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Innovation in healthcare a requirement for success
- 1. Innovation in healthcare a requirement for success Nick Dawson July 2011
- 2. the case for innovation
- 5. access to care By 2015, AAMC estimates physician shortage will reach 63,000 needed physicians According to JAMA, primary care physicians will have to increase panel size from 2,000 to 4,000 patients
- 6. Mokdad, A. H. et al. JAMA 2004;291:1238-1245
- 7. Journal of Occupational and Environmental Medicine
- 8. hospital margins AHA 2009
- 9. 7% hospital margins 2006 4.8% 2007 -7.2% 2008 AHA 2009
- 10. 32% of private health insurance enrollees are poised to be below the PPACA minimums for medical loss ratios
- 14. about innovation
- 25. the innovation process roles phases organizer conceptualize dreamer facilitator Planning (3 steps) grounder Criticize devil’s advocate
- 27. go innovate
Notes de l'éditeur
- Nick Dawson\nAdministrative Director of Community Engagement for Bon Secours Virginia\nWe are a system of 7 hospitals spanning Central VA to the shore with a multispecality medical group. \n\n[joke]\nDan said “dont worry, they have to like you, you are a current customer”\nI understand you did a customer sales role playing game yesterday...\nif everyone could just wait outside for a while, I’ll call you in when I’m ready\n\nToday - going to talk about innovation as a requirement for success in healthcare. \nDistinct time in healthcare. We’ve talked about reform before and there have been changes to the system before, but this is different. The land scape is literally being reformed. Famous jet engine analogy - trying to build while in flight. \n\nGood news - there is a solution. Innovation. \nMy wife, an expert in OD, says most great leaders went from good to great when the hit their first real crisis. The same is true for groups and industries. We’re in the crisis now. The business landscape of healthcare is not going to ever look the same. The way out , or at least the path for continued existiance for providers is innovation. \n\nWe have to get smarter about the care we deliver and the costs associated with that care. \n\nWe have to think differently about thing things we’ve taken for granted \n\nToday we’ll have three main sections to this conversation. First, what I call a state of the union on healthcare. We’ll cover the changes in the landscape, new laws, challenges facing providers, employers, payors and patients and we’ll spend some specific time talking about new models such as Accountable Care and Patient Centered Medical homes. \n\nPart two, we’ll set the stage for innovation. We’ll look at some examples from other areas and talk about what defines innovation and how innovative companies think differently. \n\nPart three - we get interactive. We’ll divide up into groups and actually work through the innovation process in a structured way. At the end, the goal is to come up with a real innovation on an every day object. This will be fun, I promise. \n\nBefore we get started - I like to keep the slides to a minimum and I prefer this to be a conversation. I’m going to ask some questions to start dialogues from time and time and will stress there is no right answer. This is your time and we should make the best use of it. To that end, before we dig in, are there any specific topics related to the provider world or even innovation that you want to make sure we discuss. What are the buzz words you are hearing on sales calls? \n\n\n
- Part one - the case for innovation. \nA state of the union of the changes and challenges facing America, physicians, employers, hospitals (systems) and payors. We’ll pay particular attention to pt medical homes and ACOs. \n\n
- [ASK] - anyone know what this date and signature are on? What bill was signed in March 2010? \n\nPPACA - also know as the ACA. \n\nThe biggest milestone in US healthcare history. \n\n[ASK] - what are some of the implications of PPACA? \n\n
