volume 6 | no. 2 | 15,80 euro
August 2014
Better Outcomes by Design Human-Centred Mental Wellness by P. Jones, J. Robinson, A. Yip, K. Oikonen, A. Starkman
Going all the Way by J. Kronqvist, M. Koivisto, K. Vaajakallio
Service Design for the Other 98% by Melanie Wendland
Touchpoint
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Volume 6 No.2
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August 2014 The Journal of Service Design ISSN 1868-6052 Publisher Service Design Network Chief Editor Birgit Mager
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from the editors
Better Outcomes by Design “The physician should not treat the disease but the patient who is suffering from it” — Maimonides (12th century scholar and physician) Too often, service design finds itself employed to serve purely commercial aims. Personas, customer journeys, and the optimisation of touchpoints are all geared towards tangible results that can be measured in dollars and numbers: Profit, sales figures and even NPS scores. But service design is capable of much more. One of the beauties of the discipline is that the techniques and approaches we use as service designers can be applied both to the biggest banks, and the smallest of lemonade stands. But it’s not only in these business settings where service design shines. For many years, it has found a significant and growing role in improving the healthcare and wellness of people around the world. And that is the focus of this issue of Touchpoint. There is no denying that healthcare is still big business: In North America alone, healthcare spending represents a staggering 17.4 percent of GDP. And among developed countries as a whole, it represents the second-biggest government expense after welfare and health/ unemployment insurance. But with costs (and profits) spiralling ever upwards, patient experience threatens to be overlooked. For too many patients, poor experiences lie at both ends of a spectrum: A cancer patient in the United States might have access to cutting-edge therapies, yet feel utterly adrift when their wellness is overlooked by specialists who focus too much on billable treatments; whereas an infant in Senegal might struggle to cope with an intestinal disease due to a scarcity of the most basic sanitation and healthcare services. Translating the human-centred nature of service design into a patient-centred focus for healthcare and wellbeing is happening worldwide, as you will learn in this issue. Reporting from behind the front lines of Britain’s NHS, for example, Julia Schaeper shares several stories of initiatives to improve outcomes and empower patients within an incredibly complex service (see page 50). We also learn of Backpack PLUS, a product-and-service framework designed by frog at the request of UNICEF, which aims to better support community health workers who work in remote and challenging environments around the world (see page 53). Turning our attention away from the theme of this issue, our Tools and Methods section introduces a new, mobile phone-based solution for user research, developed by an Amsterdambased firm (see page 78). Staying in the Netherlands, we also share a report from a ‘Service Design Work-out’ session on innovation in healthcare, which was carried out by members of our newest National Chapter: SDN Netherlands (see page 92). We are happy to officially welcome them as the fifteenth National Chapter, after having been active for many years as an independent, Dutch organisation. Last but not least, our attention is fully focused on the biggest service design event of the year, the Service Design Global Conference, to be held in Stockholm, Sweden on 7-8 October. Tickets are selling fast, but as Touchpoint goes to press, seats are still available. We look forward to seeing everyone for inspirational presentations, workshops, exhibitors, and plenty of networking opportunities!
Birgit Mager is professor for service design at Köln International School of Design (KISD), Cologne, Germany. She is co-founder and president of Service Design Network and chief editor of Touchpoint. Jesse Grimes has thirteen years experience as an interaction designer and consultant, now specialising in service design. He has worked in London, Copenhagen, Düsseldorf and Sydney, and is now based in Amsterdam with Dutch agency Informaat. Peter Jones is an associate professor at the Faculty of Design, OCAD University, Toronto and managing partner at Redesign Network. He is author of the book Design for Care, published by Rosenfeld in May 2013. Juha Kronqvist is a senior service designer at Diagonal and a researcher at Aalto University. He specialises in designing human-centric healthcare services and environments. Lorna Ross is director of design at Mayo Clinic Center for Innovation. Lorna has 24 years’ experience working in design research and innovation with the past twelve years focused on health and health care. At Mayo, Lorna directs the discovery of transformative, patient-centric care models for the organisation.
Jesse Grimes for the editorial Board test
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35 feature: better outcomes by design
44 ‘5% Design Action’:
Cancer Screening Service Innovation in Taiwan C. Yang, C. Wu, S. Ho, T. Sung
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imprint
3
from the editors
6
news
kerry’s take 10 Humanising Healthcare
Through Hands, Heads, and Hearts Kerry Bodine
Juha Kronqvist, Mikko Koivisto, Kirsikka Vaajakallio
26 Community
Intergenerational Mutual Assistance around Breakfast
Qi Luo, Jinghui Deng
30 Using Patient Insights
to Design Future Health Solutions Anouk Willems, Magali Geens
35 What Do the Remote
cross-discipline
Mountain Villagers Need?
12 Health Matters: Reframing
Fang Xu, Yuanyuan Chen, Fujian Mo
Design in Community Health Interventions
Youngbok Hong, Helen Sanematsu
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21 Going all the Way
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40 Behavioural Change
Through Co-Creation
Birgit Mager, Jennifer Loser
50 Exciting Times to be in
Healthcare
Julia Schaeper
53 Backpack PLUS Fabio Sergio, Chiara Diana, Roberta Tassi
58 Human-Centred Mental
Wellness
P. Jones, J. Robinson, A. Yip, K. Oikonen, A. Starkman
62 Designing for a Child’s
Experience of Clinical Rounds
A. O’Keefe, S. Rottenberg, A. Giese, A. Schwartz, J. Benini, J. Hageman, S. Hageman, M. Joseph-Griffin
68 Service Design for the
Other 98%
Melanie Wendland
contents
74 tools and methods 74 Differentiating Touchpoint
Experiences the Cheap-andCheerful Way
92
Stefan Engl
78 Capture User Experiences as
They Happen
profiles
Robbert-Jan van Oeveren
90 Interview: Geke van Dijk
education and research 82 Learning to Look: Design
in Health Services Research
Helen Sanematsu, Sarah Wiehe
86 Shaping a New Service
Design Programme
N. Morelli, A. De Gรถtzen
and Bas Raijmakers
inside sdn 92 Service Design Work-out on
Innovation in Health Care
Dr. Geke van Dijk, Marie de Vos, Albert Gast
97 Springtime in Denmark Rikke Knutzen
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Insider
join the biggest event of the year! For SDGC14, around 500 of the brightest minds within service design will be gathered in Stockholm in order to explore quality of life and how to create value from this for business and society. Expect a high level of interaction, co-creation and networking when dealing with topical challenges on how to foster quality of life and value for customers, employees, businesses and society. Already eight workshops, five exhibitions and three basic service design courses are defined and more are to be finalised. “We want to create the service design conference of the year, gather the strongest field possible of service design pioneers, leaders and practitioners in an inspiring setting and with a design where quality of life isn’t just something we talk about — but live and explore together.” — Stefan Moritz, Chair of Conference and Co-founder of SDN Sweden
SDGC14 provides great opportunities for knowledge sharing and networking. It will host more than twenty inspirational keynote speakers among which is global head of employee experience at Airbnb, Mark Levy, his job title states that quality of life includes your work life and, in order to create value for customers and business, you need to create value for your employees. 6
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SERVICE DESIGN GLOBAL CONFERENCE 2014 6
+20 SPEAKERS
KEYNOTE
8
WORK SHOPS
3
+5
Service
Design
EXHIBI
Basic Course
TIONS
+500 THOUGHT
2 2
LEADERS BEST 2 TIME PAR TIES
LIVE PROJECTS
PRE EVENTS
5
to visit
SURPRISES!
Other confirmed speakers are Wim Rampen, manager intelligence and brands in Delta Lloyd & OHRA, Lavrans Løvlie, service design pioneer and one of the founding partners of Livework, Wendy Lea, CEO in Get Satisfaction, Fred Leichter, senior vice president at Fidelity, Mia Kleregård, head of
stockholm
service and change in Systembolaget and Nathan Shedroff, associate professor and program chair of a number of MBA programs from California College of the Arts. More are to be revealed in the coming months. www.sdgc14.com
sponsors at sdgc14 Sponsors of this years’ Service Design Global Conference Continuum, SVID, Arla Foods, SAP, Moleskine, Airbnb, Spotify, Veryday, Doberman, Antrop, Experio Lab, the City of Stockholm and Linköping University are among the sponsors of this years conference, representing agencies, business
innovation through service design We are looking forward to the first Austrian Service Design Symposium in Vienna this autumn, which will take place on the 6th of November 2014. Wirtschaftskammer Wien is sponsoring the venue, FORUM [EPU KMU], right in the centre of Vienna. Invited are professionals and students familiar with service design and everyone who is curious to learn more about its innovative impact and who want to apply service design in their corporate
and government and creating a great platform for strengthening the value of service design, both in the pubic and private sector. Please don’t hesitate to contact the conference chair, Stefan Moritz, smoritz@service-design-network. org, +46 730 610 414, if you are an advocate for creating value for quality of life and want to be a sponsor.
context. The symposium will provide you with an overview of methods and tools of service design. Confirmed speakers range from international agencies to Austrian local businesses who will present successful case studies or who will lead practical workshops during the day. It will be a great opportunity to interact, share knowledge and network with leaders in service design. With a couple of months still to go, we are confirming new speakers every day. Keep an eye on our website for updates.
WIEN
INNOVATION DURCH
SERVICE DESIGN VORTRÄGE & WORKSHOPS
6. NOVEMBER 2014 HTTP://BIT.LY/SDNC14AT
e Satvhe ! date
sdnc13 is available in chinese!
This year, the Service Science Society of Taiwan (s3tw) and the Service Design Network, sharing the same belief and passion for promoting service design, brought a revolutionary service design movement to Taiwan! The ‘Service Design Gourmet’ is a series of five or six ‘unforum’ events. Each unforum will take place in Taipei and will last for approximately three hours after the end of the working day. In this series, the keynote speech videos from the Service Design Global Conference 2013 are used to share the international success stories and to facilitate in-depth discussions on service design issues in Taiwan. Explore and think about what Taiwan’s own service design style should be and how to make Taiwan better through service design, following the wave of global service thinking. To learn more about the different events, you can check the Facebook page at: https://www.facebook.com/ servicedesigngourmet. All details and documentation will be featured in ‘CROSS Magazine’ website. http://cross.s3tw.org touchpoint 6-2
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Insider
service experience camp
dmi: design leadership conference The Design Leadership Conference organised by DMI will be hold in Boston from 30 September to 1 October 2014. The event’s focus on ‘Lab Culture: Design as Innovation Catalyst’ will bring out case studies, stories and insights shared by innovative leaders from Maker and Media Labs, Brand Experience Labs, Incubators, Venture Capital, Robotics, Learning Labs, and Game cultures. Sign up now to understand how innovation labs are evolving and generating new kinds of value
active by design summit As a part of the Active by Design programme, the Design Council organises a one-day conference, which will be held in London, on 18 September 2014. The programme’s initiative promotes the adoption of good design to encourage a greater amount of daily physical activity and increase access to healthy and nutritious food. It is a response to 8
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while creating new experiences, services and products at striking speed. Lastly, apply these concepts in scenarios that boost and restore your team’s creative output. Together, these two days are a call for innovators to update their thinking and build creative cultures that deliver more powerful design solutions. SDN Members can enjoy a 10% discount on the ticket price! Send an email to media@servicedesign-network.org to receive your promotional code. www.dmi.org/?Boston2014
an increasing health crisis caused by low levels of physical inactivity and poor diets that affect millions of people each year. The summit will host expert speakers from designers and built environment professionals to public health specialists, all of them representatives on the front line of the Active by Design revolution. www.designcouncil.org.uk
On 13 – 14 September, Berlin will be ready to host yet another amazing event, which is a hybrid of key talks, barcamp sessions and open experiences. It targets a diverse audience, from designers and entrepreneurs to policy makers, in order to create synergies that can be translated to meaningful service experiences. While thoughtprovoking key talks from industry experts will structure the two-day event, participants will be offered a unique opportunity for sharing their thoughts and will facilitate a barcamp session on a topic of their choice. If you want to mingle with an international service-experience crowd, get your ticket here: www.serviceexperiencecamp.de
get more news! Stay in touch with SDN social media to receive the latest service design news! The Service Design Network is publishing SDN Insider, a bimonthly newsletter. You can also follow the SDN on Facebook, Twitter (@SDNetwork), and on LinkedIn Company Page. To discuss and share ideas and news with more than 8000 people from the SD community, join SDN LinkedIn group! If you are interested in SDGC14, subscribe to the speacial newsletter (www.sdgc14.com) and follow @sdnconference on Twitter!
mormedi presents ‘a european perspective on the current state and future of design’ at the international idsa conference in austin, texas The design world is changing rapidly and becoming more complex. Newer disciplines such as service design or user experience design are complementing and enriching the more traditional ones such industrial or graphic design, while design is moving towards a more strategic level. This dynamic environment inspired Spain´s top service and product innovation agency Mormedi to gather the point of view of design leaders from different industries on the current state and future of
design from a European perspective. The result of this investigation will be presented at IDSA International Conference to be held in Austin Texas, USA between August 13-16 in video format, framed by an introduction and a conclusion by Mormedi CEO Jaime Moreno and strategy director, Juliane Trummer. IDSA, the Industrial Designers Society of America is the world´s oldest society for industrial design. It runs the renowned International Design Excellence Award (IDEA) competition, hosts the International
Design Conference and five regional conferences annually and publishes Innovation, a quarterly journal on design as well as Design Bytes, a weekly e-newsletter highlighting the latest happenings in the design world.
Humanising Healthcare Through Hands, Heads, and Hearts
The following should not be news to you, but it’s sometimes easy to forget: Patients aren’t just lines in a spreadsheet, records in a CRM system, or the list of ailments in their medical records. They are people. And while lots of healthcare companies are talking about ‘humanising the healthcare experience,’ I get the feeling that they’re not always crystal clear on what that means. To develop meaningful relationships and improve medical outcomes, health service providers need to connect with their patients. Specifically, they need to touch them at three key body parts. (Don’t worry. This doesn’t require a physical exam, and it won’t be awkward at all.) HANDS
With four long fingers and nifty opposable thumbs, our hands help us do things. As healthcare consumers, we all have things that we’re trying to do when we visit a particular provider — like fixing a chipped tooth, filling a prescription, or filing an insurance claim. Healthcare companies help us accomplish these goals (or perhaps you prefer to call them ‘tasks’ or ‘jobs to be done’) by developing useful services and getting them into our hands. 10
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Wearable body monitors represent a major advancement in this area. Up until recently, we’ve had limited ability to continuously monitor what’s happening in our bodies. In 2004, I worked for BodyMedia, the maker of one of the first wearable body monitors on the market. Today, a host of companies like Jawbone (which acquired BodyMedia last year), Nike, and Fitbit market wearable devices that track everything from miles walked and calories burned to the quantity and quality of a person’s sleep. To make health-related wearables a reality, companies have had to overcome significant technical challenges like shrinking sensors and extending battery life. But of course, the real challenge now comes in developing useful services that will allow us to improve our health by taking full advantage of our quantified selves.
test Kerry Bodine
HEADS
The head is the seat of our cognitive faculties and information processing functions like perception, recognition, and memory recall. It’s our heads that help us navigate health insurance websites and fill out intake forms at the doctor’s office. These experiences shouldn’t make our heads hurt. Healthcare providers should aim to make every single patient (and payer) interaction as easy as possible. Josh Kushner, founder of venture capital firm Thrive Capital shared his frustration with the health insurance space during a recent interview on CNBC’s Squawk Box, a U.S. cable news program. “I opened my insurance bill one day and I realised that I had absolutely no idea what it meant. I’m educated, I run a growing business, and I didn’t know what my benefits were with doctors or hospitals I had in my network, how to file a claim…” Being the young entrepreneur that he is, Josh decided to create a new type of health insurance company — from scratch. His goal was to “make it simple, transparent, understandable, and relatable primarily through technology, data, and design.”
kerry’s take
The result is Oscar, a New York City-based startup with more than 40,000 physicians in its network. The Oscar website includes a robust provider search that includes physician fees and patient reviews; an online quoting tool that enables prospective customers to fill in their marital status, number of kids, income, and zip code in a quick and easy Mad Libs format; a Facebook-like timeline of the subscriber’s medical history; and, of course, clear billing information that’s aggregated per visit.
aligned appropriately. To help children’s medical imaging go from ‘terrifying to terrific,’ GE Healthcare created its Adventure Series, a set of decals that turns CT scanners, MRI machines, and entire imaging rooms into a pirate ships, jungles, and coral reefs. Similarly, my own dentist in San Francisco has placed flat screen monitors on the ceiling and plays comedy shows during exams to help patients of all ages refocus their attention and reduce their anxiety about their dental procedures.
HEARTS
KERRY’S TAKE
The heart is our metaphorical emotional core. And although we might try to deny this, it’s impossible to disconnect our functional needs from our emotional ones. This is obvious when we’re looking at a patient who’s going through chemotherapy or a woman who’s giving birth to her first son — but it’s equally true when we’re just trying to eat a healthy take-out meal or join a gym. And don’t forget that we bring our emotions with us when we go to work, so businessto-business healthcare companies aren’t off the hook in this area! Medical providers need to understand their customers’ underlying emotional drivers — both on the aggregate and individual levels — and make sure that the patient experience is
At its essence, ‘humanising the healthcare experience’ means remembering that patients are human — and connecting with patients’ hands, heads, and hearts is a critical step towards this goal. But the three H’s of customer anatomy are equally valuable for any service designer in any industry. So keep them with you as you’re working today and ask: Will this decision or action connect us with our customers’ hands, heads, and hearts?
•
Kerry Bodine is a customer experience expert and the co-author of Outside In. Her research, analysis, and opinions appear frequently on sites such as Harvard Business Review, Forbes, and Fast Company.
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Health Matters: Service Design in Community Health Interventions
Youngbok Hong is associate professor of Visual Communication Design at Herron School of Art and Design, Indiana University. She approaches design as a methodological application for diverse social and cultural problem solving. She has been engaged in numerous community based projects with the IU Schools of Public Health, IU Methodist Hospital and Indiana Legal Service.
Garden on the Go® is an obesity-prevention effort initiated by Indiana University Health. This year-round, mobile, producedelivery program provides fresh, affordable vegetables and fruit to Indianapolis neighbourhoods in need. In 2013, design researchers from the Herron School of Art and Design, Garden on the Go® leadership from IU Health and scientists from the Fairbanks School of Public Health (FSPH) at Indiana University initiated the Health Matters study. Health Matters aims to understand how individuals in underserved urban communities define health in order to make health interventions more relevant to community health perceptions. This paper, specifically focusing on an interdisciplinary academic research process, will discuss the challenges and roles of designers in integrating their disciplinary practice into health care interventions. WHAT DOES HEALTH MEAN TO YOU?
Helen Sanematsu is assistant professor in visual communication design at Herron School of Art and Design, Indiana University. Helen uses methods from design research and communication design to facilitate bi-directional communication in community engaged health research.
