Transforming care delivery through lean & human centred-design: a conversation with Ben Dolson (Twin Health)

For this article, we interviewed Ben Dolson, Director of Clinical Performance and Innovation at Twin Health, makers of the Whole Body Digital Twin™ precision health service. Prior to Twin, Ben worked for six years at One Medical where he helped develop and lead the Performance Innovation team. Before that he worked for five years at Columbia University Medical Center in various operational and quality roles.

Rik Renard (RR): Can you tell me more about your previous role at One Medical?

Ben Dolson (BD): I was responsible for helping to launch the Performance Innovation Team, which was a team of internal facilitators and consultants focused on driving process improvement and creating a culture of empowered problem-solvers. It was honestly a lot of fun. Our approach was informed by traditional lean methodologies as well as design thinking. Our goal was to empower everyone in the organization to identify problems, understand root causes, come up with hypotheses on what could improve the problem, and then design experiments to test those hypotheses. We really promoted a problem-first approach and coached teams to embrace problems as learning opportunities. We’d engage in lots of different ways to support this work - from facilitating kaizen workshops and ideation sessions, coaching leaders on how to set up their management systems, and teaching lean concepts throughout the organization. Our team was located within the Clinical Operations organization, so we typically focused on member-facing care teams and the leaders who support them, but we worked with anyone who sought our support within the organization - supply chain, recruiting, product, compliance, revenue cycle, etc. 

RR: What are your responsibilities at Twin Health?

BD: Twin has a very innovative culture and my role is to help accelerate that culture and make process improvement and innovation part of what everyone thinks about in their role every day. I’m based in the clinical operations team, so I get to spend a lot of time with the teams who directly care for our members, including coaches, nurses, and providers. I spend a lot of my time running mini kaizen workshops and working on strategic projects that need that type of support. 

RR: Do you know any other care organizations that do this?

BD:  Most academic medical centers have a team that does something like this. They may call it a Kaizen Promotion Office or Model Clinic Team, which are somewhat old school terms that come from the manufacturing environment where lean originated. Lots of these ideas started to find their way into healthcare by the 90s. Startups are more likely to refer to these teams as innovation teams or strategic operations. I prefer that more holistic framing because it creates room for other schools of thought, like human-centered design. 

RR: Can you explain the lean principles and how they help in your day-to-day job?

BD: So if you read The Toyota Way, which I think of as a mix of lean philosophy and a field manual for setting up a lean management system, you’ll learn about the 14 Lean Management Principles that Jeffery Liker distills from his work with Toyota. I will call out a couple that I think about almost every day. 

• Create processes with continuous flow: In healthcare, this often means creating processes where patients move through the system without waiting and without friction. Waiting rooms are, unfortunately, synonymous with healthcare experiences, so any organization that eliminates or greatly reduces that painful experience of waiting will have much happier patients. Care teams are constantly waiting on things to happen as well. Creating continuous flow is incredibly difficult to achieve, but even the decision to pursue it will yield benefits because it will force you to start solving a bunch of bottlenecks and friction points that get in the way of flow. 
• Create a system of visibility: Healthcare is extremely complicated so making things visual and quickly understandable at a glance is a huge deal. This includes making problems easily detectable and visual as well as visual aids and visual controls that improve clinical safety and reliability.
• Find and fix your system defects: This is related to that pursuit of continuous flow. Defects are one of the things that prevent flow. In healthcare, of course, a defect is potentially dangerous for the patient or, more commonly, an administrative burden that we pass to the patient - like completing the same forms repeatedly or repeating the same information to different members of the care team. Or, my favorite, asking the patients to fax us information. I don’t know anyone with a fax machine, so asking patients to fax us information is, inherently, a defect in the process. Finding these types of defects and friction points and moving them away from the patient experience is a great way to improve flow, safety, and the patient experience. 

RR: Can you also explain human-centered design? 

BD: In lean you can get really far by identifying and fixing process problems, but what I think can be missed is some of the empathy-driven insights that human-centered design promotes. Human-centered design is really about deeply understanding your customer - in this case the patient - and their needs throughout the experience you’re designing. This understanding yields insight, which yields a better product or service experience. I really like what human-centered design brings to ideation sessions. It’s not just about reducing the wait time in a process, for example, it’s also about understanding what the patient may be worried about while they’re waiting and addressing that anxiety in some way. 

