Public sector and policy design


Designing with municipalities – democracy in practice?

Kristin Støren Wigum

Wednesday 11:00. Room A2.

Design as a political request
Innovation in Care
Co-design methodology
Dialogue in System Oriented Design

The health sector in Norway is mainly developed as a common good and public service. 
These service systems are developed as a response to political decision making and their solution strategies, and the municipality administration is in charge of delivering the public services as requested. 

The society demography will change dramatically the next twenty years in the western countries, the population above 80 years old will increase by 50% compared to 2016. This challenge demands for innovative thinking in care structures (Ehrenfeld 2008), political discussions and a prepared administration (Digmann et al, 2012). 

Is the organisational structure of public administration actually built to handle these type of development processes? The Norwegian Official Report (Hagen, NOU 2011:11) Innovation in the Care Services, from Ministry of Health and Care Services, predicts that future solutions within care for the elderly will find place in co-operations and partnerships between businesses, public institutions, and volunteer organisations.

The N3 method (Innoco, Sintef, 2014) was developed to help the municipalities in innovative design processes in Norway. This method points to five fundaments (Carlson/Wilmot 2006) for innovation to succeed: 1. Identification of real needs, 2. Solutions that actually meet the needs, 3. A Champion who brings the vision forward, 4. A productive multidisciplinary team built by the champion, 5. Anchored process to stakeholders and the organisations involved. The N3 method underline that if one of these fundaments equal “0” then the innovation process equals zero. 

Designing solutions for the public is materializing the visions of the politicians who have been elected by the people. It is therefore a large responsibility. The expenses are common, as well as the use of the time and effort by the employees. In almost ten years The Foundation Joy of Life for the Elderly has worked as an ideal organization with development for municipalities in Norway. The two case studies, the designing and implementation of: A. a new certification system that revitalize the nursing homes in Norway, and B. a service concept offered elderly living at home meeting other elderly and young people weekly, avoiding loneliness and passivity, are both political requests. They have the same partners, and are run through the same processes, however, turn out very differently in terms of success, so far. The author has participated in both case studies as a system and product designer.

This paper will compare the two projects. How are the designer and the design team depending on co-design in developing the services? The intended effect of co-design is shared responsibility for the final solution, as well as shared ownership to the results. It may seem that the individual motivation for participation in co-designing is closely related to what degree one is the “owner” of the real problem or need. If the design task is too general it is hard to create a clear ownership in the project, and at the same time the experience shows that the participants in the co-designing is not indifferent. The success is depending on the participants seeing a clear benefit and relation to their daily tasks in joining the process. And finally, radical ideas are not necessarily hard to find, however, a new service is not completed as a design project until it has been successfully implemented. A system perspective is therefore crucial (Jones, 2013).

The co-design methodology may be compared to dialogue-methodology (Hannevig,Parker 2014). It challenges and expands everyone’s individual view. Maybe an extended dialogue within the municipality can bring an awareness of ownership to the larger design tasks? The future care for the elderly requires that employees and leaders in municipality administration see themselves in a larger context and make the organisational structure more flexible to meet the politicians requests across sectors, owning the challenges together.

Carlson, Curtis Raymond, William W. Wilmot. (2006). Innovation: Five Disciplines of Creating what Customers want. US, New York: Crown Publishing group.

Digmann, Annemette, Kirsten Engholm Jensen and Jens Peter Jensen. (2012). Vi er på vej, Offentlig innovation 2.0.(in Danish only, Eng. trans: We are moving on, Public Innovation 2.0). Gyldendal Business, København, Livonia Print: Lativia. ISSB 978-87-02-12389-0.

Ehrenfeld, John R. (2008). Sustainability by Design – a Subversive Strategy for Transforming our Consumer Strategy. USA: Newhaven and London, Yale University Press.

Hannevig, Lise and Marjorie Parker. (2012). Dialog. En praktisk veilder. (In Norwegian only. transl. Eng.: Dialouge. A guidebook for practice.) Finland, Porvoo: Bookwell OY. ISBN 978-82-92773-50-5

Hagen, Kåre. (2011). Innovation in the Care Services . (Norwegian Offical Report, in Norwegian only) Norway, Oslo: 07 Oslo AS, NOU 2011:11, ISSN 0333-ˇ2306, ISBN 978-ˇ82-ˇ583-ˇ1099-ˇ7.

Innoco, Sintef, (2014, 2017).

Jones, Peter. (2013). Design for care. Innovating Healthcare Experience. US, New York: Rosenfeld Media. ISBN: 1-933820-23-3


Introducing systemic design to support an Australian Government regulatory agency address complex problems.

Bridget Malcolm

Wednesday 11:30. Room A2.

public sector innovation
regulatory innovation
complex problems
system modelling
problem boundaries
problem framing
collaborative innovation
The problems we face today are growing increasingly complex and our current public sector practices are not adequate to manage these challenges (Eggers & Singh 2009; Bason 2014; Bourgon 2008; Mulgan & Albury 2003). Within the context of regulation, agencies are being challenged to move beyond their traditional role of enforcing pre-determined regulations, to being able to identify and address complex problems through the development of unique responses (Sparrow 2008; Organisation for Economic Co-operation and Development 2010). This shifts the role of regulatory agencies from being implementers of regulations to being designers in their own right. The proposed paper builds off the findings from an earlier stage of this research, which was presented at RSD5 and involved a case study to understand the current practice to address complex problems. These findings informed the development of a systemic design intervention which was developed within the regulatory agency context to support the project team to address a second complex problem. Key findings from the implementation of the systemic design intervention include the relevance of system maps to support regulatory staff to identify the nature of the problem beyond individual problem components, the value of collective framing of problems with broader stakeholders within the system and the identification of leverage points to target problem responses.
Case study This research involved two qualitative case studies, which were conducted within an Australian Government regulatory agency over a six-month period.
The research was conducted in line with the Design Research Methodology (Blessing & Chakrabarti 2009) to first understand the nature of the current context so that a design intervention can be prescribed to trial within that context. The first case study involved in-depth research to understand the current regulatory problem-solving practice. Considering the diverse nature of practice, a theoretical framework was constructed to understand and compare these findings. This included the context of the practice, the practitioners, the problem being addressed, the actions taken (including methods, principles, methodologies and paradigms or tacit/implicit knowledge) and the problem response.
The findings the first case study were compared to insights of practice from fields that have been developed specifically to deal with complexity – systems thinking, complexity theory and systemic design. Methodologies from systems thinking, which encourage practitioners to view the problem as part of an adaptive whole system, were identified as being highly relevant to regulatory
Tacit/ Implicit Knowledge practice based on the compartmentalised governance systems that regulatory agencies operate within and the increasing complexity of problems they are required to address which exist in complex and dynamic social systems. Four different methodologies from the systemic design field were examined to identify common systemic design principles that provide an alternative way to act against complex problems (from Jones 2014; Ryan 2014; Dorst 2015 and ThinkPlace 2016). The common principles amongst these methodologies were exploring problem framing, exploring human needs, utilising divergent thinking, using open and creative dialogue, applying whole systems thinking and experimentation to test ideas.
The findings of current regulatory practice in case study one were compared against the systemic design principles to identify opportunities for these principles to support the current practice. Based on these insights, a systemic design intervention was developed. This included problem scoping, stakeholder mapping, creating a systems map of the problem space, comparing the problem to indicators of complexity (Snowden & Boone 2007) and two co-design workshops.
Case study two involved the application of the systemic design intervention to support the regulatory agency to address a second complex problem. The researcher and the regulatory agency project team applied the initial activities in the design intervention. The researcher and managers from the project team also facilitated the co-design workshops, which included participants from four different government agencies involved in the regulation sector where the complex problem had emerged.
The findings from case study two revealed an enthusiasm for the systemic design methods, with indications that the inclusion of systems thinking and complexity theory methods and principles increased the perceived seriousness of the design approach which was appropriate within the government setting. A stakeholder journey / ecosystem map was developed with the workshop participants which highlighted the complexity of the current system and enabled staff to see the big picture, stated as “the lid of the jigsaw puzzle” by Interviewee 6. The proposed problem responses identified in the co-design workshops were not significantly different to current reward and punishment approaches, except for the inclusion of collaborative responses which were enabled through the participatory nature of the workshops. This was likely due to the relatively conservative nature of the design approach to meet the criteria of a ‘safe experiment’ within the regulatory agency. However, the development of collaborative responses with other agencies in the sector was a significant advancement from the current identified in case study one. Several barriers to the implementation of design within a public sector context were also identified.
This research progresses the understanding of systemic design practice and the opportunities and barriers for implementation within the public sector.
Supporting regulators to innovate around complex problem responses is a novel application of systemic design, but also an important one considering the nature of the regulatory role in managing social and economic problems.


