1. Human-Centered Design and Plan-Do-Study-Act
45 MINUTES
Preconception CoIIN Year 2 Meeting
January 17th and 18th, 2019
Presenter: Rachel Berkowitz, DrPH(c), MPH

2. Objectives By the end of the session, participants will…
Be able to describe the Human-Centered Design (HCD) process
Be able to identify ways that HCD can be incorporated into and support their PDSA efforts.
Understand how a human-centered approach can advance equity in their PDSA work
I will briefly review what HCD is and then share how HCD can support PDSA ahead of Lou Anne’s presentation focused on PDSA

3. Refresher: What is HCD?
Framework for the creation of innovative products in the commercial sector which has been brought into the social sector
“Iterative process for problem-solving in which the priorities, needs, and behaviors of end-users…serve as a driving force throughout a [solution’s] conceptualization, development, and distribution”
Examples include: Global scaling of antiretroviral therapy treatment programs, guide the placement of new emergency obstetric and newborn services within a village, and improve how service changes are implemented in a hospital system. We’ll hear some other examples in just moment.
Who constitutes the “end user” depends on the circumstance. It could be a patient in a clinic, a resident in a community, or a staff member in an organization. There may also be multiple groups of stakeholders who affect and are affected by a solution – in a clinic, for example, the doctors, nurses, and intake staff all affect and are affected by a given clinical protocol; understanding their perspectives is important as well. But if the ultimate target beneficiary of the protocol is a patient, then their reality must remain at the center of the process.
Who leads an HCD approach is also context-specific. Sometimes consultants are brought in to implement the approach. Other times, the Design Team can include stakeholders and end-users as well. In either case, the Design Team will engage with stakeholders and end-users throughout the process, grounding whatever ideas are generated in the reality of those most affected by the issue at hand.
Image source
Source: Chapter 9—Human-Centered Design, in Translating Life Course Theory into Practice

4. Refresher: Mindsets of HCD
HCD Mindsets help to define the culture for a Design Team’s work
Discussing and agreeing to these Mindsets is part of team formation
“Empathy is the capacity to step into other people’s shoes, to understand their lives, and start to solve problems from their perspectives. Human-centered design is premised…on the idea that the people you’re designing for are your roadmap to innovative solutions. All you have to do is empathize, understand them, and bring them along with you in the design process.” (p.22)
“Optimism is the embrace of possibility, the idea that even if we don’t know the answer, that it’s out there and that we can find it…optimism makes us more creative, encourages us to push on when we hit dead ends, and helps all the stakeholders in a project gel.” (p.24)
“By continually iterating, refining, and improving our work, we put ourselves in a place where we’ll have more ideas, try a variety of approaches, unlock our creativity, and arrive more quickly at successful solutions…We iterate because it allows us to keep learning.” (p.25)
”Creative confidence is the belief that everyone is creative…the belief that you can and will come up with creative solutions to big problems…Creative confidence will drive you to make things, to test them out, to get it wrong, and to keep on rolling, secure in the knowledge that you’ll get where you need to go…” (p.19)
“We build our ideas so that we can test them, and because actually making something reveals opportunities and complexities that we’d never have guessed were there…the goal is always to convey an idea, share it, and learn how to make it better.” (p.20)
“Human-centered designers always start from the place of not knowing the answer to the problem they’re looking to solve…By embracing that ambiguity, and by trusting that the human-centered design process will guide us toward an innovative answer, we actually give ourselves permission to be fantastically creative.” (p.23)
“…for human-centered designers, sorting out what won’t work is part of finding what will. Failure is an inherent part of human-centered design because we rarely get it right on our first try…The point is to put something out into the world and then use it to keep learning, keep asking, and keep testing.” (p.21)
Empathy
Optimism
Iteration
Creative Confidence
Making
Embracing Ambiguity
Learning from Failure
Source: IDEO.org’s Field Guide to Human-Centered Design

