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Human Cognition
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Understanding of Human Cognition and Behavior Can Help Transform Healthcare
Wednesday, April 6, 2016
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The U.S. healthcare system is undergoing rapid transformation, from a payment system that is fee-for-service to a patient outcome-based model that includes incorporating patient satisfaction, as evidenced by the HCAHPS: Hospital Consumer Assessment of Healthcare Providers and Systems survey. 

For hospital systems to survive and thrive in this new landscape, they need to adapt and innovate how they deliver healthcare. The challenge is that humans, at both the individual and group level, resist change. Indeed, a plethora of evidence demonstrates that people generally defend the status quo, avoiding chaos and disruption—especially when there has been a well-established status quo. Innovation always initiates change, the consequences of change are usually uncertain, and uncertainty breeds fear. This fear creates significant barriers for new ways of operating.

What will it take for healthcare organizations to overcome this resistance? The answer lies in understanding human psychology. Change and transformation requires time and investment to rewire an organization’s DNA. However, by understanding the forces that shape thinking and influence behavior, organizations can create a safe and nurturing environment that encourages intelligent risks and collaboration across organizational boundaries—and truly seeks deep patient and healthcare worker insights.

Barriers to Change: Cognitive Bias

Barriers to individual and organizational change are often the result of human thinking and behavior—a specific type of thinking called “cognitive bias.” Humans have mental structures (schemas) that are built on their experiences and form the expectations and assumptions that guide the way they think, act, and interpret what’s going on in the world.

A general definition of human cognitive bias is a “systematic error in thinking that affects the decisions and judgments that people make.” Many cognitive biases have been identified that demonstrate humans are not as logical and rationale as believed. Some common cognitive biases have a major on the capability of individuals and organizations to embrace change and transformation:

  • Egocentrism (“It’s all about me”): Tendency to judge everything from one’s own perspective because of an inability to see another person’s point of view.
  • Confirmation Bias (“Fit what I believe with the data”): Tendency for people to fit information into their current belief system even if they have to reinterpret, ignore, or dismiss the information so that it confirms their current beliefs.
  • Functional Fixedness (“There’s only one way to do things”): Tendency for people to limit how they use (or view) something only in the way it has traditionally been used.
  • Salience (“The loudest or most important wins” or “The last event or person has priority”): Tendency to focus what is standing out relative to issues rather than what is most important.
  • Loss Aversion (“I’d rather hang on to what I have then risk something new”): Tendency for people to strongly prefer avoiding losses to acquiring gains.
  • Group Think (“Conformity/Consensus becomes more important than active debate about best option”): Tendency of the members of a group to yield to the desire for consensus or unanimity at the expense of considering/debating alternative courses of action.

The point: When dealing with any situation where change is involved, it is critical to be self-aware and mindful of the impact human cognition and behavior has on the situation. As the degree of change and transformation increases, this awareness becomes even more important, because many of these cognitive tendencies reinforce the status quo producing resistance to change.

How can healthcare systems leverage an understanding of human cognition and behavior to improve patient outcomes, including patient satisfaction with their care?

Overcoming Bias and Resistance to Change: Cognitive Flexibility

Beyond an awareness of human cognition, individuals need to develop and apply a new mindset and skill sets to overcome their own barriers to change. More importantly, they must then influence their organizations and create a culture of innovation and intelligent risk taking, strategic thinking, and open and constructive debate to enable transformational impact leading to substantive improvements in patient outcomes and experiences.

Creating cognitive flexibility is critical. Cognitive flexibility is a mindset of openness, curiosity, creativity, and a willingness to admit that you don’t know everything (sense of ignorance and being naive) and that you may be wrong in situations. The hallmarks of a cognitively flexible mindset is one that exposes, challenges, and tests assumptions about the present and the future, as well as looking in the mirror and reflecting on what the weaknesses are current state.

Assumption is defined as “a thing that is accepted as true or as certain to happen, without proof.” So often, we accept things in our world as fact and truth when in actuality they are just assumptions. For example, Kill the Company author Lisa Bodell recommends trying an exercise in which an organization conducts an honest assessment of itself from the perspective of an outsider, such as a competitor that wants to destroy it.