Co-designing cultures within public organizational systems.

Manuela Aguirre, Janey Ro, Paulina Buvinic and Katalina Papic

Wednesday 12:00. Room A2.

systemic design capacity building
co-design as organizational culture
design cultures within social systems
co-designing democracies

How can we create the conditions for public organizational systems to become co-designing cultures? This is the question we are set to explore by comparing two co-design capacity building programs embedded within public and social service organizations in Canada and Chile (Figure 1). In co-designing cultures, the culture of co-design seeks to become deeply rooted within the organizational DNA of public service systems as the ongoing capacity to co-design by including all those who serve, are served, and are affected by a social system (Banathy, 1996). A cultural approach towards organizational co-design is different from using co-design as instrumental means (e.g. designing better public services) or as symbolic means (e.g. gaining institutional legitimacy from its macro organizational environment).

These two co-design capacity building programs can be seen as the ‘genesis systems’ of a designing community that is formed within complex social systems (Banathy, 1996). As both of these genesis systems are seeding co-designing sub-cultures within a dominant public organizational culture, we will use Schein’s model of organizational culture to unpack the relationship between an organization’s dominant culture and its emerging sub-culture. According to organizational psychologist Edgar H. Schein (1984; 2010), organizational cultures can be de-constructed into three primary layers: visible artifacts, espoused values, and fundamental values, beliefs and assumptions. Consequently, these three cultural layers can be represented using the onion model, as previously done by designers Sabine Junginger and Daniela Sangiorgi (2009). In order to compare both programs, we will adapt this three-layered analysis described by Schein. 

We can analyze the most outer layer of organizational cultures through visible artifacts. In this case, these visible artifacts will be called: structuring conditions. These are all the physical, normative, social, and symbolic structures that condition the co-design capacity building programs from the outside in. These conditions will be compared (in both programs) through the use of time and space, the formation of cross-collaborative individuals or teams, the sequencing of co-design processes, and the program’s institutional legitimacy (Figure 2). 

The second layer of analysis is what Schein (2010) calls espoused values. This is how we rationalize fundamental values – as fundamental beliefs not always correlate to how those beliefs get manifested. For the purpose of this analysis, we will call this middle layer: practice experiences. The mechanism that affect how the capacity building program translates into new practices and experiences include: role expectations and socialization, outputs and outcomes, learning from feedback, and adoption and translation (Figure 3). 

Finally, the most inner layer of organizational culture is fundamental values, beliefs and assumptions. In both cases, these will be compared in terms of: values and beliefs, identity, reflection, and mindsets and worldviews (Figure 4).

The purpose of analyzing co-design capacity building programs in relation to organizational cultures lies in the connection of building robust and resilient co-designing communities, which can develop their unique co-designing values and identity. This is the first step towards Bela Banathy’s vision (1996) of creating co-designing communities that have the capacity to design and redesign their own lives and societies – and not be slaved within systems created by others. 

“Getting ready for design and developing a design culture is individual and collective empowerment at its most robust. Such empowerment gives meaning and substance to guiding our future” (Banathy, 1996, p. 282).

For Banathy, transforming social systems into co-designing cultures may enable individual and collective empowerment, which is a form of creating co-designing democracies.


Banathy, B. H. (1996). Designing social systems in a changing world. (R. L. Flood, Ed.). New York: Plenum Press.

Junginger, S., & Sangiorgi, D. (2009). Service design and organisational change: bridging the gap between rigour and relevance. 3rd IASDR Conference on Design Research, Seoul, Korea.

Schein, E. H. (1984). Coming to a new awareness of organizational culture. Sloan Management Review, 25(2), 3–16.

Schein, E. H. (2010). Organizational culture and leadership (4th ed.). San Francisco: Jossey-Bass, Wiley.


Mind the gap! A Norwegian Trial Incentive Program to stimulate government agencies management resources.

Benedicte Wildhagen and Sissel Kristin Hoel

Wednesday 15:30. Room A4.

Public sector innovation
Service design
Systems Oriented Design
Wicked problems
User needs
Policy in practice
Triple Diamond
Design tools for policy
The Norwegian public sector is hierarchically structured and is organized in sectors, creating silo management. However, increasing number of challenges cut across levels of government and sectors. In order to make improvements, new solutions are required to bridge the gaps, but this is hampered by inexperience and a lack of skills in how to promote innovation in regulations, procedures and the exercise of authority. All though each agency performs as requested, there is a lack of overall perspective along with incentives to solve challenges in between and across agencies, sectors and levels of government. Globalization, climate crisis and digitalization, along with strained budgets tend to fuel wicked problems. Nonetheless, tighter budget frames have made the priority of main tasks within every agency even more explicit. This is how the compartmentalization of the government administration has developed. But this is not rational for the society as a whole. Many critical challenges are in need of broad systemic improvements combined with a focus on real people’s needs, demanding cooperation across several sectors. This is especially challenging in a hierarchical system, like the government administration. No one seems to be the owner of cross-cutting services, but many are responsible for individual pieces within the whole. To disentangle cross-cutting and wicked problems there is a need for innovation. But innovation involves risk-taking and the government administration is risk averse. Government agencies are focused on control and reaching performance goals, while innovation require experimentation, trial and error, courage and curiosity. This is the backdrop for the Ministry of Local Government and Modernization’s assignment to Difi to developed a Trial Incentive Program to strengthen innovative capabilities in the public sector (2016-2017). The program objectives are to stimulate government agencies to use innovative methods, including service design, to develop comprehensive services that are better for the users and provide more efficient use of resources for management. NOK 10 million is to be used during two years, to achieve actual results by the end of 2017. Approach and results 
The need for an interdisciplinary approach was evident – both to design the Trial Program, and to identify, qualify and support projects. Difi entered into a partnership with DOGA, another government agency, which possesses design expertise along with experience in public sector innovation. A total of eight projects have received support and funding from the Trial Program. They aim to invent or develop new systems, processes and services, with relentless focus on real people’s needs and reduction of management resources. Most projects aim to solve problems across agencies and sectors, and many involve digitalization of services. Management commitment and an organizational potential for innovation have been a prerequisite. 

