Can an Infant-Saving Product Prove the Death of Human-Centered Design?
Shawn Wasserman posted on October 02, 2017 | 5842 views
The NeoNurture Incubator was going to change the developing world. Instead, it flopped. The lessons Design That Matters learned from this failure led to the organization’s eventual success with the Firefly Phototherapy Device. (image courtesy of Design That Matters.)

The NeoNurture Incubator was going to change the developing world. Instead, it flopped. The lessons Design That Matters learned from this failure led to the organization’s eventual success with the Firefly Phototherapy Device. (image courtesy of Design That Matters.)

We all have our design babies. We care for them, nurture them and make them the best design they can possibly be. We love our babies and no one wants to tell a happy parent that their baby is ugly.

But what happens when our design babies are supposed to save the lives of real infants? Will anyone tell us we are designing a dud? Will we notice for ourselves?

Tim Prestero, chief executive officer at Design That Matters told the audience at solidThinking’s CONVERGE that, even when lives are at stake, no one wants to tell someone their invention is a dud.

CONVERGE highlights the intersection of design and engineering. solidThinking believes that at this intersection both have a lot to learn from the other. Prestero, who has held both roles, is a fine example of someone many engineers can learn.

“One of the challenges we all face as an engineer and designer is that we can’t wait to show you our beautiful babies,” Prestero said. “We’ve all had beautiful babies as designers where we lose our objectivity.”

Design That Matters is a non-profit organization that comes up with medical devices aimed at saving the lives of infants in developing nations. The organization is well known for the design of two products: the NeoNurture Incubator and the Firefly Phototherapy Device. 

The NeoNurture was raved as such a success before it hit the market that it landed on the cover of TIME Magazine. The NeoNurture was made from car parts. Why? Because they are some of the easiest machine parts to source in developing areas.

Wouldn’t you know it? NeoNurture actually ended up as the ugly baby. The only infant to ever make it into the device was a healthy one—one photo-op fill-in to represent all those babies it would never save. After some hard lessons learned, Design That Matters shifted to its eventual success, the Firefly Phototherapy Device.

The Problems with Human-Centered Design and Design for Inspiration

The NeoNurture takes advantage of a large resource in developing nations, car parts. But would you want your baby to be put in an incubator MacGyvered from car parts? Would it pass another country’s equivalent of FDA approval? Or would the concept alone push people away? (Image courtesy of Design That Matters.)

The NeoNurture takes advantage of a large resource in developing nations, car parts. But would you want your baby to be put in an incubator MacGyvered from car parts? Would it pass another country’s equivalent of FDA approval? Or would the concept alone push people away? (Image courtesy of Design That Matters.)

Human-centred design seems simple enough: base your designs around the people that are using it, right?

“I’m here today to abolish the term ‘human-centred design’ because it is too confusing of a statement,” Prestero declared.

“The question is, ‘who is the human?’” Prestero added. “One of the challenges is finding all the groups you work with. Which are the ones to ignore? Can you ignore the family? The patient is always watching. The family won’t accept treatment if it looks like a torture device. Maybe the doctor is the human, the person they want to design for. Well, turns out in most countries it’s the nurses that do most of the caregiving. So, is the nurse the human [in human-centered design]? Do they need to buy in?”

The list kept growing to include everyone from maintenance workers, to donors to purchasing teams and manufacturers. The question is, “who is the human in the human centered design?”

“The answer is that they are all necessary, but none of them are sufficient,” Prestero argued. “It’s a question of who will choose, use and pay the dues. The doctor and nurse don’t buy the equipment and the patient doesn’t need to know how to use it.”

Prestero argues that the NeoNurture failed because they were focusing too hard on satisfying the needs of the wrong users.

As a machine made from car parts, the NeoNurture would certainly satisfy those maintenance workers. But what about the patient’s parents? Are they going to want to put their babies in a machine MacGyvered from car parts? That’s the torture device Prestero mentioned.

What about the manufacturers? You think they can convince a country’s equivalent of an FDA that a box of car parts can keep a baby alive and safe? Do you expect them to buy the new equipment to build the thing without it being approved? How do you expect to approve it when you may not be sure which car parts are available at any given time?

Without answering these questions, how will you achieve your targeted outcome?

The Benefits of Designing for Outcomes

The Firefly is light, portable and designed to fit only one baby. It can even fit in a hospital bed with a mother or nurse. Its easiest use is its intended use. (Image courtesy of Design That Matters.)

The Firefly is light, portable and designed to fit only one baby. It can even fit in a hospital bed with a mother or nurse. Its easiest use is its intended use. (Image courtesy of Design That Matters.)

Prestero declared that the success of his Firefly Phototherapy Device can be attributed to designing for an outcome people want, instead of focusing on a device.

“It’s easy to get wrapped up in the design of a gadget and forget the outcome people want,” Prestero said. “Design-for-outcomes has many facets and that’s why our incubator didn’t become popular. You need to design for manufacturing, sales and everything else.”

So, what was the outcome of these two devices?

Well, for the NeoNurture Incubator it was meant mostly to keep a baby warm.

