Business model generation began with four different sessions aimed at mapping community resources and developing a deeper understanding of what Eli called “the mechanics that define trust and connectedness within communities.” The team met with thirty-plus families across west and south Dallas, in diverse community settings, to identify the key institutions, resources, and people who might offer valuable local knowledge for designing the new business model.
Next, having been identified by the families themselves, these trusted sources were invited to a participatory design studio focused on a single question: How might we design a new system, one that connects convenient clinical care with self-managed well-being?
The session that addressed this question brought together hospital administrators, physicians, nurses, social workers, and staff from Dallas school districts, the Dallas Housing Authority, the YMCA, and various faith-based organizations. The BIF team shared their phase 1 learnings with the group, identified opportunity spaces, and provided a sense of the big questions facing the design task. Next, the individual attendees, working independently, identified the capabilities that each of their invited institutions might contribute toward addressing the health and life problems. They captured their ideas on sticky notes. Each attendee was then invited into a group conversation at one of five tables, where they shared their individual ideas with each other and clustered the ideas around common themes.
On the basis of their combined ideas, each table was asked to imagine a new end-to-end well-being experience, from the point at which children and their families entered the experience to the point at which they exited, with specific phases identified: awareness, entry, engagement, and extension. Each of the five tables had diverse participants working together—yet they all designed much the same model. Children’s Health staff, with support from BIF, then built out a one-page value proposition that captured the new model they had created together, which they all committed to adopt.
The Children’s Health value proposition.
To capture how these system-level flows impacted the experience of individual children and their families, BIF visualized their experience journey. They elaborated on each of the four phases (awareness, entry, engagement, and extension) and included multiple steps, as well as the people and technology involved in that step. Both the functional and the emotional goals, or jobs to be done, were emphasized. As an individual came into the system to be matched with a wellness promoter through various community and clinical touch points, the wellness promoter scheduled meetings, assessed needs, set goals, and created wellness plans, together with the individual or family, and then finally reached out to a broader support network to motivate action and access resources. Finally, BIF brought experience to life by chronicling the story of particular patients and their families under different scenarios: wellness, sickness care, and chronic care management. A fourth scenario told the story of a first-generation change maker.
The Children’s Health journey map.
Designing a Learning Launch
Children’s Health and the Health and Wellness Alliance elected to move their ideas forward by conducting an experiment in a specific segment. They decided to begin with asthma, one of the most prevalent and utilization-intensive childhood diseases. Their aim was to define a common agenda and goals. Until then, few in the Alliance knew each other. Peter described their coming together:
We had no clue how we related to each other. So we put together the asthma equation, a visual model for asthma and the factors that were affecting these families and kids. When we put this together, people were stunned. We were all working on the same thing, but from different parts of the elephant. But none of us had ever looked at the whole elephant.
The early indicators from the asthma work provide strong support that Children’s Health and their Alliance partners are moving in the right direction. By progressively linking families with clinical, social, community, public health, philanthropic, educational, environmental, and government programs, the statistic that started the whole project—emergency room visits—was halved for asthma over the four-year period. Outcomes went beyond utilization of medical care. While doing home visits, for instance, the Alliance realized that many houses had asthma triggers that needed to be cleaned up, sometimes by landlords, and though the Alliance had no formal authority, it was able to work with city health inspectors to change inspection codes. “But there is no silver bullet,” Peter observed, “no simple solutions. We need multiple solutions that involve multiple stakeholders.”
A critical piece of the puzzle was how to sustainably fund the new business model. Though payment models were shifting, fee-for-service remained the dominant mechanism. How could they fund a system that required payment for services that no longer needed to be delivered? Children’s Health stood ready to make more investments, but it could not fund the entire system. Government-funded social agencies lacked the flexibility to shift priorities and reallocate funds in the short term. Community agencies lived on limited funding, year to year, in the form of grants and gifts. Relying on annual grants and philanthropy provided unreliable funding. Building a workable, sustainable economic model would require the same kind of creative thinking that developed the new business model in the first place.
Fortunately, as we have seen in other stories, individual repertoire helped the team to see new opportunities. Remember Dr. Melissa Casey’s secret life as an Australian tax expert prior to heading the psychiatric clinic at Monash Medical Centre? In a similar way, Peter’s decades of deep involvement in the insurance industry and understanding of funding led him to see what others might have missed: a chance to use the state of Texas’s Medicaid program, which covered children and pregnant women, as a funding mechanism. By combining private and public sources of funding, Children’s Health could use resources from its licensed insurance company (that resulted from enrollees’ utilizing less expensive medical care), coupled with funding from the Texas Medicaid Section 1115 Waiver program, plus philanthropy and grants.
