Tom and David Kelley of the award-winning Palo Alto-based global design firm IDEO have been helping private and public sector organizations innovate, grow and bring to market new ideas for 35 years; projects include Apple’s first computer mouse and a stand-up toothpaste dispenser for Procter & Gamble. In the Kelleys' new book, Creative Confidence: Unleashing the Creative Potential Within Us All, the brothers recount anecdotes from their work at IDEO and at Stanford's d.school (the institute of design created by David Kelley), and offer tips to help everyone build creative muscle in an era when success depends on innovation in every field. Here at the Eye, the authors share an excerpt from the book that discusses how a group of students used design thinking to invent an innovative product to improve the lives of infants in developing countries.
Sometimes a single course can change a student’s life. That’s what happened to Rahul Panicker, Jane Chen, Linus Liang, and later Naganand Murty when they used design thinking methods to move from blank page to insight to action. They turned a routine class assignment into a real-life product: the Embrace Infant Warmer, an easy-to-use medical device that costs 99 percent less than a traditional baby incubator and has the potential to save millions of newborns in developing countries.
The course was Design for Extreme Affordability, almost universally referred to at the d.school as simply “Extreme”—which pretty accurately describes both the pace and the class experience. Taught by Stanford business school professor Jim Patell and a faculty team, Extreme is a multidisciplinary melting pot in which students from departments all over the university come to the d.school to develop solutions for daunting, real-world problems.
Their project was to research and design a low-cost infant incubator for use in the developing world. No one on the team knew much about the complications of premature birth, let alone medical product design for other countries. They were electrical engineers, computer scientists, and MBA students—not public health experts.
Their first step was to look outward for inspiration. They decided to meet in an unconventional place on campus: high up in a tree, outside the CoHo coffee house. From that lofty perch, the four students Googled the global infant mortality problem and found statistics that astonished them. Each year, about fifteen million premature and low-birth-weight babies are born. A million of them perish, often within twenty-four hours of birth. The biggest preventable cause of death? Hypothermia. “These babies are so tiny they don’t have enough fat to regulate their own body temperature,” says Jane Chen, the MBA on the team. “In fact, room temperature feels like freezing cold water to them.” In India, where nearly half of the world’s low-birth-weight babies are born, hospital incubators can provide consistent, life-saving heat during those crucial first days. But traditional incubators can also cost as much as $20,000—each.
An obvious solution arose: the team could systematically reduce the cost of existing incubator designs by eliminating parts and using cheaper materials. Research done, right? And yet, one of the central principles of human-centered design is that you “empathize with the end user.” Skipping that fundamental approach to innovation wasn’t really an option. Instead, computer science team member Linus Liang got funding for a trip to Nepal in order to more deeply understand firsthand the unmet needs associated with incubators. What he saw there challenged his preconceived ideas and sparked creative insights that led to an innovative solution.
Linus was visiting a modern urban hospital in Nepal when he noticed something odd: Many of the hospital’s donated incubators were empty. Puzzled, he asked why. Why were so many incubators empty if premature babies in the region needed them to survive? A doctor explained the sad, simple truth. Many of the hospital’s incubators were going unused because the babies who needed them were often born in villages thirty miles away. No matter how inexpensive or well designed the incubator, life-and-death battles were being fought in the mother’s home, not the hospital. And even if a new mother felt well enough to travel and had the family support she needed to maintain constant skin-to-skin contact with a premature baby en route to the hospital, she was still unlikely to leave her newborn in treatment. Family needs back in the village meant that premature babies were taken home again after five or six days, even if they should have stayed in an incubator for weeks.
Linus realized that incubator cost was just one design challenge in a complex web of human needs.
Back in Palo Alto, the team discussed what to do with these insights. On the one hand, there was a clear need for something that would help moms and babies in rural areas. On the other hand, as electrical engineer Rahul Panicker put it, “Dude, that’s going to be hard.” Should they stick with the technical challenge—designing a low-cost incubator for hospital use? Or tackle the human needs—designing a solution for mothers in remote areas? “We had mixed opinions on this,” Rahul said. “Some people on the team wanted to do the more remote setting....Others—and I was one of the others—wanted to do something that could actually get finished by the end of the class.” Finally, they approached one of the teaching assistants in the class, Sarah Stein Greenberg (now managing director of the d.school), for advice. She told them, “You know, given a choice, I’d say, go after the hard challenge. That’s what puts the ‘extreme’ in Extreme Affordability.”
So instead of creating another hospital incubator, they reframed the design challenge as: How might we create a baby-warming device that helps parents in remote villages give their dying infants a chance to survive? For the Embrace team, the solution was now about the parent, not the clinician. They wrote this point of view down on the whiteboard in their workspace, and it became their guiding light for the rest of the twenty-week class—and beyond.
