How might we design health systems to promote health and wellbeing and not just treat illness and disease and manage infirmary and chronic conditions? What if health systems were about health?
If we were to apply design thinking to health systems, what might be do?
In a previous post, I suggested that knowledge translation is too important to be trusted solely to health professionals, partly because they have largely failed to take up the charge. Taking a step back — a systems thinking perspective — one realizes that to design better knowledge translation, we need to design better health systems.
Julio Frenk, Dean of the School of Public Health at Harvard, believes this too. In a 2010 paper published in PLOS Medicine, Frenk comments on the state of health systems and examines how we might re-think them in light of global health challenges.
Health systems are the main instrumentality to close the knowledge–action gap. To realize this potential, it will be necessary to mobilize the power of evidence to promote change. Yet all too often reform efforts are not evaluated adequately. Each innovation in health systems constitutes a learning opportunity.
Frenk’s article is an invitation to engage in systems and design thinking about health. Both approaches invite pause to consider what the problem is in the first place. For design thinkers, problem scoping is the first step.
For systems thinkers this is akin to setting the boundaries around the problem.
Once we set the boundaries and find the appropriate problem, we then frame it appropriately for design. Problem definition is something often over-looked or under appreciated, but is the core of effective problem solving and design.
If I had an hour to solve a problem I’d spend 55 minutes thinking about the problem and 5 minutes thinking about solutions – Albert Einstein
Health systems are typically defined in light of professional services and policies aimed at making the sick well. They are essentially illness and disease (sick care) systems. This conceptualization, still dominant in the professional and policy discourse in many Western countries, places medicine at the centre of health services with the allied disciplines working alongside, but rarely ventures its gaze beyond the institutions of care or the conditions such institutions are designed to treat.
Frenk, writing in PLOS Medicine, suggests its time to expand our view of what makes a health system if we are to truly promote and sustain global health and see three key points as provoking such re-thinking:
First, health has been increasingly recognized as a key element of sustainable economic development , global security, effective governance, and human rights promotion . Second, due to the growing perceived importance of health, unprecedented—albeit still insufficient—sums of funds are flowing into this sector . Third, there is a burst of new initiatives coming forth to strengthen national health systems as the core of the global health system and a fundamental strategy to achieve the health-related Millennium Development Goals.
In order to realize the opportunities offered by the conjunction of these unique circumstances, it is essential to have a clear conception of national health systems that may guide further progress in global health.
Frenk offers some suggestions:
Part of the problem with the health systems debate is that too often it has adopted a reductionist perspective that ignores important aspects. Developing a more comprehensive view requires that we expand our thinking in four main directions.
First, we should think of the health system not only in terms of its component elements (like human resources, financing, hospitals, clinics, technologies, etc.) but most importantly in terms of their interrelations. Second, we should include not only the institutional or supply side of the health system, but also the population. In a dynamic view, the population is not an external beneficiary of the system; it is an essential part of it.
It’s important to note the mention of the role of the population and its dynamical impact on the system. As populations change dramatically in their composition and form of residency within countries, including a greater movement to urbanization, so too will the myriad factors that influence health systems. The people are the system and thus it will change as populations change. While Frenk lists this as one point of many, it is a radical departure for reductionists or those who see health systems as being about care, not people.
A third expansion of our understanding of systems refers to their goals. Typically, we have limited the discussion to the goal of improving health. This is, indeed, the defining goal of a health system. However, we must look not only at the level of health, but also at its distribution, which gives equity a central place in assessing a health system. In addition, we must also include other goals that are intrinsically valued beyond the improvement of health. One of those goals is to enhance the responsiveness of the health system to the legitimate expectations of the population for care that respects the dignity of persons and promotes their satisfaction. The other goal is fair financing, so that the burden of supporting the system is distributed in an equitable manner and families are protected from the financial consequences of disease.
Frenk’s third challenge is to affirm the very point of health systems at all.
While not explicitly speaking of systems thinking or design thinking, there is much that both fields have in common with Frenk’s argument. Design thinkers might ask: What have we hired our health system to do?
Frenk argues that our health systems must go well beyond just making gains in measured health outcomes towards dignity, respect and social justice.
Finally, we should expand our view with respect to the functions that a health system must perform. Most global initiatives have been concerned mainly with one of those functions, namely, the direct provision of services, whether they are medical or public health services. This is, of course, an essential function, but for it to happen at all, health systems must perform other enabling functions, such as stewardship, financing, and resource generation, including what is probably the most complex of all challenges, the health workforce.
