Tragic Design

Chapter 1. Introduction

The Interface that Killed Jenny

Stories of deaths caused by badly designed interfaces, objects, or experiences are everywhere. One, in particular, inspired us to write this book.

Jenny, as we will call her, was a young girl diagnosed with cancer. She was in and out of the hospital for a number of years, then was finally discharged. A while later she relapsed and had to start a new treatment with very potent medicine. This treatment was so aggressive that it required pre-hydration and post-hydration for three days through intravenous fluids. After the medicine was administered, the nurses were to be responsible for entering all the required information into the charting software and using this software to follow up on the patient’s status and make appropriate interventions.

Although the attending nurses used the software diligently, and even though they cared very well for Jenny in every other way, they missed the critical information about her three-day hydration requirements.

The day after her treatment, Jenny died of toxicity and dehydration.

The experienced nurses made this critical error because they were too distracted trying to figure out the software. Looking at screenshots (see Figure 1-1) of the software they used is infuriating. It violates so many simple and basic rules of usability, it is no wonder why the nurses were distracted. First, the density of information is so high that it’s impossible to scan for critical information quickly. Second, the colors selected, aside from being further distracting, prevent any critical information from being highlighted. Third, any critical treatment or drug information should receive special treatment so it is not missed, which is not what we see in this interface. Lastly, the flow of recording the information after each visit, known as “charting,” requires too much time and attention to complete in a timely manner.

Figure 1-1. A screenshot of the Epic charting software used by many hospitals in the US (source: http://www.clientscorner.com/informaticslearning/scenario01.php)

As design professionals, learning about these stories is heart-wrenching. How can a critical, life-or-death service be employing such horrible software? Isn’t a person’s life and well-being worth putting the appropriate resources into good design? It’s almost impossible not to ask ourselves if we could have made a difference in preventing Jenny’s death, had we been involved in the design process.

Healthcare in the United States is facing a crisis. In 1999 a landmark report titled “To Err Is Human”^[1] concluded that 44,000 to 98,000 people a year die from medical errors, at a cost of $17–29 billion per year. A more recent study puts the estimate at 100,000–400,000 deaths per year.^[2] Here’s a quote from the latter:

In a sense, it does not matter whether the deaths of 100,000, 200,000 or 400,000 Americans each year are associated with PAE (Preventable Adverse Effects) in hospitals. Any of these estimates demand assertive action.

Jenny’s story is, unfortunately, not uncommon. These situations happen every day, and not only in the US. However, it’s important not to blame the nurses, or we miss the entire context that led up to these grave mistakes. There’s a concept used in the healthcare field called the Swiss Cheese model of accident causation. This model (see Figure 1-2) compares human systems to multiple slices of holed cheese.

There may be multiple layers to pass through before a mistake affects the patient. For example, when there is a medication error, the source of the error can occur in any of these “layers”: the doctor’s prescription, the pharmacist filling it, the medication being stocked correctly, the nurse preparing and giving it, and the mechanism used to administer it to the patient. Each layer has its own holes (flaws in the preventative measures), but together they reduce the chances of an error happening. In our example, nurses were the last layer of defense, so it’s easy to blame them for the mistake that happened. But in fact, interface design should act as the last layer in that model. It usually accomplishes that by reducing the cognitive load required to complete a task, thus allowing more resources to be dedicated to error prevention. Unfortunately, in the healthcare industry, it instead leads to making more holes.

Figure 1-2. The Swiss Cheese model of how errors can make it through many layers of imperfect prevention methods

Cognitive capacity is the total amount of information the brain is capable of retaining at any moment. This amount is limited and can’t be stretched. In the case of Jenny, the software was most likely overloading the nurses’ cognitive capacity by forcing them to figure out how to use the interface to chart the patient’s care and make the appropriate orders. Nurses (and all medical staff, really) are working in an environment and with tools that are working against them. With thousands of medical errors happening every year, it is apparent that there is more to this problem than negligence. The system is broken, and design should be doing its part in repairing it.

