Hawaii, Missiles and what healthcare can teach us about emergencies

Hawaii, Missiles and what healthcare can teach us about emergencies

The funny thing about something truly terrifying is that it doesn't create the kind of panic we see in movies. People tend to get quiet.

I was on a flight once into Pittsburg in the middle of summer. A squall line of thunderstorms popped up as we were on our approach. While I can't be 100% certain, as a pilot it felt to me like we missed our approach 3 times. Regardless, there was certainly some dramatic maneuvering, bouncing, dropping and climbing. At one point the passenger next to me leaned over and asked: do you think we're going down. No one screamed. Some people were obviously praying. And my palms sweated through the page in the book I'd been pretending to read for 15 minutes. I looked up at the fight attended who was buckled into her seat and saw a look I don't care to see on someone's face again. We made it to ground and I sat in the boarding area to see the pilots when they came off the plane. They looked like they had been run through the rinse cycle of a dishwasher.

That was, up until last week, the most scared I've ever been.

Last week we were on the Big Island of Hawaii. Around 8:15 in the morning, we were walking towards a beach trail to meet some colleagues at a nearby resort. I heard my phone make the disarming tone it makes for an amber alert and thought: that's strange to have a missing child in paradise. I looked at my phone and saw the message that's already made its way around the internet and through news cycles:


We could see people around us going through a similar range of reactions. Reach for phone, do a double take, pause for a minute, then walk quickly and quietly somewhere. Anywhere.

We headed towards the ground floor of our hotel. We quickly ruled out going to the room. Getting in an elevator didn't feel safe and the room itself was on a top floor and had an sea-facing wall of glass. We tried to get as close to the interior core of the hotel as we could.

A woman looked at us and said: This has to be a joke or hack, right? I told her I thought it looked like an official message and those would be hard to hack. I don't even know where I am, she said. I was out on a run and my family is at another hotel.

All around us people continued to walk quietly and purposefully. Many were headed to their rooms or to rendezvous with loved ones elsewhere. There was no screaming, no running, no outward panic.

The hotel's PA pierced the silence. We have received an inbound missile threat. Everything will be ok. Please take shelter in your rooms.

Having already ruled that out, we made our own plan. This resort, like many in Hawaii, is largely open-air. There were virtually no solid walls on the ground floor. By the elevators there was an emergency fire exit with one of those alarm will sound signs. That felt like the safest place to be and, besides, we'd already gotten the alarm to beat all alarms.

Cori suggested we check to make sure we could get out. Smart! She went in and tried to open the door from the other side. No dice. How could that be? We turned the handle and the latch retracted. She closed the door and tried again, this time it opened. In we went.

We sat on the stairs, a few up from the ground floor landing but not all the way to the next level. I was looking around to see if there was a better spot. What happens if this door blows inward? ... and then my mind drifted to the scariest though I'd had all day: what if we don't die. What if we survive a nuclear blast? We'll be burned and injured. I'm wearing flip flops, so that will make traveling by foot hard. We won't have cell service or wifi.

I messaged my parents:

We’re at the hotel in Hawaii. Just got a ballistic missile alert. I’m sure it’s noting. But we’re all headed inside. Will keep you posted.

Decided it wasn't worth correcting the typo.

We both refreshed twitter. Refreshed again. Kept refreshing. We started to see mentions of an error. Then a tweet from Hawaii Emergency Management Agency said it was an error. I could feel my heart rate slow and my hands stopped shaking. A few minutes later it was official - it had been an error.

We exited our make shift bunker and joined the other guests starting to come back to life. Conversations restarted, people went back out into the sun and there was a general air of shell-shock.

The hotel's PA confirmed the false alarm. A few minutes later, our phones buzzed again. Same tone, same disarming feeling. This time it was the official all clear.

We're still processing. In the hours and days after, there were some small attempts at humor and some news reports were quick to point out humor is a natural reaction to trauma. But mostly, it was the event that we all acknowledged and didn't talk too much about.


