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Applying Patient-Centered Design to Healthcare ITQualitative Research Methods Guide

What you’ll find in this handout

● Material covered during the whiteboard session● an introduction to qualitative research methods that you can use

for patient-centered design!● Initial estimates of the amount of time activities or phases would

take. We are not presenting them as absolute fact. The calculations are derived from our own experience as design researchers.

Pick the methods that are best suited for you!

Each of the methods introduced in this handout will contain the following information:

● explanation of the method● minimum time required to complete the method● recommended number of engagements or sessions● resources needed to complete the method● helpful tips to get you started● other phase(s) during which the method can be used (when

applicable)

Recruiting participants for research activities

The healthcare space presents particular challenges that are important to to keep in mind when doing qualitative research:

● Patients may not be open to sharing sensitive information about their experiences.

● Doctors and clinical staff do not have a lot of time to spare, especially if it’s not clear why you’re asking to talk to them.

● PHI needs to be considered when taking photos during on-site visits.

● Sessions with doctors and clinical staff may end abruptly if they need to address an issue that arises.

How to start if you’re just getting started

Start with a small project in a straightforward problem space. Consider trying a pilot research project with helpful colleagues. Making mistakes with people you know can help you practice new methods in a comfortable environment. If you’re eager to get started for real, always test out protocols before using them with actual participants. Seasoned researchers regularly do this as part of their practice.

INTRODUCTION

Step 1: scoping your project

Scoping is the first step to setting yourself up for success. The methods you use can shift the scope as the project progresses and that’s ok. However, watch out for scope creep so your project doesn’t balloon into something unmanageable.

Healthcare is complex. There’s a lot that can be improved upon and a lot of opinions on how to improve. It’s tempting to try to solve everything. Setting boundaries from the outset helps you stay on task. Remember that for everything you add there’s a tradeoff.

Step 2: find your starting point

Every design project is different so the starting point for each one can be very different too. Design projects can be divided into the following phases:

Exploration | investigating current state

Synthesis | raw data that hasn’t been turned into insights.

Ideation | you have guiding insights, but you don’t know what to do next

Selection | you have no problem generating ideas, but often hit roadblocks

Validation | you’ve been burned in the past by good ideas gone wrong in implementation*

*This handout does not include methods for the Validation phase. If you don’t have prior experience with prototyping, we strongly recommend consulting with professional experience designers.

Step 3: determine your role

You may want to get your hands dirty. Maybe you want to encourage others to pursue projects. The following roles are important in securing the success of a project. It’s normal to embody the traits of multiple roles.

Advocate | you foster a culture open to patient-centered research projects

Driver | you create the master plan to bring parameters to ambiguous ideas

Doer | you carry out research activities

Subject matter expert | you possess invaluable knowledge from years of experience in the field and you’re not afraid to help out when asked

Step 4: identify your constraints

There are always constraints. These help shape project parameters.

Influence | Do people listen to what you have to say and change course upon your recommendations?

Time | How many hours a week can you spend on this type of research?

Budget | How much money do you have to work with?

People | Do you have a team to help carry out research? Is it just you? Are people willing to participate in interviews and design sessions?

BEFORE YOU START USING THESE METHODS

Investigating Current State

Purpose of exploration

Exploration involves examination of your selected problem space from various angles. Even if you are embedded in the problem space, conducting interviews with other people involved in the workflow can provide you with new insights (which is the whole point!).

Methods you can use during this phase

● interviews● fly-on-the-wall observations● contextual inquiry

How long does this phase take?

It depends. It can take 2 weeks or 6 months due to many factors. Recruitment and scheduling sessions with research participants can extend the length of this phase. If time is a constraint, scope your project to ensure that your research goals are realistic.

The importance of having a notetaker

With any sessions involving participants, have a notetaker if possible. It’s difficult to take notes and listen intently to what someone is telling you at the same time. Additionally, your notetaker may catch things you missed or think of great questions to ask during the session. If you aren’t able to recruit someone to help you, consider recording the session for later reference.

EXPLORATION

Why start with interviews?

Interviews provide you with a deeper understanding of the problem space, anecdotes, and emotions surrounding the topic that you’re researching. Even if you’re directly part of the problem space you’re researching, it helps to include additional data to make it more objective.

