Service Design Impact Report - Health Sector

Service Design Impact Report:
Heath Sector
November 2017
ISBN 978-3-9818990-3-0
Published by
Service Design Network
Birgit Mager
Project Manager
Aline Alonso
Editor-in-Chief
Birgit Mager
Editorial Board
Dr Alexa Haynes
Chris Ferguson
Dr Daniela Sangiorgi
Gustav Gullberg
Mark Jones
Art Direction, Research
& Organisation
Aline Alonso
Proofreading
Anne Freis, Lektorat &
Übersetzungen
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We thank Hotwire for
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INTRODUCTION
Service Design Impact Report: Health Sector
Birgit Mager and Aline Alonso
SERVICE AND POLICY INNOVATION
Redesigning the Rules for Healthcare Innovation
Neil Collman
Changing Minds to Save Lives: Designing for Prevention
Maria Prigorowsky
DIGITISATION AND E-HEALTH
Service Design is the Future of Healthcare
Catherine Desmidt
Prototyping Citizen-Centric Access to Electronic Health Records
Jerry Koh and Shahab-Shahnazari
Achieving Better Health through a Balance
of Technology and Human Touch
Jamie Thomson
COMMUNITY ENGAGEMENT
Community Engagement: From Design to Implementation
Jessica Dugan and Dan Butt
Making Mums Matter: Beyond Tokenistic
Participation in Design for Mental Health
Paola Pierri and Dr Laura Warwick
Hospitable Hospice: Engaging an Ecosystem
to Breathe Life into End-of-Life Care
Lekshmy Parameswaran and László Herczeg
6
16
22
26
28
34
42
46
52

BUILDING CAPABILITIES
Empowering People to Innovate in the Public Sector:
Scaling Service Design Training on a National Level
Sara Tunheden, Caroline Lundén-Welden and Ulrika Lundin
Designing for Education that Designs Healthcare
Dr Kate Sellen and Dr Peter Jones
The Experio Way: Catalysing a Bottom-up Movement
for Change in Public Healthcare
Katarina Wetter-Edman
CULTURAL AND
ORGANISATIONAL CHANGE
Shifting the Balance of Power in Healthcare through Service Design
Josina Vink, Dr Dominik Mahr and Prof Dr Gaby Odekerken-Schröder
The NHS Needs a Large Dose of Service Design Medicine
Roger Donald
Using Service Design to Build the Universal Patient LanguageTM
Susan Bartlett and Elizabeth Turcotte
The Innovators Network: Growing the Innovation Muscle
at the US Department of Veterans Affairs
Amber Schleuning, Andrea Ippolito and Melissa Chapman
CONCLUSIONS
Impact and Future Perspectives
Birgit Mager and the Editorial Board
Authors100
94
86
90
80
74
68
66
60

6 SERVICE DESIGN IMPACT REPORT: HEALTH SECTOR
The Service Design Network proudly presents its third Impact
Report. Throughout the last two decades, service design has
contributed to the improvement and innovation of public and
private services all over the world. Governments are placing
service design at the heart of innovation initiatives. Companies are
building in-house capacities for service design-driven innovation.
Consultancies are acquiring service design agencies to bring their
skills and expertise in-house. And new service design agencies
appearing throughout the world. Last but not least, more and more
universities are offering service design courses and programmes,
bringing the promise of a continuous influx of new service
designers into the market each year.
We find it extremely valuable to show how service design is
engaging on different levels with the challenges our society and
our economy are facing, by sharing insights and examples of the
amazing work our ever-growing community is doing. While early
service design initiatives were mainly focussed on the innovation
and improvement of service interfaces, we observe today that
service design has matured in the meantime, and now provides a
strong influence at the strategic and transformational levels.
This year we are focusing on the value service design is delivering
in the health sector. Why did we choose the health sector? The
worldwide challenges in the health sector today are enormous.
Population aging and the impact of chronic diseases are
creating new demands on the quantity and types of care being
delivered, while at the same time budgets are under threat and
legislative changes to insurance coverage add further complexity.
Furthermore, ethical issues related to scientific and technological
advancements must be tackled. In short, the health sector is
in need of radical innovation. We can no longer try to solve the
problems of today with the same tools that created them, as
Charles Leadbeater once pointed out.
THE SERVICE DESIGN IMPACT REPORT:
HEALTH SECTOR
BIRGIT MAGER AND ALINE ALONSO

7SERVICE DESIGN IMPACT REPORT: HEALTH SECTOR
Last year's Impact Report on the public sector as a whole showed that service
design engagement in highest in the health sector speciﬁcally. This Impact
Report aims to create transparency within the service design community,
enabling professionals to build upon existing knowledge, and to connect and
deepen the understanding of the opportunities and challenges service design
is facing in this area. At the same time, it aims to create awareness for the
value of service design within domains where it has played little or no role.
We strongly believe that managers and politicians will derive great value from
seeing service design applied within their projects and organisations. As a
result, the Service Design Network is on a continuous mission to evangelise
the value of service design to organisations and individuals all over the world,
and in doing so, growing the community of practitioners, and improving the
value it delivers for the users and providers of services.
TACKLING THE BIGGEST CHALLENGES
How is service design tackling the biggest challenges within the health sector,
from framing the problems to the implementation and scaling of solutions?
To answer this question, the SDN reached to the global service design
community and sought their input. The Editorial Board - which brought
together outstanding experts and professionals within the domain of health
sector service design - put great effort into identifying the right individuals to
contribute their experience to this publication. In addition, an online survey
collected insights from more than 130 organisations and 680 projects in order
to build an overview of how service design is impacting the sector.
CARE JOURNEY
24%
PRE-CARE AND PREVENTIVE
• general wellness, lifestyle
• de-stigmatisation of illness
• prevention, awareness
• pre-diagnosis
• diagnosis, treatment
decision-making
• preparing for treatment
25%
GETTING CARE
• treatment
• acute care
• emergency intervention
• palliation
17%
POST-CARE AND MAINTENANCE
• treatment maintenance
• commodities management
• treatment discontinuation27%
ENTIRE JOURNEY
• pre-care and preventive
• getting care
• post-care and maintenance
7%
OTHER
• relating to infrastructure
• internal working/running of
a healthcare organisation
Results from the online survey conducted by the Service Design Network from July to September, 2017.
Source: 133 responses
(about 680 projects)

Last but not least, SDN Chapters activated many practitioners in their
cities and countries to share their cases with us. In fact, far too many cases
were submitted to be able to publish all of them in this report. However
we are using this huge amount of valuable content to feed it into the SDN
Case Study Database (www.service-design-network.org/case-studies),
where it will be available online to serve the community.
In the following pages, 34 thought leaders and practitioners will bring the
perspectives of different countries into focus in the areas of Service and
Policy Innovation, Digitisation and E-health, Community Engagement,
Capability Building and Cultural and Organisational Change.
The graph shows the dimensions of impact achieved by the projects' outcomes: (a) changed
organisational processes/structures, e.g. new networks between previously-unconnected
stakeholders, developing new partnerships, co-creating; (b) changed the organisational culture, e.g.
establishing user-centred values within the organisation; (c) engaged citizen/patient, e.g. community-
building for volunteer engagement; (d) educated/built capability, e.g. offer service design training
within a health sector team/organisation; (e) changed/developed policy and regulation, e.g. using
design research/prototyping to inform policy decision-making. – Results from the online survey
conducted by the Service Design Network from July to September, 2017.
54%
Improved existing
experiences
47%
Developed
new offers
According to our online survey, 54 percent of the
project outcomes focused on the improvement
of existing experiences, e.g. improving customer
experience of existing service and executing minor
changes to interface dimensions of current offers.
While 47 percent developed new offers for healthcare,
e.g. generating new solutions or targeting new markets.
– Results from the online survey conducted by the
Service Design Network from July to September, 2017.
Source: 133 responses (about 680 projects)
SERVICE DESIGN INNOVATION FOCUS
Organisational change
Cultural change
Citizen/patient engagement
Education and capability building
Policy and regulation
0% 10% 20% 30% 40% 50%
DIMENSIONS OF IMPACT

Service and Policy Innovation
Our ﬁrst chapter is about Service and
Policy Innovation. According to our
survey, 22.4 percent of the projects
were aimed at changing or developing
health-related policy and regulation. Neil
Collman opens our report by exploring
this topic. He gives an overview with
examples from around the world about
how service and policy serve as a central
pillar for innovation in the health sector,
and in the establishment of a favourable
governance frameworks and strategies.
In order to help decrease the incidence
and mortality of cancer, prevention is
considered crucial in Sweden’s National
Cancer Strategy. Maria Prigorowsky
shares this case study, in which the
Swedish association of local authorities
and regions (SKL) and Regional
Cancer Centers (RCC), together with
Transformator Design and Kapi, took
a user-centred perspective to increase
participation in cancer screening
programmes by up to 20.6 percent.
projects and organisations surveyed
authors and editors of the publication
GLOBAL COMMUNITY
The content of this publication gathers insights from more than 170 organisations, 680 projects and
34 thought leaders and practitioners applying service design in the health sector around the globe.
A CHAPTER-BY-CHAPTER SUMMARY

