Lisa Norton, a professor in the School of the Art Institute of Chicago, conducted an interview with me earlier this year for Integral Leadership Review and also published it on her own Design Being. Titled Healthcare Design as Extraordinary Service, its available both online and as a PDF article. Several paragraphs are included herein to bring this back home to Design Dialogues. She opens with:
Leveraging systems thinking, human-centered design, and information architecture, his Redesign Network serves the emergence of healthcare service systems capable of taking better care of human beings. By developing schemas for more comprehensive understanding of systemic conditions, Peter Jones is defining new intersections and innovation spaces in healthcare and information-intensive services. In the following interview, Dr. Jones shares first-person reflections and insights on patterns in organizational leadership and influence, as well as his hopes and concerns for the future of healthcare systems design.
Lisa writes: “In the developed world, every citizen is impacted on several levels by their proximity to or distance from, care services and health support. Design for Care reframes the objectified “patient” and “user” categories as health seekers. By reframing the patient role as health seeker and differentiating health seeking, (understood as ongoing and continuous throughout life) from information seeking, Design for Care makes space for a diverse range of individuals with multiple intentions. “These are patients receiving care for complex co-occurring illnesses, people improving their sleeping patterns, individuals struggling with the care needs of their family members. In nearly all cases, we have something in common – we are all seeking to improve health toward a felt homeostatic balance, the experience of a recognized sense of ‘normal’.”
I see two emerging thrusts in design for systemic change and sets of questions they suggest. One relates to clinical organizational change: How can we expand the functions of care within clinical organizations to enhance the design of service and the experience of care? How might design move from IT and other non-clinical services to the front lines? The other to health systems level: How can we design to engage and promote extraordinary care in our societies? How can we help clinicians move healthcare innovation from process improvement into a realm of “extraordinary service?”
Apparently I had a lot to say about organizational design and the relationship to new healthcare practices and new distributed models such as the ACO. Perhaps channeling Russell Ackoff’s Democratic Corporation here, I’m proposing a similar self-organizing approach of teams within (large span) hierarchies.
There are few truly flat organizations. The “hierarchy vs. network” theme is archetypal, but structure is not a solution. Networks are not flat by any means; they are lumpy and energized by power bases. Many hierarchies allow their departments to behave as if flat. Rather than characterizing by dichotomies, we might consider every system as a mix of structures, often shifting, but in slow motion. Large product companies often have vertical market segments and product lines that require separate teams and external networks, such as the large firm in We Tried to Warn You. And they are able to “learn lateral” when necessary, even in a traditional managed hierarchy.
In terms of systemic design within organizations I’ve advocated a planned combination of top-down and bottom-up strategies of soft system design. My approach connects front-line projects with broad organizational and community goals. Through structured dialogue and creative workshops, we can help stakeholders in management and in patient-facing services to discover a shared framing of goals, boundaries, and roles to align their projects toward preferred system outcomes.
Healthcare practices are very resilient, they are trained and standardized so that many clinicians can be interchangeable and perform well under a range of conditions. Changing clinical practices, workflow or procedures requires strong evidence and a clear argument, retraining and evaluation. It’s the same thing when introducing a new EMR or IT system. Healthcare organizations are designed in a sense to resist change; they hold strong norms of practice due to the constant demand to serve their communities. Therefore when consultants (and designers) want to promote innovation and change and they don’t live and work inside healthcare – hospitals or practices – their proposals will likely fail. We are not all on the same team. Clinicians have a primary duty as caregivers – what is our duty of care to the caregivers? Perhaps as designers we can see possibilities those working in the domain cannot, but that doesn’t give a mandate for change from the outside.
Healthcare is risk-averse by design. It is (in Jane Jacobs’ terms) a guardian moral system, as opposed to a system of commerce or trade. Most consultants, designers and IT people come from companies with a commercial moral system, and their operating values may be inherently at odds. Is it ethical for “us” to advocate they act like creative entrepreneurs? Technology interventions can have the effect of embedding a foreign values system, and once embedded, received without consensus.
