better health by designLearn More

Innovating for one of the climate’s biggest public health challenges

4265056770_b589d0437a_zIn a cohort of U.S. women, we found that sun exposures in both early life and adulthood were predictive of BCC and SCC risks, whereas melanoma risk was predominantly associated with sun exposure in early life. Wu et al

Furthermore according to the editor of Nature in July 2014

It is accepted that sunscreens protect against squamous cell carcinoma, and this work [research] suggests that they also protect against melanoma.

This message is not getting through to those who might be able to influence public opinion

To win the U.S. Open, tennis players must overcome fearsome opponents, grueling matches and searing heat. But for some, none of that causes quite as much angst as the prospect of rubbing on a gob of white lotion. Of all the accessories that players have at their disposal, sunscreen may be their least favorite. Some don’t wear it at all. Some apply it before daytime matches, if somewhat begrudgingly. But nobody seems to like it. Brian Costa and Jim Chairusmi

The ambient temperature in many parts of Australia early this year will be well over 30 degrees with a UV index of 11- in other words, extreme. Intelligent and well-informed young men and women may be found fully exposed to the midday sun and for hours on end. Many will not be wearing sunscreen, a hat or sunglasses. This can be observed on the beaches, on the tennis courts and on the cricket field.

The message to seek protection from harmful UV rays needs to be crafted in the context to which it is being targetted. It needs to take account of the ideas of young people who are resistant to messages that appear to impose limitations on what they can do:

Tennis players tend to sweat profusely, especially during day sessions at the U.S. Open, where high temperatures and humidity are typical. When the heat mixes with sunscreen, the sweat can form a gooey substance that gets into players’ eyes and onto their hands, affecting both their vision and their grip.

We need to understand and adapt to the perspective of those to whom the public health message needs to get through. There may be other ways to deliver the messages that are more potent. Watch these videos:

  1. The sun damages your looks
  2. It can harm your vision

Therefore, within Foggs model, the motivation to seek protection from UV light could be targetted better. Ability to apply sunscreen or wear sunglasses also needs more attention. Technology may have more to offer with more user-friendly products. Equally making the equipment currently on the market more readily available when and where they are needed will also help. Finally, it may be worth considering a trigger for the behaviour. Something that gets motivated people with the ability to perform the action to then act on a regular basis. The recipe for such behaviour is typically the traffic light. Red means stop every time. The teenager who gets on the cricket field with sunglasses and sunscreen in his bag needs to be triggered to wear them without mum or dad’s nagging voice to remind him. The behaviour needs to be anchored to something familiar- e.g. stepping onto the sand or grass and the message delivered at a teachable moment. The trigger of television advert is not enough for behaviours that need to be repeated. There is still scope to develop an effective innovation by an enterprising researcher based on the principles of patient experience design. I hope it is you.

Picture by Colin J

Innovation is a product of leadership

339113868_1052c8c6a0_zInnovation is ‘a new idea, more effective device or process’. Innovation can be viewed as ‘the application of better solutions that meet new requirements, inarticulated needs, or existing market needs’. It is the fruit that appears on the branches of an organisation where every active component or member has at least what they need to thrive. Maslow identified the hierarchy of those needs. Not every ant in a colony is the queen. Not every ant has to gather food. However if the colony is to thrive every ant must play its part or work with others to solve a problem creatively.

The leader is only ever accepted in nature when the colony thrives. If the leader or potential leader has a limited capacity to facilitate the success of their colony, they are replaced or ejected. At the moment when the team faces a challenge that could impact on their capacity to be productive the individual team members must rise to the challenge. Any solution must not risk the colony. That means that foot soldiers need to live the mission of the colony, they must know the limitations of their mandate but not have to ask the ‘most senior manager’ if it’s OK to do something that brings success in their tasks.

Leaders embody the behaviours and attitudes that give the foot soldiers confidence. They communicate effectively. They ensure an adequate supply of that which underpins creativity. They ensure that the needs, as opposed to the wants of their team are satisfied.

The list of innovations produced by a company is a litmus test of the effectiveness of its leaders. The most prolific innovators foster a culture that will continue to contribute to human welfare. Their leaders have the capacity to ensure that each and every member of their team feels valued but also understand and accept the mission of the mothership. The employees learn to behave as part of the whole and yet feel empowered to boldly solve problems in their domain. A critical component in innovative human organisations is the enlightened and selfless exercise of power where relying on the natural response to chemical pheromones is not an option. If you believe you cannot be involved in any research or innovation where you work you may have a problem. An inventory of your new ideas may be a good place to start a review.