Mad*Pow and Microsoft to investigate
how new services could help them better
serve patients, particularly across rural
areas of the region. Their aim was to find
innovative ways of engaging with patients
in order to achieve health behaviour
changes and better clinical outcomes.
Jamie Thomson shares the case of
ImagineCare, which combines mobile
devices, Bluetooth-connected sensors and
a 24/7 telehealth clinic which balances
technology with the human touch.
Community Engagement
The involvement of users and other
actors in the early stages of service
development opens the door to more
efficient, effective and customised
experiences. Stakeholder engagement is
important to understand their points of
view, their needs and their expectations.
However, service design can go further
and expand the participation to a much
bigger range of potential co-creators, co-
producers and co-providers.
Community engagement can also play
an important role in the scalability of
services. According to our research, 41.4
percent of the service design projects for
the health sector have been implemented.
Within that number, 40 percent have
been scaled (57.6 percent regionally,
40.6 percent nationally, and 16 percent
scaled to other countries). Dan Butt and
Jessica Dugan, from UnitedHealthcare,
share their insights about ensuring the
scalability of design solutions in which
90 percent of the service elements should
be fixed and 10 percent should be flexible
and adapted in a co-design process with
users before the implementation.
Digitisation and E-health
Service efficiency is often connected
to digitisation. It is also a common
entry point into the health sector for
designers. But the work of service
design goes beyond providing beautiful
screens for digital solutions; there is
a demand for bigger transformations
in the processes, service offers and
experiences. It does not make sense
to translate bad analogue services into
bad digital services. Instead technology
and digitisation offer opportunities to
radically transform the system.
Catherine Desmidt from Hotwire
opens the Digitisation and E-health
chapter by highlighting the exciting new
developments that are being designed to
help solve challenges such as population
ageing and chronic diseases, because
so-called “health tech” is destined to
have a large impact across all aspects of
healthcare.
E-health and data are hot topics for
discussion in different parts of the
world. In Ontario, a partnership between
MaRS, UHN and eHealth Ontario, with
support from MOHLTC, has enabled
personal health records to be shared
with over 14 million citizens. Jerry Koh
and Shahab-Shahnazari from MaRS
Discovery District, exemplify the risks
and opportunities uncovered, while
prototyping citizen-centric access to
electronic health records.
The academic medical centre and
regional health system of New
Hampshire in the United States –
Dartmouth-Hitchcock – partnered with

Ecosystem mapping to illustrate the range of stakeholders
involved in health sector projects applying service design:
"Which kind of institutions were involved in the projects you
participated in within the past 2 years?" – Results from the
online survey conducted by the Service Design Network from
July to September, 2017.
Health tech
start-up
Healthcare
technology
company
Durable
medical
equipment
company
Ministry of
healthWorld Health
Organization
Health data
analytics
company
Digital design
agency
Service
design
agency
Architecture
agency
Local
government
healthcare
department
Social services
department
Primary care
clinic Inpatient
clinics
Community
healthcare
services
Not-for-profit
charity
Healthcare
NGO
Care homes
Acute care
hospital Mental
healthcare
hospital
Healthcare
professional
syndicate
Patient safety
department
Innovation
unit of a
hospital
Internal
service design
team
Private
company
offering
wellness
services
Health
advocacy
groups
Health
networks
Pharmaceutical
company
Pharmacy
chain
Public health
insurance
department
Private
health
insurance
company
University
departments
related to
healthcare
University
hospital
Healthcare
research
institute
Healthcare
innovation
funds
National
healthcare
department
SERVICE INNOVATION ECOSYSTEM

Paola Pierri and Dr Laura Warwick from Mind demonstrate the
importance of the inclusion of a range of different stakeholders in the
service design process, and exemplify different levels of engagement and
participation with the case study of Mums Matter. Their article portrays
the development of the co-design process of a new service offering for
mothers in the postnatal period, a time in which they are susceptible to
developing mental health problems.
Designing for care requires a great deal of responsibility and ethics,
especially when dealing with topics that are social taboos. Who wants to
think about death and the end-of-life experience? More than ever, our
society needs to face this topic when thinking about the complex socio-
economic challenges associated with the ageing population. Lekshmy
Parameswaran and László Herczeg had to work in close collaboration with
a spectrum of key players from the end-of-life care ecosystem to rethink
the inpatient experience of hospices in Singapore. Their efforts focussed on
de-stigmatising death and dying, raising public awareness around end-of-
life issues and shifting the perception of death care and bereavement.
PROJECT OUTCOMES 41%
IMPLEMENTED
44%
SCALED REGIONALLY
40%
SCALED NATIONALLY
16%
SCALED TO
OTHER COUNTRIES
FROM THE
IMPLEMENTED
PROJECTS,
40%
HAVE BEEN SCALED
36%
SERVICE CONCEPT
e.g. delivered a
service blueprint or
recommendations
23%
PROTOTYPED/PILOTED
Results from the online survey conducted by the
Service Design Network from July to September, 2017.

Building capabilities
With the growing demand for citizen-
centred health services in the public sector,
Sara Tunheden, Caroline Lundén-Welden
and Ulrika Lundin developed a system to
scale service design training on a national
level in Sweden. The Innovation Guide is
a programme that supports teams in the
public sector with modern design tools
to develop their operations and services
in different formats: An online tool, a
seven-month training programme, a coach
training programme and a network.
Last year, Toronto’s OCAD University
launched the ﬁrst MDes degree dedicated
to design for health and healthcare.
Dr Kate Sellen and Dr Peter Jones
combine key ingredients of stakeholder
focus, inclusive processes, evidence and
implementation to design the education
that designs healthcare.
More and more, service design is valued
as an in-house capability for healthcare
institutions. Katarina Wetter-Edman
shares the Experio Way, which uses
empathy, courage and co-creation to build
service design capabilities with a focus on
collaboration, catalysing a growing, bottom-
up transformation movement within the
Swedish public healthcare system.
Cultural and organisational change
The increasing complexity of the problems
faced by the health sector combined
with the demand for more effective and
responsive service offers emphasises
the need for a different problem-solving
and decision-making approach within
and across health sector institutions.
Service design is proving to be an
impactful approach to catalyse cultural
and organisational change in the sector.
Most projects impact the processes and
structures within organisations (such as
establishing new networks and partnerships
between previously unconnected
stakeholders), as well as in the culture of
organisations (such as in establishing user-
centred values as a priority of their actions).
The complex issue of power dynamics
within healthcare is explored by Josina
Vink, Dr Dominik Mahr and Prof Dr Gaby
Odekerken-Schröder, exemplifying how
service design can rebalance power in order
to realise changes in the culture, processes
and structure of healthcare organisations.
Roger Donald shares his personal view of
the NHS Digital, and 'prescribes' service
design as a 'medicine' for the organisational
change required by the 70-year-old United
Kingdom National Health System.

14
Susan Bartlett and Elizabeth Turcotte, from
Bristol-Myers Squibb and Bridgeable, explain
how they built clear guidance on how to
communicate complex topics to patients
in the pharmaceutical industry which are
consistent, fair, accurate, understandable and
relevant to patient needs.
Amber Schleuning, Andrea Ippolito
and Melissa Chapman share a case
study of the largest integrated healthcare
delivery system in the United States –
the Department of Veterans Affairs
(VA) – which is building an ecosystem
of innovation for employees across the
VA system.
Conclusions
How will our healthcare system develop in
the coming years? There are visions of high-
tech, data-driven, robotised and knowledge-
based service delivery on the one hand, and of
more humanised solutions (such as people-
powered and networked health services) on
the other. From the pace of transformations
seen in recent years, the expectation is that
drastic changes will impact the sector in the
near future. That is what Birgit Mager and
the Editorial Board members of this edition
– Dr Alexa Haynes, Chris Ferguson, Gustav
Gullberg, Dr Daniela Sangiorgi and Mark
Jones – share in the ﬁnal article.
Service design can help in the development
of these speculative visions, in the
implementation of the innovative solutions
and in tackling the challenges to come. We
are all invited to be part of the upcoming
transformations!
“From my perspective,
there should be more
pressure for cities
to promote healthier
lifestyle. We should think
holistically and create
visions on how the city
environment can support
a healthy lifestyle, for
example with more bike
lanes, offering sports,
culture, etc.”
Anne Stenros, the Chief
Design Officer of Helsinki

SERVICE AND
POLICY
INNOVATION

REDESIGNING THE RULES FOR
HEALTHCARE INNOVATION
NEIL COLLMAN
Never before has there been so much opportunity for design to make a
positive impact on the well-being and health of citizens. Governments
worldwide recognise that patients’ expectations are rising fast and
there is a need for a fundamental change in how people interact with
health services and professionals.1
The nature of the global challenge
is hugely complex, distinctly human, systemic and intertwined, and
the scope of the opportunity hugely broad, involving stakeholders
from government agencies, non-profits, insurance companies,
hospitals, pharmacies, patients, caregivers, and doctors. Crucially
though, it is the underlying framework of policies and regulation that
need to offer the springboard for radical transformation.
THE CHALLENGE
Policy is central to the innovativeness
of the system because it provides the
governance framework and strategy for
innovation to take place – essentially
the mandate for which issues should
be tackled, why and how. It sets the
tone and direction for the solution of
these issues, impacting the mindset
of a multitude of key stakeholders,
crucial for the buy-in and support
of any solution. On a practical level,
policies and regulation deﬁne the ways
in which innovation needs to work to
be legal and supported; for example,
prescribing the way personal data is
exchanged, how quality is assured, who
can participate in the system, or how
identity is proven.

There are many factors driving
opportunities in healthcare, many of
which challenge the status quo and will
almost certainly require new regulatory
frameworks to have impact on a large
scale. The so-called quantified health2
movement and continued explosion of the
wearables market3
means it is possible to
collect and monitor just about any kind of
personal medical data you care to mention,
meaning that in theory information that
has previously been invisible is suddenly a
huge untapped resource. Emerging medical
professionals, consumers and healthtech
entrepreneurs from the Millennial
generation want and expect an experience
similar to the one they have with
companies like Google, Apple, Amazon or
AirBnB. Healthtech start-ups are gathering
pace at a frightening rate, with the global
digital healthcare market set to grow to
$206bn by 2020.4
Yet the challenges are vast. An ageing
population (United Nations statistics
predict that the number of people in the
world aged over 60 will grow by 56 percent,
from 962 million to 1.4 billion by 20305
)
paired with long-standing constraints
on public sector spending means archaic
systems, processes and workflow are
struggling to keep up with increasing
demands. Dated technology platforms
mean data standards aren’t consistent, and
concerns about the use of personal data
and privacy are front of mind. In March
2017, 26 million patients were affected by a
technology breach in the UK6
; in the US a
recent Medicare fraud case cost the federal
government $1.3 billion.7
These challenges
present risk and evoke fear of change,
which of course means that decision-
making and policy strategy need new ways
to tread the fine line between encouraging
innovation and safeguarding patients.