Such funding would give them stability for five years to experiment with the new approach to determine what kinds of outcomes they could produce. Children’s Health’s existing HMO would receive the State funding, and the prototype they were preparing to roll out would enroll twelve thousand to fifteen thousand children in their HMO. Peter explained how this would work:
Texas state Medicaid contracts with private HMOs to act as insurance intermediaries, paying them a fixed premium per month per child to provide care. This intermediary acts almost like a bank: it holds the dollars and controls spending. It can reallocate resources for more preventative care. In this way, insurance companies can be catalysts for change.
Eventually, Peter hypothesized, the new preventative model will generate profits that can be reinvested.
The team also believed that measurement would be critical—first, to establish whether the changes did in fact increase family well-being, and then to examine the link between family well-being and a host of longer-term measures around health outcomes and care utilization. Plans were already in place for systematic evaluation of the prototype, incorporating the four levels of outcomes in the Kirkpatrick evaluation model: experience in the program, confidence in the ability to improve wellness, progress against the family action plan, and improvement in the family well-being quotient—a measure of family wellness that the team developed, based on the five key dimensions of wellness that the BIF research revealed during phase 1.
As they prepared to roll out their prototype, the team prepared a simple overview of the key elements to guide the process.
Reflections on the Process
The Children’s Health story illustrates how design thinking can contribute to two core elements essential to successful strategic change: a deep, fact-based understanding of the current reality (of both stakeholders’ needs and current organizational capabilities) and a new vision for the future (a more promising value proposition and the ne
w capabilities needed to deliver it). Design thinking allowed Children’s Health to ground their discussions of the ideal future in the real world of their patients’ lives, rather than in the world as their clinicians wished it would be, “if only” patients used the system correctly. In doing so, it allowed them to devise a strategy capable of addressing all of their needs.
An overview of the new business model.
New strategies that offer dramatic increases in value creation for stakeholders and are executable within the constraints of today’s reality emerge most readily from such an approach. They do this by creating a strategic conversation that is fundamentally concerned with the two gaps that really matter in creating new business models: (1) the gap between the experience that a customer is having today versus the experience the customer would prefer to have (BIF’s experience gap), and (2) the gap between the outcomes that an organization is currently capable of delivering versus the capabilities needed to close the customer experience gap (BIF’s capability gap).
This entire backcasting process rests on the quality of insights about what is missing for customers today. Here, design thinking’s ethnographic approach in What is provides the tools for a deeper analysis of needs, as when it helped the MyChildren’s team identify the five elements of wellness and translate them into design criteria. Design thinking’s possibility-driven focus in What if allows the translation of these criteria into a set of solutions that are then tested against both stakeholder and organizational needs and constraints during What wows and What works. When the attempts to transform the existing business model of MyChildren’s ambulatory care approach failed, it was evidence of the power of the existing medical illness–centered model to resist change. This key learning freed Peter and his team from their attempts to continue to push (and likely fail) to reform the existing business model and set them instead on a new path to co-create a community-based system focused on wellness. It is design thinking’s tools and process, expertly deployed, that make all of this possible (plus, of course, courageous leadership).
As someone who had been immersed in the world of health care reform for decades, Peter reflected on how the introduction of design thinking changed the hospital’s innovation conversation. His takeaways centered on the experience of deep listening, the time it took, and power of structured conversation across the health care ecosystem:
Really reaching an understanding of the families themselves and the community social agencies that surrounded them—that was very different than anything I’ve ever done before. And I realized that there were levels of listening that I’d never understood. It took a long time to understand and reflect on that. And I had never pursued an ongoing collaboration before with such a range of uncommon partners, one with such a sense of purpose, that was pulled together in that very structured and focused way—a group of people who had all been working hard to improve health for kids, but not working together. Doing “God’s work” but with negligible impact and sustainability. Now we have a common agenda, shared measurements, and new funding opportunities. That is very different than anything I have ever experienced previously in the world of health care.
Eli, too, talked about the power of bringing design thinking and business model innovation together:
People always ask us what the right business model is, the one that will solve their problems. But the thing is that there is no right business model. A business model is a generative act. The whole notion of design thinking is that it gives us the power to work in really messy areas like this. Don’t just shy away from messy kinds of problems—find a way to frame it that feels good and powerful.
Peter concurred:
Health care badly needs new business models. That’s what I have learned on this journey. We have wicked problems. And we have a lot of programs, but what we need is whole new business models. We need to pool experiences and learn from each other. It is going to be an exciting next few years. We are going to make design thinking part of our DNA.
