The Blue Yarn

Listening to the 99% Invisible Podcast last week, I came across a story that says a lot about the Action Mill’s approach to our work, particularly with our partners working on health reform in Vermont. To understand how we think about using design as a strategy, take 10 minutes and listen to the podcast at the end of this post.

You can read the rest of this post without listening to the podcast, but trust me, taking 10 minutes to listen will make our methods and the way we focus our work a lot clearer.

This is the story of Dr. Gary Kaplan, CEO of Virginia Mason Medical Center, who needed to find a better way to manage his hospital. You probably won’t be surprised that he wound up in Japan, learning about the Toyota Production System, or even that he brought people from Toyota back to his hospital to help redesign their systems.

What might surprise you is the first thing the Toyota sensei asked the staff of the hospital to do: gathered around a map of the hospital, they were given a ball of blue yarn and told to mark the path of a typical visit for a cancer patient undergoing chemotherapy. That methodology should sound familiar to anyone who’s been through a design session with the Action Mill: it’s about two things: taking what’s in our heads and making it visual and physical so we can interact with it together, and making the everyday experiences of people the absolute center of the work.

Mapping a patient’s route through a hospital appears to be a very simple task – any individual staff member could have taken you on that tour. But when it’s done together, with a tangible model that everyone can touch, you create something new: a rich, complex, meaningful conversation about what the systems we put in place actually mean for the people who use them.

We ask our Vermont partners to do some very simple exercises – they probably seem overly simple sometimes. As someone from outside the state said in an aside after going through one of our exercises, “This feels like Identity Management 101.” This is not an uncommon response when people first work with us. It might seem like anyone working in health IT should all understand Identity Management at a very high level, until you remember two things: 1. One person’s “Identity Management 101” is another’s actual experience of the health system, and 2. When you’re trying to change a complex system, one of the most dangerous assumptions we can make is that we all understand each other, even a little.

Another person at the same meeting inadvertently showed why getting back to actual experiences and creating rich discussions are so important when he responded to a description of the “clipboard problem.” (The clipboard problem refers to the number of times in our lives we are asked to fill in the same basic medical history form.) This person was so surprised to hear about patients repeatedly filling in the same form that he was sure he had simply misheard.

Stop and think about that for a moment: this is someone who lives and breathes health data management. It is their full time job, and they are very, very good at it. And yet, the problem that people describe to me first, without fail, when I tell them that we’re working with Vermont on health data was so far off his radar screen that he didn’t believe it happened with any regularity. This is not a commentary on this individual – I make the same kind of mistake on a regular basis. The difference is that I work for the Action Mill, where we’ve built a practice that does what Toyota’s automatic looms did: it detects a particular kind of mistake and helps us stop, correct the problem, and get back on track. 

That is why we start with yarn and post-its, and we start with personal experiences, and why we always, always go back to them. Otherwise, we will wind up developing excellent systems that few people use and even fewer understand.

Which is not to say we listen to Dr. Kaplan’s story and just follow his lead. The key thing isn’t to copy Toyota, it’s to learn lessons from them: with our partners in Vermont, we are building a set of principles for health reform, and those principles will guide us in building systems that will work for real people.