THE RISE OF POLICY DESIGN
The unprecedented scale of the
challenge in the last five years has seen
leaders in government and healthcare
increasingly turning to design as a way
to transform the healthcare industry and
find structured, proven ways to develop
services that work. The burgeoning
number of public sector innovation and
policy design labs is just one indication
of this trend – they now exist in many
countries worldwide, including Policy
Lab in the UK, Mindlab in Denmark and
iGovLab in Brazil. Alongside this is the
recognition that in order to deliver true
innovation, the design process must also
involve and influence the policymakers:
to bring them closer to the needs of the
citizen, to allow for experimentation
and iteration, and to bring qualitative
insights as well as quantitative data into
the picture.
Traditionally, policymaking is very much
grounded in evidence-based research
and heavily driven by quantitative “big
data” but often not suited to the real
world of service delivery where human
behaviour or “thick data” is needed to
develop workable solutions. Back in 2011,
a review of the policymaking landscape
in the UK cited “innovative, flexible
and creative” as one of the key missing
qualities of the policymaking process,
and something that had been lacking
for many years.8
Back in 2014, the then
Head of the UK’s Government Digital
Service, Mike Bracken, explained how
“delivery to users, not policy, should be
the organising principle of a reformed
civil service.”9
One of the key themes of
this approach is to use design to prototype
and pilot possible solutions with users
and policymakers, and then influence
policy to suit the right outcome. In the
same year, also in the UK, Policy Lab was
setup as part of civil service reform with
a renewed focus on collaborative, user-
centred approaches to policy design. Since
then, Policy Lab has used design alongside
progressive data analysis and ethnographic
approaches to inform, co-create, and
prototype policy strategy. In 2016, they
used this method to explore better ways to
support people with disabilities or long-
term health conditions to get in and stay
in work.10
A GLOBAL PICTURE
This user-centred design approach to
policy has extended across the globe. In
South Korea, policy is typically made by
medical professionals, academics and
researchers who have in-depth medical
knowledge but traditionally have never
used collaborative design practices to
tackle challenging issues in new ways or
get to the heart of what really matters for
patients.
Jungha Ku, Healthcare Strategic Designer
and Co-founder of DESIGNCARE, a
consultancy based in South Korea, explains
that employing a service design approach
to emergency care policy played a pivotal
role in the buy-in and mindset of key
stakeholders.
This example is part of a broader drive
for patient-centric policy reform in South
Korea. Seoul’s Innovation Bureau11
started
out in 2013 and introduces a crowdsourced

approach to developing the best ideas
for improved healthcare, amongst other
topics. Citizens are involved at the very
earliest stages of decision-making and
submit ideas for review by civil servants.
The most powerful impact is the way
that these ideas necessarily cut across
traditional government silos and force
them to work together in new ways.
In the UK the NHS Digital web team
worked with service design company
Nile to take a service design approach to
developing innovative digital services.
NHS Digital is committed to developing
digital tools and services that support
staff to deliver better care or that help
patients to interact with their health
service. The organisation is hugely
complex, providing over 370 products,
services, audits, statistics, tools, data sets
and data collections to a wide range of
user communities. The NHS Digital web
team needed help to apply service design
thinking as a way to reimagine the way it
serves B2B users through digital channels,
bringing their users into the heart of their
future offering. Nile’s role was to support
them to shift the way that they thought
about users, enabling them to change
their approach to align better with user
needs. In particular the understanding
of regulation around the use of data was
central to ﬁnding viable ideas for the
future. Prototypes and client testimonials
quickly became a rallying point for the
NHS Digital web team, who are now using
service design to bring customers into the
very heart of their business development,
saving time and money when creating and
delivering products and services for users
across the country.
“After elaborating the patient
experience by employing
service design, we could
observe interesting changes
in the policymaking group.
The professionals naturally
started mentioning patients
and proposing solutions for
them. When the project was
started, they mostly talked
about the system itself or
the quantitative achievement
of performance, but no one
talked about patients.”
Jungha Ku, Healthcare
Strategic Designer and
Co-founder of DESIGNCARE

In Sweden, design consultancy
Transformator collaborated with the
Swedish Association of Local Authorities
to increase participation in cancer
screening programmes for women. One
of the outcomes was the introduction of a
new national guideline for the invitation
to participate in the programme and book
an appointment. The new guideline was
tested in a quantitative study and found to
boost participation by a record 11 percent
and up to 20.6 percent in some age groups.
Crucially, it was the close attention to the
needs of different groups, their motivations
and expectations, cultural barriers and
the complexities of daily life that led to a
highly visual and effective communication
that inspired action. The bringing together
of experts from many disciplines – design,
communications and medicine as well
as the patients themselves – was key to
ﬁnding viable solutions for the problem of
inattendance. Find the complete case for
this project on the following pages.
THE FUTURE
In summary, design is having an impact on
service policy and regulation in healthcare,
but there’s much more to be done. What
we are seeing is:
1. In places, designers and design are
already playing a central role in shaping
policy and regulation in healthcare,
but this is still in its infancy. Service
design is playing a larger role in some
countries more than others and is still a
very new idea for many key inﬂuencers
and stakeholders in healthcare. A renewed
campaign to demonstrate evidence for the
value of design in a way that everyone can
engage with will be important in building
credibility. There’s also a need to build
design capability more widely in the sector
so that it becomes embedded in the culture
of healthcare organisations, not a one-off
engagement or an outsourced activity.
2. Service design has great potential to
shift the mindset of policymakers and
regulators by involving users earlier.
One of service design’s simplest and most
powerful strengths is its ability to build
empathy and understanding with users
by lowering the barrier to access and by
making sense of what they tell us. This has
had a transformative effect where design
methods have been applied, and will
continue to do so in the future. This may
even lead to mandatory involvement of
users in every policy. Let’s hope so!
3. Prototyping and controlled
experimentation is more likely to make
policies work for people. Design has
the ability to cut through traditional silos
and barriers by quickly making ideas
tangible and testable, and by showing how
disparate parts of the system need to mesh
together. This can have a powerful impact
on how policies are created.
4. Service design is beginning to
facilitate the art of the possible in
healthcare. Designers have an ability
to bring disparate stakeholders, services
and patients together to develop viable
ideas from unlikely and unconventional
sources. In complex intertwined systems
of suppliers, patients and medical
professionals this will be invaluable in
the future as the stakeholder map grows
bigger. Appropriate guidelines will also

enable start-ups, digital technology and
emerging healthtech companies to “plug
into” the bigger healthcare system in a
meaningful and controlled way.
5. Data and design will continue to play
an increasingly central role, but will
need progressive regulation to enable
true innovation across the entire
system. As we generate more and more
data about ourselves from a variety of
sources, and citizens take more proactive
ownership of their own well-being, new
regulation will be needed to determine
who can access and manipulate this data.
This is similar to the recent significant
regulatory changes seen in banking,12
which aim to allow customers to share
data across different providers. Recent
speculation points to a “blockchain” for
healthcare, a centralised secure ledger of
health records, which promises to solve
the problem of data standards and security,
so patients can confidently share their data
between providers.13
The nature of innovation necessarily
means not all ideas will work and so there
will need to be a higher tolerance for
uncertainty to allow for controlled failure
and experimentation. Frameworks and
guidelines uniquely suited to healthcare
that provide a safe space and time for this
to happen whilst still allowing for iteration
will be key. The good news is that this is
being solved elsewhere, and inspiration
can be taken from successful models
for innovation in other highly regulated
sectors, like financial services. Ultimately
it is trust in this new, collaborative and
user-centred way of doing things built on
evidence of success that will lead to better
healthcare for everyone.
1 Ministerial Statement OECD Health Ministerial Meeting January 2017 http://www.oecd.org/
health/ministerial/ministerial-statement-2017.pdf.
2 http://www.wired.co.uk/article/hospital-prescribing-tech.
3 https://www.forbes.com/sites/paullamkin/2017/03/03/fitbits-dominance-diminishes-but-
wearable-tech-market-bigger-than-ever/#797888bf7f4d.
4 https://www.statista.com/statistics/387867/value-of-worldwide-digital-health-market-forecast-
by-segment/.
5 http://www.un.org/en/sections/issues-depth/ageing/.
6 http://www.telegraph.co.uk/news/2017/03/17/security-breach-fears-26-million-nhs-patients/.
7 http://time.com/4857954/medicaid-medicare-fraud-412-charged-justice-department/.
8 https://www.instituteforgovernment.org.uk/sites/default/files/publications/Policy%20making%20
in%20the%20real%20world.pdf.
9 http://www.mikebracken.com/blog/on-policy-and-delivery/.
10 https://openpolicy.blog.gov.uk/2016/02/17/prototyping-a-new-health-and-work-service/.
11 https://govinsider.asia/innovation/inside-seouls-innovation-unit/.
12 https://www.gov.uk/government/news/open-banking-revolution-moves-closer.
13 De Meijer, Carlo R.W. 2017. “Blockchain in Healthcare: make the Industry better,”
Blockchain observations (Blog). Finextra 08 March. Available at https://www.finextra.com/
blogposting/13801/blockchain-in-healthcare-make-the-industry-better.

