This is not about outcomes; this is about people. Listen to Mark Briesacher, MD and Todd Dunn talk about Design for People and why patient-focused design means getting out of the office and into the care setting.


Voiceover: Intermountain Healthcare. Healing for life.

Mark Briesacher, MD: Hi. I'm Mark Briesacher. I'm the Chief Physician Executive and President of the Intermountain Medical Group and I'm here today with Todd Dunn.

Todd and I met, it was about two years ago, and one of the early things I discovered was that I may have run into the second person in Utah who's a bigger baseball fan than I am. But in one of our early conversations, we discovered that we shared a common interest in making things better for people, both the patients and customers that Intermountain Healthcare serves, but also importantly the caregivers, the people that provide care and support patients through health and through life and through illness.

Todd, do you want to take just a few minutes and tell us a little bit about yourself, your background, and what you do here?

Todd Dunn: Sure. I've been with Intermountain about four and a half years now and I'm an Innovations Director here. But before coming to Intermountain, I worked for GE and McKesson and Siemens. Large companies, but all in the health care space. Part of my job was a little bit of a balance between operations and innovation. Through watching some of the successes and failures that we had at those companies, it really triggered me to want to make things better for caregivers, especially when I watched people use software and different solutions in the context of care, I just felt that we could do a better job of it. So it really spurred my passion to think about and start framing up innovation much better back in 2008.

Then fortunately I had the opportunity to join Intermountain and get closer to care and the people who deliver it and receive it, and was grateful to join Intermountain in late 2013. 12 actually.

Mark Briesacher, MD: It didn't take long, even in that first meeting, for us to start to have that discussion and really that casual conversation around, wow, we're doing amazing things here and we could even do better at this. The thing that attracted me was this intersection between what people think they're doing in their jobs every day, why they're doing those things and really the additional components to our jobs that I had not really thought much about before.

I'm referencing some of Clayton Christensen's work, Professor at the Harvard Business School. Can you talk a little bit about his theories and your thinking and impressions of those?

Todd Dunn: Yeah. Sure. Maybe I'll set the context, Mark. When you and I first met, I'd been thinking for a couple of years about this notion of a way of understanding people called design for outcomes, and how healthcare had been so focused on outcomes. And I remember when we sat down in your office that day and you were a bit perplexed, I would say, about my notion of wanting to call this design for outcomes. You went quiet for a few seconds and you said, "You know, this is not about outcomes, this is about people."

That started this journey, a framework for designing for people. And then you asked how would we make this real? How would we really understand it? And Clayton has a theory that he calls the Job to Be Done. And it's not the job that we think of in terms of a job like washing a car, or what have you, it's the progress that someone is trying to make in a particular circumstance is the definition of a job to be done.

And to your question, Clayton really frames that across three dimensions. There's the functional job, and that's just what is the problem I'm trying to solve or the task I'm trying to do? Pretty simple. And that's where we really get caught up, I think, in this outcome notion that's just about that functional outcome.

But there are two other dimensions that are often overlooked, I think, and that is the emotional dimension, and that is how do I want to feel when I'm doing the job? And the social one is how do I want to be perceived? And I think the more well rounded that we try to understand people through that lens and what they're doing, the better off we're going to be. And it's just this next layer to your point, I think, and Intermountain's way of thinking about people is to have a framework for really understanding, and that's what design for people is about and how we use the jobs theory to help us make sense of it.

Mark Briesacher, MD: So, as a lifelong St. Louis Cardinals' fan, I'm a big believer in you got to show me, right?

Todd Dunn: Sure.

Mark Briesacher, MD: You've got to show me the results, and so it wasn't too much time after this that you took a team up to Logan Regional Hospital to look at the GI Endoscopy Lab, and then followed that up with a visit to LDS Hospital and their Endoscopy Lab, and this was all part of us at the time figuring out what's the best way to do this for people who work in the lab, and I was surprised at what we learned. I wonder if you could share some of that.

Todd Dunn: Yeah, that was a great event, and thanks to those teams in Logan and LDS for hosting us and being so curious to want to make things better for each other within the team and make things better for their patients and their customers. The willingness to do that, Mark, I think is a great commentary on the caregivers at Intermountain Healthcare, first and foremost, that they were willing to bring these innovators in to talk about it. But our notion there was to go do observations in the GI lab to learn everything that we could around those different jobs, whether it was what was going on with or what have you.

