Design Thinking for the Greater Good

by Jeanne Liedtka

  DESIGN THINKING’S CONTRIBUTION

  Having worked with thousands of people new to design, at every level, in all kinds of organizations, we believe inspiring creative confidence is one of design thinking’s greatest gifts. In every organization, employees are waiting for the invitation to use their knowledge to generate better value for those they serve. Using design thinking’s structured processes to empower frontline staff—to give employees permission to act and the tools to act wisely at the local level—is the mission of the Ignite Accelerator program at the US Department of Health and Human Services (HHS). Ignite offers decision makers training in design thinking and Lean tools, along with mentoring, financial support, and visibility, to build the creative confidence of all employees in the agency and enable them to tackle opportunities for innovation that upper management simply cannot see.

  Despite widespread skepticism about the ability of the US government—arguably one of the world’s most intimidating bureaucracies—to innovate, exciting work is under way in Washington, DC, that is making a difference in citizens’ lives. At the US Department of Health and Human Services, one of the largest agencies of the US government, the Ignite Accelerator, a program of HHS’s Innovation, Design, Entrepreneurship, and Action (IDEA) Lab, is bringing design thinking and Lean Startup methodologies to employees across the United States.

  HHS’s Ignite Accelerator offers education and encouragement, with a small funding stipend, to boost projects that offer the hope of addressing agency problems, both large and small, with innovative approaches. The three-month Ignite Accelerator program helps HHS staff improve the way their offices carry out the agency’s mission by supporting and testing creative ideas in meaningful ways. Many of these projects aren’t the big, messy, wicked problems we are so often told that design is about. In fact, we love the smallness and nonwickedness of what Ignite encourages employees to tackle.

  Read Holman, program director of Ignite, described the rationale behind the HHS Ignite approach:

  Policies, rules, and cultural norms—once tools to standardize processes and drive efficiencies within the organization—eventually become forces that resist new ideas, that innately de-emphasize organizational innovations. It’s not necessarily that anyone out there is proactively blocking progress. Rather, it’s just that new ideas are disruptive to the social fabric and thus can be uncomfortable. Thus, experimenting with new concepts doesn’t become a priority. And the implementation of change gets back-burnered…We provide concentrated opportunity for experimentation. We provide a safe space where new ideas, cultivated by people, can grow. We take project ideas at all stages of development, from the nascent to the tested, and help them demonstrate value and get woven back into the organization so as to generate real impact.

  DO ALL PROBLEMS NEED TO BE WICKED?

  Mention the term design thinking and the idea of “wicked” problems—those famously messy multistakeholder challenges for which design thinking is famous—almost immediately shows up. But design thinking works for other kinds of problems as well. When we democratize design, we invite people to use it on problems that fall within their own jurisdiction, that lie in what Stephen Covey called each person’s circles of influence and control. Sometimes these problems are seemingly small and their solutions don’t seem to be all that novel; we see this work dismissed as not “disruptive” enough to constitute real innovation. But these problems matter a lot to the people who have them, and solving them creates real value. That is innovation enough, in our view. As Matt Collier, from the Lab@OPM story in chapter 1, told us:

  We sometimes get stuck thinking that innovation means big change that is revolutionary. We can do that from time to time, but let’s not let the search for game-changers get in the way of the incremental innovations that we can do today in the course of our daily work. In the government space, particularly, small changes to policy or process, when played out at scale, can have an outsize impact on everything from agency budgets to citizen experiences.

  Inspiring projects have already developed out of HHS’s Ignite Accelerator. One that especially intrigued us came to the IDEA Lab from a Native American reservation in Arizona, where HHS employee Marliza Rivera stepped up to the plate to make her hospital a more welcoming place for Native American elders. Marliza is in charge of performance improvement at Whiteriver Indian Hospital. Her story demonstrates the power of a program like Ignite, showing what a simple invitation reaching out to would-be innovators at all organizational levels and locations can spark.

  The Whiteriver Hospital Story

  In late 2013, Whiteriver Hospital on the Fort Apache Indian Reservation faced a serious situation: close to 25 percent of emergency department visitors were leaving without being seen, a problem attributed to long wait times. The patients leaving were rarely in crisis, but treatable minor and semiurgent complaints were turning into major, expensive issues because of the lack of medical attention. Fort Apache covers 1.6 million acres and has a population of seventeen thousand, mostly Native Americans. Whiteriver Hospital has forty inpatient beds, serving a significantly higher population per bed than the national average. Last renovated in 2006, Whiteriver’s emergency department is the reservation’s prime stop for health care, regardless of acuity level.

  Like patients in many sparsely populated areas, members of the White Mountain Apache tribe used the Whiteriver emergency room for most treatment needs, including prescription refills. On any given day, two-thirds of the emergency room visitors were not seeking crisis treatment. Nonemergency patients consistently got delayed as staff addressed true emergencies, sometimes waiting as long as six hours before being seen. Whiteriver’s history was clear: when potential patients left the emergency room (which they did at a rate twenty times the national average), midlevel problems worsened. Often, when their problems finally became true emergencies, patients needed to be helicoptered off the reservation for more-expensive care. The Whiteriver story mirrors that of hospitals across America. Experts believe that almost one in three patients who leave without being seen require emergency treatment within two days.

