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"The more complicated your process, the more important it is that you design solutions with your patients."
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How to Overcome “Improvement Resistant” Challenges

By Paul Howard | Thursday, April 12, 2018
How to Overcome Improvement Resistant Challenges

Photo by Jackman Chiu|Unsplash

Would involving patients throughout the process of designing programs or systems better meet your patients’ needs? Paul Howard, Director of Community Initiatives for 100 Million Healthier Lives at the Institute for Healthcare Improvement, shares how he went from "design thinking" skeptic to true believer in the following interview.

What are the key challenges teams face when they try to design programs, processes, or systems for patients?

Even the most well-intended improvement efforts can fail because they haven’t considered the needs, preferences, and insights of patients.

We, as humans, are hard-wired to jump to solutions. That is really useful when an animal is attacking you. You don’t want to be thinking through possible options when you’re about to be eaten. But that response has limits when we’re trying to develop new change ideas for an improvement project. Jumping straight to solutions causes problems.

At IHI, we know that “every system has been perfectly designed to achieve the results it gets.” When most of us design our processes and systems, we’re not thinking of the end user, which in our case are patients. By not seeing from their perspective, we may not be designing systems that meet their needs.

What kinds of problems arise when we don’t think about patients as end users?

I’ll use an example I think most people are familiar with to explain. Imagine your last trip to the Department of Motor Vehicles (DMV) to renew your driver’s license. Was it an efficient experience that met your needs? Did you think, “These people understand customer service!”?

The DMV might seem like an extreme comparison, but if you go into a hospital or most waiting rooms, we don’t always do much better because we haven’t often thought about the process from the patients’ perspective. When we do, we find out that people are confused about what they’re supposed to do or about the next steps in a process. They may resist following a process we’ve designed because it doesn’t make sense to them or they don’t know why something is happening. There are countless examples that could benefit from better patient-centered design, including preparing patients for medical tests, explaining the use of their wristbands, notifying them of shift changes, and explaining complex medication regimens.

What are “design thinking” and co-design? How can they be used to improve the quality of health care?

When I explain design thinking and co-design, I ask people to think about pain points. What are the parts of your system that are broken or don’t work very well? What do your patients say doesn’t work for them? Have you ever had an improvement project that was “improvement resistant”? Almost everyone can think of something.

With design thinking, instead of considering what you need from the process or the system, you reflect on what the patient needs, expects, sees, hears, and feels as they’re going through that process or system. By changing your point of view, you open a whole new range of possibilities. Design thinking helps us to formulate new ideas that would not come if we only considered our own part in the system.

Getting the patients’ perspective can include using surveys and interviews, but they aren’t enough. As you delve into design thinking, you learn more, for example, about observing people’s behavior because often what we say and what we do might be slightly different. By learning how to observe, you can learn things that you would never find out from an interview or a survey even if that person is being authentic and honest. It’s fun because you sort of feel like you’re a detective and together with the patient you can figure things out.

Co-design is part of design thinking. As you work more toward the end of the design thinking continuum, co-design is where you’re not just observing the patient and getting their insights, but actively involving them in developing, testing, and evaluating solutions and then improving on those.

What example can you share to help illustrate why design thinking is so important?

Design thinking and co-design have changed people’s lives and changed processes for the better. For example, in design thinking we’ll ask people to create a journey map where they go through every step of a process in a patient’s shoes. I’ve seen people cry as a result because they thought they were providing great care and were patient-centered, but they saw an experience meant to be healing result in patients feeling frustrated, confused, or disrespected.

They cried because they saw what they were unknowingly putting patients through, but those revelations led to breakthroughs, and a renewed determination to do change things for the better. It helps people understand that we must engage patients to make improvement.

I once worked with a group trying to get people into housing. Their clients (or potential clients) were mentally ill with substance issues and living on the streets. They followed four people through a day in their lives and then mapped their interactions with the system. On average, it took more than 400 days from first contact to permanent housing. Along the way, on average, clients had to complete more than 40 applications, all asking basically the same questions on a range of topics, including how they became homeless, their history in the criminal justice or foster care systems, and their history of abuse. The team saw how it was retraumatizing clients to answer these difficult questions again and again. They saw how none of the different parts of the system were working together.

Over time, they refined a process of over 400 days to one that used one application and took under 30 days. That wouldn’t have happened without looking at the situation from the clients’ experience. Before that, each person knew their part of the process without seeing the whole picture. They weren’t aware of all of its absurdities.

How can Design Thinking and the Model for Improvement work together?

I think of design thinking and the Model for Improvement as complementary. For example, maybe you’ve figured out what you want to improve, but you’re struggling with developing change ideas or the ones you’ve tried haven’t worked.

Design thinking makes you step back and work with patients to go beyond surveys to get insights about their experience. Those insights help generate a greater range of change ideas than can be formulated through more traditional processes. This helps speed improvement.

The Model for Improvement works well with design thinking because it provides a systematic way of testing change ideas.

What has surprised you most as you’ve taught people about design thinking?

Design thinking has been a revelation for me. When I first learned about it about nine years ago, I wasn’t sure it was going to work. I thought, “We’ve got a complex system, lots of processes, lots of things that are beyond our control, and the patients aren’t going to understand it.”

I found the opposite to be true. We’ve now trained hundreds of people and hundreds of systems and we get great feedback all the time. They start out saying things like, “We thought it was going to add extra complexities and confuse our patients,” and they end up wondering why they didn’t involve patients sooner. The more complicated your process, the more important it is that you design solutions with your patients.

Editor’s note: This interview has been edited for length and clarity.

You may also be interested in:

IHI Expedition: Design Thinking and Co-Design: Achieve Breakthrough Results

The Evolution of Patient-Centered Care and the Meaning of Co-Design

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