Interview: Peter Coughlan, IDEO
Monday, September 15, 2003
by Mark Hurst
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Consider the last hospital you entered, as patient or visitor. Was
it a good experience? Could it be improved?
Think of the stereotypes around the hospital experience: slow,
bumbling bureaucracies; impersonal treatment of patients; a sterile,
Given the immense economic and political importance of the health
care industry, it's ironic that we don't talk more about this
One firm has begun doing work in improving the health care
experience, working directly for hospitals. Palo Alto-based IDEO has
tasked Peter Coughlan and his team with this challenge.
After running IDEO's San Francisco office for a year, Peter and his
colleague Ilya Prokopoff started IDEO's "Transformation by Design"
group in Palo Alto. I interviewed Peter recently by phone.
Q - Describe your group's work.
We took IDEO's core process, and added new tools and methods to help
instigate organizational change. Our high-level operating theory is,
engage with the client, do a design project together. Use what
you've learned from that to learn about the organization. Then
redesign the *organization* to meet this offering you've created. So
- design the offering first, then design the organization to
successfully deliver that offering.
It's different from a traditional design firm; most consulting says,
here's the new offering, delivered in a tome that lays out the
strategy. If the new offering fails, it's because you haven't spent
the time to change the culture that's supposed to deliver it. Our
promise is that we can help transform organizations by giving them
the capability to design experience from a human perspective.
Q - What's an example of your health care consulting process?
The hospital says, here's a broken process with an 80-step process
map; we'll say, where's the human in the process? They say, "Humans
make mistakes, that's why it doesn't work." We say, if we create a
simple map that shows the steps in the human process, can we realign
the organization to deliver the experience around those steps?
Customers don't navigate your organization by its boundaries, but
rather by their mental model of what their needs are. They expect
the organization's silos to melt away as they go through that
experience. But that usually doesn't happen, and health care is an
extreme example of that. It's an industry that, for regulatory and
financial reasons, is concerned with optimizing, reducing error.
Guess what happens you've got thousands of functions optimized in
isolation from one another: it leads to huge inefficiencies and
frustration in battling the system. We come in and bring all the
parties around this experience to the table. We say, let's design
from the patient out, from the customer out. Otherwise, groups that
have been so siloed would never talk to one another.
Something as discrete as the postpartum experience, you'd expect to
be well-orchestrated in a hospital. It's not that big a thing:
getting two days' rest, getting the baby checked out, getting ready
to go home.
But if you see how it's actually delivered, you see how broken it
is. Admissions doesn't communicate with the postpartum floor;
therefore they're delivering eight high-acuity patients to one
nurse, while on another floor, there's only one high-acuity patient,
and nurses are actually being sent home.
There's inefficiency throughout: No communication from labor and
delivery to the postpartum floor. Breakdowns in the flow of
education materials. Breakdowns of visitors' access to patients. The
individual functions have been optimized within the silo, but not
Q - How do you get people around the table? There are so many
stakeholders in a hospital - and they're busy.
We have different structures put into place. We form a core design
team, made up of hospital employees. The IDEO team is there to
facilitate and generate content with them, to shake things up a bit.
From the executive sponsor down to front-line workers, across
functions - there are five to twelve people on the whole team. That
team meets on an ongoing basis over several months.
Then we review the hospital's various service teams, and assemble 30
to 60 other employees whose lives are impacted by the designs. They
review and provide input throughout, though not as frequently as the
We might host a brainstorm of 40 people about the postpartum
experience based on core team's research. We present prototypes or
concepts to that larger team to help in the selection and refinement
process. Ideally all employees would participate, but the hospital
still needs to run; and you can't manage that many people anyway.
Q - What's the process, starting with the brainstorm?
We get people to imagine a future when barriers are broken down. For
example, imagine if families could visit at any hour day or night,
if that was the right thing for the patient? Or if patients could
communicate directly with nurses when they had a need? That's
something the system doesn't currently provide. Or imagine if
everyone attended their education classes. Or if we didn't have to
do any education in the hospital, but conducted it all outside the
hospital? "Imagine if" statements get at frustrations or barriers to
a good experience.
That's the launching point for different tests and pilots and
experiments to help get them there. If the ideal patient-caregiver
link is with a push of a button to communicate privately with the
assigned nurse on the floor at any time with the push of a button,
what do we need to know to make that happen?
