Discovery and Innovation in the Business of Health Care


Discovering things previously unknown is one of the most important, and most enjoyable, things that anyone can do. Most people do it every day, whether as simple as finding a new restaurant they love or discovering a new comet in the heavens. Fundamentally, new discoveries come from observation, analysis, and experimentation. A husband looking for a new restaurant to try with his wife might observe something that in his experience resembles a restaurant on a street corner. He then analyzes the available information to decide if he wants to try it; what kind of food they, the opening hours, and whether it is clean and inviting. Finally he and his wife try it out, completing the process of discovery.

New discoveries are often far more difficult than finding a great new place to eat. Identifying a new comet can require expensive equipment and uncommon expertise, while sequencing the human genome, learning about subatomic particles or curing cancer are some of the slowest and most resource intensive discoveries of all. The discovery that smoking causes lung cancer followed the same observation-analysis-experimentation sequence. In the 1930s a few surgeons noticed that they seemed to be performing lung cancer surgeries on a lot of smokers. Some published their observations and that induced others to analyze the existing information and hypothesize that smoking is associated with lung cancer. Researchers then developed experiments to test the hypothesis and in 1956 the British Doctors Study provided the first convincing evidence that smoking increased the risk of lung cancer.

Service industries such as health care use quantitative and qualitative methods to make new discoveries to improve the services that they provide to their customers. As a natural science, medicine makes new discoveries using a vast array of natural science methods such as laboratory and imaging techniques. As a social science, medicine also uses surveys, focus groups, and other techniques to gain information on people and their behavior.  As a business, medicine uses social science and other techniques to continuously improve its services to its stakeholders; including patients, family, staff, and others.

This article hopes to cover some of the methods that organizations, especially medical, can use to make new discoveries. In so doing, health care professionals can find the right questions and the right techniques to answer these questions for the benefit of their patients and others. 

Benchmarking

Regardless of the type of organization, benchmarking processes and outcomes against peers is useful. Manufacturers might reverse engineer a competitor’s product to improve their own and service companies might review the literature or even use secret shoppers to find best practices in their field that they can modify and imitate. 

Quantitative Methods

Since Frederick Taylor’s Principles of Scientific Management (1911), quantitative assessment of problems in business has been the standard. This should not be surprising, since Taylor’s key ideological tenets held sway over business thinking for much of the 20th century.

1.    The primary, if not the only, goal of human behavior and thought is efficiency.

2.    Technical calculation is in all respects superior to human judgment.

3.    Human judgment cannot be trusted because it is plagued by laxity, ambiguity and unnecessary complexity.

4.    Subjectivity is an obstacle to clear thinking.

5.    What cannot be measured either does not exist or is of no value.

6.    The affairs of citizens are best guided and conducted by experts.

Quantitative methods of making new discoveries have led to great advances in business and health care. Excluding bench and other basic research, these methods generally involve large numbers, both large numbers of subjects and large numbers of data points. They tend to involve standardized instruments to evaluate characteristics of their subjects, whether monitors to measure blood pressure or surveys to measure opinions.

Timing Categories of Quantitative Studies

Examples of Quantitative Studies

Prospective

Cohort – select a risk or protective factor and compare exposed with unexposed to see what outcomes they will develop.

 

 

Clinical Trial – select an intervention and compare exposed with unexposed to see what outcome they will develop.

Retrospective

Retrospective Cohort – select a risk or protective factor and compare exposed with unexposed to see what outcomes they have developed.

 

 

Case Control – select an outcome and look back in time (survey or other measurement device) to see what they were exposed to

Current

Cross-Sectional (prevalence) – examine risk or protective factors and outcomes that subjects have now.

Such quantitative methods are widely used in medicine and even in business. Data can be collected by instruments such as blood pressure monitors or laboratory equipment depending upon the object of the study. Data can also be collected by standardized surveys when investigators want to discover personal opinions or experiences. When done properly they provide valuable information which can be generalized beyond the study group to the larger population.

Qualitative Methods

These methods often involve much smaller numbers of subjects but provide much deeper insight into the needs and opinions of a small group or each subject. Focus groups, clusters of subjects specially selected by the researchers and working together, can provide qualitative data. Commonly used in business and politics, focus groups get individual responses which are conditioned by the group. 

Individual interviews are not guided by standardized surveys with preselected responses, such as “strongly agree – agree – neutral – disagree – strongly disagree” as is found in the Likert scale. Rather, while covering standard topics, they encourage group or individual stories from the subjects which pertain to the question at hand.

Design Thinking Process

A currently popular way of getting information, especially the qualitative component, is the Design Thinking Process (DTP). While qualitative methods often try to eliminate or minimize the subjective element in problem solving, design thinking attempts to “combine empathy for the context of a problem, creativity in the generation of insights and solutions, and rationality to analyze and fit solutions to the context (http://en.wikipedia.org/wiki/Design_thinking).”

Rather than dozens or even thousands of subjects, DTP typically recruits 10-12 subjects specially selected for some characteristics of interest to the researchers. They find the subjects through social media mapping, identifying frequent users of services, or asking key staff to recommend specific users. Simultaneously investigators try to ensure a representative demographic mix. In a hospital emergency department (ED), for example, study personnel might identify key opinion leaders who write about that ED and its services in Facebook, Twitter, or a blog. They might also examine hospital records to see which people used it the most and ask ED staff to recommend patients for the study.

After potential subjects are identified they have to be screened to decide who to include. A key determiner is who has the biggest potential influence to improve patient and system outcomes. Subjects must commit not only to providing data but also to help develop solutions.

