1. 1. Understand and Address the Core Problems.

Solve the fundamental, underlying issues, not the symptoms. We recommend starting with field studies and observations of actual practice (an applied ethnography). Ask “why?” at each issue. When the answer is “human error,” keep going: why did the error occur, what could have prevented it? Core issues often include the people’s lack of understanding of the complexity and of the entire system, misaligned resources and reward structures, and the disruptions caused by the work environment, with frequent interruptions, conflicting requirements, overly-complex technology, and the need for multiple transitions among technologies systems, and people leading to continual interruptions as well as lack of complete communication between elements.

  1. 2. Be People-Centered.

People-centered means considering all the people who are involved. Using healthcare as an example, this means patients and their families, general practitioners, specialists, technicians, nurses, pharmacists, community supports, and the various staff who schedule and support the activity. There is need for careful observation of individuals doing their routine work, including between clinics, laboratories, and site locations. As boundaries erode between clinical care, public health, and the community, there will be a need to observe the engagement with businesses supporting healthcare and policy makers regulating care. In domains outside of healthcare, similar principles apply.

  1. 3. Use an Activity-Centered Systems Approach.

Design must focus upon the entire activity under consideration, not just isolated components. Moreover, activities do not exist in isolation: They are components of complex sociotechnical systems. Fixing or improving a small, local issue is often beneficial, but local optimization can result in sub-optimal global results. Focusing upon support of the activities is more important than optimization of the individual components. Systems involve multiple complex feedback and feed-forward loops, some with time delays measured in days or months. There are often tensions, conflicts, and differing perspectives among the multiple participants. Potential solutions have to be developed with the assistance and buy-in from all parties. Experts can provide essential analyses and approaches, but unless those most affected by the issues play a major role, in assuring that the suggestions are appropriate to the culture, the environment, and the capabilities and goals of the community, the results are apt to be unworkable and unsatisfactory.

  1. 4. Use Rapid Iterations of Prototyping and Testing.

Whatever the initial suggestions are for innovation or improvement, they probably are imperfect, incomplete, too difficult or expensive to implement, or unsuitable for the particular location. Implementation of changes requires patience and fortitude to try numerous trials, rethinking and repeating until the outcomes are good enough for deployment. We find that people accept repeated trials if they are active participants in their design and evaluation, where the trials are understood to be tests, not solutions, and where each is done quickly. Human-centered design starts with quick approximations, often having participants play-act the workings, providing rapid feedback. With each iteration the prototype becomes more refined and usable. Note that these tests must be applied to the intended recipients. Administrators and those responsible for devising the ideas under test should be (unobtrusive) observers, not participants.


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