Contrary to what is mainly done internationally, where public Lab’s develop and deliver solutions for public actors, we have chosen to utilize the market. In order to ensure that innovative service concepts are implemented, we have pre-qualified ten consortia that offers a competence-triangle; service design is supported by change management and KPI-development and -realization. From this pool, we procure suppliers that meet the needs of each projects. In addition, new competencies are generated among the suppliers, and an overall larger market for suppliers is accessed in the public sector. 

It is in no way straightforward to detect connections between cause and effect within complex challenges in public sector, as they tend to consist of many factors along with several gaps and multiple actors, and the relationships between them all might be incomprehensible. As a consequence, we stress the need to make a diagnosis before “describing medicine”. Subsequently we have made certain parts of our requests for proposals, less conclusive and far more open than what is customary in a public-sector procurement. We believe supplying the consortiums interdisciplinary competencies at an earlier stage, will shift a typical focus on symptoms and assumptions of what is needed to a broader systemic understanding. The projects are required to spend time to navigate the complexity, to reveal underlying root-causes and needs, as means to identify innovation potential with a focus on real people’s needs. Finally, at the end of the initial diagnosis-phase, it should be possible to define a suitable approach by which overall objectives and quality can be achieved, within the framework of change capabilities, time and budget at hand. This is added to the contract. 

Based on Difi and DOGA’s expertise in public management and -law, procurement, design and public innovation the collaboration has evolved into a per se innovation-team. We have developed both the Trial Incentive Program and the services we provide, in a hands-on, practical, tight and un-bureaucratic manner of working, with emphasis on learning by doing, curiosity, trial and error. 

Most of our projects involve several agencies across sectors, representing complex issues. Getting these government agencies coordinated is demanding. The funding has drawn initial attention to the Trial Program, but our main contribution is to mature innovation readiness in every case, by supplying innovation skills, user perspective and minimizing risk at the preparatory stage. 

Many talk about government innovation and cross-sector improvements, but not many do. Our work with the Trial Program will continue testing and experimenting throughout 2017, providing us with concrete examples, various results, diverse new insights and knowledge of: 
– how relentless focus on real people’s needs and reduction of management resources can result in improved and comprehensive cross-sector public services 
– the effect of the competency-triangle of service design, supported by change management and KPI development and realization, to innovate public sector – and why, and if, the application of the competency-triangle is relevant 
– what an i-team contributes to public sector innovation, and why it is needed (in Norway) 
– how diagnosis and the triple diamond enhance the understanding of underlying root causes, before we explore, define, develop and deliver 

Our presentation will be a lecture (ppt-presetentation) with contributions from both Difi and DOGA. The presentation will include concrete examples and results from both the ongoing projects and the program, visualizations, images and videos.

Finding the flex in complex public sector systems. Co-designing for services through systemic interventions.
Heidi Dolven and Adrian Paulsen
Wednesday 16:00. Room A4.
cross sectorial

This proposed case study offers insight in the use of design across public sector silos toward solving complex issues in regards to joint ownership, administration and policy delivery between ministries, directorates, regional and municipal service delivery. The approach demands horizontal and vertical innovation across these varying levels of government and administrative silos toward reduction in bureaucracy and improved service provision. 

In this case study we have worked on improving the process of recalling, retrieving and keeping the right to retain your driving license. As it involves three different sectors and several layers of national, regional and local government the findings have great relevance to others working toward solving similar complex issues across public sector silos and administrative levels. We have been given a mandate to innovate or improve the full set of tools in public administration – from laws and regulations, to financing structures, digitization of work processes, or simply changing forms. The work contributes to the current discourse on design for public sector service by offering insight into ongoing design practice in real life case study. 

Due to bureaucratic systems, current public service provision is time consuming for both service provider and citizen. Leading to an increased focus in cutting bureaucracy as well as solving systemic and wicked problems in public sector service management. The Agency for Public Management and eGoverment and The Norwegian Center for Design and Architecture administers the fund for public sector innovation through design (Stimuleringsordningen) on behalf of the The Ministry of Local Government and Modernisation. Within the program this case study has been lifted as the most complex and ‘wicked’ of of the public sector challenges to be solved through the use of design in combination with change management, KPI development, planning and realization. We are working with Rambøll Consulting on this particular case. 

Failings in current service provision might be perceived as merely inconvenient for individual citizens in interaction with the service system, however on a national level it has great impact in regards efficiency and societal costs. Conventional approaches have not resulted in solving these systemic challenges. The case presented offers considerable potential for redesigning the current service toward making the processes more user friendly, resource efficiency and preparing the driver’s licence system for potential disruptive scenarios including self driving cars. This case creates new knowledge on the use of design in solving cross sectoral challenges that with growing bureaucracy has developed a complexity which is increasingly hard to solve. 

Jocelyn Bailey and Peter Lloyd (2016) argues that design practices challenges important structures and culture in policy making within the UK Government. This case is addressing some of the challenges identified by Bailey and Lloyd in order to develop approaches that are more mindful of existing structures, culture and expectations for analyzing, developing solutions and decision making. The paper contributes to theory and practice by offering insight into the approach. We would like to share from our design process through a critical review of our framework and results. 

The four directorates which had joined forces did not have a common understanding of the challenges. Hence it was crucial to create the right environment to allow open conversation, creativity, and exploration of the challenges. These types of settings have been referred to as ‘authorizing environments’ (Bason, 2013; Christiansen, 2014) and ‘public innovation places’ (Selloni, Staszowski, Bason, Schneider, & Findeiss, 2013), and as such recognize the importance of the physical and social space needed for public sector innovation. Finally it has been shown that the governance model of many public services is shifting from largely designing around the delivery of services for people towards to designing to enable a better co-production of services with p eople (Mulgan, 2012, p. 20). With this in mind we have had an explicit aim of co-creating with the project group and developing new knowledge together across bureaucracy and design. 

The project was initiated around five main hypothesis on what would be keys to successful change. 

1. Identify plasticity* (*where change might occur) within the system, made visible through a systemic understanding of the structures, service flow and dependencies mapped. The inner workings of public sector can be counterintuitive and a thorough understanding of the systemic context is crucial. 

2. Dual-language project leadership, applying design-lead project leadership for precise communication and translation. The project team included design practitioners who also have long experience of direct employment within the public sector and on several administrative levels. This offered a level of ‘hybrid subjectivity’ (Aitkin, 2008 cited in De Propris & Mwaura, 2013, p.4) and acted as a key factor in knowing when and how to use design in order to solve challenges, as well as being able to use bureaucratic terms and logic as the basis when doing sensemaking with design tools. 

