Integrated thinking in health care

Brett points to The Quality Cure? (paid archive) a New York Times profile of David Cutler’s ideas for reforming healthcare in America, where providing more care without going bankrupt seems impossible. Cutler, an economist, developed financial models to show how we should “focus on improving the quality of care rather than on reducing our consumption of it. Rather than pay less, he wants to pay more wisely — to encourage health-care providers to do more of what they should and less of what is wasteful.” (see Atul Gawande’s The Bell Curve for more on measuring doctors’ performance.)

To accomplish this, he’s acknowledged that purely financial thinking isn’t enough, we need to integrate the economics with human-centered organizations, smarter use of technology and innovative organizational design:

Reoriented to managing ”health” rather than merely costs, H.M.O.’s might again become a useful part of the healthcare landscape, Cutler says. Managing care, he says, was a necessary idea that went off the tracks as H.M.O.’s became remote, single-minded cost-control freaks. His models for the future are the progressive organizations (he calls them hippie places) like Kaiser [Permanente, the insurer and provider based in California] that employ their own doctors, invest in computers and ”engage” their patients. They manage quality as well as cost.

Also see Aligning the Stars: Using Systems Thinking to (Re)Design Canadian Healthcare (.pdf).

David Byrne’s Journal

David Byrne always presents something new, something interesting, all wrapped in a consistent and genuine funky catchiness. He’s posted an mp3 of his song My Fair Lady to OurMedia, has a new album of opera-influenced songs and has been writing an online journal. From the latter, there’s introspection and honesty not common among his peers:

On reading Bob Dylan’s book

It’s beautifully written, though I think it should probably be filed under fiction. I always thought his persona, which early on was that of a young Woody Guthrie, was just that, a persona. … (Call me skeptical, but a Jewish guy from Minnesota talking and writing like a backwoods hick/poet, huh? What’s that about?)

On a Pixies show in NYC:

Charles had on some black eyeliner which I couldn’t see from my seat. (Michael Stipe does this too, is this something I should know about?) From the audience I thought it made him look like an Aztec or Mayan God, calmly but loudly issuing baffling cosmic pronouncements mixed with pain and rage.

On traffic in Southern California:

I wonder if people here realize that the rest of the world doesn’t live like this? I wonder if, as all this traffic just gets worse and worse year after year, if people will eventually confine themselves exclusively to their home communities – people in Silverlake will NEVER go to Santa Monica and vice verse, hell, people in Santa Monica will probably eventually stop going to west LA!. The area will revert to little isolated villages. It’s already somewhat like that, but as gas doubles and quadruples in price, as it’s bound to do in the not too distant future, well, then only the wealthy will be able to suffer these hellish commutes.

Co-creation and business

Migrating the practice of multidisciplinary collaboration from the product design world to the business design world can be tricky. This is especially true if taken to the level of “co-creation” — making everything together as much as is possible. There’s a bit about this in the literature (e.g. Co-Creating Health Services, HR & Management, and Fifth Generation Management), but not a lot.

Take a simple example: creating a document. Co-authoring a document with colleagues is straight-forward enough, but co-authoring it with a client is something else. The consultant is traditionally viewed as the domain expert who descends from on high to present THE DELIVERABLE (the word itself contradicts the idea of co-creation). There’s two points here: One, design thinking doesn’t rely on domain expertise, it relies on ways of doing things, such as collaboration. This allows for a productive pairing of the client’s domain expertise and the business designer’s process expertise. Two, co-creating a document goes against the grain of 100 years of consulting convention, so education is required along the way.

Something as simple as co-creating a document requires carefully balancing the roles of collaborator and trusted advisor. This isn’t your father’s consulting practice.

d.school design thinking books

Diego Rodriguez posted a list of design thinking books recommended for his class at the d.school. Diego also has a weblog, metacool.

Someone else at the CEO Read blog found the soon-to-be-released Democratizing Innovation by Eric von Hippel who shows that product and service development is concentrated among “lead users,” who are ahead on marketplace trends and whose innovations are often commercially attractive. He’s also got a page at MIT.

Human-centered corporate ethics

In the Wall Street Journal today:

  • Adelphia is close to a $725 million settlement with the SEC for a corporate looting and accounting scandal
  • AIG’s woes continue as two top executives are fired and the CEO has to decide whether to cooperate with the government’s investigation
  • The former controller of WorldCom awaits sentencing after his false accounting entries led to a $11 billion fraud and the loss of 17,000 jobs
  • A judge in Florida has ruled that Morgan Stanley helped Sunbeam conceal accounting woes that cost one investor $680 million
  • Don Imus’s ranch for sick children manged to spend $2.6 million while helping just 100 kids

…and that’s just above the fold, on the front page. And this is the Journal, not the more liberal New York Times. Inside you’ll find Microsoft’s European antitrust sanctions, a flurry of accounting restatements related to auction-rate securities, and Cantor Fitzgerald’s illegal hiring practices. It’s clear the Journal is taking a strong stand on corporate ethics.

