Human Centered Design In Healthcare: Why We Should Care - Tanya Rinderknecht, MD

most of you appreciate it that one of the things we decided to do this year was really highlight our junior faculty at the same time also as part of our professional development efforts led by dr cook and his team to engage within an exchange and with our colleagues in alabama and there's also an effort being put together by the chairs of the uc departments of surgery also to involve and share our junior faculty in the opportunity to give grand rounds so we're really excited to present um dr tanya rinderconnect who is one of our i don't know if you i haven't decided what the date the timeline is for no longer being considered new there you go i guess self self assignment is probably the best but one of our new uh faculty members in trauma critical care and acute care surgery she came to us from stanford to do her trauma fellowship here and we were delighted to recruit her to have her stay she has a broad range of interests and today is specifically going to talk to us about some of the issues related to healthcare system design so dr vindeconnect glad to have you thank you very much good morning thank you for having me i'm going to be talking today about human-centered design and healthcare and why i feel strongly that we should all care about this topic so here we go have you ever wondered why a patient didn't take a medication that seems so obviously important how it's possible in this day and age that there isn't just a better way and why a patient might rate their care poorly when you obviously performed a perfect operation these are some of the questions that plague healthcare and i would argue that the answer is because we're human beings we are not robots our needs are not always the top priorities of the way things were designed and we live and work in systems that are bigger than we are human-centered design can help us here so today let me get rid of this little box here sorry i'm going to tell you why i think i can have something to tell you about this i worked at a design firm for two years explain what human centered design is and what design thinking is and i'm going to try really hard to convince you that good design can actually help us and that we should care about it and then i'm going to tell you that we're already doing it it's all around us we just have to figure out how to engage it better so during my research years in residency we call them professional development years where i went to where i went to residency um i had the amazing opportunity to work for two years at a design consultancy in palo alto um so those of you who know tom cruml who is the chair of surgery at stanford for a long time pediatric surgeon he was very supportive of going outside of medicine going into the community especially in silicon valley and figuring out how to mobilize those resources to improve healthcare so that's part of how i ended up here so ideo is a design and innovation consultancy that helps organizations from varied industries innovate and grow lots of buzzwords there don't worry i'm also not a fan of buzzwords but i'm going to explain why these things actually matter it's specifically known for employing design thinking which is a human-centered approach to the innovation process so this is important innovation is a process it's work it there are ways to go about it it's not just genius ideas that's why they can make a whole company around doing this so ideo started as a small industrial design firm they're most well known for designing the very first apple computer mouse i put a picture of it over there in black and white for dating purposes that's where they started that's where they made their big first big splash but they grew they grew from doing just industrial design to designing services spaces and systems so some of you may be familiar with the bank of america keep the change program audio designed that and they designed an entire new school system in lima peru these are just examples of the breadth of what this type of design process can be applied to so when i worked at ideo my job was to provide provide medical expertise on their entire health portfolio so any projects that touched health health care health devices i got to work creatively as a co-designer on project teams i worked with their business development people to identify the best new project opportunities to work on and i got to represent ideo at national healthcare conferences the more unofficial things that i got to do i was the de facto company doctor this came up more frequently than you might choose to choose to engage with i made it my personal mission to talk as many people out of motorcycle riding as possible that's a crime and then this sort of the uh the one of the most important things about this i think for me and the people that i worked with was reaching out of our medical silo and trying to explain our world to other smart professionals out there trying to trying to make the world better trying to work on these hard problems because you realize they have no idea what our world is like they really don't they don't understand what it's like to work in healthcare they seem surprised when i tell them that we actually do care a lot about our patients so i think this part was was one of the most important things that i did was just provide people a window into what our daily life is actually like this was one of our surgical robotics projects i'm in my element here the designer i'm working with is just all excited to play with the robotic tools so in my two years i learned came to understand how human centered design can really help us in healthcare i learned a new skill design thinking and got to stretch my brain in a new way and this is hard getting out of our way of thinking and trying to think in the creative space it's hard i learned how the non-academic and non-medical world approaches innovation and it's very different and i was exposed to a huge breadth of projects and i came away with an unexpected insight that i think is important to share which is that the physicians in the room are always the first people to say it won't work so when we were in meetings with client teams and there was one physician or two physicians on those client teams they were always the first people to say that it can't possibly work nope it'll never work and when i was with my project teams i found myself being that person so sometimes it's for good reason we get it we know the medical world the other designers don't but a lot of the time it's actually just because we have been told over and over again that this is the way it works period end of story so this is one of the most important things that i've come away with that i try to bring to my daily problem-solving life i just try to bring down that that negative reaction and not say it out loud and leave that little door open that actually maybe something could work differently because you never know so this is a list of all sorts of different project topics that i got to work on i won't read them all but you can see there's a tremendously wide range my first project was about bovine health health and reducing the spread of bovine respiratory disease which fascinatingly is has so many parallels to covid i can't even tell you i worked on surgical robotics projects i worked on a project around death dying and what it means to be alive and i got to help build a health a new health system in lima peru from the ground up so it's really a neat and fun two years so let's talk a little bit about design design is the art or process of planning or creating something i'm going to emphasize again this is a process just like innovation is a process and design is a tool to approach it before i worked at ideo this is what i thought of when i thought of design generally not very practical sort of ugly but maybe somebody else figures out how to tell me these things are pretty i'm told those are shoes on the top left but i'm not exactly sure so this is what i used to think of but design is also this so these four things were all designed by ideo on the top left the the first automated external defibrillator designed in the 1990s a device so well designed that any bystander on the street with no medical contraining can save a life with this on the top right is an insulin injection syringe ideo has been working with eli lilly for over 20 years to create and and make uh make more user-friendly the insulin injection process by creating pre-loaded pens dose dose loaded pens and figuring out how to make them more manageable for patients on the bottom left is a mobile ekg monitor monitor that i will talk about a little bit later and on the bottom right a mobile breast pump a