In my experience, creative competencies can be established within organizations in a developmental way, but preferably not through direct “culture change” initiatives. Cultures change when internal practices reflect new values within ways of working. These practices, habits really, become communicated and valued across departments and enable significant improvements in complex work processes. I don’t believe that my role as a systems designer is to change culture however, it’s a designerly arrogance to believe we can change cultures as outsiders. We haven’t personally done that work in our own organizations, and even when I have, it was in an insider’s role of peer-led stewardship, not as a hired consultant. So how can we pretend our process design is the answer to complex sociotechnical work challenges? The best we can do is to facilitate dialogues and help internal teams design strategies for near and longer term transformations.
Depending on the discourses you follow, you might notice “design-led everything” has charged ahead with design thinking, speculative and design futures, empathic HCD and so on. Design research and advanced methods have lagged in these discourses. Emerging designers could easily believe that a product/service business case can be supported by small-sample field observations and a keen sense of empathy for participants (i.e., would-be customers). At many design schools, the belated rise of human factors (endorsed in second gen design methods) has drifted off into mixed-mashes of methods. I hate to admit how little emphasis we give to evaluation in my courses now – in the 1990’s, usability and contextual evaluations established a positive reinforcing process in competitive growth cycles. Back when money wasn’t cheap and the web wasn’t monetized by surveillance adverts, you couldn’t afford to launch a weak product. Business decisions were based on data, and we had “real data.” So the recent arguments about evidence are puzzling. Perhaps its only the difference between “evidence-based design” and what I call “design with evidence.”
Don Norman has been advocating an evolution in design thinking and education with a stronger role for evidence. Recently, Don listed a scale of levels of rigor in design practice, ranging from designerly intuition to math and engineering models. I added “inputs” to this list to suggest kinds of evidence for each mode of reasoning. Evidence can be construed as a design input, and information objects in their own right, discovered in research and evolved through practice. I break the list at 4-5, where the gap between evidence and “argument only” shows up. Into this gap I would propose “Stakeholder models,” or structured participant observers in co-creation or dialogic design. These are highly structured, qualitative but rule-based propositions elicited and validated within a purposive social context. I think they deserve a different type of evidence structure, quantitatively-informed, validated stakeholder constructs. In many cases where we’re dealing with systemic or developmental complexity (observing while changing things) stakeholder models are a useful construct.
||Inputs and Objects
|1. Craft-based, sharply honed intuition
||Design materials and repertoires.
Objects: Cases, forms, precedents
|2. Rules of thumb: heuristics
||Principles, Frameworks, Heuristics as canonical types. Objects: Cases, frames
|3. Best practices (case-based)
||Inducing patterns from cases, formalized insights. Objects: Cases, benchmarks
|4. Design patterns (modified to account for the current problem)
||Abductive, patterns adapted, catalogued and applied in new cases.
Objects: Cases, comparisons, argumentation
|X. Stakeholder models
||Structured observations by stakeholders in context.
Objects: System maps, diagrams, visual and verbal representations, narratives
|5. Qualitative rules of practice
||Observations, Categories, Participant data, Non-probability samples. Objects: Emic user data, verbal & video content and protocols, images, user prototypes, constructed, narratives
|6. Quantitative rules
||Structured data, defined variables, survey protocols, distributions from probability samples. Objects: Statistics and structured summaries, Proportional maps
|7. Computer models
||Inputs to models defined from hard cases, reference data sources, and statistics databases. Objects: Simulations, Functional models,
|8. Mathematical models
||Variables, parameters, and reference models (statistics). Objects: Algorithms, Equations
Degrees of rigor are not necessarily “better evidence.” The right type of evidence for a stage of design is more crucial than rigor. While 6-8 are conventionally more “rigorous,” they tend to hide the meaningful evidence, the particulars and discovered patterns employed in design practice. Statistics aggregate observations from a thinner set of observations, such as surveys or big data, and as such abstracts the evidence away from the source, from the people or settings of use. This is why usability evaluation in situ remains such a powerful form of evidence, as a single situation in context can be more convincing to sponsors and engineers than a large scale user survey. (Then of course, the convincing interaction may need replication or causal support from quantitative probing studies).
