The Art of Transformation: Enabling Organisational Change in Healthcare Through Design Thinking, Appreciative Inquiry, and Creative Arts-Based Visual Storytelling

Abstract

This chapter tells the story of a complex organisational change to a healthcare service, splitting rehabilitation functions across two hospitals in the same region. The design project was developed to help the healthcare providers (clinicians, nurses, and allied health professionals) from both hospitals reach an understanding of the strengths that each hospital provided to its patients, with one large hospital in a busy metropolitan area and the other a small hospital in a rural area. Using arts-based design methods including design thinking, workshops, journey maps, and photovoice experiences from both providers and consumers, the HEAL team were able to help the rehabilitation service providers see the value in the requirements of the organisational change and the potential benefits in the new distributed service.

Implementing organisational change and transformation in complex healthcare systems is a notoriously difficult process. However, change is a defining feature of healthcare as new policies, technologies, and practices (from models of care to workforce and governing structures, strategy and/or operations) are continually introduced, altered, or retired. In this chapter, we explore the value, processes, and impact of intentionally using design and arts-based approaches to engage clinicians and consumer in a reflexive dialogue about organisational change—in this example, changes to how rehabilitation care was to be delivered.

1 Healthcare Is a Complex Adaptive System, Resisting Linear, Universal Solutions

In reflecting on how best to engage people in change dialogues, it is critical to acknowledge that healthcare is a complex adaptive system: it responds in different and fundamentally unpredictable ways, defined by unpredictability, uncertainty, competing and changing demands, and high levels of interdependence and connectivity [1]. As Greenhalgh and Papoutsi [2] explain, this means—unfortunately—that there are no linear, universal solutions or set of methods, arguing that “the conventional scientific quest for certainty, predictability and linear causality must be augmented by the study of how we can best deal with uncertainty, unpredictability and generative causality” (p. 2).

Developing, in part, out of a systems thinking approach, a complexity science perspective emphasises the relationships, interactions, interdependencies and feedback loops between agents and their environments: interventions and changes in healthcare does not occur in a controlled environment. Rather, change occurs in “settings comprised of diverse actors with varying levels of interest, capacity, and time, interacting in ways that are culturally deeply sedimented, and have often solidified” [3, p. 7].

2 Using Appreciative Inquiry and Creativity for Reflection and Projection

In encouraging people to reflect on the present and reimagine the future, our unique approach to co-design thinking sprints draws on an awareness and appreciation of futures thinking, systems thinking, and complexity science, and is also strongly grounded in the strengths-based appreciative inquiry approach. First developed by Cooperrider et al. [4], appreciative Inquiry (AI) is a strengths-based model that encourages change agents to look at people, systems, and their organisation with ‘appreciative eyes’. Instead of the traditional deficit-based model of “what’s wrong? What the problem?”, appreciative inquiry is a strengths-based “earch for the best in people and their organizations.

Purposely using positive questions, such as “What is currently working?” and “What would work best in the future?”, a complete appreciative inquiry approach typically follows a four-step, 4D process: Discover, Dream, Design, and Destiny (often starting with a 5th D: Define). As Cooperrider and Godwin [5] explain, what is essential in AI is the respectful and collaborative design approach; after all, “individuals’ commitment to change is directly proportional to the degree to which they are engaged in designing the change and that everyone in the system—not just researchers and consultants—are potential ‘experts’ with valuable insights for the change process” (p. 739).

Interestingly, although design thinking and appreciative inquiry are conceptually aligned, they are rarely explicitly linked. Over a decade ago, however, the originator of AI Cooperrider supplemented it with a new framework that explicitly linked design theory with appreciative inquiry, positive organisational scholarship, positive psychology, and sustainable enterprises. Titled IPOD (innovation-inspired positive organization development), the theory of change underlying IPOD outlined three stages in creating strengths-based organisational innovation: (1) the elevation and extension of strengths, (2) the broadening and building of capacity, and (3) the establishment of the new and eclipsing of the old [5]; for another rare exception linking AI with design thinking, see also [6].

3 Arts-Based Research and Arts-Based Knowledge Translation

Alongside codesign and design thinking workshops which enable people to share their knowledge and insights, imagine the future, and cocreate solutions, creative arts-based approaches are powerfully impactful, engaging, and accessible forms of communication that serve to engage, educate, motivate, and transform. From multi-media digital storytelling to films, theatre, dance, poetry, and photography, there is growing awareness that the creative arts are a powerful tool for (1) engagement; (2) promoting new ways of understanding; and (3) knowledge translation, with the use of the arts to disseminate research-based knowledge termed arts-based knowledge translation [7].

