Post on 10-Jan-2017
ServDes 2016 – Copenhagen, Denmark !
DESIGNING THE FUTURE, ENGINEERING REALITY Prototying in the Emergency Department Clio Dosi, Antonio Starnino, Matteo Vignoli University of Reggio Emilia and Modena, Reggio Emilia, Italy
Body Level One !
Design innovation branch of the University of Reggio Emilia and Modena, Department of Management engineering. SECTORS: • Healthcare • Food technology • Embedded design thinking in organizations • DT Education
DESIGN THINKING UNIMORE!
EVALUATIVE SERVICE PROTOTYPING IN AN EMERGENCY DEPARTMENT
Our case study explores the role of service prototyping to test complex service systems.
In particular, we explore the role of evaluative holistic prototyping.
SERVICE PROTOTYPING: HOLISTIC AND SINGLE
SINGLE PROTOTYPE ! HOLISTIC !
Several touchpoints are tested at the same time. !
Single artefacts or interactions !
We observe interaction with
touchpoint !
We observe emerging human
behavioral patterns
PROBLEM: OVERCROWDING IN THE ED!
Crowding occurs when no inpatient beds are available in the hospital. Over time it can lead to stressful environments and staff burnout, and in worst cases mortality. !
KEY ISSUES WE UNCOVERED
Unpredictable access of patients
Ambulatory as a bottleneck
Aging demographic
KEY ISSUES WE UNCOVERED
Unpredictable access of patients
Ambulatory as a bottleneck
Aging demographic
SOLUTION IN A NUTSHELL
!
Vertical (Experimental Zone) !
Horizontal (Critical care area) !
SOLUTION IN A NUTSHELL
SERVICE OUTCOMES!
Increase in amount of patients !
Percentage of patients satisfied with their
experience!Average waiting time
reduction (of low complexity patients) !
Average length of stay time reduction ( of low
complexity patients) !
186 patients!
206 patients!
75.35 min!
120.4 min!
164 min!
211.15 !
38% !
22% !10% !
RESEARCH AND DESIGN
ARCISPEDALE SANTA MARIA NUOVA (REGGIO EMILIA)!
70,000+ Patients a year!
ARCISPEDALE SANTA MARIA NUOVA (REGGIO EMILIA)!Last restructured in 1990’s One of the first hospitals to have triage in Italy!
KEY ISSUES WITH THE ASMN EMERGENCY DEPARTMENT
‘Old’ non flexible structure that creates a lot of ‘dead time’.
Increasing waiting time, and patients
Burnout amongst staff especially amongst the nurses.
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STAKEHOLDERS
UNIMORE Facilitators (Service designer + Management engineer)
15 person working group (composed of nurses, doctors and management of varying seniorities)
100+ staff of the emergency department (doctors, nurses, aid nurses)
Internal Stakeholders (Hospital administration, engineering department)
Emergency department patients (totalling about 70,000 a year)
PROJECT PROCESS Redefine the
problem !
Need finding and benchmarking!
Brainstorming!
Test!
Prototyping!
Client onboard from the very beginning that we design with prototypes, understanding it as a nessecary step
ETHNOGRAPHIC AND SECONDARY RESEARCH
Our research took place over a period of 4 months with the aim of understanding the ‘human’ needs and included: • 70+ hours of direct observation
• 14+ interviews with internal stakeholders
• 5 patients interviews
• Extensive comparative analysis of similar cases.
ORGANIZATIONAL RESEARCH!
“As doctors sometimes we don’t even know who else was on shift
with you.”
“Sometimes there is this pressing by older nurses even
when it's not necessary”
PATIENT CENTERED RESEARCH!
“I felt as if they were cold to me, they saw me crying and did
nothing.”
KEY NEEDS
Know whats happening around you Lack of collaboration between doctors
Maintain concentration. High number of low acuity patients make it difficult for triage nurses to concentrate
Feel taken care of (Patients) Anxiety and distress caused by lack of staff /patient contact
CO-CREATION WORKSHOP!
PROTOTYPES
Area for low complexity patients An open space with the staff and waiting patients in the same room
Family room Room dedicated to family members while patients are treated
Process nurse A nurse that looks over the entire ED and manages internal flow.
DESIGNING THE PROTOTYPE
DESIGN PHASES
Scenario building Creating a base service experience to build from
Co-design and planning Working with internal and external stakeholders to define the service and data anlysis to determine its size.
Departmental communication Communicating to gather feedback, buy-in and manage expectations
SCENARIO BUILDING!
BENCHMARKING
A Better A&E by Lloyd Peterson
Rapid Assessment Zone by the Jewish General Hospital Montreal
!
a & e!