3. Third key is finding the right level the diagnosis, experimentation and creation of effective interventions that is shared between the sectors/actors involved. 
Understanding that the socio-economic framework differs from sector to sector, which causes conflicting points of view when it comes to prioritizing changes. It is vital to create some common perspectives, a culture for accepting opposing views and a willingness to compromise when necessary. 

4. The fourth key is bringing in Foresight methodology for the group to develop common ground, as topics are far enough ahead, not owned by a specific sector, with drivers that are universal, holistic and challenge all partners. This final key has already delivered great value with creating a space where current disagreements and past conflicts can be put aside. 

5. The fifth key is to combine our systemic design approach with the quantitative approach of “Gevinstrealisering” (KPI development, planning and realization) that Rambøll as a means to provide scale and prioritize points of potential. 

At the time of the conference our project will be in the final stage of piloting the first service intervention. Allowing us to present what then will be freshly made experiences around the initial hypotheses, in addition to more refined models and frameworks currently being developed. 

Bailey, J., & Lloyd, P. (2016). The introduction of design to policymaking: Policy Lab and the UK government. 

Bason, C. (2013). Design-led innovation in governments. Stanford Social Innovation Review . Retrieved from 

Christiansen, J. (2014). The irrealities of public innovation . University of Aarhus . University of Aarhus. 

De Propris, L., & Mwaura, S. (2013). Demystifying cultural intermediaries: Who are they, what do they do 
and where can they be found in England? 

Mulgan, G. (2012). Government with people: The outlines of a relational state. In G. Cooke & R. Muir (Eds.), 
The relational state: How recognising the importance of human relationships could revolutionise the role of the state (pp. 20–34). Institute for Public Policy Research. 

Selloni, D., Staszowski, E., Bason, C., Schneider, A., & Findeiss, A. (2013). Gov innovation labs: Constellation 1.0 . New York City. Retrieved from

Design for social change: on new practices and organization models that foster knowledge transfers from design sector elsewhere.
Lyudmila Petrova and Cristian Campagnaro
Wednesday 16:30. Room A4.
social change
social cohesion
cultural and social values
capability approach
Within the context of the “knowledge-based” economy (OECD, 1996), there is a common understanding that culture, art and design can promote innovation throughout economy and society by providing input to products and services in other sectors. (Throsby, 2001). Scholars of innovation and policymakers are beginning to recognise the critical role of the cultural and creative industries ‘spillover’ (Potts, 2011; European commission, 2012). 
Usually, the notion of the cultural and creative industries “spillovers” is associated with the transfer of economic benefits in terms of contributions to GDP, growth, and employment (O’Hagan, 2016). However, recent analysis of spillovers of these industries invites also to consider their social and cultural contributions to quality of life, integration and cohesion in the society through the realization of knowledge and network spillovers (TFCC, 2015). This goes also along with the acknowledgement of UNESCO and European Union that culture-led creativity is vital to industry, businesses, education and community development.
The diffusion of these practices changes the landscape of innovation very much, by encouraging greater openness and inclusiveness across sectors and disciplines. More than often, the process of transferring knowledge between the design sector and other unrelated sectors is marked by a context of close collaborations, cross-fertilization and mutual learning with creatives (artists, designers, architects, scientists, etc.). In this respect, design has started to be used beyond the object production, but in solving complex business and social problems. Accordingly producing design interventions is a new kind of activity, entailing a multitude of processes such as learning, sharing, creating and experimenting (Manzini, 2015; Verganti, 2009). All these new applications of design suggest dynamic changes in the organizational and institutional models within the design sector and in the way design realises knowledge transfers elsewhere. 
Acknowledging these developments, this paper first reveals the practice of design for a social change in the case study of “Costruire Bellezza / Crafting Beauty”, a permanent and interdisciplinary laboratory aimed at social cohesion. The case exemplifies the realisation of innovation through knowledge spillovers from the design sector to the social service sector. 
The project started in 2014 in Turin, a city which has a long tradition for social innovation. One particular line of development in the city is the system social innovation with the aim to produce a change in the ordinary practices and policies (Ciampolini and Porcellana, 2014). In this context, Costruire Bellezza started as a pilot focused on both the empowerment of homeless people (Sen, 2000) and on the development of skills in university students (Margolin and Margolin, 2002) through participatory and interdisciplinary approaches. 
The project is initiated and curated by the architect and designer, Cristian Campagnaro (Department of Architecture and Design of Polytechnic of Turin) and the anthropologist Valentina Porcellana (Department of Philosophy and Educational Science of Turin University) in the framework of an action research about homelessness set up in 2009 (Stefani, 2016).
The rationale of the workshops is to stimulate “beautiful heals” for the homeless through fostering their own creative potential and the experience of relationships with the others (Campagnaro, Porcellana, 2016). The creation of design outputs, that can be product, services or process (Jones, Van Patter, 2009), is seen as lasting outcome just because of the relations they produce and the stories they generate (Bourriaud, 2010). For example, while a designer is focusing to realise his/her intellectual-functional-aesthetic goals, he or she is achieving some social goals by enabling an individual, a non-artist and non-professional, to connect to other people, to experience a sense of belonging and to enhance his or her well-being. One of the goals of the creative interventions, i.e. design workshops about several issues, is to form a strong relationship among all participants and, as such, to provide opportunities for homeless people to develop or regain personal skills which will further help them achieve independence, get a job and change their status to people with an own home. Another goal is increasing the awareness of citizens and competent professionals about how they can contribute to improve the integration of people with unequal opportunities (Cross, 1982, 2001).
Second, the paper argues that in order design to contribute to systematic and structural changes in other sectors, it takes building a new context, i.e. new organizational structure and linkages with various external stakeholders. In this respect, the paper reveals the organizational and institutional possibilities and challenges which support, or hamper, the interdisciplinary collaboration between professional designers/creatives, design students, anthropologists (researchers and students) and social workers. The paper further discusses, what strategies need to be undertake in order to generate and enhance economic, cultural and social values in a new context and as such generate social changes elsewhere.

Design for The Other Side: Prison Reforms through building resilience. 
Surya Teja Bachu, Aravind Ratheesh, Bharat Kashyap, Julia Andreyyeva and Praveen Nahar
Thursday 11:00. Room A2.
Prison Reforms
Systems resilience
Design Thinking


“The Other Side” is an academic applied design research project in the context of Prison and Prison Industries in Ahmedabad, India. 

From past few decades we believe that people who commit criminal activity is prisoned and is generally coined as Criminal for rest of his lifetime. This project is about understanding what makes a person to commit crime, to introspect and change society’s perspective towards prison system, to transform small scale industries inside prison into creative work spaces through various design practices, to make inmate a creator of things within the time of conviction. 

Our mission is to build Prison environment as a place of reformation, a place of transforming mindset of inmates to think creatively through design thinking framework and adapt with socio-economic difficulties as a returning citizen. Idea is also to expose inmates in a creative environment to bring transferable creative skills through co-creation and in long term – better communication, teamwork, conceptual design skills, pragmatic making skills and enterprise skills which will support them to flourish through employment through Central prison of Gujarat 

Design methodology 

In this applied design research project, understood the prison system holistically to discover the cause of growing crime rate, conducted co-creation workshops to exchange tools and methodologies with prison system which assists inmate to build social resilience and economic growth. Designed a structured methodology to bringsocial and culture cohesion inside prison. 