CHANGING MINDS TO SAVE LIVES:
DESIGNING FOR PREVENTION
MARIA PRIGOROWSKY
Swedish women are offered two national cancer screening programmes: Pap
test screening for gynaecological cancer between 23 and 64 years of age
and mammography for early detection of breast cancer from 40 to 74 years.
The general level of participation is high in international comparison but
varies greatly depending on age and socioeconomic background. How can
we encourage more women to take the time to go to the clinics to be tested?
The key groups are younger women under 30, busy middle-aged women with
families and jobs, and particularly women with lower levels of education
and less knowledge and tradition of participating. Last but not least, this
includes women that are new to Sweden from different parts of the world
with different cultural backgrounds and varying knowledge of prevention.
New insight from actually listening to women and taking their perspective
has led to redesigning the invitations to take the mammography and
gynaecological Pap smear tests in Sweden. Improvements in these new
invitations include encouraging the women, clarifying the purpose and
benefits of participating, and using a more comprehensible language and
tone. Participation in the screening programmes has increased as a result by
up to 20.6 percent in certain target groups.
THE STUDY AND RESULT IN SHORT
In cooperation with Transformator
Design, which specialises in service
design, and Kapi, a PR agency specialised
in intercultural communication and
reaching target groups living in Sweden
from other countries and with other
cultural backgrounds, new invitations
were designed after in-depth interviews
and co-creation with 90 women from
different parts of Sweden.
A randomised test with the “old” and “new”
invitations gave clear positive results in
the Stockholm region. In comparison to
all previous initiatives and steps taken to
encourage a higher participation in the
programmes, the new invitation turned
out to be the most effective by far, greatly
impacting participation. In March 2015
the Regional Cancer centre of Stockholm
and Gotland 2015 started to send out the

BACKGROUND
In order to help decrease the incidence
and mortality of cancer, Sweden adopted
a National Cancer Strategy in 2009. The
strategy takes a long perspective on a
national level and identifies many areas
of improvement. Prevention is one area
identified as crucial in the strategy. The
Swedish government made an agreement
with SKL and RCCs to provide suggestions
for activities within the different areas
around cancer. Each of these national
projects ran for several years and consisted
of national teams including experts from
medical fields. One of these projects aimed
to increase participation in mammography
and gynaecological screenings to at
least 80 and 85 percent respectively, as
well as trying to make the programmes
more accessible for a wider range of
socioeconomic groups. The project
involved looking over the organisation
of screening and different aspects to
ameliorate screening. During the project
in 2013, this led to contact being made
with Transformator and Kapi, who were
then engaged in the process of developing
the new invitations.
Previous studies had already identified
certain factors having a significant
impact on participation which could be
addressed:
• sending invitations with a pre-booked
time for screening
• issuing reminders – sending out a
reminder letter to women who did
not show up or reschedule
• providing easy ways to rebook the
date and time both via a phone service
and online
new invitation letters to test for HPV
and cytology tests. The two different
designs were sent out every second week,
alternating between the two. All women
invited were followed up individually after
90 days. The study ran until December
2015. The new design resulted in an 11.1
percent increase of women attending,
and among those invited to the HPV
test, an increase of 14.4 percent.
THE IMPACT IN YOUNG WOMEN
The largest effect measured as a result of
the newly designed invitations could be
seen among women under the age of 30,
with an absolute increase of 20.6 percent
and 17.8 percent in the age group 51–60.
However the new invitations had little
effect in certain suburban areas around
Stockholm. The population in those areas
has a relatively low income and education
level and the level of participation
has remained historically at the lower
end. These are also areas with a higher
proportion of recent immigrants compared
to the other areas in the study. More
studies are needed to better understand
the underlying variables and how
improvements can be made.
It is very positive that young women are
participating more as this may lay the
foundation and form habits that raise the
chance of early detection of cancer and
saves lives.
The new invitations are now gradually
being rolled out and used all over Sweden
via RCCs – Regional Cancer Centres
and SKL (Swedish Association of Local
Authorities and Regions), who provide the
templates for healthcare providers to use.

24
• creating a positive experience as well as ensuring personalised
treatment at the clinic
• increasing availability and options, such as providing the option to
screen in the evening or close to where the women work, rather than
where they live
MEET WOMEN WHERE THEY ARE
AND ON THEIR OWN TERMS
All women in Sweden should have access, feel motivated and
understand why such screening programmes are important. They
should also be able to feel that the service is easy, ﬂexible and safe.
Lastly, they should understand the importance of keeping up the
programme over time.
In order for this to become reality, the information sent out needs
to address these needs, be as clear as possible, and motivate people
to take action. As a result of the service design project, some key
recommendations were identiﬁed:
• Make it possible to communicate in all channels. A woman
has to be able to make contact in her preferred channel and
language when communicating with healthcare. Using a telephone
is still important, and it is often the people with the greatest
aversion to digital services who do not participate in screening
programmes. The new invitations all provide a web address as well
as a telephone number if the women have questions or wanted to
reschedule. There are also links to information in other languages
in the new invitations.
• Certain important information and communication from
society are still expected to come via a traditional letter in the
mailbox. This may of course change over time.
• Despite digitalisation, it is important to keep up traditional
channels if we want to achieve broad participation.
• Many women prefer to get the results after the screening via
telephone rather than in the mail, even if the results are normal.
• It is important to create a recognisable and cohesive identity
around screening on a national platform using common
guidelines and templates. Today there are many senders and
healthcare providers around the country with different names and
designs. A woman can get one invitation for mammography that
looks totally different from the one for a Pap smear for example.
• The information should be serious but not intimidating or
stressful. Focusing on the fact that participating in screening is
voluntary makes it sound less daunting.

DIGITISATION
AND E-HEALTH

SERVICE DESIGN IS
THE FUTURE OF HEALTHCARE
CATHERINE DESMIDT
Over the next few years, healthtech will
have a big impact across all areas of the
health sector, from self-care to doctors’
surgeries and hospitals. It will enable
patients to manage their conditions more
effectively and improve preventative
health, allowing us to lead healthy lives
for longer. Large organisations are now
teaming up with more agile healthtech
start-ups to create solutions that meet the
needs of both healthcare professionals as
well as those receiving care.
For example, Pﬁzer recently launched
its Healthcare Hub: London, in which
three start-ups – Echo, Cera and Give
Vision – are being supported to navigate
the complex NHS system. The aim is to
have these technologies implemented
in the NHS within 12 months. Another
pharma giant, AstraZeneca, recently
launched a tie-up with UK healthtech
start-up Umotif, which focuses on
digital patient data capture techniques
for doctors and clinical researchers.
These are all great examples of exciting
technology in the health sector, but what
actually makes a great digital health
deployment? We believe it should be a
combination of usability, accessibility
and a true need to fundamentally create
a positive experience. The technology
supporting the process should
intelligently adapt to humans, based
upon spoken and unspoken needs, in
order to solve a real problem in a logical
way. Much of the resistance surrounding
the implementation of new technology
in hospitals, for example, is based on the
time and effort it takes for the clinicians
to get to grips with it.
We’re now becoming more attuned to
designing services that adapt better to
human behaviour, which will improve
usability and increase the speed of
deployment. While this is exciting for
clinicians, it’s not the only beneﬁt a great
Whatever country you’re in, you’re probably hearing the same
thing regarding healthcare systems: they’re in need of support,
and they need it quickly. Ageing populations and chronic diseases
pose serious health challenges. And despite the fact that health
technology has been slow to develop and is technically still in its
infancy, there are exciting new developments aimed at solving
these challenges.

deployment offers. It’s also a chance to
eradicate bad practices and create better
experiences for patients across the globe.
It’s too easy right now to assume that the
best approach for a digital solution is to
take an existing analogue approach and
replicate it in digital format. If solutions
make use of an outdated, clunky pathway,
users will either become disengaged or
start to create their own desire paths –
circumventing the prescribed system to
find new, more efficient ways of getting
stuff done.
The digital revolution provides us with an
opportunity to design experiences which
are fit for purpose, benefiting consumers,
clinicians and administrators alike. The
tech-enabled services need to be intuitive
and simple to make it easy for people to
achieve an outcome.
Personalisation and personalised care are
crucial aspects of healthtech. We need to
constantly think about how to create more
personal solutions for users, by learning
from their behaviour and adapting
accordingly. Technology will support us
to understand someone’s unique illness
or condition and will adapt interactions
to provide nudges to take medications,
schedule doctor appointments, or change
a diet programme.
Intelligent service design isn’t a luxury –
it’s practical, essential and life-saving. And
it’s already happening. Everything from
Ikea’s Better Shelter1
, which has been used
to house thousands of refugees in war-
torn countries, to the SH:24 online sexual
health service2
, which empowers people
by removing the stigma of STI testing, are
examples of design invoking social change.
It can also save money. The gov.uk
website3
, launched by the Government
Digital Service (GDS) in the UK, pooled
multiple, confusing, disjointed government
websites into one place, not only making
it easier for people to find services they
needed, but also saving £61.5 million4
of
taxpayers’ money in 2015.
It is an exciting time for health technology,
but it’s important that we get it right.
Intelligent and intuitive design plays a
crucial part in this. By putting patients
at the heart of decision-making, we can
not only relieve the pressure in the health
industry, but also make taking care of
ourselves much easier.
1 Angus Montgomery. 2015. “IKEA creates flat-pack refugee shelters,” Design Week 26 March.
At https://www.designweek.co.uk/issues/23-29-march-2015/ikea-creates-flat-pack-refugee-
shelters/
2 Sarah Dawood, 2016. “Review: Beazley Designs of the Year at the Design Museum” Design
Week, December 6. At https://www.designweek.co.uk/issues/5-11-december-2016/review-
beazley-designs-of-the-year-the-design-museum/
3 Tom Banks, 2012. “Government launches one-stop-shop website gov.uk” Design Week,
February 1. At https://www.designweek.co.uk/issues/december-2011/government-launches-
one-stop-shop-website-gov-uk/
4 Stephen Foreshew-Cain, 2015. “How digital and technology transformation saved £1.7bn last
year”. UKGOV, 23 October 2015. At https://gds.blog.gov.uk/2015/10/23/how-digital-and-
technology-transformation-saved-1-7bn-last-year/

