Catalyze Innovation that Advances Health

Primer on Thinking Differently


Paul Plsek, MedStar Institute for Innovation Innovator-in-Residence, Internationally recognized consultant and author on innovation in healthcare, and developer of the concept of Directed Creativity: Creative Thinking for Serious People™  

Basic Theory and Practical Application

Many incorrectly assume that creative thinking—the ability to think differently—is a special gift, bestowed on only a few. While it is true that we rarely see the extraordinary creativity of an Edison or Einstein, modern findings from the fields of the cognitive sciences indicate that the ability to generate innovative ideas for change in our work is a common “gift” that we all possess. The literature on organizational innovation and creative thought goes back to the 1930's. While the classic literature described methods derived pragmatically over time, more recent research from the fields of psychology and cognitive science has provided underlying principles that give rise to general classes of methods.

 Thinking Differently: Basic Theory

Natural thinking as mental valleys.  To understand how to think differently it is important to understand first how thought proceeds normally. The mind processes language by activating patterns of neurons that unfold a word into a rich set of images and concepts, based on past learning. This is illustrated by Edward de Bono’s [1] mental-valleys model of the mind (see figure). Just as randomly falling rain gets organized into streams at the bottom of valleys through years of erosion, so the mind learns to organize the otherwise random sounds of a spoken word into an associated stream of thought.

mental valleys

This flexible, pattern-matching mechanism is essential in daily life. Not only does it help us engage in conversation, it also enables a good diagnostician to quickly zero-in on a problem based on an initial review of the situation. The diagnostician has seen the pattern before and, therefore, has a good idea of the underlying explanation. The mental mechanism is the same whether we are preparing a budget, running a hospital or just trying to get out of bed in the morning. We use the past experiences stored in our memory as a guide for how to proceed. Thus, when one thinks of a clinic he or she immediately thinks of a physical location, with a receptionist and waiting area, where the medical assistant calls you back into an exam room before you see the provider, and so on. This thinking process occurs with minimal conscious effort and gives rise to the fact that most clinics, and their processes, are quite similar.

Thinking differently involves mental valley exploration.  Thinking differently occurs when we deliberately rise out of the usual mental valley to explore other possibilities. A video consult with a health care provider over the Internet is an innovative idea because it lies outside the current mental valley of the clinic. However, the mental valley of the Internet includes the concept of distant video connections as a normal thing to do. Creative thinking involves connecting the information in these two mental valleys. The connection can be made either purposefully or randomly. The terms mental model, assumption, paradigm, rule, tradition, the way we do things, and so on are roughly equivalent to what de Bono [1] calls a mental valley. The point is to rise out of it and explore other possibilities.

Creative thinking requires attention, escape and movement.  The process of rising out of and exploring other mental valleys in order to come up with new and useful ideas relies on three deliberate mental activities—attention, escape, and movement. [2] We must pay attention to our mental valleys, assumptions and traditions and not allow our thoughts to simply rush forward in the usual way. We must be willing to challenge these and escape, even if only for a few moments in our mind, in order to wonder “what if…?” We must also overcome the self-censoring that would draw us back into comfortable patterns of thought and, instead, move in thinking to create a brainstormed list of ideas and possibilities that arise out of the attention and escape. These three principles, in some sequence and relative emphasis, are the essence of thinking differently and can be recognized as lying behind all methods for creative thinking.

Seven types of change.  The range of what might constitute a new and useful idea, coupled with the endless possibilities that arise out of attention, escape and movement, leads to the observation that the degree of creativity of a given idea lies along a gradient. Author Rolf Smith [3] describes this gradient in his seven types of change (see box). This model can be used to reflect on the output from idea generation, or to deliberately focus a session to stimulate certain classes of ideas.

Seven Types of Change 

(Adapted from Rolf Smith)

1: Doing the right things - Effectiveness, focus and working to priorities

2: Doing things right -  Efficiency, standards and variation reduction

3: Doing things better -  Improving, thinking logically about what we are doing and listening to suggestions

4: Doing away with things -  Cutting, asking “why do we do this?”, simplifying and stopping what really doesn’t matter

5: Doing things that other people are doing -  Observing, copying and seeking out best practice

6: Doing things no one else is doing -  Being really different, combining existing concepts and asking “why not?”