Further analysis through zaltman metaphor process and workshops with inmates, officers helped to understand creative thinking skills, lifestyle in relationship with environment in prison. Analyzing and synthesizing the data aimed at coming up with structural solution to build socio-friendly environment between inmates and society. s 

Design Interventions 

In the wake of experiencing and directing rehashed visits to the prison, acquired numerous bits of knowledge how the framework functions. What’s more was watching the distinction in how the male and femaleinmate’s territory, prisoner zone works, every bit of knowledge was distinctive. Attempts to go inside and out, to re-discover association how things functions with respect to others enhanced the scope of intervention. 

Through deeper understanding and synthesis of the prison system,through discussions with Criminologists, Exempted Inmates, Psychologists, Lawyers, Journalists, Social Reformers, Educators, Design Advocates,Social Innovators, Students, Police Department and public it was possible to design case studies to facilitate workshops. 

Reflection of how certain issues emerge because of absence of appropriate correspondence gained to develop numerous interventions. Additionally mapped the experience we had in the wake of experiencing the procedure and the behavioral changes of the authorities and their constraints. Also, blemishes in the framework. 

The workshops were conducted in all possible domains to know the possibilities of co-creation in an unfamiliar setting. Some of the workshops were facilitated rather than conducting ourselves to get the best outcome in a short period of time. 

Justice through Reformation 

Insights from the research and the workshops, to make the society aware about the reformation of the prisoner and on the other hand to know the perspective of the society, to create a trigger and create a sensory etching for the same, conducted campaigns through diverse social medium like social platform, Media, Movies, Radio FM, store by inmates in public spaces with JUSTICE THROUGH REFORMATION campaign 


With positive welcome & support we are definitely certain that it’s possible to come with diverse outputs which supports inmates to build creative thoughts and self-sustain.Creative activities in the prison environmentassists building prison as home for mindful thinking through creating inspirational platform, Building creative workshops to come up with different creative product solutions. 

Build Product & Services 

Going through creative thought process for the products developed in the prison to associate inmates with the products they develop and it also encourages to come up with different creative solutions and unfold the opportunities of intervention to explore unexplored. 

Unfolding Communication Barriers 

Constructing a platform where the inmates come closer to each other to understand and share their opinions about their well-being helps them to build a brotherhood feeling. It shouldn’t end here, it should be taken ahead to further where there is social platform for peer to peer communication between Inmates, police department and Society. 

Create Values for Experience 

To organize creative activities, to stand for social cause, to invite social innovators and reformers who like to co-create with inmates for well-being of the society and to market and expand the product scope of the inmates, to provide opportunities to employ inmates and further widen scope through funding for inmates who like to be a creative entrepreneur by banks and social organizations. 

This constitutes a democratic system which stands for ONE FOR ALL & ALL FOR ONE.