PROTOTYPING CITIZEN-CENTRIC ACCESS
TO ELECTRONIC HEALTH RECORDS
JERRY KOH AND SHAHAB-SHAHNAZARI
In 2015, MaRS Discovery District’s
MyHealth project team embarked
on a project to tackle this problem
head-on, using citizen-centric design
and prototyping to understand and
deliver better infrastructure, business
models and policies. Partnering
with Bridgeable, a Canadian service
design firm, we were able to develop
and present a set of compelling and
powerful ideas to the Ministry of
Health and Long-Term Care and
eHealth Ontario.
Everyone agrees that granting citizens access to their own
personal health records would be valuable not only to families, but
also to the entire healthcare system. While the primary audience
for health records has always been medically trained healthcare
practitioners (HCPs), increased interest in consumer health
tracking – for example through the use of apps and wearables –
has demonstrated a willingness for citizens to control and manage
their own data.
In Ontario, Canada’s most populous province, progress towards
this goal has been steady, but slow. Standardising electronic health
records (EHRs) for over 14 million citizens across the province has
uncovered specific risks and opportunities for citizens and requires
a delicate balancing act between privacy and security, consumer
demand and increasingly affordable consumer health solutions,
clinical care and safety, healthcare business viability, technology
possibilities, and feasibility.
In our preliminary research, it became
clear we were missing the context
of how citizens as consumers would
use their own EHR data. Much of the
thinking on EHR implementation was
driven by healthcare administrators and
clinicians. But what would consumers
do with their own EHR information?
How would this benefit the healthcare
system? In our current state, we were
simply speculating, often using the most
conservative lens to discuss the benefits
and the worst-case scenarios.

MaRS and Bridgeable used a service
design approach that focused on
the needs of citizens. We wanted to
understand and probe deeper on:
• concerns over how people might use or
misuse their data, and how to best share
that data with others in the care circle or
with third parties
• how to ensure policies and regulations
put in place by the government are
informed by realities of usage
The design team focused their efforts on
maternal and paediatric health in the first
24 months. New mothers were deemed
the ideal group because of their multiple
interactions with the healthcare system,
along with their personal tracking of
feeding, sleeping, etc. and their market
potential for commercial solutions.
The design challenge was to look at the
intersection of data from EHRs and
information being tracked by mothers
in the first 24 months and explored
questions such as:
• What EHR data is most
relevant to mothers?
• What would data entry and
sharing look like?
• How do “personal” data and
“clinical” data work together?
• How is this designed in a way
that is attractive and usable?
At the beginning of our journey we
engaged with fifteen new mothers to
explore the value of clinical health
information in their lives, to understand
Participatory research
with mum and baby
to understand health
data tracking

where they have interactions with
health data and the health system, and
what those pivotal moments look like.
Amidst babies playing (and sometimes
crying), mothers shared their stories and
experiences, and we listened.
What we heard was that mothers did
not feel a sense of control over their
baby’s health and well-being, or in
navigating the health system in general.
The underlying issues were rooted
in what was lacking in the system
– convenience in accessing health
information, consistency in what the
health information tells them, credibility
in the source of that information,
and contextualisation in the way the
information is displayed. These “4 Cs”
moved with us throughout the design
process, serving as the anchor for our
design solution.
We invited mothers to share their needs
and desires with health innovators and
HCPs, and to work collaboratively with
them to design prototypes that would
address a specific gap or need. Putting
mothers, HCPs, and innovators in a room
together where they could listen to one
another’s needs was an inspiring and
energetic experience for the design team.
The day was filled with insightful dialogue
centred around three scenarios that had
been identified as top-of-mind concerns
for mothers during earlier research.
Mothers and babies,
HCPs, government
representatives and
healthtech innovators
participate in co-design

Through co-creation, the design team
identiﬁed three creative concepts from
which to build a solution, as well as
three major insights into what control
looks like to mothers. As a result, we
came to realise that our solution had
to centralise data, be extensible, and
provide actionable messages.
Over the next two months, we entered
into a very rapid cycle of prototyping
and iteration. The design team tested
prototypes with mothers in studio, in
HCP waiting rooms, and within their
own homes. Throughout the process,
the team was continuously adapting
and evolving their service solution, and
deepening their understanding of how
the province needed to establish its
infrastructure and policies.
The result was BabyBundle, a service
consisting of a suite of apps to help
mothers better manage their child’s health
and well-being, as well as their own.
BabyBundle’s core features included:
tracking and summarising data, giving
mothers access to their child’s health
records, and allowing them to share
information with different caregivers and
doctors in their child’s circle of care. It
provided users with a whole ecosystem
of tailored solutions that focus on
consolidating a baby’s health information,
giving mothers an at-a-glance view of
their child’s health and well-being.
The BabyBundle prototype and associated
research provided a unique starting point
in our discussions with the Ministry of
Health and Long-Term Care (MOHLTC),
The BabyBundle service consisting of a suite of personal and clinical data tracking apps

eHealth Ontario, and other health system
stakeholders. The prototype allowed us
to make tangible what was previously
only speculation on the ways in which
consumers would interact with their
EHRs and what data they did and did not
want access to. Significant roadblocks,
such as concerns over data security and
access became real and solvable in the
context of a service. For example, by
prototyping how mothers share data
with their circle of care, we saw that
maintaining secure access could be done
simply if permissions were granted on an
individual user basis.
Ultimately, applying a service design lens
allowed us to propose something that
was intrinsically compelling which also
addressed some important unmet needs.
We understood how mothers desire real-
time access to their baby’s milestones,
such as their immunisation schedule and
growth chart, particularly in the often
stressful first year of life. For mothers of
children with serious medical conditions,
we understood that EHR access meant
the ability to aggregate complex data sets
from various specialist consults, labs,
and results into one single touchpoint.
By addressing specific challenges with a
citizen-centred prototype, we achieved
greater momentum to drive system-level
changes across the province.
The BabyBundle work resulted in the
launch of Project SPARK (projectspark.
ca), a partnership between MaRS, UHN
and eHealth Ontario with support from
MOHLTC. SPARK has continued this
work to enable citizen-centric access to
EHRs, while recognising the limitations
that exist within the system: its policies,
practices and technologies. SPARK is
focused on:
• enabling access to EHR and
related data for the 14 million
people in Ontario
• involving app developers and
solution providers as intermediaries
to provide context and value-add to
the data access for their end users
• connecting app developers
and solution providers to various
provincial data assets (e.g. OLIS,
DHDR, DHIR, DI-rs, etc.)
Our biggest learning to date is that
the desire to enable access from the
healthcare system side is insufficient.
Infrastructures, systems and processes
that currently exist mostly apply to
health institutions. These need to be
redesigned and optimised in order
to enable robust, scalable and more
widely applicable access for non-
healthcare institution access. Data-
sharing agreements, or lack thereof,
are particularly thorny. We are working
through the challenges and fixing them
as we go.
In the next phase of the project, we
are aiming to connect five healthcare
provider-associated applications and
five direct-to-consumer applications.
Through prototyping and iterating,
we will continue to engage, map, and
optimise EHR data access solutions
with the goal of fully enabling high-
value access and use of EHRs for the
people of Ontario.

System map defining the variety of clinical and non-clinical data sources and caregivers

ACHIEVING BETTER HEALTH
THROUGH A BALANCE OF
TECHNOLOGY AND HUMAN TOUCH
JAMIE THOMSON
“Imagine this… Creating a hospital
that doesn’t want people to visit. Not
because we don’t care – but because
we do. Imagine a hospital that believes
healthcare doesn’t just mean treating
sickness. It means caring about our
patients enough to keep them from
getting sick in the first place.”
Dartmouth-Hitchcock’s vision of a sustainable health system1
As United States healthcare shifts slowly from incentivising only the
volume of care delivered to rewarding value and quality of care, hospital
systems have been spurred to find innovative ways of engaging with
patients to achieve health behaviour change and better clinical outcomes.
One such organisation is Dartmouth-Hitchcock – an academic medical
centre and regional health system headquartered in New Hampshire. As
a leader in population health management and value-driven, evidence-
based care, they recognised an opportunity for new technologies to help
them better serve patients, particularly across rural areas of the region.

With this vision in mind, Dartmouth-
Hitchcock founded ImagineCare – a
start-up with the mission to create a
truly proactive, human-centred service
that supports people beyond the hospital
walls, whenever and wherever they might
need care.
ImagineCare combines mobile devices,
Bluetooth-connected sensors, and a
24/7 telehealth clinic, where clinicians
monitor and care for patients with the
help of evidence-based care algorithms
and machine learning. Through the
mobile app, customers have an open line
of communication to the ImagineCare
clinical team via chat, video call, or phone
call. A trained team of “health navigators”
provides health coaching, motivational
interviewing, and general customer
support (they even deal with insurance
issues!). On-staff registered nurses
provide professional care to resolve
customers’ needs over the phone, or triage
to the appropriate medical facility.
When first starting out, the
ImagineCare team struggled to find
a technology platform on the market
that met their needs. Too many
solutions were:
• too focused on specific conditions,
rather than seeing the whole person
• too focused on physical symptoms,
neglecting mental health
• too focused on technology and
automation, diminishing the
personal nature of healthcare
To address these issues, Dartmouth-
Hitchcock partnered with Mad*Pow
and Microsoft to build a technology
platform that would solve these issues.
Microsoft brought to the table their
robust cloud platform and customer
relationship management software.
Our team at Mad*Pow provided web
and mobile app development, human-
centred design leadership, and deep
expertise in healthcare service design.