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The objective of Health Matters is to identify new, people-centred definitions of health. We know that health perceptions affect self-care: in other words, if you think you’re healthy when you actually aren’t, you won’t pay attention to your health. Biometric readings such as weight and blood pressure are clinical measurements that don’t reflect people’s perception of being healthy from individual perspectives. How might we Youngbok Hong, Helen Sanematsu
make these measures meaningful to people to motivate them to improve their health? What other measures are relevant to health perceptions and how might we learn what they are? FROM A SERVICE DESIGN COURSE CAME AN INTERDISCIPLINARY PARTNERSHIP
In 2012, we developed a project in the course entitled ‘People Centred Service Experience Design” in which we partnered with Garden on the Go®
cross-discipline
Fig.1. Garden on the Go® mobile
(Fig.1) to conduct a customer survey to learn about customers and their needs. Instead of pursuing a conventional survey method, we applied service design methods such as a customer journey map1 and personas2 that provided Garden on the Go® leadership with a comprehensive description of the people who use their service. Garden on the Go® conducted a health assessment survey with the Richard M. Fairbanks School of Public Health the previous year to see if and how the program impacted health through various biometric measures (weight, blood pressure, etc.) The study revealed that the traditional methods of collecting qualitative information in health assessment were inadequate for comprehensive health measurement in underserved urban populations, and provided limited information. The team noted that individuals with chronic health problems — obesity, diabetes, problems with mobility — would often rate their health as “very good” or even “excellent,” exposing the insufficiency of our own understanding of what health means to this group. Having seen our participatory approach to customer research, Garden on the Go® and the researchers from FSPH saw the potential of service design methods to help better understand their
population and proposed to develop a collaborative research project between the Herron School of Art and Design, Fairbanks School of Public Health and IU Health. WORKING TOGETHER: DESIGNERS, PUBLIC HEALTH SCHOLARS, AND SERVICE PROVIDERS
Since the project launched in 2013, Herron has served as the primary research conveners and has taken the lead in developing research methods, gathering data and data analysis. As of June 2014, the study is concluding its data collection phase. At the completion of the study, Herron will be responsible for disseminating study findings back to the communities involved. The FSPH partners, based on their community based research practice in the public health context, have provided consultation and assistance in aligning service design practice with academic research process and protocols. They will also collaborate with the design researchers in preparing the reports, abstracts and manuscripts to disseminate findings to the academic community. IU Health has provided logistical support and access to Garden on the Go® customers. Additionally, IU Health will assist in sharing the research findings with the community when the project is completed. THREE DIFFERENT, BUT SHARED, AIMS
Often, health promotion intervention programs are developed and implemented for target populations by touchpoint 6-2 13
Fig. 2. Camera and Journal tool kit including the consent form, instruction sheet,camera guide, and voucher
public health professionals who possess validated, yet incomplete, understandings of the people they are trying to serve. When designing health interventions, the patient’s voice should be part of the design development.3 When this inclusion does not happen, the programs are not as effective as they could be or, worse yet, may be rejected out of hand. The findings of our study aim to improve understanding of the culture of our target population — Garden on the Go® customers — with regard to their perceptions of health and what they perceive to be a healthy diet. Under this overall study objective, each project partner has defined a specific goal. The IU Health Garden on the Go® aims to gain a better understanding of what fruits and vegetables would be attractive to their customers as well as how to assist them in the selection, preparation, and presentation of fresh fruit and vegetables as part of a healthy diet for their families and themselves. They are also interested to know how 14
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Tuomo Kuosa
they might improve their service overall, and expand their On-the-Go model to other programs that would be relevant to their customers. The Richard M. Fairbanks School of Public Health aims to develop new, relevant and patient-centred measures for health, in alignment with current research agendas seeking patient centred outcomes. The service design researchers at the Herron School of Art and Design aim to establish a collaborative research model by providing relevant design methodology for rich data collection and deep analysis, connecting patients and healthcare providers/ researchers by co-designing for healthcare outcomes. DESIGN RESEARCH IN ACADEMIC PARTNERSHIPS: NEW TERRITORY FOR DESIGNERS
The main purpose of this article is to share our experiences and challenges as designers in interdisciplinary academic research settings, and to address how we can integrate our disciplinary practice into health care interventions as equal collaborators with research partners. Our research process consists of six stages: pre-research, research design, recruitment, data collection, analysis and dissemination. The project is currently concluding the data collection stage and we expect to reach the dissemination stage in the fall of 2014.
cross-discipline
Fig. 3. Completed journal pages and photos
Pre-research: An articulation of ethical practice in research Academic research goes through a pre-research phase in order to ensure that studies are ethically sound. The institutional review board (IRB) — also known as an independent ethics committee or ethical review board — receives research proposals involving human subjects and reviews and monitors biomedical and behavioural studies to protect the safety and rights of participants. IRB approval is required for all such research undertaken at the University. Current IRB review is designed for specific disciplines such as medical or social science research and is not optimally designed for design research practice. The vocabulary and overall framework of the IRB approval process emphasises ethical codes of medical research, including those relating to invasive procedures (such as drawing blood) and full disclosure of research methods. It also addresses coercion, inequities in power and social status and other potential psychological impacts. The shift into an academically rigorous research practice entails a steep learning curve for design researchers in order to navigate the review system from submission to approval. The IRB process is valuable for design researchers for considering the ethical aspects of research in design work. Questions of recruitment bias (manipulated selection of research participants), misrepresentation of study processes and potential for coercion at any point in the study are among the issues that can cross the boundaries of respect and trust and ultimately undermine the validity of the findings. What we learned: design researchers who wish to use interdisciplinary collaboration as a venue and means for validation, and those who wish to disseminate the impacts of design to the public need to become familiar with the IRB in order to engage at a level on par with specialists in other fields. Those who do not receive certification (typically, via an online educational module) are not permitted to interact with study participants or potential study participants.
Fig. 4. The photo discussion with the participants As design research becomes more integrated into interdisciplinary research, it is time for design to define its code of ethics from a disciplinary perspective, to integrate it into institutional mechanisms for research such as IRB and to educate designers about established research standards outside of commercial practice. Research design: what is beyond methods and tools? In developing interdisciplinary research projects — specifically when establishing a new project — there are a few things that require mutual understanding from project partners: what are the common goals of the research endeavour, what is the disciplinary language related to research processes and what are the methods to achieve the goal? Although this study was developed based on a shared view of the novelty and value of design research in data collection, we design researchers had only a vague touchpoint 6-2 15
Fig. 5. Service design aspects included one-on-one training sessions and consistent study visual communication
notion about what data analysis entailed in public health. In this study, we used photo, voice and group discussion as methods for data collection. Participants take photos of their daily lives relating to health, food and lifestyle (Fig.2-3) and participate in informal, but structured, follow-up discussions with the research team (Fig.4). These combined methods generate three types of data: photographs, journal entries and discussions. A cohesive approach to data analysis across data types was necessary, particularly because of the mix of disciplines within our team. Our partners’ openness to learn alternative approaches in data analysis enabled us to lead the process of analysis. This stage provided opportunities for us to reflect on the differences between public health and service design in data analysis and to further articulate the methodological aspects of design research. While data analysis in public health is executed by individual researchers (generally speaking) using a theoretical framework 16
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that feeds new knowledge back to the discipline, service designers externalise the analytical phase and facilitate collective analysis including all stakeholders who share an understanding of the defined population. For instance, we invited the Garden on the GoÂŽ counter staff and a community liaison for data analysis. While they are not certified academic researchers, they possess an intimate knowledge and the most profound understanding of the audience through their frequent interactions. What we learned: current literature in design research tends to focus on methodology and tool making. Designers who wish to work in partnership with academics will increasingly find it necessary to develop a disciplinary understanding of design research that encompasses the process of inquiry beyond the collection of data. We need to define our own disciplinary position. RECRUITMENT: BUILDING THE TEAM
Recruiting participants for research projects is frequently difficult, time consuming and inefficient. Additionally, once participants are secured, there is often a problem with adhering to the research process: participants drop out or fail to comply to research protocols. Health Matters was at an advantage in relation to study recruitment: we consulted with our partners at the IU Health outreach team and selected four of the
cross-discipline
active Garden on the Go® stops as our research sites and began working with community leaders at each stop to coordinate days for recruitment, camera pick-up and discussion. Our communication with the leadership at each of the sites was key: we were introduced at community and resident meetings, used community meeting time for discussion groups and we were able to leave boxes for camera pick-up on site in office spaces. Interactions outside of labs enabled us to build relationships with the participants, to have a better understanding of the organisational cultures and to adjust our research plan accordingly. DATA COLLECTION: DESIGNING AN EXPERIENCE OF ENGAGEMENT
Framing the participant’s experience from a service design point of view, we aimed at optimisation by identifying and connecting the touchpoints involved in the research process. From recruitment to data collection at discussion sessions, every touchpoint in engaging with research participants was carefully designed in order to optimise their experience. (Fig.5) Our approach in designing the participants’ experience was complementary to our partners’ expertise in the area of health research. The attention that we paid to the participant experience in the data collection process prioritised the person rather than the data and, in effect, put us, as designers, in a more protective role aligned with the principles for ethical treatment of human subjects as regulated by the IRB. CONCLUSIONS
Our work with IU Health/Garden on the Go® and the Fairbanks School of Public Health demonstrated the potential for simultaneous interdisciplinary collaboration in both the public realm and the academy. Design research methods yield rich, contextualised data for service design (applicable to Garden on the Go® as they expand their menu of services) and, for improved understanding of underserved populations, it is a key learning outcome for public health. In the process of our research, our partnership has raised the profile of all three groups in community health circles through
community presentations. On the academic end, the work is a cutting-edge example of community-engaged research in health, currently a broadly supported area of health research in the United States. Our process was made efficient by the clear definition of each of our roles: our association with Garden on the Go® provided institutional support that helped with recruitment, the School of Public Health provided a theoretical and discursive home for the study, contextualising our data as new findings in a field unfamiliar with design research and design provided patient-centred methods. Our next steps include codifying our methodology within public health research, and with an ultimate aim of institutionalising design research as a legitimate complement to existing data collection methods for patient-centred research. ACKNOWLEDGMENTS
This paper would not have been possible without the generous contributions of the following people: Lisa Cole and Kaliah Ligon, Indiana University Health; Terrell Zollinger and Cindy Lewis, Richard M. Fairbanks School of Public Health; Ashley Bailey, Brian Crain, Bridget Hawryluk, Andrea Haydon, and Nick Walters, Herron School of Art and Design; Niki Girls and Lynn Rodgers, Concord Neighbourhood Centre; Tysha Sellers, Edna Martin Christian Centre; Valerie Moore, Indianapolis Housing Agency. Health Matters was funded in part with support from the Indiana Clinical and Translational Sciences Institute funded, Grant Grant # UL1TR001108 from the National Institutes of Health, National Centre for Advancing Translational Sciences, Clinical and Translational Sciences Award.
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References Stickdorn, M., & Schneider, J. (2010).This is service design thinking : basics-tools--cases. Amsterdam: BIS Publishers. 2 Lidwell W, Martin B. (2012) Universal Methods of Design, 100 Ways to Research Complex Problems, Develop Innovative Ideas, and Design Effective Solutions. Gloucester, Mass: Rockport Publishers 3 PCORI Methodology Committee, (2013), The Patient Centred Outcomes Research Institute Methodology Report. http://www.pcori.org/research-wesupport/research-methodology-standards/ 1
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Photo: frog design (p.53)
Feature
Better Outcomes by Design Improving health and wellbeing through participation
Juha Kronqvist is a senior service designer at Diagonal and a researcher at Aalto University. He specialises in designing human-centric healthcare services and environments.
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Mikko Koivisto is the lead service designer and a partner at Diagonal. He has extensive experience in designing services and customer experiences across multiple sectors.
better outcomes by design An illustration of the pharmacy concept
Going all the Way Key factors for successful implementation of strategic service design
How do service designers keep their concepts intact while moving from a strategic level to implementation? This article describes the key factors that made it possible to enact large strategic changes in a conservative field. Using a case in pharmacy services, we show how service design goes beyond incremental service improvements and takes a leading role in creating a strategic vision and making sure that that vision produces concrete results. PLACING OUTCOMES FIRST
Kirsikka Vaajakallio has a doctorate in design and she works as a senior service designer and a project manager at Diagonal. She has years of experience with user-centred design, empathic design, codesign and service design.
At the 2013 Service Design Global Conference, Lee Sankey1, group design director from Barclays challenged service designers to love outcomes as much as we now love our processes. Indeed, too often we talk about models, customer journeys and methods, instead of focusing on the concrete results of our work. The reason is hardly because we are not interested in results, but that presenting them can at times be difficult. If the design is on a strategic level, the immediate results can be hard to describe before they have been implemented. Sometimes, improvements to services might be incremental rather than radical, hence they might not significant enough to report. Based on our experiences, there might be a third reason for the strong focus on processes: at times, service designers seem to have difficulties in following through with their work from concept design to implementation. Even though the design work on a strategic level can be stellar, if designers are not able to see it through, its effects can be diluted by the time arrives to implement the project. And, sometimes, it happens that the results of good processes end up on the ‘concept shelf’ without ever going live. Juha Kronqvist, Mikko Koivisto, Kirsikka Vaajakallio
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This presents a significant continuation problem for the discipline. After observing nicely crafted presentations of processes and methods, while difficult questions of results are brushed aside, clients might start looking for answers elsewhere. Without understating the importance of well-organised and innovative design process, we want to highlight the need to follow service design projects all the way to implementation and beyond. Only in this way can we create sustainable business propositions for the strategic level and take a leading role in complex transformation processes. Where service designers fail
One of the imperatives in service design is the iterative process, during which the design problem is continuously reframed. Reframing is based on a recurring learning cycle that takes place through exploring the service context, its stakeholders, generated customer experiences, business case opportunities and so on. Hence, we often end up with solutions that demand more profound changes from the service organisation than was estimated in the beginning. This constricted view towards implementation requirements can cause problems later on in the project. A budget might be reserved more for customer understanding and concept design phases but, when the resulting service elements need to be put into action, the client might be struggling to find resources. Siloed organisations present another challenge. Whereas service design can be tendered through one unit, the resulting concepts often require attention from several other units that might or might not be prepared to join the process. Sometimes the problem is simply that the client organisation is not ready to implement change. The challenges of change management might be underestimated or the person in ownership of the service design project might not be high up enough in the organisation. Service design might also be ordered to patch up deficiencies in current services without an intent to implement changes in the organisation. However, we should not point fingers at the client who is buying service design. At times, the designproject sale is closed in a hurry and difficult questions 22
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regarding the implementation budget can easily be brushed aside. Fuzzy resourcing for outcomes leaves the designers without a proper budgeting frame to guide concepts, which, in turn, might lead to inflated proposals with no realistic opportunities for implementation. With no pre-agreed frame for design from the client side, the resulting concepts can be deemed radical and too risky for implementation. At times, designers lack understanding of the culture and design legacy on which the organisation’s development processes rest.2 Problems often arise when the outcomes from strategic design point towards a major revision of the existing service or business model. Service designers might simply not have all the capabilities required to implement the new services. While the average size of service design agencies can be relatively small, implementation often requires capabilities in graphic design, spatial design, business planning and change processes, to mention a few. The client might choose not to trust the agency with all the work and to source parts of the design from other actors such as advertising agencies or business consultants. In order to maintain control of their concept throughout the project, agencies need to be prepared to offer design capabilities beyond service design. They can do this through building a crossdisciplinary team structure or maintaining a credible subcontracting network. Most of these problems can be avoided through careful planning of the implementation phase and integrating it strongly within the design process. Engaging in discussions about the implementation with the client early on is essential in ensuring this. Positioning pharmacies on the wellness map
In February 2014, a new pilot pharmacy in Helsinki opened its doors to the public. It presented a radically new concept for its customers, resulting from an intensive service design project that had gone on for a year. Our client, the largest pharmacy chain operating in Finland, wanted us to uncover a new role for them in the changing healthcare landscape and to create proposals that capitalised on emerging needs and new customer segments.
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Pharmacies are facing increasing challenges in upholding their traditional business model of selling prescription drugs. The recently introduced new regulations effectively diminish returns on the sales of prescription medicine. As customers can now more freely choose between cheap generic drugs and brand name patent-holders — which reduces the traditionally generous profit margins on drug sales — many are looking towards services as an additional source of revenue. At the same time, new opportunities emerge through an increased customer interest in holistic healthcare solutions that support their wellbeing and prevent illnesses, instead of just curing them. In response, pharmacies can try to squeeze profit margins by reducing expenditure or they can start looking for new strategic opportunities. Creating change is never easy, much less in the healthcare field. Pharmacies in Finland are highly regulated and controlled by the government. Their business model has been left relatively unchanged for decades, and it is fair to say that the actors in the field are very conservative and risk-averse. In our project, we faced the challenge of renewal in a traditional organisational culture where both service design and a customer-centred business focus were alien.
We started with an intensive design research phase, during which we studied pharmacy customers, the current operating model and engaged with experts on the future of healthcare. We gathered understanding by conducting in-depth interviews and ‘shop-alongs’ with customers, collected ideas and insights through an online customer platform, visited several pharmacies across the country and arranged roundtable discussions with professionals ranging from technology experts to philosophers. The outputs of this phase were an analysis of problems with the current model, customer profiles based on existing and new customer segments and five healthcare trends in the field. To support and guide our work we established the key indicators for evaluating success throughout the project. During concept design we generated close to two hundred ideas for future services. The resulting concept ideas were screened with online participants and prototyped at specific pharmacies. The best ideas were visualised and thoroughly documented. In order to communicate the changes in an even more concrete way, we created two service scenarios that combined several ideas into a consistent customer story. The results were presented in a concept manual, which was distributed to all pharmacies and presented in a closed seminar.
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The pilot pharmacy materialises the design vision
The end results suggested major revisions in the service model of the client. Based on our advice, they chose to pursue a new direction for their market position, including changing the chain’s name, the reformulation of their customer promise, a stronger emphasis on environmental sustainability and a radical alteration of their service concept. Overall, the work points towards a new, more active role for pharmacies in the healthcare ecosystem. Following the strategic decisions, we designed a pilot pharmacy that included an improved customer service model, a fresh interior concept and productised wellness services. The first pharmacy following the new concept opened a year after the start of the project. It concretises the business proposal and customer promise in a tangible and measurable way. In addition to sustaining the new business model, the pilot pharmacy concept has been recognised by two high-level design awards and an entry in the Finnish Design Yearbook. All in all, it embodies dozens of radical ideas, changing the perception of how a pharmacy should serve its customers. ON GOING ALL THE WAY
Our client was facing a complex challenge that had the potential of disrupting the industry. They understood that a tackling it required more than one intervention. To secure trust and continuation, we signed a two-year partnership contract that created a focus for the project and a strong basis for collaboration. We understood from the start that getting the pharmacists on board would be essential for success in the long run. During the project we collaborated directly with the 24
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CEO and reported to the board, and engaged with the pharmacists at seminars and using an online platform. This long-term relationship allowed us to concentrate on first creating a strategy and then moving on towards implementation. The central indicators for the project were based on key business drivers: customer satisfaction, profitability and internal efficiency. This kept the focus of the project and supported designers when framing the design space. Now we were able to identify and rule out ideas which did not contribute towards the established goals. The same indicators were used to adjust our designs after the pilot pharmacy had been running for a few months. We were also plain lucky: the chain obtained a new pharmacy licence just as the strategic phase was being finalised. The licence required the complete renovation of an old pharmacy property that had been damaged in a fire. This allowed us to design the interiors from scratch. The pharmacist was excited about our proposals and willing to take the risk of piloting them in her pharmacy. In addition to service designers, our office has employees with training and experience in graphic
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design and interior architecture. This meant that we could maintain the role of a concept gatekeeper when moving towards implementation. Other skills needed were sourced through our freelance network and from the client’s existing providers. In this way, the vision was kept clear and the concept did not become toned down at key decision points. Finally, the success of the new concept depends a lot on how the launch of the product is conducted. Together with the pharmacy staff, we finalised the service model and engaged in discussions about the new concept. The prescription desk designs were prototyped using full-scale cardboard mockups. By including the employees in the process, we made sure that the ownership of the new way of working is internalised instead of being simply handed down. This created a common vision and motivation for the staff. The newly opened pharmacy received generous attention from the media, which reduced the pressure to advertise the launch and generated great interest in this different kind of pharmacy experience.
ACTORS OF TRANSFORMATION
Successful service designers need to be able to manage processes of transformation. Their core abilities relate to managing change across many spectra, their clients at various level of decision making, the employees making the changes real and the customers who use the services to create a change in their lives. In our case, going all the way required a focus on building a long-term strategic partnership, working together with top-level management, basing your work firmly on customer understanding and retaining a strong focus in measuring business and experience outcomes. It is, at times, a challenging balancing act, but one that is needed in order to ensure that service design will continue to be relevant to our clients.
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References 1 Sankey, L. (2013) The New Seriousness of Design. Keynote at the Global Service Design Conference 2013. Cardiff, UK. 2 Junginger, S. (2014). Design Legacies: Why Service Designers are not able to Embed Design in the Organisation. Presentation in ServDes2014 conference. Lancaster, UK.
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Community Intergenerational Mutual Assistance around Breakfast
Qi Luo is an associate professor in School of Design & Art, Beijing Institute of Technology. She teaches Industrial Design and Service Design courses. She has won the international Reddot, IDEA and domestic Red Star design awards and held the 2012 Service Design Symposium in BIT. She is cochair of SDN Beijing Chapter
With the accelerating pace of life and rising work pressure, a growing number of Chinese citizens are confronted with health issues. The patients suffering from chronic diseases and cancer tend to be younger, which is especially obvious in the larger cities in China. Under such circumstances, it is urgent and profound to establish a health service system to reduce the health risks towards young people. Among all of the influencing factors, breakfast is very important for urban white collar workers. After studying the current situation, by applying service design principles, we aim to make it easy and convenient for young people to obtain a healthy breakfast, especially in community service. BACKGROUND
Jinghui Deng is a graduate student at the School of Design & Art, Beijing Institute of Technology. Her research field is service design.
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China is a country with the oldest culinary traditions. There is an old Chinese proverb: “Breakfast is gold, lunch is silver, dinner is copper.� From the perspective of nutrition and medicine, breakfast is essential for maintaining the energy, alertness and metabolism of we humans, and without it the risk of chronic disease increases. So, it is clear that breakfast is a meal of great importance. However, with the accelerating pace of life and rising work-related stress in big cities in China, enjoying a healthy breakfast has more and more become a privilege, rather than something we take Qi Luo, Jinghui Deng
for granted. We found there was a typical group that has been seriously affected by the absence of a wholesome breakfast: namely, young people living in modern communities. The existing breakfast services in communities, with their lack convenience and nutrition and with their excessive commercialisation, were simply not sufficient for these young people’s dietary and nutritional requirements. When we focused our research on taking breakfast in communities, the Beijing Quanfa Property Management Company hoped to cooperate with us to improve the services offered to their clients. The Quanfa Garden is a residential
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Figure 1. Stakeholder matrix to analyse demands and contributions of young people, senior citizens, and the Quanfa Company, including evaluation charts
community of some 700 residents. Its services were similar to that of other communities: rigid, dated and unattractive. To create additional value and increase user satisfaction, they needed an innovative service concept. CHALLENGE AND INSIGHT
Taking on the problem of providing a healthy, nutritious breakfast, we distributed a survey in Beijing among people aged 21-35. The results of this survey made us realise that most young people simply don’t have breakfast every day. First, they don’t have time to make breakfast at home due to their busy work schedule. Second, despite being able to buy food on the way to work, they simply do not have the time to eat it. Third, young people who have the unhealthy habit of eating late at night usually have no appetite for breakfast. As a result, it became a primary goal of this service design project to help young people to obtain a healthy breakfast more conveniently. Notably, most young people who live away from their hometowns depend a lot on their local communities.