5. Refresher: HCD process
CHALLENGE
Refresher: HCD process
Patients struggle to manage their diabetes
Who is the "end user”? – the patient
Who are other stakeholders involved in this issue?
-- clinicians, staff, family members, community orgs
One key element of HCD is that you don’t start with the solution in mind. You start with a challenge that has been observed.
This challenge may be fairly broad to begin with– “Patients struggle to manage their diabetes”. Hearing this challenge may bring up lots of questions and elicit a lot of ideas right off the bat, based on our own experiences, biases, and perspectives. But with HCD, we want to take a step back and ask ourselves:
Who is the end user?
Who are other stakeholders involved in this issue?
The answers to those questions will guide the rest of the process.
[ASK FOLK TO GENERATE RESPONSES]
The natural question that may come from this statement is “Why do patients struggle to manage their diabetes?.” This is a useful question, one worthy of research and important to consider. But this is not the question that guides our HCD process. We want to be guided by an action-oriented question. One tool I have found useful to help with this goal is rephrasing the challenge as a “How might we…?” question. The “How might we” question does not include the solution but asks us to focus on the main goal – what is the desired outcome of the end user?
[ASK THEM TO COME UP WITH ONE]
This question will likely evolve based on what is learned from end-users and stakeholders in the next phase as we gain insight into their needs, perspectives, and priorities.
Develop a “How might we…?” question
How might we help patients achieve their diabetes management goals?
Source: Chapter 9—Human-Centered Design, in Translating Life Course Theory into Practice

6. CHALLENGE UNDERSTANDING observe & inspire tell stories
synthesize insights
“How might we…?”
CHALLENGE
THIS IS NOT JUST ABOUT UNDERSTANDING SURFACE LEVEL – THIS IS ABOUT UNDERSTANDING THE “WHY” BEHIND PEOPLE’S EXPERIENCES, HISTORY, CONTEXT MATTER
Now that we have a focal challenge question and ideas of who our end-user and key stakeholders are, we can move into the first phase: Understanding
The goal of the understanding phase is “to understand the depth and complexity of a particular problem as well as the potential resources available to address it.”
“The activities and tools used during this phase are then meant to increase empathy for and understanding of the needs and context of the end user”
Before beginning this phase, you may develop a project brief (not pictured here) – the development of a project brief can provide useful context for the design team before engaging with beneficiaries directly. The brief should consist of a description of the parameters, perspectives, and realities of the challenge
Observe & Inspire/ Tell stories – Techniques such as interviews, in-context observations, user or peer documentation through photos or prose, and asset mapping are examples of the variety of methods that may be used in the Understanding phase to connect with and learn from the end user. These same methods may be used with other stakeholders who are critical for the success of the project. You can also engage with existing
Synthesize insights -- While information is being gathered, the design team should also begin synthesizing insights from what has been learned. “Insights” can be thought of as “aha moments,” which indicate something important or surprising that may have deepened or shifted the team’s understanding of the problem or users.
Revisit your HMW question – based on the insights and what you have learned, revisit your HMW question – is it getting at the core issues identified through your insights? You can adapt it to be more specific to what you have learned.
Source: Chapter 9—Human-Centered Design, in Translating Life Course Theory into Practice

7. CHALLENGE IDEATION UNDERSTANDING observe & inspire tell stories
synthesize insights
“How might we…?”
brainstorm
CHALLENGE
select ideas
With the insights and strengthened HMW question in hand, we move on to ideation.
The goal of ideation is to build on what you learned during the understanding phase to generate ideas that can “answer” your HMW question.
There are two parts: 1) to generate many ideas without self-censoring, opening oneself to any idea, big or small, to answer our HMW question – this is the brainstorming component, and 2) to sort and select 2-3 ideas that we will begin to test – the “select ideas” component.
Source: Chapter 9—Human-Centered Design, in Translating Life Course Theory into Practice