- \n-Access to care\n m/caid to 133% of FPGL - BIG change for most states. \n employers with 50 or more people have to offer insurance of pay into public pot\n 32 Million newly insured by 2015 (leaving 23M uncovered, mostly illegal immigrants)\n\n[ASK] Why does increased access to care matter?\nphysician demand\nreembursement to providers\nOne bucket\n\n-One bucket\nuninsured currently come in with high cost acute needs. They go to self pay (less than 3% of total revenue for most provers) or bad debt & charity (average is about 5% total net revenue) \n\n[Excercize]\nAsk for a doctor - front of the room, joke about clipboard or lab coat\nDivid remainder up into 2/3rd and 1/3rd. \n\n“You folks, the 2/3, have insurance. You can come see Dr. ____ whenever you want. You should feel good about that....you smug people!” ... \n\n“this is like your sales role play game yesterday... do you make it through to the next round?”\n\n“You guys, the other 1/3 don’t have insurance. You cannot see Dr. ____, I’m sorry but he has mouths to feed, big school loans, we can’t see you if you can’t pay.....but if its an emergency we’ll take care of you because we have to.... how do you feel?”\n\n“by the way, Dr. ____ you work for the health system, so you don’t really care about costs, insurance, uninsured, so long as you get your 4 weeks vacation. Things are pretty good for you”\n\n“Well, I have good news, by 2014 you are going to get some kind of health coverage...give yourselves a pat on the back, you are insured Americans with access to healthcare.”\n\n“Dr. ____ you work 60 hours a week, yeah you have that vacation and a beach house, so we don’t have a lot of sympathy, but now you have to see all of these people too. Fit them in please. How does that strike you?”\n\n“Oh, by the way, I forgot to tell you, you are also responsible for their health. If they get sick, you don’t get paid, what are your plans to keep them out of your office?”\n\n\n
- Point - facing a shortage of doctors in this country. Particularly primary care. \nTwo options, 63,000 new docs or every doc has to double the number of patients they care for. \n
- Back to our new population of patients....\n 2 of you are smokers\n 2 of you have diabetes, one of you doesn’t control it at all\n 3 of you have high blood pressure\n only 4 of you have gym memberships\n\n[ASK] Now everyone is the doctor - what are you going to do to manage the health of this population? \n\nJAMA looked the REAL causes of death in the US. Most studies look at the morbidities - daibetes, heart failure, cancer, stroke, etc. The authors of this study want to see what the real causes were...why did that patient suffer from heart failure or why did they have a stroke?\n\nGuess what they found? \n\nLifestyle and behaviors account for 40% of US deaths. \n\nSo you room full of doctors, what are you doing about items 1 2 and 3? \n\n[DISCUSS capitation, vs ffs, vs pfp]\nCapitated model - here’s $100. I’m not giving you any more than that to care for this guy over here. Keep the change.\nToday, most providers operate under Fee for Service. Ok, you want to charge $100 for every visit, we’re going to give you $25 but you can still keep the change and we’ll give you that $25 every time they come in. Fair? \n [ASK] whats your incentive to help people change their lifestyle....if you get paid every time they come to you?\nPay for Performance says “ok, here’s the deal. I’ll pay you $30 per visit, but I’m holding $15 of it back until we make sure that this guy is really getting better... that sound fair?” \n\n
- Ok, back to our core consitiuents...\n\nEmployers are feeling the burn too. The bottom line is that 3-5% of employees account for 50% of employer healthcare spending. \n\nThis slide shows a breakdown of what those causes are and the dollars per 1000 FTEs. \n\nBy the way, hospitals are employers too and guess which industry uses more healthcare than any other? (healthcare)\n\nSo we have over worked physicians, a bunch of newly insured people coming in who are all making poor choices and employers and the government are paying the tab. \n\nWith me? \n\n