Systems Thinking based Design intervention for Supporting Healthy Ageing / Ageing in Place.
John Darzentas, Helen Petrie and Jenny Darzentas
Thursday 11:30. Room A2.
Systems Thinking
Service Design
Community based Design
The application of Systems Thinking to support challenging design interventions in situations that are characterised as being highly complex and human-centric is the subject of this paper. Such situations are increasingly acknowledged as major design problem spaces requiring the participation of multiple stakeholders and use of inter/multi-disciplinary thinking tools. 
The situation treated in this paper concerns an initiative to develop innovative directions from different but related disciplines to design services for small communities. This is an ambitious aim in an open-ended project structure that yet still needs to be accountable. What this means is that the project needs to set and meet its own success criteria, when it is not at all clear about: 
• the types of opportunities that will emerge, 
• whether the collaborations across interests / disciplines are in fact feasible, 
• whether the results that are presently envisaged will be commercially intelligible. 
One very real expectation is that at a minimum, the whole endeavour will fragment into many small subprojects, each on their own of some value, but none of them able to demonstrate and uphold the vision of the ‘big picture’ (however vague that big picture might be). Again without some measure of cohesiveness to sustain it, the vision underpinning the initiative will fade and die in time. 
What can be done to give some measure of cohesiveness to this initiative? The authors proposed to support the governance of this situation by introducing a Service Design perspective that utilises Systems Thinking. The situation is complex because it is inherently social. The idea has been presented to the participants of the initiative in terms of the value of adopting a shared perspective to their work. There are two parts to this. One is engaging the power of the metaphor of services since the innovation the initiative seeks to create is based on designing services. The other is providing a shared understanding of the initiative using Systems Thinking. That is to acknowledge the problem space as a system, rather than a set of disjointed projects. A shared understanding expressed in systemic terms enables stakeholders to appreciate aspects such as: 
• the identification of as many as possible of the stakeholders 
• the situation is amenable to design interventions 
• the rich interdependencies that are present in a systemic view, and that the approach of an assemblage of small projects will reject or ignore 
• the necessity of negotiating and creating a collective understanding. 
• that there will be outcomes, both favourable and not so favourable, that cannot have been foreseen at the outset, (and that these are the result of the ‘system’s emergent properties’) 
• what systemic notions such as those of ‘requisite variety’, of ‘self-organisation’, of ‘self-reference’ may mean and what they may offer in this design space . 
Adopting the systemic perspective does more than give a shared view, it also gives a shared vocabulary with which to label developments, or to actively seek outcomes. It legitimises the need to network and to spend time on areas where one is not considered an expert, to acquire new knowledge and learn new ways of doing things, and to break down the conventions and cultures that sustain working in siloes with peers and in mutual appreciation of each other’s work, with little time or incentive to look ‘over the fence’ into another disciplinary area, or way of doing things. 
In the case of designing services for small communities the initiative described here recognises that stakeholders are traditionally independent actors with their own individual ways of working. The task is not to adopt a common vision, but to find ways to work within a similar interpretation of the situation and what needs to be done, that is comfortable and worthwhile for each stakeholder. It is commonly acknowledged that it is difficult to move towards some flexibility in previously held ideas and interpretations of a vision, and if not review them, at least lay them open to scrutiny by others. Our fieldwork so far has made use of the co-creating service design paradigm, as robust means to engage participants and work towards the shared systems based perspective. 
In this working paper, we describe the work on one relatively small scale but multi-disciplinary project that involves experts from the domains of computer science and HCI and archaeology. The overarching aim of the project is to leverage the work of groups of amateur archaeologists who organise themselves to collect data, for various purposes. This data is collected in a way that makes sense to the individual groups, but the data itself can be useful to other groups of people, including professional academic archaeologists and historians, as well as interested citizens. 
In the particular case we are looking at a group that has self-organised to collect data about their churchyard cemetery. Their starting point is taking a church graveyard plan of grave plots, and checking that the data about who is buried there is accurate. At weekends and in their spare time, the group meets to make measurements of the plot and its location, to photograph headstones and other ornaments, and to transcribe inscriptions. As they have progressed in their work they have sought the help of other groups with registering GPS locations, with using Reflectance Transformation Imaging (RTI) (a kind photography which magically reveals inscriptions not visible with the human eye because of erosion) etc. In addition, various members of the group have accommodated their own interests, for instance one is interested in photography and is the RTI expert, another one is collecting additional data about stonemasons who were responsible for the carving and inscriptions, while yet another interest is in the different types of headstones. As with all such groups, time is of the essence, as the artefacts they seek to record data about are intensely vulnerable to erosion and the passage of time. The group also maintain and run a blogspot, which gives regular accounts of activities and give talks about their work to other groups in a network of such amateur groups. In addition, the blogspot writer is talented at bringing out the human and storytelling aspects of their work, making the blog enjoyable to read. 
The initial aims of the academic stakeholders were threefold: to understand the aims of the group and see what technological interventions might support the existing practices (of recording data and inputting into a system) and how these should be designed so as to be valued by users (easy to learn and use, and better than existing paper-based collection methods(HCI); to see how the data collected might be formatted so that it fits with the already existing metadata schema for such data so that the and then can be searched over (Archaeology); and to see how best to support this team, and other such communities, in their endeavours (Systemic Design). 
From our point of view, our design problem space was that of stakeholders who were working well independently, and contributing to the large vision, although not in any well-formed way. We had a sense that although the group might disband and go their separate ways once this project was over, although the experience was already spawning interests that could be developed further by individuals, as well as inspiring others to join them to form new communities. 
What is of interest to the systemic design community was the use Systems Thinking to learn and understand and capture a Holon which includes these communities. That way, amongst other things, the motivations of the stakeholders are be uncovered. As a result it should be possible to map these to form new directions, or to give voice to previously unexpressed aims and interests. After meeting, the group by themselves, reflected on their activities and summarised them as follows: 
With the fresh viewpoint, we can begin to really appreciate how far we have come – our little team of enthusiasts has been able to combine a range of skills, knowledge, and interests to bring together a fascinating project with multi-faceted perspectives which happily complement each other nicely: 
• Updating and amending the parish church records 
• Raising awareness of the churchyard as a local heritage asset 
• Developing and sharing skills in RTI photography 
• Revealing and recording previously unreadable monumental inscriptions 
• Providing information in response to family history enquiries 
• Developing a successful working partnership between local people, church members and local heritage groups 
• Developing and researching specific interests – stone masons, iconography, cultural significance of memorials, changing artistic styles of local memorials 
• Engaging with the local primary school 
• Offering graveyard tours as a way of promoting interest in local history 
It is with such a set of ideas that the design interventions might go forward to help to implement some of these directions. Accordingly, technological support can be designed to be multi-purposed, serving both some of the soft, but extremely important, objectives (developing successful working partnerships between local people, church members and local heritage groups) while implementing clear hard goals (a common way of updating and amending parish records about graveyards). 
Taken back to the multi-stakeholder innovation initiative, this project serves as an exemplar for other small scale community projects. In systemic terms, the project has, through the interests of the stakeholders, recognised, amongst other things, emerging themes and properties in their world: 
• the Embsay research group primarily working on updating and amending parish records, but who as individuals themselves have many other co-existing interests and motivations: 
• the academics, coming from different disciplines, also with differing expectations about methodologies and end goals. 
Getting together to articulate the big picture raised the work from being simply technological support in terms of a handheld application to support the current needs of recording data, to understand the possible directions. The next step is to formulate ways to move the big picture into design interventions, inspired by the paradigm of service design (i.e. services are the main output, even if these are delivered with technological support). For this, the boundaries, interrelationships and functions of each of the directions need to be articulated, in order to understand where the interdependencies lie, and how some functions may affect interrelationships. For instance, an insistence on using a handheld app to collect field data may obviate the need for the transcribing work. However, this could mean the sessions that take place in people’s homes, especially when the weather is bad, will not be necessary, and will break down this teamwork aspect. 
The expectation is, that if each of the small community projects is able to report back, not just on the implementations they have developed, but on the results expressed in systemic terms (boundaries examined, elements considered, interrelationships revealed, and functions (or activities) existing or desired, then there is a possibility to compare projects and potentially apply findings from one to another, in order to create and maintain collaboration that is both initiative-wide and of practical use. 
Acknowledgements: We thank the Embsay Research Group.

Wellness, Flourishing Societies and “Over the Horizon” Innovation of Policy and Policy Implementation.
Sharon Matthias
Thursday 12:00. Room A2.
Flourishing communities
health and population wellness
Sustainable and Flourishing public sector organization
Public sector systems innovation

“Wellness” and “Flourishing Societies” are terms used more and more commonly. But do we mean the same thing when we use the terms? Is there yet a way to weave our different views into a common understanding? What are we learning about their etiology, and how they evolve in persons and ecosystems that can help us be more purposeful about systemic design, systemic implementation and evaluating progress. And how do we know we’re taking appropriate action and making progress towards them, whether in individual persons, in populations and in communities and societies? 

Such understanding is surely required for us to move from using them as a slogan or aspiration for the distant and unaccountable future, to having the tools and capabilities for co-creating a disciplined outcomes-based strategy and implementation plan. 

Learnings from more than 25 years of work and reflection, built on applying research, practice and personal lived experience and iterative learnings to these questions offer some initial conclusions and mental models to support personal and policy implementation that is congruent with wellness and flourishing. The author’s persistence has been fueled by a need to understand how to properly implement the policy objective stated in the Yukon Health Act of 1988. In the language of the tine, the act described the policy objective as being to protect, promote and restore Yukoners’ physical, emotional, social, mental and spiritual well-being in harmony with their physical, social, economic and cultural environments. Further, the Act’s requirements made t near that it was to be implemented in a way that honours both western and indigenous culture and science. 

Looking back at the Act now is like living T.S. Eliot’s famous poem “We shall not cease from exploration, and at the end of all our exploring will be to arrive where we started and know the place for the first time”. Now, armed with the benefit of systemic human and ecological design thinking, it is even more clear just how far ahead of its time the Act was. (In 1988, where would have been the understanding to properly operationalize the principle that “the accountability of the health and social policy decision-makers and implementors so that health and social policies and the system will be responsive to the needs of the residents of the Yukon”!) 

Even with today’s level of understanding, and armed with systemic design tools and collaborative processes, it would be an ambitious understanding to implement this innovative policy. But at that time, even with a rudimentary idea of what was intended by “physical, emotional, social, mental and spiritual well-being’, it was clear that conventional policy implementation tools and processes, with MBA informed scientific management and organization approaches, were not up to the task. A giant “if not this then what?” dilemma for policy implementation. 

