5. How might we deliver care beyond the child? Because families can play such a critical role in children’s health, the goal here was to move from a place of ignoring their influence and the whole context of a child’s environment to one of acknowledging and treating root causes and building a family network that is a positive influence. The suggested solutions would help caregivers see the whole of a child’s life, situate care within the family unit, and equip children with life skills to make healthier choices as they grow.
At this point, during phase 1, the BIF team had gathered data, identified insights, created a set of design principles, and ultimately identified a set of opportunity spaces, to conclude their foundational research. The opportunity spaces of phase 1 served as the foundation for the design brief for phase 2. Reflecting on the importance of phase 1, and the groundwork it laid for the work to come, Eli noted:
The most important point of the first four months of work is to help the institution and community stakeholders in the Health and Wellness Alliance shift their lens and be willing to look at the problem differently. I think that most organizations can’t currently see the experience gap because they’re looking at it through their own lens. So, in their mind, their system is not being used correctly, and they are focused on how to get people to do that. But maybe the system is no longer relevant or no longer meeting customers’ needs. How do we see that gap? Only when you shift your lens from the existing system to what people actually need. And then use that as the basis for new possibilities.
Phase 2: Business Model Development
Consistent with BIF’s belief that it is important to look for both incremental and transformational change, phase 2 had multiple components. It focused first on identifying improvements to Children’s Health’s existing business model and then on creating a transformational new one. Core to both processes was a focus on identifying the capability gaps—recognizing what the organization could do today versus what it needed to do to give stakeholders the experience they truly wanted and needed.
Phase 2A: Improvements to the Existing Business Model
In this phase, the team focused on MyChildren’s (as it was called at the time), the division that managed the ambulatory care centers at Children’s Health. They began with a set of clear goals in mind, aimed at improving the ability of the existing business model to better meet the needs uncovered in phase 1. First, the team wanted to engage the staff to develop a common understanding of the key organizational capabilities that MyChildren’s already had. The next priority was to identify the gaps between the existing experience that these capabilities were providing for children and their families and the criteria that the phase 1 research had revealed were needed to achieve the five elements of wellness. Finally, based on the identification of these experience gaps, specific methods for improvement could be defined within the opportunity spaces previously highlighted. The creation of a plan for the design of experiments to test the methods concluded phase 2A.
Flow of the process in phase 2A.
The first task in this phase was to help the staff at Children’s Health truly understand and inaugurate a sense of ownership for the learnings in phase 1. The belief was that, by listening to the families tell the story of their own experiences, staff would be encouraged to move from a “place of judgment to a place of possibilities,” as Eli described it. She continued:
Rather than “this is how the system works and how they should be using it,” we want to help staff shift their lens—get them out of their expert hat and into a beginner’s mindset that is willing to look at the problem differently. When you create conditions where people can listen and dialogue, then you set things up for success.
The emotional shift, not the intellectual one, was most important, in Eli’s view.
The next challenge was exploring the medical center’s capabilities as an organization and how to integrate these with capabilities in the community. Children’s Health staff were aware, BIF believed, of the say-do gap, of myths versus reality, but they hadn’t been given permission to actually articulate where the lack of alignment might be and how to address the gaps. This was accomplished through a series of capability-mapping sessions with two different groups at Children’s Health: those operating the ambulatory care centers at MyChildren’s and a second group, the executives in the population health department, who oversaw a broader set of activities, including a health insurance company, care management, information technology, the Health and Wellness Alliance, virtual health, and faith-based and school-based programs. This work served two purposes. Eli explained:
We wanted to understand the capabilities that the institution currently had so that we could use those in order to improve the existing practice, as well as be part of the new business model. We did capability mapping to understand where people were aligned and not aligned—could they articulate their business model and the capabilities they had today?
Another important role this stage played was to invite staff fully into the design process and to prepare them for the changes that would come, as Eli explained:
People feel threatened by work they think is going to disrupt their job. You have to help them to see themselves in the future. One of the great things about capability mapping is that capabilities are made up of people, processes, and technologies. Once you map out what the key capability is, you can engage them in conversation about How might we use this capability differently? That helps them see a home for themselves. And use their stories, their insight, and their expertise so that they hear their voices reflected in the future state. You co-create so that they feel like they helped build this new model. There’s an old adage that change is painful when done to you but powerful when done by you. If you can just tap into that, you’re golden.