In this project, we used two visual arts-based approaches to engage and educate. Firstly, a professional documentary filmmaker created two short films ¹ that captured the local rehabilitation experience from the perspective of clinicians and consumers. Secondly, we deployed a visual story-telling approach to build connections across these dispersed sites; despite working together for years, and being less than a 1-h drive apart, clinicians had limited knowledge about where and how their counterparts worked. As Noel Tichy explains, “the best way to get humans to venture into unknown terrain is to make that terrain familiar and desirable by taking them there first in their imaginations” [8, p. 5401] and we did that here through the visual methods of photovoice and photography.

Gillian Rose [9] has identified three reasons for the appeal of visual methods: they generate rich data; explore ‘taken-for-granted’ experience; and foster participatory, collaborative approaches to date collection and knowledge creation. Photovoice is a participatory action research strategy, where the camera becomes a research tool: essentially, people are asked to take photographs of a key issue or topic under investigation [10], with these photographs then shared to educate and create change. Alongside participants’ photographs, the project also deployed a professional photographer whose understanding of composition and lighting further enabled the creation of aesthetically and visually compelling images, supplementing and complimenting participant’s photovoice (see [11] for a discussion of the value of including both photovoice and professional photography in research).

4 The Rehab Project: Part 1, the Co-Design Sprint

The specific focus of this design sprint was exploring how one hospital and healthcare service (connecting six hospitals and health services across 10,000 kilometres) could better activate a smaller (22 bed) rural hospital as a step-down site for the rehab ward at the larger regional hospital. With the surrounding population expected to double over the next decade or so (to more than 588,000 by 2036), the broader project focus was on reimaging how rehabilitation was delivered at multiple sites. After visiting both the hospital sites, as well as a community-based facility, the HEAL project team developed and deployed a co-design sprint as a place for reflection, conversation, and creative collaboration, along with an arts-based digital storytelling and photovoice project.

In a 3-hour workshop in March 2021, over 75 clinicians and consumers shared their expectations, hopes, dreams, and fears about the proposed changes to create seamless care transitions between rehab services at the two hospitals, generating ideas about preferred priorities and solutions to the challenge of a growing and ageing population which will increase demand for public hospital services. The first part of the sprit focussed on understanding the system (Activities 1–3), with the last part (Activities 4 and 5), focused on transformation—the guiding question was: how might we create a positive, seamless rehab journey between these two hospitals for consumers, specifically our personas of Don, Ruby, or Clara.

4.1 Activity 1: Drawing, Reflecting On, and Sharing a Moment of ‘Exceptional Practice’

The first ‘ice-breaker’ activity in the workshop was for participants to draw a moment of “exceptional practice”: a moment when they were engaged, excited, and proud of their work, or (for consumers) experienced exceptional care. Figure 1 shares these sketches: when a patient spoke for the first time in 6 weeks; of taking a patient (after 14 months of in-patient treatment) to visit their rural property for a picnic; the ward Christmas party (bringing staff and patients together to celebrate); or when staff worked to bring a much beloved and missed dog into the hospital to visit its owner. The specific task instructions are outlined below.

• Recall a special moment of exceptional practice when you were really engaged, excited, & proud of your work. Take 4 min to remember & draw this experience. Add a title, key descriptors (dot points), and your name (optional).

• Table Share (3 min): Share your exceptional experience with the group: what were the common themes? Pick one story that illustrates the shared themes.

• Joint Analysis (3 min): Each table shares one story to the other groups. As a table respond to the question: what does a great rehab experience at this hospital look like? Write it down on a sheet for the research team to collect with your drawings to pin to the walls.

Whether it is sketching a self-portrait, a work experience, or initial prototype ideas, the visual language of drawing (1) enables complex and abstract ideas to be communicated in an engaging, accessible, and memorable way and (2) helps create a shared understanding between diverse stakeholders, with the focus on the positive an intentional appreciative inquiry-inspired approach (see [12] for deploying drawing in a research context).