CODESIGN AND PLANNING (INTERNAL)!
FINAL CONCEPT
Open space ambulatory that places waiting patients and doctors together in a more flexible and dynamic treatment environment, reducing dead time, and giving patients a more guided process.
!
Features: • 2 Doctor nurse teams instead of one’ • Comfortable waiting area for those waiting for exams or simple treatment • A ‘kanban’ process making it easier for doctors to track and see patients.
FINAL CONCEPT
!
DISCHARGE PHASE
Where patients would wait as they were awaiting discharge.!
TREATMENT AND EXAM PHASE
Where patients would wait to be seen by the doctor !
DOCTOR VISITING PHASE:
Where patients would wait to be seen by the doctor !
FASE 1FASE 2FASE 3
Area di presain carico del paziente e visita
Area di eventuale trattamento e attesa risultati diagnostici
Area di dimissione
SOLUTION TO BE TESTED
!
INTERNAL COMMUNICATION!
EXTERNAL COMMUNICATION!
PATIENT-CENTERED INFORMATION
EVALUATIVE PROTOTYPING DECISIONS
HOW ARE WE GOING TO TEST OUR PROTOTYPE?
PROBLEMS INHERENT WITH SERVICE DESIGN
Intangibility of services as design material
Inconsistency in service delivery
Authenticity of behaviours and contexts
Validity of the evaluation environment
Conceptualising Prototypes in Service Design, Blomkvist, 2010
We converted the old waiting area into…
Phase 1 Phase 2
PHASES IN REALITY
How to run the holistic testing, today?
READY TO START TESTING
LIVE PROTOTYPING
HOW TO RUN HOLISTIC PROTOTYPE TODAY?
!
The objective was to test whether this solution would shorten the Length of Stay and the Waiting Time, while providing a comfortable solution for patients and staff. At the same time, we needed to adjust the prototype to the needs that emerged while testing this new solution. We settled on a 5 week long continuous testing (22nd April - 31st May 2015).
LIVE PROTOTYPE AS AN ITERATIVE CYCLE
!
Observation!
Weekly meetings !
Changes communicated!
We planned a feedback strategy to be able to understand all issues and emerging practices that arose during the testing, adjusting the prototype accordingly.
LIVE PROTOTYPE WEEK BY WEEK
!
• We identified eventual critical disrupted elements
• General Impressions!OBS
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ADJU
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Week 1!
We adjusted the elements that could make the
experiment fail!
WEEK 1: CRITICAL ELEMENTS Doctors try to hide themselves behind dividers or columns. We reposition the dividers inside triage.
LIVE PROTOTYPE WEEK BY WEEK
!
• Identified additional critical points
• First ‘hacks’ emerge as well as common behaviours!O
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ITER
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MEN
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Week 1! Week 2!
We adjust the smallest critical points
We support or suppress the hacks or
behaviours that emerged !
• We identified eventual critical disrupted elements
• General Impressions!
We adjusted the elements that could make the
experiment fail!
WEEK 2: FIRST HACKS “More than rarely we need the patient to be undressed. One visiting box is not enough: we need two boxes for the area.”
WEEK 2: FIRST HACKS Creating new tools
WEEK 2: DIALOGUE Shared responsibility putting effort on doctors as much as nurses
“After awhile staying up on your feet all day is tiring.” – Doctor
“My legs are a lot more relaxed now that I don’t have to walk back
and forth all day.” - Nurse
WEEK 2: DIALOGUE Limit complaining, more open dialogue
“It’s a lot easier now to ask for advice and collaborate with my collegues.” - Doctor
LIVE PROTOTYPE WEEK BY WEEK
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OBS
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ADJU
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Week 1! Week 2! Week 3!
We suggest eventual best practices!
• Identified additional critical points
• First ‘hacks’ emerge as well as common behaviours!
We adjust the smallest critical points
We support or suppress the hacks or
behaviours that emerged !
• We identified eventual critical disrupted elements
• General Impressions!
We adjusted the elements that could make the
experiment fail!
• After getting used to the new service, the first improvement suggestions emerge
• Shared best practices emerge.
• First data analysis!
WEEK 3: DOCTOR TO PATIENT Emerging best practice: Save time and deliver better feedback if you go directly to patients.
WEEK 3: SPACE CHANGES Common behavior. “There’s no need for phase 3” & We start sharing the first data results
LIVE PROTOTYPE WEEK BY WEEK
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• Smaller changes implemented
• Data is analyzed!OBS
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ADJU
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Week 1! Week 2! Week 3! Week 4!
Live prototype closed and learnings applied!
• After getting used to the new service, the first improvement suggestions emerge
• Best practices emerge. • First service data
collected !
We suggest eventual best practices!
