When we discuss “design,” we often imagine the eccentric artist creating an evening dress, a modern home interior, or even a smartphone of singular beauty and/or utility. But design can, should, and sometimes does go far beyond individual objects, environments, and organizations to create complex systems that achieve large-scale impact.
Design has always been about understanding underlying human needs, and then taking an iterative approach to creating new solutions for those needs by manipulating and adapting what surrounds us. Design, at a systemic scale, creates individual solutions that are more powerful when combined and serve as a platform for ongoing progress.
Here is one classic example from Kaiser Permanente. A new mother, as she recovers from the birth of her child in the hospital, is often anxious about her path to discharge. Simultaneously, the nurses who care for her need an efficient way to communicate the progress of both mother and baby to one another, especially between shift changes. Kaiser has designed a low-tech solution to both issues. In each recovery room is a simple bulletin board, titled “Your Journey Home,” that has a dozen hooks on which cards are hung. The cards describe tasks that need to be completed before mother and child can leave the hospital: for example, immunizations, hearing screening, birth certificate, follow-up appointments, and discharge medications. As each task is addressed, the task card is turned over on its hook. The mother can see clearly what lies ahead. At shift changes, the handoff conversation between nurses happens in front of the board, which allows the mother to participate as well, and creates a common understanding about next steps. The success of this idea has made it the foundation of a program that extends past discharge with an electronic platform that allows follow-up and shared decision-making after the hospital stay.
The dysfunction of our modern health care system isn’t about failure of intention, but rather pursuit of siloed and sometimes conflicting priorities. The needs of clinicians haven’t always aligned with the needs of patients, and both are subject to the demands of payers and regulators, and the financial limitations and business strategy of the provider organization. When each party manipulates and adapts to meet its own needs without regard to the needs of the others, it creates the incoherent mess we call our health care “system.” Medical professionals are trapped in the episode-driven fee-for-service revenue machine that defines value by productivity rather than impact on the patient’s health. Patients are trapped in the 10-minute office visit, the formularies and preauthorizations that second-guess their physicians, and arbitrary limits on visits for physical therapy or psychotherapy that ignore their needs and their rate of progress. Patients bypass their doctor for the drugstore clinic, or just don’t bother until they’re really sick. Both clinicians and patients get lost regularly in the systems that surround them, be it EHRs that prioritize accounting or hospital campuses that haphazardly add spaces to accommodate new services or capabilities.
Fortunately, payment reform at the national level is a catalyst for health care to redesign itself. Providers will be rewarded for their outcomes, given some measure of flexibility in what they do to arrive at those outcomes, and allowed to explore more meaningful venues of care outside the clinic, where people spend most of their lives — at home, at work, and in their communities.
To capitalize on this new paradigm, the Design Institute for Health was founded in 2015 at the University of Texas at Austin, as a collaboration between its Dell Medical School and its College of Fine Arts. Dell is the first new medical school in nearly 50 years at a top-tier U.S. research university, and the Design Institute is led by two senior leaders formerly from IDEO, an international design firm that applies design approaches to solving systemic challenges. The Institute includes the participation of payers as well. By touching every aspect of an operating health system, as well as medical education and training, the Institute creates human-centered solutions in both clinical and community environments in a way that evolves the typical role of design.
Much has been made about the impact of design in domains as diverse as education, the developing world, and, of course, consumer electronics. In those arenas, design has managed to wholly reorient systems in order to create new value.
Design interventions in health care have tended to be piecemeal. They address specific aspects of the ecosystem — more friendly clinic experiences, easier-to-use medical devices, improved medication adherence, more effective care protocols — but don’t achieve the large-scale transformation that design has activated in other industries. The Design Institute for Health aspires to establish ways to achieve such transformation through a new type of collaboration.
For example, the Institute is working with an underserved community in Austin and a real estate developer to plan a new neighborhood where broad health interventions become an embedded and mostly unnoticeable component of daily life. The goal is not to establish the usual acute care clinic staffed by outsiders but to create new resources that address the social determinants of health. The development, called thinkEAST, will use 24 acres of unoccupied space from a former jet fuel storage facility to build 300 units of affordable housing that can accommodate more than a thousand residents. The related projects include:
- Providing Wi-Fi that blankets the neighborhood. Most residents will own a smartphone, but they struggle to afford the cellular data plans that make those phones useful. In addition to solving the basic connectivity problem, the project will offer residents the choice to opt in to a program that gathers a trove of data to reveal the patterns of daily life — when people are active, where they connect socially, how food plays into their interactions. The Institute will feed that data into visualization tools that help the community identify health gaps and decide where to focus energy on developing solutions. Pilots are underway to determine the best methods of collecting the data in ways that residents will find engaging and comfortable while preserving their privacy.
- Establishing a central café that both addresses food access challenges and creates employment opportunities for career development and economic empowerment.
- Offering affordable housing for trainees in health care and other disciplines — an opportunity to live, work, and learn in the communities that they will eventually serve.
All these efforts are designed to build a reinforcing web of health and social services with feedback loops that make health a central focus.
Because the new Dell Medical School doesn’t have a legacy fee-for-service business to perpetuate, it can design its clinical services from scratch with a value-based approach. What does that approach look like?
- Short serial visits with individual physicians are replaced by more in-depth multi-provider conversations through an integrated practice unit. For example, a patient with joint pain might have had to make multiple appointments under the old model, to see a physician, a surgeon, a radiologist, and a physical therapist. Under the new model, services are consolidated into a single appointment, and providers can interact with one another as necessary at the time.
- Fractured roles that prioritized the most rapid throughput (pre-op, intra-op, and recovery nurses) are combined into a single role. One nurse follows the patient through the entire surgery experience, enabling better patient relationships and greater responsibility for eventual outcomes.
- The clinical spaces are designed to create patient (instead of physician) ownership to return some semblance of control to the patient. Family engagement is actively fostered by including family members in the patient and procedure rooms so they can acquire the knowledge and skills to be informal caregivers at home.
- The traditional waiting room has been eliminated, and patients are shown to their room where the unplanned time is used for education and decision-making.
- EHRs shift from billing platforms to true decision-support tools, necessitating development of new software tools.
The governing principle is that patient and provider experiences are designed to produce a shared responsibility for the ultimate outcome, in a model that continuously learns and evolves.
To be fluent in these new models, students of medicine and other health professions need different training. At the Dell Medical School, students transition earlier than usual from classroom learning to clinical rotations in order to clear time in their second and third year, when they are taught design skills. (For example, students will learn how to conduct ethnographic inquiries to learn about the needs, pains, and motivations of clinical and social service providers in the community.) They apply those skills by identifying systemic health challenges in the community, conducting unconventional research, and then developing new solutions. The most compelling efforts are then incorporated into the strategic work of the medical school, turning students into allies of change, instead of just recipients of a traditional curriculum.
Inroads on these community, clinical, and education fronts are meant to create better individual health outcomes, but more fundamentally, to create new platforms for change. The role of design then is to shape these platforms to create a system that can behave differently from its outset and continue to evolve as an uncertain future unfolds.
George Bernard Shaw once wrote, in Maxims for Revolutionists, that “The reasonable man adapts himself to the world: the unreasonable one persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man.” Health care, in its legacy form, is populated by noble, reasonable people trying their best to operate within the confines of an irrational system. To realize true progress, we need to adapt the world to our needs, to manipulate the system that surrounds us for our collective priorities. We need unreasonable revolutionists. Or maybe, just designers.
This article originally appeared in NEJM Catalyst on March 16, 2017.