In need of transformation: the patient experience

Brenda Laurel, a highly-respected designer, researcher, writer, and currently chair of the Graduate Program in Design at California College of the Arts, had surgery last fall at the Stanford Medical Center. Brenda tweets infrequently, but here is what she tweeted following the surgery:

If you've read my "nightmare" blog, you know that Brenda's tweet would pale in comparison to the tweets I would author about my patient experience.

Were our experiences unusual? Sadly, no. After spending two days in the hospital last year with his young daughter who was undergoing some diagnostic tests, Alder Yarrow, a former colleague of mine, recounted his experience and concluded:

"Of all the industries we interact with regularly as consumers, the medical industry definitely defines the low point in quality and consistency of customer experience. Most of us emerge from interactions with the medical establishment feeling more like victims than paying customers."

Speaking of this lack of patient experience consistency, Dave deBronkart, a.k.a. e-Patient Dave (a full-time, empowered patient advocate), detailed "physicians' unwarranted variation in practice" which "has been shown to cause immense unnecessary surgery, with the resulting costs and inevitable percentage of errors and deaths after surgery that wasn't necessary in the first place."

Unnecessary deaths were addressed in a U.K. researcher's tweet in December:

According to leadership guru Steve Denning, "medical errors cause in the order of 100,000 deaths per year."

In a commencement address at Harvard Medical School last year, Atul Gawande M.D. said:

"Two million patients pick up infections in American hospitals, most because someone didn't follow basic antiseptic precautions. Forty per cent of coronary-disease patients and sixty per cent of asthma patients receive incomplete or inappropriate care. And half of major surgical complications are avoidable with existing knowledge."

A recent study by the Department of Health & Human Services revealed that:

"One in four hospital patients are harmed by medical errors and infections, which translates to about 9 million people (in the U.S.) each year. ... Hospitals are doing a poor job of tracking preventable infections and medical errors and making the changes necessary to keep patients safe."

The author added, "...hospitals don't seem to give a damn about fixing things."

Jay Parkinson M.D., viewed as a rebel in the medical community, wrote about the experience of getting his dog properly diagnosed and treated when his dog was on death's door. He contrasted that experience, which he raved about, with the experience that most humans receive in the U.S.:

"the dominant experience for most people...is unsafe and inhumane."

Donald Berwick M.D., who oversaw Medicare and Medicaid until this past December,went further:

"Health care is broken. ... We have set up a delivery system that is fragmented, unsafe, not patient-centered, full of waste, and unreliable. Despite the best efforts of the workforce, we built it wrong. It isn't built for modern times."

My patient experience was plagued from the get-go by a major misdiagnosis. So-called rare diseases -- diseases, including mine, that have been diagnosed in fewer than 200,000 people in the U.S. -- often take a long time to diagnose: greater than 5 years in many cases, according to the National Institutes of Health's Office of Rare Diseases Research (ORDR). Almost two decades were required to correctly diagnose the rare disease of a nurse I've met online who now devotes a lot of her time to educating the public about her particular disease which caused her to suffer multiple brain aneurysms.

Delayed and inaccurate diagnoses are two of several problems that tend to plague all victims of rare diseases. According to the Presdient & CEO of the National Office of Rare Disorders (NORD), other problems include difficulty finding an appropriate medical expert, few treatment options, lack of awareness and understanding of the patient's needs, and a sense of isolation. All of these were among the problems I experienced and to some extent continue to experience.

Should anyone ever need to experience those kinds of problems? My answer is, "no." Nor should anyone with any disease have to experience a healthcare system that is as broken as ours. The patient experience in the U.S. (and in many other countries) needs to be transformed. Not just improved, but transformed, as reflected in this graph from Kerry Bodine of Forrester Research. And fast -- as fast as possible.

What all contributes to such poor patient experiences?

Here is a subset of the contributors -- some of the systemic contributors, some of which overlap with others, and all of which contributed to my terrible patient experience.

Doctor arrogance

This contributor has been receiving a lot of attention in recent months. An article in The New York TImes last year started with these words:

"Doctors save lives, but they can sometimes be insufferable know-it-alls who bully nurses and do not listen to patients."

Jay Parkinson M.D. weighs in a lot on the topic of doctors being "insufferable know-it-alls." For example:

"Doctors have such a preoccupation with being right, they can't tolerate being wrong."

And the title of a report published a couple of days ago by the LA Times alone says a great deal: "Many doctors hide the truth about medical errors, study finds."

Because nurses are bullied so often by doctors, nurses more often than not do not have the courage to speak up when doctors make errors. A recent occurrence that got a lot attention in the press and on Twitter involved a doctor in Arizona who exploded with anger because a nurse corrected a patient's misunderstanding -- a misunderstanding caused by the doctor -- about treatment options. The doctor threatened to have the nurse fired and to have her license to practice revoked, and he successfully followed through on both threats. A report written by a nurse about this case stated the following:

"[the nurse's] story is one of an archaic medical model in which the doctor's word is supreme and we are all just nurse maids here to do their bidding. ... I'm really disgusted that a healthcare organization would bow to the tantrum of one very arrogant and immature physician. If there was one example of a surgeon with a God-Complex, this is one."

Not only are nurses afraid of doctors, so are patients. They often don't know when to talk and often fail to ask questions. According to Stanford's Abraham Verghese M.D., patients are interrupted when they do talk on an average of every 14 seconds. Verghese argues that the physical exam is a sacred ritual, one that doctors violate on almost every occasion.

Often, a patient's experience of his or her illness is critical information for an accurate diagnosis. As Paula Thornton put it in a recent discussion about patient experience in the Design Thinking LinkedIn group, "in the absence of a patient's story of the illness, you are practicing veterinary medicine."

Sadly, things don't always go well when patients insist on being heard. An example of such a case was when a doctor, in effect, fired a patient -- i.e., told her that she was no longer permitted to return -- when she asked to get a second medical opinion. It turned out that she was right to do so, as her first doctor's conclusions were wrong.

According to Stephen Wilkens M.P.H., an estimated two-thirds of physicians treat patients in a paternalistic way.

Lucien Engelen M.D., who heads an innovation center focused on the quest for participatory healthcare, put it this way:

"there is something very wrong with healthcare. At present it is mainly one-directional traffic. Doctors say that they talk to patients; perhaps so, but there isn't real negotiation with the patient. For a doctor, the patient too often is simply a disease that generated data on which they base their medical decisions. There is no real co-decision."

In a TED talk of last year, Jeff Benabio M.D. described the series of reinventions doctors underwent throughout history. Relatively recently, Jeff claimed, "we let our arrogance reinvent us ... we thought we were gods again."

