managing for sustainable innovation using human centered...

Managing for Sustainable Innovation using Human Centered DesignML 9

IHI National ForumDecember 2017

Kedar MateMarian JohnsonEstee NeuwirthIoulia Kachirskaia

Objectives

1. Develop management and operational

strategies for innovation in your organization.

2. Articulate the distinction between innovation

efforts and ongoing improvement work.

3. Learn about human centered design as a

fundamental approach to innovating.

Agenda12:30 Introduction & Definitions – Why

do we innovate

12:45 System: Innovation Management

1:15 Process: Creating a disciplined

Innovation Process

1:45 Break

2:00 Method: Human Centered Design

Overview

2:30 Innovation exercise

3:45 Conclusion

methodprocesssystem

Why do we innovate?

Origin Story

• National Demonstration Project on Quality Improvement in Healthcare

• 20 hospitals matched to 21 Fortune 500 companies

• September 1986-June 1987

• Process IQ lprovement knowledgQ e & coaching

• Initial and summary conference

Striking Results

Procedure times

400%

Length of Stay

50%

ED Wait Times

70%

Surg site infxns

50%

Our Mission:

To improve health and health care worldwide

1991-2006: Our Initial Innovation Process

• Integrated into project teams

• Created great ideas from

improvement work

– Bundles

– Reliability

– ‘Move Your Dot’

• Good, but not good enough

What Was Missing

• Staff with dedicated time

• A forum for collective thinking to address

problems that needed innovation

• Organization-wide understanding of innovation

• Predictable deadlines with a decision point

• A laboratory for testing

IHI Innovation Process

• A specific challenging question to be

answered

• A network of innovators, along with

other traditional methods (literature

search, prototype testing)

• A specific timeline, in this case 90

days

• A set of recommendations at the end

of each cycle

Huston L and Sakkab N. Connect and Develop. Harvard Business Review. March 2006. pp 58-66

Why do any of us innovate?

• Improve health of our

patients

• Improve value to our

customers

• Improve public value to

our society

System: How to stimulate and manage innovation

Managing innovation

• What is it exactly that we are managing?

• When do you we innovate and who leads?

• How do we resource innovation?

• How do we measure its effectiveness?

• How does it work with operations?

What is it exactly that we are managing?

Innovation is not an event

Innovation is not a product

Innovation is a process…

Moen, R. Idealized Design Process

…with many

visualizations

Innovation is related but not synonymous with Improvement

Improvement

Changing existing services to more

desirable quality—to make better

Classically done by operations

Mental model = elimination; remove

existing system faults

Limitations: Slack time of existing staff;

limited to the existing business model

Innovation

Introducing new methods, ideas, or

products—to make new

Best done by a dedicated team

Mental model = creation; remake

the system

Limitations: resources & ability to

manage and execute on innovation

Taxonomy of innovation

• Technology– New devices

– New

diagnostics

– New

therapeutics

• Delivery– New processes

– New roles

– New care

models

• Business– New provider

payments

– New waivers

– New incentives

Cost

Outcomes

1940s

Today

The role of delivery Innovation in health care

Chris Trimble, Beyond the Idea

Technology InnovationDelivery Innovation

When do we innovate & who should lead?

Three tools to change a system: Dr. Juran’s Trilogy

• Understand needs of the customer

• Manage the work

• Change & improve the work

Source: Juran Institute

“Quality Control”

“Quality

Improvement”

“Quality Planning”

Innovation

A visualization

European Observatory, 2001

Quality Control Quality Improvement Innovation

Resourcing your innovation system

© 2013 Chris Trimble

Physics of Innovation

Rtot = Rops + Rinn

From: Chris Trimble

The Critical Resource: TIME

People

Fracti

on

of

Tim

e

10%

80%

90%

70%

60%

40%

50%

30%

20%

100%

Ongoing Operations

0%0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Part Time Contributions from All

People

Fracti

on

of

Tim

e

10%

80%

90%

70%

60%

40%

50%

30%

20%

100%

Ongoing Operations

0%0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Innovation

Primary Limitation = Project Size

Full Time Contribution from a Few

People

Fracti

on

of

Tim

e

10%

80%

90%

70%

60%

40%

50%

30%

20%

100%

Ongoing Operations

0%0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

In

no

vati

on

Innovation with Full Timers

• Bigger projects

• Resources are more reliably available

• Ability to practice clean slate team design

(without breaking anything)

One example: VCU Inpatient Palliative Care

This Approach Does Not Enable Clean Slate Team Design

People

Fracti

on

of

Tim

e

10%

80%

90%

70%

60%

40%

50%

30%

20%

100%

Ongoing Operations

0%0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Innovation

How to free up resources?

