At the recent Agile Australia conference InfoQ spoke to Liam Brobst and Daniel Prager about taking a frugal innovation approach to healthcare in Australia, the challenges of making change in a heavily regulated environment and how ideas from agile development have been applied in clinical care.
InfoQ: This is Shane Hastie at Agile Australia 2014, talking with Liam Brobst and Daniel Prager about Innovation in the enterprise. Gentleman first of all thanks very much for taking the time to talk to InfoQ today, could I ask you briefly to introduce yourself?
Liam: My name is Liam Brobst, and I play the role of a Client Services Manager in the technology consulting space, aligning the skills of my colleagues with the problems of my clients. I’m most interested in a more humane way of working inside and outside of IT.
Daniel: My name is Daniel Prager and I wear a number of hats; my work is an Agile Coach consultant at the moment in Telstra Marketing, where I’m taking Agile beyond software development and IT and into other areas of knowledge work. My other hat is I’ve worked in startups on and off for several years, at the moment I have one called youpatch.com. If you are interested in Patchwork Quilts or Craft you should check that out.
InfoQ: Thank you very much. We’ve been talking about Innovation, particularly rapid innovation in healthcare. Isn’t there almost contradictory?
Liam: In Australia, I think that is probably a fair point, If we look at healthcare innovation globally, we see an appetite and willingness to innovate in the Global South. There is this interesting relationship between a country without resources, without legacy of regulation or infrastructure but the need to solve healthcare problems fast, and their willingness to try new things at scale. Whereas in Australia we are almost constrained by our position of good fortune. Our resources, regulation and systems reduce risk and we enjoy high standards of safety but innovation requires risk and permission to fail.
Daniel: I think there are some cultural factors as well: when people think of Innovation and Healthcare, what may first come to mind is development in biomedical sciences, particularly new drugs, which tend to be heavily regulated (usually rightly so) so there is this notion that Innovation will happen slowly. Unfortunately that spirit of caution appears to have been overgeneralized within the health services culture, to the detriment of innovation in work-practices.
InfoQ: So how do we speed up Innovation and still keep safety?
Liam: Yes, we need to find the balance. I draw inspiration from work that is iterative, small loops of risk and reward, measured and changed where necessary. But it takes a courageous executive somebody that is close enough to the work to feel the pain and identify the opportunity to be innovative, but senior enough to actually have a little bit of budget and discretion around trying new things. If we can find that person, and support them, then I think that gives an opportunity to find the balance.
InfoQ: So what does that person need to bring to the table and who are they bringing along on the journey?
Liam: So this person is working towards a purpose, a vision of ‘better’ or a hypothesis “we wonder if…, would that deliver a better patient outcome”. This higher purpose is aligned to the work, so they’re bringing along those closest to the work. However, this person needs to also be somebody who is savvy enough to put a plan around that and navigate a way through the bureaucracy of the system - compliance and workplace issues, engaging the Executive for support, funding, etc. So it’s a spectrum.
InfoQ: So you mention Monash, what are some of the things that are happening there?
Liam: There is a talk here at Agile Australia co-presentated between my colleague Justin Conaghan and my client Dr. Melissa Casey, Director of Psychology at Monash Health. Melissa, with her colleague Professor David Clarke, is that courageous person who has the balance of purpose and plan. Melissa’s presenting on how she was able to create an innovative opportunity within an existing public Healthcare System, the largest Healthcare System in Victoria, and the way she was able to do it; by not completely disrupting the existing system, but innovating within the constraints of the system, not easy.. In her case she started with a hypothesis to improve service delivery and treatment efficacy for mental health patients. She has developed a clinic called The Agile Psychological Medicine Clinic. The ‘agile’ is a tip of the hat to our approach to work, experimental, iterative and measured value. So she has developed this clinic as a way to test her hypothesis, but it’s separate from the primary hospital, it’s actually across the street.
It doesn’t disrupt the existing system or the existing cultural norms within the hospital, but still allows her to test the hypothesis about how we can deliver better patient outcomes faster.
Daniel: Is it the case that mental health is someone isolated rather than wired into rest of the physical health aspect which is usually the main part of the hospital?
Liam: I think that’s part of the disrupting challenge to the “system”. When we started working with Monash Health we realized, through patient journey mapping, that service design was probably the place to start and through doing that we realized opportunities for design intervention. To allow room for this intervention, we moved the service delivery out of the ‘system’, the emergency department, in this case.
InfoQ: So put it in a separate space.
Liam: Yes. A small team of clinicians providing treatment to patients in a new space, separate from the emergency department and main hospital, allowed Melissa’s team to test their hypothesis in real life in a measured and compliant way.
InfoQ: What have they drawn from the Agile philosophies, principles and practices and ways of working?
Liam: Often, a client will come to us and say: “I have a business problem” or “a service delivery problem” and now I want to buy some technology. As the old joke goes - now you have two problems.