  Marliza, a member of the Kiowa tribe of Oklahoma, was raised in Chicago after her parents were displaced due to the Indian Relocation Act of 1956. She first worked as a director and administrative officer in home health care. Finding it more rewarding to work with tribes, she accepted the job with Whiteriver.

  In 2013, an e-mail landed in Marliza’s inbox, detailing information about HHS’s Ignite Accelerator program. Sensing an opportunity to receive help dealing with the challenges facing Whiteriver, Marliza—who was new to the performance improvement job—pulled together a team of employees and sought ideas about how to utilize Ignite. Together, the team (Marliza plus emergency department supervisor Alysia Cardona, staff development officer Jose Burgos, and public health nurse Justin Tafoya) submitted seven projects. One, an electronic kiosk to improve the emergency room process and reduce wait times, was selected as an Ignite finalist.

  Though the team’s Ignite application focused on the Whiteriver situation, they noted that, if successful, the concept might be applied across the four hundred–plus Indian Health Service and tribal health care facilities in the United States.

  Marliza had come up with the kiosk idea after reading about its success at Johns Hopkins Hospital in Baltimore. There, a patient electronically signs in upon arrival, and the electronic system informs other parts of the hospital—the pharmacy, specific physicians, testing laboratories—of that patient’s potential needs. Saving administrative time, the kiosk also speeds the process of identifying the best medical approach for any particular patient.

  Beginning their Ignite journey with both anticipation and nervousness, and with solid approval from hospital leadership, two Whiteriver team members, Marliza and Alysia, headed to Washington, DC, to attend a three-day Ignite boot camp, in early spring 2014. The Whiteriver team entered Ignite with their solution already formulated: an electronic sign-in kiosk would provide in
formation to hold patients in the emergency department until treatment and would speed the process by providing a quick way to triage needs. But through reevaluation and ethnography, the team—like many Ignite finalists—discovered that their original idea wasn’t optimal for addressing the actual concerns of those involved.

  Though applicants enter the Accelerator contest with a solution in mind, starting with our What if? question rather than What is, Read and his team are aware of the risks of starting with solutions in hand. Often, what teams see as the problem, much less its solution, might not address actual stakeholders’ needs. The Washington, DC, staff of IDEA Lab therefore seeks to find the right mix of openness and delayed action to help innovators avoid false starts.

  The Whiteriver team’s initial “aha” moment about the solution they’d brought struck the first morning. The opening thrust of the boot camp experience encouraged participants to reexamine their definition of the problem by questioning the suppositions on which their solution was based.

  Marliza and Alysia had arrived in Washington confident they were on the right track. They knew the problem of wait times was significant and thought the kiosk idea best addressed it. Marliza recalled:

  We went there thinking we knew what we were going to do and nobody was going to change our mind, that this is what we need! We had all this research on it, and knew these great places doing it, and it’s the best thing ever. One of the first things IDEA Lab taught was “Challenge your assumptions. Challenge them over and over again.” And we learned to not be stuck in one place thinking this is the end-all, be-all answer. If you question everything, you’re going to probably end up in a better place and with something that is more fitted to what you really need. You’ve got to be willing to give up the ego and give up the idea that was set in stone, and work through it. You’ve got to ask the hard questions.

  The Ignite approach raises an interesting alternative to our traditional design thinking path, where we begin by asking What is? and resist moving to solutions too soon. In our model, assumption surfacing occurs later, in the What wows stage, as we move into testing of ideas. The Ignite process, however, begins with solutions, making it essential to surface assumptions much earlier.

  The important question: How would Whiteriver patients respond to a high-tech solution? Marliza thought of her eighty-seven-year-old grandmother’s likely reaction to the electronic display. She realized that many of the tribal elders, Whiteriver emergency room’s main visitors, would not be comfortable with new technology. Some did not speak or read English. An electronic system, no matter how efficient in Baltimore, might create more, not fewer, delays at Whiteriver, they recognized. The Whiteriver team, in their initial research, had clearly heard patients’ frustrations and established the wait-time problem. But their assumed solution—technology—had not come with stakeholders’ input.

  Hence, after phone calls back to Fort Apache to speak with elderly patients, the team made their first course correction in their innovation journey. The kiosk concept was replaced with a paper form that aimed to discover the acuity of patients’ medical issues as soon as they entered the emergency department. Saving time and money at the front end, the simple form literally asked patients whether they needed emergency or nonemergency care, such as a visit with a nurse or a prescription refill. Since anyone in the emergency room could help non-English-speaking patients check boxes on a one-page form, Marliza and Alysia thought that any patient, without being seen by a clinician, could then be routed to the appropriate care.

