Thinking Differently: Six Principles for Crafting Rapid Co-design and Design Thinking Sprints as ‘Transformative Learning Experiences in Healthcare’

Abstract

This chapter presents six principles drawn from lived experience of running over 30 rapid design thinking and co-design sprints on diverse healthcare topics as part of the HEAL initiative. Starting with an explanation of the value of a co-design approach to healthcare and situating these activities as transformative learning experiences for attendees, the six principles address the empathetic role of the facilitator, the importance of looking for the positive, the need to work through the hard stuff, the value of enabling consumers to have their say, ways to facilitate important conversations, and how to ensure a memorable experience. The chapter ends with a research poem that highlights the importance of thinking differently about design sprints.

In delivering the HEAL (Healthcare Excellence AcceLerator) initiative to ten hospitals and health services across the vast state of Queensland, I have designed and delivered over 30 rapid co-design sessions and design thinking sprints on diverse topics including virtual, connected, and integrated care; planning for the pandemic; reducing procedural pain; and improving patient safety and the care experience. In this chapter, I reflect on and share my process and learnings in the form of six key principles that outline the highs and lows, missteps and mistakes, stories, and lessons learnt.

1 The Value of a Co-design Approach in Healthcare

Co-design, alternatively labelled experience-based co-design, participatory design, co-creation, and co-production, is a collaborative approach to transformative problem-solving that acknowledges, privileges, and increases the participation and involvement of key stakeholders in the design, development, and implementation of solutions (see Vargas et al. [1]) for a detailed discussion of the distinction between co-creation, co-design, and co-production). Best conceptualised as form of participatory action research, in the healthcare context co-design positions consumers (patients) and staff as equal partners working together to improve the experience of healthcare by innovatively re-designing a service, initiative, or product. The experience and voice of patients is prioritized, as we see in Fig. 1—with co-design enabling staff to truly ‘see’ the patient’s experience and place at the centre of quality improvement initiatives.

Fig. 1

“Hey—you’re getting me!”. (Credit: Simon Kneebone)

While such active engagement with consumers has been described as “the new Zeitgeist—the spirit of our times in quality improvement” [2, p. 247], experience-based co-design (EBCD) emerged from pioneering work conducted in 2007 by Paul Bate and Glen Robert in an English head and neck cancer service. Bate and Robert [3] were the first to advocate for the philosophy and method of experience-based co-design (EBCD) in health, arguing that instead of redesigning health systems around the patient, services should be co-designed with the patient. Key to their participatory EBCD approach ¹ was ethnographic storytelling and visual methods (film and photography) to document key experiences and moments (touch points) in the patient journey (Fig. 2), with the aim of designing better experiences around these—from redesigning the physical environment to changing logistical or clinical care processes. As Bate and Robert explain, the task of EBCD is to (1) access patient’s “unique and precious” personal knowledge of the process, service, product, or system and (2) “utilise it in the service of a better design, and a better experience for the user” [3, p. 24].

Fig. 2

The patient journey. (Credit: Simon Kneebone)

Bate and Robert advocated for user experience to become a ‘core competency’ in understanding and reimaging healthcare, and over the last two decades numerous collaborative health research projects have demonstrated the value, benefit, and specific methods for stakeholder engagement and co-production via EBCD [4]. Typically, these initiatives have been co-led by clinicians and consumers. To date, it unfortunately remains relatively rare to see design professionals sharing this leadership role—which is the focus of this book: to recognise and strengthen what an experienced professional design lens brings to healthcare improvement (see [5, 6]). In this chapter, I will document lessons and reflections on the process of running co-design workshops—what we also often call design thinking sprints—to provide some ideas, inspiration, and resources to those project leaders who are beginning the process and seeking more information on how to facilitate such activities.

2 The Design Sprint—A Time-Constrained Creative Approach

A design sprint is a time-constrained creative approach to idea generation which, at its best, combines the principles of design thinking, innovation, positive psychology, and business strategy. Interdisciplinary teams come together to focus on one wicked healthcare challenge, and work through the phases of a design thinking cycle to rapidly develop, prototype and (ideally) test solutions. A typical design sprint can range in duration from hours to a day or a week, with Knapp et al.’s [7] Google Ventures approach a 5-day five-phase process facilitating a small group of 5–8 diverse people.

