How Children’s Health System of Texas Is Improving Care with Design Thinking
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The potential for improving the quality of healthcare has never been greater. Advances in data analytics give us the ability to look at large populations and precisely segment their needs and new technologies such as tele-medicine give us the capabilities to deliver customized experiences at scale.

But the most powerful drivers of change are not necessarily technological; radical improvements increasingly also come from applying new innovation methodologies like design thinking that focus on developing a deep understanding of patient experiences and invite patients and partners into co-creation processes.

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These methodologies free us from cognitive blinders.  Healthcare professionals often see the patient experience through the lens of their own expertise. They come with a theory about what needs changing, which they assume will improve the system.  That can be helpful, but by not looking at the experience from the patient’s own perspective, they may well not recognize where the system has lost its relevance to patients’ needs.

In order to bridge the gap between what patients need and what the system offers, healthcare professionals must begin by setting their expertise aside. This creates the conditions in which key stakeholders can explore new strategies together.   The co-creation journey involves seven steps:

Step 1: Find the future in the present.

We begin by developing insights into today’s experiences.  Exploratory research using design thinking’s ethnographic tool kit helps define the jobs that key stakeholders, patients, caregivers and partners, want or need done.

A partnership between the Business Innovation Factory and the Children’s Health System of Texas provides a good example. As its first step in addressing a decline in children’s health in North Texas, Children’s identified a number of families to study, working through what BIF called “trusted agents” such as pastors and neighbors.

The agents interviewed the patients and their families to gain a deeper understanding of patients’ lives and to gauge their “say-do” divide (the difference between what people say they will do and what they actually do). The team used journaling, journey mapping, shadowing and collage making to increase patients’ ability to reflect on their own perceptions and experiences. The following conclusions emerged:

  1. If Children’s Health wanted to improve kids’ health, it needed to focus on families, not just the kids.
  2. What families wanted was a better life, not better health. If parents needed to feed their kids fast food to get to work on time, they would do so.
  3. Families also wanted to feel in control of their health journey. This was difficult in a system where things were done to and for people, not with them.
  4. Families listened to those they knew and trusted: teachers, pastors, YMCA staff, and other families who had been through similar experiences. 

Step 2: Identify opportunity spaces

The findings emerging from step 1 translate into a set of opportunity spaces, promising areas in which to look for new solutions.  At Children’s, each such space posed a different question:

  1. How might Children’s create more convenient sources of care? Because the emergency department was often seen as a family’s most convenient source of care, making alternatives more convenient was another opportunity space, involving solutions built on leveraging trusted information sources within the community and on improvements in the attractiveness of nonemergency care.
  2. How might Children’s make children more responsible?  Because it is difficult for kids to see the link between their health and the choices they make, nudging them towards awareness and accountability was critical, suggesting solutions that made healthy goals more meaningful to children and provide frequent real-time feedback.
  3. How might Children’s deliver care beyond the child? Because families can play such a critical role in children’s health, moving from a place that ignored the whole context of a child’s environment to one of acknowledging and treating root causes and built a family network that was a positive influence was key (suggesting solutions that equipped children with life skills to make healthier choices as they grow).
  4. How might Children’s inspire, guide, and support other change agents? Because families cannot always be relied on to make and encourage good choices, reaching beyond them offered a third opportunity space, suggesting solutions that provide mentors and offer children opportunities to share their stories and get positive reinforcement.

Helping the staff at Children’s Health understand and own these opportunity spaces was critical. By listening to the children and their families telling the story of their experiences, staff could move from judging these families to co-imagining possibilities.

Step 3: Identify organizational capability gaps

Once they understood the main features of the future they wanted to create, the Children’s team began identifying, unbundling, and realigning their capabilities in order to get there. Capabilities are made up of people, processes, and technologies.

Once a key capability was identified, staff could engage in conversation about how to use that capability differently, which allowed the owners of that capability an opportunity to identify with the new future. For example, Children’s has a strong care management capability, which is largely comprised of a team of people who help patients manage their medical care, medications, etc. As Children’s began to imagine a well-being model that emphasized patient agency, it began to imagine how might it repurpose that team to focus less on managing care and more on activating agency.

