Great design in the strangest places

For the 50% of you who have not had the pleasure, let me explain what a urinal is.  A urinal is a porcelain bathroom fixture that marks the location of a pool of urine on the floor.

I wish I were joking.

Urinal designers have done their best to encourage "accuracy".  Urinals are almost wrap-around in their design, but still...  Don't wear your good shoes.   Something is missing. (Ha! Good one.)

I came across an interesting innovation while I was in Amsterdam earlier this month.  I'd heard of this concept before, but had never seen it.  This urinal was in the convention centre:

And in close-up:

The image is a little blurry (one doesn't linger over composing the shot when holding a cellphone over the urinal in a public washroom.  FYI.), so I'll point out that it's a fly on the side of the urinal. Or rather, it's a sticker with a picture of a fly, stuck on the bottom of the urinal. (The protruding, and somewhat off-putting, shadow near the bottom is from the flush handle.  Don't let your imagination run away with you.)

This urinal was in a restaurant:

A picture of a candle! Nice.

These elegant (!) examples of innovative design are supposed to encourage the user to be more accurate. I didn't actually collect data on this, as I thought I had already pushed my luck enough by taking photos in the washroom.  However, according to this article (read down to the end), Amsterdam's Schiphol airport noted 80% less spillage after implementing the urinal targets.

Good design can be delightfully simple (recent examples here and here).

Now if only someone could design a way to stop guys from talking on their cellphones while using the urinal.

I wish I were joking.

Good process design - We all do it every day

Designing a system that allows (or forces) the desired outcome sounds intimidating. We probably need a degree in Engineering or Business Administration to do it.

Or, we could rethink what system design really means and realize that we already do it every day.

I've been thinking/obsessing about system design since a couple of posts last week(1, 2). Rather than calling it "system design", I've tried to think more about "Making it easier to do the right thing". That makes it more accessible for me. I think we all do this every day. We just don't make a fuss about it.

Several months ago, I decided that I would take some vitamin and mineral supplements every day. I started off taking them reliably every morning, but after a couple of weeks, I was missing most days.

I was still committed to taking the supplements, but found it a nuisance to add one more item to my morning routine.

I keep these 3 vitamin bottles in a bathroom drawer. Getting them out, opening each bottle and shaking out the pills takes about 2 minutes, but it seems like it's a lot longer when I'm in a rush to get to work. Plus, taking the vitamins isn't a critical part of the morning flow (like breakfast or showering), so it's easy to convince myself that I can skip a day.

I re-engineered my system by getting a pill box.

I fill it on the weekend when I'm not so rushed. I keep it next to my toothbrush so it's accessible and also linked to another part of my regular morning flow. Works like a charm.

Good system design - It's not just for breakfast anymore.

Good design makes it easy to do the right thing

Every system is perfectly to achieve exactly the results it gets.


- (attributed to) Don Berwick

Here are a couple of examples of how design affects behaviour.

First, a picture of the entrance to a Walmart in Calgary. (Sorry it's a little fuzzy.)





There's a huge floormat that you must walk across as you enter the store. There's no way around it. It's long enough to let the big chunks of snow drop off your boots, and also absorb a fair bit of water from them. It must save them a lot of mopping during the spring and winter, and make it safer for customers and staff.


Nobody deliberately makes the floor slick with the runoff from their winter boots. This "push" design makes it easier to do the right thing.


Here's the tap running in one of our cystoscopy suites.







You probably can't tell from the photo, but the water is glacial- absolutely freezing. How long can someone spend washing their hands when the water temperature is so unpleasant? I know it's cold because I do wash my hands in it - over a dozen times in a morning. But, I think I would spend a little extra time under the water if it were warm. (Mmmm, warm water...) And, yes, we have called maintenance about the water temperature.


What are the little things in your workplace that stand in the way of you doing your job the way you want to do it? Why not leave a comment about it ("Anonymous" is fine!) so that we can create a list of simple changes that will improve patient care. What's bugging you?