Picture by Kasi Metcalfe

Prepare to avert a drama in a crisis

128886598_e895d6d0a0_zWe were dismayed that there were no seat back screens for our five hour flight back to Perth and there was a feeling of foreboding as we took our allocated seats on what was clearly an aged plane. As we were taxiing onto the runway the pilot made the fateful announcement:

I’m sorry to report that a warning light has flashed in the cockpit and I must return to the terminal for engineers to investigate. We regret the inconvenience caused.

When we pulled back into the gate the pilot turned off the engine and engineers boarded the plane. 45 minutes later the pilot was heard to say:

Ladies and gentlemen I have good news and bad news. The good news is the copilot has just become an uncle (applause rippled through the cabin). The bad news is that we have discovered another fault on this aircraft and we will be off loading you until safety checks are completed.

We gathered our belongings and when the seat belt signs were turned off we filed back back into the terminal. Everyone headed to the desk where the ground staff were busy apparently seeking telephone advice from supervisors. They seemed oblivious to the many anxious faces queuing for information. Ominously the crew wheeled their luggage past and headed off down the corridor. Some of the 400 passengers pushed their way to the front of the queue and demanded information. These eventually passed on the news that the flight was cancelled. Some people walked away muttering that they had given up on the airline and would stay the night. The rest of us waited for a couple of hours returning to the desk every few minutes, still ignored by the staff until eventually one said that frequent flyers would be boarding the later flight to Perth the rest would have to take their chances with other airlines or stay the night. Surely that was always the plan from the moment we were off loaded?

In such a situation the behaviours the airline would wish to see are:

  1. Staff know what to do and are instantly at action stations, reassuring, advising, assisting and redirecting. Effectively minimising the damage to reputation.
  2. Passengers queue in an orderly fashion, remain calm and reassured that the airline has a plan B. Making it less likely to make a drama out of a crisis.

The pilot could not be faulted he knew exactly what to do in the event of a potential emergency. However ground staff struggled to be polite much less organise themselves to inform all the passengers what contingencies were in place when one of their aging fleet of planes was unexpectedly deemed unfit to fly. Consequence- very unhappy customers who will blog about their experience and write complaints.

This happens in medicine all the time. The surgery is cancelled, the medication isn’t in stock, the patient has a cardiac arrest, the transplant organ is rejected, there is a flu epidemic. What makes a difference is anticipating such a crisis. Medicine too often gets this aspect wrong. Surgeons, like pilots, usually do exactly the right thing- abort the procedure, delay the treatment or place the patient in intensive care. However that isn’t the end of story. If we claim, as medicine does that we aim to support the patient through the crisis, disruption, shortage or adverse event then we need to do more than simply hope they don’t turn up at reception to ask the difficult questions. Flights are cancelled on a regular basis as is surgery. This is a set play just as everyone is shown the brace position on boarding the aircraft and as the safety announcement states:

You must know this instantly in the event that there is an emergency

However ’emergency’ isn’t just a threat to life and limb. Emergency is also a situation where there is a substantial and immediate risk to the brand. The staff behaviour did not trigger the desired behaviour from the customers. And as anyone who has done an Advanced Trauma Life Support course knows the noisiest patient isn’t the one whose life is at greatest risk. Find the one who really is going to die without a timely intervention. It seems the airline policy was to attend to those customers who were most vociferous. Many of us deemed it rude to push our way to the front of the queue. But those who had no such compunctions were rewarded with boarding passes to the few flights leaving the city that evening. We can all learn from these experiences. Health innovators have something to offer the airline industry. An industry that remains the leader in safety but not in customer service.

Picture by Alex Avriette

The value of rituals to innovators

4182291013_fc4106bde3_zEvery health practitioner engages in rituals. In general practice / family medicine they look this:

Review

Doctor: What do I know about the person about to enter the room next? Review notes.

The greeting

Doctor : Welcome. Please take a seat. How are you today?

The pregnant pause

Patient: Not so good doctor……..

The context

Doctor: Tell me how this has affected your job/ family etc

The examination

This aspect sometimes, perhaps always,  follows a ritual.  Like the one illustrated here.

The decision and the check

Doctor: I recommend you take this test/ take these pills/ see this specialist. Are you allergic to anything? Are you taking any pills at the moment?

Safety netting

If you feel any worse or you develop a rash that looks like this, please come straight back.