Try to talk to people that represent stakeholders in the problem you’re solving. For example, if you’re figuring out how to reduce imaging study delays in one of your modalities, it’s important to talk not only to patients but also to technologists, admins, imaging directors, and radiologists.

Time needed: 1 - 1.5 hours keeping in mind that some people may only be able to talk to you for 30 minutes. If they have strict time constraints, consider sending your questions as an email that the participant can answer asynchronously.

Number of interviews needed: There is no exact number we can give you. Typically between 5-8 interviews within a defined group (i.e. MSK radiologists) is a good starting point. Some groups can be extremely challenging when it comes to recruiting participants. Don’t worry if you only get 1-2 interviews….it’s better than no interviews at all.

Materials:

● research protocol containing your questions and additional information that you want to share with the participant

● notebook or laptop; audio recorder● business cards to share with your participants

A few helpful tips for conducting an interview

● Dress just slightly less formal than your participants. For example, if you know that your participant wears a suit, then dress business casual.

● Materials should be neat and organized.● Do not interview more than 1-2 people at the same time (focus

groups are not recommended)!● Avoid leading questions.● Use your research protocol as a guide, not a script.● Let your participant do most of the talking.● End on time even if the interview started late (ask the participant if

they can keep talking upon reaching your end time).● Always say thank you at the end of the interview and send a

thank-you email if you can.● Don’t give away too much about your project. It could influence the

participant’s responses.

EXPLORATION

1 1-on-1 Interviews

Mastering the art of listening and watching

As the name implies, this method involves immersing yourself quietly into a space and watching things unfold. Think undercover CIA agent. What makes this incredibly powerful is that you can observe natural interactions between people and the environment around them.

Time needed: 1 hour/observation session

Number of observations needed: 2 or 3 observations of a space is sufficient. It’s best to go at different day/times. When setting up sessions ask for recommendations for times when it’s busy and times when it’s not.

Materials:

● 1-2 additional researchers ● notebook or laptop to record notes (whatever is less conspicuous)

Public vs. private spaces

● If you’re conducting an observation in a public space (i.e. hospital cafeteria) you don’t need to give anyone a heads up.

● If you’re sitting in a waiting room, be sure to ask operational staff for permission. You don’t have to let the patients around you know.

● If you’re observing employees in an imaging department where it’s clear that you’re there to observe them, schedule in advance.

What should you be observing?

As much as you can! Take as many notes as possible. You can always review and annotate it afterwards. Here are some questions that are common no matter what you’re observing:

● What materials or signage are do you see? What are they trying to communicate?

● Do the people around you look happy, worried, bored?● What kinds of things are people saying and doing?● How is technology being used?

EXPLORATION

2 Fly-on-the-Wall Observations

A hybrid of observation and interviews

Contextual inquiry differs from interviews in that you are conducting the session in context. An example would be interviewing a technologist at their work station during their shift.

Time needed: 1-2 hours/session although bear in mind that the scenario can be unpredictable and the session may end early.

Number of sessions needed: It may not be feasible to make every interview a contextual inquiry. Even if you are only able to do 1 session, you’ll find that it contextualizes content from your other interviews.

Materials:

● Laptop or notebook● Protocol including questions you want to ask and things you want

to observe● Business cards

Helpful tips

● Everything we mentioned for 1-on-1 interviews plus…● Take pictures if you have permission and there is no PHI in the

shot.● Wear comfortable shoes if you’re going to be standing.● Typically you should only talk to 1-2 people during a session, but

certain contexts have other people around. If other people want to contribute to the conversation, that’s okay.

● If your session is occurring while your participant is working, make it clear that they can end the interview at any time if needed.

EXPLORATION

3 Contextual Inquiry

SYNTHESIS Transforming Data Into Insights

Purpose of synthesis

Synthesis is the process of transforming raw data into usable, clear insights. This part of the research phase is often cut short to use time for other things. However, devoting time for synthesis is very important. Insights represent key trends, principles, or values that you don’t want to lose sight of. As you progress into the project, you can use the insights to socialize your work and prevent scope creep.

