Observations from a Hospital Bed

I have been on medical leave, but this week I was able to return home from hospital and begin what will be an extended healing process.

I thought I would share some observations on my stay in hospital and what these can tell us about design.

I cycled through different stages in the hospital.

1. Admitting
2. Pre Op
3. Operating Room
4. Post Operation
5. Step Down
6. Recovery
7. Discharge

These observations come mostly from step down and recovery. I had a difficult and complex surgery that was brilliantly handled by a very capable team. Once the necessity was clear the surgery was booked quickly (time was of the essence) and I experienced no delays with the Canadian healthcare system. The care was state of the art. I did compare it with two private US alternatives and I am happy I stayed in Canada. Given that I was under during the actual surgery and have only spotty and disassociated memories of post-op the focus is on step down and recovery.

What follows are no more than notes, but I wanted to share them while they are fresh in my mind. I think there are some lessons here for design generally.

Gamification works (or worked for me)

I have always found the whole idea of gamification a bit 'gamey.' the team I work with has been developing rich interactives with feedback from the mid 1990s and social interactions from the beginning of the 21st C. We have generally avoided competition between people as part of this and used it more to support multi-modal understanding and reflection. Gamification seemed to be a fancy way to name what many people were already doing. But I used an interesting 'game' as part of my recovery process that gave me a better appreciation for how even simple gamification can change behaviour.

The game is simple. Inhale and try to get the three balls to rise to the top of their columns. The first time I tried I could barely get the first ball to lift into the air. This kind of annoyed me so I tried again, did a bit better, tried again, and I got the first ball to the top. By the time I went home I could float all three balls. Simple but very motivating. A lot more effective than having a nurse (or my wife) tell me to work on my inhalation and breathing. Getting the lungs to open up is an important part of recovery after thoracic surgery.

(As you can see, my recovery room had a great view of downtown Vancouver, the NorthShore Mountains, English Bay and False Creek. I could almost see my oldest son's house, which is near the hospital)

I am sure there are many other places in the recovery process where simple gamification will work well and that some of these recovery games can be delivered on smartphones.

Satisficing satisfices

Herbert A. Simon contributed many of the ideas and disciplines that shape our world. His work is instrumental in the connected areas of decision making, artificial intelligence and learning. His 1969 book The Sciences of the Artificial is worth rereading several times over a lifetime. One of the concepts he introduced is that of 'satisficing.' The word is a portmanteau of 'satisfy' and 'suffice.' A solution that works well enough for the current purpose is one that satisfices. It may not be the best possible solution, but it is a practical solution.

The healthcare system is full of this sort of solution. One that was important to me while in the hospital was a simple device whereby a rope, or rather two strips of cloth, are tied to the foot of the bed frame to form a loop reaching to about mid chest. When I was brought to the step down ward one of the first things my highly capable nurse, Sally, did was to add this to my hospital bed. It made it much easier for me to sit up, adjust my position in bed, and get out of bed once I was able to do so. It made a tremendous contribution to my agency (my ability to act on my wishes) and so to my recovery.

I asked about where this comes from and was told that a senior nurse, now retired, had brought it to the thoracic step down ward and that it was now standard practice.

Not everyone likes the idea at first. One nurse told me of a patient who had just come to the ward and when seeing the nurse preparing the rope asked 'Are you going to tie me down?' I can imagine the confusion and fear that even a simple thing can cause in a stressed place like a step down ward.

Another example of satisficing is the way cell phones are being used by nurses. VGH seems to be a a paper driven organization and a lot of information is entered into and conveyed through paper forms. I was surprised by the amount of paper, but this was during the time when Rogers triggered a massive failure in cell phone and Internet coverage, so maybe paper should still play a role.

Nurses would take photos of instrument readouts, they would have photos of key parts of my care guide on their phones for quick reference, and used the camera phone to send photos of my wounds to doctors when they needed to ask questions. The mobile phone as a camera, note taking, collaboration device has a lot of untapped potential in healthcare.

User experience takes incremental evolution

I do a lot of work in the innovation space, advising people on how to create value and then price that value. There is always a lot of buzz around about disruptive innovation (this term has a precisely meaning thanks to Clayton Christensen). Disruptive innovations are important and fascinating, but the vast majority of innovations are incremental and sustaining. They take an existing solution and edge it forwards, making it a bit better for a specific environment. Sustaining innovations are an example of incremental evolution, or the kind of trial and error exploration that leads to satisficing solutions.

Hospital gowns

The hospital gown is a great example of incremental evolution. I had never thought much about hospital gowns, they are often the theme of off colour jokes, but in fact they are wonderful garments. They fit all sorts of body types and the different ways in which patient's bodies are compromised. They are very comfortable and easy to put on and take off, with snaps that let the sleeves open up completely, an opening and a pocket at the front for telemetry. The open back makes examination easier. I also found the open back more comfortable for sleeping.

Of course not everyone agrees with me. Some find the design demeaning and awkward (I did not) and that it marks a person as a patient rather than a person (again, this does not bother me). There is an active and fascinating conversation going on on how to redesign the hospital gown for the 21st C. I am looking forward to listening in on these conversations as they evolve. The whole debate is a good example of design thinking.

'Undignified' 100-year-old hospital gown design in desperate need of redesign, doctor says

Digital interfaces

While in the hospital, and able, I asked nurses and technicians about their experience with the different technologies they were using on me ('using on me' is pretty true to the experience). The overall impression I got was that medical technology companies are investing more in user interface and user experience but there is still a long way to go. Basic design principles of framing, context preservation, scaffolding and simplicity are generally not well followed.

An example is the very fancy x-ray machine that was used for my swallow test. The swallow test is used to see if all the critical parts from mouth to intestine are connected and working. This device takes a 3D video of a liquid as it flows through the digestive system. I listened in as the technicians set up the device and could hear them using checklists (thank you Dr. Gawande for The Checklist Manifesto).

I asked about the experiences they have with these sorts of advanced systems and there seemed to be a consensus that the more advanced the functionality the harder it was to use and the more opportunities there are for error. I sometimes feel that acceptance of this tradeoff is built into the design process. The more advanced the functionality the harder it is to use. Is this a necessary design tradeoff? I don't think so. It is the result of design processes that are built on technical specifications and regulatory approvals rather than a deep understanding of design and modern disciplines like design thinking.

Quality of care is about care (and feeling cared for)

The most important thing I took away from my twelve days in hospital is that quality of care is about care and feeling cared for. At every step of the long process I felt that people cared about who I was, were concerned for my fear, and did what they could to make me feel comfortable and connected. I have a long road back to health but my treatment has put me on that road. Healthcare providers, pharmaceutical companies, medical technology companies and the technology and data services that are stitching them together need to organize around how they contribute to the patient's journey. Formally this is done through patient journey maps. Weaving the experience of care into patient journey maps. Flipping this, using journey maps to improve the quality of care could help a lot. This is something that British Columbia (where Vancouver General Hospital is located) has begun to do. There are some interesting examples of patient journey maps being developed and I hope used in BC on the BC Patient Safety and Quality Council website. Similar work is being done in other places.

I am feeling cared for. My deep thanks to everyone, inside and outside the medical system, who contributed to my care over the past month. I will align my work to contribute to care for others going forward.