Background: Quality Improvement (QI) is a methodology for solving complex systems problems, and QI methods have been adapted from industry and spread widely across healthcare over the past two decades. QI methods are particularly well-suited for examining clinical processes for effectiveness, reliability, and efficiency. However, Design Thinking (DT) is a problem solving methodology that applies a different lens and examines a problem not only in terms of the underlying process, but from the perspective of the patients, providers, and others who use a given process, product or system. DT methods complement QI methods by allowing practitioners to examine both human and process components of a system and navigating the common tension between robust clinical process effectiveness and underlying human needs. Here we describe the use of design thinking in a contemporary QI project to improve breastfeeding in a neonatal intensive care unit. We further describe a hybrid model of ‘human-centered QI’ combining the best parts of these two methodologies.

Purpose: DT is a powerful methodology for improvement focusing on identifying the emotional needs of people and designing solutions to meet those needs. This approach compliments other approaches widely used in healthcare quality improvement that focus on clinical process effectiveness. By demonstrating how DT methods work alongside contemporary QI, we provide a starting point for organizations to leverage this human-centered approach.

Description: We illustrate how DT and QI tools were used together in a neonatal intensive care unit (NICU). NICU clinicians received feedback that mothers were dissatisfied by not meeting key breastfeeding goals after discharge even though the clinical process appeared to be performing well. The team used the Double Diamond model of DT to understand the human needs of new mothers attempting breastfeeding in addition to the process components that had already been captured using QI tools (process map, fishbone diagram). The team conducted human-centered design interviews with NICU mothers and providers and used DT tools including empathy maps and user journeys to define the underlying human needs in the system. The DT tools quickly revealed how the human side of the process was leading to failure. The key insight was that the provider and the mothers’ definitions of ‘success’ differed, leading to process failure. NICU clinicians felt the current system was performing well if infants were receiving breast milk, even if pumped, in line with current guidelines. In contrast, mothers expressed an unmet need to bond with their infant through feeding at the breast and felt disappointed when not supported in that experience earlier. The team used these human-centered insights to develop a shared problem definition and craft both a DT ‘challenge statement’ and QI aim statement. The team then ideated with patients, providers, and staff to generate solutions rooted in the design insights, ultimately converging on the idea of creating a team of NICU nurses with dedicated time to assist mothers with breastfeeding each shift. Data was plotted on a statistical process control chart and demonstrated early signals that the innovation had improved performance.

Conclusions: Using DT alongside QI is feasible and leads to better outcomes in improvement work by defining human-centered needs alongside process components. Practitioners of QI should learn DT methods and integrate them into improvement work.


IMAGE 2: QI and design tool integration