USC's Dave Logan, in one of his TED talks, described the five stages that tribes -- groups of people -- go through:

1. Life Sucks
2. My Life Sucks
3. I'm Great
4. We're Great
5. Life's Great

According to Dave, the problem with healthcare is that doctors are a stage 3 tribe -- people who most often talk in the terms of "I," "me," and "my." Stage 3 tribes are comprised of people who think that others should just shut up and do what they say.

Atul Gawande M.D., whom I referenced earlier, says that "We train, hire, and pay doctors to be cowboys."

In a TED talk, Dr. Brian Goldman M.D. argued that physicians live in a culture of denial, unwilling to admit to or talk about their mistakes.

"If I were to walk into a room filled with my colleagues and ask for their support right now and start to tell [stories of all the mistakes I've made], I probably wouldn't get through two of those stories before they would start to get really uncomfortable, somebody would crack a joke, they'd change the subject, and we would move on. ... That is the system that we have -- it is a complete denial of mistakes. ... [However,] errors [in medicine] are absolutely ubiquitous."

Wendy Levinson M.D. references yet another culprit in stating that "perverse incentives have contributed to physicians developing 'efficient styles' that squeeze out time to listen [to patients]..." However, perverse incentives are probably not alone responsible for this, as scores of empathy levels of young physicians correlate with patient outcomes better than any of medicine's traditional metrics.

I've tweeted very little about my patient experience, but one day I couldn't hold back:

This neurologist totally dismissed my recollection of what happened to me (to the extent that she permitted me to tell my story), claiming, for example, that the seizures that had me flopping all over the floor in a semi-consicous state must not have been seizures at all. According to her, they must have only been "muscle twitches."

As a doctor who tweets and blogs anonymously recently wrote:

"One of the worse maladies plaguing the medical field is piss-poor communication, and [my own] orthopedist has about the communication skills of a mentally-retarded clam."

A report from The Onion that weighs in on this topic is entitled, "Patient Referred to Physician Who Specializes in Giving A Shit":

"NORTH PLATTE, NE -- After visiting his primary care physician Tuesday with complaints of intense pain in his left leg, computer programmer Dan Fields was referred to a specialist who focuses on giving a shit. "I want to send you to someone who specializes in not dismissing you brusquely after three minutes," Dr. Paul Niles said as he hastily scrawled out a referral and pushed Fields to the door. "Dr. Lewis is really one of the best out there at regarding patients as actual human beings. If anyone's going to listen closely without resenting you for taking too much of his time, it's him."

Doctors do not think creatively

Jay Parkinson M.D. has written:

"Medical education and residency is pretty militaristic. You fall in line or you're out. Trust me, I've been there. If you are an 'outside the box' thinker, this doesn't last long in medical school or residency. The egos of your superiors are too threatened. This is an important fact. Doctors have such a preoccupation with being right, they can't tolerate being wrong. This is of course needed because who wants to go to a doctor known for being wrong all the time?"

And in both his TED talk and his Medicine 2.0'11 talk, Jay said:

"the medical culture is not only uncreative, it is anti-creative. ... Why should doctors be creative? ... Doctors only have pills and scalpels. ... Our reality is very different from an innovative, creative culture. ... We fall into line. ... Whenever we treat patients we treat them with algorithms. We regurgitate; we don't think creatively. We also have this thing called a god-complex... And we're just so frickin tired... And we're terrified of the law."

And they are terrified to fail board exams, as suggested by a recent news report about extensive cheating by doctors around the country taking an exam to become board certified in radiology. I mention this particular report because of the huge role radiologists played in my misdiagnosis.

As the representative of NORD tweeted during a tweetchat last summer:

According to James Howenstine M..D., "conventional medical practice in the United States largely ignores the possibility of parasitic disease" -- which is the disease that nailed me. He wrote that in 2004 but reiterated it in email to me last year. Parasitic disease is most associated with third-world countries where it isn't classified as "rare."

Doctors' dismissal of things patients learn via the internet

"You can't believe what you read on the internet," remains a common refrain among doctors -- a tribe of people who don't much care for their knowledge to be challenged. I've experienced this refrain repeatedly from multiple doctors, many making claims about my disease that my very careful research using the internet reveal to be completely false. "You simply must have not understood what you read," is the followup reaction when I present printouts of my research findings. This reaction is so common that even the few doctors who do use and know how to rely on the internet are afraid to say so:

High prevalence of medical personnel handoffs

Extending my earlier quote of Atul Gawande M.D.:

"We train, hire, and pay doctors to be cowboys. But it's pit crews people need."

However in healthcare, those pit crew members are usually separated by organizational boundaries:

"Patients experience healthcare horizontally -- with many individuals from many teams. Most breakdowns happen in the handoffs."

Some of the supportive data:

"In the past year, 42 percent of Americans reported coordination gaps related to medical records or tests, or communication failures between providers. A fourth said that their medical records or test results were not available during a scheduled visit or that tests were duplicated."

And this results in more than mistakes:

"Frequent handoffs in transitions of care, increasingly common today, make time to connect with patients even more challenging."

Other contributors exist, including difficulty finding and getting access to doctors with the needed expertise, which, as I mentioned earlier, is particularly hard for people suffering from a rare disease. And I've made only a veiled reference to the huge role played by insurance companies. However, I now turn from consideration of contributors to poor patient experiences to (potential) solutions.

What might be done to transform the patient experience given such contributors to poor patient experiences?

Here are some of the efforts that are in progress or that have been proposed.

Screening medical school applicants for people skills

Some medical schools have begun to use what is called a multiple mini interview, or M.M.I., as part of their admissions process to determine whether candidates have the social skills and the perspective needed by a good doctor. During the M.M.I. at one school, candidates are given eight minutes to discuss an ethical conundrum which they were presented with only two minutes earlier; this happens 26 times for each candidate, once for each of 26 ethical conundrums.

"Candidates who jump to improper conclusions, fail to listen or are overly opinionated fare poorly because such behavior undermines teams. Those who respond appropriately to the emotional tenor of the interviewer or ask for more information do well... because such tendencies are helpful not only with colleagues but also with patients.

Candidate scores on [the M.M.I.] have proved highly predictive of scores on medical licensing exams three to five years later that test doctors' decision-making, patient interactions and cultural competency."

At the time this article was published (July 2011), eight schools in the U.S. and 13 schools in Canada were using the M.M.I.

Teaching soft skills to medical students

Instead of or in addition to screening medical school applicants for social skills, how about training those who get into medical school? As Wendy Levinson M.D. stated in the Journal of the American Medical Association:

"medical schools and residency programs provide relatively little education about effective communication skills compared with the educational time devoted to teaching science and technology. Furthermore, medical students and residents are rarely observed during their interactions with patients or given specific feedback to improve their communication."

