The State Hospital grounds in Traverse City, MI. (pic from flickr)

How designers make hospitals awesome

Recently I stood on a stage in front of an audience of healthcare executives and directors from around the country. The multi-day event aimed to help them learn how to improve the health care ‘experience.’ I was speaking on a panel of patients on the topic of self-tracking, representing the patient voice in front of this somewhat rarified audience, and our moderator was Larry Chu, executive director of the Medicine X conference.

When it was my turn to speak, I introduced myself as a patient and designer working in healthcare, and asked how many people in the room came from institutions that have some kind of design practice intended to improve the patient or provider experience. Of more than 100 people, perhaps 3 tentative hands raised into the air.

It’s not that this group wasn’t interested. But the need for design and UX has not fully seeped into hospital culture, and it often hasn’t been clearly articulated at the highest levels of these organizations. Many have Process Improvement departments or clinical leads (say, a doctor and a nurse) dedicated to improving efficiencies and ‘experience.’ ‘So,’ some might be thinking, ‘why would we need additional people — and why should we set aside extra budget to hire those people — to improve the hospital experience? Isn’t it a matter of better leveraging the resources we have?’

Allow me to break it down. I’ll describe what ‘user experience design’ means, how it can be applied in a health system setting, what the benefits and value are, and why designers have a unique perspective that is hard to find in hospital staff and other ‘healthcare natives.’ This article is intended for healthcare leaders, but I bet even my dad would find it interesting.


What do User Experience Designers do?

When you think of design, what comes to your mind? Do you think of a very fancy chair from Herman Miller, or perhaps a colorful band poster? A well-laid-out wedding invitation? In a hospital setting, design probably brings to mind modern waiting rooms, more comfortable inpatient rooms, and other interior design improvements.

All of these things are types of design, but none of them are really the kind of design I do as a User Experience (UX) Designer. Across industries, UX Designers are concerned with much more than visual decoration (how something looks;) we are focused on improving entire experiences. For example, a designer working for an airline might be focused on transforming the experience of flying by anticipating customers’ needs and providing a special experience they can’t get elsewhere. Virgin Airlines and JetBlue come to mind as airlines that have paid special attention to the entire flying experience from start to finish — including both digital touchpoints (booking a flight, checking in at a kiosk,) and physical touchpoints (checking in with an agent, and of course boarding and flying in a plane.)

JetBlue kiosks are friendlier, faster, and less tedious to use than other airline kiosks. This is no accident. This is good design. (pic from flickr)
Virgin Airlines provides a unique, discotheque-like flying experience. (pic from flickr)

I’ll bet you are already thinking about how this type of ‘customer experience’ could apply to healthcare. From the experience of booking an appointment online, to navigating through a large, maze-like building, to having a conversation with a healthcare provider, there are endless design opportunities in healthcare.

Let me share a few recent examples of the type of UX work I have recently done in a hospital setting. I’ve worked to improve the clinician experience of reading and writing inpatient clinical notes in the Electronic Health Record (addressing what they call ‘note bloat,’) which resulted in a new type of note template that makes it more efficient for providers to get clinically-relevant information. On another project I helped improve communication to parents staying inpatient with their kids; through a printed guide, we helped parents and families understand all of the resources available to them and how things worked on the inpatient unit. This helped them get more consistent information and reduced the burden on staff. On a third project, I held a workshop to gather information about the emotional experience of cancer patients so that we could create more patient-oriented, emotionally-sensitive materials for newly diagnosed patients. The result of this work is a guide for newly diagnosed patients that gives ‘just enough’ information; patients love it and tell us they’ve never seen anything like it.

The overarching goal of my work is to improve the experience of being a patient, health care provider, or another ‘user’ of the health care system. Designers like me have a toolkit of methods that help us work through tangled problems, develop appropriate solutions, and work with teams to bring those solutions to life. Here are some of the ways we do our work.


Perform detective work

In each of the projects I’ve done at the hospital, I acted as a detective would; I set up innumerable interviews, observations, and meetings to learn more about technology constraints, business processes, the people involved, their workflow (in the case of employees,) their emotions, their context (the place and space in which they move,) their questions, and the relationships between these different things.

As a designer dedicated to these projects, without other ‘full-time staff responsibilities,’ I had the time and space to do this work thoroughly, and in-person. Hospital culture is still very much addicted to email, but a detective on the case does not knock door-to-door via email; they show up in-person, talk, and observe. That is how they notice the suspicious mark on the wall, or the faltering voice of their witness. That is similarly how I noticed a lack of signage on the pediatric floor, and heard about a knowledge gap in clinical note-writing residents.

