Slownovation in Healthcare?
Atul Gawande travels back in time through the lens of the history to uncover biases in sociotechnical practices and finds an archetypal problem: Fixation on technology, while ignoring the simple field fix. He compares two medical practice innovations from over 150 years ago, in the recent New Yorker article Slow Ideas. The invention of general anesthesia allowed doctors to spend enough time working on a patient to actually get the job done. Modern surgery was impossible without it. But nearly coinciding with this invention was the discovery of antiseptic (and thereby sterile technique) by Joseph Lister. Using carbolic acid to clean hands and instruments saved patients the horrible death by infection following a reasonably successful surgery in the late 1800′s. Dr. Gawande asks “why did it take so long for antiseptic practice to diffuse into practice?” Its a good question. Read it. Then solve the puzzle for yourself of innovation’s diffusion.
I thank Anne Aretz (on her Tumblr Shouts and Mumbles) for bringing this article to my attention on Twitter. (Even though I follow Atul on Twitter, Twitter has never addressed its ‘value that scrolls off the timeline’ problem built into activity streams. So I never saw his discussion of the article.)
Anne’s added points have real value. She nails the point I make several times in Design for Care:
The problem is not just the complexity of the solution, but the jarring, disruptive introduction. We are infatuated with disruption. But guess what? It is called disruption for a reason?—?it is a conflicting, diametric change from the existing. It can be fabulous, but it is unknown.
Anne links Don Norman’s recent post to Gawande’s Slow Ideas to hammer it shut:
Don Norman on the Paradox of Wearable Technologies. Wearable technologies, namely Google Glass, provide infinite benefits to the wearer that are a step ahead of our heads-down Smartphone-centric behaviors. While the benefits are clear, the adoption and reactions to it are mixed. “We are entering unknown territory, and much of what is being done is simply because it can be done.”
We are doing things just because they can be done. Its short-term, feel-good pseudo-innovation. That’s always been the case in our culture – Hasan Ozebkehan wrote a seminal critique of this mindset in 1967 The Triumph Of Technology – Can Implies Ought. Evgeny Morozov’s recently published To Save Everything, Click Here eviscerates the triumph of “Solutionism,” which has morphed beyond technology and technique to a general mindset directing Silicon Valley style management of “open government,” media production, and civic engagement. I write in Design for Care:
Disruptive innovations that we see in other industries may have less of a role in healthcare, even though the opportunities for new technology are clearly present. Healthcare facilities are not early adopters. New software, devices, and systems take time to learn and socialize, and the investment of professional time and budget in training and ramp-up is quite expensive. The expense of these social costs can outweigh the benefit of adoption. For example, desktop computers took years to infiltrate hospitals, and by the time they were ubiquitous in the clinic, they had become common in homes. Minimal training was necessary because the technology was already pervasive. The use of mobile devices is following the same late adopter cycle, allowing for a more natural (less forced) introduction of new devices into high-performance, high-risk clinical environments.
I’m aware not everyone agrees, and I’d say that’s fine. After nearly ~20 years experience in designing (and seeing into production) dozens of global, corporate, professional and web-based information products and services, I’ve learned how to research innovation risk. That’s my day job. And I try to advise my clients not to build things they or their customers don’t really need or want to buy. (That’s why I don’t design retail.) Different domains have their own cycles of adoption, and their diffusion into enriched work practices. Healthcare is slower than most domains because every decision must account for the increased risk of lives and costs.
But the cultural dimensions of healthcare practice are significant drivers here. Gawande’s article points to the different social practices that quickly accepted anesthetic (increased time to operate) and the trade-offs with antiseptic practice. Some hand-washing was done, and instruments were usually cleaned. But these practices were based on effects, not causes. Physicians still had limited knowledge of actual microbial behavior and infection vectors. There was little training in practice. “Alpha doctor” norms were dominant for decades (and still are!). And so on.
Now consider a truly disruptive technology – not another mobile app, but the Da Vinci robotic surgery system. But how did that disrupt practice actually?
We might reframe the purposes of disruptive innovation in institutional healthcare based on the experience with platforms and devices. The da Vinci system performs operative functions that surgical teams can understand and integrate within well-defined routines. It doesn’t disrupt the function of surgery, but rather the way routine operations are physically performed. Information technologies tend to disrupt clinical work in ways that may reduce efficiency of performance. New systems require training and ramp-up time (away from patients). Additional time must be allocated for electronic entries for the purported benefit of administration, not patients.
As an innovation research consultant working with healthcare services, I’d say one of the most significant trends in the last two years has been the creation of multidisciplinary, cross-service healthcare innovation centers. In a recent interview with Clinical Innovation and Technology magazine, I learned about their recent issue which featured this trend and revealed new developments I had not encountered in my book research (most of which was more than two years ago!)
All Rise with Innovation (by Beth Walsh)
A number of US institutions are establishing innovation centers for organizing clinical and knowledge competencies across the organization for internal enterprise-wide impacts. While some of the rationale for their development is attributed to the changes caused by the Affordable Care Act, some hospitals are getting into innovation because others are finding it valuable.
In another article in the same issue, Lyle Berkowitz supports my thesis in Design for Care by indicating the emerging drivers for innovation are being driven by cost and reimbursement, repeatable value propositions, rather than devices and technologies (which may add value and costs). New care practice models and workflows will be necessary as organizational and financial models change over the next 3-5 years as well. Healthcare practices take more time to validate and scale than, say, IT systems which have less risks to life and insurance with their deployment. I definitely agree that business model innovation will become a necessary and critical design process.