Here is one example of something that will be done along these lines as reported by CBS in Chicago this past October:

"A Chicago couple thinks a doctor's bedside manner is so important, they're giving the University of Chicago $42 million dollars to teach it. Matthew and Carolyn Bucksbaum are backing the Bucksbaum Institute for Clinical Excellence at the University of Chicago. It will be led by Dr. Mark Siegler -- who's been the couple's physician. They say he's the kind of doctor students should emulate. Carolyn Bucksbaum said the couple was motivated to make the donation after she once had a bad experience with an arrogant doctor who dismissed her illness."

Systems for patient rating of doctors & hospitals

Several efforts are underway beyond the use of Yelp to enable patients to rate doctors and hospitals. For example, there is a business in the U.K. called Patient Opinion which collects patient stories -- good or bad -- about experiences of U.K. health services and then passes those stories on to the right people so the stories can make a difference. Patients also have access to stories others have submitted.

There have been multiple calls for more systems of this nature (e.g., "Choosing a doctor should be like the Amazon shopping experience"). And several articles have been written arguing that patient complaints and poor ratings provide an opportunity for doctors and hospitals to improve (e.g., "Great hospitals permit patients to rip them to shreads").

Organizations devoted to achieving change

Two organizations of particular significance have been formed. One is the Society for Participatory Medicine (a.k.a. S4PM), a society that claims to be "bringing together e-patients and health care professionals," though it appears to have become mostly a voice for or of the patient community; S4PM says it is part of "a movement in which networked patients shift from being mere passengers to responsible drivers of their health, and in which providers encourage and value them as full partners." The other organization, aimed more strongly at the medical community, is The Beryl Institute, billed as "the global community of practice and premier thought leader on improving the patient experience in healthcare." Oddly and unfortunately, neither organization appears to communicate with or know very much about the other.

There are a handful of other organizations with related missions, including the Center for Health Transformation, the Group Health Cooperative, and the Radboud Reshape & Innovation Center. And there are a few design consultancies focused largely if not entirely on healthcare; of these, "the future well" warrants special note, as it was co-founded by none other than Jay Parkinson, the rebel M.D. whom I've referenced above a couple of times and will reference yet again below.

Online patient communities

A major development has been an increase in the number and sophistication of online communities designed to provide support to patients and to enable patients to help each other. Notable examples include: PatientsLikeMe.com, which spans a wide range of diseases; Crohnology.com, developed by a patient with Crohn's disease; and RareDiseaseCommunities.org. Online communities have helped many to get the care they need to the point, in some cases, of saving people's lives; interestingly, one of the most publicized examples of this happened via the use of Facebook.

An article published this month in Forbes identifies and describes a few more of these online offerings. A comprehensive list is badly needed.

Convincing patients to change their ways via articles, blog postings, white papers, videos, webinars, workshops, tweetchats, talks, conferences, ... from enlightened/empowered/engaged patients

Several of the online communities just referenced provide this kind of help, along with the Society for Participatory Medicine. A large number of individuals are providing this kind of help as well.

Some of the articles and other forms of communication or interaction provide guidance for becoming e-patients; Tom Ferguson's 2007 seminal white paper entitled, "e-patients: how they can help us heal healthcare," and Fred Trotter's January 2012 blog posting entitled, "Epatients: The hacker of the healthcare world" are two examples.

e-Patient Dave's contributions, including his TED talk, are particularly well-known. Dave has recently begun to offer a series of e-Patient Boot Camps around the world. Additional patients, including myself, are also speaking out in various ways. A patient experience speakers bureau was launched just last month.

Convincing doctors to change their ways via articles, blog postings, white papers, videos, webinars, workshops, tweetchats, talks, conferences, ... from enlightened medical personnel

Doctors and other medical personnel are beginning to make contributions of this nature, some of which I've referenced above and some via the The Beryl Institute also referenced earlier. A popular blog offered by Kevin Pho M.D. features postings from a large number of medical personnel; many postings there are duplicates of postings that can be found elsewhere on the internet. Of course, since doctors aren't, on the whole, big users or fans of the internet, the reach of many of these offerings are somewhat limited.

Recent conferences of relevance include Medicine 2.0'11 held at the Stanford Medical Center, the Patient Experience: Empathy and Innovation Summit held at Cleveland Clinic, Transform 2011 held at the Mayo Clinic, and the ECRI Institute's 2011 Conference focused on Patient-Centeredness in Policy and Practice held in the offices of the U.S. Food & Drug Administration. The first three have 2012 versions upcoming. A conference that looks promising is Stanford Medicine X which will convene for the first time in September.

Some medical conferences have been criticized for failing to feature e-patient speakers or for not catering to potential e-patient attendees. A symbol was recently developed for use by conferences if patients have been adequately and appropriately considered and represented.

An interesting approach taken by NORD was the publication of an insert for a July 2011 issue of the Washington Post. NORD also sponsors an annual Rare Disease Day. However, potentially more helpful with respect to select rare diseases, including mine, was the 2011 publication of a book entitled, "Wicked Bugs: The Louse that Conquered Napoleon's Army and Other Diabolical Insects"; the author was interviewed on many television and radio programs including NPR's Fresh Air and KALW's West Coast Live. These publications, events, and programs were targeted at the public in addition to the medical community.

Employing alternative healthcare models

The most relevant change advocated is one in which healthcare becomes patient-centered. Such a model changes the role of the patient to, as referenced earlier, that of a driver rather than a passenger -- to that of someone medical personnel do things "for" rather than "to." As put by one M.D., "we need to treat our patients as people and not as disease states."

Jain and Rother have contrasted the views of patients as knights, knaves, and pawns:

"If a society conceived of patients as well-intentioned knights, it assumes that the will and values of patients should drive the structure and organization of health care... The role of policy and payment is mainly to empower patients and physicians working together toward shared aims; insurance coverage should make these interactions as facile as possible.

If a society conceives of patients as knaves, policy, management, and education efforts are designed to work against patients, not with them. Waste and even fraud are the behaviors that come most naturally to the knave -- and it is the role of physicians and health insurance companies to monitor for this behavior...

If societies conceive of patients as pawns, efforts are applied to building systems that ensure patients do what is right for themselves and for the health care system, because patients cannot be trusted to do so on their own accord.

...the patient in the United States today is seen either as a knave or a pawn and is seldom viewed as the knight. Patient-centeredness is lost in a tangle of insurance arrangements."