wearable mobile breast pump the willow which has entirely changed the way breastfeeding mothers can function in this world so this is also design so as i mentioned human centered design is a tool it's a way to approach the innovation process it's a way to approach change and problem solving there are lots of different approaches it's not the only one but i think it's a particularly good one it is all about focusing on the user or the human first putting that at the center always and it's about being nimble and thinking outside of the usual box and fixing things that are broken but what really differentiates it from all the other ways to go about change is making sure you always put the user first so every good presentation has to have a venn diagram i happen to like them quite a bit um but this really gets it the thesis of design thinking so innovation good innovation happens in the middle in the blue and design thinking always starts with the human so over here on the left side the desirability what do humans need what do they want what do they what are they going to use you start with that always and then you have to follow that something has to be viable it has to work from an organizational standpoint from a financial standpoint and it has to be feasible the technology has to be there to build it and if you can get those three things to overlap and you started with the human need you're in a real good spot for creating something new that actually contributes and sticks so this is what the process looks like the first thing you do is empathize you have to figure out how to develop a really deep understanding of the challenge you're addressing and the people you're trying to serve once you do that research to get that understanding then you define your problem you clearly articulate the problem you're trying to solve so most of our projects start with the problem right we all usually start with the problem is blank we clearly declare that we know what the problem is this is where design thinking is so different from so many other approaches design thinking assumes that we don't actually know what the problem is we see a vague design challenge in the world but the first thing is to check yourself and say but i don't actually know if i'm solving for the right problem let me go and do all this research and figure out what the people involved actually need and want and i might realize that the problem is actually something totally different from what i saw from my perspective so spending time in this purple empathize area is actually the most important part of this process once you've defined your problem then you go on to the fun part the ideation that's brainstorming so you get all your brainstorming rules wild crazy ideas suspend judgment build on other people's ideas and the reason for that is this is how you get your breath this is how you really get at those things that aren't just your ho-hum well i think this problem is this and therefore i'm to do blank this is where you get your your broad ideas and really try to think outside the box and once you have a number of those and you think about those and you talk to people about those then you prototype you build things whether it's a tangible object or a visual representation or a space that you can mock up for people to walk through you try to bring your ideas to life in a rough way you're not making a fin a polished product here you're trying to create a really rough draft of something so that you can get then go and test that because what your goal is here is to put things in front of users and get feedback as soon as possible so that you can go back and start making your next version of whatever it is that you've designed and if you wait too long if you wait until you have a nice polished final product you're not going to want to change that again you put way too much work in it it's become your baby and you're committed to it so the goal is to put rough rough drafts in front of people as soon as possible so that you can then go back and ideate all over again so this is what the process looks like and if you're anything like me this makes you a little uncomfortable because you are a more linear thinker and you like to have a plan and you like to have steps to follow and you want there to be an answer but this is why it's uncomfortable and this is why it's different and this is why other people can help us do this so like i talked about the first part of empathizing you got you have to go really deep and you you can you diverge you go all over the map to learn about your problem and then you converge you define your problem and just when you think you're starting to settle into a more comfortable space again you diverge again and brainstorm all these wild and crazy things that in the back of your mind thinking you're thinking there's no way this is ever going to work or make any sense but then those things start to evolve you prototype you test you cycle back you create some more ideas and eventually things start moving towards the final product but there's a lot of back and forth and a lot of time spent where you're really not sure what direction your project is going to me it felt like this mostly um tremendously uncomfortable i'm very honest um but you learn to trust the process just like many other parts of life so how does this work what are the methods that we use in design thinking so let's think about traditional research in general we have clear hypotheses that we outline and we define ways to test them we work in a relatively controlled setting we want lots of data lots of data lots of people more and more enrollment we want to study it and we want to prove things design thinking is total opposite it's all about stories and narratives it's about getting inspired not proving anything you're looking for inspiration that will help you innovate and change better than somebody who's just looking at the average user and assuming they know the answer so you're looking at eight to twelve qualitative interviews not a bunch of quantitative research this is important to sort of be very clear about because this is a hard gap to bridge when you're working with scientists um and as the physician on a design team working with physicians and from other companies this was one of the hardest things for them to grasp is that you could do research that didn't end up in graphs and data points and proving something because the research isn't about that for this it's about getting inspired so let me tell you about a couple of the methods and it'll make a little more sense so we start with the concept of ethnographic research this is the insider view how people live their lives what are they doing in their homes what is their day-to-day actually like it's inherently subjective and narrative qualitative not quantitative it seeks out attitudes and emotions things that are really hard to measure and have to be described in words not tables and it really gets at this question of are we solving the right problem and this takes humility over and over again because we want it we want to know what the problem is so badly but we have to step back and listen and let people tell us and show us what the problems are this is a gentleman we interviewed on my bovine health project took took me all over the u.s to feedlots catalogs all sorts of places i would never be otherwise so this is a question why not just do this why not the linear approach observe something interesting in the world and then based on your understanding start generating ideas we all know how to brainstorm right so the argument design thinking here is that when you get outside of that concrete thinking into the abstract and when you start asking not just how can i solve this thing this interesting thing but what's driving that to happen what are the people doing that's where the empathizing comes in trying to really understand what is making that interesting thing so interesting and then based on that new understanding from those users that's where you start generating ideas and that gives you something totally different to build on henry ford is often quoted he's known as a great innovator he said if i had asked customers what they wanted they would have said a faster horse and where would we be today right so he had the insight to say yeah people want faster horses can't make those what do they actually need though they're saying they want a faster horse but what is it that they need and why do they want that they want a car but they didn't know it so this really gets at the fact that you can ask people questions but people actually can't always tell you what they need they might be able to show you through their actions because they're thinking and feeling and doing