Service Design and Design for Public Services
Deaunne Denmark and Danielle Olson. A communications canvas to improve and individualize patient engagement in healthcare systems redesign
Current healthcare systems are rife with extensive barriers to information transfer. Exacerbated by rapidly increasing volume and time constraints, these are considered a core wicked problem and key driver of healthcare system dysfunction. Thus, redesign efforts focused on collaboration and facilitating efficient, transparent, and bilateral communication are paramount to dissolving these barriers and effecting positive, sustainable system-wide transformation.
It is now clear that action in two critical areas can leverage radical health information and system reform: repositioning patient needs to the center of local and extended ecosystems (patient-centered care), and enhancing patient involvement at every stage of health information transmission (patient engagement). Allowing patients and caregivers to initiate, direct, and manage information flow aligns health decisions with the individuals primarily affected. Benefits include substantial delivery cost reductions, elimination of waste, and increases in treatment efficacy. Such a shift is a profound and necessary departure from the historically passive role of the patient as a less-knowledgeable recipient of health goods and services to a highly-informed leader in disease management and prevention, and importantly, lifelong health promotion. Designing for constructive communication and relationships between diverse actors may thus be an especially potent strategy to develop infrastructure that supports and encourages this shift.
To this end, we have created a communications-centered design tool (canvas) to help providers or organization managers improve patient engagement within a healthcare space, and designers, as they become increasingly more involved as agents and implementers at various levels of health systems change. The canvas is organized in a clean visual format that is flexible and approachable for diverse users and situations. Although simple in appearance, each section is inquiry-driven, requiring research, deep thinking and iteration to refocus the provider/designer on the patient’s perspective and individual needs. Drawing largely from innovation principles of user- or human-centered design, the canvas also reframes the context of health relationships by using the terms ‘health-seeker’ (Jones, 2013) and ‘health-advisor’ to diffuse assumptions of hierarchy, agency or unequal responsibility.
Hans Kaspar Hugentobler. Design Science in Health Care: co-designing an optimized patient pathway at a gynecological clinic of a large hospital in Switzerland.
Jones mentions that “Healthcare is a complex system that deals with at least two irreducible sources of complexity: The institutional (distributed provider systems and hospitals) and the personal (the biological and social setting of the human body). Furthermore these realms cannot be isolated, because the purpose of the institution is to serve individuals.” (Jones, 2013a, xviii) Hospitals operate as institutional actors under pressure to navigate changing health care contexts where patients become more knowledgeable and more demanding. The challenge for design thinking is to “transforming organizational practices by continually repositioning real human beings in the center of design and service management decisions.” (Jones, 2013a, xvii) Dubberly et. al. (2010) go even further, describing a shift where patients eventually become self-managing designers of their own well-being based on designed enabling infrastructures.
This design research project aims at demonstrating the value of the design approach vis-à-vis a care team at a gynecological clinic with regard to improving pregnant women´s experiences along the patient pathway. The scientific goal is to demonstrate how design research can yield evidence and derived design propositions to drive improvement and innovation efforts through a co-creation approach informed by an “understanding of an understanding” (Krippendorff, 2005) of women that told their stories of giving birth, generated by means of a grounded theory approach.
The research team facilitated a workshop with 8 clinic professionals (midwifes, nurses, breastfeeding counselor, department managers, clinic director), 3 patients and 1 external midwife. They crafted a model and issues-related design propositions – later to be tested in situ – of an optimized version of a patient process. The results are evaluated against the “design capability for health practice and care organizations” framework of Jones (2013b, 5) with a specific focus on design as caregiving and co-creating care (Rethinking Care), design for patient agency, patient-centered care service (Rethinking Patients), as well as innovating points of care and systemic design in healthcare innovation (Rethinking Care Systems). The results are triangulated with 2 Scandinavian, design-related projects that focus on patient pathways. The project contributes overall to an evidence creation capability of design research at the intersection of organizational and design science.