The solutions are less easy to identify. Surfaces causes cited have been:

  • Uncreative approaches to revenue targets
  • Failure of leaders to send the right message
  • Lack of incentives for people to actively do the right thing, e.g. report unethical behavior of co-workers
  • Cover-your-ass solutions like policies and handbooks that “The Office” so rightly lampoons
  • Employee anxiety caused by occasional and disruptive change, e.g. mergers
  • Allowing some dishonesty, which in turn breeds more dishonesty

I think ethics needs to be baked-in to an organization’s DNA. I think it needs to be a constraint that is always followed, in the form of customer representation on projects and a service-not-office style of working. I think the human-centered approaches inherent in customer research, empathetic designers and design thinkers in general are needed, and companies are feeling enough pain to change.

CPH127: Design and Innovation are Boarding

CPH127 is a promising new blog from like-minds in Copenhagen:

This is a brand spanking new blog about the major influence of design as a motor for innovation, and like wise the other way around. We are neither 100% design-focused nor are we 100% business-focused. Our team consists designers, MBAs, dot-com entreprenours and all the other folks you would never expect to be on this kind of blog. Welcome aboard – we are about to take off!

Thanks to Gavin for the heads up.

Quotes on design thinking and business

I’ve started collecting quotes and references to get an overview of who’s saying what about design thinking as applied to business. The idea is still young and in development; it seems we’re only now reaching the conversation stage that leads to differing points of view.

An example:

We should not underestimate the crucial importance of leadership and design joining forces. Our global future depends on it. We will either design our way through the deadly challenges of this century, or we won’t make it. For our institutions – in truth, for our civilization – to survive and prosper, we must solve extremely complex problems and cope with many bewildering dilemmas. We cannot assume that, following our present path, we will simply evolve toward a better world. But we can design that better world. That is why designers need to become leaders, and why leaders need to become designers.
—Richard Farson, Management by Design, 2000

Human-centered sales targets

Carol Hymowitz of the Wall Street Journal has been investigating aggressive revenue targets and the effects on employees, summed up by this quote from Roger King from Lloyd’s TSB Bank:

In over 30 years as a banker, I have seen the toll that the relentless pressure to turn in ever better quarterly and annual numbers has … on business and personal ethics, too.

I believe this is an area where design thinking can play a helpful role, refocusing attention away from Sales as the way to generate sales, and giving managers more creative methods for improving business. The numbers myopia — which I believe is typical of traditional management consulting — is illustrated by Cecily Franklin, formerly a manager at Consolidated Natural Gas and a vice president at Mellon Bank:

It is only possible, or safe, to lose weight slowly. … There comes a point when the goal is to STOP losing weight and work on maintaining it. It would be possible, though dangerous, to turn weight loss into a pure numbers game. By amputating an arm, one would clearly see numerical results, but one would also suddenly find it more difficult to do almost everything. And if a new ‘stretch’ goal arises, then another and another body part may need to be removed in order to replicate — notice I didn’t say sustain — those results. In the end, one would lose the capacity to function altogether.”

A beautiful aspect of design thinking is human-centeredness. A good business design solution would not consist of “push the problem down to the individual and let personal financial panic solve the problem.” Management needs the more creative solutions that design thinking can bring.

HP taking lessons from Apple?

HP bought Snapfish, but I think the comparison to Yahoo/Flickr is less interesting than a comparison to Apple. Apple enhanced hardware by adding software and services (iTunes -> Music Store), lengthening the value chain and creating an integrated system that makes it easy for people to buy what they want. It’s also a razor/blades situation. HP is doing the same thing, connecting their cameras to a service to printers and supplies.

Information Esthetics lecture series in NYC

A group calling themselves Information Esthetics have formed to examine “making data meaningful” with an expansive view on how that happens. They plan a promising lecture series including folks like Judith Donath and Bill Buxton which will be right around the corner from my office and cost a whopping $3. Bless them.

When marketing isn’t enough

Recently I was telling an insurance industry executive about Tonik, an affiliate of Blue Cross of California that only offers health insurance to “the young invincibles” — people in their 20’s. At first glance he thought this was niche marketing, nothing new. But Tonik is different, it’s a whole new subsidiary that created new products tailored to their audience. The marketing is important to initially lure prospects in, but relevant products, easy-to-understand forms, and online-based service are more likely to convert prospects to long-term customers. They’re offering more by going beyond marketing-as-facade.