But one of the memorable "aha" moments for us is we were literally observing, with part of the team from the GI lab and part of us who were going as observers, in the scope cleaning room, of all places. We noticed that the caregiver who was cleaning the scopes, she was pretty tall, but yet the sink was really short, and so she had, if you can visualize, she had to have her feet spread apart quite wide because the sink was so low and she couldn't stand up too quickly because the cabinets above her were so low that if she stood up too quickly she would hit her head. So the sink was completely designed probably in the CAD system somewhere, but it wasn't designed for a person.

So we started asking her questions. What's it like? And that day she cleaned 63 scopes. And so she would go home at the end of the day with a very tired back and it just made her job very difficult. That sink wasn't designed for people, it was designed for a functional thing of just getting scopes cleaned. So we came back and we shared that, frankly. They have now changed the sink height there. We were able to take that information and share it with Dixie Regional, and Mitch Cloward and the team, and they adjusted sink heights there.

So those insights, because the caregivers allowed us into their world, did a great deal of help for that role that frankly, possibly, is often overlooked, and that was just one of the just amazing aha moments that we solved because we were in their context. We didn't bring them into our conference room, we went into their context to try to learn.

Mark Briesacher, MD: What I liked about that day, up at LDS Hospital, when you invited me to come at the very end, was, first of all, what a tremendously diverse team. Physicians were on the observation team and they were focusing on clinical care that was delivered, and you had managers and nursing colleagues from those departments who were observing their own colleagues, and it struck me that the, again, the amazing commitment that they had to understand that, even though they are already doing such a great job, they could do even better for their patients.

But I was also struck by the fact that while I expected to hear the software could work better this way, when we talked to the caregivers who were doing the work about how they felt, we talked to patients about what were they hearing? What did we observe others feeling as they were doing their work? That's what actually provided the deepest insights into what could be better. And, what I think is so remarkable, is how many simple things, like adjusting a height of a sink or widening a door so that you don't hit your hands when you're pushing a gurney through the door, or discovering that oxygen tubing can come down through the ceiling so that the workplace becomes safer, it's those types of things that just amaze me about that day.

Todd Dunn: Yeah, it's quite powerful, Mark, and the thing that was refreshing for us, too, is to see the care that the caregivers had for each other. They were observing each other and everyone was so comfortable in being observed by their team mates because they knew that their team mates, their fellow caregivers, were there to help make things better for them, and so it was very collegial. And that's why we design for people, is to make it better for the people who are in our facilities, whether they're caregivers or families of caregivers, or whether they're patients themselves.

Mark Briesacher, MD: So, Professor Christensen, in his book, he talks about that people ... we actually hire things. It's an interesting framework of I think what I would typically say is, well, I'm going to buy this, right? I'm going to buy this service or I'm going to buy this product, but he actually talks about people are actually hiring that product or that service for the job. Explain that a little bit more.

Todd Dunn: One of Professor Christensen's greatest stories is the notion of a milkshake, and one of the large fast food restaurants hired Clayton and his team to help them improve the sales of milkshakes. So they literally went in at breakfast time and they found out that about half of milkshakes are sold for breakfast. And so, of course, that team asked people in a natural language, not really natural language, why did you hire a milkshake for breakfast? And people kind of gave an odd look. But then the follow-up question was: when you didn't hire milkshake, what did you hire? "Well, I hired a bagel or a banana or a smoothie, or something else."

What he talks about is the progress that people are trying to make. So they were hiring the milkshake in the morning so that they could hold something in their hand, for a long commute, that wouldn't burn off by 11 o'clock in the morning. So they were hiring it for certain reasons, to solve certain progress that they were trying to make, and so they had to make the milkshake have a stronger viscosity to it, to make it last longer, to have more calories.

But in the afternoon, people were hiring the milkshake for something completely different. After work or after school, you pick up the kids; you were hiring it kind of as an emotional dimension of that progress that you were trying to make as spending time with your kids or rewarding them for a good day at school, but yet the design of that milkshake had to be completely different in the afternoon because it was being hired for a different purpose.

