s kind of infectious. One of our peri-op nurses saw a problem with office supplies being thrown away or left unused. She took inspiration from her neighborhood association and created a Google Docs tool as a trading post for office supplies. It took her about five hours over three weeks to go from oh, to ah-ha to ummm. A week after it launched, she came in with a list of five more design challenges she wanted to work on.

One grand experiment

Organizations often want culture change to happen like a Big Bang. Henceforth, we will be patient-centered and patient-centered only! (The proverbial beatings will continue until morale improves.) Our leadership and innovation team are taking a different approach. What happens when over 300 separate, little, independent om moments happen?

Deep in the basement caves of the champagne houses of France, there’s a very special, peculiar job. To make bubbly, well, bubbly, additional yeast is added to still wine before its bottled. That yeast has to be discharged to keep the champagne clear. The trick is to store the bottles in a rack with the necks inverted and to rotate them so the yeast settles into the neck and can be expelled. But, there’s a catch. In the days of fragile hand-blown bottles, if you moved them too violently, the carbonation caused them to explode under pressure.

That’s where the riddler comes in. A riddler riddles the bottles. Two times a day, the riddle goes into the caves and turns each bottle 1/8th to 1/4th of a rotation. They use two hands, moving from bottle to bottle the way a street hustler runs a shell game.

We’re not asking an entire organization to adopt a wrought process for patient engagement (whatever that term even means), and we’re not demanding people make 180 degree changes in their mindsets. Instead, we hope we’re giving everyone in the organization the opportunity to feel that wonderful sense of satisfaction of creating something new, to solve for the needs of someone else, and to feel creative again — one quarter rotation at a time.