Most healthcare systems are attempting to deliver services that are efficient, effective, and value for money. To this end, there is a continual emphasis on how the delivery of services can be changed or improved. Many different improvement techniques and methodologies have been tried within healthcare settings and there is currently a growing interest in how design and specifically Service Design could be beneficial. Because healthcare delivery is complex, any attempt to improve or innovate in the delivery of services requires the balancing of multiple different perspectives.
In this article, healthcare specialists Mark Mugglestone from the UK NHS (National Health Service) Institute for Innovation and Improvement and John-Arne Røttingen, Director of the Norwegian Knowledge Centre for Health Services, discuss with Service Designers Ben Reason and Lavrans Løvlie from Livework how these different perspectives interact.
This article by Livework founder Lavrans Lovlie was originally published in Touchpoint Journal, Service Design Network (Volume 1, No 2, October 2009).
This discussion began during a seminar on design for healthcare at the Norwegian Design Council. The discussion identified the opportunity for Service Design to play a part in meeting healthcare challenges. There was agreement that Service Design can help to improve services by providing a patient-led and ‘whole system’ approach. However, we recognized that health services have unique characteristics and challenges. It is essential for Service Designers to better understand the context and priorities of healthcare organisations if they are to have a significant impact.
What is the challenge for Service Design in healthcare?
John-Arne Røttingen: As a physician mainly with a research background, I have come to the field of service innovation and improvement gradually and very much with my medical background and culture as baggage. I think we need to consider how medical doctors, nurses, and other health professionals are trained and ‘cultivated’ to understand the healthcare environment. A medical doctors’ education is very much about establishing individual knowledge and skills and about individual patient interventions including technologies like drugs, i.e. how to diagnose and treat a patient. There is very little emphasis on how to work in a multidisciplinary team, on communication skills (even though patient communication skills have now a much larger emphasis), on logistics and service delivery, or on organisational issues – skills that are central to Service Design. This mismatch between training and needed skills suggests why it has been difficult to engage health professionals in service innovation.
There is broader interest in research and innovation for new diagnostics or therapeutics, i.e. product innovation and development, and it seems that there is a belief that as long as we have the technologies the rest will come by itself. We need to change this misconception, and demonstrate that true radical innovations will to a larger extent be about new service processes and delivery arrangements.
Ben Reason: I feel that Service Design and design in general has a challenge in relation to more established approaches in healthcare because of its focus on “efficient, effective, and value for money”. Design is seen, and often is, a quality thing rather than an efficiency thing. Design as the value-add is an established argument. That may be OK if you are a commercial company looking to differentiate or add value in a competitive market but in an almost monopoly health service I imagine that it can feel like an indulgence. In healthcare improvement this can look like designing ideal world scenarios where unavoidably traumatic experiences with accidents or illness are smoothed and made more bearable and comfortable. This chimes with the ‘customer’ culture that is popular in policy in the UK. The question is, can Service Design contribute to the more pressing quality of care, safety, and efficiency agenda? To be effective, Service Design has to ensure that patient experience work is not just about a ‘nice’ experience but about spotting the health issues that, if fixed, would improve both the experience and the well-being and safety of a patient. Service Design offers the ability to prototype and improve designs before larger scale investments are made, such as with health IT projects. The methods also work on a small scale when used to empower healthcare teams to be more innovative and develop local solutions to issues they face.
How might Service Design need to adapt for health services
Mark Mugglestone: It is interesting, one of the things that we find in our work at the NHS Institute is that quality and efficiency go hand in hand. Whenever you do work to look at quality, you usually make the service more efficient. A simple example would be that, from a patient’s perspective, multiple attendances at a hospital can be frustrating. Redesigning services to mean fewer attendances will improve the experience of that service from the patients’ perspective. Having fewer attendances should also make the service as a whole more efficient, so everyone wins.I think Service Design in healthcare may feel like an indulgence because we are so used to evolved services, where no explicit design has taken place – so we do not understand or consider how the design component is a valid investment. I think that some responsibility also has to go to designers, Service Designers and the design culture overall. My experience of design within healthcare is that it is easy to do nice demonstrations that using a design perspective could make things better for patients, but they remain as demonstrations. Although some of this may be down to it being a new domain that is just really getting established, but I think it is also due in part to the design focusing too much on ‘experience’ and not also the other components of healthcare delivery.