In my design consultancy and as chief innovation strategist at Barnes and Conti, I work with a variety of organizations in industries, including healthcare and medical devices, to build the mindset and skill-sets for individual and organizational competency through immersive, experiential, blended learning workshops and user research.

Here are a few examples of core mindsets and skill sets that are critical to transform the delivery of healthcare for the future.

Empathy. Walking in the shoes of someone else. Seeing the world with the eyes of another. Listening with the ears of another. Feeling with the heart of another. Whatever metaphor you use, empathy is about stepping out of “your” view of the world and seeing the world through “someone else’s” perspective. To transform the world around us, we have to truly know what it is like to them.

During one engagement, I had a healthcare business team experience what it was like to be a patient with incontinence. Over the course of a weekend, they were asked to go through a patient journey: they were asked to purchase adult diapers, wear them, and if they felt comfortable to use the product as a patient would in real life. Through this immersive experience, they were able to truly understand what incontinent patients go through on a daily basis. The team saw the world from a less technical viewpoint and a more a socio-emotional position that affected how they saw potential patient products and solutions. It’s about perspective taking and not being egocentric.

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Observation. If asked, people will provide a response of how they do things. However, what people SAY they do is not what they actually DO. In addition, when people talk about their pain points, they are viewing the world as it is and what they would like to improve, including incremental improvements. In many cases, there are more transformational opportunities that could be achieved by creating new solutions to meet user needs that they are not even aware of or do not know there are alternative solutions. As Henry Ford stated, “If I had asked people what they wanted, they would have said faster horses.” Similarly, Steve Jobs once said, “You can’t just ask customers what they want and then try to give that to them. By the time you get it built, they’ll want something new.”

In another engagement in healthcare, I worked with a team that was exploring a potential new market. We spent numerous hours shadowing and observing clinical staff and patients. Through this research, we were able to identify the workflow, the information requirements for completing tasks, artifacts used to document activity such as forms, and the various roles to be accomplished by the care team or patient or caregiver. We also were able to pinpoint the socio-cultural relationships between various stakeholders in the care ecosystem, such as aligned or misaligned relational expectations between care team members. It’s about seeing the unseen for opportunities (breaking out of functional fixedness), not just focusing on the loudest voice (salience), and forcing oneself to fight the confirmation bias.

Compelling and Clearly Defined Vision. So often, the problem is that everyone is not aligned around the real problem. Defining the right problem—and gaining insights—can lead to major progress on tough and seemingly intractable challenges. Furthermore, by defining the challenge in a compelling way engages everyone involved and focuses everyone’s energy down the same path. Transformation requires harnessing the collective power of all with their intellect and just as importantly their heart. (For more on this, check out the works of Switch by Chip and Dan Heath and Heart of Change by John Kotter.)

During a recent strategic thinking session with a healthcare device maker, one participant was able to reframe his problem in a compelling way that would change the trajectory of a project that was on the verge of losing funding—just by spending time with a diverse group of colleagues. It’s about fighting the status quo and resisting change, and getting everyone on the same page about what the problem is.

Collaboration. Use the power of diversity of thought when creating teams to solve problems. Gerard Kleisterlee, CEO of Philips Electronics, noted in a 2004 industry speech: “Overall, I think we need to employ more anthropologists and fewer technologists.” When developing a new product, companies too often focus on technological performance, functionality, and manufacturing constraints, without paying enough attention to how the product will actually perform in the customer’s hands. Regardless of the industry or the nature of your offering (whether product, service, or technical in nature), mix it up and create diverse groups of smart people who are able to think beyond the status quo.

Steven Johnson, in his book Where Good Ideas Come From, talks about this as the liquid network, in which one’s hunches can connect and reconnect with hunches in other minds. Eric Weiner, in his book Geographies of Genius, discusses how great periods of creativity were always associated with a mash up of diversity and a forum to incubate the ideas through lively conversation and critique (coffee houses, clubs, agora).

Constructive Debate. Along with diversity of thought, it is critical to create an environment where constructive debate is expected and where ideas are continually critiqued and built upon. In Creativity, Inc., author Ed Catmull describes how Pixar uses a technique called “plussing” in which ideas are pitched and reviewed with the caveat that any criticism needs to be followed by how the idea can be improved. They believe that this process creates new and better ideas faster and prevents an idea from becoming too personalized and aligned with the idea generator. The last thing Pixar wants is a bad idea being polished to perfection for too long of a period of time.

