How ‘design science’ can help achieve the triple aim set of goals

Issue: October 2011

ByPamela K. Greenhouse, MBA

ByAnthony M. DiGioia III, MD

Anthony M. DiGioia III

Pamela K. Greenhouse

Health care leaders have focused tremendous effort on improving care delivery. Yet, despite the best of intentions, morbidity, mortality, patient safety, access, fragmentation and cost continue to be enormous challenges. We also have a long way to go before patients are satisfied with their care. Nationally, 67% of patients responding to a recent Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey checked the most positive score for “overall hospital rating.”

There are a lot of good ideas about how to improve care delivery, yet implementing, sustaining and then exporting them for widespread adoption has been difficult. Care delivery improvement is traditionally accomplished through either clinical or process efforts. Clinical improvement efforts rely on evidence-based practice and clinical pathways, while process efforts typically involve rapid cycle techniques such as Six Sigma, Toyota Production System (TPS) and Lean. Both clinical and process improvement efforts are vitally important and result in good ideas that can and should be replicated. What is needed is a methodology that can take these local efforts and accelerate their adoption broadly.

We suggest that design science and experience-based design (EBD), which focus on the patient and family care experience, can build upon clinical and process efforts as a third and equally important tool for care delivery improvement. Design science and EBD can help us to achieve thorough implementation, sustainability and acceleration to transform care delivery improvements both locally and nationally.

Design science and EBD

Nobel Prize laureate Herbert A. Simon introduced the concept of design science in his 1996 book, Sciences of the Artificial. Simon put forward the analogy that the relationship of natural science to a forest is as the relationship of design science to farming. The forest is the natural environment, while farming is man’s attempt to achieve a goal by acting upon the forest. Similarly, natural science is to the human body what design science is to health care delivery — i.e., health care is the intentional intervention on the natural state of the human body with the goal of improving the health status of the patient. In typical design science professions, such as engineering and architecture, the engineer applies scientific principles to practical situations in order to improve the operation of machines, processes and systems for the end user, and the architect uses scientific principles to create a design that meets the functional and aesthetic goals of the client. The commonality between health care and these other design professions is the concept of making things better for end users. EBD is a related technique in which experiences, co-designed with the end user, inform the redesign to meet the end user’s needs and goals. In co-design, patients and family members provide real-time input while health care staff lead the design effort, creating a partnership in which each participant fulfills an equal role in bringing true patient-centeredness to bear on the health care experience.

Our reliance on clinical and process improvement efforts has left out the day-to-day care experiences of patients and their families. The health care system is so complex that it’s overwhelming; we can imagine an ideal experience, but we don’t know where to start to create and sustain that goal. How do we get from the current state to the ideal? What tools can we use and how can we get there simply and without additional resources? Design science and EBD put the focus on the patient and family by viewing all care as a complete experience through a full cycle of care and by providing the tools to allow health care professionals, patients and families to co-design simple solutions even in our complex systems.

Only a few experts in the design sciences and EBD have begun to take this concept into the health care realm. Paul Bate and Glenn Robert make the point that patient feedback has largely taken the form of self-reported impressions via after-the-fact methods (e.g., surveys), and that these methods lack the necessary vitality and urgency necessary to effect widespread transformation. Understanding patient experiences at a deeper level is necessary to improving those experiences. They advocate putting design on an “equal footing with process and clinical goals” by placing the experience of patients at the center of the design process. This is done, they say, through direct observation and real-time conversation in which the experience is reflected upon and synthesized into words — bringing the user experience to life through a process called EBD.

Examples in practice

We feel that design sciences and EBD provide a valuable framework for transforming end user experiences. Through the use of these tools, we can move from any current state to the ideal and focus on rapid and widespread implementation. The Patient and Family Centered Care Methodology and Practice (PFCC M/P) is one example of this approach that shows promise in improving quality, outcomes, satisfaction, patient safety and cost. An easy-to-learn six-step methodology that views all care experiences through the eyes of patients and families, it can be quickly implemented with little lead time and no incremental costs. PFCC M/P uses a technique called shadowing, in which the patient and family experience is clarified, leading care givers to feel a sense of empathy and urgency to drive change. Care experience flow maps are created, providing an accurate visual representation of the care experience and opportunities to improve efficiencies, quality and safety. Improvement projects are then co-designed by patients, families, and front-line care givers to close the gap between the suboptimal and ideal experience. The PFCC M/P provides the framework for co-design, which gives patients and families exactly what they need; resulting in the optimal use of health care resources. The number of front line care givers and leaders that participate in the PFCC M/P leads to cultural transformation and ease of spread both within an organization and then regionally as well. In areas where the PFCC M/P has been initiated, we are seeing gains not only in patient satisfaction, but in clinical outcomes and reduced costs.

Achieving the triple aim

Initially developed by the Institute for Healthcare Improvement (IHI), the Centers for Medicare & Medicaid Services (CMS) has recently adopted the triple aim as a set of goals for the U.S. health care system: improving the health of the population, enhancing the patient experience of care and reducing the per capita cost of care. Donald M. Berwick, MD, MPP, administrator of CMS, has written that the possibility of achieving the triple aim is no longer scientifically debatable; rather, the barrier now is simply the perception that achieving the three goals will require painful disruption to institutions and habits.

We suggest that design science should be the new and “third” science for health care improvement, incorporating EBD through methods such as the PFCC M/P and the NHS’s EBD initiative. Used in conjunction with the clinical and process sciences, design science can play an important role in achieving gains in all three areas of the triple aim in a way that positively engages front line care givers, health care leaders, patient populations and families to move care delivery toward its ideal.

References:

Bate, Paul & Robert, Glenn. Experience-based design: from redesigning the system around the patient to co-designing services with the patient. Qual Safe Health Care. 2006; 15: 307-310.

DiGioia A, Lorenz H, Greenhouse PK, Bertoty DA, Rocks SD. A patient-centered model to improve metrics without cost increase. J Nurs Adm. 2010;40(12):540-546.

DiGioia A, Greenhouse PK. Patient and family shadowing: creating urgency for change. J Nurs Adm. 2011;41(1): 23-28.

Anthony M. DiGioia, III, MD, is the editor of Emerging Techonology & Innovation. He can be reached at Renaissance Orthopaedics, PC, and Pittsburgh, Pennsylvania Innovation Center, Magee-Women’s Hospital of UPMC, Pittsburgh; email: tony@pfcusa.org.

Pamela K. Greenhouse, MBA, is the president of Pamela Greenhouse Associates. She can be reached at 5622 Melvin Street, Pittsburgh, PA 15217; (412) 422-2613; email: pamelagreenhouse@gmail.com.

Disclosures: DiGioia and Greenhouse have no relevant financial disclosures.