What the name change did represent was a complete rethinking of the way they would pursue their mission to improve the quality of life for children in Dallas: by combining design thinking with strategy to rethink the fundamentals of their business model.
This story starts, as so many of our stories do, with a seemingly straightforward problem that resisted straightforward solutions: the increasing frequency of emergency room visits for primary care needs that could have been treated more cost-effectively and conveniently outside of high-cost emergency rooms. Children’s Health leadership had assumed that the problem was access; however, a network of sixteen ambulatory care centers placed throughout the community had failed to reverse the trend, and unreimbursed costs were escalating quickly.
CEO Chris Durovich reached two critical insights, one about patients and one about financials: (1) despite the high-quality medical care that Children’s Health was providing, health outcomes for the children they served were not improving; and (2) as the funding model shifted from fee-for-service to population health, their business model was not sustainable. Chris believed that a different model was needed. He reached out with an invitation to a colleague he had known for years, Peter Roberts, an expert in population health with broad experience on both the insurer and patient sides of health care, to help Children’s Health look beyond existing solutions.
Peter believed that the options represented by existing paths were inadequate and that Children’s Health would need to invent new possibilities better suited to the community. To be able to effect sustainable change, Peter told Chris he would need three promises: strong support from the board and CEO, direct reporting to Chris, and the freedom to operate without asking permission—or obtaining consensus—at every step along the way. He got them all, joining the Children’s Health executive staff as the president for population health and insurance services in September 2011. His first step was to develop a deeper understanding of the population Children’s Health served and the communities in which the families lived. Peter was committed to placing the children and their families at the center of the design process.
Peter called on the help of Michael Samuelson, a nationally known expert in prevention and wellness. They started a door-to-door listening tour throughout the Dallas community to “meet the neighbors” and get to know the health care providers, social service agencies, school systems, faith-based community, and city government. Peter explained how this led them to design thinking:
We spent time in the pediatric emergency room, talking to staff, to patients and families, and we kept seeing the same kids coming in week after week with asthma problems. Why? We realized that there must be a deeper story that we didn’t understand. That caused us to start down the design thinking path.
With the help of John Kania, an expert in the Collective Impact approach, they formed the Health and Wellness Alliance for Children, a community-based organization of more than seventy-five organizations and agencies serving children. However, the Alliance was missing the active involvement and voice of the families themselves.
Enter a team of partners from the Business Innovation Factory, a nonprofit firm with a mission that complemented Children’s Health’s: to achieve transformational change in social systems, directed by the communities themselves. Founded by Saul Kaplan, a business manager and consultant with diverse experience across industries, BIF was a unique organization, combining traditional strategic know-how with leading-edge innovation methodologies to achieve an unusual mandate: creating a real-world laboratory to explore new business models and systems solutions to wicked problems in the areas of health care, education, and government. Saul believed that, by combining big thinking with small experiments and by helping leaders to incrementally improve their existing model in parallel with building a new one, breakthrough—and sustainable—new business models could be created. BIF’s job, as Saul saw it, was to help leaders change their lens and imagine new possibilities, allowing them to escape the straitjacket of their existing business models. BIF’s approach emphasized competency building because capabilities were, in BIF’s view, the core building blocks that allowed organizations to deliver new outcomes.
Saul brought in a colleague, Eli MacLaren, to lead the Children’s Health/BIF team. With more than a decade of experience in managing social ventures, Eli was a systems thinker and an early mover in social entrepreneurship, with a track record of success. Creating a new business model began, in the BIF process, with understanding the kind of new future that a client wanted to create, so that they could “backcast”—work from the future backward to assess what needs to change today. Exploratory research made that possible by producing insights that first defined the jobs that people wanted or needed done and then fostered the identification of opportunity spaces that defined the boundaries of the search for solutions.
In July 2012, Eli’s team and Children’s Health staff began work on a multiphased deep listening journey at Children’s Health that brought design and strategy together, focusing first on understanding the kind of new future that they wanted to create and then unbundling and realigning their capabilities to get there.
Phase 1: Laying the Foundation
Phase 1 lasted four months and provided the foundational research to inspire new thinking about business model possibilities. During phase 1, the team focused on identifying insights to guide their design work, based on research into the lives of children and their families and the role played by health conditions. They then translated these insights into design principles and used these principles to highlight areas of opportunity to close the gap between the experience that stakeholders were having and the one that they wanted and needed to have.
WHAT IS A BUSINESS MODEL?