The team then worked to turn these insights into innovation. They did this by cycling rapidly through four or five rounds of rough prototyping to develop a simple but powerful solution. Shaped like a tiny sleeping bag, it contains a paraffin-based pouch that, once warmed in a heater, can maintain its temperature for up to four hours. The solution could be used outside of hospitals to keep a baby warm at the correct temperature anywhere in the world.
Their next step: test the prototype with parents and stakeholders in rural villages.
They took the prototype to India, where they sought to understand the cultural nuances that could lead mothers to accept or reject the device. Along the way, they discovered factors they could never have found if they had stayed at home in Silicon Valley. For example, one day Rahul was in a small town in Maharashtra state showing the prototype to a group of moms. At that time, the prototype had a built-in temperature indicator, like the LCD thermometer on a fish tank or a fever strip that indicates a child’s body temperature.When Rahul told the moms to warm the heating pouch to thirty-seven degrees Celsius to help regulate the baby’s temperature, he got a surprising and unsettling response. One of the village mothers explained that in her community they believed Western medicines were really powerful, and often too strong. So if the doctor prescribed one teaspoon of medicine for her baby, she told Rahul, “I give him just half a teaspoon. Just to be safe. So if you ask me to heat it to thirty-seven, just to be safe I would heat it only to thirty or so.” Alarm bells went off in Rahul’s head.
Traditional engineers might have blamed this on random “user error” and moved on. But the Embrace team just iterated the design. Now, when the baby warmer reaches the correct temperature, an indicator simply changes to “OK,” so there is no numeric value for parents to second-guess. In this instance, prototyping with end users in the field led to an improvement that may make the difference between life and death.
At the end of the class, the students faced a hard decision about what to do next. They could have stopped with a working prototype. Both Rahul and Linus had already started working at promising tech startups. Jane was fielding job opportunities as she finished her MBA. And one of the original team members, who had recently become a father, decided he couldn’t continue to commit to the project full-time. In the end, however, the team couldn’t let the project die. They began to apply to social entrepreneurship challenges and fellowships to raise the money to continue. Later they incorporated as a social venture and moved to India to launch their solution into the market. “At some level we did not have the heart to walk away,” Rahul told us. “Knowing that we could have actually made a difference, but walking away because we had ‘better opportunities’? No. I did not agree with that thinking. I wanted to devote the best years of my life to doing something meaningful.”
For two years, the team traveled in India talking to moms, midwives, nurses, doctors, and shopkeepers. “The whole philosophy of Embrace is that you have to be close to your end user to make a really good design,” says Jane. “Being here we have learned so much, and it’s been critical to the success of this product.” There were countless logistical hurdles to overcome. They had to keep iterating the design based on user feedback. “We were completely naïve,” Rahul says. “We knew nothing about how to bring a medical device to market. How do you rigorously develop a product and test it and maintain standards while also maintaining low cost? How do people think about health care in towns and villages? How do goods and services reach there?”
In December of 2010, Embrace was featured in a segment of the ABC News show 20/20. The show included images of a five-pound baby girl in Bangalore named Nisha, the first child to use the Embrace infant warmer in their clinical trial—and possibly the first life saved by the device. The show also included an emotional interview with a woman named Sudatha. She had lost all three of her newborn children, each a low-birth-weight baby too small to keep itself warm. Carefully examining the Embrace infant warmer, Sudatha observed, “If I had this...I could have saved my babies.”
The team has come a long way since that TV episode aired: the company has now grown to ninety people. They continue to evolve the design of everything from the product itself to the distribution model to their organizational structure. They have begun selling the product to government facilities, giving them greater access to the poorest areas of India. But that institutional channel brought with it new constraints and required new design changes.
“Little did we know the time and capital it would require for us to get from a concept to a manufactured and clinically tested product—not to mention what it would take to build a distribution channel to sell our product,” Jane wrote recently in a blog post for the Harvard Business Review. Another challenge they hadn’t foreseen was that in spite of the compelling need for the product, they still had to persuade parents to change traditional behaviors to get them to use the new infant warmer. To increase acceptance, they have worked on educating mothers about hypothermia and conducted clinical studies to meet European medical device standards.
We don’t know yet how many mothers will be spared Sudatha’s fate, thanks to the team’s inventiveness and perseverance. So far, however, they have helped over three thousand babies. And after launching a successful pilot program in India, they are working with NGO partners in nine more countries, have struck a global distribution deal with GE Healthcare, and recently have launched a version of the warmer that can be activated by hot water instead of electricity.
Reprinted from the book Creative Confidence: Unleashing the Creative Potential Within Us All by Tom Kelley and David Kelley. Copyright 2013 by David Kelley and Tom Kelley. Published by Crown Business, an imprint of the Crown Publishing Group, a division of Random House LLC, a Penguin Random House Company.