Fig. 1

Moments of exceptional practice

4.2 Activity 2: Empathy Mapping, in Storyboard Comic Form

Continuing with the visual language of drawing, participants were asked to create (draw) a comic strip to illustrate a typical rehabilitation patient journey between two facilities: before, during and after admission to hospital, using one of two provided personas. Table 1 illustrates these: 82-year-old Don (carer for his 78-year-old wife, Ruby, who has diabetes and had a stroke a week ago) or 59-year-old Clara, whose complex medical history and multiple comorbidities included kidney disease, early-stage chronic obstructive pulmonary disease (COPD), and frequent falls. A fall from her mobility scooter led to an infected gash, sepsis, and a stay in ICU, triggering a referral to rehab.

Table 1 Introducing Don and Clara

After selecting one of these personas (or creating their own), the groups created a story of transitioning between facilities through the medium of a comic. They were asked to show the best and worst scenarios, along with what patients, their families, and staff “think, feel, and do” as they engage with the rehab system. Participants were shown some examples of comics, and remined that they did not need to be a professional artist to tell a story, but to use drawings and thought clouds, speech bubbles, and captions to narrate the experience. Comics were pinned to the wall for discussion, with participants using “callout cards” to add scenes or comments to other groups’ scenarios. Figure 2 illustrates how, in a playful and engaging manner, the comic strips illustrated key touchpoints in the patient journey.

Fig. 2

Empathy mapping, in storyboard comic form

4.3 Activity 3: Reflecting on the System and Change, with the Fears, Hopes, Myths, Legends Matrix

The workshop continued with a systems analysis, designed to identify and surface deeply-held feelings about the proposed changes. Using separate post-it notes for each category, participants was asked to individually list their Hopes, Fears, Myths, and Legends—from two different perspectives: clinicians and patients, as Fig. 3 illustrates. Participants individually wrote and pinned these to the corresponding butchers’ paper on the wall, before the HEAL team led a quick overview summary of insights back to the entire group.

Fig. 3

System analysis matrix, shown here ‘Hopes’ (left), and ‘Fears’ (right)

Hopes centred on maintaining and improving care standards, reducing waiting lists, developing virtual care and for supportive leadership so that “the rehab ward can continue the amazing work that we do”. Fears highlighted concerns about coordinating care and sustaining quality (“how do I know patients are receiving good care?”), and of “letting go”, and of “change, not being in control, and not been told”. Myths centred on a handful of common areas, mainly from the clinician perspective: (1) workload—that they would be over-worked due to a lack of resources, (2) patient safety—that patients would fall through the cracks, and “rural hospitals are just for maintaining patients and can’t provide all appropriate care”, and “will this older facility have the resources?”, that “effective rehab cannot be done [just] anywhere”, and “we’ll have no visibility of the patients”—in other words, trust. Finally, Legends (which is a question about what we believe to be true) centred on staff pride and commitment: as the best rehab in the state, a leader in the field, with a great team culture. The value of the Hopes, Fears, Myths, and Legends (HFML Matrix) activity is that it quickly surfaces organisational culture, highlighting cultural norms and values, as well as beliefs and fears about the proposed change—information which provides change leaders important insight into the blocks and barriers that impeding the change, while also identifying the supports and stories that could be amplified and built upon in messaging [13]. Given the strength of emotion around the changes, a stretch afternoon tea break was scheduled after this activity, to provide a physical and psychological break between activities.

4.4 Activity 4: Ideation—Creative Brainstorming, with a ‘Perspective Storming’ Lens

The last hour or so of the workshop centred on transforming the system, through creative brainstorming (aka, ideation activities). With open, creative and informed mindsets developed from the previous activities, participants now engaged in a creative brainstorming process—to explore what could be done to create a positive, seamless Rehab journey for Don, Ruby, or Clara. To spark diverse ideas, each person at the table was instructed to (1) speak from a specific perspective (either as the patient, the carer/family, the staff, the space, the technology, or the communication) and (2) to explicitly consider key touchpoints in the patient’s journey map—before, during, and after rehab. The focus here was generating multiple ideas quickly (a minimum of 10 per table), but also to encourage multiple different perspectives—which is why participants were asked to be “the voice” of a specific lens, and to explicitly consider how technology might improve this, and how a space lens might, etc.