Once researchers have a suitable number of the right volunteers, data gathering – individual interviews of each subject – begins. The first step is to develop a “journey map” for each subject. For a study to improve ED services in a community hospital, the map may begin when the patient first developed the symptoms that led them to the ED. They may be asked questions like this:

1.    Where and when did you first think that you might need to seek care? Why did you decide to go, and how did you get there? Please describe in detail what happened and how you felt.

2.    Who did you interact with at each location in the process? At home with family? With the EMS personnel? In the ED?

3.    What touch points did you have with the medical system? How was your interaction with each?

4.    What is your impression of the areas that you encountered? It is useful at this point to show patients pictures of pertinent locations, such as ED exam rooms, waiting rooms or front desks. These key areas color peoples’ opinions of everything and everyone else in the process.

5.    What could you see, hear, smell, feel, or even taste at each area? Was the environment hot, cold, too dark, too bright, too noisy, or something else?

6.    Were you given educational information? If so, was it useful? Why?

7.    What did you experience that was unexpected?

8.    Did you experience negative emotions? Which ones? Why?

9.    Did you experience positive emotions? Which ones? Why?

10.Was your experience seamless or fragmented?

Journey maps may begin even earlier. The first interaction that one person has with another or that a person has with an organization may be the expectation that one has of the other. Stakeholders may know, or think they know, well known people and organizations simply from their reputations. Therefore it is incumbent on everyone to consider how to improve others’ expectations of them, not just the physical interactions.

Journey maps also end later than the final physical interaction between people and organizations because of memory. A patient may have a wonderful experience in a hospital overall but have one truly bad interaction at discharge. That person’s memory of terrific care will be tainted and maybe even superseded by that last memory. Since memories of prior experiences color future expectations, people and organizations must manage them if they hope to please their stakeholders. The time-based process of interactions can be described like this:

Expectation

Does the customer or other stakeholder have expectations of the person or organization? If so, what are they, and how can they be improved?

First Impression

What does the customer or other stakeholder encounter the first time they make physical contact with services?

Discovery

Assuming the customer or other stakeholder stays with the person or organization, both parties begin to discover what the other is really like. Expectations and first impressions give way to lasting experience.

Usage

Assuming that discovery is satisfactory to all involved, they begin working together to accomplish mutual goals.

Memory

Eventually the interaction, whether an episode of care or something else, is finished. All parties remember their interactions, for good or for ill, and these memories shape future expectations.

Interactions between stakeholders and organizations do not occur only in time but also in space, and journey mapping also discovers these interactions. Some interactions happen directly to a stakeholder, such as a patient having surgery. Other interactions happen to their family or friends, such as a desk clerk being kind, or rude, to visitors trying to see the patient after surgery. Still other interactions happen in the public sphere, such as when a stakeholder sees a news story or an advertisement about a hospital. Innovators can find valuable clues on how to improve a customer’s (or a patient’s) experience by considering both time and space in their interactions with the organization.

For ongoing interactions between an individual and an organization, having the customer (patient) keep a week long journal of her interactions with the organization is useful. It is important to interview the subject in her context, such as home or work, to get the most insightful answers. Once each person has described their journey, researchers will begin to identify commonalities between them on the journey maps. They should use those commonalities to make a journey map of the subjects, which is called the Experience Map.

Simultaneous with gathering information from customers, known as patients in the health care setting, investigators begin selecting key organizational actors to participate. These may be doctors, nurses, and health care administrators, and their task is to join with the patients and solve the problems identified. First they write a blueprint of how the current service is designed. The blueprint helps match the front end experiences that the patient sees with the back end processes that the providers do. In the ED example, these staff members would carefully outline the current processes for screening and treating patients, as well as other pertinent processes. They would also identify principles that need to guide their thinking. For example, interactions with patients and other staff must be pleasant while at the same time being meaningful. “Pleasant and Meaningful Interactions in the ED” then becomes a key principle, known as an “Experience Pillar”, in the process.

Solving the Problem

The data gathering process is iterative; new data will constantly appear and be integrated into thinking on the research question and hypothesis. The solution process is also iterative; new data will modify the proposed solution and suggest improvements. Just as customers and staff are integrated into the data collection efforts, so customers and staff should be integrated into the problem solving efforts. The team that does this is the Co-Creation Team.

Looking at the service blueprint and the experience map, the Co-Creation Team uses Ideation sessions to look at the problems and at ways to fix them. They identify many possible solutions, but especially those that are small scale, low cost, and can be implemented quickly. The team presents its recommendation to decision makers and if all goes well their ideas are piloted. The easiest and quickest approach to the pilot project is to begin with the minimum viable solution tested in the minimum viable service. For example, rather than piloting a new mobile phone application to help patients coordinate their care with hundreds of patients in many different clinics and diagnostic categories, organizations can pilot a small version with a few dozen patients in one clinic in one diagnostic category.  In the National Capital Region, our pilot will involve a few dozen amputees in the Wounded Warrior clinic.

How to Optimize Discovery

Benchmarking, quantitative and qualitative methods are not contradictory but complementary in discovering how to best make a widget, provide a service, or care for a patient. In general terms, quantitative research and benchmarking can identify what is happening and where, while qualitative research can show how it is happening and why.

Conclusion

In a world of constant change, individuals and organizations must continually improve. To do this we must think differently, constantly making new discoveries. Using benchmarking, quantitative and qualitative methods provides a good means to do that.

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