TRANSCRIPT: UX Week 2010 – Chris McCarthy & Christi Zuber
Don’t Forget the Humans!
Chris McCarthy: Did anybody else get teary during that ending presentation?
Christi Zuber: Yes, yes, yes.
Chris McCarthy: So I feel a little emotional right now. Which I think is really appropriate, actually, for the kinda work that we do, because we’re trying to bring humanity back into the workplace, getting away from mindless experiences and mindless work.
So we are from Kaiser Permanente’s Innovation Consultancy, and we were founded in 2003 in a very experimental way. We weren’t sure if this kind of thinking could actually work in an old-fashioned industry like healthcare. So what we decided to do is to experiment in 2003 by really trying to get to understand the humans in our environment, which means patients, doctors, and nurses at Kaiser Permanente.
But let me tell you a little bit about Kaiser, for those of who are not familiar with our organization. We’re mostly based in California, although we’re in many other states. We service 9 million patients; 8 million of them are in California. We have 12,000 doctors. It’s the largest private practice in the world. We have over 400 clinics. We have 35 hospitals, 169,000 employees. So basically what we’re saying is we’re a big organization. And there’s only 3 of us to do that work. But we’re growing.
Christi Zuber: Small but mighty.
Chris McCarthy: Small but mighty. And what we hope to share with you over the next 30 minutes is our journey of trying to bring user experience into this kind of organization and some of the tips and tricks that we’ve learned along the way, some of the techniques that have really, really worked well for us, and then show you some of the output of some of that work.
So the first thing you should know is that the cornerstone of most industry is probably customer-centricness, and in healthcare, that means patient-centered. And since 1999, the Institute of Medicine has made this pretty much the cornerstone of all of improvement work in the workplace. But that creates a bit of a creative tension, because we are trying to do human-centered design. And the creative tension is that if you design just for the customer – or just, in our case, for the patient – you’re forgetting about all the other people that have to live in the environment, which are your doctors, your nurses, your staff that support all of those people.
So we kind of enjoy the creative tension because it really does allow us to think more critically about the kinds of experiences that we are designing. And once we explain that we’re not necessarily tossing the patient but really what we’re trying to do is optimize the relationships for people in our system, and we want our clinicians and our patients both to have the best experience that they can, utilizing our spaces, tools, roles, and processes at Kaiser Permanente.
So again, in 2003, it was an experiment. We were trying to figure out whether these methods could actually work. And one way that we knew it was working was from pictures like this. This is seven years ago. You can tell ’cause I don’t have gray hair. And there’s a few things that I love about this picture. One, you can clearly see some of our techniques all in action at the same time. Handmade constructions – you can see these props in the back that we quickly built. Enactment, where we’re actually acting out a scenario here, a workflow, a user experience, the intangible thing.
But what really stood out for us, why we knew we were on the right track, is that – look at this nurse’s face up there. You don’t see that when you do business process redesign. I mean, that is just a really boring thing. And traditionally, that’s how we created new workflow. That’s how we created new experiences was by going to a conference room and doing business process engineering. And, again, we never saw that kind of joy trying to build something new.
And so as a transformative exercise for us in our organization, it was powerful, and also it yielded something equally powerful, which is an innovation called the Journey Home Board. The Journey Home Board is a tool that’s in all of our hospitals at Kaiser Permanente now. It is a tool that allows – when a mom first has a baby, her and the dad and the family and the caregivers will see this board in the room, and they can use it to understand the things that a mom has to do to get out of the hospital and get to that rocking chair with her baby that she wants to be in, in the home. And so you can see there’s some checkmarks there, and the clinicians can flip over tasks as they get completed. So it’s a really wonderful communal tool for the care team, for the mom, for the dad, to create a common understanding.
This tool was developed in less than three months, and it went viral in our organization in less than a year. That also was transformative. That really helped us understand that this way of thinking, this way of co-designing, which is the foundation of our group – co-designing means having the patients and the doctors and the clinicians, along with us, work together every step of the process to come up with new experiences and innovations for Kaiser Permanente. That, along with this innovation, really set into motion our future as a design group.