Administration

Note writing, charging etc.

Each of these phases in the ritual offers an opportunity to ‘anchor‘ a new habit. In a previous post I wrote about how to trigger health practitioners to act in a specific situation where their motivation and ability are favourably aligned. For example one might like the patient to be offered a particular screening test on or after a specific birthday, the greeting might prove a good trigger. Doctors might look for specific information to include in the greeting e.g.

Welcome, I see it was your birthday last week. A belated Happy Birthday! We might want to talk about a new test we are recommending people at this age. Is it OK to add that to what we need to discuss today?

Another example may be to refer people with a specific problem to a specific place. This trigger can be anchored to the point at which the doctor is completing the medical record. If the trigger results in behaviour that is rewarding to the doctor it will become a habit within a relatively short period. The key issue for innovators is to identify where in the ritual to anchor the trigger, what reward is available immediately and to work with the practitioner to establish the behaviour as a habit.

Picture by Laura4smith

Innovate to enable rather than motivate

3174335892_a08c3f044b_z

 

A perennial issue is how to trigger behaviours that are likely to result in good outcomes for the individual. Smoking cessation, regular exercise, more fruit and vegetables, less alcohol….the list is long. There is no magic bullet. Again I make reference to BJ Fogg who offers the most easily digestible way to ponder the question. He promotes the philosophy that innovation is about making it easier for people to do what they already want to do and then triggering that behaviour until it becomes a habit. There are four scenarios:

High motivation and easy to do

An individual in pain will need very little to trigger the relevant behaviour- i.e. take the pill that is stocked in the cupboard.  It might be enough to suggest:

Why don’t you take something for that headache?

There are many such scenarios ranging from the life threatening to the debilitating.  The symptoms may be enough to trigger the behaviour and act as a ‘signal’ for the patient. Unfortunately many chronic and even life limiting conditions are asymptomatic until complications ensue and the patient may not be motivated simply by knowing they have diabetes or similar with potentially serious complications. The motivation may also wane in time- as happens in the case of many acute infections where as the symptoms abate the motivation to persist with antibiotics drops. The longer the duration of the treatment the less likely that the patient will complete the course.  In the case of life long treatments for asymptomatic conditions the probability is low. On the other hand when a patient has perceived that they can do the needful, for example when someone has sourced advice on how to stop smoking, and is motivated to do so, then a simple ‘trigger’ is enough in many cases. Here is some empirical evidence. Health practitioners can provide such triggers- the results will depend on the extent to which motivation and ability are also aligned. Pharmacists may be able to trigger a medical consultation simply by advising it. Perhaps this is the most fruitful avenue for innovation at a time when people are becoming more enabled to self care.

High motivation but hard to do

Many people find it hard to give up bad habits. The mother whose child has suffered another asthma attack is motivated to stop smoking but may perceive it as difficult to achieve. The man who has gained weight in the last decade may feel that more effort is required than he is able to commit to dieting and exercise.  The teenager who has recently been in hospital may be advised to inject insulin and give up chocolate may soon quit the regimen. Unfortunately much effort is expended on developing programs to ‘enable’ patients to do ‘hard’ things in this context. It is critical that what needs to be done is made easier or perceived as easier. A  ‘facilitator’ trigger in this case would give access to something that is ‘affordable’ in terms of time and effort. Sadly this is also the stomping ground of charlatans who might trigger ‘quick cure’ schemes, things that promise more than they can possibly deliver to vulnerable (highly motivated and paying) individuals. Effective innovation comes from developing better, cheaper treatment regimens and then triggering them as in scenario one above. Often what is developed is not perceived as easier and the innovation fails.

Low motivation and easy to do

In this situation the patient is not motivated to do something from which they might benefit and is easily available. The influenza vaccine is offered at the requisite time each year. Uptake remains a cause for concern. The reasons for poor motivation need careful consideration- they may not be rational and the ‘spark’ trigger- something that will increase motivation to the point where action may be problematic or need a local solution. The challenge is always that motivation is hard to influence- people’s entrenched beliefs are difficult to shift. If the public believes there is a link between a vaccine and a serious illness, it will be challenging to trigger parents to bring their child for vaccination. Much effort is expended on ‘educating’ people who attend health practitioners. Motivation may increase to the point where it can be triggered but the amount of the effort expended by practitioners is governed by Fogg’s formula B=MAT. Practitioners may not behave consistently or effectively for a host of reasons and as has been shown through research this strategy has disappointing results.