Over the rest of the week Hawaii Public Radio ran many stories about reactions. They played audio recordings of people describing what they did. Some called loved-ones, some sat with their families and prayed, some sought any form of shelter they could find. HPR also ran stories featuring childhood psychologists with tips about helping children process what had happened.

I'm a designer with a rather myopic focus on healthcare. I've spent my entire career working in or around hospitals. And while our healthcare system is far from perfect, there are some lessons our emergency response system might borrow.

Over the last 20 years, simulation has become an integral part of training physicians, nurses, and first responders. Fortunately, true disasters are fairly rare. So emergency room teams regularly conduct simulations to drill things like a mass shooting, plane crash or natural disaster. It was pretty clear to us that neither our hotel or local agencies had done any kind of simulation. The accidental alert was unfortunate but it could be a prime opportunity for everyone to think through what should happen. Does going to rooms make sense, or should there be a central gathering point? Is the messaging helpful or confusing? What do people need, how do they behave and what systems do they need to put in place to account for those reactions?

Healthcare has also had the tragic opportunity to learn from some sad errors. For a long time, it was too easy to mix up an oxygen line with a vacuum line. We still worry about and put systems in place to try and prevent drug-drug interactions. Things like bar codes, 'break the glass' firewalls in electronic systems and color coding have helped a lot.

Here's the screen the Hawaii emergency team was using the day of the accidental alert.

Setting aside that it looks like a webpage from 1993, there's very little to distinguish a drill from the real thing. Any user interface designer would have a field day reimagining this screen. And that's an opportunity. Hawaii should hold a series of challenges; call it Design for Hawaii or Code for Hawaii, or whatever they like. But get smart, skilled people in the room to work on these challenges.

We're also in the midst of an awesome trend of co-designing new approaches to healthcare with patients and families. The idea is to bring the people with the most lived experience to the forefront of reimagining processess, services, and treatments. What would it look like if state and federal agencies engaged the people of Hawaii? What actions did they take? Where did they feel equipped and where did the feel unprepaired? What ideas do they have for future alerts?

Lastly, we're just starting to talk about truly integrated healthcare delivery. We're starting to understand that physical pain and trauma is often accompanied by mental anguish. Both require attention, treatment and acknowledgment. Hawaiians and visitors will be on heightened alert for some time —not just because of the false alarm, but because of the world we find ourselves in today. An integrated approach would acknowledge the caustic effect of heightened stress. Perhaps we might even come to think of our current state of diplomacy as what healthcare calls a never event.

Invisible Building Blocks of Digital Innovation: the Internet of Things in a Hospital

Invisible Building Blocks of Digital Innovation: the Internet of Things in a Hospital

Innovating —the act of doing anything new in a creative way — is inherently disruptive. This is doubly true inside complex systems and regulated industries. And organizations are built to avoid disruption. Often, what we see as an example of a simple innovation is actually the result of small, invisible — but nonetheless crucial — enablers. I love these enablers and how they allow us to innovate with much less discomfort. They are the unsung heros of change and rapid cycle development. Lately, we've been on the bleeding edge of inexpensive Internet of Things technology in the hospital. And none of it would be possible without these enablers having laid some invisible bricks of digital innovation.

A few years ago, our team got very interested in voice-first interfaces; or, for the less nerdy, Amazon Echos. We were working on a project to give patients more control over their hospital rooms. It felt like voice control was a prototype worth pursuing. We were early enough to express interest to Amazon and cleared their waiting list quickly. We unboxed our magic cylinder, plugged it in, and then realized the next big hurdle: wi-fi!


our digital pal

this Echo sits in our team's space and spits out jams all day long!