The co-design sprints and sessions I describe in this chapter have a very different flavour, purpose, and structure—typically 2–3 h to a day at most, and up to 80–100 people in the room. Especially during the COVID-19 pandemic, it has been challenging to expect busy clinicians to devote significant time to the process. While true EBCD projects can take months of engagement, there is a place for shorter, focussed events that engage, educate, inspire, and connect. As chapter “Empathy in Action: A Rapid Design Thinking Sprint for Paediatric Pain—Perspective-Storming, Pain Points, and the Power of Persona” in this collection shows [8], when focussed and engaged, even a 1-h sprint can produce high-quality ideas, concepts, and innovations that project teams can take forward to be further developed, co-designed, tweaked, and tested with end-users. As an external university-based facilitator, I tend to pragmatically view these co-design sprints—which are typically embedded in larger projects—as a first critical space for inspiration, excitement, dreaming, and exploring, with the problem owners subsequently taking carriage of the project management and strategic decisions needed to propel the next steps in the process.

3 The Co-design Sprint—A Place for Transformative Healthcare Learning Experiences

While it is relatively well-established that co-design workshops/sprints enable the sharing of ideas and generation of improvement initiatives, an under-appreciated benefit of the type of sprints we run is that they can also serve as transformative healthcare learning experiences. Before discussing how a transformative learning experience might look like in healthcare, a reminder that transformative innovation is shifting failing systems so that they are viable for the future. As Leicester [9] explains it, transformation is more than change or improvement: it is a fundamental and intentional systemic shift that is part of a continuous longer-term change process with differing phases (emergence, diffusion, reconfiguration) at different levels in the system (micro, meso, macro; or landscape, regimes, or niches), influenced by mechanisms, processes, and actors, with different personalities, perspectives, priorities, and worldviews. Of course, the transformation process is complex, messy, and imperfect, and requires people becoming comfortable with—not overwhelmed by—complexity. Denning [10] famously explained that:

Transformational innovation entails a transition from a mode of operating that is known and secure to one that is unknown and potentially chaotic. Transformational innovation requires offering or doing something fundamentally different; a metamorphosis most organizations don’t excel at…. Such a shift will never be easy because it puts in question existing strategies, jobs, careers, processes, brands, customers, and culture [10, p. 11].

Healthcare is intensely focussed on innovation, improvement, and transformation, acutely aware of the need to provide value-based care: better, high quality, yet more efficient patient care at a lower cost. As transformational innovation is not easy, Austin [11] argues for an organisational vision that emotionally engages as well as scenario planning that begins in the future, enabling people to imagine and ‘step into’ multiple alternative futures. Future-orientated co-design sprints and workshops enable participants to look at things in a different way, and thus are an activity that helps to create a future-ready, change-ready workforce. Indeed, the entire co-design and design thinking process, as outlined throughout this book, begins with empathetic engagement with the experience of others, followed by collaborative framing and idea generation, prototyping, and testing.

Designed with reflection and intention, co-design sprints and workshops can serve as a critical transformative learning experience, helping equip and empower participants for the changes facing healthcare. Sociologist Jack Mezirow’s Transformational Learning Theory [12] argues that adult learners can adjust their thinking based on new information—transformative learning begins when individuals purposely and critically reflect upon and question their assumptions of what they believe to be real, true, or right. By definition, a transformative learning experience goes beyond simple knowledge acquisition as exposure to a disorienting dilemma that challenges typical mental schemas and triggers a significant shift in an individual’s perspective or attitude.

Mezirow [12] argued this occurs through ten distinctive elements of transformative learning: a disorienting dilemma, self-examination, critical assessment of assumptions, recognition of discontent and identification with similar others, exploration of new options, planning, acquiring knowledge for plans, experimenting with new roles, building confidence, and reintegration into one’s life. Alongside having a clear problem to solve (the disorienting dilemma), my primary intent in designing and running any co-design/design thinking sprint is to create a transformative learning experience for participants. This requires intention, planning, and clear communication, and is guided by six key principles, described below.