Likewise, during a strategic innovation workshop with a healthcare company, teams worked on a challenge posed by an executive sponsor. After multiple rounds of iterative feedback and prototyping, one team pitched their prototype solution and preliminary business case and was provided funding by the executive sponsor to move forward on the solution. A core success factor was the fact that the team collected a lot of feedback that it leveraged (instead of dismissing it) and built upon it to move their idea and prototype solution forward. It’s about breaking down silos, avoiding the confirmation bias, and avoiding groupthink through constructive debate and critique.

Prototyping. People have difficulty envisioning something that does not exist. In the book Inventology by Pagan Kennedy, Martin Cooper (inventor of cell phone) discusses his experience when Motorola tested pagers at Mount Sinai Hospital. Initially, hospital staff did not know what to do with the pagers but as they discovered uses for it, they became enamored with it.

The tricky part is that before a new experience exists, few people understand it. They may even hate the idea. So you have to put the machine in their hands in order to awaken a new desire and explore new possibilities. Cooper states, “They [doctors and nurses] now could not conduct the business of the hospital without pagers.” In order to test out new ideas, it is critical that participants understand the new reality that is being proposed in concrete terms. As the saying goes, “People don’t know what they don’t know!” Prototyping is a fast and inexpensive way to create a “future state” so potential users can envision what’s to come and provide feedback that validates an idea before expending significant resources, according to Lean Start-Up by Eric Ries.

In one engagement with a healthcare company, I was on a team that explored whether technology could be used to increase patient engagement regarding chronic diseases in emerging markets. We used social media and web-based technologies to track patient behavior from awareness to calls to action. The tools we used to collect data and conduct experiments were low-cost and non-scalable. Our goal was to learn; we were not concerned about the scalability of the solution. Certainly, prototyping is a powerful way to try out different approaches in an experimental fashion, collecting robust data by painting a concrete picture for users, and not spending significant resources. It’s about testing your assumptions without risking a lot, which will hopefully reduce the likelihood of loss aversion.

Bottom Line: Transformation Is Difficult

No doubt, managing change is a major hurdle in an organization—and healthcare is no exception. However, deliberately and consciously becoming aware of and fighting against the inertia of our natural human tendencies is the first and most important step. Then, using mindset and facilitation tools to apply a different perspective on the challenges of healthcare will lead to a different and improved clinical workflow for care providers (clinical burden) and enhanced patient outcomes and experience.

Interested in learning more? Join me November 13-15 in San Antonio at ATD's Healthcare Executive Summit.

About the Author
Dr. Nelson Soken is CEO of N.H. Soken Consulting and Chief Innovation Strategist for Barnes and Conti Inc.. As a consultant, author, and thought leader, Dr. Soken is passionate about helping others see things differently. At N.H.Soken Consulting, he assists client companies in developing their innovation and design thinking strategies and competencies through innovation program and strategy development and inspirational presentations. He has conducted innovation and strategic thinking training across the United States, Europe, and Canada for Fortune 500 companies, including IBM, Abbott Labs, Texas Instruments, Honeywell, Citibank, New York Life Insurance, Yahoo, and the Hass Business School at UC Berkeley. Currently, Dr. Soken a usability consultant for Andamio Games on the iNeuron project, which is funded by NIH and CytoAssist (funded by NSF), to create STEM games for high school students. Dr. Soken also has been a consultant in the healthcare industry, including medical device companies. Formerly, at Medtronic he used his science and engineering background, coupled with excellent communication and networking skills, to create and drive a patient-centric strategy that changed the corporate mindset about how to approach and gather research data in emerging markets. In addition, at the Mayo Clinic’s Center for Innovation, he developed an innovation curriculum that immersed healthcare professionals in innovation and design thinking with the goal of equipping healthcare professionals with mindset and skills to better serve patients. Dr. Soken co-authored Lead the Pack: Sparking Innovation That Drives Customers Wild, a book on the psychology of innovation.  
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