Hospitals, even among regulated industries, take data privacy and security even more seriously than most. We also have lawyers with keen eyes on protecting patient data and mitigating the organization's risk. So, like any sophisticated large organization, our Wi-Fi networks are rather locked down. Unlike the set-up most of us have at home, joining wi-fi at the hospital requires a corporate username and password. While that authentication mechanism is easy enough on a laptop or smartphone, it's outright impossible for most consumer-oriented devices. Simply put, there's no way to put a corporate username and password into an Amazon echo.

Around the same time, we met someone (who would quickly join our team) who knew how to move quickly in the digital world. Matt strolled into our innovation studio one day and immediately belted out: "I know what this place is!" We often say we know our kind of weirdo when we meet them and Matt was clearly our kind of weirdo. In joining our team, he helped us create our Digital Services model. We cribbed notes from our friends a few miles across town in the federal government — the U.S. Digital Service. That team was formed to bring modern, Silicon Valley-style tech skills to existing U.S. government teams.

For us, and our friends in the U.S. Digital Service, digital services is different from IT. Where IT is responsible for designing and maintaining our networks, electronic medical records, and business systems, digital services is all about building and testing new things quickly to address the needs of end-users and innovators.

Matt's presence on the team expanded our horizons about what could be possible. We realized we needed a safe sandbox —a place to safely test our ideas before going public. We implemented our own entirely separate, airgapped network. We installed a commercial-grade business line for Internet from a different Internet service provider than the one used by the hospital. We set up our own wi-fi network to be completely separate from any of the hospital's corporate infrastructure. We also set up a second network dedicated to Internet of Things devices like the Amazon echo.

Having our own separate infrastructure provided a platform on which to rapidly experiment with emerging technology without putting the organization or patients' data at risk. And having a platform in our team's control means we can get devices up and running without burdening another team in the hospital.

Today, we have expanded our network to cover large portions of the hospital. It enables us to test new devices and concepts in patient rooms, waiting areas, and clinic spaces. Our innovation network has also given us the ability to help others in the organization in ways never before possible.

A few months ago, The head of our case management department approached our innovation team's lean engineers with a challenge: she needed a new way to capture data on the types of services and programs that patients needed. She wanted something like the famous Staples easy button. Matt had been waiting for a use case like this, and knew exactly what he wanted to deploy.


a stack of Amazon Dash buttons awaiting deployment



Around the time Amazon introduced its echo device, it also came out with something called IoT buttons. Originally offered as a convenient way to reorder frequently consumed products, the unbranded versions are amazingly flexible. Imagine something the size of your thumb with adhesive on the back and a button on the front. You attach them to your wi-fi network and can easily program them to do internet-y things. Well, someone like Matt can easily program them.

Matt set up five of the $20 IoT buttons for case management. Each one corresponded to a type of patient need. When pressed, they automatically create a row in a Google Sheet spreadsheet; instant data capture. When our radiology department needed to capture data on patient flow, the IoT buttons let them log things like arrival time, navigational issues and reasons for being late to an appointment. Matt and the lean engineers deployed them in hours at nearly zero cost.

We've also been using the IoT buttons in a patient-facing prototype. For another project, we want to capture real-time feedback from people about their experiences. Matt and team mounted some of the buttons in a cardboard box, covered it with a slickly-designed label, and we had an instant, wireless feedback device. We were able to iterate on how we asked questions about patient experiences quickly and deploy the experience boxes into patient areas without any obstacles. And, since they are easily programmed, we can get the data in really convenient ways. When a button is pressed, not only is it logged into a Google Sheet, but a robot pops a notice into our team's Slack board telling us what the feedback is and from where in the hospital it originated.

There is so much neat tech in the world and we're in a time when the release cycle is speeding up exponentially. Taking advantage of these things for testing, inspiration and innovation is a game-changer. But, it requires some building blocks like a sandboxed network and digital services leads like Matt. Investments in those enablers pay dividends in efficiency and expediency and they do it in ways we haven't traditionally embraced in healthcare.

version 1, 2 and 3

IoT button-powered patient feedback boxes 

Cutting through traditional organizational silos or finding outside contracted partners takes time, burns momentum and all too often stifles innovation entirely. Teams that want to move quickly need the resources and people who make speed and agility possible and inexpensive. It also reduces the cost of failure. Find a Matt for your team, get a mobile hotspot or your own network and you start changing healthcare with $20 buttons.