**Update (March 15, 2011): The water in the cysto unit today started out freezing, but warmed up a lot sooner than usual. Thank you Water Heater Fairy.

**Update (March 24, 2011):  Freezing again today!  Curse you Water Heater Fairy!

Prevention = Simplicity

Health: A state of complete physical, mental, and social well-being and not
merely the absence of disease or infirmity.

- World Health Organization

I figured out the connection between my recent anti-smoking tirade and simplicity in healthcare: Prevention = Simplicity.

So much of what we consider modern medicine is acute-care, high-tech, expensive rescue treatment for conditions related to behaviour. Think of sun exposure and skin cancer, obesity, driving while intoxicated, and of course, all the illness caused by tobacco addiction.

I wonder if some health economist has done the math on the relative cost of interventions to prevent disease and interventions to rescue us from the effects of disease? I suppose it would be (relatively) simple to tally up the cost of chemotherapy drugs or ICU stays, but I wonder how human suffering fits into that equation?

The ultimate simplicity is to avoid all those illnesses with primary prevention. But, healthy living is so boring. How can you compete with all those commercials for fast food? (Mmmmm, bacon.) Look how much fun those guys are having at the bar. ("Drink responsibly")

We need a marketing campaign for healthy living.

Leaders: Clear the path and your team will do their best work

Something a healthcare senior leader said recently gave me pause for thought.

As part of a group discussion around healthcare improvement, the perennial topic of electronic medical records (EMR) came up. While everyone at the meeting agreed that EMR would be hugely beneficial to patient care, X opined that technology couldn’t change attitudes.

Here’s the context: The group had already agreed that the primary driver behind healthcare improvement should be the philosophy of patient and family-centred care (PFCC). X’s point was that having EMR would be great, but it wouldn’t convert anyone from being provider-centred to patient-centred.

I spent the next few minutes of the meeting on a thought tangent.

X’s assumption was that providers are fixed in a self-centred existence. They have to be “re-educated” and convinced to embrace PFCC. EMR and other technology don’t influence behaviour.

But, what if there’s a different explanation? Let’s assume that every nurse, doctor, clerk and housekeeper would get tremendous satisfaction from applying PFCC principles in their daily work. They may not be familiar with the formalities of PFCC, but they understand what it means to be kind and caring. Further, assume that all newly-hired providers come to their first day of work with the desire to do their best to serve their patients. What happens after that?

We beat the PFCC out of them! We put obstacles in their path, fail to reward (or even punish) sincere efforts to put patients first. We make it easier to be self-centred than patient-centred.

Here’s an EMR-related example from my practice: A man is referred to me with pain in his side, possibly related to a kidney stone. I recommend a CT scan to locate the kidney stone. He tells me that he already had a CT scan done at his local hospital. The referral letter didn’t indicate that a CT had been done, so I didn’t have the opportunity to look at it prior to this visit. I try to access the CT films using the online x-ray viewing system, but as is frequently the case when we try to do this from our office, the system is not working. I tell the man that I will check his CT the next day when I’m at the hospital and can use that system. He leaves without a definite diagnosis or treatment plan.

Another common example is the “missing” lab test. When a patient has already had a certain blood test performed, but the attending physician doesn’t have access to it (e.g. it’s a weekend and the family doctor’s office is closed), it’s just “easier” to poke the patient with another needle and repeat the test. The physician ordering the repeat test isn’t deliberately cruel; if the results were easily available (EMR!), it wouldn’t be necessary to stick the patient again, and it wouldn’t be done.

My conclusion was that X should think about healthcare providers’ behaviour differently. Rather than presuming the worst, X should assume that providers naturally want to provide PFCC, and that “the system” impedes them. If we assume the best, then our approach would change from one of trying to educate providers in PFCC, to one of trying to remove the barriers that prevent them from fulfilling their natural inclinations.

Here’s what this means for a leader: If your staff isn’t delivering PFCC, it’s not because they don’t want to. It’s because you have not created an environment that lets them do their best work.

Clear the path. Unleash the potential.