In spite of this dominant, negative perspective of the patient in the U.S. today, Jay Parkinson leveraged technology to develop a patient-centered practice:

"'...decades ago doctors served their neighborhoods, took cash, and didn't charge a lot because there was so little overhead. So I designed a process that went back to this model, looking at it from the patient's perspective, and just injected a little technology.'

With $1,500, he set up a house-call-only practice in his Brooklyn, New York, neighborhood, serving only two zip codes. He created a website through Applie's iWeb that featured his resume, and posted his schedule on a Google Calendar so patients could enter in an appointment time online.

He also opened a PayPal account for payments, and used Formstack to create forms for gathering patient medical histories and to create specific questionnaires for particular ailments.

Whereas most practices deal with significant costs in office management, Parkinson's start-up costs went to getting his license and buying tools, such as an otoscope and doctor's bag."

Though Parkinson's practice was solo, he used technology to consult with other experts if he needed additional insight. Indeed, a trend still in its infancy is to move medicine "from an individual to a team sport. Solo medical practices are disappearing. in their place, large health systems -- encouraged by new govenment policies -- are creating teams to provide care coordinated across disciplines. The strength of such teams often has more to do with communication that the technical competence of any one member."

The authors of The Innovator's Prescription contrasted a serial, solo approach with a team approach via the following story:

"A friend of ours has suffered from asthma for much of his life. Each specialist he saw seemed to have another possible remedy. It got to the point where he was taking multiple medications with multiple side effects, whose combined cost at one point exceeded $1,000 a month. Then he visited the National Jewish Medical and Research Center in Denver Colorado... a solution shop focused on pulmonary disease, particularly asthma... When our friend arrived, they administered a unique battery of tests, then assembled an allergist, a pulmonologist, and an ear, nose and throat specialist -- to meet together with him. They integrated their perspectives on his long medical history together with the test results, told him what was causing his symptoms, and prescribed a straightforward course of therapy that finally solved his problems."

Delightfully, designers have begun to address healthcare on this level. A team of designers headed by Hugh Dubberly wrote in interactions magazine about a healthcare model of self-management that is considerably patient-centered. The nearby table -- click to enlarge -- contrasts this model with the traditional model. The section at the bottom of the table reveals how the traditional focus for the designer changes as well.

And Jay Parkinson advocates the use of design to transform:

"Going to the doctor, having routine surgery, buying bulk medications online -- all could be radically reinvented with the application of one type of medicine: designed disruptive innovation. Combining the principles of disruptive innovation with design thinking is exactly what health care in America needs. We need to disrupt the current business model of health-care delivery. And we need these disruptions to be designed experiences that are consumer-focused."

Additional models have been proposed by designers, including a model described by Matthew Diamonti, UX Director at the Mayo Clinic -- a model based on the behavior of spiders rather than the current model that is based on the behavior of bees; I'll leave it to the reader to investigate the intriguing details of that proposal further.

Other efforts are underway or have been proposed, but I consider many of them -- such as improving the design of waiting rooms and billing doctors for time patients are forced to spend sitting in them beyond appointed meeting times -- too much about "putting lipstick on the pig." One additional significant effort underway is the replacement of paper patient records with electronic records; that huge effort has been plagued with all sorts of problems due in no minor part to designs that take into consideration the behavior and needs of neither the doctor nor the patient.

I've also made no reference to the growing number of medical apps and devices that have been developed to help people monitor their bodies and their behaviors. Though such apps and devices have received an enormous amount of attention and funding, I tend to agree with Jeff Benabio M.D. who has said:

A few days ago, David Shaywitz reported that a FutureMed extravaganza put on in Silicon Valley last week was not much more than "a celebration of technology for its own sake." And Jay Parkinson, focusing on body data tracking devices, has stated:

"I personally believe that body data tracking is just hype for many reasons. The amount of money these companies are raising is way out of proportion to actual benefit to society."

But controversy isn't new to Jay. When he began his web-facilitated, house call practice described above, Jay was investigated by the New York State Office of Professional Conduct.

"I knew I had plenty of haters given the heated debate in the medical blogs and news stories about my practice. I need to point out that I never once received any criticism from patients or the general public. The only criticism I've ever received came from within the medical community. So someone, somewhere called the state and complained...and given the online discussion I can only assume the complaint was made by a doctor."

The stage 3 tribe known as medical doctors has attempted to undercut other efforts as well. For example, some doctors now ask patients to sign "mutual privacy agreements" that transfer ownership of any public commentary the patients might write so that the doctors can censor their patient reviews if so desired. Of course, taking steps to have a nurse fired and lose her license to practice for educating a patient, as mentioned above, is another example of behavior against patient education and empowerment.

As I've written in my "nightmare" blog, I've made the committment to doing what I can so that others will not have to experience the kind of hell that I was forced to experience when dealing with the U.S. healthcare system. I appeal to all readers to get involved at least to the point of becoming an e-patient. I also ask you to share with me your ideas as to what else can be done -- what all I might do -- in the effort to meet that committment.

As an attendee of Health 2.0 San Francisco 2011 tweeted:

The time is ripe for a healthcare revolution -- an Occupy Healthcare movement -- a patient experience transformation. As Saul Kaplan stated in a Harvard Business Review blog:

"We need a new health care system that ... is designed for patients to champion their own pathways to wellness."

Everyone can play a role in achieving that change.

---

A duplicate of this posting appears in my "nightmare" blog.

No more worshiping at the altar of our cathedrals of business

A version of this article was published in the January+February 2012 issue of interactions magazine.

I've been reviewing an excellent manuscript for a book on design thinking and reading about a new game and kit developed by IDEO to help explain it. These things delight me, since for years, I've been focused on expanding the role of design/UX to be a full participant in defining business strategy and in being a catalyst for that change. More recently, participation in defining social strategy became an important part of that focus. Design thinking came to be advocated by business visionaries to be a major part of a fix to a broken strategy definition process. Jon Kolko and I published our and others' writings about such things in interactions when we were Co-Editors-in-Chief.

So, I have been intrigued by proclamations that design thinking is a failed experiment, that it is misguided to attempt to describe the process, and that design thinking must be recognized as the purview of the trained designer. Innumerable attempts at explaining the usually less ambitious "user-centered design" have been greeted by similar negative reactions over the years.

Just what is going on here? Why the negative reactions? Sometimes stepping aside to look at comparable happenings in a seemingly different context can provide some insight, so allow me to describe some of what is happening in the world of healthcare.

In today's world of healthcare, a ballooning number of patients seek at minimum full participation in defining their diagnostic/treatment strategy. Why? Because of an outrageous number of medical misdiagnoses, because of what is often an insulting patient experience involving doctors who don't listen to or even bother to touch their patients anymore, because doctors tend to just "regurgitate (knowledge) rather than think" and disregard limits to their knowledge and experience, because a system of referrals and approvals prevents direct and ready access to doctors with needed expertise, ... -- in short, because of a healthcare system declared to be "broken" by speaker after speaker at Medicine 2.0'11 held at the Stanford University Medical Center.