IoT enabled in-room signage (version 1.0)

IoT enabled in-room signage (version 1.0)

When one person's failure is another's innovation: The About Me Boards Story

I wrote recently about one of our team's favorite axioms: solve within arm's reach. This is our reminder it's not only easier, but considerably more enjoyable to quickly chip away at a challenge rather than trying to boil the ocean. The trick, particularly for me as someone inclined to things that are big and bold and disruptive, is learning to foresee complexity in a project. Often, the thing we think seems simple enough can get overwhelmed by red tape, complexity, and the cacophony of minor obstacle. Those moments are exactly the best time for someone with fresh eyes to see the simplier path forward.

Three years ago, we were working on improving the transition from a hospital stay to going back home. One particular interview with a patient became the spark ignighting one of my favorite design projects. Today, as I reflect on the project, I think of it as a story of gratitude for our nurse colleague who figured out how to solve within arms reach.

One of my innovation team colleagues and I were visiting with a patient in their room. We were interviewing him for this transitions of care project. Initially, the patient, while not standoffish, was also not particularly talkative. He was, however, keeping a journal with his own meticulous notes. During our visit, a physician entered the room without knocking. The physician did not introduce himself to the patient or my colleague and I. Instead, he briskly pulled back the patient's sheets, looked at the surgical site, and announced: "Looks good. You'll probably go home tomorrow". With that, the doctor turned on his heels and left.

We then asked the patient: "Tell us what that experience, that encounter just now, was like for you?" The patient sat up in bed. He turned his notes to us and said: "I've been keeping track of everyone who comes in my room. I've also been noting who washes their hands. Your nurses are fantastic, I think they're at 100% with handwashing. That doctor didn't wash his hands." The patient became more animated. "Also," he said "I'm a physician too. He didn't have to speak to me so abruptly. In fact, I would like to have discussed some details."

We were both blown away! My colleague asked: "what else do you wish that physician had known about you?"

"Well," he started, "I run a national network of long-term care facilities. We tell all of our patients to bring in pictures of themselves so everybody can see who they are when they are not in the hospital. That way, nobody ever gets treated as the knee in room 428."

There it was was. That was the spark. It immediately felt consistent with themes we heard from other conversations: most people, when lying in a hospital bed, don't think of themselves as the patient first (or even at all). We asked the brainstorming question:how might we help anyone entering a patient's room see that person's non-patient identity? The brainstorming didn't take long. We immediately turned to the newest member of our team, our engineer in residence.

Together we conceived of a display that would sit over the head of the patient's bed. The contents of the display —photos, a real-time pain scale, and a list of hobbies or interests —would be in control of the patient or their family through some kind of mobile device interface. Technically the concept is fairly easy to implement. We even had a small grant to cover a pilot in 5 to 10 patient room. But, the deeper we got into the project, the more unforeseen tiny obstacles started to add up and feel insurmountable. While we were ringing her hands over little things like getting access to a Wi-Fi network, or a determination if Bluetooth met our HIPAA security requirements, Matt, a nurse on our team, seized the opportunity.

Matt began iterating on the idea quickly. He used PowerPoint to create a poster template. Whenever there was a new admission, he would spend 30 minutes getting to know the patient, their interests, their background, and their hopes and goals. He would then quickly fill out his PowerPoint template and print on our large-format poster printer. He started hanging the posters above or near patient's beds.

Matt soon realized even his expedited process was a bit too intense for him to maintain. He made a smaller version of the template and trained some of the hospital's volunteers on filling it out. Together, Matt and the volunteers begin to realize the value was in the conversation they were having and the printout with simply an artifact.