After an in-depth exploration of their lifestyles and psychological demands, we gathered insights into their expectations for breakfast — they wanted to eat healthily and to ‘feel at home’, which influenced us to consider more emotionally-related factors when redesigning the service for the community. When we explored the needs of young people living in Quanfa Garden, a special group — new retirees in the same community — caught our attention. This is a large group within the community that has an abundance of time to enjoy breakfast. It is important to mention that, in China, elderly people are willing to enrich their lives by helping younger generations. Meanwhile, a majority of them who live apart from their children need assistance when they encounter problems in their daily lives. We found it was possible to establish an intergenerational, mutual-assistance relationship between young people and senior citizens in the Quanfa community. Therefore, the redesigned service system would not only focus on young people’s breakfast needs, but would also foster a healthier community relationship among all the residents. touchpoint 6-2 27
What did we do?
Analysis & Evaluation
Field research, interviews, questionnaires and observations were employed to understand different groups’ behaviours and lifestyles. Subsequently a customer journey map, a stakeholder map and a stakeholder matrix were used to analyse and deduce the reasons behind the behaviours of the residents and to gain some insight on and to identify and define the problem. Then, we used the techniques of brainstorming, storyboarding and system mapping to create, visualise and systematise the new service concept. Our service system included two stages. The current stage focused on how the young people could conveniently obtain a healthy breakfast. We developed a breakfast service platform on WeChat, a popular IM app with a considerable user base in China. Young people could register addresses and order breakfasts, and the senior citizens could upload the breakfast information on the same platform. The service system matched both parties according to the distance between them. The next morning, the elderly people sent the breakfasts that they had prepared to the young people on their way to morning exercises. The young people only needed to pay a nominal fee, which was mainly used to subsidise the cost of the breakfast ingredients to the elderly people and to support the day-to-day operations of the service system. During this stage, both groups in the community established comparatively stable modes of social contact. In the next stage, we plan to broaden the range of the intergenerational mutual assistance beyond mere breakfasts. For example, the obstacles involved when elderly people use high-tech products and the everyday problems they encounter caused by the ageing process require the assistance of younger people. Meanwhile, temporary child and animal care — and even caring for the younger people’s houseplants — need the assistance of elderly people. The service platform we envisage creating would match the demands of both groups, forming a strong community mutual assistance bond — a model similar to reciprocal altruism.
The three largest stakeholders involved in the service are the young people, the senior citizens and the Quanfa Property Management Company. Satisfying the demands of all three sides is the most important criterion in evaluating the service system’s feasibility. We applied a stakeholder matrix to analyse the demands and contributions within the service (See Figure 1). Young people were able to easily order breakfast on their mobile phones, which offered them convenient and healthy breakfast services and the satisfying emotional experiences that they lack, being away from home. The regularly scheduled breakfast times provided by the service platform helped young people to form healthy breakfasting habits. Also, the self-service selection based on address matching and the on-line payment method, with which the younger people are extremely familiar, rendered the service eminently usable. With the stable social circle established, young people could directly obtain assistance from senior citizens. This service allows young people to experience greater levels of satisfaction in their breakfast with a relatively cheap outlay. At the current stage of development of the service system, senior citizens mainly obtained psychological and emotional satisfaction by assisting young people with their breakfasts. However, they, in turn, would directly obtain assistance from the younger residents after the establishment of a social circle. Thus, they actually spent relatively less time and energy solving the problems they encountered in daily life. For the Quanfa Company, the service satisfied one of the most practical demands of the residents in the community, established the social system of mutual assistance and increased the activeness and satisfaction of the owners in the community. For a community service company, it is more important to provide better social service than to concentrate simply on profit. We developed a breakfast service program module for the Quanfa Company on the existing WeChat platform, then tested and evaluated the resulting prototype using twenty retired residents and twenty young professionals in the Quanfa Garden residential community.
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Prototype test of breakfast service app function module on WeChat platform and delivering breakfast box The prototype-testing process went smoothly: most of the target groups enjoyed the service. They not only pointed out the shortcomings in many design details, but also suggested broader mutual-assistance potentials in the community that would be advantageous for forming a circle of mutual social assistance. As for responses from the younger people, the breakfast ordering process was simple and effective: it saved both time and effort. They acknowledged the fact that having breakfast would make their lives healthier, and knowing the breakfast content and makers in advance made them feel ‘at home’. They did, however, want the breakfasts to be stored well. In return, they were willing to help the elderly people in the community. The senior citizens thought that the instant voice messaging function on WeChat was very easy to use, which meant that they could easily publish the breakfast
menus, although they thought that more communication with the younger people about breakfast suggestions and healthy dietary reminders would improve the service even further. CONCLUSIONS
This project has redesigned the community service system of Beijing’s Quanfa Garden residential community, using breakfast services as the starting point for the design. The existing breakfast options were not convenient enough, and the extant community services were simply not attractive enough for the residents. In this project, we established a unique service mode of community breakfasts, as well as of mutual assistance, which maximised relative benefits for each of the three stakeholders. This innovative service system will continue to promote healthy lifestyles, constructing a harmonious and friendly community atmosphere.
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Using Patient Insights to Design Future Health Solutions Collaborating with patients through online communities
Anouk Willems is Research Innovation manager at InSites Consulting. With an education in marketing, and passion for co-creation, Anouk connects brands with consumers through online research communities. She is part of the ForwaR&D lab of InSites Consulting. In her current role she focusses on innovating the community solutions and specialises in long-term communities.
Magali Geens is managing partner & head of healthcare at InSites Consulting. She is one of the managing partners of the company and a commercial executive. Magali is currently heading a number of global life sciences & healthcare accounts including UCB, TEVA Pharmaceuticals, Johnson & Johnson and Pfizer.
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The challenges of living with a chronic disease Today, patients have more information than ever before about their diseases and treatment options. Think about the wealth of data on the online community PatientsLikeMe, where more than 220,000 patients share their stories about over 2,000 conditions and Patient.co.uk, which has 16 million visits each month. Patient empowerment is one of the main trends in today’s digitalised healthcare landscape. People with a chronic condition are increasingly taking active control of their health, sharing information about treatments and finding great support in their interaction with fellow patients. But while large numbers of patients connect with distant fellow sufferers via online communities, they often have a harder time communicating about their disease in their immediate environment: with family, friends, neighbours or colleagues. Those close to them do not always seem to understand them as well as fellow patients do, leaving them at times feeling powerless, rather than empowered. The problem is that many symptoms — such as fatigue and depression — and their impact are hard to explain. Patients struggle to communicate these less-tangible problems to the people closest to them, causing physical and emotional distress. Living with a chronic Anouk Willems, Magali Geens
illness, for example rheumatoid arthritis (RA), can take its toll on the patients’ wellbeing and personal relationships. To overcome communication challenges in relation to these ‘significant others’ and to avoid social isolation, InSites Consulting and UCB, a biopharmaceutical company focused on chronic diseases, created a research community for patients diagnosed with a chronic condition. The goal was to identify opportunities for patient solutions that help them improve their ability to communicate about their illness to their loved ones and others who they socialise with.
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Three routes detected to help patients better reflect on their feelings, articulate their status and talk to others
EMPOWERING PATIENTS IN AN ONLINE COMMUNITY
We invited fifty US participants with chronic health conditions, more specifically RA (62%) and epilepsy (38%). A three-week online research community was the backbone of this patient research project. The objectives of the community were to • connect participants from all over the country on an online closed platform • enable participation in a flexible asynchronous way to maximally accommodate patients’ abilities and • allow participants to share their stories and exchange tips and tricks in an inspiring learning environment The community research project started with ‘patient immersion’, a one-week online ethnographic multimedia module where patients shared their personal stories with the moderator in a private forum. In the
second week, the participants were invited to connect with peers who were suffering from the same chronic condition, to discuss common grounds and shared needs in an online discussion forum. In the last week, we invited all participants together (across therapy areas) for the patient brainstorm discussions, to ideate about potential patient communication support services for the future. This gradual approach helped patients to open up to the moderator and to each other, resulting in 2,552 posts and 367 photos and video testimonials. Furthermore, the community approach helped to bring new insight to the table touchpoint 6-2 31
“It was very interesting to allow patients with epilepsy and RA to communicate with each other, as patients struggle to express themselves in both disease areas. This was a great way to group the UCB teams of different areas to think about solutions serving more than one patient group.” and bring down the ‘silo thinking’ of the different departments involved within the organisation. Carl Vandeloo from UCB explains: THREE ROADS TOWARDS IMPROVED COMMUNICATION
The research confirmed that patients risk becoming isolated if they fail to be understood by their peers and loved ones. Patients participating in the research brought up three potential routes for UCB to facilitate patient communication. The first and most important route according to patients is to raise public awareness. Patients are not ‘armed’ to educate their broader circle of friends and acquaintances about their condition and its impact. Examples of how to raise public awareness include more general public campaigns about their condition or simple instruction sheets explaining to ‘outsiders’ which critical incidents may occur. Patients would benefit greatly from the public having an increased knowledge about their condition. They would experience it less as a stigma and would not need to explain things that are self evident. 32
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The second route is to trigger communication planning about their condition with their significant others. The ‘excuse’ for not engaging in the conversation about their condition is often the ‘lack of opportunity’ or that they never ‘planned’ to talk about it. Patients do not even realise that their significant others others cannot read minds and that they need to integrate routines for discussion into their lives. A systematic self-reflection by the patient can be of great help, such as a diary to keep one’s finger on the pulse of one’s status and current needs. It stimulates talking about the condition, avoiding frustration or even isolation. The third route is to support patient expression. Patients who have a difficult time expressing their thoughts and feelings about their disease should have tools that facilitate communication, particularly when they need practical support or emotional relief. The community members made us realise that many patients are in need of simple status expression aids. For example, refrigerator mood magnets are a tool that can enable patients to express their status, both in terms of how they are feeling and for rating the physical burden (e.g. from 0 to 10). These 3 routes could help patients better reflect on their feeling, articulate their status and talk to others. While this research is merely the starting point in tackling a big problem for patients dealing with a chronic disease, it can inspire the health industry to take patient-support services forward.
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WHY IS IT RELEVANT TO SERVICE DESIGN?
This study illustrates the huge potential of patient collaboration for the health industry to co-create relevant patient services. First of all, chronic patients participating in online communities become more knowledgeable, feel better supported socially and more empowered. Second, the results present new opportunities for health care providers such as UCB to improve the patient experience, for caregivers and for patients living with a chronic disease.
“My husband said to me, ‘Honey, I love you, but if you don’t tell me how you’re feeling how am I supposed to know how I can help you? I can’t read your mind.’ He was so right. I had to trust him enough to confide in him when I expected him to be there to support me.” — RA patient
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Custom-designed Talk To Me patient community
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better outcomes by design
What Do the Remote Mountain Villagers Need? Villagers’ notion of wellbeing A typical phenomenon for many rural villages in southwest China is that young adults have moved into town to seek higher income jobs, leaving their aged parents and children behind. This change in family structure has caused far-reaching effects to all aspects of village life. Using Tongguan, a remote mountain village as a case study, a group of volunteers worked together with villagers for three years to tackle this increasingly common dilemma. Applying the principles of service design, they created a multi-purpose sustainable platform, a new villagers’ centre project that not only effectively responded to the village’s most urgent needs, but also helped rebuild villagers’ confidence by promoting a sense of belonging. BACKGROUND
Tongguan, a remote mountain and Dong minority village in Liping county, Guizhou province, southwest of China, has been wrestling the impact of the country’s modernisation over recent years. Like many other rural villages in the region, a typical phenomenon is that young adults have moved into town to seek higher income jobs, leaving their aged parents and children behind. For Chinese families, typically characterised by extended-family life, filial piety
Tongguan village in the morning mist
and stable intra-familial support, this transformation in family structure has caused far-reaching challenges to all aspects of village life. Intimate familial relationships are becoming unsustainable and its collective culture is quickly fading. Senior villagers remain as the only workforce on farms and have to look after their grandchildren. Meanwhile, younger generations lose their commitment to life in the countryside after years of working away from home. Many traditions that have been developed over generations by the Dong minority, from their unique carpentry skills to cultivating nativeFang Xu, Yuanyuan Chen, Fujian Mo
Fang Xu is the coordinator of environments/spatial design, COFA, UNSW Australia. Fang’s expertise is drawn from his cross-cultural background, wide range of professional design experience and interdisciplinary research interests. His recent research concentrates on the role of public participation, community engagement, social innovation and design intervention in service design practice.
Yuanyuan Chen is a director of Charitable Foundation Brand Project at Tencent, Shenzhen, China. She has engaged and facilitated Tencent Building New Rural Project to promote rural areas development since 2009.
Fujian Mo is an associate professor at environmental arts design department, Guangxi Arts Institute, Nanning, China.
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bred Kam Sweet Rice, face the danger of falling out of use. For a village whose history revolves around its inhabitants and traditions, this dramatic shift has brought pressure and fear to those who have decided to leave and loneliness and helplessness to those who have been left behind. Furthermore, as more of the population choose moving towards modernity over preserving the past, the village’s weakening sense of identity has increased uncertainty about its future. The Rural Poverty Reduction Program (RPRP), an initiative of both central and regional governments, aims to overcome some of these issues. It typically involves upgrading infrastructure in rural areas, such as building more schools and constructing more accessible roads. Training programs are in place to better educate schoolteachers. The program sponsors also regularly donate seasonally needed goods to children and aged villagers, such as winter clothes and dry food. These efforts have mainly focused on closing the gap between rural villages and the more modernised cities. It targets the villages’ most obvious inadequacies that have been highlighted as a result of modernisation and improves them by providing basic living necessities. However, what current programs have been unable to provide is a solution to address the psycho-social wellbeing of the villagers that are failing to be protected as a result of this fast-paced demographic shift. In response to this situation, a team of volunteers consisting of designers, public servants and government officials sought an innovative approach in fulfilling both the tangible and intangible aspects of the villagers’ wellbeing. Sponsored by 36
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the Charitable Foundation Brand Project of Tencent, they worked alongside Tongguan villagers over three years to confront some of the most difficult issues that each individual faced. Through exploring and engaging the process of service design, the team not only successfully addressed the tangible aspects through creating sustainable job opportunities, but also the intangible aspects through restoring villagers’ self-confidence and sense of security in the village’s future. LESSONS FROM PREVIOUS APPROACHES
Understanding the constraints of the current approach the team identified three primary barriers that exist with RPRP and other government sponsored projects. 1. Projects could only respond to observable tangible issues without thoroughly understanding the underlying factors: projects focused mainly on introducing new infrastructure and little on people’s mental and psychological needs. 2. Government or sponsors were the only decision makers for projects; the program did not reflect the priorities of the community accurately. 3. The approach often used urban city lifestyles as a standard for reforming traditional village lifestyles, without proper consideration for the preservation of the region’s values
Volunteers & villagers after a working meeting
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ESSENCE OF SERVICE DESIGN
PROCESS OF NEW APPROACH
The essence of service design provided a theoretical framework for the team to seek a new approach. According to Shostack1,service design is an activity that integrates material components (products) with immaterial components (services). This combinatorial character has been further specified by Eiglier & Langeard2, Normann3 and Morelli4, they emphasised its co-existent nature of being both created and used by the user at the same moment. This is very different from standard products that are usually created before being purchased and used. Morelli5 also proposed three key factors that must be accounted for in order to properly manage the process of service design: 1) appropriate analytical tools need to be in line with the identification of users; 2) possible service scenarios need to respond to the sequences of any action; 3) physical and nonphysical elements need to integrate to represent the service. The most meaningful part is the emotional value generated as a result of this process, which should last far beyond the final product. Through emphasising users’ involvement, multidisciplinary collaboration and interaction, service design is able to effectively address Tongguan’s constraints by generating holistic user experiences, co-creation and long-term value of the product. Firstly, villagers were afraid to deal with outsiders due to long-term poverty and isolation. They needed a platform that empowered them to play the main role as both the users and designers. Secondly, the project was constrained by resources, time and cost. It needed to creatively integrate with the villagers’ daily lives and available resources. Thirdly, rather than forcing the villagers to change their habits to accommodate for the product, the end product had to reflect complex traditional cultural values with new social values, a process, in which the result can effectively recognise the necessity of balancing modernity for progress with traditionalism for security — the notion of the villagers’ wellbeing.
The project’s planning phase began with team members living and interacting with local inhabitants. Through first-hand experience of the richness of the villages’ most original trades and customs, the team set the objective for an outcome that would preserve and promote the village’s tradition and craftsmanship in its purest form. Despite being located on a remote mountain, the volunteers noticed that the village and its environment integrated harmoniously. Every aspect of the village reflected the natural style of the Dong minority that had learnt to adapt and maintain its habits to the surrounding environment. Hand-built houses made of fir wood aligned neatly among crystal clear streams and tree-clad hills. Due to long-term isolation from the outside world, the villagers have developed various types of craftsmanship that have became survival tools for families to maintain their daily lives: building homes by hand, weaving cotton for clothes, crafting silver for jewellery and catching fish for food. Many of these skills and craftworks have been passed down from generations to form part of a collective culture and the people of Dong minority developed a traditional polyphonic choral performance — The Kam Grand Choir — that echoes both their environmental and cultural spirits. It was with these distinctive characteristics in mind that the team shifted its focus from pursuing ideas from external resources to seeking inspiration from the village itself. Through vesting in users’ involvement, many local inhabitants became key players in the team. Team meetings debated the project’s objectives by exploring its possible schemes, suitable location, feasible resource and desirable outcome. It was evident that, whilst the villagers wanted to continue their traditions, they yearned for more exposure with the outside world. Thus, interaction between locals and visitors would become a core context to be capitalised upon, fostering an interdependence. Meanwhile, selecting the project location aimed to minimise its impact on scarce arable land and to integrate with the village’s existing landscape. The team assessed the feasibility of the project by directly engaging locals with construction touchpoint 6-2 37
Villagers’ centre design birds-eye view experience in vernacular buildings. Villagers’ native craftsmanship and accessible regional raw materials could replace modern construction equipment to solve the difficulty of transportation to their remote location. Taking these key objectives into account, the team and the villagers reached an agreement to build a villagers’ centre, which would become a perfect complement to the cultural riches of the village. The villagers’ centre would consist of a group of two- to four-storey timber buildings. It acted as an agent to reflect the unique outcome of service design and serve multiple functions in both the short and long term. Firstly, it would become a craft hub that unites dispersed villagers and their unique craftsmanship. This would also preserve the village’s history by permanently displaying some of the most ancient apparatuses, including farming equipment, hand-made craft works, forestry tools, etc. Secondly, the villagers’ centre would create multiple interior and exterior venues to celebrate local festivities and be utilised as day-to-day socialising spaces for the young and old. Finally, it caters for future visitors who may come to purchase local crafts and explore the village by providing both accommodation and local cuisine. 38
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EVALUATION OF THIS CONCEPT
The decision to build a villagers’ centre was far more than a construction project; rather a sustainable selfsupporting platform that met the short and long-term needs of the villagers. It has potential to generate longterm value far beyond the product itself and innovatively reinterprets the notion of wellbeing for the villagers. 1. Despite their initial hesitation and scepticism, the villagers gradually increased their involvement to become the main drivers of the project design process, reflecting the core essences of service design. Collaboration amongst villagers promoted the collective culture and strengthened the relationships of neighbourhoods and families. 2. The project carefully took advantage of the accessible building materials in the local area, such as stone, wood and bamboo, which have been used for construction in the village over hundreds of years. It not only saved the cost of using external labour and transportation, but also increased the villagers’ knowledge of the ecosystem and sustainable development of their village’s environment. 3. The project provided a resolution to the village’s tangible issues caused by modernisation. It attracted many young adults to return to the village in light of
better outcomes by design Villagers are discussing the structure of the project
new job opportunities in their home environment. Through working with senior villagers during the building process, young adults inherited the traditional building skills of the Dong minority, which otherwise would have been lost to their generation. More importantly, the process helped them witness the richness of their deep-rooted cultures and has caused them to reassess their attitude towards modernisation and commitment to preserving their traditions. 4. Furthermore, the project addressed the villagers’ emotional concerns by reuniting families and providing them with the opportunity to persist traditional characteristics in its means of supporting and protecting family members. The history of modernity in China has been a process of continuous adaptation in which people respond to new social conditions rather than abandoning old traditions completely. In this sense, the design and execution of the villagers’ centre successfully took into account processes that are thought to be important for modernity, and the specific cultural values deemed significant for the villagers. 5. Active participation in the project helped villagers of all ages realise the value of their history, which largely increased their sense of identity and belonging. It helped them revitalise their traditional craftsmanship and techniques through their collective working place and the opportunity to sell their craft works as commercial products in the villagers’ centre. At the same time, it also maintains and protects old traditions through continually encouraging the younger generations to engage with these traditions. 6. The project provided villagers’ with a more certain outlook on the future development of their homeland and therefore more incentive to stay. Its construction and operation creates sustainable job opportunities and by-products related to service, hospitality, entertainment and management. Unlike most other commercially-oriented projects run by external developers, the villagers become the owners and managers of the villagers’ centre. It will significantly improve their living standards and, in the long run, help develop many other opportunities that will be beneficial to all members of the community.
Onsite meeting every morning 7. For local governments and charity organisations, the visible outcomes as a result of service design in Tongguan village will provide an alternative model to help villages facing a similar phenomenon. To address the notion of wellbeing for villages like Tongguan requires understanding the villagers’ needs. Ultimately, the solution must not only account for the visible impacts of modernisation, but also embrace the villagers’ cultural roots and traditional values.
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References 1 Shostack, L. G. (1984). ‘Design Services that Deliver.’ Harvard Business Review 62(1): 133-139. 2 Eiglier, P., & Langeard, E. (1977). Marketing Consumer Services: New Insights. Cambridge, MA: Marketing Science Institute. 3 Normann, R. (2000). Service management: strategy and leadership in service business. Chichester; New York, Wiley. 4 Morelli, N. (2006). ‘Developing new PSS, Methodologies and Operational Tools’. Journal of Cleaner Production 14(17): 1495–1501. 5 Morelli, N. (2002). ‘Designing product/service systems: A methodological exploration’. Design Issues 18(3): 3–17.
