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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:

“BALLISTIC MISSILE THREAT INBOUND TO HAWAII. SEEK IMMEDIATE SHELTER. THIS IS NOT A DRILL.”

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.

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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.

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.

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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.

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Rule 2

 

A.B.D!

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..."

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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.