None of us predicted just how powerful that artifact and conversation would be. Patients began taking their printout — which at this point we began calling About Me posters — home with them. One family wrote a note to Matt telling him it was the first time they had ever kept something from a hospital. Another one of Matt's older patients, sadly, passed away. Shortly after the funeral, his adult children contacted Matt tell him they had taken his About Me sign to his funeral and set it near the casket. They said: "this was one of the last conversations dad had with anyone."

Last year, shortly before we opened our new patient care tower, Matt came forward with an idea. He had identified some unused section of wall space in every patient room. He suggested we install a simple whiteboard pre-printed with three questions:

  • Please Call Me:
  • What I would like you to know about me:
  • What I value/love most:

Those simple prompts were distilled from Matt's iterations with the poster and smaller printout versions of the signs. He called it the About Me Board and successfully lobbied to have one installed and every patient room in the hospital. The goal was to give everyone a simple tool to enable the same powerful conversations he had been having with his patients. Anyone who enters a room could instantly and confidently find something to talk about with the patients; something human and personal to them, something outside of the clinical relm, something that builds a deeper connection.

There have been some amazing stories from the About Me boards. One patient told their nurse all about their two dogs and how much they meant to her. The nurse asked the patient to email her some pictures of the doggies. She printed them out at her nursing station and taped them to the About Me board in the patient's room. In another story, a physician entered a patient room for daily rounds. She glanced over at the board and saw the patient wanted to be called "birdman". She looked at the patient and said, "I certainly will not call you bird man!"

To which the patient replied laughingly: "I just wanted to make sure you were going to read it."

About Me boards have woven themselves into the fabric of our organization. For clinicians, they provide a humanizing reminder that the person in the bed is not their diagnosis. For managers, in a second's glance, they bolster confidence by providing an opportunity for a non-clinical conversation. But most importantly, for patients, the About Me boards provide an opportunity to feel valued, heard, and treated like a full person.

Rules for radical innovators

Rules for radical innovators

There's an inherent tension in introducing a highly creative process into a highly complex system. When it works, that tension resolves into a harmony with a sum greater than its parts. When it's discordant the results feel like chaos.

For the last year, we've undertaken a huge challenge: create the largest rollout of human-centered innovation in any hospital, ever. Our organization charged every leader -from nurse managers to C-suite executives -with identifying, running and sharing two human-centered design based innovation projects. In addition to training and coaching those leaders, we still had several large-scale, patient-facing projects on our plate. The volume of work alone forced our innovation team to go headfirst into rethinking how to systematize a process which is normally characterized by non-linear paths, creative doubling back and a general whimsy. We've come to know these axioms as Hub Rules.

We wanted a way to give people, including our own team, guard rails; operating guidelines for the work. But we didn't want the rules to be so constraining they'd stifle the work itself. We wanted sign posts that a traveler would fine encouraging, not daunting. The rules themselves needed to feel optimistic, intuitive, and even slightly disruptive.


Rule 1:
Empower Everyone

democratize design!

Rule 1: empower everyone: let's face it, even the word innovation is loaded. To some it means iPhones and to others it's just a rebranding of strategy. If you're an incumbent player in a space, like a radiology tech who's worked their whole career in known model, innovation may sound like code for being obsoleted. We couldn't have that, not if we need people to want to come to this work. Empowering everyone is all about making the process open, easy, clear and accessible. We heeded Empower Everyone when we created our simplified process and tools: Listen, Imagine, Do.

We changed our language to make innovation feel normal, like things anyone would do every day; we just put those things in a purposeful order. It also means going to the gemba, or going to where the work is. It's more empowering for a coach and supplies to go to a nursing station than ask nurses to leave their post and come to our studio.


Rule 2



always be designing!