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Behavioural Change Through Co-Creation An insight into the ‘MakeMove — Bewegt in die Arbeitswelt’ research project
Birgit Mager is Professor of service design at Köln International School of Design (KISD), Cologne, Germany. She is founder and director of sedes research, the Centre for Service Design Research at KISD.
Jennifer Loser is a designer and research associate at sedes research. She specialised in service design during her studies. She has experience in qualitative research, user-centred design and co-creation.
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Many young people are today suffering from ‘physical activity allergy’, a condition that is proliferating due to new digital lifestyles. The media refer to sedentary lifestyles as ‘the new smoking’, which is having disastrous effects on our health. Hence, there is an urgent need for targeted research into interventions that promote physical activity. An interdisciplinary research team consisting of sports scientists and designers used a service design-specific research approach to provide a holistic insight into the target group’s physical activity behaviour patterns, attitudes and motivations. A physical activity health promotion programme was developed, implemented and evaluated in a parallel top-down and bottom-up approach. This allowed us to evaluate the effect of participative design in this area. BACKGROUND AND OBJECTIVES
The aim of the project is to sustainably improve the individual physical activity behaviour of students who are training for a profession characterised by sedentary work. The main aims are increasing minimal activity rates and introducing more breaks during long periods of seated activities. Vocational colleges are the last opportunity to reach young adults before they commence employment, after which Birgit Mager, Jennifer Loser
they will be difficult to contact. School is the focus for implementing potential concepts aimed at delivering preventive measures to prepare for work life. At the end of the project, it is planned to establish a best-practice platform of successful interventions, which will then be made available to vocational colleges in Cologne, Germany. APPROACH
The cooperation between sports scientists and designers and the application of designbased methods from the area of service design enabled us to adopt an approach that was inspiring for all participants. The design-based, qualitative research approach focuses on exploring young people’s physical-activity behaviour patterns and preferences and on developing interventions to promote physical activity. In the sports science-based quantitative approach, students’ physical activities were recorded before, during and after interventions using activity trackers and questionnaires.
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Regular measurements by using activity trackers take place in all three schools in order to examine and compare the efficiency of the interventions.
Creation process This interdisciplinary qualitative-quantitative approach focused on two aspects: firstly, the general possibility of influencing young people’s physical activity behaviour through interventions in the context of vocational colleges and, secondly, the question as to whether the effect of these interventions is enhanced by co-creation. The design research project cooperated with three vocational colleges: in the top-down strategy used in College A, an interdisciplinary team of sports scientists, designers and teachers developed interventions based on earlier studies, while, in the bottom-up strategy used in College B, the students developed interventions during project work, supervised by an interdisciplinary team. College C served as a control group.
whole site. The points are labelled with QR codes. When scanning the codes with a smartphone, a YouTube video starts, showing exercise instructions filmed by students. The Stay Active Talks are active breaks involving physical activities of a maximum duration of five minutes. Students act as instructors and are responsible for integrating the activities into lessons. For each Stay Active Talk, there is a student who guides the exercise and communicates its
Design probes
CONCEPTS
In the bottom-up approach used at College B, the ‘Stay Active’ concept was developed in cooperation with the students. Its main elements are the ‘Stay Active Talks’ and the ‘Stay Active Parcours’. In the Stay Active Parcours, both the school and its furniture and fittings are converted into exercise equipment. Short, easy activities can be carried out at various points across the touchpoint 6-2 41
Co-creation workshop — the idea-generation was supported by different design tools and games use. The students were trained in a ‘Train the Trainer’ workshop, giving them the necessary knowledge and skills to do the Stay Active Talks. The ‘Stay Active Goes Business’ competition was conceived as an additional incentive to promote physical activity beyond college by motivating students to transfer individual elements of the Stay Active concept to their workplace and motivate their colleagues to integrate more physical activities into their work life. Physical activity breaks were also introduced during lessons in the top-down approach used at College A. In contrast to the method used at the bottom-up college, the breaks were coordinated and guided by teachers. Additionally, at College A, physical education lessons were used for interventions, and, in an eight-week teaching program, there was a different thematic focus each week. Sports scientists from the Deutsche Sporthochschule Köln developed training units that would be easy to integrate into everyday school life and would counteract the risks, both in a preventative and curative way, resulting from lack of physical activity. Besides equipping students with the skills necessary for integrating physical activity into their lives as and when they see fit, 42
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students were also shown different exercise options. In another intervention, motivational and informational slogans were put up in the hallway of the college.1 FIRST FINDINGS
Since physical activity is not of major importance to many young people, their motivation to co-create physical activity-promoting interventions is also limited. In future projects, significantly more time must be attributed to enhance students’ awareness of the importance of this issue. In this project, additional activities, such as competitions and PR work, improved motivation, meaning a high level of extrinsic effort was necessary. In the co-creation process at College B, it became obvious that, besides clear structures and tasks, students constantly needed new impulses because they became easily sidetracked. Concentration, attention and productivity can be guaranteed when new incentives or stimuli are provided on a regular basis. Students basically work in a result-oriented way, but they tend to have difficulties with the process of idea-generation. In this context, design games such as the ‘idea mixer’, where the mixing of gadgets and trend cards promotes associative thinking and supports leaps of thought, proved to be a useful method for getting students to develop new ideas. Left to their own devices, students’ willingness to act and to implement their self-developed interventions was limited. Teachers needed to coordinate activities and remind students to become active. However, when gently
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pushed, students carried out the exercises independently and reliably. They did not use the course in the school building on their own initiative: the course was only used when teachers integrated it into their lessons and when it was used together with the whole class. Publicly exercising in the school building is often stymied by a feeling of embarrassment. Therefore, students found it easier to carry out exercises in small groups. In the Stay Active Talks, the whole class carried out an exercise simultaneously, which resulted in increased participation and success. During long periods of concentration and work, the students from the bottom-up school initiated the physical activity breaks themselves. This could be seen as a first small success. So far, we also know of one student who joined a gym during the project phase. At College A, the design of interventions in collaboration with teachers was significantly more dynamic: motivation was high and both willingness and ability to develop ideas were very strong. The willingness to integrate interventions into lessons, and hence to allow for the necessary time windows, was also very high. Due to the teachers’ strong commitment, the frequency and regularity of implementing interventions were very high. We do not yet have the quantitative results from the three colleges. For the time being, we can formulate the hypothesis that, in the short term, the top-down approach will be more effective, since the implementation of interventions is guaranteed by the teachers’ structuring their lessons accordingly. However, to effect a long-term behavioural change in students, intrinsic motivation must be reinforced. In this context, the bottom-up strategy is seen as the more effective approach. In a next step, the results of readings and observations will be analysed and both students and teachers will be interviewed. The evaluation phase will provide insight into motivators and demotivators and will highlight successes and failures. The findings will then be integrated into the design of the best practice platform.
Interventions to promote physical activity in the school
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References 1
See also Touchpoint Vol. 2, No. 1, “Look Outside the Box”
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‘5% Design Action’: Cancer Screening Service Innovation in Taiwan
Chen-Fu Yang is a project manager at the Industrial Technology Research Institute, a Ph.D. candidate at the National Taiwan University of Science and Technology and the founder of 5% Design Action. Chih-Shiang Wu is a project consultant at the Industrial Technology Research Institute, a Ph.D. candidate at the National Taiwan University of Science and Technology and a co-founder of 5% Design Action. Shu-Shiuan Ho is a Ph.D. candidate at the National Taiwan University of Science and Technology a and co-founder of 5% Design Action. Tung-Jung Sung is a distinguished professor in the Department of Industrial and Commercial Design at the National Taiwan University of Science and Technology.
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Public health service is a complex and highly specialised discipline, which has made it a tough nut to crack in terms of effective service design. Making use of an open and innovative structure, this article aims to share a public health service innovation in Taiwan — an innovative and sustainable design for a cancer screening service — through which we hope to discover how organisations engage in learning and co-creation with their stakeholders. The World Health Organisation1 has predicted that in the next two decades, the number of global cancer patients will rise by as much as fifty-seven percent. Deaths caused by cancer will also rise from 8.2 million to 13 million per year. Cancer has been at the lead of the top ten causes of death in Taiwan for thirty years running. On average, one Taiwanese person is diagnosed with cancer every five minutes and forty seconds. An even more astonishing fact is that the Taiwanese government spends US$1.83 billion on cancer-related treatment a year, which accounts for twenty-seven percent of the total budget of the National Health Insurance system. In fact, more than fifty percent of cancers could be prevented or diagnosed earlier if people led healthy lifestyles and received regular cancer screenings. To increase
the cure rate and reduce the cost of cancer treatment, Taiwan has begun the provision of free-of-charge screenings for oral cancer, breast cancer, colorectal cancer and cervical cancer, but the number of people who have taken up this opportunity has been low thus far, resulting in unnecessary increases in social and medical costs and, despite the good intentions behind the program, placing a great burden on the shoulders of health and welfare policies. SERVICE INNOVATION: A WEAK SPOT IN CANCER SCREENING
Designers have consistently encountered obstacles when trying to introduce innovative ideas into public health services, and the cancer screening service serves as a good example of this in three ways:
Chen-Fu Yang, Chih-Shiang Wu, Shu-Shiuan Ho, Tung-Jung Sung
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Process and concepts of 5% Design Action
First, innovative ideas simply based on user orientation seem to be incompatible with the inherent specialisation and authoritativeness of cancer screening services and, therefore, medical and public health personnel may not be able to implement such ideas. On top of users’ needs and feelings, the validity and legitimacy of the service provider are essential parts of service design. In addition, Taiwan’s cancer screening service involves a wide range of stakeholders, including government departments, medical institutions, and relevant non-profit organisations. Because of this, holistic innovative experience cannot be implemented unless these stakeholders are effectively incorporated therein. Second, public health services are resistant to innovation. Unlike general privately owned business, public services do not face frequent external competition and the pressure to continuously innovate and make breakthroughs. Most public health service personnel offer only one standard option, just like the Ford Model T. The professionalism and authoritativeness that have been established in the health discipline result in people’s firm adherence to specific services. Such adherence is a major obstacle standing in the way of innovation: for example, demanding that physicians with authority to take into account the needs of their patients and their families or persuading hospitals with enormous profits to introduce service design is a task of tremendous difficulty. Third, a certain level of social cost may be inherent in public health service. The National Health Insurance program is a compulsory service in Taiwan, and everyone has the ‘right’ to get cancer screenings, but most people do not realise that such screenings are also somewhat of
an ‘obligation’. The additional medical costs caused by late diagnosis are shared by society as a whole, including those who get regular cancer screenings. This strange form of social inequality needs to be changed by incorporating an innovative model into cancer screening services.
5% DESIGN ACTION: INNOVATION IN CANCER SCREENING SERVICES
‘Social innovation relies not so much on ideas of design as practical design action’. Such is the principle behind 5% Design Action, a non-profit design platform initiated by Taiwanese designers in the spring of 2013. However, in the past, there are few opportunities for many designers to participate in the service development process, even though they are passionate about social issues. As a result, 5% Design Action plays a critical role as being a platform that invites designers and other professionals from a range of fields to pitch in five percent of their free time. Therefore, they can join 5% Design Action with the main service providers and stakeholders to provide their knowledge and professional skills in designing new solutions to societal issues or challenges. Centred around service design, the objective of 5% Design Action is to uncover potential innovation opportunities and solutions, and the platform’s first project was titled ‘Innovating in Screening Services and Cancer Prevention’. The project consisted of five stages: 1. Target 2. Recruit 3. Co-Create 4. Transfer 5. Share touchpoint 6-2 45
non-profit organisations Formosa Cancer Foundation Hope Foundation for Cancer Care Taiwan Breast Cancer foundation Sunshine Social Welfare Foundation
excutive departments
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Taipei City Hospital 12 health service centers in Taipei city
Health Promotion Administration Department of Health. Taipei City Government
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This map could delineate the stakeholders of cancer screening service TARGET
From the very beginning of this project, 5% Design Action wanted the participation of designers with an ambition for social innovation. To cut straight to the core of the problems involved, the platform’s research team started to collect and analyse secondary data, invite relevant stakeholders to take part in in-depth interviews and to construct a network of cooperation. At this stage, the primary goal was to identify problems and focus on producing practicable results that satisfied the needs and conditions of service providers. This goal was achieved through discussion between organisations and experts who had been working in this field. Through these initial results, 5% Design Action was 46
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able to determine reasons behind people’s decisions not to get cancer screenings, including the feeling that they were too healthy, too busy, too embarrassed or too old to get one. At the end of this stage, the objective of this project was agreed upon: to improve the overall cancerscreening experience and increase people’s screening acceptance and participation rates. RECRUIT
After discussing with the stakeholders, clarifying the problems, and agreeing upon the objective, 5% Design Action made the next step forming a cooperative connection with various organisations, including: 1. Government institutions (Health Promotion Administration and Department of Health of the Taipei City Government); 2. Executive departments (Taipei City Hospital and twelve health service centres in Taipei City); and 3. Non-profit organisations (four cancer prevention foundations).
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Designers: Li-Ru Jiang, Pei-Shan Xie, Yu-Hsin Chen, Ya-Hsun Tsai, Chi-Chung Hu
Afternoon tea into the cancer screening service to change people’s preconceptions
At this stage, 5% Design Action recruited volunteer designers with an interest in this theme: a total of eighty volunteer designers were willing to participate in this project, with areas of expertise spanning graphic design, product design, interactive design, service design and fields related to public health. CO-CREATE
In the third stage, 5% Design Action divided the eighty volunteer designers that they had recruited into twelve groups. Each group worked individually in exploring service gaps and innovation opportunities pertaining to oral cancer, breast cancer, colorectal cancer and cervical cancer. The exploration results were discussed by the connected organisations as 5% Design Action sent representatives to the screening sites to observe and interview the people there. Service design inspired 5% Design Action to visualise the needs of ordinary people and service personnel to guide co-learning. It also helped in identifying the core problems in the complicated context of a service system. Moreover, a series of discussions were conducted in the form of workshops and online platforms to develop innovative design concepts and service models. TRANSFER
Near the end of this project, 5% Design Action developed ten concrete-innovative concept designs, such as visualising the cancer screening process to reduce people’s fear of it, establishing brand images that related to the citizens’ lifestyle and promoting cancer screening service through networks of friends, family and neighbours. While the guest designers have returned to their work, the research team continues to exploit the result. Many details and minor modifications still remain to be worked out through discussions with executive departments. After six months of discussion, 5% Design Action is preparing to launch four new services in the third quarter of 2014, and is aiming to continuously innovate in various service procedures.
SHARE
In the last stage, ‘Share’, 5% Design Action yielded results that were not specifically targeted at the design of the cancer screening service, but rather for the co-learning and co-creating ‘process, as a cooperation between designers from a variety of fields and related participating institutions. The course of this project has also been made into a documentary2, in an effort to systematically accumulate and transfer knowledge or to create new values in the future built on the existing foundation. In 2013, 5% Design Action also organised a premiere and a conference built around the project documentary, inviting people from important organisations related to cancer. The premiere was a huge success, attracting social and media attention, as well as constructing a channel for communication between cancer screening service providers. Furthermore, 5% Design Action developed a design thinking toolkit for training healthcare personnel. With the toolkit and the results of this project, more people will be able take part in service innovation in cancer screening. In addition, this project was invited to share its results and findings at the 2013 National Cancer Prevention Conference, in which more resources were expected touchpoint 6-2 47
Designers: Yu-Min Chen, Hsiao-Wen Wang, Cheng Tsao, Chung-Min Wang, Yi-Jia Li
This innovative idea delivers cancer information to parents through their children, gaining an awareness of the cancer by creating cartoon figures and co-operating with schools to be provided for 5% Design Action in the future, and the phrase ‘innovation in cancer screening services and cancer prevention’ was adopted to convey to healthcare experts the value of service design. DISCUSSION AND CONCLUSIONS
5% Design Action has been developing service innovations for cancer screening and other healthcare issues. Given the results and findings of this project, we have come to the following conclusions, provided as a reference for others working on the practical side of service design: Co-seeing, co-learning and co-creating Empathising with users may be important for good service design, but designers and service providers must respect each other’s professions and attempt to communicate from each other’s perspective. A superior service design involves a long dialectical process, by which attractive, practicable solutions 48
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can be co-created. This faintly echoes the “collective impact” proposed by Kania and Kramer (2011). Complex social innovation should not be confined to a closed system of thoughts involving only one area or unit. Interdisciplinary observation (of demands and problems), learning and action are the only solution for applying comprehensive thought and innovation to a service system. The crucial role played by nonstakeholders Innovation is far from a new thing to both the organisations and the personnel involved in cancer screening: the problem is that competition and dependent relationships within the ecosystem have led to a lack of communication and cooperation. Organisations would rather be described as being ‘responsible’ than invest effort in finding ways to improve the service experience and increase screening test-participation rates. In response, the designers of 5% Design
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Action engaged this problem from the angle of the non-stakeholder: they provided assistance to these responsible organisations in implementing feasible innovations. This approach, surprisingly, increased these organisations’ willingness to cooperate. This is similar to the concept of the “free agent”, as developed by Kanter and Fine (2010). They believed that, in the social networking era, free agents will be regarded as necessary promoters of social innovation and design through crowdsourcing. Recording, accumulating and re-creating knowledge The average tenure of a public health nurse in Taiwan who performs cancer screenings is 2.7 years. This high turnover has obstructed the passing on of experience. To accumulate results for long-lasting participation, a documentary was made about this project, and the premiere and events established an interdisciplinary platform of dialogue. Moreover, 5% Design Action has summarised its research findings, as well as the demands and perspectives of users and of executive departments, for the purpose of educational training. It even produced ‘innovative ideas cards’
All participants attended the documentary premiere of 5% Design Action to accumulate knowledge and continue encouraging the output of innovative ideas in a systematic way. With the experience and knowledge acquired from this project, 5% Design Action expects executive departments to get acquainted with the ideas behind the methods and values of service design and to gain innovative energy from inside their organisations. In addition, design can be introduced to more healthcare areas, thereby co-creating more innovative solutions and opening up more valuable opportunities.
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References 1 Kania, J., & Kramer, M. (2011). ‘Collective impact’. Stanford Social Innovation Review, 9(1), 36-41. 2 Kanter, B., & Fine, A. (2010). The networked nonprofit: Connecting with social media to drive change. San Francisco, CA: Jossey-Bass.
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Exciting Times to be in Healthcare
Across the world, there is a realisation and understanding that existing healthcare systems will not deliver what the future requires. The World Economic Forum estimated that, unless current trends reverse, chronic diseases will cost the world $47 trillion in treatments and lost wages by 2030.1 At a time when healthcare finances are so constrained whilst demands are increasing, the need to design more effective solutions is self evident. Healthcare providers seem to face clear choices: they can work towards containing healthcare spending by restricting services, or request often-overworked staff to work even harder. Alternatively, of course, they can seek to think differently about the way they deliver their services using available resources and design fundamentally different service innovations. But not only is this harder to do, it also brings more risk than working with existing process parameters because whole-service innovations are more complex and likely to question existing organisational boundaries, or to challenge current healthcare management. This, let’s face it, is a scary prospect for 50
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some. And yet, we know that simply removing unwanted variation and non value-added activities from existing healthcare processes won’t deliver the more significant quality and productivity gains we need. While the economic realities of current healthcare models tell a different story, we are starting to see compelling signs of change against some of the unsettling healthcare challenges. The NHS responded by creating its own ‘Change Day’ and School for Health and Care Radicals, two frontlineled movements designed to inspire and mobilise staff, patients and the public to collaboratively improve health and care.2 Despite slow governance processes, a multitude of health, lifestyle, wellness and social tools are also being developed for the healthcare industry. As designers, in this context we are
presented with a great chance to help healthcare leaders create and embrace new service innovations and develop services that are poised to improve health outcomes in the long run. Rather than viewing future predictions as overwhelming obstacles, healthcare leaders and entrepreneurs are starting to see a landscape full of opportunities by focusing on some emerging healthcare themes:3 EMPOWERED PATIENTS
Equipped with more knowledge about their conditions and lifestyles, citizens are starting to take a key role in determining when they interact with the healthcare system and how their care is delivered. New services are emerging to help empower patients with technology and to provide access to social communities and peer-to-peer advice before visiting a professional. As a result, patients will be better prepared to communicate with their doctors during consultations to ensure optimal health outcomes and treatment plans. The Healthtap4 start-up offers an online service that lets you instantly connect with a clinician via the net and ask personalised
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medical questions to help diagnose common conditions professionally and quickly. It is reported that more than 7 million people visit the site each month, trading questions and answers with a pool of about 46,000 doctors. MORE JOINED-UP CARE
Healthcare providers are starting to use new technologies, social platforms and data systems to streamline the way information is spread across organisations to deliver a more personal and consistent model of care. Secure online platforms are offering new ways for doctors to share research and advice about conditions that fall outside of their expertise, while analytics tools interpret patient data to support diagnosis. Digital platforms have evolved to facilitate communication between doctors, patients and staff, ensuring that patient records and treatment plans are readily accessible and cutting down internal inefficiencies. The NHS Hack Day5 aims to understand some alternative models for procurement within health technology and brings together healthcare and technology professionals to improve NHS IT. Patients Know Best6 lets patients and clinicians easily access medical records that would typically be trapped in siloed IT systems. It gives patients anytime access to their medical records and to doctors who may be located across the world, and can, for instance, interpret blood tests remotely. NUDGING BEHAVIOURS
New tools and incentives are being designed to improve decision making about personal healthcare and treatment options by promoting more proactive models of health and by helping people better track and understand their day-to-day behaviours. Mobile technologies provide deeper insights and individualised coaching to activate users around wellness and exercise. New feedback loops often encourage users to make small behavioural changes over time. Early outcomes show healthier citizens less reliant on public resources.