As part of this work I set up a series of 1-on-1 meetings all over the hospital, which let me work more rapidly than if I’d had to worry about scheduling large group meetings. (In a hospital, it can take weeks to schedule a multi-person meeting, especially if the meeting includes practicing doctors.) During these meetings I got tips about other people or departments I should speak with, ‘leads’ if you will, and I had the freedom to set up those additional meetings as well.

The type of investigation I’ve been describing is also called ‘design research.’ Hospitals need dedicated designers and design researchers who are trained and comfortable with exploring the space, people, and context with an open mind; who are excellent listeners; and who can help uncover root problems that have, over time, become invisible to the people who live in this system.


Make the invisible visible

In order to really understand something, often you just need to see it.

During and after design research detective work, designers need to ‘distill’ what they have learned — to put together key insights. Part of that process might involve moving around a lot of sticky notes, and it often involves creating a diagram to help us see what we’re hearing.

Have you ever watched a detective television show and seen the big wall where they put up photos of suspects with annotations and various pieces of colorful yarn stretching between them? They do this to try to make sense of their hundreds of clues, knowing that they can’t keep all of the information in their minds at once. Visualizing the information helps extend their cognitive capabilities so that they can make new connections and see the invisible. This is the same principle designers are acting on when they create maps and diagrams of flows, processes, and relationships — they are externalizing their knowledge to help increase their team’s understanding and enable ‘aha’ moments.

Finding trends in what we heard from people we interviewed. Sometimes this is ‘what work looks like.’

We need to do this because the healthcare system is complicated and not readily visible; things like billing processes, shift handoffs, and relationships between people and departments can be hard to grasp. How information gets distributed to patients over time — for instance, what letters, brochures, and phone calls new cancer patients receive through their diagnosis process — is difficult to understand in a system of distributed responsibility (e.g., ‘I am responsible for handing out this brochure, and you are responsible for that paperwork.)

Roughly making sense of the cancer patient journey — what happens, who is involved, what info patients receive. I developed this through conversations with various staff members, and then had them vet it with me. We included a version of this in the final patient guide.

Another benefit of visualizing processes and flows is that hospital employees can see their own place in it; this helps them better understand how their work impacts and is impacted by others, and it helps teams identify breakdowns and opportunities for improvement. Below is a thumbnail of a diagram showing how clinical progress notes move through the medical system; who looks at them, and how they are reviewed and approved. Creating this visual helped get the team on the same page about what the process ‘looks’ like and how we could more effectively design a new progress note within this system.

Visualizing how clinical notes move through the approval system.

These types of diagrams and visualizations help us identify systemic breakdowns and opportunities for improvement, and they can also serve as ‘products’ themselves. The HELIX Centre in London is a design studio embedded in St. Mary’s Hospital in London. Recently, their designers worked on a project to help improve the cancer patient experience, and as part of this process they spoke with numerous cancer patients, providers, and other staff members. They mapped out what they had learned in a series of diagrams, and these diagrams were eventually incorporated into a brochure for patients.

Cancer Pathway Planner — Image courtesy of Lenny Naar and the HELIX Centre

The brochure is intended to “help cancer patients understand their individual care pathway, who their clinical team are, where the key locations of their care are, and what third party services (such as charity support) are available to them.” By visualizing the patient journey, this printed piece sets patients’ expectations about what’s going to happen, which helps reduce their stress.


Help teams build empathy

Through talking and observing ‘end users’ and communicating the results to their teams, designers help their teams empathize with others. What do I mean by empathy? Basically, “I understand what you’re going through.”

Since groups and departments can be so physically dispersed in a hospital system, sometimes even working on different campuses, it can to be easy to start to see them as ‘the other’ — especially if, as in the case of billing and coding representatives who flag insufficient documentation and send it back to doctors, it seems like they’re out to get you.

On my recent clinical documentation project, I sat with these billing and coding folks to understand how they do their jobs, what their goals were, and what they thought of our proposed solution. They described their workflow and gave their approval of the solution, saying that even though it might add one small step for them, they understood that it would save doctors time. I took this back to the doctors on my team, and it was refreshing for them to hear that the billing department empathized with them. They had more in common than they’d thought.

Designers can also help us build empathy with patients and families. Working in a health system does not automatically produce an understanding of patients’ fears, hopes, behaviors, and needs; in fact, and I’m going to go ahead and emphasize this:

Many employees in a hospital have little or no patient contact. This allows misconceptions and stereotypes to flourish in the absence of regular, authentic experiences with patients and families.

A lack of contact with our end users gives us free reign to waste time talking in circles about what ‘we think’ people would do or want, or worse, what we ourselves would want. The end result is that we end up, for example, writing patient-facing materials in corporate-speak instead of tailoring our words for people who may be in an extreme state of stress.