Frenk did not identify specific solutions, but did pose some key questions for health systems design.
If we were to take this challenge up as designers and systems thinkers, what might we do? Here are some suggestions for inquiry:
- Consider new definitions of health like the one posed in the British Medical Journal that emphasizes looking at the social and environmental influences on health beyond just the absence of physical symptoms. Further inclusion of a psychology of human flourishing might add to this definition.
- Map out a new system visually with people at the centre, not professionals or institutions. What does that look like? Tools like a Gigamap might provide the kind of multi-media, multi-sensory visual way to conceive of the interrelationships that make up health system. System dynamic models can help this out as well.
- Engage people across this system to validate this map and co-create possible future models that could serve to shape discussion at multiple levels and mobilize civil society to support healthy environments.
- Create small scale, safe-fail / fail-forward, prototypes of small-scale innovations that can be tested, developmentally designed, and rapidly re-developed as needed to start shifting the system as a whole.
Designing health requires designing health systems. Applying new thinking and envisioning a system that is dynamic, comprised of people and just institutions is a start.
Photo: Bartolomeo Eustachi: Peripheral Nervous System, c. 1722 shared by brain_blogger used under Creative Commons Licence
Design Thinking is trending is some educational circles. Edutopia recently ran a design thinking for educators workshop and I attended two great workshops at SXSWedu 2013 on Design Thinking:
Design Thinking is a great skill for students to acquire as part of their education. But it is one process like the problem-solving model or the scientific method.
It’s fair to imagine that one of the 2013 ‘words of the year‘ will be MOOC (which is not really a word, but an acronym that stands for Massive Open Online Course). It seems that everywhere you look in the higher education and professional development space we are seeing MOOC’s talked about and debated.
HBR editor Eric Hellwig, writing for the HBR blog, reported on a recent panel on MOOC’s held at the recent World Economic Forum in Davos with leaders like Bill Gates, Peter Thiel and Larry Summers. His report reflects the exuberance of the MOOC and the techno-deterministic spirit of much of the discourse on these tools:
The advent of massively open online classes (MOOCs) is the single most important technological development of the millennium so far. I say this for two main reasons. First, for the enormously transformative impact MOOCs can have on literally billions of people in the world. Second, for the equally disruptive effect MOOCs will inevitably have on the global education industry.
One of the panelists was Stanford professor Daphne Coller, the co-founder of Coursera, one of the largest MOOC providers offering more than 200 courses to millions of students worldwide. Coller has convinced top faculty at leading universities to provide high quality digital courses through Coursera for free and the result has surprised her.
We’re at 2.4 million students now. The biggest lesson I’ve learned on this is I underestimated the amount of impact this would have around the world. I really didn’t envision this scale and this impact this quickly.
Of these panelists, Peter Thiel may be the most controversial. He has spoken at length about the need to revamp education and sees technology and platforms like Facebook as a means to do it. (It’s worth noting that Theil was also an early investor in Facebook). He points to the multiple roles that education plays well beyond learning and suggests that when we go beyond that goal we start creating false economies of value within higher education:
You have to ask yourself, ‘What is the nature of education as a good?’ Ideally you want it to be learning. But it also functions as insurance. Parents will pay a lot of money for insurance against cracks in our society. Education as insurance has something to be said because it connects to the economy. You know computer science, you can get a job. But education also functions as a tournament. You do well if you go to a top school but for everyone else the diploma is a dunce hat in disguise. People need to understand what they’re trying to do? Is it insurance? A tournament? Learning?
Among Thiel’s biggest concerns is with the current educational system’s ability to support the kind of innovative thinking needed to make technological and scientific breakthroughs. So steadfast is he in the belief that some of the best minds are rotting in traditional classrooms that he founded the Thiel Fellowship, a scholarship fund to support promising young entrepreneurs in dropping out of school to pursue their ambitions of making social impact.
Thiel is disrupting education by taking learning away from the educational institutions charged with providing it. MOOC providers are seeking to develop a business model that puts them in the drivers seat of education and learning, drawing potential revenues away from traditional educational institutions. This will no doubt add to the pressures that universities and colleges are already facing as they rationalize ever more of what they do.
Education For All, Learning For Whom?
Free online learning of the calibre provided by Stanford University, Caltech, Harvard University, University of Toronto, MIT, and the Santa Fe Institute for anyone, anywhere sounds like a dream come true.
