Transforming Community Health through Systemic Design
This story is a case study in a forthcoming book on systemic design. Help me out by adding your feedback below.
How do you use systemic design to disrupt a system that is firmly entrenched in an outdated business model?
Marc Matthews, Leslie Ruckman, Allison Matthews, and Rose Anderson from the Mayo Clinic’s Center for Innovation have lived this experience for the past four years as part of the Community Health Transformation project. Allison is a service designer, trained as an architect, who also attended the Mayo Clinic School of Medicine. Leslie and Rose are service designers with industrial design education. Marc is the Associate Medical Director, Mayo Clinic Office of Population Health Management. Together, they have redesigned the primary health care delivery model towards a collaborative, team-based model that provides a superior patient experience, empowers all health care professionals to operate at the top of their licensure, and improves system level efficiency and effectiveness.
Phase I: Scanning and framing
The Community Health Transformation project began in July 2010 when Allison and Rose were embedded in the Kasson Clinic in Dodge County, a rural agricultural region of southeastern Minnesota. The project did not start with a well framed problem. Rather, Allison and Rose brought open minds and the keen eyes of designers to the challenge of improving primary health care. During phase one of scanning and framing, their ethnographic research had two aims: to understand what primary care was, and to identify what might be impactful in terms of change.
One year of observing and questioning patients and doctors and conducting research provided a deep grounding for the project in the lived experiences of users and providers of primary health care. During scanning and framing, two key issues emerged. First, the care team was not functioning effectively at all. Second, many patients were presenting with issues requiring social services, rather than pure health care issues. To address these issues, Allison and Rose initiated two interrelated design projects. The Optimized Care Team redesigned the primary care experience as a wrap-around team-based model of care. Meanwhile, Dodge Refreshed created a partnership between the Dodge County community, the Kasson Clinic, and the Center for Innovation to jump-start a wellness movement in the local community.
Allison recalls the key observations that would inform the design of the Optimized Care Team:
One of the things that I noticed was that the care that was being provided at a physician level, or by a physician, wasn’t necessarily at a physician level in terms of acuity.
We got to the point where every time I would walk out of the room with one of the providers, I would ask: what did you do today in that appointment that required you, as a physician, to be in the room? Often the answer was “nothing.”
We started to recognize that the people who could provide care were not necessarily only the physicians, and we recognized that there is a skill set within the rest of the team. That skill set for say a nurse, is that they are often very good at providing education, but physicians aren’t as well trained in providing education, so patients may get more value out of having an appointment with someone else.
We began to look at the needs of the patients that were coming in. We started to gather data about who we, in theory, thought that people should be seeing and started to put together a team that would work together.
Dodge Refreshed was also informed by design research. In Mower County, immediately south of Dodge County, the Center for Innovation began ethnographic research in 2010 that resulted in a community engagement movement called Mower Refreshed. The ethnographic research Rose and Allison performed in Dodge County confirmed that a similar movement could be of value in their community, which led to a recommendation to put in place a community engagement coordinator, and to experiment with replicating the Mower model.
Rose explains how observations and insights across both projects came from a wide range of methods: observation, talking with people, informal and formal interviews, world cafes, forums, and workshops. Three hour community workshops were held in local venues, including cafes and an assisted living community:
For each workshop we would create artifacts to help elicit conversations and connections between people; help understand the system from their perspectives, but also help people grow in their creative confidence as well. I think that relates to the idea of creating capacity.
In the clinical setting, creativity and flexibility were key to eliciting insightful input.
You had to embed in the flow of the clinic and also be super-respectful of the people who were working there and the job they were trying to get done and not get in the way of that, but find creative ways to engage them even in a limited time.
Workshops in the Kasson Clinic were held over lunch so as not to interrupt work schedules. A simple yet effective way to gather patient perspectives while they were waiting for their appointments was to give them a sheet titled:
“I wish Kasson Clinic had…”.
In addition to ethnographic and design methods, their research was informed by systems theory. Rose reflects:
I’m coming into this experience of being a service designer at Mayo clinic from being a traditionally trained industrial designer… so the steps of understanding user needs and framing the problem, and rapidly prototyping and iterating on that, I’m very comfortable and well versed on that…. I learned so much through this process of what it means when the design materials are components of a complex system.
