2013/10/11 10:15 “Systemic Transformations in Health Care by Design, Stories from the Center for Innovation at the Mayo Clinic” | Manuela Aguirre and Josina Vink | Relating Systems Thinking & Design 2013

Digest from #RSD2 of @JosinaVink @ManuelaAguirreU talk with @playthink sketchnote on Systemic Change by Design at Mayo Clinic  at Relating Systems Thinking and Design 2 at AHO Oslo School of Design and Architecture

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This digest was created in real-time during the meeting, based on the speaker’s presentation(s) and comments from the audience. The content should not be viewed as an official transcript of the meeting, but only as an interpretation by a single individual. Lapses, grammatical errors, and typing mistakes may not have been corrected. Questions about content should be directed to the originator. The digest has been made available for purposes of scholarship by David Ing.

Recent graduates from programs at AHO and OCAD, hired on the same day at Mayo Clinic

If you approach Mayo Clinic in Minnesota, seems like building a mountain

Why do people travel from so far away, and then seem siloed?

Started in the 1800s, first to have a patient record

  • First to be collaborative around the needs of the patient

Built a Center for Innovation, started with Ideo and two doctors

  • Embedded in a clinic center, started in obstetrics
  • Grew to 70 employees last year
  • Interdisciplinary, 15 designers last year, programmers

Mayo started in 1800, 12 specialities in 1925, now 4500 employees

With all of the changes, the exam room from 1963 looks the much same in 2013

  • Good scientific revolutions in medicine, but the interactions with patients haven’t changed

Culture at Mayo Clinic different from new centres

  • Evidence based versus possibility based
  • Rational versus creative
  • Linear versus divergent

Disruptive Trnasformation of the Outpatient Practice: Project Mars

  • Halfway through project
  • In 3 years, reduce outpatient practice costs by 30% while improving patient experience

Did co-creation sessions, everything trained to do

  • Had follow-up sessions with patients via video, so don’t have travel for a 5-minute meeting
  • Problem: identified a solution, a technology part, and had to measure with small-scale experiments
  • After working on these service offerings, thinking about:  what are the purposes of all of these experiments?
  • How are these creating a system?

Pre-visit:

  • How to know psychological needs? e.g. chronic patients, better meeting in a group?
  • Not one standardized way
  • Smart sense:   How to make sense of this?  Which patient with which provider?  Adaptability within system?

Started working on tiny experiment on remote recheck

  • Needed to see in light of the total service line

Outpatient practice is also within the larger context of inpatient

Also siloed in seeing patients that focus on part of a body

  • Chronic procedural
  • Could get a richer picture

Start with service offering –> larger systems

Mayo Clinic has ambitious goal:  from 2 million patients to 200 million patients

  • Shift in mentality
  • About trusted and synthesized medical knowledge

Curry and Hodgson 2008, Journal of Future Studies

  • Want more powerful relationship between patients and care providers

Challenges in Systems Change

  • Challenged in scales
  • Confronted by challenges in trying to do systems change

When arrived at outpatient clinic, people already had a lot of other change requests:  change fatigue

  • More pressures to do things
  • One more person knocking on the door

Confronted with “Prove it” mentality (as Roger Martin from Rotman School describes)

Struck with how much leadership and middle management about where they wanted to be

  • 30% increase in efficiency within the same model
  • Even though epoused about being on Mars
  • Goal to shift from narrow vision to being more long term

Culture eats strategy for breakfast (as say Michael Porter)

  • Success meant complacency
  • Strong physician-led hierarchy
  • Photo of co-creation workshop, can see tensions in room

Pressure towards risk mitigation, as opposed to optimization

  • e.g. moving from patient records on paper, and paper chart on notes to Electronic Medical Record or Journal
  • Replicated paper
  • Now, it’s so hard to move, within the electronic structure
  • People were trying to downscale to their previous ways

Structure drives behavior:

  • Working within current practice at current time, experimenting things for future
  • e.g. fee for service model, way they’re paid now to see more patients
  • Had to make space for experimentation

Additive versus disruptive innovation

  • People could easily think of additive, e.g. a navigator
  • e.g. group visit, make some time on Friday afternoon, but then patients were starting to value other patients rather than physician, then lack of interest

Did discover some strategies for successful change

Making space for change:

  • Change fatigue, people on overload
  • Make a space for something different to happen
  • First had to work on a different care team model
  • Had to make space for less to do, so could do preventive medicine
  • Need to be able to rearrange

Embracing the unintended

  • From a designer, not looking for control
  • Would seed ideas in many places
  • Intention of working on a shared care plan
  • Would have conversations that seem sporatic
  • 2 years later, some of work was exploding, and didn’t have clarity of vision of how that would come about

Enabling practice champions, people invested in an idea

  • Had code awards, with funding and support

From positive deviance, building on what is working

  • While many working on same structures, were people who did something a little different, that could amplify
  • Physician who was dictating notes after record, but wanted to dictate while patients were in the room, allowed patients with trust, and they could correct what they said
  • Built into smart space

Identifying strategic levers that hit deep seeded notes

  • Wholistic model
  • Huddle for 20 minutes to go through all patients of the day, who would best handle, e.g. bed management
  • Disrupted dynamic of the whole care team, who had best power to handle, enabling teaching

Connecting the dots

  • While certain things didn’t exist, some resources could be reused
  • Family of dementia and Alzheimers, didn’t have tie with caregivers
  • Found that caregivers had significant needs, some people dying before the person with dementia, taking away keys, etc.
  • People at Mayo had the knowledge, could support

See a lot of opportunities within institutional care of hospitals

Challenge?