Patient efforts to meaningfully pierce the diagnostic/treatment process have been greeted with claims that patients lack the skills/training to do this successfully, that only doctors can diagnose and prescribe correctly, that anything patients learn via the internet is highly suspect, that reducing diagnosis/treatment to a process in which patients can participate ignores the fact that the practice of medicine is as much of an art as a science, ... -- reasons coming from members of a community (i.e., doctors) classified as a stage 3 (of 5) tribe: "I'm great, and you're not."

You should be seeing a lot of parallels...

In spite of proclamations against greater participation of patients, the "epatient" movement is growing rapidly, with peer-to-peer healthcare increasingly seen as an essential part of a fully functional healthcare system in which social media play vital roles. A Society for Participatory Medicine has been formed as part of this movement "in which networked patients shift from being mere passengers to responsible drivers of their health, and in which providers encourage and value them as full partners." I'm even seeing suggestions of a need for an "Occupy Healthcare" movement. Meanwhile, medical rebels such as Jay Parkinson are showing how a patient-centered healthcare practice can work in spite of active resistance from the medical community, and programs are being designed to train medical students how to listen and talk to patients.

The following observation by an attendee of Health 2.0 San Francisco 2011 speaks to all of this:

And as I write this, the Occupy Wall Street protests are going global. As Thomas Friedman states in The New York Times:

"Occupy Wall Street is like the kid in the fairy story saying what everyone knows but is afraid to say: the emperor has no clothes. The system is broken."

Indeed, the businesses in which many of you work are broken, operating and/or structured in ways more appropriate for an earlier era. Many of these businesses are faced with the need to become genuninely user- or customer-centered and connected/social. To achieve this, design/UX leadership is badly needed. However, as Samantha Starmer warned after learning that design/UX personnel are not the ones getting the many newly created Chief Customer Officer positions:

"Given the current power of CX at the C-level, UX practitioners must step up our game, otherwise we will lose progress we have made to be more deeply involved in strategy beyond just performing usability services. We need to act now to be part of the broader CX solution. If we don't proactively collaborate across divisions and organizational structures, we will be stuck playing in the corner by ourselves. If we don'f figure out how to manage partnerships with other departments in a collaborative, creatice, customer focused way, the discipline of UX as we know it is at risk. CX management will take over."

New social, user/customer-centered businesses are needed. "Citizen-centered" social strategy is needed. And design (thinking) can lead the way.

Describing/explaining the design process for others to understand -- to enable their effective participation -- is essential for this to happen. However, more educational programs akin to that provided by the Austin Center for Design are needed. Perhaps a new professional association -- a resurrection of a sort of Computer Professionals for Social Responsibility -- fully focused on this kind of participatory design would be helpful.

We've reached the point of no more worshiping at the altar of our cathedrals of business. The marginalization of design (thinking) and UX is finally on its way to the rag pile.

It is a very good time to be a design( think)er.

Community manager -- hmm, that role sounds kinda familiar...

Having seen more and more references to a role called "community manager" in recent months, I decided to find out what people in that role do. In doing so, I found out that I had been a community manager -- a very good community manager -- in different contexts for years.

Wikipedia refers to this role as the "online community manager," and the role is sometimes confused with that of the social media manager. Some have tried to clarify how these two roles are distinct, but UserVoice's Evan Hamilton is one of probably many community managers who find themselves performing the social media manager role in addition to others.

Indeed, community managers often play a wide variety of roles, as revealed at a recent community manager breakfast hosted by Evan. Roles played by one or more of the community managers in attendance include:

• helping customers (i.e., the community members) have a great experience;
• trying to get customers to stay customers;
• finding product bugs;
• giving feedback to product managers;
• being a gatekeeper for all customer communications;
• figuring out the right kind of metrics to use to measure their own effectiveness;
• managing social media activity;
• driving the brand voice;
• advocating for users;
• organizing events/contests/...

Attendees reported that they work in businesses of a wide variety of sizes and find themselves positioned organizationally in a wide variety of departments, including marketing, engineering, product, customer service, and sales support. Views varied as to which department community managers should report to, but all thought it best that the role evolve to be a "horizontal, strategic role" touching all parts of the company and that it should eventually include a C-level role known, perhaps, as the Chief Happiness Officer.

All these topics and many more were discussed by ~200 community managers nearly a week ago at the Community Leadership Summit (CLS) West 2012 held at eBay Town Hall in San Jose, CA. CLS West was an unconference with a packed agenda of 40 different sessions, and all attendees were enthusiastic participants.

Why so much attention to the role of community manager? A John Hagel and John Seely Brown blog posting from earlier this week provides one answer:

"Building an effective virtual community is no simple task. Most importantly, it requires a deep understanding of the unmet needs of potential community members rather than simply approaching it as a marketing opportunity for the company. It is no wonder that so many have tried to create these communities and yet so few have succeeded."

However, what is most interesting to me about all this is the similarity of some of the community manager roles and challenges and aspirations to some of the roles and challenges and aspirations of user/customer experience personnel: advocating for users; understanding their unmet needs; helping customers have a great experience; providing input to product managers; figuring out the best location in the organizational structure; evolving into strategic roles; the Chief Experience or Customer Officer; ...

Also of interest to me is how many of these roles and challenges and aspirations are among those which I dealt with in my past roles as a community manager (though I never had that specific title). Having had extensive experience with the world's first online community -- PLATO -- while in graduate school, I developed and oversaw the use of social media tools modeled on PLATO's tools to employees working at Pacific Bell, then became much more of a community manager during the founding and early years of BayCHI. After years of serving the BayCHI community, I became a manager of an international community of community managers in the role of SIGCHI's Local Chapters Chair. In this role, I provided support to (potential) local community leaders in multiple forms, including workshops and articles, some of which remain of relevance to community managers of today. Two examples:

• The Social Design of a Local SIG: this discussion of the key elements of the design of cutting-edge virtual communities is as fitting today as it was in 1997;
• Challenges Facing CHI Local SIGs: (potential) community managers of today can benefit from being aware of these lists of challenges identified by a large international group of CHI local chapter leaders in 1998.

As suggested earlier, user/customer experience personnel also have (had) experiences that should be of interest to community managers. I'd like to someday see a large-scale meeting (of the minds) of UX/CX personnel and community managers to the probable benefit of both communities.