Keren Perla. The Pledge, the Turn, and the Prestige: Re-imagining facilitation through trials of systemic design for public policy
As the experiment with systemic design for public policy continues to grow, those who call ourselves facilitators – by trade – are found grappling with new approaches for guiding complex dialogue that both re-enforce the critical role of facilitation as well as challenge the fabric of ethics and values upon which the practice is founded. In this presentation we explore how facilitation of systemic design efforts, particularly where participants have limited appreciation of the underlying methodologies, necessitates a new understanding of the facilitator – one that expands and pushes the boundaries on core concepts such as ‘impartiality’, ‘consensus decision-making’, ‘facilitator as process guide’, ‘results versus emergence’, and ‘topic vs process disclosure.’ Similar to a magician’s code, these tenets have been critical for creating acceptance of and belief in facilitation to guide cultural change; however diversity and complexity in the field continues to proliferate. As such we argue that this destabilizing effect of systemic design provides an unmapped space to re-imagine the traditional art of facilitation to not only better adapt the discipline to more diverse uses in geographical, political, organizational and community settings but provoke transformational responses and actions in today’s legacy social systems.
Marc Matthews, Allison Matthews, Rose Anderson, Jo Bernau and Lorna Ross. Reevaluating the value of Primary Care using Design Thinking
Primary care is at a critical crossroads. Our current delivery systems are unsustainable and lack the resiliency to survive in new environments where total cost of care, patient experience, and patient centered outcomes are the primary determinants of success. In order for primary care to remain relevant and viable, new solutions must be created that are practical and transformative, attract and retain new patients and provide high value, high satisfaction services that meet their consumer needs. Primary care has to especially think about how we can demonstrate our value in coordinating care, especially in managing populations of patients and subpopulations with multiple chronic conditions. Our cost of care must come down and our quality must remain high in order for us to be able to deliver affordable care in future reimbursement realities. However, we cannot solve this problem with the same thinking that got us into this predicament in the first place.
Primary care providers have traditionally seen their value in maintaining a longitudinal provider-patient relationship. Research and experience have demonstrated that, when fully realized, this relationship decreases total healthcare expenditures with improved quality outcomes. However, regulatory and payment changes that started about a decade ago are now gaining momentum and will have significant impact on the ability of primary care providers to maintain this same depth of relationships with all of their patients. More people will now have access to health insurance and because of this there will be increasing demand on a shrinking pool of primary care providers. One option would be to simply continue as we always have and try to maintain relationships with more and more patients. Widely cited research shows that to accomplish all the necessary preventive services for the current average panel size would take 27 hours a day. And yet, because the work necessary to keep people healthy isn’t valued enough to be reimbursed properly, primary care practices have become places where acute illnesses are treated while long term health goals are pushed aside to maintain higher and higher volumes and productivity. Another option would be to look around us at the dedicated nursing and support staff in our clinics and tap into their vastly underutilized skills and knowledge to distribute the work of maintaining relationships and caring for more and more patients.
Karen Oikonen, Adam Starkman, Peter Jones and Andrea Yip. Human-Centring a Mental Health Service System
A university-based research team completed a service design research study for the OCAD University Health and Wellness Centre, developing a service concept, student-centred journey, and a system map to illustrate solutions and recommendations for extending the service concept broadly across post-secondary campuses. The research identified both extremely local solution states for improving student awareness and experience of mental health, and discovered broadly systemic factors applicable across all campuses. Systemic problems included the student negotiation of major life transitions while resolving uncertainties and social risks in mental health seeking and the recruitment of social and clinical services in the maintenance of resiliency. Service and system maps will be presented to illustrate the student pre-service mental health journey and system-level solutions proposed for post-secondary education.
John Darzentas and Jenny Darzentas. Systems Thinking for Service Design: a natural partnership
In the 1930s, nations’ economies broke down their figures into three main sectors. These were, in order of economic importance, Agriculture, Manufacturing, and whatever was not either of these was grouped under the title of Services. Today, the growth of what is traditionally called the ‘‘service sector’’ can be seen in the gross domestic product (GDP) statistics of nations. As currently measured, developed countries have 70–80% of their GDP and employment in the service sector (government, healthcare, education, retail, ﬁnancial, business and professional, communications, transportation, utilities), with 15–25% in the manufacturing sector, and about 5% in the agricultural sector (Spohrer et al. 2010, Maglio et al, 2009).