4 Principle 1: Reflect on Your Facilitator Role, to Be an ‘Empathic Provocateur’

I would like to start by considering the role of the facilitator. In planning a design thinking/co-design session, as well as the design literature, there is a large invaluable body of work on the group facilitation process; Heron [13], for example, has identified six dimensions of facilitation: planning, meaning, confronting, feeling, structuring, and valuing, with an associated key facilitative question to consider for each domain:

• 1. Planning—How shall the group achieve its objectives?

• 2. Meaning—How shall meaning be given to and found in the experiences of group members?

• 3. Confronting—How shall the group’s consciousness be raised about these matters?

• 4. Feeling—How shall the life of feeling and emotion within the group be handled?

• 5. Structuring—How can learning be structured?

• 6. Valuing—How can such a climate of personal value, integrity and respect be created?

Explicit consideration of such questions means asking oneself: “if I was a participant, what would I want to see, learn and experience?” [14, p. 16]—that is, looking at the experience, not from the facilitator perspective, but from the participant perspective. Jones [14, p. 16] recalls being told by one person how they were in a staff meeting and knew there were 84 ceiling tiles and 24 fluorescent lights in that meeting room: you do not want to design an experience like that for your participants!

In contrast, the best design sprints serve as transformative learning experiences. The best facilitators, Mezirow reminds us, should act as an “empathic provocateur” moving between affirming and questioning, intentionally shifting, disorientating, and transforming participants’ frame of references: “encouraging participants to face up to contradictions between what they believe and what they do … and discrepancies between a specific way of seeing, thinking, feeling and acting and other perspectives” [12, p. 366]. As an “empathic provocateur”, our words and actions challenge and reframe participants’ frames of reference—and shape the co-design/design thinking experience. From the facilitator’s perspective, Judi Apte [15] has developed four helpful rules for facilitating transformative learning, and argues that each session should: (1) confirm and interrupt current frames of reference; (2) work with triggers for transformative learning; (3) acknowledge a time of retreat or dormancy; and (4), finally, develop the new perspective.

In designing a co-design/design thinking session, it is helpful to remember, as Peter Senge [16] reminds us, that generating change is about creating creative tension: the gap between the vision (what we want to create, our aspirations; the way things could be) juxtaposed against the current reality (the truth; the way things are). Senge [16] encourages us to imagine a rubber band stretched between our vision and current reality: when stretched, this rubber band creates tension—and the only way this can be resolved is to be pulled, either towards the vision or reality. Whichever occurs, Senge [16] argues, depends on whether we hold steady to the vision—and the co-design/design thinking process can be a powerful tool for generating support for that vision.

5 Principle 2: Embrace an Appreciative Inquiry—Inspired Approach by Sketching a ‘Positive Moment’

A defining feature of my design sprints is that we get right to work; perhaps in contrast to other facilitators, I rarely have people formally introduce themselves to the entire group, instead we dive straight into the creative design process. I typically start with an appreciative inquiry—inspired approach—see chapter “The Art of Transformation: Enabling Organisational Change in Healthcare Through Design Thinking, Appreciative Inquiry, and Creative Arts-Based Visual Storytelling” [17], asking participants to recall and then sketch a moment at work when they felt inspired and at their best; a ‘positive, inspiring moment’. Participants label and describe their sketch, also signing it if they wish. These sketches are then shared at tables, with a few shared with the broader group—this process of recalling, drawing, and then sharing positive moments creates an energising buzz, creating a positive energy and start. It is also a wonderful way to remind participants that the workshop is not about perfection, but about communicating and developing ideas.

Figure 3 shows some of these images from recent sprints—participants drew patients when they achieved health rehabilitation goals (standing or walking for the first time), when service or health system changes had a positive impact (accessing rehab services over the weekend), or how they had successfully implemented changes that boosted morale (a weekly online Teams meetings, where each member shared a win), with the honest, authentic character of these sketches resonating. The art and process of sketching helps participants better explore, explain, and envision concepts and ideas, playing a critical role in stimulating collaborative group reflection and dialogue (see Miller [18], for an exploration of using drawing and sketching in a research project focused on creatively depicting hopes, fears, and expectations of ageing).