- I was out in Colorado a few times this winter. What I said about 3% generating the cost... so I tore both of my ACLs skiing. I tore the 2nd one on the one year to the day anniversery of the first. \n\nYou know that old joke about a country boy’s famous last words? “hold my beer and watch this” I gave my camera to my dad and said ski down and film me, I’m going to send it to my doctor... Turns out, my doctor loved it...he said something about putting his children through college. \n\nYeah, so out in colorado, and you wouldn’t think we are in a recession by looking at the lift lines. There is a subtle clue though, if you listen you can tell what the difference is? Any guesses? (accents, American’s arnt traveling) \n\nHere’s the situation with hospitals\n[CLICK]\nin 2006 the AHA tells us hospitals had, on average, a healthy margin. Around 7%\nIn 2007 it drops to below 5%\nin 2008 most providers reported a 1/2 year margin (this report came from mid-year) of -7.8%\n\nDiscuss Bon Secours uninsured - tracked about 6 months after unemployment numbers. \n\nGood news, we’ve bounced back a bit, people are working again, we’re back up to about 2-3%\n\nMost hospitals are making 1/2 of what they made less than 5 years ago. \nHere is where I have to innovative. We don’t have the money we once had. Projects get prioritized. We have equipment which reaches the end of its useful life... that MRI has to get replaced and that comes from that 3% margin...something has to give. \n\n\n
- I was out in Colorado a few times this winter. What I said about 3% generating the cost... so I tore both of my ACLs skiing. I tore the 2nd one on the one year to the day anniversery of the first. \n\nYou know that old joke about a country boy’s famous last words? “hold my beer and watch this” I gave my camera to my dad and said ski down and film me, I’m going to send it to my doctor... Turns out, my doctor loved it...he said something about putting his children through college. \n\nYeah, so out in colorado, and you wouldn’t think we are in a recession by looking at the lift lines. There is a subtle clue though, if you listen you can tell what the difference is? Any guesses? (accents, American’s arnt traveling) \n\nHere’s the situation with hospitals\n[CLICK]\nin 2006 the AHA tells us hospitals had, on average, a healthy margin. Around 7%\nIn 2007 it drops to below 5%\nin 2008 most providers reported a 1/2 year margin (this report came from mid-year) of -7.8%\n\nDiscuss Bon Secours uninsured - tracked about 6 months after unemployment numbers. \n\nGood news, we’ve bounced back a bit, people are working again, we’re back up to about 2-3%\n\nMost hospitals are making 1/2 of what they made less than 5 years ago. \nHere is where I have to innovative. We don’t have the money we once had. Projects get prioritized. We have equipment which reaches the end of its useful life... that MRI has to get replaced and that comes from that 3% margin...something has to give. \n\n\n
- I was out in Colorado a few times this winter. What I said about 3% generating the cost... so I tore both of my ACLs skiing. I tore the 2nd one on the one year to the day anniversery of the first. \n\nYou know that old joke about a country boy’s famous last words? “hold my beer and watch this” I gave my camera to my dad and said ski down and film me, I’m going to send it to my doctor... Turns out, my doctor loved it...he said something about putting his children through college. \n\nYeah, so out in colorado, and you wouldn’t think we are in a recession by looking at the lift lines. There is a subtle clue though, if you listen you can tell what the difference is? Any guesses? (accents, American’s arnt traveling) \n\nHere’s the situation with hospitals\n[CLICK]\nin 2006 the AHA tells us hospitals had, on average, a healthy margin. Around 7%\nIn 2007 it drops to below 5%\nin 2008 most providers reported a 1/2 year margin (this report came from mid-year) of -7.8%\n\nDiscuss Bon Secours uninsured - tracked about 6 months after unemployment numbers. \n\nGood news, we’ve bounced back a bit, people are working again, we’re back up to about 2-3%\n\nMost hospitals are making 1/2 of what they made less than 5 years ago. \nHere is where I have to innovative. We don’t have the money we once had. Projects get prioritized. We have equipment which reaches the end of its useful life... that MRI has to get replaced and that comes from that 3% margin...something has to give. \n\n\n