Because the team wanted people to surface where they actually were versus where they’d like to be, part of the workshop asked them to identify five or six myths and used the kind of visualization approach we have seen in so many stories in this book. They staged a “graphic jam”: staff were asked to think visually about their organizations, the key things that they needed to be able to do in order to deliver on their core business model, and how these things were organized. Eli asked them to draw individual images and then posted the results for review, using the images to spur reflection on what was going on. Thinking about the resistance she often encountered to drawing, she observed:
At Children’s, they will often groan when I come into an executive team meeting, and say, “Please don’t make us draw, Eli.” And I can’t draw to save my life. But you have to stop trying to use your language to understand. Draw me a picture, because your words are full of meaning that nobody else shares. So it’s about trying to get at people’s mental models and really tease out the differences, to understand how far apart people are.
Examining the differences between how staff from various functional silos viewed their capability set allowed work to be done across the Children’s Health system. The involvement of community stakeholders also highlighted the lack of integration between the medical care systems and the community service agencies.
Ethnography in Phase 2
Meanwhile, Children’s Health staff and the BIF team engaged in more ethnographic fieldwork to identify critical experience gaps—differences between the actual, present patient experience and the experience that families needed to help them take ownership of their personal wellness. The previous phase 1 research had focused broadly on families’ lives; this phase 2 research focused more narrowly on their health care–related experiences. The team interviewed patients and their families before and after medical appointments, observed primary care practices in action, and shadowed patients through both well and sick care.
Emerging from this work was a clear strategic insight highlighting the current model’s false assumptions: “It was apparent that the medical home model in use was designed based on the existence of a set of behaviors and mindsets that the popula
tion it serves rarely possess,” Eli explained. Comparison of the assumptions underlying MyChildren’s existing delivery design with their target stakeholders’ actual positioning along the five elements of wellness illustrated the central dilemma. To work well, MyChildren’s existing model assumed that patients and their families already occupied the “wellness” end of the continuum and had a balanced outlook, exploratory mindset, strong support network, stable sense of self, and connected knowledge. In reality, few families in the Dallas population enjoyed many of these elements. Their realities were more often a reactive outlook, an avoidance mindset, a weak support network, an unstable sense of self, and a disengaged information flow. This disconnect was a key factor contributing to the inappropriate use of emergency services that Children’s Health was experiencing.
BIF also used another tool we have seen before in our stories, jobs-to-be-done analysis, to specify more clearly some of the critical functional, emotional, and spiritual tasks that needed to be accomplished to move families toward the wellness end of the continuum.
Jobs to be done to move families toward wellness.
The BIF team’s research eventually identified twelve specific experience gaps, all relating to one of the five elements of wellness. For each gap, team members described the experience currently delivered by MyChildren’s, compared it with aspirations for meeting the phase 1 wellness goals, and specified the capabilities needed to close the disparity. For instance, the presence of a strong (versus weak) support network was an aspect highlighted by phase 1 research, yet generally only parents were engaged in any child’s medical process. A potential answer could be to develop a new Children’s Health educational or social capability aimed at enlarging a child’s health network. Within the support network concept, existing MyChildren’s practices focused almost exclusively on the child, whereas research made clear that family health was a strong influence on children. Hence, targeting family health became another capability-building opportunity.
A second clear insight accounted for other factors influencing a family’s use of medical care services: the nonmedical determinants of health had a much greater influence over a family’s health and well-being than medical factors had. The Centers for Medicare and Medicaid Services has estimated that clinical care accounts for only 20 percent of the modifiable factors that influence health. Other critical factors include socioeconomic status, transportation, housing, and social or environmental Stressors—essentially, anything in a family’s environment that influences the health of various family members. For example, the nonmedical determinants of health, which were not being addressed by insurance companies or medical care providers, might include asthma triggers in substandard housing environments, which cause a child to have repeated asthma attacks and lead to frequent use of the emergency room.
The Growing Role of the Alliance
At Children’s Health, the realization dawned that addressing this constellation of medical and nonmedical influences on health, which families faced each and every day, was a wicked problem that required a systems approach, collaboration between uncommon partners, and a bundle of interventions that were aligned and integrated. The Health and Wellness Alliance would play a critical role as the integrator, aligning and focusing individual community initiatives focused on children, under a common agenda, to achieve measurable impact in selected areas, such as childhood asthma.