In some ways it is. In others, it’s an illusion.
It’s been suggested that less than 10 per cent of those enrolled in a MOOC complete it. And of this 10 per cent, it isn’t clear what they learn, how well they learn it, and what kind of application (if any) that content is made to issues away from the course. Online courses with video tutorials, self-organized learning and largely uni-directional teaching bring together the best of former teaching methods like instructional TV, self-help, and classroom lectures.
The problem is that this ‘best’ isn’t particularly effective. A 2000 meta-analysis of distance instructional methods found:
There does not appear to be a difference in achievement between distance and traditional learners. Of the ten instructional features that were analyzed, only three had an impact on student achievement. These three features were type of interaction available during a broadcast, type of course, and type of remote site. There was an insufficient number of studies to ascertain whether or not the education level of the distance learners effected their achievement in the course (Machtmes & Asher, 2000).
While this review was done before widespread Internet use, the methods included reflected the same list above with one- or two-way audio and video. The studies were also done on programs that were designed for credit, not voluntary non-credit courses. Research on motivation will show that optional programs are far less likely to engender behavioural shifts than those that are mandated.
So who then is benefitting from MOOC’s? We don’t yet know, but it is likely those with time to attend to the content, high levels of intrinsic motivation (< PDF), the technological tools to succeed, and the environment that is ready to support integration of content into practice. That’s a tall order.
We are in the early days of MOOC’s and its too soon to tell how successful they will be. However, theoretically there is relatively little reason to expect that they will produce the kind of results worthy of hyperbole — at east not with those already accustomed to alternatives. To offer a MOOC from a world-class university to a learner somewhere in the world where education is but a distant dream achieves a great deal. But to transfer MOOC’s to replace more interactive and engaging methods — usually face-to-face — and expect great learning is a bit implausible.
Yet, with what we are offering now to students in the form of large classes, disconnected curricula, and didactic instruction MOOC’s offer an attractive option. What it loses is the experience of learning that is not packaged in a class. This means a change to campus life, the informal and serendipitous learning that comes from being in the same physical space interacting with each other, and may seriously limit the use of thinking and creative tools that design thinking and applied creativity demand. (for a detailed look at MOOC’s and the modern university check out Nathan Harden’s essay in the American Interest).
There is much ado about MOOC’s, but is this a Shakespearian tragedy in the making for learners?
Photo credit: iStockPhoto used under license.
Post-secondary and continuing education is continuing to be rationalized in ways that are transforming the very foundation of the enterprise. Funding is a major driver of change in this field: how much is available, when it flows, where it comes from, what is funded, and who gets the funding are questions on the minds of those running the academy.
At the centre of the focus of this funding issue is the job market. Training qualified professionals for the job market in various forms has been one of the roles a university has played for more than a century. Now that role has become central.
Let’s consider what that means and what it could do in shaping the various possible futures of the university. This second in a series looking at the post-secondary and continuing education focuses on the metrics of jobs.
“What are all these people going do?”
The employability of graduates is now the holy grail of education industry statistics. Earlier this year I was sitting on the stage at an academic convocation with a senior colleague staring out at a sea of soon-to-be-graduates when he leaned over and asked the question quoted above. Staring at a sea of masters and doctoral graduates numbered in the hundreds and knowing that this ceremony was held twice per year, the question stuck and remains without an answer.
Maybe there were enough jobs for that cohort, but this process gets repeated twice each year at universities around the world and each year that I’ve been a professor those numbers (of graduates) seem to go up. Some of our programs in the health sciences are admitting three times the number of students than they were just ten years ago. There is much demand for education (as judged by departmental applications), but are there jobs demanding this kind of education in its current form?
Yes, the Baby Boom is moving into an age of retirement and increasing needs for health services, but do we need to graduate 80+ Physical or Occupational Therapists to meet this need this year? Do we need a few dozen more epidemiologists or health promotion specialists to add to the pool? How about psychologists or social workers: how many of those do we need? The answer from my colleagues in these fields is: We don’t know.
Chasing the Wind
Jobs are a red herring. It’s one thing to have a job, but is it the job that you trained for? (And is having that job even a reasonable goal?) Being employed is not the same as building a career. What if you were trained perfectly for a job that no longer existed? Imagine a Blacksmith in the 20th century or a Bloodletter. These questions are not asked, nor is much asked about quality of education relative to the pressures of recruitment, cost-cutting and educational rationalization. Most of us don’t know what quality education is in real terms because we are measuring it (if we are measuring anything at all besides jobs) by standards set for the jobs of the past, not the future (or even the present?).
