How Design Thinking Is Improving Patient-Caregiver Conversations

Design Thinking Medical

Technical developments tend to grab the headlines in health care. Predictive analyticstelemedicineelectronic health records — technology is rightly seen as a transformative force in health delivery.

But it’s not the only one. At Rotterdam Eye Hospital, hospital administrators have found that through their ongoing design-thinking program, lower-tech measures can also improve health care. Simple measures such as building a more intuitive website, replacing harsh fluorescent lighting and cold linoleum floors with softer lighting and wood parquet, and giving children and pediatric ophthalmologists matching T-shirts have reduced patient fears. Addressing patients’ fears is important because fear can make an eye operation difficult or even impossible. Moreover, less fear translates into greater patient satisfaction.

Now, Rotterdam Eye Hospital has integrated a measure that is even lower-tech: better conversations. People have a deep-seated fear of eye surgery, and patients naturally want to discuss their conditions and their treatment options with their doctors. But as the hospital’s design-thinking team observed those discussions, they realized that not all patients are looking for the same conversation. The team — which included one of us (Roel) — saw that most patients fit into one of four categories: Google patients, who are obsessive about information; dominant patients, who like to be firmly in charge of their case; quiet patients, who will say everything is fine, even when it isn’t; and emotional patients, who, more than anything, just want reassurance that their caregivers are looking after them.

After researching the different ways in which people respond to fear, the coach on the design-thinking team trained hospital staff to look for the distinctive set of verbal and nonverbal cues that marked patient behavior as belonging to one of four types and then respond appropriately (see the exhibit “Improving Patient-Caregiver Conversations”).

Improving Patient-Caregiver Conversations

Patients react differently in discussions about their medical problems and care options. They fall into four categories, and someone behaving one way in one situation may behave otherwise in another.


Biggest fear: Uncertainty and fear of irrational behavior of others

Symptoms: They know their own health records, believe they know the cause of their symptoms, and ask questions to confirm their opinion. If that opinion is not confirmed, they may question the caregiver’s judgment. Should the information presented strike them as incomplete, vague, or contradictory, they may become angry.

These patients move around very little, making short, brief movements and controlled gestures. They will shake your hand briefly, provided you take the initiative. They speak softly and in a monotone, tend to pause while talking, and will sometimes look away during a conversation, as if thinking.

Prescription: Provide clarity and order. Give the patient detailed information during the consultation in brochures and on websites and be transparent about medical outcomes and risks.


Biggest fear: Coming across as soft or weak

Symptoms: They may get angry if they have to come back multiple times; they hate sitting in waiting rooms and are often impatient. They walk purposefully and rapidly, and use their time, movements, and words efficiently. They shake your hand in a short and vigorous manner. They speak loudly and rapidly; they keep everything brief but comprehensive and try to get to the point immediately.

Prescription: Develop an efficient appointment process and treatment system that delivers services on time at hours that are convenient for patients. Be direct with the patient and skip the social talk.


Biggest fear: Change

Symptoms: They dislike giving negative feedback to their caregiver to the point that they tend to wrap their suggestions in a story or an example. They make only small gestures with their hands, and shake your hand softly. They speak softly and melodiously.

Prescription: Don’t take “yes” or “good” for an answer. Keep asking questions even when they say everything is fine. Find occasions for one-on-one conversations since these patients don’t like to be the center of attention in a group.


Biggest fear: Feeling alone and left out

Symptoms: They move around a lot, and make dramatic gestures, using their whole body. They shake your hand for quite some time and may pat your shoulder. They speak loudly, quickly, and often melodiously. Small talk is important for them: They begin with an introduction to establish the nature of the relationship, after which they explain the context of their problem.

Prescription: Spend time engaged in social talk and build a personal relationship. During treatment, reassure the patient that everything is going well and the caregivers are looking out for him or her.