things that are different from what they're actually saying and this gets at the importance of truly observing people going to their homes getting at this other stuff other than what can you learn over a phone survey that's how you really get very different different results so empathy exercises this is something that designers do as part of their projects so this is an old photo from an ideo project long ago that gets talked about very classically uh the idea was engaged to do a patient experience project with a small hospital and the design team was all young designers who had never been to a hospital and so they said we got to really understand what this is like for patients so with the hospital's permission this designer faked an ankle injury and took himself to the emergency department and took his little camcorder which also dates this project uh with him and essentially just recorded his experience so that he could then not report back verbally to his team but show his team and have them experience with him what this was like and when he went and showed his team the video this was the video a whole lot of the ceiling so they showed this to the executives at the hospital who had hired them this project and this was this was the aha moment for those hospital executives they had been thinking of patient experience in terms of okay registration and then ed bed and then inpatient bed allocation but the patient's experience was actually just hours of lying on their back looking at a ceiling so this was the first observation in a series of many that led to a whole patient experience project with this hospital in context research this is about going to patients where they are and looking at what they do so this was a project about adherence to medication and you know the question why don't why don't people take their medicines they know they're important so the design team talked to a bunch of patients and they went to this elderly patient's house who was suffered from polypharmacy and they asked well you know do you have a hard time with the pill bottles we hear that's a problem and the patient said well yes i do well how do you get them open and took them over to her if you don't know what this is my husband didn't he was very confused he thought it was a cd player of some kind this is a meat or a bread cutter this is a spinning like a saw essentially so this patient is sawing off the top of the plastic pill bottle and you can see the arthritic hands it's not going to end well this is going to be a hand trauma shortly but if they had just called and said you have any trouble opening your pill bottles and the patient had said yes that would have been that but seeing this in context created a whole different sense of how real this problem really is so inspiration so how do you innovate better than the person next door who's innovating so you have to get inspired to have bigger better ideas that are going to create a bigger change move the needle more so we like to use extreme users so let's say you're doing a project on type 1 diabetes you want to figure out how to improve type 1 diabetes cares for your patients you could go to the middle of the bell curve the average users 10 joshua's who have type 1 diabetes and ask them what do you do how have you made your diabetes care better and and you might be able to maybe incrementally improve something a little bit but what about going to the extreme users and learning what people do when they have much bigger challenges than the average people not because you're designing for those people necessarily but because those people might give you ideas that can better inform the design for the average person so in a type 1 diabetes patient you might go interview a family with a child of type 1 diabetes that presents totally different challenges from an adult who can manage this themselves or you might go some of you might recognize this person here uh you might go to the ultra marathoner who manages to run ultra marathons with type 1 diabetes and figure out well what did what did you do to get your to keep your lifestyle going with this disease and this that then helps us create better design for the people in the middle analogous inspiration so we have lots of problems in healthcare turns out some of them are really similar to problems in other industries but we seem to think they are so special to us so in a project around or efficiency and and improving teamwork a design team thought okay well what other industries in the world have fast-paced environments where safety is key and people have to work together in an environment where it's actually sort of hard to communicate and so they ended up talking to a nascar pit crew and the idea here is we might not do we know the end end result isn't similar taking care of patients and driving cars not that similar but what can we learn about the teamwork and how they've optimized that to bring that learning into what we do so sometimes looking outside will give you new things rather than going to 10 other hospitals and asking well how does your or team work well probably pretty similar to ours so this is about getting new ideas to bring into our world prototyping this is a huge part of human centered design prototyping just means building things to hold in your hand so that you have something other than words to communicate with okay so this is a famous ideo example if you google prototyping this is one of the first images that comes up so year decades ago this project ideo was working with nasal surgeons or surgeons to create a new nasal surgery device and the surgeon was there trying to describe the tool that he wanted to hold and how he wanted it to feel and how he approached the nose and the team was really struggling to sort of imagine what this man was trying to describe so one of the designers grabbed things that were around a marker a paper a plastic clip and a film canister which again dates this example remember the last time i saw the film canister and used some scotch tape and taped these things together and said is this what you're talking about and that gave the team something to look at something to hold in their hands and the surgeon could say well yes but this part needs to be longer or it needs to sit in my hand this other way and just by creating something physical no matter how rough even though it doesn't look anything like a surgical tool gave them something to talk about and help them move their conversation forward much faster than just more words so the idea behind prototyping is that you are building to think that creating something physical helps you think better helps you iterate on it more helps you move the design forward faster and this is really important when it's rough we see potential when it's polished we see flaws this is why pilot studies are often far too late in the game to be a good idea because they've already been so evolved and sort of created and packaged and somebody's invested in them succeeding that it's really hard to then give feedback and make them better so the rougher the better really with prototypes and with ideas if you can share something really early you will get such good feedback to make a better version much sooner than if you spend a bunch of time trying to get closer to perfect and this is this idea we call it failing fast and it's not really failing it's getting feedback but it's sacrificing ideas early to then get a better your next better version sooner with rapid iteration so i think these are good examples of prototyping on the top right this is a prototype of an app it's not digital nobody created wireframes it took probably about two minutes for someone to draw you stick it on a telephone and put it in someone's hand and it gives them a sense what is what does navigating this maybe look like oh i don't want that button here i want it over here no this this part is too big this part should be smaller and you're already on to your next version before you've even opened a computer to digitally create anything on the bottom right this is a good example of space design this is a waiting room for a healthcare system built entirely out of foam board so it's quick to make cheap and can be taken down and changed pretty much immediately but when you talk about designing a new space don't you want people to be in it and react to it and see what they actually do in it before you commit to it rather than just having it on a 2d piece of paper so this really brings things to life and lets you get feedback early and then on the bottom left is a couple dozen prototypes of the willow breast pump so thank you to 3d printing for making prototype so much prototyping so much easier but you can see the versions and versions and versions