It is important to note that a better user interface alone is not the solution. Since it’s our area of concern, however, we should study its role and improve that layer as best we can. Technology and design in healthcare should be used as a protective layer, to ensure mistakes don’t happen. In the case of Jenny, technology was instead a key factor in a tragic error.

The Role and Responsibilities of Designers

If you ask 10 designers what their role is, chances are you will get 10 completely different answers.

Design, as Jared Spool so succinctly put it, is “the rendering of intent.”^[3] While that is a very correct, logical, and concise way of boiling it down, for user experience designers it misses one important element: people. We would define design, especially in the sense of designing products and software people will use, as “the planning of a product’s interaction with people.”

Good designs are the ones that are transparent, delightful, and/or helpful. Therefore, bad designs are the ones that collide with human behaviors and cause undesired friction. When we create things without the end users in mind (or with some vague sense of them as customers), we almost always end up creating bad designs. Badly designed products serve their creator (or sponsor) first and the users second. Good design attempts to understand the intended users and create an experience that serves their needs. A good design is a worthwhile one; one whose existence isn’t a burden on its users, but instead makes their lives better in some way. Fortunately, good design isn’t just a bunch of goodwill and pleasant feelings—it’s good business too. Spending resources on design is a worthwhile investment. Some professionals go as far as saying that every dollar spent on user experience brings up to $100 in return.^[4] If one product serves its creator first and its competitor serves the customers, then it’s most likely that the customers will choose the latter. In today’s technology landscape, it’s easier than ever for competitors to match features and scale up to millions of users. Thus, user-centered design, because of its accessible nature, becomes the main differentiator.

The Client Paradox

Designers often, and rightfully, claim credit for the success of a product. Wouldn’t it be fair to blame them for unsuccessful products too?

There are many blogs that specialize in cataloging examples of bad design. When we witness such examples, it seems natural to blame the designers (and laugh, let’s be honest) for their poor work, lack of empathy, or basic skills. However, this doesn’t paint the complete picture. The reality is often that the designer answers to a client. Tim Parsons, in his book Thinking Objects: Contemporary Approaches to Product Design (AVA Publishing), criticizes this aspect of the design practice. The paradox comes from the fact that designers aren’t always in charge, since they get paid by a client that has a vision, business needs, objectives, etc., and not by the users that will end up using the design. This places the designers in a rather awkward position. We have heard countless times, “I ended up doing what the client wanted.” Unfortunately, there is no magical solution to this issue.

When commissioned with a project that “feels wrong” to them, designers should do everything in their power to educate their client. It might take more time, but the responsibility falls on them. If they have the means, they can simply refuse to do the work, but that is quite idealistic, and we understand that only privileged designers and design firms can take such a drastic stand. Moreover, if one refuses to do the work, a less scrupulous designer may end up doing it, and probably cause even more damage.

We know that, at some point in our careers, we all have to make tough calls. Sometimes we have to choose our client’s needs over the users’ needs. When this is acceptable and when it is not is a difficult line to draw. Many occupations have established codes of ethics that are taught in school and enforced by their professional orders. These guiding principles help in making fair decisions in complex situations, while protecting the clients, the users, and the professionals doing the work. Several codes for graphic design exist, but none are widely distributed or enforced. While the International Council of Design’s model of a code of conduct (http://www.ico-d.org/database/files/library/icoD_BP_CodeofConduct.pdf) is a good start, we feel it’s incomplete and won’t help in making a fair decision in many of the situations cited in this book. The best code of conduct, in our humble opinion, was written by a group of students and professors and is called “Ethics for the Starving Designer” (http://www.starvingforethics.com). The first principle is a great starting point:

Finding the most ethical course of action will sometimes be difficult, but that difficulty will not deter me from striving to find the most ethical solution to any problem I may encounter. If I find myself in a situation where I have made a decision that I am unhappy with, I will instead endeavour to make an ethical decision for myself and for others in the future. While some circumstances may force me to compromise at times, I will not resign to turning to compromise in future situations, and will face my next ethical decision with a renewed determination to find the best outcome.