So to take us through some of the process, I’m gonna turn this over to Christi.
Christi Zuber: So what Chris and I are going to do for the next 20 minutes is go through the main steps of our process that we take to design for the human interaction together. So these steps themselves probably won’t sound that different to you all. Some of the tools, we’ve heard different speakers mention over the past few days, which has been great. So what we’d like to share is how we use them and what we’ve gotten from them.
So first, we always start with understanding what’s really happening in those interactions. What are the needs of the people that we’re actually trying to serve?
So one of the really simple techniques that we’ll use is drawing exercises, so that will be – I remember when we first started trying this, Chris wasn’t the biggest supporter of this. It felt a little silly.
Chris McCarthy: Well, I did take the comment class yesterday, so I’m now a believer.
Christi Zuber: He’s a believer now. So basically, just going out to – these are actually drawings from our nurses. We also do the same thing with our patients. In this example – so we’ll tell you a little bit of a story about medications, giving medications.
So in the examples that we show, these are from a project that we did around reducing medication errors. So I mean, I know you all have heard about medication errors that happen various times in the news stories and things like that, and it is a significant problem.
So we wanted to – we were asked to tackle that issue, so a very serious issue that traditionally is tackled in extremely serious ways. But we decided to take a different spin on it and really start to understand as we’re talking about the interaction between the people and the processes and where that might be breaking down.
So we went into our hospitals and we were observing nurses when they get the medication, and they’re responsible for doing all the safety checks of the medications before they go to the patients. When you ask nurses, “How is that process for you?”, they say, “It’s frustrating, but it’s fine. I deal with it; it’s fine.” When you ask for them to actually draw what that experience is like for you, you get these pictures. So I don’t know about you all, but that doesn’t look very “fine” to me. You know, this whole frayed hair up on the end was the common theme that we saw out of probably 100 images that our nurses drew for us.
So what this does is it allows us to have a tool to then talk to them about that and say, “Tell me a little bit about – it says chaotic interruptions, unclear process. Tell me about what that means to you.” And then you can actually start to engage in a dialogue about really what’s deeper into the surface for them. So that’s a technique that we found is very, very simple but very, very powerful when you’re using it with people.
This next thing that we’re going to queue up is video ethnography. So we use video ethnography in a number of different ways. What we’re going to show you is a video of a patient’s caregiver in their home. So, again, video ethnography is yet another way to tell stories and to share stories among people.
When you’re beginning to try and co-design, what’s really, really important is that, one, you get the viewpoint of other people so that you start to see how other people are experiencing things. You rarely ever have the opportunity to walk in someone else’s shoes. Video ethnography helps you to do that. So we’re gonna queue a little bit of a video that we took of a patient that was in one of our hospitals. And this is a video of his wife and what actually happens when she leaves and goes back home, and how she organizes her medications, which was very insightful for our clinicians. See what you think.
[Video begins playing]
Female: I took it to the clinic because the endocrinologist may have questions, but normally it stays right here, because I have it arranged – when he was discharged from the hospital, this is what they gave me. Amy, do you have the oxycodone? Yes, it stays on the stove.
Male: You do the same thing at lunch. You put it in the cup and –
Female: Yes.
Male: – have him –
Female: I always do it with a cup.
Male: Okay, got it.
Female: And it goes with his meal.
[Video ends]
Christi Zuber: So beyond the obvious – that she doesn’t cook; this is where she keeps her meds – I think part of the insight that our clinicians started to get from this is, “Wow, we don’t think about what happens when people actually go home from our hospitals. We have professional staff that are organizing all of those medications. When we send them home and they bring all their things home in a bag and they have to re-set up in their lives and make this work in their lives, that’s pretty powerful.” So from things like that, you can start to gain a deeper empathy and a deeper understanding in that connection.