By viewing the community as a complex system, the team drew on insights from theory, including Donella Meadow’s Thinking in Systems, Margaret Wheatley’s Leadership and the New Science, and literature on development aid, to establish three principles:
1. Add capacity versus dependency
2. Approach with understanding versus authority
3. Establish goals that reinforce results versus effort
The first principle ensured that the community engagement coordinator would connect, catalyze, and build on existing community initiatives. The second principle built skills in appreciative inquiry, a strength-based approach to collaborative redesign. This helped avoid what Meadows calls the policy resistance trap, where actors expend considerable effort maintaining the status quo even when it is dysfunctional. The third principle sets goals for outcomes, rather than outputs, avoiding the systems trap of seeking the wrong goal. Deep, meaningful impact was more important than racking up large numbers of community events.
Phase II: Experimentation
Armed with these insights from observation and theory, the designers moved into phase two, which they called experimentation. This phase was not yet solution oriented, but was focused on learning more about the problem and testing assumptions. Allison and Rose produced low resolution prototypes and used them to gather more data from the clinic. They created half-sheets to hand out to physicians to ask:
Who should have been in that appointment today?
They found that of every five patients seen in the clinic, just one needed to see a physician. Three could be served by a care team, while one could be served with non-visit care. The designers created “rough and tumble” paper prototypes and care team models to generate multiple options. They played with prototypes such as adding student volunteers to the care team to meet the social needs of patients.
The learning from iterative prototyping and experimentation resulted in a stable and robust care team model that had survived testing and feedback from providers in the field. The new model, shown in Figure 1 below, built a wrap-around team to transform the patient experience from being “on a conveyer belt” of individual transactions, to being at the center of a care team. The core team of eight consisted of three Providers (a Doctor of Medicine and Nurse Practitioner / Physician Assistant mix), a Registered Nurse, three Licensed Practical Nurses or Medical Assistants, and one Scheduler. A Wellness Navigator created a connection to the community to address non-medical barriers to health. After six months of experimentation, the model was ready to test under clinical conditions.
Phase III: Prototyping
Then, they waited.
It took nine months to get approval to proceed to phase three, prototyping. Actually deploying a working prototype in the clinical environment required permission from many stakeholders: the practice lead, the people who manage reimbursements, the owners of the space, and the people who communicate with patients about their care team. Leslie led the prototyping phase, which was intended to develop and test the foundational elements of the optimized team care model.
With approvals and a working prototype in place, 1300 patients were seen over seven weeks in the Kasson and Baldwin Family Medicine Clinics. Marc was the lead physician at the Kasson clinic. The care team were collocated in a team room to promote shared situational awareness. Team huddles allowed information sharing about patients prior to their visit, while patients articulated their visit goals in a half-sheet to capture what they hoped to accomplish with their visit, as well as noting any other issues or concerns. This enabled both a more efficient allocation of care team members and a more holistic treatment of the patient’s condition. The care team was encouraged to make use of non-traditional visits. If patients were required to see multiple members of the care team separately, then the team ensured a warm hand-off. The difference was clearly noted in patient feedback: “It seemed continuous even though there were three people coming in. They knew what I said to the others.” Another patient reported: “I liked that everyone seemed to know about me.” Finally, process measures and exit interviews helped to evaluate the Optimized Care Team model’s performance.
“I liked that everyone seemed to know about me.”
The Optimized Care Team performed well on every metric. It worked. Everyone agreed it was better.
Even initially skeptical patients reported having one of the best appointments they’d ever had. Patients were asked: Did your care providers know your story and reason for visit? Of 164 respondents, 138 said yes, 25 said somewhat, and just 1 said no. For visit satisfaction comparison, of 164 respondents, 72 reported higher satisfaction, 84 reported the same, and 8 reported lower satisfaction. Health care providers spent more time practicing at the top of their licensure. Of the 839 patients data was collected on, 143 visits were performed by integrated team members, and 80 were delegated to nurses. Another 305 patients could have been delegated to integrated team members and a further 132 to nurses, indicating significant potential for further efficiencies and empowerment of allied staff members. Non-visit care also increased, with 70 patients receiving care over the phone and a further 147 assessed as potential non-visit care recipients.
Team members reported increased sense of purpose and self-valuation, while satisfaction increased in direct correlation with increases in team communication and autonomy. The prototype demonstrated the Optimized Care Team was more efficient and reduced costs while increasing patient and provider satisfaction. After working for a week in the multidisciplinary design lab, which was set up to support team-based behaviors, one care team member voiced a sentiment that was shared by the team: “Can’t we just stay here? Do we really have to go back to the real world?”
