Mission Drift: Systems Design & a Lose of Focus
Dr. Meghan Bausone argues that American maternity care isn’t broken. It is working toward something else
Meghan Bausone came to design through birth. Before she worked as a product and service designer, she studied midwifery and co-founded a nonprofit publication about childbirth. Startups followed, then projects inside larger companies. She recently finished a doctorate in design on rural access to maternal health care, written in her spare time around a full-time job. On CX Pod she told Sheev Davé it was the kind of thing only an insane person would do.
Her subject is grim. America has the highest maternal mortality rate among rich countries, and black and indigenous women bear the worst of it. By her count, around 35% of rural counties are maternity care deserts, with more at risk as hospitals close their labor and delivery units.
Most people call this a broken system. Dr. Bausone thinks that misses the point. American health care is driven by cost reduction and profit, and it delivers both. Healthy mothers are a hoped-for byproduct, not the goal. The system is not failing at its purpose; it is succeeding at a different one.
Her study of Donella Meadows, an environmental scientist at Dartmouth, gave her a way in. Meadows’ work focused on what leverage points for change exist in systems. She ranked the places where a system can be changed by how much difference each makes. Money sits near the bottom; information sits much higher. Dr. Bausone thinks that is where designers can matter most, because those in power restrict it. One illustrative story she provides for this is the physician she interviewed described an uninsured patient quoted $13,000 for a hysterectomy. With insurance, the hospital billed $40,000 and accepted $2,000. Nobody could say what the operation actually cost. That information was restricted.
The system is large. It is defined as hospitals, insurers and payment flows. Changing that, Dr. Bausone suspects, is a fight designers cannot win. But history can offer guidance: in 1900 most American women gave birth at home, attended by a midwife the community knew, and which knew her. That is an information flow, and one that worked for hundreds of years. Is such a small entity a system? Dr. Bausone thinks so. The question, therefore, is what would emerge for maternal health if designers built for that system, instead of trying to change one tuned for a different goal entirely.
Full Interview:
Make the System You Mean To
Dr. Bausone’s question is what would emerge if designers built for the system people actually need, instead of the one tuned for a different goal. You know that question from the inside. The research is done, the need is clear, and then the build drifts toward whatever the organization already knows how to make. When leadership asks why, you have instinct but no method to point to.
The HCD Production Guide is that method. It takes you from research to requirements to something people can use, through ideation, testing and iteration, with six reusable exercises and case studies from NASA, GSA, VA and CDC. It gives you a path you can repeat, teach and defend.
From the Masthead
Dr. Bausone, our guest this week, spent her doctorate studying rural maternal health care in the U.S. Listening to her conversation with Sheev Davé, I was struck by the gap between what that system says it does and what it actually does. Its stated mission is healthy mothers and babies. Its working purpose, as she describes it, is controlling costs and turning a profit.
A gap like that is not damning on its own. Most systems drift from their mission, and some of the drift keeps them alive: a hospital that earns a margin can keep its doors open. The trouble starts when nobody corrects it, because then the working purpose quietly makes the decisions.
Scale is one of those decisions. In a system built around people, one of the hardest choices is whether to treat as many people as possible, which means going big, or to treat each person as an individual, which means staying small. In a system built around profit, that choice never comes up. The answer is always to scale.
I wish there were a tidy alternative, such as small, local and non-profit. There isn’t. Small systems need oversight as much as large ones, and some cases, like treating a birth defect, need specialties that only a large hospital can support. There is no perfect scale for a complex situation.
What there can be is correction. Systems thinking is usually taught as a way to understand a system as it stands. That is only half the work. The other half is finding where the system has drifted from its mission and bringing it back. A mismatch between mission and purpose is not a verdict, but it is a red flag, and it tells you where to look.
This will matter more, not less, as AI is built into large systems. The people who run and oversee them will be making these calls more often.
So what should they measure against? Whatever size a system grows to, the yardstick should be one person: the mother who has to drive a long way to an appointment, the parent hunting for a school newsletter across five apps. We build these systems for humans. A human is the right unit to measure them by.
Together in the work,
Ana & the Ishmael Interactive Team
Deliver the System You Know Works
“The system is not failing at its purpose; it is succeeding at a different one.” If you have ever launched something good and watched it fade, you have met this system. The pilot worked. Six months later everyone was back to the old spreadsheet, and nobody had decided to kill it. The organization simply kept doing what it was built to do.
The HCD Delivery Guide is about that stretch after launch, where most good work quietly ends. It covers change management, training, stakeholder mapping and sustainment, drawn from work with the VA and GSA, and scales from a one-day effort to several weeks.
What We're Into This Week
Aaron
Meghan’s talk about leverage points made me think about How to Peel a Banana, a recent essay by Marina Nitze in which she finds, improbably, that licensing was the leverage point at which she could transform Rhode Island’s foster care system.
Ana
Licensing! That’s so deep in the system. At the other end of it: people. Like, messy people who provide excellent healthcare despite the system they’re caught in, which reminds me of Jake Hirsch-Allen’s recent podcast with Public Practice, The Humans are Your Innovation Strategy. I’ve been really into that one this week.
Scott
Innovation is never going to come from models, even models interacting with each other. The problem is: those models don’t have experiences. This was really perfect timing with a recent article called In Praise of the Detour, by Giorgia Lupi. The outputs of AI are what researchers call “visual elevator music”, which is the phrase most descriptive of sadness that I’ve ever heard.
Aaron
Oh wow, Scott. That IS so sad.
Ana
Yeah I’m going to need to go walk outside now.
Aaron
Don’t look at your phone!
Ana
I wont!*
Ed’s note: Ana left her phone on her desk.
Credits
Guest: Dr. Meghan Bausone | Host: Sheev Dave | Line Producer: Aaron Meyers | Producer: Ana Monroe | Text: A. Adams