Given this deep understanding, the mental health team asked themselves what the purpose of any new system design should be. For an answer, they reached back to their roots in psychology and were inspired by the work of Erik Erikson, who, building on Freud, argued that a good and wholesome life is being able to live, love, and work. “People are presenting to us because there’s been some fundamental fracture in some of these core elements of being able to live, love, and work,” Melissa explained. She continued:
That, then, should be our purpose, taking it back to that basic level. When people engage with us, what we’re trying do is help them get back on trajectory where they can start a recovery journey. Of course, we know that somebody’s not going to get over having schizophrenia, but we are trying to get to the heart of the person’s life and, within the context of what they’ve got to work with, optimize the outcomes that they can actually have, help them find purpose and meaning in their lives. That’s why we needed to go back to the basics of what we need as human beings to live a fulfilling life.
JOURNEY MAPPING
Journey mapping is one of the simplest yet most powerful tools in design thinking’s arsenal. It captures stakeholders’ journeys as they experience them, paying particular attention to the emotional highs and lows as each stakeholder seeks to accomplish the job to be done. It is usually summarized in a flowchart or other graphic format. Journey mapping can be used throughout the design thinking process and is especially useful during What is to capture the current journey.
Armed with this sense of purpose, the team captured a set of insights from their exploratory work:
• All roads lead to the emergency room if patients want to see a physician urgently. If the team wanted to impact outcomes, members would need to design a system that incorporated what happened at what was usually the first face-to-face contact, in the emergency room.
• Many adults present in crisis and receive primarily crisis treatment. Examining the nature of the care encounter in the emergency room revealed an important gap: at the front end, emergency medical services—often drugs—were available, but longer-term therapeutic services were not. Melissa explained:
Say a patient intended to kill himself and took an overdose. He or she would go into the emergency department and be treated for that particular incident rather than the underlying mental health condition that had predisposed him to vulnerability in the context of a life stressor. The patient would react by, say, taking paracetamol and would come into the emergency department. She would be treated and then discharged. So people were coming back frequently. They had gotten over their biological incident, but the underlying mental health disorder that was creating the vulnerability in the first place wasn’t being treated. They were often just discharged to their general practitioner for follow-up.
• The team realized that Monash needed to focus on what patients needed now and how clinicians could help, versus spending time discovering and analyzing the patient’s history. Clinicians were traditionally trained to use a structured assessment process. What the patient mapping revealed was that patients who presented frequently were being assessed repeatedly. Rather than conversing with patients about their current issues, clinicians were asking them the same set of standard questions over and over again.
• The paperwork burden had become a serious inhibitor to delivering patient care. “We are just inundated, as I think everywhere around the world is, with paperwork, particularly related to regulatory needs,” Melissa said. “As each new change comes out, we develop a new form. Rather than looking at the system as a whole, we just respond to the immediate pressure.” Here, again, the unintended result was a disruption to the clinician’s ability to focus on the patient. “How can you relate to another person,” Melissa asked, “if you’re head down, filling in all of these forms during that patient’s session?”
Redesigning the Mental Health Experience at Monash
Armed with the insights they uncovered during their attention to the What is? question, the mental health team was ready to ask What if? They prototyped a new clinical process aimed at creating a therapeutic working alliance that asked patients about their needs and monitored, on a continuous basis, whether patients believed their needs were being met. The focus of the new clinic, which they named “Agile” in a nod to its embracing of the principles of Agile development, would be on improving longer-term outcomes instead of only triaging for suicide risk reduction and symptom management.
To accomplish this aim, Monash moved specialist treatment to the front end of the processes and set a goal of offering every patient a follow-up appointment within seventy-two hours of an emergency room visit or phone call to PTS. The intention was to keep patients safe in the short term by providing crisis services, but then to quickly move into treatment to reduce patients’ fears while helping them gain confidence and remain safe in the long term.
The new approach would assign a patient to one clinician, who would “hold” the patient as their primary contact. Patients would be asked to use a session-rating scale for each session, to provide feedback about how the clinician did, what the experience was like, whether it met their needs, and what they wanted to address next.
AGILE DEVELOPMENT
Agile, a methodology for developing software, has a lot in common with design thinking. An alternative to a traditional software design approach that emphasizes sequential planning followed by testing, Agile works in fast iterative feedback cycles and emphasizes cross-functional collaboration. We will talk more about how Agile and design thinking methodologies can work together, in chapter 10, which relates the story of the Transportation Security Administration.