The efficiency gains allowed the care team to step outside the paradigm of the 15 minute consult and employ non-traditional visits for complex care situations. Allison’s story shows why this matters:
Marc had a patient who we will call Frank and he was sick. He would get sick in a lot of different ways, but he was a chronically ill person who would get these acute episodes that would send him to the Intensive Care Unit (ICU) frequently. He would go to the ICU maybe once a month. Then he would have to have a follow up appointment with Marc. There’s this constant battle of trying to keep him out of the ICU, but he wasn’t able to provide him a service in the clinic, in the 15 minute visit, that would have any impact.
We sat down as we saw that Frank was coming in in a couple of days. We were looking over Marc’s schedule and I asked, “What would really provide some value to this patient?” He said, “I can’t do it here. I don’t really know how this guy lives. I don’t know what his priorities are.” We decided to give Frank a house call. While that sounds pretty normal in medicine, it’s pretty rare nowadays.
We got in the car and drove up to Frank’s house. We talked to him and his sister was there and she helped him, but he lived by himself. He had this big bucket of medications that he had to take every day. We asked him what his personal goals were in terms of his health. It was nothing about his disease, but he wanted to be able to walk a line of 10 trees in front of his house so he could get to his lawnmower and mow his lawn. That’s what he wanted to be able to achieve.
Marc, knowing that information, was able to change the regimen of medications that he was on. He was able to set up a check and balance system for Frank to recognize whether or not he was getting really sick so that he might be going to the ICU and help him make a plan for if he saw some of the indicators that he would be getting really sick. He also gave him his cell phone number and said, “The next time you think you’re on your way to the emergency room, give me a call and I’ll come in with you and we can talk about the best plan while we’re there.” It went from him going in every month to the ICU and he hasn’t been in the ICU for two years since.
For Dodge Refreshed, a successful model already existed in Mower Refreshed, where the initial prototyping was performed. However, it was not just a simple matter of copying and pasting a ready-made solution from one county to the next. While the two movements share ideas, resources and document templates, the movements are also unique because they each began with the different priorities and values of their local community. Figure 2 below shows the vision of transforming Dodge County towards the refreshed ideal, where currently disconnected groups coordinate, communicate and connect to improve population health.
The Dodge Refreshed movement connects the Kasson Clinic with the community and intervenes upstream from primary health care in the social determinants of health. Under the old metrics — the number of clinic visits — this initiative could actually reduce the performance of the clinic. However, as health care shifts towards assessing total cost of care, wellness is a key lever to improve population health and reduce the per capita cost of care.
The Optimized Care Team also acts on a key lever for systems change. In response to primary care physician shortages, there has been a lot of attention devoted to improving individual physician efficiency and productivity. Yet the return on investment for individual improvements are marginal when compared with the efficiencies that can be gained by an empowered health care team, considering that just 20% of presenting patients require treatment that only the physician is licensed to provide. Studies have shown that individual task efficiency varies by a factor of 10, but team task efficiency varies by a factor of two thousand. There is far more leverage in building high performing teams than improving individual physician performance.
The two levers for systems change are interconnected. Rose observes that “The clinical setting is where those non-medical barriers to health might come out in conversation — it’s a safe space.” The wellness navigator on the care team can recognize unmet social needs, such as affordability of healthy foods, and serves as a vital link between team care and community wellness.
Phase IV: Implementation
Having developed a deep understanding of the primary health care system, iteratively prototyped an innovative care model, and collected evidence of the superior performance of the Optimized Care Team model for patients, providers, and the system, the team moved into the fourth and final phase, implementation. The model has been demonstrated as successful and is now being scaled up. Mayo Clinic’s Office of Population Health Management (OPHM) is disseminating the Optimized Care Team to over 80 clinics across three states of the U.S. over a three year period.
The Mower and Dodge Refreshed initiatives have also been scaled up. In February 2013 the team was asked by the OPHM to integrate the Refreshed initiatives with population health innovations in other clinics across the U.S. Midwest. Ethnographic research from visits to Midwest clinics informed a 100 person design workshop to create the Mayo Model of Community Care version 1 (MMoCC 1, pronounced Mach 1). The workshop elicited feedback on how to make the transition from fee for service to total cost of care. Innovations across care management (including team-based care), partner management (including community engagement), finance management, and operational management were identified and sequenced to inform the OPHM’s strategic plan. The team borrowed the Step-Stretch-Leap terminology from product design. This helped participants to think of population health as feature sets that are feasible today (Step, MMoCC 2), operate under a mixed model (Stretch, MMoCC 3), and implement the full-featured vision of population health (Leap, MMoCC 4). This enabled a cohesive framework to be developed, while acknowledging that clinics are at different maturity levels. It also anticipated an iterative approach to implementation, based on active listening, continuous learning, and refinement of the model over time.