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Note that I've played the role of community manager in another context as well (Co-Editor-in-Chief of interactions magazine), and it is possible that I will be playing the role again in yet another context in the future. Will the label of "community manager" finally be appropriate for me then? We shall see.

Out with the Old, In with the New: A Conversation with Don Norman & Jon Kolko

I've interviewed many people -- individuals and pairs -- on stage, including Doug Engelbart (with Tim Lenoir), Alan Kay, Bill Buxton (once with Cliff Nass, once with Mitch Kapor), Sara Little Turnbull (three times, once with Stephanie Yost Cameron), Clement Mok & Jakob Nielsen, Joy Mountford, Paul Saffo & Jaron Lanier, Alan Cooper, Don Norman (four times, once with Janice Rohn), Bill Gaver & Wayne Gray, and Bill Moggridge. (Transcripts of the only three interviews that were recorded have been published in interactions magazine.) I've also moderated several panels of three or more people.

However, the best of these, for multiple reasons (some very personal), might have been the most recent: a "conversation" with Don Norman and Jon Kolko, which took place at the Academy of Art University (AAU) in San Francisco the evening of September 30, 2011. The ~2-hour exchange with and between Don and Jon and the audience (comprised mostly of AAU students) was particularly engaging, thoughtful, rich, and delightful.

The title I gave to the event was, "Out with the Old, In with the New: A Conversation with Don Norman and Jon Kolko on Trends in the Overlap between Art, Business, and Design."

Topics addressed included the nature of and the difference between art and design, whether design should be taught in art schools (such as AAU), Abraham Maslow, usability, what design (or all) education should be like, the problem with "design thinking" courses, the destiny of printed magazines and printed books, aging and ageism, the relationship between HCI and interaction design, Arduino, simplicity, social media, Google, privacy, design research, the context in which design occurs, the Austin Center for Design, solving wicked problems, whether designers make good entreprenuers, politics, Herb Simon & cybernetics, the strengths & weaknesses of interconnected systems, and how designers should position themselves.

The video of this event appears at bottom of this posting. I encourage you grab a cup of coffee (or a beer), start the video, sit back, and enjoy. For those interested in reading some of what Don and Jon said, here are just a few of the highlights (not necessarily in the sequence in which they occurred during the session):

-------

Regarding the user experience:

Jon:

"Most people attach the experience in which they have received a thing to the thing, which makes it much more important."

"...enjoyable and pleasurable ... and magical and sexual and sensual and poetic -- these are the words I use; ... if you can encourage the more ethereal and fleeting qualities, the rest comes with it."

"Design that is discursive and has a personality -- that is intended to evoke reflection of an end user -- that is the stuff that is succeeding in the market right now, and it doesn't even have to be well-done. That is what consumers are responding to."

Don:

"Usability is important, but it is not the most important thing. There are lots of parts of (the iPhone) that are completely unusable, and you know what? It doesn't matter."

"You can have negative components, and you can have things that are difficult or aren't yet well-finished or well-developed. As long as the total experience is wonderful and your memory is wonderful -- that is what matters."

-------

Regarding the "design thinking unicorn" (as Jon called it):

Don:

"Engineers and MBAs are fantastic at solving problems, but they aren't any good at making sure it is the right problem... The difference between that and designers:" (designers explore and learn and watch people and try things, Don said, via a detailed example regarding the task of designing an automobile)

Jon:

"Now, if you get an MBA, you might take a class called "design thinking," where you will learn a bunch of design methods. You'll learn a method called, "empathy." For 4 days, you learn about empathy, and then you are now certified to be empathetic. Clearly, it can't be that reductive. The problem is not that it is being taught that way; the problem is that the MBA comes out armed with this knowledge and is managing YOU, and making more money than YOU, is YOUR boss, and is telling YOU how to do your job when they don't know how to do it themselves. I've seen that happen a lot."

Don:

"If you really want to be in control of your own destiny, go get an MBA in addition to your design (degree)."

Jon:

"Something that might make more sense is getting a public policy degree, particularly if you want to cash in on whatever this design thinking thing is and applying it in a way that is really impactful."

-------

On Google:

Don:

"Google doesn't understand people -- doesn't understand consumer products; they're all about technologies... They believe in algorithms. They don't care about people. Larry and Serge are brilliant technologists, and they believe they can solve everything with an algorithm... They don't believe in designers -- they believe in testing: we'll see what people like best. What that does is give you design by committee. What is Google's product? The product is not search; the product is not advertising. The product is you. ... They are selling you to their advertisers. Their customers are the advertisers, and their product is you. So they don't care if their products work very well."

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On design research, the context in which design operates, and solving wicked problems:

Don:

"You have to figure out what it is that people need, how people function, how do I put this technology so that it effortlessly fits their needs and functions well, and ideally is also really pleasurable and enjoyable."

"The problem I've discovered -- even though it makes great logical sense: how can you build something unless you really understand the population you are building it for and what people are doing and their needs? -- is there is never time. ...in thinking about that, I decided it was a bad idea to teach people to do design research first, because in reality, you never were allowed to do it."

Jon:

"A couple of things have changed or represent an alternative point of view. I worked at frog for about 4 1/2 years, and when I started, we had a design research practice that was small. When I left, companies were hiring us to do design research engagements -- 4 or 5 hundred thousand dollar engagements -- where all we did was do design research. ...what changed was the relationship between empathizing with end users and building something which resonates on the market, which is different than understanding the problem you are trying to solve. I think there is a subtlety there of 'I conduct design research to understand how a coffee maker works' versus 'I conduct design research to understand what it means for this person to brew coffee,' one of which is more touchy-feely, fuzzy, subjective, and interpretive. ...all of the concerns shared by Don are true, and the anecdote of the product manager saying, 'Yeah, yeah, yeah, next time you can do your great process; this time... you know what to build, just go build it' embraces the corporate structure of quarterly profits, time to market, the artificial race to get product out, build it and iterate on it, fail fast and fail frequently, ... Increasingly, I think those are all wrong, and I think they are really wrong and harmful as well, because you can take design out of the context of business and stick it in other contexts ...such as public policy and social problems... You can stick it in a lot of contexts, because it is a discipline. It is artificially embedded in the context of business, and when it is, you have to embrace the rules of business... You don't have to buy into that, though. And what I've seen is that most of the students that I run into ... don't want anything to do with that, but they don't know any other route. They are told to go corporate or go consultancy, (as if) there is no other choice. But there are a lot of other choices. All those things (Don said) are true, and that is usually the reason the right process is cut. But you don't have to buy that."