The paperwork process would also be streamlined. To figure this out, the team gathered all forms required in the existing process and imagined an actual patient answering the myriad, often duplicate and triplicate questions. They determined which questions were essential to preserving the patient–doctor bond or therapeutic alliance and which had to be retained for governmental and Monash health protocol and regulatory reasons. They tried to eliminate the rest.
Learning through the Learning Launches
The team selected one clinic site to conduct their initial learning launch and then iterated week by week. After staff worked out the initial recipe for success, Monash expanded to two other Agile clinic sites. Throughout the process, Melissa was mindful of the need to stay open to new changes:
I wanted us to remember that we’re always learning. There’s no such thing as putting in a change and then we’re done. What we’ve found is that we’ve had to make modifications as we went, and we really used the prototype for twelve months as an intense learning experience.
One key issue was getting staff who had not been on the design team to change from crisis control to longer-term thinking. Integrating the hospital’s new referral concept required both an emotional and a practical investment. “I use the analogy of paramedics knowing how to keep people in their ambulance alive, and they do that very well and they’re entirely focused on that,” Melissa explained. “If you were to ask paramedics what treatment any patient was going to get in the emergency room, they’re not even thinking that way.” The Agile clinic concept required them to think more broadly:
We didn’t understand that, right from the start, we were asking emergency department caregivers to do a different sort of assessment, not just get patients through their crisis situation. Thinking about referring to Agile meant that staff had to do their work assessments differently.
At first, few referrals to the clinic came in, and the seventy-two-hour appointment slots weren’t fully utilized. Only when Agile clinic personnel were literally in the emergency room or on the phone with emergency department staff did staff refer mental health patients for therapeutic sessions. When Agile staff weren’t present, the emergency room returned to its old crisis mode and any spike in referrals disappeared. Melissa and her team had, of course, consistently advertised the Ag
ile service to emergency room personnel and explained the new process and referral pathways in staff meetings, but those interventions couldn’t overcome the status quo of old practice. “We needed to do something fundamentally different,” Melissa explained. The team decided to try to influence other parts of the systems to accelerate the change.
Their first experiment aimed at increasing referrals. The Agile team decided to open up the referral process to any mental health clinician and to general practitioners in the community. Ten sessions of therapy were offered for people with depression or anxiety. On a Friday afternoon, the team sent out an e-mail to general practitioners and mental health staff with the offer. By Monday morning, every potential appointment was booked, many by the original clinicians who had previously not been referring. The tipping point leading the original clinicians to act was apparently the possibility of losing an option that they’d previously been ignoring.
Moving Forward
Within a year, the Agile clinic demonstrated major improvements. Its key measure of success, increasing the time between presentations, was achieved: the interval between patients seeking mental health care grew longer after the Agile clinic model was introduced. A pre- and post-intervention comparison quantified that Monash patients’ overall re-presentation rate decreased by 60 percent. Meanwhile, key indicators of patients’ mental health all improved, as did patients’ satisfaction with the quality of their experiences.
DON’T FORGET THE ON-RAMP!
As innovators, it is tempting to think of our job as being over once we have answered the four questions and created and tested what we know to be a valuable new product or service. But, as the Agile clinic staff discovered, the task is not complete until you have figured out a way to get other key stakeholders to adopt your new idea. This involves designing an “on-ramp” that helps them gain awareness about your innovation, try it out, and incorporate it into their practice. Attending creatively to the on-ramp is critical, lest your great new idea languish because of a lack of awareness. Designing the on-ramp often requires a whole new design project—the four questions must be answered all over again, just as carefully as you answered them when you created the solution itself.
Outcomes of the Agile clinic.
Melissa observed:
Patients are still coming back, but after longer intervals. Equally important, caregivers are enthusiastic about the new system as well. Staff love it. Clinicians felt that the prior system was blocking what we really wanted to do, and we now feel that we can actually do it and are rejuvenated.
Monash, she reported, is “tapping into new staff energies.”
Most difficult, the team said, was moving up the on-ramp from learning launch mode to transitioning to “business as usual.” Monash has opened two additional Agile Psychological Medicine Clinics and two other, related clinics, Agile Complex Mood and Agile Recovery from Trauma. In scaling and integrating the new approach, the prototype team has been instrumental. But the proof mentality still lives on. “We think we’ve proven our idea and so people should just get on with it!” Christine explained. “But they haven’t.” Melissa elaborated:
We’ve proven it in our world but not theirs, which is just an indication that we haven’t proven it at all. We can say that our clinical outcomes and patient satisfaction have improved and that we’re co-designing and iterating with consumers. And the psychologists and clinicians that we’ve had working on the Agile clinic have really embraced it, as it is so energizing and so wonderful to be part of. They’re getting consumed by that experience and so they think, “Well, why can’t other people see it?”
