This presentation was given to a medical audience in Toronto in 2014. It discusses the research that supports design-based innovation in the patient experience. For further details contact me at dunne@rotman.utoronto.ca
4. Summary
• Patient experience is all about getting the right
outcomes – not “patient satisfaction”
• Design of patient experience is an act of
conscious creation
• There are massive opportunities to solve
healthcare problems through design …
• … for example …
• How the process works
• Case study: Mayo Clinic Center For Innovation
• Challenges and how to deal with them
2014-‐07-‐02
David
Dunne,
Ph.D.
6. Patient satisfaction is not patient
experience
• To think of patient experience is to see the
experience from the patient’s perspective
• Patient satisfaction is typically a short-term
quantitative score that misspecifies the
experience and obscures the story
• Well-designed patient experiences achieve
desirable goals for all: satisfaction vs.
outcome is a false dichotomy
2014-‐07-‐02
David
Dunne,
Ph.D.
8. The
era
of
paternalis/c
medicine,
where
the
doctor
knew
best
and
the
pa/ent
felt
lucky
to
have
him,
has
ended.
We
don’t
worship
authority
figures
anymore.
Our
health-‐care
system
has
become
impersonal,
mechanized,
and
hollow,
and
it
has
failed
millions
of
people,
many
of
whom
want
to
find
a
way
to
regain
control
of
their
own
medical
decisions.
Michael
Specter
“The
Operator”
The
New
Yorker
Feb
4
2013
Read
more:
hJp://www.newyorker.com/reporMng/2013/02/04/130204fa_fact_specter?
printable=true¤tPage=2#ixzz2KjLIuKHd
2014-‐07-‐02
David
Dunne,
Ph.D.
11. Can we reframe this?
• Instead of thinking of patient satisfaction and
health outcome as either-or, can we see them as
linked?
• Patient satisfaction measures are influenced by:
– Outcomes
– Expectations
– Human interaction
– Process … etc.
• A good experience is a good process that leads
to a good outcome
2014-‐07-‐02
David
Dunne,
Ph.D.
13. 2014-‐07-‐02
David
Dunne,
Ph.D.
If we put a fraction of the effort into understanding the patient
experience that we invest in understanding diseases, we
could immeasurably improve healthcare
14. DESIGN IS AN ACT OF CONSCIOUS
CREATION
2014-‐07-‐02
David
Dunne,
Ph.D.
15. Design is an act of conscious creation
• The needs of the individual user/patient are
paramount*
• Design thinking does not come naturally: it
requires training, method and attitude. Most
of all, attitude
• Its purpose and methods are different from
science. It proceeds by learning from low-
resolution/low-risk field trials.
2014-‐07-‐02
David
Dunne,
Ph.D.
*(P.S.
Frustrated
staff
do
not
deliver
good
paMent
experiences)
16. Nobody experiences the system; they
experience their own pathway through it
2014-‐07-‐02
David
Dunne,
Ph.D.
What is the “lived experience” of healthcare
from the patient’s perspective?
19. This (well-intended) finger wagging is
often ineffective …
2014-‐07-‐02
David
Dunne,
Ph.D.
We are different from patients
We do not understand their
experience, because:
• We don’t see everything they see
• We don’t live their lives
• All patients are not the same
• We are biased observers
20. There is a better way
2014-‐07-‐02
David
Dunne,
Ph.D.
Understand
Frame
Create
Patient-
Centred
Design
Develop a deep,
empathetic, intimate
understanding of the
context patients live in
Define the problem to be
solved as the patient
would define it
Explore – i.e. make –
solutions to learn more
21. Medicine, Science and Design are
different ways of thinking
2014-‐07-‐02
David
Dunne,
Ph.D.
Synthe'c)Analy'c)
Symbolic)
Real)
Science&
Design&Medicine&
Analy&c(
Symbolic( Synthe&c(
Symbolic(
Synthe&c(
Real(
Analy&c(
Real(
Owen
2007
Design proceeds by thoroughly
understanding patients’ lives,
by making connections, by
experimenting to explore the
problem.
Medicine proceeds by testing
hypotheses one at a time, by
understanding before acting and
by doing no harm.
22. THERE ARE MASSIVE OPPORTUNITIES TO
SOLVE HEALTHCARE PROBLEMS
THROUGH DESIGN
2014-‐07-‐02
David
Dunne,
Ph.D.
