Care Redesign

Human-Centered Design and Performance Improvement: Better Together

Article · June 28, 2018

Performance improvement (PI) has contributed to health care quality and safety gains over the past two decades. Health care organizations pursue excellence by systematically identifying improvement opportunities and implementing initiatives to eliminate defects and enhance existing care processes and pathways. The concepts, principles, tools, and techniques of improvement methodologies have demonstrated value in a wide range of industries, including health care.

Chief among these methodologies are Deming’s System of Profound Knowledge, the Juran Trilogy, and the Toyota Production System — all of which share the perspective that any effort to improve a system, its processes, or its products and services must begin with customers and the people doing the work. The tools and mind-sets of human-centered design (HCD) can support PI and take it to the next level in health care, allowing a more complete understanding of patients, family members, staff, and providers — and supporting collaboration among them — to understand ambiguous challenges and develop innovative solutions to address them.

Fusing PI and HCD is becoming a trend across industries as organizations such as IBM integrate HCD with agile software development and Six Sigma. Health care is catching on, too, and Kaiser Permanente is integrating these capabilities on a scale of 12 million members.

HCD at Kaiser Permanente

In 2011, after nearly a decade of applying HCD, Kaiser Permanente began introducing it into existing internal PI training; practices for obtaining deep customer understanding, creative brainstorming, and rapid solution prototyping bolstered improvement specialists’ toolkits. In 2015, Kaiser Permanente expanded on traditional HCD by developing an organization-specific CoDesign model — a systematic approach to incorporating end-to-end partnership with patients, families, and all customers throughout PI and innovation work.

CoDesign is a central principle of practicing HCD at Kaiser Permanente. To support integration of CoDesign into organizational practices, Kaiser Permanente has developed a CoDesign recipe rooted in a fusion of methods from HCD (e.g., journey mapping, brainstorming, rapid prototyping, and storyboarding) and PI (e.g., metrics that matter to both the organization and customers, planning tests of change, Plan-Do-Study-Act).

In 2016, CoDesign training became part of the core curriculum for all improvement advisor programs at the internal Improvement Institute at Kaiser Permanente; more than 900 improvement advisors and Lean Six Sigma Certified Black Belts have since been trained. In 2017, the Improvement Institute at Kaiser Permanente launched an advanced capacity-building effort, imparting deeper skills in HCD and CoDesign to 26 internal staff, who have trained more than 200 colleagues and exposed hundreds of others to HCD methods by leading collaborative work. In 2018, even greater demand exists across functions for integrating HCD throughout the organization.

The HCD Human-Centered Design Kaiser Permanente Compass

  Click To Enlarge.

Value of HCD

Using HCD generates deeper engagement in PI efforts among Kaiser Permanente patients and family members, who have expressed positive experiences of being involved in projects using HCD. In a survey of 48 members participating in CoDesign activities through a virtual platform, top reasons for satisfaction included “Opportunities to express my views and opinions” (90%), “Making a difference for other members” (69%), and “Influencing decisions being made” (63%). In one example from 2015, a lead project manager for transplant services convened a team of eight caregivers of transplant patients to develop a support structure for fellow caregivers who help their loved ones through the complicated journey of receiving a bone marrow transplant. The group has continued to stay engaged in ongoing projects.

Using HCD methods in PI work has value for Kaiser Permanente staff. In a recent survey of 26 newly trained HCD practitioners, 100% felt they could get better customer engagement with HCD and that learning HCD tools and methods was helpful in improving work outcomes. Most also felt that they were able to produce solutions that were more innovative (88%) and that using HCD will enable solutions that better meet customer needs (85%).

Staff members using HCD reported feeling that they “rediscovered joy in their work” and “re-engaged with the organizational mission” and that HCD helped them “see the value in the services we provide to patients.”

A team at a Kaiser Permanente Northern California medical center worked on an improvement project to increase the efficiency of transporting patients for nuclear stress testing. PI methods helped the team create a value stream map, identify pain points, and uncover root causes. The team simultaneously used HCD methods to understand the human impacts of the pain points, quickly learning that what was most important to patients and staff went beyond system efficiency: Patients wanted more human connection, and staff desired empowerment to ease patient anxiety.