and versions and that's how you arrive at something that ideally works well multi-disciplinary project teams are an absolute must in human centered design this is a team i was working with on designing a new version of a port we had a mechanical engineer an industrial designer a human factors researcher and a physician and within the realm at ideo you also have business designers to get at that viability part of the venn diagram architects communication designers interaction designers and the idea is you're coming at the problem from all sides both to lend breadth to the project to get new ideas but also to check yourself along the way to make sure all these things could actually be are actually going to be desirable and feasible and viable so just for a note of levity here the colonoscope many of you are familiar with so sometimes the best way to illustrate the importance of good good design is to give example of bad design so this is a device that has two dials and your hand has one thumb so i'm just going to just going to put that out there clearly this was not designed with the user at the forefront okay design thinking and medicine how is this going to help us as i mentioned this is not going to solve all our problems this is one tool but it can be used to address some of our most challenging problems and that's why i think it's important to talk about it's not just for devices devices often make for the best examples because they're visual and they're pretty and they have this nice finite thing that's done at the end but what's amazing about design thinking is that you can apply it to pretty much any pro problem in any realm so when i was at idea i worked at i worked on devices and products but i also worked on adherence i worked on disease support and learning materials for patients patient experience and employee experience come back to that a little bit later designing health systems preventing disease animal health building hospital innovation centers so that people could do this in their in their own institutions and informing the national conversation on innovation in health care so we'll come back to these questions why don't patient take why don't patients take their medications how is it possible that there isn't a better way and why patients rate care poorly even though you performed a good operation i would say these play gus daily so this is an example of a project that worked on adherence so designers made the appropriate observation that when a patient has seven pill bottles at home it's really hard to figure out what to take and when they worked with a company called pillpack and ultimately the product of their project was a total repackaging and rethinking of how you how you distribute prescribed medications working with the pharmacy rather than package a medication by type in a bottle they package the patients medicines by when things need to be taken so a patient would receive a box in the mail with a two-week supply of drugs and they would take out their monday 8 a.m envelope and it would have the four things that they need to take at 8 a.m and then their monday 1 pm and their monday 6 pm never have to open a bottle never have to look at a paper that says okay this one's three times a day but this one's six times a day so do i stagger those that whole math problem was gone just the envelope that they have to take with the time on it and they listened to patients and they heard that even this can be stressful because medications are stressful for people and then they miss a dose and they're not sure what to do should they take it late should they skip it what should they do so with this product of this prepackaged medication had to become some sort of support system so they designed an app with essentially direct access to a pharmacist to help troubleshoot those questions that come up that are often so hard to get an answer to because you're not sure do i call the pharmacy do i call the doctor do i call the clinical advice nurse so they really tried to create a holistic offering here with both a repackaging that'll that solves for both the bottle situation of not being able to open it and the difficulty of sticking to these dosing schedules and the support in the back so devices this is something that i got to work on while i was at ido this is about mobile ekg monitoring so the holster monitor we've all said oh yeah patient should get a holder monitor on discharge has anyone ever worn a halter monitor turns out it's not particularly easy it's not particularly comfortable so there's been some innovation in this space already zio patches are an improvement um it's sub-optimal when they tear the skin off people's chests but there is a company that worked with ideo interested in improving the mobile ekg monitoring space so the photo on the left is not just a gratuitous spare chested selfie these are our this was two of our designers who as part of the empathy exercise and trying to understand what the pain points were for patients agreed to where holter monitors themselves for two weeks the gentleman on the top is from france working in san francisco so he wore his halter monitor while he traveled from sfo to heathrow to charles de gaulle and went through tsa security about a million times and back again just to get a sense of what is it like when patients are told to just oh yeah wear these for two weeks and the designer on the bottom is an avid athlete so he tried to wear his as he did his swimming and running and his bike commuting just to get a sense of what patients are dealing with when they talked with patients we learned that they needed devices that are easy to use these cannot be complex this cannot be complex technology that becomes confusing they need to be affordable they need to be portable they need to be trusted and importantly they needed the ability to share the information with their doctors so eventually we created this device that you can see on the right it's a freeform device that you literally just touch two electrodes with your fingers and it will put your ecg tracing on a phone it now exists in an apple watch band you can stick it to the back of your phone if that's your preferred form factor a really interesting part of this project that i thought that was useful for the design team to have a physician involved was the initial idea was we're just going to send all the data to the doctor real time so we took a step back and we said okay but what doctor is actually sitting around wanting to watch someone's essentially a cardiac monitoring strip just waiting for the bad ekg to come through so solving some of the system on the on the other side of that is well do you provide patients with a professional ekg reading service do you have an alert that tells them when they should call their doctor about a tracing how do what do you do with all this data that you're generating this is a classic thing in medical design in the consumer space is everybody thinks creating data is better you can put tests in patients hands people companies love to prey on pregnant women oh yes pregnant women are anxious let's give them all these things they can test for at home well then what do they do with it right so creating this other end of what do you do with all that data and how do you help patients understand it and manage it is a huge part of good design in these healthcare situations so patient experience i'm going to talk about this briefly um this is a hard topic and i think we've all heard enough of it that it simultaneously we know it's important but it also maybe makes us cringe just a little bit because it's so it feels over talked about and it gets put into these realms oh and we're getting we're getting rated our our medical care is being judged based on how patients rate their experience and then immediately we we fairly have a reaction to it as uh my surgery was good why does it matter if they didn't like the color of the hospital walls right so we worked with a big um health care system in the u.s that provides women's health uh to help improve patient experience and we we touched on lots of different stuff we created digital teaching tools so that patients could come to appointments more informed we worked on space design around waiting rooms and clinic areas to improve privacy and comfort and we digitized all their forms and records to get rid of the endless paperwork and to improve privacy for that but i want to talk more generally about patient experience healthcare is a business but it is not a usual consumer experience and i think this is why patient experience becomes such a tricky thing to talk about and to improve on patients needs and their desires and their outcomes and their experience they all overlap and they're