Fig. 3

Sketching a ‘positive, inspiring moment at work’

Sketches are then pinned to the wall, creating a powerful visual wall of positive moments. In one session, a participant shared they had once coordinated a similar reflective drawing activity and the power of these sketches meant they subsequently formed the cover of their organisation’s annual report. What is clear is that this process of thinking and communicating visually is an enjoyable way to commence a codesign sprint/workshop, enabling people to distil and communicate what motivates them very clearly, quickly, and memorably. Sketching is a critical component of the design and design thinking process [19], which is why the idea pitching process in HEAL projects frequently had participants craft a media ‘headline’ (newspaper, magazine, or online) simply conveying their concept idea alongside an illustrative drawing, as in Fig. 4, towards the end of each session.

Fig. 4

Headline exercise examples

This pitch process is an important component, as this is where participants can convince others of the value, impact, and importance of their idea—and that the organization should commit time, resources, and money to it. The best idea pitches are compelling: they have a memorable name, concept, and slogan, typically starting with an empathetic story (linked to the consumer voice or persona) illustrating the challenge and the proposed transformative solution. A quick note here on the quality of ideas. As management guru Peter Drucker [20] pointed out, more than 30 years ago, we must remember that we are often poor judges of the potential impact of an innovative, game-changing ideas:

In the innovative organization, the first and most important job of management is…to convert impractical, half-baked, and wild ideas into concrete innovative reality…. Top management, in the innovative organization, knows that new ideas are always ‘impractical.’ It knows that it takes a great many silly ideas to spawn one viable one, and that in the early stages there is no way of telling the silly idea from the stroke of genius. Both look equally impossible or equally brilliant [20, p. 540].

Participants will then typically rank the proposed solutions on different criteria (is it doable, timely, sustainable, transformative, impactful etc), with one project developing and using a four R rating scale which asked: is the idea radical (disruptive potential); relevant (momentum in the system); realistic (in a resource constrained environment) and resilient (sustainable)? Increasingly, I have asked groups to collaboratively rank and allocate large ‘fake’ Monopoly—style money to their preferred ideas, as Fig. 4 illustrates.

Over longer sprints/workshops, participants can develop and share more sophisticated prototypes illustrating their pitch; for example, in a 3-day design sprint during Singapore Design Week 2022, focussed on medication management for seniors, one group brought in a pineapple on banana leaves to illustrate their concept of food as medicine while another presented their idea in song and a third developed more sophisticated prototypes of their app idea. A well-presented pitch and prototype enables people to emotionally connect with and remember the idea, but as Brown [21] astutely reminds us, prototypes “should command only as much time, effort, and investment as are needed to generate useful feedback and evolve an idea” (p. 19). As audiences increasingly have shorter and shorter attention spans, sketching remains a powerful tool for clearly and compellingly connecting people with alternative visions. There is magic in sketching, for the process of turning internal thoughts, feelings, and thinking into a tangible and visible drawing provides critical perspective and distance from the problem [22].

6 Principle 3: Purposely Surface, Don’t Dodge, the Hard Stuff

While it can be tempting to focus on the more exciting and positive process of idea generation, often the topics discussed may be contested. If that is the case, then engaging in structured activities that surface people’s worries and fears is worthwhile. The activity I like to use is entitled: Hopes, Fears, Myths, and Taboos—what I call a HFMT Matrix. Ask people to silently, individually, complete a separate post-it note for each hope, fear, myth, and taboo (things people know but cannot say) about the proposed change, and to then put the post-its on the appropriate butchers paper on the wall. I often ask participants to complete this task from two different perspectives: staff and consumers, and to write an S or C in the corner of the post-it. Tables may choose to discuss these issues, or to move to the next phase: using sticky dots to indicate the issues they agree with most. The facilitators might choose to group these, or simply to call out the top few issues for a group discussion. The HFMT Matrix is a powerful tool for surfacing and discussing simmering issues, and can provide leadership teams with some deep and tangible insight.