What do we really know about evidence-based design? Is it a developing design practice trend, or more of a mode of design research that drives design decisions? Is it premature or perhaps overstating the case, perhaps we might find more agreement if we described models of “designing from evidence?”
Evidence-based design (EBD) has already been reframed, in different ways, from architecture, design education, research and practice. EBD is not a thing, yet. It’s not what we think it is. This is not a monolithic practice that threatens design traditions. In practice, understanding the contributions of science and standards of evidence contribute to better design decisions in any complex sociotechnical system. Evidence is not a passive construct, it requires a process of data collection and interpretation. Collecting data about or during a design inquiry doesn’t diminish creative or interpretive design approaches.
But perhaps another concern is more that a turn toward evidence alters the balance of power designers have worked so hard in the last decade to achieve. Design thinking and co-creation practices have been endorsed as powerful allies in business and social innovation, and perhaps in some ways a strong evidence approach competes with co-creation. I would suggest this is a necessary return to balance of the reality of the purposes of design thinking – to ensure effective and desirable products and services are developed based on an honest appraisal of the humans in the social systems of use. These are customers, end users, organizations, marketplaces. Evidence returns some power to the reality of current needs and functions, perhaps at the expense of conducting longer, more experimental projects. However, in domains such as healthcare, public service, and many high-risk applications, the necessity for not just managing costs, but employing systemic design to drive down costs while serving constituents is one of the main drivers inviting design practices into these otherwise forbidding arenas.
Most systems I’ve designed have included both types (or multiple methods) of design research. Certainly when working with development teams and product managers, the “harder” evidence – user data – is always more convincing than generative or conceptual design cases.
There’s been a long tradition of evidence-based design in healthcare, based in studies of environmental design and architecture in facilities and care practices. Its major proponents have been doing safety and systems-oriented research and intervention since the early 1980’s, and if you search “healthcare design” these are the precedents that show up. (See the venerable Center for Health Design) CHD studies have made a huge difference in quality of care and patient safety over the last 30 years. Design enhancements such as in-room artwork, access to natural scenery and living plants have resulted in decreased length of stays, improved service experience, and other softer outcomes, such as lessened anxiety. We can measure these things and make a convincing case for expensive and significant facility changes (to make any change to hospital environment is expensive, as it must be durable and repeatable option for all patient rooms or locations). The now-current knowledge that “single patient rooms lead to better health outcomes” is both patient-centred and evidence-based. But hospitals would never accepted the expense of essentially doubling the number of rooms based on patients preferring it. They do measure hard outcome data, and outcomes are a major design criterion.
Evidence is not necessarily a positivist position, even if the tradition of EBD tends to be so. Evidence is merely “based on data” as opposed to expert judgment or collective agreement, which are interpretive modes. In fact, collecting interpretive data from users, rigorously, is evidence. Patient narratives are a type of evidence. If we don’t collect data, we’re at significant risk of interpretive risks in making design decisions that affect safety, human welfare and finances. So just as scientists argue about the meaning of data, so ought we.
Evidence and its alternatives are not an either/or proposition. In fact, there is no “or” to be found. There is little risk of epistemological contamination by adopting the value proposition for evidence in design.
In systemic design there needs to be a balance of methods and perspectives, as complex systems (at least) are many-sided and many-functioned operations which no one person can understand in whole. Every contribution to knowledge helps.
In healthcare, the trend that is balancing evidence-based care is patient-centred care. But very few organizations have produced meaningful approaches that all understand as patient-centred. There’s pretty good agreement around “levels of evidence” and research standards, there’s almost none for patient-centred care. The definition of PCC seems to be getting fuzzier, not clearer, as more stakeholders adopt a patient-centred view, and then are stopped by the uncertainty, perhaps, of how to best implement the value in real care setting.
PCC is not patient experience, or patient satisfaction, PCC is interpreted very differently between clinical professions, and differently across institutions.