This ‘perspective—storming’ approach is inspired by Edward de Bono’s Six Thinking Hats [14] mindset, where people are explicitly asked to mentally adopt a different mindset or ‘hat’: the yellow hat is the mindset of optimism, the red hat represents intuition, the green hat creativity, and so on. Building on and expanding the thinking hats mindsets, Miller and Cushing [15, 16] developed what they term ‘theory-storming’, which encourages people to view a built environment challenge through the lens of a specific design theory (e.g., playable design, inclusive design, biophilic design); similarly, in this activity, we explicitly instructed participants to view and advocate for potential solutions through the lens of a specific perspective, which is why we have termed this approach ‘perspective-storming’. The value of such an approach is that enables diverse, divergent thinking, and it is also sometimes easier for participants to share ideas under the guise of what ‘technology might do’ than framing the solution as their own idea. Ideas were written on coloured post-it notes (a different colour for each perspective—e.g., green for space, yellow for technology), and pinned to butcher’s paper around the room. All participants were encouraged to walk around the room, to be inspired by the diversity of ideas all teams generated, and to vote for their favourites.

4.5 Activity 5: Designing Change—Developing and Pitching Your Prototype

In the final workshop activity, back in table groups, participants picked one idea to develop and pitch to the room as a prototype for designing change. The idea could be one they had originally developed, or it could be one they had seen from other groups, or (ideally) an amalgamation of ideas. In the intentionally short time of 20 min, participants were instructed to develop a prototype (a low-fidelity representation of their idea) to show and pitch to the room. They could use whatever method suited them; for example, drawing, the comic form from earlier, or annotating printed maps on their table depicting the two hospitals. The pitches centred on how clinicians ensure the planned changes supported their shared values of providing a quality, effective, and consumer-centred rehabilitation care experience, with two teams proposing a bus service between the two hospitals, with other ideas including developing a suite of digital resources showcasing the care experience and tips for continuing rehab at home. Teams pitched their ideas, with participants voting on the winner. What is significant is that, in a fast-paced 3 hours, fears and hopes about the change were surfaced, alongside ideas to improve the experience—with this feedback providing invaluable insight for management teams leading the change initiative.

5 The Rehab Project: Part 2, Photovoice, Photography and Digital Narratives

Several weeks after the co-design workshop, clinicians and patients at both hospitals were invited to participant in a photovoice project for an exhibition designed to showcase the rehab experience at both sites. Participants asked to take a photograph, with an accompanying narrative story, about something that was meaningful to them about the rehab experience in that location, with a professional photographer and documentary filmmaker also visiting both sites. Figure 4 highlights some of these images, as well as the exhibition boards in situ at the larger hospital, with the exhibition sharing the photographs alongside the co-design processes and findings. The exhibition was exhibited at both hospitals, with positive feedback.

Fig. 4

Visual images, photovoice, and professional photography, in the exhibition

From the moment of installation, the exhibition had a positive impact and achieved its goals of engaging and education. For example, one of the images is of a small herbal tea garden (comprising of mint, chamomile, lemon thyme etc) in a planter box at the smaller hospital, which clinicians encourage patients to tend for and pick, to create their own fresh herbal drink every morning as part of the ‘Boonah Breakfast Club’ (as depicted in the right image of Fig. 4). As we were installing this image on the walls of the hospital, clinicians at the larger hospital commented on what a great initiative this was, and how they were not aware this was taking place at the smaller hospital. As intended, the exhibition effectively broke down barriers and facilitated communication and idea-sharing across the two-healthcare setting, while also serving as a powerful reminder of the importance, processes and life-changing impact of rehab. This is demonstrated in middle photograph in Fig. 4 which depicts Linda, the stroke Clinician Consultant shaving a patients face. When taking this photo Linda shared that “it’s not always the big things—it’s the little things that make me feel like I’ve made a difference”.

6 Conclusion

Both the co-design workshop and visual methods provided opportunities to connect people in an honest, respectful, and transformative dialogue about the possibilities and challenges of change. One of the most important, yet often under-appreciated truths of system change is that it must engage, educate, support, and connect people, because as Rieger et al. [17] explain:

Transforming a system is really about transforming the relationships between people who make up the system. For example, far too often, organizations, groups, and individuals working on the exact same social problems work in isolation from each other. Simply bringing people into relationship can create huge impact [17, p. 7].

Our arts-based design thinking processes provided a collaborative, visual mechanism to rapidly explore creative solutions, providing a (1) unique place for clinicians and consumers to connect to discuss the proposed change and strategies to enable quality care, while (2) the visual methods enabled reflection and then new conversations about care practices.