7 Principle 4: Amplify Consumer Voice—Storytelling, Personas, and Empathy Maps

Often the most memorable and transformative components of co-design is when clinicians learn from and collaborate with consumers, who bravely share their most personal of experiences to help improve the system for others. While it is ideal to have consumers engaged to directly share their experience, the reality is that the honest sharing of personal health challenges in public forums requires significant engagement, energy, and courage; therefore, instead of and/or alongside the direct voice of consumers, personas (fictional characters) are a critical component of design sprints/workshops. Ideally, personas are research-based, created from workshops, interviews, observations, quantitative and qualitative data, or, in the medical context, drawing on actual cases to trigger deep reflection and discussion, helping ensure any initiatives are connected to the real-world context.

HEAL project personas have typically been developed collaboratively, with consumers and clinicians, with this process taking significant time and attention. Table 1 shows how, in one project, we worked with ten consumers to craft three distinct personas and scenarios that were a representative composite of their experiences—and during the workshops, one consumer presented each persona to the large group, who then re-designed the experience of healthcare for Mae, Skylar or Will. Good personas will ring true, so that in the discussion of them, the characters and situations resonate, enabling us to imagine, and step into the shoes of another—to have empathy and use that empathetic imagination to guide our actions. By serving as archetypes, personas assist with strategizing and communicating, and are critically important in the first step of the designing thinking process (Empathize), where participants are asked to complete an empathy or journey map.

Table 1 Co-creating personas and scenarios with consumers

In a different project focussed specifically on virtual care and remote patient monitoring in the regions, we presented three different personas for the one scenario: a GP, specialist and a consumer, Anne, who had COPD. The persona of Anne so resonated with one consumer in the workshop that he publicly shared his wife’s journey with the group: his wife died in the car outside a regional hospital, was brought back to life, and then spent the next year in and out of hospital (living away from her regional home, in a large city), before receiving a lung transplant. Geoff shared his hope that contemporary technologies might have enabled him and his wife to stay at home, rather than have COPD disrupt their lives quite as much. Whether it is through personas, empathy maps or the powerful narratives of real-life consumers, good design—and good healthcare—always starts with listening and deep empathy. Sometimes the first empathy task in a workshop might be for participants to select and co-create their own persona and develop a scenario that works from their own lived experience.²

8 Principle 5: Holding Space for Engaged, Meaningful, and Creative Conversations

Whether it is an incremental shift in thinking or radically new ideas, co-design sprints offer invaluable space, time, and air for teams to reflect, share thoughts, feelings, and beliefs, to co-create and imagine, and to have engaged and meaningful conversations about the very real wicked problems they face. All facilitators have a different approach and style, but what distinguishes a design sprint/workshop from other gatherings is that it follows a ‘designerly’ future-focused, inspiring, visual, and practical methodology. As facilitator, it is your role to provide a psychologically safe space where creativity, collaboration, and innovation can thrive. This is not easy, as you must balance different and dominant personalities, interpersonal power dynamics, and internal politics and agendas.

Thoughtful and inclusive facilitation, however, proactively manages any dissent and moves the group forward. Rehearsing potential answers to challenges is helpful, as is proactively monitoring teamwork processes and group mood to minimise people being disengaged and distracted by “dissent, inertia, resistance, or criticism” [23, p. 128]. Having chocolate on the tables helps, as does remaining engaged your facilitator role—to help keep participants authentically engaged in the process, you must remain alert, watchful, and truly present. This means actively listening and ‘floating’ across the different individuals and table groups, listening, engaging, supporting, directing, and redirecting groups, as appropriate.

In reflecting on the facilitation process, I am reminded of a common saying in tertiary education: ‘from sage on the stage to the meddler in the middle’, which essentially reframes the role of teaching from presenting/lecturing from a lectern to being actively co-learning on tables with students. Facilitation is similar, in that you must ‘float’ across groups, to help ensure they are listening to, learning from, and building on the ideas of others.