- I was out in Colorado a few times this winter. What I said about 3% generating the cost... so I tore both of my ACLs skiing. I tore the 2nd one on the one year to the day anniversery of the first. \n\nYou know that old joke about a country boy’s famous last words? “hold my beer and watch this” I gave my camera to my dad and said ski down and film me, I’m going to send it to my doctor... Turns out, my doctor loved it...he said something about putting his children through college. \n\nYeah, so out in colorado, and you wouldn’t think we are in a recession by looking at the lift lines. There is a subtle clue though, if you listen you can tell what the difference is? Any guesses? (accents, American’s arnt traveling) \n\nHere’s the situation with hospitals\n[CLICK]\nin 2006 the AHA tells us hospitals had, on average, a healthy margin. Around 7%\nIn 2007 it drops to below 5%\nin 2008 most providers reported a 1/2 year margin (this report came from mid-year) of -7.8%\n\nDiscuss Bon Secours uninsured - tracked about 6 months after unemployment numbers. \n\nGood news, we’ve bounced back a bit, people are working again, we’re back up to about 2-3%\n\nMost hospitals are making 1/2 of what they made less than 5 years ago. \nHere is where I have to innovative. We don’t have the money we once had. Projects get prioritized. We have equipment which reaches the end of its useful life... that MRI has to get replaced and that comes from that 3% margin...something has to give. \n\n\n
- Not sure if I mentioned this, most of these pictures are my one. I took this one as I was making some sausage. I make my own dry cured meats, sausages, bacon...anything porky. My wife brews beer. We are a cardiologist’s dream! \n\nThe old joke - two things you don’t want to see made, laws and sausages. \n\nThe same is true for insurance. You don't want to know how it works. These payors aren’t doing much better. \n\n[ASK] anyone know the term “Medical Loss Ratio” \n - explain it? \n\nFor most payors, the average MLR is estimated to be between 40 and 80%. That means between 40 and 80 cents per premium dollar are spent paying healthcare bills. Where does the rest go? \n\nOverhead\n\nM/Care is in the mid 80s%\n\nPPACA says payors must have minimum MLR between 80-85% (not applicable for self-insured employers) \n\nToday, 32% of all people covered, would be covered by a plan which does not meet that minimum. In 9 states, 1/2 of all insured people would be below the threashold. For those Americans, the insurance company is using more than 20 cents on the dollar for overhead. \n\n\n\n\n\nSOURCE American Journal of Managed Care - 2011\n\nResults: In 2009, using a PPACA-adjusted MLR \ndefinition, we estimated that 29% of insurer-state \nobservations in the individual market would have \nMLRs below the 80% minimum, corresponding to \n32% of total enrollment. Nine states would have \nat least one-half of their health insurers below the \nthreshold. If insurers below the MLR threshold \nexit the market, major coverage disruption could \noccur for those in poor health; we estimated \nthe range to be between 104,624 and 158,736 \nmember-years. \nConclusion: The introduction of MLR regulation as \npart of the PPACA has the potential to significantly affect the functioning of the individual market \nfor health insurance.\n(Am J Manag Care. 2011;17(3):211-218)\n
- We’ve talked about PPACA, Access to care, providers, payors... who is missing? \n\nPatients\n\nBreifly, lets look at the patient centered medical home model. Its emerging, its a standard and look to all primary care physicians to become really interested if they aren’t already. \n\nThe model came out of a joint venture between CMS and national quality foundation\nPCMHs must:\nbe primary care focused\nhave navigators\nhave pay for preformance contracts\npractice wholistic (whole patient) care\nenhance access\n Two components to that one- tech, eVistis\n Mid-level providers\n\nAnd while its not spelled out, they pretty much have to meet meaningful use guidelines for electronic medical record usage. \n
