Healthcare Design as Extraordinary Service

Peter JonesDesign for Care, Organization, Systemic Design

Lisa Norton, a professor in the School of the Art Institute of Chicago, conducted an interview with me earlier this year for Integral Leadership Review and also published it on her own Design Being.  Titled Healthcare Design as Extraordinary Service, its available both online and as a PDF article. Several paragraphs are included herein to bring this back home to Design Dialogues. She opens with:

Leveraging systems thinking, human-centered design, and information architecture, his Redesign Network serves the emergence of healthcare service systems capable of taking better care of human beings. By developing schemas for more comprehensive understanding of systemic conditions, Peter Jones is defining new intersections and innovation spaces in healthcare and information-intensive services. In the following interview, Dr. Jones shares first-person reflections and insights on patterns in organizational leadership and influence, as well as his hopes and concerns for the future of healthcare systems design.

Lisa writes: “In the developed world, every citizen is impacted on several levels by their proximity to or distance from, care services and health support. Design for Care reframes the objectified “patient” and “user” categories as health seekers. By reframing the patient role as health seeker and differentiating health seeking, (understood as ongoing and continuous throughout life) from information seeking, Design for Care makes space for a diverse range of individuals with multiple intentions. “These are patients receiving care for complex co-occurring illnesses, people improving their sleeping patterns, individuals struggling with the care needs of their family members. In nearly all cases, we have something in common – we are all seeking to improve health toward a felt homeostatic balance, the experience of a recognized sense of ‘normal’.”

I see two emerging thrusts in design for systemic change and sets of questions they suggest. One relates to clinical organizational change: How can we expand the functions of care within clinical organizations to enhance the design of service and the experience of care? How might design move from IT and other non-clinical services to the front lines? The other to health systems level: How can we design to engage and promote extraordinary care in our societies? How can we help clinicians move healthcare innovation from process improvement into a realm of “extraordinary service?”

Apparently I had a lot to say about organizational design and the relationship to new healthcare practices and new distributed models such as the ACO. Perhaps channeling Russell Ackoff’s Democratic Corporation here, I’m proposing a similar self-organizing approach of teams within (large span) hierarchies.

There are few truly flat organizations. The “hierarchy vs. network” theme is archetypal, but structure is not a solution. Networks are not flat by any means; they are lumpy and energized by power bases. Many hierarchies allow their departments to behave as if flat. Rather than characterizing by dichotomies, we might consider every system as a mix of structures, often shifting, but in slow motion. Large product companies often have vertical market segments and product lines that require separate teams and external networks, such as the large firm in We Tried to Warn You. And they are able to “learn lateral” when necessary, even in a traditional managed hierarchy.

In terms of systemic design within organizations I’ve advocated a planned combination of top-down and bottom-up strategies of soft system design. My approach connects front-line projects with broad organizational and community goals. Through structured dialogue and creative workshops, we can help stakeholders in management and in patient-facing services to discover a shared framing of goals, boundaries, and roles to align their projects toward preferred system outcomes.

Healthcare practices are very resilient, they are trained and standardized so that many clinicians can be interchangeable and perform well under a range of conditions. Changing clinical practices, workflow or procedures requires strong evidence and a clear argument, retraining and evaluation. It’s the same thing when introducing a new EMR or IT system. Healthcare organizations are designed in a sense to resist change; they hold strong norms of practice due to the constant demand to serve their communities. Therefore when consultants (and designers) want to promote innovation and change and they don’t live and work inside healthcare – hospitals or practices – their proposals will likely fail. We are not all on the same team. Clinicians have a primary duty as caregivers – what is our duty of care to the caregivers? Perhaps as designers we can see possibilities those working in the domain cannot, but that doesn’t give a mandate for change from the outside.

Healthcare is risk-averse by design. It is (in Jane Jacobs’ terms) a guardian moral system, as opposed to a system of commerce or trade. Most consultants, designers and IT people come from companies with a commercial moral system, and their operating values may be inherently at odds. Is it ethical for “us” to advocate they act like creative entrepreneurs? Technology interventions can have the effect of embedding a foreign values system, and once embedded, received without consensus.

In my experience, creative competencies can be established within organizations in a developmental way, but preferably not through direct “culture change” initiatives. Cultures change when internal practices reflect new values within ways of working. These practices, habits really, become communicated and valued across departments and enable significant improvements in complex work processes. I don’t believe that my role as a systems designer is to change culture however, it’s a designerly arrogance to believe we can change cultures as outsiders. We haven’t personally done that work in our own organizations, and even when I have, it was in an insider’s role of peer-led stewardship, not as a hired consultant. So how can we pretend our process design is the answer to complex sociotechnical work challenges? The best we can do is to facilitate dialogues and help internal teams design strategies for near and longer term transformations.