Small Step Service Design Thinking – The Case of the Patient Appointment

As we last week, M2 authored a chapter entitled “Using Small Step Service Design Thinking to Create and Implement Services that Improve Patient Care,” in Service Design and Service Thinking in Healthcare and Hospital Management published by Springer. Today we share highlights from the first case study we feature in the chapter.

Big leap versus small step service design

“At the heart of design thinking is the intention to improve products by analyzing and understanding how users interact with products and investigating the conditions in which they operate,” explain Rikke Dam and Teo Siang in a piece published by the Interaction Design Foundation. In health care, understanding how users interact is often the purview of engineers or project managers looking to improve the waiting room experience, or decrease wait times. We call these “big leap” service designs because they take significant time, commitment, and funding from health care organizations.

A small step design, we argue, truly aims to understand the patient’s point of view, instead of forcing a person to work around a process designed to make things easier for health care providers or organizations.

Patient appointments – boring but essential

While the health care system is moving away from fee-for-service reimbursement, it is still the dominant payment approach in the U.S. This means unreimbursed services, for example, setting appointments, are often outsourced to patients. From a patient’s point of view, not scheduling an appointment, or not showing up for one, can mean diagnosis or treatment delays which can lead to worse health outcomes. From a systems perspective, missed appointments are costly and inefficient. Perhaps most importantly from a design perspective, research shows that missed appointments are often blamed on patient inaction which can cause providers to develop negative attitudes and feelings toward patients leading to a decrease in communication and lack of empathy. Missed appointments can also lead to “increased costs of care delivery…reduced patient satisfaction and negative relationships between patients and staff.”

In a fee-for-service environment in particular, it makes sense from the point of view of the provider to recommend a follow-up appointment or make a referral for care, and expect the patient to book the appointment. But appointment nonadherence is a major problem in the U.S. health system with estimates ranging from 20 to 80% appointment nonadherence depending on the type of condition, site of care, and patient demographics.

Is this a people problem, or a process problem?

Since it benefits the patient, it seems obvious that he or she would set a recommended follow-up appointment, or appointment with a practitioner that has been referred to him or her by her current provider. But we know the frequency at which this doesn’t happen is quite high. As Chip and Dan Heath encourage readers to understand in Switch: How to Change Things When Change Is Hard, we may be attributing the patient’s behavior to “the way they are, rather than to the situation they’re in.”

First, let’s empathize.

Design system thinking recommends defining the problem by first empathizing with the end user. A large accountable care organization (ACO) in the Northeast we studied for the book chapter realized they were not immune to the problem of missed appointments, and recognized it was preventing their organization from helping patients achieve optimal outcomes.

The ACO’s small step service design innovation started with empathy. The ACO first worked to understand why their patients failed to follow-up on referrals. If you are not a patient, the answer may surprise you: Patients didn’t feel like they had the expertise to make the best choice.

From a patient’s point of view, they want the best care they can access, of course, but they don’t necessarily know what the “best” care is, or which providers are able to deliver that care for their particular set of circumstances. Further, a list of referrals with several provider names patients are often handed at the end of an appointment can make this anxiety worse. What tools does a patient have to discern between the providers on the list? Is there a difference in quality? Price? Years of experience? Bedside manner? Cultural competency?

Patient-first design extends clinical expertise

The small step service design tested by the ACO in our case study was a coordinated appointment and referral system (ARS). Driven by research showing a patient is more likely to attend a clinical appointment if that appointment is set before the patient leaves the office of the current clinician visit, the clinical leader of the ARS worked with colleagues to pilot a referral and appointment-setting process at the ACO that changed internal processes so patients left appointments with a follow-up or referral appointment already scheduled.

Our case study of the ACO in the Northeast provides a more complete picture of the design steps they used to create a unique appointment and referral system to improve patient adherence to referrals and follow-up appointments. While not the subject of this blog, it should be noted that empathizing with patients was just the first step of the process. Encouraging providers to be more involved in the appointment setting and referral process required building the case for chance across a broad range of internal stakeholders, not the least of which were the staff and clinical experts who would be asked to help patients make this important choice. The goal was to take some of the work off the patient’s plate, but this required building the case with the ACO’s doctors and health care providers for why they should do something differently.

The clinical expert leading the effort explained to us, “I try to tell doctors that we have insider access as clinicians. We get preferential treatment when we are trying to interact with the system. Imagine extending that reach for our patients.”

Through a provider’s eyes, it seems obvious that patients should schedule appointments the provider recommends. But through the patient’s eyes, it becomes more clear that the barriers to appointment-setting may have less to do with lack of interest and more to do with lack of expertise. Extending clinical expertise and “insider access” to patients to improve the rate of appointment setting may seem like a mundane process change, but the ACO in our case study thinks it will have an outsize impact on patient outcomes.