Every designer should write down what they stand for, what they think is acceptable or not. Having this “will never do” list will help you make difficult decisions when they arise.

Understanding and Identifying Hidden Costs

Often, those of us who are passionate about technology get caught up in the science and exploration of it. We gawk over all the possibilities it enables, and rarely stop to think about the “why” of it. We are responsible for what we bring into this world, in the same way that parents are responsible for their children. Yet we often create at a whim, chasing the next idea, the next dollar, the next trend. Asking if what we are building should even exist is important not only from a philosophical or moral standpoint, but also from a business perspective. Furthermore, we must ask ourselves: is our success coming at a hidden cost? For some companies that might be at the cost of the environment; for others, it can be at the cost of their own employees’ well-being or their customers’ trust. We are often fooled into thinking that what we made was successful, when in reality the cost is hidden or externalized. Failing to identify all of the hidden costs and the impact of our designs on the world around us can lead us to blindly and unintentionally cause harm to others.

In order to identify and avoid these potential hidden costs, we suggest creating lists of “goals,” “non-goals,” and “anti-goals” (also called “hazards”). They can be added to the product brief or creative brief, if your company uses these. While the concept of “goals” is pretty straightforward, the two latter sections are rarely found in product design briefs. The list of “non-goals” aims at setting objectives that are explicitly out of scope for the current effort. While this might sound unnecessary, in our experience there is value to being explicit about things that are out of scope, in case there is ambiguity about the boundaries around one or more goals, or any tendency toward “scope creep.” The third section, “anti-goals,” is used to describe things you really, really don’t want to happen. This section should be followed by descriptions of how you will make sure the anti-goals don’t happen, with precise test objectives. We call these “safeguards.”

For example, here’s what a brief for a new subscription page on a website might look like with the three types of goals outlined:

• Goals (this feature will):

  • Allow customers to sign up to the service.

  • Make the subscription flow seamless to make sure we don’t lose conversions in the process.

  • Highlight all the benefits of our service by comparing them to our competitor.

• Non-goals (this feature shouldn’t):

  • Impact the content on the home page.

  • Change the login and password validation.

  • Impact the first page seen once logged in.

• Anti-goals (this feature will not):

  • Confuse the potential customers with a hidden pricing structure.

  • Hide the fact that the service charges automatically unless they unsubscribe from it.

  • Make the cancellation flow more complex.

  • Have an impact on the amount of customer service tickets.

• Safeguards:

  • We will test that the potential customers understand the pricing structure and the subscription model before they sign up. We will do this through user testing.

  • We will monitor customer service calls and will offer modifications to the page, should we notice confusion.

Conclusion

Without good design, technology quickly turns from a help to a harm. It can kill, but that isn’t the only negative effect. It can cause emotional harm, like when a social app facilitates bullying. It can cause exclusion, like when a seeing-impaired person doesn’t get to participate in socializing on a popular website because simple accessibility best practices have not been attended to. It can cause injustice, like nullifying someone’s vote, or simply cause frustration by neglecting a user’s preferences.

Designers are gatekeepers of technology. They have a critical role to play in the way technology will impact people’s lives. It is up to us to ensure the gates are as wide open and accessible as possible.

In the following chapters, you will read testimonials from people generously recounting how technology impacted them negatively. We also have interviews with great designers who all try, in their own way, to benefit society through their work. We will dig deep into stories of how bad design interferes with people’s lives in very real ways. We will explore extreme examples, as well as more common ones that designers may face in their careers. While we do our best to add practical pieces of advice about how we can tackle these difficult issues, we don’t claim to have all the answers. Our main goal is to shed light on these areas, to call attention to how bad design affects people’s lives. That’s the most important step to solving any big problem: highlighting it.

Key Takeaways

1. Blaming the last people involved in a process for making a costly mistake is not productive. They are generally just one of the multiple layers of the Swiss Cheese model.

