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  IKEA is the largest furniture retailer in the world and a global powerhouse.

  
  
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  The IKEA model offers huge lessons on how simplicity, quality, affordability, and customer engagement, can achieve success across scores of countries and in dozens of languages.

  
  
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  What can our healthcare system learn from the IKEA model? And how can that model both reduce costs and save lives?

US health care is fractured, impossibly expensive, inconsistent in quality, and fraught with misaligned incentives. The medical system is on target to cost nearly 20% of the GDP—1 dollar out of every 5 spent in this country. And our outcomes, according to the Commonwealth Fund, were dead last again in 2014 among 11 similar nations, as they were 4 other times in the last 10 years. The Journal of Patient Safety reported in 2013 that unintended medical harm claims as many as 440,000 lives each year—the nation’s third leading cause of death.

These results come from the way the system is designed. We are getting exactly the results one might expect when everyone plays by the rules, regulations, and incentives of the game. It’s enough to leave the vastly well-intended provider community—those whose primary driver is to take good care of patients—feeling jaded and frustrated.

Imagine then how it feels when you are a patient. Far too often, a chronic or serious medical problem blindsides us—taking us to an alien world where we don’t understand the rules, and outcome and cost are wildly unpredictable. There are no “re-dos.” There is a sad irony in health care: you as a patient are the one with the most at stake, the least “insider” knowledge, and the greatest likelihood of living with potentially devastating consequences of this ignorance and powerlessness.

I learned this the same way most of us who are not medically trained do: when it happened to my family. I was a career news reporter before losing my father in 2006 to complications of a hospital-acquired Clostridium difficile (C. diff) infection that ruptured his intestines. I wondered how it could have happened; why no alarm bells sounded; why my questions weren’t answered. My reporter’s training kicked in—the deep certainty that solutions emerge when we are honest about realities. Since then I’ve worked, at a grass roots and policy level, to (a) understand the world of the patient, (b) understand the landscape in which providers and payers operate, and (c) attempt to bridge understanding between the 2, so they can work in better partnership.

I believe metaphor is a powerful tool to bridge understanding. This led me to use IKEA, the largest and most successful furniture retailer in the world, as a metaphor for fixing health care. Customers have made IKEA the world’s largest furniture retailer. Founded in 1943 by 17-year-old Ingvar Kamprad in Sweden, IKEA owns and operates 315 stores in 46 countries (including 38 stores in the United States). In the fiscal year ending August 2014, 716 million visitors worldwide plunked down 28.7 billion euro ($39.3 billion US dollars). The company published 217 million catalogs in 30 languages—the most widely circulated publication in the world. Today, IKEA founder Ingvar Kamprad, 89 at this writing, lets his 3 sons mostly run the place, but IKEA is still very much a reflection of his vision and values. Kamprad describes the objectives for the Swedish furniture maker’s “democratic design” as the trinity of attractive form, inexpensive production, and high function. That idea, combined with what Kamprad calls “the underdog’s obsession with always doing the opposite of what others were doing,” impelled him and his young, risk-taking associates along a path of constant innovation and experimentation.

Compare this mission to the “Triple Aim” of health care, as described by the Cambridge-based Institute for Healthcare Improvement (IHI), a leading voice in healthcare quality: “Improving the health of the population, enhancing the patient-care experience, and reducing the per capita cost of care.”

Interestingly, whether by accident or cosmic alignment, the goals of good health care have, at least on paper, a striking commonality with the goals of IKEA.

As I researched the company, I found many lessons for both consumer and provider within a context of shared success. Below are the categories in which these lessons emerged, which turned into chapters of If IKEA Designed Health Care: 9 Ways It Would Fix Health Care & Save Lives:

By using the IKEA framework, we’re breaking down the healthcare beast into relatable, digestible chunks. Then we can begin to chew on the countless opportunities to codesign our own medical choices and the outcomes that arise from them. In what follows, we’ll dissect the best practices that turned IKEA into the brand it is today—one that represents self-sufficiency, cost savings, and high customer satisfaction—and identify how these core principles can change our healthcare system.

Lesson 1:

If IKEA Designed Health Care… Instructions would be understandable to a fifth grader

IKEA sells billion of dollars’ worth of assembly-required furniture each year to consumers in 46 countries, in 27 languages. They’ve obviously figured out how to communicate successfully across diverse populations and cultures. How do they do it? IKEA assembly instructions use as few words as possible, with many pictures to illustrate how you put the parts together. Designers work at creating intuitive designs that try to make it obvious how the piece of furniture should be assembled. As author and risk management specialist Dr. David Hillson writes in his white paper The IKEA Approach to Risk, “The goal is to make the task of self-assembly foolproof, so that anyone can construct the furniture correctly by following the simple instructions.”