  • Doing the same, but doing 30% better?
  • Spread
  • Limitations came up
  • Digging deeper, getting an opportunity to frame differently, important

Commonalities?

  • How can needs be meet within clinical specialties, and not just a lung patient
  • Could make more changes in the primary care setting, thinking about whole person rather than a specialty practice
  • Power dynamic

Future-oriented, when someone outside of the brief challenges the brief from the designer?  Mayo scaling up from 2 million to 200 million could be evil.  Should the Cleveland Clinic, John Hopkins and Mayo scale up, or should they look for ways so that they don’t have to scale up

  • Coming from a perspective of how to make medicine irrelevant, not there yet
  • Outside perspective on healthcare as a fix-it model, social determinism
  • They may not embrace that whole-heartedly
  • Have to decouple providing care and providing knowledge:  what essence can be captured from encounter into cases that could impact other people?
  • It may not matter, just to make a big leap
  • Problem is people taking that too literally, e.g. seeing more patients, shortening period

How did you get into project?

  • Hired as designers to do this work
  • Mayo was looking for systems thinkers to supplement industrial designers, etc.

Ability to influence culture through processes?

  • Rethinking of business model, made some changes at the leadership level, as compared to experiments
  • Had the ear of leadership, use that work, make strategy for leadership
  • Creation of a new center around knowledge
  • Thinking on the center was there, but may not have come to fruition
  • Additive innovation rather than a wholistic patient with fundamental restructuring

Evidence-based attitude as a barrier.  Think more of an AND.  Learn more about evidence, as it’s a powerful factor in medicine, want doctors to use state of the art procedures.  Research on how design works?  Learning from other industries?  Donald Norman has asked profession to be more aware, prove that design works.

[Abstract of talk from http://www.systemic-design.net/]

Manuela Aguirre and Josina Vink
Transforming Health Care Systems through Design: Stories from Mayo Clinic Center for Innovation.
Abstract: Realizing change within the health care industry is notoriously difficult, not to mention amid the constraints of a historically successful health care institution that has been around for over a century. Recently, design has been gaining a reputation for leading much needed innovation of health care products and services to improve the patient experience. Still, affecting lasting change and addressing underlying issues within health care systems requires a focus beyond isolated care models and an extension of conventional design methods.Within the Mayo Clinic Center for Innovation, designers are beginning to embed systems thinking and systems approaches into their design methodology in an attempt to seed critical systemic shifts. These shifts support the evolution of clinical systems and re-orientation of the organization enabling it to play a progressive leadership role within the industry into the future. The evolving, collaborative design process involves working across scales to understand complex relationships and experiment with strategic levers throughout the existing systems. It integrates systems thinking in the process of: research, visioning, idea generation, prototyping, synthesis, communication, visualization,and so on, enhancing standard design methods to embrace the complexity of dynamic systems. This necessary extension of design enables the development of holistic, creative solutions that have the potential to make profound and sustainable changes to radically improve health.A number of project examples from the Center for Innovation illustrate how this work is beginning to take shape. The first is a project set out to design the future of the outpatient practice, influencing a shift from a robust and stagnant practice to an adaptive, intelligent practice. The second is strategy work completed for the organization and new center within the enterprise that supports a shift from care to knowledge as the essential offering of the Clinic.

While systemic design is increasingly necessary for the problems the Center for Innovatio seeks to solve, this work does not come without its own set of challenges. Some of the key barriers that the Center for Innovation continues to face as it works within the context of a traditional health care institution are:

  • Change fatigue,
  • Short term thinking,
  • “Culture eating strategy”,
  • Mitigation vs. optimization,
  • Structure driving behavior,
  • Hesitance around disruptive innovation
  • The “prove it” sentiment.

However, the Center for Innovation has found some significant successes in instances when: innovation comes from within the institution and designers act as facilitators to support the process (e.g. CoDE Awards), as well as when connections and ideas are built over years with the hopes of growing into a much larger movement at an unexpected time and place (e.g. Shared Care Plan).

As the capacity and methods around systemic design for health care continue to be developed and honed, the future possibilities and potential impact within the field of health care is infinite. This timely practice has the opportunity to not only reshape outmoded health care practices, but also move beyond clinical walls into people’s everyday lives and communities, where health is truly defined.

Manuela Aguirre

Josina Vink