Design Principles to Optimize Ultrasound Programs

Nudge Theory

  • Definition: Nudge theory states that design adaptations to a product or environment can influence behavior and decision-making.
  • Classic example: Putting a basketball hoop over a trash can to motivate people to dispose of trash properly.
  • Healthcare usage: Common in electronic health records (EHR) to prompt better clinical decision-making or to prompt handwashing via soap dispensers.
  • Applications in POCUS:
    • Place ultrasound machine locations near a cleaning station to promote cleaning after use.
    • Affix Sani wipes to the ultrasound cart to prompt probe cleaning.
  • Practical takeaway: Use design cues to steer provider behavior without restricting choice.

Lean Thinking

  • Definition: Lean thinking aims to eliminate waste and unnecessary steps to improve value and efficiency.
  • Healthcare goals: Reduce waiting, minimize inventory, eradicate defects, and decrease movement of patients, staff, supplies, and equipment.
  • POCUS examples:
    • Mount a dedicated ultrasound machine in a fixed trauma resuscitation bay to avoid searching for a machine (Fig. 23.2).
    • Use premade nerve block kits to reduce time and provider movement when gathering equipment.
  • Practical takeaway: Map workflow to remove non-value-added steps and streamline the POCUS process.

Affordances and Signifiers

  • Definitions:
    • Affordance: Inherited properties of an object that suggest its use.
    • Signifier: Extrinsic indicators that communicate how to use an object.
  • POCUS examples:
    • Ergonomic probe design and intuitive button layouts create perceivable affordances.
    • Signifiers like labeled workflows or numbered steps inform order of operations (Fig. 23.3).
  • Practical takeaway: Design devices and processes so users can intuitively understand how to perform tasks; use signifiers when affordances alone are insufficient.

Cognitive Load and Streamlining

  • Cognitive load: The amount of working memory required to complete a task.
  • Problem: Complex POCUS apps increase cognitive burden, reducing accuracy and focus.
  • Streamlining: Modify workflows to reduce cognitive burden by eliminating unnecessary steps.
  • POCUS example: AI tools to remove manual measurements or to shift emphasis to qualitative assessments (Fig. 23.4).
  • Practical takeaway: Simplify interfaces and tasks to enhance performance and reduce errors.

Behavioral Economics

  • Definition: The study of psychological, emotional, cognitive, cultural, and social factors in decision-making.
  • Healthcare examples: Publishing user metrics and performance feedback to influence behavior.
  • POCUS implications: Sharing performance metrics can motivate improvements in imaging, documentation, and workflow.
  • Practical takeaway: Use behavioral insights to design feedback loops and incentives that improve practice without coercion.

Fogg Behavior Model (FBM)

  • Core idea: For a behavior to occur, three elements must converge: motivation, ability, and a prompt.
  • Formalization: A behavior B happens when M × A × P is sufficient; often represented as a multiplicative relationship: B = f(M \times A \times P) where M = motivation, A = ability, P = prompt.
  • Applications in design: Use prompts (e.g., QR codes, nudges) when motivation and ability are present or can be quickly facilitated.
  • Example (Fig. 23.5): When a machine breaks, a user is motivated to repair and can do so via an online form prompted by a QR code.
  • Practical takeaway: To drive a behavior, ensure users have both the means and the incentive, and provide a clear prompt.

Crowdsourcing

  • Not a standalone design principle but a strategy.
  • Definition: Gathering input from a large group, typically via the Internet.
  • POCUS applications: Use organizational listservs, social media, or broader communities to crowdsource solutions.
  • Benefits: Leverages collective wisdom and accelerates problem solving.
  • Practical takeaway: Before reinventing the wheel, check if a solution already exists or has been peer-tested by others.

Overall Strategic Program Design

  • Shift from micro-design to macro-design: Set overarching goals and strategies for the POCUS program to align smaller initiatives.
  • Key principles: Goal definition, stakeholder engagement, evidence-based approaches, flexibility, sustainability, and measurable impact via KPIs.
  • Focus areas: Alignment with clinical care, education, administration; integration with institutional priorities such as research, billing, and safety.

Defining Goals

  • Start with a mission statement for the ultrasound program that summarizes main goals as a division or section.
  • Ensure alignment: Evaluate how every component and activity supports clinical care, education, and institutional priorities.
  • Benefit: Facilitates resource allocation, training needs, and quality assurance decisions.
  • Integration: Include both institutional and departmental goals in the program design for coherence.