And when we look at Uber; Clayton also talks about Uber. People hire Uber. The functional job of Uber is exactly the same as a taxi: move me from A to B. Or a limousine service. But on the emotional dimension of it, we often hire Uber because we don't have to turn over a credit card, or we know who's coming to pick us up and it removes the anxiety of knowing what time the car will get us, or what time we're going to be there, or the price ahead of time, and so it's on the emotional dimensions that Uber is really winning for riders and for drivers, because it's better for driver cause they know who they're picking up, they know they're going to get paid, et cetera. So that framework, Mark, really highlights the reasons, the full complete reasons, why people hire us to do things.

Mark Briesacher, MD: Let's take Uber and milkshakes and think about one of Intermountain's key strategies going forward, which is caring for whole populations, the health of population, so both healthy people and people who are seeking preventative care, and then people who have ongoing medical conditions.

Todd Dunn: Sure.

Mark Briesacher, MD: What do you think we should do as we redesign our current teams and all the services we provide and how we're organized, what should we do to help inform how we should go about that?

Todd Dunn: That's a fantastic question, and, as you know, my brain doesn't turn off often. It's what I've been thinking about a lot since you and I met, and the changing nature of the business model of healthcare. What you're alluding to, Mark, is that the center of the world is not a clinic or a hospital anymore, the center of the world is the person, and that has really changed in the jobs, in the progress that people are trying to make.

What I think we ought to do is get away from this notion or add to the notion ... I talk about the three Cs of design disease, or the three locations, and it's a conference room, a conference call or a cube, and how we make so many decisions and assumptions in those settings about what people are doing in the context of where they live. As Clayton would describe it: in the circumstances that people find themselves in. And so for me, what would we do differently? I think we would do our best to spend more time getting closer and closer to the context of where people are trying to make progress.

Liz Joy, one of our wonderful caregivers, talks about this notion of where people live, work, learn, pray and play, and I think we need to add to the skill of getting out of our context and into the context of where people are trying to make progress, whether it's following a home care nurse or caregiver to someone's home to really learn about the emotional and social dimensions of that or the functional dimensions, or whether it's following someone who's super healthy who wants to be even healthier, and to learn more about the individual jobs they're doing, and then how they measure us. We could talk about that, but it's something that I term as a love metric.

Scott Cook, who's the founder of Intuit, and a good friend of Clayton, calls it a customer benefit metric, but I would first start by trying to learn more about the circumstances that people find themselves in and all the little jobs that are happening there, and then learning how to measure what's really important to people.

Mark Briesacher, MD: So, in the Intermountain Medical Group, over the past four months, our clinical teams have really done amazing work to improve access to care. They've begun to stagger when they come to work and when they take breaks so that phones can stay on and patients have access to nurses and doctors throughout the entire day, and they might be listening now and thinking, "What's out there that we can reach out to get some help or support in doing the thing you just talked about?" You know, getting even closer to patients to understand what their needs are and the jobs that the patient and the customer's trying to solve as they reach out to us for help and support.

Todd Dunn: Sure. Let me preface it by saying that I believe that caregivers hired medicine to take care of people, because it's an emotional dimension of our lives. I don't think it was just to have a great career. I think that the deep motivations of caregivers is to really help me help other people.

With that notion, Mark, we've talked about or mentioned design for people, and when we started design for people a long time ago, couple of years ago when we decided this was we said, look, this isn't about creating teams to go watch people, this is about building a capability of learning how to learn better ourselves within the context of where we are, whether it's a clinic in Panguitch or in Holladay or somewhere else in Idaho, it's how do we develop that skillset to really see the world through the lens of functional, social and emotional dimensions? So that's where people can go. We designed that around building a skill on a capability, spending a little bit of time. Just teaching the fundamentals.

It doesn't take an MD degree to know how to observe, or a nursing degree, so that's where they can go, and they can reach out to us and we'll spend time with them in their context. They don't have to come to us. We go to them in their context so that we can better understand the progress they're trying to make, because the circumstances may be very different in Salt Lake City than they are in St. George, and for us to go there and understand the circumstances that they're dealing with, and the progress that they're trying to make, is the key. But that's how we do that.

Mark Briesacher, MD: I completely agree. We are not going to solve things here, like you said, in a room, on a conference call. The best ideas and the best solutions are actually in the clinic, in the operating room, in the emergency department where care is being delivered, and, again, from the examples of what we learned just with working with the GI labs, there are things that we could change almost immediately that would make things better for people and the patients they care for.