I’m not as optimistic about claims for informal “design thinking” approaches and rapid prototyping by teams that haven’t the experience in design and innovation. Unlike process improvement, what is meant by design thinking isn’t a set of methods to follow to result in better outcomes. Its a mindset shift similar to the gap between science and design. Contrary to the myth of “creativity” and invention, innovation consists of at least 50% research, with many of its methods quite unknown in most clinical settings. Innovation has serious discipline, skills learned in practice, and is not a project management tool for doing today’s work better. I’ve found that many clinical organizations are skeptical of the value of in-house innovation. There are opportunity costs for ineffective projects. There may be credibility issues if the innovation proposals are not measurably significant.
I think each organization’s approach must differ, if it is to be aligned with organizational competencies and the regional patient profiles. While the value proposition of each center is different, the universal theme is moving the larger organization toward the patient-centered paradigm and whole-person care.
One of the case institutions is the University of California Center for Health Quality and Innovation in Los Angeles, which consolidates knowledge and expertise from across the UC research centers. Their director is Terry Leach, a registered nurse (a good sign) who told the magazine:
Among its five medical centers, UCLA had expertise in virtually every field and could support a multidisciplinary innovation center and began to do so in October 2010. The bumps in the road have come in cataloging where that expertise lay and learning how to identify and disseminate best practices.
The center does not aim to reward researchers for autonomous behavior, she says. “The only way we’re going to survive as a system is if we inculcate collaboration into our mission. But there is no science of teamwork or collaboration.”
One of the major questions for all projects is how to work with patients as partners in their healthcare. “That’s a whole new paradigm for academic medical centers,” Leach says. RFPs are geared to rechannel the “vast intellectual capacity at the University of California and help us create a cadre of innovators.” Those that receive funding are expected to mentor others, take advantage of the institution’s leadership training and participate in the center’s annual colloquium to share their work.
These articles show that care practice and business innovation are emerging across the field in the US and beyond. However, the demand will soon outstrip the supply. The need for design, technology support, training, development, and facilitation overwhelms capacity. Clinics are not hiring design and innovation talent to support the desired competency, they are often trying to build the competency organically, which will essentially reify process improvement regimes. Moving clinical staff into innovation roles is similar to moving designers into clinical roles. We need experienced preceptors and “innovation attendings.” (I recommend something like this for engaging designers at the deep sociotechnical level of clinical work). It can be done, but with a huge helping hand from experienced consultation.
The shift to innovation management is a serious challenge for commercial product development firms that design and build technologies for sale in a competitive market. How much more so for institutions who are also in the midst of a patient-centered care shift, a community care shift, and an Obamacare shift? And whose mindsets have not changed substantially in decades?
Zimmerman verdict: A green light for racist vigilantes
Nice Day for a Lynching
The bloodhounds look like sad old judges
In a strange court. They point their noses
At the Negro jerking in the tight noose;
His feet spread crow-like above these
Honorable men who laugh as he chokes.
I don’t know this black man.
I don’t know these white men.
But I know that one of my hands
Is black, and one white. I know that
One part of me is being strangled,
While another part horribly laughs.
Until it changes,
I shall be forever killing; and be killed.
Kenneth Patchen, Selected Poems
Design for Care was written with the help and advice from a book development community (on the Ning platform). Recently converted to a practitioner hub, the Care Design Network offers a full-featured online community for continuing with the journey of design engagement. The previous URL designforcare.com now points to the Rosenfeld Media site for the book.
But wait, don’t buy the book on Amazon! The publisher site offers a better deal, providing the print book plus digital versions for PDF, ePub & Mobi.
The community hosts about 500 people now, from around the world, but primarily North America. The intention is to enable design practitioners, researchers, consultants, and healthcare professionals to find each other’s good work, learn from one other, and post events and opportunities for projects or conference teams.
I will be giving ongoing talks and workshops related to the book, and with the book writing done, I will have more time for innovation and research projects. I’ll post excerpts from the book, relate them to current news and events, and share images for your further enhancement or hacks.
The Evolution of Online Communities
While Ning provides good support features, maintaining engagement is not a simple task. A few years ago, many of us believed the future of online engagement was going toward well-defined project community sites such as this. A purposeful community with shared interested would be more likely to hold deep discussions, exchange ideas and papers, and find like-minded people. What I’ve observed instead is a kind of community exhaustion that occurs after initial spike of participation.
Some of this may be generalized to internet habit, and some specific to the Design for Care participants (who may have moved on after initial contributions). While Facebook and Twitter have perhaps established a hegemony of sociality (systemically reinforced habits), I have noticed that very few professionals I collaborate with are on Facebook at all (like me). Few are on Twitter as well, that font of self-promotion. So I expected more follow-on engagement on caredesignnetwork.com than I’ve seen so far.
I have created, moderated and participated in numerous online communities of practice, preferring the dedicated social network immensely to the general purpose consumer-based personal data tracking networks like FB. It may take a third-party wrapper to glue all these networks together, but in the meantime it seems North Americans are not concerned enough yet by PRISM and advertising trackers to leave Facebook and communicate within smaller networks. But the other
We held the Toronto book launch for Design for Care: Innovating Healthcare Experience at OCAD University July 10, with Rosenfeld Media and Strategic Innovation Lab as cosponsors. I spoke on Design Research for Human-Centred Healthcare, introducing the emerging opportunities for integrating design-led research to improve patient experience and clinical performance. Josina Vink and George Shewchuk shared their work related to contributions in the book’s cases.
Josina is a recent graduate of the SFI program, with healthcare design experience from Mayo Clinic Center for Innovation and her recent employment at CAMH. George, a current SFI graduate student, shares approaches to visual sensemaking to help clarify understanding and methods for community engagement in health issues.
The presentation is on Slideshare, and the full video will be up on sLab’s website as events become archived.