"Not all problems are equally worth solving. It seems like we've taken it for granted that every activity within the context of design is worth doing, whether it is a drinking bottle or a microphone or a website for your band. I don't know if that is true, and I'd like to challenge it and would like more people to challenge it more regularly. That is the focus of the Austin Center for Design: problems that are socially worth doing, and broadly speaking, that means dealing with issues of poverty, nuitrition, access to clean drinking water, the quality of education, ... These are big, gnarly problems, sometimes called 'wicked' problems, and it seems incredibly idealistic to think that designers can solve them -- I agree, I don't think designers can solve them. In fact, I'm not sure anyone can solve them, but I think designers can play a role in mitigating them -- a really important role because of all of the design thinking stuff that we've already talked about: the power of that can drive innovations that are making millions of dollars for companies; it seems that that same power can be directed in other ways."

Don:

"I've seen too many designers who think they know the answers to the problems of education or the problems of health or poverty or drinking water in Africa -- it is amazing how many times design students in America are solving the problems of Africa or southern Asia as opposed to the real problems we have in the United States. If you a trying to solve problems in far-away places, you are fooling yourselves if you think you understand the problems."

Jon:

"That is the easy part. The hard part is that you are exporting your value structure, and people don't want it or understand it. We talk about empathy and how it can't be taught in 40 minutes -- empathy is a long-term thing... Right now, I'm on a tear against project-based learning, because every time you have a project, the project ends, and then you go to the next one. That is true in a consultancy, too. But that can't be true if you are talking about affecting the homeless population in San Francisco, because once you form a repoire with someone, if the project ends, you still have that repoire with someone, because they are a real person."

Don:

"My favorite quote is from (H. L.) Mencken, a journalist from the 1930s: 'Every complex problem has a simple answer, and it is wrong.'"

And related:

Jon:

"The research that is done in the (HCI) academic world is focused on appropriating technology in new ways, in clever ways, in new wild and fancy ways... There's a lot of masturbation, for lack of a better word -- gratuitous use of technology just for technology's sake. If you could reign in that intellectual powerhouse, it could actually solve some problems that are worth solving -- it would be pretty incredible."

-------

More advice for designers and design students:

Don:

"You have to be true to yourself. Whether you are working as a lone designer designing chairs, or whether you're working as one of several hundred people on a team trying to (solve) some complex sustainability problem..., you have to be true to yourself. Even if you're one voice of many. If everyone had this view, your one voice gets amplified."

Jon:

"It is the best time in history to be a (good) designer, by any metric..."

Don:

"It is a great time to be a designer, because the technology world is changing rapidly in exciting ways which gives all sorts of wonderful potential. ...it is quite often that when there are economic difficulties, the exciting ideas get started."

"Don't try to be the great name designer. The total number of great name designers will always be just a handful. We need a great many designers; we don't need star designers. A star designer is a nuisance rather than a virtue."

-------

The full ~2-hour video:

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Thanks much to Kathleen Watson, Associate Online Director of AAU's School of Web Design & New Media, who asked me to put together a session of this nature for AAU, and to Lourdes Livingston, Graduate Director of the same school. Thanks also to Susan Wolfe for the first photo appearing in this blog entry; all other still images were taken from the video.

We are planning to do more sessions of this nature at AAU during 2012. To learn of these sessions, follow me on Twitter.

Impact of the role of the Chief Customer Officer

Back in May of 2005, I wrote about the role of the Chief Experience Officer, beginning with Challis Hodge's 2001 description of the role (as first held by Marc Rettig) and culminating in Jeffrey Rapport's 2005 advocation of the creation of the role in modern companies. In mid-2007, I updated the story, describing additional advocations of the creation of the role, a conference panel discussion I led of the pros and cons of the role, and the 2007 highly-publicized hiring of a Chief Experience Officer by Cleveland Clinic.

Forrester Research's initial advocation of the creation of the role in 2006 referred to it as a CC/EO -- a Chief Customer/Experience Officer. Subsequently, the word "Experience" in the title lost favor, and creation of the role of the Chief Customer Officer has taken off. There is even a (somewhat dated) book available about the role and a member-led advisory network of CCO peers.

Who is filling these roles? According to Forrester's Paul Hagan:

"The majority are internal hires who have a significant history at their companies: median time at their firms among those we studied is nearly eight years. A third of the CCOs previously held division president or general manager roles, and almost as many worked in a marketing and/or sales position. On the flip side, about one-fourth of these CCOs formerly held operations positions."

As noted by Samantha Starmer in UX Magazine, UX people are not the ones getting these newly created C-level positions. Plus, all sorts of departments are expected to be scrambling to play a major role in customer experience (CX) moving forward. This has prompted Samantha to warn:

"Given the current power of CX at the C-level, UX practitioners must step up our game, otherwise we will lose progress we have made to be more deeply involved in strategy beyond just performing usability services. We need to act now to be part of the broader CX solution. If we don't proactively collaborate across divisions and organizational structures, we will be stuck playing in the corner by ourselves. If we don't figure out how to manage partnerships with other departments in a collaborative, creative, customer focused way, the discipline of UX as we know it is at risk. CX management will take over."

In her article, Samantha emphasizes the need for UX to partner with marketing, an entity with which UX has had a strained history. Such partnerships have the potential to work wonderfully well, as suggested by the successful merger of user experience research and market research to form a Customer Insights organization a few years ago at Yahoo! (see "User (experience) research, design research, usability research, market research, ..." and "Why Designers Sometimes Make Me Cringe").

Partnership with organizations other than marketing is also important. Successful examples, led by UX, include those described by Secil Watson in "The Business of Customer Experience: Lessons Learned at Wells Fargo" and me (and others) in "Improving the Design of Business and Interactive System Concepts in a Digital Business Consultancy" and "Perturbing the ecosystem via intensive, rapid, cross-disciplinary collaboration."

How do you partner successfully? Genuine collaboration is a key, and the keys to collaboration are many, as I've addressed in past blog entries. See, for example:

• "'Check your disciplines at the door' when beneficial" (also in UX Magazine);
• "Soft skills" & "The need for good facilitation";
• "Breaking silos" & "What to do about those organizational obstacles";
• "Work space" & "Walls";
• "'The three-legged stool of collaboration'";
• "Effective collaboration and fun";
• & "Collaboration sessions."

Learning about other organizations' needs, goals, ways of working, etc. is also key. Take a look at what Misha Vaughn did to enable UX to impact and be appreciated by Oracle's sales force.

All of this and more -- e.g., getting UX moved from a cost center to an investment center (Brandon Schauer, MX 2011) -- may be essential to ensuring UX plays a vital role in the ballooning world of CX and CX management and to getting UX management personnel recognized as among the stronger candidates to fill the CCO role.

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For more, see "Audio and slides for 'Moving UX into a position of corporate influence: Whose advice really works?'", "Ownership of the user-customer experience," and "Where should 'User Experience' be positioned in your company?".