“Skate where the puck is going, not where it’s been.” – Wayne Gretzky
Jobs are living things and very few in 2013 will resemble what they did even 10 years ago. The citizens of the developing world are entering this rapidly changing job market ready for change (See also McKinsey Global Institute report on future of work in advanced economies) because they don’t have the old ways to rely on. They are primed for change and if professional education is to meet the needs of a changing world, it needs to change too. It means getting serious about learning.
If education is rationalizing itself to focus more on jobs, then it also needs to get serious about clarifying what jobs mean, defining what ‘success’ looks like for a graduate, and whether those jobs are designed for where the proverbial puck is now or for where it is going.
Disruptive Learning / Disturbed Education
“The Only Thing That Is Constant Is Change -” ― Heraclitus
I’ve pointed out that learners have an uneasy relationship with learning principally because it means disrupting things. This is a topic I’ll be covering in greater depth in a future post, but if one considers how our social, economic, and environmental systems are changing it is not unreasonable to call this the age of disruption .
Change in complex systems is often logarithmic, not linear. It may be massively punctuated like a Lévy Flight or it could be closer to a random walk. In environments with a change coefficient that is large the level of attention must be more fine-grained than 5-year reviews. It requires developmental evaluation methods and learning organizations, not just conventional approaches to generating and assessing feedback. It requires mindful attention and contemplative inquiry to guide a regular reflective practice if one is to pay attention to the subtleties in change that could have enormous impact.
For example, if journalists and news media waited every five years to assess the state of their profession, they would have missed out on Twitter and come late to blogging, two of their (now) powerful sources of competition and tools of the trade. Some have waited, which is why they are no longer around. Metrics for journalism education today might consider the amount of exposure and proficiency in social media use, digital photography, use of handheld tools for communication, and real-time reporting skills. Metrics of the past might focus on newspapers and radio broadcasting. Which mindset, skillset and toolset would you rather be trained in today?
Questions for educators, learners (and evaluators):
Whether health sciences, journalism, human services or any field, what might some questions be that can help determine the role of job training in professional education? Here are five starters:
1. What is the state of your profession right now and are you training people for existing in this state? Are you preparing people for the next evolution?
2. Where is your field of practice going? What are the possible futures for your profession in the next 5, 10, and 20 years? Will it still exist? Are you a blacksmith looking for more horses in the automobile age or Steve Jobs waiting to attract people to a new graphical user interface?
3. Is your mindset, skillset or toolset in need of re-consideration? Does it still do the job you’ve hired it to do?
4. What do people need that your skills can help with? What unfilled needs and expectations are there in the world that your mindset, skillset and toolset could solve?
5. What would happen if your field of practice disappeared? How else could you apply what you know to making the contribution you wish to make and earn a living? What other skills, tools and ways of thinking would you need to adapt?
Design thinking can greatly help shape the way that one conceives of a problem, works through possible options, and develops prototypes to address the needs of the present and the future. Foresight methods help lay additional context for design and systems thinking by providing ways to anticipate possible futures for any given field. Lastly, knowing what the state of things are now and how they got to where they are now can help determine the path dependencies that education may have fallen into.
We can’t change what we don’t see and better foresight, hindsight and present sight is critical to better ensuring that education outcomes are not imagined, but based on something that can actually improve learning.
Since R. Martin and others hijacked the term 'designthinking', there is an ongoing dispute. Two thought worlds exist and possibly these can be united by laying bare the essential characteristics of a 'design thinker'.
Design thinking frames the verb 'design' as a specific cognitive activity in order to solve problems and is discerned from other ways of thinking such as decision making.
Design thinking is hot and under fire. Just as its miracle properties are misleading, so too are the claims that it is dead or dying.
If design thinking didn’t have something going for it no one would talk about it.
In a well-laid out essay on design thinking (and its timely death) William Storage points to the concept’s origins and proceeds from there to point to how it no longer serves a purpose given the panoply of voices arguing its merits.
Design Thinking has lost its focus – and perhaps its mind. The term has been redefined to the point of absurdity. And its overworked referent has drifted from an attitude and guiding principle to yet another hackneyed process in a long line of bankrupt business improvement initiatives, passionately embraced by amnesic devotees for a few months until the next one comes along. This might be the inevitable fate of brands that no one owns, spawned by innovators, put into the public domain, and consumed by consultancies who prey on business managers seeking that infusion of quick-transformation magic.