RR: What would that ideation process look like?

BD: Ideation is often what people consider the fun part - and it is! - but it’s the reward of having gone through the less fun part of untangling and documenting the problem you’re trying to solve. Really good ideation sessions have to include the people who do the actual work or process and those who are building the product or process you’re working on. It should also include the patient perspective - whether through a persona, an empathy map exercise, or an actual group of patients where that’s possible. Ideation sessions are typically facilitated by 1-2 people who know how to structure the ideation or brainstorming session so that it is centered on the problem at hand, invites a wide range of divergent ideas, and then converges on a handful of testable ideas. IDEO has a lot of great resources for learning how to facilitate ideation. Ultimately you want your ideation sessions to yield something that can be tested or experimented on right away. You’ll hear the facilitators asking questions like, “These are great ideas. So what are we trying on Monday?” This helps keep the team grounded in a practical learning cycle where they’re trying something new, learning how it goes, and then iterating on the idea. Otherwise it was just a fun brainstorming session and nothing changes. 

RR: You mentioned the empathy map and brainstorming, are there other frameworks that you use in your day-to-day?

‍BD: I really like the Waste Walk or Waste Analysis where people who do a process write down all the things that are not going well in the process with as much objectivity as possible. You can do this on sticky notes or digitally in a slide deck or programs like FigJam. This is where we’ll remind teams that we can be “hard on the process, not the people,” meaning these problems are no one’s fault and they’re also everyone’s responsibility to improve. This type of exercise needs to be facilitated by someone who can help create an environment of trust and mutual ownership of improving the problems that are surfaced. 
I also like having people draw their ideas during ideation sessions. Making things visual is always so helpful - show, don’t just tell. A really good before and after illustration - even with stick figures and arrows - can be so powerful in getting buy-in on a new idea. 

RR: Many early-stage startups don’t have the money to establish a Performance Innovation Team, so what advice would you give them?

BD: Early-stage companies are already rapidly innovating in most cases. One thing I would encourage early-stage companies to do is to build a culture of standards early on so that they can weigh innovation against this standard. Even if those standards change frequently, having a baseline to innovate against and train to is incredibly helpful when it comes time to scale. Writing standard operating procedures (SOP) or standard work can sound boring and almost antithetical to an innovative culture, but writing stuff down, in whatever format works for the organization, will become a strength for those who start early. 

RR: You mean standardizing your care processes? 

BD: Exactly. It’s so hard to keep all of your care processes updated and fresh, but finding a standardized way of updating them and communicating it to the broad care organization is so important. A healthy way to think about standardization is that it is the best known way to do a thing today, but tomorrow we may discover a better way to do it and that becomes the new standard. So if innovation is about beating your current standard, then it requires knowing exactly what that current standard is. 

RR: How do you solve the tension between the clinical team and the product team?

BD: I can share some things that I’ve seen work well. One of the first ingredients would be having the leadership of those two teams collaboratively build roadmaps and future state plans. This aligns the resources of those teams to the same goals. A lot of product teams already have great practices of shadowing, interviewing care team members, and creating internal user personas. Beyond that, what you ultimately want to see is your care team and product team working together as co-collaborators focused on a common problem. From there, they can ideate together, run some experiments or simulations, and build something based on that shared learning and insight. Once the teams are working together in this way there is room for healthy tension - colleagues should be able to challenge one another when they’re working towards a common goal.

RR: Final question for today, but what’s a great efficiency metric?

BD: The first one that comes to mind for me is the ratio of patients to care team members. In other words, how many patients can your care team sustainably care for. Underlying that metric is a bunch of really important stuff, like how you manage the existential problem of care team burnout and provider shortages. It also reveals the overall quality of the system you’re building and how effectively it enables care teams to actually provide care while minimizing all the other stuff that comes with providing care - documentation and administration. 

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Quick intro: we’re Thomas and Rik, building Awell - a low-code platform allowing care teams to design, implement and optimize care flows in days, not months. CareOps grew out of our years spent improving CareOps at innovative providers.