We step back, ask the client to be patient, not to buy or build anything, but first understand the problem, map it out and present it in lo-fidelity. We shared our findings with the wider group, clinicians and executives, through stand-ups and presentations.
Frugal Innovation is something very familiar to those doing work in Healthcare in the Global South. For example OpenMRS, an openly available medical records system, being developed iteratively, with user-centric design at Mirebalais University Hospital in Haiti.
We did end up finding a place for technology and just started building it while using it at the clinic. We collaborated daily with clinicians and users, making changes as we went until we developed an application to help them measure the right things. In this case, a timeline with treatment value measures from the patient’s perspective.
InfoQ: And how do you extrapolate that out? How does Innovation grow from there, if this works, how do we disrupt the system?
Liam: Then we have to get back into the system, because the system is what pays for these things. Melissa’s plan is to first test the hypothesis and see if it validates, we are about 3 or 4 months into that project and looks like it is. She and her team just won the Monash Innovation and Quality Award for this clinic. If it looks like it’s providing better patient outcomes, and it does, we will go back into the system to ask for more funding, let that funding open two more clinics and continue this almost iterative approach to deliver innovative Healthcare Services, that iterative approach is something that we are familiar with in terms of Agile technical delivery, so there is a nice interplay between an Agile approach delivering technology and an Agile approach to delivering Healthcare services.
InfoQ: Daniel, anything else you’d like to add to this point?
Daniel: I’ve been sort of cheering from the sidelines but it’s interesting that this question of having done the pilot, the small success – what will it take to go bigger? I think that’s where drawing on the Agile toolkit it will be really interesting to have a retrospective on the whole activity and also to take it on the road, see where it can be applied. Where else is the pain in Healthcare? Having worked in health solutions in previous roles, one of the things that I was made very aware of is that on the one hand there is uncapped demand for medical services, and on the other hand the spend on Healthcare cannot continue to rise indefinitely as a proportion of GDP.
So that’s more of a comment I suppose: it seems bizarre that there isn’t more interest, this has worked clearly, there’s more work to be done in taking the story and spreading it. Now you have a reference story and you’ll have more by the sound of it. The cultural change is going to be large.
Liam: I hope so. That’s right, exactly, and the more people I meet in the Healthcare system, the more I see that by and large people care about delivering effective treatment, better patient outcomes, this is a sector which has social impact that affects us all. It’s a very rewarding place to work and I almost feel that the system’s constrains the good intentions of the professionals that work in it. So what I hope that we are able to show through this particular project is how we found the balance between good governance, health and safety, all those things that should be there, yet still allow us enough room to try new things to see if we can do better.
Daniel: One of the things that I’m trying to figure out is: there are a lot of people who’d like to help out within Healthcare, but how do we leverage network effect? I’ve been asked: “Can you come and help out with Healthcare” and I’m going as an independent Agile coach, “that one is too big for me to take on” but I would love to be able to partner up with others and to create the opportunities to do so.
It isn’t an opportunity that’s going away but it’s one which it’s going to take a little while and I think a fair bit of a bit of understanding as well – we can’t just march in there with our knowledge from IT and expect to be welcomed with the open arms, especially as there are very brilliant people working in there already.
Maybe some of the things that we’ve learned about Systems Thinking and Knowledge Work in an increasing range of industries have something to offer in Healthcare, but there will be unique features and finding out the road of entry is the real challenge.
Liam: I think that road of entry, at least in the Public Healthcare System, is that person that is close enough to the work to feel that pain and see those opportunities, but also influential enough to try something new, that has the authority to do so. I would echo Dan’s statement about the network effect. As consultants and technologists, we are often not Healthcare professionals, we are partners in helping our clients do the best things, better…
InfoQ: Gentlemen thank you very much, we look forward to see what happens with Agile and Healthcare!
Editor’s Note: Since this meeting at Agile Australia, the clinic has won the Monash Health award for Innovation and Quality. A video about their work has been released. The early measures from the clinic such as treatment efficacy and clinician satisfaction are pointing to an improvement in service and validation of the hypothesis.
About the Interviewees
Daniel Prager has been programming creatively since his teenage years, before taking his PhD in mathematics, and promptly fleeing academia and crossing into software development. Nowadays he divides his professional time between Agile/Lean coaching and more entrepreneurial endeavours, including youpatch.com. He still programs for pleasure, especially in modern functional languages like Racket, tweets as @agilejitsu, and resides in Melbourne, Australia with his quilting wife (YouPatch co-founder, PatchAndi), two kids, and dog.
Liam Brobst works with clients on technology projects to deliver customer value faster. Trying to balance pragmatism within the systems we find ourselves and disruptive innovation to change the system itself. It's not always easy and often he doesn't get it right, but he keeps moving with curiosity, teamwork and purpose. And when he's not at work; trying to grow something edible and not lose it to wildlife on his two acre patch in the eastern hills of Melbourne.