The paper describes the concepts of “wellness” and “flourishing societies” through multiple lenses, based on practice experience of public sector systemic innovation and causal layer analysis. It weaves concepts and theories from multiple fields of knowledge associated with wellness and flourishing societies (including human ecology, brain development and neurosciences, positive mental health, cognitive complexity developmental stages, relational competency, family and community health and development, to anthropology, anarchy, anthropology, therapeutic landscapes and organizational sciences), to provide learnings to date, including: 

– an integrated sense of what persons’ wellness and flourishing societies means, some aspects of their etiology, and the trajectory of development using a capability based whole person whole life whole society learning frame; 
-degree of innovation required of policy implementation approaches, and the need for ways to disrupt one’s world view and archetypal narrative to achieve ‘over the horizon’ level of innovation in systemic design and implementation; 
-implications for individuals, programs, organizations and systems who aspire to support a person or society to develop to their potential levels of wellbeing and flourishing, with mental tools and practice examples including an Adaptive Organization Canvas, Whole Person and Whole of Society Policy Implementation Frameworks, Systemic Maturity Models and Systemic Learning Evaluations for Policy Implementation innovation, and Population vs Whole System Strategy Frames; 
-Putting ‘Aging’ and ‘Flourishing’ in the same sentence – offerings for personal actions.

Systemic design towards user-centered sustainability in medical treatments.
Amina Pereno
Friday 11:00. Room A2.
systemic design
patient-centered care
chronic diseases
medical devices
Nowadays, health systems are facing significant societal and organizational challenges that require enhancing their resilience and sustainability. The impressive increase of noncommunicable diseases and long-term care is accelerating the ongoing transition towards a major reorganization of the health systems. A paradigm shift is required to re-balance the relations between health stakeholders: people have to play an active role in their care, changing their behaviors for preventing and managing diseases. We are moving from a provider-led perspective to patient-centered care. This transition is both delicate and complex and demands a holistic and interdisciplinary approach to design products and services that will be used by new caregivers (patients) in new environments (home care). Besides technical and medical innovation, it is crucial to identify the actual needs of people to make them able to understand and use these new products and services. Usability, utility, and acceptability are key criteria to enhance self-care and help patients to cope with the complexity of health care. The approach of design thinking to manage user-focused problems is attracting interest in healthcare stakeholders. Design tools and methods are perceived as useful and valid to bring innovative products and services in health care, starting from the social, cultural, and operational needs of users. 
At the same time, health systems are struggling to recover from the global crisis, and the need for reducing hospital expenditure is still current: this profoundly affects the innovation processes in the health sector. Economic benefits are an essential feature of all new products and services. The innovation in self-care and e-Health has positive economic implications, but it alone is not enough to ensure economic sustainability. Health systems are endeavoring to optimize processes, resources, and supplies, also driven by the increasing attention to their environmental. The health care sector is, indeed, responsible for significant environmental impacts, which often represent big economic problems too: waste production and medical infectious waste, use of chemicals and disposable materials, pharmaceuticals in the environment, radioactive pollution, etc. 
Therefore, the interest in what is called “Sustainable Healthcare” has grown sharply in recent years: although in a fragmented manner, European countries are promoting new strategies in the field of Sustainable Healthcare, encouraged by international organizations which bring together hospitals, patient associations, companies and other health stakeholders. There is no common definition of Sustainable Healthcare, but all the approaches to this topic focus on making health care environmentally, economically and socially viable. To date, policy and education research are the domains that have most addressed Sustainable Healthcare, investigating the implementation of policies and actions to foster sustainability, as well as the promotion of education programs to encourage sustainable behaviors in healthcare practice. Although design could successfully address some crucial environmental issues of health care (from waste reduction to resource optimization), design research made almost no contribution to this field. The present work aims at investigating the role of design towards Sustainable Healthcare, to propose, through case study experience, a systemic vision of the topic. Specifically, we addressed the environmental issues of chronic hemodialysis, a life-saving treatment for people with chronic kidney disease. Hemodialysis has a high impact on the environment: each session uses large amounts of water and energy and produces an enormous quantity of ordinary and infectious waste. All these problems must be addressed from a system perspective since they involve products, equipment, and users, as well as the hospital system itself. 
When dealing with medical treatments, we must face big challenges because of the technical and operational complexity, that is further complicated by strict and multi-level regulations. Moreover, several users interact with the system, and design has to meet all their direct and indirect needs, to provide them a safe and positive care experience. So, how can design address environmental sustainability in such a complex system, while maintaining the focus on patient empowerment and user-centered care? Traditional design approaches cannot tackle the complexity of healthcare alone, dealing with all aspects of economic, social, and environmental sustainability. A holistic approach is needed to envision eco-innovative treatment systems. Systemic Design integrates systems thinking and human-centered design methodologies to support designers working on complex design projects in multi-stakeholder and multi-environment systems. Systemic Design defines the material and cognitive flows characterizing the primary system, and thus it allows to establish new connections between the users and the contexts they are immersed in. 
The first step, in our case study, was the definition of all the items which make up the system, and the users that directly or indirectly interact with them (Figure 1). We found four items that represent four levels of the system: products (packaging, disposables, devices), equipment (dialysis machine), treatment (hemodialysis as a whole) and local environment (policy and management strategies). The second step is to establish the correct methods to use: we combined different approaches borrowed from sustainable design and human-centered design to analyze each item (Figure 2). A qualitative-quantitative methodology has been used for analyzing packaging and product. It is a proven and field-tested method developed by the Politecnico di Torino, within the Observatory of Eco-Pack. The equipment has been assessed through a disassembly analysis based on Design for Disassembly, that aims at evaluating usability, accessibility and component layout in relation to the final shape. If products and equipment are designed for the world market, the treatment and the organizational strategies are very variable depending on the country, the region and the hospital. In order to establish a general framework, we compared three different dialysis units and hospitals, in three different countries (Italy, Sweden, Denmark). A specific routine analysis has been set out to assess task types, staff interaction, and patient empowerment. Finally, the local environments have been analyzed by defining the tasks and goals of each stakeholder (region, hospital, unit, home) and the relative decision-making power on environmental strategies. This comprehensive analysis allowed us to set specific guidelines for each item, taking into account technical, operational, social and environmental requirements. The organizational analysis provided us a comprehensive overview of which policies and strategies are being implemented towards sustainability and how they are affecting the other items. Overall, a systemic approach to hemodialysis allowed us to set out specific guidelines for all the items included in the system, considering the needs of direct and indirect users. The comparison of three international case studies highlighted how design must work on product and equipment to improve environmental sustainability on a global scale while addressing local systems and their specific needs to improve sustainability on a local level. MAIN REFERENCES: Barbero, S., Pereno, A., & Tamborrini, P. (2011). Qualitative/quantitative cross analysis to design eco-pack. Paper presented at International Symposium on Sustainable Design. Recife, UFPE, 105-115. 
Dorst, K. (2011). The core of ‘design thinking’ and its application. Design Studies, 32(6), 521-532. 
Evans, S., Hills, S., & Orme, J. (2012). Doing more for less? Developing sustainable systems of social care in the context of climate change and public spending cuts. British Journal of Social Work, 42(4), 744-764. 
Jones, P.H. (2013). Design for Care: Innovating Healthcare Experience. Brooklyn, NY: Rosenfeld Media. 
Piccoli, G.B., Nazha, M., Ferraresi, M., Vigotti, F.N., Pereno, A., & Barbero, S. (2015). Eco-dialysis: the financial and ecological costs of dialysis waste products: is a ‘cradle-to-cradle’ model feasible for planet-friendly haemodialysis waste management? Nephrology Dialysis Transplantation, 30(6), 1018-1027.