“Business model” is a term much used but often little understood, in either the business or the nonprofit worlds. It is much more than a description of a new product or service. A business model not only describes key activities; it lays out the value proposition behind an offering (how it creates value for a defined set of stakeholders) and the capabilities and resources needed by the organization to implement that value proposition. It also considers sustainability from a financial viewpoint. In other words, a business model lays out both how an organization creates value with a particular strategy and how it sustains that value as a result of doing so. Business models, in that view, are just as critical in the social sector as they are in the for-profit world.
To start, Eli spent two days in Dallas, interviewing staff and patients and getting a high-level sense of the situation. Using this information, a design brief was created, focusing on the question of how to inspire healthy communities with citizens at the center. The team knew that they wanted to focus their work on needs, motivations, behaviors, and value systems—the human factors.
Flow of the process in phase 1.
This desire shaped the research agenda, which was multifaceted. The team began by looking at available statistics to determine who was repeatedly using the Children’s Health emergency department for primary needs, despite the inconvenience and disruption for families of doing so. They discovered that locals were brought to the emergency room primarily by preexisting pulmonary conditions like asthma. Metabolic diseases like diabetes were a secondary area. Accordingly, the team’s research program, and the work of the Health and Wellness Alliance, focused on children with chronic pulmonary conditions, largely from south and west Dallas. The team also wanted a variety of patients in the research sample—some with no conditions but struggling to maintain good health; some with chronic conditions and some without. The sample included nonemergency patients who faced similar socioeconomic conditions.
During the recruiting process, the design team identified families by relying on what BIF called “trusted agents,” such as pastors, neighbors, and directors of YMCA branches. These collaborators would prove critical to successfully engaging the community at the outset, and then again in crafting solutions. The init
ial research involved thirty-two semistructured interviews and led to shadowing to get a deeper understanding of patients’ lives and to gauge their “say-do” divide—the difference between their statements and their actions, or what people say versus what they do. The team used journaling, journey mapping, and collage making to increase patients’ awareness of and ability to reflect on their own perceptions and experiences. They observed and interviewed stakeholders in different locations, including ambulatory care centers, grocery stores, playgrounds, and schools. They hosted conversations called “community whiteboards.” The aim throughout the research was to identify the experience gap, the difference between the situation patients were experiencing and what they actually needed and wanted.
Findings: The Five Elements of Wellness
A set of high-level insights emerged:
1. If Children’s Health wanted to improve health, it needed to focus on families, not just on kids.
2. What families wanted was a better life, not better health. If parents needed to feed their kids fast food to get to work on time, they would do so, placing health at a lower priority.
3. Families also wanted to feel in control of their health journey. Yet, in medical care, Peter noted, “we do things to people and for people, not with them.”
4. Families listened to those they knew and trusted—teachers, pastors, YMCA staff, and other families who had been through similar experiences.
As the team dug deeper, they uncovered a set of insights about the key elements of wellness. These five elements critically influenced the health and well-being of children and their families. They included the following:
1. Balanced outlook. The research uncovered two differing outlooks that were fundamentally shaping family behaviors and decisions in Dallas. One was a reactive, short-term, “quick fix” attitude in which families, who were often dealing with poverty and resource constraints, struggled from one crisis to another. This outlook led to activities aimed at escaping reality, like watching TV, and a tendency toward actions based on convenience. Thinking in the short term, these reactive patients focused on treating symptoms rather than addressing the root cause of any problem. Because emergency room visits require less planning than making appointments at ambulatory care centers, emergency room care was the norm for reactive families. A proactive outlook, on the other hand, encouraged families to take a longer-term perspective and to focus more on preventative care.
2. Personal power. Here, again, the team identified two ends of a continuum. Families with a protective mindset limited their children’s exposure to stress and to the people or environments in which threats developed. Though seemingly positive, this protective nurturing had a negative effect on a child’s sense of self-efficacy and encouraged overreliance on parents. Families with an exploratory mindset, on the other hand, trusted their children to manage their own health, which increased children’s sense of personal power and encouraged them to develop accountability for their own decisions.
3. Sense of self. A child’s sense of self develops out of experiences and relationships. A child with a chronic condition like asthma can develop an unstable sense of self, often resulting from a lack of quality time spent with family because of continuous crises and hectic schedules. These children can come to see themselves as having something “wrong” with them and to allow their illness and its limitations to define them, leading to resignation and a vulnerability to negative influences. Children with a stable sense of self, in contrast, develop identities that are not tied to their condition. They are more likely to be motivated to see themselves as “normal” and less likely to let setbacks define their fate.
