Design Matters - Healthcare Systems Edition

Design Matters – Healthcare Edition

In his book The Opioid Crisis Wake-Up Call, Dave Chase quotes Dan Munro by writing, “The [healthcare] system was never broken, it was designed this way.”

 

I’m a fan of Debbie Millman’s podcast, Design Matters. When we are making something that other people will use and engage with, it is important to think about all the various aspects of how the thing will be used and how it can meet the needs and expectations of others. Whether what we are producing is art, a branding campaign, or a national healthcare system, design matters.

 

Unfortunately, the Untied State’s healthcare system wasn’t built on a design matters philosophy. We see inefficiencies everywhere, with some people getting care they don’t need while others can’t get routine basic care that could save their lives. Dan Munro says that the system was built this way, meaning that the inefficiencies, the inequalities, and the high costs were part of the system from the beginning, intentionally built in. The dysfunction we see in the system, according to Munro, is not so much a bug but rather a feature, helping someone make a profit or get priority access to the healthcare they want.

 

I think Munro is a little wrong. I think the system is a hodgepodge of pieces smashed together over the years. It is an incoherent patchwork of tools and players that has been haphazardly assembled over the years, with some working to truly do good, and others taking advantage of design flaws for their own aims. The system, in my argument, was never designed at all.

 

Design matters and what needed to happen decades ago was a real conversation about how the country would design a healthcare system that could innovate, that could meet the needs of citizens, that could ensure basic access to medical services, that could help provide preventative care rather than just emergency interventions, and that could be sustainable. Instead, doctors went about providing medical services, insurance companies popped up to help pay for some pieces here and there, and eventually businesses got in the mix and offered health insurance to employees. Each new step in healthcare in the Untied States has happened almost randomly, without a lot of deliberate planning.

 

Now the system is so large and complex that planning feels impossible. Legislation to address the challenges of the system is thousands of pages long, and because the most comprehensive law to restructure the program adopted the namesake of the nation’s first black president, a Democrat that became a polarizing figure, half the country derided the attempt to design something better. We can try to reshape bits and pieces of the system now, but design matters, and I understand why so many want to hit a restart button and rebuild a system from scratch.
Workplace Design

Workplace Design

One of the things I am secretly fascinated by is workplace design in our modern knowledge work economy. I’m not so interested in where the copy room is located, how the office kitchen is built out, or what furniture/decorations are around, but the big high level design question: where will our employees sit to do their work? (or stand sometimes if your company is cool like that)

 

A lot of companies today are trying to get away from standard cubicle models for offices. The traditional work-space where senior team members have their own office while junior members are in cramped cubicles feels anachronistic, especially for modern tech companies. The alternative has been open office spaces, where dividers between employee workstations are minimized. Companies want to be innovative, to spur conversation between creative individuals, and they also want to create environments where employees would actually want to be, rather than soul sucking cubicle farms.

 

However, thinking and focusing in open work-spaces can be challenging. As Cal Newport writes in his book Deep Work, “Both intuition and a growing body of research underscore the reality that sharing a work-space with a large number of coworkers is incredibly distracting – creating an environment that thwarts attempts to think seriously.” When it comes time to buckle down and focus to get an important project done, an open work-space can become a major hurdle.

 

In his book, Newport encourages more of a hub and spoke style office. He doesn’t say if he thinks everyone should have their own office or be in a dreaded cubicle farm, but he thinks that people should be split by departments/teams into hubs where people can get a little more quite space to do deep work. He encourages developing open pathways to the bathroom, kitchen, or conference rooms that encourage serendipitous connections with others, to help spur some creative encounters that might otherwise not happen in individual offices. He doesn’t think we should all just be isolated away in our little hubs, but in a sweet spot where we have space to think as well as chances to interact and share different ideas and perspectives. “Isolation is not required for productive deep work. Indeed, their example [Bell Labs] indicates that for many types of work – especially when pursuing innovation – collaborative deep work can yield better results.”

 

I’m still not sure exactly what the perfect office space would be for different types of companies based on Newport’s thoughts. Should a CPA firm have a hub and spoke style office, or do they really need their own walled off offices? How exactly do you balance the need for focus spaces with the need to actually interact with other human beings, to prevent employees from going to work but never interacting with anyone? Space for deep work is important, but Newport also advocates for bumping into other creative people at reasonable intervals to foster creativity and heighten innovation and productivity. I’m not sure where exactly we will end up with workplace design, but I don’t think it will be in a space where everyone has their own office or a space where no one has an office.