Are some hospitals advocating a trend “away” from evidence and toward “patient centricity” when they don’t agree what that is? And when they get closer to it, PCC may tend to blow up the business model and workflows.
Unless design thinkers make a culture out of evidence, it will become a complementary mode driving research, and helping designers make “unassailable” design proposals in complicated and risky situations.
If non-clinicians actually look at how the evidence behind medical practice is treated, they’d realize that no expert “lets the evidence decide.”
The reliance on clearly established precedent and the “literature” is a starting point for clinical decisions – diagnostics, medications or surgical therapies are complex decisions and require the best known answers before expert judgment is applied. The risks are too high not to. Yes, in hospitals residents execute much of this and they don’t build long-lasting personal relationships. They are residents. But nurses, who have championed patient-centred care and tend to practice it philosophically even if it’s not standardized, demonstrate in many ways affective and interpersonal qualities we associate with PCC.
Certainly clinicians who actually work in healthcare are not going to wish away evidence supported decisions anytime soon. When we seek to deliver design value at organizational and social/policy levels, we’re dealing with high degrees of complexity and the difficulty of sustaining a presence long enough to make a difference. Gaining agreement on courses of action is critical in these domains. Evidence helps us build the case for stakeholder agreement, especially across strongly contested views and positions, where power is involved or people have possible losses.
But service design and whole system (integrated IT and process) design require both evidence-based and x-based. And I’d like to hear more of what those other “x’s” are, because I never saw a conflict between research-led design and exploratory design. They are usually different stages, but I will say that in corporate work I’ve found you rarely get paid to explore. In design school our students usually want to just explore and save evaluation for “later in the career.”
To make better cases for systemic work with mission-critical services and integrated systems, we need to move beyond our own prejudices of what these categories might mean. We have to read studies, learn from scientific research and design research, from our peers and dialogues. And I would make a case for integrated methods and multi-perspectives.
We held a participatory design workshop at Urban Ecologies 2015 (June 19) to test-run a process with the Flourishing Cities canvas, a system map for citizen co-design for planning future governance commitments and preferred future outcomes The Flourishing Cities framework adapts a design tool from the Flourishing Business Model, a planning system for constructing strongly sustainable business models. The design tool in both cases is a visual organizer for engaging stakeholders in co-creating values-centred operational guidance, in the Cities case, adapted for civil society engagement with urban planners and local governments. This is based on research work developed from OCADU sLab Strongly Sustainable Business Model group as applied to the flourishing of cities and settlements.
As suggested by the “strongly sustainable” terminology, the normative commitment of the planning system is toward a fullY-integrated social system of an organization with its inclusive societal contexts, human participants, and the natural ecosystem.
A significant design challenge of our time is anticipating the relationships of multiple environmental and social problems as a complex system of nonlinear effects. Consider how climate change debates stay mired in the unproductive positions of critique or techno-utopian solutionism. Climate change offers us the perfect example of a long-term complex problem system. We are largely arguing about symptoms and how to treat them, as the root causes (if not formal causes) of climate change are in trade, economic investment, and industrial subsidies from generations ago. As we face the consequent effects on human migration, energy, transportation, and urban planning, we remain largely unable to influence the politics of global capital. So even if Canada elects a more climate-friendly government after the disastrous Harper regime, South Asia and China’s development and climate impacts remain untouchable and arguably worse than our last 100 years of aggressive growth.
However, we cannot model or think about nonlinear and atemporal relationships very well, especially in deliberative groups and decision making processes. We need not only better engagement and dialogue processes for citizen deliberative problem solving, we require relevant tools. We are aiming to design a framework from the common language of business model tools, adapted for city and community decision making models.
This proposed visual model enables a participatory mapping of propositions, values, and preferences that might yield significantly better group decisions for sociocultural and ecological development and governance in any planning engagement. The frame for Flourishing is drawn from John Ehrenfeld’s decade of research and promotion of “sustainability as the possibility that humans and other life will flourish on Earth forever.”
The Flourishing Cities canvas is an experiment in creative engagement for constructing strong sustainability models for city and regional urban governance.