A related discussion on the LinkedIn group devoted to design thinking on this very topic prompted a lively debate. The impetus from that discussion came from the topic of a panel discussion at next week’s DMI conference in Portland entitled: Is Design Thinking Dead?
Bruce Nussbaum’s oft-cited assertion that design thinking is a failed experiment was one of the higher profile critiques. He asserts that the experiment of design thinking has failed, whereas I argue that we haven’t even begun our research in the first place to make that claim.
Returning to Storage’s essay, he concludes:
Design Thinking is hopelessly contaminated. There’s too much sleaze in the field. Let’s bury it and get back to basics like good design. Everyone already knows that solution-focus is as essential as problem-focus. Stop arguing the point. If good design doesn’t convince the world that design should be fully integrated into business and society, another over-caffeinated Design Thinking book isn’t likely to do so either.
To the first part of this argument, I agree wholeheartedly. Any concept that catches fire as broadly as design thinking that lacks a definitive intellectual home is bound to be tied to the hype cycle (discussed here and here in past posts). I would suggest to anyone interested in design thinking that they follow anyone’s claim about the idea with a question: what do you mean by that term?
Where I have problems with Storage’s argument is in its implication that good design is its own merit and that its benefits are obvious. To this point, I disagree wholeheartedly. The same foolishness is applied to healthcare around use of good evidence: high quality evidence that is “self-evident” is rarely so and even then inconsistently translates into practice with ease. Were that the case, the field of knowledge translation in health wouldn’t exist and evidence-based practice would be a pointless term.
If the benefits of good design were that obvious, every intelligent manager, strategist, executive and front-line staffer would be working towards it. They don’t.
There is little indication that design thinking in a form that would resemble common practice exists in any of the sectors I work in (and no, use of sticky notes and a white board does not equate to design thinking by itself). There simply is not enough reflective and documented practice in design thinking to provide the kind of wisdom to separate out the “sleaze in the field”, yet that isn’t reason to throw the baby out with the bathwater. We do not have good research to either venerate or denigrate design thinking based on anything other than the popular use of the term and rhetoric.
Einstein, as he often does, provides words to consider:
The attempt to combine wisdom and power has only rarely been successful and then only for a short while. – Albert Einstein
The ideas that lay behind design thinking are powerful, yet the wisdom of the field has not yet flourished enough for us to abandon the idea on anything other than the immature notion that it is popular and therefore can’t possibly be serious. In an age where wicked problems are more commonplace, new ways of thinking, seeing and acting are being required of organizations seeking to survive and thrive and design thinking offers some prospects for how to navigate through this. Not all designers deal with wicked problems.
Which leads to my disagreement with Storage’s assertion that design thinking equals design. Designer’s regularly apply the kind of problem exploration and applied creativity that is central to design thinking, but they alone are not design thinkers. Were that the case, then the concept would have found little purchase outside of that discipline. His argument also implies that good design is evident, another point that I contest (and will save argument for another day). Good design is contextual and thus the standards that make it so must therefore be negotiable. It therefore cannot be claimed outright.
A “good” chair is dependent upon who is sitting in it, where it is placed, and the resources required to produce it and sustain it. By that argument, “good” design thinking may fall into the same lines. But unlike design, which has wisdom and experience broadly dispersed in society and different fields of practice, design thinking has no such equivalent. What is the evidence that it produces more useful or effective outcomes? What are its central theories? How is it linked to other fields of creative thought and action? Are there fields better suited to applying design thinking? What do effective practitioners look like? These questions remain either unexplored or poorly done so. The process of design thinking has received the treatment it deserves and it is that which has garnered the attention, admiration and scorn of the blogosphere and beyond — the space where the “over-caffeinated” books might sell.
Scholars such as Nigel Cross have done much to advance our understanding of what designerly ways of knowing might look like as practiced by leading designers. But few systematic examples exist outside of design contexts alone. This is changing and books like Wicked Problems by the group at AC4D provide one such example.
It is time to pull design thinking from the embers of hyperbole and placed under the microscope and macroscope of reflective practice and research. Once there, we might better comment on what this idea means for business, social innovation, human services and our overall wellbeing by pointing to something other than an exclamation mark to make our point.