To err is human — so let’s design for it together

How can we use co-creative design to improve the culture of patient safety?

By Mubnii Morshed

In 2013, I attended a talk by Deb Matthews, who was the Ontario Minister of Health and Long Term Care at the time. She began her talk by summarizing the trajectory of healthcare over the last few centuries: “Healthcare began as something done to patients. Then, it was something done for patients. Now, we’re finally realizing that healthcare has to be done with patients.”

This idea of working with patients has gained traction in many facets of healthcare. Now more than ever, healthcare experts are looking beyond static data collection and are employing a wide range of methods to better understand the patient’s perspective. Reporting tools such as on-site feedback, patient advisory boards, and in-field observation are only a few examples. These methods provide us with deeper insight into how stakeholders are actually experiencing and interacting with the healthcare system, helping us to better understand what their needs and key areas of concern are. Such insight can support a variety of quality care and patient experience initiatives, patient safety included.

With our ability to collect more data than ever before, one has to wonder how all this information is being leveraged and applied to the design of new solutions. Currently, the onus still falls on healthcare experts to extrapolate from this data and look for solutions. Unfortunately, the solutions devised are often layered interventions, applied on top of the legacy systems and processes that are causing medical errors in the first place.

Let’s use hand hygiene as an example; in Canada, infections associated with healthcare visits kill approximately 8,000 to 12,000 people every year. In an effort to reduce this number, hospitals provided education to their staff on best hand washing practices, including posting visual reminders on all hospital sinks. Despite their efforts, the practice of hand washing wasn’t being adopted into the hospital culture. Shortly after, it was discovered that the visibility and location of sinks in the hospital environment had a sizable impact on hand washing compliance. For every meter a healthcare worker had to walk, the chances of them washing their hands was reduced by an astounding 10%.

This type of fragmented problem solving begs the question: why are we divorcing the design of patient safety solutions from the people they’re designed for? If the hospital staff were engaged prior to implementing this intervention, the roadblock of sink location and visibility would have surely come up.

In healthcare, we need to shift our thinking of what it means to “work with” others

It’s increasingly evident that patient safety doesn’t revolve around the patient alone. Nor does it focus solely on physicians and other front-line staff. It’s the complex relationships between these stakeholders, and the systems and environments they interact with that influence the culture of safety. In order to understand barriers and work towards realistic and sustainable solutions, we need to involve all stakeholders in designing what the future of patient safety looks like.

At Bridgeable, we use an approach called co-creation to help solve design challenges. You may have heard of co-creation by one of its many other names such as co-design, cooperative design, or participatory design. Co-creation is not a new concept. In fact, it’s been around since the 1970s and is widely used in the fields of architecture, product design, and urban planning. More recently, the value of co-creating is becoming apparent in designing (or re-designing) complex healthcare services.

Co-creation brings together internal and external stakeholders who may never have been in the same room otherwise. In the healthcare space, this can include patients, caregivers, nurses, physicians, hospital administrators, researchers, academics, experts, or anyone else who interacts with the health system in a meaningful way. The goal of a co-creation workshop is to engage all of these voices through generative design activities that elaborate our understanding of unmet needs, and incorporate diverse perspectives into the solutions we build together as a team.

Co-creating allows participants to get a look into how somebody else interacts with the same system they do, and for many, it’s the first time they’ve done so. This simple idea can expose subtle nuances that static data alone cannot provide. At a recent co-creation session with healthcare professionals, we mapped out what the typical lines of communication look like between physicians and their patients.

One physician states that he rarely receives phone calls from his patients. “They all wait until their appointment to ask me questions.”
His nurse navigator, who is in the same workshop group, speaks up and clarifies, “Yes, it’s because I make sure you don’t get them. They all call me, and I handle it!”

This interaction reveals how each person’s perceived needs and challenges can be vastly different, even while working within the same clinic.

For true collaboration, stakeholders need to be engaged at every stage of the design process

A common trend I’ve witnessed in healthcare is what I refer to as bookending of stakeholder involvement, a phenomenon particularly common where patient and front-line staff are concerned. The qualitative experiences of these stakeholders are mostly found before or after the implementation stage of a project (hence, bookending), perhaps in the form of evidence-based data, or feedback during project evaluation activities. Although we claim healthcare is becoming more patient-centric, the absence of the patient, caregiver, and front-line’s voice in the ideation, planning, and execution stages of healthcare is both baffling and concerning.

This bookending practice can limit the success of interventions and services. For one, it assumes that current mechanisms for gathering feedback are effective, leading to limited or incomplete views of complex healthcare challenges. In another co-creation session, we heard from a patient that she didn’t report side effects from her cancer treatment, not because she didn’t know how to, but because she was afraid that her treatment would be stopped. Without this patient perspective, it would have been easy to misconstrue why side effect reporting was low, and blame it on lack of communication options. Instead, it turned out to be a more nuanced issue involving patient education, decision-making, and trust.

Bookending also reinforces divisions and silos that already exist within different levels of healthcare. Each stakeholder’s experience is considered in a vacuum, when in fact they are all intertwined. In contrast, when patients and front-line staff are given the opportunity to design solutions alongside other healthcare experts, the results not only work better in practice, but the participants also have a sense of ownership and agency for the initiative. Everyone involved in the design of a solution ends up with a vested interest in making it thrive. We see this time and time again in our work, and reflected in the literature.

The future of patient safety

“To Err is Human: Building a Safer Health System” was published in 1999. This groundbreaking report brought patient safety to the forefront of healthcare management. It sparked the need for better understanding of how patients and healthcare staff interact with each other and their environments. And while healthcare models and environments have evolved significantly in the 17 years since publication, the report does impart significant, and universally relevant advice; if we are to design an effective solution, we need to consider the humans that we are designing them for.

To do this well, we need to redefine what it means to work with patients, and not just use their feedback to validate our already-formed ideas. Instead, they should play a role in shaping these ideas and solutions. To do this, we need to facilitate dialogue between people at all levels of healthcare and design for the diversity of needs, challenges, and values that exist between them. Most importantly, we need to do this with all stakeholders at the table and in the same room, working as equal partners towards creating a better culture of safety in our healthcare system.

Illustrations by Shelley Chen and Kyle Schruder

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