The presentation deck for the workshop (available in PDF).
The workshop in action. This was our first, and I (with the Strategic Innovation Lab) would be happy to develop custom Flourishing City workshops for planners or stakeholder groups. Contact me or join the SSMBG on LinkedIn if you’re interested in this developing area.
Co-Evolving SDD Practice
In several short years, many leaders and institutions now openly acknowledge the necessity for inclusive social transformation. We also now find stakeholders raising the concern that social change must be driven by participatory and democratic processes. We recognize the fact that our third millennium world needs new methodologies and new tools capable of harnessing the collective wisdom of people from all walks of life in order to protect its sustainability and foster up harmony into its evolution. The practice of Structured Dialogic Design is positioned as a powerful tool in this context.
A group of nearly 30 practitioners and scholars met in Limassol Cyprus for May’s international meeting not to revisit the history of the past 40+ years but to “create the history of the future.” The community of scientists and practitioners of the science of dialogic design has now expanded to include people from all parts of the world and a variety of languages and cultures. A dedicated community of scientists, students and practice leaders gathered for a week to deliberate on how to evolve SDD and retain its scientific credibility together with its cultural sensitivity.
As Yiannis Laouris states: “No claim is being made about the superiority of Structured Dialogic Design, even though there is substantial empirical evidence, from more than 1,000 applications in the arena, to this effect when dealing with the management of complexity.”
Laouris and Christakis have emphasized for many years the critical importance of performance in the Arena, of citizen and stakeholder-level action resulting in sustainable, persistent outcomes. All evaluation of quality and effectiveness must be tested by its effects in real discourses and decisions. The Symposium was a necessary, all too rare meeting of the College, the community of practice and scholars. However, immediately after the week-long meeting, a significance team stayed in Cyprus to plan and deliver five (5) back-to-back Colaboratories. That’s commitment to the Arena.
In my view of the modes and outcomes of practice, I can identify four contexts of Dialogic Design engagements:
- College – The Community of Practice and scholars who sustain the scientific work, the theoretical development, the scholarly publishing.
- Lab – The Lab context is the crucible for tinkering with new concepts, building methods upon theory, and the source of methodological innovation. As designers, we might also call this the “Studio” context, because its working with peers and informed stakeholders on designing processes and applications. Unlike the contemporary notion of Social Labs, I see labs as back-room workshops where designers and planners work with problem owners in building new engagement methods and designing better ways to manage and analyze dialogue and its artifacts.
- Arena – The Arena is the center of engagement, the Co-lab, the place where stakeholders meet and deliberate in a context of communicative action hosted by a team of 3-4 SDD facilitators. SDD organizes a stakeholder designing process in which every member is empowered to decide and to take action in collaborative outcomes.
- Agoras – Agoras are evolutionary dialogues disclosed by processes of dialogic design. The new Agoras we speak of are spaces for citizen dialogue, in the continuity of places like the Future Worlds Centre in Cyprus or Design with Dialogue in Toronto. The are becoming possible online, with mixed-methods and staged temporality.
The included presentation was on the relationship of design and design principles to systems practice and SDD.
SDD offers a significant, developed theory base and unlike most systems methods, it is a validated and published method. Yet SDD was never developed as an integrated design methodology, it was formulated from the beginning as a powerful systems approach for multi-stakeholder deliberation and strategic decisionmaking in complex and high-risk domains. What would it take to reconfigure SDD as a design-led multi-stage process for collaborative foresight for social systems planning and design?
We might start by integrating design and research methods from underrepresented creative and social science disciplines, including strategic foresight, participatory action research, organizational design, and developmental evaluation. The pre-Definition and execution phases in particular can be considerably enhanced. Both the Discovery (preceding SDD co-labs) and Action Planning (following co-labs) have significant potential for mixed-method design processes. Today we typically customize a research and facilitation strategy for a client, but do not always measure or compare outcomes or publish findings. The Cyprus symposium provided a venue for practitioners to share the magic of approaches learned in the Arena.