Methods for this phase

● Experience mapping● Affinity diagramming● System mapping

How long does synthesis take?

For a set of 5 interviews, synthesis could take a few hours of organizing the data and several hours for the methods themselves. For larger research projects, reserving 2 or 3 full days for synthesis should be sufficient.

SYNTHESIS

1 Experience Maps

How do you map experiences?

Experience mapping is a way to structure data captured during interviews into chronological order. As we mentioned before, research protocols are a guide. Your participants can take it in a completely different direction (which means that you’re learning something new!). Creating experience maps helps you group content into facts and expectations, and captures the fluctuation of emotions during the experience.

How many maps do you need? One per interview is ideal

How long does it take to make a map? Between 1-2 hours

Materials:

● Data from your interviews● Excel spreadsheet or post-its and sharpies

Extracting the highs and lows; and finding trends

If you’re trying to improve patient experience, there’s no better way to get started than to have documentation of when the participant was happy, indifferent, or upset. You can use different ranges as long as you capture the extremes.

Are five out of five of your participants getting upset at the same point in the experience? It’s important to note that trends are easier to find when you’ve put thought into your research protocol. Even if you deviate from the protocol, making sure that you’ve covered key areas will make this activity more successful.

SYNTHESIS

2 Affinity Clustering

So that’s what all those post-its are for?

If you’ve seen a picture of people looking at a wall covered in post-ts, chances are they were affinity clustering. This is a classic technique to expose trends across raw data.

How long does it take to affinity cluster? Between 1-1.5 hours of time clustering... Writing out the post-its is what takes the most time. If you have people who can help you write, divide up the interviews evenly. 1 interview could take between 30-45 minutes to transcribe onto post-its. While it seems like a time sink, it actually is a chance for you to review the data again.

Materials:

● 3X3 inch Post-its in various colors● Sharpies● Wall or a whiteboard

Can I use this method in other phases? Yes! {ideation and selection phases}

Naming clusters = creating insights

When you’ve created a group that’s an appropriate size, you’re ready to name it! You want a catchy phrase to represent the commonality across the post-its you’ve grouped together.

Helpful tips to get you started

● Recruit a partner or two, so that you can discuss why you’re grouping post-its together.

● Write in all-caps so you can read from far away.● Do several rounds of grouping and naming.● Take pictures as you go for documentation and reference.

A cluster named, “With this info, I can plan my next move.”

SYNTHESIS

3 System Mapping

How is this different from experience mapping?

Experience maps focus on how a person felt during something that happened to them. System maps visualize steps in a service or process. Emotions or personal expectations are not typically captured in system maps. System maps are powerful in communicating complexity and showing breakdowns.

How long does it take to make a system map? Between a few hours and a few days, depending on the complexity of the system you’re mapping.

Materials:

● 3X3 inch Post-its in various colors● Sharpies● Wall or a whiteboard● Paper and pencils

If you want to socialize the map...

Be mindful that others who are unfamiliar with the project or research may have a hard time understanding your system map. If you want to use the map for socializing your work, spend extra time in polishing the content so that it’s easy to consume. If you’re presenting it to key stakeholders, get feedback from colleagues on your map first.

A system map of toast making (photo: drawtoast.com)

IDEATION Generating Ideas

Core elements of ideation

The purpose of spending time on ideation and using techniques is to manage your time wisely. In an hour you can come up with several dozen ideas to talk about!

When we talk about ideation as part of a design process, we encourage starting with quantity over quality. Why? It’s hard to be creative when you’re under pressure to come up with the best idea on the spot. Once you’ve created a whole bunch of ideas, you devote time to selecting the best of the bunch (that’s covered in the next section).

Methods for this phase

● Mental warm-ups● Mindmapping● Group brainstorming

How long does ideation take?

Up to 4-6 hours in total is all you need. However, you can take as much time as you want. You’ve likely already starting thinking of ideas in earlier phases or even before you started the research project. Be sure to include those ideas too!

IDEATION

1 Mental Warm-ups

Getting ready to get creative

Being creative is not easy or natural for everyone. It’s a certain way of thinking. Even if you don’t consider yourself a creative person that doesn’t mean that you can’t be creative at all. Mental warm-ups ease you into the headspace and help remove any negative thoughts you may have about your ability to generate ideas. You can use these on your own, but they’re especially helpful in a group setting to make people feel comfortable participating.