all intertwined and patients unlike unlike somebody who wants to go buy a new pair of shoes patients often aren't choosing or wanting to engage in healthcare so the whole concept of is it desirable well nobody actually wants to be in the hospital right so that's that's one way that it doesn't match the usual consumer experience but the other part is that patients generally aren't the direct payers and they often don't have a direct choice and we are disconnected from those things in the same way so this is why i think this is such a such a hard space but i would make the argument that patient experience really matters and primarily well first it matters for its own sake on the one hand as i will admit as a physician i have definitely thought to myself does it really matter if the like if the chicken that the hospital serves for dinner isn't good who cares you're getting you're getting good medical care right but on the flip side of that if my mom were in the hospital i would want her to have a tray that is edible and ideally good why not why shouldn't it just be good for its own sake so fine but what if patient experience could actually improve outcomes what if a subjectively better patient experience could help improve kelp lead to an improved objective patient outcome that should get all of us really interested right what if part of making patients do helping patients do better is about improving their experience is it possible that a patient with a better experience in the hospital might actually be able to engage better in understanding what's going on with them and then maybe would adhere better because they actually get it is it possible that if they were having a better experience overall they would trust their providers more and be more likely to follow up or listen to their suggestions and if we had better educational tools maybe patients could actually engage in the informed decision making we talk about so much and are really not very good at helping patients engage in and i will flip this to us what about the provider experience i would argue that for its own sake it matters we should want less burnout better recruitment improved job satisfaction why wouldn't we want those things right that seems obvious but what if i could make an argument that there might be a way for provider experience to improve patient outcomes what if a better subjective provider experience could help improve the objective patient outcomes could you imagine a world where a happy or rested or appreciated or valued provider actually was a better provider or where that provider was then better at building relationships with patients or had more capacity for attention to detail this is hard to prove but i think you can you can imagine how this might actually matter in a not only we want it because it's better for us way but we want it because it might actually be better for patients right so this is the part where i tell you we're doing it already and so the systems are there to engage in we can do this we can make this this type of design work for us so it's all around us it's in fully formed efforts innovation consultancies all these things and it's also in components the empathy part seeing it from the patient side we do this this is part of being a human being this doesn't have to be this huge leap we all have the ability to be empathic and we do it thinking outside the box it's happening prototyping building and trying it's happening i'll give you some examples so the pandemic in all the ways that it's been terrible has been a forcing function we have had to be agile and nimble we have had to work in sub-optimal conditions we have had to be creative and do things in ways that aren't proven and tested by years and years of trials and studies so these iv pumps are outside the icu room because we needed to reduce the number of times that nurses go in to reduce their exposures it took extension tubing it took foley stickers to hang the a-line set up on the icu doors to keep it at the right level but people figured out how to do this even though they even though the equipment isn't actually designed for it and the space isn't designed for it some genius engineer figured out that if you take a breast pump and reverse the suction it can actually be functional as a ventilator not sure anyone resorted to needing this but this is the kind of stuff that we're talking about right being nimble being creative and obviously medicine is a world where we want proof that things are safe we want proof that things work but the pandemic showed us that even in medicine we have the ability to innovate much faster and much more nimbly than we usually do it's it's everywhere so these are just a few examples but so many pla institutions medical schools hospitals are already doing this they might not call it human-centered design it might be called an innovation lab it might be called a design consultancy they might call it human-centered but it's happening in all these places they're recognizing that they have to figure out a more structured and discreet approach to problem-solving and to bring in ways to think about things that are not just our typical health care ways so kaiser has an in-house design consultancy they've been doing this for decades they're really good at it actually um cleveland clinic very well known for their work and patient experience so these are just a few examples but it's all around us at uc davis there's there are so many resources that i didn't even know existed until i started putting this talk together and this is part of the problem right they're all out there we have to figure out how to make them more cohesive there's a department of design at the in the on the undergraduate institution there are designers working on smart clothing that will help people sense when their stoma bags are full who knew i have no idea if they have any physicians working with them but that's out there that's happening the team lab the translating engineering advances to medicine lab is super cool they have a prototyping and design lab if you want to do three if you want to 3d print something they'll help you do it they'll help you understand the prototyping process the other component of that lab is the molecular prototyping and bioinnovation lab that we heard about last week so it's both on a sort of molecular scientific level and on a building level um but the the end of last week's conversation was that yeah we got to get it from grand rounds we have to get a whole group of people together to start talking about these ideas that's what this is right it's trying to put people in the same room who think differently about similar resources so that we can use them better aggie square is being built everybody's heard bits and pieces about it it's a little bit hard to understand exactly how it's going to work but that but the idea is is totally there it's bring industry and academics together to foster collaboration to build and improve faster right so putting people in the same place so that they interact and share these ideas and then at uc davis medical center we have a recently hired chief experience officer who has tons of background in doing human centered design so all these components exist and the question is how do we put them together to actually help us solve our problems so our surgeons are already doing this so some of you may recognize i was just perusing some local design firms and what they were doing in healthcare and i was going through the site and i said huh i recognize that the back of that person so this is rachel calcutt uh ucsf so she did she worked with a design firm to create a video to communicate a vision around how to use a new technology that relies heavily on generating empathy in in the people watching this video because how do you convince people that something is important you have to you have to figure out how you're going to communicate effectively we call this storytelling in the design world but this is about you might have this amazing technology or this great idea and if you can't make people feel that it's great and important you're not going to get anywhere so this is a great example of of using these principles in a way that might not feel quite as important when you're designing the project on paper but figuring out how to talk about what you're doing is tremendously important the video is online i can direct you to it if you like so this is the part where i bring up my good friend here who i hope you guys recognize dr djrkovic um our surgeons are doing this all the time we're all empathic personal experience is one of the main ways we build empathy and the way we provide care is often sort of redesigned based on our personal experience if you've ever