So along that deeper empathy and deeper understanding, another really good tool for being able to show videos or be able to tell stories is a way that – if you’re going to co-design, one really significant thing about co-designing is one I’d mentioned, understanding other people’s viewpoints, but also feeling heard yourself, because if you can’t feel like someone understands where you are, it’s hard to design solutions that might change what your current state is.
So one of the things that we do actually – what you’ll see in this video – is this is a side-by-side. This is actually a photograph that we took every minute during a nurse’s shift, and we cut it down, so we’re not gonna show you the whole thing. But we took one photo every minute of what a nurse is doing during an eight-hour shift at the hospital. Then we also took a photo every minute of what the patient is seeing in their hospital room. And when we brought people together for a design session, we actually showed this to them so that the patients could see and the nurses could see what the differences or the similarities were in those worlds. So take a look at that and see what you think.
[Video plays, with music]
So it was really another big sort of “ah-ha” moment, one for our clinicians to say “Wow.” When our patients say, “Why aren’t you in here? Spend more time with me. I’ve got some more questions for you,” they didn’t realize the stillness in the world of a patient when you’re sitting in the hospital staring at a wall, hour after hour after hour. And when a nurse comes in there, you have so many questions. When another clinician comes in there, you have so many questions. You haven’t seen someone.
So bringing in that emotion to that – and also, on the flip side, for the patients that were designing solutions with the nurses, to say, “I had no idea all that was going on outside of my room. I think of them as chit-chatting with their colleagues, and why aren’t they taking care of me.” So there became this empathy in the two worlds together, so that they could look at, well, how can we design for those interactions between our worlds together.
So now we’re going to talk about what happens after we start to create this empathy, this understanding, look for these patterns that are happening, and begin to design solutions together.
Chris McCarthy: Right. So this is where our co-designers get very excited. This is where they get to bring out their dreams, their aspirations, and show us what these things are going to look like. And, again, you probably experienced some of these techniques over the past few days. I think in Gamestorming they did some of this stuff, and as designers, hopefully you’re familiar with some of these tools.
But, again, the key thing here is that these are co-designers, meaning temporary designers: nurses, doctors, and patients. So during the ideation and prototype phase for us is usually about two days at our innovation center, which is pictured up here. And what you see on the screen is some handmade construction, and you see an enactment going on, on that side of the screen.
And what they’re doing is demonstrating a few sets of ideas that they thought would make medications better in our hospital. And so this team tore apart a bed and created the “Ferrari of all med beds.” It had a microwave built in it. It had a refrigerator. It had I think a closet built in or remote-controlled television, including the toaster and the kitchen sink. But those are important things for them to quickly build out and show us what they’re doing through enactments, because often it’s not really the “Ferrari of med beds” that’s important; through the enactment, it’s demonstrating the needs of what having everything really at fingertip reach could do for that intangible thing called the workflow that we’re trying to change.
What I really love about this video – about this picture is that you’ll notice in the background this little woman circled. She had an incredible handmade construction. Her handmade construction was simply a smock with lettering on it that said “Leave me alone.” In her enactment, she had a doctor, and a patient in a bed, and she was demonstrating giving medications, and the doctor came to interrupt her. And she turned to the doctor and said, “Leave me alone.” It was very, very clear what her idea was, if you couldn’t tell from the vest. And we got a little bit of chuckling and a whole lot of “no ways.” People were just like, “This will never fly.” Usually those are indicators, when people are laughing or you get kind of like a lot of little grumbling going on, that there’s something special there. So that is a trigger for us to pay attention.
So we’ve heard over the past few days, people trying to do enactments and people in their own environments wondering how these things really work. So over the years, we’ve perfected our techniques of doing an enactment, and we call it video enactment. The first few years, we used to have folks build their handmade constructions and show us how these things worked. Well, I don’t know about in other industries, but in healthcare, folks are very, very serious, and when you give them the opportunity to play, sometimes they play a little too hard and the whole thing becomes a really big comedy routine. And although playfulness is really, really important, what we have found is, by doing video enactment – so asking them to perform for a video for two minutes – really gets them to still be playful but really focus in on what they’re trying to demonstrate as their new concepts. So it’s a really great technique that we started using just this past two years, so here’s an example.