- This all brings us to the good parts - Accountable Care and the Triple Aim. \n\n[ASK] - everyone has heardthe unicorn joke about ACOs, right... Everyone knows what they look like but no one has seen one. \n-Homestead reference. Asked who was exploring. everyone. asked who could define. no one. \n\n[exercise] draw the components of care\n[ask] what are the various components of healthcare. Lets start listing them out. \nPCPs\nspecialists\nacute\nhome care\nmental health\nothers\n\nDraw ACO over top. patient comes in, care is coordnated, data goes back out. money comes back, gets distributed. \n\nACOs have three points:\n provider led orgs strong in primary care accountable for quality and cost across contimium of care for a population of patients\npayments linked to quality and efficency (cost reductions)\nprogressivly more sophisticated preformance measures to prove savings are acheived through improvements in care\n\nPlane language: remember capitation? Here&#x2019;s $100, thats it? Well ACOs are a form of capitation. Here&#x2019;s $5,000,000 for a population of patients. The healthither they stay, the less services they use, the less they use, the less cost you have, so the more of that $5M you keep in your pocket. Think banking. Use the AMT or online, they charge you when you go in. \n\nBut there are some kickers. Health matters. So there is a pay for preformance part. We don&#x2019;t just give you the money. In fact we may give you monthly payments, but the bulk comes almost 3 years later. Why? So we can tell how good your care is. If they aren&#x2019;t healthy you get less. So you can&#x2019;t just refuse to see them like banks. \n\nCMS defines population of at least 5,000 patients. Providers cannot know who is in the population and who is not. So you could be responsible for the health of someone who goes to a competitor for surgery. \n\nACOs exist:\n9 current pioneers in the pilot program \nsome already exist fully - gesinger, HealthCare Partners, Kaiser...and soon HSHS and BSV\n\nThis is a big deal. Its very hard for providers to get on board. \nwho owns legal structure\nDoes doctor now &#x201C;work&#x201D; for hospital? \nShould PGs or PHOs own? \nHow are savings distributed?\nWhat about those specialists, where&#x2019;s the money, have you seen their school loans?\nWhat about services that were profitable? Imaging for example. What was a commodity is now a liability. <Give Knee example - manual test vs MRI, what level of accuracy is needed>\n\nThe triple Aim our seque into innovation\nbriefly - came out of Berwick&#x2019;s time at IHI. Says three things: \n* better care\n* better health\n* lower costs\nBerwick says the way to get there is to innovate around care. CAn you see how the model supports it? They don&#x2019;t perscribe how you care for patients, just create a landscape where you can and you have to in order to pocket the money. \n
- Whew! deep breath. Lets pause for a second and see what questions you have? \n\nOk, switching gears, this is fun stuff. Lets talk about innovation. \n
- [ASK] who is this guy? \nHint - his Birthday was Tuesday\n \nAny guesses? \n\nhere&#x2019;s a hint\n
- Answer - George Washington Carver\n\nWhy do we care about Carver? \nInvented peanutbutter, right? \n\n[excersize]\nWho had a cookout this weekend? \n\n-ask what had\n-list corn products\n\nCorn is in everything we eat. In fact, some economists tie the proliferation of corn abundance and government subsidies to cheap food as the root cause of obesity. Remember our causes of death slide? Its also in plastic and now in the gas we put in our cars. And thats largely thanks to GWC and his peanut obsession. \n\nIn late 1890s, as director of agragculture for tuskagee institute he realized if you rotate legumes, like peanunts through crop fields they were more productive. Its because they &#x201C;fix&#x201D; the soil by adding nitrogen, all other plants consume nitrogen. \n\nWhen farmers followed his advice they ended up with more peanuts than they knew what do to with. They began to rot en mass. Carver developed over 300 uses for peanuts - the one we think about most often? Peanut butter!\n\nCarver innovated in two ways - he found two very simple solutions to probllems. first, rotate beans through your rotation and you get a bigger corn yeild and 2nd, he too an excess of something and innovated a new product out of it. Now farmers could sell corn AND peanutbutter - whole new business out of something that helps them anyway. \n\nThere&#x2019;s a lesser known, sad epilogue to this story. In 19018 Fritz Haber won the nobel prize for chemistry for innovating on earlier work. He tweaked a process and found a way to produce nitrogen fertlizer. The result is that some credit 1/7th of the worlds entire population to the food increase that he helped usher in. \n\nAnyone heard of him? \n\nHere&#x2019;s the sad part - he went on to invent Zyklon B gas for the nazis in WWII. Its a poignent lesson history forgets innovators who do evil things. \n \n\n