Sherpaa7 provides patients and businesses with 24/7 access to doctors over the internet to stem rising healthcare costs and to provide more personalised patient care. Online consultations are designed to resolve health concerns quickly and conveniently, whilst companies' healthcare spending is analysed to suggest ways to save money, boost benefits and to expand coverage to more employees. Across the globe, we can see early adopters acknowledging some of the emerging healthcare themes and creating alternative services that have the potential to make the wider system more resourceful. This presents an exciting new paradigm and framework for designers to work within too, where healthcare is seen as an ongoing conversation between people, rather than something that happens when someone falls ill.
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References 1 http://www.weforum.org/news/non-communicablediseases-cost-47-trillion-2030-new-study-releasedtoday 2 http://changeday.nhs.uk and https://changeday.nhs.uk/healthcareradicals 3 http://www.psfk.com/publishing/future-of-health-2014 4 https://www.healthtap.com 5 http://nhshackday.com 6 http://www.patientsknowbest.com 7 https://sherpaa.com
Julia Schaeper is head of service design and patient experience at IC/Health (http://www. ideacouture.com/health/). With extensive experience in healthcare and service design, her work focuses on using design methodologies to address big healthcare issues and to develop new services that make a real difference to people‘s lives.
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better outcomes by design
Backpack PLUS A comprehensive toolkit to empower community health workers
Community health workers (CHWs) are often referred to as the ‘last mile’ of healthcare delivery in resource-challenged communities around the globe, but while their impact and value has been widely proven, their crucial role is still often questioned by the larger healthcare system. UNICEF and the MDG Health Alliance commissioned frog to develop a concept for a comprehensive toolkit that could empower CHWs to do their job more efficiently and ultimately deliver better quality care to their communities, hence saving more lives. Designed as a holistic ecosystem that reconceives public health strategies as an integrated suite of products and services, Backpack PLUS offers a systemic solution to meet the daily and long-term needs of CHWs. The vast majority of the seven million children who die every year in the developing world never see a doctor or visit a clinic in their lives. They often rely instead on Community Health Workers (CHWs), who are a critical link in delivering basic health services to underserved populations. Every day, this dedicated — and largely volunteer — network of CHWs visits patients, helps screen for life-threatening diseases and dispenses medication, often with little training or support.
Widely recognised as one of the biggest untapped resources in global health, in almost every low-resource country where they are present, CHWs lack support and resources. They often lack regular training sessions, suffer from sporadic access to crucial medical supplies and their efficacy is undermined by fragmented data management systems. “The whole system is really fragmented, we need to find a way to harmonise things better.” — UNICEF regional director, Senegal Fabio Sergio, Chiara Diana, Roberta Tassi
Fabio Sergio is vice president of creative at frog. He is globally responsible for frog’s social impact activities, leads the firm’s experience-strategy practice and is one of frog’s healthcare experts.
Chiara Diana is creative director at frog. She is one of frog's experience-strategy leads, with deep expertise in communication, interactive and service design, and a focus on complex productservice systems.
Roberta Tassi is principal design researcher at frog Milan, where she leads the research practice with a focus on how visual tools can facilitate user participation and support system thinking.
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Participatory Design — Kiboga, Uganda
Backpack PLUS toolkit in use
UNICEF and the MDG Health Alliance asked frog to develop a comprehensive solution to empower and activate CHWs to do their job more efficiently and to improve the quality of health service provided to the communities they serve. The goal was to define an integrated set of tools, commodities, processes and related services — across physical and digital touchpoints — to enable a well-orchestrated experience for CHWs and their patients, especially children. Such a multi-faceted challenge required the project to focus in parallel on multiple layers of intervention. 1. Define a reference strategic framework to gather best practices, assess gaps and align partners to scale up existing and future CHW initiatives. 2. Design an integrated system of physical and digital tools to empower and activate CHWs, improving the quality of the healthcare services they provide. 3. Create an emblem to be used by the public health community for advocacy and large-scale fundraising. METHODOLOGY & PROCESS
The complexity and systemic nature of the challenge forced an integrated approach to design, making Backpack PLUS a relevant example in terms of combined adoption of human-centred innovation processes, collaboration and engagement models and multidisciplinary methodologies. 54
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The team relied on a Human-Centred Design process to shape solutions for CHWs that were based on a deep understanding of their day-to-day experience and real-world, longer-term needs. To this end, the project included extensive field research in Uganda and Senegal with CHWs and local experts, but also leveraged the extensive domain expertise of over sixty organisations (Gates Foundation, WHO, USAID and BRAC, amongst others). In addition to ethnographic research methodologies, the team engaged CHWs directly through the use of participatory design & rapid prototyping techniques, to iteratively shape and refine solutions together with their intended end-users in the intended context of use. As a complement to the direct involvement of CHWs in the design process, the project included a sequence of co-creation workshops in the US and in Africa with a large group of local and global public and private-sector partners. These multi-disciplinary workshops were used to review and discuss insights gathered during the various research phases, but also to collaboratively refine all the various elements of the Backpack PLUS toolkit. The engagement and collaboration of such a large group of partners ensured bottom-up support of the toolkit, but also guaranteed real-time dissemination
better outcomes by design Design Research Activities — Mpigi District, Uganda Second Project Workshop, discussing emerging opportunity areas — Kampala, Uganda
of the outcomes of the project, a goal that was also supported by live reporting of research activities and by the publication of the entire documentation produced during the project. SOLUTION
The Backpack PLUS solution is comprised of a set of strategic frameworks brought to life by enabling services and products. Together they define a strategy for the ideal experience that community health workers should be provided across the various key phases of their journey: from recruiting and training, to service delivery, to rewarding and upgrading. Backpack PLUS is unique as it places CHWs at the centre of the health ecosystem, rather than on the periphery, often as a marginalised extension of the doctors and nurses who typically receive most of the investment in health care. Designed as a holistic system, the Backpack PLUS toolkit includes key physical, digital, and service-level components. It departs from the current disconnected set of diagnostic tools and medical commodities and brings together strategic intervention frameworks, packaging, informational materials, decision-support tools and mobile services into one well-orchestrated experience for community health workers that integrates and reinforces their workflow.
Backpack PLUS radically improves the current inflexible solutions for storing and carrying supplies. It combines a large modular box for long-term home storage of supplies with a lightweight backpack with easy-to-access compartments and pockets for specific tasks like patient assessment and treatment, in addition to data logging. Backpack PLUS also dramatically improves communications between the CHW and other healthcare stakeholders, including patients and CHW supervisors, with innovations such as streamlined assessment tools and redesigned drug packaging that includes disease-specific colour-coding and consistent age-range indicators. Adding mobile tools to Backpack Plus further extends its ability to augment traditional paper-based information, letting CHWs upload patient information, receive reminders and restocking alerts, take refresher courses and access educational materials for the communities they serve. As the veritable ‘glue’ holding all the individual pieces of the system together, Backpack PLUS also includes a strategic framework that maps out the essential physical, digital and service-level components as they relate to the different key actors in the health ecosystem. The framework evolved across the entire length of the project and was both iteratively enriched and simplified based on evidence from the field and input and feedback from experts and partners. touchpoint 6-2 55
Backpack PLUS strategic framework
Backpack PLUS toolkit overview 56
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The power of giving graphic tangibility to the invisible connections and relationships that characterise complex systems of people, products and services cannot be overstated. All along its various graphic representations, the Backpack PLUS framework enabled the team to have rich and meaningful conversations with country-level, regional and global stakeholders, instigating informed discussions, building over time a common understanding of the opportunity area and ultimately driving alignment among key players in the CHW ecosystem. Once in its final expression, the Backpack PLUS framework was useful in remapping current CHW programmes, showing misalignments and possible improvements, and promising to potentially become an effective reference to help map and deploy future CHW programmes. The framework is ultimately intended to be an evolving tool that will help countries and organisations compare, map and assess existing CHW programmes, and also plan for future interventions, reinforcing the centrality of the role CHWs play for all key stakeholders. Backpack PLUS interventions will also be easily identifiable, thanks to a unified and easily recognised emblem. This symbol can become a tangible expression of the integrated system bringing together its tangible and
intangible components, a quality seal across the elements of the toolkit and its future extensions and a strong recognition of the value of CHWs and the essential role they play in their communities, but it will also be used to support advocacy and large-scale fundraising. IMPACT
Recognising Backpack PLUS in its ‘Breakthrough Innovations that Can Save Women & Children Now’ initiative (path.org/innovations2015 ), PATH described it as an inexpensive system that could help reduce the annual death toll of 6.9 million mothers and children under the age of five. A first pilot test of some of the key components of the toolkit is planned to take place in Uganda in 2014, thanks to the interest of the local Ministry of Health and to the continued support of organisations like UNICEF.
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References and details about the design solution frogdesign.com/work/backpack-plus-toolkit.html unicefstories.org/model/chwbackpackplus/ chwplus.tumblr.com/
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Human-Centred Mental Wellness Discovering touchpoints before a service encounter
Peter Jones is an associate professor at the Faculty of Design, OCAD University, Toronto. Jennifer Robinson is a clinical director at the OCAD U Health and Wellness Centre, Toronto. Andrea Yip is a research coordinator at the OCAD U Health and Wellness Centre. Karen Oikonen is a graduate student in the Strategic Foresight and Innovation MDes program, OCAD U. Adam Starkman is a graduate student in the Strategic Foresight and Innovation MDes program, OCAD U.
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North American universities have proactively supported student mental wellness, to facilitate their educational mission to successful graduation. Campus mental-health services are typically delivered today within an on-campus health and counselling setting focused on traditional medical and counselling treatment approaches. Our research went beyond the normative model of clinical service, into the experience of students seeking wellness resources. We discovered today’s students seek a more responsive relationship to health services, influencing our approach to designing for ‘soft service moments’. At Toronto’s OCAD University, a faculty-led student research team conducted a human-centred service design study over 3 phases: 1) Discovery and Research; 2) Design and Mapping; and 3) Prototyping and Implementation. The discovery field research observed the clinical setting at OCADU’s Health and Wellness Centre (HWC), conducting structured observations, interviews and focus groups with staff and students, to understand current health services and client-service interactions. Through ethnography, participatory design and system mapping, we developed a rich understanding of the
student experience and potential points of improvement. We discovered opportunities for the HWC to engage students on their own terms that might intervene in advance of seeking help. SERVICE REDESIGN RESEARCH
Our research uncovered experiences preceding a service encounter, to formulate a student orientation to wellness services. A service redesign was proposed following this field-level research. A blueprint of the current HWC service defined a starting point (Figure 1). Interviews with six student clients and further observations of five staff and providers followed. We produced a current service journey and
Peter Jones, Jennifer Robinson, Andrea Yip, Karen Oikonen, Adam Starkman
better outcomes by design
Referral HCP, staff, faculty
Phone
Online Website Email Social media
help seeking
Outreach Events, fairs
OCADU health and wellness centre flow arrival
Talk Friends, staff, relatives, faculty
triage
counseling sessions
leave or transfer
follow-up
Walk-Ins Crisis
identified provider improvements, including service workflow, the receptionist’s role, improved client forms and interaction and website enhancements. The service redesign process led to some early achievable outcomes. After studying the HWC work environment and roles, initial service enhancements were proposed, ranging from room layout and campus location to specific contributions of providers and coordination and communication methods. While campus location was not immediately implemented (plans are underway), the process design led to a walk-in counsellor service, where counsellors rotate their availability for short, immediate appointments. Students said the ability to see a counsellor immediately, even for a few minutes, was extremely beneficial. Providers noted these short introductory sessions helped align clients with counsellors and led to rapid development of meaningful counselling relationships. While we did not conduct a service evaluation, participants reported the essential clinical service model to be very effective for student counselling. Only minor workflow enhancements were recommended, aside from the on-call counselling . The most significant discontinuities in the student’s experience were related to the physical environment of the centre, the rooms, layout and facility. The interior redesign proposals were allocated to phase 3 (Implementation) for an integrated final design.
Figure 1. Mental Health service workflow or illness. Yet the vast majority of student experience relevant to mental health happens well in advance of seeking counselling, and this inaccessible experience usually remains unknowable to providers. Dialogues from workshops and groups supported this emerging student experience. From interviews and dialogues held with students and community representatives, we developed findings from four service perspectives: Societal, Psychological, Institutional, and Student. SOCIETAL
Mental health is a critical public health issue at the national level, as supported by evidence from healthcare, economics and workplace health and safety. For instance, one in five Canadians will experience a mental health concern in their lives, and related outcomes cost the economy over $50 billion. Canadian mental health in general was criticised for being an ‘old school model’ focused on efficiencies, lacking sensitivity to cultural difference and structured around medical diagnosis and treatment. Participants argued that mental health is complex and systemic, implicated with all personal health modalities (physical, emotional, spiritual). Simplistic linear response systems were found to be inadequate. Instead, a cultural shift of practice was called for, requiring people everywhere to recognise a responsibility to care and to respond locally and nationally.
STUDENT PERSPECTIVES ON MENTAL WELLNESS
The most critical (and dynamic) participant in the mental-health social system is the client, the student seeking help. The provision of mental-health services depends largely on a person becoming aware of their perceived need for help in coping with life stressors
PSYCHOLOGICAL
The psychological perspective offered a focus on the individual and their interactions with the world. Participants noted that individuals struggle with mental health issues in isolation, and highlighted the importance touchpoint 6-2 59
Figure 2. Student Personas of social networks in sharing relevant experiences and getting support. The creation of online resources, virtual help networks and peer support and therapy groups were mentioned as strategies to help reduce isolation and increase people’s connectedness to their social environments. Mona
First Year Undergrad Student Bachelor of Fine Arts, Drawing and Painting
Mona moved from Lindsay, Ontario which is about an hour North-East of Toronto to attend OCAD University. Throughout high school Mona enjoyed drawing and painting and had always done really well in her art classes. Her parent’s weren’t particularly supportive of her choice to enroll in “art school” but agreed to let her try it for a year. Mona knew of one other girl who had gone to OCAD U but really didn’t have any friends when the semester started. Her aunt lives in Richmond Hill but that is at least 45 minutes from campus. Mona poured her heart and soul into her first projects but after getting her first set of marks and critiques she felt that her instructors and peers unfairly tore her apart. She felt defeated, depressed and worried that her parents would make her drop out and come home. After a couple of weeks of not eating or sleeping Mona and her new friend Marcus walked into the Health and Wellness Centre and asked to see a doctor.
Olivia
Second Year Graduate Student Master of Fine Arts, Criticism & Curatorial Practice
ur ghout d weren’t ol” but
Olivia and her husband moved to Toronto from Halifax, Nova Scotia when she got accepted into the Master of Fine Arts in Criticism & Curatorial Practice Program at OCAD University. Olivia had worked at the Art Gallery of Nova Scotia for about four years and saw the program as an ideal opportunity to elevate her career to the next level.
but . Her s from
Just before graduating from undergrad Olivia had been diagnosed with borderline personality disorder. While in Nova Scotia she saw a few different psychotherapists, and for the most part was doing very well managing her symptoms.
t after er eated, drop
Lately however Olivia and her husband have been fighting a lot, and he noticed that she seems more depressed. Olivia agreed that it was becoming more and more difficult to manage the extremely demanding course work and her parttime job.
nd her Centre
With her husband’s encouragement Olivia reached out to the Health and Wellness Centre to inquire about how to find a Cognitive Behavioural Therapist in Toronto.
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INSTITUTIONAL Olivia Second Year Graduate Student The university’s structural, political, and cultural design has Master of Fine Arts, Criticism & Curatorial Practice an implicit influence on the perception of mental health. One Olivia and her husband moved to Toronto from Halifax, Nova Scotia when she got accepted intothat the Master of Fine Arts creates in participant noted “structure culture.” An active Criticism & Curatorial Practice Program at OCAD University. Olivia had worked at the Art Gallery of Nova Scotia for about student participation in university decisions was deemed four years and saw the program as an ideal opportunity to tonext ensure elevatenecessary her career to the level. inclusion of their voice. A ‘wellness approach’ was considered crucial tohad promote mental health holistically, Just before graduating from undergrad Olivia been diagnosed with borderline personality disorder. While in Nova creating and supportiveandenvironments, understanding the root Scotia she saw a fewsafe different psychotherapists, for the most part was doing very well managing her symptoms. causes of wellbeing and working from a clear values base Lately however Olivia and her husband a (e.g., empathy). Thesehave arebeen keyfighting factors to fostering a stigma-free and lot, and he noticed that she seems more depressed. Olivia agreed open that it was becoming more and more difficult to culture. manage the extremely demanding course work and her parttime job.
STUDENT With her husband’s encouragement Olivia reached out to the Health and Wellness Centre to inquire about how to find a Student health seeking Cognitive Behavioural Therapist in Toronto.was a central
theme gleaned from research. The need was expressed for the university to actively attend to and to appreciate their campus experience. Several factors were quite significant: • Generational shift: today students face unique challenges and participate and communicate with peers using social media and text channels • Student participation: student participation in planning and decision-making was considered a critical means of acknowledging their experience and their voice. Students advocated for grassroots change-making, challenging traditional top-down decision-making models • Support networks: student networks (e.g. teachers, staff, friends and family) are critical social support systems. Peers were noted as especially valued, to meet students at their level of relationship BRINGING THE STUDENT EXPERIENCE TO LIFE
While no persona sample adequately represents trends or issues across Canadian universities, a new service model must define situations and drivers of responses to mental healthcare. Two personas (Figure 2) were selected to highlight unique issues encountered in art and design schools that make a difference for the service moments provided within pre-clinical stages.
better outcomes by design Figure 3. Student Mental Health-Seeking Journey lack of awareness
uncertainty
Current State
isolation
access to services
Higher State of Anxiety
Proposed New Interventions
#mentalhealth HWC Pop-ups with supported materials
Reimagined online portal with FAQs Use of Facebook & Twitter Resources for Tips & Strategies
Reduced State of Anxiety Mentorship Peer-to-Peer Program Group Workshops
build greater
facilitate better
create increased
awareness
understanding
connection
ENGAGING STUDENTS IN HEALTH-SEEKING
A four-stage service journey (Figure 3) integrates our evolving hypothesis of service moments mapped to actual student concerns and psychosocial needs. The health-seeking journey identifies stages of initial engagement to empowerment. The stages of Awareness, Understanding, and Connection suggest interventions as well as internal encounters faced by the student. At each stage one resolves (or fails to resolve) a continuing and increasing level of intra-personal stress related to internal and external anxieties. (More serious crises or illness patterns are not considered here). A relative anxiety scale (1-10) at the Health and Wellness Centre entry point indicates the level of cumulative anxiety associated with the student’s presentation at the clinic. • Awareness: awareness of one’s experiential state and available services can reduce anxiety. Awareness results from the quality and accessibility of messages and resources in the campus and social environment • Understanding: online accessibility is important for the current generation of students, who rely on mobile media to navigate concerns before risking time or anxiety with formal channels. Online access enables understanding, and poor accessibility may be associated with higher uncertainty, significantly adding to stress • Connection: peer support, both through social media and in groups, helps resolve isolation and self-concern
access to services
and reduces experienced stigma. An increase in connectivity can mitigate anxiety and help a student determine their course of action • Health & Wellness Centre: at the point of access to the HWC, the student should experience significantly reduced anxiety and concern. The stages also correspond to the standard behavioural change model: Contemplation (Understanding), Preparation (Peer Support), Action (HWC) and Maintenance (HWC continuity). This model enables designers and clinicians to align the student’s level of awareness and anxiety to available service moments. The service map reveals a type of sociopsychological system, of the inner journey of the student related to their campus and social environments. While some immediate service revisions have been made already (such as the on-call service), the Implementation stage is underway to design communications and a student-peer web presence to enable self-informing in advance of counselling. There are corresponding service engagements that satisfy the information and interpersonal demands at each stage, related to campus awareness, network development and community support. This approach affords a wider range of possibilities for reaching health-seekers to help them recognise the value and support from any mental health services.
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Handshake designed by Sam Garner from thenounproject.com
welcome to the HWC
Promotional Posters
Designing for a Child’s Experience of Clinical Rounds A participatory design challenge
Amy O’Keefe is a service design instructor and associate director of Northwestern University’s Masters of Engineering Design and Innovation Program. Sarah Rottenberg is a lecturer and associate director of the University of Pennsylvania’s Integrated Product Design Program. Ann Giese is a paediatrician at Northshore University Health System Division of Paediatrics. Amy Schwartz is a portfolio director at IDEO. Julia Benini is a senior design researcher at IDEO. Joseph Hageman MD is an emeritus attending paediatrician at Northshore University Health System and director of paediatric resident research, Pritzker School of Medicine, University of Chicago. Sally Hageman BSN RN CPN is a paediatric nurse at the Ann and Robert H. Lurie Children’s Hospital of Chicago. Monica Joseph-Griffin is a paediatrician at Northshore University Health System Division of Paediatrics.
