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Design for Care

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Participation in Healthcare Systems: Patients aren’t Customers

My favorite healthcare blog KevinMD posts every so often with an eloquent heartfelt piece on the problem of patients as customers. In This is Why Patients Cannot be Customers Dr. Tanya Feke points out that:

A study in the British Journal of General Practice showed how patient satisfaction surveys can be skewed. More than 980,000 patients were surveyed across 7,800 practices. Doctors who prescribed more antibiotics were perceived more favorably than family doctors who doled out fewer antibiotics. When you consider U.K.’s National Institute for Health and Care Excellence estimates more than 10 million antibiotic prescriptions are inappropriately prescribed every year (antibiotics do not treat colds and other viral infections), there is a serious disconnect.

We continue to borrow from inappropriate language constructs to make arguments about desired outcomes without thinking through the anticipatory ancillary effects. If we propose that patients are persons, as Tanya does, that’s a start. Individuals have unique needs and when we treat them as patients, we are authorized to treat them within the context of an institutional role.  However, patients are not customers, and if we treat them as such, we risk converting healthcare into a neoliberal market system. Customers have vastly different expectations and roles in a systems that recognizes the customer-supplier relationship. Rather than elevating “patient experience” this role transformation risks the destruction of human caring in the organization and the larger social system.

Theories of service define value as co-created in the exchange value of an offer, in the delivery and active acceptance of expected service. However, in health care, the direct service of clinical treatment is only the potential value. The realized value of care is in full relief or the outcome of treatment. If the health service provided is a simple intervention such as a wart removal, value realization may be immediate. If the service is iterative for a complex diagnosis, value realization may be diffused, it may arrive in stages. While people may inherently understand this to be the case, the responsibility of the patient to co-create “realized value” of their health is not typically acknowledged. In Design for Care five contexts of participation are identified:

  • The patient as health seeker, a self-directed agent responsible for his or her own health and well-being
  • The patient as a participant in the healthcare system and subject to the rules and roles this entails
  • The patient as a customer of a service, who seeks and pays for treatment directly
  • The health seeker or patient as a subject of user research for innovation
  • The patient as a person under care, located in a community in a particular society and culture.

If we adopt a view of the health seeker, we start treating persons as active agents in charge of recovering their health, relying on and partnering with the care resources of their providers, in their community, and in digital services.

Rethinking “Design” in the Public Sector

(Edited version first published in Jan 2016 Canadian Government Executive )

Government is widely perceived as lagging and fragmented in providing integrated online services to citizens. In the meantime, people take to the Web for managing nearly every service and information requirement. We have learned to expect a high quality of customer service online, well-designed sites and experiences, and thoughtful consideration to the management of personal transactions.

There is a reason why the quality of online engagement has been steadily perfected by the private sector: it is because it has put a premium on “design.” The intentional rethinking of the so-called user experience, combined with continual research into customer preferences, and evaluation of new features and design changes, has made all the difference. Amazon, Facebook, Google, and Microsoft have built their holds on the public by a constant dedication to user-centered design and service engineering. They have set a high bar for access and usability that public services must address, or risk becoming less relevant in citizen’s lives. We could say this is an emerging digital divide between customers and citizens. Design thinking and human-centred design contributed much of the significant difference in experience.

New design and management approaches learned from two decades of online service design are needed to bridge this gap in public-facing services. The risk of a citizen service digital divide has implications beyond that of efficiency, good government and cost savings. If two generations of digital natives become identified more with their online social networks more than their civic communities, the idea of a common public service could be challenged by disruptive non-governmental alternatives, similar to Uber or AirBnB.

Today’s situations calls for a more fundamental rethinking and redesign of public service delivery. From Curitiba, Brazil to British Columbia, San Francisco to Ottawa, creative rethinking of service delivery has led to enhanced citizen experience, value, delight, and cost reduction, changing how people view the role and engagement of public services. While each government centre may be starting with different public needs and public goods, the similar trend connecting these advancements is the creative redesign of public service systems and their service delivery.

As a leading example, take the Government of Alberta’s CoLab. Created in 2014, it is a systemic design and foresight studio staffed by a multidisciplinary team with a mandate to work across government agencies. In its first two years Alberta CoLab completed over 60 collaborative projects involving every Alberta ministry, ranging from energy strategy and climate change to social innovation ecosystem mapping and early childhood development. The ministries of Health and Advanced Education have also set up dedicated teams (hiring recent graduates from OCAD University’s MDes in Strategic Foresight and Innovation) focused on the redesign challenges within their ministries.

While these collaborative in-house labs have been evolving to supply design thinking capacity to critical government projects, a quiet evolution has been transforming how public service functions are envisioned and delivered in the emerging digital era. Human-centred design process and direct field research are replacing traditional modes of expert planning in many service areas, a process that might prove to be revolutionary as well as evolutionary. As design process and thinking derive value from the end user of services, good design can be seen as a requisite public good for future policy and governance.