While few can claim to find IKEA assembly instructions flawless, the premise of universal instruction is key to its global reach—IKEA ensures that its customers will achieve the same results regardless of their native languages or literacy rates.

In health care, payers and providers often do a poor job communicating with those they serve. Currently providers trot out “poor health literacy” as one reason it’s fruitless to invest resources in engaging or educating patients. They are right about one thing: the way we do things now often misses the mark, as seen in these examples:

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  An elderly woman sent home from the hospital develops a life-threatening infection because she doesn’t understand the warning signs listed in the discharge instructions.

  
  
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  A man flummoxed by an intake form in a physician’s office reflexively writes “no” to every question because he doesn’t understand what is being asked.

  
  
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  A young mother pours a drug that is supposed to be taken by mouth into her baby’s ear, perforating the eardrum.

These examples, provided to The Washington Post by healthcare workers or patient advocates, illustrate a pervasive and underrecognized problem in the United States: America’s alarmingly low levels of health literacy. About 36% of US adults have “basic” or “below basic” health-literacy skills.

According to the National Action Plan to Improve Health Literacy, “Two decades of research indicate that today’s health information is presented in a way that isn’t usable by most Americans. Nearly 9 out of 10 adults have difficulty using the everyday health information that is routinely available in our healthcare facilities, retail outlets, media, and communities.”

Without clear information and an understanding of prevention and self-management of conditions, people are more likely to skip necessary medical tests. They also end up in the emergency room more often, and they have a hard time managing chronic diseases, such as diabetes or high blood pressure. Studies link poor health literacy, which disproportionately affects the elderly, the poor, and recent immigrants, to higher rates of hospital readmission, expensive and unnecessary complications, and even death.

The problem goes even deeper than that.

Furthermore, people who have difficulty reading or understanding health information are sometimes ashamed. They often hide the problem. In addition, low literacy isn’t obvious. Researchers have reported poor reading skills in some of the most poised and articulate patients.

This litany of failures not surprisingly adds up to higher costs. A 2007 study at the University of Connecticut says the cost to the US economy is as much as $238 billion a year.

Practical Tips and Tricks

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  Assume everybody has a literacy problem. A process now gaining ground called “teach-back” engages the patient in a 2-way conversation, with promising results. This method debriefs the patient to determine what he or she understands and ensures he or she has an action plan following discharge. The premise is akin to when we were school students: we resolve questions while we’re in class with the teacher, so we can be successful later doing our homework (incorporating the learning).

Such a simple, low-tech teaching tool worked beautifully at the Mayo Clinic. From its website:

Victor Montori, MD, an endocrinologist at the Mayo Clinic and lead investigator of the study, recommends using this tool as a decision aid to spark conversation between physicians and patients about medication. It consists of an easy-to-follow guide with answers to 4 questions tailored to individual patients:

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   What is your risk of having a heart attack in 10 years?

   
   
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   What are the benefits of taking statins as compared to not taking statins?

   
   
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   What side effects can you expect from statins?

   
   
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   What do you want to do now?

“Conversations with patients about prescription medications tend to be brief and incomplete, but we found that when a decision aid was introduced, it was the start of a conversation in which the patient, now better equipped with information—felt empowered to participate in deciding whether a statin would be appropriate for them,” Dr. Montori says.

Patient-focused events such as teach-back, good hand hygiene, and making sure patients always know who is in charge of their care are gaining momentum as so-called “always events.” (This is in contrast to “never events,” such as infections and wrong-site surgeries, a label that has dominated the language of healthcare quality improvement.) Stefan Gravenstein, MD, clinical director at Rhode Island–based Healthcentric Advisors, whose work with teach-back has won national attention, says we can do teach-back better. “Even better than ‘ask-back’ would be if the patient or caregiver would ‘write-back.’ In other words, write down what they think they are supposed to do, even if it is already printed for them.” This would be akin to the student taking notes about homework while in class, to prompt his memory later.

The Institute for Safe Medication Practices puts it this way: Patient education requires a new approach—assume that everyone has a literacy problem. After all, people at all literacy levels prefer simple, straightforward instructions and written materials. Whether you’re filling in a form or talking with a patient, here’s what they say works:

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  Offer small amounts of information at a time. First, tell patients what they truly need to know to follow directions. Emphasize desired behavior, not the medical facts.

  
  
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  Provide written materials at a fifth-grade reading level or lower. Use clear captions, ample white space, and pictures, diagrams, or videotapes to help explain concepts. Most people, even those who read well, depend on visual clues to reinforce learning and spark memory.