On my recent pediatric floor project, I spent time shadowing rounds and observing parents who were staying with their kids. One interesting thing I noticed was that many of them hardly ever left the room; they were effectively ‘stuck’ in the room with their child for long periods of time. This was an important piece of intelligence, and I took it back to our team and told stories about what I’d seen — some parents had not left their child’s room in days, and some had no change of clothes. Our team decided to design our solution with parents ‘stuck in the room’ in mind, and this helped us make decisions (and settle disagreements) about what features and content to include. Should we include parking maps? No — by the time they are stuck in the room, the parents have already figured out parking. But things like food, coffee, and laundry were very important for them to know about.

In the workshop with cancer survivors, participants spoke about what it’s like to be diagnosed. They talked about overwhelming fear and anxiety, and about not being able to ‘hear’ what their providers were saying to them. At that point, emotional reassurance was more important than getting large amounts of information. Understanding what these new patients were going through helped us redesign our materials for new cancer patients in a more emotionally-sensitive way.


Save money by ‘failing fast’

You have probably been in a brainstorming session at some point. Sooner or later, the group usually comes to a consensus about what the best idea is and decides to move forward with implementation. But this can be dangerous. How do we know that the idea is a good idea? How can we get a hint whether it will succeed or not? What if we waste a lot of time (and money) implementing an idea that was not strong enough to begin with?

This is where prototyping and testing comes in, and it’s an integral part of the design process. Whether the idea being considered is for printed material, an in-person interaction, an app, a website, or the redesign of a physical space, it can be prototyped and tested with real people! And this can happen quickly — in a matter of hours, or at most a few days, you can validate your idea and find out whether it has legs. Paper prototypes of app- and web-based concepts can be put in front of real end users in a mini-usability or concept-testing session; physical signs, brochures, or other printed material can be cheaply put in front of people before they are produced; physical space redesigns (like a hospital room) can have a prototype unit built so that people (especially those with physical limitations) can pilot the space and help identify areas for improvement.

Example of testing a paper prototype. This is an awesome way to get fast feedback and stay on the right course. Pic from flickr.

While many people will be uncomfortable with putting seemingly unfinished work out into the world for people to see, this is the way designers operate. This process helps us ‘fail faster’ and understand what is and is not working, so that we can make improvements (and decide whether to continue to pursue the idea at all.)

In a healthcare setting, prototyping and testing also helps us ‘fail safer’ by testing solutions in such a way that they do not jeopardize patient or provider safety. For example, the Hub @ Sibley is an innovation center at Sibley Memorial hospital in Washington, D.C. Recently their design team ran a 24-hour ‘design sprint’ to address the problem of needle sticks — of nurses and staff inadvertently getting stuck with needles during the course of their work. The team learned about the problem from OR nurses and staff, gathered inspiration for potential solutions by visiting a Chipotle kitchen (where the chefs wear a type of chainmail to prevent being cut by the sharp knives) and the National Zoo (where snake handlers have a clear verbal protocol when working together with biting reptiles.) They then went back to their lab and created a number of quick prototypes, which they tested with staff.

A quick needle stick prevention prototype created by the team — image courtesy of Nick Dawson

Even though the subject was needle sticks, the team was able to prototype and test ideas rapidly and without anyone getting injured, and the sprint concluded with a few viable ideas to further explore. That is a huge win.

The process I just described probably sounds quite different from the way ‘work’ usually gets done in a corporate environment — often in a series of 1-hour meetings spread out over vast periods of time. People are used to projects taking months, if not years, to complete. Sometimes these timelines are necessary, but not always.

One secret goal of early and iterative prototyping and testing is to create a culture of learning and nimbleness within the organization. Following a design process like the one I’ve described can help shift the organizational mindset so that it is acceptable — and even expected — that a team can make large amounts of progress in a week, or even a day.


Make things real

It’s not enough to stop at prototyping and testing, obviously. At some point we need to make this thing real, get staff to buy into it, put it out into the world so people can start using it, and evaluate how it’s doing. This is a very interdisciplinary process, but designers can help facilitate it in a few ways.

When the thing you are creating finally gets into production, there will be hundreds of small decisions that pop up along the way. No one can anticipate all of the tiny details up-front. Designers will have an excellent understanding of the end user’s needs by this time, and they can work with the production team to make sure those little decisions and tiny details keep the product as user-centered as possible. The risk of not having a designer involved is that the production team, having good intentions but insufficient knowledge of the end user, will inadvertently make something that’s not quite right — like those hideous robots that look almost like humans.

Over the course of a project, designers tend to build relationships with a number of users and stakeholders — people they’ve interviewed or tested a prototype with. Some of these people will be staff, and they can be wonderful champions and partners when it comes time to launch your new product or process and ‘sell’ it to others.