Patients were very nervous about the test, and nursing and transport staff felt powerless to help calm them and deliver the best care experience. Reducing pre-test patient anxiety thus became as important as transport efficiency. As patients were engaged to codesign new workflows, nursing and transport staff felt both less tension about transport efficiency and a renewed sense of purpose. The approach that was developed reduced transport time by 83% (from 80 to 13.5 minutes), and none of the 10 patients interviewed during the Plan-Do-Study-Act reported feeling anxiety or stress.

HCD provides a framework for more deeply connecting diverse stakeholders in collaborations that generate creative interdisciplinary solutions. It can also help participants see multiple stakeholders as customers whose needs can be met and lead to design solutions that meet a broad range of those needs. For example, a Kaiser Permanente Northwest team is working on supporting family caregivers of patients with dementia. Patients and caregivers are often unclear about what follows an initial diagnosis by a primary care provider, and PCPs often feel inadequately equipped with resources to address next steps.

A group that included family caregivers, PCPs, memory clinic specialists, social workers, and an Alzheimer’s Association representative created a prototype of a pre-configured electronic health record feature to trigger appropriate referrals that PCPs could use to initiate a smooth and timely care path. PCPs who didn’t participate in the CoDesign session tested the prototype, reporting that their confidence about providing appropriate support and resources for caregivers increased more than threefold, from 1.8 to 6.2 on a 10-point scale. The feature met the needs of caregivers, PCPs, and social workers and is currently poised for spread throughout Kaiser Permanente Northwest.

Deeply understanding customer needs also helps improve patient experiences outside care delivery. A Consumer Financial Service Experience team at Kaiser Permanente worked to increase billing transparency for cost-sharing patients receiving imaging services. Using interviewing for empathy, contextual customer observations, and partnering with patients, the team learned about the personal nature of cost communications preferences and how and when patients wanted to be alerted to cost changes and connected to a financial expert. During prototype testing of a new approach for communicating imaging costs, patients said their likelihood to recommend to others the way KP communicates about imaging costs based on their preference increased more than fourfold (from an average score of 1.67 to 7.47 on a scale of 0–10).

What HCD Helps Kaiser Permanente Learn

PI can rigorously dissect systems and processes to identify root causes of defects and breakdowns; HCD focuses on human needs and helps identify which parts of a process matter most to people and how the process fits into their lives.

PI and HCD fit together naturally, following a similar process of assessing/understanding, identifying ways to improve and innovate, and testing and implementing solutions. During the assessment stage of uncovering opportunities, HCD techniques like interviewing for empathy, observations/shadowing, and journey and empathy mapping can provide a deeper perspective on the needs of patients, family members, and staff and a framework for organizing their experiences.

While developing solutions, HCD offers creative brainstorming techniques to explore a range of possibilities, methods for gaining inspiration from other industries addressing similar needs, and setting the stage for interdisciplinary collaboration. HCD approaches to rapid iterative testing can enhance learning from early Plan-Do-Study-Act cycles, increasing the team’s comfort with rough prototypes and exploring a range of solutions before settling on one. HCD can help bridge the gap from developing a new idea to broad use by ensuring that implementation is more people-centered and positions new solutions in a way that speaks to staff and patients.

Methods may vary, but most health care organizations practice some type of PI to which HCD can be joined. While Kaiser Permanente continues to spread this integration of PI and HCD throughout the organization, experience to date suggests beginning with three steps:

  • Invest in building HCD capability across organizational functional areas with a focus on applying methods in service of better outcomes and a stronger organizational culture. Create a core group of HCD experts to coach and mentor others. Develop a common language — a shared organizational vocabulary everyone uses to talk about HCD — and create content and curriculum materials that reinforce both language and practices. Incorporate HCD into experiential training at deepening levels of competency.
    • Budget time upfront for staff to learn and practice HCD in their roles. On an ongoing basis, allocate the time needed to identify and engage with customers, conduct interviews and shadowing, and bring stakeholders into interdisciplinary collaboration. This investment can help avoid long-term pitfalls. In the recent survey of HCD training graduates at Kaiser Permanente who worked on improving care and services, while only 23% felt that their work would go faster with HCD, 65% felt that it would reduce rework and 73% reported that applying HCD helped them avoid working on the wrong problem.
  • Create a discipline of leveraging PI and HCD processes and methods throughout projects to help understand opportunities, create and test solutions that deliver even stronger outcomes, and spread solutions more easily.
  • Select a mix of initial projects that align with top organizational priorities to illuminate the value of applying PI and HCD together and share the case studies to educate and inspire. Leverage leadership support to select priorities and identify appropriate outcomes.