  
  
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  Involve patients. Use focus groups of patients to help write personally relevant and culturally sensitive education materials. After they understand the information, ask patients how you should explain it to others.

  
  
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  Verify that the patient understands. Avoid asking yes/no questions and instead ask patients to show and tell you how they would take their medicine so that you can spot problems. (This is what teach-back is about.)

  
  
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  Keep your eye on evolving technology. New tools take the guesswork out of communicating: talking prescription labels (Talking Rx from Millennium Compliance or En-Vision’s ScripTalk); pill bottle caps, connected through technology to our pharmacy to remind us to take our medicine (rxvitality.com); recording devices for prescription instructions (ASKO Corporation’s Aloud); and electronic pill organizers and reminders (e-pill, epill.com) are now being tested or are already on the market.

Until those patients who consume the most healthcare resources are more engaged users of technology, our best hope to move us forward with patient engagement is to meet patients at their own level, to go where they are—not where we want them to be, or where it’s convenient for them to be. That means approaches and technologies that embrace and do not intimidate them.

As a business like IKEA extends its reach around the globe, and the wider and more diverse its customer base becomes, the more critical it is that products, instructions, store layouts, websites, and everything it produces embody this consistency, simplicity, and intuitiveness. That should be top of mind for those designing healthcare products, handouts, hospital buildings, and even exam gowns—everything that touches patients.

Lesson 2:

If IKEA Designed Health Care… We’d get tools for success when we walked in the door

Why does IKEA invest in providing customers with bags, catalogs, measuring tapes, pencils, lists, maps, and carts—before they even walk onto the showroom floor? Because they want them to have tools for success: to accomplish their goals and to have satisfying, stress-free experiences (which in turn facilitates satisfaction, sales, and profits). IKEA designs its tables, bookcases, and even sofas so you can put the whole thing together with a simple Allen wrench. Then they make sure you have the Allen wrench: it’s sealed in the carton. And there’s a supply of twine at the loading dock to secure items to the roof of your car. (Imagine millions of IKEA customers every day fumbling around for paper and pencil, store map, Allen wrench, and twine!) IKEA has clearly thought through not just how to design, manufacture, pack, ship, and present products you’ll want, but how to make tools available for you where and when you need them. They are your partner in maximizing your success not just while in the building, but once you’ve left the store.

In contrast, think of the hospital patient. As a marketing executive at a major hospital group described to me a couple of years ago, “There are 2 groups of people in this country who enter big institutions and are forced to hand over to strangers all their personal things, stripped of everything that gives them identity and comfort: their clothes, wallet, jewelry, shoes, and underwear—even their eyeglasses and dentures. One group is prisoners. The other is hospital patients.” If there’s a more disempowering experience a person can go through, I can’t imagine it. We are totally at the whim of others for health, food, water, bathroom, information, and attention. How easily we can become convinced we don’t matter that much. And this is just the introductory phase of our stay. Once we’re “in the system,” the environments we live in can be even more disempowering.

“Smart people can sometimes be remarkably stupid,” said the late designer and architect Michael Graves.

You may remember Graves as the guy who for 20 years brought sleek, affordable design to everyday items we can buy at Target (such as a teakettle or a telephone). In 2003, a rare illness left him paralyzed from the chest down. He was thrust into life in a wheelchair—and into a world of bad design. (He often told the story of lying on a hospital gurney after a night of excruciating pain, thinking only, “I don’t want to die here… because it’s so ugly.”) Spending 3 years in 8 hospitals and 3 rehab centers, trying to adjust to life in a wheelchair, inspired Graves to design better tools for patients. “They didn’t make big mistakes… they just made the most frustrating mistakes you could ever imagine, and made your recovery more difficult. Your room should make it easier for the physicians and the aides and the patient. But instead it does just the opposite.”

At a rehabilitation center, for instance, Graves wheeled himself into the bathroom one morning. When he reached for the sink faucet for hot water, the handle was out of reach. So was the toothbrush and toothpaste. He looked for an outlet for his electric razor. The outlet was near the base of the wall near the floor—also out of his reach from the wheelchair. The biggest aggravation, he said, was that the rehabilitation center was built for people in wheelchairs. “When I went through some of the struggles that were caused by my room, I lost the self-empowerment that I was supposedly gaining during the days in rehabilitation,” said Graves. “I was no longer self-reliant, but dependent. This makes you feel terrible as a patient—as a paraplegic. You’re feeling at the will of others.” He stayed at one glossy, new hospital with a 4-story glass atrium and expansive lobbies. But that hospital’s patient rooms were so small that those in wheelchairs and hospital employees had a hard time maneuvering.