In spite of these successes, implementation has been slow and often challenging. Allison acknowledges: “It’s always an uphill battle with whatever we do because our change is so disruptive. Just when you think you’ve broken through and people are going to do it, there are more barriers.” The Optimized Care Team challenges some of the most deeply held beliefs of physicians.
There’s a sense of mourning, a sense of loss. There’s a threat. Primary care providers in the United States really cling to owning the relationship with their patients, and they think that they’re best people to own that relationship…. I think that there was a perceived threat that we’re asking the providers to give up their relationship with their patients…. It’s really ingrained in their education and the social networking of medicine.
In the past, if they don’t see as many patients as they possibly can and own the relationships with all the patients, they don’t get paid. They don’t get a bonus, so we’re essentially saying work against everything that you’ve ever known.
In theory, it makes a lot of sense to everyone. It makes a lot of sense to keep people healthy, it makes a lot of sense to spread out the work, but when it comes down to the nitty-gritty day to day, it’s hard.
To provoke change in a system against such ingrained resistance requires persistence, courage, and a certain mindset. I asked Allison to reflect on this:
That is a little bit to do with my personality and the fact that I don’t really hear that authority. If we weren’t able to ask the really obvious questions, and to ask the questions that it’s assumed that you understand because of culture, I think the project is lost completely.
It made, at times, the project very uncomfortable. It made people really upset. It made people angry. It made people question their value in the clinic and so we had to be careful about how we did it and when we did it.
Marc added the following insight on what sets Allison apart:
One of Allison’s real strengths is that she has the medical background, so she is able to spot behaviors that are driven by current cultural assumptions in health care, rather than latest clinical knowledge. When a provider is trying to say “Oh, no. We couldn’t possibly do that because this is medically necessary,” she knows enough to say no, that’s not true.
While culture has been the predominant challenge, it is not the only one.
Maintaining design intent is also a challenge. For Allison:
We say this is more of a care philosophy, and there’s a strong desire to turn it into a checklist and maintain your practice as is, and just do these extra things. This isn’t extra things, it’s changing the way you’re doing things.
Incentive mechanisms also work against the Optimized Care Team model. While the U.S. health care system is shifting from fee for service to total cost of care, this is a very slow change. Right now, primary health care providers are being asked to do one thing while they’re still getting paid to do another. This means leadership at all levels is required to create the space for innovation. Rose says it is important for leaders to “create a pocket of oxygen in the organization for that spark of innovation to take flame before the ‘prove it’ question comes down on it.”
“create a pocket of oxygen in the organization for that spark of innovation to take flame before the ‘prove it’ question comes down on it.”
At a systems level, there is the challenge of reconciling innovation and integration. When human-centered design gives voice to patient needs that contradict institutional assumptions, it creates opportunities for innovation. Yet without the support of the institution, those innovations will never be integrated into large scale institutional routines. Marc and Allison speak to the need to create a dialogue between the patient voice and institutional advocates to ensure that innovation is integrated into the current system:
We’ve learned that when we find something that seems to contradict what we have heard from the institution or our institutional assumptions, to very openly tell that story quickly in a way that creates a dialogue. It doesn’t just say here’s what people think.
It says: here’s what people think. Is this different than what you think? If it is different than what you think, how should we continue our experiments to push it one way or the other? When we were doing our initial work we thought that it was a collaborative process, but I think we could have been more collaborative.
In spite of these challenges, the team remain optimistic that the Community Health Transformation project will make positive and lasting systems change.
Notes
For more on the Mayo Clinic’s Community Health Transformation initiative, see:
- Mayo Clinic Center for Innovation. (2013). 2013 Community Health Transformation: Overview: Insights, Projects and Future Work.
- Mayo Clinic Center for Innovation. (2013). 2013 Community Health Transformation: Optimized Care Team.
- Mayo Clinic Center for Innovation. (2013). 2013 Community Health Transformation: Patient-Centered Care Plan.
- Mayo Clinic Center for Innovation. (2013). 2013 Community Health Transformation: Wellness Navigators.
- Mayo Clinic Center for Innovation. (2013). 2013 Community Health Transformation: Community Engagement.
- Olive, L. (2014). Dodge Refreshed Community Engagement Coordinator Role. Mayo Clinic Center for Innovation Report.