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In the life of a hospitalised child, each day brings different challenges, hopes and fears. However, once a day, something unique happens: a team of physicians, residents, medical students, nurses and specialists visit the child’s room. Those visits, called family-centred medical rounds (FCR), are crucial opportunities for conversation between the patient, the family and the medical team that determine the course of the patient’s medical care. Aside from the patient, all participants of this critical exchange are adults. In the United States, such rounds last on average 8.7 minutes per visit. In those brief minutes, where the room is filled with parents’ questions and the medical team’s discussions, how might we benefit the most important actor of the conversation: the child? To answer this question, we brought together a participatory design team of design innovation graduate students from the engineering schools of two top-tier U.S. research universities, healthcare practitioners, parents, children and professional designers for a weekend design challenge. We focused on understanding hospitalised children’s perspectives and improving their experience during rounds.
In a period of just 24 hours, our team gathered insights, brainstormed, prototyped and tested services, products and interactions that encourage shared experiences between young patients and the medical staff. The students designed tools and methods to give children choices, control and alternate communication methods, encouraging them to be more active participants in conversations during rounds. This case study shares the process, tools, insights and impact this brief experience has had on the students’ perspectives and the medical team’s interactions with their patients. We also explore how minor changes to the rounding experience might influence paediatric patients’ experience, well-being and satisfaction.
Amy O'Keefe, Sarah Rottenberg, Ann Giese, Amy Schwartz, Julia Benini, Joseph Hageman, Sally Hageman, Monica Joseph-Griffin
better outcomes by design
Testing prototypes in the mock hospital room MEDICAL ROUNDS: UNDERSTANDING THE PAEDIATRIC
PARTICIPATORY DESIGN: STAKEHOLDERS IN FAMILY-
PATIENT’S PERSPECTIVE
CENTRED ROUNDS
The practice of family-centred rounding is a recent innovation in paediatrics. Prior to 2003, hospital rounding often took place in conference rooms or the hallway outside the patient’s room. Separate from the patients in their care, the medical team discussed patients and generated plans to be implemented by the doctors and nurses. In general, children and families were not involved in decision-making or care delivery. Dr. Joseph Hageman, Paediatrician at the Pritzker School of Medicine, University of Chicago, recalls those days: “Whether we rounded in a conference room or at the bedside, we did not involve the family until a care plan was in place.” As with many innovations in healthcare, FCR adoption has been slow. Over the past decade, less than half of in-house hospital paediatricians have adopted FCR, with estimates of 44% of hospital physicians in the United States regularly using FCR in 20141. In practice, FCR has increased the number of participants in the rounding process. The typical team includes an attending physician, resident physicians, medical specialists, medical students and nurses. The healthcare team visits patients and families, discussing each patient’s diagnosis and plan at the patient’s bedside. This format encourages parents and patients to participate in creating a treatment plan that works for the medical team as well as the patient and family.
Given the complexity and brevity of the FCR exchange and the relatively unexamined perspective of young patients, we thought family-centred rounds would provide opportunity for innovation and would make it a rich topic for our participatory design challenge. Our interdisciplinary design team included three paediatricians, two paediatric residents, one paediatric nurse, two healthcare designers, four innovation design instructors, 39 engineering, design, and innovation graduate students and a number of children and parents who had experience with health-related services or hospitalisation. Participatory design is central to teaching and practice in both Northwestern University’s Engineering Design and Innovation program (EDI) and the University of Pennsylvania’s Integrated Product Development program (IPD). However, most medical professionals aren’t predisposed to think of their patient interactions as a topic relevant to design. Not only is the participatory design format unfamiliar to physicians, the qualitative nature of the design process contrasts with quantitative innovation and testing standards in the healthcare domain, where randomised controlled trials can take years to develop and are considered the goldstandard of scientific evidence. touchpoint 6-2 63
Students interviewing Dr. Joseph-Griffin during Stakeholder Speed Dating
Testing prototypes with children
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TEAM ASSIGNMENTS: PATIENT PROFILES
THE 24-HOUR DESIGN CHALLENGE: EMPATHY IMMERSIONS
We assigned each of the design innovation graduate students to one of 10 teams. Each team was composed of students trained in human-centred design in graduate programs at Northwestern University and the University of Pennsylvania. The teams were multidisciplinary, with diverse talents in interaction design, product engineering, industrial design and service design. The teams also had gender balance. To encourage focus and diversity of insights, each team was assigned a specific patient profile: • Frequent admission young patient (ages 4-11) • Frequent admission adolescent patient (ages 12-18) • First-time admission young patient (ages 4-11) • First-time admission adolescent (ages 12-18) • Paediatric patients without adult or family participation in their care
AND RAPID ITERATIONS
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We set up the weekend challenge, bringing together graduate students from two universities, so our students could work with professionals to address a real-world problem and experience the significant ways in which a focused, fast-paced participatory design exercise can dramatically impact design outcomes and participants’ perspectives. Our first evening began with an inspirational keynote from Yuri Malina, a founder of SwipeSense, a point-of-care hygiene and analytics start-up that began as a human-centred Design for America student project and has since been recognised as a finalist in the Wall Street Journal’s 2013 Start-up of the Year competition. After we presented the design challenge, students gathered in groups of four and were introduced to the practice of FCR: its actors and their current challenges, as well as physical and space-related requirements. The remainder of the evening, half of the students replicated a patient room using foam-core, drawings and found materials while the other half of the group researched the history, origins, practice and patient perspective on FCR. The following morning, students interviewed stakeholders, including medical professionals and children
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and their parents participating in the weekend challenge, in a two-hour ‘speed-dating’ format. This exercise put students on the physicians’ shoes by mimicking the dynamics of the family rounds. Then, student teams spent several hours synthesising their findings, brainstorming and ideating with the support of stakeholders. In the afternoon, students spent three hours prototyping ideas and gathering feedback from children and their parents on several small, rapid iterations. At the end of the second day, each team presented their insights and prototypes and received feedback from the design challenge participants. This 24-hour design challenge jump-started future enhancements to the hospital’s FCR engagement with paediatric patients. After just one day, students and practitioners had prototyped ideas, using low-fidelity mock-ups, role-play and video that now represent a foundation to new, comprehensive, thoughtfully designed service touch points within FCR. THREE METHODS FOR ADDRESSING HEALTHCARE RESEARCH CONSTRAINTS: A DOSE OF CREATIVITY
In order to design for FCR, students needed to rapidly develop empathy with all FCR stakeholders and develop an understanding of the needs of the child. Students also needed to develop an appreciation for the context and constraints of the hospital environment, as well as for healthcare practitioners’ roles and motivations. Finally, students needed to experience the limited space of the patient’s room in FCR’s overcrowded time. All with the goal of recognising each stakeholder has different priorities in those precious minutes together and understanding potentially competing needs and goals of the medical professionals, parents and especially of the young patients. 1. Building the Context for User Testing: Replicating Hospital Rooms Onsite observation in a patient’s room would not have been feasible for a group of 39 design students. Limited patient access and patient privacy constraints required an alternative approach to design research. Students
created low-fidelity mock-ups of a hospital room and a paediatric ward playroom based on photos. Mocking up the space where FCR happens was instrumental to our design efforts. The mock-ups informed and inspired the entire participatory design team throughout the design process, from research, to prototype, through evaluation and iteration. By using the mocked-up spaces, students experienced what it feels like to be lying in a bed surrounded by adults and their complex, confusing conversations. The space served to reiterate the importance of context. It also encouraged participants to embody their roles and convey emotional needs and concerns, as if they were on actual rounds. 2. Stakeholder Speed-dating: Rounds Reversed During a two-hour ‘stakeholder speed-dating’ session, each student team spent 10 minutes interviewing 10 FCR stakeholders, including a sample of physicians, residents, nurses, patients, parents, children and healthcare designers. With only two minutes in between interviews, students and stakeholders experienced key elements of FCR: the intense information exchange, the critical need for team integration and open communication and the sheer exhaustion that comes with interviewing, synthesising and developing a course of action at such a rapid pace. The health care professionals also found themselves on the opposite side of the rounding experience: they became the focus of teams’ questions as teams researched, discussed and coordinated a course of action. Some patients and parents were interviewed in advance to maintain anonymity. Their views were represented by the student-interviewers during the ‘speed-dating’ rounds. Interviewing multiple healthcare practitioners and families with hospitalisation experience helped students understand the context and the roles of physicians, residents and nurses in FCR. Stakeholders’ true stories, often loaded with emotion, gave students a window into paediatric patient needs. touchpoint 6-2 65
doctor fills out doctor‘s card
kid and parents receive the doctor draw gift
kid meets with the doctor
parents read doctor‘s card to the kid; kid draws a picture of the doctor
3. Real Reactions: Participatory Design with Children Children of different ages and varying experience with healthcare were invited to participate in the design process as users. Children equally participated in the interviews, design, and testing as well as any other stakeholder. Our students experienced for the first time how shy children often are when meeting an adult for the first time. Students witnessed children being pulled out of their shells as they explored simple prototypes and communication platforms together. They also experienced participant’s becoming quickly overwhelmed by overly complicated prototypes. This empathy exercise had a significant impact on the design and design outcomes. One of the students noticed: “When testing our prototypes, we soon realised that four college students just walking in the room was uncomfortable for a lot of the children and we got little reaction to our prototypes because of it. We used this observation to simplify our solution to focus on the initial interaction, rather than try to solve everything.” Participating in the design process positively impacted children as patients, too. An adolescent participant stated: “It was great to be at the centre of this project, the design students were interested in my hospital experience and worked hard to come up with ways to make future experiences better: they really listened to me.” 66
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One of the concepts tested with the children was Dr. Draw, a service designed to lessen anxiety and encourage children and physicians to communicate personal interests and attributes by drawing pictures based on descriptions of doctors read aloud by parents. Descriptions of the doctors might include such personal information as: “Dr. Z wears glasses. She loves to take her golden retriever, Jemma, to the beach.” The children were encouraged to draw pictures of both the doctors and themselves to hang in their rooms. The act of sharing personal information and expressing individual interests through drawing gave the patients a foundation for building an inter-personal relationship with the doctor on more equal terms than the FCR format generally supports. After being introduced to the concepts, one 5 year-old patient said: “That was fun!”. An 8 year-old patient volunteered other situations in which the tool would be valuable when meeting other grown-ups in professional environments, such as meeting a principal or a new teacher. The feedback positively influenced the designers: “When we tested Dr. Draw with the children, their reactions were priceless. Not only did they like drawing, but they couldn’t stop smiling.”
better outcomes by design ‘Doctor Draw’ designed to build relationships between the paediatric patient and the physician
DESIGN OUTCOMES: CONTROL, CHOICE AND COMMUNICATION METHODS
The design teams proposed solutions that focused on addressing a few main themes that emerged in their research. For the younger age groups, design solutions focused on creating relationships and offering alternate means of communication during FCR. For the adolescentage groups, solutions largely focused on offering choice and control during FCR. The idea of creating shared experiences became very important across all ages and resonated strongly with the FCR stakeholders. In response to one solution that involved using photo business cards with personal statistics on the back, one physician said: “As I have watched you present solutions, I have realised how many very personal questions I ask my patients and their families and how little they know about me. I love the idea of making the FCR conversation reciprocal and sharing a bit about myself with my patients.” BENEFITS OF THE SHARED EXPERIENCE
While the design challenge provided a tremendous opportunity for students to practice human-centred design, the participating healthcare practitioners also had an overwhelmingly positive response to the experience. Physicians at NorthShore University Evanston Hospital are in the early stages of implementing versions of several design concepts from this design challenge to use with hospitalised paediatric patients. According to Dr. Hageman: “Had we started working with humancentred designers like these energetic, intelligent students 30 years ago, our approach to engaging with children and their families would be much more refined and our communication skills much improved over where we stand today.”
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References 1 Mittal VS et al. Family-centered rounds on pediatric wards: a PRIS network survey of US and Canadian hospitalists. Pediatrics, 2010;126(1):37-43.
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Service Design for the Other 98%
Melanie Wendland is director of service design & innovation at M4ID, a social enterprise providing innovative communication and service design for the health and development sector. Melanie leads M4ID’s expanding global innovation portfolio and brings service design thinking to some of the most challenging issues faced by under-served populations, especially women and children, in the world today.
M4ID is a Helsinki-based social enterprise whose mission is to reduce social inequalities and improve access to health care in low-resource settings through innovative communication and service design. In January 2014, M4ID launched the Better Outcomes in Labor Difficulty (BOLD) initiative together with the World Health Organisation (WHO). The BOLD project, funded by the Bill & Melinda Gates Foundation, seeks to research and design a set of new tools and services to support health workers in providing appropriate care during childbirth and to increase demand for respectful, quality care among communities in low-resource settings. EVERY TWO MINUTES A WOMAN DIES GIVING BIRTH
Even today, having a baby is still the leading cause of death among young women globally. Every day, almost 800 women die in pregnancy or childbirth. Every two minutes, the loss of a mother shatters a family and threatens the well-being of surviving children. Of the hundreds of thousands of women who die during pregnancy or childbirth each year, ninety percent live in Africa and Asia. Ninety-eight percent of these deaths are preventable. Pre-eclampsia, a disorder characterised by high blood pressure and an elevated level of protein in the 68
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pregnant woman’s urine, and post-partum haemorrhage, severe bleeding after birth, are the two main causes of death for pregnant women or women giving birth in low-resource settings. Unsafe abortion and infections due to poor hygiene practices are other leading causes of maternal mortality. In high-income countries, these life-threatening health conditions are almost fully eliminated thanks to modern antenatal check-up services and facilitybased deliveries. However in Sub-Saharan countries, like Nigeria or Uganda, these conditions persist, especially for rural and poor women. Millennium Development Goal 5 (MDG 5), improving maternal health, set
Photo by Reima Rönnholm
better outcomes by design
Labour room at a hospital in Uganda
A rural hospital in Uganda
the joint targets of reducing maternal mortality by 75% and of achieving universal access to reproductive health by 2015. But, so far, progress in reducing mortality in developing countries and in providing family planning services has been too slow to meet the targets. RESPECTFUL AND APPROPRIATE QUALITY OF CARE IS RARE
This two-year service design project is the first of its kind to be undertaken under the WHO’s leadership that addresses these issues through a human-centred design approach. There is an abundance of academic research that has documented the social, economic and geographical challenges in tackling maternal morbidity and mortality. Hospitals are crowded, understaffed, far away and with infrequent access to drugs and supplies. Staff are under immense pressure due to resource constraints, are at times unskilled and unmotivated due to a lack of reward and retention schemes. Abusive and disrespectful behaviour by health care providers towards women in labour
is common in many of the high mortality and morbidity countries. On the other hand, cultural norms, harmful traditions and superstitions related to giving birth influence a women’s perception of facility-based delivery and care. And, last but not least, in many of the lowestincome countries, giving birth at home without the help of anyone is considered honourable and a way for a woman to show strength. SHIFTING PERSPECTIVES AND BEHAVIOUR USING A HOLISTIC APPROACH
Rather than analysing single bottlenecks and challenges in the delivery and demand for quality maternal and newborn care, the service design project seeks to understand the complete journey of a pregnant woman from the community to the hospital and back. This involves looking at the women’s perception and experience, influences and decision-making within the community, as well as the perspective of the facility as a service system and its stakeholders. touchpoint 6-2 69
/ Perceptions of pregnancy and childbirth / Resource availability and access
/ Influence of sociocultural context and care experiences on decision-making / Perceptions of quality of care
pregant woman care provider / Perceptions of community behaviour and practices / Incentives and motivations for behaviour change / Design driver for SELMA
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The women’s journey This approach, with a complementary health facility and a community level component, is unique and has the opportunity to transform maternal and newborn health: at the health-facility level, the WHO will carry out research to develop a new model for a digital, simplified labour-monitoring and action tool. This tool will redesign the partograph, the paper-based tool currently in use to monitor the progress of labour and to support decision-making. The usability of this tool will also be one of the key tasks for the service design team to design and develop. In parallel, M4ID will, together with community groups and care providers, design novel solutions that will seek to address, among others, community information access, transport issues, health facility reception and respectful care provision from the woman’s perspective. 70
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The solutions that will be developed in to final, testable service prototypes will be selected by the project’s steering committee, comprised of the world’s leading academic and medical experts, representing all regions of the world. The final set of tools will then be piloted and tested across multiple, low-resource countries over the next five years. REMOTE RESEARCH AND CO-DESIGN
The twelve-month, initial service design process for this project has been adapted to fit the challenges in various ways. During the desk research, an extensive review of existing academic literature and expert interviews were conducted to create a hypothesis for the field research. At the beginning of May, M4ID went on an initial preparatory trip to Uganda to meet stakeholders and to establish collaborative relationships with the facilities, community and innovation partners.
better outcomes by design
Design of solutions: From rapid prototypes to minimum feasible level prototypes that can be tested in the field with real users
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Gathering of data: / In-depth interviews / Direct observation / Shadowing / Design workshops
The team was able to get an initial picture of the challenges that facilities, staff and women face. A main goal of the trip was to bring onboard a local research partner who would function as a local anchor, guiding and supporting the work from a cultural perspective, as well as supporting the service design team in remote research to gather insights during time spent outside the target country. Based on these initial insights, the service design team will plan a research and codesign phase on site. The service design team will spend time in the facilities and communities, conducting interviews with staff, stakeholders and women and carrying out observations and shadowing with staff and community workers. During the co-design, the team will, together with women and staff, come up with ideas for solutions and build quick prototypes to test them in the context. As a doctor in a Ugandan facility noted:
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Developing prototypes together with target users: / In-depth interviews / Workshops / Field testing kit
The iterative design process
“Communities may have the ideas and know solutions to their problems but lack the opportunities to communicate and realise them.” Solutions will be refined after testing and fleshed out in a detail design phase before testing and codesigning the final prototypes on site. With this exciting project just having started, the service design process itself is a hypothesis to be tested and refined along the way. FOLLOW AND GET INVOLVED
If you want to follow the service design project check in at boldinnovation.org If you want to get involved in helping to shape digital activism to advance women’s health worldwide, join our Facebook group for Mimba, where we share our progress and call for help in designing a digital-activist platform to advance women’s health issues worldwide.
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Tools and Methods Service design techniques, activities and deliverables
Differentiating Touchpoint Experiences the Cheap-andCheerful Way For most organisations, designing touchpoint experiences that resonate with customers and communicate their brand is a costly endeavour. Yet, differentiation does not necessarily have to be expensive. Stephan Engl works as a senior human-centred design consultant at Swisscom in Switzerland. Positioned at the intersection of customer experience, branding and strategy he pilots new approaches to service design. He recently developed and cofounded the Customer Centricity Score www.ccscore.com, a KPI for organisational maturity, and he regularly blogs at www.stephanengl.com.
The global economy is shifting towards an experience-based economy in which customer experience itself becomes the product. Thus, many organisations strive to orchestrate touchpoints that differentiate their customer experience from those of their competitors. This often results in additional development and implementation costs for both service design and branding projects. We believe that it is possible to create differentiated touchpoint experiences without additional costs by reallocating resources to those aspects of the experience that really matter to your customers and to your organisation’s brand. Therefore, at Swisscom, Switzerland’s biggest telecommunications provider, we set out to pilot this belief by creating a ‘Touchpoint Dashboard’ that shows us where to focus resources at our bricks-and-mortar shops. COMBINING DESIGN RESEARCH AND TRADITIONAL MARKET RESEARCH
We started by figuring out what customers actually experience during 74
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their visit to Swisscom shops. Using service design research methods, we gathered over 100 individual customer journeys through observations and qualitative interviews. They covered everything that customers did and experienced before, during and after their shop visit. From this basis, we synthesised a generic model of the overall in-shop experience and its various aspects. We grouped and labelled these into different stages that the majority of existing Swisscom customers might experience during a shop visit, regardless of the purpose of their visit (the ‘trip mission’). This model shows how every single aspect of the shop experience performs. We used it as a basis for a quantitative survey by asking customers to rate their satisfaction concerning the different aspects of the shop experience on a scale from 0 (not satisfied) to 10 (fully satisfied). We also enquired if they accomplished their trip mission and grouped the results in two different line charts (see Touchpoint Dashboard).
tools & methods
Product demo and explanation at a Swisscom shop
The main purpose of the survey was to find out which aspects of the shop experience turned out to be more important than others. That is why customers also had to rate their overall satisfaction with the shop experience, as well as their perception of the Swisscom generic brand attributes and the touchpoint-specific brand attributes in the shop. By running statistical models for those three dimensions, we were able to compute correlations with each of the twenty-eight aspects of the shop experience and ranked them with colour coding from 1 (high correlation) to 28 (low correlation) at the bottom of the Touchpoint Dashboard.
Customer exploring handsets at a Swisscom shop
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aspects of aspects the experience
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correlation o each aspect f witof h… correlation each aspect with...
overall customer satisfaction overall customer satisfaction attribute s generic generic brandbrand attributes
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3 RESULTS
Most of the different aspects of the Swisscom shop experience score high on the customer satisfaction ratings: a testimony to Swisscom’s on-going focus on customer experience, yet a somehow undifferentiated experience that is costly to maintain. So where might opportunities lie for differentiation by reallocating resources? Seating accommodation (1) scores the lowest of all aspects concerning customer satisfaction. Should Swisscom improve its seating accommodation? Does that aspect really matter that much to customers and the Swisscom brand? It has a low correlation with overall customer satisfaction and brand attributes. So it seems acceptable to have an average, or below average, experience with seating accommodation. We should not focus too many resources here and instead reallocate them to aspects that are more relevant for our customers and the Swisscom brand. One of those aspects is the shop agent’s commitment to the customer’s ‘trip mission’ (2). It reveals strong correlations with overall customer satisfaction and brand attributes. Hence, we should make sure that this not only remains a positive aspect, but also becomes a highlight of the shop experience. 76
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1 Unfortunately, the results are not always as clear and uniform as with the two examples above. For instance, appearance (3) hardly correlates with overall customer satisfaction. It does, however, demonstrate medium correlation with the generic brand attributes and high correlation with the touchpoint-specific brand attributes. Removing resources from this aspect of the experience would most likely not impact customer satisfaction in the short run, but might undermine Swisscom’s brand perception in the long run. On the other hand, product demo and explanation (4) shows a strong correlation with customer satisfaction, but only a medium-to-low correlation with brand attributes. Cutting resources here would probably have an immediate negative impact on overall customer satisfaction, but not so much on brand perception. So, if you want to differentiate your shop experience further, which of the two last-mentioned aspects will you take resources away from — accepting that its performance might decrease — and reallocate them to the other aspect, thus trying to create another distinctive highlight of the shop experience? Which one would you favour and why?
