Future Health services require the use of new technology and new solutions. The need for reorganization and more efficient utilization of available resources are increasing, both for hospitals and the local health services taking place in the municipalities. At the same time as the overall services are to be renewed and rationalized, it is a principal objective in health policy to create "the patient's health service". But how do we find good solutions?
This article is also available in Norwegian (pdf).
Service design/ design thinking is a methodical approach for developing innovative solutions based on real user-needs, and where co-creation contributes to solutions that can be integrated into the services while also giving users better opportunities to manage and handle their own lives and health.
The Center for Health Innovation, Helse Møre og Romsdal by Kristiansund Hospital, Hospital pharmacies Mid-Norway, SINTEF and Kristiansund municipality have an ongoing innovation project (2017-2021) where service design is used to realize service innovation and establish new practices. The project title is "Intravenous antibiotic treatment in hospital@home –a new model for interaction across services with the use of welfare technology and telemedicine". The overall objective of this project is to develop, test and evaluate a new patient pathway, which, through the use of interaction and technology, will contribute to empower patients to become active participants in their own treatment. New solutions will enable long-term intravenous antibiotic treatment and following-up of patients in their own home. The new model includes welfare technology and telemedicine approaches. New interaction between levels of the health care providers means that patients are followed-up at home by the municipal regional response center and nurses in the response team according to the individual treatment plan, and where the hospital physician initiate treatment and are responsible for the patients when they are at home.
A formative evaluation of the project will be carried out to elucidate the process, whether and to what extent the user-groups experience benefits, and to uncover barriers and challenges that need to be improved. Practice-oriented research methods and service design is used to elucidate the research questions. The insight will be used to assure quality and further development of the new patient pathway. A research-based approach to service innovation will provide new knowledge of new opportunities, provided through the use and implementation of technology and innovative health care interaction, how it can contribute to more user friendly solutions which can be implemented and put into practice, and might have the potential to rationalize health care services. Participatory research might also provide information about the generalizability to other diagnostic groups, treatment-methods and geographical areas. The project is organized into four work-packages (figure 1).
Figure 1: Timeline and content in the project's work-packages
Service design process in work-package 1 (the pre-project): The organization of the new patient pathway is complex, across institution, health care levels and different disciplines. This demands increased knowledge about both patients' and employees' needs, common understanding of the problem, commitment and shared enthusiasm. Service design was chosen as a method to address these needs. The processes in the first part of the project has focused on the four phases of the double diamond (Figure 2).
Figure 2: The double diamond (AHO, the School of Architecture and Design in Oslo and KS R&D. The time for service design? Introduction for municipal innovation processes. Oslo: KS, Design for public services, Designit, EGGS, Halogen and Livework; 2015.
The investigation phase: One of the main principles of service design is to create meaningful services based on user needs. The process started with mapping out the needs of the various stakeholders when moving the treatment and following-up of patients in need of long-term intravenous antibiotic treatment from the hospital to the patient's own home. Insights were obtained from the following stakeholders; persons over the age of 18 who have received intravenous antibiotic treatment at home (n = 3), persons over the age of 18 who have received traditional treatment in hospitals (n = 4), next of kin (n = 4) and professionals involved in delivering the new service from both specialist and primary health care services (n = 9). The methods we used in the investigation phase were conversation groups and semi-structured interviews. Interview guides were used to ensure that human, organizational and technological conditions were highlighted. The conversations and interviews were documented with quotes and sound-recordings to ensure a rich datasource and to substantiate and disseminate findings.
The analysis phase - from data to findings: Collected data was analyzed, and significant needs were identified in order to develop a safe, secure and attractive service for users and their next of kin. Results obtained in the insight work indicates that, continuity in the patient follow-up at home, access to personnel with the same expertise as in hospitals, user-friendly technology and good user-training is essential for the users to experience the new service as equally safe as traditional treatment inside the hospital. We used notes, pictures and sound recordings to analyze and structure data from the interviews and group-discussions. Findings were thematically divided into main findings, and presented with both illustrations and quotes. For each of the findings, a description of important inclusions was produced (Figure 3).
Figure 3: Presentation of main finding nr.1 (in Norwegian)
The idea- development phase: Several workshops were conducted with various stakeholders, where the findings from the insight phase were presented. The brainstorming-workshop 1 was conducted with patients, next of kin and employees from regional response team. We presented preliminary findings visually, and based on the first prototype of the blueprint we asked for feedback and correction from the participants. Did we understand the needs correctly? We had a special focus on security; when and where could the participants find weaknesses in the prototype of the patient pathway? Participants were given time for themselves to explore the new pathway, ask about things they were wondering about and then handed out post-it notes where they were encouraged to write down weaknesses and/or challenges. The notes were sorted thematically. New insight after the workshop included deeper knowledge about the needs of and support from the next of kin. During the brainstorming workshop this group expressed the feeling of an enormous responsibility in the new patient pathway. Checklists for training and knowledge sharing with the next of kin were included. This is just one of several ideas that emerged during the workshop. In brainstorming- workshop 2, we searched for ideas of how the needs of the patient- and the next of kin may vary according to different demographic factors. Several differences in the needs of elderly users and users with young children were uncovered.
