Keywords

Can healthcare innovate itself? Answering this question is central to making progress against the many pressing challenges that beset the sector globally. Eminent healthcare design scholar Professor Peter Jones considered this question in the very first chapter of his 2013 book ‘Design for Care: Innovating Healthcare Experiences’ [1]. With respect to the North American care system, Professor Jones suggests that ‘innovating’ itself is not something healthcare has done particularly well—one only needs to look at the how fragmented and incomprehensible some parts of the healthcare are (sometimes as a direct result of purported innovation activities). Through case studies and commentaries, the rest of the book builds a focused case for change (and partnerships with design disciplines) to support future transformation efforts.

The ideas, challenges and experiences described in ‘Design for Care’ share similarities with the case studies and reflections contained in previous chapters of this book. Together, they underscore the vast untapped opportunities for transformative change for healthcare organisations to make investments in design partnerships. As the HEAL initiative has shown, ‘triads’ of healthcare teams, consumers, and designers, seem to invariably succeed more frequently (and more sustainably), as discussed in chapter “‘It Takes a Village’: The Power of Conceptual Framing in the Participatory Redesign of Family-Centred Care in a Paediatric Intensive Care Unit” [2], than when healthcare teams and consumers choose to prosecute an innovation agenda alone. What conclusions can be drawn from this?

Ever since the seminal 2001 Institute of Medicine report ‘Crossing the Quality Chasm’ [3], many of the persistent problems in healthcare quality have been described in the language of gaps, omissions, shortfalls, and deficits. Within that framing, it is tempting to express the problem of innovation as a mere deficit (in design skills, access to expertise and so on). However, the experiences accrued across the many HEAL projects completed so far suggests the impacts of our design partnerships have been more catalytic than that—transformative rather than transactional.

It has been fascinating to witness the HEAL program evolve into its present form—from its modest germinal phase in 2019, to a period of explosive and opportunistic growth during the early months of the COVID-19 pandemic, to more recent maturation of relationships between the QUT design community and local health services into streams of longer-term steady collaboration. Along the way, we have had the opportunities to observe, interpret, connect, and interpolate findings from the rich body of collaborative work compiled over the past 4 years. Unexpectedly, working with designers has taught me as much about healthcare as it has about design practice and the creative disciplines. From my vantage as the co-director of the HEAL Bridge Lab, it’s been increasingly apparent to me that the role designers can play in healthcare goes far beyond the technical and creative design skills they ‘add’ to improvement projects. Rather, designers (through the vehicle of embedded collaborations with healthcare teams) can catalyse shifts that make healthcare more conducive, receptive, and accommodating to design interventions—in other words, designers can make healthcare more ‘designable’ (and, by extension, innovation-friendly). At first glance, this may seem a trivial point, however the implications for healthcare innovation practice are profound.

1 Promoting ‘Designability’—The Art of Making ‘Hard Systems’ More Malleable

Most experienced colleagues in healthcare improvement will agree that change-making in healthcare is not for the faint of heart. Priorities are often hotly contested, consensus (if ever achieved) can be fleeting, resources are rarely enough, and even well-resourced initiatives will often see ‘improvements’ expelled as soon as the project concludes. Indeed, the acknowledged failings of the ‘improvement science’ paradigm in healthcare is a central reason for the emergence of new fields like implementation science [4], and greater interest in alternative ‘complex systems’ approaches [5]. Unfortunately, implementation science has little offer when ‘implementable’ research evidence is weak (or when practice change is driven by other factors—like consumer expectations). On the other hand, while complex systems science offers deep insights into system performance issues and the nature of change-making in complex systems, the language and methods of the field can be a little mystifying (even inaccessible) for the average clinical improvement team. Thus, in the Venn-diagram of the myriad healthcare improvement challenges today, the bulk of ‘in-the-trenches’ rapid service enhancement work falls in ‘white space’ between a traditional improvement paradigm and the emerging implementation paradigm. These are perhaps best understood as clinical innovation opportunities, and typically where HEAL projects were deployed. But unlike the familiar arc of most improvement projects, we saw entrenched issues seemingly dissolved through collaboration with designers. Even more remarkably, design collaborations catalysed journeys for various teams that did not fall away after the ‘active’ phases of projects finished. Designers left ‘traces’ in our system in ways that continued to enable innovation and an orientation towards ‘designerly’ thinking as teams went on to work on adjacent problems. What is occurring here?