Acknowledgments: We gratefully acknowledge the expertise at integrating HCD and PI and at program assessment of Alice Ducey, Jennifer Cunha, Nicole Tuite, Elaine Carty, Andrew Black, Deborah Jones, Jennifer Burciaga and Jeff Hall and the contribution of many, especially Ben Grossman-Kahn, Sami Packard, Jennifer Cunha, and Melissa Chevalier in shaping the HCD@KP compass. Lisa Schilling and Dennis Deas provided critical input, and Jennifer Green and Jane Roessner provided editing support.

Call for submissions:

Now inviting expert articles, longform articles, and case studies for peer review


A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Care Redesign
Epic OB Hemorrhage PPH Risk Assessment Tool and Alerts at PSJH - Preventing Maternal Death

Improving Maternal Safety Through an EMR Risk Assessment

After a mother died of postpartum hemorrhage, Providence St. Joseph Health made organization-wide changes to prevent future maternal deaths and injuries.

Most Health Care Organizations Have Palliative or End-of-Life Care Programs

Survey Snapshot: Challenging the Resistance to “Palliative”

NEJM Catalyst Insights Council members agree that palliative care is gaining traction, but one of many barriers is getting providers over their resistance to the word “palliative.”

The Assessment of Care Tool - Consisting of Six Visual Analog Scales Corresponding with the IOM Six Dimensions of Perfect Care

Real-Time Pursuit of Outcomes That Matter to Patients

A simple and affordable tool to use at the point of care to drive value creation within clinical microsystems.

Many Patients Who Would Benefit from Palliative - End-of-Life Care Do Not Receive It

Care Redesign Survey: The Power of Palliative Care

Our NEJM Catalyst Insights Council survey on palliative care reveals an interesting dichotomy: While the great majority of organizations have a palliative or end-of-life care program, 60% of patients who would benefit from such services don’t receive them.

Heart Safe Motherhood and Way to Health Two-Way Texting for Blood Pressure Monitoring for Postpartum Women with Preeclampsia

Heart Safe Motherhood: Applying Innovation Methodology for Improved Maternal Outcomes

At the Hospital of the University of Pennsylvania, a text message–based blood pressure surveillance program for postpartum women with preeclampsia improved blood pressure management, reduced readmissions, and increased patient and provider satisfaction.

VHA Whole Health System diagram

Finding the Cause of the Crises: Opioids, Pain, Suicide, Obesity, and Other “Epidemics”

Until we redesign our health care system to address our patients’ personal determinants of health, we will continue to inadequately address our multiple chronic disease crises.

Leff06_pullquote home-based medical care for homebound patients

Using Quality to Shine a Light on Homebound Care

How two thought leaders in the fields of home-based medical care, geriatrics, and palliative medicine advanced a quality-of-care agenda for homebound adults.

Charlotte Yeh head shot - hearing aids hearing loss

“You’re Old Without Hearing Aids”— Addressing the Silent Epidemic of Hearing Loss

Hearing loss isn’t a normal consequence of aging. But it is associated with a higher risk of dementia, depression, and falls. The Chief Medical Officer for AARP Services talks about combating this huge but silent epidemic that impacts all ages.

Dentzer01_pullquote - Stone-Age Policies Stifle Modern Virtual Care Solutions

Stone-Age Policies Stifle Modern Solutions

Health care leaders must advocate for regulatory and reimbursement changes to unlock the potential of innovative technology and care team approaches to Parkinson’s and other suitable conditions.

Idiopathic Pulmonary Fibrosis IPF Multidisciplinary Collaborative Care Model

From Consulting to Caring: Care Redesign in Idiopathic Pulmonary Fibrosis

A multidisciplinary collaborative model to address the palliative care needs of patients with idiopathic pulmonary fibrosis resulted in improved end-of-life care and decreased hospital deaths.


A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »


How a State Advances Whole-Person Health…

Pennsylvania addresses social determinants of health by bringing together managed care and social services organizations…

Quality Management

177 Articles

Improving Maternal Safety Through an EMR…

After a mother died of postpartum hemorrhage, Providence St. Joseph Health made organization-wide changes to…

Design Thinking

18 Articles

Heart Safe Motherhood: Applying Innovation Methodology…

At the Hospital of the University of Pennsylvania, a text message–based blood pressure surveillance program…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now