Now, let’s say you’ve already launched the thing. How do you know if it’s working? There are a number of people and groups who can help with this evaluation (think Quality Improvement and IT, for starters.) Usage statistics and analytics can provide some clue, if the thing you’ve launched is digital. Designers can help by helping interpret analytics, conducting usability testing sessions and observing people, and they can offer opportunities for improvement. Did I say improvement? That’s right, this process does not end at ‘launch.’ There are always opportunities for refinement and evolution ‘post-launch’ — some large, and some small. It’s important to continue to pay attention to how your solution is faring.


How else do designers make hospitals awesome?

I’ve just talked about the ‘hard skills’ of being a designer — investigative detective work, empathizing with people, visualizing concepts, testing and prototyping, and facilitating production. But designers can also help transform the way teams work together through other soft skills like meeting facilitation, communication, and storytelling.

Support more collaborative (and thus efficient) work

Many projects in hospital systems have core project teams that are made up of people who work in completely disparate departments (often in different physical locations) and who have another primary job that takes 99% of their focus and attention. How can they get work done in this environment, when they are effectively working ‘remotely’ and don’t have project teams dedicated to success?

One way is by rethinking meetings. Often meetings involve a lot of talking, and perhaps a powerpoint presentation. But talking can be an inefficient way to get things done, especially when we need to do creative work. Designers can help facilitate fun, interactive, creative and collaborative meetings by turning them into more of a workshop. This can involve whiteboarding, having team members sketch or write thoughts on sticky notes, and generally visualizing ideas instead of only talking about them.

We are having way too much fun. (Work can be fun.) Image courtesy of Jeremy Beaudry

Below is a photo of a session where I used sticky notes to gather feedback from Patient & Family Advisory Council members on a draft of the Pediatric guide. Instead of using our meeting time to talk through all of the feedback, I had each person review the draft and put their feedback on a sticky note on the wall, so that others could see it. Then we talked about the highlights. This helped us get make better use of our time, and it also got people out of their seats and moving around.

Getting patient advisor feedback on a draft of a printed guide at UVM Medical Center

I’ve also helped one of my teams be more collaborative by introducing a project Slack channel. It was a little tough to get everyone signed up, but once we started using it our conversations became much more fast-paced and less burdensome than communicating over email.

Better collaboration and communication means teams waste less time and have more fun. When people are having more fun, they are more creative and have better ideas. Supporting collaborative work is an important superpower that designers can bring to your organization.

Connect people and ideas

One important aspect of my work is sharing what I’m up to, so that more people around me get exposed to the way I’m working and the impact my teams are making. This is the storytelling part of design.

I do this verbally, of course, but also visually — by posting my work up in staff areas. People love to see my process and learn about the great work the hospital is doing.

In my short time working within a hospital system, as I’ve told stories and inquired about others’ work, I’ve found that it’s common for people from different departments to be working on similar (or identical) projects and not be aware of one another’s existence. Because of the way designers traverse the hospital system, during the course of their detective and outreach work, we are well-positioned to identify duplicate or complementary work.

Helping forge new connections between staff

When that has happened, I’ve either made an introduction between the two people who are working on similar projects; or, in the case that I discover someone who is working on a similar project to my team, I’ve shared our team’s intelligence and progress in hopes that the projects can merge or at least share information back and forth. In this way, designers help serve as connective tissue (so to speak) of diverse initiatives and projects, helping to share knowledge and prevent duplicate efforts.

This is also a reason to hire more permanent, full-time designers, instead of consultants who jump in and out of your system. Full-time designers have the opportunity to learn more about what’s going on, tell stories to more people, and make valuable connections.


Are you ready to hire a designer?

That is great! I could write a whole post about what type of person you should be looking for.

They might have titles like User Experience Designer, Service Designer, or User Experience Researcher. They should be seasoned enough to articulate their process, be comfortable presenting and defending ideas, and be curious and outgoing.

But I want to stress that it’s not enough to just hire someone. You also need to advocate for them, empower them, and give them space to define and develop their own process. Designers need to be able to follow leads and information trails so that they can uncover core problems; again, we never know at the beginning of a project what we will learn by the end.

Eventually, design should have representation at a more strategic level of the organization. While a great start, it’s not enough to have a few ‘worker bee’ designers buzzing around doing great work. For design to take hold in an organization there needs to be a culture shift; a change in the way complex problems are considered and approached from all levels.

To start, let designers set a more user-centered agenda, identify opportunities for making a big impact through design, and show their teams how design creates better outcomes. Think about the biggest problem you need to tackle, and pull a designer in to help you with it. Soon enough, everyone else will be clamoring to help out.

I’m grateful for the collaboration and input on this article from some my healthcare design friends: Jeremy Beaudry, User Experience Strategist at UVM Medical Center; Nick Dawson, Executive Director of Innovation at Johns Hopkins Sibley Hospital; and Lenny Naar, Design Strategist at HELIX Centre.