Ideas Over Implementation: Where Design Thinking Goes Wrong

I participated in a three-day innovation workshop recently that was inspiring but also frustrating due to what I would call “unconstrained brainstorming.” Each group did have one community representative to help us better understand the culture and context, but our ideas ricocheted wildly and ambitiously without hardly any understanding of whether they could actually be implemented. There is no shortage of good ideas in healthcare, but there is a shortage of successfully implemented and sustained solutions. I am interested in that gap.

Design thinking has been under the microscope in the last few years: Design thinking was supposed to fix the world. Where did it go wrong? We teach design thinking in our Applied Learning Health Systems course, and learners from healthcare, research, or government emphasize their newfound appreciation of spending time to understand the pain points of all stakeholders and brainstorming solutions before settling on one. In my experience, there are some basic problems with the way design thinking is implemented.

1) Generating ideas is not the hardest part of designing good solutions--figuring out how to implement and pay for them is. 

Critics have argued that its short-term focus on novel and naive ideas has resulted in unrealistic and ungrounded recommendations. 

Design thinking is often facilitated by external consultants who deliver recommendations and write reports but do not go on to build and implement the solutions. Lack of expertise in how to implement breeds many unimplementable ideas. This is true in research as well. In one of our projects, researchers worked with stakeholders over several months and generated 93 ideas that were then handed over to us as the digital health collaborators on the project. We found almost none of the ideas to be feasible.

2) Because the designers or researchers often hand over the ideas, there is seldom any feedback about what worked and what didn’t--the process is linear rather than a learning cycle. A facilitator of design workshops at Google followed up with teams to learn which workshop ideas had made it to production. 

He saw that for all the excitement and Post-its they generated, the brainstorming sessions didn’t usually lead to built products or, really, solutions of any kind. 

3) Not enough time is spent understanding the problem and generating early evidence that a solution will have the hoped for effect. In our recent innovation workshop, one reason our brainstorming was so unconstrained is that the problem we were there to solve was too broad and ill-defined. We were guessing at the causes of the problem using the experience of one community member to guide us and brainstorming ideas for every possible cause. But we had little evidence about the causes for the problem, no data to define the scope for each cause, and no knowledge about which solutions were more likely to succeed in the context. 

The main outcome driving criticism of design thinking is that it promised to democratize design but may have done the opposite. Design Thinking Is Fundamentally Conservative and Preserves the Status Quo:

Design thinking privileges the designer above the people she serves…and limits the scope for truly innovative ideas, and makes it hard to solve challenges that are characterized by a high degree of uncertainty

I just finished the book Unlocking Leadership Mindtraps, and the first mindtrap is putting too much faith in simple stories. Simple solutions developed in a board room or classroom are not capable of “equitably serving diverse communities and solving diverse problems” that exist in complex systems like healthcare. 

As long as design remains in the halls of consultancies and ivory-tower institutions, its practitioners may continue to struggle to decenter the already powerful and privileged.

My colleagues and I are trying to incorporate the following principles into the work we are doing in the Centre for Digital Transformation of Health:

• Think of implementation and include diverse types of expertise from the beginning--people with lived experience, health economists, informaticists, and implementation scientists are as important in the brainstorming phase as the designers, clinicians, and researchers.

• We need to be embedded as collaborators in the environment where we are trying to solve problems. I learned that early in my career watching Scott Evans at LDS Hospital and then Gerry Douglas in Malawi, Africa, but it’s surprisingly hard to execute when housed in a university. 

• Applying theoretical frameworks can constrain brainstorming and guide prototyping in ways that are more likely to succeed--Tom Reese combined design thinking and theoretical constructs in one of the first in-person seminars we hosted as a Centre, back in February 2020! 

• Rapid learning cycles where we collect data, observe practice, interview stakeholders, and perform small experiments to generate early evidence will refine our understanding of the problem and validate potential solutions before embedding them in the real context.`

The next step in our innovation workshop is to pitch our idea to a panel of judges. We came up with a solution we are enthused about, and if we win the pitch contest, we will immerse ourselves in the community and do a lot of what I wish we had done before settling on a solution. 

If we truly want to think about stakeholders, if we want to have more levels of affordances when we design things, then we can’t work at the speed of industry. Wes Taylor, associate professor at Virginia Commonwealth University.

It is true that research goes too slow. At the same time, industry (and healthcare) produce a lot of waste by implementing solutions too quickly.