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tools & methods Swisscom Shop Touchpoint Dashboard: for reasons of confidentiality, aspects not covered in this article are blurred out
product demo and explan ation
buy & exit buy & exit
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commitment to customer's trip missi on
commitment to customer's trip missi on
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Legend line chartline chart Legend trip mission trip accomplished mission accomplished (N=689)(N=689) total (N=825) total (N=825) trip mission accomplished (N=136) (N=136) trip not mission not accomplished Legend correlations Legend correlations 1
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22 22 WHAT WE LEARNED
We have found that the Touchpoint Dashboard is a suitable instrument to identify aspects of and discuss opportunities for differentiation with decision makers. At Swisscom, the Touchpoint Dashboard is now used by Swisscom’s company-wide shop management team for reviewing existing activities and aligning new ones related to the shop experience. As we highlighted in this article, those aspects of a touchpoint experience that have a high or low correlation with both customer satisfaction and brand attributes are easy to differentiate by reallocating resources. However, those aspects with differing correlations are a bit trickier to handle, yet they can help to facilitate discussions about the specific relevance of brand attributes and customer satisfaction related to touchpoint design. Still, there are some limitations inherent in the method presented here. It primarily supports differentiation of existing aspects of a touchpoint experience, but does not indicate which new aspects to add to the experience or what exactly to change about existing ones. Working with correlations, one should keep
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medium to strongto correlation medium strong correlation 1 weak weak correlation 28 correlation
in mind that they do not imply causality. It is important to cross-check correlations with the rich insights gathered during service design research. Service designers can use those insights as an inspiration for changing or adding new aspects to the touchpoint experience that the method itself cannot reveal. There are vast possibilities to further extend and improve the approach that we have presented. One area of interest could be the tracking of cross- and multichannel touchpoint experiences. Another might revolve around the integration of, and correlation with, more business-related data. As a community committed to service design, let’s further develop and compare Touchpoint Dashboards such as this in order to get a better understanding of how to effectively differentiate touchpoint experiences the cheap and cheerful way.
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Capture User Experiences as They Happen Using smartphones to gain user insights
Robbert-Jan van Oeveren is partner at Koos Service Design. During his work, he spotted the opportunity to introduce the smartphone platform to user research and set out to create such technology. Contextmapp™ is aimed at driving the innovation process with more relevant insights, in less time and with greater efficiency.
The advent of mobile research provides radical new opportunities in the field of user research. Smartphones allow us to capture data that is both real-time richer in content, bringing us closer to the moments when and where experiences actually happen. While some organisations have been active in the field of mobile research for several years, it is still not being implemented across the mainstream. However, smartphone and tablet penetration has risen to seventy-five percent in developed countries, paving the way for mobile research to become a serious alternative to some more traditional methods. Mobile research offers several advantages: • Whenever, wherever: users wake up and go to bed with their smartphones giving us constant access to their daily lives, anywhere they go, at any time. • Rich data: smartphones allow us to collect all kinds of data like video, audio, photos, quotes and images, reflecting the diversity of the user’s life. • In-situ data collection: capturing the defining (true) moments as they happen, instead of hazy memories after the fact. • Metadata: smartphones automatically provide us with valuable metadata such as time, duration and GPS locations. This combination of users’ active and passive feedback (data and metadata, respectively) blurs the traditional line
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between qualitative and quantitative data. • Real-time monitoring: progress is monitored in real-time, allowing a leaner and more dynamic process — the learning comes faster. The nature of smartphones means that they are currently best suited for capturing bite-sized responses, instead of extensive, detailed feedback: users are not likely to engage for more than a few minutes at a time. Whilst mobile research participants won’t give long, drawn-out responses, it is possible to keep ‘checking in’ and to capture feelings and behaviour over a period of time — weeks, for example — as opposed to more traditional research, which relies on spending an hour or two with a respondent, or an evening at most.
tools & methods
Create an assignment While mobile research is still in its infancy, new functionalities will open up new opportunities and applications in the future. The question is: where does its application harness the best results? To date, we have found that our mobile research platform, ContextmappTM, yields excellent results in the following three types of user research. • Mobile diary studies Use it as a sensitiser, or as a stand-alone explorative study to capture behaviour over extended periods (e.g. the course of a week) and uncover the ebb and flow of user needs. • Customer journey research Let people map their experiences and gain direct insight into their needs throughout the customer journey; discover how they experience a brand’s touchpoints. • Explorative product and service research Zoom in on people while they are preparing a meal, consuming media or installing a digital television set. Get a detailed impression of their lives using photo and video, all the while saving time by not having to actually be with the respondent.
Respondent making an assignment
A PRACTICAL LOOK AT CONTEXTMAPP TM
The work that we have done for Philips Kitchen Appliances nicely brings to life the benefits of using mobile technology. The goal of the research was to find out which kitchen appliances people were using: which ones they liked best; why they preferred these; how they were using them; and the overall context in which they used them. In pursuit of this, a group of people were asked to participate in a mobile diary study, over the course of a week. With studies like this we usually invite between fifteen and thirty people. It is not a hard and fast rule, but we find that this ‘sweet spot’ allows enough insight to bring some robustness, without beginning to be overwhelmed by the volume of data. However, in this particular case, we built a landing page and asked, via Philips’ Twitter account, for people to join, which led to forty-five completed diaries. The research was prepared using the ContextmappTM dashboard. Our dashboard enables one to easily setup research projects by creating several assignments. These assignments consist of a set of questions: open, multiple choice, multiple image (e.g. a set of emoticons) or ratings/sliders and photo, audio or video tasks. Depending on the type of assignment being created, types of question can be chosen, as well as the statement to be reviewed. In the case of Philips, we posed suggestions like: ‘Take a picture of the ingredients of your meal’ and asked them questions touchpoint 6-2 79
Research data
such as: ‘What kitchen appliances do you like best and why?’ Automated push notifications helped respondents remember to complete assignments at the right moment. As soon as the project was live, users were asked to complete assignments on their smartphones. Participants could choose the order of assignment in the way that suited them best. Results were uploaded immediately, allowing both us and the client to have real-time monitoring of progress. In other, more linear, projects, we could set a particular order of assignments or it could be a set of repeatable assignments, allowing for self-reporting. As soon as the first participants finished, the hunt for interesting insights started! The online dashboard gives two options: ‘Export Data’, which results in a downloadable Excel and folder with media files, or ‘Visualise Data’, which offers three choices: • A chronological timeline, where all results are plotted. It is a visual representation of the journey of the participant, which we call ‘experience storyboards’, 80
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enabling a dive deep into one person’s story • A selection of results, which can be made in any format. Questions are chosen and the results are visualised for all participants, which makes it easy to compare differences between participants • Search for results, enabling one to find all results that contain a certain keyword, like ‘blender’ or ‘irritating’ The research Philips conducted helped them to create a segmentation based on cooking behaviour and pinpointed particular needs and problems, per segment. The team from Philips was particularly excited about the richness of the data. As the client said: “It was good to not only get the answer, ‘I’m cooking pasta’, but to also be able to see what kind of pasta it was, whether or not the person cut the vegetables themselves, the kitchen they were preparing it in, and so on. We got answers to questions we didn’t ask!”
tools & methods
SIX MOBILE RESEARCH PRINCIPLES
Along with Phillips, we have conducted many similar projects and, in doing so, learned a great deal. Based on our experiences, here are six research principles: simple guidelines that help you set-up your project, should you be interested in doing so. 1. Make it fun! Using visuals, gamification elements and a light tone of voice helps to enhance the experience and thus engagement of the participants: creating a place where they can be creative helps to get more out of them. 2. Fit around the user’s life Try to anticipate and understand how the research fits into the life of the user; smart usage of push notifications and timely reminders can help people remember to participate in a way that is also convenient for them. 3. Improve and test Always conduct the research upfront yourself. You’ll find that some questions and assignments are best asked differently. Iterate, then iterate again. 4. Ask ambiguous questions Ambiguous questions allow your participants to fill in the assignment as they see fit. This way, you will get the answers that really matter to them, as opposed to steering their answers in a certain direction. 5. Monitor progress See who is on track and help slower respondents if needed. This is far better than a cultural-probe exercise being completed just before the actual interview takes place, as we have sometimes experienced using traditional methods. 6. Visualise results Use the rich data that you have gathered. It helps you during analysis to understand needs and behaviour, it inspires during ideation and concept development and it convinces clients, because they can literally see what is going on.
Altogether, mobile research is an area in rapid development, where a lot of (technical) innovation is still to be expected. Think about text mining, smart algorithms, automatic face and image recognition, integration of ‘iBeacons’, co-research and automatic data processing and visualisation. And we haven’t even mentioned wearables, such as Google Glass. We’re entering an exciting new time, where we don’t think of people as simply consumers, but as collaborators in the design process. We have built our mobile tool with that philosophy at its centre. And although we’re not fully there yet, we have learned a lot and keep learning more every day. And improving. And learning. And improving. We’re interested in getting in touch with other agencies that want to share or gain experience with mobile research.
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Learning to Look: Design in Health Services Research You can find a home for service design in existing research in health, if you know where to look.
Helen Sanematsu is assistant professor in visual communication design at Herron School of Art and Design, Indiana University. Helen uses methods from design research and communication design to facilitate bi-directional communication in community engaged health research.
Sarah Wiehe is a paediatrician and public health researcher in children’s health services research at Indiana University School of Medicine, codirector of the Community Health Engagement Program, Indiana University Clinical and Translational Sciences Institute, an affiliated scientist at the Regenstrief Institute for Health Care, and adjunct associate professor of geography and public health.
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Since 2006, the voice of the patient in healthcare has been supported by a pronounced effort from the United States federal government in the form of two major initiatives in clinical and translational science and patientcentred outcomes research (PCOR). Both provide significant funding to academic research institutions to advance health, with patient and community perspectives in mind. Design can, and should, play a pivotal role in these projects. At the Indiana University School of Medicine, we are currently working as a service design research team at the centre of a large, five-year, five-million dollar grant from the Agency for Healthcare Research and Quality (AHRQ, a division of the U.S. Department of Health and Human Services). Our involvement in the grant, while highly unusual when viewed from the health sciences perspective, is a relatively routine application of service design methodology. A lack of understanding between the two fields threatens to maintain a gulf of practice despite holding fundamental principles in common. We hope that by sharing what we know about the frameworks for test Sanematsu, Sarah Wiehe Helen
health research, what the role of design is as exemplified in this grant, and what distinguishes design from conventional research methods in health services, we will help illuminate the potential for other designers to contribute to this important pillar of health improvement in the US and elsewhere. FRAMEWORKS FOR HEALTH SERVICES RESEARCH
Design research finds a place in the agendas of both translational research and patient-centred outcomes research and in the approach indicated by community-based participatory research. PATIENT-CENTRED OUTCOMES RESEARCH
(PCOR) The aim of patient-centred outcomes research is to help people make informed healthcare decisions and improve the quality of healthcare. The Patient-centred Outcomes Research Institute, established in 2010 as part of the Affordable Care Act, is the primary source of support for this area of research in the United States (pcori.org).
education & research Parents of children with ADHD identified a desire to participate in the study and found the discussion group setting its most compelling aspect. They also expressed that while they would welcome learning about the study during regular office visits, they did not want to be approached first and preferred to initiate discussion themselves.
The sixty clinical and translational sciences institutes (CTSI) across the US are another recently established area of study that could from the application of design.1 Charged with accelerating the pace at which medical discovery moves from the Ivory Tower to application in clinical settings and beyond, the Institutes were established in 2006 and explicitly call for increased community engagement in research.
methods and protocols to make them more relevant to patients, while maintaining scientific rigour. Our core consists of one paediatric health sciences researcher, one project coordinator, and three design researchers. We meet with the principal investigators of the studies to learn about their study aims, participant recruitment strategies, and data collection methods, then work as a team applying concepts from service design to optimise patient experiences.
COMMUNITY-BASED PARTICIPATORY RESEARCH (CBPR )
HOW WE WORK
Community-based participatory research (CBPR) aims to make research more impactful through intense and long-standing collaboration between researchers and communities. In CBPR, communities are engaged in research from the initial formulation of research questions through all stages of the research process through to dissemination. CBPR measures the quality of research in the community using twelve well-established measures ranging from “Recognising community as a unit of identity” to “Involving systems development using a cyclical and iterative process.” (Minkler 2012)
For our work on the study on attention-deficit hyperactivity disorder (ADHD), we held two patientdiscovery sessions, discussion groups that used drawing and mapping as key means of learning about the experiences of patients through the experiences with their parents (we hope to conduct a patient-only session in the future). Our sessions focused on study recruitment and study measures. As a result of our sessions, we both developed study materials that let the parents learn about participation and its benefits of the study at their own pace, an aspect of study communication that was prioritised by our participants, and improved a reporting worksheet — a one page touchpoint between the parent and the doctor that represents a binder-full of educational handouts and resources — by making it more user-friendly, tailored to the study, and inclusive of the ADHD patient. For the first time, the patient themselves is provided an opportunity to connect with their doctor using a common format with their parent. Also notable
TRANSLATIONAL RESEARCH
DESIGN’S ROLE IN HEALTH-SERVICES RESEARCH
The AHRQ grant funds the Center for Pediatric Comparative Effectiveness Research at the IU School of Medicine, which in turn provides the infrastructure for four separate studies in paediatrics, and four specialised ‘cores’ that provide services to those studies. The patient engagement core is tasked with helping tailor study
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is that our design research uncovered new indicators of patient improvement, what we term ‘patient measures’, that are being incorporated into existing surveys because they add to our understanding of how ADHD works and how it impacts patients lives and the lives of their families. (See fig 1 brochure and 2 reporting sheets) WHY USE DESIGN IN RESEARCH?
We might distinguish design research from conventional quantitative research methods in health services by the qualitative nature of its findings, or because its tools (in our case, highly interactive discussion sessions and, ultimately, sessions that involve co-design and rapid prototyping) leverage the expertise of study participants in ways that exceed standard expectations for study participation. Viewing patients as partners in research — in a way similar to how non-designers participate 84
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on-par with designers in co-design — directly ties our work to the principles of CBPR, which hold parity and shared inquiry between researcher and research subject as its highest priority and patientcentred outcomes research, in which the patient supplants the illness as the focus of scientific inquiry and health improvement. The key distinction between design research methods and non-design research is the ‘design deliverable’, which makes manifest research findings and provides a focal point for further investigation. Synthesising findings into designed solutions also provides a platform for interaction that is
education & research
ADHD treatment chart expansion. The standard treatment chart tracked medications above other forms of treatment such as behavioural therapy and school services. Our new chart demonstrates the desired state of a four-armed treatment including the addition of parenting techniques. It pairs with a separate chart for ADHD patients so they may reflect on their day with their parent. This additional chart validates the patient experience while empowering patients in relation to illness and treatment.
more accessible than conventional means of research dissemination, such as journal publications and that directly addresses research application and patient relevancy. Other studies in health produce design as an outcome within different frameworks (Zender, 2011) and, in some places, an application-driven, user-centred process is utilised at scale, but in public services rather than research contexts. (House of Commons report) In our contributions to health services research, solutions (design deliverables) at the end plant the seed for the next study and put the results of the current one into immediate application. Designed deliverables add a concrete outcome of patient relevancy to the end of the research process and align our work with the objectives of translational science by speeding up discovery to application. CONCLUSION
The inclusion of the patient-engagement core in the Center for Pediatric Comparative Effectiveness Research is evidence of a growing interest in the potential of design when applied to health services research. While the ultimate impact of our work remains to be seen and we have only worked on two of the four studies at the Center, we have added measures to the evaluation of ADHD through our work, and have modified existing study materials according to patient (and doctor) needs. In the process, we have engaged three patients so far to participate at an institutional (IU School of Medicine) level on protocol development that has implications for the entire School. Design research processes and design deliverables result in tangible outcomes in health services that have direct bearing on health improvement. Frameworks exist to support design in health services. Designers who would like to extend their practice into health services research can find a place there if they look for it.
ACKNOWLEDGMENTS
The authors would like to acknowledge the members of the patient-engagement core for their exceptional work: LaToy Brooks, project coordinator and to Dustin Lynch and Courtney Moore, designers. Thank you to the Investigators at the Center for Pediatric Comparative Effectiveness Research, Nerissa Bauer, William Bennett, Maria Finnell, Tamara Hannon, Vaughn Rickert and Dorota Szczpaniak. Aaron Carroll is the principal investigator. This project was supported by grant number R24HS022434 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.
•
References 1 ncats.nih.gov/files/factsheet-ctsa.pdf — indianactsi.org Minkler M, Garcia A, Rubin V, & Wallerstein N. 2012. Community-Based Participatory Research: A Strategy for Building Healthy Communities and Promoting Health Through Policy Change. Berkeley, California: University of California PolicyLink, School of Public Health, UC Berkeley Zender M, Brinkman W, Hartl J, Rawe L, Meylo M, Fearing MC, Shi G, Stuckey R, Pang F, Han Y. 2011. Design Collaboration in Medical Research: Designing Doctor-Patient Interaction. Delft, The Netherlands: Proceedings of IASDR2011, 4th World Conference on Design Research, October 31 — November 4, 2011. TUDelft, 2011. House of Commons Public Administration Select Committee, UK. User Involvement in Public Services, Sixth Report of Session 2007-8, 24 April 2008.
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Shaping a New Service Design Programme The Service Systems Design Master in Copenhagen
Nicola Morelli is professor MSO at the Department of Architecture, Design and Media Technology (AD:MT) at Aalborg University. He has contributed to the development of programmes of education and research in service design.
Amalia De Götzen is assistant professor at the department of AD:MT, she will coordinate the Service Systems Design Master.
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The growing interest in service design calls for specific education programs, at a moment in which the framework for the discipline itself is still under construction. Service design represents a quite complex domain: a service design education should include insights from management, systemic thinking, design techniques and should propose their application based on concrete case studies. This represents one of the main challenges in planning an educational programme in service design. This article describes the structure of the Master in Service Systems Design at Aalborg University in Copenhagen, with its aims and its challenges. The growing interest in service design calls for specific education programs, at a moment in which the framework for the discipline itself is still under construction. Service design represents a quite complex domain: a service design education should include insights from management, systemic thinking, design techniques and should propose their application based on concrete case studies. This represents one of the main challenges in planning an educational programme in service design. This article describes the structure of the Master in Service Systems Design at Aalborg University in Copenhagen, with its aims and its challenges. Nicola Morelli, Amalia De Götzen
The Service Systems Design Master programme at Aalborg University (AAU) started on September 2012 with the idea of focusing on the systemic approach and a more holistic view of services. This programme is held in Copenhagen and attracts international students with different backgrounds. AAU’s general teaching approach is based on Project Based Learning (PBL). This approach tends to create strong links between theoretical and methodological contexts and practical problems (Kolmos 2004). According to this approach, teachers are facilitators in a process that support the students’ ability to develop their own learning strategy.
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Figure 1. System maps and service journeys. First semester project by August Grube, Jonas Rauff Mortensen and Linnea Forss The programme consists of three teaching modules (5 ECTS1) and one project module (15 ECTS) per semester. The teaching modules are meant to provide the fundamental theoretical and methodological knowledge, whereas the project module is an opportunity to apply this knowledge to a practical problem. In each semester, the complexity of the problem to solve is succinctly described by the semester’s general theme. In the project module, companies or institutions propose project areas in which the students will work to generate solutions. The programme is offered by the Faculty of Engineering and Science at AAU, which means that the technical aspects related to the discipline of service design will be stressed. This explains the strong presence of technical subjects, such as programming and distributed systems. This also implies a broader perspective of service design, including the study of methods and tools to analyse and design both the front office (touchpoints, interaction, user experience) and the back office (systems organisation, workflows and business flows).
THE PROGRESSION
The programme is structured on the basis of a progression that gradually increases the dimension of the design problems. In the first semester, the student is introduced to service design. Here the focus is on different aspects of services, including technical aspects, aspects related to user interaction and on design methodology. Teaching activity is supported by a wide literature review of case studies and theoretical contributions on methods and tools that refer to those aspects (Polaine and Løvlie, 2013, Stickdorn and Schneider, 2011). The title of the semester, ‘The Craft of Design’, suggests that students are introduced to service design as pupils were introduced to the craftsman’s workshop, to learn the state-of-the-art methods and tools to touchpoint 6-2 87
business strategies scale up reproducibility industrialisation
organisation programming
social innovation large scale service
user participation co-creation
interaction single instance
prototyping ethnography
blueprints use cases
service journey narrative
Figure 2. Map of the logical and dimensional aspects of the Service Design Master design a single service. The first semester looks at the ways designers can create a specific instance of a service (e.g. how a local restaurant can personalise its meal service), possibly starting from a product (e.g. a hospital bed, a bus stop) and looking at the system around it. The title of the second semester, ‘Services as Systems’, introduces a new level of complexity: services are analysed as configurations in which technical, social and design aspects form systemic structures (e.g. the way services can coordinate informal or formal resources in a city). The problem to solve, for the student at this level, is about integrating those aspects, while refining methods and tools that address technical and userrelated issues. The third semester, titled ‘The Business of Services’, adds the strategic 88
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and business-related dimension of service design. Here, the students place service design in a business context and focus on organisational aspects, including reproducibility of services, scalability, modularisation, competences and strategies. Finally, the fourth semester is dedicated to the integration of the acquired knowledge in a final project. NAVIGATION MAPS
The main progression suggested at the beginning of this paper, based on logical progression from craftsmanship to industrial services, can be articulated in further layers that consider the different dimensions of service design, from a technical dimension to social aspects. A map of such aspects, like the one shown in Figure 2, would provide a logical and visual framework of the curriculum of the programme. However, different other dimensions (e.g. experience/aesthetic vs. organisation) may also apply to the body of knowledge for this master. Given its complexity, the discipline of service design would suggest different possible interpretations.