23. There are massive opportunities to solve
healthcare problems through design
• Many studies support the link between
experience and outcome
• Increased importance of chronic conditions,
where the patient is main actor
• Patients make choices … and not always
choices you’d like
• Well-designed experiences reduce cost and
make patients happier and healthier
2014-‐07-‐02
BUT
every
paMent
is
different
…
and
experiences
the
same
processes
differently
David
Dunne,
Ph.D.
24. The elephant in the room: adherence
14% to 21% never fill their original prescriptions.
60% cannot identify their own medications
30% to 50% ignore or compromise medication
instructions
25% admissions related to poor self-
administration.
12% to 20% take other people's medicines.
… AND BTW …
For a chronic disease like diabetes, 95% of
treatment is self-administered
2014-‐07-‐02
David
Dunne,
Ph.D.
31. To understand design thinking, you need
to understand three things
2014-‐07-‐02
David
Dunne
31
ObservaMon
Quant
&
qual
interviews
Storytelling
Understanding
the
user
and
context
Rapid
prototyping
Bodystorming
Walk
throughs
Making
as
a
way
of
thinking
Root
causes
PerspecMve
flips
Systems
thinking
User
experience
Reframing
the
problem
32. PCD emphasizes ‘lived experience’
• Focus on groups of individuals, not ‘general
public’
• Empathy – attempting to see the experience
from the patient’s perspective
• Understand what drives behaviour so we
can achieve better outcomes
• NOT the same as ‘pampering’ patients
2014-‐07-‐02
David
Dunne,
Ph.D.
33. Diabetes: the old way
"The
needles
were
enormous,
and
they
came
with
liJle
pumice
stones
so
that
you
could
sharpen
them.
They
oken
became
dull
and
developed
barbs
on
the
end.
And
in
order
to
sterilize
them
they
had
to
be
boiled
for
twenty
minutes."
2014-‐07-‐02
David
Dunne,
Ph.D.
34. A problem well-framed is a problem
solved
• We do not accept the problem ‘as given’ but
look to reframe it based on
– Patient perspective
– Underlying issues
– Analogies
• Reframing is more important than
brainstorming
2014-‐07-‐02
David
Dunne,
Ph.D.
35. CHANGING FOCUS AT SINAI EMERG
INITIAL
FRAME:
“WHY
CAN’T
I
GET
ANY
PRIVACY?”
REFRAMED:
“WHY
ARE
THERE
SO
MANY
PEOPLE
AROUND?”
2014-‐07-‐02
David
Dunne,
Ph.D.
36. Get physical, early and often
• Prototypes can be
anything
– Rough models
– Role plays
– Sketches/collages
• They force you to get your
idea clear and explicit
• They help others to see
what you are talking about
• They allow patients to
respond, experience and
comment
2014-‐07-‐02
David
Dunne,
Ph.D.
38. … and the right attitude
2014-‐07-‐02
David
Dunne
38
Empathy … to appreciate the user’s problem even
when they are very different from you
Curiosity … “mind of a child” who keeps asking
“why?”
Openness … to different forms of knowledge and to
new perspectives
Nonattachment … to one’s own ideas, or to those of
the team
Mindfulness … to see the inherent possibilities
39. A nonlinear, iterative process
2014-07-02
UNDERSTAND CONTEXTREFRAME
CREATE
STATE AND RESTATE THE PROBLEM:
WHO NEEDS WHAT BECAUSE WHY?
DEVELOP DESIGN PRINCIPLES
EXPLORE SOLUTIONS
DRAW, MAKE, DO
REFINE AND ITERATE
DEVELOP PATIENT INSIGHT
UNDERSTAND THE SYSTEM
ITERATE:
WHAT
DO
OUR
FINDINGS
INDICATE
ABOUT
THE
PROBLEM?
ITERATE:
WHAT
DO
OUR
SOLUTIONS
TELL
US
ABOUT
THE
PROBLEM?
ITERATE:
WHAT
INSIGHTS
MAY
LEAD
TO
SOLUTIONS?
WHAT
DO
OUR
SOLUTIONS
SUGGEST
WE
NEED
TO
KNOW?
UNDERSTAND
REALITY
FRAME THE
NEED
CREATE POSSIBILITY
David Dunne, Ph.D.
40. MAYO CLINIC CENTER FOR INNOVATION
CASE STUDY
2014-‐07-‐02
David
Dunne,
Ph.D.