The ImagineCare project kicked off with an abundance of passion
in early 2015, and our ﬁrst step was translating passion into product.
The ImagineCare team had lots of great ideas and strong clinical
expertise, but they needed help determining how customers and
clinicians would interact via the service. After conducting stakeholder
interviews, we held a design workshop with clinicians, product
managers, and executive leadership to help everyone get on the
same page and start visualising their ideas. Design isn’t just for ‘the
designers’ – it’s something everyone takes part in.
These early activities provided a ﬁrm foundation of principles that
guided our work, from customer research and design exploration to
narrowing in on the minimum viable product for launch.

PRINCIPLE 1: ‘CUSTOMERS’, NOT ‘PATIENTS’
The language we use when designing a service should be deliberately
crafted. Consistent terms and definitions enable clear communication
within the service team, as well as between service providers and
constituents. But the dialect of a service is not only about clarity and
efficiency – it is also a key ingredient in the organisation’s culture, with the
power to reinforce the principles and values of the service.
For example, ImagineCare decided early on that the team would use the
term ‘customer’ instead of ‘patient’ to refer to users of the service. The
term ‘customer’ reminds us that their needs must always come first – a fact
that often gets lost with all the financial middlemen in the US healthcare
system. ‘Customer’ is also more inclusive of people in their day-to-
day context – even people managing chronic conditions don’t think of
themselves as ‘patients’ 24/7. They’re just people, living their lives.
PRINCIPLE 2: TECHNOLOGY THAT BUILDS SELF-EFFICACY, NOT
JUST ENGAGEMENT
In the design of health apps, organisations often see engagement with
the technology as the primary goal, when it’s really a means to an end.
We must stay focused on the true goal – helping people take control of
their health, so they can take the best possible care of themselves and see
measurable improvements.

Our design process at Mad*Pow leans heavily on self-determination
theory 2
to support people in changing their health-related behaviours.
So, we were thrilled to hear the Dartmouth-Hitchcock team talk about
the staples of this framework – supporting human autonomy and
building competence in the skills required to achieve their goals.
Designing for health management and behaviour change is not just
about pushing notifications and spitting data at people – the tone
that you use with people, and the ways communication occurs, are
critical in building motivational relationships. ImagineCare never
attempts to dictate or control. Both the humans and technology of
ImagineCare are designed to be patient and understanding – a great
listener who provides a sense of calm. They use non-pressuring,
informational language that is emotionally aware and cognizant of
the customer’s needs, wants, skills, knowledge, and priorities. While
app messages and phone calls are used to nudge patients, these
always consider the communication preferences the customer has
expressed in his or her profile.
The one exception is clinically dangerous situations, for which
ImagineCare’s 24/7 staff will always initiate a phone call. In early
research, we wondered if users would find this ‘someone is always
watching’ factor to be creepy. But we’ve found the exact opposite – in
the words of an ImagineCare customer, “The real-time interaction
with the ImagineCare team makes me feel like someone is looking out
for my health and best interest.”
PRINCIPLE 3: A HUMAN SOLUTION, ENABLED BY
TECHNOLOGY
Automation and digitisation are not panaceas; the human element will
always be critical in healthcare.
When we tested potential chat messages customers might receive from
ImagineCare, our research participants strongly preferred messages
that were attributed to a user with a human photo and name. Based
on this finding, we debated using automated messages that appeared
to come from a human, to entice customers into conversation or make
them feel more accountable to the service. However, the ImagineCare
team had a strong desire to build trust and always be authentic with
its customers, so we settled on the ‘ImagineCare Team’ bot as the
purveyor of automated messages.

At the core of ImagineCare is this idea of forming authentic
personal relationships – understanding the whole person – beyond
their medical data to their stressors and favourite sports teams.
An understanding of their everyday lives helps us suggest realistic
strategies to help them take control of their health. Of course, this
is a lot of data to manage, so we worked closely with the nurses of
ImagineCare to co-design a dual-screen dashboard that provides a
robust set of customer data with minimal clicks – all in an interface
that is as warm and friendly as the ImagineCare customer app.
Even though much of this data is machine-readable in the customer’s
proﬁle, building a nuanced understanding of the person and
cultivating rapport and trust is something only humans can do well
at this point – Siri, Alexa, and the rest just aren’t there yet. For now,
ImagineCare divides the labour smartly, letting machines do what
machines are good at, and letting humans do what humans are good at.

PILOT IMPACT & FUTURE GROWTH
As a start-up within an academic medical centre, ImagineCare was
designed to be tested and iterated on early and often. The minimum
viable product focused on hypertension, congestive heart failure,
COPD, and diabetes – prevalent conditions with clear treatments that
struggle for efficacy in the real world. While the initial pilot targeted
a speciﬁc set of conditions and sensors, ImagineCare is designed to be
condition- and device-agnostic, so it can be extended to any condition
by adding the appropriate clinical algorithms and sensors. Also
currently supported are core health pathways of activity, sleep, and
behavioural health.
More than 2,700 customers enrolled in the 2016 pilot. The
ImagineCare clinician services received a 95 percent satisfaction
rate from customers, and the programme engagement was four times
the national average for employer health and wellness programmes
(Towers-Watson 2013/2014 Staying@Work survey).
Customers with hypertension experienced a 50 percent reduction
in poorly controlled blood pressure, and compared with a matched
control group, the pilot population saw:
• 56 percent reduction in hospital admissions
• 23 percent reduction in emergency room costs
• 6 percent reduction in avoidable emergency room visits
• USD 255 total cost of care savings per member per month
ImagineCare, Dartmouth-Hitchcock spun it off as a stand-alone
venture. More than a dozen entities bid for ImagineCare, and in 2017
it was purchased by Swedish company LifecareX, which is continuing
its development. Mad*Pow continues to support the design and
development of the solution as it advances to its next pilot test in the
autumn of 2017.
1 https://www.youtube.com/watch?v=ntSFa0GztCQ
2 https://vimeo.com/131690121

COMMUNITY
ENGAGEMENT

COMMUNITY ENGAGEMENT:
FROM DESIGN TO IMPLEMENTATION
JESSICA DUGAN AND DAN BUTT
As service designers at UnitedHealthcare,
a large healthcare organisation that
serves millions of unique members who
have many needs and are from all walks
of life, we are often tasked with designing
solutions that can scale across multiple
lines of business and multiple markets.
Over time, we have come to learn that
in order to ensure scalability, at a basic
level, the elements of a well-designed
service need to be 90 percent fixed and
10 percent flexible. And it’s in this last
10 percent – during the implementation
process – that a service can be refined,
adapted, and customised to fit the unique
needs of a new community or population
and also increase the likelihood of
adoption and buy-in.
Knowing how a service needs to scale
will help determine the elements of
the service that need to be fixed or
flexible and will dictate to what extent
infrastructure needs to be built to
support operations on the ground,
especially when there is limited
organisational capacity to assist in
implementation.
We are going to use three case examples
to illustrate our insights into community
engagement: Claim More – a diabetes
prevention service for African-American
women; myConnections myCommunity
Connect Center – a platform of solutions
to address the social determinants of
health in an urban setting; and Rural
Health – an approach to filling the
resource gaps in rural America.
CO-DESIGNING THE
LAST 10 PERCENT
The process of incorporating co-design
into the implementation of a service
begins with the identification of an
influencer who is willing to participate in
the customisation of the service and quite
Itiswellunderstoodthatco-designingwithusersthroughouttheservice
design process is critical to the creation and adoption of meaningful
service experiences. Practitioners following the traditional service
design process, which incorporates co-design during the ideation
phase of a project, are often successful in creating thoughtful solutions
that are well-received by the population for whom it was designed. But
co-design can also help ensure that our well-thought-out designs will
scale – that they will be able to reach beyond our initial user base to
others who can benefit from the same solutions. We believe that co-
design also has a place in the implementation process.

often take ownership for all or a portion
of the service delivery. An influencer is
someone who has significant credibility
in the community or population you
are engaging, has an ability to create
change within this community, is well
established, and has a stake in the issue
you are solving for.
Influencers have three core roles in
supporting co-design: connecting
stakeholders with the environment,
navigating cultural dynamics, and
executing and customising the delivery of
the service experience.
In the case of Claim More, the identified
influencer was an entity, the African-
American church, and more specifically
the First Lady (or another respected
female) of the congregation. The First
Lady, the wife of the pastor, often has
celebrity-like status in her community
and is frequently responsible for driving
social programmes and initiatives with
the church.
In one church community that piloted
the Claim More service, the First Lady
(called a Church Champion) harnessed
her visibility and influence in the
church to not only connect with and
recruit female congregation members
for the programme but also hold
them accountable for attendance and
participation in the wellness service. She
tailored the content of service to match
the theme of the liturgy preached by her
husband and engaged the whole church
in the platform, going as far as to hire a
composer to create a Claim More theme
song to be played at services.
For the myConnections myCommunity
Connect Center (CCC), the influencer was
a trusted, local community development
organisation in Phoenix, AZ, Chicanos
Por La Causa (CPLC). The organisation
had been catering to the needs of an
underserved, largely Spanish-speaking
population for decades and became not only
the metaphorical front door to the platform
of myConnections services, but also the
physical delivery location. Working with
CPLC to understand cultural dynamics, the
Phoenix CCC featured culturally relevant
artwork and messaging, and staff members
were well-versed in the needs (and
language) of the local population.
Through our research into Rural Health,
we learned that each small town had its
own unique influencer. For some, as in
rural Mississippi, it was the local mayor,
for others, as in rural South Dakota, it was
the guidance counsellor at the local high
school. These influencers not only sought
out support from large organisations like
regional health systems, but also worked
to ensure execution of their efforts such
as providing transportation for students
to a mobile dental care van. While doing
work in Kansas, a local Community Health
Coordinator, an employee of another local
payor, connected our team with key players
across the ecosystem who were, in turn, able
to support us in creating a picture of the
gaps and assets in the region.
DETERMINING HOW TO SCALE
Designing the fixed 90 percent of the
service helps us establish several things: (1)
the core value proposition we’re delivering,
(2) the key service elements needed to