The collaborative strategy envisioned in the evolving Children’s Health model brings with it the complex task of coordinating the network of partners and establishing priorities and capabilities. But it also brings a deeper pool of resources, understanding, and commitment on the part of the partners working together. They have a common (or should we say uncommon?) shared sense of why the existing health care model is neither successful nor sustainable, and they see a shared possibility that their collaboration can move toward a different, truly healthful future.
Yet, at some level, this seemingly complex task of marshaling support and consensus across such a diverse set of partners seems very simple to Peter:
If you’ve sat in different chairs, listened deeply, you start to understand what success looks like. Families want their kids to be able to play sports. Medical center folks want no crises in asthma control, no emergency room visits. Docs want families to follow the medical directives prescribed for their child. Insurers want reduced utilization—and data. The YMCA needs funding. Pastors want people to go to church. Social service agencies want stronger family ties. Each stakeholder needs to be rewarded. So my job is actually pretty easy: I just listen.
PART III
Moving into Action: Bringing Design Thinking to Your Organization
In the ten years that we have been teaching design thinking, we have worked with individuals from many backgrounds— elementary school teachers, MBA students, doctors and nurses, NASA scientists, business managers, accountants, and leaders from the government and nonprofit worlds. Many came with serious doubts about their ability to think creatively and lead innovation in their organizations. They believed that, without support from wonderful design experts like those we have met in our stories—like Kingwood consultant Colum Lowe at BEING, or Eli MacLaren at BIF, or CTAA’s Peer Insight team—they could not introduce and practice design thinking in their organizations. But our experience working with people new to design tells a different story: we all have these abilities within us, waiting for an invitation to show up!
Remember Ken Skodacek at the FDA, Marliza Rivera at Whiteriver Indian Hospital, and Dr. Don Campbell at Monash? None of these inspiring innovation leaders had any formal training in design. What they had was a passion for exploration and learning, and the courage to try.
In part 2, each of the ten organizations we met chose a combination of tools to suit its purpose. Some emphasized exploration tools like journey mapping, personas, or jobs to be done. Others focused on testing tools like assumption surfacing and learning launches. Nearly all used visualization, ethnographic interviewing, and prototyping. They often gave differing attention to the four questions—some emphasized the exploration of stakeholder needs, asking What is? and What if?, while others focused on testing solutions, asking What wows? and What works?
The organizational paths they chose were equally varied. Some established innovation labs, ran workshops, and offered mentoring. Others worked with consultants, universities, or other outside partners. Nearly all offered some kind of training in design thinking—though their specific approaches were as varied as the partners they worked with.
The richness of this variety is both stimulating and intimidating. So many tools and methods, so little time. For the novice, and especially for the Georges among us, raised in an Innovation I world, the array of choices can seem bewildering. Where to even begin? What tools to use and questions to answer?
In answering this, we think back to Carolyn Jeskey’s advice to her CTAA partners: keep it simple. Learning a new approach—especially one as different as design thinking seems—can be intimidating. Success requires support and structure. Fortunately, the support we need can come from the process itself.
In this section, our focus is on helping you to take learnings from the inspiring stories in part 2 and make design thinking work for you. In these final chapters, we will look at one more story of a group of innovators hard at work making their own small slice of the world a bet
ter place. This story, however, differs from the stories in part 2. In this story, we will tag along, step by step, on the journey of a group of dedicated educators, Joan Wells and her team at Gateway College and Career Academy (GCCA), as they work through their challenge, using a comprehensive design thinking method we have developed at Darden.
Our experience teaching people who are new to design tells us that using this kind of detailed end-to-end process to guide learners’ initial design thinking efforts significantly aids in developing mastery. Structure and specificity reassures and motivates those practicing design thinking methods for the first time. It helps them see where they are headed and teaches them how to transition successfully between the exploration, idea generation, and testing phases.
As discussed in part 1, the design thinking method we use focuses on four simple questions: What is?, What if?, What wows?, and What works? In our design thinking tool kit, these questions are accompanied by fifteen specific steps that lead innovators through the process as they seek answers.
Steps in the design thinking tool kit.
Once innovators get comfortable with design thinking’s methods, tools, and mindsets, they mix and match the steps, emphasizing some and skipping others, and pick and choose among the variety of tools offered. As design thinking becomes more natural and intuitive, they adapt our process to fit the needs of their specific projects. But, in the beginning, those learning design thinking benefit from a systematic approach. The four-question, fifteen-step methodology creates an educational environment in which the ambiguity of the innovation space feels (and is) more manageable. The process reassures team members that it is safe to convene new kinds of conversations.
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