Traditionally the academic disciplines that worked on services were those of management and marketing, operations research and engineering, but not only. Information Systems specialists were also active in this area, but with the move to self-services and more recently e-services, the area requires specialists in information systems and computer science. Moreover, it is not an area that can be broken up easily, as it needs this multidisciplinary treatment. Indeed, recently, IBM, understanding that its core business is no longer in hardware manufacture, but in services, has championed the understanding of services as ‘complex systems’ in which specific arrangements of people and technologies take actions that provide value for others.
Designers for the last two decades have been realizing a shift in working practices and output from product to systems design, that is, understanding the wider system in which the designed product is to function. This incorporates, the users, producers, (including the designers themselves) the activities and functions expected, as well as the context of use, and constraints and freedoms offered by technologies used in the product. Such work has recently gone on under other labels, such as interaction design and/or user experience design (UX). Lately, systems have begun to incorporate services, and service design has taken hold, as evidenced by a dedicated conference series and a number of researcher and practitioner networks and courses.
Helena Polati Trippe. The Home as a Service: A service and systems design approach to ownership, development and value
The home is a node situated at the intersection to complex systems of value, exchange and interaction. These include a multitude of policy and institutional interventions that may be fiscal, social, infrastructure related or environmental in nature, as well as the legal and financial systems that support housing provision. As users we are being asked increasingly to act as ‘prosumers’, entering into reciprocal relations of resource integration and value creation.
The home is also not just about shelter, it’s function as a commodity extends beyond its original use value. It is a cornerstone of asset based welfare, where “individuals are expected to accept greater responsibility for their own welfare needs by investing in financial products and property assets that appreciate over time.”1 It is expected that the home will mitigate effects of networks of capital flow on individual households. The affordability of homes poses a barrier to this vision, as the high value of and rising costs of living means people struggle to meet these costs.It is difficult to imagine that trends in asset based welfare, facilitated by the commodification of housing policy and finance, are reversible or even viable.
If the role of the home in asset based welfare is considered from a design perspective, the home is another interface, or ‘tap’, from which to draw welfare goods. This tap, however, does not rely solely on the government as its source but rather on a range of complex arrangements of institutions and services. Delivery through this tap involves more risk, uncertainty and complexity, as governments’ ability for delivery is subject to other agents and wider economic forces. If the view of the home as an interface is broadened, it could involve designing it as a platform where a range of services combine to support asset realisation, governments’ ability to deliver welfare goods and enhance the ability of asset holders, to utilise them as a productive force. This broadening of access, can in part, be used to ease risks associated with the complexity involved in delivery of welfare goods. New development and ownership models, can in turn democratise this access to asset accumulation by broadening its range and form.
David Ing. Incubating Service Systems Thinking: New frames for collaborating on a pattern language for service systems
“Service systems thinking” is proffered as a label for an emerging body of work that: (i) builds on social systems thinking (i.e. socio-psychological, socio-technical and socio-ecological systems perspectives) to advance a transdisciplinary appreciation of service systems science, management, engineering and design; (ii) explores opportunities to enrich Alexanderian patterns and categorized pattern catalogs into a generative pattern language; and (iii) collaborates on new platforms, moving from inductive-consensual wiki pages to a multiple-perspectives (federated) wiki.
The service systems thinking community can learn from work organization methods, tools and licensing well known to the open source community. First steps in the collaboration can follow the incubation patterns demonstrated by the Apache Software Foundation and the Eclipse Foundation. This initiative has been initially endorsed by leaders in the International Society for the Systems Sciences (ISSS), International Council on Systems Engineering (INCOSE) and the International Society of Service Innovation Professionals (ISSIP).