rounded with dr jerkovich which i did as a fellow you know that he walks into the room and he lets everybody else look at the monitor and look at the drains and he goes right he talks to the people he wants to know the story he wants to know why they're there he wants to know how they're doing he wants to know how they're weathering their hospital stay it always struck me almost 25 years ago he gave the presidential address at western trauma i'm going to read you a couple of excerpts as examples of what it means to be empathic as a physician and what you can learn from it a review of the charges of my treatment shed some light on the frustration irritation anger and cred and incredulousness of patients as they try to understand today's medical system i can echo this having had my only hospital experience giving birth early about a year year and a half ago it's crazy we need to be attuned to the emotional well-being of our patients because that emotional well-being is critical to their recovery and survival right this is empathy and then it will surprise no one that dr durkovic managed to one-up me by having this observation 25 years ago before i presented this talk that the hospital in which i received my care the hospital which i practice is modern well-equipped clean and reasonably attractive but the ceiling in my room had one large water spot on it that i could not ignore lying on my back for many hours contemplating my newly diagnosed cancer patients are most often on their back looking up at the ceiling it is not a common perspective for doctors or administrators but it is after all the patient's perspective and that should matter the most so i guess i could have just read this and skipped the whole talk but so i'm going to start concluding here i hope that i have convinced you that we should care about this i hope that i have convinced you that it can help us that it can be a tool that we can employ to help solve some of our hardest problems good design stems from understanding human needs behaviors and desires and i would argue that good good health care does too i am not saying it's easy okay so i'm going to try i had a couple other slides listing all the barriers that i figured people would be thinking about in their heads i'll just stick to a few change is hard especially when the system already feels like it's barely sticking together right being asked to change a behavior a way you do something when you're barely barely have enough time to do everything that you have to do is really hard i acknowledge that innovation takes work it's not just a little light bulb that pops into someone's head someday it's a process that's why we have a way to approach it because it really does take work and we have real barriers in our day to day we're busy failing fast is not generally the way we uh encourage people to work in surgery um many problems that we face are messy and multifaceted and even though i've been talking about putting at the human the human being at the center there are competing priorities people are trying to run an institution that has to be financially viable like that's just a reality that we have to acknowledge but if we keep coming back to the human i think we will make better changes and we work in a culture that favors tradition randomized control trials proof final solutions and that's not going to change and nobody's suggesting that we stop doing trials or that we skip the science but when we think about some of our problems and how how broad and and multi-part they are i think design can really help address some of those alternate components of them and it's important we need help who are we kidding healthcare is such a hard industry and there are so many other industries that are thriving around us they have to be able to help us somehow and we have to facilitate that because they don't get they can't get it they don't work in this world we have to help them help us we need better solutions to so many different types of problems and design thinking is such a versatile tool that i really believe that we can't afford to ignore what it has to offer us so where do we start um you know i don't think none of us is going to walk out of this room and embark on a huge project takes a tremendous amount of time it's a full-time job for teams of people to do this but there are things that you can do in your everyday that i think will help so catch yourself before you declare that it won't work just try next time you think this is a terrible idea just don't say it out loud let the conversation play out humor it for a little while be humble enough to make room for creativity so this is about be humble enough to ask yourself well do i really know what the problem is do i really know that the way i'm thinking about it is the right way and to follow try to get at the abstract part of that well how do i figure out how do i figure that out who do i have to talk to what do i have to go watch what do i have to see and then when you're thinking of new ideas try to go abroad go to other industries go to other people go to extreme users look for inspiration in new places because otherwise it's we have the limited limited sort pool of things to draw from in our healthcare experience and try out a rougher draft than you're comfortable with this is hard um especially in healthcare settings where things are very regulated but take it out of the immediate clinical environment with your other with your other projects with your processes with your system stuff see if you can get people to try something before you know for sure that it's the right answer because you will learn from doing that and you will arrive somewhere better and then all these resources that exist around us tap into them help help people help you this is my thinker outside the box and i'll take any questions well doctor connect that was fabulous thank you and i remember so well when we were talking about you staying here at uc davis to join our faculty and you saying you know well what i do and what i did in my professional development years is different i remember promising you we would find a way i'm not sure we're there yet but this is a great example of you know the the new thinking that you that is so important that you bring to what we do and you're right medicine has got to change this we've been doing it the same way for like basically since the flexner report i mean it's been a really long time and we've really the time is right so it's fabulous let's open it to questions i'm going to start inside um with dr kappa great talk um i think one of the things that people underestimate is the power of the non-medical audience and so i think in designing and doing these innovations that piece about bringing in that other perspective even when we talk about simplistic things to us like mortality is someone alive or dead we think that's a very concrete uh definition but when you actually talk to people outside of medicine the interpretation of even that is difficult so i wonder if you can talk a little bit about sort of the value of that audience and how you get that audience is really at the center of some of the pcori work that you're involved with yeah so i guess it depends a little bit on what you're working on but this is what we talk about in terms of being narrative so to dr calcutt's point of not even death or being dead or alive is clear you have to go and talk to people and see what they're doing and understand how they're experiencing it and what they define those things to mean and then you have to be willing to say okay even though we have this definition on our side the world doesn't necessarily see it that way and and taking that step to then go to your audience to your users and say we're going to define it the way you do because we are designing for you and even though it's not convenient for us necessarily adjusting to that is how you then help those people better the pcori thing that she referenced the patient centers outcomes research initiative that is all about studying ways to make patient experience better and that to do that you have to ask them the project that i'm working on has a family advisory board that we meet with it's literally 20 plus parents who have experience in the projects about pediatric trauma they had a children with traumatic injuries that required hospitalization and listening to them and hearing from them that they don't actually care how complicated it is on our end they just want to feel reassured they want to know where they're going to park and understanding that side of the experience is how is really the only way we're going to make it better for them does that answer your question but uh from the professor aigen wang had a comment he says that was a