Tag Archives: creative thinking

Where do innovators start?

Lean innovators can’t help themselves. They see ideas every where. Inspiration is to be found where ever there is a problem and healthcare is full of problems. I’m going to mention three problems:

1. Health care is rationed. Even in countries where it appears to be on tap- it is rationed. For example when it was launched by Britain’s then minister of health, Aneurin Bevan, on July 5 1948, the national health service was based on three core principles:

That it meet the needs of everyone
that it be free at the point of delivery
that it be based on clinical need, not ability to pay

No one believes this is true and the experience of many is that even if it is ‘free’ you may still have to wait for it even if your need is great- simply because the ‘gatekeeper‘ doesn’t recognise the urgency of your need. Here is scope to innovate.
2. Health care is organised around the needs of the provider. In many countries you have to make an appointment at a time, and a place that suits the practitioner. This might mean taking a day off work, traveling a long distance, sometimes, as in my country several hundred kilometers to consult the expert. It is possible that you don’t fit the mould designed for the ‘patient’ in that system. Your culture may clash with the provider- so that you struggle to be understood, cause or take offense and generally find that things are lost in the translation. Consequently inequity characterizes most if not all health care systems. Another prime opportunity to innovate.
3. Health care can harm you. It is possible, some would say probable that at some point in your life the drugs or procedures designed to relieve your suffering may actually harm you or at best do nothing for you.

Simply being a patient in an acute care hospital in Australia carries, on average, a 40-fold greater risk of dying from the care process than from being in traffic, and a 400-fold greater risk than working in the chemical industry.  Australian Patient Safety Foundation

Further honing the indications for tests, prescriptions and procedures may do much to improve outcomes for most of us. For example it has been shown that the participants in trials of most drugs bear little resemblance to those for whom those drugs are prescribed in practice.

Although 61% of new cases of cancer occur among the elderly…..studies indicate that the elderly comprise only 25% of participants in cancer clinical trials.  J Clin Oncol.2003 Apr 1;21(7):1383-9.

Similarly potentially harmful tests are performed unnecessarily and many invasive procedures are carried out for dubious reasons. Finding ways to reduce the scope for harm is therefore a priority.

Why innovators should learn to embrace feedback

Lean innovators often work in isolation and not surprisingly the innovator is emotionally invested in her idea. She has conceived the idea, developed it, spent time and resources on bringing the idea to life. This makes criticism of her brain-child very hard to bear.

The temptation is to be defensive. To shout down the critic. To take the view that the person offering an opinion hasn’t understood the brilliance of what has been brought to the world. The cure for this sort of pain is to begin with the end in mind.
Consider who is this innovation is for? Who needs to cooperate to make it available to the end user? Who will pay for it, either with hard cash or with their time and effort?

Another way to get a better understanding of the real problem you’re trying to solve is to write a short letter to the person you want to solve the problem for. A crucial part of innovating is to tell the story of the invention effectively, to make the people who need to care in that moment, care. It’s worth investing the time to get your story right and to seek out people you trust to give you honest feedback before you have to tell the story for real.

Rethinking The Benefits Of Expensive Medical Research

In the developed world the really scary diagnoses are very uncommon. More often than not a patient’s symptoms can be safely interpreted as benign. This has engendered a false sense of security because there is evidence that doctors fail to recognise presentations of some nasty diseases.

Innovators in medicine have been focused on this problem for some time. For example a research team reported in 2009 that skin cancer was much easier to diagnose with the aid of a handheld device that draws attention to cancerous changes. The problem however is that doctors need to attend a course on dermatology and take an exam before it is safe to let them lose on people with the instrument. The published report was upbeat despite the fact that one in three doctors didn’t complete the required training. The outcome of this research (and many other research programs funded using millions in taxpayer dollars), was an academic paper that will never impact on the early diagnosis of the disease.

Less than five years later some of the same team were back to test a simpler device but with a similar requirement for education of doctors before successful deployment. The negative results were hardly surprising. The team concluded that cancer was more likely to be diagnosed early if doctors followed guidelines.

History has taught us that just because an intervention may be of benefit to patients, that doesn’t mean it is likely to be embraced by overburdened care providers trying to earn a living. The most successful innovators understand the need to tailor interventions to meet the needs of both the health professional and her patient. They realise that tools that are inconvenient or cumbersome are doomed to novelty status.

Committees that determine which ideas are worthy often deny the lessons of agile, intuitive, creative and effective innovations. These are more likely to be reliable, developed relatively cheaply and don’t need an instruction manual.
How hard is it to adopt your innovative ideas in practice?

Seven trends influencing lean medical innovation

Innovators recognise that the their circle of influence is contingent on an awareness of their customers’ world view. Seven trends now impact on whether people are likely to welcome innovation into their lives.