• Bring all of your current ‘innovation’ activities to

light. Look for– Projects that are not resourced to meet goal

– Redundant activities

– Activities that are non-strategic

– High-risks that are unlikely to be met

• ‘Celebrate’ the end of some of these

Innovation & Operations

Purpose, Structure, & Culture VaryOperations Innovation

Purpose • Efficiency, current profit,

predictability

• Growth, future value, unknown

Structure • Designed to deliver specific

product, on time & on-spec

• Formal, mechanistic

• Designed to foster creativity and

learning

• Adaptive, loose

Culture • Task mastery

• Risk-averse

• Consensus-driven

• Customer-driven

• Risk-taking

• Speed & agility

• Experimentation-driven

• Seeking edges not medians

Competencies • Operational efficiency

• Management

• Entrepreneurship

• Design

Stresses • Deliver best care, reliably, each

and every time

• Consistently develop new ideas

• Meet milestones for growth

The Elia Experiment

Don’t rush to implement innovations…build will for change

Current Situation Resistant Indifferent Ready

Low Confidence

that current change

idea will lead to

Improvement

Cost of

failure large

Very Small Scale

Test

Very Small Scale

Test

Very Small Scale

Test

Cost of

failure small

Very Small Scale

Test

Very Small Scale

Test

Small Scale Test

High Confidence

that current change

idea will lead to

Improvement

Cost of

failure large

Very Small Scale

Test Small Scale Test Large Scale Test

Cost of

failure small Small Scale Test Large Scale TestImplement

Intentional design of a learning system

Different stimulants apply:

Everett Rogers, Diffusion of Innovations, 1962

InnovatingCreativity & ambiguity

Starting something

Relationship

ImplementingNormative pressure

Payment

Regulation

Measuring Effectiveness

Outcome measures

• Usually some of return on investment.

• R&D is almost always an overhead expense:

– ROI measured in revenue (dollar for dollar)

– Results (outcome for dollar)

– Reputation (marketshare for dollar)

IHI Innovation Outcome Measures

• Revenue

– 30% of R&D projects from prior year are used in

revenue producing work

• Reputation

– 30% of R&D projects from prior year are contributing

to IHI’s thought leadership

Creating a disciplined innovation process

Components of a disciplined system

• Pace

• Staff with dedicated time

• A forum for collective thinking

• Organization-wide understanding of innovation function

• Predictable deadlines with a decision point

• A laboratory for testing

One Process

IHI 90-day Learning Cycle

Question Pose &

refine question to be answered

Scan Review

literature, conduct interviews, identify exemplars T

heory

Build

ing Identify

core underlying principles & theories

Focus &

De

sig

n Develop a new concept design for testing

Test

Work with one or more settings to test new concept

1. Define the topic

• What is the problem that really needs to be

solved?

– Is the innovation question scoped properly?

– Is the question leading – does someone want you to

get a specific answer?

– Is the question aligned with a larger strategic aim?

2. Look for ideas: SCANNING• Read the literature: High level – know enough to be informed

• Find the experts: What names come up repeatedly?

• Find the connectors - the passionate improvers: Who has been thinking about this and trying to fix it in their daily work?

• See the problem: Where can you experience or observe the problem?

• Look elsewhere: What other industries have similar underlying challenges?

• Ask someone not involved: Who can you ask about his/her experience or thoughts on the problem?

• Find anyone who has worked on the problem in the past: Has anyone in your organization already tried to solve this problem? What did they learn? Why were they not successful?