2. Good visual design reduces the cognitive load required to complete a task.

3. Badly designed products serve their creator (or sponsor) first and the user second.

4. Designers are not always in charge, since they often answer to a client. When confronted with design solutions they are not comfortable with, designers have the responsibility to educate their clients.

5. Hidden costs often fool us into thinking that what we made was successful, when in reality the cost is hidden or externalized. Failing to identify all of the hidden costs and the impact of our designs on the world around us can lead to blindly and unintentionally causing harm to others.

6. Designers are gatekeepers of technology. They have a critical role to play in the way technology will impact people’s lives. It is up to us to ensure the gates are as wide open and accessible as possible.

Interview with Amy Cueva

The following is an interview with Amy Cueva, Founder and Chief Experience Officer at Mad*Pow. Mad*Pow is an award-winning agency that works with a wide variety of companies ranging from Fortune 500s to startups. It organizes a yearly conference for healthcare design called HXD and is located in Portsmouth, NH.

1. How do you see bad design affecting healthcare?

There is plenty of bad design in healthcare. As an industry, it lags in its acceptance of and investment in design. Design problems manifest through visual design, interface design, information design, and usability. But the biggest issues are systemic and experiential in nature. Examples of those issues include:

Electronic medical records (EMRs)

The need to interact with an EMR takes a lot of time and also creates a physical boundary and distraction between the patient and the doctor, removing the humanity from the interaction and making it more transactional in nature. EMRs are essentially the interface to a database of medical information on a patient.

Health insurance plan selection (US)

People have a hard time figuring out which plan is right for them because they are comparing plans based upon terms they don’t understand or that are difficult to put into context. It is hard to discern what your overall cost and quality of care will be with one plan vs. another plan.

Silos and aversion to risk

Health organizations are siloed inside themselves and among themselves. This inhibits the collaboration that would lead to better designsfor an improved health experience. Health organizations have been built to avoid risk, but in order to innovate a small amount of risk is necessary to explore new concepts and test them. This involves a culture shift that is difficult, and takes time.

Decision support and interventions

We have reams of data around the treatments that are most efficacious and the care pathways that will work best. We talk about big data, but we struggle to get the right information to the right person at the right time. This is a design problem, but also a technology and organizational problem.

Prevention is difficult to monetize

[The US] healthcare system is mostly sickcare. The system is designed to care for people once something happens to them, not work with them to prevent something from happening. Prevention is an investment, and one many organizations are not willing to make because there is no immediate profit to be had or it is deemed to be someone else’s problem. Now that the healthcare system is getting to the crisis point it is becoming a problem for all of us.

2. How do you think design will be able to change healthcare?

I believe that human-centered design will inspire our direction, fuel business innovation, and deliver positive human impact, helping us to improve the experience of health. I believe design and designers play an essential role in improving the experience of health. As designers we advocate for the people who will be affected by our designs, we are engaged by our empathy, we envision a better future, we paint the picture for everyone to see, and then we bring people along with us to make that future a reality.

We need to make the customer, the patient, the person the focus of our efforts, because right now they are left to navigate a very disconnected ecosystem on their own. The health system functions but does not get as close to whole health as we would hope possible considering our human capacity to care, connect, and innovate. But we can move beyond the transactional. We can build trust with those we serve. We can be there when they need us most. We can begin to become their partner throughout their health journey, tracing their path through the ecosystem, identifying unmet needs and organizations that have shared objectives. We know that silos exist both inside and outside of our health organizations, but I believe that new forms of collaboration will help us to break down walls and will lead to unprecedented innovation and unimaginable results.

New partnerships and shared services will help us start to break down walls and address the pain points and unmet needs present in the current health ecosystem.

3. How can designers help?

Designers can help by understanding the needs of the people they are designing for as fully as possible and advocating for those people. Designers can connect the experience that will be of most benefit to the people the organization serves back to the organization’s purpose, making the business case for investing in it. Designers can make the risks associated with bad design and the benefits associated with good design clear. Designers can practice human-centered design methods and invite others to the table to participate so that their eyes can be opened to the efficacy of the approach.