[Video plays of enactment]
Male: Action.
Female: Hi, we tackle the issue of how might __________
Female: Hi Honey, How are you doing?
Male: Lousy
Female: What’s wrong?
Male: Well, I can’t get enough sleep. I don’t wanna be here. I didn’t wanna spend my vacation time ____________ earplugs.
Female: Well, see they’ve given us this readiness checklist that we can fill out together, and in fact they have that we can choose earplugs. How about we do that? We’ll choose the earplugs, and then look, it’s recyclable, and it’s also a “do not disturb” sign.
Male: ______________
Male: I’m the ____________ coordinator and I see that the patient in 348 needs earplugs. So I’m gonna write that on the request form.
Female: Well, I think we have a _____ malfunction.
Male: That’s fine.
Female: ________________________________ and I’ll go get you a new one. ___________________ and pick up _________________ Well, I see the status is ________ Great.
[Video pauses]
Chris McCarthy: Very sophisticated electronic medical board.
[Audience laughter]
[Video resumes]
Female: Oh, my gosh, I had so many discharges today; now I have another admission today.
[Video pauses]
Christi Zuber: She’s in character.
[Video resumes]
Female: Mrs. Jones, how are we doing this morning?
Female: __________________________________________________
Female: Mrs. Jones, how are you today?
Female: Hi, I’m the department manager here, and I’m thrilled with what the staff is coming up with in terms of making our department more ready for the next shift.
Female: And this is, we have an idea wish list that we work on at the end of every day and we work __________ideas. So the Concepts that we have discussed today have been Concept 5 ________request list, Concept 52 a broken supply _________, Concept 53 is clean your hands clean your mind, Concept 54 is ____________.
[Video ends]
Chris McCarthy: So in that enactment, the woman in pink was actually the CEO of a hospital. We had a patient, a doctor, a nurse, and almost everybody is playing a different role. They’re not playing their own roles.
Christi Zuber: Had an IT guy.
Chris McCarthy: And an IT guy. You can see there was a lot of handmade construction. There was a lot of interaction that we were trying to demonstrate through workflow redesign. But what was really special, of course, about the video enactment is that now this is a living artifact. So as we’re co-designing and field testing and trying ideas, we can always go back and take a look at some of the original enactments to really see what people were trying to get across from the original concept. It most certainly will not stick to that. But, again, it’s a really great way to check yourself to see “Am I staying true to at least some of the original ideas that was coming from this?” So with that, back to Christi.
Christi Zuber: All right. So we’ll pick back up the story with how then – so we’ve got ideas, so sort of following along, we went out and we understood what’s really happening. What are people struggling with? Where are they frustrated? Because, again, the title of this talk, “Don’t Forget the Humans,” this is about what the basic fundamental needs of people are. And not only understanding those needs, but engaging and involving those people to help create what the future state’s going to be.
So we’ve now brought them together. Chris walked you through how they’ve generated ideas. They’ve brainstormed. They’ve prototyped ideas. They’ve built them together. They’ve done some enactments. And now we’re at the point of saying, “Okay, let’s actually go back out into the field and begin to try ideas with them, get feedback, and see what actually happens from that.”
So remember this woman, the “leave me alone” woman? So after that was over, as Chris said, we were kind of intrigued. There were many – hundreds and hundreds of ideas that came from that design session. So we’ll just walk you through the example of one that’s a pretty tangible example to be able to tell the story of.
So the “leave me alone” woman, as she left, went back and started caring for patients in our hospitals. And within a couple days, we were able to run by Home Depot and decided let’s take her idea and let’s go buy a vest at Home Depot, and let’s try out this idea. Ten bucks, we can go and try out this idea.