Generating change ideas

• Bright-spotting

• Direct observation

• Using change concepts

Bright-spotting

Direct observation

• Shadow patients and families to learn what they really want and need

• Engages key stakeholders in co-design and co-production

• Asking vs. observing

Using change concepts

Change concept = A general notion or approach found to be helpful in developing specific change ideas that result in improvement

See: • The Improvement Guide, page 132, for a list of 72 change concepts; Appendix A provides detail on each

• IHI Improvement App

Complete List of Change ConceptsEliminate Waste

1. Eliminate things that are not used

2. Eliminate multiple entry

3. Reduce or eliminate overkill

4. Reduce controls on the system

5. Recycle or reuse

6. Use substitution

7. Reduce classifications

8. Remove intermediaries

9. Match the amount to the need

10. Use Sampling

11. Change targets or set points

Improve Work Flow12. Synchronize

13. Schedule into multiple processes

14. Minimize handoffs

15. Move steps in the process close together

16. Find and remove bottlenecks

17. Use automation

18. Smooth workflow

19. Do tasks in parallel

20. Consider people as in the same system

21. Use multiple processing units

22. Adjust to peak demand

Optimize Inventory23 Match inventory to predicted demand

24 Use pull systems

25 Reduce choice of features

26 Reduce multiple brands of the same item

Change the Work Environment

27. Give people access to information

28. Use proper measurements

29. Take care of basics

30. Reduce de-motivating aspects of pay system

31. Conduct training

32. Implement cross-training

33. Invest more resources in improvement

34. Focus on core process and purpose

35. Share risks

36. Emphasize natural and logical consequences

37. Develop alliances/cooperative relationships

Enhance the Producer/customer relationship

38. Listen to customers

39. Coach customer to use product/service

40. Focus on the outcome to a customer

41. Use a coordinator

42. Reach agreement on expectations

43. Outsource for “Free”

44. Optimize level of inspection

45. Work with suppliers

Manage Time

46. Reduce setup or startup time

47. Set up timing to use discounts

48. Optimize maintenance

49. Extend specialist’s time

50. Reduce wait time

Manage Variation51. Standardization (Create a Formal Process)

52. Stop tampering

53. Develop operation definitions

54. Improve predictions

55. Develop contingency plans

56. Sort product into grades

57. Desensitize

58. Exploit variation

Design Systems to avoid mistakes59. Use reminders

60. Use differentiation

61. Use constraints

62. Use affordances

Focus on the product or service63. Mass customize

64. Offer product/service anytime

65. Offer product/service anyplace

66. Emphasize intangibles

67. Influence or take advantage of fashion trends

68. Reduce the number of components

69. Disguise defects or problems

70. Differentiate product using quality dimensions

Change concepts vs. change ideas Vague, strategic, Improve process to reduce

creative anxiety

Give patients and families

access to information #27

Use text messages for family & friends waiting

Specific, actionable, Pilot using text updates to

ideas for change families of all surgery patientsfor one day next week

Taking a concept and getting to actionable

(testable) ideas

3. Begin to generate a content theory

• Put your ideas onto paper in a way that they can be explained to

others:

o Driver Diagram

o System diagram

o Image

o Tool

Begin to build your theory

• Organize your ideas – in a way that makes sense to you

• Note what comes up repeatedly

• Note what successful approaches look like

• Note what is missing from some approaches

• Group your ideas into a format that works for you and the theory – consider:

• Are the pieces independent?

• Do you need to show interaction?

• How will people react?

• Can you layer your theory?

Health Care Monitoring

CommunitySupport

Manage Activities of Daily Living

Reliable Caregiver10

Primary Drivers

•Easily available social activities•Volunteer opportunities2

•Support networks•Interactions with multiple age groups3

•Physical activity options•Spiritual support4

Secondary Drivers (Remote Monitoring Enabled)•Telephone/email access to providers (Telemedicine, phone, internet)•Tools for monitoring health care conditions (scale, glucose monitor, blood pressure monitor, etc.) (Technology enabled devices, telemedicine, technology linked to provider)1

•Strong relationship with provider that guarantee remote access will be available•24-7 access to health care provider (nurse able to be at the home within a few hours)•Care plan including advance directives

•Recognizes when level of care needed (either health care or ADL) has changed (Visiting nurse, attendant, or AERS)•Coordinates appointments if necessary •Provides or arranges for misc. services if necessary •Trained to look for signs of decline (Visiting nurse, attendant, family, friend, AERS)•Prepared to deal with urgent situations and rapid decline11

•Respite care available

•Ability to perform the following either alone or aided:•Bathing•Dressing•Toileting•Continence•Eating (Meals on Wheels)7

•Ability to recognize when level of need changes (Visiting nurse, attendant, or Adult Evaluation and Review Services (AERS))8

•Modifications to home to allow individual to safety stay in the home (Nurse, attendant, AERS, volunteer)19

•Access to transportation for appointments, etc.