For example, we experimented with direct patient-nurse communication
by giving them walkie-talkies. That solution failed for various
reasons - bandwidth issues, too noisy, lack of privacy. So we moved
to a paging system, because it was the quickest and cheapest way to
continue to test the concept. But we learned that pages are
miserable for the patient to deal with. You have to dial 20 numbers
to make a simple request. In an ideal world you'd triage requests,
so, depending on the urgency of the request, maybe the nurse doesn't
get ice cubes; that's the assistant, or a volunteer, who brings the
ice and chats with the patient for few minutes.
Through experiments, we learn what actually works in the setting.
We're not forcing an idealized or unrealistic solution on people. So
we experiment every week, and think about experiments two to five
Then we go into contextual inquiry. We tell people: we're new here,
so tell us, what are the things that we need to see to help us
understand how things work and don't work? List 50 or 60 things we
must see. We also have people do mock experiences - like for
postpartum, two IDEO team members (a husband and wife) were put
through the process. Most administrators and caregivers haven't
actually had to experience their own process.
We also bring the core design team to analogous contexts outside the
hospital. Like in postpartum, the mother and baby are separated; the
baby goes to a nursery. So what's a case where you give up something
dear, and entrust it to someone. Maybe we'll go to a car dealership,
where you give up your brand new Lexus to mechanics covered in
grease. Or to the veterinarian - how do they assure you that things
will get taken care of, that your pet will be in good hands? Or for
process issues, how does a hardware store stock and track items?
We just try to get people into another setting. We try not to go to
places like hotels or spas, since they're well-worn metaphors.
They're worthwhile, but it's also good to go to outliers, because
you're not sure what you'll find.
While on these trips, people bring cameras and document things
visually. That's new for health care. They come back, sort through
the data, look for themes, and we map it to a "journey framework" -
the major steps in the experience - maybe "getting into the
healthcare setting; finding my way; treatment; leaving; accessing
We then use these stories as rich jumping-off points to create a new
experience. Take "finding your way": how do we apply that in a
hospital setting? The brainstorm session is preceded by
story-telling: a mix of positive things, and challenging things,
that people observed in those outside contexts.
We then brainstorm to generate hundreds of potential solutions. It's
exciting for participants because generally they don't think of
themselves as creative people. People see a side of their colleagues
they had never seen before - having fun, getting frustrated, a whole
After the brainstorm, we sort the ideas, and see which ideas will
have the biggest potential impact on the overall experience for the
patient. We see the patient as the arbiter of the best solution. All
other considerations being equal, prioritize the patient experience,
though we also give caregivers - hospital employees - improvements
for their own lives.
We then list prototypes or experiments that we can try to test our
ideas. For example, maybe there's an idea around a team report. We
form a small group within the core design team, and within thirty
minutes, they design a preliminary team report with clipboard,
paper, and marker. They take that report around to the various
stakeholders and get their reaction, on the spot.
Ordinarily the hospital spends a year or two in committee, create
what they think is the perfect team process, and then goes out and
tries it and fails. At IDEO we say, "fail early to succeed sooner."
So after a half hour bringing into the field, we see how colleagues
use it. Then we come back and revise it. So we get rapid prototyping
in place. Previously it was death by committee.
At end of a 12-week project, we'll deliver a set of design briefs to
the client, one or two-pagers on what each piece looks like. After
that, for implementation, the client may hand those briefs to an
internal IT team, to a graphic design firm, to us, or to someone
else. Our process has made them better consumers of design: they
can tell you exactly what they want. They already have one or two
prototypes that clearly articulate their needs. So for our
postpartum project, we created a map, some collaboration tools, a
new visitor policy. We brought some of these prototypes to the next
level so they could see what they should be asking for.
The nice thing about this method is that people are able to see
immediate results. Their behavior starts changing on day one. It's
not like planning a new hospital wing, and seven years later it's
built and the people who planned it are gone, no one remembers the
intention, why it was designed this way, and people are forced to
fake their way into the new space, creating new protocols and
behaviors. Instead, we ask, what's the solution we can develop today
that will help us move in a step-wise fashion to a shared vision of
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The Art of Innovation, by IDEO general manager Tom Kelley, describes IDEO's process in more detail.
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