7: Doing things that cannot be done - Doing what is commonly thought to be impossible, questioning basic assumptions, breaking the rules and being a bit crazy

Innovation funnel.  Research reveals that the process of innovation in an organization is not a linear, deterministic process. It almost never happens that a team comes up with a single idea, their first test of it is perfect, and they seamlessly transition to successful full-scale implementation. Trying many new things, and failing on most but learning and adapting as you go along, is an essential part of the process. This observation is summarized in what the innovation literature refers to as the innovation funnel. The ratio of 100 brainstormed ideas to one successful new product or service highlights the importance of not restricting idea generation with premature judgment. At the same time, the narrowing of the funnel calls attention to the need for progressively applying judgment regarding investment of resources as the process moves along over time.

innovation funnel

Directed creativity and innovation.  The concepts above support the notion that thinking differently in an organization can be a deliberate process, directed to specific ends. We can facilitate attention, escape and movement out of our existing mental valleys aimed at producing ideas for change. We can also systematically harvest and develop ideas along the pipeline illustrated by the innovation funnel. Organizational innovation can therefore be described as: directed creativity implemented.

Thinking Differently: Practical Application

These basic concepts for thinking differently give rise to methods, tools and processes to facilitate directed creativity and innovation in an organization.

Directed Brainstorming. Most people are familiar with Alex Osborne’s [4] guidelines for a brainstorming session: criticism is ruled out, freewheeling is welcomed, quantity is wanted, and combination and improvement is sought. These guidelines encourage mental movement and escape from premature judgment, but they do not provide guidance about what to pay attention to or which mental valleys to escape. Therefore, adding some direction for thinking will enhance any brainstorming session. This direction can come from the seven types of change (e.g., Based on the data we have seen, what could we do better? What are examples of things that others are already doing that we should consider?) or through use of a variety of verbs (e.g., What can we combine? What can we do away with? What can we substitute?). Participants, working alone or in small groups, focus on one such question at a time, writing down multiple ideas, each on a separate card or self-stick note. These are then arranged on a wall, combined and categorized as necessary, and voted on relative to some criteria in order to begin the innovation funnel process.

Mental Benchmarking. When we think of doing what others are doing—Smith’s idea type #5—we tend to think only about other healthcare organizations. However, many of the basic issues we face are common to a variety of industries. We can often find new mental valleys to link to if we state the challenge in plain English and remove the healthcare jargon. For example, in healthcare we talk about “access,” “patient flow,” or “matching up the correct patient with his or her medications.” But these are really common issues across many industries. McDonald’s deals with access by providing a drive-thru window; Disney World deals with waiting time for its rides by providing stimulating visual input to make the time pass more quickly; and FedEx certainly knows a thing or two about how to match up packages with the correct delivery truck. How can we adapt these concepts to our challenges in healthcare? To use mental benchmarking:

  1. State the issue in its plainest or most general terms (escape the mental valley of healthcare jargon)
  2. Select an industry or business at random, or one that you know deals with a similar issue (escape the common healthcare tradition)
  3. Describe how that industry naturally thinks about the issue (attention to other mental valleys)
  4. Borrow and adapt concepts to apply to your issue (movement back to healthcare)

Break the Rules. Identifying existing design rules, assumptions and traditions that drive what we currently do, and then moving on to explore alternatives is yet another method for thinking differently. For example: Intensive care is a specific unit in a hospital. Alternative: Consider intensive care as a set of people, equipment and capabilities that can be deployed anywhere in a healthcare system, centralizing the highest skilled, highest cost clinicians via remote monitoring. Each entity in a healthcare system must close its books each month, and that gets rolled up to system-level.