Rule 2: always be designing: It goes like this: "so we're ready to hire the coder/videographer/doctor/whomever, right?" Well, maybe not so fast. Do we know the script for the video? Have we tested it? Can we make a prototype film with a smart phone? Can we mock up the app in PowerPoint first and get people to test it? If we haven't exhausted our opportunities to get input and feedback from users, then let's keep designing. This might sound counter intuitive to those of us who believe in the always be shipping mantra of the startup world. If we keep designing, are we chasing perfect instead of accepting good? The key here is to recognize that the process of iterating ideas and prototypes still produces impact! If a team of mid-level managers creates a pretty good iPhone video as a prototype, they can get it deployed as a test so much faster than hiring a video company. And when they want to make a change, it's a 15 minute effort, not months of work and dollars spent. ABD also means we inculcate the notion that a good design is never finished, it's only getting better.

Rule 3:
Solve Within Arm's Reach

(or how we learned to always go smaller)

Rule 3: solve within arms reach: If there were one rule to rule them all, this would be it! We've all tried to boil the ocean -those projects where in the first meeting we've already identified 20 contingencies and resource needs. If a nurse comes and says I want to redesign discharge for our hospital, which executive wouldn't embrace that energy with open arms? So the nurse tries. Before he gets started, someone else takes them aside and suggests who else they need to include in the project. After 3 months of trying to align the schedules of 15 people, the meeting happens. Some know immediately what must be done. Others don't know why they are there. And somewhere, someone is running it up the flagpole that they weren't included. We should probably meet again, right? Maybe monthly? And so the discharge committee gets formed. People debate best practices, egos get bruised, and the courageous nurse who stared the project feels more defeated than if he'd never bothered at all.

Solve Within Arms Reach is all about short-circuiting that. To that nurse we say: "awesome! Let's get started. What part of the discharge process can you work on first? Which part can you and maybe a small team affect on your own?" Often, it turns out, that scope is pretty small. It might be constrained to reimagining the last sentences you say to someone going home. But we can work on that! We can get started today! We can make an impact on that and tell the story and get others doing it too. That's how innovation spreads. That's how we go to scale!

SWAR has another benefit. People do and make quickly. And that's something we don't get to do enough in this modern life. It feeds the soul and makes us feel productive. Who wouldn't rather go home and say: "today, I started doing discharges differently"? That's so much more rewarding than: "we had our monthly discharge project meeting today..."


Rule 4
Run Towards

The Challenge

because it CAN be solved!

Rule 4: Run Towards the Challenge: One of my dad's favorite lines is action conquers fear. What happens we we see a challenge and run headlong towards it, believing it can be solved? Too often, in corporate settings, we start by failing to start. We have meetings, we study the problem, we debate who has the right to work on it, who can work on it and what the solution must be. Some of the best innovators I know flip that it's head. The early pioneers in the United States Digital Service and early Presidential Innovation Fellows speak about this often. These were some of the brightest folks culled from Silicone Valley. They came with the mindset it's easier to start tackling a problem when you run towards it head on. We've borrow that energy and encourage our colleagues to do the same.

Running towards is all about optimism. Think about every action movie where the heroine is outrunning imminent danger. She gets to a chasom, the metal airlock door slowly sealing itself on the other side. What to they do? They taking a running start, leap across and know the rebells will have cracked the code, opening the door on the other side by the time they've gotten there. Whew!

Rule 5
Design With,

Not For

together is always better

Rule 5: Design With, Not For: perhaps no other industry is as plagued by paternalism as healthcare. We have a culture of doing for, not with. But for innovations to take hold, they have to be things we all feel good about and see value in. There's nothjng more empowering than involving people. When we have a team of patients, innovators, doctors and administrators, all on equal footing, all participating in creating the solution, it's unlike anything else. It completely obliterates the need to sell ideas and concepts back to someone. No groups feel left out. No one feels like they have to paint the barn shed.

These, like all rules, should be questioned. They should be bent, and broken and reformed. And if they are as helpful to you as they have been to us, then pass them along.

The journey is the Innovation

The journey is the Innovation

Sometimes it's not the impact of the project, it's the experience that makes all difference to patients, staff and innovators. 


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