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While this may be considered as a limitation, because it would make it hard to provide a clearly defined profile for the master, it could also be seen as an advantage, because of its capability to provide a wide range of professional profiles that address a diversified demand for competences within the area of service design. The problem-based learning (PBL) approach is also contributing to shape the master in a way that supports students in creating their own interpretation of the discipline and the profession of service design. In fact, the choice of specific project themes in each semester gives the supervisors and the students the possibility to shape — with a certain margin of freedom — specific professional perspectives. The early semesters of this master, for instance, have proposed projects in collaboration with the public sector, thus emphasising professional aspects related to social innovation, user participation and distributed systems. CONCLUSIONS
The Service Systems Design Master at AAU is proposing two new challenges: • Extending the domain of service design from the area of interaction between services and users, to the whole organisation of a service, including its technical and organisation aspects, and; • Navigating the complexity of a new disciplinary area, which is still in a phase of expansion and definition Many studies on service design focus on the area of interaction between services and users: the area that is very much on the visible/perceivable side of the line of visibility. This is because several service design studies are strongly
linked to interaction studies or experience design. Being framed in an engineering faculty instead, this master is an attempt to delve deeply into the analysis of the technical, organisational and systemic implications of the design of services, which, indeed, encompasses both sides of the line of visibility. The two traditions this master refers to — interaction studies and engineering — cover different solution spaces, but the PBL structure, and the strong problem solving orientation it implies, can offer good grounds for bridging the two areas on real-world projects. This approach, however, extends the service design domain, thus increasing the complexity of this disciplinary area. The aim of the master is not to control and reduce such complexity, but rather to navigate in it. To do so, the programme provides the tools that would be useful to ‘master’ the discipline. At the end of the programme, the students will have their own toolbox, which will be used in the design profession. It is impossible, in any course of study, to provide an overview of a complete and comprehensive toolbox. Not all the tools and methods available in service design can be included in this programme: only some of them will be familiar to service designers and will be adapted according to their experience and sensitivity. Learning how to select the right tool for the right project is one of the main aims of this course and will be supported by the strong operational focus provided by the structure of this programme.
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References 1 European Credit Transfer and Accumulation System (ECTS) is a standard for comparing the study attainment and performance of students at higher education institutions across Europe Kolmos, A., X. Du, et al. (2008). Facilitation in a PBL Environment. Aalborg, Aalborg University, Centre for Engineering Education Research and Development. Polaine, A. and L. Løvlie (2013). Service Design: From Insight to Implementation. Brooklyn, New York, Rosenfeld Media. Stickdorn, M. and J. Schneider, Eds. (2011). This is Service Design Thinking. Amsterdam, BIS.
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Photo: Thomas Schönweitz
Interview: Geke van Dijk and Bas Raijmakers In this issue, editor Jesse Grimes interviews Geke van Dijk and Bas Raijmakers and learns about their involvement in service design networks, their Anglo-dutch company STBY, and design research. Dr. Geke van Dijk is co-founder and Strategy Director of STBY in London and Amsterdam. She has a background in ethnographic research, usercentred design and services marketing. Geke is the initiator and co-founder of the Service Design Network Netherlands. She is also a co-founder and active member of the REACH Network for Global Design Research. Dr. Bas Raijmakers is co-founder and Creative Director of STBY in London and Amsterdam. He has a background in cultural studies, the internet industry, and interaction design. Bas cofounded the REACH Network for Global Design Research, and is also Reader in Strategic Creativity at Design Academy Eindhoven.
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Back in 2008, you both took part in the the first of the SDN’s Global Conferences, in Amsterdam. That puts you in a good position to look back on the growth of service design in Holland in the years since then. What are the developments you’ve seen, and what challenges remain for Dutch service design practitioners? In 2008 only a relatively small group of people in The Netherlands were aware of service design. There has been a huge growth in the involvement of practitioners in this field since then. There has been an strong uptake in industry (among both agencies and client organisations) as well as in education
and government. By now service design has firmly spread across many different sectors, such as health care, utilities, transport, telecom, and hospitality. It has also been integrated in pioneering innovation programs between industry and academia, such as the CRISP programme (2011-2015) where 60 organisations from academia and industry collaborate to create knowledge about designing Product Service Systems. The main challenge at the moment in all these settings is to move from projects to partnerships. Projects simply don’t achieve enough lasting or systemic change and the issues that are addressed are often too big or ‘wicked’ to be
profiles
solved in a single project. When you aim to change how governments engage with citizens and other stakeholders in policy development, or if you want to develop a service in a traditional product-oriented company, organisational change is needed and that won’t be achieved with a single project. It needs longer partnerships that result in change on an organisational level. There has been the (independent) ‘Service Design Netwerk Nederland’ established for many years. Who makes up that group, and what activities have you carried out? In the summer of 2008 we initiated the Dutch service design network as a result of an inspiring meet up between the four agencies who were at that time pionering under the banner of service design. The initial meet up was actually triggered by clients who told us that it was crazy that we did not know each other yet. So we had a drink and decided to organise shared activities for a wider community. One of our first activities was to support SDN with organising the international service design conference in Amsterdam. Since then we have organised more than 50 local events, such as talks, discussions, workshops, drinks, etc. After a few years of happily co-existing next to the international SDN, we discussed this year to maybe to transform the Dutch network into a chapter within the international network. It makes more sense now the field is growing so much and also consolidating internationally. We have now extended the core group of organisers with extra people for industry and academia. It is a nice mix of enthusiast professionals. STBY operates both in the UK and Holland, two countries where service design is at its most established. How do you handle this way of working, and what prompted this expansion? When we founded STBY 10 years ago, we immediately started in both London and Amsterdam. So there was never an expansion from one country to the other, STBY is a truly Anglo-dutch company. We saw equal opportunities in in both countries, and were already
spending much of our time in London, so for us as directors it really made sense to establish ourselves in both countries. The two studios virtually operate as one, with projects sometimes happening across the two locations. As the directors, we spend about 50% of our time in each studio, and the rest of the team also has a lot of contact with each other, to share knowledge and sometimes offer a different perspective. These different perspectives come naturally with the two locations we work in, but also the multinational and multicultural team we have, with currently five nationalities. Our perspectives and local knowledge are even much more diverse with Reach, STBY’s partner network for global design research currently comprising 11 companies around the globe. For global companies we do design research in several countries simultaneously, always with locally based teams. Design research is your area of expertise, and it’s an area that I believe is sometimes overlooked by service design practitioners. What recommendations would you make to Touchpoint readers on how to incorporate research into their projects, especially if they face time or budget limitations? The most important advice is to not see design research as separate from service design. It is an integral part and cannot be separated from the rest. It does not make sense to do one without the other. To do proper service design you need to do proper design research. This way of thinking and doing also removes the time and budget limitations: if you have little time and budget for a service design project, you have to be modest with your ambitions for the service you are creating, and not just modest with your research ambitions.
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Service Design Work-out on Innovation in Health Care
Dr. Geke van Dijk is co-founder and Strategy Director of STBY in London and Amsterdam. She is the initiator and co-founder of the Service Design Network Netherlands.
In April 2014, the Dutch chapter of the Service Design Network organised the 6th Service Design Work-out. Around thirty participants from various backgrounds came together to discuss the added value service design can bring to the healthcare sector. The session kicked off with a presentation by Jiska de Wit, innovation manager at the UMC (Utrecht Medical Center). She discussed the trends and issues the care sector currently faces. After a brief Q&A, the participants worked in groups on tackling the three questions below. This article summarises some of the outcomes of these discussions.
Marie de Vos is a design researcher at STBY and coorganiser of the Service Design Workouts in The Netherlands.
HOW TO BETTER SUPPORT INCREASINGLY
Albert Gast is founder and owner of Think+DO, a design consultancy working in the areas of brand design, service design and social innovations. He is an active member of the Sevice Design Network Netherlands.
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DEMANDING CARE CONSUMERS?
While a decade ago it was still obvious to first turn to a specialist in case of medical problems, patient routines have gradually changed. An increasing number of people now turn to the internet first to look up their symptoms and then decide whether or not to consult a specialist, or to question a given expert diagnosis. As a result, the interaction with the medical professional has changed. How to deal with this trend? And how can this be turned into an advantage for better services? Taking the patient seriously is at the core of answering this trend. Shifting the mindset of medical staff from ‘patients’ to test
‘consumers’ is needed for the high quality care the medical professional should aim for. A service design approach can support this, for instance by identifying different type of patients, and indicating the different ways one can interact with them. Taking patients seriously also entails helping them to better understand the complexity of their situation. For instance, by making the costs of care more transparent, and giving patients the opportunity to better compare different care providers, patients can decide for themselves what they find most important and want to pay for. Further thought should also be given on how to use this trend as an advantage. What type of information
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would be most useful to provide to patients? Sharing personal experiences between patients who have similar diseases would enable the exchange of tips and tricks and help them to cope better with a disease. Also, providing high quality information on what is good, and why, could be useful for prevention purposes. Related to this is the idea of the ‘quantified self’: by developing a better understanding of your own body and behaviour, behaviour change can be triggered in a positive way. In return, using this data for research purposes can be very interesting for the medical professionals. CAN A HOSPITAL IMPROVE ITS SERVICE LEVEL DESPITE THE NEED TO CUT COSTS?
The first remark made here was that cutting costs does not necessarily have to lead to a lower level of service or a decline in the patient experience. The big challenge for healthcare is to become more efficient and, at the same time, improve the patient experience.
Could hospitals differentiate their service level to specific target groups? This would give the healthcare consumer more freedom of choice, while the hospital would be able to manage their revenues and margins more effectively. The group questioned if this ‘airline-type of service segmentation approach’ could be translated to healthcare, while safeguarding sensitivity to ethical issues. Another way of improving the service level without extra costs would be to better align specialists, based on a more integrated patient approach. This could lead to both an improved experience for the patient and a smoother internal process. Patients could also be given better information and guidance beforehand, so that they better know what to expect. This would create a better flow and experience during their healthcare process. Hospitals could, for instance, involve previous patients as volunteer ‘experience experts’ to better prepare the new patients. The new patients would get more attention than currently, which could lead to less stress, a smoother care process, and an improved experience at the same time. touchpoint 6-2 93
HOW CAN SERVICE DESIGN THRIVE IN A HEALTH CARE SECTOR THAT IS DOMINATED BY A FOCUS ON EFFICIENCY AND MEASURING EFFECTS?
Instead of opposing the efficiency and evidence-focused management approach, it seems more effective to explain that service design is actually valuable in a complementary way. In many sectors, efficiency control and experimentation are equally important to safeguard continuity and innovation. It would definitely help service designers to develop a useful metaphor to explain the value of service design in terms that resonate with management aspirations. For instance, how does a five-star restaurant innovate? Building up a portfolio of best practices from projects in other organisations and sectors is also a useful way to convince stakeholders in management. These references show how service design contributes to effective change and innovation. This evidence from parallel fields gains ambassadors in the organisation permission to experiment on pilot projects and to demonstrate their value. 94
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These ambassadors can be found on any level in the organisation. They are willing to try things out and showcase the results to their colleagues. Service designers should help them to show the added value of service design. Creating visual evidence from all stages in the project to illustrate how service design contributes to real change. As the management team does not have the direct experience on the ground, they rely on this type of evidence. Make sure the ambassadors can tell the story, it will have a stronger impact when they tell the story. Attention should also be given to actively creating opportunities to measure the success of the service design project from the start. This issue should be addressed early to be able to integrate ways to measure the value of the results. This could be increased customer satisfaction, but it might also be a new type of key performance indicator (KPI). In health care, and specially in academic hospitals, it seems that being the best in class or the first to do something, is very important. service designers should thus also look for aspects that will help hospitals be the best or first in something.
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CONCLUSION
In a plenary wrap-up to the session, we shared the results from the various group discussion and reflected with Jiska how this could contribute to her daily work in the UMC. She mentioned that the discussions really inspired her: “…it was good to be amongst service designers again.” She also seemed very fired up by the last discussion and indicated that it would really help if service designers were able to find a way to the connect the ‘efficiency and measuring’ culture of hospitals, thereby lowering the threshold of experimenting with it. The objective of the Service Design Work-outs is to offer an opportunity for people working in service organisations to present some of the issues they face in their work and ask the service design community to think along with them. The informal setting enables the members from the network to mingle and share their thoughts. We tend to focus on ‘unusual suspects’ for service design, meaning those organisations that currently do not yet hire service designers for projects, but who might if they knew better what it was and what they may get.
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Master of Science in Engineering Design & Innovation Learn more here. www.segal.northwestern.edu/edi
INTELLE T OF AN ENGINEER. I M AG I N AT I O N OF A DESIGNER.
inside sdn Rikke Knutzen is working at MAN PrimeServ as a business developer, and the company are a co-founder of Service Design Network Denmark.
Springtime in Denmark Spring is the time when blossoming and growth is initiated, and for Service Design Network Denmark it has also been a busy time. Denmark is a very small country in Northern Europe with just 5.6 million people but, nevertheless, we see that service design is growing in both private companies and public organisations, and even in politics. At our events this spring we have tried to represent what is going on in all three areas. At our last event in Copenhagen in June, the newly founded Alternativet party (the alternative) presented their experience and challenges of involving citizens in shaping the party. It has not been an easy process to dedicate the foundation of a party on co-creation but, by doing so, they hope to get a more modern democratic system where citizens are truly involved. Imagine the effect it could have!
An inspiring event in Dome of Visions in Copenhagen about user-driven politics
MAKING SERVICE DESIGN USEFUL TO EMPLOYEES AT NURSING HOMES
At an event in May, the focus was on service design and welfare technology. Inge, who is a health care employee at a Danish nursing home, presented how she has applied service design to redesign the service of implementing welfare technology in elderly people’s apartments. Amazingly, it only took a six-week course for her to be able to use basic service design methods and start improving processes and services directly at her work. What an inspiration! VISIT FROM THE STATES AND NATIONAL COLLABORATION
One of the amazing things about being part of an international network is the possibility of connecting with people from all over the globe. In early January, we created an event together with CIID (Copenhagen Institute of Interaction Design) around the visit to Denmark by David Sherwin from frog in San Francisco. David presented his thoughts on how design will be the next big disruption in lifelong learning. A true eye opener! Stay tuned on our website or join the group on LinkedIn or Facebook.
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David Sherwin from frog visited Denmark and opened our eyes into the next big disruption in lifelong learning. touchpoint 6-2 97
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T ou chpoint, the S D N S ervice D esign J ou rnal, was lau nched in M ay 2 0 0 9 and is the f irst j ou rnal on service design worldwide. E ach issu e f ocu ses on one topic and f eatu res news and trends, interviews, insightf u l discu ssions and case stu dies. P rinted issu es of T ou chpoint can b e pu rchased on the S D N web site. www.service-design-network.org
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by Le
volume 5 | no. 1 | 15,80 euro
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May 2013
January 2014
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Beyond Necessity, the Beauty of Service
Deep Dive: Collecting Relevant Insights
Designing Citizen-Centred Public Services
The Service Design Promise
Social Innovation in Local Government: Sustaining Success
Discovering the Beautiful in ‘Service as Expression’
By Julie McManus and Emma Barrett
by Kipum Lee
Public & Collaborative: Designing Services for Housing
Aesthetics, Provocation, and the Social Enterprise
By Chelsea Mauldina and Eduardo Staszowski
by Terri Block, Elsa Wong, Spencer Beacock
Are Free Public Libraries Still Needed?
True Beauty
By Ben Reason
Purpose-Driven Research as Key to Successful Service Design By Stefan Moritz and Marcus Gabrielsson
When Design and Market Researchers Join Forces By Remko van der Lugt and Gerrita van der Veen
by J. Paul Neeley
By Mikko Mäkinen and Richard Stanley
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May 2011
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January 2012
May 2012
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Organisational Change
Learning, Changing, Growing •
Being Led or Finding the Way?
•
Mary Cook and Joseph Harrington
Better Services for the People Sylvia Harris and Chelsea Mauldin
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Innovating in Health Care – an Environment Adverse to Change
By Tennyson Pinheiro, Luis Alt and Jose Mello
Francesca Dickson, Emily Friedman, Lorna Ross
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Service Transformation: Service Design on Steroids
Learning the Language of Finance Gives Your Ideas the Best Chance of Success
Using Service Design Education to Design University Services Jürgen Faust
Service Design on Stage
Design Principles for Eating Sustainably
Service Design Creates Breakthrough Cultural Change in the Brazilian Financial Industry
Jesse Grimes and Mark Alexander Fonds
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Eat, Sleep, Play
From Sketchbook to Spreadsheet
Overcoming the ‘Monkeysphere’ Challenge
A Performing Arts Perspective on Service Design
By Michelle McCune
By Raymond P. Fisk and Stephen J. Grove
Hospitality Service as Science and Art
Boom! Wow. Wow! WOW! BOOOOM!!!
By Kipum Lee
By Markus Hormeß and Adam Lawrence
Reinventing Flight. Porter Airlines: a Case Study
By Jürgen Tanghe
The Lost Pleasure of Randomness and Surprise
By Christopher Wright and Jennifer Young
Melvin Brand Flu
Designing Human Rights
By Fabio Di Liberto
By Zack Brisson and Panthea Lee
01 01
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April 2009
Touchpoint
First Issue
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October 2009
Touchpoint the journal of service design
the journal of service
Health and Service Design
What is Service Design? • •
Dutch Design: Time for a New Definition
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Design’s Odd Couple
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Service Design: From Products to People
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a y 2010
esign
Be ond Basics
• Do you really need that i
• Designing motivation or motivating
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hone
Fergus Bisset and Dan Lockton
Mark ones
Designing from within
2 : hat does the future hold and how can we shape it?
Revealing experiences Christine Janae-Leoniak
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B2B service engagements Ben Shaw and Melissa Cefkin
Bruce S ether and leana Stigliani
• Charging Up: energy usage in
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How Human Is Your Business?
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Stuck in a Price War? Use Service Design to Change the Game in B2B Relations.
Lavrans Løvlie and Ben Reason
Lotte Christiansen, Rikke B E Knutzen, Søren Bolvig Poulsen
households around the world
Great expectations: The healthcare journey
Geke van Dijk
Gianna Marzilli Ericson
service design network
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• Design and behaviour in complex
• Service Design 2
Fran Samalionis and James Moed
Lavrans Løvlie
Service Design – The Bottom Line
Steve Lee
Julia Schaeper, Lynne Maher and Helen Baxter
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Business Impact of Service Design •
design? Exploring Service Design, motivation and behavioural change
pp?
Marcel Zwiers
September 2010
Service Design and Behavioural Change
oe eapy
Lavrans Løvlie, Ben Reason, Mark Mugglestone and John-Arne Røttingen
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May 2010
the journal of Service Design
• Make yourself useful
A healthy relationship
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to u c hp o i n t | the jo u r na l o f s erv i c e des i g n
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O rder online at www.service-design-network.org/read/tou chpoint-shop/
B u y the T ou chpoint C ollection and, in one f ell swoop, get the whole b ack catalogu e of T ou chpoint ( f rom the V ol. 1 , N o. 2 to V ol. 5 N o. 3 ) as well as a su b scription to the V olu m e 6 at an irresistib le price!
download single articles volume 4 | no. 3 | 12,80 euro
January 2013
Cultural Change by Service Design Living Service Worlds ¬ How Will Services Know What You Intend? Shelley Evenson
Complete Small, Affordable and Successful Service Design Projects By Chris Brooker
A Time Machine for Service Designers By Julia Leihener and Dr. Henning Breuer
volume 2 | no. 3 | 12,80 euro
T he articles pu b lished in T ou chpoint since its f irst pu b lication are availab le online! T he f orm atted P df s of single articles are now downloadab le at no cost f or S D N m em b ers and can b e pu rchased b y non-m em b ers. Y ou have the opportu nity to search articles b y volu m e and issu e, b y key words or b y au thor!
free acces s for sdn membe rs!
Connecting the Dots •
Service Design as Business Change Agent
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MyPolice
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Service Design at a Crossroads
Mark Hartevelt and Hugo Raaijmakers
Lauren Currie and Sarah Drummond
Lucy Kimbell
http://www.service-design-network.org/read/online-articles/
Photo: Bjรถrn Olin/imagebank.sweden.se
About Service Design Network The Service Design Network is the global centre for recognising and promoting excellence in the field of service design. Through national and international events, online and print publications, and coordination with academic institutions, the network connects multiple disciplines within agencies, business, and government to strengthen the impact of service design both in the public and private sector. Service Design Network Office | Ubierring 40 | 50678 Cologne | Germany | www.service-design-network.org