Alternatives: Close the books at system-level only… OR… Close the books at service-line level and then roll-up to system level… OR… Close the books only every 6 or 8 weeks Alternative design rules lead to different processes, staffing levels and costs. The only way to know if these differences are better is to play out the scenario. The break the rules method is particularly useful if your aim to do things that no one else is doing, or things that others say cannot be done—Smith’s idea types #6 and 7. The flow of a breaking the rules ideation session generally proceeds as follows:     

Attention. Begin by selecting a specific process or system of work as the focus. It might be helpful to construct a high-level process map to describe the current flow and the boundaries of the process. Ask: What rules, assumptions and traditions drove us to design the process this way? Capture each design rule in one column of a table, no matter how seemingly necessary and unchallengeable it is.     

Escape. In the second column of the table list 1-4 alternatives to each design rule. Avoid self-censoring; one never knows where a different design rule might lead.     

Movement. Participants will naturally begin moving in thinking and see possibilities as each alternative is stated, thereby developing some intuitions about which alternatives to explore further.

Attention. Based on these intuitions, select several alternative design rules to explore.

Movement. Reconstruct the process or system based on the alternative design rules. It is not necessary to create a detailed redesign, simply play out the scenario enough to get a rough idea of its potential impact on key indicators. A drawing, process map or bullet list of key points is a good way to summarize the thinking. The multiple scenarios created by this method can now be prioritized, developed, tested on a small scale, and evaluated (innovation funnel).

Idealized Design. If there were no existing structures or processes and we were just now creating something anew for this process or system, what would we create? This question immediately escapes the constraints of the current way of doing things and invites attention and movement toward an ideal state. Participants often experience it as “freeing” and have little difficulty imagining and agreeing upon better ways of doing things. Setting up an idealized design session requires the creation of a scenario that captures relevant elements in the environment beyond the organization’s control (e.g., customer needs, competition, reimbursement, availability of workforce) but describes the organization as a newcomer, or one that has not previously consider the issue. It is often helpful to break a large group down into subgroups to allow for more variety in thinking. The output of each subgroup is, again, a drawing, process map, or a bullet list of key points. With the picture of the ideal in mind, the group then shifts back to reality. What are we willing to change to move us away from status quo toward this vision of the future? This discussion exposes current design rules, assumptions and traditions and might lead to the application of one of the other tools described above.

  • At a minimum, it exposes the really difficult questions that stand in the way of true transformation. These can be framed for decision-making outside the team (i.e., at executive level).
  • Fully played out, the discussion leads to a transformation plan to transition the organization in a logical manner, over time, from current state to something approaching ideal.

Stepping Stones. It has been said that “necessity is the mother of invention;” that is, creative thinking often occurs at times of crisis. If this is so, then it makes sense to create an imaginary crisis and ask what we might do. That is what a stepping stone provocation does. For example: A strange virus that only attacks nurses has left us with only 20 nurses to staff the entire hospital, what are we going to do? Such a scenario escapes the status quo and cause one to focus attention on prioritizing work, eliminating unnecessary tasks and creating better skill-tasks alignment. The scenario can be designed to target thinking about any resource—staff, equipment, appointment slots, etc. As with idealized design, after stretching thinking in the extreme scenario, the group comes back to reality with new insights that can be applied to transforming the current state.  

Resources from MI2

These are but a few of the many ways to stimulate thinking differently in yourself or your group. For further reading, see: Plsek PE (2013) Accelerating Health Care Transformation with Lean and Innovation: The Virginia Mason Experience. CRC Press.      

For MedStar Health - If you are a MedStar Health associate you can download our Think Differently App which will guide you through a series of exercises to help unstick your stuck-thinking. If you want more support, ask MI2 to help you design and facilitate creative thinking exercises to match your specific challenges and time budgets. Contact Paul Plsek, MI2 Innovator-in-Residence, for more information, or to schedule a coaching session: [email protected].


  1. de Bono E (1969) Mechanism of Mind. Penguin Books.
  2. Plsek PE (1997) Creativity, Innovation, and Quality. ASQ Quality Press.
  3. Smith R (2007) The Seven Levels of Change: Different Thinking for Different Results (Third Edition). Tapestry Press.
  4. Osborn A (1953) Applied Imagination. Charles Scribner.