Coordination

NORC, Villages, Local programs5

Home evaluations that assess and provide: durable and disposable medical equipment, changes to physical layout6

Keeping People (over age 65) in Their Homes •Preventing or Delaying Readmissions to Hospital or Admission to Long-Term Care Facility

4. Theory validation and modification

• Go back to the experts: What is their reaction?

• Go to someone new: What do they think about your proposal?

• Go to a system thinker: Where are the holes?

• Find the black hat: Where can you poke holes (as many as possible) in your

theory?

• Update your theory

4/5. Build a prototype and start testingPrototype – a first, typical or preliminary model of something from which other forms are developed or copied

• Components of a prototype

• Prototypes are TANGIBLE – you can see, touch, and interact with them

• Human centered design – others have to be able to use them

•

•

5. Refine and summarize

• Synthesize the:

• Scan – what did you learn

• Process – how did you advance the thinking

• Testing – what worked, what didn’t

• Improvements – how did you change the theory

• “Final” deliverable – where did you end

From

Observation to

Proven IdeaDevelop

a theory

(Hypothesis)

Organize and Apply Observations

Observe a Dynamic Raw Event (Phenomenon)

Transition Point

Pilot

and

Spread

Prototype test

(Find anomalies and update theory)

Validate the

theory

Six Themes for IHI Innovation Projects

Standardization CoordinationImproved

Decision Making

Find Analogous

SituationsSimplification

Removal of

accepted system

faults

Quality

Management

System

Behavioral health

in ED and

community

Value

management at

the front-lines

Access & FlowAge-Friendly

Health System

Pursuing health

equity

High reliability

systems

Safe transitions for

elderly patients

What matters to

YouRisk resilience

Remote monitoring

of patients

Most valuable

primary care

Production system

design

Transitions for

health systems Antibiotic

stewardship

Improving

handoffs

Real-Time

Demand Capacity

for Flow

Triple Aim

definition

Goal is to create value for patients and systems

© 2017

Estee Neuwirth, PhD

Human-Centered Design @KP

Ioulia Kachirskaia, PhD

Kaiser Permanente Design Consultancy

©2017 HCD@KP | POWERED BY THE IMPROVEMENT INSTITUTE

3 things we will cover today:

Managing innovation on a strategic initiative

Building organizational capabilities at scale

Learning the CoDesignrecipe

67

Human-centered design is a creative problem

solving methodology that puts people and

their needs at the center of all solutions.

Human Centered

design methods

and mindsets

are used by many

companies

Lew McCreary

Harvard Business Review

Kaiser Permanente’s Innovation

on the Front Lines

“…democratizing health

care, giving patients

and caregivers a louder

voice in designing for

the future.”



NKE+

RAD

Buy to Pay

National Transplant

ServicesBehavioral

Health

Transitions in Care

Cancer Care

Consumer Financial Experience

Lantern

Imagining Care Anywhere

Project Move

Vision 2025

Redwood

71

Maternal and Child Care

http://healthaffairs.org/blog/2015/04/22/health-care-reform-and-the-trap-of-the-iron-law/


Xcelerating Learning and Spread (XLS)

Framework for Integrating the practice of design and science of improvement to accelerate learning and spread across the organization.

