The UX Design of Caring for Veterans

Earlier this year, America was stunned to hear of the terrible treatment of veterans at the famed Walter Reed medical center. Whatever any of us think of the wars in Iraq and Afghanistan, there is consensus that injured veterans should receive the best possible care.

On the heels of the scandal, President Bush convened a panel of experts, led by Bob Dole and Donna Shalala, to investigate the matter. Their report, released earlier this week, revealed an unexpected surprise. To get inside the problem, the commissioners took an unconventional approach: they assumed the perspective of the patient.

The President made note of this fact at his press conference:

They took a very interesting approach. They took the perspective from the patient, as the patient had to work his way through the hospitals and bureaucracies. "WhiteHouse.gov":http://www.whitehouse.gov/news/releases/2007/07/20070725.html

Charged with investigating a crisis spanning some of the largest bureaucracies in the world, Dole and Shalala led one of the most important pieces of user research done in recent years.

To quote from their final report (PDF):

Our recommendations are few, but they are actionable. They are based on the priorities of patients and families. Essentially, our recommendations hope to accomplish three goals: To serve those injured in the line of duty while defending their nation, to support their recovery and successful rehabilitation and to simplify the sometimes overly complex systems that frustrate some injured service members and their families and impede efficient care.

To see immersive user research succeeding at this level is truly inspiring. Looking closely at its components, it clearly offers a case study for designers of all variety embarking on large projects in unwieldy organizations.

Reinterpret your mission

The objectives of the project were defined by the White House in an official "Charge to the Commission." Like many project charters, the goals were defined in the language of the client. The White House uses words like "effectiveness" and "coordination." They want to know how they can provide "high-quality" service.

But what do all of these buzzwords mean? What can you do to really dig into the problem if your starting point is this kind of lingo?

You reinterpret your objective.

It is almost cliche\xC3\xC5 now to find examples of a wounded Marine having initially been treated by a Navy Corpsman, find himself medevac\x82\xC4\xF4ed by an Army helicopter to undergo emergency surgery at an Air Force Theater Hospital. Air Force LtCol Andrew E. Moore

To put it another way, the individual soldier, sailor, or marine doesn't care what uniform the doctor struggling to save his or her life happens to be wearing.

Beginning with this premise, the Commissioners turned their charge on its head. Their mission wasn't to assess the organizations and their "effectiveness," it was to assess the whole experience of soldiers as they interact with a number of sprawling organizations.

Choose your research methods carefully

In a few short months, the nine members of the Commission visited a variety of treatment facilities, met with service members and their families, and distributed a nation-wide survey that received a thirty-percent response rate. In addition to employing their own methods and relying on the unique strengths of their team, they also evaluated the findings of earlier commissions.

When pressed for time, it is essential to use carefully targeted techniques to gather new information, while also looking to old assessments for additional information. Just because the last set of research findings were left in a storage room doesn't mean they can't offer solutions to current problems.

Redefine the problem

With the experience of wounded soldiers as their starting point, the Commissioners identified and defined where the system was failing and where it was succeeding.

A significant finding was that the first touch-point of a wounded service member's experience was very successful. Individual patients were impressed by the battlefield medicine they received. The military was also pleased by the success rate of battlefield medicine, and how the speed of evacuation increased the survival numbers of service members with serious injuries.

In the Vietnam era, five out of every eight seriously injured service members survived; today, seven out of eight survive, many with injuries that in previous wars would have been fatal. This is a remarkable record.

So with all this success, where does the problem come from?

From their own experiences with the different stages of a veteran's experience and the direct discussions with patients, the Commissioners concluded that the problem was located where the tectonic plates of bureaucracies collide.

Despite accomplishments in clinical care, problems do occur\x82\xC4\xEEparticularly in handoffs between inpatient and outpatient care and between the two separate DoD and VA health care and disability systems.

By breaking down the individual experiences of wounded service members, the Commissioners were able to separate the good from the bad in the current system. This is often the hardest part of evaluating any system. When the end result is failure, it is easy to call for wholesale change.

We designers are very good at wanting to do a complete redesign, or to make an entirely new product. Instead, the right answer is often to tweak what's wrong with the current structure or product. Incremental change, though less dramatic, is often more effective. The other side of the conservative lesson is that if you are going to call for wholesale change, make sure that you understand every step of the problem and what about each piece is broken.

The solution is in the system

In their report, the Commissioners made a number of recommendations ranging in scope. Among their recommendations is a radical shift in the structure of the disability and compensation system.

Only from the perspective of the patient would you see this single piece as the key to unlocking the crisis.

After their survival is assured, injured service members undergo a process to assess whether they can return to military service. If they must be discharged of their duties, military doctors assign them a rating to determine what level of benefits they receive.

Now a veteran, the patient must choose whether to receive their benefit from Veterans Affairs or from the Department of Defense. With little or no information, they are asked to immediately evaluate which package is better and make a choice.

It is this choice the Commissioners want to eliminate. This single bureaucratic hurdle is where too many veterans trip. At no fault of their own, they often choose poorly and are blocked from the best care possible for the rest of their lives.

Explain how your solution impacts the bottom line

To sell this radical solution, Shalala argued in the language of the bottom line. By rethinking the system, the government would eliminate a large portion of its overhead. The improvement in user experience could also result in dramatic cost savings that could then be reinvested elsewhere.

Other recommendations, such as early treatment of brain injuries, could also be funded by this restructuring.

Learning from this process

Whether the report's recommendations will be implemented is still an open question. Some have criticized the report for not investigating the role the Bush administration played in setting the stage for this crisis.

Regardless, there is much to learn from the process that Dole and Shalala used to complete the Commission's work. They reinterpreted their mission by assuming the perspective of the user instead of the organization. Focussed research enabled them to then clearly define the nature and source of the problem. The recommended solutions emerged from this clear understanding of the entire system and how changes to key pieces could make the most difference.

This process mirrors the ideal strategy and research phase of the design process, and we designers can learn a valuable lesson: If focussing on user experience can uncover solutions to the most intractable problems of large government bureaucracies, surely it is the right approach for our clients.