deliver that value proposition and (3) our
organisation’s defined role in the process.
Allowing for a flexible 10 percent gives
us the ability to add or adapt additional
service elements, service nuances or
service delivery partners depending on
the existing local context. Determining
how much flexibility needs to be included
in the last 10 percent depends on the
strategy by which we want to scale.
If the service is scaling across a similar
affinity group, as with Claim More, where
the platform was scaling across different
African-American church communities,
the customisation happens within the
nuances of the service, while the service
model, platform and the touchpoints,
for the most part, remain fixed. While
the environment is relatively similar,
the specific preferences and contexts
of who is leading and/or participating
in the service are different and needs
to be accounted for in the delivery. For
example, in the Claim More service, the
Church Champions could customise the
templates with the name of the church
and establish and name small support
teams which were referred to in the text
messaging platform.
If the service is scaling to a new
environment, as with the myConnections
CCC, where the service platform scaled
across different urban geographies,
the service customisation happens
within the internal and external service
delivery roles, as well as within the
context and culture in which the service
is being delivered. When scaling to a
new environment, the service model
and platform remain fixed, but key
operational touchpoints need to adapt.
For example, when myConnections
established a second presence in Detroit,
MI, they offered the same core services.
However, this time, they partnered with
a variety of social service partners, such
as Dream Center Pontiac, to coordinate
and deliver the core components of
the platform in multiple locations
across Detroit. myConnections also
had to consider the different cultural
context in each city, looking to tailor
the welcome materials and messaging
to a predominantly African-American
population.
If the service is scaling to a new
ecosystem, as with Rural Health, where
the needs of the community and the gaps
in the service would broadly differ, the
customisation happens in the service
model itself. In this case, the environment
and nuances may be so different from
one implementation to the next that you
may need to reconsider the best approach
to solving unique local problems or
engaging the right stakeholders. New
service elements might also be added to
meet specific needs. However, the service
platform and value proposition would
remain intact. For example, in Rural
Kansas, we discovered that the primary
lever to improve access to care was to
improve access to specialty care. A series
of models addressing this issue became the
starting point for scaling health services to
that particular ecosystem.
Understanding how your service needs to
scale helps determine elements that need
to be customised for the local context.
Each layer builds on the layer below it,

for example if a service is scaling to a
new ecosystem, the service model, the
delivery of that service, and nuances of
the service all must be considered.
SCALING THE LAST 10 PERCENT
To achieve true scalability it is not
possible for a large company, such as
UnitedHealthcare, to work hand-in-hand
with each individual influencer who is
implementing a service. To that end, the
fixed components of the service need to
be accessible and approachable enough
for an influencer to pick up and execute
on their own, to varying degrees.
For Claim More, the Church Champion
was given access to a variety of
presentation slides, templates, and a
video and text messaging service that
contained diet and nutrition information
which were designed in collaboration
with an African-American Nutritionist.
At a minimum, access to a computer and
an Internet connection was all that was
needed to enable delivery.
In the case of the myConnections CCC,
UnitedHealthcare has a more hands-
on role including dedicated local staff
members who work with the influencer
to determine the right services to offer,
the right cultural framing of the service,
and the right mix of partners to deliver
those services. However, the influencer is
responsible for the day-to-day operations
and service delivery.
In Rural Health, the service coordination
was to be largely directed by local
and state business partners across
UnitedHealthcare who would have
access to a toolkit to help assess the local
rural ecosystem and determine a plan
of action to move forward. They would
engage the influencer to help assess the
gaps in the ecosystem and connect to
local delivery partners.
KEY LEARNING
Co-design is a powerful tool in the
arsenal of any service designer. While
sometimes relegated as an ideation tool,
it can be used effectively across the
design process to enable trust, buy-in,
and successful implementation of a new
or re-engineered service model.
FLEXIBLE SERVCE COMPONENTS
Service Model
Service Delivery
Service
Nuances
EMPOWER LOCAL
INFLUENCERS WITH:
Fixed platform, Flexible models
Gaps/Assets assessment
Context assessment tools
Range of service models
Fixed platform, Fixed platform
Culture/Context assessment tools
Customisable templates forkey
operational touchpoints
Fixed model, Fixed platform,
Fixed Touchpoints
Customisable tools and templates
to enable delivery nuances
HOW DO YOU
NEED TO SCALE?
To a New Ecosystem
What changes? Key stakeholders,
local problems to solve, available
local resources
To a New Environment
What changes? Local context and
culture, internal + external roles
and relationships
Across a Similar Affinity Group
What changes? Specific delivery
site preferences and context

MAKING MUMS MATTER:
BEYOND TOKENISTIC PARTICIPATION
IN DESIGN FOR MENTAL HEALTH
PAOLA PIERRI AND DR LAURA WARWICK
Studies show that up to 20 percent of women will develop
a mental health problem in the perinatal period (which is
the period from pregnancy to the child’s first birthday),
including problems such as: antenatal and postnatal
depression, obsessive compulsive disorder, PTSD and
postpartum psychosis1
.
In June 2015, Mind, a mental health organisation in the
UK, decided to design a new, branded service for women
in need at this time in their lives. Mind is the largest
mental health service provider from the voluntary sector.
They are a federated organisation with a network of 140
local organisations, which are all independent charities in
their own right.
As part of a wider programme to embed service design
in the organisation, Mind started a collaborative process
to involve users and other key actors to understand the
issues and identify the possible solutions. They used
social media and the organisation’s website to recruit
women with lived experience of perinatal mental health
problems to work with them on this project. They received
100 applicants and from those, they selected five women
who became the co-designers and co-researchers for
this work. Alongside two other local mental health
organisations, these five women formed part of the
co-design group whose aim was to uncover values and
unmet needs of women with perinatal mental health and
translate this into a service offer.

CO-DESIGNING ‘MUMS MATTER’
‘Mums Matter’ is a new service for mums
with perinatal mental health that was
co-designed by a mixed group, comprised
of: one designer who acted as facilitator;
five mums with lived experience, who
were actively involved in the design work
and acted as design researchers and co-
designers; and two managers from two
local mental health organisations, who
brought to the group their expertise on
service delivery and perinatal mental
health. Experts from different fields
(communication, resilience and well-
being, etc.) were also invited to join
during the key stages of the design work.
The service was developed in monthly
workshops: Set-up, Explore, Generate,
Make and Grow. Each workshop was
split into three parts:
• discussing the design activity the co-
researchers had done in the run-up to the
session;
• using their findings to shape and refine
the service proposition;
• and then discussing and planning the
next stage of the process.
Immediately after the set-up phase,
when the group established its own aims
and defined its role (with the mums
as active co-designers and not passive
commentators), the mums took part in a
day-long training session in which they
were introduced to the principles of the
design process and the research phase in
detail. This helped the co-designers to
become more confident and familiar with
the process and learn how to ask the right
questions and work in a designerly way.
Once they felt more confident in using
a design language and the process, the
co-design group defined the research
brief and the key research questions
they wanted to explore. The fact that
this was developed collaboratively by
all the actors involved, and drew on the
personal experience of the five women,
helped us to identify rich questions
and unpack complex dynamics that
were raised from the different points
of view represented in the group
(service delivery, management,
lived experience). The research was
conducted entirely by the five co-
designers, who interviewed 20 women
with lived experience, one relative and
eleven experts.
It was during the analysis and idea-
generation phase that the group
collectively decided to focus their new
service on the post-natal period, as in
this phase there was more evidence
of demand and commonality of needs.
They analysed their main findings,
and from these created a design brief
that outlined the opportunity that they
wanted to address. The group then
generated ideas on ways to address
the main needs, and each of the co-
designers described the idea that they
liked the best in a storyboard. From
the testing, iterating and combining of
the different ideas, the group identified
the ideal service offer, which they
named ‘Mums Matter’. In subsequent
workshops, particular attention was
paid to how the service should be

presented and described to potential
service users, with prototypes produced to
test key ideas.
The final design the mums developed was
a six-week course, which would introduce
key content on:
• How to manage the everyday.
The research showed that mums needed
strategies to help them to address their
mental health needs, alongside the
demands placed on them as a parent);
• Dispelling myths about maternity.
We found that in times of distress mums
can be given advice and information, for
example “sleep when the baby sleeps”,
that could make their own circumstances
worse, by putting more pressure on them
to ‘fix’ things);
• Advice on how the women can
nurture themselves, both their bodies
and minds.
Our findings showed that mums need
ways of reconnecting with their identity to
be able to still do things they used to enjoy.
The mums can access a fully paid-for
crèche, so that they had time and space
to share their feelings without needing to
look after their children. At the end of the
six weeks, mums would be encouraged to
meet up in the community with members
of the group, supported by their facilitator,
to help them get used to supporting each
other with their children around.
There is also an optional session, separate
to the course, for supporters of the mums
(this could be a partner, relative or friend)
to learn more about perinatal mental
health and how to help them.
ITERATING AND SCALING-UP
Following the end of the design phase,
the Mums Matter service idea was
developed further with the help of a
perinatal mental health practitioner,
who used the prototypes and a service
blueprint to create the content that
the mums described. The service was
then tested twice with service users
experiencing real need across locations.
After each weekly session, the designer
held a debrief with the facilitator to
capture the key learning about the
course. These reflections were combined
with service user data, including mental
health questionnaires to assess well-
being at the beginning and end of the
course, service feedback questionnaires
and an independent interview, to help the
team reflect on the design of the course
before the next prototype began.
In each prototype, the data showed that
the women had all valued the course and
their well-being had improved, but there
were still improvements that could be
made to the service experience. The table
below outlines some of the insights that
came out of the reflective session on the
prototypes, and the resulting changes
made to the service in the next prototype.
Feedback from mums showed that the
service was of real value to them: Mum
A from Cohort 1 said “It helped me
identify ways to constantly work on my
mental health and I’ve made some good
friends,” while Mum B from cohort 3
said “I feel like it exceeded my
expectations. I was not expecting the
bonding and open sharing which made
me realise that I was not alone.”