As Agile staff worked to manage the change process, Melissa reflected on how people influenced systems development and how systems, in turn, influenced the behavior of people:
Why is there such a lag time between discovery and practice, a disconnect between the know-what and the know-how in health care? I’m really interested in looking at the human phenomena when we think of design and change because, bottom line, that’s where it’s at. You know, our intellectualization of the process is only one component. I think it often works to our detriment in health care: we have intellectualized and abstracted phenomena so much, we’ve lost the relationship to what actually happens.
Initiative: Long Patient Stays
In August 2014, Monash began to tackle the challenge of extended-stay patients. Long-stay patients represented only 2 percent of patients but used 25 percent of hospital bed days, so minimizing long stays had significant value. And since few people want to spend extended time in a hospital, it had obvious value for patients as well—each additional day’s stay tended to have less medical efficacy and to produce more stress for the patient.
Monash’s design team began by drafting a short design brief to lay out their objectives. The twelve members of the long-stay team then immersed themselves in the What is stage, both in analysis of the avalanche of existing quantitative data and in the experience of long-stay patients, conducting extensive interviews and using patients’ real-life description of their needs to deepen their understanding of the problem. They created journey maps that captured patient experiences. They also spoke to frontline medical staff to understand obstacles to delivering care. Emerging from these conversations was a strong sense of what the new system needed to accomplish, which the team elected to formalize in a single statement: “The MMC Long-Stay management system ensures that patients who are at high risk of an extended stay in the hospital receive appropriate, high-quality, safe, and waste-free care in partnership with the patient and caregivers.”
One key insight that emerged from Monash research was that each case was unlike any other; patterns were difficult to find. Another was that the patients enjoyed simply being asked how they were. That simple human connection helped their emotional and, therefore, physical state.
To engage staff in generating new possibilities during the What if stage, Don and Keith broke the design thinking process into short, intense ideation “sprints” to accommodate team members’ rotating block schedules. Out of these came a comprehensive set of solutions. Chief among them was the opportunity presented by better tracking and monitoring of patients with elevated long-stay potential, in a way that was easy and intuitive for busy clinicians. This need led to an idea that resonated with all: an iPad app to allow frontline team members to quickly and easily enter long-stay risk factors, like infection. Besides predicting long-stay risk, this information would support doctor/patient decision making and allow staff to track issues as they arose. It would also enable staff members to request assistance with patients who were “stuck” because of hospital processes and systems.
The app prototype also included such information as “courtesy card” surveys, which asked patients what was bothering them (care related or not) and had a quick, color-coded scheme so that each caregiver could quickly compare the patient’s situation against a set of risk factors for becoming “stranded” in a long stay. Finally, the aggregate information from the app promised to cut down meeting time among operations managers, who would be able to swiftly review all the needed information about patients at risk of long stays.
As part of determining What wows, the team worked to create a vivid picture of what the future under the new approach might look like, prototyping a detailed journey map that traced the new and improved experience of patient “Larry Longstay.”
A journey map showing the experience of a patient at risk of a long stay.
In the What works stage, team members iterated through multiple learning launches with the concept. Keith and team member Damien Burns first worked with a carefully selected single group composed of early adopters. Initial results were encouraging, and Damien suggested bringing a second team into the testing process. Keith, on the other hand, was a believer in going slow: “It is too fundamentally important to go about it except in a learning manner. We want to make sure we give it the best possible chance to work.”
Adding
the ability to message other departments for things the nurses could not handle themselves was next on the agenda. Keith and Damien wanted to introduce site management messaging before extending the launch, because it showed the staff how they benefited. They expected iterations to go on for years.
The findings of these learning launches led to an increasing focus on the app’s usefulness to frontline staff in identifying patients who were at risk of long stays, and then working to prevent additional days in the hospital. Multiple learning launches produced an unexpected benefit: they created a conversation space around the importance of the project and facilitated the development of trust between frontline teams and executives.
Don talked about why he saw this as critical:
I am more and more convinced that the value of prototypes and learning launches is that they make concepts tangible and create a conversation space for engagement. Language is about the creation of shared meaning. This is achieved through conversations that establish trust and that lead to commitment. Systems matter more than software. Design tools work on the conversation and embody the nature of the commitments that bind us. The ethical transformation of people and their commitment to work with each other that underpins design thinking is based on people listening before they act, not a set of inflexible requirements. In essence, complexity demands loosely coupled systems rather than evidence of compliance. To enable and support this, a conversation space based on trust must be opened up.
Design Thinking for the Greater Good Page 11