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


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?


  • 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


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


  • 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

#design, #healthcare, #mayo-clinic, #rsd2, #systemic, #transformation

2013/10/10 15:00 “Design for Care: Human-Centering in Healthcare Service Systems” | Peter Jones | Relating Systems Thinking & Design 2013

Digest from #RSD2 by Peter Jones @designforcare at Relating Systems Thinking and Design 2 at AHO Oslo School of Design and Architecture

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.

European launch of Design for Care, publication is at http://rosenfeldmedia.com/books/design-for-care/

Presentation is available at http://www.slideshare.net/designforcare/european-book-launch-rsd-symposium-oslo


Introduction by Birger Sevaldson

[Peter Jones]

Trying to start a new program on healthcare design at OCAD

Current program on Strategic Foresight and Innovation, looking 50 years out

  • More policy work and large scale design

Rosenfeld Media started 5 to 6 years ago with craft-oriented book

  • Now on second generation design of book
  • Worked with James Caldwell on this book look

Two books before:

  • Team Design (now rarely used)
  • We Tried to Warn You:  a single case study

Healthcare is different to talk about credibly, not a clinician

  • Had worked in point-of-care informatics
  • When deep in healthcare, it’s impossible to get context around the field
  • Depth becomes breadth

Book has 9 chapters, different cases, methods appropriate across different sectors

  • Person at home, in everyday life
  • Clinical context, providing care services
  • Organization / institutions in health policy

Stories about how people experience fragmentation

Main question:  What if designers were included in the team, as care professionals?

  • Designers working in healthcare aren’t included uniquely, unless they’re in niche
  • Wicked problem

Designers are not helping systemically

  • Fields of design are fragmented
  • User experience / interaction design
  • Service design
  • Evidence-based design
  • Environmental design
  • Participatory design
  • Generative design
  • Disruptive innovation

Rethinking sociotechnical systems

  • Complex service systems, but they don’t benefit from the knowledge of service systems

In North America, no accepted design process

  • Institutions are reinventing design language
  • Sociotechnical systems, absent service design

DFC003: Figure 1.2

Adapted from Humantific, 2007-2003:  design geography, scales of design

  • Design 1.0:  Traditional design
  • 2.0:  Product / service design
  • 3.0:  Organizational transformation design
  • 4.0:  Social transformation design
  • Healthcare involves all 4 levels
  • Complexity increases at each level
  • Design skills do not transfer up (and may not even transfer down, that well)

In healthcare, at various scales:

  • Design 1.0 and 2.0:  Differencing, as opposed to making sense
  • Branding, clarity in communications
  • e.g. wayfinding can be done by a single experienced designer, not a team of designers
  • About making things stand out

Design 3.0 might have straightforward service design, e.g. providing vaccination

  • Could be designing IT services

Design 4.0:  Healthcare may not be at level of transformation

  • In Canada, at current rate, healthcare will be 100% of tax dollars in 15 years
  • Integrating services to architecture, can’t touch on in book
  • Accountable Care Organization (coming with Obamacare) is a new business model being pushed down into organization

Financial incentives to push costs down

  • But following yesterday’s processes
  • Aren’t likely to change unless institutionalized
  • Opportunity for designers at policy level to make changes
  • A high-authority environment

Let’s get designers started in healthcare

Contexts of care services

  • Human
  • Work and activities
  • Organization
  • Industry

3 human-centered contexts

1. Persons, not users, or patients

  • People as health seekers, service customers
  • Evidence-based care, as scientific approach, almost ignores the perspective of nurses who take a strong care approach

2. Clinical work practices

  • Healthcare business must also be designed

3. Healthcare system

  • Design

Character: Elena

  • Single mother taking care of farther and daughter
  • Care giver’s journey


1. Health seekers

  • As human beings, we are homeostatic
  • Whether we aim for optimal health, or just normal health (where normals are measured differently)
  • Think of selves more as agents than as patients (unless we’re in bed)

Elena’s journey as situations:

  • Caregiving
  • Health incident
  • Diagnosis
  • Treatment
  • Living With

Coulter, Entwistle Gilbert (1999) Sharing decisions with patients, British Medical Journal: Information touchpoints

  • 1. Understanding what is wrong
  • ….
  • 12.

DFC042: Figure 6.1

An end point:  Patients Like Me, started by a man whose brother died from ALS

  • Became a self-managed disease site
  • People track daily
  • Open and free
  • They are e-patients, agents in changing the way patients are treated

2.  Designing for clinical services, around clinical informatics to answer questions at point of care

  • Doctors don’t want to read journal articles, or 14-page summary
  • They want 3 to 4 pages
  • Workflow today, IT wants to take templates that know have worked in past, and then adapt workflows

Richard Bohmer:  Designing Care: Aligning the nature and management of health care, HBR press, talks about care contexts

  • Sequential services
  • Iterative services: a mix of conditions
  • Now 30% of patients are showing signs of diabetes or obesity in a mix of conditions
  • Care should be iterative
  • Uncertainty should be reduced during care, it’s like research through design
  • Improvements to treatment have to be done by trying them
  • More a problem-solving approach

Elena, seeing multiple specialists (for her fainting spell)

  • Elena is flooded by information

In clinical context, gold rush in Electronic Health Records systems number in hundreds, although only 5 are in use in the U.S. due to reimbursement systems

(Diagrams from book are available in Flickr)

Project Synapse, by IDEO and California HealthcCare Foundation 2012 (by Kauffman Foundation)

3.  Healthcare Systems

  • Call Big Box Healthcare
  • Michael Porter:  value-based healthcare system, driven by policy, not innovation
  • Cost will be the big disruptor

Center for Innovation in Complex Care in Ontario, Morra 2012 Reconnecting the pieces to optimize care in Atrial Fibrillation in Ontario

  • Patient-centred system

Value-Based Care, Porter and Lee in October HBR with Cleveland Clinic

  • Integrated practice units, distributed across organizations
  • Cost and outcome measurement

Designing Services to Scenario

To Design for Care is to Design for Health


Evidence-based medicine?

  • TR Reid, bad shoulder, reported across multiple systems
  • Can improve a lot of things in healthcare they won’t impact costs
  • Could be Health 3.0 or 4.0, may require policy changes

Design for care

Peter jones

[Table of contents for book at http://rosenfeldmedia.com/books/design-for-care/table-of-contents/]

Table of Contents

Part One: Rethinking Care and Its Consumers

  • Chapter 1: Design as Caregiving
  • Chapter 2: Co-creating Care
  • Chapter 3: Seeking Health

Part Two: Rethinking Patients

  • Chapter 4: Design for Patient Agency
  • Chapter 5: Patient-Centered Service Design

Part Three: Rethinking Care Systems

  • Chapter 6: Design at the Point of Care
  • Chapter 7: Designing Healthy Information Technology
  • Chapter 8: Systemic Design for Healthcare Innovation
  • Chapter 9: Designing Healthcare Futures

#design-for-care, #healthcare, #rsd2, #service-systems