Interactions and relationships

For the Mx (Managing Experience) 2008 conference, I was asked to do a session that addressed the everyday reality that managers of user experience live in, to reflect on that reality, and to share some approaches and ideas for that reality. I decided to focus largely on some of the interactions and relationships that comprise that everyday reality, but particularly those by managers intent on enabling experience research and design to play a strategic role in their companies. I entitled, the presentation, "Interactions and Relationships."

A description of this presentation can be found in my April 2008 posting entitled, "Realities, dilemmas, framings, ..." Here I provide the slides I used, which are rich with provocative insights. Since I've been asked for these slides a lot...

View more presentations from Richard Anderson.

The first 9 slides accompanied introductory remarks that set the context for the presentation. A particularly important slide includes a collage of photos of the managers and executives who made guest appearances at a multi-week course I taught just prior to Mx '08 entitled, "User Experience Managers and Executives Speak." The course was wonderful, as reflected in the glowing course evaluations, and I decided to provide some of my guest speakers with a bigger stage via my Mx '08 presentation.

Slides 10 through 32 were borrowed from my presentation at a little conference in Rome called, "HCI Educators 2008." These slides address challenges experienced by management and non-management experience design practitioners, and you'll find several slides present words of relevance to these challenges from the guest speakers of my course.

The final 33 slides present even more words from the guest speakers -- words of relevance to examples of the ways these managers and executives have framed such challenges in order to address them. Attendees were asked to consider whether such framings would be beneficial in the companies for which they worked.

Enjoy the slides. And my hearty thanks to the managers/executives who "joined me on stage" both during Mx 08 and my course: Jeremy Ashley, Lisa Anderson, Klaus Kaasgaard, Jim Nieters, John Armitage, Christi Zuber, and Jeff Herman.

P.S. The slides AND AUDIO are once again accessible for a related conference session: "Moving UX into a position of corporate influence: Whose advice really works?"

Organizational and market maturity

Jon Kolko and I have been discussing whether the pace of corporate adoption and acceptance of comprehensive and strategic designer participation in business has been increasing. Look for a portion of that discussion in a piece we'll be calling something like "On designers as catalytic agents..." to appear in interactions cafe, our conclusion to the January+February 2010 issue of interactions magazine.

While we were having that discussion, Charles Kreitzberg kicked off a short discussion in IxDA's discussion list on what you need to say to a CEO to convince him or her of the need for "user experience design" in a company. As if all it takes is the right collection of words...

A response to Charles suggested that the maturity of the market the company is in is likely to impact the effectiveness of such a collection of words. And though Jon and I were talking about designer participation in a broader sense -- i.e., beyond user experience design, we discussed the concept of market maturity as well as corporate maturity, both of which have been addressed in numerous discussions over the years and for which numerous scales have been delineated. Since many may not be familiar with those scales, I thought I'd point to a few here.

Actually, I've pointed to a couple already in this blog. In "Developing user-centered tools for strategic business planning," I pointed to Jess McMullin's 2005 "design maturity continuum." Jess updated it a tad in December of 2008 and published the image of this version that appears nearby (click to enlarge). In his December 2008 post, Jess points out that his design maturity continuum is actually additive -- each higher level represents the addition of greater responsibility and scope for design.

Most other corporate scales I've seen are not additive but instead describe different stages organizations (or parts thereof) pass through. The first scales of this nature that I ever saw came from IBM Consulting in the early- to mid-90s and were used to rate the "usability management maturity" of their clients. Two of IBM's several scales, which appeared in little blue books they'd give to their clients, appear below:

HCI Resources

1. Little or no investment in qualified people, prototype/simulation tools, equipment, and/or usability evaluation facilities.
2. Some qualified people are available. There is limited availability of tools and equipment. A usability evaluation facility is available.
3. Sufficient investment made in qualified people/tools. Budget for user involvement exists.
4. Resources are applied effectively at proper stages and levels of the development process.
5. HCI resources are fundamental to the development process and considered essential in planning product costs.

Integrated Design

1. Various aspects of the design (panels, helps, pubs, installation, etc.) are designed separately or added late in the cycle.
2. The need for interdisciplinary design teams is recognized, but efforts are uncoordinated.
3. Plans for integrated design exist and are executed on a selective basis.
4. Integrated design teams are normally established. Teams are effective in improving overall usability.
5. All aspects of design evolve equally and in parallel. Designs provide users with solutions to needs.

In a 1994 book chapter, Kate Ehrlich and Janice Rohn delineated four stages of organizational acceptance of user-centered design. They are described in the table below (click to enlarge) which I took from Timo Jokela's 2001 dissertation.


Variations and extensions of this have appeared in a couple of international "standards," including the 1998 "ISO/DIS 13407 Human Centred Design for Interactive Systems":

0. Need unrecognized
1. Need recognized
2. Considered & encouraged
3. Implemented
4. Integrated
5. Institutionalized

Jakob Nielsen's 2006 version of such a scale -- which I've discussed in two earlier blog entries, including "Changing the pace or course of a large ship" -- combines elements found in all the above scales:

Stage 1: Hostility toward usability
Stage 2: Developer-centered usability
Stage 3: Skunkworks usability
Stage 4: Dedicated usability budget
Stage 5: Managed usability
Stage 6: Systematic usability process
Stage 7: Integrated user-centered design
Stage 8: User-driven corporation

(See "Corporate Usability Maturity: Stages 1-4 and Stages 5-8.")

Other such scales -- older and newer -- exist, but they look a lot alike though they tend to not be accompanied by references to any of the others. One of the more recent examples of these is Forrester's five levels of customer experience maturity, shown nearby via an image from a Bruce Temkin July 2009 blog posting.

Have you found any of these types of scales to be of help to you in places at which you have worked? Have you observed any corporate progressions not addressed in the scales described here that you think should be captured in a scale? (I can think of a couple.)

As for market maturity, the example referenced in the IxDA list discussion should suffice -- the four stages delineated by Jared Spool earlier this year (see "Deriving Design Strategy from Market Maturity: Part 1 and Part 2"):

1. The Technology is Worth the Pain (such as "when a new product category emerges," there are "no competitors or the users have no choice")
2. Building Out the Features (which usually happens "once a competitor joins you in a category" in order to catch up)
3. Focus on the Experience (when "customers stop focusing on new features and start asking for simplicity")
4. Supporting a Commodity (when "the things we're designing are embedded into bigger experiences")

Do such stages of market maturity trump the delineated stages of organizational maturity? Not at all, but they intersect. Consider both when trying to figure out what needs to be done for designers to be more effective and/or to expand their role in a company.