26 Oct 2020
Designing better healthcare - why everyone should know more about design
In our second episode of the Re-imagine Medical webinar series, Dr Amanda Sammann discusses the importance of human-centred design when it comes to medical products and healthcare in general.
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Dr Amanda Sammann, MD, MPH, has dedicated her life to making things better. As well as being a trauma surgeon at the Zuckerberg San Francisco General Hospital and Trauma Centre (ZSFG), she’s also the founder and executive director of The Better Lab, a venture that uses design to study and find new ways to fix healthcare challenges.
She talked to Investec about the role of human-centred design in healthcare, and why all healthcare professionals can benefit from knowing more about it.
What is human-centred design?
The word ‘design’ means to do or plan something with a specific purpose or intention in mind. For two years, Sammann worked at IDEO, a Silicon Valley design firm that uses ethnographic research to find out what people really need. Taking the broad application of design a step further, IDEO defines human-centred design as “a problem-solving approach that starts with people and ends with innovative solutions that are tailor-made to suit their needs”.
“In a healthcare context, while design can be applied to things like equipment used in a hospital ward or operating theatres, human-centred design recognises that anything you do, touch, or move through can be designed. Through this lens, it can apply to almost everything to do with healthcare, from a hospital’s morning routine, to the way a clinic runs and the instruments they use, to the way healthcare students study. All these aspects have actually been designed in some way – although this has often been done so unintentionally, and therefore poorly,” Sammann comments.
Why human-centred design matters
When it comes to innovation, Sammann outlines the three things needed to bring a new product or service to market. Firstly, there has to be desirability, a need for whatever is being offered. Secondly, it has to be financially viable so that it’s not too expensive. Thirdly, there needs to be the technology available to do it.
She adds, “There are many examples of products and services that had plenty of money and great technology behind them, but that never saw great success. More often than not, the reason is that the offering didn’t meet a particular human need.”
One recent example of this was Google Glass, the search giant’s augmented reality headset product. While the technology was slick with a huge amount of funding behind it, it was a technology that seemed to be looking for a solution rather than meeting a specific unmet need. Sammann also cites the California education system as another example - while the state spends a huge amount of money on it, it doesn’t meet the needs of students and teachers and so isn’t successful.
Why HCD works
The first hallmark of human centred design is empathy. In the context of healthcare, one often thinks of empathy as something healthcare workers have towards patients. And while that’s how clinical care should be approached, what about when it comes to quality improvement, research, policies, or clinic design? It turns out that empathy is important there, too.
Sammann says that The Better Lab uses techniques like semi-structured interviews and observations to get to a sense of empathy so that they can go beyond simply the answers someone gives to a question to find out how they actually feel. “The premise here is that people’s explicit needs and behaviours – what they say and do – are often very different from their implicit needs and/or their values and beliefs. The goal is to use ethnographic research to uncover the motivations and feelings that derive a person’s behaviour,” she says.
“If you can understand those needs, you can design something new and innovative – and revolutionary.”
The second hallmark of human-centred design is iteration. “Fail fast, and fail early,” remarks Sammann, which essentially means to start designing and get feedback before you think you’re ready. Especially in a healthcare context, Sammann says experts are supposed to know everything and have all the answers. “But all too often, healthcare challenges are approached with finding a solution while not really understanding the unmet needs. Because of this, something is designed that ’sounds’ right, even though it may not be. By the time it’s implemented though, there’s so much emotional energy, time and money invested, that it’s too far gone to be allowed to fail.”
Iteration is the solution to this, says Sammann. By starting with low-fidelity prototypes and testing them across the whole design process, you get ideas and feedback on seemingly ‘bad’ ideas early on that make the end product a much more useful one.
The human-centred design process almost always follows the same basic journey:
Interview and observe:
Ideas are synthesised using traditional data analysis, which can include analogous research where other environments with similar challenges are observed.
Individual feedback is brought together and common themes identified. This results in an insight, which Sammann defines as a novel take on a challenge. Put another way, it’s about identifying a tension, or an unexpected association, which indicates a design opportunity.
The insights and ideas are used to find opportunities for a new solution.
Low-fidelity prototypes are broadly tested and then iterated based on user feedback.
Case study - Adherence technology for tuberculosis medication in Uganda
One example of human-centred design applied to a very narrow healthcare challenge is when Sammann collaborated with a pulmonary doctor to implement new digital adherence technology for tuberculosis (TB) patients in Uganda. While TB is the leading infectious cause of death worldwide, it is curable. Treatment success rates in Uganda are estimated at between 60% to 75%, which is well below the World Health Organisation target for treatment success at 90%.