wonderful talk i think you would be a great faculty member for the bme quarter at aggie square program engineering students can help with your projects and they could learn a lot from your innovation program too i would be happy to help make the connections for you and our department to be in the in college of engineering that'd be great i actually there's a cool thing going on in one of the biomed engineering courses this this quarter where they're designing around covet so there are a bunch of different student teams and i've been working with them a little bit to provide feedback on their covet designs it's a really fun thing if anybody else wants to participate i'm happy to pass that along thank you well thank you i enjoyed your talk i think that um i just want to emphasize your point about defining the problem we had an experience at stanford stanford really when with the previous ceo really focus on patient-centered care and i think that was very important because when you when you describe human design there's a lot of competing humans especially in a you know in a medical center and what we found with the patient they were trying to improve patient experience with wayfinding and the waiting rooms and all that stuff and what we found was that what they what the patients defined as the episode of care was very different than what we defined as the episode of care and it turned out that when patients returned their press gaining scores the longer they took to return their score sheets the lower the score they got and we realized that what they consider the episode of care extends far beyond when they leave and it created this whole process with how to make sure that labs were ordered easily more easily and and radiology and that there was good follow-up and so forth and it was really an an example of understanding what the actual problem was it wasn't so much that the chairs in the waiting room were old it was that they you know they some patients weren't getting what they need my question for you is related this competing human design so you know medical record is an is an example but there's thousands of of of examples within the medical center where the medical record really is designed right now as a billing tool and it really doesn't meet you know that certainly doesn't meet the needs for the physician and i'm not sure if it really enhances patient care so my question for you is when you're approaching a problem where you clearly have competing human design needs how can you describe a framework for how to address that and either develop priorities or develop a plan because i think that's a real challenge in our complex system for moving forward i can try i mean i can't solve the medical record unfortunately but maybe you can i think i think dave lush occurs all over that but so you're exactly right the medical record is designed with something else at its core and we talk about that venn diagram usability and our needs as physicians are not the primary focus of the medical record and i think if you you have two options you can either try to totally redesign it but then you have to figure out how to meet all those needs and that is exceptionally challenging or you can say okay within what's there that has to serve the billing function how do we make it more human-centered and there are actually some efforts ongoing if you talk to the medical records team they will come and sit with you and watch you use the medical record and try to help you sort of um oh gosh what's the word adjust it for your own preferences as much as possible and there's actually a tremendous amount of variability within the medical record that i personally don't know how to access but that component of somebody coming and sitting next to you and watching you use it to see what your needs are while you're using it that is one way that's a band-aid because ideally it would just work to serve us automatically um is there a technology that could actually just record how you're using it and in a sort of ai kind of way adjust and automatically show you what you need to see that would be amazing um but i don't i don't know that i have an easy answer to how to fix that problem because you're absolutely right that is one area where billing got put first similar to how some of our systems are built with efficiency put first cost efficiency there's there's some real institutional questions about how you prioritize and then you can ask should they be totally separate should we have a different way to communicate as physicians from how we build do they have to do they have to live together i don't have an easy answer but that's sort of how i think about it i want to congratulate you first of all on a fabulous talk but the second thing i wanted to mention is this is the most inspired grand rounds that i've heard since i've been here and i can't tell you how many ideas are running around in my head when i hear you talk about this because this is truly where we need to be and i'm so proud that you're in this department and you're doing all this good work um the question that i have is more because i'm super jealous that you have that experience as a resident to do something like this the question is for the residents how did you have the courage to decide to go in to do this for your professional development years and how would you inspire the residents to look for these opportunities outside of the world of medicine because this is what we need we don't need to be doing medicine over and over and over again otherwise we get very myopic so my question is for the residents but because i'm sad that i didn't have that opportunity myself well thank you first of all but i think i think that's a great question because i was lucky to be supportive i was at stanford um tom crummell was exceptionally supportive of all things innovation i mean when i was an intern i still remember he told us if you dream it we can do it right and that is just his approach to the world so one one part is that it was supported it was okay for us to choose things outside of basic science i have two basic scientists in my immediate family i have tremendous amount of respect for what they do it is not what i'm cut out to do it's not what i'm good at um so for me this was a way to try to understand how am i going to contribute to surgery how can i make what make things better for our patients in a in a route other than basic science but i think you were absolutely right to acknowledge that it is it's hard it's awkward um it's hard to figure out how to talk about it in a in a field where publications are our currency um this isn't this isn't stuff that you study a lot of data on or you you could so there are lots of people who are doing this and then studying the outcomes of their projects in the consultancy version that didn't work because people came to us and they took their companies elsewhere but if you were to do this in-house you could you could study it you could publish about it but that is a real thing of figuring out how to talk about this kind of thing in a field that has a much more traditional way of seeing science and research and and figuring out how to operationalize it when you have a new job is hard i i'm still trying to figure out how to do that but what i would say is that our job is to figure out how to help take care of patients better and thinking about that broadly whether it's are you going to get a master's in education to be the best surgical educator you can be and bring new educational strategies to surgery are you going to do design to figure out how to work on some of this system stuff we had people who did policy programs during residency to help get into health policy i think all of those are really important ways to contribute back to medicine and to help the field grow i think what you have to do is be honest with yourself about what's interesting to you and engage with that because as you look as residents look everybody looks into a career a long multi-decade career figuring out what's actually engaging and motivating to work on that's where they're going to have success so i would encourage the residents to be thoughtful about that and to be open to trying new things and seeing where these these domains overlap and then figuring out what is exciting to them you know one of the things that we so that just brings me thank you for the segway to our upcoming you know we call it resident research day but you know as we've defined skeeter doesn't like it when i called the tracks but when certainly when i came to davis there were so many things that were unique about davis that you know how can we leverage how can we leverage being in the capital public policy and the people who do that kind of work