The service was submitted for funding to
Comic Relief, who subsequently invested
£120,000 to pilot Mums Matter at scale
in Wales over two years. Thanks to this
investment, local Minds will support 200
women with mental health problems in
the post-natal period. The pilot will also
allow the team to gather clinical evidence
and costings, which will help the
organisation to package Mums Matter
as a fully developed and costed product,
available for other local Minds to deliver
under licence.
INFLUENCE AND PARTICIPATION
THROUGH DESIGN
Voluntary and community sector (VCS)
organisations that operate in healthcare
have traditionally played a role in
ensuring that the patients’ voice is heard
and services are shaped accordingly.
This service design case study builds
on the experience and expertise of the
sector in service users’ engagement,
and there is an ongoing tradition of peer
support and expert users. Listening
is possibly one of the most important
aspects of the engagement work. People
with lived experience of mental health
problems often feel that they have not
been heard in other parts of their lives,
so listening to what people have to say
is where a good practice of design in
mental health starts. Although there is
still limited evidence that participating
in co-design intervention could have a
positive impact on mental health2
, some
anecdotal evidence emerged from this
project that design can have an impact
on people’s mental health and well-
“I feel like it exceeded
my expectations. I
was not expecting the
bonding and open sharing
which made me realise
that I was not alone.”
Mum B from cohort 3

being. Similar research available on
mental health and co-production would
lead us to think that this effect should
be positive, and by increasing people’s
confidence and their feeling of being
worth, truly participatory design could
have a positive impact on increased
well-being. But we are also aware that
taking an active role in a design project,
as our co-designers did, could create
stress and anxiety for some participants.
The impact of co-design on participants’
well-being needs further research and
understanding.
But the real value of service design in
mental health is about its capacity to
think systemically and in a creative way,
going beyond just the users, and to use
people’s stories and experiences and turn
them into real opportunities and service
ideas, which can be visualised, tested and
delivered.
On the other hand, what design can
learn from the VCS tradition is the
ethos towards a value-based system
of participation, which looks at the
value of users’ engagement, not only
from the perspective of more efficient
services, but also from the point of
view of democratisation, as people – as
citizens – have the right to participate
in the design and delivery of the health
services they use.
After four years of working to embed
service design in a mental health
organisation, the authors are highly
convinced that from the encounter
of design and value-based systems of
engagement, an enriched definition of
participation in design can be developed
and flourish, and users could be
supported to go up in the ladder of
engagement, towards co-design and
beyond, to co-production3
.
Summarising, in this enriched definition
of participation in design for healthcare:
• Innovation in services comes from the
act of listening to the lived experience of
users and their families and friends and
their involvement in all the key phases of
the design.
• The designer gives away their exclusive
professional role, to recognise new and
diverse stakeholders and their expertise.
• Time is allowed for people to grow
in their confidence in using design
techniques and building on their
lived experience and knowledge,
and for co-design to move beyond
quick-fix solutions and open up more
transformative change.
CONCLUSIONS
Our Mums Matter case study demonstrates
a different way of doing service design,
which includes a different range of
stakeholders, and also exemplifies
a different level of engagement and
participation of those stakeholders (from
passive commentators of the design work,
to active co-designers).
For those working in healthcare who
would be interested in replicating a similar
model and expanding the participation
in the design phase to a wider range of
actors in the ecosystem, we can share the
following learning and reflections, which
we hope will be useful:

1. Users are still the most
underutilised resource in the
healthcare system.
Training and support to transform
passive users into active designers are
fundamental. For people to genuinely
take part, they need to learn in advance
what design involves, what the next
steps will be, and what it entails to work
in a designerly way. Conﬁdence in these
new skills takes time to grow but is the
best way to tap those underutilised
resources and to move people from
simple engagement to becoming
responsible for the design of a service.
2. Values are central to
motivating people to take part
and act in this field.
Users are tired of tokenistic exercises
for participation and they immediately
recognise whether the engagement is
merely for making your services more
effective or for getting new ideas, or
whether you value their experience
and knowledge and believe in true
democratisation of service design
and delivery.
1 The cost of perinatal mental health problems (2015) Annette Bauer et al. LSE's
Personal Social Services Research Unit and the Centre for Mental Health
2 Vink, Josina, Katarina Wetter-Edman, Bo Edvardsson, and Bård Tronvoll. 2016.
“Understanding the Influence of the Co-Design Process on Well-Being.” In ServDes
2016. Fifth Service Design and Innovation Conference, 390–402.
3 Co-production can be defined as “A relationship where professionals and citizens
share power to plan and deliver support together, recognising that both partners
have vital contributions to make in order to improve quality of life for people and
communities.” From “Co-production in Mental Health. A Literature Review”, nef
2013 available online at http://b.3cdn.net/nefoundation/ca0975b7cd88125c3e_
ywm6bp3l1.pdf.
3. Real co-design (or co-production)
needs time and resources.
Although this is sometimes perceived to
be a way for saving money, with users and
other stakeholders taking a more active
role for free, truly participatory co-design
needs greater investment.
4. The impact of co-design on
participants’ well-being is ill
understood.
Attention and care should be given
to managing any potential negative
impacts, particularly when working with
vulnerable people.
5. Making the case for co-design
(or co-production) is key to getting
healthcare professionals, clients and
public services on board.
As this process can be more expensive and
take more time, it is necessary to make
sure that the value can be articulated from
the start and on different levels. Good
co-design in healthcare, we believe, can
have in fact multilevel impact, on the
individuals involved, the service designed
and the wider health ecosystem.

HOSPITABLE HOSPICE:
ENGAGING AN ECOSYSTEM TO
BREATHE LIFE INTO END-OF-LIFE CARE
LEKSHMY PARAMESWARAN AND LÁSZLÓ HERCZEG
Who wants to think about death and dying? It’s a taboo subject, one that we
struggle to talk about with even our nearest and dearest, even when the time
comes. And yet in most societies we face complex socio-economic challenges
brought about by an increasingly elderly and frail population, ageing within
health and care systems that were never designed to cope with such a volume
of demand for long-term care. We can no longer afford to ignore the issues that
naturally arise at the end of life...
In 2013 the Lien Foundation and Ang Chin Moh Foundation, two thought-leading
philanthropic organisations that are based in Singapore, joined forces and
invited us to rethink the experience of end-of-life care, specifically the inpatient
experience of hospices in Singapore. The project, called Hospitable Hospice, was
a first-of-a-kind design exploration that formed part of their ongoing efforts to
de-stigmatise death and dying, raise public awareness around end-of-life issues,
and shift perception of death care and bereavement.
It was essential to work in close collaboration with a spectrum of key players from
the end-of-life care ecosystem – hospice service providers, patients and their
caregivers, funeral service providers and domain experts – applying participatory
service design methods to understand the complexity of issues that exist around
end-of-life care. Together we were able to co-design a set of new strategies and
solutions, some of which have since been implemented in Singapore.

From the outset, the project was designed with the Singapore end-of-life care
ecosystem in mind because the overall goal was to achieve tangible impact.
Therefore three leading local hospices were engaged as project partners,
each of whom were interested in participating because they were actively
transforming their services and each designing and moving to new facilities in
the coming few years.
Taking a human-centred design approach, we conducted insights research
with key stakeholders from each hospice to understand in detail their speciﬁc
issues, needs and expectations along the end-of-life care journey. This
included ﬁeldwork to shadow and interview twelve terminally ill patients and
their family caregivers, accompanying them at different service touchpoints
between home, hospital and hospice. As well as this, ethnographic
observation of hospice care teams in action was conducted, followed by
interviews and interactive group sessions with three hospice CEOs, eight
volunteers and more than 30 different palliative care professionals from
healthcare, psychosocial care and pastoral care disciplines to understand the
current challenges and aspirations for delivering end-of-life care in hospices.
St Joseph’s Home in
Singapore opened in
2017 and acts as a
beacon for the local
community, offering
services that aim to
destigmatise ageing,
death and dying.

In addition we interviewed five domain
experts who could bring in a variety of
perspectives on the future of hospice
care – from health and social care policy
and clinical practice to technology
infrastructure and the death service
industry. They helped map the overall
end-of-life care landscape and identify
the key trends that will shape it.
This participatory approach continued
into the design phase of the project,
where the same key stakeholder groups
were engaged again, this time to validate
and enrich the final insights, as well as
react to a set of new design concepts
and strategies based on those insights.
Co-creation activities were most effective
when designers were able to take this
lead in translating insights into visualised
concepts that stakeholders could then
react upon, enrich and use to create their
own ideas. Insight-based co-design toolkits
were designed to be creative triggers and
act as building blocks for stakeholders to
create and communicate their own ideas in
tangible and visual ways.
As a result, the final outcomes of the
project were fully shaped and owned
by the ecosystem for which they were
designed, building momentum for change
and making implementation a natural and
desired next step.
A snapshot
of Singapore
hospice life.

Service Design Impact Report - Health Sector

Service Design Impact Report - Health Sector

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