  Returning to Arizona, the team prepared to move into What works, taking the new paper-based concept into testing in the actual hospital. Then the next shoe dropped. IDEA Lab staff connected them with the Centers for Medicare and Medicaid Services, and the team discovered that the Emergency Medical Treatment and Labor Act of 1986 made the use of any pre-examination form illegal. In an effort to prevent emergency rooms from turning away those without insurance, this “no dumping” law stipulates that everyone who comes into an emergency department must be assessed by a medical clinician.

  “We were not trying to violate the law—we were trying to help!” Marliza explained. “But HHS legal advisors said, ‘No. As long as that door says Emergency and they walked in and they’ve registered, you can’t send them anywhere else until they’ve been evaluated.’”

  THE POWER OF ASSUMPTION TESTING

  Every idea that fails can be traced back to some assumption we made about the world that proved not to be true. It could be that we assumed our users wanted the new offering and then they didn’t, or that our organization could successfully make it happen and then we couldn’t. Paying careful attention to what we are assuming is true and then challenging that, as Marliza and Alysia did with their kiosk, and looking for ways to test it, is the surest way to reduce the risk of any new idea. We believe that the most efficient and effective place to begin this surfacing and challenging of our assumptions is in how we define the problem in the first place, long before we reach the solutions stage.

  Abandoning the paper form, the team circled back to What is, visiting other hospitals and gathering more face-to-face data from patients. Guided by the data, the Whiteriver team moved to their next iteration: a fast-track system that placed medically qualified personnel at the emergency room entrance to quickly—within fifteen minutes—assess each patient’s condition and direct appropriate visitors to nonemergency services. Looking for existing data to evaluate their latest solution, Whiteriver turned to other Arizona hospitals that used fast-tracking in their emergency departments, such as Yavapai Regional Medical Center, Mercy Gilbert Medical Center, Summit Healthcare, and Mountain Vista Medical Center. They discovered that less than 2 percent of patients in these facilities left without being seen. Though all these hospitals were significantly larger than Whiteriver and handled proportionately fewer emergency room patients, their fast-track approaches were similar to the team’s idea—and seemingly effective.

  The Whiteriver team then designed and ran a four-day learning launch, arranging for an experienced physician to greet each emergency room arrival. The results were impressive. The percentage of arrivals abandoning Whiteriver’s emergency room without treatment was reduced from 17.75 percent on the control days to 1.25 percent during the experiment. When Marliza and Alysia did a rough calculation of the effects such a reduction would have on hospital finances, they came up with $6 million savings against a cost of $150,000 to do the work required to redesign the emergency department and separate patients with basic medical concerns from those actually needing emergency services.

  Starting with the existing performance indicators (in this case, wait times, costs, and lost revenues), the Whiteriver team estimated how these would change with the implementation of the suggested innovation. The team knew that the Indian Health Service was losing money when potential patients left without being seen, but they had to quantify the effect to demonstrate the value of their ideas to administrators. They did their own basic, conservative math. The team’s cost analysis included factors that few urban or suburban hospitals will ever consider. Because Whiteriver is so far from major medical centers, most seriously ill patients are flown to Tucson. But since so many emergency room visitors with minor problems leave and then return when they are seriously ill, catching patients in the middle zone, when they can be admitted to Whiteriver, leads to higher bed-use efficiency and more income from the federal government.

  LEARNING LAUNCH

  A learning launch is a small, inexpensive experiment that tests an idea in the real world. In a typical scenario, in an Innovation I world, we might devote significant time to planning and justifying a new idea before we try it out. We’d analyze it in detail. In a learning launch, analysis is replaced by experimentation. You move your idea through one or more small, quick tests, as the Whiteriver team does here, using existing resources (a physician who already works there) and a prototype of the new idea (he or she greets all arrivals) but without actually
redesigning the physical space or hiring someone for the new role—things that would involve a significant investment. You just start with a quick and simple mock-up and get it out in front of a small group of real users quickly.

  Beginning with the unrecovered revenue from the 20 percent of potential patients who left without being seen, the team used the hospital’s average daily income of $384 per patient to calculate slightly over $3 million in uncaptured revenue. In addition, basing their calculations on the average patient, they estimated that the eight thousand patients who left would also have needed some $2 million in pharmaceuticals. Finally, the mean cost to transfer patients from Whiteriver to bigger hospitals was $1,700 per patient. Although one thousand patients were flown elsewhere in an average year, the team decided to use a conservative estimate that roughly one-third would still require transfer, which put that cost savings just over $1 million. To simplify the calculation, the team did not include lost lab and testing fees or the cost of having to admit patients to intensive care, deciding that those figures were too tenuous.

  When the team presented the figures, Whiteriver Hospital leadership found the fast-track idea compelling. Administrators budgeted $150,000 for emergency room renovation in the next budget cycle. The new design moves the reception staff from behind a glass window to a desk in the middle of the waiting area, where the triage expert (probably an EMT or a medical technician) will quickly analyze each case and send patients either to true emergency services for further triage or to one of two fasttrack rooms for quick response to nonthreatening issues, such as providing prescription refills and setting appointments for specialist visits. Signage will be improved, and two new assessment rooms are being added. In the meantime, a second clinician has been added to allow fast-tracking to continue during peak times, even before the renovation is complete.