So I think something that’s really key about this, as I start to tell you this journey, is this is all about really doing very small tests of change, not trying to think you’ve gotta solve for everything. Now, remember, we’re trying to solve for reducing medication errors. That’s a pretty gnarly problem, but we are starting with small tests of change. While we were trying this, we were trying many, many things, but trying things at a small scale so that you can fail – don’t think that once you have an idea, you can sit around in a conference room and come out with perfection. You’ll never have perfection, and being in a conference room certainly is not the way that you’re ever going to have perfection. So just try it. Throw it out to your users. Get feedback.
So we took what we would consider sort of an innovator and early adopter and said, “Hey, would you mind throwing this vest on while you’re working and caring for patients? During one time that you’re giving medications to your patients, would you wear this vest? And what happens is, when you wear this vest, no one should be interrupting you unless it’s an emergency.” Well, there clearly is no policy that says no one can interrupt her, so in order to try it really quickly, we became the policy, so we were sort of running around her like this, and she’s giving her medications – thank you, policy. As she’s giving medications, we were the policy around her saying, “I’m sorry, she can’t be interrupted now; she has her vest on. I’m sorry, she can’t be interrupted now; she’s giving medications.”
So what happened is she went through this whole process, and we said, “Okay, how did that feel? We just wanna know, what is that like?” And she said, “Well, first off, I wouldn’t wear this vest.” So, good to know. But she said, “But what’s interesting is a couple things. One, by the act of putting it on, I thought about giving medications differently. I was focused. I knew I wasn’t supposed to be multitasking. It was a trigger for me. So I knew I was supposed to be focused on something.” And she said, “And on top of that, I actually got all of my medications done on time because nobody was interrupting me, so that was really amazing.” She said, “I like this, but I wouldn’t wear this.”
So in our home-down way of actually trying to “Well, let’s try it out cheaply again,” we said, “What would you like? What do you think would be better?” And she said, “I’d like to – I think it’s a good idea to try it again, but something smaller.” So we came back with a sash, and the woman tried it quickly and got some of the same feedback about “It felt good trying this out, but I felt like I just won a beauty pageant.” Which she’s a lovely lady. She could’ve. And she said, “So something a little sleeker, a little sexier,” and we said, “How about red vinyl?”
So we brought back red vinyl and learned a couple really key things about this. So it was smaller; that was nice. But mainly, it could be cleaned, so we learned infection control. That’s really important. You’re going from room to room. You need something that can be cleaned. Cloth couldn’t be cleaned like that. We also, because we couldn’t sew the bottom of it, we connected it with a magnet and learned that’s actually an important design feature, because they need to be able to have it quickly removed in case a patient starts to fall to the floor and they try to grab them. So things like that. Never thought of that, but in trying things really quickly, we learned that. Finally, we settled on sort of this reflective sash. It’s reflective on both sides. You can see it at night. You could roll it up and put it in their pocket.
So a very tangible idea, and I know not all the ideas that we work on are like this. We work on workflows. We work on technology. We work on a number of things. But in this example, you can easily see how just getting things out there very quickly, starting to get feedback, not giving yourself time to fall in love with your ideas, doing very small tests of change, change with very willing innovators, is a great way of trying to iterate through your ideas and not giving yourself a chance to fall in love with them.
What this all actually resulted in is a process that we now call KP MedRite. It spread to, what, 24…?
Chris McCarthy: Twenty-five hospitals.
Christi Zuber: Twenty-five of our Kaiser hospitals, so that means thousands and thousands of people are doing this on a daily basis. There are a number of things that comprise what KP MedRite is. If you were a healthcare audience, I’m sure you’d be really intrigued to know. Since you’re not, I’ll spare you those details.
But I think what’s important is just knowing the impact of how we went through this, how we learned what the people in the system really need, not just the nurses, but what the patients also need. And we involved them in a process so that they could co-design their future state together.
And what resulted from that, actually, is, in this example, KP MedRite, which now has spread to many places, and it is – nurses are now interrupted less, which means they’re doing things in a more safe manner, and medication errors have gone down. So it’s very, very significant. We’ve actually already seen a 105 percent return on investment in the couple years that it’s been in place.
