Sunday, October 27, 2013

Designing the Intro to an Innovation Curriculum for Medical Residents

[ ] Indicates language that should be verbally communicated to the audience or an exercise that should be performed

Target Audience: medical trainees interested in innovation

Course to Proceed as Follows:
Step 1:
[Ask residents the following to understand their pain-points and level of understanding:
-What do you want to get out of this experience?
-What do you know about value-based care?
-What do you know about innovation?]

Assuming they are not opposed to learning about skills that will allow them to excel in their careers a clinician leaders (not necessarily start companies or work in the private sector), then proceed to Step 2.

Step 2:
Provide bridge from clinical outcomes-oriented thinking to value-oriented thinking on a level that medical trainees understand: inspiring leaders

Simon Sinek: How great leaders inspire action
[Show Video of Simon Simonek] 

[Summarize Simon’s talk and apply to the perspective of a trainee:

Medical trainees at top-tier Academic Medical Centers (AMCs) commonly aspire to be leaders in healthcare. Although Simon Simonek uses a lot of business jargon, trainees can likely emphasize with his central thesis: “Great leaders inspire action by why they do not by what they do.”

Simon Simonek elaborates on his thesis of inspiring leadership through his idea of the Golden Circle.]


[Exercise: Have residents complete the Golden Circle for their own careers]

One way a medical trainee could fill in the Golden Circle with their own experience is:

What: delivery excellent clinical care, publish lots of papers
How: learn the most clinical knowledge and practice at the most prestigious institutions; position for best ability to get research funding via K-award, R-award, etc
Why: Eliminate suffering, Eliminate social injustice

[Provide the following interpretation:

With the rapidly evolving health care system, the current "how" and “what” or career path may not help medical trainees achieve the full potential of their impact.

More specifically, the health care system is rapidly changing from volume-based care to value-based care. There is decreasing incentive for scientific discoveries that lead to incremental improvement in outcomes (3% increase in 5 year mortality rate) at an enormous cost (billions of R&D budget for a drug). There is a shift away from fee-for-service reimbursement and toward managed care. Readmission penalties are climbing to 2% in 2014 and 3% in 2015. Hospital revenue will be plummeting 5-15% over the next several years as care is redirected to the community. (References available upon request)

The bottom line is that our livelihood and ability to impact change are at risk with the current limited skills that we are acquiring in clinical training. In order to survive and thrive in the future health care delivery and reimbursement system, medical trainees need to be familiar if not expert in value-based thinking.]

Step 3: Define Value
Value = outcomes/cost [Porter]

*of note, blind cost containment does not offer real value to patients, just fudges the equation

Triple Aim [Berwick]

(From IHI, 2009)

Step 4: Building the Lexicon: Tools and Methods for Describing and Delivering Value
[Verbally summarize:

To preface this section, it’s important to note that the following content and exercises may help you in the long term in your career, but in the short term may also help residents identify projects for Academic Development in residency or Fellowship Projects.

In order to achieve the triple aim, residents should be familiar with a combination of improvement science and innovation methods.

Improvement Science
Improvement science methods, such as Quality Improvement, provide a skill set that enables the clinician to measure and impact outcomes on a real-time basis. QI offers the opportunity for a clinician to impact at least one of the triple aims, improving population health.]

Methods in Innovation
[Define and describe steps of Lean Startup Thinking and Design Thinking:

Other approaches to delivery innovation facilitate not just practice improvement, but rather the creation of entrepreneurial, potentially high-risk new products or processes driven by consumer adoption.

Lean Startup Thinking
Lean Startup Thinking is a management process that aims to create a minimal viable product (MVP), which is an intervention with the fewest features needed to get an end-user to pay with a scarce resource such as money, time, or attention.[Reis] Similar to the Plan-Do-Study-Act cycle of Quality Improvement [Langley], the Build-Measure-Learn cycle of LST is a continuous process of building a prototype, testing and measuring the impact of the intervention, and learning from the results of testing to inform the refinement of the prototype. [Figure 3] This cycle is rapidly repeated until there is sufficient validation of an MVP or until there is sufficient invalidation to change course or pivot toward another MVP.


(From Ostrovsky A & Barnett, 2013 in review)

Although traditional implementation science and LST share the same origins of Lean Management, Six Sigma, and the scientific method, the outcome being tested in LST is not a statistically significant difference between two interventions or an improvement in clinical outcomes. Rather, LST focuses on the confirmation that a patient, provider, or payer is willing to pay for a new product or service.[Reis] The benefit of using LST as the foundational methodology for incubation at AMCs is its emphasis on end-user validation, which creates consumer-driven rather than clinically driven incentives to prioritize patient-centeredness, minimize costs, and optimize clinical outcomes. The alignment of these incentives and the inherent for-profit orientation of LST works towards generating sustainability through generating revenue. In contrast, traditional implementation science approaches may produce or discover interventions that lead to improved clinical outcomes, but if end-users do not perceive value in those outcomes, then the interventions risk never being utilized or the cost of those interventions may go unchecked. The end goal of LST is the creation of a product or service that builds on the three pillars of quality improvement [Berwick] to achieve the “quadruple” aim: improve patient satisfaction, decrease costs, improve care quality, and be commercially self-sustainability.

Design Thinking
Unlike LST, which is rigorous iterative process of testing that converges on a single solution, DT is a divergent process that combines empathy and creativity to generate insights into the deep-seeded problems faced by end-users.[Kelly] The design process can be outlined in 5 steps: 1) empathizing with the end-user to understand the root of their problem, 2) defining that problem, 3) thinking outside the box for ways to solve the problem, 4) building a prototype of the solution, and 5) testing the ability of the solution to solve the original problem. [Plattner] [Figure 4] Design Thinking adds granularity and a deeper understanding of the end-user’s context, and it complements LST in discovering solutions that fit the unique needs of the end-user. With empathy as the central tenet underlying both clinical practice and DT, clinician-innovators are uniquely qualified to be Design Thinkers.]


(From Ostrovsky A & Barnett, 2013 in review)


Explore problems faced by medical trainees by having trainee present a problem in front of group or have participants document their problems on post-it notes. Have facilitators review the problems/pain-points as a group and dissect the problem into its component parts (empathize). Then go through the Design Thinking process to come up with potential prototype solution to the problem.]


Berwick D, Nolan TW, & Whittington J. The Triple Aim: Care, Health, and Cost. Health Affairs. May 2008: 27(3). 759-769.

Porter ME. What Is Value in Health Care? N Engl J Med 2010; 363:2477-2481.

Reis E. The Lean Startup: How Today's Entrepreneurs Use Continuous Innovation to Create Radically Successful Businesses. 2012

Langley et al. “The Improvement Guide: A practical approach to enhancing organizational performance.” Jossey-Bass Publishers. 2009.

Kelly T. The Art of Innovation: Lessons in Creativity from IDEO, America's Leading Design Firm. Random House. 2007.

Plattner H. The Stanford Approach to Design Thinking. 2013. Institute of Design at Stanford.

p.s. Great quotes from Simonek talk:

Why matters more than what you do:
“Apple- everything we do we believe in challenging the status quo and thinking differently; user friendly products; computers”

“Wright brothers- Change the course of the world by redefining boundaries between man and bird; new way of travel, commerce, communication; airplane”

“TIVO- if you’re the kind of person that likes to have total control over every aspect of your life, boy to do we have a product for you”

“MLK- not until all laws created by man were aligned with laws of authority”

“[MLK] gave the “I have a Dream” speech not the “I have a plan” speech”

Now apply the “why matters more than what” to a career as a clinician innovator. 

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