As a facilitator, you must also clearly communicate the day’s agenda, processes, and outcomes, and keep a close eye on the clock: do not disrespect people’s time and busy schedules by going over time. You must start and finish on time, and that may mean adjusting your planned schedule. For example, at a recent full day co-design sprint, we intended to have the afternoon focussed on developing and then pitching improvement ideas. Our original intent was to ask teams to apply the SCAMPER technique as they developed their idea from seven different perspectives about what could be: Substituted, Combined, Adapted, Modified/Magnified, Purpose, Eliminated, and Rearranged/Reversed (SCAMPER). However, this group was finding the process of generating creative ideas challenging enough, and so we decided on the day to not undertake the SCAMPER activity, and instead to allocate more time on idea generation and development. HEAL projects typically developed and use large pre-populated handouts, known as a design canvas, which groups completed, which is easier logistically than blank butchers paper when working with larger groups.

As facilitator, you should also build in a critical and self-reflective review process after each codesign sprint/workshop, asking: what did we learn, what worked well, what did not, and where to next? Consistent with this open spirit of reflection and improvement, HEAL has been characterized by an intentional focus on open innovation [24], which means that where possible all the processes, outcomes, reflections, and resources, (including videos) are freely available online for others to access, ³ facilitating the sustainability, scale, and spread of our approach.

9 Principle 6: Make the Experience Memorable, by Engaging with the Peak-End Rule

Finally, a thoughtfully-designed session that results in a transformative learning experience is one that—in its construction—has paid close attention to participants’ experience and the peak–end rule, a psychological heuristic in which people judge an experience based on how they felt at their ‘end’ and its most intense point—the ‘peak’. The session needs to create multiple opportunities for participants to be ‘wow-ed’ by hard-hitting memorable moments and then finish with a ‘peak-end’ experience—typically, the final idea pitch and voting process serves as an emotionally engaging peak-end experience, and I will then summarize the journey and activity outcomes on the walls and tables surrounding us.

As Daniel Kahneman [25] explains in his work on cognitive biases, people have two types of “selves”: the ‘experiencing self’ who is living in the moment, and the ‘remembering self’, who looks back and ‘re-narrates’ the experience. As the facilitator, your focus needs to be on creating such moments—whether it is the HFMT Matrix, the appreciative inquiry sketch, the empathy created from the personas, or the hum of energy generated as participants brainstorm diverse ideas, develop, and share their pitch. As HEAL projects have been collaborative, at the end of the sprint, the project owners (clinicians and project managers) we worked with to formulate the focus, activities, and objectives have the core responsibility to integrate the knowledge generated into the broader organization; typically, a report is compiled and ideas selected to continue for further development.

10 Conclusion

Running a good co-design sprint/workshop, and crafting a transformative learning experience, requires thought and intention. Well-crafted co-design sprints and workshops provide a safe space for inter-professional shared learning, for people to connect with diverse others, to question and challenge long-held assumptions, to reflect, and to explore and share different ways to tackle the wicked challenges facing healthcare. To thrive in today’s VUCA (volatile, uncertain, complex, and ambiguous) world, people must become ‘change-ready’—as futurist Alvin Toffler [26] explained, the illiterate of the twenty-first century will not be those who cannot read or write, but those who cannot learn, unlearn, and relearn.

Such transformation does not just magically happen. I argue that the iterative processes of exploring, explaining, and envisioning that occurs inside good co-design sprints/workshops provides the perfect transformative space for unlearning and relearning. Such questioning, reflecting, learning, relearning, and transformative change is often uncomfortable but required for transformative innovation. I end this chapter with a poem (from [23, p. 130]) which shows how, at their best, participatory co-design sprints/workshops really can be powerful transformative learning experiences that foster creative innovation and thinking differently—we are transformed; not “the same coming out as we were going in” [23, p. 129].

• Out there in the air,

• there is a field where fresh ideas come and go.

• Joining, we start to move with new frequency in relationship with ourselves,

• with others, and even the field itself.

• Moving more freely, we see new things;

• and the old, familiar views, a-new.

• This opening, this broad space, is the place of letting go,

• of running, where so much is born.

• We see a beautiful, broad field in red-orange-yellow.

• We’ve entered this broad space, by design.

• Leaving all we know behind hoping to find what we are looking for:

• Big thinking, brainstorming, ideation.

• Rhythm. Relationship

• It is in this open, seemingly boundless place,

• that things often get too open.

• Too loud, too fast, too loose.

• A little … wild.