Source: Rotterdam Eye Hospital

One complicating factor is that patients — and their loved ones, for that matter — behave differently in different contexts. Someone might be quiet as a patient but feel the need to dominate the room if he is trying to find out what the doctors are planning for his elderly mother. Or when the reality of a difficult diagnosis sinks in, she may go from being a Googler to an emotional patient. Given that people do sometimes switch between types, it’s even more important to be aware of patients’ verbal and nonverbal signs. A change can indicate that a patient is afraid or feels helpless. In both situations, it’s critical for a caregiver to respond appropriately.

The program is now seven years old. A trial group was trained in 2010, and the entire staff is now trained on a yearly basis. The training takes two days. On the first day, participants get acquainted with the different patient types. They find out what type of person they are, and in small groups they discover how they can recognize other types and how they can respond to them. Then participants go back to their jobs and are invited to apply what they have learned. After two to three weeks have passed, participants come together and share their experiences.

Besides the yearly training, the principles of the patient types are reviewed at every morning staff meeting in a Trivial Pursuit–style card game that also includes questions on issues such as infection prevention, medication safety, and checklist management. The purpose is to discuss current topics and difficult issues in a playful and accessible way. To ensure the insights generated by the card questions and activities stick, the results are shared with the group the following morning.

After each training program, the caregivers who participated are surveyed annually for several years. In 2016, the staff at Rotterdam Eye Hospital gave the annual training sessions an 8.7 on a 10-point scale. Ninety-nine percent of the participants said they would recommend the program to a colleague; 96% said they would like to attend a follow-up training session.

Many hospital staff members have told us these sessions are helpful. “Thanks to the yearly training, I now have fewer difficult patients, because I can recognize their fear signs and know how to respond,” one medical resident said.

An ophthalmologist said: “I always thought the more information, the better. Now I know that is only helpful for some patients, whereas other patients become more and more afraid when I tell them what is going to happen.”

The benefits of the method were also reflected in high levels of patient satisfaction. In 2016, MediQuest, an independent research firm, surveyed 850 of the Rotterdam Eye Hospital’s patients to obtain a Net Promoter Score (NPS). It asked them to indicate on a 0 to 10 scale (0 was very unlikely and 10 was very likely) the likelihood that they would recommend the hospital to family and friends. The percentage of patients who answered between 0 and 6 was subtracted from the percentage who answered 9 or 10. In 2016, the hospital’s outpatient care received an NPS of 54.7%, one of the highest scores of the group of 31 Dutch hospitals that were surveyed (the average for all participating health care institutions was 42.7%). For hospital care, Rotterdam Eye Hospital received an NPS score of 70.6% (the average for all the 39 surveyed hospitals was 42.2%).

This program differs from conventional design-thinking work in that its positive impact goes well beyond “the customer.” The annual training sessions to identify the four types of patient have also improved how the staff members work with each other.

“The training taught me how to provide feedback to a dominant colleague, and he recognizes it!” one nurse said. “I thought that getting straight to the point was being rude. But that was my perception.”

This program has worked out so well at Rotterdam Eye Hospital that in 2014 Irishof, a special nursing home for the visually impaired elderly, decided to adopt the system. The home, operated by Zorgpartners Midden-Holland, used the same categories but extended them to include details about how these four types of patients deal with grief and declining health. Its caregivers like the program.

A rehabilitation center operated by Zorgpartners Midden-Holland is currently testing the system. The center wants to design motivational programs tailored to the patient’s particular needs, taking into account how fears of delirium and dementia affect different patients. Initial results — for patients and staff — are very promising. All participants said they would recommend the program to a colleague, and 99% of the trained caregivers would like to attend a follow-up program.

As far back as the ancient Greeks, physicians have understood that personality plays an important role in human health. Hippocrates himself once wrote, “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” In this technology-focused age, it’s easy to forget that there are times when only human beings can give each other what they most need.


Dirk Deichmann is an assistant professor at Erasmus University’s Rotterdam School of Management.

Roel van der Heijde is a partner at N3Wstrategy. He previously worked as a senior consultant and trainer at the Rotterdam Eye Hospital.



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