properly to the veterinary school and the engineering school and some of the unique at the ag school i mean the intersection between you know our environment and health and food is really uh an important part so there are it is hard as you said it was really interesting to say the the linear thinking that surgeons develop at the goal-oriented way we are it's hard to change that thinking we often talk about we advise you you can be depressed for the first month after you try to switch from your line or you're thinking get solve all the problems and you're going to start going into the quote the lab or your professional development years and it's like 10 o'clock in the morning and you haven't done anything you know you have to check out any boxes what do i do okay now it's noon i'll have lunch whoever had lunch when they were an hour too so it's difficult and the next the piece about failing and failing again i remember saying you have to write 10 grants before you get one published and that's really hard to get one accepted and it's not going to be your best and that's hard for a surgeon because we're not used to thinking well i'm going to have 10 patients die before one makes it you know so but yeah try it it doesn't work try it again it doesn't work it doesn't matter don't be so invested but it's switching that thinking and it's hard to be nimble so i think you really described that incredibly well if i describe it better than i do it just yeah to be totally honest right i'm not perfect at this this stuff is still exhaustingly hard for me just because i talk about it and got to do it for as long as i did i think that was my point of this acknowledging how hard this is i don't pretend to be an expert at change this is something we're all working on in our field we're we intend to not be risk-averse that's what happens to medicine and it's that was a great talk tanya i think that you know one i'd like to echo what elizabeth said is it it's really inspiring for our our residents and the trainees and i would i would suggest to them actually that they're the ones that are actually going to make the real changes in this i think by the time you're in your late 30s or you know and you're certainly working in the field your ability to innovate is actually really hard um and i've seen that time and time again i'd say that our sisters in the bay are ahead of us a little bit in terms of innovation but i would i would also say that there's plenty of people at uc davis on the davis campus and here that are really interested and committed to innovation the problem is that we're still a little bit too siloed and that's changing and i would suggest that the advent of aggie square which is real is is going to change how we do it's going to be like qb3 and the biodesign center at stanford in terms of allowing the intermingling of of disciplines to be able to do some real innovation here my question for you has to do with the fact that i love all the patient-centered stuff and i tell you that there was a patient transport elevator that i was in at ucsf that had the most disgusting ceiling in the world it was actually the back of the wards and i kept on saying like when we roll our patients down to ct this is what they look at it was literally like it looked like bird droppings on the top and it was like the most horrible thing and i remember like all of us talked about it nothing ever changed but my question is actually more about hospital systems in general and the fact that um the public perception is that doctors can do all this stuff and we should have to lump it because we make a lot of money but the truth is that if you look at the system from the bird's eye view the people that are actually doing the work the docs right over the past you know 15 20 years have been asked to do much much more work deal with much much more complexity and actually have a lot of work that used to be clerical placed upon them now specifically through the medical record and other things i like my question is um and also frankly the ergonomics in the operating room are just horrendous and like so there's more work safety and osha requirements based on people that put together cars than first surgeons frankly and we all end up with physical ailments because of it my question is what's it going to take and when are we going to start paying attention to the docs and when are we going to try and use real um out of the box thinking to make this system work because the people that are really burning out are the ones are actually adding value to the system that's a great question a great point and a very motivating one and i think the the easy answer to that is that's why we have to engage because nobody is nobody is feeling bad for us nobody is out there saying how can we help the doctors be more comfortable it's just not happening because partially people just don't know and that was sort of the the point i was trying to make about one of the most valuable parts of my experience at ido was spending time with all these smart professionals their engineers their you know their you know all sorts of things that i don't know about lots of stuff and they know nothing about what it's like to work in a health care system and so until we push to have those problems fixed i honestly don't think they will ever be addressed so i think it takes people like colorectal surgeon to decide that the colonoscope just needs to be better i mean we have better video game consoles than we do scope controls right and it just takes someone to care enough to make that their priority and then there's a business opportunity there and you have to figure out the right price point and all these things but certainly those things can evolve but i think it has to come from us and that's why i think trying to figure out how to connect to more of these resources is really valuable because we sit in our offices and we have these great ideas these moments like this should be better and then we go on because we have 700 other things that we have to do but we don't have the time and space to do these huge innovation projects on our own but that's where hopefully some of these other resources come in um jim kovach is in charge of aggie square and i was actually talking to him the other day about how if if i could envision something for aggie square that would help us it would be something almost like a concierge desk where you could walk in and say look i have this idea who do you think i can talk to that could help me think about it or flush out some options just to sort of get the wheels turning because we often sit with our ideas and our needs and don't have anywhere to put them we need to sit there yeah yeah offices in the same place yeah so let me put in a plug i guess so just to wrap this up this fabulous presentation and some with great ideas to make it somewhat actionable i'm going to put a plug in for dr wang's quartered aggie square it's the first time there's going to be a class that the undergraduate engineering students can take where they will be on the sacramento campus and what he needs are surgeons for them to shadow and you know this experience from tom cruml's effort but just having them walk around with you with a different perspective in the operating room when they see the trash they see the challenges of doing this gives ideas so he is looking for volunteers to not do much more than have someone hang out with you and talk to them and i think that's that's a little way that and all of us can get involved and then you'll form a relationship with one of these bright young engineering students and develop different ideas and so that's just step one but i think that we have two big footprints the department of surgery going in aggie squares actually three now so we will likely have a huge cornerstone one in the food uh space with the center for metabolic and elementary research so that is going to be one of the anchoring spots the other is going to be the engineering and the bioengineering uh corner if you will and the other one will be the information um sort of technology and ai sort of arm of things there so we we have not so quietly you know insinuated ourselves into having a big footprint there because i actually do think that surgeons tend to be people who are at the cutting edge of being able to identify what are the needs and what are the problems and so we should stay tuned stay involved stay engaged talk to folks because we're the people ready to jump in so thank you again for that and i think we look forward to lots more

Channel: UC Davis Department of Surgery

Views: 289

Rating: 5 out of 5

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Id: MV90cwhsud4

Length: 66min 24sec (3984 seconds)

Published: Mon Feb 22 2021