Mobile communication

For many people mobile phones have replaced their wrist watch, camera and PDA. Phones are now used not only to keep in touch but also to access information with two taps. This is achieved on a ubiquitous device that is getting cheaper and more portable. An allied trend is for tablet computers that are little bigger than a phone to obviate the need for a laptop.

Testophilia

People now demand validity for professional advice that until recently was accepted as gospel because an authority figure proffered it as the truth. This means that you no longer trust me simply because I am a doctor. What’s more people want the results of medical tests in a format that makes sense to them regardless of their ability to digest complex information .

Quantified self

There is an increasing desire to measure and record whatever can be measured as if that in itself will be enough to influence our behaviour. Everything from blood pressure to how much we sleep. Quite what people are doing with all this information is a matter of debate but people are seeking ways to access this information.

Information overload

Because of the almost unlimited source of information at their fingertips people are actively filtering data. A quick Google search for ‘best diet’ revealed 625 million results with page upon page of conflicting and confusing advice. On the one hand you could opt for intermittent dieting or you could take the advice to ditch the diet altogether. As I hold the view that it has to be proved scientifically before it can be deemed true I more or less ignored (i.e. didn’t read) anything that didn’t appear to conform to my own worldview for valid and reliable advice.

Dr. Google.

Concerned people want relief from the outpouring of adrenalin with its unpleasant physical effects. In a Googlised world iving with uncertainty is regarded as unnecessary. This means as a clinician you have to assume people will have done some homework before they speak with you. Either what you say will resonate with their ‘ informed opinion’ or your advice will be rejected unless you are able to say or do something that changes how they feel about their problem and or the treatment.

Commercialisation

The cost of staying healthy increases every year . In Australia the cost of attending a doctor have fast outstripped the rate of inflation. As we age and need more maintenance we will either spend a greater proportion of our income on medicines or look for cheaper alternatives. There is now a compelling business case for marketing cheaper and more effective ways to deal with health problems that until recently required doctors’ appointments.

Want it now

Anyone living with a teenager knows that they no longer accept the wait for Christmas. If you want it, there must be a quick, cheap and immediate way to get it, preferably delivered to your door with a money back guarantee. Therefore speed of delivery is necessary, but not sufficient for success. Innovations that do what they say on the tin, at a reasonable price and come with excellent after sales service are almost guaranteed a bright future.

Lean medicine is about working in a world that has an insatiable appetite for quick, convenient, cheap solutions. The seven trends outlined here have a significant impact on the diffusion of innovation in healthcare. How have they impacted on the success of your ideas?

Innovating at the interface between service providers

At least one in a hundred patients seen in general practice are referred to hospital.

In many countries the referral process hasn’t changed in decades. It’s still done with pen and paper and even in 2013 in some developed countries it still involves a fax machine. What’s interesting about the process is that once the letter is received at the hospital, it is read and then triaged by someone to determine when the patient should be offered an appointment. The decision is made in less than a minute. Everything, perhaps even life or death situations. hinges on the impression created by the writer of that letter.

In a government subsidised system, where there is a need to ration appointments, a patient might be seen next week, next month or six months from now. The reality is that in some cases a patient might wait longer than is ideal and the outcome for them may be compromised, because of what was in the referral letter and how that was interpreted. Who then is to blame, the doctor who was consulted first, or the hospital that arranged a deferred appointment? How can innovation help in this situation?

I’ve been involved on teams that have studied this problem from many different angles culminating in a randomised trial of an innovation in 2012. We came to a number of conclusions. Firstly involving people in innovation when they don’t believe they have a problem is frustrating. Many doctors think their letters are just fine, or that the recipient hardly reads them. Its difficult to innovate in a busy clinic where doctors are working flat out, and the truth is that if the innovation doesn’t make life easier for the doctor as well as the patient then it’s going to be hard to implement.

Secondly colleagues are reticent to demand change from one another, especially when they work in different parts of the system. So, as a hospital specialist I might not feel I have any mandate to require that referral letters contain the details that I like to have. It’s even worse when the paymasters across the sectors are different. In Australia hospitals are funded by State governments, whereas primary care is funded by the Federal government. What’s more primary care providers work to a ‘pay for service’ model. Which effectively means that primary care survives on profits.

Thirdly, it is unsafe to assume that all colleagues apply the same criteria about what clinical scenarios should be allocated an urgent specialist opinion, even within the same specialty, in the same healthcare system, and with reference to nationally accepted guidelines. That was unexpected!

Some problems require a whole systems approach. A problem that has seemingly obvious roots, with a strong(ish) evidence base can be difficult to crack with a lean medicine approach. Where multiple individuals are involved across health sectors, it is absolutely necessary that innovations make everyone’s life easier. Requiring letters to be written a certain way, and demanding that the process is enforced by the recipients, when there isn’t local consensus on what is an urgent case, is not going to work without something else to make it worthwhile for all concerned. What this problem calls for is more innovation when it comes to making the decision to refer. Perhaps more sensitive near-patient tests, which are better able to predict who is most likely to benefit from limited national resources.