© Kaiser Permanente 2016, reproduce by permission only 74

https://www.youtube.com/watch?v=KLjXU6tU0aE

© 2017

Kaiser Permanente Mental Health and Wellness Strategy

7

6

[kah-my]

Greek for “on the ground” or

“on the earth”

© 2017

1 in 4 people struggle with mental health challenges each year

1 in 4 people struggle with

mental health challenges each

year*

*Evidence from NIH 2017; Image Credit: MyStrength Website

© 2017

70% do not receive effective care or support*

*Evidence from Rand 2017; Image Credit: MyStrength Website

20172018

2019

XLS applied to Project Chamai

© 2017

Analogous

observations

Interviews with subject

matter experts

Interviews with members,

clinicians, and leaders

Activity kits with

members

Surveying the

landscapeAnalyzing data

UNDERSTAND

© 2017

Education platformMobile optimized education platform with multiple types of content, organized around common stressors

ToolsSet of curated tools to offer to members for longer term skill building

Metrics & InsightsValidation metrics to assess effectiveness of the solution set. Qualitative insights from prototyping with end users.

WorkflowsProcesses and pathways to engage members through clinicians and other touchpoints.

Minimum Viable Product MVP: Prototype package

© 2017

Chamai Demo Website

• Transactional Education Content (articles, videos, podcasts, books, exercises)• Immersive Content (Apps, CBT programs)

Online platform for education content, self-care tools and personalized support


Lessons learned

Theme team Staff to win Demonstration site partners

CoDesign sprints Build excitementFunding

Design strategistDesignerSMEPI…

Service & Experience Design ~ Visual Design ~ Nursing ~ Anthropology/Sociology ~ R&D Business Administration ~ Hospital & Group Practice Management ~ UX/UI ~ Public Health Molecular Biology ~ Performance Improvement ~ Biomedical Engineering ~ Architecture ~ Operations

The Design Consultancy @ KP

© 2017

87

People want a different way to work that is more people-centered and more creative.

“People are hungry for this”


The opportunity

88


KP’s approach and strategy

1. A shared approach, common language and an

easy-to-teach system

2. Treating human-centered design as a

discipline with deepening competencies over

time

3. Complementing HCD@KP with other methods

when and where appropriate for accelerating

learning and spread.


1: A shared approach,

language, and system


CoDesign at Kaiser Permanente

© 2017

• Maternity Journey

• Transplant Services

• Hospital Care

• Behavioral Health

• Cancer Care

• Complex Care

• And more…


HCD@KP


Many People,

Shared Knowledge

Experts

Everyone

Trainees

Few People,

Deep Knowledge

96© 2017

2: A discipline with deepening competencies


450 people a year

Improvement

Institute

NEW Advanced Program 2017Focusing on advanced HCD@KP and

training practitioners and facilitatorsInfrastructure of Mentors,

PI Directors, Lead IAs and IAs across

regions, medical centers, and National

Business Functions

In the last 2 years trained 900+

improvement advisors and Black Belts

in CoDesign


Estee NeuwirthDesign Consultancy

Dennis DeasPerformance Improvement

Jennifer LiebermannGarfield Center

Tim KieschnickMSSA

Ioulia KachirskaiaDesign Consultancy

Program Lead

Katerina SalidoClinical and Operational Improvement

Operational Lead 98

Program sponsorship

Program leadership

Executive program sponsors

Pat Courneya, MDExecutive VP and CMO Hospitals,

Quality and Care Delivery Experience

Patti Harvey, RN, MPH, CPHQSVP, Medicare Clinical Operations &

Population Care

Executive Director, CMI

Lisa Schilling RN MPHVice President, Quality and Care

Delivery Effectiveness

Advanced HCD@KP

© 2017


• Trained 228 peers in HCD@KP• Trained 148 Improvement Advisor students in CoDesign• Led 15 CoDesign sessions • Involved 306 staff and 52 members and caregivers in CoDesign

99

Accomplishments of 2017 Advanced HCD@KP graduates

© 2017


Case study: Supporting Caregivers of Dementia Patients

100

Team: Nicole Tuite, Director, Service Strategy and Care Experience

Andrew Black, Director Project Management and Training

Elaine Carty, Improvement Advisor

Coach: Ioulia Kachirskaia, Design Consultancy

Sponsors: Janet O’Hollaren, Interim President NW Region

Nancy Lee, VP Quality and Service

Bryan Waide, Sr. Director CDRMO

“I wish there was someone to guide me

through the process, stages and steps

of dementia care with more sensitivity

and coordinated care.”

- Caregiver

“We are really great at diagnosis and

treatment. With dementia, there is no

good treatment. So we often diagnose,

and then send people home.”