But what does “good design” mean for the creation and delivery of a public good or policy implementation? A conventional, rationalist perspective suggests that good design improves outcomes by increasing efficiency and quality while lowering costs, and achieving this while maintaining service satisfaction and usability.
These were typical aims in the past, and may be necessary but insufficient. A broad systemic design view reconsiders not only the measures of success but the meaning of success. We design for the future as well as present-day service concerns and competition. We consider the scope of future service complexity, reconsider the roles of citizens and stakeholders, and aim for transformative goals. Anything less might be a waste of resources, missing the mark and sustaining the gap with the digital citizens.

The figure represents four domains of design I teach in the Strategic Foresight and Innovation Master of Design program at OCAD University where we employ design thinking and foresight research for business and policy innovation. Our program is uniquely focused on socially complex, longer timeframe challenges that are underserved by design and business programs, which are typically short-term and profit-driven. The four design domains have become well-known in healthcare applications (as discussed in my book Design for Care, 2013) and have relevant applications across policy design and public service, similar to healthcare.
The fours domains are not stages, as there is no inherent necessity to advance from Design 1.0 to 4.0. They represent capabilities adapted to situations characterized by increasing complexity and the demand for a higher variety of stakeholders. They embody design processes for:

  • 1.0 Traditional craft and aesthetics driven design for well-understood problems. Visual, artifact and communications design managed by small project teams.
  • 2.0 Product and service design: Higher complexity and highly complicated design for value creation and user engagement (including most service design, product innovation, user experience). Requires range of skills from a multidisciplinary team, but is more user-driven than stakeholder focused. Also the conventional public service design approach.
  • 3.0 Organizational transformation: Stakeholder-driven design for redesigning work practices, business strategy, and organizational structures. Strategic design for culture, new strategies, work practices, requiring organizational participants, multiple team experts, facilitated and collaborative design methods. The Alberta CoLab fits this model.
  • 4.0 Social transformation: Stakeholder-driven design for community and social systems (healthcare, mental health, urban design, social policy). Range of methods and diversity of stakeholders needed for co-creating service change for complex social concerns.

New design teams, labs and methods are proliferating across Canada, slowly but effectively. Several fledgling service design labs sprouted up over the last year, with the Service Lab for Industry Canada in Ottawa perhaps the leading example. OCADU’s MDes graduates are being snapped up by the Government of Alberta’s innovative Systemic Design group, which has been leading new creative practices across the ministries. In Alberta, Energy and Healthcare have been early leaders in employing the internal labs, leading to new policy and delivery approaches informed by systems thinking and foresight. In Ontario, the MaRS regional innovation centre hosts the Solutions Lab, which organizes system change events, coordinates design workshops across MaRS constituents, and connects across the other Canadian labs as an integrator.

Service design labs and citizen-informed policy design have been well-received in the UK and Scandinavian governments, and have only recently circulated in North American jurisdictions. While we are faced with the challenge of adapting these practices to our different governance contexts, there is now much more to work with, precedents and models in federal and provincial governments.

However, government service and innovation labs are still quite new in their roles as integrators and co-creators. The shift in government’s design processes has perhaps registered a move from Design 1.0 to 2.0 (service design and delivery innovation). The Alberta group has seen shifts in organizational practice and performance (Design 3.0). Many of these labs have the aim of social system changemaking (Design 4.0). However, most remain limited by the internal focus of government itself, and the difficulty in co-creating with stakeholders from the public and leading projects to implementation.

Integrative Design Healthcare Charette

Prof John Marshall, program director for the new Stamps School of Design Integrative Design MDes, invited us to facilitate a multi-stakeholder charrette in December with their students and professors to develop proposals for the Ann Arbor VA Hospital and community. Working with John and the VA’s key stakeholders for innovation and ambulatory care, the Redesign team employed a modified Basadur Simplexity structure to guide the proceedings.

The charrette included medical industry professionals, design leads and managers from Guardian Industries, Stryker, U.S. Army veterans, and of course stakeholders from the VA Healthcare System to work in small groups to identify, map out and explore core challenges for proposing focal points for action. The Stamps graduate design students produced excellent footage and photographs to document the session.


Redesign partner Patricia sketched the full-length visual narrative to capture the process, stages, and plenary results from the day’s sessions. The focus of the workshop entailed two significant challenges:

  • How do we develop different ways of understanding what is important to VA patients?
  • How can we go about creating connections with our patients beyond their disease process or treatment?










































Continuing documentation of the Stamps MDes student work continues online with process, stories, and progress.


Kenneth Boulding: Designing the Designers

“I suppose what I am really suggesting is a kind of third order mutation to redesign the institutions that design the designers of the designers. This may sound ambitious, but it is, I think, the only response which is likely to deal with quiet extraordinary crises of our times.”