Designers can follow, contribute to, and relate aspects of the Designers Oath (http://www.designersoath.com) to the focus of their organization. Designers can scan the ecosystem for organizations that have shared objectives and explore how those organizations or other existing information, resources, or services could be integrated into the solution.

Designers are engaged by their empathy, envision a better future, and paint the picture for others to see. Designers serve an essential role of imagining and illustrating that there is a better way and can get people excited to blaze that new trail together.

4. How can the layperson help?

The layperson can make it their business to know what an organization stands for—what is its purpose beyond profit, and how that organization brings that purpose to life in all that it does. Then they can make decisions around who to do business with based upon how the organization’s purpose aligns with what they are passionate about as individuals. A layperson can ask an organization how it involves patients, customers, people in the creation and improvement of its processes, policies, and systems.

5. What role does design have in making the world a better place to live?

Customer focus and empathy-inspired design is not idealism, it is good business—and a practice that can also deliver positive impact at the societal level. In her [2015] Harvard Business Review article “Corporate Empathy Is Not an Oxymoron,” Belinda Parmar says, “There is nothing soft about it. Empathy is a hard skill that should be required from the board-room to the shop floor.” And this empathy will inspire how we design our products, services, partnerships, and organizations. It is an experience economy. Organizations in other industries have realized this. In financial services, for example, it is not about just selling products and services or enabling customers to complete self-service transactions easily; it is about the relationship the people have with the organization and the perceived benefits of that relationship. Imagine the potential here, if a large national bank helped its customers save 5% more. That would be of benefit to that bank, and of course to those individuals, but it would also have tremendous impact on society as a whole.

As organizations operationalize their purpose, we will see the Corporate Social Responsibility and Customer Experience disciplines converge. And it goes beyond the marketing message or the advertising campaign; purpose-driven companies will build momentum and traction around their purpose by weaving it into all business functions and gain competitive advantage as a result. It isn’t enough to make a profit anymore. This calls us to move beyond the standard boundaries that have defined our organizations in the past.

We see these boundaries begin to shift as insurers aim to help their members get healthier and not just be their “adjudication partner” and as pharma companies explore digital “therapies” in addition to drugs.

Profit can be delivered with consideration for customer needs and motivations and without taking advantage of them. A decided understanding of how the decisions an organization makes will impact society, unintended consequences, and associated ethics will be required.

Consumers are more and more aware of the impact corporations make on society every day and it is informing the decisions they make around who to do business with. Impact-focused organizations will align with the passions of their customer base and will thereby be differentiated in the marketplace. This stance requires taking the long view, an understanding of long-term impact and not just short-term returns.

6. What can designers add to their process in order to avoid causing harm in this way?

We can become students of the problem, inclusive in our approach. In getting outside the four walls of our typical environment and getting face time with the people we serve we can come to a deeper understanding of what will drive real meaning and value in the context of their lives—what will truly motivate, engage, inform, guide, and comfort. Humans are complicated. The richness of detail in the story provides us with both information and inspiration.

Clayton Christensen discusses the importance of theories in guiding disruptive innovation and points out that “it is by understanding the people we serve in the present that we construct a theory about the future.” Ethnographic research, where we talk with and observe real people in their “native habitat,” helps us to develop a rich understanding of current problems and unmet needs such that we can create solid theories that will guide our efforts moving forward. In addition, it activates our empathy and provides needed inspiration for our creativity. For example, if we want folks managing chronic conditions to not use the ER as their primary care office, have we been in the ER and spoken with people there or are we making assumptions around why they are there and how the situation might be improved?

Integrate empathy-building activities into the process and start to focus on empathy as an organization. We can encourage stakeholders at our organizations to get involved in ethnographic studies, participatory and collaborative design methods, and validation activities like usability, usefulness, desirability, and efficacy testing. Companies that do this on an ongoing basis will receive the rich information that will guide experiential improvements for years to come.