It allocated a portion of the team’s time to serving as “coaches” and a new protocol was developed to help the team understand the differences in the role that they would be playing. In an agile and experimental process, the team participated in reimagining this new role, critiqued it and iterated on it, helping them feel that they were leading change rather than being subject to it.

Step 4: Test critical assumptions

Before an organization actually applies a new strategy, it must test the critical assumptions underlying it. To do this, the Children’s Health team designed, with patients, two programs.

The first was called “Your Best You” and involved self-discovery and education for self-knowledge through a six-week summer camp that aimed to activate kids’ sense of self by marrying hip hop education and Design Thinking.  This helped the kids to figure out who they were, what they wanted to do in this world, and who could help them achieve their goals.

The second program (“What’s Cookin’, Dallas?”) engaged family members in curating a food and nutritional experience for other families in their communities. This measured people’s sense of connection and belonging, as well as their sense of agency and control.

Step 5: Co-create the new model with key partners

The opportunity spaces Children’s identified pointed toward a transformational business model that was wellbeing (versus sickness) centered, citizen (versus physician) driven, prevention (versus intervention) focused, partnership based, and community supported.

In four opening sessions, the team identified the key institutions, resources, and people who might offer valuable local knowledge for designing the new business model.  They then invited these partners to a participatory design studio focused on a single question: How might we design a new system that connects convenient clinical care with self-managed well-being?

The new healthcare delivery model that Children’s came up with from these processes consists of a series of twelve activities, from generating family awareness of the child’s needs and the available resources, through to the creation of a wellbeing plan, and culminating in sharing and comparing treatment experiences.  For each stage they identified the people who needed to be involved, the medium of the meeting (face-to-face/phone/e-mail/online), and the goals of the interaction, both functional and emotional.  For instance, in assessing the barriers getting in the way of health needs the professionals interacting with the children and families would have a functional goal of raising the children’s and families’ understanding of those issues and an emotional goal of making sure that the children and family felt heard.

Step 6: Find sustainable funding for continued experimentation

In a world still dominated by fee for service, it is often a challenge to sustainably fund new business models.  Children’s identified a way to combine private and public sources of funding.   It could use resources from its licensed insurance company (funded by the savings from enrollees’ utilizing less expensive medical care) coupled with funding from the Texas Medicaid Section 1115 Waiver program, plus philanthropy and grants. This package would give them five years to pilot the new approach.

Children’s recruited 15 families for 16 weeks to engage in a change process centered on family meals where families met the supportive coaches who would act as their “navigators” to access the wide range of community services that could improve children’s wellbeing. Families did an exercise where they were asked what the one thing was that they wanted to address. Navigators contracted with relevant agencies to deliver this service (for example, providing a gym) and checked in frequently to assess and guide progress.

 Step 7: Measure progress

Children’s developed a metric of family wellbeing, based on five key dimensions: family members’ sense of control over their healthcare, their understanding of their wellness goals, their sense of self, the quality of their access to information and knowledge, and the quality of the community support system. The test was administered both before and after the pilot, as was the family’s adherence to the model. At the end of the program these metrics were then correlated to observed changes in health management behavior (for example, compliance with prescriptions).

Children’s observed that the pilot engaged people in their wellbeing. With a greater sense of control in their lives, people also started taking greater control in their health management by, for example, regulating their blood pressure and following through on smoking cessation programs.  Following the pilot, the program was rolled out as a core health offering through its HMO.  The program is currently being rolled out with other populations.

New strategies that offer dramatic increases in value creation for stakeholders, and are executable within the constraints of today’s reality, emerge most readily from the kind of bottom-up, patient-centered approach that the Children’s story illustrates. This approach involves combining a deep understanding of the realities of patients’ lives with a critical assessment of organizational delivery capabilities to create a real conversation about marrying the two.

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