What are your ideas for improvement that don’t require people to donate time and effort for no personal gain? Pushing out innovation is not enough, if there isn’t a pull from those at the coalface to adopt those ideas. It isn’t safe, even in medicine, to assume that people will do it, use it or promote it simply because they recognise that patients will benefit.

You don’t need permission to begin innovating

imageLast weekend I spent four hours in the air sitting bolt upright crammed next to a fidget on a budget airline. The plane was full of sunburnt youngsters flying back from Bali. Years from now they’ll turn up at the doctors convinced that a mole has changed. Sadly malignant melanoma is the commonest malignancy in this part of the world.

Maybe much sooner they’ll be worried that the insect bite on their shoulders is infected. Spots, sores, moles if I had a cent every time someone wanted reassurance about one of those I’d be doing well. I’m sure many of my colleagues would agree that it would be great to have a reliable way to keep an eye on skin lesions that change when the doctor isn’t there to inspect them. It’s also hard to look between your shoulder blades. On the other hand the doctor in me wouldn’t want you to use your phone to make a diagnosis, it has been shown that technology can’t do better than a doctor with a good eye. Nonetheless we need something to track changes in our skin, to alert us if things aren’t looking the same. It would also we helpful to have a record of lesion changes to show when we turn up at the clinic.

Taking photos on a smart phone might help but tracking symptoms and measuring changes in the appearance of something that might need to be removed is a good idea. iMockApp is a free app that enables anyone to create wireframes. I used it on my iPad mini (on that flight from Bali) to develop the idea for an app that could monitor skin lesions. Of course it would need a lot more work before it was made available to the public, but it was a start and spending time on the idea stopped me reaching across to strangle my fellow passenger who had just managed to punch me, accidentally I think, in the side.

The point is that as an innovator you are rarely without the tools to create—diaries, iPads, laptops, note books, napkins, pens, pencils, whatever. You don’t need a whiteboard, a ‘team’, a budget, grant or a mandate from the ‘boss’ to create something new. The world appears divided into two simple typologies- creators and consumers. Will you wait for someone to give you the permission to innovate, or have you taken out pen and paper and begun sketching your design already?

See demand in context and respond creatively

9645066390_babd98c3f1_zHello Jill, Oh, I’m sorry I have no appointments to offer you today. the doctors are all fully booked. If your son has a fever try him with some paracetamol and call back on Friday when I might be able to squeeze him in with Dr. Jones. Ok, bye.

Many years ago I overheard this conversation in my reception. Our receptionist giving medical advice without any qualifications. The surgery was over booked. She was harassed, doctors were grumpy and the patients were being turned away without being assessed by anyone.

We noticed that there was a seasonal pattern to this demand for appointments. Most doctors were aware of this trend because there were specific weeks of the year when they avoided taking holidays. Our reception staff kept meticulous colour coded records of such ‘same day’ appointments. When we entered this data on a statistical database there could be no doubt of a seasonal pattern with definite peaks and troughs. What’s more, we could predict the demand for ‘same day urgent appointments’ with reasonable confidence. At this point, it may be important to stress that doctors in the UK are paid a ‘capitation fee’ for serving patients. That means they are paid an annual fee no matter how many times they see the patient.

Understanding that people have a fundamental desire to talk to the decision maker, we settled on the notion of putting the doctor in charge of making the appointment. Patients who requested a ‘same day’ appointment were offered a telephone consultation with a general practitioner initially. Not with a nurse, as happened in some practices, but with their doctor. We believed patients wanted to speak with a medical practitioner, not because the advice they received was necessarily better than that given by another member of the team, but because people in distress want a doctor. Whatever the reason it worked. Important policy makers noticed. Doctors could deal with most requests within a couple of minutes, offer a ‘same day’ slot or something else without the need for a face-to-face appointment. We calculated a 40% reduction in demand for such appointments. Patients loved it, reception staff loved it too (no more arguments about lack of appointments with irate patients) and doctors found themselves in control of their workload. What’s more, we could prove that this simple intervention worked from the impact on longitudinal seasonal trend.

By allowing patients to speak to their doctor when they felt they couldn’t wait our practice chose to treat this small minority of patients differently to those who were happy to make a routine appointment. We acknowledged that these patients had a need that warranted a creative solution. Perhaps you have a group of patients who would benefit from being treated differently too? What is the context in which they seek help? The tired mother with a fevered child does not have the same needs as the young professional who requires a convenient appointment to obtain a prescription for the contraceptive pill. Both might seek an urgent appointment.

Picture by Marjan Lazerveski