Outpacing Design

The United States of the American Revolution and of 1787 (the year the US Constitution was written) was dramatically different than the Untied States of today. The 1787 Constitution written for that time was meant for the country and the world in which the country existed during our nation’s young independence. Our nation today in many ways does not resemble the nation of 232 years ago, and in many ways has moved far beyond what the Constitution was imagined to deal with.

 

In New Localism authors Bruce Katz and Jeremy Nowak look at the ways in which the American economy and American governance are changing and co-evolving and what that means as we move forward. With regard to the Federal Government and Constitution they write, “Programmatically, the basic architecture of the American Federal Government is in contrast to the fact that American demography and wealth are metropolitan.” 

 

At the time that our constitution was written, our nation was more agrarian than industrial. Wealth was tied up with land owners who had vast plantations and farms. Many of our founders, like Jefferson even though he was absent when the Constitution was written, praised bucolic values and had an almost romanticized notion of the good life being one of space, freedom, and simple farming lives.

 

Our nation today has moved far away from the view of the nation that our Constitution was designed for. We have outpaced the imaginations of our framers and the way we live and the lives we romanticize are far different than the visions of the framers. American cities are dynamic engines of productivity and economic growth today, while American farms are often forgotten, have become large conglomerates, and are often stuck in a battle between hiring cheap immigrant or low skilled labor and automation. For the time being, government is reacting by not reacting. Instead of changes and adaptations at the Federal level, we see a shift in governance and problem solving to the local level. The shift involves not just local government, but new networks that have come together in an adaptable framework to include actors and groups outside government. This is helping, for the time being, cities and metropolitan areas to respond to the challenges of the world today with new and innovative solutions, helping our nation which has outpaced its design adapt to a new, globalized world.

Designing for Two Goals

“Savvy institutional designers,” Write Kevin Simler and Robin Hanson in The Elephant in the Brain, “must … identify both the surface goals to which people give lip service and the hidden goals that people are also trying to achieve. Designers can then search for arrangements that actually achieve the deeper goals while also serving the surface goals-or at least giving the appearance of doing so. Unsurprisingly, this is a much harder design problem. But if we can learn to do it well, our solutions will less often meet the fate of puzzling disinterest.”

 

In public policy research, there is a framework that is used to understand the legislative process called the Social Construction Framework (SCF). When examining the world through the SCF, we look at the recipients of particular policies and ask what social constructions are at play that shape the type of legislation surrounding these recipients. We also group the recipients into four broad groups: Advantaged, Contenders, Dependents, and Deviants.

 

Advantaged are those who have strong political power and public respect, like veterans and small business owners. Contenders have lots of political power, but are not viewed as warmly in the public eye, such as big business or unions. Dependents are socially sympathetic groups that don’t have much political power, such as sick children who can’t vote but evoke sympathy. The final group, Deviants, are socially scorned and politically weak, such as criminals or drug users.

 

The way we think about who belongs to which group is a social construction. That is, we attribute positive or negative qualities to groups to make them seem more or less deserving. Businesses always highlight the jobs they bring to communities, the innovations they create to make our lives better, and the charitable activities they contribute to. This is all an effort to move from a Contender status to an Advantaged status. Similarly, we see movements where people look at drug addicts and criminals in new ways, seeing them more as victims of circumstance than as entirely bad actors, moving them from Deviants to Dependents.

 

The reason this is important is because we introduce policies that either reward or punish people based on the groups they belong to. It all ties in with the quote from the book because we can either openly distribute a reward or punishment or distribute it in a hidden manner. Our policies might have stated explicit goals, but they may also provide a big business a hidden tax break. Our policies might be unpopular if they directly provide aid to former felons as they leave prison, but offering policy that is nominally intended to help the poor may provide a greater benefit to formerly incarcerated individuals than anyone else.

 

Hanson and Simler call for more sophisticated policy design that addresses our stated high-minded motivations and at the same time helps fulfill our more selfish and below the surface policy goals. SCF is a powerful framework to keep in mind as we try to develop policies and think about ways to actually enact policy that has both open surface level implications and addresses our deeper hidden purposes. This can, of course, be used for good or for ill, just as the tax code can be used to hide tax breaks for unpopular companies or help new homeowners, and just as social programs can be used as cover to assist individuals who are typically seen as Deviants.

A Father-Daughter Science Connection

Amanda Gefter’s book Trespassing on Einstein’s Lawn is about her journey with her father through the world of physics and how she crash landed in a career as a science journalist. Early on in the book she describes how she and her father connected through science, with a quick passage that I think many of us can relate to. “As a dogmatically skeptical teenager, I had my own Zen-like practice of zoning out when adults offered me advice, but when it came to my father I listened—maybe because when he spoke it sounded less like an authoritarian command and more like the confession of a secret. It is all an illusion. Now here he was speaking in the same quietly intense tone, leaning in so as not to let the other diners overhear, asking me how I’d define nothing.”