Conceptualization phase: The results of the creative processes and priorities of the workshops led to a new prototype of the new patient pathway. In our project, the prototype is a blueprint, a technical drawing that functions as a process description. The blueprint defines the patient's actions from inclusion to exclusion of service, the user’s contact with the health care service, the health service's actions both visible and not visible to the patient, and which tools / technical aids / procedures are needed for both patient and healthcare personnel throughout the journey. The process description further says something about who should do what, and form the basis for further testing and implementation.
The project team, with an expanded number of participants, attended a tabletop-testing in order to examine whether a real user test could be carried out (Picture 1 and 2). A review of all the details of the patient pathway was performed, visually presented in the form of the blueprint. Those responsible for the electronic patient journal (EPJ), from both levels of the health care services, municipality and hospital, completed a test of documentation flow between the municipality and the hospital for a fictive test user. Employees helped to assure quality and highlighted important factors that must be mapped in order for the service to be carried out in a professionally and responsible way, where the users' need for information security and privacy are ensured.
Picture 1 and 2: Prototype test; A review of all details in the patient's home-based hospital, visually portrayed in the form of a blueprint, was performed. An observer was responsible for documenting in a matrix what emerged during the review of the blueprint; strengths / weaknesses, what is in place / what is lacking, what comes at the wrong / correct time in the process, challenges, who is responsible etc. Tags in the matrix are marked in the blueprint illustration, and form the basis for further adjustment, concept testing and elaboration of a new prototype.
Tests were also conducted to choose the proper type of infusion pumps, to ensure a good choice of equipment for venous access, and to choose the best solution of welfare technology. Three different infusion pumps were tested on patients in the medical department at Kristiansund Hospital. The user safety in a scenario like Hospital@home was considered. The choice of venous access was made on the basis of experience gained in reference projects and state of the art. The choice of communication solutions and welfare technology solutions was based on knowledge about the user needs and based of the state of the art at the regional response center. The need for further professional training and standard operating procedures was uncovered and resulted in the generating of a procedural portal, this portal will be made public in work package 2. Further testing and completion of technological communication solutions, routines, instructions and procedures for interaction between the specialist at the hospital, municipal health care service, regional response team and hospital pharmacy were needed before we could start including patients in the new service. This is now completed and the first pilot patient has received and completed treatment at home.
Experiences from working with co-operative service design methodology to develop the new patient pathway:
We find that the actual project organization facilitates co-creation. Employees from the five equal partners in the project make up the project-group, who meets weekly to ensure common understanding and progress of development. All participants are equal partners and have skills that complement each other to develop user-friendly, sustainable and feasible services. Nurses from hospitals and municipalities, doctors, disease control officers, IT managers, EPJ officers, technicians, clinical pharmacists, service designers, innovation advisers and researchers are represented to ensure that different competencies, perspectives and experiences are ensured. The development of the new solution is designed in close cooperation with the service providers from all affected agencies, and we believe this has been a decisive factor in designing a good solution that could not have been achieved without the participation of all these participants. Co-creation has ensured a strong ownership and a common understanding of user needs, and not least that the service becomes feasible and sustainable in normal operation.
The vast majority of the members in the project-group do not have previous experience working with service design, and several have repeatedly communicated that they are humble working with this new approach, where we actually develop the service with the patient, and not just for them. Increasingly more health care workers recognize that they are trained to be solution-oriented and soon to initiate new measures, even before having a full understanding of the real user needs. The fact that the users are involved, as they are in the case of hospital@home, is of great importance to get insight into their needs. The users have expressed gratitude for being heard and allowed to contribute to the development of a new service, and they have given us valuable input to the choice of solution.
Participants in the project group highlight the visualization of the service model (using Blueprint) as a success factor for a good work process. Blueprint has been an important tool for co-creation and for establishing common understanding during the process. Several participants emphasize that this tool has helped to keep track of all the details of the patient pathway, and that it was a very useful tool when performing prototype testing.
The starting point for the project was an idea for a concept that would help to substantiate the "patient's health care service" and at the same time meet resource challenges that we are facing in the health care system. By using service design methodology, we have become aware that other solutions can be better suited for giving greater value to the user groups. We have found it important to not commit to a concrete concept prematurely, but rather to be open for different approaches. We are trying to keep this in mind and apply it in our working process. In hospital@home we are constantly adjusting the concept to new ideas and suggestions that we receive from both users and health care givers.