Todd Dunn: Absolutely, and that's the focus of all of it, Mark. I think Intermountain has always been an amazing leader in wanting to get better. It's this insatiable part of the DNA and appetite of the company, and I think this is another way of rewarding and recognizing the fact that people innovate where they are.

Clayton talks about workarounds, and workarounds are really just microcosms of innovation, whether they're a workflow workaround or whether an emotional workaround, whatever they may be, then you give people that framework and all of a sudden they start to see that their ideas are really very powerful, It's just our job to help them uncover them or bring them to light, because they're doing it so often it just seems natural to them. When in reality it's a great opportunity for those of us who support them in their very difficult jobs to innovate in a way that makes sense for them.

Mark Briesacher, MD: A couple of months ago I was at a national meeting and I was listening to a speaker from Carolina's health system; I think somebody you know. We got to the Q&A part and I raised my hand and got the microphone and there was several hundred physician and operation and nursing leaders from great systems across country in this room, and Zeb and I got into this really great discussion around these very concepts and ideas, and it struck me that Dr. Brent James and his work with the Advanced Training Program was this innovative and care process models and clinical programs, that was an innovation that really put Intermountain on the map with respect to making care better and safer for people-

Todd Dunn: Absolutely.

Mark Briesacher, MD: ... and that has been emulated across the country, across the world. Not only do other systems have they adopted, they've come to Salt Lake and learned about this and have implemented similar things in their organizations, but countries from Europe and East Asia have come to learn this.

Based on that discussion I had that day, and the number of people that came up to Zeb and I after our discussion, it strikes me that this could be an area that we lead out on as a national and international thought leader.

Todd Dunn: I think we can. I think we're incredibly fortunate to have Dr. James here and the way that he has taught and thought about a better delivery model. He has these clinical process models, and you and I have talked about an innovation process model, and how do you effectively innovate? How do you know if you really should innovate? What are the causal mechanisms that make me do what I do? Why do I hire a milkshake or why do I hire a Toyota over a Tesla, what have you?

Mark Briesacher, MD: Or Intermountain Healthcare over some other delivery system-

Todd Dunn: Exactly.

Mark Briesacher, MD: ... or some other clinic.

Todd Dunn: Why am I hiring TOSH over something else, from an orthopedic perspective or a clinic's? And this framework helps us understand the functional, social and emotional dimensions that people want to have satisfied to hire us. And it makes the point, Mark, that it might not just be about the functional job. It could certainly be about the social and emotional advantages. You probably talked to Zeb. One of the reasons that people hire Telehealth is just to help me get back to work. It was more about the emotional thing of remove the anxiety of me not being able to go to my employment, than it was about make me physically feel better. I'll go back feeling rough, just get me back. And when we think about those dimensions of why people are coming to us, but just to be aware of it.

I don't think it's that we doesn't pay attention to them. It's like a clinical process model. That model makes you aware of the things that you need to be aware of, and the functional, social and emotional dimensions do the same. Then we get to the point of this customer benefit metric and figuring out how to measure why they hired us. I think it goes beyond HCAHPS, although I understand the reasoning for HCAHPS, but this goes beyond it to what I think Intermountain is passionate about being, and that's be a model system.

The more that we lead out with this type of thinking, the better off we are, not only in providing better care and experience to our caregivers and patients, but to help influence the world to get better as well. I absolutely think we ought to lead out on it. And it's a framework. It's not fluffy, it's a theory, but you can test it and learn it and improve it, and Intermountain's been doing this since April 1st 1975, so I don't think this a big leap for us, I just think it's the next evolution of getting even better.

Mark Briesacher, MD: So, Todd, thank you for the discussion today. I know that people can reach out to you if they have questions. I would encourage everyone to actually contact their region medical directors and operations officers who are aware of this program and can help with the process of how do we get involved in this type of work? It's great work. It's totally rewarding work, because you know you're really helping people.

Todd Dunn: When you know at the end of the day when you're in a support role like innovation, or what have you, that you've made it better for a customer, a caregiver, you can put your head on your pillow at night and know that what you hired medicine to do for you is coming true. So yeah, let's go do it.

Mark Briesacher, MD: Great. Thanks.

Todd Dunn: You're welcome.

Voiceover: Intermountain Healthcare. Healing for life.