Time needed: Activities should last only 10 minutes at most.

Examples

Rapid Sketching | Draw as many pictures as you can in 60 seconds! You can use this template.

Sound Ball | Make a sound as you throw a ball to a member of your team. They have to repeat the sound when they catch it. Play several rounds.

Charades | Act out the word written on the card...no talking!

IDEATION

2 Mindmapping

Doodling and daydreaming at the same time

When was the last time you set aside an hour to actually think about something without being distracted or interrupted at all? Mindmapping is time you allow yourself to just think about ideas without the pressure of defending them or justifying them. It’s not just thinking, it’s thinking thoroughly about an idea and actually exploring it.

Time needed: 1 hour

Resources:

● Notebook● Pencils● Whatever helps to put you in a relaxed mood

How to mindmap

● Remove all distractions. You cannot answer emails phone calls or be disrupted.

● Start by thinking about a focus question that relates to addressing one of your insights.

● Starting thinking, let your thoughts wander without judging them.● Sketch or write key words as you think. Draw lines as you connect

ideas together. There is no wrong way to do this!

IDEATION

3 Group Brainstorming

We meet again, post-its

If you’ve seen a picture of people looking at a wall covered in post-its, they might also be participating in a group brainstorm session. These sessions involve people coming up with ideas.

Time needed: Do not spend more than 2 hours a day brainstorming. It is mentally taxing to generate ideas and by the end of a brainstorming session you’ll feel it. Schedule as many 2-hour sessions as you need to feel like you have a big enough stack of ideas to work with, just spread it across several days. From our own experience you don’t need more than 2 sessions.

Materials:

● 3X3 inch Post-its in various colors● Sharpies● Large wall or a whiteboard● Snacks (optional but always encouraged)

What differentiates a good session from a bad one?

● Planning ahead to make sure you have the room and materials you need.

● Keeping the group small (no more than 5 people).● Starting with a quick mental warm-up.● Encouraging creative thinking through thought provoking-prompts

(which should be prepared ahead of time).● Add to ideas rather than dismissing ones you don’t like.

Always have a designated session facilitator

All the planning you put into organizing a session is wasted if you don’t have a session facilitator. It doesn’t have to be you. It has to be one of the participants in the group. The session facilitator is in charge of keeping time, explaining prompts, and guiding discussions. Structure ensures that that time is used efficiently. Participants appreciate this and will be more likely to agree to additional sessions.

SELECTION Selecting the Best Ideas

Why is there a phase just for selecting ideas?

The goal in choosing an idea is that it should be the best one for the problem you’re trying to address. The word ‘best’ can mean many things, especially in healthcare where stakeholders have different motivations. The techniques we’ve included intend to help you bring alignment across decision makers, gain buy-in, and use your time efficiently.

Selection techniques

● Patient experience venn diagram● Impact-cost matrix● (Modified) KJ technique● Circles of influence

How much time do you need to select ideas?

Selecting ideas should take around 2-4 hours total IF you prepare ahead of time. We recommend starting to schedule sessions with stakeholders a month ahead of time if possible to reduce the risk of delays. Schedule 2 sessions just in case. You can always cancel the second session if you get everything done in the first one! Each session shouldn’t be more than 2 hours long so that participants don’t get too exhausted.

The art of layering

You aren’t limited to choosing one idea during a session! Try out several methods with the same set of ideas and compare the ideas that are chosen. Pursue ideas that get selected using various methods.

SELECTION

1 Patient Experience Venn Diagram

A custom method for patient imaging experience!

This method was developed at UPMC Enterprises specifically for evaluating ideas to improve patient imaging experience. Design researchers found that conversations around patient satisfaction also included points involving imaging quality as well as overall patient outcome. To ensure that ideas were considered thoroughly we developed the venn diagram as a visual reminder.

Use this to balance experience against quality and outcomes

The patient experience venn diagram is a good technique to begin the selection phase. It weeds out ideas that either don’t contribute to or negatively affect imaging quality or patient outcome. For this technique it’s important to include operational and clinical stakeholders.