“Of the 4 million babies that die every year before their first birthday, about half of them would make it if we just kept them warm for the first day or week,” Prestero said. “In many countries with little means, kids get bundled up. You can’t always tell if they are suffocating, bleeding or in need. These kids needed incubators.”

So, what went wrong? How hard can it be it to give kids a clean, warm place? Well, it can be pretty hard when a nurse isn’t trained how to use the machine. Or when there are no manuals in that nurse’s native language. Or when the easiest way to use the device isn’t the right way to use the device. This didn’t just lead to NeoNurture’s failure, but also the failure of many Phototherapy Devices in developing nations.

“We talked to a lot of people about what is wrong with incubators,” Prestero said. “We talked to nurses, asking questions like ‘how often do you change the filters?’ They didn’t know [the filters were] even there. These tools are very complex and understanding the challenges is very complex.”

The common question Prestero team asked was “what is wrong with incubators? What would make using the device easier?” This lead to an inspirational product.

“We talked to people, did research, made prototypes, got a lot of feedback. It turns out that design-for-inspiration is a terrible model,” Prestero said. “We are not even designing a product. We are designing an outcome. ‘Designs That Matters’ was our name, but we are still saving zero. Not the outcome we were shooting for.”

For the Firefly, however, the outcome is to keep the baby under a blue light to treat jaundice. The blue light breaks down the bilirubin in the blood, the cause of jaundice. Without treatment, the kids can develop deafness and other disabilities. Two-thirds of all newborns develop jaundice. This can become a significant medical nightmare for a rural population.

Instead of just asking people how to improve phototherapy devices, this time Prestero’s team did hands-on research in the field. 

To be treated properly one baby needs to be directly under the light for the proper outcome.

Unfortunately, this isn’t how the device is always used in the field. Prestero’s team saw devices with multiple babies inside. Not only does this risk the complications of jaundice, it risks the spread of other illnesses. The solution, design the bassinette to hold only one child.

Intended use of a phototherapy device with a baby in Northern Vietnam (left) versus actual use in a hospital in a busy urban hospital in the Philippines (right). (Image courtesy of Design That Matters.)
Intended use of a phototherapy device with a baby in Northern Vietnam (left) versus actual use in a hospital in a busy urban hospital in the Philippines (right). (Image courtesy of Design That Matters.)
Comparison of effective phototherapy treatment between traditional phototherapy devices (left), traditional device with multiple babies (middle) and the Firefly (right). Placing multiple babies in one device will not result in effective phototherapy. (Image courtesy of Design That Matters.)
Comparison of effective phototherapy treatment between traditional phototherapy devices (left), traditional device with multiple babies (middle) and the Firefly (right). Placing multiple babies in one device will not result in effective phototherapy. (Image courtesy of Design That Matters.)

“Design-for-outcomes means designing for how people will actually use the device,” Prestero said. “The biggest difference to working as an engineer verses working as a designer is that, in design, there is no such things as a dumb user, only dumb products. There is no good excuse for failure, no partial credit when trying to save a baby’s life. You need to design for actual use.” This is a lesson engineers need to learn and can only learn when designers and engineers meet like at CONVERGE.

The team also worked with manufacturers to ensure that the Firefly looked the part of a medical device. They learned their lesson about MacGyvering around with medical devices.

“Everyone has a TV and has watched ER. They know what hospital equipment is supposed to look like,” Prestero said. “It might sound dumb but hospitals would rather have no equipment than junky-looking equipment. Everyone aspires to affordable technology. No one aspires for cheap. Design-for-outcomes means appearances matter.”

The team also learned to work around the translators. Remember how Prestero said that no one wants to tell you your design baby is ugly? Turns out he knows from experience. Understanding a few languages, he overheard a translator say, “This man has come a long way to visit your hospital. You better have something nice to say. I know, I don’t understand it either.”

From then on, it was cue cards with direct translations. It helped with keeping eye contact between the designers and interviewers. It also helped in ensuring the designers get the answers they need to improve the design, instead of gaining useless praise for an ugly design baby.

Want to see how a device will be used? Ask the nurse to start using it. Find out how the nurses might put a blanket over the heat exchanger, risking fire. It happened.

Learn how the baby might get wrapped up in blankets, shielding the infant from the healing lamps all because it looked cold under the blue lights. It happened.

The solution: Prestero’s team added lamps under and over the bassinette to ensure the baby will still get phototherapy, even while under covers. You can’t design for all user error, but you can ensure that the easiest way of using the device is the right way.

“Think it’s portable? Give it to a 4-ft tall 80-lbs nurse. Does she think it’s portable?” Prestero asked the audience. “Does it fit in a bed? Can you turn it on in the bed? There is no substitute for getting out there and trying. There is a whole map of stakeholders. It’s not just human-centred designs.”

It took two-and-half years of development, but, by 2012, the Firefly was in production. Then it was in volume production by 2013. Now, it’s in 23 countries. It has treated over 100,000 kids all thanks to designing for the outcome of keeping a baby under a light.

As for the outcome to Prestero’s talk at CONVERGE? Altair ended it by announcing a $10,000 donation to Design That Matters. That should keep more than a few babies healthy. A successful exchange thanks to the intersection of engineering and design.

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