 

Gefter’s quote about her dad really resonates with me. We all want to be included in important discussions and we all want to feel that we are on the inside of a secret. A way to connect with people and spark their interest in science and challenging subjects, is to pose challenging and almost paradoxical questions in a way that encourages wild answers and gives the other person a chance to be part of the secret inside team trying to find the best possible answer. I listen to a lot of science podcasts, and many of the best engage with their audience in this way. They may not be in the same room washing dishes with me or in the car driving down the freeway with me, but they still manage to pose a question which sounds simple, but requires deep and complex thought. Personally I think the public in general needs to be more engaged with science and scientific thinking, but in particular, this is something we need to instill in our children from a young age. Gefter, as an teenage outsider, was inspired by her father’s questions about science in a way that she was not inspired by her actual classes at school.

 

The way we speak with kids and teenagers is important. I do not have kids, but I did coach cross country and track and field as I worked through my undergraduate degree, and I hope to find a way to get back to working with high school students in the future. Gefter’s quote shows us the importance of how we craft messages to teenagers. The content alone is not enough to inspire teenagers and if we have a lesson or a message that we think is crucial for them, we must find a way to brand that message so that it is not an authoritarian command driving them to zone out and ignore us. We must take our important messages and lessons and communicate them in a way that is interesting and in a way that allows teenagers to investigate for themselves and begin to build their own abilities to reason with the world. Gefter’s father was a radiologist, and as a medically trained scientist he had the authority to speak on various science topics, but he did not just throw answers at his daughter like knives shooting through her doubt to tear her faulty reasoning apart, he invited her to offer answers and theories, and then invited her to work through her thoughts with him.

 

Whether we speak with teenagers, toddlers, or grown adults, I think the message holds. Invite curiosity and place your ego in the back seat. Do not challenge your audience with difficult scientific questions just to demonstrate your superior knowledge of a subject, but rather use challenging questions to show the complexity and vast beauty of unknown science. Invite your listener to be part of the secret team trying to think through the challenges of our time.

Design Matters

One of my favorite podcasts is Debbie Millman’s Design Matters. She interviews architects, artists, marketers, designers, and other creative people about their work and their place in the world. It is an excellent show to learn about people who see the world differently and to see what people did to reach success, often without following a traditional path. A common theme running throughout Millman’s show is that design matters. It matters a lot when we look at the built world around us and ask questions about why things operate the way they do, about why people behave the way they do, and about why society is designed the way it is. Design matters because the built environment and the societal structures we adopt or inherit shape who we are as people. Everything hinges on the design we give the world around us: our futures, our possibilities, our idea of what is possible, and our understanding of what is reality.

it is incredibly important that we think about design as a society because poor design leads to inequality and bad outcomes for individuals and for society as a whole. I thought about this when I returned to a sentence I highlighted in Michelle Alexander’s book, The New Jim Crow. Alexander writes, “The unfortunate reality we must face is that racism manifests itself not only in individual attitudes and stereotypes, but also in the basic structure of society.” When we think about design we can begin to connect the inequalities, the disparate impacts, and the problems with society today to the attitudes and behaviors of the past. In his podcast series, Seeing White, on his show Scene on Radio, host John Biewen reflects on the structural elements of racism in our society as opposed to the individual elements. Individual racism is easy to see, easy to condemn, and easy to change, but structural and institutional racism is hard to see, hard to understand, and very difficult to change. However, just because it is hard to see and understand does not mean that structural racism is any less of a threat to society or any less real for the people impacted.

We should be honest with ourselves and accept the idea that structures and systems designed by people who were openly racist can still impact the lives of people today. System and procedures were designed with the interests of white people and white culture in mind, and part of the decisions that were made involved the oppression, the limitation, and the containment of black people. We still must deal with many of these systems, even if their design has been slightly changed, because the original design was effective in allowing some to prosper while others were limited. These designs mattered, and they still matter today. A system that deplores individual racism while supporting hidden and structural racism can influence and shape the lives of individuals and the direction of society arguably more effectively than a system that encourages individual and open racism. To move forward, our nation needs leaders who can be honest about systems and structures and understand that design matters when thinking about government, society, services, communities, and neighborhoods. By becoming more aware, all of us can recognize the way that systems which are currently in place can shape our quality of life and the perceptions we all share, and we can push for new systems that compel us to interact more with our fellow citizens, and encourage us to see each other as people as opposed to enemies.