Striving for Vuja De: Developing Eyes for Creativity

Striving for Vuja De: Developing Eyes for Creativity

By Marilyn P. Chow, RN, DNSc, FAAN (Expert Panel member) and Christi J. Zuber, RN, MHA, Kaiser Permanente

Health care workers are all familiar with the issues that plague health care organizations: medication errors, communication breakdowns, poorly designed facilities, etc. We often recall many failed efforts to improve these issues. We try the same solutions repeatedly and are surprised when we get the feeling of déjà vu—the feeling that we have been here before and are seeing the same results…again. Einstein's humorous definition of “insanity” is trying the same thing over and over again and expecting to get a different result. Perhaps it's time to approach the issue you have looked at many times before with fresh eyes, like you are seeing it for the first time. At Kaiser Permanente, that's what we call “Vuja De.”

There are several effective ways of creating Vuja De for clinicians who are trying to address difficult issues. For example, Kaiser Permanente improvement teams have used field observations, storytelling, brainstorming, and rapid prototyping.  We have also found creative ideas using lesser-known techniques, including analogous site observations.

Analogous Site Observations

“We are going to do WHAT?” said the team members in response to the agenda we presented for the day. We repeated it: The attendees for our Medication Administration “Deep Dive” team would be split into groups to visit either a flight school, a car dealership, Safeway, the local American Automobile Association (AAA), or a professor of forensic science. We anticipated it would shake up their thinking on how to reduce medication errors, and we were right. When asked where people do most creative thinking, you rarely hear the answer “sitting at my desk” or “while I am working.” So we made plans for our clinicians to experience a non-health care setting to force the question: What issues do we have in common and what are they are doing to address them?

For example, the airline industry does an excellent job of trying to identify the root cause of crashes. In a number of cases, as well-intentioned pilots were conducting the complex job of taking off or landing a plane, they were also having unrelated side conversations with each other. Critical steps were missed because these pilots were not focused on the task at hand. This distraction resulted in sometimes-fatal accidents. Sound familiar? The nurses, hearing this scenario at the flight school visit, related to times they had side conversations at the Pyxis machine while preparing medications, multitasked in the hallway with medications in hand, or administered medications in a chaotic patient room. The pilots' solution is a “sterile cockpit,” which means that for the first 5,000 feet during take-off and the last 5,000 feet before the plane lands, no conversation or activity occurs that does not directly deal with the task at hand—safely flying the plane. Pilots have a specific safety check process where focus is expected. The flight school visit prompted hundreds of new and creative ideas about how to apply the “sterile cockpit” concept to the process of administering medications to patients.

This anecdote was only one of many “ah-ha's” that the clinicians experienced during their analogous site observations. The ideas were unique because of clinicians' firsthand experiences.

Tips for Planning Analogous Site Observations

When planning analogous site observations, consider taking the following steps:

  • Identify the key attributes or characteristics of the issue you are trying to solve. For medication administration, we identified important attributes such as the need for focus, streamlining the process, closing the loops, and teaching complex topics.
  • Brainstorm on other industries, organizations, or trades that apply the same attributes. For our topic, we explored other industries that are complex and have a need for great focus (airline), require a streamlined supply-chain (grocery and automotive), must close the loop after tasks are completed (emergency and road-side repair), and have experience teaching complex topics (higher education).
  • Identify industries that have multiple attributes. The airline industry, for example, met the criteria for all four of our focus areas; therefore, it was a priority setting.
  • Think about the companies that are physically near you to make it possible for a team to visit them in person. Bringing “experts” to you is another option if an onsite visit is impractical.
  • How many people you plan to send will determine which companies you can visit; some may not be able to accommodate large groups. Additionally, consider the need for single or multiple site visits to create different experiences.
  • Make early contacts with the companies you identify to explain your goals and how their help could address the problem you are trying to solve. For example, provide a letter or e-mail that they can use to inform their management about the visit.
  • Provide questions in advance so they can plan for your visit.
  • If possible, provide a financial contribution to the company or individual who spends time with your group. We provide $100 cash with a thank you note at the end of the visit.

The French novelist Marcel Proust said, “The real act of discovery consists not in finding new lands but in seeing with new eyes.” So if you want to find untapped innovation opportunities, look at the world around you with fresh eyes. Strive for a sense of Vuja De and prepare yourself for the creative ideas that follow.


  1. Zuber CD, Alterescu V, Chow MP. Fail often to succeed sooner: adventures in innovation. The Permanente Journal 2005 9(4):44-49. Available at: Accessed August 7, 2007.
Publish Date: 03/24/08
Date Last Updated: 09/12/12

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