One of the definitions of good design that we use a lot is: Good design = Performance + Engineering + Aesthetics of experience?We often argue that the experience component is the missing link, but it needs integrating with the other two elements, rather than being a standalone – and I think that because of where designers come from, they usually focus on this area. Maybe less designers, more engineers and accountants is what we need to develop the discipline of Service Design?
Is Service Design responding to these challenges?
Ben Reason: Responding can be challenging because there is a medical culture that discounts the importance of non-medical aspects of services that can be extremely significant. For example, we know that experience and environment have a significant impact on outcomes in maternity care in the UK but there are still mothers experiencing a totally medical model of care. The cost of the caesarean is significant and the numbers for emergency caesareans is still rising. This suggests there should be Service Designers creating new maternity services all over the country but that isn’t the case.
In response to the suggestion that Service Designers may need to work closer with accountants Livework is rising to the challenge. We can see that this is a barrier for us and that we need to work with people who can help us make the business case for Service Design. We recently led some innovation work with a local government group and then engaged experts to create a cost benefit model so we can show how much of a financial impact a new service or redesign would need to make the upfront investment worthwhile. This leads to the third point – engineers. We have learned that the most successful projects for us are when we work with the right ‘geeks’ (and geek is akin to expert in my world). They may be a transport economist, an insurance actuary or a nurse.
What is interesting is that private clients get this and hire us to complement their geek team. In our NHS work we have been much more stand alone on the patient experience side of Service Design and not found it more challenging to find the scientists of whatever hue we need to collaborate and really succeed. I’m not sure if this is the NHS or us but we now work hard to make sure we have the engineers we need.
Where does Service Design have the largest potential to create value?
John-Arne Røttingen: Service Design has, in my impression, most to offer for patients with a long standing and repeated contact with the health service, i.e. chronic conditions, care for the elderly etc. However, that does not mean that Service Design cannot be utilized for other user groups as well. One example of the latter may be to create a first line of care that rely on self-assessment and the use of pre-decided advice for simple acute conditions. Service Design may be a good approach to developing such self-care systems. Regarding types of organisations, it would be easy to point towards institutions like hospitals and nursing homes where more complex services are given. Again, several examples of Service Design are related to community care and home care indicating that the type of organisational setting does not seem to be a good discriminator.
Lavrans Løvlie: John-Arne mentioned that the greatest potential for radical improvement is in innovations in processes and systems rather than in medical technology. At the same time, I believe there is great potential in developing ‘service technologies’ such as telemedicine, journals that can be managed by patients themselves as well as phone- and web-based access to services.
John-Arne Røttingen: One example may be how for instance the combined health plan and delivery organisation Kaiser Permanente in California, US has invested heavily in empowering patients by giving them access to parts of their patient records, different lab results and the opportunity to interact with their physicians via a personalized web interface.
Lavrans Løvlie: Both in preventative care and with chronic diseases, patients have direct influence of the results of their own treatment, and services can be designed that allow them to be more active and engaged in the improvement of their own health. Development of more and better self-service offerings will give patients more power in the relation to the healthcare system, but may also be requisite in order to keep costs down as medical technology becomes more expensive.
In which ways can Service Design drive innovation in the health sector?
Ben Reason: I agree that the user-centeredness that is central to Service Design has a lot of potential in health services. It would be wrong to say that nurses, doctors and administrators don’t focus on the patients, but as John-Arne explains, these are highly complex systems where one professional’s view of the patient may differ from another with a different point of view.
Someone in the private sector recently told me: “Our organisation is so complex, that the only one who can see the big picture is the customer.” I think bringing the ‘big picture’ to the table goes for the health sector as well. What Service Designers can bring to the table is a shared view of the patient and their needs that complex teams with mixed expertise can unite around. If everyone has the same picture of who the patient is and what is important to them, it is easier to align conflicting interests and processes.
The tools are simple: Show examples of how users experience the services, visualize opportunities, make ideas tangible, and make it clear how it creates value. As Mark says, quality and efficiency often go hand in hand. When the patient experience becomes a primary driver for innovation, we are also likely to find solutions that are economically and medically viable.
How can one combine an evidence-based approach with innovation?
John-Arne Røttingen: An evidence-based approach to healthcare means to rely on evaluations of effectiveness and safety when considering what kind of treatments and interventions to offer patients. This can easily be integrated with innovation and Service Design since the evidence base for the effectiveness of care very much indicates what kind of services should be delivered. With Service Design taking a strong user approach, this also lends an opportunity to inform patients in a good way about the existing treatment options and their different benefits and harms based on evaluations. An evidence-based approach is thereby very much about empowering patients given them a tool to explicitly ask for information about their care.