Prioritizing Goals

  • Purpose: Clear goal prioritization guides strategic planning and execution, enhances stakeholder engagement, and improves outcomes.
  • Common techniques:
    • Effort–Value (2 × 2) matrix: Axes are Value (V) and Effort (E). Tasks are placed into four quadrants:
    • High value, low effort (top-left) – highest priority.
    • High value, high effort (top-right)
    • Low value, low effort (bottom-left)
    • Low value, high effort (bottom-right) – lowest priority.
    • Example figure: An example 2 × 2 matrix with tasks placed accordingly (Fig. 23.6).
    • Represented conceptually as: tasks are categorized by their ROI in terms of effort vs value.
    • Eisenhower Box: Urgency vs Importance.
    • Most important and urgent items are done first; those not urgent or important may be dropped.
    • MOSCOW model: Must Have, Should Have, Could Have, Won't Have.
    • Used to categorize goals by necessity and impact. Example mapping of goals to these categories is shown in Table 23.1.
  • Example content for MOSCOW and SMART mapping is provided in Tables 23.1 and 23.2 (see below for SMART details).
  • Practical takeaway: Use these tools to prioritize goals, align with stakeholders, and focus on high-value, feasible initiatives.

Goal Mapping

  • Goal-mapping techniques help break down a single goal into actionable steps.
    • SMART method: Specific, Measurable, Achievable, Relevant, Time-bound (Table 23.2).
    • Mind mapping: Central idea with branches for necessary tasks.
    • Gantt charts: Activities plotted over time with start/end dates, overlaps, and dependencies.
  • Purpose: Provide a disciplined approach to achieving goals and communicating plans.
  • Practical takeaway: Use SMART for concrete goals; use mind maps or Gantt charts for planning and tracking.

Program Redesign

  • Three redesign scenarios:
    1) Problem-driven redesign (RCA): When a problem is identified and understood.
    2) Ambiguity-driven redesign (design thinking): When a problem is identified but poorly understood; involves stakeholders and empathy.
    3) Proactive redesign: When problems are not yet realized; proactive exploration through user-centric design.
  • Design Thinking (user-centric design) framework (Fig. 23.8): Empathize → Define → Ideate → Prototype → Test.
  • Benefits: Clarifies ambiguous problems, uncovers unmet needs, fosters collaboration, sparks creativity.
  • Drawbacks: Resource-intensive; success often depends on cross-disciplinary collaboration.
  • Utility in POCUS: Helps reimagine learning experiences, clinical workflows, or device interfaces by involving diverse stakeholders.

Root Cause Analysis (RCA)

  • Central to healthcare quality and safety; helps identify underlying causes of a problem.
  • Simple method: Five Whys (Table 23.3): Repeatedly ask why to reach a root cause.
    • Example problem: Physicians fail to save ultrasound images due to time pressure and undervalued documentation.
    • Example chain: Why time pressure? Why not see value of saved images? Why is training lacking? Why is leadership not incentivizing? Why is there lack of awareness?
    • Root cause: Undervaluation of comprehensive documentation training by administration, leading to poor awareness among physicians about the benefits of image saving.
    • Solution: Educational sessions, admin incentives for proper documentation, feedback loops showing benefits and risks.
  • Fishbone diagram (Ishikawa) for root-cause analysis (Fig. 23.7): Place problem at the head and major contributing categories as bones.
    • Common categories: People, Machines, Materials, Environment, Methods, Measurements.
    • Helps visualize multiple contributing factors beyond personal oversight.
  • Pareto principle (80/20 rule): Often 80% of outcomes come from 20% of inputs.
    • Application in ultrasound programs: 80% of scans may be performed by 20% of users; 80% of denials may come from 20% of payers.
    • Use: Focus redesign effort on the critical 20% that drives most outcomes.
  • Practical takeaway: Use RCA methods to define and solve problems; combine RCA with design thinking when user input is essential.

Design Thinking Framework (Detailed)