So a very powerful system. It’s not only spreading across Kaiser, but because we’re not-for-profit, all of these things are shared openly, so now it’s spreading to other places. And it’s really powerful knowing that these solutions were built by the people that are doing them. And we think something that’s incredibly important about that is, that means that these solutions will probably be more sustainable in the long run.
So quickly to sort of highlight some of the tools along the steps of the process. So understanding and looking for patterns, drawing your experience, video ethnography, time-lapse video – these are some really basic, really strong and powerful tools to tell the story and to understand. Ideate and prototype, so handmade constructions, getting in there, building out what your ideas are, getting very physical with them through building them and doing the enactments and starting to see how the tools, how the workflows, how all these things work together. Trying out ideas and getting them out there so that people can actually respond to them, doing very small tests of change, not giving yourself a chance to fall in love with your ideas, getting feedback very quickly, and not trying to go with the people who just don’t wanna do anything. Connect yourselves with those innovators and those early adopters, to really give it a chance to breathe a little bit of life into it and see if there’s some possibility behind those ideas.
Chris McCarthy: And the next, final slide. Great. So ultimately, we really see ourselves as trying to bring humanity back to the experiences in the healthcare system. Started off talking about mindless experiences and mindless work. And I think because of the techniques that we use, because of the way that we co-design with our patients and clinicians, we’ve been able to achieve a very large level of success. You can see across the top, those are the years going across, and we have some major innovations that have spread not only to all Kaiser Permanente hospitals but to other countries, including Canada, the United Kingdom, Australia, of course many states within the United States.
And more and more healthcare organizations are starting to bring folks like us, designers, into – in house. So we’re seeing more and more replications of the kinda work that we do, budding out into other healthcare organizations. So we think this is a really important way of working. It’s an emerging field, and user experience in the live, human experience is a really important thing. So thank you. Want a hug?
[Audience applause]
Christi Zuber: [Laughter] Yeah. There, there. [Laughter]
Audience Member: There was a comment – I won’t say from whom, but Twitter will make it available to anybody who bothers to search on it – from one of the attendees who said, “I’m always a little suspicious when user-centered design gets too close to outsourcing design responsibility to users,” right? So involving the nurses, involving the folks in the design process. What is the role of the designer in crafting the solution versus just, like, “Well, have them figure it out” kinds of stuff? How do you strike that balance?
Christi Zuber: Yeah. I’ll take a crack, and then you can build on it. You know, I think that some of it – this has been a journey for us, and I think we’ve found a good balance between getting feedback and also seeing the bigger picture of what would be beneficial in the system.
So I think Chris at some point in the presentation had talked about when they were designing the Ferrari of beds, we didn’t take that literally and say, “Okay, the users say we need an amazing bed.” But we took that as, what they are looking for is things at their fingertips. So sometimes it’s not taking verbatim what the idea is, but understanding more deeply what is the need that’s surfacing that idea. So I think that’s where, as a designer, when you’re looking at trying to create solutions, you’ve gotta understand that and dig a little deeper to understand what the needs are, because sometimes the ideas they surface aren’t so much about the ideas, but they’re about the need behind the idea.
Chris McCarthy: And I would say, in 2003 when we started, I think we thought we were going to offload this onto our end users, that we would train people with the very basics of design, and they would be able to redesign their lives. And what we discovered over the years, that that indeed is not possible. And so the designer’s role on our teams is to lead the design.
But we have co-designers ’cause we know, in our system, that if they are not involved with every step of the way, the ideas almost always are rejected. So by having their DNA infused not only in the actual design but in the observation, in the field testing, and even in the piloting of some of these ideas, you’re not only creating better ideas, but you’re generating the will to want to implement these ideas. And then you’re generating champions who will carry these ideas to be spread in other environments. So we’re not just making them co-designers for the design process; we’re actually creating change agents through this work as a side benefit.
[End of Audio]
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