WHAT IS AN UNCOMMON PARTNER?
An important cornerstone of BIF’s philosophy is the value of actively seeking what they call “uncommon partners,” collaborators who live in a different part of the ecosystem that surrounds your challenge. As BIF’s Saul Kaplan described it: “Collaborators are everywhere …New ideas, perspectives, and the big value-creating opportunities are in the gray areas between the unusual suspects. It seems so obvious, yet we spend most of our time in our respective silos.” He advises enabling “random collisions,” because “magic happens in the interstitial space between us.” We see this idea play out in the asthma example, where different communities were all working hard to address the issue, all doing “God’s work,” as Peter described it, but all with limited resources, capabilities, and reach. Architecting a committed and coordinated ecosystem that works together—pooling resources and building on each partner’s differing capabilities, knowledge, and relationships—lets the magic begin.
The changing of the institution’s name from Children’s Medical Center of Dallas to Children’s Health System of Texas was an important symbolic step in publicly recognizing that the role of the medical center in the community needed to change. Peter explained the rationale:
We wanted to help people (staff) understand that the future payment system was going to move away from paying strictly for the actual costs of medical services to paying for health outcomes; they would move from paying for individuals to paying for populations and their health. If we’re going to be responsible for population health and we know that nonmedical issues are even more important than medical ones, we knew that we had to look at ourselves differently, to see our responsibility as much broader than just medical care. That is why we changed our name.
Implementing the New Approach
Now that the team had identified the experience and capability gaps, they went to work with MyChildren’s primary care practitioners to begin to implement the new approach in the existing business. This effort did not go as planned, and they did not achieve the results they had hoped for. As Peter explained:
After a while, we realized that focusing on the physician was just not going to work. In retrospect, it was never going to work. Why it didn’t work was quite logical, but we didn’t see that at the time. First, the doctors were organized to deliver acute care services. That’s what they got paid for delivering. Insurance reimbursed them for individuals. They didn’t see their role from a systems perspective, from a family perspective. It was unrealistic of us to think those organizations would take responsibility for the health and wellness of a family. They had no time and no capacity to integrate their work with the social agencies who could, in fact, be a great help to pediatricians. We realized then that we couldn’t drive the change from the perspective of primary care. We needed a separate integrator function.
The team concluded that if the medical homes could not be the integrator—they were too individual-patient focused and reactive, didn’t see their role in the larger system, and didn’t have the time or the capacity to work at that level—then the team would need to create a separate integrator function. No one stakeholder could take the lead by themselves. Peter noted:
The key learning that I hadn’t realized before was the need for an integrator function. These uncommon partners don’t naturally work together unless there is an integrator. In our new model, the lowest-level integrators are the individual coaches and navigators; at midlevel, we have the Alliance; the highest level is changing policy—working with government and insurers.
Phase 2B: Business Model Generation
Phase 1 provided the foundational research to identify population needs; phase 2A examined My-Children’s existing practice to identify experience gaps and the missing capabilities driving them, which needed to be addressed to accomplish Dallas families’ well-being goals. Cumulatively, these activities highlighted the need for change at a broader systems level and pointed toward the need to design a transformational business model that was wellness (versus sickness) centered, citizen (versus physician) driven, prevention (versus intervention) focused, partnership based, and community supported. The new model, team members believed, needed to be rooted in a decentralized yet integrated system of support for both the health and the well-being of families, as defined and directed by families themselves, leveraging trusted sources within the community.
Critically important, a financially sustainable system of wellness also needed to be created. To accomplish this, the Health and Wellness Alliance and the BIF team focused the next stage of the process on a highly parti
cipatory design approach, aimed at engaging a diverse group of thinkers and consumers from the Alliance to help them explore what a revolutionary model might look like. Together, they would construct a new ecosystem.
Flow of the process in phase 2B.
Eli talked about why this approach was critical:
I’m a big proponent of participatory design—designing with the population and not just for them. There is often this tall wall that institutions try and build between themselves and their users, and they overthink participatory design and make it more difficult than it needs to be. They wonder about concerns like who are the right people to engage and will they show up? That’s used as the point of resistance for not doing it. But just go out and talk to somebody. I once read this tweet that said it doesn’t take ten thousand hours to perfect the art of talking to a customer—just start a conversation with the person next to you.
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