  • Overview: A five-step, user-centered problem-solving approach.
    1) Empathize: Understand barriers and unmet needs from stakeholders’ perspectives. Techniques: direct interviews, empathy maps, surveys, journey mapping, and experience emulation (e.g., using a device with the other hand or in a wheelchair) to reveal pain points.
    2) Define: Synthesize insights into a problem statement describing the user, issue, and a key observation. This sets the basis for ideation.
    3) Ideate: Generate a large set of diverse solutions. Include people with varied skill sets; brainstorm freely with prompts to expand thinking.
    4) Prototype: Build a tangible representation of a chosen solution using low-fidelity materials (paper, foil, pipe cleaners, clay, cardboard) or storyboard processes.
    5) Test: Demonstrate the solution in the target environment and collect rapid feedback (e.g., bodystorming demonstrations or slide decks).
  • Benefits: Clarifies ambiguous problems; uncovers unmet needs; fosters collaboration; can yield a design sprint (short, intense sessions).
  • Drawbacks: Resource-intensive; success depends on involvement of multiple stakeholders.
  • Design sprint example (Table 23.4): A 60-minute sprint to improve FAST performance in a trauma bay, involving diverse stakeholders, with structured steps (Empathize, Define, Ideate, Prototype/Test, Final Discussion).
  • Practical takeaway: Use design thinking to explore and resolve complex, human-centered issues in ultrasound programs.

Practical Summary and Recommendations

  • Ultrasound program directors should actively apply design principles from multiple disciplines to optimize clinical care, education, and administration.
  • Start with crowdsourcing solutions when possible to tap into broader expertise.
  • Define clear goals aligned with organizational strategy and prioritize them using tools like the 2×2 effort–value matrix, the Eisenhower Box, or the MOSCOW method.
  • Map goals using SMART criteria and visualization tools (mind maps, Gantt charts) to operationalize plans.
  • Implement RCA or design thinking based on problem clarity and stakeholder input; use fishbone diagrams and the Five Whys where appropriate.
  • Leverage design thinking for user-centric investigations and redesigns; consider design sprints for focused, time-bound problem solving.
  • Integrate ethical, philosophical, and practical implications: ensure patient care quality, education quality, and safety are central; maintain transparency in metrics and feedback; consider resource equity and staff well-being when implementing changes.

Key Concepts and Formulas (Quick Reference)

  • Fogg Behavior Model: Behavior requires the convergence of Motivation (M), Ability (A), and Prompt (P):
    • B = f(M \times A \times P)
  • 2 × 2 Prioritization Matrix: Value vs Effort (quadrants) to rank tasks
  • MOSCOW prioritization: Must Have, Should Have, Could Have, Won't Have
  • SMART goals: Specific, Measurable, Achievable, Relevant, Time-bound
  • Five Whys: Repeatedly ask "Why?" to uncover root causes (up to five iterations)
  • Fishbone diagram: Categories typically include People, Machines, Materials, Environment, Methods, Measurements
  • Pareto principle: 80/20 rule – 80% of outcomes often arise from 20% of inputs
  • Design Thinking steps: Empathize, Define, Ideate, Prototype, Test

References (from the chapter)

  • 1. Harrison JD, Patel MS. Designing nudges for success in health care. AMA J Ethics. 2020;22(9):E796-801.
  • 2. Null N. What is lean healthcare? Catalyst Carryover [Internet]. 2018 Apr 27;4(2).
  • 3. Orn A. Crucial role of affordances and signifi… in medical device design [Internet]. Research Collective. 2024.
  • 4. Aldekhyl S, Cavalcanti RB, Naismith LM. Cognitive load predicts point-of-care ultrasound simulator performance. Perspect Med Educ. 2018;7(1):23-32.
  • 5. Behavior Design Lab. Fogg Behavior Model. Stanford resources.
  • 6. Joint Commission Resources. Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel and Adverse Events, 7th Edition.
  • 7. Brown T. Change by design: how design thinking transforms organizations and inspires innovation. HarperBusiness, 2009.

Tables and Figures (Referenced Concepts)

  • Fig. 23.1: Nudge theory examples – floor markings and premade workflows to prompt standard imaging guidelines (ACEP).
  • Fig. 23.2: Lean thinking – fixed ultrasound machine in trauma bay and premade nerve block kits.
  • Fig. 23.3: Affordance and signifier example – ergonomic probe design and numerical labels for workflow order.
  • Fig. 23.4: Streamlining with AI to reduce cognitive load in measurements.
  • Fig. 23.5: Fogg behavior model example – QR code prompt for reporting a service issue.
  • Fig. 23.6: Example of an effort–value 2×2 matrix for goal prioritization.
  • Fig. 23.7: Fishbone diagram illustrating multiple contributing factors for underutilization (six common categories: people, machines, materials, environment, methods, measurements).
  • Fig. 23.8: Design-thinking framework diagram (Empathize, Define, Ideate, Prototype, Test).
  • Table 23.1: MOSCOW prioritization example.
  • Table 23.2: SMART goal mapping example.
  • Table 23.3: Five Whys example.
  • Table 23.4: Stepwise design sprint example for FAST in trauma bay.