- Ah, Apple. \nDoes any company scream innovation more loudly than apple? \n\nI don&#x2019;t want to be confused as a zealot or anything... excuse me while I check my email <pull out iPhone>\n\nWhere were we? Yes, Apple. \n\nAnyone have an iPhone, iPad, iPod, Mac? \n\nOn March 14th 1987, Apple stock dropped from $15 to $7, almost an all time low for the company. Steve had been fired a few years before. Here&#x2019;s what Steve said to Louis Rukeyser around that time.\n\n<CLICK PLAY>\n\n[ASK] what do you take away from that video? What are they key points? What was Steve&#x2019;s answer to help apple? \n\nSteve came back to Apple in the mid 90s. Here&#x2019;s what he did right away. \nHundreds of SKEWS (products) down to only a few. He focused the efforts. An innovation. \nHe disrupted (the most powerful kind of innovation)\n Didn&#x2019;t invent the mp3 player. They were around for years. They innovated\n can&#x2019;t have a player without software\n can&#x2019;t play music without a store. Can&#x2019;t have a store wihtout contracts...\n user experience - best in class\n Retail - when I was a kid, you ordered a computer in the back room of an office supply store. This week I was in apple and it was packed...with kids... its the hottest play in the mall to be. They innovated retail. Everything is hands on. DO touch. Sales staff have a line, do you know what it is? Its never &#x201C;oh, let me show you how it palys video. Or can I help you?&#x201D; its always &#x201C;I see you using a Mac, is there anything I can show you how to do?&#x201D; Its a different retail experience\n One more - iPad. Aluminum back. Others can&#x2019;t make it because they don&#x2019;t have the parts. Apple started machining alumium 4 years ago for internal parts. Then they made a unibody mac. Then they could make the air. and now they are the only ones who can afford to get a device this thin and still make a profit. How? They innovated the manufacturing process. \n\n \nBy the way, yesterday apple closed at $358 and has the largest market cap of any tech company. \n\nWhat happene \n
- Did I say I&#x2019;m not an apple zealot? I lied. \n\nHere&#x2019;s the part where I get to drink some water. \n\nWant to show you this video from a TED talk. Does everyone know about TED? Technology, Education and Design. Big thinkers giving inspirational talks. Check &#x2018;em out online. \n\n[CLICK PLAY]\n\n[ASK] Does that idea make sense? Inside out vs outside in? \nIn healthcare is a hospital thinking inside out when it buys an MRI because the competetor has one? Apple doesn&#x2019;t build something because Microsoft did. Is there an apple xbox? Hardly.\n\nBridge duffy was the cheif patient experience officer at cleveland clinic. She gave a great talk at the GEL conference in 2009 where she highlighted a huge change to the patient experience. Anyone know what it was, what Clevland changed that made every patient feel more comfortable insstantly? \n\n-gowns. They had them close in front, made out of nice materials and they made them just slightly fitted. Boom - dignity regained. They didn&#x2019;t invent the gown, they innovated it. That&#x2019;s a company who thinks &#x201C;we have a mission to care for patients, we just happen to be a hospital and our gowns will help you feel dignified, want to come?&#x201D;\n\n\n