Through research we come to understand emotion. Emotion will show us where we need to focus, where we are doing well, and where we need to improve. The emotions of the people we serve matter. They affect the trajectory of their path forward. Not just the emotion of the people we serve, but our emotion as well. We need to allow ourselves to feel. Emotion moves us beyond cognitive knowing to visceral knowing—that gut feeling we get inspires our curiosity, powers our imagination, enhances our wisdom, leads us to take action, and motivates us to persevere.

We can consider the full range of emotions and situations people will bring to their experiences via personas. In walking in the shoes of the people we serve we can explore how to make things better for them. Personas can contain not just demographic information, but also behavioral, psychographic, and emotional information. Personas can guide our teams in making decisions about the experience, but personas alone are not enough.

We can formulate a “hierarchy of needs” based on research insights to focus our experiential efforts and measure our performance. For example: Trustworthy—I got the information and utility I needed at every touchpoint I needed it; Easy—This company, product, or service is easy to do business with; Kind—I felt like they were considering my needs and that I was treated well; Meaningful—It was meaningful to my life, I achieved a greater outcome or received an unanticipated benefit; Very Cool—Wow, that was actually very cool.

Many in our industry suffer from “shiny object syndrome,” where we oftentimes want to jump to very cool without having delivered trust, ease, kindness, and meaning. We can audit the ecosystem of interaction, examining each touchpoint from the perspective of each persona and their hierarchy of needs, starting at the bottom and working toward the top.

We can scan the marketplace to understand what other solutions and entities are in the picture and figure out how to integrate with them or cooperate with them and be aware of them so that we can start to connect elements of the experience together on behalf of the patient. We can audit present experiences and future state theories against the organization’s purpose beyond profit as well.

The experience is a byproduct of how we are organized internally to deliver it. If we are a mess on the inside, the resulting experience will be a mess as well. It isn’t enough to imagine an amazing experience. We also need to bring that experience to market. In order to deliver exceptional experiences, we will need to help our organizations transform themselves into being empathy driven and customer focused in all they do. We will continue to investigate models for communicating the benefits of empathy-inspired design to executives and decision makers, immersing them in the process, and providing them with essential training, methods, and tools to aid their efforts. And training does help! Telefonica Germany was able to see a 6% improvement in customer satisfaction within six months of implementing an enterprise-level empathy training program.

In the HBR article I mentioned earlier, “Corporate Empathy Is Not an Oxymoron,” Belinda points out that empathy can be measured, but also that “Serious people will regularly dismiss empathy for the more concrete and defensible virtues of rational analysis.” I would argue that rational analysis does not supply the richness of inspiration that empathy and human-centered design do—inspiration that will fuel both experiential and disruptive innovation. But don’t stop with measuring your organization’s empathy. Consider how to measure performance on the customer hierarchy of needs and the organization’s purpose. Create incentive programs and bonus structures that stem from these measures. Many companies have found that when incentive programs aligned with customer-focused measurements, rapid improvements were achieved in short order. One company that we work with has assembled an interdisciplinary team that evaluates whether business decisions will have a positive, negative, or neutral impact on the customer experience. If the anticipated impact is negative, there is an escalation path available to remedy the situation. Decision-making frameworks can help, but avoid creating a culture where numbers strip the humanity out of the decision-making process.

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^[1] Kohn, Linda T., Janet M. Corrigan, and Molla S. Donaldson, eds. “To Err Is Human: Building a Safer Health System.” Washington, DC: The National Academies Press, 2000.

^[2] James, J. T. “A New, Evidence-Based Estimate of Patient Harms Associated with Hospital Care.” Journal of Patient Safety 9:3 (2013): 122–128. doi:10.1097/pts.0b013e3182948a69

^[3] Spool, Jared M. “Design Is the Rendering of Intent.” UIE, December 30, 2013, https://articles.uie.com/design_rendering_intent.

^[4] Spillers, Frank. “Making a Strong Business Case for the ROI of UX [Infographic].” Experience Dynamics, July 24, 2014, http://bit.ly/1t6a1rk.