4. System of support. In this element, the continuum ranges from limited support to strong. Limited support networks can often force parents to leave children alone, which may allow children to behave in ways that impede their health, like eating junk food, or render them more susceptible to peer pressure and the adoption of unhealthy attitudes and behaviors. A strong support network, on the other hand, enhances children’s development by exposing them to a broader network of positive (and sometimes negative) role models and encouraging them to make healthier choices. These families often have a closer relationship with the child’s doctor, as well, treating the physician as a trusted advisor.
5. Connected knowledge. This final element of wellness was related to communication and the extent to which families are able to gather and process information about a child’s health. Families characterized by disconnected information flows are prey to misconceptions and false beliefs and generally don’t share information openly and effectively with caregivers. In families with connected information flows, children, parents, and caregivers reveal information freely and establish trust and consistency.
These five elements of wellness, the team believed, need to be in place to drive families toward healthy behaviors and outcomes.
The five wellness factors.
Translating Findings into Design Principles
From these elements, the team created a set of design principles, or criteria, to guide the development of solutions:
• Personalize the experience. Invite co-creation and give people choices rather than one-size-fits-all solutions.
• Meet families where they are. Pay attention to the reality of families’ lives, and try to bridge the gap between what should, and what can, be done.
• Honor children’s role in their own development. Encourage children to play a role in their own health, allowing them to test their autonomy and to feel accountable for their choices.
• Facilitate an open and transparent dialogue. Improve communication flows and build a common language.
• Build both individual and collective knowledge. Encourage a child’s broader support network to be involved in achieving better health outcomes.
• Foster sustained engagement. Build habits and reinforce healthy behaviors that keep health in the foreground of attention, rather than only during crises or interactions with caregivers.
These design principles, in turn, pointed the team toward the identification of a set of opportunity spaces where team members believed successful solutions that met these criteria could be found.
Identifying Opportunity Spaces
Rather than defining specific solutions, the opportunity spaces identified promising areas in which to look for new concepts. BIF looked for three categories of opportunity: product or service, organizational structure, and systems and partnerships. A broad set of opportunity spaces was critical to the process, as Eli described:
It is a challenge if your opportunity space becomes so narrow that it’s only about a particular product or service. We go through exercises that think about opportunity spaces in three categories. First is product or service. The second is organizational structure—brands, roles, product extensions. The third is in terms of systems and partnerships, things that are external for the organization. One and two are going to get you point solutions. Three is where you’re going to find systemic solutions. You need to have a set of solutions from categories one and two that support the core business. But it’s the solutions that come from that third horizon that are transformational.
As in earlier steps, the intent still was to improve the wellness of children with asthma, in particular, and to identify concepts that channeled families away from the emergency room and into other sources of care. Getting clarity on specifically what a transformation looked like was key, and a preferred method for doing this involved the use of the “from-to” construct. For each opportunity space, the transition from an existing situation to a preferred one was specified.
Each opportunity space posed a different question:
1. How might we facilitate a greater sense of control beyond the emergency department? Because research suggested that many families used the emergency department when they felt a lack of control, the team’s goal was to seek ideas that helped the family move from fear and helplessness to a sense
of power and an ability to plan. The team suggested solutions that, for example, provided access to better information, decentralized care planning, and helped children articulate their feelings and experiences, while providing a safe environment for exploring limits.
2. How might we create more convenient sources of care? Because the emergency department was often a family’s most convenient source of care, the team’s second goal was to move families from decisions made on the basis of ease to co-creation between families and caregivers, which identified flexible options better suited to the reality of the family’s circumstances. The suggested solutions in this area built trusted information sources within the community itself and improved the attractiveness of nonemergency care.
3. How might we make health more tangible for children in order to engage them? Because it is difficult to see the link between their health and the choices they make, children do not always understand or attend to the consequences of their behaviors. The team’s goal was to nudge children and families from limited understanding of the impact of their actions to awareness and accountability. The suggested solutions included making healthy goals more meaningful to children, sharing those ideas widely across any child’s support network, and providing frequent real-time feedback.
4. How might we inspire, guide, and support first-generation change agents? Because families cannot always be relied on to make and encourage good choices, it made sense to try to reach around them to work with the children themselves. The goal here was to move from a place where children feel isolated, uninformed, and unsupported to one where children are able to connect with others facing similar issues and to lead their families in the right direction. The team suggested solutions that would provide mentors and offer children opportunities to share their stories and get positive reinforcement for their achievements.
Design Thinking for the Greater Good Page 25