• Identified additional critical points
• First ‘hacks’ emerge as well as common behaviours!
We adjust the smallest critical points
We support or suppress the hacks or
behaviours that emerged !
• We identified eventual critical disrupted elements
• General Impressions!
We adjusted the elements that could make the
experiment fail!
WEEK 4 & 5: NOISE Attempt to reduce noise levels
FINAL PRESENTATION TO DEPARTMENT AFTER
!
1. Showed the results, with photos and documentation.
2. Shared an updated blueprint from the engineering department
3. Got final feedback from everyone, with shared decisions.
OUR RESULTS AFTER 5 WEEKS
!
Stop the experiment due to its temporary nature the noise levels were too high, requiring the need for final structural implementation. Lowered waiting time and length of stay overall while increasing patient satisfaction. Implemented more private spaces (boxes) into the final blueprint of the space – potentially saving thousands of dollars in restructuring costs.
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CONCLUSION
OUR LIVE PROTOTYPING PRINCIPLES
Intangibility of services as design material à Experience prototyping, role playing, design games, … were not enough
Inconsistency in service delivery à Feedback from 150 employees, with very different expertise and capabilities
Authenticity of behaviours and contexts. à How can I gain authentic feedback notwithstanding the fact it is a prototype?
Validity of the evaluation environment. à How can we ensure the prototype recreates real world conditions?
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Inconsistency in service delivery.
Testing parts is not like testing holistically.
Conceive your prototyping as a learning experience for the organisation (and for you !), not as a material artefact.
OUR LIVE PROTOTYPING PRINCIPLES
1 !
Don’t get scared if you see the organization losing part of its competences in the first weeks, and be ready to restore them.
OUR LIVE PROTOTYPING PRINCIPLES
“In bananas” - The first 2 weeks are the most expensive in terms of energy and stress.”
Inconsistency in service delivery
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Be ready to reassure users that new behaviors could emerge and, if needed, they will be structured and officialised.
OUR LIVE PROTOTYPING PRINCIPLES
Inconsistency in service delivery
“I can’t manage to stay behind everything, including the teams.”
1 !
Intangibility of services as design material
How can I gain feedback from 110 employees, considering that everyone of them is going to change his mind at least twice while he experiences the prototype, and that the prototype is lively changing?
OUR LIVE PROTOTYPING PRINCIPLES
2 !
Intangibility of services as design material
Identify your Networking Angels (NA),
• NAs are from your the groups that participated into the design process, because they need to know why design choices were made as they are
• NAs need to cover each profession, so that doctors can answer to doctors, nurses to nurses, aid nurses to aid nurses.
• Among each professional cathegory, you need to have at least a senior professional.
!
OUR LIVE PROTOTYPING PRINCIPLES
2 !
Intangibility of services as design material
Coach your Networking Angels. Those actors are your referents on the field, and answer to colleagues’ questions/feedbacks (sometimes aggressive questioning!).
• Prepare them to: Encourage, receive and look for positive feedback
• Bring the general perspective: Explain ‘why’ some choices were made
• Support them, they put their face in the project and are going to be overloaded by expectations “No, listen, I am going to have a heart attack !” !
OUR LIVE PROTOTYPING PRINCIPLES
2 !
Authenticity of behaviours and contexts.
Choose a testing length so that:
• Everyone can test it at least 3 times “Until, it’s a one week simulation that’s ok, but I won’t accept that forever”
• You gain data significance “Two weeks are not enough”
OUR LIVE PROTOTYPING PRINCIPLES
3 !
Authenticity of behaviours and contexts.
• Make the decisional process on the prototype as transparent as possible. It has to be clear to the whole organization why changes in the prototypes are made.
• Live test in a safe and ordered way. The entire staff has to know how and who to contact in case of questions for change, and weekly report are disclosed to everybody and summarized by Networking Angels.
OUR LIVE PROTOTYPING PRINCIPLES
3 !
Validity of the evaluation environment.
The validity of the prototypes depends on how similar the test and implementation contexts are.
OUR LIVE PROTOTYPING PRINCIPLES
4 !
Validity of the evaluation environment.
Do not surrender to short cuts to make your testing life easier:
• Do not change shifts to include only the smartest people during the test. We asked for extra time of an expert staff to help in case of coaching.
• Do not ask for extra resources or only put the smartest people to test the prototype if you are not sure you are going to have them
• Do not let assumptions derail testing. “This is not a very big town, people want to decide, relatives will never accept to be divided
OUR LIVE PROTOTYPING PRINCIPLES
4 !
THANK YOU!
Clio.dosi@unimore.it, matteo.vignoli@unimore.it, antoniostarnino@gmail.com
!