Make Culture Change Possible Through Design

Article by guest authors Thomas Fisher, University of Minnesota and Jess Roberts, Allina Health

We hear a lot about the culture of health and it now seems clear that we cannot improve the health of Americans without a change in a cultural context that makes unhealthy behavior the default. But how can we change something so large and diffuse as a culture?

Some things clearly don’t work. Doing yet one more study to document what we already know about the ill health of Americans and publishing the results may help us understand the problem in more detail or with greater nuance, but that alone will not change the culture of un-health. Telling people to eat healthier food and fewer calories or to get more exercise and physical activity may help reinforce two primary ways of improving public health, but it too will not achieve the cultural change needed.

We cannot change a culture without confronting and altering the larger forces behind it. Nor can we change it if we continue to practice in the same ways we have before. Cultures cannot be demanded to move in a new direction simply with inspiring mission statements, re-branding exercises, or yet another new initiative or project. Culture is the result of how we have designed the world in which we live, intentionally and unintentionally, and that applies not just to our health systems, but also to the communities in which we live and work; culture is at the same time both the activity and the result of design.

Having designed an unhealthy world for ourselves, we might turn to design as a way to create a healthier one. Design provides a rigorous method of reframing the conversation about ill health, re-defining the nature of the problems and re-imagining new and less conventional approaches to addressing it. In the process, design changes cultures.

It does this by bringing together people and points of view that rarely if ever work together to come up with new ideas and better solutions, creating a new culture through radical collaboration. This might mean having not just medical personnel deal with health matters, but also having teams of people - including youth, parents, the business community, civic leaders, educators and the long-lived elderly, among many others -  look at the issue from a wide range of perspectives and lived experiences. Design, in this sense, builds new cultural connections and pathways simply through the process of engaging in it.

Design also changes culture by empathetically understanding the needs of people and the conditions affecting their behavior and their health, uncovering in the process previously invisible connections and insights. This often leads to asking unconventional questions that can prompt new and more productive explorations of solutions. What would it take, for example, to make health the default condition in our society, to make it the easy, cheap, and fun alternative for everyone? What if we thought about health as a chronic condition? Or what if health had nothing to do with clinics or clinicians in their current form? The answers to such questions are not obvious, but they are the kind of questions design thinking leads us to ask, forcing a re-examination of the deeply held assumptions about health as an event rather than a lifelong trajectory.

Finally, design changes culture by creating opportunities for people to prototype possible solutions to the problems they have identified, learning their way forward and proving or disproving the assumptions that often derail public health programs. Too often, change doesn’t happen because we think it has to entail a lot of work and a great deal of expense, time and expertise. Design works differently, by doing quick, low-cost explorations of new ideas that can serve as prototypes to test assumptions and engage stakeholders. This greatly lowers risk and encourages more experimentation of less conventional thinking without the fear of failure. Cultures evolve by prototyping new possibilities and the culture of health will evolve the same way.

So how, specifically, can we change organizational culture through design? Given our experience leading this work at large institutions, we have identified four key orientations for the design of culture change:

Abundance Mindset: Most efforts to change culture focus on the resources you think you need, not the resources you have, yet all you need to design for culture change already exists. Instead of seeking what you think you need, which often hinders the design process, allow existing constraints and human capital to drive your design approach and scale (even if that means that you will not have a 20 person team or that sexy “innovation” space).

Outside-In Focus: Few breakthroughs occur from the same set of stakeholders using the same approaches to address the same problems (in fact, Einstein called such an approach the definition of insanity). Instead, insight and inspiration often lives with those people, organizations, and sectors outside of your own.

Humanize Problems and Work: Problems can become abstracted when viewing them as data sets. Instead design seeks to more fully understand problems (and possible solutions) from the lived experiences of those dealing with them on a daily basis. Equally important is the ability to understand the diverse experiences and perspectives of those working to address these problems. Doing so directs teams to organize around the problems as they exist and with whom they exist rather than around artificial organizational structures or disciplinary skill sets (silos).

Adapt Practice: Many organizations paralyze themselves, waiting to make changes until there is stability (be it financial or policy changes), not recognizing that change in healthcare is the only constant. Just as design must be responsive to the needs of your user, it must also be responsive to the financial, cultural and hierarchical realities of your organization or team. The practice of design cannot be a stock set of tools or activities, instead it must respond to its context and should look and function differently community-to-community and organization-to-organization.