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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, forbidding environment.

Given the immense economic and political importance of the health care industry, it's ironic that we don't talk more about this customer experience.

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 across it.

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 core team.

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 years out.

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 physicians again."

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 range.

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 the future?

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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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