Viewing Tonik as a business rather than a product line (or niche marketing) helps us understand its implications. I think Tonik qualifies as a disruptive attack in the insurance industry, because:

  1. It focuses on a low-margin audience other companies are ignoring
  2. Through self-service and use of the Internet they keep their costs down
  3. As this audience gets older they will naturally look to Tonik for expanded coverage

I don’t think marketing as traditionally understood would be enough to create Tonik, it requires business design skills:

  • Traditional disciplines like marketing aren’t holistic enough to address the entire challenge
  • Abductive thinking is needed to create something new and better
  • There is no discrete problem statement in this projects; tools are needed to prioritize and synthesize variables in the environment, like integrating creative product potential with financial potential

If we take the term Business Design literally — the designing of businesses — we get a sense of the scope of the challenges at hand. Design thinking excels at dealing with “wicked” problems that are complex and ill-defined, requiring abductive and integrative thinking to address the creation of whole businesses.

The Story of the Weeping Camel

“The Story of the Weeping Camel” is the best movie I’ve seen recently. Their description introduces it nicely…

An enchanting tale about a family of herders in Mongolia’s Gobi desert who face a crisis when a mother camel unexpectedly rejects her newborn calf. Uniquely composed of equal parts reality, drama and magic, the movie provides a window into a different way of life and the universal terrain of the heart.

Published
Categorized as Film

The Wisdom of Crowds: cognition problems

More notes from James Surowiecki’s The Wisdom of Crowds

As an example of solving cognition problems, he discusses decision markets like The Iowa Electronic Markets (IEM), which has generally outperformed election polls. Over time, they are also less volatile than polls, changing less dramatically to new information. The IEM is not big or diverse, involving only about 800 people, mostly men from Iowa. It and the Hollywood Stock Exchange (HSX) work well without much — or any — money at stake. David Pennock found that status and reputation proved incentive enough to encourage serious investment of time and energy in what is, after all, a game.’

Bees in a hive send out scouts who return and do a waggle dance to indicate the quality of nectar they’ve found. The dance attracts a certain number of forager bees according to how intense the dance is. It’s a natural way to distribute the hive’s resources across finding opportunities and pursuing them. The bees scout and explore simultaneously rather than scout, analyze and act.

Overly-homogenous groups, even smart ones, are less able to find good solutions over time than more diverse groups, even if the latter’s overall intelligence is lower. James G. March, an organizational theorist, said that groups that are too much alike find it hard to keep learning, because each member brings less and less new information to the group, and ‘they spend too much time exploiting and not enough time exploring.’ Irving Janis found homogeneous groups are more susceptible to groupthink. Soloman Asch found individuals will deny what they believe is the truth in order to confer with a group (although this is easy to rectify).

Expertise is, in many contexts, overrated. Expertise can be narrowly focused, as Herbert Simon found in his study of chess players. Experts’ judgments are often not consistent with other experts’ judgments , and experts aren’t good at judging the accuracy of their own judgments (exceptions were bridge players and weather forecasters). Wharton professor J. Scott Armstrong’s ‘seer-sucker theory’: ‘No matter how much evidence exists that seers do not exist, suckers will pay for the existence of seers.

Design thinking isn’t just for designers anymore

My colleagues and I realized recently that although designers are (obviously) a primary source of the design thinking at the heart of business design, the proposition that only designers possess the thinking skills required is a little arrogant and even a little separatist. In fact, the most interesting writing on the subject thus far has come from the academic community.

Edward de Bono has argued that our present situation — relying on judgment thinking — began as a matter of ignorance…

Most people, in business and elsewhere, have done very well on judgment thinking. Such people are rarely aware of the need for ‘design thinking’. They find it difficult to conceive that there is a whole other aspect of thinking that is different from judgment thinking. It is not that such people are complacent. It is simply that they do not know that there is another aspect to thinking.

As design thinking enters the business world, I’ll be interested to see the proportion of designers to managers involved.

The Wisdom of Crowds: Intro

James Surowiecki’s The Wisdom of Crowds is the best book I’ve read in a while. In it he forwards a compelling thesis:

If you put together a big enough and diverse enough group of people and ask them to make decisions affecting matters of general interest that group’s decision will, over time, be intellectually superior to the isolated individual no matter how smart or well-informed he is.

This strikes me as a useful tool in the business design toolbox, where constant collaboration with people with a diversity of opinions and from multiple disciplines raises the quality of work.

He addresses three kinds of problems:

  • Cognition problems, that have or will have definitive solutions
  • Coordination problems, that require members of a group to figure out how to coordinate their behavior with each other
  • Cooperation problems, that involve the challenge of getting self-interested, distrustful people to work together

And he identifies four conditions that characterize wise crowds:

  1. diversity of opinion (each person should have some private information, even if it’s just an eccentric interpretation of the known facts)
  2. independence (people’s opinions are not determined by the opinions of those around them)
  3. decentralization (people are able to specialize and draw on local knowledge)
  4. aggregation (some mechanism exists for turning private judgments into collective decisions)

The rest of the book is dedicated to telling stories that illustrate and explain the above four conditions. More in future posts…