- KP provider

SMART SET for KP HealthConnect


Case study: Bill Transparency of Imaging Services

101

Team: Deborah Jones, Senior Project Manager, Consumer Experience

Satbinder Mann, Director, Anticipate Costs Program

Coach: Jennifer Burciaga, Consumer Financial Service Experience

Sponsor: Nancy Falk, Senior Director, Consumer Experience &

Marketing Vendor Management

“Getting this email would have

been great so that I can budget

the extra amount and not be

surprised when the bill comes.”

- Member

prototype notification system that alerts patients to cost changes and offers a connection to a financial expert

© 2017

Integration of capabilities

Performance Improvement

Human-Centered Design

Care Experience

Risk & Patient Safety

3: Complementing methodologies for best outcomes


A common language and methods

A discipline with deepening competencies

Complement with other methods

103


Learning the CoDesign recipe

105

Conclusion

"3 Formulating New Rules to Redesign and Improve Care." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health

System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.

New Rules to Redesign and

Improve Care

1. Care based on continuous

healing relationships. .

2. Customization based on

patient needs and values.

3. The patient as the source of

control. .

4. Shared knowledge and the free

flow of information.

5. Evidence-based decision

making.

6. Safety as a system property.

7. The need for transparency.

8. Anticipation of needs.

9. Continuous decrease in waste.

10.Cooperation among clinicians.

Radical Redesign Principle Definition

Change the balance of power Co-produce health and wellbeing in partnership with patients, families, and communities.

Standardize what makes sense Standardize when possible to reduce unnecessary variation and increase the time available for

individualized care.

Customize to the individual Contextualize care to an individual’s needs, values, and preferences to obtain an understanding of “what

matters” in addition to “what’s the matter.”

Collaborate/Cooperate Eliminate silos and tear down self-protective institutional and professional boundaries that impede flow

and responsiveness.

Eliminate walls Recognize that the health care system is embedded in a network that extends beyond traditional walls.

Leverage community assets to optimize the social, economic, and physical environment while creating

unconditional teamwork between patients, providers, and communities.

Assume abundance Use all the resources that can help, especially those brought by patients, families, and communities.

Return the money Return the money from health care savings to other public and private purposes.

Make it easy Continually reduce waste and all nonvalue-added requirements and activities for patients, families, and

clinicians.

Move knowledge, not people Exploit all helpful capacities of the modern digital age and continually substitute better alternatives for

visits and institutional stays. Meet people where they are, literally.

Create wellbeing Focus on outcomes that matter most to people, appreciating that their health and happiness may not

require health care.

Create joy in work Cultivate and mobilize the pride and joy of the health care workforce.

Four important lessons

1. Identify a challenge, don’t over-articulate the solution

2. Don’t make decisions, design experiments (PDSA/tests)

3. Don’t just set off fires, prepare the organization for them.

4. Don’t just give people time, remember there are other resources they will need.

Nathan Furr and Jeffrey H. Dyer. Leading your team into the unknown. HBR December 2014

“What the great leaders we’ve studied know is that

when competing on innovation, sustainable

advantage comes not from the superiority of any

particular invention but from the superior ability of

leaders to foster an organization that can learn

from mistakes faster, more efficiently, and more

consistently than competitors do.”

Nathan Furr and Jeffrey H. Dyer.

Leading your team into the

unknown. HBR December 2014

Open Questions

R&D @ 101. Triple Aim

2. Campaigns

3. Collaboratives

4. Value management

5. Open School

6. Health equity

7. Advanced Flow

8. Care bundles

9. Scale framework

10. Trigger tools

Thank You

Kedar S. Mate, MD

Chief Innovation Officer

Institute for Healthcare Improvement

Weill Cornell Medical College

[email protected]

Twitter: @KedarMate

Marian Bihrle Johnson, MPH

Director, Institute for Healthcare Improvement

[email protected]

Estee Neuwirth, PhD

Senior Director for the Design Consultancy, Kaiser Permanente

[email protected]

Ioulia Kachirskaia, PhD

Principal Consultant @ Design Consultancy, Kaiser Permanente

[email protected]

managing for sustainable innovation using human centered...

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