One can take the evidence-based approach one step further, like we do at the Norwegian Knowledge Centre, and say that not only clinical interventions should be evidence-based, but also the way we organize, finance, and deliver care. From this perspective, service innovation should be followed by a robust evaluation on the effectiveness of the new or improved process, asking wether it is more effective and efficient that the existing delivery of care. I think that both these approaches to combining evidence-based practise and innovation are crucial, and links back to demonstrating both value and cost-benefit as Ben said.
Lavrans Løvlie: The evidence-based approach is an interesting challenge for designers, who often have been trained to value great ideas as a goal in itself. I find it obvious that a solid evidence base should be fundamental to Service Design, and few designers would disagree. It is more challenging to create systematic ways to test and measure concepts in a rigorous way. At the moment we are seeing that the practise of rapidly prototyping and piloting services with real users is becoming embedded in the field of Service Design. The key to success is to start light and do many, evolving prototypes, involving more and more people. I believe such a practise can bring detail and trustworthiness to service innovations at a quick pace, and spread good ideas much faster than we see today.
What about the value-based approach?
John-Arne Røttingen: There is an increasing focus on value-based healthcare, and this approach is particularly related to a move from the focus on processes of care, what kind of services and interventions are offered, to the outcomes of care and that patients actually improve and are treated with dignity. Still, much of the value-based approach is related to the providers’ and professionals’ perspectives. The potential strategic impact of Service Design would be to strengthen the user/consumer perspective. It is how users consider the results, outcomes, and long-term impact of care that is important. Bringing users in both, on the design of services, and on how services should be assessed and monitored should go hand in hand. The introduction of the so-called PROMs (patient-reported outcome measures) in NHS may create many opportunities for Service Designers. The NHS is asking patients about their health, functional status, and quality of life before they have an operation, and about their status and the effectiveness of the operation after it.
This may have dramatic effects upon the focus of providers and professionals since the experience of the patients will become a key performance measure. This possible change of mind set may make healthcare ripe for approaches that utilize the experience and knowledge of their users when designing the services.
Together we believe that Service Design can add something new to existing healthcare improvement strategies and practises, rather than looking to replace what already exists. First, there is an increasing prominence of prevention and self-care in healthcare. For instance, the Norwegian Health Minister has just released a reform on integrated care where stronger primary care and better preventive measures are central. The success of such approaches relies heavily on buy in and adoption by patients and on new ways of interacting with (and also between) patients. Second, as a public service healthcare needs strong support from the public. Even though most surveys indicate that patients assess the health services more positively than the general public, the ‘aesthetics of experience’ of healthcare needs to be improved to levels comparable to other – and often private – services. This must not, however, be carried out as a stand-alone approach. It must be integrated with the professional and business perspectives of healthcare. Thirdly, there is a need for a paradigmatic shift in healthcare from almost always attempting finding solutions in new single medical products to disentangling the real challenges through innovative delivery approaches and the dissemination and effective implementation of best practise.
Service Design is an enabling tool for this cultural change. However, we believe that not only can Service Design benefit healthcare, Service Design can also get something back. The strong emphasis on evaluation and evidence in medicine may inspire Service Designers to not only promote and sell ideas and processes, but also demonstrate and document that they achieve the impact. In healthcare “the customer is always right (as long as he pays)” does not always apply. One important challenge is overuse and misuse of services. Too many lab tests and radiology scans are carried out and too many drugs are prescribed without added value for the patients, even though they may feel well cared for and have a positive experience with the service provided. The user-led approach has its limits. Information and knowledge is the central currency in healthcare. Data and evidence is needed for informing decisions (ex ante evaluations) and improving practise (ex post evaluations). Service Design may facilitate patients using and learning from their own data (e.g. web-based patient records), the experiences of others (e.g. through networks) and general best evidence (e.g. electronic libraries and web-based resources). Service Design may also assist the providers in collecting and utilizing data to improve the services (e.g. by identifying and measuring critical elements). As one of us has argued elsewhere, data is the ‘New Oil’ – especially in healthcare. Designers, users, and medical doctors and other professionals should work together to exploit it to create new patient, provider, and social benefits.