While traditional (mechanistic, structural) conceptualisations of healthcare cannot offer satisfying explanations as to where from or why resistance emerges, complexity theory does offer some crucial clues. First, despite apparent ‘inertia’, complex systems are held in states of equilibrium through dynamic and dissipative (energy expending) relationships. Therefore, ‘resistance to change’ under a complex systems framing is better described as an adaptive and active phenomenon where a network of interdependent (human, technological and procedural) structures can experience tension (or torsion) when a certain change is imposed on the system, which then leads to the generation of several counteractive forces to return the system to its previous state of homeostasis. Practically, this can be seen when service changes create problematic trade-offs—such as when initiatives cause clinicians to juggle new priorities in addition to old ones, or when one group of consumers suffer service disruptions to accommodate others.

Overcoming resistance in a complex-systems framing entails navigation of the dynamics that hold systems (which include people) in current patterns, and altering them (weakening of some links while strengthening others) to allow new patterns to emerge. This idea is encapsulated neatly in a quote ascribed to legendary designer, systems theorist, and scientist, Buckminster Fuller: “You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete.” Although HEAL designers (to our knowledge) did not explicitly apply systems thinking tools in HEAL projects, they operated in ways that were nonetheless aligned.

Repeatedly, HEAL design partnerships led to new insights about presenting problems that engendered novel ways of moving forward. The VOICeD program described in the chapter “Co-creating Virtual Care for Chronic Disease” [6] is an early exemplar. The experience designer engaged to support the clinical team took the brief (which was to lead the codesign of an interdisciplinary telehealth service for chronic disease management), but expanded the conversations ‘upstream’. Jess, using design methods like journey mapping and persona development, worked with the project leads to unpick various assumptions about who service users were and how they might use the planned service innovations. By expanding the envelope of possibilities early (allowing more of the platform’s eventual features to be subject to consumer co-design), the designer was able to make the end-product more ‘designable’. Another example of designers transforming inflexible assumptions about what was possible in a system into a more malleable form came from the PICU liberation project. In chapters “‘It Takes a Village’: The Power of Conceptual Framing in the Participatory Redesign of Family-Centred Care in a Paediatric Intensive Care Unit,” “Bringing the University to the Hospital: QUT Design Internships at the Queensland Children’s’ Hospital Paediatric Intensive Care Unit (PICU),” and “NICU Mum to PICU Researcher: A Reflection on Place, People, and the Power of Shared Experience” [2, 7, 8], the clinical project leads describe how HEAL designers took a request for support (framed around what was thought to be feasible) and transformed it into what was necessary to achieve the ultimate goal of a reimagined care experience for children under intensive care and their families. The PICU liberation partnership morphed into a many-armed demonstration project, showcasing a multitude of design touchpoints across the entire consumer experience. Crucially, the PICU clinical team has continued down a design-led pathway as they seek to address new priorities for service change. This comes long after Bridge Labs-funded support has ceased. In this instance, the team’s views on what is ‘re-designable’ in their environment of work has been permanently transformed through working with designers.

While the previous examples highlight how design partnerships can shift perspectives within the system, we saw that designers in healthcare were fundamentally changing the system itself. Another HEAL project in the paediatric setting (but not discussed in this book) involved the use of play-based ‘probes’ to codesign a codesign toolkit to work with young children (who have just received a life-long diagnosis) in an outpatient setting. The First 100 Days project sought to build the tools that are needed to engage young people and their families fully and meaningfully in codesigning service innovations. The ground-breaking implications of such a toolkit have been recognised beyond the borders of the project with the larger health service looking to incorporate the findings and artefacts from the work into their strategic program for service codesign. This is another example of design partnerships making the system more designable, but in this instance, giving the system bespoke tools to ‘innovate itself’.

The presence of HEAL projects in some health services also led to system leaders recognising how risk aversion was getting in the way of vital innovation within these organisations. Simple inquisitive questions like ‘why not?’, asked by credible academic design professionals, became powerful catalysts for systemic reworking of approval pathways, and of risk management procedures, creating conditions more conducive to solving the problems at hand.

2 The Future of Healthcare Design Partnerships

The HEAL initiative is still at the very start of what needs to become a global movement to reinvent and innovate the paradigm of healthcare improvement. Individuals who gravitate to healthcare disciplines are often naturally empathetic and humanistic. This should form the ideal substrate for consumer-centric service innovation. However, healthcare systems are often configured and incentivised in frustratingly complex ways, such that the lived reality of delivering and receiving care can seem impersonal and mechanical. At the sharp end of improvement work, design partnerships can help re-humanise care but, perhaps most importantly, organisations that support design partnerships at scale might be able to re-humanise their systems making healthcare a safer and higher quality experience for all.