42. Igniting a SPARC
• SPARC (see/plan/act/refine/communicate)
was started in 2000
• This became the Center for Innovation (CFI)
in 2008
• CFI uses design approaches:
1. Topic framing
2. Research
3. Design
4. Implementation
2014-‐07-‐02
David
Dunne,
Ph.D.
43. The intent: to understand and improve
the delivery of care
2014-‐07-‐02
David
Dunne,
Ph.D.
44. Redesigning outpatient practice: Jack
and Jill rooms
2014-‐07-‐02
David
Dunne,
Ph.D.
Based
on
the
observaMon
that
physical
exam
takes
up
a
small
porMon
of
Mme
ConversaMon
room
Treatment
room
45. CFI Mission, Goals and Approach
2014-‐07-‐02
David
Dunne,
Ph.D.
Mission
The Center for Innovation's mission is to transform the experience and delivery of
health care.
Goals
• Focus on the human experience to identify needs and design services, products
and business models to meet them
• Innovate care delivery that's accessible, affordable and value-driven
• Collaborate openly — internally and externally
• Generate economic value by demonstrating financial return from sustainable
delivery models, services and products
Approach
The Center for Innovation works with a "Think big. Start small. Move
fast.™"philosophy.
• Connect. Bring people together in new ways inside and outside of Mayo Clinic.
• Design. Identify opportunities and realize solutions that transform care delivery
and experience.
• Enable. Facilitate and accelerate innovation across Mayo Clinic.
47. The RED engineering project
2014-‐07-‐02
David
Dunne,
Ph.D.
Goal
Pay for performance è enhanced need for better care at lower cost
Method
‘Interview and Observation
Key Insights
• “Patients don’t get vacations”.
• Medical and non-medical considerations were interwoven in the
dialysis experience, but there were gaps between them.
• The patient care team was often patients’ sole source of
support – not just medical, but emotional too. Because of this,
patients were often reluctant to leave the hospital.
• Patients and healthcare providers spoke different languages,
but had common goals and intentions.
48. What they learned
2014-‐07-‐02
David
Dunne,
Ph.D.
In the middle of a lot of stress and acute illness, we were asking them
to make big decisions: do you want dialysis tonight? You don’t need to
do it, but of course if you don’t use dialysis you’ll probably die by
tomorrow morning … What kind of dialysis do you want? OK, now
you’re on dialysis, goodbye; you can be dismissed from the hospital.
Good luck with your new life. We realized that this did not set our
patients up for success in the future.
Dr. Amy Williams, MD, Nephrologist
49. What they did
2014-‐07-‐02
David
Dunne,
Ph.D.
Exploration and Experimentation
• Mapped the experience
• Developed an integrated care team approach that took into account
medical and non-medical aspects.
• In-depth patient understanding à new educational materials
Outcomes
• Hospital admissions fell by 40%
• Reductions in in-hospital dialysis.
• Patient satisfaction, provider and care team satisfaction all
increased.
• Quality standards were met and there were significant cost savings.
51. The challenges
• Lack of (or passive) on-the-ground
cooperation
• Mental models:
– It’s about pampering patients/customer service/
marketing … all stuff other people do
– It’s about low-priority issues
– It’s not scientific
– It leads to higher costs
– It’s too time-consuming
• The lure of the incremental
2014-‐07-‐02
David
Dunne,
Ph.D.
52. The major risks
• Isolation and lack of cooperation
• Getting overloaded with incremental
projects
• Lack of departmental engagement
• Too few visible results
2014-‐07-‐02
David
Dunne,
Ph.D.
53. Fortunately, others have faced these
challenges
Strong, public, vocal top-level support
Project work:
Find early wins
Protect unallocated time for “banner” projects
Engage departmental teams
Internal relationship strategy:
Communication and engagement
Find allies and draw them in
Have someone who knows networks intimately
Establish and support communities of practice
2014-‐07-‐02
David
Dunne,
Ph.D.
54. Summary
• Patient experience is all about getting the right
outcomes – not “patient satisfaction”
• Design of patient experience is an act of
conscious creation
• There are massive opportunities to solve
healthcare problems through design …
• … for example …
• How the process works
• Case study: Mayo Clinic Center For Innovation
• Challenges and how to deal with them
2014-‐07-‐02
David
Dunne,
Ph.D.