Supporting co-design in complex healthcare systems through the affordances and metaphors of tangible tools.
Karianne Rygh
Friday 11:30. Room A2.
Healthcare systems
Service design
Tangible tools

The healthcare challenges of our society are placing increasing pressure on limited resources available due to an aging population and a substantial growth in patients with chronic diseases (Engström 2014). Due to these challenges, the Norwegian healthcare system is often referred to as being in crisis. However, these challenges alone do not cause healthcare crises, rather crises develop when there is an incapacity to rethink how we meet these challenges, how care is designed for and how care could be provided differently (Helse- og omsorgsdepartementet 2013; Oslo: Helse- og omsorgsdepartementet. 2014). To avoid devastating financial and societal consequences in the long run (Jones 2013) and to respond to the wicked problem (Rittel and Webber 1973) of healthcare provision, there is a need for immediate and innovative solutions. 

Service design and co-design are therefore increasingly being called upon to offer approaches and methods to facilitate collaboration and to harness available resources (Baxter, Mugglestone, and Maher 2014). Services are described as complex, hybrid artefacts made up of things, places and systems of communication and interaction, but also of human beings and their organizations (Meroni and Sangiorgi 2011). Healthcare systems alone consist of multiple stakeholders (i.e. consumers, patients, clinical staff, administrators, insurers), that need to interact with multiple services (i.e. primary care to academic institutional networks) in multiple sectors (from clinical practice to insurance and government) (Polaine, Løvlie, and Reason 2013). The communication between these diverse stakeholders needs to be supported in order to be able to re-think and innovate healthcare provision.

High expectations are put on multi-stakeholder collaborations to produce innovative outcomes despite extensive challenges in the relationships between stakeholders, such as the lack of an internal team culture, team communication (Sarin and O’Connor 2009) and a common understanding and a shared vision of the object of development (Molin-Juustila 2006). The motivations, needs and relations of and between, stakeholders need to be understood and regularly taken into account, as relationships also need to evolve and shift through time, (Polaine, Løvlie, and Reason 2013; Wetter-Edman et al. 2014; Sangiorgi 2012; Clatworthy 2013; Jones 2013). 
Effective use of communication tools during design processes has been regarded as an effective means to bridge the evidence based culture of the medical world with the working cultures, perspectives and languages of the other fields. Three-dimensional communication tools are here referred to as tangible tools and are defined as “material components used in participatory design activities” (E. B.-N. Sanders, Brandt, and Binder 2010). The use of tangible tools in co-creation workshops with diverse stakeholders has shown to support co-design by facilitating knowledge exchanges and understanding between participants from various fields. However, there is a lack of discourse in terms of what actually makes such tools successful, in other words, what designed attributes of tangible tools lead to successful outcomes. 

Tangible tools (i.e. design games, artefacts, boundary objects, cultural probes) can facilitate the development of a common language, a shared understanding and a shared vision between diverse stakeholders. In addition, they are a means for service designers to intervene in complex contexts using design thinking (Buchanan 2014; Kimbell 2011; Kimbell 2012) and systemic design approaches (Sevaldson 2011; Sevaldson 2010). One aspect of tangible tools that seems to be important is the use of affordances and metaphors in tangible tools. These interrelated terms can offer great potential for enabling co-design processes through offering a means to represent and visualize abstract ideas or modes of thinking, as well as documenting and describing outcomes of co-design processes. According to Gibson (1979), affordances are the action possibilities of objects with reference to the physical condition of the user, while in Norman´s interpretation (2013), it is the perceived information with reference to the mental and perceptual capabilities of the user. Affordances are closely linked to metaphors which are beneficial in making abstract concepts tangible for the user, allowing them to more easily express and discuss topics through representations and associations. 
As service design and design thinking have both been described as being highly empathic and user-centred, the two fields have also both been critiqued for excluding the more provocative and challenging aspects of design, such as aesthetic competence and critical perspectives (Akama 2009). In literature, tangible tools are often described as being successful because they were ´visually appealing´, ´they caught the attention of participants´, or ´triggered a playful atmosphere´ (Gaver, Dunne, and Pacenti 1999; Brandt 2011; Mattelmäki 2008; L. Sanders and Stappers 2013; Clatworthy, Oorschot, and Lindquister 2014; Buchenau and Suri 2000; L. Sanders and Stappers 2014). Such accounts support that the aesthetics and visual aspects of the tools were indeed successful, but say little about the design process and design choices that determined the final physical outcomes. This gives few insights to support designers in developing tangible tools, meaning the actual design of tools is often developed on a trial and error basis. Unsuccessful workshop interventions challenges the trust that service designers have built with participating stakeholders. There is therefore a need for a framework and design specifications to support designers in their process of designing successful tools for co-design in complex systems. 

This contribution to the RSD6 symposium presents several examples of tangible tools that illustrate the use of affordances and metaphors, highlighting where design specifications for tangible tools are needed and where they could be beneficial. The examples are designed by the author as part of an ongoing research by design PhD focusing on how collaboration can be fostered in the development of healthcare services through affordances and metaphors in tangible tools for co-creation. Through describing the examples, this contribution proposes approaches to creating a scaffolding for designers to assist with the designing of tangible tools. This is expected to consist of design patterns of successful tangible tools, that could lead to the development of a pattern language of tools within service design. Furthermore, the contribution will elaborate on the aesthetic impact that tangible tools have on participants in co-creation workshops and explore what role designers´ aesthetic competence can play in the complex systems that affect citizens´ healthcare and wellness.

The A.R.T. of the Waiting Game: Navigating Assisted Reproduction in Ontario, Canada.
Denise Philpott, Laura Halleran, Sonia Tagari and Windemere Jarvis
Friday 12:00. Room A2.
Patient experience

In Ontario, Canada, one in six couples are impacted by infertility at some point in their lives. Additionally, Statistics Canada reports the average age of first-time mothers in Canada has increased to 30 years old, to-date the oldest recorded. In this harsh reality lies the fact that women are having children outside their ideal reproductive window. Coupled with the prevalence of reproductive disability and disease, this reality has created a need for assisted reproductive technologies. Ontario’s Fertility Program was established to regulate these technologies and provide them as a service for Canadian women. Unfortunately, a current gap in the program is the lack of a unified resource that empowers women with the information necessary to address their reproductive health and navigate this system. Online ethnographic investigation of infertility support forums and a thorough literature review of peer reviewed and white papers formed the research basis of the argument for a unified tool. 

This gigamap and report theorizes a response to this unmet need by serving as a tool to assist women in their navigation of a complex socio-technical system, while also showcasing ways in which policy is hindering optimal access. Through a combination of systemigrams, causal loops, and patient journey maps, this gigamap provides a holistic understanding of what is required to complete a publically funded round of IVF in Ontario. Furthermore, it also highlighting gaps in policy and points for potential legislative intervention. Taking a woman-centered view of population health by centralizing the reproductive journey and using accessible, personalized language, this gigamap considers how cultural expectations for women and fiscal and personal resources influence the use of assisted reproductive technology. This is an ongoing project that continually incorporates user feedback to best address the needs of the women it serves.