8. EXPERIMENTATION & IMPLEMENTATION
UNDERSTANDING
IDEATION
EXPERIMENTATION & IMPLEMENTATION
observe & inspire
tell stories
synthesize insights
“How might we…?”
brainstorm
CHALLENGE
select ideas
Once you have your 2-3 ideas in hand, you will want to prototype, or develop and test out these ideas in order to determine which idea you will move forward with.
Prototyping involves creating examples of ideas and testing out those ideas with relevant end users and stakeholders. Depending on capacity, the design team may decide to initially pursue multiple ideas from the Ideation phase, conducting several rounds of prototyping for each. Each prototype may be geared toward answering a particular question or different aspects of the solution.
The more quickly the design team can learn while minimizing cost, the better the product will be when it is ready to move into larger and more resource-intensive experimentation implementation.
Experimentation & Implementation: The goal of this phase is to make the ideas tangible and to receive feedback from the end users to refine the idea to better meet the users’ needs. “Making things tangible” could involve making a poster with a storyboard to describe a service. It could mean making small-scale paper or foam models to represent the idea in a physical way that users can interact with and modify.
Based on prototyping, you may be able to identify which idea to focus on, and then develop ways to test and refine that idea, starting small and building on lessons learned to ultimately bring the idea to scale.
Important to note, however, is that you may need to return to previous phases and iterate. For example, you may find, as you are prototyping and testing an idea, that ultimately that idea is not the right fit based on user and stakeholder feedback. You may need to return to your ideas from the ideation phase and reflect anew. During the ideation phase, you may realize that you need more information from end users and stakeholders, and so you may decide to revisit or redo activities from your understanding phase and move forward again from there. As described in the mindsets, iteration is a natural part of the HCD approach to ensure that you are truly centering you ideas on the needs, priorities, and perspectives of end-users.
prototype
focus idea
test & refine
scale, sustain, spread
Source: Chapter 9—Human-Centered Design, in Translating Life Course Theory into Practice

9. PDSA Source: Institute for Healthcare Improvement
Lou Anne will get into the details of PDSA in the next segment, but broadly speaking, PDSA is a cyclical and systematic approach to quality improvement in which participants plan the desired solution, test out the solution, assess the data of the solution, identify changes that need to be made based on the data, and repeat.
Source: Institute for Healthcare Improvement

10. HCD and PDSA HOW WHAT WHY
“The tools and mind-sets of human-centered design (HCD) can support [performance improvement] and take it to the next level…allowing a more complete understanding of patients, family members, staff, and providers – and supporting collaboration among them – to
understand ambiguous challenges and develop innovative solutions to them.”
WHY
Source: “Human-Centered Design and Performance Improvement: Better Together”
Dr. Ioulia Kachirskaia, Dr. Kedar Mate, and Dr. Estee Neuwirth
Kaiser Permanente Design Consultancy and Institute for Healthcare Improvement (IHI)

11. HCD and PDSA – Specifics1. 2.
Understanding
HUMAN CENTERED
Empathy
Iteration
Making
Embracing
Ambiguity
Optimism
Creative
Confidence
Learning from
Failure
Ideation
So how do we do this?
One clear way is to use an HCD process as the way to IDENTIFY the challenge and potential solutions before enacting the PDSA cycle as the method for the HCD prototyping, experimentation and implementation
A deeper way is to also fuse the HCD mindsets and human-centered approach throughout the PDSA cycle by bringing patients, family members, and other stakeholders INTO your PDSA team to help with planning, implementing, studying, and adapting the intervention.
FUNDAMENTALLY, continuing to return to the HUMAN-CENTERED value of HCD throughout PDSA -- consider how end users and stakeholders can influence and drive the PDSA cycle, how their perspectives can inform the PDSA approach
Prototype, Exp., & Imp.
Plan Do
Study
Act

12. Example: CoDesign @ Kaiser Permanente
HCD Mindsets
Center the process around people
Ground QI in HCD mindsets
Incorporate the HCD process and tools
KP fused HCD and quality improvement in 3 ways – [READ]
Now this is an entire system integrating HCD into their whole system of QI. But the SAME APPROACH can be incorporated into your own quality improvement effort and PDSA cycle! The Pocket Guide is a great resource as you consider this.
HCD Process
Source: “Human-Centered KP Pocket Guide”

13. HCD, PDSA, and Equity Source: Robert Wood Johnson Foundation
As we see in this visual, we cannot assume that the same intervention will work for everyone
Additionally, we KNOW that populations have been systematically prevented from fully participating in society and the achievement of health – it is not INDIVIDUAL, it’s SYSTEMIC
Therefore, we must build systems that CORRECT these injustices in order to achieve health equity
This REQUIRES a deep understanding of the needs, priorities, assets, perspectives of those who you hope will benefit from the intervention –ALL different groups, and with particular attention being paid to those who have historically been UNDER-PRIORITIZED
HCD can serve health equity when ALL HUMANS are centered in the process, particularly those whose voices have historically NOT been centered in order to CORRECT the INEQUITIES built into our current systems, whether by characterizations race, class, able-bodiedness, language, gender
Source: Robert Wood Johnson Foundation

14. Thank you!
45 MINUTES
Rachel Berkowitz