Kobus Cilliers | On 04, Aug 2019

Darrell Mann

Back in December of last year we started to explore the connection between the Kano Diagram and TRIZ/SI, with particular attention to the integration possibilities of Kano’s concept of ‘exciter’ and the Outcome Mapping tool. The promise at the end of that article was that we’d return to the model with a worked example. And so here we are. As usual we face the problem of not being able to talk about many of the case studies we’ve been involved in with clients. Which means we find ourselves looking at a public sector story, as it happens from the healthcare sector: what happens to a patient entering the hospital system through the Accident & Emergency (or ‘Emergency Room’) route. For the sake of argument (and familiarity), we’ll focus on the National Health Service in the UK.

First up a small recap of the December article. Here’s where lazy-Darrell ended up at the close of the first article:

Figure 1: Integrated Kano 2×2 And Outcome Map – Best Bang-Per-Buck

The mauve-coloured boxes in the matrix represent the ‘best bang-per-buck’ places to go to look for potential delighters. Those are the two boxes we’ll stick with in this example: we’re looking at intangible outcome desires of the individual (‘ME’) and the people around them (‘WE’).

 

This immediately requires us to define who the individual might be. In a wide-reaching system like healthcare there are, of course, many individuals involved, and so if we were going to be thorough, we ought to construct the Map for each of them. What we’ll actually do here is focus on one of those individuals, in many ways the main ‘customer’ of the system, the patient that has just been in an accident or has suffered an emergency.

As soon as we’ve defined the ‘ME’, that then automatically defines the ‘WE’ as the people around that individual. In this case, that means the friends and family that might have accompanied the patient to the hospital or are at home worrying about them.

Next, we can start focusing on the meaning of the ‘intangibles’ element of the Matrix. This is the part of the story where we’re examining feelings and emotions and all the things that are typically difficult to survey people about, or indeed make any kind of measurement about. The fact that intangibles are difficult to measure is one of the reasons why we’re likely to find ‘delighters’ on this side of the Matrix. ‘What gets measured gets done’ says the aphorism, and so, by corollary, what doesn’t get measured doesn’t get done. The intangibles are always present in any system because humans always feel before we think. And if service providers like the hospital aren’t thinking about them, that means they’re probably going to be negative rather than positive.

What we know clearly about the intangibles story is that, when we distil human emotions down to first principles, we end up with four basic outcome needs that need to be taken into account as shown in Figure 2:

Figure 2: ABC-M Core Human Intangible Outcome Needs

One of the reasons for choosing healthcare for this case study is that, in my experience, the sector (the public part at least) is strongly focused on measurement and because none of A,B,C or M are easy to measure, they’re not managed. Consequently, as soon as we’re forced to think about these four outcome needs we quickly begin to see, per hypothesis, they are all negative:

Autonomy – the moment we cross the threshold of the A&E Department entrance it is made very clear to patients that we are handing over control to the hospital staff. Whatever is going to happen next is purely determined by those staff members and not the patient. Or the friends and family that might be accompanying them.

Belonging – from the moment of an injury or onset of their illness, the patient has in effect left their normal ‘tribe’ and is now an unwilling member of a new tribe, the tribe of ‘sick people’. This is not normally perceived as a good thing to belong to, and so, as a consequence, the ‘B’ part of the intangibles equation is also in the negative.

Competence – again, the moment we cross the threshold of the A&E Department entrance it is made very clear to patients that everything that’s is going on around them is stuff they don’t understand. Especially given the fact that they’re ill and not thinking straight. Patients entering hospitals feel incompetent, and, moreover, very often the clinical staff like it that way. A compliant patient is a good patient. Tell me about your symptoms, the clinical staff seem to say, then let me get on with the process of triaging you, and then, when we’re ready, treating you. Probably doing a whole bunch of things that you’ve got no idea about, other than they will hopefully make the pain go away. Patients, in other words, are also very definitely feeling negative competence.

Meaning – whatever else is meaningful in our lives, when we’ve just been struck by injury or illness, all we’re thinking about is our symptoms. Our health is one aspect of what makes life meaningful, and we just lost that health. Our Meaning-meter is also, therefore, very likely to be in the negative when we enter A&E.

Overall, then, the patient is likely to have a full-house of negatives in relation to the ABC-M first principles. In this regard, for any hospital hoping to deliver some new ‘delighters’, the only way is up.

For the friends and family that might be accompanying the patient, things aren’t much better: their Autonomy is in the negative, because the hospital staff make it clear that they, the staff, are in charge. Sense of ‘Belonging’, on the other hand is very likely heightened since friends and family have – willingly or otherwise – been forced into the position of being the people who’ve taken the responsibility for the well-being of their fellow tribe-member. While this part of the Belonging story is in the positive, that very likely means it is negative towards the hospital staff: they’re not from the same tribe, they are ‘them’. Competence-wise, the friends and family are perhaps even more in the dark than the patient. Especially when the patient gets whisked away from them periodically to places unknown. Friends and family are left waiting with no indication of what’s happening, or when. Finally comes ‘Meaning’, where, like Belonging, as far as their relationship to the patient is concerned, the friends and family are in a place of high Meaning – they are literally responsible (in their minds) for the well-being of their sick loved one. They have emotional ‘skin-in-the-game’. As far as their Meaning relationship with the hospital is concerned, however, things are not quite so clear. Do the hospital staff care? Do they have ‘skin in the game?’ I’m not quite so sure about this one. From my limited personal experience, I’d say a yes and a no respectively to the two questions.