How to use this technique

You can work by yourself or with several people. Going through each idea, think about where it would have the highest impact. Toss any ideas that would negatively impact quality or outcome.

SELECTION

2 Impact-Cost Matrix

Simple yet extremely powerful

This technique is straightforward and accessible. The impact-cost matrix is useful for teams who need clear reasoning and parameters within which to chart ideas.

Materials:

● Ideas written out on Post-its (reuse the ones from your brainstorming sessions if you have them)

● A large whiteboard or piece of paper to draw out the matrix

Facing your constraints head on

Many of your ideas are great. But are they feasible? At the beginning of this handout we talked about identifying your constraints. Being aware of your constraints when you’re weighing ideas prevents unpleasant surprises after it’s too late.

How to use this technique

1. Define what your ‘cost’ should be. For some teams it could be time while for others, it could be cost in dollars. Pick the one that is the biggest show-stopper.

2. Write each idea on a post-it (if you don’t already have post-its from brainstorming session).

3. As a group, decide where on the graph each idea belongs. 4. Start off with ideas that are high impact and low cost. Ideas of

higher cost can be evaluated further to determine how to address the high cost.

SELECTION

3 (Modified) KJ Technique

Spending your time on the ideas that matter most

The KJ technique is a relative of affinity clustering. It was developed by a Japanese anthropologist in the 1960’s and has been adopted as a tool within project management and planning.

We adjusted this method so it could be used during the selection phase. It works wonderfully when team dynamics are complex. It structures the decision-making process in such a way where everyone feels their voice is heard. Lively discussions are reserved only for the top ideas.

Materials:

● Ideas written out on Post-its● Post-its with numbers 1-5 written on them● Wall or large white board● Small stickers

The session facilitator is important here as well

The rigid structure of this method makes sure everyone’s time and viewpoints are respected. Because it requires individuals to work in silence, it helps to have a facilitator who can explain the guidelines and talk through each step.

How to use this technique

1. Put up Post-its with all the ideas you’d like to choose from.2. Each member of the group is given 5 stickers. Each sticker

represents a vote. Without speaking (this is key!), the group votes on the ideas they like best.

3. After voting, the facilitator groups ideas based on how many stickers it has.

4. The group can begin discussion around the ideas with the most votes!!

Ideas arranged by number of votes

SELECTION

4 Circles of Influence

Are you able get your idea off the ground?

What are your circles of influence? Are you able to influence decisions on your team, your department, your hospital, your organization? It is likely that your influence diminishes at some rate.

The design team at NGI has often talked about circles of influence in informal conversations around our projects. Recently we used it as a tool for assessing who had to be involved in order for a solution to succeed.

Materials:

● Post-its with your ideas written on them● Large whiteboard or piece of paper

How to use this technique

1. Draw out the circles (however many apply to you)2. Write down the key stakeholders of each circle...the stakeholders

that you have the least influence over3. Place post-its by how much they would need to be influenced in

order to get the idea off the ground

WANT TO KEEP LEARNING?

Resources

Here are some useful resources if you would like to keep learning about design research and check out applications of this methodology. If you face constraints in influence or with time, you can start here first!

Books

Universal Methods of Design: 100 Ways to Research Complex Problems, Develop Innovative Ideas, and Design Effective Solutions by Bruce Hanington and Bella Martin.

The Design of Everyday Things by Don Norman

Research Design: Qualitative, Quantitative, and Mixed Methods Approaches, 3rd Edition by John C. Creswell

Envisioning Information by Edward Tufte

Websites

Draw Toast! | This provides a fun introduction to systems thinking

Adaptivepath.org | A leader in experience design and research, Adaptive Path offers articles around the process. The website has additional information about events and courses.

Case Studies

Frog Designs a Life-saving MRI machine for Newborns

Designing the future, Engineering Reality: Prototyping in the Emergency Department

Design Conferences

IXDA | February 3-8, 2018| Lyon France

HXREFACTORED | June 20-21, 2017 | Cambridge, MA

UXPA | June 26-28, 2018 | Rio Grande, Puerto Rico

Reach out to the authors!

Susanna Zlotnikov: [email protected]

Anna von Reden: [email protected]