Mayo Clinic is one of the most respected medical institutions in the world, providing some of the most advanced treatments available. But a recognition that the infrastructure of medicine—everything from the layout of buildings to the way appointments are conducted, at Mayo and elsewhere—hadn't changed significantly since the 1950s led LaRusso and others to question whether a better designed system could deliver better medical care.

Through questioning assumptions, observation, brainstorming, and experiments in care delivery, collaboration between medical staff and designers has led to many changes including a rethinking of the exam room, new options for patients to consult with doctors remotely via video link, and shifting of administrative responsibilities so care teams are spending more time practicing at the top of their competencies. Qn talked with Dr. Nicholas LaRusso, the medical director of the Mayo Clinic Center for Innovation about what happens when design thinking is applied to medicine. A Yale SOM case study looks at the work in detail. Yale SOM's director of case research, Jaan Elias, conducted this interview.

Q: What were the challenges of bringing the Center for Innovation's design thinking approach to Mayo Clinic?

Initially within Mayo, when I mentioned that I was hiring designers, most people, whether they were physicians or administrators, thought that all designers did was make clothes and furniture. They were totally unfamiliar with how much attention design thinking is getting in other industries. They didn't understand how many areas of sub-specialization, just like in medicine, exist within the broad discipline of design.

Design thinking is an approach to problem framing and solving. It is a methodology. Physicians tend to be anxious to get to the "how" without spending a lot of time focusing on the "what." One challenge was to get members of the internal team, who were not designers, to understand what design thinking was about, and the value designers brought to rethinking the healthcare delivery process. Equally important was for the designers to recognize that non-designers can understand design thinking.

The Center for Innovation is only three years old, so, until recently, the major mechanism of education was participation. When people actually came to a brainstorming session, or would sit down and meet with our designers and saw the process in motion, which was the most effective form of education, but it also takes a long time and doesn't extend beyond a limited number of people.

We now have educational tools in place, but there is also much more interest than we have the capacity to easily accommodate. The rapidity with which we developed a significant degree of institutional credibility has been surprising to me. I think what we've done is create a fusion of the traditional scientific method with design thinking, by finding an intersection of hypothesis generation and testing. There's a lot more similarity and synergy in the two approaches than would be apparent at first glance.

Q: What does the CFI do within Mayo?

Increasingly, we're being seen as the go-to group to help accelerate the progress of an idea to a project. We're coming to be seen as an internal consulting group, available to the whole institution. People not only want access to us, they want access to our methodology, our curriculum, even our new space—because it's so unusual and so collaborative in the way it's organized.

Q: How is innovation introduced into an institution?

There are a number of ways that a formal innovation initiative can arise within an organization. When A.G. Lafley was the head of Proctor & Gamble, he said he wanted an innovation initiative and directed his team to figure out how to do it. A Steve Jobs model might be more along the lines of, "I don't need an initiative. I got plenty of innovative ideas. Just do what I tell you." A third way, the way it arose at Mayo, began in isolation for a while, following the Lockheed Martin "skunkworks" model.

When I initially got interested in this, I was the chair of the department of medicine; I had the resources to get things started. We kept it relatively small—sotto voce. When we had enough to talk about, then we engaged in a series of discussions with institutional leadership and the CEO decided to expand our innovation initiative beyond the department by putting it in the context of a center that would serve the whole organization. It's not necessarily bad to be isolated to begin with, but I don't think you're going to go anywhere within a large organization without senior leadership support.

Q: The Yale SOM Case Study on Mayo Clinic looks at a number of issues, but the dilemma at the end of the case is how to balance incremental and transformative innovation. How has the thinking changed within Mayo since the case came out?

First of all, if you believe Larry Keeley and other innovation gurus, then both types of innovation are equally important and equally valuable, although when you define them, sustaining innovation—I don't like the word "incremental," it has a mundane tone to it—so sustaining innovation, doing what you're doing, but doing it better, doesn't have as much panache as transformative or disruptive innovation, doing something totally new, but I think it's very important, and Larry will tell you, you need 85% of your resources devoted to sustaining innovation.

We've taken an approach within one of our platforms, which may be informative here. This is the Practice Redesign Platform, which currently is focusing on a new model for an outpatient delivery system. We have two components. One we acknowledge is sustaining, and it's got 17 individual projects. The other is Project Mars, which is the potentially disruptive arm. Its concept is, if we were going to Mars to start a totally new system and we had no constraints, what would it look like? Now the risk associated with this project is much higher. It would be foolish for us to just focus on that. But if Project Mars, whose goal is to reduce our expenses by 30% by the year 2014, were to be successful, that would be seen within Mayo as incredibly disruptive.

On the other hand, something could appear to be sustaining but evolve into disruptive. That relates to the philosophy we approach all of this with which is "think big, start small, move fast." Let me give you an example—last year we saw a million patients. If currently 95% of all Mayo Clinic care activity is "physically onsite" and 5% is "physically offsite," but if five years from now, we've pushed sustained changes that resulted in 25% is of our clinical activity being offsite through remote subspecialty consultations, the impact of this would be so substantial that it would be completely disruptive.

Disruptive, as I'm thinking about it, increasingly has to do with the impact of the implementation of an idea, as much as the novelty of the idea. I think that there is very little now going on in healthcare redesign that's novel. It's the ability to implement, scale, and diffuse where the opportunity really enters.

From a financial point of view, the impact of the change would be substantial, because even if the percentage of patients we see onsite has dropped from 95% to 75%, if the majority of those people coming in person were there for a major procedure—a new hip, a bone-marrow transplant, etc—these are high net operating income generating activities, that would be hugely beneficial to the institution.

Q: Speaking of implementation, that's typically where the designers hand off a project. What are the challenges you've come across with that?

We've had, from our perspective, highly successful projects. We've learned a lot. When we were still in the department of medicine, we did a project where, like at an airport, instead of having to interact with a person to check, in patients used a kiosk. It was hugely successful in the sense that the efficiency was greater than the face-to-face encounter. Patients liked it. The desk attendants liked it. But we lacked an implementation arm, so it never went anywhere.

What we learned from that is that the project is more likely to work if the concept is one of co-creation. That's easier when someone comes to you with an idea. But if it's going in the other direction, you really need to get somebody from the affected areas involved early on. For example, we think there's a huge opportunity for projects in pediatric medicine, so I need to bring in the new chair of pediatrics early. If we co-identify an area for change and co-brainstorm we make sure they're passionate and committed. Then if the project winds up appearing to be beneficial, they're in a position to run with it, because our job is to contribute what's unique and special about our skill set, and then turn over continued operation. I need to be able to retrieve my team and put them onto something else.