Low motivation and hard to do

In many circumstances those who stand to gain the most are the least likely to act on health care advice. People in deprived communities often have fewer choices and have more to contend with then health practitioners are able to address. In these circumstances changing the environment in which people live may have more of an impact then attempting to trigger behaviours that are difficult if not impossible to attain by people with competing priorities. At an individual level a person may get to a point in their life where they are sufficiently motivated and can see a way to achieve a target behaviour. Until then they are unlikely to be triggered

Picture by Hamed Parham

What triggers health practitioners to act?

3710480047_41a4b79be1_z

There are four circumstances in which health practitioners might need to act, again with reference to BJ Fogg.

High motivation and easy to do

Imagine a patient who presents with a typical history of some potentially life limiting pathology. Health professionals are highly motivated to act, not least because failure to respond in these circumstances is the commonest reason for litigation. The presentation of the problem can itself trigger the behaviour one might conceive as appropriate. Think of:

  • Red light = stop
  • Green light = go

There are several such ‘signals‘ in medicine:

What the practitioner senses (sight, hearing, touch)

Abnormal physiological sign- abnormal blood pressure, erratic pulse, rapid breathing.

Sign of pathology- abnormal heart sound, a lump or bump.

What patient says

I’m bleeding, I can’t swallow, I’m going deaf, I can’t see

Did you spot the sign in the picture above? The problem with this scenario is that the signs of symptoms do not always evoke the necessary response. It may be too subtle, it may be presented when the doctor is distracted or it may not be recognised. Unfortunately in some instances the condition may be life threatening and therefore it is critical that the ‘signal’ is reliable. Much effort is expended in training health practitioners to be able to respond when required, unfortunately this effort is rarely maintained beyond the initial years of training.

High motivation but hard to do

This relates to patients who could be offered a treatment that the health practitioner knows might help but is hard to provide in the particular circumstances. Imagine traveling abroad and wishing to communicate with someone who doesn’t speak your language. Or wanting to donate money to a charity and not having access to the means to do it.

The triggers to act in these circumstance are what Fogg has dubbed  ‘facilitator triggers‘. Think of:

  • “Tip jars” at the cash register
  • “Add to cart”
  • ” Click on this link”

There are several such ‘facilitators’ in medicine:

  • In house referral cues
  • Desk top protocols for prescribing unfamiliar drugs
  • Charts with instructions from an expert

This trigger has to be available while the practitioner is consulting the patient. It has to be recognised as relevant to the patient concerned and it has to be reinforced by a good experience when it triggers the relevant action- usually a referral or prescription. The trigger both prompts and makes it easier to act.

Low motivation and easy to do

In these circumstances the practitioner is not motivated to do the action but it is easy to do and that behaviour is triggered by something that increases the motivation.

Think of littering.

In medicine this might include:

  • Prescribing an expensive drug when cheaper alternatives are available
  • Ordering unnecessary tests
  • Ignoring warnings of potential drug interactions

There are several ‘spark triggers‘ for such behaviours in healthcare.

What the patient, their family or an expert say or are perceived to say

I demand /recommend this test / prescription / referral.

How the practitioner is feeling or even the time of day

Tired people will behave irrationally or even irresponsibly (e.g. littering)

What the practitioner believes at the time
  • Promotional material from a pharmaceutical company- pens with company logos

In this case the focus is on removing these triggers or making it more difficult to act on the unhelpful trigger. Health care funders often seek solutions in this category. Occasionally a behaviour is desirable- e.g. referral to an NGO for support, in which case the trigger needs to be generated.

Low motivation and hard to do

When people believe they have nothing to gain from an action and they perceive that is it too difficult to respond the action cannot be triggered.

These circumstances are easy to recognise:

  • Being invited to donate a large sum to a cause that does not resonate with your interests / values
  • Spending time on an activity at great opportunity cost.

Several examples in healthcare include:

  • Offered to do research when there is little or nothing to gain from being involved personally
  • Being invited to specialise in a condition that rarely presents in practice.
  • Asked to employ someone who does not generate value to the business / clinic / institution

Often innovators are urged to find triggers for this category. In the first instance those who wish to promote these behaviours fail to recognise /accept that the practitioner is not motivated and underestimate the cost to that practitioner. One answer may lie in reframing the issue so that either motivation or ability are improved and the behaviour is then more likely to be triggered. Another answer is to accept that it is not possible to for practitioners to do everything we might want them to do.

Picture by Debs