So, now let’s think about what we now need to do to find those ‘delighters’. As detailed at the end of the December Part I article, we’ve got eight basic questions to think about, four relating to the individual patient and four to the ‘WE’ around them:

• • What new feature or attribute would give an Autonomy delight for the individual?
  • What new feature or attribute would give an Autonomy delight for the people around them?
  • What new feature or attribute would give a Belonging delight for the individual?
  • What new feature or attribute would give a Belonging delight for the people around them?
  • What new feature or attribute would give a Competence delight for the individual?
  • What new feature or attribute would give a Competence delight for the people around them?
  • What new feature or attribute would give a Meaning delight for the individual?
  • What new feature or attribute would give a Meaning delight for the people around them?

But what characterizes a ‘delighter’? The best way to answer this question I think is to examine the dynamics of what evokes ‘wow’ reactions from people. By Kano’s definition, a delighter is non-linear: a little bit goes a long way. If I can push that a little further, thinking about the dynamics of ‘wow’, a delighter involves some kind of a discontinuous step-change. In traditional TRIZ terms, this then means one of two things, either the addition of a new function or attribute, or the resolution of some kind of a contradiction. The former is the thing that Kano traditionally focuses on – it being about adding something new that customers weren’t expecting. The latter, however, in broader innovation terms, is the more frequent success strategy. When a contradiction gets resolved, it creates a wow reaction because when customers start to make the inevitable value calculation they obtain an unexpected result. We put on a sticking plaster to cover a wound knowing that it will hurt when we eventually come to rip it off. Our past history with the product sets our expectations: in order for the plaster to stay on, it needs to have a strong glue, ergo, when I remove it, it will hurt. But then, the day when you experience a plaster that stayed on, but also didn’t hurt when you removed it, that’s the day you experience a wow. Your expectation of pain was confounded, and the resulting wow delivers delight.

Those two strategies make up the overwhelming majority of ‘wow’s. When it comes to the intangibles side of the Outcome Map story, however, there is a third kind of non-linearity. Well, actually, it is often not strictly speaking a non-linearity at all, it merely feels like one. If an intangible outcome need is currently negative and it switches to a positive, even though the actual shift might be small, because the negative/positive boundary has been crossed, we experience it as a step change. Rather like what TRIZ Inventive Principle 35, Parameter Changes tells us – change a parameter to such an extent that a phase-transition occurs.

If we arrive at the Reception area of the A&E Department and the staff member gives us a re-assuring smile, we don’t experience a wow if next time we get a bigger smile. On the other hand, if our previous experience of Reception staff is that they don’t smile, the day we arrive and we receive a smile, we are likely to experience a mini wow moment.

There, perhaps, is a first example of how we might look to create the first new delighter for the A&E example: have the Reception staff smile.

Of course, nothing is quite that simple. If patients perceive a fake smile, that very definitely isn’t going to be a delighter. The smile needs to be a genuine, empathetic one. Ditto for the friends and family. In fact, experience tells us, perhaps even more important to offer the smile to them. The experience here being several years of trawling through patient and ‘friends and family’ stories using our PanSensic software on the copious amounts of patient feedback the NHS routinely gathers. Patients are unwell and therefore are less aware of their surroundings than the people accompanying them. Friends and family are by far the ones most likely to complain afterwards. For the simple reason that they are acting as the eyes and ears of the patient, looking out for them and wanting to make sure they receive the best possible treatment by the ‘them’. A genuine smile for the people accompanying the patient can, we know from the PanSensic experience, go a very long way.

So, let’s expand on this start by examining each of the eight questions from the perspective of each of the three different delighter strategy options:

Table 1: ABC-M Core Human Intangible Outcome Needs

This Table is not to say that all of these ideas could or should be implemented, and in precisely what form their implementation might take. These kinds of question can only be answered in the specific context of a given hospital situation. We do know from actual projects, by way of an example, that the ‘encourage the reception staff to authentically smile’ was implemented in one UK hospital (Medway, Kent) and they saw a 40% increase in their patient experience rating, and a 30% increase in ratings from their friends and family experience feedback scores.

Teaching hospital staff to pay more attention to the emotions of friends and family is a bigger, longer-term exercise, and so we don’t as yet have any results in from any hospital trusts we’ve been recommending try it. This despite the fact that – as may be noticed from all of the suggested strategies, none of them requires any significant financial investment to conduct a trial. Or indeed, fully implement. As the saying goes, ‘a smile costs nothing’.

Important, finally, is to recognize that the taxonomy of the Table is not to ensure ideas go in the ‘right’ category. The taxonomy is merely there to encourage solution-finders to explore the problem from different perspectives. The aim is to get beyond the ‘insert miracle here’ instruction to generate some ideas, and to a place where problem solvers are given some clear solution search spaces and questions to explore.