- Ok last one. Because its my other hat. Social media. \nI&#x2019;m on the board of Mayo&#x2019;s center for social health. They didn&#x2019;t invent facebook or twitter. In fact, their PR guy, Lee Aase was in the lobby one day and saw these two octogenarians playing paino with a crowd gathered around them. ITs an amazing thing. He pulled out his iPhone, put it on youtube and a week later was on Good Morning America with the elderly couple. He didn&#x2019;t invent that stuff, he innovated. \n\nToday over 600 top tier provers are using social media. Some, like mayo and Bon Secours are looking at it as a tool patient care. \n\nRemember that problem of access - 2,000 patients to 4,000...32M new insured, ACO says we&#x2019;re responsible for their health? Savvy doctors and hospitals are texting patients and saying &#x201C;did you check your blood sugars? Did you remember to run today? I care about you. Do you need an appointment?&#x201D; \n\nThe behavior changes, health improves... money is saved.\n\neVisits - big on the horizon. How do we bill for them? Not through insurance. Is there a TU product that would help? I dont know...something to think abut\n
- Ok, one more deep breath. \nHome stretch. What questions do you have? \n\nThis is really fun. See we are escalting in fun. When I&#x2019;m gone you day will be so dull. This is really the best thing ever isnt it? \n\nWe&#x2019;re going to innovate. So get comfortable, we&#x2019;re going to get a little weird. \n
- [ASK]\nWhat is this? \n\n-Jiffy pop\n\nSomeone describe to me the timeline of putting popcorn on the stove until its finished. What happens\n\nslow, not much action, things get hot, few pops, then frenzy, then it quites down and then you eat. \n\nThats the innovation process. \n
- By the way - here is a building about a mile from my house. A local archatech named Hague Jamgochian got the idea for it from a jiffy pop container. Pretty innovative huh? \nThat top section is the world longest continious sheet of aluminum. Apple would be jealous. \n
- Here is our map. This is going to be our guide. \n\n[excercize] we are going to break up into groups of 3 or 4. No more than 4 if we can help it. \n\nLets do that now. Everyone get up, move around, stretch a bit... find your group of folks near you. \n\nWe are going to come up with an innovation. \n\nMost groups have a few diffrent roles and we all tend to shift roles. There are organizaers, people who plan the meetings and set the agendas, there are facilitators who help move discussions along, grounders who keep us focused, and devils advocates who challenge ideas.\n \nToday I want us all to be dreamers. \n#1 rule of dreaming - there are no bad ideas. Fro the next 20 minutes, no one can use the word &#x201C;but&#x201D;. Ok, got it? No bad ideas. You can&#x2019;t look at the guy next to you and say &#x201C;yeah but...&#x201D; you can only build on their idea. If you don&#x2019;t like it then spin it. \nNO BAD IDEAS\n\nThis is known the disney process for those who care. \n\nhere are the phases. We&#x2019;re going to spend about 5-7minutes conceptualizing. That&#x2019;s when you all as dreamers shine. Throw ideas against the wall. I love this because its when us conceptial folks run wild and the highly structured people get really nevious and antsy. \n\nNext we&#x2019;ll move into planning phase. Here&#x2019;s the deal, you can come up with 3 steps to implement your innovation. Thats it. 1 2 3. Keep them simple. If I&#x2019;m apple and my innovation is a iPod, then my steps are 1) apply what we know about design 2) build device 3)sell it in our stores. Got it, simple. Three steps. \n\nLast stage - we all shift from dreamers to devils advocates. Poke holes in the idea. For those of you sitting on your &#x201C;yeah buts&#x201D; this is your time to shine. &#x201C;Ok, but we can&#x2019;t make an MP3 player because where do people get music? they steal it and its bad quality and they&#x2019;ll think our device is bad quality and quality is everything don&#x2019;t you people understand that we&#x2019;re all going to die if we build MP3 players...<deep breath>&#x201D; Thats it. Poke holes.\n\nWe&#x2019;ll go through this process at least two times. If we run short remember this - its really a four step process. YOU HAVE TO come back to conceptualizing. You cannot EVER end on criticizing. \n\nAfter we are done with each round, I&#x2019;ll ask someone from each group to give us their innovation, their steps and their one or two &#x201C;yah buts&#x201D;\n\nready?\n
- here are your items. \nfork\nstop light\nchair\nfire hydrant\n\nWe&#x2019;ll go around the room, each group gets one, more than one group can have the same thing\n
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