“The new adherence technology, called 99 DOTs, was introduced in Uganda with the aim of increasing TB treatment success rate by ensuring patients took their medication. The technology consisted of an envelope fitted over a blister pack of medication, with a phone number assigned to each daily set of pills. Once the patient had taken their pills, they’d call the number, hear a beep and hang up, as a way of ‘marking’ that they had taken their medication for the day,” Sammann explains.
The problem was that this technology’s design wasn’t optimised for the local context. While it had been designed in India and tested in Asia, it had never been tested in Uganda. To solve for this, Sammann and her colleague conducted research with Ugandan patients, families, health officers and community health workers.
They identified several themes and insights to help them adapt this technology to improve adherence:
- The social stigma of having TB in Uganda may be feared as much as the disease. TB medication needed to be more discreet, so that the medication pack wouldn’t be a form of ‘forced disclosure’ that someone had the disease.
- Health is defined by a return to normal strength and capability to return to work, which occurs before treatment completion. While the treatment programme for TB is six months long, people typically start feeling better months before this, and so may stop taking their medication which then prevents recovery. The team needed to bridge the gap between when patients felt better and didn’t feel like taking their medications (often involving long trips to the clinic), to when the treatment programme actually ended.
- Feeling a personal connection with healthcare workers is as important as receiving medical care. In Uganda, as opposed to countries like the US, patients have a desire to please their healthcare workers, or be rewarded by them. How could the team leverage the relationship between patients and community health workers in order to personalise the treatment experience?
A potential implementation
Using these identified opportunities, and through various iterations, the team ended up with a final prototype of a redesigned pill pack. Sammann elaborates, “The cover was more discreet, displaying a map and a calendar to help patients track their medication over time. A chevron colour scheme was used to help people navigate down the pill pack in an orderly way, and the traditional phone icon (which most Ugandans didn’t understand) was changed to the much more recognisable cellphone icon. On the inside cover, they made space for customisable stickers, and space for the healthcare worker to write their phone number and a personalised message. They also discovered that while literacy was sometimes a challenge, words meant a lot, so they used meaningful pictures and icons to help people better understand how to take their medication.”
While results from the testing are currently emerging, adherence rates are shown to be rising from an average of 70% to 80%.
Rethinking how a hospital could support the community during Covid-19
In early March, when the Covid-19 pandemic first hit New York City, it became clear that the American healthcare system – although relatively wealthy compared to many other countries – was woefully underprepared. Watching this devastation from afar and waiting for the wave to hit California, Sammann and a group of designers founded the Emergency Design Collective of over 700 volunteer healthcare workers, designers and tech employees from all over the world.
One of their main challenges was how to help Californian emergency rooms handle the coming wave of Covid patients. To do this, they selected a small community hospital in a high risk area of California’s Central Valley. While their initial goal was to help the hospital with the impending influx of Covid patients, they soon realised their hypothesis was wrong: the hospital wasn’t overwhelmed at all. In fact, ER visits had dropped by 50% in April compared to March before the pandemic hit.
From a hospital perspective, ER is a major revenue source and so this had created a major financial crisis. The challenge therefore quickly morphed into how the team could help the hospital support their community and help them feel safe coming to the hospital if they were sick.
“What the team found that there weren’t fewer sick people – they were just sick at home,” says Sammann. “This meant that even people suffering from serious conditions like cardiac arrests and strokes were not coming into hospital to seek treatment. After three weeks of research, the team found that the community viewed the hospital as an ‘infectious reservoir’ to be avoided at all costs. They were also not informed about the risk mitigation efforts at the hospital to help keep them safe from Covid, and they were lacking confirmation from their doctors about when it was appropriate to go to the ER.”
From these insights, the team came up with a solution to help assuage fears and get the ER back to its pre-Covid occupancy levels. “The first change was to divide the ER into respiratory and non-respiratory wings, giving staff and patients visual representations of what was Covid related and what was not. The second step was to implement a communication campaign across local news, social media and email channels of what was being done to keep non-Covid patients safe, and when they should go to the ER.”
Changing the expert mentality
From these examples, it’s clear that human-centred design can help reframe the ‘expert mentality’ – to dig deeper, to know that we don’t know everything, to learn from others, and to iterate early and allow oneself to fail.
When a solution is implemented in this way, chances are that the final solution will be much better than it was at the outset.
About Dr Sammann
Dr Amanda Sammann, MD, MPH, is a general surgeon practicing trauma surgery, acute care surgery and surgical critical care at the Zuckerberg San Francisco General Hospital and Trauma Centre (ZSFG), and is the founder and executive director of The Better Lab.
She obtained a bachelor’s degree in human biology through Stanford University, a master’s degree in Public Health from Columbia, and a medical degree from the University of California, where she completed her surgical training. Following her fellowship in surgical critical care, Dr Sammann spent two years as medical fellow and medical director at Silicon Valley design firm IDEO.